Malaysian Journal of Public Health Medicine 2023, Vol.

23 (3): 208-215

ORIGINAL ARTICLE

PARENTS’ ATTITUDES REGARDING CHILDHOOD VACCINATION WITH FOCUS ON

ROTAVIRUS VACCINATION IN BISHKEK, KYRGYZSTAN

Iana Kirillova1, Nimetcan Mehmet Orhun2, Alabed Ali A. Alabed3 and Salih Mollahaliloglu2
1Public
Health Department, Institute of Health Science, Ankara Yıldırım Beyazıt University, Türkiye.
2Public
Health Department, Faculty of Medicine, Ankara Yıldırım Beyazıt University,Türkiye,
3Community Medicine Department, Faculty of Medicine, University of Cyberjaya, Cyberjaya, Selangor, Malaysia

Corresponding author: Iana Kirillova

Email: [email protected]

ABSTRACT

The aim of this study is to determine the parental attitudes regarding childhood vaccinations with focus on rotavirus
vaccination. It is a cross-sectional study using the Parent Attitudes about Childhood Vaccines (PACV) questionnaire. This
study was conducted among parents, who have at least one child in Bishkek city, Kyrgyzstan, that began on April 4th 2023
- 4th May 2023. At enrollment, parents completed the PACV questionnaire, to screen for vaccine hesitancy. PACV is a
questionnaire that includes 15 questions with three factor domains: “General attitudes”, “Behavior” and “Safety and
efficacy”. The prevalence of vaccine hesitancy was 21,3% among the participants in this study. Parents had concerns
about safety of vaccine shots 19,9%, side effects of rotavirus vaccine 24,8%, efficacy of rotavirus vaccine 13,6% and the
number of administered vaccines (18,1% to get fewer vaccines and 29,8% for more shot). This study investigates the
differences in childhood and rotavirus vaccine hesitancy by ethnicity (p=0.01) and educational background (p=0.04). The
study findings show that there is a vaccine hesitancy among the parents (21,3%) in Bishkek city regarding childhood
vaccination and rotavirus vaccine. Concerns of the parents were mostly associated with vaccine shots safety in general,
as well as about the side effects and efficacy of rotavirus vaccine.

Key words: childhood vaccination, vaccine hesitancy, rotavirus vaccination, attitudes, Kyrgyzstan

INTRODUCTION attributable to rotavirus infection 4. The burden of

rotavirus infection is supported by studies from
Vaccination is one of the main preventive other countries. The study regarding the
measures in national health care systems. Over the significance of burden of rotavirus infection
past years newer vaccines have been rapidly conducted in Libya, demonstrated high incidence
introduced or are under the consideration to be of rotavirus diarrhea among children aged 5 years
introduced into the National Immunization and below5. Another study regarding rotavirus
Programmes (NIPs) across the globe. There is an vaccination among children conducted in Libya
established system of immunization in Kyrgyzstan, have identified, that 57% of diarrhea that is
with coverage rates of more than 96% of the treated in hospital, was caused by rotavirus
population for main types of antigens. However, infection in Libyan children under 5 years old 6.
there are still emerging infections that continue Severe rotavirus burden and rotavirus-related
causing high rates of mortality and morbidity mortality across the globe require effective
among the population and that requires immediate interventions7. Thus, the introduction to the
bold actions at the country level. National Immunization Schedules of rotavirus
vaccines is recommended by World Health
Globally, rotaviruses are the leading cause of Organization (WHO) since 2009. The Ministry of
severe, dehydrating diarrhea in children under five Health of Kyrgyzstan has introduced RotaSiilTM,
years of age that led to about 500 000 childhood based on successful roll-outs in India, Niger and
deaths. It is also the reason of big amount of Uzbekistan7,8. Over the past years India was
hospitalizations which were about 2 million in considered as a reliable producer of vaccines,
20001,2. According to WHO estimates, about which are WHO pre-qualified with safety, high
215,000 children under five years die each year quality and effectiveness ensured9,10.
from rotavirus infections and with majority of
cases in children from low-income countries. In Distribution and development of vaccines
Kyrgyzstan, approximately 54 deaths occur from considered to be public health’ greatest
rotavirus annually among children under five achievements, leading to child survival and
years3. And according to WHO estimates, about improved health outcomes globally11,12. The Global
40% of hospitalizations in Kyrgyzstan are Vaccine Action Plan (GVAP) for 2011-2020, set
Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

targets for childhood vaccinations, i.e. to reach Participants were also informed that they have full
90% vaccination coverage with all vaccines in the right to discontinue or refuse to participate in the
NIPs by 202013. The Immunization Agenda 2030 study. The survey was adapted for the use in the
which is the GVAP’s successor, was developed to Kyrgyzstan context, e.g., education level (primary
further increase and ensure an equitable access to school 4 years, lower secondary school 5 and upper
all routine vaccinations, and proposed to increase secondary school 2 years, bachelor degree and
the number of zero-dose children who have missed master’s degree/PhD).
by current immunization programmes in every
country by 203014,15. Therefore, maintaining and IBM SPSS Statistics version 23.0. was used to
sustaining high vaccination coverage is vital for analyze the data. Each of the 15 PACV survey items
Immunization Agenda 2030 targets according to the Opel et al.’s approach19 was
achievement16,17. However, the fast production, scored as follows: hesitant responses are assigned
distribution and introduction of new vaccines into as 3, ‘don’t know or not sure’ as 2, and non-
NIPs has raised questions, possible suspicions, hesitant responses as 1. Item scores were summed
concerns among the population that all somehow in an unweighted fashion to obtain a total raw
may influence the parenteral acceptance of score. The total raw score was then converted to a
childhood vaccines. Thus, in order to develop and scale ranging from 0 (least hesitant) to 100,
test interventions to address these barriers it is indicating the highest level of vaccine hesitancy,
crucial to understand the barriers of immunization using simple linear transformation, with a score <
acceptance among vaccine-hesitant parents (VHP). 50 that identified non-hesitant parents, while a
Vaccine hesitancy is very complex and may appear score ≥ 50 that identified vaccine hesitant parents.
with different vaccines, different time and place. For significancy level we used p= 0.05 and Chi
Vaccination delay or refusal may be as a result of Square was used.
such factors as confidence in vaccines,
complacency or convenience18. Sustaining high RESULTS
vaccination rates is a priority for National
Immunization Programmes. It is therefore Total 411 participants have completed the
important to address such barriers as vaccine questionnaire. However, the database cleaning
hesitancy as a growing issue globally18. The aim of process have revealed some missing answers in
this study is to assess the attitudes of parents of questionnaire items and 8 participants were
Kyrgyzstan and concerning childhood vaccination excluded from the data analysis, finally 403
with a focus on rotavirus vaccine. participants were included into this analysis.

MATERIALS AND METHODS Participants’ socio-demographic characteristics

The most commonly reported age range was 30-39
This study was designed as a cross-sectional study. years (36%) and female participants made up the
Quantitative method was used in order to assess majority of this study (62,5%), the majority were
and analyze the attitudes of parents regarding the married (75,4%), and the majority of the
childhood vaccination with focus on rotavirus participants were Kyrgyz parents (74,4%). More
vaccine. Data for the study was based on the than half of participants had bachelor’s degree
Parent Attitudes about Childhood Vaccines (PACV) (60%). The majority of respondents had 2 – 3
questionnaire, that included 15 questions with children (67,7%) Table 1.
three factor domains: “General attitudes”,
“Behavior” and “Safety and efficacy”. The target Overall, 21,3% (n = 86) of participants were
population were parents with children. identified as vaccine hesitant and 78,7% (n=317) of
Participants were selected using convenient non-hesitant parents (Table 1). The Chi-Square test
sampling technique from Bishkek city of has revealed that there were statistically
Kyrgyzstan. The PACV questionnaire was translated significant differences in childhood and rotavirus
into Russian and Kyrgyz languages prior to the vaccine hesitancy by ethnicity (p=0.01). Kyrgyz
distribution among the study respondents. The participants were more vaccine hesitant compared
data was collected through google survey between to other ethnic groups and educational background
April 2023 - May 2023, with the description of the (p=0.04) of the participants, the highest hesitancy
objective of this survey distributed through social was found among bachelor degree graduated
media (What ‘sap and Facebook). The privacy of parents followed by secondary school graduated
participants was kept and the questionnaire did parents. There were no statistically significant
not include personal information, such as name, differences by other socio-demographic
address, phone number and email address. characteristics of the participants (p value > 0.05).
Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

TABLE 1: The level of vaccine hesitancy among study respondents by socio-demographic characteristics.

Variable Vaccine hesitancy P value

Non-hesitant Hesitant

F % F %

Age range (years) .584

18-29 35 8.7 6 1.5
30-39 114 28.3 31 7.7
40-49 93 23.1 24 6
50 and above 75 18.6 25 6.2
Gender .430
Male 120 29.8 31 7.7
Female 197 48.9 55 13.6
Ethnicity .016
Kyrgyz 245 60.8 55 13.6
Russian 37 9.2 20 5
Other 35 8.7 11 2.7
Marital status .386
Married 244 60.5 60 14.9
Divorced 54 13.4 19 4.7
Widower/widow 19 4.7 7 1.7
Occupational status .474
Healthcare worker 34 8.4 4 1
Housewife 58 14.4 16 4
Government servant 47 11.7 12 3
Private sector 90 22.3 25 6.2
Other 88 21.8 29 7.2
Educational level .043
Illiterate 1 0.2 1 0.2
Primary school 2 0.5 2 0.5
Lower and upper 63 15.6 28 6.9
secondary school
Bachelor’s degree 198 49.1 44 10.9
Master’s degree/PhD 53 13.2 11 2.7
Number of children .279
1 child 64 15.9 16 4
2-3 children 218 54.1 55 13.6
4 children and more 35 8.7 15 3.7
Total 317 78.7 86 21.3 .410
*Chi-Square test - P value = 0.05

Parenteral attitudes about vaccination childhood vaccine shots. Further, only 3,7% of
A summary infographic of individual survey items parents reported delaying a vaccination for their
and results depicting vaccine hesitancy is provided child for reasons other than illness or allergy, and
above in the Figure 1. Overall, 78,7% of survey 4,2% reported deciding not to have their child get
respondents held positive attitudes towards a rotavirus vaccine shot for reasons other than
childhood vaccination and considers vaccine- illness or allergy.
preventable diseases to be severe and vaccines
against these diseases to be effective. The vast Vaccine hesitancy
majority of respondents recognized the efficacy of Parents’ answers to the 15 items (PACV) used to
vaccines. Overall, 72,7% of respondents believed calculate the vaccine hesitancy score presented in
that it would be better for their children to get a the Figure 1. Overall, parents’ answers in this
shot of rotavirus vaccine rather than to develop study were generally in favor of vaccines including
immunity by getting sick. Only, 8,2% were vaccination against rotavirus infection. However,
“disagree” or “strongly disagree”. 88,8% of parents results of our study showed that parents had
also recognized the importance of following the concerns regarding safety and efficacy of vaccines.
recommended shot schedule of rotavirus vaccine. 24,8% of parents were concerned if their children
73,7% of parents indicated them self as “not will have a serious side effect from a shot of
hesitant at all” and “not too hesitant” regarding rotavirus vaccine and 18,6% of parents were not
Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

sure. Moreover, 19,9% of parents were “somewhat shots to their children. 71,7% participant was not
concerned” and “very concerned” regarding the sure if it is better to get fewer vaccines at the
safety of vaccine shots. Furthermore, 27,2% of same time. PACV questionnaire scores of
respondents had concerns whether rotavirus participants are presented in the figure 2. The
vaccine is enough efficient to prevent the disease. findings of the survey demonstrated the majority
The vast majority of respondents were not sure of participants were non-hesitant to childhood
whether the illnesses that shots prevent are vaccination. The highest scores were reported by
severe. The highest number of vaccine hesitant 53 participants who got 47 scores while 48
participants (29,8%) and “not sure” answers participants got 45 scores. Only few participants
(38,7%) was associated with the number of vaccine got more than 58 scores in this study.

Number of paeticipants (Total n=403)

It is better for children to get fewer vaccines at the same time? 41 289 73
It is better for my child to develop immunity by getting sick than to get a shot of rotavirus vaccine 293 77 33
Children get more shots than are good for them. 127 156 120
I am able to openly discuss my concerns about vaccines with my child’s doctor 376 207
I trust the information I receive about vaccines. 354 31 18
Overall, how hesitant about childhood shots would you consider yourself to be? 297 34 72
HowHow concerned are you that a vaccination against of rotavirus infection might not prevent the disease? 293 55 55
All things considered, how much do you trust your child’s doctor? 354 25 24
If you had another infant today, would you want him/her to get all the recommended shots including rotavirus
vaccine? 329 57 17
How sure are you that following the recommended shot schedule of rotavirus vaccine is a good idea for your
child? 358 12 33
Have you ever decided not to have your child get a rotavirus vaccine shot for reasons other than illness or
allergy? 386 017
Have you ever delayed having your child get a rotavirus vaccine shot for reasons other than illness or allergy? 388 015
How concerned are you that any one of the childhood shots might not be safe? 300 23 80
How concerned are you that your child might have a serious side effect from a shot of rotavirus vaccine? 228 75 100
I believe that many of the illnesses that shots prevent are severe. 330 61 12

0 100 200 300 400 500

non-hesitant not sure hesitant

FIGURE 1. Responses to individual PACV survey items

60
53
50 48
Number of participants

39
40 35
32 32
30
30 26
23
20 15
13
9 9 8
10 7 6
5
1 1 2 1 1 2 1 2 1 1
0

PACV Survey score

FIGURE 2. PACV questionnaire scores of participants.

Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

DISCUSSION used PACV instrument to determine vaccine

hesitancy rates. For instance, results of the study
In this study we have gathered essential using PACV in Irish population22 showed that 6,7%
information about parents’ general attitudes, of parents were vaccine hesitant. Another study
behavior and intentions about vaccination with conducted in Quebec, Canada23 showed that 15% of
different educational and occupational parents hesitant about the vaccination of their
backgrounds with at least one child. Our findings children. In Malaysia24, findings of another cross-
show that most parents (78,7%) held positive sectional survey showed 11,6% of vaccine hesitant
attitudes toward vaccination, while 21,3% of parents. There were different rates of vaccine
participants were vaccine hesitant. The similar hesitancy in different similar studies, for example
findings were observed in the study conducted in in Seattle 25 with 26% of vaccine hesitant parents
Türkiye, where 72,2% of parents had good and also in Italy with 35% of parents that
attitudes about the vaccination of their children20. represents a higher level of vaccine hesitancy.
It is noteworthy that despite the relatively high
level of parents that considered to be hesitant In this study the issues that parents were mostly
regarding childhood shots (21,3%), they still decide concerned about were doubts in safety of vaccine
to follow the recommended shot schedule shots with 19,9% of vaccine hesitant parents and
including rotavirus vaccine and represented 88,8% also doubts in believing that many of the illnesses
of parents in our study. However, in our study that shots prevent are severe with 15,1% of
71,7% of respondents were not sure if it is better parents responding “not sure” and 3% who were of
for their children to get fewer vaccine at the same “strongly disagree”. There were also concerns
time, as well as another 18,1% of parents were regarding rotavirus vaccination, in particular
strongly disagreeing with this statement. The regarding the side effects of rotavirus vaccine,
highest number of vaccine hesitant responses in representing 24,8% of vaccine hesitant parents.
our study were associated with the item saying 13,6% of parents responded “not sure” and 13,6%
children get more shot than are good for them “very concerned”, thus have expressed concerns in
with 29,8% of parents who were strongly disagree rotavirus vaccine efficacy that allegedly might not
with this and 38,7% of parents who were not sure. prevent the disease. These findings are in line with
These findings may be associated with insufficient the study results that was conducted in 2014,
or inappropriate level of knowledge regarding aimed to determine parental preferences
vaccine-preventable diseases and immunization, regarding rotavirus vaccination of their child. The
misinformation and miscommunication about study found that parents were mostly being driven
vaccination among participated parents or lack of by out-of-pocket costs, vaccine effectiveness,
communication with healthcare practitioners. frequency of severe side effects and duration of
These findings are in line with one of the protection. Parents were even willing to accept
conducted studies, aimed to understand the lower effectiveness of vaccine if this would imply a
psychological determinants of parents’ acceptance lower frequency of severe side effects 1 in
to vaccinate their children with rotavirus vaccine. 1,000,000 instead of 1 in 10,00026.
Study results demonstrated that parents
increasingly became aware and supportive about Another cross-sectional study has been conducted
the national vaccination program in Ethiopia, assessing the vaccine hesitancy
recommendations and specifically when this was regarding COVID-19 vaccine and it’s reasons that
delivered by healthcare practitioners, as identified high vaccine hesitancy rates associated
healthcare providers are knowledgeable and hold with fear of side effects and vaccine
positive attitudes towards rotavirus vaccination effectiveness27. But again, 81,6% of parents
and national immunization programmes declared that would vaccinate future children,
generally21. This study is one of the examples which suggests that while parents have concerns in
reiterating that proper communication and work number of vaccine shots at the same time, vaccine
between healthcare providers and general safety and side effects, they may still choose to
population is crucial in order to avoid unnecessary vaccinate their children despite these concerns.
delays or rejections to vaccinate their children and The fear of side effects is one of the most frequent
thus to ensure high vaccination coverage. reasons when parents refusing at least one shot of
a vaccine for their children. This statement is
Although, the prevalence of non-hesitant supported by previous studies and considered as an
respondents was relatively high, 21,3% of parents important barrier for vaccine uptake. The results
had a score of 50 or higher on the PACV scale that of the multivariate regression analysis of a cross-
represents a high level of vaccine hesitancy, this sectional study conducted in Italy26,27 showed that
also indicates that vaccine hesitancy is an vaccine hesitancy was more likely among parents
important issue in Bishkek. These findings are who were worried about the side effects and
comparable with other prevalence studies that vaccine safety. Therefore, increasing parental
Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

knowledge about vaccine safety and importance of vaccine into their NIPs, reported a large decline in
childhood vaccination through educational rotavirus disease and associated hospitalizations.
materials and healthcare workers must be a Thus, the benefits of rotavirus vaccination in
priority21. Interestingly, the biggest number of infants have been found to outweigh possible small
parents expressing concerns in vaccine safety were risks of intussusception.
with high level of education, i.e. with bachelor
degree (51,6%) following by participants graduated A number of limitations should be taken into
from lower and upper secondary school with 9 or account when interpreting findings of this study
11 years of education (19,4%). Results of our study due to study design and methodology. Firstly, is not
also revealed a big difference among participants possible to establish the temporal direction of the
with different ethnicities, Kyrgyz by ethnicity association between the outcomes of interest and
participants made up the major proportion (13,6%) the influencing factors in the cross-sectional study.
of vaccine hesitant participants. Similar study was Secondly, this study does not assess knowledge of
conducted in USA that assessed parental vaccine parents regarding childhood vaccination and
hesitancy and examined differences in coverage therefore we only can assume or hypothesize the
owing to hesitancy by ethnicity. Study results nature of findings. Thus, there may be a need in
revealed that hesitancy towards childhood another in-depth research with larger sample size.
vaccines was associated with child’s ethnicity/race Lastly, this study was not designed to identify
and educational level of mothers. Study results which measures might be taken to address the
demonstrated that non-Hispanic white population problems in it. A strength of this study is the use of
were less vaccine-hesitant (16,4%) compared to a previously validated survey instrument (the
non-Hispanic Black (37%) and Hispanic (30,1%). PACV) to determine vaccine hesitancy in parents.
Moreover, study revealed that mothers with less
then a high school education were more likely to CONCLUSION
be vaccine hesitant (31,9%) then mothers with
college education and above (13%) 30. Further, In conclusion, majority of the participants (78,7%)
noteworthy that among the healthcare workers had positive attitudes towards childhood
participated in this survey were the lowest number vaccination, while 21,3% of them had vaccine
of vaccine hesitant responses, which may be hesitancy in Bishkek city. This study found that the
assumed with the nature of their profession and differences in childhood and rotavirus vaccine
knowledge on health-related issues. hesitancy by ethnicity and educational background
of the participants. The findings of this study
These results are supported by the study aimed to report that most of the parents were non hesitant
examine healthcare practitioners to deliver the in numerous areas, such as intention to vaccinate
vaccine21. Study results demonstrated a general their children with rotavirus vaccine, trust in
positive attitude in healthcare providers to deliver information about vaccines. Parents expressed
national vaccination programmes, specifically their concerns regarding the safety of vaccine
rotavirus vaccination to the population. The study shots in general, efficacy of rotavirus vaccine and
also revealed that public knowledge and potential side effects of rotavirus vaccine.
acceptance of rotavirus vaccine is better when the
recommendations are delivered by their ETHICAL CONSIDERATIONS
healthcare practitioner. Moreover, according to The approval for this study was granted by Social
WHO, all available rotavirus vaccines are and Human Sciences Ethics Committee Ankara
prequalified by WHO with good safety profile. Yildirim Beyazit University (AYBU).
Intussusception, which is an intestinal invagination
resulting in obstruction, is the only adverse event AUTHOR CONTRIBUTIONS: Study design, data
associated with rotavirus vaccine and no other side collection, original draft preparation, formal
effects has been reported or identified4. Thus, the analysis Iana Kirillova; Contribution to study
findings of prospective study in USA31 suggested an design, review and editing the draft Salih
increased risk of intussusception associated with Mollahaliloğlu, Nimetcan Mehmet Orhun and Abed
monovalent rotavirus vaccination. This finding is in Ali. All authors have read and agreed to the
consistent with findings from other countries, for published version of the manuscript.
example the study in Mexico showed a significant
increase in the risk within 7 days after the first FUNDING: This research received no external
dose of the monovalent vaccine32. The study in funding
Brazil revealed a doubling of the risk within 7 days
after the administration of the second dose of ACKNOWLEDGMENTS: The research team would
monovalent rotavirus vaccine32. However, the well- like to acknowledge and thank the parents who
documented benefits of rotavirus vaccine need to completed the survey.
be considered as countries that included rotavirus
Malaysian Journal of Public Health Medicine 2023, Vol. 23 (3): 208-215

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