Influenza is a highly contagious respiratory illness with rapidly changing viral strains and high transmission rates, especially in crowded settings such as universities (Borkenhagen et al., 2021; Javanian et al., 2021; Virk et al., 2017). Although generally self-limiting, it can lead to substantial morbidity and mortality in vulnerable groups, including the elderly, pregnant women, and immunocompromised individuals (Li et al., 2021; Chen et al., 2021). Globally, seasonal influenza affects about one billion people each year, with 3–5 million severe cases and up to 650,000 respiratory deaths (Lafond et al., 2021; Paget et al., 2023; Lampejo, 2022). And remains a significant cause of lower respiratory complications in young children (Wang et al., 2020).

Annual influenza vaccination is required due to continual viral mutations (Houser and Subbarao, 2015), yet vaccine hesitancy remains a major barrier. Common obstacles include limited knowledge, misconceptions, and concerns about vaccine effectiveness and safety, all of which reduce willingness to vaccinate (Ahmed et al., 2023; Hwang, 2020; Suryadevara, 2021). Similar patterns appear in Saudi Arabia, where additional misconceptions, such as the belief that the vaccine can cause influenza, further hinder uptake (Almansour et al., 2022; Mallhi et al., 2022; Haridi et al., 2017; Abalkhail et al., 2017). Socioeconomic factors present a complex landscape, as income levels can influence vaccine acceptance both positively and negatively (Al-Mohaithef and Padhi, 2020). Socioeconomic and educational differences also contribute to variability in acceptance (Al-Mohaithef and Padhi, 2020). Although the Saudi Ministry of Health provides free vaccines and conducts extensive awareness campaigns, hesitancy remains high despite strong evidence supporting vaccine safety and effectiveness (Alhatim et al., 2022; Alabbad et al., 2018; Fayed et al., 2021; Alghalyini et al., 2023).

University students in Saudi Arabia represent a high-risk group where behavioral barriers intersect with the challenges of densely populated living and learning environments.

(Sheldon et al., 2021; Nichol et al., 2005; Alhatim et al., 2022). Many young adults underestimate their risk, which affects vaccine uptake despite the Ministry of Health offering free seasonal influenza vaccines (Siegel et al., 2007). However, limited research has applied the Health Belief Model to understand the psychological factors shaping hesitancy in this population. This study aims to examine how perceived risk relates to influenza vaccine hesitancy among university students in Saudi Arabia, with the goal of informing strategies to improve vaccination coverage and public health outcomes.

A total of 450 university students have completed the questionnaire. The detailed results are presented in Table 1. The mean for perceived susceptibility was 3.06 (SD = 0.54); most students (78.4%) showed a moderate level of susceptibility. For perceived severity, the mean score was 3.43 (SD = 0.57), with almost half of the participants (47.6%) considered the risk to be high. Perceived barriers mean score was 3.73 (SD = 0.67), which means that 62.4% of students reported important barriers to vaccination. The average of perceived benefits was 3.74 (SD = 0.82) with most students perceiving high (66.7%), moderate (28.4%), or low (4.9%) benefits.

Among the studied population 99 (22%) accepted flu vaccine (Table 2). The acceptance rate was significantly higher (44.1%) in students suffering from chronic conditions compared to students without such conditions (20.2%), p = 0.002. However, the effect size was small (Cramér’s V = 0.153). Furthermore, among those who perceived low barriers to vaccination, the acceptance rate was higher (60%) than those who perceived high barriers (27.8%) and low barriers (11%), with a p-value of <0.001. The effect size was small to moderate (Cramér’s V = 0.217). Finally, the acceptance rate from students who acknowledged the low benefits of the flu vaccine (36.4%) was higher than high (24.0%) and moderate (14.8%) benefits with p = 0.029. However, the effect size was small (Cramér’s V = 0.126). Figure 1 represents students’ participation from different colleges. The result indicates that most of the students were from pharmacy colleges (44%), followed by those from engineering colleges (20.7%).

Based on the three factors identified in the feature selection, the logistic regression models were established as model A and model B, respectively (Table 3). In model A, not adjusting for other factors, moderate perceived barrier (P < 0.001) and moderate perceived benefit (P = 0.036) were associated with the vaccine acceptance variable. Perceived benefit was not significantly associated with vaccine acceptance after adjustment for sociodemographic characteristics (model B). On the contrary, a moderate perceived barrier found a good association with vaccine acceptance (P < 0.010).

This national online survey presents novel findings that contribute to the understanding of risk perception theory and influenza vaccine hesitancy among university students in Saudi Arabia. Our results indicate that vaccine acceptance is influenced by a multifactorial interplay, with perceived barriers identified as the strongest predictor. Specifically, a majority of respondents reported high barriers to vaccination; conversely, individuals who perceived low barriers demonstrated significantly higher rates of acceptance. A noteworthy paradox emerged in that, despite high perceived benefits, this did not correlate with increased vaccine acceptance rates when sociodemographic factors were accounted for.

While university students are typically at lower risk for mortality, the relevance of these benefits lies in mitigating morbidity and preserving academic continuity. As demonstrated by Nichol et al., influenza significantly impairs university students’ academic performance and increases healthcare resource utilization (Nichol et al., 2005). Furthermore, high coverage in this group is essential for reducing community transmission to vulnerable populations. However, our data indicates that students are already largely aware of these advantages; therefore, this finding suggests that enhancing perceived benefits may be less critical than reducing perceived barriers in the formulation of effective intervention strategies. This lack of predictive power can be attributed to the “overriding” effect of barriers. Within the HBM framework, while perceived benefits provide the motivation to act, perceived barriers function as the immediate impediments to that action. Since substantial proportion of our sample reported high barriers, these practical and psychological hurdles likely negate the positive influence of benefit awareness, effectively severing the link between knowledge and actual behavior (Liu et al., 2025).

The findings of this study both align with and diverge from existing research regarding attitudes toward influenza vaccination and the associated barriers at the university students’ level. The observed contradiction between the perceived high barriers (62.4%) and the high benefit scores (66.7%) in our study corresponds with similar patterns identified in studies conducted across various countries. Furthermore, multiple studies have identified barriers related to safety (Mallhi et al., 2022; Benjamin and Bahr, 2016), knowledge (Hashmi et al., 2016; Su and Chen, 2023), and time/convenience (Ryan et al., 2019; Abushouk et al., 2023). The consistency of this factor suggests that the impediments to vaccination are not confined to individual institutions but rather indicate broader issues affecting the student population.

Healthcare education has emerged as a significant factor across various studies. The observed lower perceived barriers among healthcare students aligns with findings from multiple prior studies, which demonstrate that healthcare students exhibit markedly higher vaccine acceptance, as assessed through knowledge scores (Mallhi et al., 2022; Al Nufaiei et al., 2023) or vaccination rates (Ryan et al., 2019). This trend may imply that formal health education fosters a more comprehensive understanding of the benefits and risks associated with vaccines. However, a recent study conducted by Zou et al. in China indicated that medical students displayed greater hesitation compared to their social science counterparts, indicating possible differences not only in health education between countries but also in cultural aspects of healthcare education itself (Zou et al., 2023). These variations highlight the necessity of considering cultural and contextual factors when formulating educational interventions.

Variations in the relationship between gender and vaccine perceptions across different studies have been observed. While prior research has produced conflicting results, our study identified an increased likelihood of females experiencing moderate barriers to vaccination. Some studies indicated that females were more inclined to support vaccination (Abushouk et al., 2023; Silva et al., 2021), whereas others found no significant gender differences (Al Nufaiei et al., 2023; Bednarczyk et al., 2015), and additional studies reported contrary trends (Zou et al., 2023). This variability suggests that the influence of gender on vaccine acceptance is highly context-dependent. In the specific setting of Saudi Arabia, the increased perception of barriers among females may reflect distinct logistical and social challenges documented in regional literature. Previous studies indicate that women in Saudi Arabia often face greater difficulties accessing healthcare facilities due to reliance on male family members for transportation and competing domestic responsibilities (Mobaraki and Söderfeldt, 2010). Furthermore, women often exhibit higher health anxiety and concern regarding vaccine side effects compared to men, which contributes to the ‘psychological’ aspect of the HBM barriers construct (Fisher et al., 2020).

The role of health awareness and risk perception in relation to vaccination acceptance emerged as a prominent theme; however, significant variability was observed. Our study indicated notably higher acceptance rates among students with chronic conditions, although the specific relationship was not directly investigated in the studies under comparison. Notably, Bednarczyk, et al. showed that healthy status was identified as one of the contributing factors to vaccine hesitancy, with 29% of unvaccinated students reporting the belief that “I do not need it because I am healthy” (Bednarczyk et al., 2015). Furthermore, the study revealed that awareness regarding the protection of high-risk groups significantly enhanced the willingness to vaccinate among 71% of previously unvaccinated students. Collectively, these findings suggest that both personal health perceptions and awareness of susceptibility—both for oneself and for others—play a crucial role in influencing vaccination behaviors; nonetheless, the specific pathways may vary depending on the setting and population.

This discrepancy between individuals’ improved attitudes toward vaccines and the actual rates of vaccination uptake is a paradox that will not go unnoticed. Our findings showed that individuals who perceive few benefits exhibited higher acceptability rates than those who acknowledged more significant benefits. Nonetheless, prior research has indicated positive associations between perceived benefits and vaccine acceptance (Mongeau et al., 2023; Dopelt et al., 2023). Murray and Caron offer a potential explanation for this counterintuitive observation, utilizing the framework of the HBM, which suggests that perceived susceptibility and severity may outweigh perceived benefits in the decision-making process (Murray and Caron, 2018). In other words, various moderating factors influence the relationship between perceived benefits and acceptance. As highlighted by Su and Chen, experiences and social influences are critical determinants of benefit perceptions (Su and Chen, 2023). This social dimension introduces an additional layer of complexity to vaccine acceptance, indicating that interventions aimed solely at individual knowledge or perceptions may prove inadequate.

Knowledge gaps constituted a significant barrier overall; however, the context of these specific gaps varied across the studies examined. In our study, a strong perception of benefits correlated with high barriers, whereas Hashmi et al. reported that more than half of the students acknowledged a deficiency in knowledge regarding flu vaccines (Hashmi et al., 2016). Likewise, Mallhi et al. highlighted the discrepancies in knowledge levels between healthcare and non-healthcare students (Mallhi et al., 2022). These findings suggest that traditional educational strategies may prove inadequate in addressing the multifaceted dimensions of knowledge, perception, and behavior.

This study offers substantial insights into the factors influencing the intention to receive the influenza vaccine among university students in Saudi Arabia. It has been demonstrated that perceived barriers serve as the most significant predictor of vaccine acceptance. Although the advantages of vaccination are widely recognized, actual acceptance remains low, indicating that merely emphasizing these benefits may not be adequate. Future initiatives should aim to enhance vaccine uptake by addressing not only cultural barriers but also the educational barriers as perceived by students. Implementing campus-wide vaccination campaigns may also help increase vaccination rates by delivering the vaccines directly to the students instead of inviting them to visit primary healthcare centers. Furthermore, additional longitudinal research is required to assess how these perceptions evolve over time; ideally, vaccination programs should also be implemented within the region. It is imperative that a systematic approach is adopted to improve the targeting of public health efforts, thereby enhancing influenza vaccination rates and overall health within this population.