Determinants of influenza and COVID-19 vaccine intent or uptake in Lebanon: a scoping review of the literature

Background Vaccination is essential to protect from influenza and recently from COVID-19, yet uptake in Lebanon is suboptimal. Several factors determine uptake including knowledge, attitude and policies. We conducted a scoping review of the literature to explore the determinants of influenza and COVID-19 vaccine intent or uptake in Lebanon. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, thirty one peer reviewed studies indexed in six databases Pub Med, EMBASE, Scopus, CINAHL, Medline, and the Cochrane Library were screened. Two students, a senior Librarian and an Associate Professor in nursing searched for eligible studies. The library search strategy followed a combination of three broad concepts (viral influenzas; vaccines; Lebanon). The search timeframe was up till December 31, 2022. Determinants of influenza and COVID-19 vaccine intent or uptake were categorized following the constructs of the Theory of Planned Behavior. Results Nine studies investigated influenza vaccine intent or uptake among the public community, parents and healthcare workers. Twenty one studies investigated COVID-19 vaccine intent or uptake among the public community, older refugees, university students, patients with cancer, dentists, and social media users. One study investigated both types of vaccines. A conceptual model of the determinants of vaccine intent and uptake within the Lebanese context was developed. Various determinants included environmental factors, norms, knowledge, perceptions, attitudes, past experiences, behavioral control and hesitancy. Conclusions Research on vaccine intent and uptake in Lebanon is still in its infancy, while that of COVID-19 is on the rise. Multifaceted reasons behind the low vaccination rates were observed yet few attempts were made to target vulnerable groups. Further research studies are needed to target vulnerable groups.


Background
The seriousness of the impact of both influenza and Corona Virus Infectious Disease (COVID-19) is notable.A survey from eight Lebanese hospitals showed that between 2018 and 2020, 30-40% of the 1,238 severe acute respiratory infections were due to viral influenzas [1].During February of 2020, the weekly mortality rate due to influenza across Lebanon was between 20 and 50 deaths [1].In terms of COVID-19, there have been more than 1.02 million confirmed cases of COVID-19 and 9,890 deaths in Lebanon as of February 2022 [2].Unfortunately, determinants of influenza and COVID-19 vaccine uptake were not thoroughly explored and modeled within the Lebanese context.Exploring these determinants is of particular importance to the global community, the Lebanese Ministry of Public Health (MoPH), health care administrators and individuals as well.At the global level, the World Health Organization (WHO's) position paper called for a number of recommendations including studies to understand the drivers of influenza and COVID-19 vaccine uptake in low and middle income countries such as Lebanon, a country that doesn't meet the WHO recommendations to control for influenza transmission and decrease disease burden [3,4].At a national level, understanding the drivers and barriers of influenza and COVID-19 vaccine uptake fulfils an essential primary health care objective.It aids in designing/testing effective interventions to overcome poor influenza and COVID-19 vaccine uptake.
Vaccine is an essential measure to prevent the spread of viral influenzas [5,6].Yet, influenza and COVID-19 vaccine uptake rates in Lebanon, a Middle Eastern and North African (MENA) country are consistently suboptimal.They are estimated at less than 20 doses/1,000 compared to 275 doses/1,000 individuals in American countries [7]; thus not meeting the WHO recommendations [4].Similar to influenza vaccines, COVID-19 vaccine uptake rates are also suboptimal.By June 19, 2023, the Lebanese MoPH stated that the cumulative rate of COVID-19 vaccine uptake in Lebanon was 2.75 million (single-dose recipients), 2.41 million (double-dose recipients), and 0.67 million (triple-dose recipients) [8].However the percentage of COVID-19 vaccine coverage within the adult Lebanese population (≥ 12 years old) remains low (44.4% and 27.6% for double and triple dose recipients respectively) [8].The Lebanese population seems to be lagging behind in terms of both influenza and COVID-19 vaccine uptake rates.For vaccines to have a desirable impact on the short-term, vaccine coverage should be at least 70% to avoid a less needed surge of pandemic in a country witnessing multiple crises and a limited health-care capacity [9].
Determinants of influenza and COVID-19 vaccine uptake in the MENA region were reported by many researchers [10,11].For instance, in terms of social influences and recommendations, a physician's advice to get vaccinated against influenza and COVID-19 were associated with higher vaccine uptake rates in Iran [12][13][14].In terms of risk perceptions, the perceived susceptibility / severity of influenza and COVID-19 were commonly reported in many MENA countries [15][16][17].In some countries, mandates played a role in influencing people's decision to get vaccinated against influenza and COVID-19.Other factors included socio-demographics, health-related, context-related, attitudes, hesitancy and others that varied between populations.Populations in the MENA region consist of diverse yet unique ethnic, linguistic, sectarian, familial, tribal, religious, socioeconomic, and national identities [18].However, the sociocultural fabric in Lebanon differs from its neighboring countries [19].In Lebanon, the predominant culture is fundamentally conservative that exhibits a great deal of respect for traditions and customs, despite the influence of Western cultures on some life aspects [19].This indicates that there is a need to explore the determinants of influenza and COVID-19 vaccine uptake within the Lebanese context.
The Strategic Advisory Committee on Immunization Practices (SAGE) -the principal advisor for WHO on the overall global vaccine policies and strategies -routinely revises the various determinants of vaccine uptake reported in literature [20][21][22][23][24][25][26][27][28][29].Therefore the body of literature in Lebanon needed an evaluation on this matter.In addition, SAGE recommends more research on vaccine hesitancy in low to middle income countries and in under researched populations, to better understand its context-specific determinants [29].Last but not least, influenza and COVID-19 vaccine uptake were not conceptualized within the Lebanese context.
Interestingly, the COVID-19 crisis influenced influenza vaccination negatively in some instances and positively in others.Prior the pandemic, the rate of influenza vaccine uptake among the general Lebanese public was 27.6%.In terms of COVID-19 vaccine intent, almost 59% of the Lebanese public community were willing to get vaccinated which showed that some Lebanese had a negative attitude towards the importance of COVID-19 vaccines [30].The general public community in Lebanon might have missed on taking the quadrivalent seasonal influenza vaccines during the COVID-19 pandemic, while it motivated health care workers to get the influenza vaccine (flu vaccination uptake has risen from 32.1% in 2019-2020 to 80.2% in 2020-2021 [31].There was a 12% increase in influenza vaccine uptake rate during the COVID-19 pandemic among Lebanese dentists [32].This contradiction can be attributed to many factors.At the policy level, the Lebanese MoPH memorandum No. 149 (issued on October 6th, 2020) recommended influenza vaccines mainly to health care workers.In Lebanon, influenza vaccine itself was not included in the national immunization programs before or during the pandemic, neither mandated nor funded by the Lebanese MoPH.Moreover, the national data on annual influenza vaccine coverage in Lebanon was not clearly mapped and reported.At the primary health care level, more than half of the surveyed health care workers in one study did not properly identify candidate patients for influenza vaccination, and less than half of them did not promote for the importance of getting the influenza vaccine [31].Insufficient amount of influenza vaccines was also a significant barrier reported by health care workers in the same study.The health care workers' decision to get vaccinated against influenza was directly influenced by their fear of co-infection (influenza and COVID-19) and the recommendations of CDC [31].
Between January 2020 and December 2022, thirteen review studies addressed influenza vaccine related topics; whereas 24 review studies addressed COVID-19 vaccine related topics.It was evident to us there was no scoping review studies of the Lebanese literature to identify and model vaccine determinants.Between 2006 and 2016, one review study focused on influenza vaccine policies, use, recommendations and coverage within the MENA region [33].This review only pointed to two studies from Lebanon.Therefore a scoping review study was needed to examine the extent and direction of the literature on influenza and COVID-19 vaccine status in Lebanon.Pinpointing the determinants of influenza and COVID-19 vaccine uptake in Lebanon is of particular interest to the Lebanese policymakers and researchers, and at a global level to international experts at SAGE who might be interested in the vaccination status in this country.Last but not least, a scoping review study is capable of pinpointing knowledge gaps related to influenza / COVID-19 vaccine status in Lebanon.

Methods
This scoping review study followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [34].The stages of this study included: identifying the research question, identifying the relevant studies, selecting the studies, extracting the data, collating, summarizing, and synthesizing the results.

Identifying the research question
The research questions included: • What were the studies that investigated influenza and COVID-19 vaccine intent or uptake in Lebanon?• What were the characteristics and outcomes of these studies?
• What were the determinants of influenza/COVID-19 vaccine intent or uptake in Lebanon?

Identifying the relevant studies
Peer reviewed journals indexed in Pub Med, EMBASE, Scopus, CINAHL, Medline, and the Cochrane Library were screened.Studies published in subscription journals (restricted or paid access journals) were retrieved from the Saab Medical Library at the American University of Beirut.Two students, a senior Librarian and an Associate Professor in nursing searched for eligible studies.The students successfully completed an advance course on systematic reviews and meta-analyses.The library search strategy followed a combination of three broad concepts (viral influenzas; vaccines; Lebanon) (Table 1).Under each concept, specific medical subject headings (MeSH) terms were combined and searched in each data base using the common Boolean operators.The timeframe for the reviewed published studies was up to December 31, 2022.The date of data collection for each study was also inspected.The geographical space of the published studies was limited to Lebanon.

Selecting the studies
Studies retrieved from the databases were compiled into a reference software manager (Endnote x7).Duplicate studies were rapidly identified by Endnote, confirmed by the research team and then removed.Next, a first round preliminary review of titles and abstracts for the selected studies was performed based on the inclusion and exclusion criteria stated in Table 2.After excluding ineligible studies, the remaining studies were subject to a second round of thorough review (full version), to confirm that the selected studies met the eligibility criteria.The full texts of the remaining studies were retrieved using the Uniform Resource Locators (URLs).

Extracting the data
The two students independently extracted data.Data extraction followed a structured tool developed by the research team and tailored to the study needs based on the work of Schmid et al. 2017.Schmid et al. conducted a large scale systematic review of 470 studies on influenza vaccine intent and uptake after screening 13,575 globally published studies from 13 databases [29].The extracted data were compared and in case any dispute was encountered, it was resolved by a third investigator.The tool captured the study characteristics, i.e. the journal's name/impact factor, the year of publication, the date of data collection, the setting, and the study design.The characteristics of the populations targeted by these studies were collected (such as age, disease, occupational groups or the general public).Influenza and COVID-19 vaccine intent and uptake were described.Studies that investigated vaccine intent were included since a number of studies on COVID-19 vaccines were conducted prior the introduction of these vaccines to the Lebanese market (2019-2020).Synonymous terms for vaccine uptake included vaccine rate, behavior, coverage, or compliance.Synonymous terms for vaccine intent included vaccine willingness, readiness, and registration.In case a study did not report vaccine intent or uptake, its main study outcomes were reported.

Synthesizing the results
Determinants of both seasonal influenza and COVID-19 vaccine intent or uptake (at the bivariate and multivariate levels of analyses) were categorized under the constructs of the Theory of Planned Behavior (TPB) [29,35].
The TPB is an etic approach theory that has been used to predict and explain a wide range of behaviors, including vaccination [36].The reliability, validity, and model fitness of this theory have been reported to be significant in replete number of studies [29,[37][38][39][40].The constructs of TPB include environmental factors (access to vaccines, quality of health care systems, policies, and other contextual factors related to influenza vaccination), social norms, socio-demographics and health related factors, knowledge, source of information, past experiences with influenza/COVID-19 and their vaccines, risk perceptions and attitudes, and the degree of behavioral control [41].Any determinant extracted from the reviewed studies that did not align with these constructs was grouped in additional constructs, such as the constructs of vaccine hesitancy.Vaccine hesitancy has been conceptualized by the SAGE group into the '5 C' vaccine hesitancy model with determinants related to confidence, complacency, constraints, calculation and collective responsibility [42,43].Determinants were also stratified by the vaccine type (seasonal vs. COVID-19 vaccines).

Controlling of potential biases
Reviews are prone to potential biases, so every effort was made to control them.Study investigators revised all eligible studies and presented all possible determinants, thus eliminating any chance of committing evidence selection bias.Critical appraisal of studies passed through two sequential levels.Study investigators refrained from revising studies in which they were part of or in case they were in a direct relationship (social or professional) with their authors.This was disclosed among all study investigators a priori.Data were revisited and validated by the research team via random checks.The quality of the 20 screened journals was examined and its impact factors ranged between 0.2 and 4.96 as per the 2023 master journal list of the Web of Science and journal websites.

Results
Up till the end of December 2022, 31 eligible studies were included in this review study (Table 3).As shown in the PRISMA flow chart, 99 studies were excluded (Fig. 1).
Studies were excluded if they investigated vaccine effectiveness, viral characteristics, disease control strategies, and disease burden.Editorials, systematic reviews and meeting reports were also excluded.

Characteristics of the included studies
The authors' names, the publication year, date of data collection and targeted populations are listed in (Table 3).Four studies were published in the journals "BMC Public Health" and "PLOS One" each.Three studies were published in the journal "Vaccines(Basel)".The list of journals in which the studies were published is presented in Table 4.In terms of the date of publication, the majority of the eligible studies (n = 29) were published during the COVID-19 pandemic (2020-2022).More importantly, data from 23 studies were collected during the COVID-19 pandemic.Nine studies investigated influenza vaccine uptake, 21 studies investigated COVID-19 vaccine uptake, and one study investigated both types of vaccines.Out of the 31 studies, 9 studies were conducted in multiple MENA countries one of which included Lebanon.One study investigated COVID-19 vaccine booster uptake.The ultimate majority of the reviewed studies adopted a cross-sectional design.Most of the studies targeted the general public population (n = 13), among whom subgroups in some studies were analyzed (age or disease specific groups).Other studies targeted healthcare workers (n = 8) including physicians, dentists, pharmacists, nurses, and others.Few studies targeted children (n = 4), refugees (n = 2), patients with cancer (n = 1), elderly adults (n = 1), university students (n = 1).Few studies were guided by a theoretical model, such as the Health Belief Model (HBM), Integrated Behavioral Model (IBM), Precaution Adoption Process model (PAP) and the Extended Parallel Processing Model (EPPM) [31,56,58,63,66].

Study outcomes
The revised studies either reported vaccine uptake rate, vaccine registration, vaccine intent rate, vaccine acceptance or hesitancy, vaccine refusal or readiness to pay for a vaccine.As shown in Table 5, the highest rate of influenza vaccine uptake rate was observed among children (3-6 years = 73.3%)and health care providers (67.3%), compared to other populations [31,46].The lowest rate of influenza vaccine uptake was among children (6-12 month = 7.7%) and the general public (10.3%)[46,49].

Determinants of influenza and COVID-19 vaccine intent or uptake
Determinants of influenza and COVID-19 vaccine intake or uptake in Lebanon were reported by 22 studies, whereas 9 studies did not report any determinant.Variables that were statistically significant (at the bivariate and multivariate levels of analyses) were extracted and tabulated in Table 6.Following the constructs of the TPB, these determinants were indexed under environmental constraints, norms, socio-demographics, health related factors, attitudes, personal agency, knowledge, habits and salience of behavior, and vaccine hesitancy (Table 7).All these determinants were conceptually modeled in Fig. 2. The most frequently reported determinants of influenza and COVID-19 vaccine intent or uptake were the "Perceived benefits of vaccines to self or community" (n = 7 studies) and the "Perceived susceptibility to vaccine side effects" (n = 6 studies), followed by the "Source of information about vaccines" (n = 5 studies), the "Perceived severity of viral influenzas" and the "Knowledge on vaccine benefits, indications to vulnerable groups" (n = 4 studies each).Other determinants -stratified by the vaccine type-are presented in Table 8.
The conceptual model in Fig. 2 illustrates the relationship between various determinants of influenza and COVID-19 vaccine intent or uptake.At the interpersonal level, contextual determinants include the access to vaccines, national vaccine policies/ campaigns, and the health care systems that deliver them.At the same level, a set of social norms and influences play a role in the individual's decision making to get vaccinated    During this stage, the individuals' past experiences and their level of control over their actions (vaccine affordability and accessibility) influence their decisions and might facilitate/delay the period between their intention to get vaccinated and the vaccine uptake.

Discussion
Determinants of influenza and COVID-19 vaccine intent or uptake are discussed at the interpersonal and intrapersonal levels, and then compared to findings from neighboring countries.Implications to practice and research are stated throughout this section.

Determinants at the interpersonal level
Contextual factors, such as vaccine availability, accessibility, and affordability, are usually specific to a setting or population that might play either a facilitating or a hindering role in the uptake of influenza or COVID-19 vaccines [29].For instance, some residents in Lebanon complained of unavailable certain types of COVID-19 vaccines, which delayed their COVID-19 vaccine uptake [77].Even in high income MENA countries like the United Arab Emirates, vaccine unavailability issues were reported in some regions [78].Low influenza or COVID-19 vaccine uptake might be due to a limited access to the healthcare systems [29,61].Previous studies from Saudi Arabia and Turkey showed that individuals who have access to a primary health care center are more likely to interact with healthcare workers and get advised on influenza and COVID-19 vaccine uptake [79,80].Lebanon has primary care centers distributed across its eight provinces, but transportation might be a constraint to some people [81].In terms of vaccine affordability, influenza vaccine in Lebanon costs USD18, while COVID-19 vaccines are currently provided for free [50,82].Waiving off influenza vaccine costs was associated with higher vaccine uptake rates in Jordan where healthcare workers benefited from 80 to 90% discounts on influenza vaccine costs [83].Therefore, a convenient access to clinics, affordable vaccines, and empowerment positively contribute to a higher vaccine uptake [29,84].Social norms that are pro vaccines were associated with higher vaccine uptake rates [29,58].For instance, being a requirement by some Lebanese schools made it a norm for parents to vaccinate their children against influenza every year [46].On the other hand, healthcare workers from Turkey stated that social influences affected their decision to get vaccinated against influenza [85].Healthcare workers are always reminded about the importance of getting vaccinated as a protective strategy for themselves, their community and families [31,50].A salient vaccination behavior is the one that is widely observed within clustered communities or confined within a period of time [52].For instance, in terms of COVID-19 vaccines, one of the negative prevailing norms in Jordan and Saudi Arabia was "waiting for others to get vaccinated" [86,87].Furthermore, vaccination drives are launched prior the influenza season every year, and it is not uncommon for many individuals to seek vaccination in groups [49,50].Mass scale vaccination campaigns have been associated with higher vaccine uptake rates in Saudi Arabia [88].This will probably encourage unvaccinated individuals to reconsider their decisions [31,49].
The relationship between socio-demographics and vaccine uptake was inconclusive across many studies, despite being important when surveying homogeneous populations [29].This relationship is probably

Influenza vaccination Research study
Determinants (El Khoury & Salameh, 2015) [44] Older age R ; Higher educational level R ; Having a health insurance; Good financial situation; Cigarette smoking; Alcohol drinking R ; Physically active R ; Frequent visits to a physician R ; Has respiratory disease R ; Good knowledge; Positive attitude; Sources of information (pharmacists/physcians) (Kmeid et al., 2019) [46] Locals (Lebanese) higher than refugees (Syrians); Child's age(3-6 years) R ; Father's age(> 31 years); Mother's age(> 31 years); Parents with higher levels of education; Mother's profession (private sector); Having a health insurance; Place of medical consultation / vaccination (Pediatrician clinic); Regular visit to a pediatrician; Vaccine required by school/day-care; Vaccine cost (Tassi, 2020) [47] Good knowledge about influenza; Believed that influenza vaccine is important for elderly adults; Believed that it should be taken yearly; Believed that it prevents serious complications; Believed that life immunity is not enough; Believed in vaccine effectiveness; Believed that influenza is a mild illness; Believed that vaccine is necessary; No fear of vaccine side effect or needles / injection; Did not adopt an alternative protective measure; Believed that the vaccine is affordable; Exposed to recommendations from doctor and patients (Taleb et al., 2018) [45] Younger age R ; Convenient time; Lower perceived risks associated with vaccines' side effects; Perceived vaccine benefits; Affordability of the vaccine; Good knowledge.(Alame et al., 2021) [50] Having a motive to protect themselves, community and family; Believed in boosting immunity; Believed that vaccines decrease the severity of the infection and the risk of complications; Feeling at high risk of infection; Believe in virus evolution; Did not have any vaccine efficacy concerns; Did not fear vaccine side effects; Did not belief the natural immunity is enough; Believed that the vaccine is affordable; Exposure to sources of vaccine recommendations; Good knowledge; Being a nurse; Past vaccination.(Moussa, 2020) [48] Good knowledge; Perceived that vaccines are safe and prevent infection; Acknowledged that the vaccine should be taken before the influenza season; Believed that vaccines are required for children, medical staff, patients with chronic diseases, and elderly; Being worried about influenza; Believed that the vaccine is a protective strategy against influenza infection; Being advised by families and friends to take the vaccine; Exposed to doctor's recommendation; Believed that influenza is serious (Zakhour et al., 2021) [51] Younger age; Higher school level; Paternal employment; Higher income; Exposed to awareness campaigns by SMS; Exposed to doctors' recommendations; Perceived vaccine safety and efficacy; No vaccine misconceptions; Good knowledge; Had vaccine trust; No hesitancy; No concern about side effects.(Choucair et al., 2021) [49] Being a healthcare worker; Older age; Being married; Having children R ; Self-rated good knowledge about influenza R ; Exposed to vaccine recommendations by physician; Higher perceived risk of influenza R

Research study
Determinants of study outcomes (Dalal Youssef, Berry, et al., 2022) [31] Female gender R ; Health care worker working in the frontline R ; Previous influenza vaccination R ; Living in urban areas R ; Previously diagnosed with COVID-19 R ; Disagreed on the idea of novel vaccine R ; Believed in vaccine safety R ; Believed in the reliability of manufacturer R ; Vaccine accessibility and availability R ; Exposure to reliable and adequate information about the vaccine R ; Exposure to recommendations by health authorities, health facilities and a family member R ; Good perceived COVID-19 vaccine benefits: protects them and their close contacts R (Abu-Farha et al., 2021) [52] Nationality(Highest in Saudi Arabia); No issues with vaccine cost; Preferred Pfizer-BioNTec; Exposed to source of information (governmental), Holding a medical related degree R ; Higher income R ; Being married R ; Country of residence(Saudi Arabia) R ; Having received influenza vaccine previously R ; Low fear score R ; feeling at risk of getting infected with COVID-19 R ; Female gender R .(Salibi et al., 2021) [61] No issues with the novelty of the vaccine; No need to wait to know more about it; Preference to maintain public health precautions; Belief that vaccines are essential; Not worried about vaccine side effects; Trust in the health care system; Residing in a formal settlement in a host country R ; Good perceptions of vaccine safety R and effectiveness R .(C. Kasrine Al Halabi et al., 2021) [30] Male gender R ; Single marital status R ; Lower hesitancy scores.(Hamdan et al., 2021) [58] Adherence to universal precautions; Previous influenza vaccination; Did not believe in conspiracy beliefs (Commercial profiteering, manipulation by a higher power, the vaccine taking away personal freedom and governmental control); Good knowledge (transmissibility) R ; Perceived vaccine safety R ; Pro-vaccine descriptive norms R (Elissar Moujaess et al., 2021) [62] If the vaccine follows international recommendations; If the vaccine did not interfere with their treatment; Desire to know more about the consequences of the vaccine in other patients with cancer; Considered themselves more vulnerable to COVID-19 (Nasr et al., 2021) [32] Desire to protect their themselves and families; Wanting the pandemic to end quickly; Desire to return to their normal social life; Not concerned about the possible long-term side effects of COVID-19 vaccines or the rapidity of vaccines' development; Believed in the effectiveness of the vaccine against new viral variants; Good knowledge R ; Previous influenza vaccine uptake during the COVID-19 R ; Visiting the medical doctor R (Ghaddar et al., 2022) [65] Young age group; lower level of education; Being employed; Trust in news from the WHO, MoPH and radio/TV with statistically significant differences; Male gender R ; Having trust in Facebook R ; Not affected by fake news R ; Do not belief in the man-made theory or the business control theory R ; Trust in news from MoPH R (Karam et al., 2022) [69] Higher level of education; Higher salary; Perceived severity of COVID-19 Table 6 Determinants of higher influenza and COVID-19 vaccine intent or uptake rates was higher among the younger Jordanian, Palestinian and Syrian adults (18-35 years old) compared to older age groups, whereas the rate of COVID-19 vaccine intention was higher among Israeli older adults [89,90].The individual's health condition and lifestyle characteristics such as smoking, alcoholism, and physical inactivity were associated with influenza vaccine uptake [44,51].For instance, a study from Kuwait stated that non-smokers reported lower perceived risk of contracting COVID-19 [91].Some researchers noted that patients had more desire to get vaccinated compared to students and health practitioners probably due to their pre-existing medical conditions [92], or since they regularly interact with their healthcare providers which makes them routinely exposed to medical advise [29].Even within the same academic institute, students from different faculties differed in their COVID-19 vaccine intention rates [93].

Determinants at the intrapersonal level
Knowledge about influenza/COVID-19 infections (etiology, method of transmission, signs/symptoms) and its vaccines (indications, frequency of taking it and providers) is a key determinant of vaccine uptake [29,44,47].Besides the theoretical knowledge, individuals also rely on past experience with getting infected with influenza/ COVID-19 and vaccines before making their decision to get vaccinated [31,50].In the absence of this knowledge or past experience, individuals are not expected to engage in the decision making process to take the vaccine.A study from Pakistan showed that postpartum women who experienced COVID-19 were more likely to accept the COVID-19 vaccine than women with no prior experiences [94].Students from UAE showed that those who reported being previously infected by COVID-19 reported higher intent rates to receive the vaccine compared to their counter group [95].Raising awareness triggers a transient decision making process [31,44,50,51].One study showed that 56.8% of the Lebanese public were aware of influenza vaccine benefits, yet they did not regularly seek influenza vaccination [44].
The source of information and the level of trust in these sources also play a role in vaccine uptake [31,51,52,61,65].For instance, the Lebanese who sought information about influenza vaccines from health practitioners and family members were more likely to get vaccinated [44,92], while those who sought information from the social media were reluctant [44].Parents of children who received adequate information about COVID-19 vaccines reported higher intent rates to vaccinate their children in five Arab countries in the Middle East [96].Knowledge about influenza/COVID-19 and their vaccines are expected to enhance the individual's control over their vaccine behavior that is their ability to overcome any barrier to vaccination [29].Past experience and knowledge both play a facilitating role in overcoming these barriers [29,31,51].Last but not least, behavioral control becomes more stringent when individuals interact with healthcare practitioners and follow their recommendations [29].Cognitive risk perception dwells on how individuals evaluate the risk of contracting influenza, while emotional risk perception is how much individuals worry about contracting influenza or receiving its vaccine [50].A perceived relative risk entails how individuals compare themselves to others in relation to these risks [29,97].High risk perception related to contracting influenza/ COVID-19 was associated with high vaccine uptake in many MENA countries [98,99].Confronting some individuals -such as the health care workers -with the fact that they might transmit influenza or COVID-19 to their patients have been often used as an ethical argument to get them vaccinated [100].In Saudi Arabia, the most frequently reported motivation to get vaccinated among healthcare workers were 'self and 'patient protection' [101].
When attitudes are not in favor of vaccines, it means that vaccines are not important enough to actively overcome any barrier [29].Some individuals might have negative pre-existing attitudes towards influenza vaccines, yet base their decisions on "utility maximization" i.e. if the vaccine was conveniently provided to them [102].For instance, Saudi Arabian healthcare workers reported vaccine convenience as an important factor in vaccine decision-making [102].
Healthcare workers usually report better attitude towards influenza vaccines compared to the general public [50].Negative attitude towards COVID-19 vaccines is sometimes based on the unforeseen / undiscovered problems of vaccines or unresolved suspicions in pharmaceutical companies / health authorities [58].However, the severity of COVID-19 pandemic -compared to seasonal influenza-played a detrimental role in enhancing the individuals attitude towards COVID-19 vaccines [69].Therefore, informing individuals about both the personal and societal benefits of vaccines (herd immunity) can play a role in enhancing the individual's attitude towards vaccines [29].
Vaccine hesitancy or reluctance overlaps with intention and it might delay or prevent vaccination [103].It is a transient state of internal cognitive / emotional conflict that hinders the translation of intention to an actual behavior [103].If an individual is not confident in the vaccines' benefits or the system that provides them, they are more likely to become hesitant and delay vaccination [104].In Tunisia, patients with cancer reported less hesitancy towards vaccines since they considered vaccines a gateway towards ending the pandemic [105].However, if some individuals get vaccinated it doesn't imply that their hesitancy is resolved [103].Therefore, the intention to get vaccinated or even vaccine uptake should not be accounted as an indicator of vaccine acceptance.This is important as vaccination is recommended every year, and vaccine-hesitant individuals might refrain from seeking vaccination in the upcoming year, even if they get vaccinated at present.

Strengths and limitations
This scoping review study has to be seen in light of few strengths and limitations.Evaluating the current body of research on influenza and COVID-19 vaccines in Lebanon serves as a guide to future researchers by identifying knowledge gaps, research priorities, under-researched settings and populations.This review probably presents the first conceptual model on influenza and COVID-19 vaccine uptake within the Lebanese conext.This review also exposed the commonly used research measures and theoreticl models followed by the Lebanese researchers who investigated influenza and COVID-19 vaccines.In addition, this review presented a list of journals that researchers can consider when planning to publish their research findings.
Few limitations can be reported in this scoping review.In terms of space, the search strategy was limited to one country which might limit the generalizability of its findings elsewhere.However, the Lebanese population share alot of common features with populations residing in its neighboring countires, such as Syria and Jordan.In terms of time, the rate of publications peaked in 2022 and it is expected to show a steady increase in the coming years due to the emergence of COVID-19.Many of the captured studies in this review investigated COVID-19 vaccine intent rates compared to studies on COVID-19 vaccine uptake rates.It is expected that the latter studies will continue to present more updated information on the COVID-19 vaccine status in Lebanon.This can be addressed in future review studies and the proposed model can be adjusted accoridngly.The protocol for this scoping review study was revised by a PhD thesis committe.It was not registered at the international database

Conclusions and research propositions
Research on influenza/COVID-19 vaccine uptake in Lebanon is still in its infancy.This review conceptualized vaccine uptake within the Lebanese context and presented its multifaceted determinants.Few attempts were made by the Lebanese researchers to target vulnerable non-health occupational groups, as per the National Institute for Occupational Safety and Health, such as public administration, educational services, transportation, accommodation and food services [106].Therefore, there is a need to evaluate the influenza and COVID-19 vaccine uptake within vulnerable non-health occupational groups.Fundamental causes of vaccine hesitancy were not investigated in Lebanon.This needs macro-level studies to compare the determinants of vaccine uptake across populations that vary by their socioeconomic status, nativity, area of residence and health care privileges.The multiple crises that Lebanon has witnessed lately have deteriorated the socio-economic status in the country.This threatened a sustainable service provision (limited vaccine supplies) and made some Lebanese incapable of purchasing vaccines [29].Evaluating the effectiveness of vaccination programs also requires a multi-country study to compare the Lebanese vaccination programs to international ones.

Fig. 2
Fig. 2 Conceptual model of influenza/COVID-19 vaccine intent and uptake in Lebanon

Table 2
Inclusion and exclusion criteria [53]ctive: Test the effectiveness of a health education intervention in improving the knowledge, attitudes, and practices (KAP) toward influenza and its vaccine among secondary schools' students in South Lebanon.Objective: Assess the willingness of Middle Eastern Arab publics to receive COVID-19 vaccines and investigated the factors behind any reluctance to receive them (Kaadan, Abdulkarim, Chaar, Zayegh, & Keblawi, 2021)[53]* 2021 Jan Community

Table 3
List of eligible studies included in the scoping review study

Table 8
Assess the acceptance rate of the COVID-19 vaccine among HCWs and to identify its determinants.
. These factors contribute to raising awareness about influenza and COVID-19 seriousness, about vaccine benefits, and about the sources of vaccines.Socio-demographic and health related determinants are universal variables that should be analyzed when investigating influenza or COVID-19 vaccine intent or uptake.For instance, being an elderly individual or having pre-existing medical conditions are expected to be more concerned about influenza/COVID-19, so they are more likely to seek vaccination.At the intrapersonal level, awareness is the individuals' familiarity with the disease and vaccines on different aspects (vaccine benefits/indications, frequency of taking it and vaccine providers).Knowledge affects perceptions, i.e. the perceived Objective: Assess the acceptance of COVID-19 vaccine booster doses in low, middle, and high-income countries of the East Mediterranean Region (EMR) and its determinants using the health belief model (HBM).(P.Hanna, A. Issa, Z. Noujeim, M. Hleyhel, & N. Saleh,

Table 4
Screened journals

Table 8
(continued)of Prospectively Registered Systematic Reviews (PROS-PERO) since they do not accept the registration of scoping review studies.