RRL haha

Arceo, E., Dizon, J. C., Chavez, M., Cordero, P. K., de Leon, M. R., de Luna, J., ... & Tiongco, R.
E. (2021). Knowledge, attitude, and practices of mothers from a rural community in Pampanga,
Philippines toward childhood immunization: A cross sectional survey. Vacunas (English Edition),
22(3), 183-188

Many studies report that a significant portion of mothers have good knowledge and a positive
attitude toward childhood vaccination, yet compliance or practice sometimes lags behind. For
example, one study found 72% of mothers had good knowledge and 100% had a positive
attitude, but practices varied. Another found good knowledge (86.3%) and attitudes (94.8%) but
only 43.3% showed good vaccination practices
Almutairi, W. M., Alsharif, F., Khamis, F., Sallam, L. A.,
Sharif, L., Alsufyani, A., Alshulah, F. N., & Alqasimi, R.
(2021). Assessment of Mothers' Knowledge, Attitudes, and
Practices Regarding Childhood Vaccination during the First Five
Years of Life in Saudi Arabia. Nursing reports (Pavia, Italy),
11(3), 506–516. [Link]

Many studies reveal that a significant portion of mothers hold good knowledge and positive
attitudes toward childhood immunization, yet their actual vaccination compliance or practices
may not fully align with this knowledge. For example, in a Sudanese study, the average
maternal knowledge score about vaccine names and timing showed some gaps, despite 99.2%
having a positive attitude toward immunization. Only about half of children were fully immunized,
with factors like hospital delivery and vaccination card availability linked to higher completion
rates. This suggests that while mothers generally understand vaccine importance, practical
barriers sometimes limit full compliance, emphasizing the need to address such barriers
alongside education efforts
Ali, A. H. M., Abdullah, M. A., Saad, F. M., & Mohamed, H. A. A.
(2020). Immunisation of children under 5 years: mothers'
knowledge, attitude and practice in Alseir locality, Northern
State, Sudan. Sudanese journal of paediatrics, 20(2), 152–162.
[Link]

Research consistently shows that even when mothers have positive attitudes toward
vaccines and believe in their safety, gaps in detailed knowledge about vaccination
schedules, purpose, and vaccine-preventable diseases remain. For instance, some
mothers may not fully understand the timing or rationale of specific vaccine doses.
These knowledge gaps can negatively affect adherence to recommended immunization
schedules, signaling a need for more targeted education focusing not only on vaccine
benefits but also on logistical details to improve compliance.​
Webb, J. A., & Williams, A. L. (2018). Maternal vaccine knowledge in low- and
middle-income countries: An overview of barriers and opportunities to improve
immunization coverage. Vaccine, 36(52), 7908-7914.
[Link]

RRL
Importance of infant immunization for child immunization for child survival

The importance of infant immunization for child survival is well-established through

extensive research and literature. Immunization programs have significantly reduced
infant and child mortality rates by preventing vaccine-preventable diseases such as
measles, diphtheria, pertussis, poliomyelitis, and neonatal tetanus. Studies estimate
that vaccination has contributed to a substantial decline in global infant mortality
since the 1970s by protecting infants from fatal infections and reducing morbidity. For
example, a comprehensive analysis showed that without vaccination since 1974, infant
mortality rates would have been considerably higher worldwide, confirming that
vaccines have played a major role in the observed decline in infant deaths.​
Infant immunization plays a crucial role in child survival and is supported by extensive
studies and literature worldwide. The immunization programs have significantly
increased the infant survival rates by protecting against vaccine-preventable diseases
such as, measles, diphtheria, pertussis, poliomyelitis and neonatal tetanus. According to
Shattock et al. (2024), when the expanded vaccination program started in the 1970s, it
greatly contributed to the decline of infant mortality for about 40% of the rate. That
saves an estimated of 154 million lives by protecting the infants from the fatal diseases
through conducting the vaccination program
In India, the Universal Immunization Program(UIP), initiated in 1985, aims to protect
children and pregnant women from the infectious disease through systematic
vaccination. The program has made a significant contribution in reducing infant and
under-five (5) mortality through the increase of vaccine coverage. Kumar, S. (2024)
indicates that immunization not only affects the decreasing rate of mortality but also
improves the long-term outcome, such as children’s educational attainment and overall
health as they grow. Additionally, in the study of Mirza et al (2023) it showed that the
vaccines under the expanded program on immunization (EPI), does not only contribute
to preventing disease-related deaths but also provides a much broader health benefits.
One of the given examples is the measles vaccine that provides in strengthening the
immune system, which helps to protect the body from other infections and diseases.
Children who received the full basic vaccine under the Expanded Program in
Immunization (EPI) by 12 months, performed better results in cognitive test in reading
(OR: 1.60), writing (OR: 1.77) and math (OR: 1.87) compared to the partially or
unvaccinated children, indicating that having children immunization improved the
cognitive development and educational outcomes (Joe, W. & Kumar Verma, A., 2022).

Furthermore, Garcia et al. (2016) emphasized that appropriate and timely immunization
has a significant impact for the child's survival. Despite the challenges posed by the
lack of balance in socio-demographic factors in vaccination coverage, global efforts
prevented millions of child deaths and decreased the burden of the infectious diseases
especially the infants in low-resources areas. Showing the critical role of vaccination in
reducing the long-term health consequences that are associated with the disease such
as having disabilities and lifetime maintenance, that emphasized the survival and
quality of life (Nandi et al., 2020)

In summary, this literature shows a strong support on how critical the role of infant
immunization is in child survival by reducing the infants mortality and morbidity
associated with the vaccine-preventable diseases (Nandi et al., 2022). Stating that
immunization is one of the essential foundations in public health strategies aimed in
protecting infant lives and promoting sustainable health improvements across the
population ( Tamir et al., 2025).

Stating that immunization is an essential foundation in public health strategies aimed at

protecting infant lives and promoting sustainable health improvements across the
population ( Tamir et al., 2025).
Shattock, A. J., Johnson, H. C., Sim, S. Y., Carter, A., Lambach, P., Hutubessy, R. C., ... & Bar-Zeev, N.
(2024). Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded
Programme on Immunization. The Lancet, 403(10441), 2307-2316.

Kumar, S. (2024). The Effects of Childhood Immunization Program on Health and Education:
Micro-Evidence from India. IZA-Institute of Labor Economics.

Mirza, I., Lemango, E. T., & Lindstrand, A. (2025). Expanded Programme on Immunization (EPI): A
Legacy of 50 Years and the Road Ahead. Vaccines, 13(6), 649. [Link]

Joe, W., & Kumar Verma, A. (2022). Association of basic vaccination with cognitive and learning
ability among children: insights from the India Human Development Survey, 2004–05 and
2011–12. Journal of Biosocial Science, 54(2), 243–256. doi:10.1017/S0021932020000760

Garcia, É. M., Waldman, E. A., Toriyama, A. T. M., & Sato, A. P. S. (2016). Delayed vaccination of children
up to 2 years of age. Public Health Nursing, 39(6), 1188-1194.
Nandi, A., & Shet, A. (2020). Why vaccines matter: understanding the broader health, economic, and
child development benefits of routine vaccination. Human vaccines & immunotherapeutics, 16(8),
1900–1904. [Link]

Nandi, A., Summan, A., Ngô, D. T., & Bloom, D. E. (2022). Childhood vaccinations and demographic
transition: Long-term evidence from India (No. 15508). IZA Discussion Papers.

Tamir, T. T., Tekeba, B., Techane, M. A., Alemu, T. G., Wubneh, C. A., & Wassie, Y. A. (2025). Coverage
of complete basic childhood vaccination and its variation by basic characteristics among children aged
12–23 months in 41 low-and middle-income countries: A Meta-analysis of demographic and health survey
reports between 2015 and 2025. Vaccine, 54, 127019.

Immunization. In this study, this term refers to the process of making an individual resistant to a

disease by administering a vaccine to the body in order to stimulate the immune system to

recognize and fight the disease-causing agent and build up immunity against the disease (World

Health Organization [WHO], 2025).

​ Vaccination. This term refers to an act of receiving a vaccine through injection or oral

dose that contains a small amount of weakened or dead part of the disease-causing agent for the

body to build an immunity against it. (World Health Organization [WHO], 2019).

​ Knowledge. In this study, this term refers to the understanding and awareness of the

mother towards the context of immunization, its importance, benefits and as well as the right

schedule of the vaccination for their children (Maryati et al., 2025).

Attitude. This term refers to the individual’s feelings, beliefs, and predispositions

towards immunization that affects their intention and behavior towards vaccine

acceptance (Tamir et al., 2025).

Compliance. In this study, this term refers to the extent to which an individual follows

the recommended vaccination schedule and public health guidelines provided to them.
 Public Health Efforts. This is defined as organized activities and strategies carried out

by the health authorities and organizations aimed at promoting, supporting, and

implementing the vaccination programs to prevent disease and improve community

health.

Expanded Program on Immunization (EPI). A global public health initiative that is

established by the World Health Organization (WHO) in May 1974 to provide a routine

vaccination to all children, in all countries, protecting them to vaccine-preventable

diseases such as diphtheria, pertussis, tuberculosis, polio, tetanus, and measles ( World

Health Organization [WHO], 2025).

Infant. This term refers to the child from birth up to 12 months of age, which is the

primary target group for the immunization due to their vulnerability and having a high

risk of acquiring vaccine-preventable diseases (World Health Organization [WHO],

2025).

Vaccine hesitancy is defined as the refusal of an individual to a vaccine despite the

availability of the vaccination services. In 2019, the World Health Organization (WHO)
named the Vaccine hesitancy as one of the top 10 global health threats slowing down
the progress of some vaccines and cause of failure to achieve the optimal
immunization coverage worldwide (Bussink-Voorend et al., 2022).
In several studies that explored how mother’s attitudes affect their decisions towards
their children’s vaccination. Some shows that it is influenced by many factors, in the
study of Hemelka, t., et al (2025) it shows that a mother’s belief, fears and
understanding towards the vaccines strongly influences the compliance of the mother
to the vaccination schedule recommended by the healthcare team. A mother having a
positive attitude towards the healthcare workers, knowing the effectiveness and having
enough knowledge about the vaccine, can result in better compliance. However, if the
mother has a lack of knowledge about the vaccine, has distrust in the government
system and fears unknown adverse effects will increase the vaccine hesitancy and
more likely to delay or refuse the vaccination that can put the infant into a greater risk of
acquiring the vaccine-preventable diseases (Elbert, B et al., 2023).

According to Reñosa, M.D.C., (2023) misconception can also causes to increase the
hesitancy of the mothers towards the vaccine, such as thinking that it can cause illness
or any unnecessary side effects just because of what witness from the previous vaccine
such as the Dengvaxia controversy or the dengue vaccine in the Philippines, causing a
big negative impression towards the following vaccine, such as the decline of measles
vaccination from 88% in 2014 to 55% in 2018 and also revealed the delay of vaccination
among Filipino infants, approximately 39.3% of infants had delayed completion of
vaccination). Also, the misinformation from social media about false health risk can
change the mothers attitude and reduce the intention of their children being vaccinated
(Kuatewo, M. et al, 2025). Also, the ethnicity and socio demographic factors plays a
significant role in shaping the maternal attitudes towards the childhood vaccination as
the study in United States shows that a among the three groups, Black participants had
greater vaccine hesitancy (OR: 2.84 ), than South Asians (OR:1.66) and Middle East
Asians (OR: 1.48) (Nguyen, L.H., 2021).

Overall, the maternal attitude was constructed by complex factors including the
personal beliefs, cultural background or ethnicity, the level of trust for the healthcare,
and the exposure to different vaccine-related information that affect and address the
vaccine hesitancy and improving the childhood immunization coverage across diverse
populations.

Overall, maternal attitude is a complex construct influenced by personal beliefs, cultural

background, trust in healthcare, and exposure to vaccine-related information.
Addressing vaccine hesitancy at the maternal level is vital to improving immunization
coverage and protecting children from vaccine-preventable diseases.

Bussink-Voorend, D., Hautvast, J. L., Vandeberg, L., Visser, O., & Hulscher, M. E. (2022). A systematic
literature review to clarify the concept of vaccine hesitancy. Nature Human Behaviour, 6(12), 1634-1648.

Reñosa, M. D. C., Endoma, V., Sornillo, J. B., Bravo, T. A., Landicho‐Guevarra, J., Aligato, M., ... &
Inobaya, M. T. (2023). “Respect my opinion and I'll respect yours!”: Exploring the challenges, concerns,
and informational needs of vaccine‐hesitant caregivers and pregnant women in the Philippines. Public
Health Challenges, 2(3), e105.
Hemelka, T., Dedi, B., & Badi’ah, A. (2025). Mother’s Compliance in Providing Basic Immunization for
Infants Aged 0–12 Months. Journal La Medihealtico, 6(5), 1226-1247.

Kuatewo, M., Ebelin, W., Doegah, P. T., Aberese-Ako, M., Lissah,

S., Kpordorlor, A. G., Kpodo, L., Djokoto, S., & Ansah, E.
(2025). Fake news, misinformation, vaccine hesitancy and the
role of community engagement in COVID-19 vaccine acceptance in
Southern Ghana. PloS one, 20(6), e0316969.
[Link]

Nguyen, L. H., Joshi, A. D., Drew, D. A., Merino, J., Ma, W.,
Lo, C. H., Kwon, S., Wang, K., Graham, M. S., Polidori, L.,
Menni, C., Sudre, C. H., Anyane-Yeboa, A., Astley, C. M.,
Warner, E. T., Hu, C. Y., Selvachandran, S., Davies, R., Nash,
D., Franks, P. W., … Chan, A. T. (2021). Racial and ethnic
differences in COVID-19 vaccine hesitancy and uptake. medRxiv :
the preprint server for health sciences, 2021.02.25.21252402.
[Link]

Data gathering procedure

Elbert, B., Zainumi, C. M., Pujiastuti, R. A. D., Yaznil, M. R.,
Yanni, G. N., Alona, I., & Lubis, I. N. D. (2023). Mothers'
knowledge, attitude, and behavior regarding child immunization,
and the association with child immunization status in Medan City
during the COVID-19 pandemic. IJID regions, 8(Suppl), S22–S26.
Advance online publication.
[Link]