Abstract

Background

Vaccines have contributed to the disappearance of various diseases, and almost eradicated others across the world. Studies have shown that in Lebanon a profoundly small percentage of Syrian refugee children were fully immunized by routine vaccination services. Exploring the knowledge, attitudes, and practices of parents towards vaccination is of crucial importance, given the role of parents in children鈥檚 immunization. This study aims to investigate the knowledge, attitudes, and practices of the Syrian refugee mothers in Lebanon towards the immunization of their children.

Methods

This is a cross-sectional study conducted using questionnaires targeting Syrian refugee mothers whose children were born on Lebanese grounds, are below the age of five, and are following the Lebanese vaccination schedule.

Results

Majority of refugee mothers considered vaccination to be safe (89.9%) and stated that vaccination should be initiated at birth (87.2%). Almost all of the interviewed mothers plan to vaccinate their children according to the National Lebanese Vaccination Schedule. Concerning the children鈥檚 immunization status, 51.4% of Syrian refugee children were fully immunized and 48.6% had aberrant vaccination.

Conclusion

Although refugee mothers had some knowledge gaps regarding vaccines, the main issue lies within the accessibility. A collaborative coordinated approach involving governmental and non-governmental agencies seems to be an effective approach to improve rates of immunization.

Background

Amongst the various primary prevention methods used in the public health sector, vaccination is regarded as one of its most highlighted achievements [1]. Vaccination鈥檚 importance and effectiveness have been proven by its ability to reduce death and morbidity due to infectious diseases worldwide, saving 2 to 3听million lives yearly [2]. In fact, its benefit is not only limited to those vaccinated but also grants herd immunity to those who are not, which further limits the spread of communicable diseases [2]. Vaccines have contributed to the disappearance of various diseases (i.e. smallpox), and almost eradicated others (i.e. polio) across the world. It also helped decrease infections caused by many viruses and bacteria in most of the developed countries, granted by their advanced healthcare system [3]. Despite this evolution in the healthcare systems worldwide, about 19.4听million children, predominantly among refugees and people in areas of conflict, remain unimmunized and suffer from high morbidity and mortality from vaccine-preventable diseases, as they have restricted access to vaccination [4, 5]. It is unfortunate that almost half of the pediatric deaths are accounted for preventable communicable diseases [6].

Since 2011, the situation in Syria has been deteriorating causing the displacement of many Syrian citizens to the neighboring countries such as Lebanon [7]. According to UNHCR, a total of 976,000 Syrian refugees were present in Lebanon up till 31st July 2018 [8], and that constitutes about 30% of the total population [9]. The Syrian conflict has caused constant displacement of refugees mostly to areas that were already crowded and lacked proper sanitation. This has led to outbreaks of infections across Syria and the neighboring countries, damaging its healthcare system and causing loss of information concerning their vaccination status; more than 50% of the 1.8听million children born since this conflict couldn鈥檛 get access to vaccination [10,11,12]. A study has shown that in Lebanon only 12.5% of Syrian refugee children were fully immunized by the routine vaccination services. These numbers are quite low compared to the 46.6% of the children in the Lebanese households. Thus, the importance of vaccination among displaced populations must be addressed given their intangible human right for healthcare, including vaccination [10, 11]. Exploring the knowledge, attitudes and practices of parents towards vaccination is of crucial importance given the role of parents in children鈥檚 immunization [13]. The factors that influence these variables should also be taken into consideration [14]. For instance, many parents exhibit vaccine hesitancy as they do not believe in the advantages of vaccines and doubt their extent of safety, all while assuming that vaccination is not crucial for their child. Some parents also fear the side effects that vaccines can cause, as they believe that side effects would be more serious than the preventable disease itself [14].

To complete the picture on immunization among Syrian refugee children below five years of age, this study aims to investigate the knowledge, attitudes, and practices of the Syrian refugee mothers in Lebanon towards the immunization of their children. The primary hypothesis of this study is that the immunization rate among Syrian refugee children in Lebanon is suboptimal. We further hypothesize that this low rate is associated with specific maternal factors, including sociodemographic characteristics, and the presence of knowledge gaps or reservations regarding childhood vaccination.

Methods

Study design, area, and participants

This is a cross-sectional study conducted through questionnaires that were distributed in four different regions in Lebanon where Syrian refugees mostly reside: Beirut, Bekaa, South, and North Lebanon. The participants were Syrian refugee mothers whose children were born on Lebanese grounds, are below the age of five, and are following the Lebanese vaccination schedule.

The participants were approached during their visits to pediatricians or family physicians at different healthcare centers serving mostly Syrian refugees including Tahaddi and Ibad Al-Rahman healthcare centers in Beirut, Ghiras Al Khair and Barelias medical centers in Bekaa, Serepta and Al- Bunyan healthcare centers in South Lebanon, and Al-Iman and Al Qubba Islamic (Ibn Sina) healthcare centers in North Lebanon.

Sample size and data collection

The questionnaire was designed in English and translated into Arabic by the investigators (Appendix 1). It included questions on sociological and demographical characteristics of the study population, questions assessing knowledge, attitudes, and practices of mothers regarding immunization, and questions regarding vaccine uptake according to the National Lebanese Vaccination Schedule (Appendix 2) [15].

A pilot study on 20 participants was conducted before starting the data collection. To ensure cultural and contextual relevance, the questionnaire was reviewed by healthcare professionals with experience in the Syrian refugee context and then pilot-tested with a small group of Syrian refugee mothers. Feedback from the pilot helped us refine questions to improve clarity and appropriateness for the target population.

Data collection took place from July 2018 to January 2019. Convenient sampling was used to select the participants who were stratified by governorate. The sample size calculation was based on a power of 80% and a significance level of 0.05, estimating that a sample of 384 participants would provide sufficient power to detect the proportion of fully immunized children. To account for incomplete responses of 20%, we set the target sample size at 480.鈥�

Due to the unequal distribution of Syrian refugees across different regions in Lebanon, we employed a stratified sampling technique. We determined the sample size for each governorate based on the proportion of the refugee population residing in that region, ensuring representation across Beirut, Bekaa, South Lebanon, and North Lebanon. This proportional allocation allowed us to reflect the regional diversity within the Syrian refugee population in our sample. According to UNHCR, a total of 976,000 Syrian refugees were present in Lebanon up till 31 July 2018. The distributions according to regions were as follows: 254,993 in Beirut, 351,972 in Bekaa, 117,500 in South and 251,537 in North Lebanon [7]. Thus, a total of 126 participants were included from Beirut, 175 from Bekaa, 58 from South and 125 from North Lebanon.

During the interview, the mothers were asked to present their child鈥檚 vaccination card, if accessible, for the assessment of their immunization status. For mothers who did not have the vaccination card at the time of the interview, we asked about each vaccine their child received and documented completeness based on their responses. Among the participants, 226 mothers had the vaccination card during the interview, 232 reported having it at home, and 24 did not possess a vaccination card at all.

To ensure accuracy, we compared the proportion of fully immunized children between those who had a vaccination card present and those who did not. We found no significant difference in immunization rates between these groups. Additionally, the associations between immunization completion rates and sociodemographic variables remained consistent, regardless of whether a vaccination card was available.

Statistical analysis

SPSS 23 was used for analysis. For descriptive purposes, continuous variables were displayed as means鈥壜扁�塻tandard deviations. Categorical variables were presented as numbers and percentages. A chi-square test for independence was employed to evaluate the associations between categorical variables, including sociodemographic characteristics and immunization status.

Results

Sample characteristics and immunization status

A total of 484 Syrian refugee mothers participated in this study. Among these, 51.4% reported that their children were fully immunized according to their age. The age of the interviewed Syrian refugee mothers ranged from 15 to 47 years (mean age of 26.73鈥壜扁��5.97 years). Regarding the educational level, the highest percentage recorded (31%) was for mothers reaching secondary school. The majority of the participants were unemployed (90.9%). Neither education nor employment status was associated with vaccination status of the respective children. The residency of the mother was significantly associated with the child immunization status (p-value鈥�=鈥�0.002) in a way where those who lived in an apartment/house had the highest percentage of children vaccinated (64.3%).As for the regions in which the Syrian refugees were distributed, those who resided in Beirut had the highest percentage for children who were fully immunized (63.5%), with a significance of 0.019. The age of children of interviewed mothers ranged from 1 to 58 months (mean age of 20.23鈥壜扁��15 months). Other characteristics regarding the demographics of the sampled mothers are recorded in Table听1.

Table 1 Association between sociodemographic characteristics and immunization status

Knowledge of childhood immunizations

As shown in Table听2, most respondents (79.8%) stated that the purpose of vaccination was the prevention of vaccine-preventable diseases but also many (73.3%) thought that vaccines can prevent non-communicable diseases as well. Over half of the participants (54.8%) interviewed thought that vaccines actually treat diseases. As for diseases that could be prevented by vaccination, polio and measles recorded the highest percentages with 85.5% and 87.2%, respectively. It was also noted that hepatitis B recorded the highest percentage (74.9%) for a fatal disease that was believed to necessitate vaccination. Around 23% of mothers had the perception of diabetes mellitus being one of the vaccine preventable diseases. There is no statistically significant difference between mothers of immunized and never-immunized children when it comes to knowledge regarding purpose of vaccination.

The majority of the mothers considered vaccinations to be safe (89.9%) and 87.2% stated that vaccination should be initiated at birth. Around 65% of the mothers stated that vaccination causes side effects, most of which were pain at the site of injection (79.2%) and mild fever (97.4%). Most mothers stated that otitis media (74.6%) and common cold (75.4%) were contraindications to vaccination. There is no significant difference between the immunization status of the child and the belief that vaccination adverse effects are dangerous.

43.4% of mothers with fully immunized children do search around for information about immunization versus 31.1% of those who have incomplete or absent immunization. This difference is statistically significant (P鈥�=鈥�0.009).

Table 2 Mothers鈥� knowledge regarding child鈥檚 immunization

Attitudes towards childhood immunizations

When asked whether the mothers were in favor of vaccination, about 98.0% responded that they were. Of mothers who search for information regarding immunization, around half revealed that they rely on healthcare providers. Almost all of the interviewed mothers plan to vaccinate their children according to the National Lebanese Vaccination Schedule. Table听3 further details more information about the attitudes of the interviewed mothers.

Table 3 Attitudes of mothers towards vaccination

Practices of mothers regarding childhood immunizations

Of the interviewed mothers, 95% said that their child has an immunization card. Doctors were considered the main source of information to mothers (79.1%) regarding the immunization of children. Most of the participants initiated the vaccination of their children at birth. Among those who mentioned that side effects occurred once vaccinations were given (30.6%), the most common side effect reported was mild fever (27.9%) which they mostly chose to relieve by administration of anti-pyrectics. The minority could recall the next or last vaccine that their child needs to take or have taken. Further information regarding the practices of mothers is listed in Table听4.

Table 4 Practices of mothers regarding vaccination

Discussion

This manuscript explores the knowledge, attitudes, and practices regarding childhood immunization among Syrian refugee mothers in Lebanon and sheds light on their association with sociodemographic factors.

The demographic characteristics emphasize the challenges faced by Syrian refugee mothers, with a considerable proportion being unemployed and having a primary education level of secondary school. Literature discusses the potential reasons leading to low vaccination rates, including parental, recipient, and vaccination-process factors. For parental factors, lower vaccination rates were previously noted among parents, especially mothers, with low or no academic education, along with those who are young of age. Both conditions could signify a lack of awareness regarding vaccines and their efficiency which negatively affects vaccination [6, 9, 16]. However, in our study, there was no difference in vaccination rates of one鈥檚 child when it comes to educational or work status of the mother, including having no formal education (p鈥�=鈥�0.071), being unemployed (p鈥�=鈥�0.605), or even the age of the mother (p鈥�=鈥�0.98). This might be indicative of potential presence of confounding barriers to healthcare access or other socio-economic challenges that go beyond the conventional predictors of immunization behavior.

The place of residence seems to be associated with the immunization status, with mothers residing in apartments or houses displaying a higher percentage of fully immunized children. Our data shows that only 48% and 46.9% of refugee children settling in North and Bekaa, respectively, were immunized. This suggests a potential link between living conditions and access to healthcare services. Coinciding with the Syrian refugee鈥檚 influx to Lebanon, there was an increase in the hepatitis A cases up to 2鈥�3 folds, along with other infectious diseases like measles and mumps around 3鈥�5 folds, especially in Beqaa and North governorates settlements [9, 17]. A surge in infectious diseases among refugees has also been witnessed in other countries receiving refugees, and that is expected as the preventive services and crowding control measures inside refugee camps are suboptimal [18, 19]. Indeed, the crowding and the lack of sanitary infrastructure in refugee camps makes infection transmission more likely [10]. Further investigation into factors contributing to this association could reveal critical insights for targeted interventions.

As for factors concerning the child, while the child鈥檚 gender did not affect vaccination rates [16], lack of continuous follow-up with a pediatrician, a coinciding illness at the time of vaccination, as well as a child鈥檚 age (p鈥�<鈥�0.001) all played a significant role and match up with the information we have from previous studies [6, 9, 16]. In our study, infants up to 6 months of age had more adequate patterns of vaccinations compared to older children between 6 months and 5 years of age, coinciding with literature [9].

Approximately 48.6% of the children in our study exhibited aberrant vaccination patterns, indicating either partial or complete lack of immunization, whereas data collected in 2015 showed that 79.9% of Syrian refugee children in Lebanon had incomplete vaccination [20]. Wide efforts have been made by the Lebanese MOPH in collaboration with UNICEF and WHO within this timeline to reduce the occurrence of vaccine-preventable diseases to the least possible by ensuring timely and complete access to vaccination for the entire population, focusing on the most vulnerable [21]. The difference in data between this study and data in 2015 presumes the successful contribution of these interventions in the improvement of vaccinations rates, even amidst several national health and economic crises. Despite minor knowledge gaps among refugee mothers, targeting health education, raising awareness among healthcare workers about their vital role, improving provider communication, and providing Arabic informational materials may further support vaccination efforts among the studied population.

In Syria, vaccination rates dropped to almost half by 2013 in some areas due to the ongoing war, especially for diseases like diphtheria, tetanus and pertussis, as they are considered to be the main vaccine-preventable ones [4, 10]. 33.9% of the children in our study were either partially or never immunized. It seems that partially vaccinating children with a single dose is a common trend [16, 22], but this could also be due to missed vaccinations as a consequence of the ongoing crisis. Vaccination catch-up should be structured to replenish the missed immunity, especially if the vaccination schedules among host and origin country differ [19]. Noteworthy is the acknowledgment of the widespread impact of the SARS-CoV-2 pandemic-which occurred later-on the global immunization rates. This reality is highlighted by a study conducted in Romania, revealing a significant decline in MMR and hexavalent vaccination rates to below 60% and 70%, respectively, during the pandemic [23]. This emphasizes the importance of ongoing research to direct and respond effectively to the dynamic factors influencing childhood immunization in the wake of global health crises.

In comparison, Lebanese children have higher prevalence of vaccination even though many vaccination campaigns were organized to target Syrian population since the refugee鈥檚 influx [16]. Unfortunately, there are limited capacities for the health sector in Lebanon to cover the needs of the increasing number of refugees and accompanied outbreaks despite virtually all mothers participating in our study planning to vaccinate their children according to the National Lebanese Vaccination Schedule [9, 16]. It has been proposed that the medical needs of these refugees were never adequate [7], and they themselves believe their health status in general is below the required level, mainly due to the high costs [24]. Healthcare system in Lebanon is mostly dominated by private institutions, leaving hardship for access by refugees [12]. The negative impact of this situation can be seen through the low compliance to non-obligatory vaccines versus obligatory ones (approximately 20 vs. 40%) [9]. This difference can be accounted to the price of the non-mandatory vaccines, compared to the mandatory counterpart which are free by the Ministry of Public Health [9]. The obligatory vaccines (Appendix 1) are those mandated by the Lebanese ministry of Public Health and every child living on the Lebanese grounds must receive them [15]. Said vaccines are readily available for free in dispensaries across all the districts. Non-mandatory vaccines, while often still available at the dispensary of healthcare centers, had a fee ranging from 55 US dollars to 70 US dollars, which likely affected the willingness to vaccinate. There were some attempts to provide some degree of free healthcare, such as the polio vaccination campaigns organized in several schools and camps starting November 2013 [25]. This study assessed general attitudes toward vaccination without differentiating between vaccine hesitancy and specific concerns about particular vaccines. Future research could explore this distinction to gain deeper insight into vaccine-specific attitudes among Syrian refugee mothers. The knowledge assessment reveals a generally good understanding of vaccination purposes among the respondents. However, the perception of non-communicable diseases being preventable by vaccines and the belief that vaccines can treat diseases highlight areas where targeted education campaigns may be beneficial. In a study about immunization knowledge in Nigeria, some women did not even know the purpose of vaccinating children, and this lack of knowledge, along with a low level of education, is found to be the main culprit of low vaccination rates [26].

The overwhelmingly positive attitude towards vaccination, with 98.0% of mothers expressing favorability, aligns with global trends supporting immunization. The reliance on healthcare providers for information underscores the pivotal role of these professionals in shaping parental attitudes. Strengthening this patient-physician relationship could further enhance vaccination advocacy.

Vaccination was considered safe among Syrian refugees in Lebanon, as only 10.1% had safety concerns. In comparison, a cross sectional study done in 2022 revealed that the fear of vaccine adverse reactions represented 26.6% of reasons causing Romanian parents to decline their children鈥檚 vaccination [27]. More studies need to investigate the reasons behind such reasons for hesitancy and different rates among populations. The finding that a considerable proportion of mothers considered otitis media and the common cold as contraindications to vaccination is intriguing. This misconception could be addressed through focused health education initiatives to clarify the distinctions between contraindications and common side effects, potentially mitigating vaccine hesitancy. As for one of the misconceptions that trended among parents in the past decade, only 1% of refugee mothers believed vaccines could possibly cause autism consequently.

Limitations

This study did not assess parental vaccination status. The literature makes a valid point regarding parental tolerance to vaccination; they are more accepting if they, themselves, had taken the vaccines previously and with no side effects [6]. Moreover, due to accessibility, we have not included the fathers鈥� educational level and knowledge about vaccination into analysis. Finally, the use of convenient sampling in this survey introduces a risk of selection bias, potentially affecting the representativeness of the results. Future research employing more rigorous methods, like random sampling, could reduce these biases and provide a clearer understanding of Syrian refugee mothers鈥� views on children鈥檚 vaccination.

Conclusion

It appears to be that the knowledge of Syrian refugees鈥� mothers towards vaccination and its side effects is not the major issue when it comes to vaccinating their children. However, the issue lies with the inaccessibility of vaccines for the population. It is obvious that the Syrian refugees鈥� mothers seek to validate their information and strengthen their knowledge in the topic of immunization from reliable resources.

The outcome of this study emphasizes the importance of addressing both knowledge gaps and access barriers in vaccination programs, particularly among vulnerable populations.

Finally, the results highlight the value of collaborative approach and coordination between governmental and non-governmental agencies in times of crises, particularly when it comes to the provision of essential health services like immunization.