Abstract
Despite significant advancements in worldwide vaccination, the coronavirus 2019 pandemic has disrupted primary care and vaccination programs. This study aimed to assess parents’ attitudes toward compulsory childhood vaccination and the determinants of vaccination acceptance in Algeria based on the Health Belief Model (HBM). Using the snowball and convenience sampling methods, a cross-sectional study was conducted from November 1 to December 15, 2022, among parents with at least 1 child eligible for compulsory vaccination. Data were collected using an online questionnaire with 3 sections: parents’ sociodemographic characteristics, children’s characteristics, and a questionnaire based on the HBM. A total of 391 parents responded to the survey. Among the respondents, 90% believed that compulsory childhood vaccines could effectively protect against infectious diseases and 87.5% reported a scarcity of information available on vaccines. The logistic regression model showed that easy access to healthcare facilities significantly increased vaccine uptake by 98% compared to difficult accessibility (adjusted odds ratio [AOR] = 0.02; 95%CI = 0.001–0.12; P < .001). Parents who said no and maybe [i.e., when asked if their children can spread illness to others when not vaccinated] showed significantly lower vaccine uptake by 25.49 (AOR = 25.49; 95%CI = 1.95–470.29; P = .019) and 12.16 (AOR = 12.16; 95%CI = 1.65–111.62; P = .018), respectively when compared to those who answered yes. Parents who reported that vaccines may weaken natural immunity had significantly higher odds of vaccination uptake by 92% than those who answered yes (AOR = 0.08; 95%CI = 0.01–1.26; P = .033). Identifying factors that influence vaccine acceptance can offer policymakers valuable insights for designing strategic intervention programs aimed at increasing acceptance rates.
Keywords: childhood vaccination, compulsory vaccination, COVID-19, essential health service delivery, parent attitude towards vaccination
Key points.
High level of routine vaccination coverage was maintained after the COVID-19 pandemic in Algeria.
The Health Belief Model could identify predictors of parents’ acceptance of vaccination.
Identifying factors associated with vaccine acceptance could help policymakers with shaping strategic interventional programs.
Greater distance to the nearest health center was linked to decreased vaccination uptake.
1. Introduction
Vaccines are one of the most significant advances in world health and development. Vaccines have successfully lowered the severity of infectious diseases such as polio, measles, and smallpox for >2 centuries, allowing children to grow healthier.[1] Vaccination safeguards against infectious diseases by mimicking the natural interactions of pathogens with the human immune system. This process helps fortify the body’s defenses, reducing the likelihood of complications and death in the event of a subsequent infection.[2] Vaccination acts as a preventive measure, actively contributing to the enhancement of immune fitness.[3] Vaccines are effective tools for managing and eliminating life-threatening infectious illnesses, with an estimated annual saving of 2 to 3 million lives. Vaccinations stand out as highly cost-effective health investments, specifically targeting well-defined groups. Evidence-based strategies ensure accessibility even for the most challenging-to-reach and vulnerable populations.[4] Although progress has been tremendous, there is still an opportunity for improvement in worldwide vaccine coverage rates. In 2014, over 19 million newborns were not immunized routinely, including 3 doses of the Diphtheria, Pertussis, and Tetanus (DPT) vaccine. Notably, more than 60% of these children are from 10 African and Asian countries, highlighting regional disparities.[5] Similarly, outbreaks of vaccine-preventable diseases in high-income countries demonstrate the need to extend or alter immunization efforts globally.[6] While vaccination coverage has shown an overall increase in the past decade, notable disparities persist. Particularly, the poorest and least-educated rural regions lag behind in achieving adequate vaccination rates. Vaccination programs have concentrated on expanding coverage and targeting the most vulnerable children, but vaccine timings are as crucial since delays expose children to illnesses.[7]
Despite significant advancements in worldwide vaccination, the coronavirus 2019 (COVID-19) pandemic has disrupted primary care health services and lowered rates of regular vaccination among children and adolescents.[8–11] With the implementation of various public health and social measures (stay-at-home instructions, physical distancing, and domestic, and international travel restrictions in place) to mitigate viral transmission, there was a concern that children would be exposed to COVID-19 while receiving immunization in medical centers.[8,12] Many countries have reported a decrease in vaccination coverage.[13] The Centers for Disease Control and Prevention reported significant decreases in regular children’s vaccination delivery during the first wave of the COVID-19 pandemic, which occurred between March and May 2020.[14] Moreover, approximately 22% of infants in the World Health Organization's European Region experienced interruptions in their vaccination schedules.[15] The World Health Organization also warned about the significant decrease in the three-dose doses of DPT for the first 4 months of 2020.[16]
Following the introduction of compulsory childhood vaccination in Algeria in 1969, the incidence of infectious diseases decreased significantly.[17] Almost all Algerian children received the Bacillus Calmette-Guérin vaccine, and 91% received a third dose of DPT, and 80% of the children were immunized against measles.[17] Yet, there are no studies that have estimated childhood vaccination coverage in Algeria during the COVID-19 pandemic. Therefore, it is still unclear how much disturbance can be caused by low immunization and coverage levels on childhood health and economics. Parents’ hesitancy towards COVID-19 vaccination was obvious especially if they had chronic diseases,[18–20] and we speculate that this may affect their attitude towards compulsory vaccination. Considering the paucity of relevant literature, we conducted the present study to assess parents’ attitudes towards compulsory vaccination. The primary objective of the study was to investigate the reasons behind incomplete or non-vaccination despite the overall good vaccine coverage of vaccine-preventable diseases in Algeria based on the Health Belief Model (HBM). The HBM is a theoretical framework that can help explain individual behaviors related to health and healthcare. It consists of several key factors that influence people’s decision-making process regarding immunization.[21,22] Immunization coverage in Algerian children post-COVID-19 may be influenced by various factors, as explained by the HBM. These factors include parents’ perception of susceptibility and benefits, perceived barriers such as logistical and financial challenges, cues to action like reminders and effective communication, self-efficacy in navigating the healthcare system, sociocultural factors, and trust in the healthcare system. Disruptions in healthcare services during the pandemic and vaccine hesitancy may exacerbate these issues.
2. Materials and methods
2.1. Study setting
This cross-sectional study was conducted from November 1 to December 15, 2022, using the HBM to assess parents’ attitudes towards compulsory vaccination in Algeria. The questionnaire was designed as an anonymous electronic Google form. In addition to Arabic, the questionnaire was distributed in 2 languages (French and English). The link was distributed through social media like Facebook, Telegram, WhatApp, and Messenger. The Global Researcher Club, a nonprofit, nongovernmental organization, recruited collaborators from Algeria, and managed the data collection process. This collaboration ensured that data collection was conducted efficiently and following the study’s methodology, while also leveraging local expertise to enhance the reliability and accuracy of the gathered data.
2.2. Sample size, inclusion criteria, and sampling method
Applying a 5% margin of error and a 95% confidence level, along with assuming a 50% acceptance rate for the compulsory childhood vaccines, we calculated a minimum sample size of 384 parents from Algeria using Epi-info 7.2. Inclusion criteria stipulate that parents must be 18 years or older, have at least one child eligible for compulsory vaccination, and reside in Algeria during the COVID-19 pandemic to be eligible for participation in this survey. The data collection was executed through a snowball and convenience sampling approachs.
2.3. Data collection tool
The electronic questionnaire was divided into 3 sections:
Section I included parents’ sociodemographic characteristics (i.e., mother’s age, education, working status, number of children, relationship with the child) (mother or father), and responsibility for making health decisions regarding his/her child (i.e., father, mother, or both). Data on attending antenatal care (ANC), place of delivery, and distance to the nearest healthcare facilities (HCFs) were included.
In Section II described the characteristics of children such as age, sex, birth order, history of chronic diseases, and compulsory vaccines uptake. Compulsory vaccines uptake was divided into 3 categories: those who were fully vaccinated (received all compulsory vaccines, including oral polio vaccination, Bacillus Calmette-Guérin, and DPT), partially vaccinated (missing at least 1 dose of any compulsory vaccine), and those not vaccinated at all (received no compulsory vaccines). Both partially vaccinated and not vaccinated at all groups were combined into one group in the analysis, namely not fully vaccinated. Additionally, this section sought information about vaccination history against specific diseases, including meningococcal, pneumococcal, rotavirus, and seasonal influenza.
Section III contained 14 questions constructed using the HBM.[23] The HBM-based section had 5 domains. (i) The perceived susceptibility domain had 2 items (i.e., my child acquires infectious diseases more easily than others, and the child is at a higher risk for infectious diseases if not vaccinated). (ii) The perceived severity domain had 3 items (i.e., if children are not vaccinated, the disease may be more severe than usual; they may suffer from growth- and development-related problems if they are not vaccinated; and if children are not vaccinated, they can spread the illness to others). (iii) The perceived benefits domain included 2 items (i.e., vaccines effectively protect against infectious diseases and are safe). (iv) The perceived barriers domain had 5 items (i.e., no available information about vaccines, vaccines are not necessary, vaccines are unsafe and have side effects, vaccines weaken natural immunity, and there is no need for vaccination of breastfed infants). (v) The cues to action domain had 2 items (i.e., parental opinion about routine vaccination may be affected if information about vaccine safety and efficacy is available, when, and where to obtain it, and if routine vaccinations are available in nearby HCFs). Parents should respond to all the questionnaire questions using 3 responses (yes, no, and maybe). Before data collection, we conducted a pilot study to assess the feasibility and accessibility of the survey, as well as the time required to complete the questionnaire and the response rate. Based on the findings, minor adjustments were made to improve the readability and language of the questionnaire. The time required to fill out the questionnaire was determined to be between 9 to 12 minutes. Cronbach alpha of the questionnaire was >0.7 for the 5 domains.
2.4. Ethical considerations and approval
This study was approved by the Ethics Committee of the Faculty of Medicine at Alexandria University, Egypt (IRB 00012098/0305755). The focal collaborator from Algeria reported that the approval obtained from Egypt was sufficient. The invited parents received information on the study’s objectives, anonymity, confidentiality, voluntary participation, and privacy statements that was displayed on the survey cover page. The parents requested to click on one of 2 choices “I accept to participate” or “not to participate.” Those who selected “I accept to participate” could access the questionnaire. Data were encrypted and saved on a password-protected computer that was accessible only by the principal investigator.
2.5. Statistical analysis
Statistical analysis was performed using R version 4.1.1. Categorical variables were reported as numbers and percentages. Pearson chi-squared test was used to compare 2 independent categorical variables. To test the assumptions of the model, a logistic regression model was built using variables that showed significance in the bivariate analysis. The variable of the “main decision taker” made infinite confidence intervals; therefore, it was removed from the model. Moreover, 3 questions from the HBM section (i.e., a child is at a higher risk for infectious diseases if not vaccinated, vaccines weaken natural immunity, and if the vaccines were available in nearby HCFs may affect my opinion) were removed. This is because they had a variance inflation factor > 10, indicating multicollinearity that negatively affected the model. A P-value is considered significant at < .05.
3. Results
3.1. Characteristics of parents and the children
In this study, 391 parents participated. 91.8% were primarily from urban areas and 64.7% had 2 children or less. 48.8% of mothers aged bewteen 31 and 40 years and 51.7% of them were not working. The study included children both equal ≤ 2 years (48.8%) and older than 2 years (51.2%). There was a slightly higher representation of female children (56.0%) compared with males (44.0%). Most children were either 1st or 2nd in terms of birth order (72.9%). A small percentage of children (3.3%) had a chronic disease. A significant proportion of mothers attended ANC (92.1%). Almost all deliveries took place in HCFs (99.7%). Most respondents reported easy accessibility to HCFs (95.9%). The decision-making process regarding child health was predominantly shared between mothers and fathers (90.0%). A varying percentage of children received different vaccines, with the pneumococcal vaccine having the highest coverage (93.6%) (Table 1). The majority of the parents reported that their children were fully vaccinated (90%), while 9.2% indicated their children were partially vaccinated. Only 0.8% reported that their children were not vaccinated at all (Table 1). The most common causes of non-vaccination or incomplete vaccination were unavailability of the vaccine (35.9%), long distance to HCFs (28.2%), fear of side effects (15.4%), and lack of information about vaccination (12.8%) (Fig. 1).
Table 1.
Characteristics of the study participants.
| Variables | Overall = 391 n (%) | |
|---|---|---|
| Who is responding | Mother | 363 (92.8) |
| Father | 228 (7.2) | |
| Place of residence | Rural | 32 (8.2) |
| Urban | 359 (91.8) | |
| Number of children | Two or less | 253 (64.7) |
| More than 2 | 138 (35.3) | |
| Mother’s age (years) | 20–30 | 120 (30.7) |
| 31–40 | 191 (48.8) | |
| 41–50 | 80 (20.5) | |
| Mother education | Illiterate | 5 (1.3) |
| Less than high school | 69 (17.6) | |
| Technical school graduate | 47 (12.0) | |
| High school graduate | 55 (14.1) | |
| University/college | 191 (48.8) | |
| Postgraduate | 24 (6.1) | |
| Mother employment | Not working | 202 (51.7) |
| Working | 189 (48.3) | |
| Child age | ≤2 years | 191 (48.8) |
| >2 years | 200 (51.2) | |
| Child gender | Female | 219 (56.0) |
| Male | 172 (44.0) | |
| Childbirth order | 1st or 2nd | 285 (72.9) |
| 3rd or more | 106 (27.1) | |
| The child has chronic disease | 13 (3.3) | |
| Attending ANC visit at least once | 360 (92.1) | |
| Place of delivery | Healthcare facilities | 390 (99.7) |
| Home | 1 (0.3) | |
| Healthcare facilities accessibility | Easy | 375 (95.9) |
| Difficult | 16 (4.1) | |
| Main decision maker regarding child health | Mother and father | 352 (90.0) |
| Father only | 29 (7.4) | |
| Mother only | 9 (2.3) | |
| Other relatives | 1 (0.3) | |
| The child got compulsory childhood vaccination | Fully vaccinated | 352 (90) |
| Partially vaccinated | 36 (9.2) | |
| Not at all vaccinated | 3 (0.8) | |
| The child got the seasonal Influenza vaccine | 12 (3.1) | |
| The child got the rotavirus vaccine | 28 (7.2) | |
| The child got the pneumococcal vaccine | 366 (93.6) | |
| The child got the meningococcal vaccine | 38 (9.7) | |
ANC = antenatal care.
Figure 1.
Causes of non-vaccination or incomplete compulsory vaccination uptake among Algerian children.
3.2. Bivariate analysis of factors associated with compulsory vaccination uptake
Higher rates of vaccination were observed in parents who lived in urban areas (91.9%, P < .001), children aged > 2 years (93.0 %, P = .045), mothers who attended at least 1 ANC visit (84.6%, P < .001), easy access to HCFs (92.8%, P < .001), and when decisions made by both parents (91.5%, P < .001). Moreover, higher rates of vaccination were observed in children who received non-compulsory vaccines, such as Influenza (66.7%, P < .023), Rotavirus (71.4%, P < .003), Pneumococcal (93.2%, P < .001), and Meningococcal vaccines (71.1%, P < .001) (Table 2).
Table 2.
Characteristics of the study participants by compulsory vaccination uptake.
| Complete compulsory vaccination uptake n (%) | ||||
|---|---|---|---|---|
| Variable | No 39 (10) |
Yes 352 (90) |
P | |
| Place of residence | Rural | 10 (31.2) | 22 (68.8) | <.001 |
| Urban | 29 (8.1) | 330 (91.9) | ||
| Number of children | Two or less | 24 (9.5) | 229 (90.5) | .663 |
| More than 2 | 15 (10.9) | 123 (89.1) | ||
| Mother’s age (years) | 20–30 | 14 (11.7) | 106 (88.3) | .629 |
| 31–40 | 19 (9.9) | 172 (90.1) | ||
| 41–50 | 6 (7.5) | 74 (92.5) | ||
| Mother education | None | 1 (20.0) | 4 (80.0) | .302 |
| Less than high school | 8 (11.6) | 61 (88.4) | ||
| Technical school graduate | 4 (8.5) | 43 (91.5) | ||
| High school graduate | 3 (5.5) | 52 (94.5) | ||
| University/college | 18 (9.4) | 173 (90.6) | ||
| Postgraduate | 5 (20.8) | 19 (79.2) | ||
| Mother employment | Not working | 23 (11.4) | 179 (88.6) | .336 |
| Working | 16 (8.5) | 173 (91.5) | ||
| Child age | ≤2 years | 25 (13.1) | 166 (86.9) | .045 |
| >2 years | 14 (7.0) | 186 (93.0) | ||
| Child gender | Female | 18 (8.2) | 201 (91.8) | .191 |
| Male | 21 (12.2) | 151 (87.8) | ||
| Childbirth order | 1st or 2nd | 25 (8.8) | 260 (91.2) | .193 |
| 3rd or more | 14 (13.2) | 92 (86.8) | ||
| The child has chronic disease | Yes | 2 (15.4) | 11 (84.6) | .379 |
| Attending ANC visit at least once | Yes | 29 (8.1) | 331 (91.9) | <.001 |
| Place of delivery | Healthcare facilities | 38 (9.7) | 352 (90.3) | .1 |
| Home | 1 (100.0) | 0 (0.0) | ||
| Healthcare facilities accessibility | Easy | 27 (7.2) | 348 (92.8) | <.001 |
| Difficult | 12 (75.0) | 4 (25.0) | ||
| Main decision maker regarding child health | Mother and father | 30 (8.5) | 322 (91.5) | <.001 |
| Father only | 4 (13.8) | 25 (86.2) | ||
| Mother only | 5 (55.6) | 4 (44.4) | ||
| Other relatives | 0 (0.0) | 1 (100.0) | ||
| The child got the Seasonal Influenza vaccine | Yes | 4 (33.3) | 8 (66.7) | .023 |
| The child got the Rotavirus vaccine | Yes | 8 (28.6) | 20 (71.4) | .003 |
| The child got the Pneumococcal vaccine | Yes | 25 (6.8) | 341 (93.2) | <.001 |
| The child got the Meningococcal vaccine | Yes | 11 (28.9) | 27 (71.1) | <.001 |
Bold values indicated P < .05.
3.3. Health belief model distributed across routine vaccination status
A total of 87% of parents reported that their children did not develop infectious diseases more easily than others did, 55% disagreed that their children were at a higher risk of contracting infectious diseases if they were not vaccinated, 91% reported that children could be subjected to more severe diseases than usual if not vaccinated, and 85.2% said that their children would suffer from growth-related problems if they were not vaccinated. Regarding non-vaccination, 84.9% of parents believed that their children could spread the disease to others, 90.0% believed that vaccines effectively protected against infectious diseases, 58.3% agreed that vaccines were safe, and 87.5% reported a scarcity of information regarding the vaccines. Most of them disagreed that vaccines were not necessary (87.7%), unsafe (62.7%), had weakened natural immunity (63.9%), and had no need for them for breastfed babies (88.2%). Having sufficient information about the safety and efficacy of vaccines could encourage 92.8% of parents to vaccinate their children. A total of 93.9% were assured that they could vaccinate their children if vaccines were available in the nearby HCFs. All items of the questionnaire showed statistical differences between those who vaccinated their children and those who did not, except for one item (i.e., My child gets infectious diseases more easily than others). (Table 3).
Table 3.
Health belief model distributed across routine vaccination status.
| The HBM items | Complete compulsory vaccination uptake n(%) | P-value | ||
|---|---|---|---|---|
| Overall = 391 | No 39 (10) | Yes 352 (90) | ||
| Perceived susceptibility | ||||
| Q1. My child gets infectious diseases more easily than others | ||||
| Yes | 36 (9.2) | 4 (11.1) | 32 (88.9) | .918 |
| May be | 14 (3.6) | 1 (7.1) | 13 (92.9) | |
| No | 341 (87.2) | 34 (10.0) | 307 (90.0) | |
| Q2. The child is at higher risk for infectious diseases if not vaccinated | ||||
| Yes | 88 (22.5) | 21 (23.9) | 67 (76.1) | <.001 |
| May be | 88 (22.5) | 11 (12.5) | 77 (87.5) | |
| No | 215 (55.0) | 7 (3.3) | 208 (96.7) | |
| Perceived severity | ||||
| Q3. The disease may be more severe than usual if not vaccinated | ||||
| Yes | 356 (91.0) | 16 (4.5) | 340 (95.5) | <.001 |
| May be | 28 (7.2) | 19 (67.9) | 9 (32.1) | |
| No | 7 (1.8) | 4 (57.1) | 3 (42.9) | |
| Q4. Children may suffer from growth and development-related problems if not vaccinated | ||||
| Yes | 333 (85.2) | 7 (2.1) | 326 (97.9) | <.001 |
| May be | 34 (8.7) | 18 (52.9) | 16 (47.1) | |
| No | 24 (6.1) | 14 (58.3) | 10 (41.7) | |
| Q5. If children are not vaccinated, they can spread illness to others | ||||
| Yes | 332 (84.9) | 7 (2.1) | 325 (97.9) | <.001 |
| Maybe | 42 (10.7) | 22 (52.4) | 20 (47.6) | |
| No | 17 (4.3) | 10 (58.8) | 7 (41.2) | |
| Perceived benefits | ||||
| Q6. Vaccines effectively protect against infectious diseases | ||||
| Yes | 352 (90.0) | 20 (5.7) | 332 (94.3) | <.001 |
| Maybe | 29 (7.4) | 11 (37.9) | 18 (62.1) | |
| No | 10 (2.6) | 8 (80.0) | 2 (20.0) | |
| Q7. Vaccines are safe | ||||
| Yes | 228 (58.3) | 8 (3.5) | 220 (96.5) | <.001 |
| Maybe | 74 (18.9) | 15 (20.3 | 59 (79.7) | |
| No | 89 (22.8) | 16 (18.0 | 73 (82.0) | |
| Perceived barriers | ||||
| Q8. No available information about vaccines | ||||
| Yes | 342 (87.5) | 26 (7.6) | 316 (92.4) | <.001 |
| Maybe | 17 (4.3) | 7 (41.2) | 10 (58.8) | |
| No | 32 (8.2) | 6 (18.8) | 26 (81.2) | |
| Q9. Vaccines are not necessary | ||||
| Yes | 24 (6.1) | 7 (29.2) | 17 (70.8) | <.001 |
| Maybe | 24 (6.1) | 12 (50.0) | 12 (50.0) | |
| No | 343 (87.7) | 20 (5.8) | 323 (94.2) | |
| Q10. Vaccines are unsafe and have side effects | ||||
| Yes | 38 (9.7) | 16 (42.1) | 22 (57.9) | <.001 |
| Maybe | 108 (27.6) | 11 (10.2) | 97 (89.8) | |
| No | 245 (62.7) | 12 (4.9) | 233 (95.1) | |
| Q11. Vaccines weaken the natural immunity | ||||
| Yes | 45 (11.5) | 17 (37.8) | 28 (62.2) | <.001 |
| Maybe | 96 (24.6) | 9 (9.4) | 87 (90.6) | |
| No | 250 (63.9) | 13 (5.2) | 237 (94.8) | |
| Q12. No need for vaccination for breastfed babies | ||||
| Yes | 34 (8.7) | 13 (38.2) | 21 (61.8) | <.001 |
| Maybe | 12 (3.1) | 7 (58.3) | 5 (41.7) | |
| No | 345 (88.2) | 19 (5.5) | 326 (94.5) | |
| Cues to action (Factors that may affect parents’ opinion about routine vaccination) | ||||
| Q13. If information about vaccine safety, efficacy, and when and where to get it are available | ||||
| Yes | 363 (92.8) | 29 (8.0) | 334 (92.0) | <.001 |
| Maybe | 16 (4.1) | 7 (43.8) | 9 (56.2) | |
| No | 12 (3.1) | 3 (25.0) | 9 (75.0) | |
| Q14. If the vaccines were available in a nearby healthcare facilities | ||||
| Yes | 367 (93.9) | 32 (8.7) | 335 (91.3) | .004 |
| Maybe | 9 (2.3) | 4 (44.4) | 5 (55.6) | |
| No | 15 (3.8) | 3 (20.0) | 12 (80.0) | |
Bold values indicates P < .05.
3.4. Determinants of compulsory vaccination coverage
Easy access to the HCFs significantly increased vaccine uptake by 98% compared to difficult accessibility (OR = 0.02; 95% CI = 0.001–0.12; P < .001). Parents who said no or maybe when asked if their children could spread illness to others when not vaccinated showed significantly lower vaccine uptake by 25.49 (OR = 25.49; 95% CI = 1.95–470.29; P = .019) and 12.16 (OR = 12.16; 95% CI = 1.65–111.62; P = .018), respectively, when compared to those who answered yes. Those who said that vaccines may weaken their natural immunity had significantly higher odds of vaccine uptake by 92% than those who said yes (OR = 0.08; 95% CI = 0.01–1.26; P = .033) (Fig. 2).
Figure 2.
Logistic regression showing the predictors of non-vaccination.
4. Discussion
The COVID-19 pandemic has disrupted essential service delivery worldwide, including vaccination services. From January to December 2020, 30.0 million (27.6–33.1) children are expected to miss the third dose of DPT immunization, and 27.2 million (23.4–32.5) children are expected to miss the first dose of measles-containing vaccine. Despite improvements in coverage rates in many countries, millions of children remain vulnerable to infectious diseases such as measles.[24] Our study aimed to assess parents’ attitudes towards compulsory vaccination and the determinants of vaccination acceptance using the HBM 2 years after the COVID-19 pandemic in Algeria. Algeria witnessed the highest vaccination coverage in Africa during the pandemic.[25,26] The COVID-19 pandemic, like other pandemics, is known to have the greatest impact on the most vulnerable households and socioeconomic categories, disturbing the already inadequate and overburdened health infrastructure in low-, middle-, and high-income countries.[26] Fortunately, in this study, most of the parents had already received all compulsory vaccines according to the national vaccination program. Similarly, Alves et al,[27] investigated the immunization patterns among Brazilian children during their first year of life. They determined that there was no compelling evidence of a substantial decline in patterns at the national level during the research period, or before and after the pandemic. However, the average number of immunizations per person was lower than that for the target. Hagander et al,[28] evaluated the robustness of Sweden’s national immunization program for children up to 5 years of age during the early phases of the pandemic. They reported that child immunization had been prioritized, family communication had increased, and there was greater flexibility at all organizational levels of child healthcare. Furthermore, the vaccination supply was maintained, and child health centers continued to operate.
The observed increase in the number of children living in conflict areas and fragile settings, where access to vaccination is frequently difficult, the increase in infodemics on social networks, as well as COVID-19-related problems such as service and supply chain interruptions, resource diversion, and containment restrictions that limited access to vaccines, all played a role in reduced vaccination uptake during the COVID-19 pandemic.[29] Moreover, economic constraints have reduced government funding for regular immunization.[30] Finally, many parents did not receive vaccination services during COVID-19 because of their fear of catching the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection themselves or their children. It is worth noting that Abbas et al,[31] weighed the health advantages of sustaining routine child immunization in Africa against the danger of developing SARS-CoV-2 infection by visiting routine vaccination service delivery locations. They revealed that by continuing routine childhood immunization, 84 (95% uncertainty interval [UI] 14–267) extra COVID-19 deaths due to SARS-CoV-2 infections acquired during normal vaccination clinic visits might be averted in Africa. For vaccinated children, the benefit-risk ratio is 85,000 (4900–546,000), 75 000 (4400–483,000) for their siblings (<20 years), 769 (148–2700) for their parents or adult caregivers (20–60 years), and 96 (14–307) for older people (>60 years).[31]
The current study highlights the most common barriers to vaccination and non-vaccination, including vaccine unavailability, difficult accessibility to HCFs, and fear of vaccines. A systematic review also reported various factors associated with low vaccine rates, such as the distance to access points, financial deprivation, and distrust in vaccines and immunization programs.[32] Similarly, Kaufman et al,[33] reported that the cost of vaccine or service delivery and transportation, distance, long clinic waiting times, and lack of vaccine availability are the most frequent challenges to childhood vaccination. Additionally, the bivariate analysis in our study identified many factors associated with reduced vaccination uptake, including residence in rural areas, age <2 years, attending ANC, access to HCF, decision-makers, and vaccination against influenza, rotavirus, meningococcal, and pneumococcal infection. Consequently, to maintain the delivery of the vaccination service and avoid any vaccination dose, a persistent catch-up campaign appears to be required. The vaccination procedure should be facilitated by reducing the waiting time for immunization at HCFs, addressing parents’ fears and worries about SARS-CoV-2 infection, increasing vaccine supply, and encouraging access in rural locations. Countries must maintain appropriate immunizations to avoid the negative consequences of future pandemics on vaccination programs.
4.1. Health belief model
In this study, perceived child susceptibility to infections, perceived severity of infectious diseases, perceived benefits of routine vaccination, perceived barriers to vaccination, and cues to action to vaccinate children were significantly associated with routine vaccination uptake in the bivariate analysis. However, in the multivariate analysis, perceived severity of infectious diseases and perceived barriers to vaccination were the only significant predictors of childhood vaccination uptake. In the United States, Reindl and Catma,[34] discovered that the association between parents’ desire to vaccinate their children with the COVID-19 vaccine and structures within the theoretical framework of the HBM is a critical point in the construction of effective COVID-19 vaccination programs among parents. Li, Lau, and Chan,[35] investigated to what extent Hong Kong parents wanted to vaccinate their children. After controlling for parental and child demographic variables (e.g., gender and age), multilevel regression revealed that parents’ intention to vaccinate their children was greater if they had higher levels of perceived susceptibility, perceived benefits, positive attitudes, subjective norms, and lower levels of perceived barriers. Positive views were the most powerful predictor of parental intention. Another example of using the HBM to assess parents towards vaccination was demonstrated by Smith et al.[36] who investigated the relationship between parents’ views on vaccination, their decision to postpone or refuse immunization for their children, and vaccination coverage among children aged 24 months. They used information from 11,206 parents of children aged 24 to 35 months at the time of the 2009 National Immunization Survey interview to establish their children’s immunization status at 24 months. Parents who were less likely to think that vaccinations are important to preserve their children’s health, believe that their child may contract a disease if not vaccinated, or believe that vaccines are safe had considerably lower coverage for all childhood immunizations.[36]
4.2. Ease of access and vaccination of children
In this study, greater distance to the nearest health center was linked to decreased vaccination uptake. Sato et al, [37] reported that 78.2% of 21,369 Nigerian children aged 12 to 59 months had ever been immunized. A 1 km walk to the nearest clinic lowered the chance of receiving a vaccination by approximately 5% [OR:0.952, 95% CI = 0.935–0.969]. Distance to the nearest clinic is seldom associated with dropout rates in the vaccine series, although it does cause delays in immunization. This highlights the importance of providing vaccination services to all children in urban and rural areas to improve vaccination coverage.
4.3. Strengths and limitations
This is the first study to assess the coverage of the extended immunization program in Algeria using data collected from the parents themselves. However, recall bias might have affected the quality of the results. The non random sampling technique is another limitation that may affect the generalizability of research findings. The interviews were conducted online. Given that only 60% of the population in Algeria has internet access, this approach may introduce a bias by excluding a significant portion of the population who are not connected. As a result, the findings may not accurately represent the perspectives and experiences of those who do not have internet access. Considering the lack of generalizability, it is crucial to acknowledge the limitations of the study and exercise caution in applying the findings to the wider Algerian population.
To address these limitations, future research could explore alternative data collection methods that encompass a more diverse range of participants, including those without internet access. This could involve conducting face-to-face interviews, utilizing telephone surveys, or implementing community-based approaches to ensure broader representation.
5. Conclusions
Fortunately, a high level of routine vaccination coverage was maintained after the COVID-19 pandemic in Algeria. The study reported that the primary reasons for non-vaccination included unavailability of the vaccine, long distances to HCFs, fear of side effects, and lack of information. Factors associated with higher vaccination rates included urban residence, older age of children, attendance of at least 1 antenatal care visit, easy access to HCFs, joint decision-making by parents, and receipt of non-compulsory vaccines. The HBM revealed that a significant proportion of parents believed in the efficacy of vaccines, perceived the severity of diseases without vaccination, and acknowledged potential risks if their children were not vaccinated. Easy access to HCFssubstantially increased routine vaccine uptake, while parental beliefs about their children spreading illness and concerns about vaccines weakening natural immunity influenced vaccination rates. The study highlights the importance of conducting future studies to address the impact of improving accessibility issues and dispelling misconceptions on improving routine vaccination rates.
Author contributions
Conceptualization: Ramy Mohamed Ghazy, Alsaleem Mohammed Abadi, Assia Salah.
Data curation: Ramy Mohamed Ghazy, Assia Salah.
Formal analysis: Marina Saleeb, Ehab Elrewany.
Investigation: Noha Fadl.
Methodology: Ramy Mohamed Ghazy, Assem Gebreal.
Project administration: Emad A.A. Ismail.
Resources: Emad A.A. Ismail.
Software: Marina Saleeb, Ehab Elrewany.
Supervision: Mohamed R. Abonazel, Mai Hussein, Noha Fadl.
Validation: Noha Moustafa.
Visualization: Assem Gebreal, Ehab Elrewany, Noha Moustafa.
Writing – original draft: Ramy Mohamed Ghazy, Naglaa Youssef, Assem Gebreal, Noha Moustafa.
Writing – review & editing: Ramy Mohamed Ghazy, Alsaleem Mohammed Abadi, Mohamed R. Abonazel, Mai Hussein, Noha Fadl.
Abbreviations:
- ANC
- antenatal care
- AOR
- adjusted odds ratio
- COVID-19
- coronavirus 2019
- DPT
- Diphtheria, Pertussis, and Tetanus
- HBM
- Health Belief Model
- SARS-CoV-2
- severe acute respiratory syndrome coronavirus 2
The authors extend their appreciation to the Deanship of Scientific Research at King Khalid University for funding this work through the General Research Project under grant number GRP/52/44. Researchers Supporting Project number (RSPD2023R1060), King Saud University, Riyadh, Saudi Arabia.
Informed consent was obtained from all the subjects involved in the study. The survey cover page had an “agree’’ option, where eligible parents who accessed the electronic survey should click on it before accessing the survey questions. All authors confirm that this manuscript has not been published elsewhere or submitted to any other journal. The final version of the manuscript has been approved by all authors, and they have agreed to its publication.
The study was conducted in accordance with the Declaration of Helsinki guidelines and was approved by the Ethics Committee of the Faculty of Medicine at Alexandria University in Egypt (IRB number:00012098/0305755).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Ghazy RM, Abadi AM, Salah A, Ismail EAA, Youssef N, Saleeb M, Abonazel MR, Gebreal A, Elrewany E, Moustafa N, Hussein M, Fadl N. Post-COVID-19 pandemic immunization coverage in Algerian children: A cross-sectional study. Medicine 2025;104:8(e41494).
Contributor Information
Ramy Mohamed Ghazy, Email: ramy_ghazy@alexu.edu.eg.
Alsaleem Mohammed Abadi, Email: Mabade@kku.edu.sa.
Assia Salah, Email: assia-salah@outlook.fr.
Emad A.A. Ismail, Email: Arabiaemadali@ksu.edu.sa.
Naglaa Youssef, Email: Nfyoussef@pnu.edu.sa.
Marina Saleeb, Email: marinaraouf@marsresearchhub.com.
Mohamed R. Abonazel, Email: mabonazel@cu.edu.eg.
Assem Gebreal, Email: assem.Ahmed1801@alexmed.edu.eg.
Ehab Elrewany, Email: ehabelrewany@alexu.edu.eg.
Noha Moustafa, Email: nohaosama@alexu.edu.eg.
Noha Fadl, Email: nohaosama@alexu.edu.eg.
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