INTRODUCTION:

According to the World Health Organisation (WHO), immunisation is the process of developing a person's resistance to or immunity to an infectious illness, typically by the administration of a vaccine¹. The body's natural immune system can be stimulated by vaccinations to help ward off future illnesses and infections. Immunisation, then, demonstrates one's capacity to build immunity.

Immunity is the quality of possessing adequate biological barriers to ward off disease, infection, or other undesirable biological intrusions. Additionally, immunity demonstrates the body's capacity to prevent any hazardous germs from entering it².

The largest impact on treatment costs, health interventions, mortality, and fewer hospital admissions comes from immunisation, which is also one of the most affordable options³. There are various obstacles to immunisation, such as false information about vaccines, vaccine side effects, diseases that can be prevented by vaccines, and the emergence of diseases after the administration of vaccines⁴. Low rates of full immunisation continue to be an issue in under developed countries, notwithstanding recent improvements in vaccine coverage in rich countries. Studies have indicated that vaccinations can save about one third of under-five-year-old fatalities.

The Expanded Programme on Immunisation (EPI) of the World Health Organisation (WHO) advises all countries to vaccinate against poliomyelitis, diphtheria, pertussis, tetanus, measles, and tuberculosis (TB) infection in countries with a high incidence rate⁶. Additionally, it was anticipated that every country's national immunisation programme would include the Hepatitis B vaccination by 1997⁷.

In Malaysia, the immunisation programme started with the DPT vaccination nearly 40 years ago. The BCG vaccine and the OPV vaccine were added later, in 1961 and 1972, respectively. Measles vaccination was added to the scheme in 1984, and vaccinations against rubella and hepatitis B followed in 1988 and 1989, respectively. In 2000, 99.97% of Malaysians received the BCG vaccine, 95.3% received the third dose of DPT, 95.4% received the third dose of OPV, 88.4% received the measles vaccine, and 93.5% received the third dose of hepatitis B.

Parents' choices on immunisation are crucial for boosting immunisation compliance and rates as well as for reducing any potential immunisation mishaps.⁸ the main elements influencing parents' vaccination decisions are their knowledge and practises about immunisation. Studies have indicated that raising parents' vaccine knowledge impacts immunisation rates and the effectiveness of immunisation campaigns. This is so because parents make the majority of choices about their children's health. The immunisation status of their children is significantly influenced by their parents' knowledge and practises about immunisation.

Good vaccination knowledge is needed to raise parents' awareness. Therefore, doctors, chemists, nurses, and other healthcare professionals should teach parents about the advantages and disadvantages of vaccinations. Communication between parents and information providers or vaccine providers is the most significant element determining parental practise. Parents' perceptions of the advantages and hazards of immunisations will change as communication improves. The purpose of this study is to ascertain the level of knowledge, attitudes, and practise of child immunisation among parents living in Sungai Petani, Kedah, Malaysia, as well as to evaluate the various factors affecting this knowledge, attitudes, and practise.

METHODOLOGY:

A cross-sectional study design was used throughout the entire process of this research study. Once the questionnaire was established, a validation process was done before producing the finalized questionnaire for the survey. This study was approved to be conducted by the AIMST University Human Ethics Committee (AUHEC) with the reference number of AUHEC/FOP/2021/26

This observational study was conducted from May 2021 to August 2021 to identify the level of knowledge, attitude and practice of parents towards child immunization in Sungai Petani, Kedah, Malaysia. A total of 203 parents were included in this study. Questionnaire used for this study consists of 3 sections which include demographics, 15 questions from knowledge and 11 questions from attitude and practice. It has been validated and internal consistency was found to be 0.7.

Informed consent was obtained from the parents who were willing to participate in this study. Numerical values collected from participants were analysed using SPSS Version 26, using the collected data, a descriptive analysis had been done. Once done, the normality of the data had been checked by using Kolmogorov-Smirnov test and Skewness and Kurtosis test. For the normally distributed data, parametric test such as One-way ANOVA test and independent t-test was used. For not normally distributed on the other hand the data was analyzed by using non-parametric test such as Fisher’s exact test and Chi-square test. P-value of less than 0.05 was considered as statistically significant.

RESULTS:

The demographic of current study was including different race, gender, age, number of children, employment status, education level and family income. Table 1 show that Malay parents are having more adequate knowledge as compared to the Chinese and Indian parents. Male parents are having more adequate knowledge compared to female parents, only by a slight difference. Parents having one child have shown more adequate knowledge compared to other parents. Parents working in private sector seem to have more adequate knowledge as compared to other parents. Postgraduate parents are having more adequate knowledge as compared to parents with lower educational status. Parents having income more than RM 4001 seems to have more adequate knowledge.

For the attitude and practice levels, all the parents had shown positive attitude and practice. However, Malay parents have shown a higher positive attitude and practice as compared to Chinese and Indian parents. Female parents have shown a higher positive attitude and practice compared to male parents. Parents having three children have shown a higher positive attitude and practice compared to other parents. parents working in government sector have shown a higher positive attitude and practice compared to parents working in private sector and unemployed parents. Parents whom studied till primary have shown a higher positive attitude and practice compared to parents having other educational status such as secondary, graduate and postgraduate. Finally, parents having income more than RM 4000 have shown a higher positive attitude and practice.

Table 1: Overall knowledge, attitude and practice levels with different variables (*Mann Whitney u test / Kruskal Wallis test)

Variables	Knowledge			Attitude and Practice
Variables	Adequate N(%)	Inadequate N(%)	p-value	Negative N (%)	Neutral N (%)	Positive N (%)	p-value
RACE
Malay	72 (97.3)	2 (2.7)	0.052*	0	0	74 (100.0)	0.043*
Chinese	66 (98.5)	1 (1.5)		0	0	67 (100.0)
Indian	56 (90.3)	6 (9.7)		0	0	62 (100.0)
GENDER
Male	97 (95.1)	5 (4.9)	0.745	0	0	102 (100.0)	0.387
Female	97 (96.0)	4 (4.0)	0.745	0	0	101 (100.0)	0.387
NUMBER OF CHILDREN
1	26 (100.0)	0 (0.0)	0.757	0	0	26 (100.0)	0.291
2	65 (95.6)	3 (4.4)		0	0	68 (100.0)
3	67 (94.4)	4 (5.6)		0	0	71 (100.0)
4	31 (93.9)	2 (6.1)		0	0	33 (100.0)
≥ 5	5 (100.0)	0 (0.0)		0	0	5 (100.0)
EMPLOYMENT STATUS
Government	88 (96.7)	3 (3.3)	0.085	0	0	91 (100.0)	0.044*
Private	87 (96.7)	3 (3.3)		0	0	90 (100.0)
Unemployed	19 (86.4)	3 (13.6)		0	0	22 (100.0)
LEVEL OF EDUCATION
No Formal Education	0 (0.0)	0 (0.0)	<0.001**	0	0	0 (0.0)	0.054
Primary	3 (75.0)	1 (25.0)		0	0	4 (100.0)
Secondary	21 (80.8)	5 (19.2)		0	0	26 (100.0)
Graduate	142 (97.9)	3 (2.1)		0	0	145 (100.0)
Postgraduate	28 (100.0)	0 (0.0)		0	0	28 (100.0)
Family Income (in Ringgit Malaysia)
≤ 2000	3 (60.0)	2 (4.0)	<0.001**	0	0	5 (100.0)	0.030*
2001- 4000	47 (88.7)	6 (11.3)		0	0	53 (100.0)
≥ 4001	144 (99.3)	1 (0.7)		0	0	145 (100.0)

DISCUSSION:

The choices made by parents about immunization are crucial for boosting immunization compliance and rates as well as reducing any potential immunization mishaps. The main elements influencing parents' vaccination decisions are their practices and understanding of immunization. Studies have indicated that raising parents' vaccine knowledge impacts immunization rates and the effectiveness of immunization campaigns. This is so because parents make the majority of choices about their children's health. The immunization status of their children is significantly influenced by their parents' knowledge and practices about immunization. This study looked on parents' knowledge, attitudes, and practices towards immunization of their kids in Sungai Petani, Kedah, Malaysia. In general, parents should be knowledgeable about immunizations in order to ensure and promote a healthy life for their children. The success of an immunization programme will not be impacted by parents' strong knowledge if they lack a supportive attitude and practice about child immunization. Therefore, regardless of demographic circumstances, it is essential for parents to have adequate knowledge, a positive attitude, and a practice regarding child immunization. Based on the findings from the survey and questionnaire disseminated via Google Forms, the knowledge, attitude, and practice of parents towards the immunization of their children in Sungai Petani, Kedah, Malaysia, were discussed in this section. According to three separate criteria—parents' knowledge, attitudes, and practices towards immunization of their children in Sungai Petani, Kedah, Malaysia—the results have been presented and discussed, and a comparison with other studies has also been made. Based on the study that was done, it was explored how race affected parents' understanding about child immunization. There was no effect size and the p-value was 0.052. The factors showed no hint of significance. Parents from a mix of Malay, Chinese, and Indian backgrounds participated in this poll. Compared to Chinese and Indian parents, Malay parents have more adequate information. According to a study conducted in Pahang, Malaysia that was compared to this one, Malays and Muslims generally have better knowledge and practice than non-Malay and non-Muslim parents.¹⁰

According to a survey done in Sungai Petani, Kedah, the majority of Malays and Muslims had superior knowledge and practice than those of other races and religions.⁹ According to a study among Korean, Chinese, and Vietnamese Americans, this variation can be attributed to the availability of samples from other ethnic groups.¹¹ Based on the study that was done, it was examined how gender affected parents' awareness about child immunization. The factors showed no hint of significance. There was no effect size and the p-value was 0.745. Parents of both sexes had taken part in this study. Parents of either gender have demonstrated a high level of understanding. However, compared to female parents, male parents possess more adequate information. This demonstrates that the vast majority of the male parents were aware of the study's title.

The Knowledge and Practice towards Childhood Immunization among Parents in Rompin, Pahang, Malaysia study by Lee SP et al.10, which was compared to this study, found that females have good knowledge and practice when compared to males. This is due to the fact that women interact with the maternal clinic more frequently, improving knowledge and practice. Studies carried out in Malaysia, Nigeria, and Saudi Arabia revealed similar results.^12,13,14 The impact of the number of children on parents' understanding about child immunization has been explored in light of the study that was undertaken. The factors showed no hint of significance. There was no effect size and the p-value was 0.757. All of the parents demonstrated that they were adequately informed about child immunization. However, compared to other parents, parents with one child have demonstrated more adequate understanding. When this study was compared to another, it was shown that the number of kids and immunization defaulters were significantly related. It was discovered that the likelihood of a child defaulting rises as there are more kids living with them.¹⁵ Similar results were seen in other Malaysian studies, which demonstrate that having several children contributed to insufficient immunisation.^16,17This would imply that having more children in a family made mothers work harder, lowering the level of care provided to the kids.¹⁸ The study's findings were used to analyze how parents' understanding of child immunization was impacted by their work position. The factors showed no hint of significance. There was no effect size and the p-value was 0.085. Parents with various work statuses participated in this poll. Compared to other parents, parents who work in the private sector seem to have better expertise. The results of this study were contrasted with those of a study by Mindlin M et al., titled Maternal employment and indices of child health: According to a thorough examination of preschoolers in OECD nations, public employees were found to have strong knowledge and skills. This is comparatively greater than parents who are self-employed, employed by the government, or jobless. The conclusion was backed by a study carried out in other regions of Malaysia and in OECD nations, which showed that, in contrast to parents who are unemployed; having a job has a favorable impact on a child's immunization status.¹⁹ The impact of educational level on parents' understanding of child immunization had been explored based on the study that was completed. The variables were found to be significant. There was no effect size and the p-value was 0.001. Parents from a range of educational backgrounds participated in this poll. Compared to other parents with lower educational status, postgraduate parents have more adequate information. When this study was compared to a previous one done in eastern Uganda by Nankabirwa V et al., it was found that children born to mothers with diplomas or less tend to follow the immunization schedule more than those born to mothers with bachelor's degrees or higher. The education level of the mother may also affect one's awareness of childhood immunization, which may ultimately affect one's choice regarding their children's health.²⁰ Education of mothers has an impact on how they seek out medical care for their children; among moms with higher education levels, education boosts knowledge and fosters a better understanding of immunisation.²¹ The impact of family income on parents' understanding of child immunisation has been explored based on the study that had been done. The variables were found to be significant. There was no effect size and the p-value was 0.001. Parents from a range of family income levels participated in this poll. Compared to other parents, parents whose income is over RM 4001 appear to have more adequate knowledge.

This runs counter to other research done in Turkey by Betsch C et al²²and Ahmad Hamidi A et al²³ that found that having a greater income increases access to doctors and other healthcare professionals as well as increases knowledge about vaccines. This could happen as a result of access to quality healthcare for families with higher income. In the current study, it demonstrates the correlation between various racial groups among the parents residing in Sungai Petani, Kedah, Malaysia. Indian, Chinese, and Malay parents participated in this study. The ethnicity component had no discernible impact on behavior or attitude. This demonstrates that the parents' beliefs and practices regarding child immunization in Sungai Petani, Kedah, Malaysia are unaffected by this variable. Compared to Chinese and Indian parents, Malay parents have demonstrated a more positive attitude and practice. Overall, attitudes and practices around child immunization are favorable across all racial groups. The outcome may have been as a result of parents having sufficient knowledge and comprehension about child immunization. The results of the previous study, which was done in the Northwest of Ethiopia by Abdnur Abdela et al. in 2015, were contrary to this one since the respondents hailed from various regions of Ethiopia and were of various races and ethnicities. According to 81.7% of respondents, HBV vaccination is recommended for all OHCWs. Only 2% of the respondents had, however, received all three doses of the HBV vaccine.²⁴ In a Canadian study, it was discovered that there are differences in attitudes and perceptions between different religious groups, which is indicative of ethical and religious discrepancies.²⁵ The Malaysian government has taken steps in the preparation of Halal vaccines in cooperation with Saudi Arabia in response to a study on the effects of religion and minimizing bias and making vaccines available, which shows that religious beliefs have strongly influenced the fundamental immunization schedule.²⁶ According to a study done in the Malaysian state of Pahang, there is no evidence of a substantial relationship between race or religion and vaccination decisions or practises.¹² The effect of gender on parents' attitudes and practices regarding child immunization is also covered in the current study. Parent participants in the study included both male and female parents. The factors showed no hint of significance. The parents had all demonstrated a good attitude and practice. However, compared to male parents, female parents have demonstrated a higher level of positivity and practice. This study was compared to a prior study titled Assessment of Knowledge and Attitude of the Practice of Parents towards Immunization of Children in Taif City, Saudi Arabia, which was carried out in the same city in Saudi Arabia. According to the study, parents in Taif, Saudi Arabia demonstrated inadequate vaccination practices and little understanding about childhood immunizations. By contrasting the findings with those of an Italian study, it can be seen that there is no correlation between a parent's gender and their attitude towards immunisation.²⁸ Gust DA et al. conducted a relevant study in America on parents' attitudes about immunization and the influence of awareness on such attitudes. The findings indicated that females had a relatively positive attitude in comparison to males.²⁹ the impact of the number of children on parents' attitudes and practices regarding child immunization were also explored as one of the variables in the study that was done. The parents had all demonstrated a good attitude and practice. However, compared to other parents, parents of three children have demonstrated a higher level of positivity and practice. These associations weren't very important. These findings were contrasted with those of Smith et al. (2011), who discovered a statistically significant correlation (p=0.028) between demographic traits and the practice of immunizing children. Parents who delayed or refused to vaccinate their children were more likely to have four or more children overall.³⁰ The study's demographic component found no evidence of a relationship between parents' attitudes and practices about child immunization and their employment level. According to statistics, there was no correlation between parents' attitudes and behaviors and their work situation. According to the data collected, all parents, whether they were working for the government, the private sector, or were jobless, had a good attitude and way of life. In contrast to parents working in the private sector and parents who are not employed, parents who are employed in the public sector have demonstrated a little more positive attitude and practice. This might be as a result of their awareness of the value of adopting positive attitudes and behaviors regarding child immunization, which is advantageous for not only their own children but also for the entire society. In this study, it was discovered that parents' educational attainment was not significantly related to their attitudes towards and practices surrounding the immunization of their children, towards which almost all of them displayed favorable attitudes. The aforementioned results are contrasted with those of a study done in Turkey, where the author discovered that a mother's higher education level was significantly associated with the practice of immunizing her children, with mothers who had at least completed primary school being eight times more likely to do so.³¹ A study of parents in West Africa reported a similar conclusion.³² A Dutch study with conflicting findings revealed that parents who were less educated were less likely to support vaccination because they thought it was ineffective or would have negative impacts on their children.³³ In contrast to the findings of the current study, a study carried out in America came to the conclusion that parental attitudes and beliefs are influenced by education level, and that the higher the education level, the more accepting the parents are of vaccinations.³⁴ Family income is one of the elements influencing this particular study. According to this demographic segment, there was no evidence that family income had a major impact on parents' beliefs and practices regarding immunization of their children. The parents had all demonstrated a good attitude and practice. These findings were at odds with those of Smith et al. (2011), who discovered a statistically significant relationship (p=0.028) between demographic traits and the routine administration of infant vaccines. Parents who delayed or refused to vaccinate their children were more likely to have yearly household incomes that were 400% or higher than the federal poverty line.³⁰Similar results were observed in a research of 1,527 parents conducted in the United States, where it was discovered that refusal to receive a vaccination was substantially correlated with household income (p=0.004) and household size (p=0.004).³⁵ According to a different study carried out in Bengaluru, Karnataka, India, parental income is yet another variable that may have an impact on children's immunisation status. According to the report, the proportion of kids receiving all of their vaccinations also increases as family wealth rises. Children from families with lower incomes had a lower likelihood of receiving all recommended vaccinations. The low income group may prioritise generating money for their family over preventive health care due to their low level of knowledge.^36,37

CONCLUSION:

The results of the study show that parents generally have good vaccination practises, attitudes, and knowledge. Gaps were found despite parents' adequate practise and knowledge of several aspects of childhood immunisation. To improve parents' awareness, educational interventions are required. Parental decisions about their children's vaccinations throughout the last few decades have been deemed inadequate. The parents' actions have been disagreeable because of the uncertainty surrounding the safety of vaccines and the assumption that they may include ingredients that are prohibited. Parents tend to think that their choices only have an impact on their immediate family, but in reality, they have a larger impact on the community. The current outbreak of diphtheria among Malaysians serves as evidence of the effects. Comprehending and bringing attention to these problems through appropriate investigation can assist in mitigating the ensuing effects.

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Received on 30.03.2023 Modified on 26.08.2023

Research J. Pharm. and Tech 2023; 16(11):5372-5377.

DOI: 10.52711/0974-360X.2023.00870