Vaccination is the most economical method to prevent many infectious diseases that cause morbidity or mortality (Dumpaet al., 2019). However, the instability of vaccines limits their utilization in many developing countries where adequate storage facilities are unavailable (Lahariya, 2014). Most vaccines have poor thermostability; they require uninterrupted storage at 2-8ºC from the manufacturing of the vaccine until it is administered to a patient (Dumpaet al., 2019).

The history of vaccines and vaccination starts with the first effort to prevent diseases (Dumpaet al., 2019). Smallpox (like many other infectious diseases including measles) was well known since ancient times and believed to have originated in India or Egypt, over 3,000 years ago (Lahariya, 2014). Historians and physicians have sometimes referred smallpox as ‘Indian Plague’, which suggests that the disease might be widely prevalent in India in the earlier times (Lahariya, 2014). The goal of a vaccine is to induce immunity to an infectious disease without having to suffer the pathogenesis associated with natural infection (Payette and Davis, 2001). Vaccines have traditionally been classified into three broad categories: live attenuated, whole killed, and subunit vaccines (Dumpaet al., 2019). Live attenuated vaccines are based on the attenuation of pathogenic organisms to the point that they no longer cause disease but are still capable of inducing immunity (Lahariya, 2014). Whole killed vaccines are based on the inactivation of pathogenic organisms through processes such as formalin fixation (Abdullahiet al., 2014). Finally, subunit vaccines are based on the isolation and purification of components from microorganisms, or their synthetic production, that can be used to induce protective immunity (Lahariya, 2014). Throughout the history of vaccinology, scientists have strived to combine experience with knowledge in an effort to develop new weapons in the fight against infectious disease (Payette and Davis, 2001).

Most nations have high vaccination rates for infants (Dumpaet al., 2019). Nonetheless, certain vaccinations result in transient immunity (Payette and Davis, 2001). In these situations, it is advised that booster shots for the vaccinations previously given during childhood or infancy be given later in life (during adolescence, for example) in order to preserve immunity conferred by the vaccine (Lahariya, 2014). Ensuring appropriate coverage of both primary and booster vaccination doses is imperative (Dumpaet al., 2019). The childhood immunization programs have, on the whole, succeeded in achieving a high vaccination rate (Abdullahiet al., 2014).

The healthcare system in Pakistan is incredibly dynamic and lively, consisting of 1,279 public sector hospitals, 5,527 Basic Health Units, 686 Rural Health Centers, and 5671 dispensaries (Abbaset al., 2023). In the nation, there are 108,474 nurses, 22,595 dentists, and 220,829 doctors (Abdullahiet al., 2014). For the 2019-20 fiscal year, the government would spend PKR 203.74 billion on public healthcare services, 3.29% more than in prior years (Abbaset al., 2023). Indicators for the nation’s health revealed the opposite situation, with neonatal mortality of 42 deaths per 1,000 live births, infant mortality of 62 deaths per 1,000 live births, and under-5 mortality of 74 deaths per 1,000 livebirths, in spite of the substantial healthcare infrastructure that is still being developed (Abdullahiet al., 2014). The rates of infant and child mortality are shown to be greater in rural than in urban settings (Abbaset al., 2023).

Most developed nations worldwide have put in place programs to vaccine at least part of the high-risk segments of society because to the convincing research supporting influenza vaccination for high-risk groups (Abdullahiet al., 2014). In two significant investigations looking at the worldwide usage of influenza vaccines, it was found that, with Japan being the exception, 21 out of 22 developed nations advised immunization for those with high-risk medical conditions (Polandet al., 2001).

Pakistan is still reporting wild poliovirus cases in 2016, which made up the majority of cases reported worldwide (Abbaset al., 2023). The situation in Pakistan is still concerning even though the caseload is less than it was in prior years (Payette and Davis, 2001). Pakistan continues to be the sole source of endemic poliovirus transmission worldwide and the only obstacle to the eradication of polio worldwide (Abdullahiet al., 2014). In Pakistan, polio has been reported in the Federally Administrative Tribal Areas, Quetta, Northern Sindh, and Karachi (Habibet al., 2017).

Demographic and Health Surveys, which are carried out on a national sample of households, offer important data on immunization coverage and timeliness at the individual level as well as a variety of factors that may affect immunization practices (Abdullahiet al., 2014). Prior research conducted in the nation has examined factors associated with immunization in narrow geographic areas, frequently as a component of interventional studies with limited potential for generalization (Payette and Davis, 2001). This paper’s objectives are to examine factors that contribute to vaccine completion and to characterize immunization coverage rates and timeliness based on DHS data (Zaidiet al., 2014).

Parents’ KAPs on their children’s vaccines have been linked to sociodemographic characteristics as family size, income, and parents’ age and educational attainment.⁷ For instance, parents who lived in towns, had more educational attainment, and were older tended to have more negative sentiments (Zaidiet al., 2014). In 16 studies that directly asked parents about their intentions, the highest report (98% of the 54 participating parents from Canada) and the lowest (75% in a study including 200 parents from the United States) measured parents’ intentions to vaccinate their children for one or more antigens (Nassaret al., 2023). This systematic review of parental vaccine attitudes and beliefs measured parents’ intentions to vaccinate their children for one or more antigens (Zaidiet al., 2014; Nassaret al., 2023).

The Expanded Program on Immunization (EPI) was launched by world health organization in 1974 (Hasanet al., 2010). It stands as a global endeavor to ensure equitable access to life saving vaccines for every child regardless of their location or socioeconomic status (Zaidiet al., 2014). It has a greatest impact on regional and global immunization indicators such as maternal and neonatal tetanus, poliomyelitis eradication (Habibet al., 2017). Despite a lot of efforts by government Pakistan’s immunization has benchmarks (Abbaset al., 2023). The EPI program in Pakistan annually targets 5.8 million children aged below 1 year to protect them against vaccine preventable diseases and around 5.9 million pregnant women to protect them and their newborns from tetanus through routine immunization services (Nassaret al., 2023). Private sector in Pakistan provides 3% of immunization injections through 6000 fixed centers and it involves almost 10000 vaccinators that includes paramedics who are trained in EPI, 6000 lady health visitors and other paramedics. On a pilot scale EPI program was started in Pakistan and was expanded country wide by 1978 (Hasanet al., 2010). Now new vaccines and technologies are invented to increase more parental awareness about immunization (Hasanet al., 2010).

Cost of vaccine is a major factor in child immunization (Lahariya, 2014). If cost of vaccine manufacturing is high it will lead to less potential profit (Payette and Davis, 2001). For low- and middle-income countries, majority of equipment, consumables and personnels will need to import for years and this will further low benefits to country (Abbaset al., 2023). Low- and middle-income family parents especially benefit their children just with low price vaccines and they do not vaccinate their children with high-cost vaccine (Plotkinet al., 2017). Child vaccinations are highly influenced by the parental knowledge, attitude and practices. Therefore, the present study was conducted to evaluate the knowledge of parents regarding child immunizations as well as the factors affecting the parental knowledge.

A multi-centered, cross sectional observational study was conducted to evaluate the knowledge of the parents regarding their child immunization in Lahore, Pakistan. Quantitative research methodology involving validated questionnaires and research tools were utilized in order to evaluate the knowledge of the parents regarding their child immunization. Study population was 353 parents belong to urban and rural areas of Lahore having children of different ages were recruited for this study. The incomplete responses were excluded from the final study. Ethical approval from Institutional Ethical Review Board and Bio-Ethical Committee (BEC) of Lahore university of Biological and Applied Sciences was attained for this research project.

The inclusion criteria for this research included parents or guardians from different rural and urban areas of Lahore who willingly participated in the current study by signing the Informed Consent Form (ICF). However, the parents whose children were above 4 years and do not provide full information and do not complete the questionnaire were excluded.

Sample size was calculated according to the convenient sampling technique. Approximately 353 parents were approached for the data collection. Study settings of this research were the rural and urban areas of Lahore. Study duration was of 6 months approximately.

The data collection form contained demographic section involving information on age of parents and child, relationship of parents with child, gender of child, occupation of parents, number of children, living class, residency, marital status, religion and healthcare provider in family. The questionnaire contained 10 knowledge related questions about child immunization, effectiveness of vaccination, schedule of vaccination, parent’s belief regarding their child immunization, benefits of EPI program, side effects of vaccination, diseases prevented by vaccination, child immunity, mortality rate and disability. The questionnaire was designed after an extensive literature review of the published research. Afterwards, it was reviewed to ensure it aligned precisely with our objectives, and any questions that elicited unnecessary or sensitive information were removed. Content validity was attained by sending it to 3 academicians who were expert, as the result of their suggestions the questionnaire was modified and face-validated by checking on small number of respondents. The pilot study was conducted on small number of parents and Cronbach’s alpha value of 0.76 was attained for knowledge questions. The results of pilot study were not included in the study’s results. Each correct answer by the respondent was scored 1. The cut off points were decided on 60% scores for appropriate knowledge.

The data collected from the study subjects was analyzed and interpreted by using SPSS v21, IBM. Descriptive and inferential statistics were applied to summarize the variables. Categorical variables were presented as frequencies and percentages. To find factors regarding associations between independent variables, chi square tests (Pearson chi square) were applied and where assumptions of chi-square analysis requirements were not met, Fisher exact tests were applied to calculate p-values. p-values less than 0.05 were considered as statistically significant values.

The current study recruited 353 parents from different private and government hospitals. Demographic details of the respondent are represented in Table 1.

Most of the parents were had to wait for about less than 15 min i.e. 48.4% and time spent on their child immunization were less than 15 min i.e. 53.8% to get their child immunized as presented in Table 2.

Table 3 demonstrates knowledge of parents regarding their child immunization stating that majority of the parents have inappropriate knowledge (64.0%), graphically represented in Figure 1.

According to questionnaire session, the parent’s knowledge of effectiveness of vaccines against infectious diseases was 17.8% appropriate and 82.2% inappropriate. The study subject’s response to knowledge related question items is summarized in Table 4 and graphically represented in Figure 2.

Table 5 provides the association of demographics variable with parent’s knowledge. It is observed through statistical analysis that the occupation, no of children, residency, living class and health care providers in respondent family shows highly significant statistical association (p<0.001) with patient knowledge regarding their child immunization.

Child immunization is a nationwide program in Pakistan. There are many factors contributing to the effectiveness of immunizations programs and this study has tried to look upon some of aspects. Diseases like pneumonia, measles and pertussis that can be prevented by vaccination continue to be the major contributors. During present study, the questionnaire about knowledge survey was given to 353 parents who had children below 2 years of age in rural and urban areas of Lahore, Pakistan. The source from where the participants get information about immunization plays a pivotal role in adherence to child immunization schedule (Payette and Davis, 2001).

The results of our study regarding parental knowledge shows the effectiveness of vaccine against infectious diseases was only 17.8% appropriate and 82.2% inappropriate, knowledge about vaccination schedule was 22.7% appropriate and 77.3% inappropriate. Furthermore, only 24.9% of parents believed in the necessity of vaccination for a healthy child while 75.1% do not believe. 21.0% understood the benefits of the Expanded Program on Immunization while 79.0% did not understand. The parent’s perception that vaccination causes side effects was 13.9% appropriate and 86.1% inappropriate. The parent’s knowledge about the diseases that can be prevented by vaccination was 20.1% appropriate and 79.9% inappropriate. The parent’s knowledge about type of vaccines that should not be given during a medical condition of sickness is 19.0% appropriate and 81.0% inappropriate. The parent’s perception about strengthening the child immune system was 17.8% appropriate and 82.2% inappropriate. The knowledge regarding decrease in mortality rate was 21.0% appropriate and 79.0% inappropriate. The parent’s perception about vaccination does not causes disability was 22.4% appropriate and 77.6% inappropriate. The high percentages indicate lack of awareness and knowledge specifically in rural areas (66.3%) with high percentage comparable to urban areas (33.7%). The low percentages (appropriate%) indicates a pressing need for educational intervention to improve parent’s knowledge regarding child immunization.

The study assessed parental knowledge regarding child immunization revealing concerning statistics. Our results indicate that only 36.0% of parents had appropriate knowledge while a significant 64.0% had inappropriate knowledge. The result of our current study is due to the low level of awareness, lack of educational programs in rural areas, low human resource management, low staff training, less use of digital platforms for monitoring and reporting. The similar results were noted in peri-urban slums of Karachi, Pakistan which is mixed method study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12-23 months, held in 2017, that revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated, the main reason behind these results are lack of parent knowledge, awareness and misconception about vaccines and socioreligious factors (Yazdaniet al., 2021).

The similar cross-sectional survey was conducted in immunization clinic at Vanivilas hospital, a government tertiary care center attached to Bangalore Medical College and Research Institute and a private pediatric clinic in Bengaluru (Josephet al., 2015). Data were collected from 200 parents/guardians (100 from each set up) using structured questionnaire administered by the investigators that revealed that 86% of total children were vaccinated, out of them only 28% parents were aware about vaccination, 70% didn’t know why vaccinations are given and 2% of total think that these are just nutritional supplements (Josephet al., 2015). The reason behind these results were unawareness, inaccessibility, in-convenience (Josephet al., 2015).

Figure 1:
Parental knowledge regarding child immunization.

Figure 2:
Response of parents to knowledge related questions.

A study conducted in Georgia shows similar outcomes in which the research is a cross-sectional study, 188 mothers with children from three to five years of age, were surveyed in 7 kindergartens of Tbilisi (capital city of Georgia) (Verulavaet al., 2019). The result in this study shows that 32% do not have sufficient information about the routine vaccination schedule. The reasons for incomplete vaccination are a lack of knowledge about a routine vaccination schedule (25.5%), limited information about the necessity of the second or the third dose of vaccination (18.6%), fear of post-vaccination side effects (16%) and fear of a child illness (9.6%) (Verulavaet al., 2019).

In contrast some studies show good knowledge of parents about child immunization. As stated in this study which is held in Iraq, A mixed method has been utilized in this study: a retrospective cohort study was used to evaluate immunization completeness; a prospective cross-sectional study was used to evaluate immunization knowledge of parents (Qutaibaet al., 2014). 528 children born between 1 January 2003 and 31 June 2008 were randomly selected from five public health clinics in Mosul, Iraq (Qutaibaet al., 2014). Immunization history of each child was collected retrospectively from their immunization record/card showing 66.1% of the parents was found to have adequate knowledge scores. The main reason is the parents’ good perception of vaccination benefits and risks; the parents thought that the immunization was mandatory; and/or the parents knew that immunization was required for school registration or day care attendance (Qutaibaet al., 2014).

Another cross-sectional study from Bangalore, India opposes our results and show that parents have better knowledge about child immunizations (Patelet al., 2017). The was a prospective study carried out on 110 parents residing in rural areas of Bangalore who had children below 5 years of age (Patelet al., 2017). The sociodemographic details of the parents were collected, and they were made to fill a KAP Questionnaire (Patelet al., 2017). Assessment of the extent of knowledge about child vaccination showed that a majority of them 72.7% had good knowledge score (Patelet al., 2017). The level of knowledge about child vaccination amongst parents is often determined by their education level and several studies have tried to find association between these two variables (Patelet al., 2017).

Similar study from the Kingdom of Saudi Arabia, also gives appropriate parent’s knowledge about child immunization (Alagsam and Alshehri, 2019). The study is a cross-sectional online survey study that was carried out in 500 parents having at least one child in Saudi Arabia for 2 months from October and November 2018 (Alagsam and Alshehri, 2019). The questionnaire included four different parts i.e., the first part involved questions about the demographics as age, education, working status, and a number of children (Alagsam and Alshehri, 2019). The higher knowledge level was significantly related to female gender, urban area residence, and higher educational degree (Alagsam and Alshehri, 2019).

According to the association of knowledge with demographic factors reveal significant trends. The study revealed that there was a significant relation with occupation, number of children, residency, living class and health care professional in family, showing highly statistical association (p<0.001) with parent knowledge of child immunization. The association of knowledge with occupation is (p<0.001) having health care providers (99.2%) appropriate knowledge and (0.8%) inappropriate and non-health care providers (3.8%) appropriate and (96.2%) inappropriate knowledge. The health care providers are more likely to have access to medical knowledge, making them more informed about immunization compared to non-health care providers. Similarly, the number of children shows highly significant statistical association (p<0.001) with the parents having 1-2 children had appropriate knowledge (99.2%) and (0.8%) inappropriate knowledge. The parents having 3-4 children had only (7.7%) appropriate knowledge and (92.3%) inappropriate knowledge. The parents having 5-6 children had (4.3%) appropriate knowledge and (95.7%) inappropriate knowledge, the results shows that parents with fewer children have more time and resources to learn about health care practices while those with more children are less informed. The association of knowledge with residency is highly significant (p<0.001) which includes urban area with (99.2%) appropriate knowledge and (0.8%) inappropriate knowledge and rural area with (3.8%) appropriate knowledge and (96.2%) inappropriate knowledge, showing that urban areas have better access to health education resources compared to rural areas where the resources may be scarce. Similarly, moving towards living class, having highly statistical analysis (p<0.001), the upper class had (99.1%) appropriate knowledge and (0.9%) inappropriate knowledge, the middle class had (7.7%) appropriate knowledge and (92.3%) inappropriate knowledge and lower class had (4.3%) appropriate knowledge and (95.7%) inappropriate knowledge, stating that higher socioeconomic status correlates with better access to education and health care resources, enabling upper class parents to be well informed about immunization. The association of knowledge with health care professional in family is (p<0.001) indicating, health care professional in family had (99.2%) appropriate knowledge and (0.8%) inappropriate knowledge, and without health care professional in family had only (3.8%) appropriate knowledge and 96.2% inappropriate knowledge as, families with health care professionals are likely to receive accurate health information which enhances immunization knowledge.

The association results were similar with the study revealing parents of 7695 children 19 to 35 months of age sampled by the National Immunization Survey were administered the National Immunization Survey Parental Knowledge Module between the third quarter of 2001 and the fourth quarter of 2002 (Smithet al., 2006). Health care providers were defined as a physician, nurse, or any other type of health care professional stating that the association of healthcare providers in family had a positive association with knowledge among children whose parents believed that vaccines were not safe, those whose parents’ decision to vaccinate was influenced by a health care provider had an estimated vaccination coverage rate that was significantly higher than the estimated coverage rate among children whose parents’ decision was not influenced by a health care provider (74.4% vs 50.3%; estimated difference: 24.1%) (Smithet al., 2006).

Another similar cross-sectional study using a pre- and post-test intervention survey of a single group was conducted among Malaysian parents (Awadhet al., 2014). Changes in total knowledge score before and after the intervention were measured using a validated questionnaire which states that Parents’ knowledge about childhood immunization increased significantly after the intervention compared to the baseline results (p<0.001) (Awadhet al., 2014). There were significant differences between parents’ knowledge and their educational level and monthly income (p<0.001, p=0.005), respectively (Awadhet al., 2014).

Similarly, some other studies related to association is a mixed method study: a retrospective cohort study was used to evaluate immunization completeness; a prospective cross-sectional study was used to evaluate immunization knowledge of parents (Qutaibaet al., 2014). 528 children born between 1 January 2003 and 31 June 2008 were randomly selected from 5 public health clinics in Mosul, Iraq showing a significant association of immunization completeness with total knowledge groups (p<0.05) was found (Qutaibaet al., 2014).

A similar association study relating to our study is a prospective cross-sectional study design in Iran (Al-lelaet al., 2014). Immunization knowledge and practices among 528 Iraqi parents were evaluated through validated questionnaire, showing significant associations for knowledge-practice groups with father’s education level, mother’s education level, mother’s age at delivery, number of preschool children, parent’s gender, family income, provider types, and birth place (p<0.05) (Al-lelaet al., 2014).

The presence of healthcare professional in family is observed to be positively associated with the level of knowledge of parents, in the present study. However, a cross-sectional observational study conducted in Lahore, Pakistan upon knowledge, attitude and practices of respondents on oral health, presented similar results i.e., presence of healthcare professional in family greatly enhances the knowledge of respondents (Shahidet al., 2024). Similarly, another study conducted on Pakistani population on knowledge, attitude and practices of Japanese encephalitis also presented the similar results that presence of healthcare professional is family is positively associated with the knowledge of respondents (Shahidet al., 2024).

The majority of parents do not have appropriate knowledge regarding their child immunizations; this could lead to potential adverse effects on children’s health, leading to increase in the incidence of vaccine preventable diseases. Public health awareness campaigns should be conducted to enhance the knowledge of parents.

The study emphasizes the critical need for educational interventions to improve parenteral knowledge regarding child immunization particularly in rural areas, where the awareness of child immunization is significantly lower compared to urban areas. A substantial percentage of parents lack appropriate knowledge about vaccination which correlates with various demographic factors such as education level, number of children, living class, residency, occupation and health care in family. It states that enhancing access to health education resources and addressing misconceptions about vaccines are essential steps to increase vaccination to ensure better health outcomes for children.

The authors would like to acknowledge the Lahore University of Biological and Applied Sciences for ethically approving this research project. Moreover, the authors would like to present their sincere gratitude to all the study participants who willingly participated in this research project.