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Background: Misconceptions and inadequate knowledge about vaccination represent an important barrier against adherence to vaccination schedules.
Objectives: To assess the knowledge and attitude of mothers of children under five years of age with regard to standard childhood vaccination.
Subjects and methods: A cross-sectional study was conducted at Taif Children’s Hospital (a subsidiary of the Ministry of Health), Saudi Arabia, among a sample of mothers of children aged below five years attending the hospital’s outpatient clinics during the study period of May-July 2021. A valid questionnaire was utilised for data collection, comprising demographic questions as well as an assessment of respondents’ knowledge and attitude towards childhood vaccination.
Results: The study included 397 mothers, more than half of whom (53.9%) were aged between 20 and 30 years. Overall, the total knowledge score ranged between 5 and 10, with an arithmetic mean of 9.03 and standard deviation of (± 1.25). Higher-educated mothers (university or above) were more knowledgeable about childhood vaccination than lesser-educated mothers (mean ranks were 200.44 and 123.35, respectively), p=0.020. Overall, the total score for attitude towards childhood vaccination ranged between 5 and 10, with an arithmetic mean of 9.15 and standard deviation of (± 0.48). Married mothers expressed a more positive attitude towards childhood vaccination than divorced mothers (mean ranks were 200.83 and 144.81, respectively), p=0.014.
Conclusion: The knowledge about, and attitude towards, childhood vaccination among mothers in Taif, Saudi Arabia are excellent. However, some misconceptions require correction
Keywords: Childhood immunization, Vaccination
According to the World Health Organization (WHO), the administration of vaccines stimulates the human immune system to protect the individual against infectious diseases through a process called immunisation [1]. Immunisation is the most cost- effective intervention; it prevents nearly 3 million deaths per year and can save the lives of about
1.5 million children per year, globally [1,2]. Furthermore, it has been documented that successful immunisation reduces hospitalisation, cost of treatment, and mortality [3].
Misconceptions and inadequate knowledge about vaccination represent an important barrier against adherence to vaccination schedules. These miscon- ceptions and inadequate knowledge cover aspects including the definition of a vaccine, its adverse effects, vaccine-preventable diseases, and develop- ment of diseases after the administration of vaccines [4].
Low rates of complete childhood vaccination still exist in many developing countries. This represents a public health problem; the United Nations Chil- dren’s Fund (UNICEF) has reported that nearly one third of mortality in children under five years can be prevented by vaccination [5]. The success of childhood immunisation programmes depends on many factors, some emphasis, you could say on the improvement of parents’ knowledge regarding vaccines [6]. Since parents are the primary health decision-makers for their children, their knowledge and attitude towards immunisation significantly im- pact the immunisation status of their children [7]. Mothers’ understanding of the reasons for childhood vaccination, as well as barriers against vaccination, is crucial when it comes to designing campaigns to
improve vaccination uptake in Saudi Arabia; the present study therefore aims to investigate the knowledge and attitude of mothers of children under five years towards standard childhood vaccination.
This cross-sectional study was conducted at Taif Children’s Hospital (a subsidiary of the Ministry of Health) located in the centre of Makkah Region, in the western part of Saudi Arabia. It is the fourth- largest city in the region, with an area of approximately 13,840 km 2 . The population of Taif Governorate was estimated at 993 800 people in the year 1435H corresponding to the Gregorian year 2013, representing 12.8% of the region’s total population [8].
Participants eligible for inclusion in this study were mothers of children aged below five years who attended the outpatient clinics of Taif Children’s Hospital (MOH) during the study period of May- July 2021. Mothers who did not have children below the age of five, and severely ill mothers who could not cooperate properly with the researcher, were excluded from the study.
The sample size was computed using the statisti- cal formula for a cross-sectional survey:
n=Z 2 XPXQ/D 2 based on the following values: n: Calculated sample size Z: The z-value for the selected level of confidence
= 1.96 P: Estimated prevalence of lowest level of good knowledge about childhood vaccination =37.1% (0.37), based on a previous Saudi study carried out in Riyadh [8]
Q: (1 – P) = 62.9% (0.63) D: Maximum acceptable error = 0.05 Thus, a total of 394 mothers were invited to participate in the study, giving a sample of 358 mothers with 10% was added to the total sample size for the non-respondents. We used non- probability convenience sampling to collect data from all mothers who fulfilled the inclusion criteria, until the sample size was attained.
An interview questionnaire was used in this study, which was used previously in another Saudi study carried out in Arar [9]. It includes three main parts:
- Demographic data of participants (age, current marital status, number of children, education, job status and residence, and parent’s age, education and job status).
- Knowledge assessment questions, with “yes” and “no” responses, covering various aspects of awareness and knowledge of childhood vaccination (10 questions).
- Questions regarding attitude towards vaccination (9 questions).
Before giving the questionnaires to the mothers, informed consent was requested from each of them; everyone had the right not to participate in the study or to withdraw from the study prior to completion. The researcher explained the purpose of the study to all of the respondents, and the respondents’ confidentiality and privacy were guaranteed.
The data were collected and verified by hand, and then coded prior to computerised data entry. The Statistical Package for Social Sciences (SPSS) software, version 26.0, was used for data entry and analysis. We applied descriptive statistics (e.g. number and percentage) and analytic statistics using non-parametric statistical tests for non-normally distributed data, as evidenced by significant Shapiro- Wilk test. The Mann-Whitney test was applied to compare two groups, while the Kruskal-Wallis test was applied to compare more than two groups; a p- value ≤ 0.05 was considered statistically significant.
Demographic characteristics
The study included 397 mothers. Their demo- graphic characteristics are summarised in Table 1. More than half of them (53.9%) were aged between 20 and 30 years, and their husbands were in the same age group (57.4%). The majority (96.7%) were currently married and 47.3% had two children, including the index one. The majority of the mothers (97.5%) and their husbands (93.7%) were university graduates or above, and living in Taif City (95.7%). Approximately half of them (50.9%) were house- wives.
Knowledge about childhood vaccination
All of the surveyed mothers could recognise that vaccinations play a role in child health. The vast majority were sure that vaccinations are important for their children (99.7%), were aware that even healthy children require vaccination (99.7%),
Vaccination is a method proven to control and eliminate life-threatening infectious diseases, par- ticularly among vulnerable groups such as children,
One (n=55)
(Yes)
influenza vaccine? (Yes)
sufficient? (Yes)
life? (Yes)
(Yes)
Housewife (n=202)
The present survey revealed that more educated mothers (university or above) were more knowl- edgeable about childhood vaccination than the lesser-educated groups. In a similar study carried out in Riyadh, factors associated with parents’
In Sudan, more than half of the respondents (55%) had negative attitudes towards vaccination of children in vaccination campaigns [16]. In Jerusalem- Palestine, the majority of mothers (94%) considered vaccination to be the main activity in maternal and children’s clinics [17]. In Georgia, the majority of mothers (97%) had a positive attitude toward immunisation and believed that vaccination plays an important role in preventing infectious diseases [18]. Again, comparison of these studies, including the present one, is not always practical, mainly due to demographic differences and the use of different tools to assess attitudes towards childhood vaccination. The current study showed that married mothers expressed a more positive attitude towards childhood vaccination than their divorced counterparts. In a study conducted in Riyadh [13], factors associated with parents’ attitudes towards immunisation were gender, residence and education level. In Malaysia, mothers’ education, age and job status were significantly associated with their attitude towards childhood vaccination [19] while in Georgia, mothers’ education was significantly associated with their attitude regarding immunisation [18].
The present study has some limitations that bear mentioning. First, it is a single-centre study, which could affect the generalisability of the results. Being a cross-sectional study is also considered a limi- tation, as this can prove only association, and not causality, between exposure factors and outcomes. Finally, the use of an interview questionnaire in this study renders it subject to bias. Despite these limitations, the study addresses a topic of public health importance and its assessment could assist decision-makers in Taif City, Saudi Arabia.
The knowledge of, and attitude towards, child- hood vaccination among mothers in Taif, Saudi Arabia, are excellent. However, there are some misconceptions that need correction. More edu- cated mothers (university or above) were more knowledgeable about childhood vaccination thanthe lesser-educated groups, and married mothers ex- pressed a more positive attitude towards childhood vaccination than their divorced counterparts. Based on the findings of the present study, our recommendations are as follows:
| Father’s age | |
|---|---|
| 20-30 | 57.4 (228) |
| 31-40 | 38.8 (154) |
| ≥41 | 3.8 (15) |
| Mother’s current marital status | |
| Married | 96.7 (384) |
| Divorced | 3.3 (13) |
| Number of children, including the | index one |
| One | 13.9 (55) |
| Two | 47.3 (188) |
| Three | 30.7 (122) |
| ≥Four | 8.1 (32) |
| Mother’s education level | |
| Secondary school/below | 2.5 (10) |
| University/above | 97.5 (387) |
| Father’s education level | |
| Secondary school/below | 6.3 (25) |
| University/above | 93.7 (372) |
| Residence | |
| Inside Taif City | 95.7 (380) |
| Outside Taif City | 4.3 (17) |
| Mother’s job status | |
| Housewife | 50.9 (202) |
| Working | 49.1 (195) |
| Father’s job status | |
| Government employee | 80.1 (318) |
| Private sector employee | 12.3 (49) |
| Military | 5.5 (22) |
| Business/trade | 2.1 (8) |
| believed that vaccination reduces the probability of | and is estimated by WHO to prevent almost three |
| death or illness in a child (99.5%) and reduces the | million deaths every year [10]. The |
| transmission of infectious diseases (99.5%), were | attitude/cooperation of parents, particularly mothers, |
| aware that some vaccinations are accompanied by | regarding vaccination is essential to improve the |
| side effects such as fever (97.2%), and believed that | vaccination rate and adherence to the childhood vac- |
| vaccinations should be given after certain age (95%). | cination schedule. Studies have shown that, among |
| Only 59.9%, on the other hand, were aware that some | other factors, parental knowledge and beliefs had a |
| vaccinations can cause convulsions and skin rash, as | major impact on starting and continuing children’s |
| illustrated in Table 2. | vaccination [11, 12]. |
| Overall, the total knowledge score ranged between 5 | In the present survey, among the participating |
| and 10, with an arithmetic mean of 9.03, standard | mothers, the total knowledge score regarding child- |
| deviation of (± 1.25), a median of 10 and IQR of 8- | hood vaccination was excellent; its median value was |
| 10; Shapiro-Wilk test, p<0.001. | 10 out of a maximum possible score of 10. Nearly all |
| Higher-educated mothers (university or above) were | the participants, with very few exceptions, could |
| more knowledgeable about childhood vaccination | recognise that vaccinations play a role in child health, |
| than lesser-educated mothers (mean ranks were | were sure that vaccinations are important for their |
| 200.44 and 123.35, respectively), p=0.020, as shown | child, were aware that even healthy children need |
| in Table 3. | vaccination, believed that vaccination reduces the |
| probability of death or illness in a child and reduces | |
| Attitude towards childhood vaccination | the transmission of infectious diseases, were aware |
| mandatory vaccination believed vaccination them immunisation their (99.7%), when believed from after Table vaccinating relatives the All 4. there followed were first that of that programme important was schedule/programme the week keen and vaccines, the their the friends mothers more to vaccination of government’s their complete child life or is than to sufficient. considered very (96.5%), (99.5%), gave vaccinate child’s all one programme their vaccination important, (99.7%), support The as dose and their children illustrated compulsory majority felt childhood (99.7%), children advised for started secure doses and the the of in | that effects should smaller some rash. observed Riyadh, vaccination diseases, vaccination knowledge importance of multiple some vaccinations The such be proportion particularly and in given was vaccinations to same schedule doses in as another, children’s the fever, the observed after good of of timing may prevention regarding [13]. and them the similar, certain cause immunity level are in believed same of However, (59.9%) that accompanied the age. convulsions study of of the vaccine, study certain first that of However, knowledge were general a administration carried regarding poor vaccinations dose aware the infectious and by level role only under- out in skin side was that the the of of in a |
| hood arithmetic 0.48), test, Overall, p<0.001. vaccination a median the mean total of of ranged 9 score 9.15, and between for IQR standard attitude of 9-9; 5 deviation and towards Shapiro-Wilk 10, with of child- ( an ± | standing tiple immunity, influenza, Arar (KSA), vaccines that and vaccination the simultaneous has contraindications majority no negative of of children parents administration impact to against were vaccination. on aware a seasonal of child’s mul- that In |
| tude mothers spectively), Married towards (mean mothers p=0.014; childhood ranks expressed as were illustrated vaccination 200.83 a more in and Table than positive 144.81, divorced 5. atti- re- | vaccinations that diseases, child vaccination vaccinations health. and reduces are believed Almost important reduce the that probability the two-thirds vaccinations for incidence their of children, death believed of have infectious or a thought illness role that in |
| IV. DISCUSSION | in a child. Only a minority of them (6.8%) were |
| aware that some vaccinations are accompanied by |
| Mothers’ responses to questions regarding awareness/knowledge about childhood vaccination | |
|---|---|
| Questions Correct | answer |
| N | % |
| Are you sure that vaccinations are important for your child? 396 | 99.7 |
| Do you think vaccination reduces the probability of death or illness in a child? 395 | 99.5 |
| Do you think vaccinations reduce the transmission of infectious diseases? 395 | 99.5 |
| Do you think vaccinations have a role in child health? 397 | 100 |
| Do you believe that vaccinations correspond to certain age? 377 | 95.0 |
| Are you aware that there are many types of vaccines? 278 | 70.0 |
| Are you aware that some vaccinations are accompanied by side effects such as 386 | 97.2 |
| fever? | |
| Are you aware that some vaccinations may cause convulsions and skin rash? 238 | 59.9 |
| Are you aware of the serious diseases that are preventable by vaccination, such as 327 | 82.4 |
| polio, measles and meningitis? | |
| Are you aware that even healthy children need vaccination? 396 | 99.7 |
| Factors associated with mothers’ | knowledge about | childhood vaccination | ||
|---|---|---|---|---|
| Total | knowledge score | (0-10) | p-value | |
| Median | IQR | Mean rank | ||
| Mother’s age (years) | ||||
| <20 (n=36) | 10 | 8-10 | 194.36 | |
| 20-30 (n=214) | 10 | 8-10 | 204.41 | |
| 31-40 (n=133) | 10 | 8-10 | 192.78 | |
| ≥41 (n=14) | 9.5 | 7.75-10 | 187.32 | 0.728** |
| Father’s age | ||||
| 20-30 (n=228) | 10 | 8-10 | 202.64 | |
| 31-40 (n=154) | 10 | 8-10 | 195.35 | |
| ≥41 (n=15) | 9 | 8-10 | 181.10 | 0.633** |
| Mother’s current marital status | ||||
| Married (n=284) | 10 | 8-10 | 200.06 | |
| Divorced (n=13) | 9 | 7-10 | 167.77 | 0.271* |
| Number of children, including the index one | ||||
| Two (n=188) | 10 | 8-10 | 190.76 | |
| Three (n=122) | 10 | 8-10 | 211.39 | |
| ≥Four (n=32) | 9.5 | 8-10 | 187.67 | 0.313** |
| Mother’s education level | ||||
| Secondary school/below (n=10) | 7.5 | 6.75-10 | 123.35 | |
| University/above (n=387) | 10 | 8-10 | 200.95 | 0.020* |
| Father’s educational level | ||||
| Secondary school/below (n=25) | 9 | 8-10 | 177.60 | |
| University/above (n=372) | 10 | 8-10 | 200.44 | 0.288* |
| Residence | ||||
| Inside Taif City (n=380) | 10 | 8-10 | 197.48 | |
| Outside Taif City (n=17) | 10 | 9-10 | 233.06 | 0.168* |
| Mother’s job status | ||||
| Housewife (n=202) | 10 | 8-10 | 194.32 | |
| Working (n=195) | 10 | 8-10 | 203.85 | 0.361* |
| Father’s job status | ||||
| Government employee (n=318) | 10 | 8-10 | 201.11 | |
| Private sector employee (n=49) | 10 | 8-10 | 200.67 | |
| Military (n=22) | 9.5 | 7-10 | 171.80 | |
| Business/trade (n=8) | 9 | 8-10 | 179.56 | 0.588** |
| *Mann-Whitney test | **Kruskal-Wallis | test |
| sponses to questions regarding attitude towards childhood vaccination | |
|---|---|
| Percent (n) | |
| ur child all the mandatory vaccines? (Yes) 100 (397) | |
| r child’s compulsory immunisation schedule/programme? 99.7 (396) | |
| tional immunisations for your child, such as the annual 99.5 (395) | |
| (Yes) | |
| government’s support for the vaccination programme is 100 (397) | |
| r relatives and friends to vaccinate their children? (Yes) 99.7 (396) | |
| t the vaccination programme begins from the first week of 99.5 (395) | |
| mplete all vaccine doses when there is more than one dose? 99.7 (396) | |
| How do you feel | after vaccinating your child? 96.5 (383) |
| What is your assessment | of the child vaccinations? |
| Important | 79.8 (317) |
| Very important | 20.2 (80) |
| Factors associated with mothers’ attitude | towards childhood vaccination |
|---|---|
| Total | knowledge score (0-10) p-value |
| Median | IQR Mean rank |
| Mother’s age (years) | |
| <20 (n=36) 9 | 9-9.75 211.40 |
| 20-30 (n=214) 9 | 9-9 200.36 |
| 31-40 (n=133) 9 | 9-9 196.29 |
| ≥41 (n=14) 9 | 9-9 172.14 0.460** |
| Father’s age | |
| 20-30 (n=228) 9 | 9-9 199.33 |
| 31-40 (n=154) 9 | 9-9 202.20 |
| ≥41 (n=15) 9 | 9-9 161.10 0.172** |
| Mother’s current marital status | |
| Married (n=284) 9 | 9-9 200.83 |
| Divorced (n=13) 9 | 8.5-9 144.81 0.014* |
| Number of children, including the index one | |
| One (n=55) 9 | 9-9 199.16 |
| Two (n=188) 9 | 9-9 190.13 |
| Three (n=122) 9 | 9-9.25 211.08 |
| ≥Four (n=32) 9 | 9-9 204.80 0.163** |
| Mother’s education level | |
| Secondary school/below (n=10) 9 | 8.75-9 192.80 |
| University/above (n=387) 9 | 9-9 199.16 0.806* |
| Father’s educational level | |
| Secondary school/below (n=25) 9 | 9-9.5 200.84 |
| University/above (n=372) 9 | 9-9 198.88 0.9078 |
| Residence | |
| Inside Taif City (n=380) 9 | 9-9 199.83 |
| Outside Taif City (n=17) 9 | 9-9 180.47 0.335* |
| Mother’s job status | |
| Working (n=195) 9 | 9-9 199.59 0.887* |
| Father’s job status | |
| Government employee (n=318) 9 | 9-9 200.87 |
| Private sector employee (n=49) 9 | 9-9 196.47 |
| Military (n=22) 9 | 9-9.25 196.64 |
| Business/trade (n=8) 9 | 9-9 146.69 0.312** |
| *Mann-Whitney test | **Kruskal-Wallis test |
| that even healthy children require vaccination [9]. In | knowledge of childhood immunisation were gender, |
| a previous study carried out in Taif (KSA), the | residence and educational level [13]. |
| majority of parents (91.9%) could recognise the role | In Nigeria, the mothers’ age, education level, job |
| of routine vaccination in protecting children from | status and family structure were significantly |
| certain infectious diseases and their complications, | associated with their level of knowledge [10]. In |
| and knew the timing of the first dose in the | Malaysia, the mothers’ age, education level and job |
| vaccination schedule (86.9%), while only 41.6% | status were significantly associated with the |
| could recognise that administration of multiple doses | vaccination knowledge score [19]. The present survey |
| of the same vaccine is important for children’s | also revealed a very positive attitude of mothers |
| immunity [14]. Outside the Kingdom, some similar | towards childhood vaccination, with a median score |
| and some different findings have been observed. In | of 9 out of a maximum score of 10. Nearly all of the |
| Nigeria, all mothers were aware of vaccination and | mothers gave their children the mandatory |
| most had a good knowledge about vaccination of | vaccinations, considered childhood vaccination |
| children under five years [15]. In Sudan, the majority | important or very important, believed that the |
| of mothers (90%) had heard about vaccination and | government’s support for the vaccination programme |
| slightly more than half of them (52%) had poor | is sufficient, followed their child’s compulsory |
| knowledge about the number of routine doses given | immunisation schedule/programme, advised their |
| to children under two years [16]. In Jerusalem- | relatives and friends to vaccinate their children, were |
| Palestine, inadequate knowledge about vaccines and | keen to complete all vaccination doses when there |
| vaccination schedules was observed [17]. In Georgia, | was more than one dose, believed that the vaccination |
| almost one third of respondents (32%) did not have | programme started from the first week of life, and felt |
| sufficient information about the routine vaccination | secure after vaccinating their child. In Riyadh-Saudi |
| schedule and, as a result, vaccination was incomplete | Arabia, the attitude of parents towards childhood |
| in 36% of children. Re- ported reasons for | immunisation was positive, except in a few aspects |
| incomplete vaccination were lack of knowledge | relating to vaccination side effects and the probability |
| about a routine vaccination schedule (25.5%), low | of occurrence of diseases against which the child was |
| awareness of the necessity of the second or third | vaccinated [13]. In Arar-Saudi Arabia, most parents |
| vaccine dose (18.6%), fear of post- vaccination side | gave their children all the mandatory vaccines, |
| effects (16%), and fear of illness among children | followed their children’s compulsory immunisation |
| (9.6%) [18]. The use of different knowledge | schedule/programme, and felt secure after vaccinating |
| assessment tools, as well as a difference in age | their children [9]. In Nigeria, all the mothers |
| categories of the participants’ children, could explain | expressed a positive attitude towards vaccination and |
| some of the differences in findings between the | 86.4% had fully vaccinated their children [20]. In |
| abovementioned studies and the present one. | Uganda, the majority of mothers (93.5%) believed |
| The present survey revealed that more educated | that childhood immunisation protects children from |
| th ( i it b ) k l | |
| In Sudan, more than half of the respondents (55%) had | -More health education is needed at outpatient |
| negative attitudes towards vaccination of children in | clinics and primary care centres, particularly for |
| vaccination campaigns [16]. In Jerusalem- Palestine, | less educated mothers, to improve awareness and |
| the majority of mothers (94%) considered | correct certain misconceptions regarding childhood |
| vaccination to be the main activity in maternal and | vaccination. |
| children’s clinics [17]. In Georgia, the majority of | -Further study is warranted to include mothers from |
| mothers (97%) had a positive attitude toward | different settings in Taif, in order to provide a |
| immunisation and believed that vaccination plays an | clearer view of the situation. |
| important role in preventing infectious diseases [18]. | -Parents should be included both in health ed- |
| Again, comparison of these studies, including the | ucation activities and in further research, as they |
| present one, is not always practical, mainly due to | could have a positive role in increasing coverage |
| demographic differences and the use of different | and adherence to childhood vaccination schedules. |
| t l t ttit d t d hildh d |