Abstract
BACKGROUND:
Immunization is the primary means of protecting people from a wide range of serious illnesses worldwide each year. Although coverage rates are high, vaccine-preventable diseases remain a concern, particularly in regions where gaps in mothers’ knowledge exist. To assess the extent of maternal knowledge regarding immunization and to determine the full immunization status of the children according to maternal characteristics and other determinants.
MATERIALS AND METHODS:
A cross-sectional study was conducted at Al-Andalus Primary Health Care Center. A convenience sample of 100 mothers was selected, and interviewed when they brought their children for vaccination from 1 September to the end of November 2025.
RESULTS:
Of the 100 mothers in the study, 89% completely vaccinated their children, 9% partially vaccinated, and 2% had not vaccinated their children at all. Findings from the current study (80%) demonstrated an increase in mothers’ knowledge about vaccination after the COVID-19 pandemic. The Primary Health Care Center was the main source of information for the mothers with fully vaccinated children (52%), whereas the family doctor was reported as a less frequent source (48%). Regarding mothers’ educational level, 100% of the college-educated mothers had fully vaccinated children, 90% of secondary school mothers had fully vaccinated children, whereas low-educated mothers constituted 67% of the group with incomplete vaccination, and this difference was statistically significant. The lack of vaccine supply was the major reason for the discontinuation of vaccination.
CONCLUSION:
Mothers in the study sample demonstrate good and satisfactory knowledge. However, despite this, 11% of them had incomplete immunization. Therefore, greater efforts are needed to increase awareness and address persistent misconceptions. Dissemination of accurate information, large-scale campaigns, and family involvement are the key factors for the success of the program.
Keywords: Mothers’ knowledge, primary health care center, under-five children immunization
Introduction
Immunization plays a crucial role in the health and security of nations.[1] It was described by the World Health Organization (WHO) as the most effective public health intervention in preventing childhood vaccine-preventable diseases (VPDs).[2] The WHO and the World Bank consider immunizations as highly cost-effective health measures that has considerably reduced global morbidity and mortality.[3] Over the past century, the integration of vaccination into the routine health care services in many countries has given healthcare providers with substantial control over infectious diseases, particularly among infants and children.[4] Over the past decades, integration of immunization into routine primary health care services has resulted in remarkable achievements. International immunization initiatives have led to the eradication of smallpox and the elimination of poliomyelitis in different regions.[5] Extensive immunization programs have significantly reduced the incidence of measles, diphtheria, neonatal tetanus, and rubella in many countries.[6]
In Iraq, VPDs represent a great challenge because they are an important cause of death among children under five years of age. In 2022, an estimated 14.3 million young children did not get the first dose of the diphtheria, tetanus, and pertussis (DTP) vaccine, indicating limited access to vaccinations and other health services. Moreover, 6.2 million more kids were only partially vaccinated. In contrast, Iraq has achieved relatively high immunization converge, with approximately 97% of children receiving the first dose of the DTP vaccine. This suggests that the percentage of zero-dose lower than the global average, reflecting improved access to routine vaccinations. The pentavalent vaccine is an important vaccine, so inadequate knowledge, negative attitudes, and low awareness may reduce access to vaccination programs. Enhancing mothers’ awareness through effective health education.[7]
However, even with the importance of immunization recognized by mothers, some studies have shown that there still exist some who are hesitant to vaccinate their children. Factors that influence vaccine hesitancy may include convenience, complacency, and confidence in the immunization services.[8] Parental forgetfulness may have an important role in a child not being fully immunized with the recommended vaccines. Hesitancy may be influenced by several factors including concerns about vaccine safety and effectiveness, socio-economic factors, unawareness of vaccine importance, lack of knowledge, low perception of risk, and lack of access to preventive services, all may influence mothers’ intention to vaccinate their children.[9]
Currently, maternal knowledge regarding childhood immunization is of particular importance. Previous studies have identified inadequate knowledge as a major determinate of delayed or refused vaccination.[10] However, limited data are available regarding the mothers’ knowledge and its relationship to immunization status in AL-Ramadi city. Therefore, the present study aimed to assess mothers’ knowledge regarding childhood immunization in post-COVID-19 period and to identify factors associated with the immunization status of their children in AL-Ramadi.
Concerning limited data, assessing mothers’ knowledge in relation to childhood immunization and the vaccination status of their children is mandatory for improving health education programs for reinforcement immunization services at primary health care center in AL-Andalus, and support health care providers and formulating specialized health education programs.
Materials and Methods
Study design and setting
This is a cross-sectional study included 100 mothers who came to vaccinate her children in (AL-Andalus) Primary health care center (PHCC) in AL-Ramadi district/Anbar province/Iraq, which is one of the largest center cover large number of population in the period from 1st of September to the end of November 2025.
Study participants and sampling
Mothers having children of less than five years attending the routine immunization on the date of the interview were included. The sample size was calculated using G * power The The program was used to calculate the 95% confidence intrerval (CI) and the significance level of 0.05. A G * Power determined a sample of 200 participants. However, due to time constraints, only 100 participants were included and considered adequate.
Data collection tools and techniques
The study involved questions on knowledge about vaccination and the socio-demographic profile of the mother. During their interviews, the participants said that the researchers explained to them the purpose of the study and assured them that the information obtained would be used for the study only.
Background questions covered the following: demographic, education of mothers, occupation, parity, age of child and the source of immunization information and reasons for partial immunizations. Regarding the scoring of the tool, there were three possible responses and the marks (0–5) poor, (6–10) satisfied, (11–15) good and according to immunization status into completely immunized and incomplete immunized defined as those who missed any one vaccine out of the program. The variables analyzed with respect to the socio-demographic characteristics of the mother, education, source of information of vaccination, occupation, impact of education and mothers’ work, partial immunization and also with respect to children of the studied mothers (gender, age, place of birth parity, and immunization status).
Criteria of inclusions
Mothers attending children under five years of age and were willing to participate in the primary health care center.
Criteria of exclusions
Mothers who are unwilling to participate in the study.
Sample size
The sample size was calculated using the G power program, which was used when identifying a 95% CI and the significant level of 0.05 A G * power analyses was revealed a sample of 200 participants; however, because of shortage of time, a total of 100 participants were included and considered adequate and representative for the study.
Ethical consideration
Ethical approval from the research and ethics committee in the College of Medicine, University of Anbar. No. 97 Date 9/10/2025 was reviewed. Written informed consent was obtained from all participant after explained the aims of study and all data were stored securely.
Statically analysis
The results were computed by utilizing IBM (SPSS) version 26 software, descriptive statistics were used including frequency and percentage with means and standard deviations. A Chi-square test and Fisher’s exact test were performed and used for the overall knowledge and anxiety score. A Cronbach’s alpha coefficient greater than 0.70 was considered acceptable.
Results
The majority were aged 21–25 years (36%), and 51% of them had more than three children. The highest percentage of the mothers were of secondary school (38%) and 70% of them were housewives [Table 1]. Sixty-seven percent of the studied children were aged below 18 months and delivered at the hospital (92%). Child’s gender: male (57%), female (43%).
Table 1.
Socio-demographic characteristics (n=100)
| Question | Answer | No. | % | |||
|---|---|---|---|---|---|---|
| Age of the mother | <20 | 10 | 10 | |||
| 21–25 | 36 | 36 | ||||
| 26–30 | 32 | 32 | ||||
| 31–35 | 14 | 14 | ||||
| >35 | 8 | 8 | ||||
| Mother’s level of education | Illiterate | 9 | 9 | |||
| Primary | 27 | 27 | ||||
| Secondary | 38 | 38 | ||||
| University | 26 | 26 | ||||
| Mother’s occupation | House wife | 70 | 70 | |||
| Employer | 30 | 30 | ||||
| Age of the child | 0–1.5 years | 67 | 67 | |||
| 1.5–2 years | 13 | 13 | ||||
| 2–5 years | 20 | 20 | ||||
| Parity | <3 | 49 | 49 | |||
| ≥3 | 51 | 51 | ||||
| Place of birth | Home | 8 | 8 | |||
| Hospital | 92 | 92 | ||||
| Child gender | Male | 57 | 57 | |||
| Female | 43 | 43 | ||||
| Family size | ≤4 | 76 | 76 | |||
| >4 | 24 | 24 |
Table 2: Most mothers show good knowledge of routine immunization, especially BCG (79%), OPV (76%) Hepatitis B (77%), and measles (75%). Knowledge was lower for DPT (62%), MMR (60%), rotavirus and pentavalent vaccines (60%). However, 97% believed that vaccinations prevent fatal diseases, and there were misconceptions of jaundice as a contraindication.
Table 2.
Mean values of knowledge of mothers’ information about vaccinations (n=100)
| Questions | Mean±SD | Yes% | No% | |||
|---|---|---|---|---|---|---|
| Knowledge on BCG vaccination | 2.8±0.871 | 79 | 21 | |||
| Knowledge of Hepatitis B vaccination | 2.18±0.812 | 77 | 23 | |||
| Knowledge of DPT vaccine | 2.96±0.787 | 62 | 38 | |||
| Knowledge of OPV vaccine | 2.23±0.798 | 76 | 24 | |||
| Knowledge of measles vaccine | 1.84±0.836 | 75 | 25 | |||
| Knowledge of MMR vaccine | 2.08±0.737 | 60 | 40 | |||
| Knowledge of Rotavirus vaccine | 2.21±0.726 | 60 | 40 | |||
| Knowledge of Pentavalent vaccine | 1.97±0.919 | 60 | 40 | |||
| Is fever a contraindication to vaccination in pediatric patients? | 2.98±0.792 | 66 | 34 | |||
| Is jaundice a contraindication to vaccination in pediatric patients? | 3.07±1.079 | 73 | 27 | |||
| Knowledge of correct date of vaccination | 2.85±0.979 | 92 | 8 | |||
| Does it take you more than 30 minutes to reach the health centers? | 1.97±0.919 | 11 | 89 | |||
| Do you use a car to reach the health center? | 2.98±1.046 | 75 | 25 | |||
| Did you know that the COVID-19 pandemic influences knowledge about vaccinations? | 2.85±0.79 | 20 | 80 | |||
| Did you know the vaccination preventing killing diseases | 2.49±0.903 | 97 | 3 | |||
| Did you read about the vaccinations in the media? | 1.97±0.979 | 25 | 75 | |||
| Did you receive any vaccination during pregnancy? | 1.85±0.814 | 90 | 10 | |||
| Did you have the vaccination cards? | 2.49±0.0903 | 96 | 4 | |||
| (Did you receive information about vaccination from your family doctors) Did your family doctor provide you with information about childhood vaccination | 2.53±1.091 | 48 | 52 | |||
| Did you receive the vaccination from the PHC? | 2.07±0.636 | 52 | 48 | |||
| Did you get information about vaccination from friends and neighbors? | 2.48±0.802 | 29 | 71 | |||
| Does the health center provide a comfortable and adequate waiting area for individuals receiving vaccinations? | 2.78±0.88 | 79 | 21 |
BCG=Bacillus Calmette, DPT=Diphtheria, Pertussis, and Tetanus vaccine, OPV=Oral Polio Vaccine, MMR=Measles, Mumps, and Rubella
Table 3: Mothers’ age (P = 0.002), parity (P = 0.014), birth order (0.006), and family size (P = 0.014) were significantly associated with the knowledge level. However, education level and occupation showed no significant association.
Table 3.
Relation between socio-demographic characteristics and the score of knowledge of mothers
| Characteristic | Poor No. % | Satisfactory No. % | Good No. % | P | ||||
|---|---|---|---|---|---|---|---|---|
| Mothers’ age <22 | 7(43.75) | 8 (50.0) | 1 (6.2) | 0.002 | ||||
| Mothers’ age ≥22 | 8 (9.5) | 66 (7.8) | 10 (11.9) | 0.002 | ||||
| Parity <3 | 10 (16.9) | 47 (79.7) | 2 (3.3) | |||||
| Parity ≥3 | 5 (12.2) | 27 (65.8) | 9 (21.9) | 0.014 | ||||
| Illiterate | 0 (0) | 4 (100) | 0 (0) | |||||
| Primary | 7 (25.9) | 16 (59.2) | 4 (14.8) | |||||
| Secondary | 5 (12.2) | 31 (75.6) | 5 (12.2) | |||||
| College | 3 (10.7) | 23 (82.1) | 2 (7.2) | 0.299 | ||||
| House wife | 12 (16.7) | 51 (70.8) | 9 (12.5) | |||||
| Employed | 3 (10.7) | 23 (82.2) | 2 (7.2) | 0.509 | ||||
| Child age ≤1.5 years | 12 (17.9) | 48 (71.6) | 7 (10.5) | |||||
| 1.5–2 years | 3 (30) | 4 (40) | 3 (30) | |||||
| 2–5 years | 0 (0) | 22 (95.7) | 1 (4.3) | 0.508 | ||||
| Birth Home | 0 (0) | 7 (1) | 0 (0) | |||||
| Birth Hospital | 15 (15.2) | 67 (2.8) | 11 (12) | |||||
| Child gender Male | 8 (14) | 24 (73.7) | 7 (12.3) | |||||
| Female | 7 (16.3) | 32 (74.4) | 4 (9.3) | 0.869 | ||||
| Birth order <3 | 10 (16.1) | 50 (80.7) | 2 (3.2) | |||||
| Birth order ≥3 | 5 (13.1) | 24 (63.1) | 9 (23.7) | |||||
| Family size ≤4 | 10 (16.9) | 47 (79.7) | 2 (3.4) | |||||
| Family size >4 | 5 (12.2) | 27 (65.9) | 9 (21.9) | 0.014 |
Score of Knowledge: Poor=0–5, Satisfactory=6–10, Good=11–15
Table 4: Mothers’ education (P = 0.013) and mothers’ occupation (P = 0.021) were significantly associated with the status of immunization, while mothers’ age, parity, child age, birth order, gender, and place of birth showed no significant association.
Table 4.
Relationship between socio-demographic characteristics and status of immunization of children
| Characteristic | Full immunization No. % (n=89) | Partial immunization No. % (No. 9) | Non-immunization No. % (No. 2) | P | ||||
|---|---|---|---|---|---|---|---|---|
| Mothers’ age <22 | 12 (75) | 3 (18.7) | 1 (6.2) | |||||
| Mothers’ age ≥22 | 77 (91.7) | 6 (7.1) | 1 (1.2) | 0.051 | ||||
| Parity <3 | 54 (91.5) | 4 (6.8) | 1(1.7) | |||||
| Parity ≥3 | 35 (85.4) | 5 (12.2) | 1 (2.4) | 0.333 | ||||
| Illiterate | 3 (75) | 1 (25) | 0 (0) | |||||
| Primary | 21 (77.8) | 5 (18.5) | 1 (3.7) | |||||
| Secondary | 37 (90.3) | 3 (7.3) | 1 (2.4) | |||||
| College | 28 (100) | 0 (0) | 0 (0) | |||||
| Occupations House wife | 61 (84.7) | 9 (12.5) | 2 (2.8) | |||||
| Employed | 28 (100) | 0 (0) | 0.021 | |||||
| Child age ≤1.5years | 60 (89.9) | 5(7.5) | 2 (2.9) | |||||
| 1.5–2 years | 7 (70) | 3 (30) | 2 (2.9) | 0.93 | ||||
| 2–5 years | 22 (95.6) | 1 (1.4) | 0 (0) | |||||
| Birth home | 5 (83.3) | 1(16.7) | 0 (0) | |||||
| Birth hospital | 84 (90.2) | 8 (7.6) | 2 (2.2) | 0.213 | ||||
| Child gender male | 50 (87.7) | 7 (12.3) | 0 | |||||
| Female | 39 (90.6) | 2 (4.7) | 2 (4.7) | 0.637 | ||||
| Birth order <3 | 56 (90.3) | 5 (8.1) | 1 (1.6) | |||||
| Birth order ≥3 | 33 (86.8) | 4 (10.6) | 1 (2.6) | 0.589 | ||||
| Family size ≤4 | 54 (91.5) | 4 (6.8) | 1 (1.7) | |||||
| Family size >4 | 35 (85.4) | 5 (12.2) | 1 (2.4) | 0.333 |
Discussion
Vaccination is a mandatory program in Iraq, and efforts were taken by the government and international agencies to raise vaccination coverage as extensively as possible. But despite these efforts, a small percentage of children (2%) still have no access to vaccination, although mothers’ knowledge about vaccination demonstrates a good level. This may be due to efforts exerted by the Ministry of Health and primary health care centers. Immunization coverage in Iraq, data from UNICEF and WHO indicate that Iraq’s routine immunization services have reached 93% of children under five years with the third dose of DTP3. The last study (survey) in Iraq, conducted (Iraq 2024–2025) WHO-UNICEF, found the coverage rate for immunization as follows: BCG 95%, DPT three doses 97%, polio vaccine 90%, measles vaccine lower than 95%. Similar results were observed during the pre-COVID period (2018–2019) with coverage reaching (93%). During COVID-19 pandemic (early 2022), decline in coverage due to the disruption of health system, and implementation of a general curfew, coverage rate after pandemic increases again to 90% and above.[11] This finding explains the continuous availability of routine childhood vaccines, increased public awareness of the importance of (COVID-19) vaccinations; this led to the improvement in mothers’ knowledge about immunization.[12]
About (97%) of respondents were in favor of vaccination and believed that it prevents deadly diseases and (96%) possessed vaccination cards because the majority of the respondents had available services at primary and secondary health care levels, and these health facilities seem to be most readily available and accessible to the people. This finding is consistent with a study conducted in Pakistan in 2020.[13] The findings of the present study showed that about (80%) of mothers increased their awareness and knowledge of immunization after the COVID-19 pandemic. This may be attributed to mass media exposure and the influence of the health education programs during the pandemic. The pandemic likely increased public understanding of infectious diseases, herd immunity, and the role of vaccine in reducing morbidity and mortality, indirectly enhancing routine immunization knowledge. Eighty-nine percent of the children were fully immunized and this may be explained by increase in awareness about VPDs.[14] However, incomplete immunization were observed in 11% of children, indicating that there were still some children who lost the chance to be fully vaccinated.
The most common reason for incomplete child vaccination in this study was the lack of vaccine (72.72%), suggesting systemic supply chain challenges rather than parental hesitancy. This indicates that structural barriers may play role than knowledge deficits in limiting full immunization coverage, emphasizing the need for reinforcing vaccine logistic and mothers knowledge about childhood vaccination and vaccine stock monitoring systems at primaryHealth Care Centers and mother sickness (54.54%), and forgetting day (63.63%), forgetting the day of vaccination represent a behavioral rather than structural obstacles. Thus emphasizing the need for notification systems such as mobile text messaging or community health worker follow up. Structural obstacles may contribute to incomplete immunization, thus emphasizing the need for notification systems such as mobile text messaging or follow-up by community health workers. The main source of information about immunization in our study was the primary health care center (52%). This may be attributed to the ease of access to the center, the availability of healthcare staff, and the comfortable waiting environment reported by mothers (79%). This finding differs from a previous study conducted in India, which reported a notable level of vaccine hesitancy among mothers, with a consequent effect on childhood vaccination uptake.[15]
The reasons reported by mothers for incomplete child immunization are presented in Table 5. The most commonly reported reasons were lack of vaccine availability (72.7%), forgetting the vaccination day (63.6%), and concern about vaccine safety (54.6%). Mother sickness was also reported by 54.6% of mothers, while social engagement was reported by 45.7%. Other reported reasons included long-distance walking, absence of personal reasons, complications from a previous vaccine, and lack of money.
Table 5.
The reasons for incomplete child immunization were reported by mothers
| Reasons for incomplete immunization | Yes | % | No | % | ||||
|---|---|---|---|---|---|---|---|---|
| Concern about vaccine safety | 6 | 54.6 | 5 | 45.5 | ||||
| Long-distance walking | 4 | 36.4 | 7 | 63.6 | ||||
| Lack of money | 2 | 18.2 | 9 | 81.8 | ||||
| Absence of personal | 4 | 36.4 | 7 | 63.6 | ||||
| Lack of vaccine | 8 | 72.7 | 3 | 27.3 | ||||
| Forgetting the day | 7 | 63.6 | 4 | 36.4 | ||||
| Mother sickness | 6 | 54.6 | 5 | 45.5 | ||||
| Social engagement | 5 | 45.7 | 6 | 54.4 | ||||
| Complication from the previous vaccine | 4 | 36.4 | 7 | 63.6 |
The statistically significant relationship between mothers’ age and the immunization status of their children showed that children of older mothers (≥22 years) had higher immunization rates than those of younger mothers. This may be related to greater childcare experience, better health education, and stronger interaction with primary health care centers. In contrast, younger mothers may have less experience and access to information. This finding emphasizes the importance of providing targeted immunization education and counseling to younger mothers, particularly those with limited childcare experience, to improve their knowledge and promote timely and complete childhood immunization. This goes with a study carried out in Sub-Saharan Africa in 2021.[16] In our study, the score of knowledge of mothers not affected by level of education this is unexpected and suggests that immunization knowledge in Iraq may be not be limited to academic education level. This is in contrast to a study in Saudi Arabia 2021.[17] This can be explained by a relatively small sample size, which may have changed the statistical association to detect indirect differences. High percentage of respondents (79%) knew about BCG vaccine. This may be contributed to increased awareness campaigns and endemicity of tuberculosis in Iraq, similar to the findings reported in a study conducted in Ethiopia, 2021.[18]
According to our result, the statistically significant association between birth order (≥3) and knowledge score may be explained by increased experience of mothers with each successive birth. Although the birth order non-significantly related to immunization status it was noticed to be an important cause of vaccination non-adherence and this goes with study in Italy 2021.[19] A study conducted in El-Fayoum Egypt found that there is a significant association between the birth order of the child and this agrees with current study.[20] A recent study from India shows that as birth order increase, the probability of children receiving full immunization decline. Specifically, compared with first-born children, those of higher birth order. This study is consistent with my findings.[21] Although the relationship between mother’s occupation and state of immunization was statistically not significant, we found that all housewife mothers completely immunized their children indicating potential influences of time availability on adherence and mother’s job affects child immunization, and this agrees with a study conducted in Libya.[22] Although the education level was not significantly associated with child immunization, yet the highly educated mothers would be less aware of the seriousness of the issue. Educated mothers are more likely to understand vaccination schedules. This study is similar to a study in Saudi Arabia.[23] A statistical association was observed between family size and Maternal knowledge. This finding contrast with some studies that reported higher knowledge levels of mothers among large families possibly due to accumulated child care experience, repeated exposure to vaccination.[24] In the present study, the child’s gender did not have a significant impact on the immunization status and a similar finding was reported in a study done in Saudi Arabia.[25] Besides, the place of delivery having no significant correlation with immunization status was another finding. This could be attributed to the fact that most women were aware of the availability of vaccinations, regardless of whether they gave birth in a hospital or not.
Strength and limitations
The current study is the first time done in Al-Ramadi city by evaluating mothers’ knowledge and vaccination in the primary health care center. Include face-to-face interviews to collect data. General limitations of the study include a small sample size and a single primary health care center, which limits generalizability and introduces selection bias.
Recommendation
This study represents the first study conducted in a primary health care center in AL-Anbar Governorate, AL-Ramadi District. To clarify the situation, more research should be done on this significant issue in other regions of AL-Anbar Governorate.
There is a necessity and also a desire to conduct health education program sessions for mothers of children under five, with a main focus on vaccination and VPDs, which will help in raising awareness and also breaking the old beliefs of the people. Providing accurate information, intensive a warencess campaigning, and family participation are very important for the success. campaigning, and family participation are very important for the success of the program. program’s success.
Adding communication skills to health worker training curricula may be a significant tool to enhance mutual understanding between health workers and the mothers attending child clinics. Consequently, it could lead to better vaccination adherence.
Conclusion
It can be concluded from the study that there was a good knowledge amongst the majority of mothers regarding immunization and its importance. The incomplete immunization is more related to supply and logistic obstacles rather than poor or good mothers’ knowledge. The widespread impact of the COVID-19 has played a significant role in increasing mothers’ knowledge and understanding the importance of immunization. And this knowledge was found to be a predictor of immunization status of their children, and fortunately, poor knowledge was not found to be a barrier. But despite this, some mothers do not come regularly for vaccination of their children. As a result, they forget the day of vaccination and mother sickness. Low literacy level of some mothers is a matter of worry. The child’s gender, education, residence, and the mother’s job affect the pattern of immunization.
Some mothers do not know about the diseases for which their child is being immunized and most of them reported jaundice and fever as a contraindication to immunization. And, as expected, the parents’ level of education directly affects the status of immunization of children. childhood immunization.
AI policy statement
The author used an artificial intelligence (AI) for language tool, solely for language editing, grammatical correction and improving of English clarity and readability. the AI not used for generate or modified scientific data, perform statistical analyses, interpret study findings, or formulate scientific conclusion. The author reviewed and verified all AI-assisted text and take full responsibility for accuracy, originality, integrity, and scientific content of the manuscript.
Ethical approval
Ethical approval from research and ethics committee in the college of medicine, University of Anbar, no. 97 date 9/10/2025 was reviewed. Written informed consent was obtained from participant after explain the aim of the study and all data were stored securely.
Author’s contributions
The author confirms that he is the sole contributor to this research. All stages of the study, including conceptualization, study design, data collection, data analysis, manuscript preparation, and final proofreading, were completed entirely by the author. No other individuals contributed to the conception, conduct, analysis, or preparation of this manuscript.
Data availability statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Conflicts of interest
There is no conflict of interest.
Acknowledgment
The authors would like to express their sincere gratitude to the administration and health care staff of AL-Andalus primary health care center, AL-Ramadi city, for their support and cooperation during the data collection period.
Funding Statement
There was no funding.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.