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Original Research (Original Article) 


Khulood Marzooq Aloufi et al, 2019;3(1):055–059.

International Journal of Medicine in Developing Countries

Prevalence and determinants of delayed vaccination among children aged 0–24 months in Al-Madinah, Saudi Arabia

Khulood Marzooq Aloufi1*, Hanan Mosleh2,3

Correspondence to: Khulood Marzooq Aloufi

*Medical Intern at College of Medicine, Taibah University, Al-Madinah, Saudi Arabia.

Email: khullood-2050 [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 20 November 2018 | Accepted: 30 December 2018


ABSTRACT

Background:

The suboptimal compliance with vaccinations continues to be a major public health problem worldwide.


Objectives:

To estimate the proportion of children who have delayed vaccinations and to investigate the factors associated with such delays.


Methods:

This cross-sectional study was conducted at the Maternity and Children Hospital in Al-Madinah Al-Munawarah, Kingdom of Saudi Arabia from January to March 2018. The participants, including 149 mothers with children younger than 24 months, were recruited from this hospital. Face-to-face interviews were conducted using a 15-item questionnaire that asked about socio-demographic characteristics, the vaccination statuses of their children, and the causes of delayed vaccinations if available.


Results:

Only 40.9% of the children had received vaccinations either on time or with delays of a few days, while vaccinations for 59.1% of the children had been delayed for longer periods of 4 weeks or more. The most common risk factors for delayed vaccinations were an illness of the child at the vaccination time (42.2%), unavailability of the vaccine (22.9%), negligence (17.4%), and other delays based on a physician’s advice (16.4%).


Conclusions:

A large proportion of children have poor compliance to vaccination appointments, and vaccination providers should be alert to all opportunities to improve the immunization coverage and the need to provide accurate knowledge about the real contraindications to vaccination.


keywords:

child vaccination, delayed vaccination, delayed immunization.

Introduction

The Expanded Program on Immunization (EPI) aims to achieve and maintain at least 90% vaccination coverage in every country worldwide and this is one of the most cost-effective means of preventing serious infectious diseases. It is estimated that over 2.5 million deaths are avoided through vaccination every year. In spite of the increases in routine vaccination coverage in the past three decades, the World Health Organization reported in 2016 that around 19.5 million infants worldwide are still missing out on basic vaccines [1,2].

It has been documented that a substantial proportion of children from developing and developed countries are currently not being vaccinated on schedule. They not only fail to receive protection from preventable diseases at times when they are most vulnerable but are also at increased risk of never fully completing the vaccination course. Both outcomes compromise successful childhood immunization programs and put children at risk for serious illness [3].

The most common factors for such delays are difficulties with the appointments, upper respiratory tract illnesses, late birth orders, delays based on the advice given by physicians, transport problems, negligence, and not remembering the vaccination schedules. Furthermore, most of the parents of these children are not concerned about the vaccination delays [4,5].

It is essential to realize that low overall rates of the targeted diseases mask the persistent threats they pose if compliance to vaccination schedules declines [3]. Thus, determining and understanding the factors associated with delayed vaccinations allow us to take a better approach to the at-risk populations for such delays and target the efforts at reinforcing the importance of immunizations. This study was done to estimate the proportion of children less than 2 years of age who had delayed vaccinations and to investigate the determinants of such delays, to provide policymakers with insights into this situation so they can design and implement appropriate interventions.

Subjects and Methods

This was a cross-sectional analytic study conducted over a period of 3 months from January 2018 until the end of March 2018. Participants were recruited from the inpatient wards, emergency room, and outpatient clinics at the Maternity and Children Hospital in Al-Madinah Al-Munawarah. Only mothers with children aged 24 months or less (as per the reported dates of birth) and who live in Madinah were included in the study. The study excluded non-Arabic speakers and children who were more than 2 years of age. Vaccinations were considered as delayed if they took place four or more weeks after the designated time [6,7]. The data were collected using a pre-tested 15-item questionnaire in Arabic that was filled in by the interviewer. The questionnaire included the socio-demographic data and vaccination statuses of the children, as well as the causes of delayed vaccinations if available.

The sample size was calculated using OpenEpi (open source statistics for public health) online [8]. Inputs that were entered for sample size calculation for infinite populations hypothesizing a frequency of delayed vaccination at 9%, an absolute precision of 5%, and a confidence level of 95% yielded a sample size of at least 126 participants.

The data were collected using an interview questionnaire in Arabic. The questionnaire included two parts. The first involved socio-demographic data, including age, gender, nationality, the mother’s and father’s ages, the mother’s educational level, residence, and child order. The second part included the immunization status of the child, the vaccinations that had been received, the latest received vaccine, whether the child had had all immunizations at the appropriate time and, if not, the duration of the delay, and finally, the reasons for the delay if available.

The questionnaire was prepared by the authors, reviewed for validity by two consultants in family and community medicine, and then pre-tested for comprehension on 20 subjects who were not included in the study.

The data were entered and analyzed using SPSS version 21 [9]. Descriptive statistics were performed using frequencies and percentages for categorical variables. Multivariate analysis was performed using binary logistic regression to investigate factors such as the ages of the children, the sexes of the children, their residences, the educational levels of the mothers, and the child order, which are independently associated with delayed vaccination. Statistical significance was set at a p value less than 0.05.

All research procedures were done according to the Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects [10].

Results

One hundred and forty-nine mothers with children younger than 2 years of age were interviewed. The ages of the children ranged between 1 and 24 months, the median age was 9, 55.7% were males, and 96.6% were Saudi (Table 1).

Only 40.9% of children received vaccination on time, whereas 59.1% were delayed for a period ≥ 4 weeks. In all children, at-birth vaccinations were given on time; the delay appears later, as shown in Table 2.

Table 1. Socio-demographic characteristics of the studied group (n = 149)

Socio-demographic variable Frequency Percent
Sex
Male 83 55.7
Female 66 44.3
Nationality
Saudi 144 96.6
Non-Saudi 5 03.4
Mother education
Illiterate 17 11.4
Less than secondary 23 15.4
Completed secondary 43 28.9
University 65 43.6
Higher than university 1 00.7
Residence
Urban Medina 132 88.6
Rural Medina 16 10.7
Child age
Birth to 2 months 4 02.7
2 to 4 months 23 15.4
4 to 6 months 23 15.4
6 to 9 months 21 14.
9 to 12 months 19 12.8
18 to 12 months 28 18.8
24 to 18 months 31 20.8
Child order
1st 31 20.8
2nd 20 13.4
3rd 26 17.4
More 72 48.4
Immunization status
Vaccinated on time 40 26.8
Delayed less than 4 weeks 21 19.3
Delayed 4 weeks and more 88 80.7

Table 2. Immunization status of 149 children in different age groups

Percent of completed vaccination
Age groups At birth 2 months 4 months 6 months 9 months 12months 18months 24 months
Birth to 2 months 100%
2 to 4 months 100% 26.1%
4 to 6 months 100% 73.9% 13%
6 to 9 months 100% 100% 85.7% 47.6%
9 to 12 months 100% 100% 100% 73.7% 36.8%
12 to 18 months 100% 100% 92.4% 92.9% 85.7% 60.7%
18 to 24 months 100% 95.2% 95.2% 85.7% 71.4% 66.7% 14.3%
24 months 100% 90% 100% 100% 90% 90% 70% 0%

The most common reasons for vaccination delays were illness of the child at vaccination time (42.2%) and unavailability of the vaccine (22.9%); in 16.4% of cases, the delay was based on a physician’s advice, while only 6.4% of study participants identified lack of transport as a risk factor (see Table 3).

The age of the children was found to be the only statistically significant determinant of complete vaccination (p = 0.012). Only those aged 0 to less than 2 months were 100% vaccinated, which was significantly different from all other age groups. Table 4 shows the determinants independently associated with delayed vaccination in the studied group.

Discussion

Timely immunization is necessary for the prevention of disease. The targeted population of this study was children younger than 24 months. The findings showed that at birth, 100% of children received vaccinations on time, which may be attributable to mandatory vaccination of newborns before discharge from hospitals. However, nearly 59% of children in the current study did not receive vaccinations on time. This proportion was higher than the results of previous studies in KSA. A study at King Abdulaziz University Hospital in Jeddah, KSA, which investigated delayed primary vaccination among 227 infants, reported that only 9% were not given primary vaccinations on time [6]. Another study assessing the immunization status of 351 children at five primary health care centers and two tertiary governmental hospitals in Jeddah, KSA reported that only 24.2% had delayed vaccination [7]. A similar study conducted in Sao Paulo, Brazil to assess risk factors for incomplete vaccination among 258 children less than 18 months of age showed that 10.9% of children had incomplete vaccination [11].

Table 3. Reasons for no/delayed vaccination among the studied group

Causes of no/delayed vaccination Frequency (n =116) Percent
Illness of the child at
vaccination time
46 42.2
Unavailability of the vaccine 25 22.9
Negligence 19 17.4
Physician advice 18 16.5
Lack of transport 7 6.4
Others 9 8.3

Table 4. Determinants of delayed vaccination among the participants

Predictors p (B Exp) % 95 CI
Age group of the child 0.012 0.772 0.945–0.630
Sex of the child 0.094 1.975 4.377–0.881
Education of the mother 0.757 1.067 1.608–0.708
Age of the mother 0.840 1.012 1.132–0.904
Age of the father 0.257 1.048 1.136–0.967
Residence 0.808 0.952 1.415–0.641
Child order 0.264 0.861 1.120–0.662

However, higher frequencies of delayed vaccination were reported by 2009 National Immunization Survey to assess Parental Delay or Refusal of Vaccine Doses [12], in which the data of 11,206 children aged 24–35 months were analyzed. Results showed that a total of 39.8% had delayed and/or refused vaccination, specifically 25.8% had only delayed vaccination, 8.2% had only refused, and 5.8% had both delayed and refused vaccines. Another study conducted in 2001 to assess risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique documented that 28.2% of children (n = 668) had not completed the vaccination schedule by 2 years of age [13]. In a 2008 study at five hospitals in different departments of Argentina, 39.7% of children ≤ 24 months old were on a delayed vaccine schedule [14]. Moreover, a 2015 study to evaluate the incidence of delayed vaccination among children under 4 (n = 3,610) in the Expanded Program of Immunization (EPI) covering the outskirts of Iranian cities concluded that 56.6% of vaccines were administered outside of recommended timeframes [15].

Minor illness represented the most common reason for delayed vaccination, identified by 42.2% of participants. Similarly, 59.3% of parents interviewed in the 2009 National Immunization Survey were more likely to say that they did so because their child was ill [12]. In contrast, the 2018 study in different locations of Jeddah, KSA showed that traveling at the recommended time of vaccination was identified by 21.3% of participants as the cause of delayed vaccination [7]. The 2017 study at King Abdulaziz University Hospital in Jeddah revealed that the most common identified reason for vaccine delay was difficulties with the appointment (30%) [6].

In the present study, 22.9% of mothers reported that unavailability of the vaccine was the reason for the delay. This agrees with the results of two studies done in rural Mozambique [13] and the Gambia [16], which showed that 54.1% and 22.5% of children, respectively, did not have required vaccinations on time; the mothers in those studies referred to vaccine unavailability in the health facility as an important cause.

The least identified reason for delayed vaccination was lack of transportation (6.4%). This contrasts with a 2004 study conducted in four diverse, medically underserved areas of the United States to measure immunization coverage among preschool children, which concluded that the main reason for delaying vaccinations was lack of transportation (46%) [17].

In the present study, only the age of the child was found to be a statistically significant determinant of complete vaccination (p = 0.012). This was similar to a 2013 study conducted in Athens, Greece, where the child’s age was strongly associated with incomplete vaccination for all vaccines (p < 0.001) [18], and contradicted a 2015 study in Iran, where birth order and the mother’s educational level were the most important predictors of delayed vaccination [15].

Conclusion

A substantial proportion of children aged ≤24 months have delayed vaccination, particularly considering that all children are completely vaccinated at birth. Parents demonstrate poor compliance with vaccination appointments and consider minor illnesses as a reason for non-vaccination. Vaccination providers should take advantage of all opportunities to improve immunization coverage and overcome barriers causing delayed vaccination.

Acknowledgment

The authors wish to thank Anbar Al-Saadi for her help in implementing the survey.


List of Abbreviations

EPI Expanded program on immunization


Consent for publication

Informed consent was obtained from all participants.


Funding

None.


Declaration of conflicting interests

The authors declare that there is no conflict of interest regarding the publication of this article.


Ethical approval

Ethical approval was obtained from the scientific research ethics committee at Taibah University, reference ID: 007-1439, dated 17-10-2017.


Author details

Khulood Marzooq Aloufi1, Hanan Mosleh2,3

  1. Medical Intern at College of Medicine, Taibah University, Al-Madinah, Saudi Arabia.
  2. Associate Professor of Community Medicine, Department of Family and Community Medicine, Faculty of Medicine, Taibah University, Saudi Arabia.
  3. Assistant professor of Community Medicine, Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Egypt.

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How to Cite this Article
Pubmed Style

Almukhlifi TS, Alanzan AAA, Alghuwainem SOA, Alotaibi STM, Alokifi MAA, Alkhathlan MSBA, Almalki KF, Al-Ghannam AK, Alkhashlan NN. Knowledge of breast cancer among rural women among Saudi Arabian population. IJMDC. 2019; 3(9): 55-58. doi:10.24911/IJMDC.51-1556807668


Web Style

Almukhlifi TS, Alanzan AAA, Alghuwainem SOA, Alotaibi STM, Alokifi MAA, Alkhathlan MSBA, Almalki KF, Al-Ghannam AK, Alkhashlan NN. Knowledge of breast cancer among rural women among Saudi Arabian population. http://www.ijmdc.com/?mno=46727 [Access: September 23, 2019]. doi:10.24911/IJMDC.51-1556807668


AMA (American Medical Association) Style

Almukhlifi TS, Alanzan AAA, Alghuwainem SOA, Alotaibi STM, Alokifi MAA, Alkhathlan MSBA, Almalki KF, Al-Ghannam AK, Alkhashlan NN. Knowledge of breast cancer among rural women among Saudi Arabian population. IJMDC. 2019; 3(9): 55-58. doi:10.24911/IJMDC.51-1556807668



Vancouver/ICMJE Style

Almukhlifi TS, Alanzan AAA, Alghuwainem SOA, Alotaibi STM, Alokifi MAA, Alkhathlan MSBA, Almalki KF, Al-Ghannam AK, Alkhashlan NN. Knowledge of breast cancer among rural women among Saudi Arabian population. IJMDC. (2019), [cited September 23, 2019]; 3(9): 55-58. doi:10.24911/IJMDC.51-1556807668



Harvard Style

Almukhlifi, T. S., Alanzan, . A. A. A., Alghuwainem, . S. O. A., Alotaibi, . S. T. M., Alokifi, . M. A. A., Alkhathlan, . M. S. B. A., Almalki, . K. F., Al-Ghannam, . A. K. & Alkhashlan, . N. N. (2019) Knowledge of breast cancer among rural women among Saudi Arabian population. IJMDC, 3 (9), 55-58. doi:10.24911/IJMDC.51-1556807668



Turabian Style

Almukhlifi, Talal Saad, Ali Abdulaziz A Alanzan, Sultan Obaid Abdullah Alghuwainem, Sayil Turki M Alotaibi, Mohannad Abdullah A Alokifi, Mohammed Saad Bin Abdullah Alkhathlan, Khalid Fahad Almalki, Alwaleed Khalid Al-Ghannam, and Nada Nasser Alkhashlan. 2019. Knowledge of breast cancer among rural women among Saudi Arabian population. International Journal of Medicine in Developing Countries, 3 (9), 55-58. doi:10.24911/IJMDC.51-1556807668



Chicago Style

Almukhlifi, Talal Saad, Ali Abdulaziz A Alanzan, Sultan Obaid Abdullah Alghuwainem, Sayil Turki M Alotaibi, Mohannad Abdullah A Alokifi, Mohammed Saad Bin Abdullah Alkhathlan, Khalid Fahad Almalki, Alwaleed Khalid Al-Ghannam, and Nada Nasser Alkhashlan. "Knowledge of breast cancer among rural women among Saudi Arabian population." International Journal of Medicine in Developing Countries 3 (2019), 55-58. doi:10.24911/IJMDC.51-1556807668



MLA (The Modern Language Association) Style

Almukhlifi, Talal Saad, Ali Abdulaziz A Alanzan, Sultan Obaid Abdullah Alghuwainem, Sayil Turki M Alotaibi, Mohannad Abdullah A Alokifi, Mohammed Saad Bin Abdullah Alkhathlan, Khalid Fahad Almalki, Alwaleed Khalid Al-Ghannam, and Nada Nasser Alkhashlan. "Knowledge of breast cancer among rural women among Saudi Arabian population." International Journal of Medicine in Developing Countries 3.9 (2019), 55-58. Print. doi:10.24911/IJMDC.51-1556807668



APA (American Psychological Association) Style

Almukhlifi, T. S., Alanzan, . A. A. A., Alghuwainem, . S. O. A., Alotaibi, . S. T. M., Alokifi, . M. A. A., Alkhathlan, . M. S. B. A., Almalki, . K. F., Al-Ghannam, . A. K. & Alkhashlan, . N. N. (2019) Knowledge of breast cancer among rural women among Saudi Arabian population. International Journal of Medicine in Developing Countries, 3 (9), 55-58. doi:10.24911/IJMDC.51-1556807668