Abstract
Immunization can contribute to a dramatic reduction in number of vaccine-preventable diseases among children. The aim of this study is to investigate mothers’ awareness about child vaccines and vaccination in Jordan. This study was a community-based, cross-sectional study that was performed at public places in Irbid City. Data was collected from 506 mothers. After verbal approval, mothers were interviewed to assess their knowledge, attitudes, and practice toward vaccination. Results show that majority of mothers had acceptable knowledge and positive attitude toward vaccination. Most of mothers (94.7–86.8%) were able to identify vaccines that are mandatory as per the national vaccination program. Lower knowledge was observed among mothers (71.6%) for HIB vaccination being mandatory. Most mothers (97.2%) had vaccination card for their baby form the national vaccination programs. Vaccination delay was reported by about 36.6% of mothers and was shown to be associated with significantly (P = 0.001) lower vaccination knowledge/attitude score. Additionally, mothers who reported to be regularly offered information about vaccination during visits and those who identified medical staff members as their major information source had significantly higher vaccination knowledge/attitude score (P = 0.002). In conclusion, vaccination coverage rate is high; however, some aspects of knowledge, attitudes, and practice of vaccination need to be improved. Knowledge and attitudes of mothers were directly associated with their practice of vaccination. Medical staff education about vaccination during each visit seems to be the most effective tool that directly reflects on better practice of vaccination such as reducing the possibility for vaccination delay.
Keywords: vaccination, knowledge, practice, attitudes, mothers
Introduction
Vaccines are unquestionably one of the most cost-effective interventions in the health system. It costs a little, although, it presents enormous benefits for the health and well-being of populations. According to WHO records, 10.6 million children die yearly before the age of 5; while an estimated 1.4 million of those are due to diseases that could have been prevented by vaccines.1,2 Worldwide, vaccines can save more than 3 million lives yearly; in addition to protecting millions more people from diseases and disability.3 For example, it was also estimated that 5 million people are walking today who would probably have been paralyzed by the poliovirus, since introduction Polio vaccine.4 Therefore, maintaining a high level of immunization coverage is important in the control and elimination of many cases of vaccine-preventable diseases.
In Jordan, the National Program of Vaccination covers on a rate of about 95%. It provides vaccines for all children against 11 diseases free of charge. The vaccines included in the national vaccination schedule are Bacille Calmette Guerin (BCG), oral polio vaccine, diphtheria-pertussis-tetanus (DPT) vaccine, measles-mumps-rubella (MMR), and hepatitis B (Hib) vaccine.5
Although they have huge benefit, a proportion of people still do not use vaccinations effectively in terms of either not vaccinating at all, or not completing their vaccination programs.2,6-8 Characterizing reasons for non-vaccination is a key in order to increase coverage rates and implement interventions for control and elimination of vaccine preventable diseases. In this study, we used community-based survey of mothers about vaccination status, knowledge, attitudes, and practice of vaccination. This study is aimed to help health policy makers to determine the priorities and plan interventions to improve the vaccination coverage.
Results
General Characteristics of the Participants
The study sample consisted of 506 mothers out of 605 approached (83% response rate). The mean age was 30.95 ± 20.76 y. About 97% of mothers were married. Concerning educational level of mothers, about 45% hold university degree and more, followed by about 44% with secondary qualifications. The majority of mothers (about 74%) were not working. About 26% of mothers were workers, of whom, about 9.9% worked between 20–40 h per week. Most mothers (60.5%) reported that their family monthly income was less than 400 JD. Mothers reported having children within the range of 1 to more than 3. The age of last child varied between <6 mo (31%), 6–12 mo (about 34%), and >12 mo (about 35%) (Table1).
Table 1. General characteristics of participants.
| Variable | Values |
|---|---|
|
Age (y) (mean ± SD) |
30.95 ± 20.76 |
|
Social status N (%) Married Divorced Widowed |
493 (97.4) 10 (2) 2 (0.4) |
|
Mother’s education level N (%): Primary Secondary University and higher Illiterate |
53 (10.5) 222 (43.9) 225 (44.5) 6 (1.2) |
|
Mother’s work N (%) Not-working* Medical profession Non-medical profession |
376 (74.3) 52 (10.3) 74 (14.6) |
|
Mother’s working hours per week N (%) <20 20–40 >40 |
42 (8.3) 50 (9.9) 33 (6.5) |
|
Family monthly income JD N (%) <400 400–800 >800 |
306 (60.5) 152 (30) 29 (5.7) |
|
No of children N (%) 1child 2 children 3 children More than 3 children |
118 (23.3) 144 (28.5) 102 (20.2) 142 (28.1) |
|
Age of last child N (%) <6 mo 6–12 mo >12 mo |
157 (31) 170 (33.6) 179 (35.4) |
These mothers were not working but were generally responsible for housekeeping related work at their houses.
Knowledge about Vaccination
Mothers’ knowledge about vaccination is shown in Table 2. The majority of mothers (63%) reported that the National Vaccination Program requires to be initiated at first month of life of a child. Most mothers (94.7–86.8%) were able to indentify vaccines that are mandatory as per the National Vaccination Program. Lower knowledge was observed among mothers (71.6%) about HIB vaccination being mandatory. Concerning vaccines that are not mandatory by the National Vaccination Program, 18.8–42.6 of mothers reported influenza, rota, pneumococcal, and varricella vaccines as being mandatory. Moreover, about 76% and 68% of mothers reported their agreement that hepatitis A and meningococcal vaccinations are mandatory, respectively (Table 2).
Table 2. Knowledge of mothers about national vaccination program.
| Variable | Participants | |
|---|---|---|
| Frequency (N) | Percentage (%) | |
| The initiation of vaccination program is at delivery or first month | 480 | 94.18 |
| Mandatory vaccines include | ||
| BCG | 462 | 91.3 |
| Polio | 479 | 94.6 |
| DPT | 479 | 94.7 |
| MMR | 43 | 86.8 |
| Measles | 467 | 92.3 |
| HBV | 465 | 91.9 |
| HIB | 364 | 71.9 |
| Hepatitis A | 382 | 75.5 |
| Meningococcal | 342 | 67.6 |
| Influenza | 176 | 34.8 |
| Rota | 214 | 42.3 |
| Pneumococcal | 95 | 18.8 |
| Varricella | 167 | 33 |
Attitudes toward vaccination
Information about mothers’ attitude toward vaccination is shown in Table 3. Majority of mothers had positive attitude toward vaccination as they agreed or strongly agreed that carful safety checks are performed for vaccines, vaccination is an indicator of child’s good health, vaccinations strengthen immune system, provide immunity for child against diseases, and protect children against spread of contagious diseases. However, majority of mothers (77.2%) had the incorrect perception that vaccines are medicines, which are capable to kill bacteria and viruses. On the other hand, majority of women disagreed or strongly disagreed for allowing non-immunized children to be sent to school (63.6%), for using alternative ways to protect their children from infection (66.6%), and not offering vaccination to children because of injection associated pain (78.1%). Only 39.2% of women strongly agreed or agreed that vaccines lead to side effects. Finally, most women strongly agreed or agreed that they were satisfied with national vaccination program (86.8%), and with nursing services through which vaccines are introduced to their child (81.6%).
Table 3. Attitudes of mothers toward vaccination.
| Statement | Strongly agree/agree | Neutral | Disagree/ strongly disagree | |||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Available vaccinations are carefully checked for safety | 458 | 90.5 | 37 | 7.3 | 11 | 2.6 |
| Immunizing a child is an indicator of his good health | 368 | 72.5 | 60 | 11.7 | 78 | 15.4 |
| Vaccines strengthen the immune system. | 422 | 83.4 | 61 | 12.1 | 23 | 4.6 |
| Vaccines are administered at intervals to keep long- term effect | 359 | 70.9 | 88 | 17.4 | 59 | 11.7 |
| Vaccines protect my children against spread of contagious diseases | 358 | 70.7 | 59 | 11.7 | 89 | 17.6 |
| Vaccines are sufficient to provide immunity for my child against diseases | 288 | 56.9 | 84 | 16.6 | 134 | 26.5 |
| Vaccines are medicines that are capable to kill bacteria and viruses | 391 | 77.2 | 45 | 8.9 | 70 | 13.9 |
| Mothers should be allowed to send their child to school even if not immunized | 130 | 25.7 | 54 | 10.7 | 322 | 63.6 |
| I think vaccines cause side effects. | 198 | 39.2 | 92 | 18.2 | 216 | 42.7 |
| If there is alternative ways to protect my child from infection, I may not give him the vaccine | 114 | 22.5 | 55 | 10.9 | 337 | 66.6 |
| I do not offer vaccination to my children because of injection associated pain | 74 | 14.6 | 35 | 6.9 | 395 | 78.1 |
| I am satisfied with vaccination program offered by Ministry of Health. | 439 | 86.8 | 42 | 8.3 | 25 | 5 |
| I am satisfied with nursing services through which vaccines are introduced to my child | 413 | 81.6 | 51 | 10.1 | 42 | 8.3 |
Practice of vaccination
Vast majority of mothers (97.2%) had vaccination card for the national vaccination programs (Table 4). Vaccination delay was reported by about 36.6% of mothers, and about 8.7% reported that at least one vaccine has never been given to their baby. About 8.3% of mothers reported that they ever vaccinated their child while the child was sick. On the other hand, most mothers had a child who suffered side effects from vaccination (83.2%). The places for vaccination included public health centers (50.2%), and maternity and child health centers (35.4%). Information about vaccination was mainly from medical staff (62.8%). Finally, education about vaccination by medical staff during visits was reported by 82.4% of mothers (Table 4).
Table 4. Practice of mothers for vaccination: relation to knowledge and attitudes toward vaccinations.
| Variable | Frequency (N) | Percentage (%) | Knowledge/attitude score Mean ± SD |
||
|---|---|---|---|---|---|
| Yes | No | P value | |||
| Do you have a vaccination card? | 492 | 97.2 | 61.2 ± 9.9 | 64.7 ± 8.3 | 0.310* |
| When you vaccinate your children, did you ever: | |||||
| -delayed vaccination | 185 | 36.6 | 59.5 ± 9.6 | 62.4 ± 10.1 | 0.001* |
| -never given vaccination | 44 | 8.7 | 61.5 ± 8.1 | 61.3 ± 10.1 | 0.892* |
| -given vaccination while child is sick | 42 | 8.3 | 61.2 ± 8.7 | 61.3 ± 10.0 | 0.931* |
| -had a child who experienced side effects from vaccination | 421 | 83.2 | 61.2 ± 9.7 | 61.4 ± 9.9 | 0.918* |
| Do you usually get offered information about vaccination by medical staff during visits? | 417 | 82.4 | 61.9 ± 9.7 | 58.5 ± 10.0 | 0.002* |
|
Vaccination place Public Health centers and government hospitals Maternity/childhood centers Private clinics or hospitals |
262 179 65 |
51.7 35.4 12.8 |
0.005# | ||
| 60.7 ± 8.2 | |||||
| 61.1 ± 8.2 | |||||
| 64.5 ± 9.6$ | |||||
|
Vaccination information source Medical staff TV-Radio-Internet Health center posters/brochures Family members, friends, and neighbors |
318 55 62 72 |
62.8 10.9 12.3 14.0 |
0.002# | ||
| 62.7 ± 10.0$ | |||||
| 58.5 ± 9.6 | |||||
| 59.0 ± 9.9 | |||||
| 58.6 ± 9.2 | |||||
Data analysis was performed using un-paired t test. # Data analysis was performed using one-way-ANOVA followed by the Tukey post-test. $indicate significant difference from other categories (i.e., mothers who vaccinated their children at private clinics or hospitals had significantly higher knowledge score compared with those who vaccinated their children at public health centers and government hospitals, or maternity/childhood centers. Additionally, mothers who got the information about vaccination from medical staff had significantly higher knowledge score than those who got information from TV-radio-Internet, health center posters/brochures, and/or family members, friends, and neighbors)
Correlation between vaccination awareness score and sociodemographic variables and practice of vaccination
Scores for mother’s knowledge/attitude toward vaccination were calculated to facilitate studying possible correlation between knowledge and attitudes toward vaccination and sociodemographic variables, and the actual practice of vaccination. None of the demographic variables including mother’s age, social status, education level, type of work, number of working hours, monthly income, number of children, and age of last child/infant were significantly associated with vaccination knowledge/attitude score. Concerning practice of vaccination, it was shown that those who delayed one vaccine for their baby had significantly lower vaccination knowledge/attitude scores (P = 0.001; Table 4). Additionally, those who reported to be regularly offered information about vaccination by medical staff during visits had significantly higher vaccination knowledge/attitude scores (P = 0.002). Additionally, mothers who got their information about vaccination from medical staff had higher vaccination knowledge/attitude scores compared with those who got the information from TV-radio-internet websites, posters/brochures offered by the medical center, and family members friends or neighbors (P = 0.002, Table 4). Finally, it was found that those who got their vaccination at a private clinic or hospital had higher vaccination knowledge/attitude scores compared with those who got their vaccination at public hospitals, health centers, or maternity and childhood centers (P = 0.005, Table 4).
Discussion
The primary aim of this study was to assess knowledge, attitudes, and practice of/toward vaccination program, and to examine the relation among these variables. To the best of our knowledge, this the first study to report the knowledge, attitudes, and practice of Jordanian mothers regarding vaccinations. Related studies were performed in other countries,6,9-13 however, better attitudes and more knowledge were reported in this study among Jordanian mothers. This could be related to a number of factors such as low prevalence of vaccine-preventable diseases, availability of vaccination centers and information about vaccination, relatively high educational level among mothers, and different methods used to measure immunization status.
In this study, mothers’ knowledge about vaccination was assessed by asking mothers to identify vaccines that are mandatory according to the National Vaccination Program. Most mothers were able to identify mandatory vaccine, yet, a significant percentage (18–76%) identified non-mandatory vaccines as being mandatory. Concerning mothers’ attitudes toward vaccination, the proportion of mother’s that showed positive attitudes toward vaccinations was high compared with other studies.6,9-11,13 This finding could be explained by the presence of awareness programs about vaccines safety as part of the National Vaccination Program.
The actual practice of vaccination in Jordan was almost all (97.2%) through the National Vaccination Program. Only a small percentage (<10%) of mother never gave a single vaccination to the baby or had the baby vaccinated while sick. About 36% delayed a vaccination, and those had lower overall knowledge and less favorable attitude toward vaccination, as indicted by having significantly lower vaccination knowledge/attitude score. In accordance, previous studies showed that education about vaccination leads to increased vaccination coverage rate.14,15 Medical staff being the information source for vaccination, and mothers getting regularly offered information about vaccination by medical staff at each visit, were associated with better knowledge and attitude toward vaccination. This is in correlation with previous studies showing that education by medical staff is associated with better awareness and more favorable attitude toward vaccination.16,17 Finally, being vaccinated at a private setting such as a clinic or a hospital was associated with better knowledge and attitude toward vaccination. This could be related to socioeconomic status, where previous works have shown that higher economic status is associated with generally better awareness and attitudes toward vaccination, and much less under-immunization rates.18-20
In conclusion, the vaccination coverage rate is high in Jordan; however, some aspects of knowledge, attitudes, and practice of vaccination need to be improved. Knowledge and attitudes of mothers are directly associated with their practice of vaccination. Consistent medical staff advice and educational programs at each medical visit seems to be the best tool to achieve favorable vaccination attitudes and practices.
Materials and Methods
This is a cross-sectional study. Data collection was performed over the period from June to August 2012. The sample was obtained from different places at Irbid city/Jordan. Participants were approached at their homes, work places, or public places such as parks, hospitals, and health care centers. All married/previously married women over the age of 18 y who gave birth at least for one child were enrolled in the study and administered a questionnaire in the form of semi-structured interview. Mothers, but not both parents, were targeted because as per cultural norms in Jordan, mother is the parent who takes care of the baby’s immunization issues. The investigator collected data personally using structured questionnaire. Consent forms were signed by all those who participated in the study. The official approvals for this study were granted by the Institutional Review Board (IRB) at KAUH and Jordan University of Science and Technology (JUST). The collected data was used for the purpose of the current study only.
Constructing questionnaire
The questionnaire used in this study was divided into 4 sections. The first section concerns with general characteristic of participating mothers and included the following questions: age of mother, social status, mother’s education level, nature of mother’s work, mother’s working hours per week, family monthly income, number of children, and age of last child. The second section concerns with mother’s knowledge about various vaccinations according to the National Vaccination Program offered by the Jordanian Ministry of Health.5 The third section was concerned with mother’s attitudes toward vaccination as shown in Table 3. The fourth section concerns with practice of vaccinations as shown in Table 4. Mother’s responses were measured on Likert scale that is consisted of 5 responses: strongly agree, agree, neutral, strongly disagree, and disagree, or “yes,” “no,” and “I do not know” choices.
The questionnaire that was used in this study was prepared by the research team, and was validated by first having it reviewed by several colleagues in the field, then by conducting a pilot test on 20 mothers, who were not included in the sample of the study. The results were analyzed to assess the clarity and comprehensibility of the items in the questionnaire. In addition, the participants of the pilot study were asked to give any feedback they had about the questionnaire items. Their feedback was considered in preparing the final version of the questionnaire.
Demographic data and categorical variables were summarized using frequency tables using the Statistical Package for Social Sciences (SPSS), version 17. Vaccination knowledge/attitude scores were calculated for each subject as the sum of all individual questions related to vaccination knowledge and attitude. Each question was scored from 1 to 5 giving the highest score to the most appropriate response. Analysis of data pertaining to vaccination awareness score was performed using un-paired t test for items with either yes or no answers. One-way-ANOVA followed by the Tukey post-test was used to compare vaccination awareness scores according to vaccination place (public health centers and government hospitals, maternity/childhood centers, or private clinics/hospitals). One-way-ANOVA followed by the Tukey post-test was also used to compare vaccination awareness scores according to vaccination information source (medical staff, TV-radio-Internet, health center posters/brochures, or family members, friends, and neighbors). Data were presented as number and percentages. P value of <0.05 was considered significant.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
Acknowledgment
The authors would like to acknowledge Jordan University of Science and Technology, Irbid; Jordan, for their financial support (grant number 125/2012).
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