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Parental attitude and beliefs towards child vaccination:

identifying vaccine hesitant groups in a family health center,
Erbil city, Iraq

Awring Maroof Raof

Correspondence:
Dr.Awring Maroof Raof
Department of Community Medicine
Hawler Medical University
Erbil,
Iraq
Email: awringmaroof62@yahoo.com

Received: April 19, 2018; Accepted: May 10, 2018; Published: June 1, 2018
Citation: Awring Maroof Raof. Parental attitude and beliefs towards child vaccination: identifying vaccine hesitant groups
in a family health center, Erbil city, Iraq. World Family Medicine. 2018; 16(6): 17-26. DOI: 10.5742/MEWFM.2018.93386

Abstract
Objectives: The current study was conducted to Conclusion: The current study showed parents
determine parental hesitancy toward vaccina- had some positive aspects related to vaccination
tion inside Erbil city, Iraq, and to find associations and defects in some domains were recognized.
between the parents’ position towards vaccination Identifying these parents is important in order to
and the outcome of immunization. implement the necessary measures to maintain
and improve the vaccines uptake.
Methods: A descriptive study was done during the
period from 1st of January 2014 till 1st of July 2015. Key words: parental concerns, trust, vaccination
The data were collected through a self-adminis- coverage, vaccine safety, immunization; parental
tered questionnaire. It included two sections: The attitude; parental belief; vaccine.
first section related to the demographic character-
istics of clients. The Parent Attitudes Childhood
Vaccines (PACV) questionnaire, was used as the
second part to detect parents who have concerns
about vaccination.

Results: Parental position in respect to immu-

nization of their child revealed that 65.3% were
unquestioning acceptors, 20.6% were cautious
acceptors, 9.9% were hesitant, 3.5% were late or
selective vaccinator and only 0.7% were refusal.
Immunization behaviors of parents among differ-
ent groups showed that, 20.9% postponed their
child’s vaccination for causes other than sick-
ness or sensitivity, while 73% were provided with
immunization on time. More than two thirds
(65.9%) were completely sure that, it is a good
idea to follow the schedule of immunization for
their child and only 26.6% were not sure.

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As the concept of “vaccine hesitancy” is quite new,

Introduction
the accessibility of obtainable research is inadequate,
Immunization leads to a remarkable reduction in cases especially in this region. The aim of the current study
of vaccine-preventable infectious diseases between was to address parental hesitancy toward vaccination
children. The rise in immunization conflict has encouraged inside Erbil city, Iraq, and to find associations between
several researchers to investigate childhood vaccination parents’ position towards vaccination and the outcome
and parental judgment. Parents’ decisions regarding of immunization. There is no evidence of such a study
immunization can impact immunization rates, including being conducted in the Kurdistan region or even in Iraq.
access to vaccinations, the communication of risks and The investigator found it necessary to conduct the current
benefits, the maintenance of accurate vaccination records, study in order to address this issue.
and strategies for vaccination reminders. Parents were
divided into groups according to their attitudes and beliefs Methods
about childhood vaccination. Parents accepting vaccination
Study design:
without questioning were called unquestioning acceptors
A descriptive study was conducted during the period from
and the hesitant group were called the questioning group
the 1st of January 2014 till the 1st of July 2015.
(1). Vaccine hesitancy was defined as postponement of
vaccination regardless of accessibility of services (1).
Researchers classified families into two groups according
to the definitions published by Leask et al (8). The first
Attention to hesitant parents was essential for consideration
group included the Unquestioning acceptor (vaccinate with
and for stabilizing rising immunization opposition. They
no specific questions) and Cautious acceptor (vaccinate
constitute a much bigger group than the other group who
despite minor concerns). The second was the hesitant
absolutely refuse immunization (2) and were possibly the
spectrum which included; the hesitant parents (vaccinate
most liable to change their behavior because they were
but have significant concerns; focused on vaccine risk;
influenced by evidence from child health care workers
trust in healthcare provider and have high levels of vaccine
about immunization (3). The best way is to approach
knowledge).
hesitant parents to report their worries and to convert
their concern about immunization into practical points for
The second were called Late or selective vaccinator (had
discussion (4-8).
concerns about vaccination results in this group choosing
to delay or select only some recommended vaccines; they
Other studies have recommended, that uncertainties in
have highest level of vaccine knowledge). The third were
respect to vaccination were habitually ignored and not
called Refusal of vaccines (they have strong and specific
addressed.(7) This deficit leads to incomplete immunization
religious, cultural or philosophical beliefs with lower levels
of children, who will subsequently be susceptible of
of vaccine knowledge).
acquitting infectious diseases such as mumps or measles
(9,10,11).
The data were collected through a self-administered
questionnaire. The questionnaire was distributed to them
The directions of the national immunization campaigns in
by researcher for one time only and it was anonymous.
Iraq recommended, that a child less than one year of life,
The first section of the questionnaire enquired about the
must be immunized through regular immunization with:
demographic characteristics of the studied sample. This
BCG vaccine; three doses of DPT (Diphtheria, pertussis,
part included education of parents, ethnic group, marital
tetanus); polio vaccine (four doses), Hepatitis-B (three
status, number of children, and the parent answering
doses), and measles for nine months old children. On
the questions - whether the father or the mother. The
reaching the age of fifteen months MMR is given. WHO
second part was the Parent Attitudes Childhood Vaccines
guidelines, considered a child as fully immunized if they
(PACV)(10) questionnaire, an instrument used to detect
took DPT vaccine (three doses), polio vaccine (three
parents who have concerns about vaccines. The PACV has
doses), BCG (one dose), and measles vaccine, at twelve
four domains. The first domain was about immunization
months(12).
behavior, which consists of ten items. The second part
was opinions about vaccine well-being and effectiveness
In respect to the coverage of immunization in this region;
consisting of four items and the third domain was attitudes
approximately 91 per cent of children aged 12 to 23 months
to vaccination and exclusions which included two items.
received BCG during the first twelve months of age, and
The fourth domain is trust and also included two items. The
about 85 percent received the first dose of DPT. However,
total items numbered eighteen items to identify vaccine-
the percentage declines for the subsequent doses DPT:
hesitant parents. Scored from 0 to 100, the higher scores
75 percent for the second dose and 64 per cent for the
on the PACV corresponded with under-immunization
third dose (12).
and hesitancy. Parents were considered to be hesitant
toward vaccines if they scored ≥25. The tool had three
However, the success of an immunization program
different response formats on a Likert scale (e.g., yes/no/
depends on high rates of acceptance and coverage.
don’t know); a five point Likert scale (e.g., strongly agree,
Refusal of vaccine results in outbreaks as evidence shows
agree, not sure, disagree, strongly disagree), and an 11
(4).
point scale (e.g. responses ranging from “0: not sure at
all” to “10: completely sure”). The 11 point response scale

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was used to maximize the

Results
information obtained regarding
trust and overall hesitancy (10). The
Table 1: Distribution of the studied sample by socio-demographic
outcome of immunization among the
characteristics of the studied population
hesitant parents was found.

Sampling: method and sample size

There are three family centers in Erbil
city, two of which are under renovation;
one health center was the setting of this
study. The family health centers are
public health clinics that provide two
immunization days per aweek, before
12 pm. About twenty children were
vaccinated in the clinic. The vaccines are
provided by public clinics only and it is free
for all. According to the Multiple indicator
cluster survey, (12) a total of 120,000
children were to be immunized inside the
city. The present study used this number
as the total population from which the
sample size was drawn. An automated
software program (Raosoft sample size
calculator for study: http://www.raosoft.
com/samplesize.html) was used to
calculate the sample size required for this
study. With an accepted margin of error
of 5% and a 95% confidence interval, the
sample size required was 383 with the
addition of 30% to the estimated sample
size in order to overcome erroneous
results and increase the reliability of the
results and the conclusion. However, a
sample of 600 parents were approached
but only 564 parents responded and the
response rate was 94%.

Data analysis
The data were analyzed using SPSS
for windows (Statistical Package for
Social Science) version 21.0 and ≤0.05
was used as level of significance. For
measuring associations between nominal
variables, the Chi-square test was used,
and t-test used for finding difference in the
mean scores between non-hesitant and
hesitant groups. This scoring was used
to find the degree of parental hesitancy.

Ethical consideration:
The proposal was submitted to the
Directorate of Health of Erbil city. Approval
from DOH was taken to assist the data
collection by a researcher from the family
clinic. The parents and health workers
were well informed about the aim of the Table 1 shows 564 parents who participated in this study. Relation to the child,
study. The parents were approached; in 64.5% of the sample was the mother who answered the questionnaire in
informed verbal consent was taken, the clinic, while in only 35.5% the fathers did. Number of pre-school children
before filling in the questionnaire and was between two to three children in 53% of the sample.
confidentiality was assured.

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Table 2: Distribution of the studied sample by immunization behaviors

Table 2 shows immunization behaviors of parents among different groups. About 20.9% delayed the vaccination for reasons
other than infection or sensitivity, while 73.8% had the immunization on time. More than two thirds (65.9%) were completely
sure that to follow the suggested program is protective for their child and only 26.6% were not sure. Asking about the role of
parents to question shots shows that two thirds (60.3%) disagreed and strongly disagreed with the idea, while 19.7% strongly
agreed and agreed while, 20% were not sure. Those who considered themselves not hesitant about childhood shots were
58.5%; 20% were hesitant and another 20.6% not sure.

The difference between the unquestioning group and the questioning group (caution, hesitant, refusal, late or delay) was
statistically significant in respect to immunization behaviour items when the mean was compared.

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Table 3: Distribution of the studied sample by Beliefs about vaccine safety and efficacy

Table 3 shows that 34% of the studied sample agree and strongly agree that children get more shots, while 46.51% disagree
and strongly disagree. For the second item concerning shots preventing severe diseases, 20.9% agree and strongly agree, and
56.1% disagree and strongly disagree. 16.6% agree on developing immunity by getting sick, while about 70% disagree. One
third agreed on giving children fewer vaccinations at the one time, 51% were not disturbed about side effects of vaccines and
41.8% had concern about this issue; 70.9% were not concerned that vaccination will not give protection.

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Table 4: Distribution of the studied sample by general attitude and trust

Table 4 shows that 8.2% of parents revealed that the only reason to get a shot is for entering the day care center, while 86.2%
answered no. The majority (83%) believed the instructions they obtained regarding immunization, and 7.81% don’t trust the
information they receive about shots. Table 4 also shows that 77.4% discuss their worries about vaccine with health workers and
10.3% did not discuss their concern with the child’s doctor. Parents in questioning acceptor group scored higher for attitude and
trust mean score compared to parents in the second group (the unquestioning group).
Table 5: Distribution of the studied sample by hesitant parental position and vaccination outcome*

Chi-square =54.87 P=0.0023 between Hesitant and non-Hesitant group.*

Table 5 shows that 80 out of 564 (14.2%) parents were among the three sub-groups of hesitancy spectrum. 56 out of 80 (70%)
were among the hesitant. The second late or selective vaccinator was 20 out of 80 (25%) and the third sub-group who refuse
vaccination were only 5%. Among the hesitant 57% of their children were fully immunized, 14% were a selective immunizer and
only 3.5% were unimmunized. The refusing parents show that 2.5% were unimmunized and the fully immunized among the non-
hesitant group of parents was 99.41% with a statistically significant difference (p=0.0023).
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Table 6: Distribution of the mean PACV screening score with presence of hesitancy or not*

*t- test was used to compare between two independent samples.

Table 6: The immunization behaviors domain mean score for the hesitant and non-hesitant was 45±4.1 and 22±3.2
respectively with statistically significant difference (p=0.001). The beliefs about vaccine safety and efficacy domain
mean score was 42±1.2 and 20±4.2 respectively for the hesitant and non-hesitant groups with statistically significant
difference (p=0.025). The overall mean score was 42±3.1 and 20 ±3.1 with statistically significant difference between
the two groups.

Parents’ behavior toward vaccine consisted of higher

Discussion
compliance than refusal. With the majority (94%) answered
no when asked if they have ever chosen not to vaccinate
The demography of the participating parents showed that
one of their children for other causes than infection, a
mothers were more responsible for children’s vaccination
minority of 4.6% answered yes, and 1.1% were not sure.
(64.5%) which is expected since all participating parents
Comparing these results to a Canadian study (88%, 7%,
had under 2 years old children who are usually more under
5%) (19), it was obvious that the Canadian parents’ have
the mother’s care (12). The mean age of parents’ was 34.9
relatively similar views to our sample parents. The non-
years in the current study, similar to an Italian study (33.4
medical exemption in USA reaches to 26% which is
years mean age) (13) with more than two-thirds of mothers
higher than our result (20). Two thirds and more (65.9%)
(69.6%) being of high-school education or higher.
considered, following the recommended vaccination
schedule is for the benefit of the child. The study of Taif
Our finding showed that 65.3% of the parents in the center
Saudi Arabia (21) reported higher figures (73.9%). In the
were willing to vaccinate their children without hesitancy
study of Michigan 90% (22) of parents overwhelming
or questioning, with another 20.6% who were slightly
contributed to the idea that vaccines are a perfect approach
concerned but still maintain a positive view on vaccination
to protect their children from disease. Asking about shots
(totaling 85.9%), a comparatively higher percentage
preventing many of the illnesses, the answer was yes for
than Dutch parents (43%)(14). While hesitant continuum
20.9% of the parents in the current study.
parents (Hesitant, Late vaccinator, Refusal) were 14.18%
of our sample out of these 80 parents were in the hesitancy
A study was conducted in Tennessee and California (23);
spectrum. Hesitant, Late vaccinator, and Refusal were
the mothers were given vaccine information at screening
70%, 25%, and 5% respectively, comparing these results
and 92% showed a positive attitude toward vaccine
to Australia’s study 34%, 55%, and 11% (15). The current
preventing diseases. A study in India (24) showed 70% of
study finds that hesitancy was higher but late vaccinator
mothers thought that vaccination prevented diseases. The
and refusal of vaccination is lower than previous studies.
low figure in our study is explained by lack of information
The refusal in the Dutch parents’ was 11% which is also
about vaccination. In an overcrowded health center,
higher than our results(14). In the study of USA (16) 71.7%
the health worker doesn’t have the time to give health
of the parents had no vaccine doubt and 28.2% were in
messages about immunization to these hesitant parents.
the vaccine doubt group.
Perception of sample parents that children currently get
Delaying the vaccination on the other hand accounted for
more shots than is good for them was 34%, slightly higher
20.9% of parents which is relatively higher than USA’s 13%
than American parents (29.7%) (25). About 16% of parents
(17). Immunization was delayed by 36.6% of Jordanian
thought, becoming sick is better than immunization,
parents’(18). This can be related to either vaccine hesitancy,
comparatively similar to American parents (16.6%) (25).
or parents’ lack of commitment toward vaccinating their
Another study in Atlanta reported a higher figure (24%).
children. Lack of education about vaccination during visits
The parents agreed that the body protects itself without
seems to be the reason behind poor practice of vaccination
vaccines (26) or it could be due to brief visits, making
and the possibility of vaccination delay.

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it difficult for the parents to request information about the vaccine hesitant mothers. In the study of Mosul, Iraq,
vaccine. Another explanation was that the immunization 54.2% completed vaccination (31). A study in Diayla, Iraq
does not challenge other tasks inside the primary health (32) showed that 70% were fully vaccinated, 24% partially
care center. A study in Jordan also reported a higher figure vaccinated and 6% not vaccinated. In an Indian study (33),
(26.5%) than the current study (18). 86% of the children were found to be fully vaccinated for
their age and 14% were partially vaccinated. Parents with
In a study in Tennessee and California (23) 62% agreed lower PACV scores (the non-hesitant group), 99% of their
that a child’s immune system will be overloaded with children were fully immunized, with significant difference
multiple vaccines on one occasion. In a study in Malaysia with parents who had higher scores (the hesitant group)
(27) 93% agreed that a child is excessively immunized in (p=0.0023). The under immunization was explained by
the first two years of their life. vaccine hesitancy. The Malaysian study reported similar
findings (34).
In our study 66.6% have no concern about vaccine safety, a
lower figure (46%) was reported in the study of Tennessee A comprehensive approach is needed to provide accurate
and California (23) that has no concern about vaccine information to parents who are concerned about the
safety. Regarding routine immunization protecting children safety and necessity of vaccines. Local population-based
from communicable diseases and its fatal complications strategies need to be developed inside Erbil city, to direct
the answer was yes for 70% of parents; a study in Saudi provider-to-parents communication strategies and groups
Arabia (21) reported higher figures than our study (91%). to assess the effectiveness of social media interfaces to
In the study in Jordan (18) 90% agreed that the available address questions from vaccine-hesitant parents. The
vaccines are carefully checked for safety. investigators believe that the current study provides
another critical arm of this comprehensive approach in
While perceived efficacy showed that 71% were not at that it addresses several aspects identified by parents
all concerned or not too worried that vaccine might not as important or challenging in this effort. The study can
protect the child from occurrence of diseases, was similar be implemented in other settings; the tool can address
to USA’s 72.7% (25) and lower than Canada’s 86% (19), concerns in the first visit requiring vaccines, and the tool
while a study that was done in Mosul city, Iraq reported can be used in the clinic under the supervision of a health
that 80.4% of parents agreed about vaccine preventing care providers.
diseases (28).
The current study has several limitations. First, the study
More than half (51.1%) of parents were not at all concerned only targeted children younger than two in one center
or not too concerned that vaccine might be associated with inside Erbil city, who may not represent all Kurdistan
serious side effects. Concerns from serious side effects region children. The convenient sampling and cohort
of Immunization were reported by 41.8% of parents. In design further limited the generalization of the findings to
Saudi Arabia’s study 57% (21) agreed on this statement. the entire Erbil governorate.
Assessing knowledge of parents’ in Mosul, Iraq (28)
revealed that 43% of them consider vaccination as harmful Another limitation of our work is that parents’ concerns
and causing side effects. Another study in Mosul (29) about vaccine safety and parents’ decisions to vaccinate
revealed that 23% of parents were concerned about side their children were not measured continuously over the
effect of vaccine. In the study among Canadian parents’ period during which children were administered vaccines.
68% (19) were concerned. The study in the USA (25) Therefore, our data cannot show whether parents’ attitudes
showed that 61% were concerned about vaccine safety and beliefs will be modified over time to positively influence
and efficacy. An internet based study in Germany showed the vaccination status of their children.
that 12.2% were concerned about overloading the immune
system, would be side effects of immunization (30). Conclusion
In the current study 8.2% of parents do agree on vaccination The current study showed parents had some positive
before school entry. Trust in the information received aspects related to vaccination and defects in other domains
about shots was shown by 83% of parents. In the study in were recognized. Identifying these parents was important
Jordan (18) 63% of parents agreed on the importance of in order to implement the necessary measures to maintain
preschool immunization. The low figure in our study could and improve the vaccination coverage in this region. The
be explained by lack of awareness about the immunization investigator recommends an educational intervention
schedule. There are many causes behind parent’s non- study; to be conducted among vaccine hesitant parents
medical exemptions to vaccination before entry to school to find if any changes occur in the measured parental
(18). However this issue has not been tackled here. attitudes toward vaccines.
According to a Multiple indicator cluster survey, the
proportion of children who were completely immunized at
the age of twelve months is 45%, and 57% at any time
before the survey was conducted (12). This figure is near
to the figure reported in the current study (57.5%) among

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77(3):224-9. Available from: https://www.ncbi.nlm.nih.gov/

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