Vaccination Adherence Among Parents of Preschool-Aged Children

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BACKGROUND

An increasing number of people who refuse or delay vaccination could pose a serious obstacle for achieving epidemiological well-being.¹ As of 2024, global immunization coverage remained unchanged since 2022 and has not returned to the levels observed in 2019. In 2023, 84% of children received three doses of the diphtheria, tetanus, and pertussis vaccine, which is a key indicator of immunization status. Concurrently, the number of children who had not received a single dose of the vaccine increased from 13.9 million in 2022 to 14.5 million in 2023.¹ This reflects persistent problems related to the adherence of the population to vaccination.¹

Several examples demonstrate the serious consequences of neglecting vaccination. For instance, in 2019, over 1200 measles cases were reported in the United States, marking the highest number since the disease was eliminated in the country in 2000. This epidemiological setback occurred because of a decrease in vaccination rates among the population. The Orthodox Jewish community in New York City was among the most adversely affected groups, exhibiting the lowest vaccination coverage rates. From 2001 to 2019, 160 measles outbreaks were reported in the United States, with an average of 6 each year [1].

The 2017 measles outbreak in Italy was one of the most significant in recent history. The outbreak attracted attention to the issue of vaccination worldwide. Deaths from complications associated with measles have been recorded, most of which occurred among infants [2]. Epidemiological investigation revealed that increased tourism, an influx of migrants, and insufficient immunization coverage were the main factors that contributed to the outbreak. Overall, Italy’s immunization coverage was 85.3%; however, it was lower in the 7 most affected regions, where 4015 (90%) of the reported measles cases occurred [2].

Low vaccination adherence is a critical and multifaceted social phenomenon continually studied by foreign and Russian researchers [3–5]. In 2019, the World Health Organization identified lack of confidence in vaccination as among the global threats to humanity, together with air pollution, climate change, and antimicrobial resistance. Attitudes toward immunization and reasons for low vaccination compliance vary by region, vaccine type, and change over time.²

This study aimed to assess vaccination adherence among parents of preschool-aged children in selected cities in Russia and Belarus.

MATERIAL AND METHODS

A descriptive, cross-sectional study was performed using anonymous online questionnaires. The respondents were parents of children attending preschool educational institutions. The study was conducted from April 2023 to October 2024.

The study included adults from five cities in the Russian Federation and one city in the Republic of Belarus. Overall, 801 individuals were surveyed: 161 from Kazan, 111 from Almetyevsk (Republic of Tatarstan), 230 from Nizhny Novgorod (Nizhny Novgorod region), 76 from Makhachkala (Republic of Dagestan), 114 from Rybnoye (Ryazan region), and 109 from Gomel (Republic of Belarus).

The 16-question survey was developed using the Google platform. It included single-choice questions to obtain sociodemographic data, such as age, education level, number of children in the family, and income level, and multiple-choice questions to assess parents’ awareness of and attitudes toward vaccination aspects. The introductory section of the questionnaire provided parents with information about the purpose of the study and its anonymity. The collected information did not contain personal data. Before administering the survey in the participating cities, a pilot survey was conducted to confirm the validity of the questionnaire.

Statistical analysis was performed within the R 4.3.1 environment (RStudio)³. The type of distribution was determined using the Shapiro–Wilk criterion and QQ plots. Absolute values were presented as means with standard deviations (M ± σ) and relative values as intensive indices with a 95% binomial confidence interval (95% CI) or as a proportion with its standard error (P ± p). The mean was compared using a t-test for independent samples under the condition of normal distribution and the Mann–Whitney and Kruskal–Wallis criteria for independent samples with asymmetric distribution. Differences were considered significant at p < 0.05. All charts were plotted using Microsoft Excel.

CHARACTERISTICS OF RESPONDENTS

The parents who participated in the survey were predominantly women. The majority (85%) of respondents were aged 25–44 years. More than half of the respondents had higher education (50.5%–80.2%). Parents’ assessments of their income levels differed between cities. The largest percentage of high-income earners was among respondents from Kazan and Almetyevsk, whereas the largest percentage of low-income earners was among respondents from Makhachkala (61%). Overall, 70% of the families had 1–2 children. The largest number of families with ≥3 children was found in Makhachkala, Kazan, and Almetyevsk (Table 1).

 

Table 1. Characteristics of the respondent groups

Characteristics of respondents	City of residence
	Almetyevsk, n = 111 (%)	Gomel, n = 109 (%)	Kazan, n = 161 (%)	Makhachkala, n = 76 (%)	Nizhny Novgorod, n = 230 (%)	Rybnoye, n = 114 (%)	Total, n = 801 (%)
Women	111 (100)	108 (99)	137 (85)	75 (97)	219 (95)	114 (100)	728 (91)
Age
18–24 years old	20 (18)	2 (2)	42 (26)	4 (5)	3 (1)	3 (3)	74 (9)
25–34 years old	46 (41)	59 (54)	51 (32)	32 (42)	111 (48)	60 (53)	359 (45)
35–44 years old	44 (40)	46 (42)	45 (28)	34 (45)	105 (46)	48 (42)	322 (40)
≥45 years	1 (1)	2 (2)	23 (14)	6 (8)	11 (5)	3 (3)	46 (6)
M ± σ (years old)	33.4 ± 4.5	34.9 ± 5.6	33.8 ± 9.8	36.0 ± 7.1	29.6 ± 11.3	34.2 ± 5.8	33.7 ± 7.1
Education
Higher	89 (80)	55 (51)	126 (78)	51 (67)	183 (80)	71 (62)	575 (72)
Secondary vocational	22 (20)	36 (33)	34 (21)	9 (12)	32 (14)	33 (29)	166 (21)
Secondary	0	18 (17)	1 (1)	16 (21)	15 (7)	10 (9)	60 (7)
Income level
High	53 (48)	1 (1)	91 (57)	3 (4)	55 (24)	29 (25)	232 (29)
Upper-middle	45 (41)	11 (10)	57 (35)	23 (30)	81 (35)	37 (32)	254 (32)
Average	12 (11)	48 (44)	11 (7)	41 (54)	86 (37)	45 (39)	243 (30)
Lower-middle	1 (1)	8 (7)	2 (1)	5 (7)	5 (2)	2 (2)	23 (3)
Not specified	0	40 (38)	0	4 (5)	3 (1)	1 (1)	49 (6)
Number of children in the family
1	37 (33)	33 (30)	46 (29)	7 (9)	88 (38)	34 (30)	245 (31)
2	30 (27)	46 (42)	44 (27)	26 (34)	110 (48)	59 (52)	315 (39)
3	44 (40)	28 (26)	50 (32)	34 (43)	27 (12)	13 (11)	196 (24)
≥4	0 (0)	2 (2)	21 (13)	9 (12)	5 (2)	8 (7)	45 (6)

Note: M ± σ, mean ± standard deviation.

 

RESULTS

Parents play a critical role in deciding whether to vaccinate their children. Therefore, epidemiologists have focused on identifying factors that influence adults’ attitudes toward vaccination [6].

The majority of survey participants had a positive attitude regarding vaccination. The proportion of positive responses ranged from 56% in Makhachkala to 91% in Kazan, averaging 76.17% ± 11.7%. However, some respondents expressed a “distrustful,” “negative,” or, in a few cases, “strongly negative” attitude concerning vaccination (Fig. 1).

 

Fig. 1. Parental attitudes toward childhood vaccination in different cities.

 

Parents’ adherence to specific immunoprophylaxis was assessed by the proportion of responses, “I vaccinate my child with all vaccines in due time.” This indicator exhibited a significant variation, ranging from 22.5% ± 4.0% among respondents from Almetyevsk to 60.6% ± 4.7% among parents from Gomel. The ranking slightly changed when delays in vaccination were adjusted, such as when a child was temporarily withdrawn because of an illness. For example, the percentage of parents who responded to the relevant question ranged from 22.4% ± 4.8% in Makhachkala to 64.0% ± 4.5% in Almetyevsk.

The reasons that motivated parents to have their children prophylactically vaccinated varied (Fig. 2). The majority of parents (68.8% ± 7.3%) stated that they chose vaccination to prevent their children from contracting virulent infections. This was the most common response among respondents from Nizhny Novgorod (79.5% ± 2.7%). Some respondents (16.2% ± 9.6%) demonstrated a passive and unconscious attitude. They consented to vaccination because they feared that without it, their children would be denied admission to an educational institution. Compared to respondents from other cities, Kazan residents were the most likely to provide this response (28.6% ± 3.6%). Persistent recommendation from healthcare providers motivated 9.1% ± 5.8% of parents to vaccinate their children. Makhachkala residents were more likely to choose this response than those in other cities (15.8% ± 4.2%). The least prevalent response was “I vaccinate because vaccinations are compulsory and free,” chosen by 2.2% ± 1.3% of respondents (although it was chosen more frequently by residents of all other cities included in the study, p < 0.05). It was also selected by 3.9% ± 1.1% of Makhachkala respondents.

 

Fig. 2. Factors motivating parents to vaccinate their children.

 

Generally, 19.1% ± 1.4% of parents recognized the benefits of vaccination. However, the parents did not administer all age-appropriate vaccines to their children. The reasons for refusing individual vaccines among all respondents were as follows:

• “Afraid of adverse reactions to certain vaccines” (108 respondents, 13.5%)
• “It is possible to vaccinate a child against only dangerous infections” (73 respondents, 9.1%)
• “Not all vaccines are safe for children” (66 respondents, 8.3%)
• “Medical contraindications to vaccination” (47 respondents, 5.9%)
• “It is not necessary to vaccinate a child until a certain age” (33 respondents, 4.1%)

The study involved parents assigning a score to each vaccination, with 1 point for the least important and 5 points for the most important, according to their opinion. Considering the challenging epidemiological situation of pertussis and measles in both countries^4,5 to date [7], the results of a survey on parents’ perceptions of the importance of vaccines for these diseases were examined (Table 2).

 

Table 2. Prevalence of the response “very important” regarding measles and pertussis vaccination among parents across different cities

City	Measles vaccination, % (95% CI)	Pertussis vaccination, (95% CI)
Almetyevsk	75 (66.3; 83.7)	73.7 (64.8; 82.5)
Gomel	66 (53.2; 78.8)	62.3 (49.2; 75.3)
Kazan	31.7 (23.6; 45.1)	21.7 (15.4; 28.1)
Makhachkala	34.2 (28.8; 39.6)	34.6 (23.9; 45)
Nizhny Novgorod	73.7 (68.0; 79.4)	68.4 (62.4; 74.4)
Rybnoye	71.4 (59.6; 83.2)	70.9 (58.9; 82.9)

Note: CI, confidence interval. For measles and pertussis, p < 0.05 for Makhachkala compared with Nizhny Novgorod, Rybnoye, Almetyevsk, and Gomel and p < 0.04 for Kazan compared with Nizhny Novgorod, Rybniy, Almetyevsk, and Gomel, respectively.

 

Significant differences were noted in attitudes toward these preventive vaccinations depending on the place of residence of the surveyed parents. The majority of parents from Almetyevsk, Rybnoye, and Nizhny Novgorod considered the measles and pertussis vaccines “very important,” whereas respondents from Kazan and Makhachkala underestimated the importance of protection against these infections.

Among the participants interviewed, 66.2% were informed about the possibility of additional vaccines not included in the vaccination calendar. The highest proportion of informed parents was found among those from Almetyevsk (93 respondents, 84%; p < 0.05 compared with the other cities), and the lowest was found among those from Makhachkala (32 respondents, 42%; p = 0.031).

Of the parents surveyed, 47.6% demonstrated the need for more information about preventive vaccinations. The highest proportion of these parents was found in Nizhny Novgorod (221 respondents, 61.8%), followed by Kazan (85 respondents, 52.8%; p < 0.05 compared with the other cities), and the lowest proportion in Gomel (37 respondents, 33.9%).

Another set of questions aimed to identify the most crucial and desirable sources of information on vaccination. The most common response regarding the source of basic information about vaccination (e.g., vaccine composition, indications, contraindications, adverse reactions, and complications) was a primary care pediatrician. This was selected by 76.5% of respondents (95% CI: 73.71–79.29) in all the cities and was considered the most trustworthy source. Internet resources, including forums and social networks, were ranked second, with a significant margin of 37.12% (95% CI: 33.95–40.3), followed by scientific literature at 25.25% (95% CI: 22.39–28.11) and acquaintances/relatives at 22.5% (95% CI: 19.75–25.25). The least frequent responses regarding information sources on vaccination were mass media (e.g., television, radio, and newspapers) at 7.62% (95% CI: 5.88–9.37) and religious literature (religion not specified) at 0.87% (95% CI: 0.26–1.49). The importance of different information sources varied across cities. The highest proportion of people who chose a primary care pediatrician as their source of information was reported in Kazan (143 respondents, 88%) and Almetyevsk (97 respondents, 87.4%). The Internet was the most popular source of information in Almetyevsk (55 respondents, 49.6%), Kazan (75 respondents, 46.6%), and Nizhny Novgorod (83 respondents, 35.9%). In Almetyevsk, scientific literature was the dominant choice (51 respondents, 46%). Additionally, acquaintances and relatives were asked more often in this city (51 respondents, 46%). Parents from Almetyevsk, Nizhny Novgorod, and Kazan more likely used mass media (12 respondents, 10.9%; 23 respondents, 10%; and 15 respondents, 9.3%, respectively).

Regarding the preferred sources for information about future vaccination, the majority (78.3%) of respondents indicated conversations with physicians. A significant proportion of parents revealed a preference for receiving information through leaflets (28.3%) or specialized websites (23.2%). Additionally, 17.2% preferred online lectures, 15% wanted a hotline to address vaccination-related issues, and 11.9% opted to receive information through social networks (Fig. 3).

 

Fig. 3. Preferred sources of vaccination information (summarized across all study cities).

 

DISCUSSION

The majority of parents in all cities included in the study demonstrated a positive and informed attitude toward the vaccination of children. Most of the respondents were women, which may be a study limitation. Data obtained by other researchers showed that women were more uncertain about vaccination than men [4]. A significant proportion of respondents (21.8%) expressed distrust in vaccination, owing to concerns about potential adverse effects and harm to children’s health. Awareness and trust in myths concerning the risks of vaccination are inadequate. Thus, 9.1% of parents believed that vaccination against only a few diseases is sufficient. However, parents generally do not place much importance on vaccines for diseases such as measles and whooping cough, which are currently the most significant from an epidemiological perspective. Notably, 76.5% of the respondents identified a pediatrician as their primary source of vaccination information, and most preferred to receive future information from a pediatrician. These figures exceed those obtained by other researchers, which ranged from 67% to 70% [6, 8]. However, medical practitioners often lack the persuasiveness and persistence for effective vaccination promotion. In a study by Briko et al., only 80% of physicians had a positive attitude toward vaccination [3]. Another study by Timoshkova et al. showed that 36% of outpatient pediatric physicians expressed concerns about the safety of vaccines, 26.5% doubted their effectiveness, and 62% responded that they lacked compelling and evidence-based information about vaccination [9]. Insufficient information about the safety of vaccination procedures may lead to frequent, unjustified withdrawals from vaccination. This may result in lower vaccination coverage and worsening of the epidemic situation [10, 11].

A high level of interest in medical information was demonstrated by the parents, especially in specialized medical websites, information leaflets, and lectures available on the polyclinic website. Approximately half of the respondents indicated that they obtain information from non-scientific sources, such as social networks and relatives/acquaintances, but only 11.9% of respondents expressed a desire to continue receiving information from social networks. These findings emphasize the crucial role of pediatricians in parents’ decisions regarding vaccination of their children. This fact imposes a high degree of responsibility. Conversely, it provides hope that, with reliable information, pediatricians will be able to effectively work with parents to increase vaccination compliance, which contributes to population health.

The differences revealed in the residents’ questionnaires may indicate the influence of various factors on the population’s attitude toward vaccination, including living standards, education, and availability of medical personnel. Further studies are required to understand these differences.

CONCLUSION

A positive attitude toward vaccination was demonstrated by 76% of the respondents.

The most common reasons for refusing vaccination were fear of adverse effects and underestimation of the importance of receiving scheduled vaccines on time.

For most respondents, the main source of information about vaccination was a physician. Parents showed a high degree of readiness to receive information about vaccination from specialists. Therefore, all available information and educational resources, such as informational websites, special leaflets, lectures, and hotlines, should be used by medical professionals.

Additional information

Author contributions: G.N.A.: study design, data curation; Kh.G.R.: data curation, writing—original draft, writing—review & editing; S.N.V.: project administration, data curation, writing—original draft, writing—review & editing; M.L.P.: data curation, formal analysis; M.S.G.: data curation, formal analysis. All authors approved the version of the manuscript to be published and agree to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments: The authors express their gratitude to A.A. Ryabinin, sixth-year medical student at Kazan State Medical University; M.S. Kolesnikova, epidemiologist at Rybnoe District Hospital; and R.Kh. Isaeva, assistant at the Department of Epidemiology at Dagestan State Medical University, for their assistance in conducting the parental survey.

Ethics approval: The study was conducted in the form of an anonymous online survey. No personal data or organizational information were collected. Therefore, approval from an ethics committee was not required. The study was not registered.

Informed consent: Not applicable.

Funding sources: No funding.

Disclosure of interests: The authors have no relationships, activities, or interests for the last three years related to for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality: No previously published material (text, images, or data) was used in this work.

Data availability statement: The data are under embargo until December 31, 2025. The database includes materials related to aspects of the studied problem that were not addressed in the present article. These data are planned to be analyzed and presented in future publications.

Generative AI: No generative artificial intelligence technologies were used to prepare this paper.

Provenance and peer review: This paper was submitted unsolicited and reviewed following the standard procedure. The review process involved three external reviewers, a member of the editorial board, and an in-house scientific editor.

Дополнительная информация

Вклад авторов. Г.Н.А. — разработка и детализация плана исследования, сбор данных; Х.Г.Р. — работа с данными, написание черновика, пересмотр и редактирование рукописи; С.Н.В. — координация исследования, работа с данными, написание черновика, пересмотр и редактирование рукописи; М.Л.П. — сбор и анализ данных; М.С.Г. — сбор и анализ данных. Все авторы одобрили рукопись (версию для публикации), а также согласились нести ответственность за все разделы работы, гарантируя надлежащее рассмотрение и решение вопросов, связанных с точностью и добросовестностью в любой её части.

Благодарности. Авторы выражают благодарность: А.А. Рябинину — студенту VI курса Казанского ГМУ, М.С. Колесниковой — врачу-эпидемиологу Рыбновской районной больницы, Р.Х. Исаевой — ассистенту кафедры эпидемиологии ДГМУ за помощь при проведении анкетирования родителей.

Этическая экспертиза. Исследование проведено в виде анонимного онлайн-анкетирования. Персональные данные и данные организаций не собирались. В связи с этим одобрение этического комитета не требовалось. Исследование не регистрировали.

Согласие на публикацию. Не требовалось.

Источники финансирования. Отсутствуют.

Раскрытие интересов. Авторы заявляют об отсутствии отношений, деятельности и интересов за последние три года, связанных с третьими лицами (коммерческими и некоммерческими), интересы которых могут быть затронуты содержанием статьи.

Оригинальность. При создании настоящей работы авторы не использовали ранее опубликованные сведения (текст, иллюстрации, данные).

Доступ к данным. Эмбарго до 31.12.2025. База данных содержит материалы относительно аспектов изучаемой проблемы, которые не рассматривались в данной статье; планируется анализ этих данных с представлением результатов в последующих публикациях.

Генеративный искусственный интеллект. При создании настоящей статьи технологии генеративного искусственного интеллекта не использовали.

Рассмотрение и рецензирование. Настоящая работа подана в журнал в инициативном порядке и рассмотрена по обычной процедуре. В рецензировании участвовали три внешних рецензента, член редакционной коллегии и научный редактор издания.

 

¹ United Nations [Internet]. New WHO Immunization Data: 35 Million Children Worldwide Are Unprotected Against Measles. Available at https://news.un.org/ru/story/2024/07/1454221 Accessed on February 16, 2025.

² who.int [internet]. Ten threats to global health in 2019. [cited 16 February 2025]. Available at https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

³ The R Foundation [internet]. Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available online: https://www.r-project.org

⁴ On the Sanitary and Epidemiological Well-Being of the Population in the Russian Federation in 2023. State Report. Moscow: Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 2024. Available at https://rospotrebnadzor.ru/documents/details.php?ELEMENT_ID=27779. Accessed on March 1, 2024.

⁵ sputnik.by [Internet]. Rada Speaker: Preparations for Ukraine’s election have already started. Available at https://sputnik.by/20240422/minzdrav-v-belarusi-otmechaetsya-rost-chisla-zabolevaniy-koryu-i-koklyushem-1085664653.html Accessed on March 1, 2024.

About the authors

Nadezhda A. Gerasimova

Kazan State Medical University

Email: nivanova-00@mail.ru
ORCID iD: 0000-0002-4932-0000

Leading specialist-expert, Depart. of Supervision of Hygiene of Children and Adolescents

Russian Federation, 49 Butlerova st, Kazan, 420012

Gulshat R. Khasanova

Office of Rospotrebnadzor for the Nizhny Novgorod region

Author for correspondence.
Email: gulshat.hasanova@kazangmu.ru
ORCID iD: 0000-0002-1733-2576
SPIN-code: 6704-2840
Scopus Author ID: 6507469219
ResearcherId: AAH-6849-2019

MD, Dr. Sci. (Medicine), Professor, Head of Depart., Depart of Epidemiology and Evidence-based-medicine

Russian Federation, Nizhny Novgorod

Nikolay V. Saperkin

Privolzhsky Research Medical University

Email: saperkin_nv@pimunn.net
ORCID iD: 0000-0002-3629-4712
SPIN-code: 3318-6323

MD, Cand. Sci. (Medicine), Assistant Professor, Depart. of Epidemiology and Evidence-Based Medicine

Russian Federation, Nizhny Novgorod

Lyudmila P. Mamchits

Gomel State Medical University

Email: epidem@gsmu.by
ORCID iD: 0000-0003-3660-030X
SPIN-code: 1649-2051

MD, Cand. Sci. (Medicine), Assistant Professor, Depart. of Epidemiology and Evidence-Based Medicine

Belarus, Gomel

Sabiyat G. Magomedalieva

Dagestan State Medical University

Email: magomedalieva.s@yandex.ru
ORCID iD: 0000-0002-1369-8001
SPIN-code: 7145-1292

Assistant Lecturer, Depart. of Epidemiology

Russian Federation, Makhachkala

References

Supplementary files