6,913
Views
0
CrossRef citations to date
0
Altmetric
Acceptance – Review

Factors affecting childhood immunization: Thematic analysis of parents and healthcare workers’ perceptions

& ORCID Icon
Article: 2137338 | Received 16 Apr 2022, Accepted 14 Oct 2022, Published online: 03 Nov 2022

ABSTRACT

Immunization against common childhood diseases is an important strategy as it is critical for reducing the global child morbidity and mortality. This review explores the perceptions of parents and HCWs toward childhood immunization. The PRISMA guideline was used to search and include the studies. Relevant electronic databases were systemically searched for the years ranging from 2000 to 2021 to identify studies reported in English. Themes were then identified using thematic analysis. A total of 44 studies met the review criteria and were summarized and categorized into 4 themes: barriers to immunization, parental knowledge, attitude and behavior (KAB), health system factors and HCWs’ KAB. This review found that immunization decision-making is a complex process. Parental KAB leads to immunization decisions. HCWs were also noted to be the trusted sources of immunization information. Further research can be conducted on how to improve parents’ perceptions of immunization and immunization practices.

Introduction

With the support of the World Health Organization (WHO), the Expanded Program on Immunization (EPI) was officially established in 1974 with the goal of immunizing every child to counter vaccine-preventable diseases (VPDs).Citation1 WHO has described immunization as the single most effective public health intervention in preventing childhood VPDs.Citation1–3 However, EPI has set the priority for developing countries since high prevalence of VPD and inadequate service delivery for immunization has been observed in these countries.Citation4 Immunization is defined as the process of giving a vaccine to incur immunity against a disease in an individual.Citation5 It has been estimated that immunization has prevented approximately 10 million deaths globally between 2010 and 2015.Citation6 The implementation of routine and mass immunization programs has led to the eradication of smallpox and elimination of poliomyelitis in many regions of the world, together with the control of once life-threatening diseases like diphtheria and tetanus.Citation7 Immunization programs help reduce the global burden of VPDs and decrease healthcare costs.Citation8

Immunization against common childhood diseases is an important strategy as it is critical for reducing global child morbidity and mortality.Citation8–12 However, some studies have shown that even with the importance of immunization known to parents, there still exists parents who are vaccine hesitant. Vaccine hesitancy is also influenced by factors such as complacency, convenience and confidence.Citation13 Parental forgetfulness can have a substantial impact on a child being fully immunized with all the recommended vaccines.Citation14 Parental attitudes, experiences and social grade are influential in determining whether a child receives a vaccine.Citation14,Citation15 Healthcare workers (HCWs) have an important role in immunization of children as they are the main trusted source of information. However, given the important role of HCWs, their attitudes toward immunization can impact parental perceptions. By understanding the barriers and attitudes to immunization, policymakers and HCWs can effectively address parental concerns and develop strategies to increase the immunization rates.Citation15 The objective of this review was to explore the perceptions of parents and HCWs toward childhood immunizations.

Methods

Search strategy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used as a search strategy for this review. A literature search was conducted through electronic databases and included all methods of studies. These databases included ClinicalKey®, EBSCO®, Embase®, GoogleScholar®, ProQuest®, PubMed®, ScienceDirect® and Scopus® from years 2000–2021. The Mendeley® software was used for reference management. Papers were chosen based on the key terms used in previous studies. The reference lists of the chosen articles were screened and then searched to find additional articles relevant to the subject of this review. Studies that reported on immunization, barriers, attitudes and perceptions on parents, caregivers and health workers that were involved in the immunization process and primary healthcare nurses and family and general practice physician were chosen.

The search strategy used “Boolean” terms such as (AND, OR) with key terms such as: “Immunisation,” “Immunization,” “Vaccination,” “Parents,” “Belief,” “Default*,” “Hesitan*,” “Healthcare workers,” (“barriers” OR “challenges”) AND (“attitudes” OR “perception”) AND (“vaccine*” AND “immun*”) AND (“practice” AND “knowledge”) OR (“awareness” AND “Role*”) OR (“health workers” or “health care professional” OR “healthcare provider” OR “maternal child health nurs*”) OR (“Parents” OR “caregivers” OR “mother*” OR “father*”).

Selection criteria

All types of studies (qualitative, quantitative and mixed method) published globally were considered in this review to extract relevant studies on childhood immunization and perceptions of parents and HCWs. The studies published from 1 January 2000 to 31 December 2021 and published in English language were examined and included from peer-reviewed journals, published books and WHO reports with full texts available.

Systemic review studies, studies with full text not available and the studies that reported on immunization pertaining to adolescents, adults, other HCWs (such as dieticians and medical students) that were not involved with immunization in their practice; studies conducted on immunization on children more than 5 y of age and school immunizations; studies that were done before 2000; reports, reviews and studies in other languages were excluded.

Selection process

The selection process began by cross-checking all the titles and abstracts of the studies to identify relevant studies. After the abstracts, the full texts on the remaining studies were checked to see if they were applicable to the current research study. The studies were also checked for duplication and only the studies that suited the inclusion and exclusion criteria were retrieved from the search engines. The quality of studies was assessed using different critical appraisal tools that were developed for a variety of study designs. The studies that failed to meet the criteria focused on reporting results as well as the methodology were considered as low-quality studies. Once the studies were retrieved, the references of the studies were perused to find additional studies that could be used in this review. The selection process is shown in .

Figure 1. Article search and selection process.

Figure 1. Article search and selection process.

Data extraction and analysis

For each included study, data was extracted into a data extraction sheet on Microsoft Excel® on the characteristics of the study design; characteristics under study; the group under study (parents, caregivers, HCWs); and the outcomes of the study. Thematic analysis was used to analyze the data. Themes were identified by reading the articles and identifying similar concepts seen in them. A data extraction table was developed to extract the relevant information needed for further analysis and to create themes for the study ().

Table 1. Data extraction sheet.

Results

Characteristics of studies

The 44 studies were conducted across the globe in Europe, the United States of America (USA), Canada, Asia, Africa, Australia and New Zealand and show that most of the studies were quantitative ().

Table 2. General characteristics of the studies.

Thematic analysis

From the 44 studies, factors were identified related to the perceptions of parents and HCWs toward childhood immunization. They were subsequently summarized and categorized into four themes: Perceived barriers; Parental KAB; Health system factors and HCWs’ KAB.

Theme 1: Perceived barriers

Factors such as work schedules; distance to the health facility; adverse weather on the appointment day; being young mothers; economically deprived households; being a patriarchal system; and a greater number of children in the family posed high risk at not being up to date with the schedule.Citation9,Citation17,Citation33,Citation34,Citation42,Citation46 A single study highlights that movement to another place; HCWs not opening vials unless a certain number of children are present; poor interaction between HCWs and mothers during sessions; perceived adverse reactions; and a lack of proper informationCitation19 are some of the factors that may affect immunization services and coverage. Negative perception and negative publicity can create fear and doubts about the vaccines.Citation29

Theme 2: Parental KAB

Most of the articles reported that some of the parental factors were parental education, religious beliefs, limited knowledge about vaccines and socioeconomic factors. Ten articles identified the factors such as low maternal education,Citation28,Citation35 fathers’ involvement and a patriarchal systemCitation9,Citation17,Citation33,Citation46 and religious beliefs such as vaccines that were perceived to be dangerous or ‘haram’Citation14,Citation25,Citation41 being some of the factors affecting immunization services. Four articles stated that personal experience or an acquaintance’s experience influenced immunization decision-making.Citation14,Citation18,Citation23,Citation39 Five articles mentioned the importance of fathers’ involvement and role in immunization.Citation17,Citation20,Citation22,Citation33,Citation46 Two papers noted that immunization coverage was high among parents who had adequate knowledge regarding immunization and quoted HCWs as important sources of immunization information.Citation23,Citation49 Two papers noted that parental religious belief system and the community the parents live in play an important role in the immunization coverage.Citation25,Citation28

Theme 3: Health system factors

One paper highlighted that supply and health system barriers and demand-related barriers can act to impede immunization coverage.Citation52 Furthermore, it was found in two papers that the distance to the health facility was an important obstacle to adequate coverage.Citation23,Citation24 Health system factors such as language barrier, HCW information not being clear enough for the parents, low quality of service, and having a poor or uniform recall or reminder system impede adequate immunization coverage.Citation34,Citation51 A paper suggested that one-size-fits-all approach to immunization information and intervention is not appropriate.Citation31 Two papers highlighted how HCWs shared parental concerns and sentiments regarding the number of injections at single visits and for there to be the introduction of a new vaccine to an existing immunization schedule.Citation47,Citation52

Theme 4: HCWs’ KAB

There were eight articles which emphasized how trust in HCWs was integral as they were important sources of information.Citation27,Citation29,Citation32,Citation34,Citation36,Citation38,Citation40,Citation45 Three articles highlighted the importance of proper and correct communication and imparting of vaccine information.Citation23,Citation47,Citation51 Two articles stressed how HCWs’ own beliefs and attitudes toward vaccines and immunizations can impact services and coverage.Citation48,Citation54 Two other articles found that rudeness, poor attitude, insensitivity and unpleasant immunization operating procedures including long waiting hours, extended time of exposure of the child, accessibility of the services, poor respect of client rights, cleanliness of the facility can deter parents from coming in for their next appointment.Citation49,Citation55

Discussion

The international studies and some Pacific Island studies (New Zealand and Australia) have shown that even with the importance of immunization known to parents, there is still vaccine hesitancy among the parental group. Perceptions of parents and HCWs regarding childhood immunization need to be addressed effectively. As children fall under the vulnerable group, immunization is an effective way of preventing VPDs.Citation8,Citation9

Inadequate knowledge; maternal factors such as maternal education, work schedule, social network, lack of social support, transportation; the subordinate role of women in society, socioeconomic factors; the number of other siblings in the family; transportation are some of the factors that may influence the parental decision-making process.

This review found that HCWs are the primary source of vaccine information. Parents need reassurance and information about the addition of any new vaccines to the schedule, the likelihood of developing post – immunization fever and post-immunization management.Citation36 Furthermore, this research showed that better parent–HCW communication is associated with higher knowledge, a better attitude and practice in immunizationCitation50 and also that perceived safety is associated with uptake.Citation40

The condition of the health facility; poor HCW attitudes and behavior; rudeness and unpleasant operating methods; poor communication skills affect; inconvenient facility opening hours; perceived bad organization of services; and a recall or reminder system not being uniform can deter parents to come in for the next appointment.Citation51–53Citation55

Furthermore, HCWs’ beliefs and perceptions about immunization can have an influence on parents. The research found that while having great trust and a positive attitude toward vaccines and immunizations, there can be some doubts and hesitancy by parents and HCWs when new vaccines are being added to an existing schedule.Citation48,Citation49,Citation52,Citation54

Conclusion

The review systemically explored the findings of 44 studies. It is important that vaccine providers are aware of specific barriers to immunization in their parts of the world. Health ministries must address the practical and communicative challenges the world is facing in order to increase vaccine uptake. Parental education and family socio-economic background have a significant influence on immunization decision-making and, hence, immunization uptake. Mothers mostly rely on networking for accessing immunization information and services, and fathers need to be more involved in the immunization process and decision-making. Better parent–HCW communication is associated with higher vaccine uptake and coverage. Poor attitudes of HCWs, long waiting hours and unpleasant immunization operating procedures such as long periods of exposure of the child can deter parents and caregivers from returning for the next appointment.

HCWs need to be more vigilant in identifying and addressing the factors which affect immunization adversely, and this could be done by proper communication and surveys. HCWs need to have more in-service training and workshops to improve their skills and attitudes. Health ministries should work in partnership with media to impart correct information to the public about. The health ministry should include other stakeholders such as community leaders and groups to spread awareness and correct information about immunization.

Abbreviations

ANC=

Antenatal Clinics

EPI=

Expanded Program on Immunization

FGD=

Focus Group Discussion

HCWs=

Healthcare Workers

IDI=

In-Depth Interviews

IPV=

Inactivated Polio Vaccine

KAB=

Knowledge, Attitude and Behavior

NHS II=

National Health Service Immunization Information

PRISMA=

Preferred Reporting Items for Systemic Reviews and Meta-Analyses

RVGE=

Rotavirus Gastroenteritis

SAGE=

Strategic Advisory Group of Experts

VPD=

Vaccine Preventable Diseases

WHO=

World Health Organization

Contributions

The design of the study was undertaken by both authors. Data were collected, analyzed and interpreted by PB. The study was guided by MM. Both authors contributed toward the manuscript preparation and approved the final manuscript for publication.

Limitations

Only full-text studies were included in this review. About 72 studies could not be retrieved as they could not be accessed.

Acknowledgments

We would like to thank Mrs Julie Sutherland for editing this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.

References

  • Keja K, Chan C, Hayden G, Henderson RH. Expanded programme on immunization. World Health Stat Q. 1998;41:1–15.
  • Paterson P, Meurice F, Stanberry LL, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34(52):6700–06. doi:10.1016/j.vaccine.2016.10.042.
  • Adhikary M, Haque R, Tanira S. Determinants of child immunization under expanded programme on immunization (EPI) in a rural setting of Bangladesh. J Dhaka Med Coll. 2015;22(2):201–06. doi:10.3329/jdmc.v22i2.21543.
  • Rainey JJ, Watkins M, Ryman TK, Sandhu P, Bo A, Banerjee K. Reasons related to non-vaccination and under-vaccination of children in low and middle income countries: findings from a systematic review of the published literature, 1999–2009. Vaccine. 2011;29(46):8215–21. doi:10.1016/j.vaccine.2011.08.096.
  • World Health Organization. The power of vaccines: still not fully utilized. [ Online]. 2019 [accessed 2021 Jan 20]. https://www.who.int/publications/10–year–review/chapter–vaccines.pdf.
  • World Health Organization. WHO mission vision 2030. [ Online]. 2020 [accessed 2020 Aug 9]. https://www.who.int/immunisation/documents/general/WHO_Mission_VIsion_Immunisation_Vaccines_2015_2030.pdf?ua=1.
  • Bonanni P, Sacco C, Donato R, Capei R. Lifelong vaccination as a key disease–prevention strategy. Clin Microbiol Infect. 2014;20(Suppl. 5):32–36. doi:10.1111/1469-0691.12537.
  • Martino GD, Giovanni PD, Girolamo AD, Scampoli P, Cedrone F, D’Addezio M, Meo F, Romano F, Sciascio MBD, Staniscia T. Knowledge and attitude towards vaccination among healthcare workers: a multicenter cross–sectional study in a Southern Italian region. Vaccines. 2020;8(2):248–58. doi:10.3390/vaccines8020248.
  • Ntenda PAM, Chuang K, Tiruneh FN, Chuang Y. Analysis of the effects of individual and community level factors on childhood immunisation in Malawi. Vaccine. 2017;35(15):1907–17. doi:10.1016/j.vaccine.2017.02.036.
  • Esposito S, Principi N, Cornaglia G. Barriers to the vaccination of children and adolescents and possible solutions. Clin Microbiol Infect. 2014;20(Suppl. 5):25–31. doi:10.1111/1469-0691.12447.
  • Dessie DB, Negeri MA. Determining factors of full immunisation of children among 12–23 months old in rural Ethiopia. Am J Public Health Res. 2018;6:160–65.
  • MacDonald NE. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161–64. doi:10.1016/j.vaccine.2015.04.036.
  • Jong KM, Sikora CA, MacDonald ME. Childhood immunization appointment reminders and recalls: strengths, weaknesses and opportunities to increase vaccine coverage. Vaccine. 2021;194:170–75. doi:10.1016/j.puhe.2021.02.034.
  • Pearce A, Marshall H, Bedford H, Lynch J. Barriers to childhood immunisation: findings from the longitudinal study of Australian children. Vaccine. 2015;33(29):3377–83. doi:10.1016/j.vaccine.2015.04.089.
  • Yarwood J, Noakes K, Kennedy D, Campbell H, Salisbury D. Tracking mothers’ attitudes to childhood immunisation 1991–2001. Vaccine. 2005;23:5670–87. doi:10.1016/j.vaccine.2004.11.081.
  • Grossman Z, Hadjipanayis A, Degani A, Somekh E. Tracking changes in vaccine attitudes and decisions: results from 2008 and 2016 parental surveys. Pediatr Infect Dis J. 2019;38(4):e75–76. doi:10.1097/INF.0000000000002147.
  • Abdullahi MF, Williams JS, Sahlèn K, Bile K, Kinsman J. Factors contributing to the uptake of childhood vaccination in Galkayo District, Puntland, Somalia. Glob Health Action. 2020;13(1):1803543. [accessed 2020 Sep 1] doi:10.1080/16549716.2020.1803543.
  • Jani JV, De Schacht C, Jani IV, Bjune G. Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique. BMC Public Health. 2008;8(1):161. doi:10.1186/1471–2458–8–161.
  • Kagoné M, Yé M, Nébié E, Sié A, Müller O, Beiersmann C. Community perception regarding childhood vaccinations and its implications for effectiveness: a qualitative study in rural Burkina Faso. BMC Public Health. 2018;18(1):324. doi:10.1186/s12889-018-5244-9.
  • Mapatano MA, Kayembe K, Piripiri L, Nyandwe K. Immunisation–related knowledge, attitudes and practices of mothers in Kinshasa, Democratic Republic of the Congo. S Afr Family Pract. 2008;50(2):61–61e. doi:10.1080/20786204.2008.10873699.
  • Lopez AL, Harris JB, Raguindin PF, Aldaba J, Morales M, Sylim P, Wannemuehler K, Wallace A, Ehlman DC, Hyde TB, et al. Introduction of inactivated poliovirus vaccine in Philippines: effect on health care provider and infant caregiver attitudes and practices. Vaccine. 2018;36(48):7399–407. doi:10.1016/j.vaccine.2018.09.028.
  • Raji MO, Sani AA, Ibrahim LS, Muhammad H, Oladigbolu RA, Kaoje AU. Assessment of the knowledge of fathers, uptake of routine immunization, and its associated factors in a rural community of Northwest Nigeria. Ann Afr Med. 2019;18(2):97–102. doi:10.4103/aam.aam_41_18.
  • Topuzoğlu A, Ay P, Hidiroglu S, Gurbuz Y. The barriers against childhood immunizations: a qualitative research among socio–economically disadvantaged mothers. Eur J Public Health. 2007;17(4):348–52. doi:10.1093/eurpub/ckl250.
  • Tuma JN, Smith SM, Kirk RH, Hagmann CE, Zemel PC. Beliefs and attitudes of caregivers toward compliance with childhood immunisations in Cameroon. Public Health. 2002;116(1):55–61. doi:10.1016/S0033-3506(02)90061-2.
  • Syiroj ATR, Pardosi JF, Heywood AE. Exploring parents’ reasons for incomplete childhood immunisation in Indonesia. Vaccine. 2019;37(43):6486–93. doi:10.1016/j.vaccine.2019.08.081.
  • Pugliese-Garcia M, Heyerdahl LW, Mwamba C, Nkwemu S, Chilengi R, Demolis R, Guillermet E, Sharma A. Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka, Zambia. Vaccine. 2018;36(37):5617–24. doi:10.1016/j.vaccine.2018.07.042.
  • Alstyne JAM, Nowak GJ, Aikin AL. What is ‘confidence’ and what could affect it?: a qualitative study of mothers who are hesitant about vaccines. Vaccine. 2018;36(44):6464–72. doi:10.1016/j.vaccine.2017.09.007.
  • Bondy JN, Thind A, Koval JJ, Speechley KN. Identifying the determinants of childhood immunization in the Philippines. Vaccine. 2009;27(1):169–75. doi:10.1016/j.vaccine.2008.08.042.
  • Biezen R, Grando D, Mazza D, Brijnath B. Why do we not want to recommend influenza vaccination to young children? A qualitative study of Australian parents and primary care providers. Vaccine. 2018;36(6):859–65. doi:10.1016/j.vaccine.2017.12.066.
  • Bond L, Nolan T. Making sense of perceptions of risk of disease and vaccinations: a qualitative study combining models of health beliefs, decision–making and risk perception. BMC Public Health. 2011;11(1):943–57. doi:10.1186/1471-2458-11-943.
  • Brunson EK. How parents make decisions about their children’s vaccinations. Vaccine. 2013;31(46):5466–70. doi:10.1016/j.vaccine.2013.08.104.
  • Campbell H, Edwards A, Letley L, Bedford H, Ramsay M, Yarwood J. Changing attitudes to childhood immunisation in English parents. Vaccine. 2017;35(22):2979–85. doi:10.1016/j.vaccine.2017.03.089.
  • Danis K, Georgakopoulou T, Stavrou T, Laggas D, Panagiotopoulos T. Socioeconomic factors play a more important role in childhood vaccination coverage than parental perceptions: a cross–sectional study in Greece. Vaccine. 2010;28(7):1861–69. doi:10.1016/j.vaccine.2009.11.078.
  • Harmsen IA, Bos H, Ruiter RAC, Paulussen TGW, Kok G, de Melker HA, Mollema L. Vaccination decision–making of immigrant parents in the Netherlands; a focus group study. BMC Public Health. 2015;15(1):1229–37. doi:10.1186/s12889-015-2572-x.
  • Huang Z, Sun X, Wagner AL, Ren J, Boulton ML, Prosser LA, Zikmund–fisher BJ. Parent and caregiver perceptions about the safety and effectiveness of foreign and domestic vaccines in Shanghai, China. PLoS ONE. 2018;13(5):e0197437. doi:10.1371/journal.pone.0197437.
  • Jackson C, Yarwood J, Saliba V, Bedford H. UK parents’ attitudes towards Meningococcal group B (MenB) vaccination: a qualitative analysis. BMJ Open. 2017;7(4):e012851. doi:10.1136/bmjopen-2016-012851.
  • Kyprianidou M, Tzira E, Galanis P, Giannakou K. Knowledge of mothers regarding children’s vaccinations in Cyprus: a cross–sectional study. PLoS ONE. 2021;16(9):e0257590. doi:10.1371/journal.pone.0257590.
  • Limaye RJ, Malik F, Frew PM, Randall LA, Ellingson MK, O’Leary ST, Bednarczyk RA, Oloko O, Salmon DA, Omer SB. Patient decision making related to maternal and childhood vaccines: exploring the role of trust in providers through a relational theory of power approach. Health Educ Behav. 2020;47(3):449–56. doi:10.1177/1090198120915432.
  • McNeil DA, Mueller M, MacDonald S, McDonald S, Saini V, Kellner JD, Tough S. Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination. BMC Public Health. 2019;19(1):49–60. doi:10.1186/s12889-018-6338-0.
  • Morin A, Lemaître T, Farrands A, Carrier N, Gagneur A. Maternal knowledge, attitudes and beliefs regarding gastroenteritis and rotavirus vaccine before implementing vaccination program: which key messages in light of a new immunization program? Vaccine. 2012;30:5921–27. doi:10.1016/j.vaccine.2012.07.050.
  • Périnet S, Kiely M, de Serres G, Gilbert NL. Delayed Measles vaccination of toddlers in Canada: associated socio–demographic factors and parental knowledge, attitudes and beliefs. Human Vaccines Immunotherapu. 2018;14(4):868–74. doi:10.1080/21645515.2017.1412899.
  • Ueda M, Kondo N, Takada M, Hashimoto H. Maternal work conditions, socioeconomic and educational status and vaccination of children: a community–based household survey in Japan. Prev Med. 2014;66:17–21. doi:10.1016/j.ypmed.2014.05.018.
  • Vezzosi L, Santagati G, Angelillo F. Knowledge, attitudes and behaviors of parents towards varicella and its vaccination. BMC Infect Dis. 2017;17(1):172–80. doi:10.1186/s12879-017-2247-6.
  • Wagner AL, Boulton ML, Sun X, Mukherjee B, Huang Z, Harmsen IA, Ren J, Zikmund–fisher BJ. Perceptions of Measles, Pneumonia, and Meningitis vaccines among caregivers in Shanghai, China, and the health belief model: a cross–sectional study. BMC Pediatr. 2017;17(1):143–52. doi:10.1186/s12887-017-0900-2.
  • Handy LK, Maroudi S, Powell M, Nfila B, Moser C, Japa I, Monyatsi N, Tzortzi E, Kouzeli I, Luberti A, et al. The impact of access to immunization information on vaccine acceptance in three countries. PLoS ONE. 2017;12(8):e0180759. doi:10.1371/journal.pone.0180759.
  • Rammohan A, Awofeso N, Fernandez RC. Paternal education status significantly influences infants’ measles vaccination uptake, independent of maternal education status. BMC Public Health. 2012;12(1):336–312. doi:10.1186/1471-2458-12-336.
  • Charania NA, Watson DG, Turner NM. Perceptions of caregivers and providers regarding the potential introduction of the varicella vaccine to the childhood immunisation schedule in New Zealand: a qualitative exploratory study. J Paediatr Child Health. 2018;54(1):28–35. doi:10.1111/jpc.13661.
  • Filia A, Bella A, D’Ancona F, Fabiani M, Giambi C, Rizzo C, Ferrara L, Pascucci MG, Rota MC. Childhood vaccinations: knowledge, attitudes and practices of paediatricians and factors associated with their confidence in addressing parental concerns, Italy, 2016. Eurosurveillance. 2019;26(6):1800275. doi:10.2807/1560-7917.ES.2019.24.6.1800275.
  • Khan MU, Ahmad A, Aqeel T, Akbar N, Salman S, Idress J. A cross–sectional survey of healthcare workers on the knowledge and attitudes towards polio vaccination in Pakistan. PLoS ONE. 2015;10(11):e0142485. doi:10.1371/journal.pone.0142485.
  • Matta P, El Mouallem R, Akel M, Hallit S, Khalife MF. Parents’ knowledge, attitude and practice towards children’s vaccination in Lebanon: role of the parent-physician communication. BMC Public Health. 2020;20(1):1439–48. doi:10.1186/s12889-020-09526-3.
  • Musa S, Skrijelj V, Kulo A, Habersaat KB, Smjecanin M, Primorac E, Becirovic D, Jackson C. Identifying barriers and drivers to vaccination: a qualitative interview study with health workers in the Federation of Bosnia and Herzegovina. Vaccine. 2020;38(8):1906–14. doi:10.1016/j.vaccine.2020.01.025.
  • Nkwenkeu SF, Jalloh MF, Walldorf JA, Zoma RL, Tarbangdo F, Fall S, Hien S, Combassere R, Ky C, Kambou L, et al. Health workers’ perceptions and challenges in implementing Meningococcal serogroup a conjugate vaccine in the routine childhood immunization schedule in Burkina Faso. BMC Public Health. 2020;20(1):254. doi:10.1186/s12889-020-8347-z.
  • Owino LO, Irimu G, Olenja J, Meme JS. Factors influencing immunization coverage in Mathare Valley, Nairobi. East Afr Med J. 2009;86(7):323–29. doi:10.4314/eamj.v86i7.54146.
  • Picchio CA, Carrasco MG, Sagué–vilavella M, Rius C. Knowledge, attitudes and beliefs about vaccination in primary healthcare workers involved in the administration of systematic childhood vaccines, Barcelona, 2016/17. Euro Surveillance. 2019;24(6):1800117. doi:10.2807/1560–7917.ES.2019.24.6.1800117.
  • Udonwa NE, Gyuse AN, Etokidem AJ, Ogaji DST. Client views, perception and satisfaction with immunisation services at primary health care facilities in Calabar, South–South Nigeria. Asian Pac J Trop Med. 2010;3(4):298–301. doi:10.1016/S1995-7645(10)60073-9.