https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Knowledge and Attitude of Mothers about Children Immunization and Barriers to Adherence the Program, in Erbil City ABSTRACT INTRODUCTION Immunity can be defined as a state of cre- ating sufficient biological defenses in the body to fight harmful microbes (including bacteria or viruses) to avoid infections, dis- ease, or another unwanted biological invasion. Immunization is one of the pro- cesses of enhancing the immune system against certain infectious diseases. There- fore, immunization can develop an im- mune system and body resistance against Background and objective: Immunization programs are one of the most important meth- ods to prevent infections and sickness among children. We can overcome many obstacles if mothers have the necessary knowledge and attitude regarding vaccines. The study aims to assess mothers’ knowledge, attitudes, and barriers related to immunization programs and associations related to socio-demographic characteristics. Methods: A cross-sectional study design was carried out in Erbil city across six primary health care centers (Hawkari, Azadi, Runaki, Shadi, Mala Afandi, and Nazdar Bamarni) dur- ing the period of January 5, 2021, to April 8, 2021. Non-probability convenience sampling methods were used. The sample consisted of 410 mothers ages 18 and older. A question- naire with four parts (socio-demographic characteristics, knowledge, attitude, and barriers to adherence immunization programs) was used to collect data. Statistical package for so- cial science (version 23) was used for data analysis. Chi-square and Fisher exact tests were used to determine the association between socio-demographic characteristics and knowledge and attitudes. Frequency and percentage were used to identify barriers. Results: The study findings showed a statistically significant association between the knowledge of mothers and their age, educational level, occupation, and socioeconomic status. Mothers have a high attitude regarding immunizations. The majority (69.3%) of mothers have not had any missed opportunities for not given immunizations. The most common reasons for not giving immunizations were mothers being busy and child sickness at the time of immunizations. Conclusions: There was statistically significant association between mother’s knowledge and age, education, occupations, and socioeconomic status. A high level of attitude was recorded among mothers regarding immunizations. Mothers reported being busy on the day of the immunizations and child sickness as the most common barriers to receiving im- munizations. Keywords: Childhood immunization; Mothers; Knowledge; Attitude; Barriers. Suham Mirhamad Abdullah; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: suham.barza@gmail.com) Ibrahim Hasan Mustafa; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 51 Erbil Journal of Nursing & Midwifery Received: 30/11/2021 Accepted: 01/02/2022 Published: 30/5/2022 mailto:suham.barza@gmail.com?subject=suham.barza@gmail.com https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article harmful infections [1]. Immunizations are cost-effective methods to prevent death and disease caused by harmful infectious diseases. Globally immunization itself rep- resents the gateway to providing compre- hensive health care to which all children have been entitled. Moreover, pediatric immunization programs played a vital role in eradicating many childhood infectious diseases [2, 3]. Many studies indicated the importance of knowing parents' impres- sions toward vaccination to find the posi- tive and negative attitudes and emphases on vaccine rejection. Therefore, there is a need to carry out studies to understand people's behavior, which plays a role in the failure to comply with the vaccination, and then to find scientific recommendations about targeting efforts to fight misinfor- mation on certain deviant types. These are also giving rise to a new research approach such as studying all these factors that are focusing on underlying attitudes that goes beyond notions of vaccine acceptance, in- cluding knowledge of communities, knowledge about how they relate and trust the institutions involved with vaccination services, and knowledge of how much ac- tive demand there is for vaccination at the community level and others [4]. A study carried out in Sub-Saharan Africa to identi- fy the best methods for achieving the de- sired levels of immunizations found many barriers mothers face in giving vaccinations to their children. These barriers include social and environmental barriers (gender, beliefs, and socio-culture factors) and bar- riers related to the health care system. The study recommended combined efforts of healthcare systems and providers, appro- priately addressing socio-cultural factors among the communities and emphasizing scientific evidence on effective interven- tions to address these barriers and achieve higher vaccination rates. Vaccination is one of the leading public health methods for preventing many infectious diseases, espe- cially among children. There is a need to encourage parents to involve their children in immunization programs and improve compliance with immunization programs [5]. The study aimed to assess mothers' knowledge, attitude, and barriers to im- munization programs. A descriptive study was carried out across six primary health care centers (PHCC) in Erbil city from January 5, 2021, to April 8, 2021. Due to social distancing and preven- tative measures against COVID 19, only a few centers (Hawkari, Azadi, Runaki, Shadi, Mala Afandi, and Nazdar Bamarni) were randomly selected to be included in the study. The sample size was calculated us- ing the STATSTM micros phot program (California Inc., California University, 1998), which depends on the population. The sample consisted of 410 mothers dis- tributed among the six PHCCs depending on the proportions of visitors in each PHCC (Hawkari: 50, Azadi: 117, Runaki: 60, Shadi: 53, Mala: 68, and Nazdar Bamarni: 62). Da- ta were collected by using the non- probability convenience sampling tech- nique. Mothers aged ≥18 years were in- cluded. A questionnaire was constructed for data collection consisted of four parts. Part I includes mothers’ socio- demographic characteristics, including age, years of formal education, family income, occupation, and socio-economic status (SES), family income classified according to monthly income, and daily physiological needs In this manner, income was classi- fied as insufficient if it did not cover daily needs, sufficient if it did cover daily needs but without extra, and surplus if it covered daily needs while saving money. Hasan (2010) [17] adapted the SEC. We give ten points for educational level (half a point for each year of study), ten points for 52 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Shadi, Hawkari, Nazdar Bamarni, and Azadi primary health care centers for data collec- tion. The required information was ex- plained, and informed oral consent was obtained from all participants. Confidenti- ality was assured about the participant’s identity and personal information. The da- ta collected were stored in the SPSS file was password protected. Table 1 shows the socio-demographic and socioeconomic characteristics of the study population. More than half (53.4%) of the population were in aged 22 to 31, and only 2.2% were aged 42 and older. 40.2% of mothers graduated college, 9.3 % of moth- ers were postgraduates, and 39.8% were intermediate and secondary graduates. Approximately half (51%) of mothers worked unskilled jobs, 10% were unem- ployed, and 26.8% were migrants. Results show that 22.2% of mothers had exceeded income for daily needs, 40% were of medi- um socio-economic status, and a little over a quarter (26%) were of low socioeconom- ic. Table 2 describes mother’s knowledge related to vaccinations. Most women (95.1%) have knowledge that measles is prevented by vaccination, 75.1% of women have no knowledge that diphtheria is pre- vented by vaccination, and 67.1% of wom- en have no knowledge that hepatitis B can be prevented by vaccination. Most of the mothers (99%) in the sample have infor- mation that vaccination prevents infec- tious diseases. 91% of women reported that vaccinations help maintain their health, and 82% report that vaccinations help reduce child mortality and protect children from complications. The highest percentage (64.4%) of mothers reported rash as a side effect of vaccines, followed by fever (61.2%), swelling (52%), and red- ness (51%). husbands' education, eight points for crowding index, five points for mother oc- cupation, five points for husband occupa- tion, four points for house ownership, and three points for car ownership (with some modifications). The total total score was 45, which was divided into three parts: Low (15), Middle (15 to 30), and High (15) scores (30 to 45) [6]. The mothers' occupa- tions were classified. Part II related to mothers’ knowledge about immunization and was assessed by 14 items. The questionnaire was scored and rated on two options (1 for Yes and 0 for No). The mothers' knowledge is catego- rized into three levels: low (a score ≤ 4.7), middle (a score between 4.8 to 9.4), and high level (a score ≥ 9.5). Part III related to mothers’ attitudes and was assessed by 14 items scored on Likert scales as recommended by Polite and Hungler (1999) [8]. Mothers’ attitudes were classified into three levels: (1) low attitude (a score ≤ 14), (2) no idea ( a score between 15 to 28 ), and (3) high attitude (a score ≥ 29). Part IV related to barriers to adherence to immunization programs assessed by 20 questions on a Yes or No scale. Data were analyzed using the statistical package for social science (SPSS, version 23). The mean was calculated to summa- rize numerical variables, and proportions were calculated for categorical variables. Chi-square test was used to compare the proportions of two groups’ socio- demographic characteristics and knowledge and attitude. Fisher exact tests were used in case 20% or more of cells have less than five. The Scientific and Ethical Committee of the College of Nursing Hawler Medical Univer- sity approved the study protocol. In addi- tion, formal permission was granted by the Erbil Directorate of Health planning depart- ment to Braiaty, Kurdistan, Mala AFandi, 53 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 54 Erbil Journal of Nursing & Midwifery Table 1: Distribution of study sample by socio demographic and socioeconomic characteristics Variables n=(410) No. (%) Age group <22 47 (11.5) 22-26 107 (26.1) 27-31 112 (27.3) 32-36 65 (15.9) 37-41 70 (17.1) 42+ 9 (2.1) Educational levels of moth- ers Primary 44 (10.7) Intermediate 72 (17.6) Secondary 91 (22.2) Institute and college 165 (40.2) Postgraduate 38 (9.3) Occupation of mother Unemployed or housewife 41 (10) Unskilled 208 (50.7) Professional 119 (29) High professional 42 (10.2) Immigration status Migrant 110 (26.8) Resident 300 (73.2) Monthly family income Sufficient for daily needs 157 (38.3) Insufficient for daily needs 162 (39.5) Exceed for daily needs 91 (22.2) Socio-economic status Low 105 (25.6) Medium 162 (39.5) High 143 (34.9) Table 2: Descriptive Statistics related to mothers’ knowledge about vaccination Variables n=(410) No. (%) Disease controlled by oblig- atory vaccination 1.Measles Yes 390 (95.1) No 20 (4.9) 2.Poliomyelitis Yes 327 (79.8) No 83 (20.2) 3.Tetanus and Pertussis disease Yes 237 (57.8) No 173 (42.2) 4.Diphtheria Yes 102 (24.9) No 308 (75.1) 5.Hepatitis B virus Yes 135 (32.9) No 275 (67.1) 6.Mumps Yes 269 (65.6) No 140 (34.1) What are the important of vaccination 7.Prevent infectious diseases Yes 405 (98.9) No 5 (1.2) 8.Reduce child mortality rate Yes 335 (81.7) No 75 (18.3) 9.Protect child from complication Yes 336 (82) No 74 (18) Vaccine side effect 10.Fever Yes 251 (61.2) No 159 (38.8) 11.Rash Yes 264 (64.4) No 146 (35.6) 12.Redness Yes 207 (50.5) No 203 (49.5) 13.Pain Yes 173 (42,2) No 237 (57.8) 14.Swelling Yes 213 (51.9) https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article and mothers’ knowledge and socioeco- nomic status (p<0.001). Table 5 shows the associations between mothers’ attitudes and their Sociodemo- graphic and socioeconomic status. Most mothers (93.4) expressed a high level of attitude toward vaccination. There was no statistically significant association between mothers’ level of attitude related to im- munizations and their age (p=0.116) or ed- ucation levels (p=0.064). The results show that 63 % of mothers with a medium level of attitude worked unskilled jobs, and 40.8% of mothers with a high level of atti- tude worked professional jobs. A statisti- cally significant association was observed between mothers’ attitudes and \occupa- tions (p=0.024). There was no significant association between mothers’ attitude and their levels of income (p=03.65), and socio- economic status (p= 0.083). Table 6 shows that the majority of mothers (69.3%) have not had any missed opportu- nities for immunization. Among those who had one or more missed opportunities, 19 % have one missed opportunity to the giv- en immunizations for their children. Table 7 shows that, in general, most mothers report no barriers to giving im- munizations to their children. The most common barriers reported were mothers busy on the day of immunizations (43.4%), and children's sickness at the time of im- munization (29%). 55 Erbil Journal of Nursing & Midwifery Table 3 describes the mother’s positive and negative attitudes towards vaccina- tions. Most of the sample (73%) report mi- nor side effects with immunization, and 91% of mothers believe that vaccines help children’s health. The data shows that 17.2% have no idea about health authority (education role) in the vaccination pro- grams and that 87.1% of mothers have a positive attitude towards reducing missing opportunities of child vaccinations. The majority of mothers (82.9%) believe that it is essential to advise other mothers to vac- cinate their children. The data shows that 66.1% of mothers prefer a female vaccina- tor. 69.0% of the sample believe in delay- ing baby bath till two days after BCG vac- cination, 42.9% have no idea if a child who came in contact with another child with measles should not be vaccinated against measles, and 48% of mothers believe that it is better to get immunity by catching a disease instead of by being vaccinated. Table 4 describes the associations between mothers’ level of knowledge and their So- cio demographic and socioeconomic sta- tus. Mothers with a high level of knowledge (53%) were aged 37 to 41 years, and mothers with a low level of knowledge (32.2%) were aged 22 to 26 years. Forty percent of mothers with a low level of knowledge have primary and inter- mediate levels of education, and 68% of mothers with high levels of education graduated from college and institutes or were postgraduates. Mothers with low and medium levels of knowledge (46% and 45%, respectively) report a medium socio- economic status, while mothers with a high level of knowledge report a high soci- oeconomic status. Statistically significant associations were observed between mothers’ age and their knowledge about immunizations (p<0.001), levels of educa- tion and knowledge (p<0.001), occupation and knowledge of mothers (p<0.001), https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 56 Erbil Journal of Nursing & Midwifery Table 3: Descriptive Statistics of sample according to their positive and negative attitudes toward vaccination Items No. (%) 1. Do you believe that minor side effect occur with immunization? Correct 298 (72.7) No ides 53 (12.9) Incorrect 59 (14.4) 2. Do you believe that vaccination helps the child’s health? Correct 373 (91) No idea 27 (6.6) Incorrect 10 (2.4) 3. Do you believe that health authority should emphasize the im- portant of immunization (education role) of children? Correct 326 (79.5) No idea 70 (17.2) Incorrect 14 (3.4) 4. Do you believe that the responsibility of mothers reduce missing opportunity of child vaccination? Correct 357 (87.1) No idea 32 (7.8) incorrect 21 (5.1) 5. Do you believe less knowledgeable mothers do not support immun- ization in the community? Correct 12 (2.9) No idea 93 (22.7) Incorrect 305 (74.4) 6. Do you believe that advising other mothers for vaccinating their children? Correct 340 (82.9) No idea 59 (14.4) Incorrect 11 (2.7) 7. Do you believe that child with allergy to egg is contraindicated to be vaccinated? Correct 152 (37.1) No idea 246 (60) Incorrect 12 (2.9) 8.Do you prefer vaccination at public health centers Correct 271 (66.6) No idea 126 (30.7) Incorrect 13 (3.2) 9.Do you believe that vaccination of children having cold and cough should be delayed until full recovery? Correct 300 (73.2) No idea 97 (23.7) Incorrect 13 (3.1) 10. Do you believe that preferring female vaccinator than male? Correct 271 (66.1) No idea 78 (19) Incorrect 61 (14.9) 11. Do you believe that delaying baby bath till two days after vaccina- tion BCG? Correct 283 (69) No idea 99 (24.1) Incorrect 28 (6.8) 12. Do you believe that communicable disease weakens the immune system? Correct 77 (18.8) No idea 191 (46.6) Incorrect 142 (34.6) 13. Do you believe that children who come in contact with a child who got measles should not be vaccinated against measles? Correct 63 (15.4) No idea 190 (46.3) Incorrect 157 (38.3) 14. Do you believe that it is better to get immunity by catching to a disease instead of by being vaccinated? Correct 38 (9.3) No idea 176 (42.9) Incorrect 196 (47.8) https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 57 Erbil Journal of Nursing & Midwifery Table 4: Association between mothers’ level of knowledge with their socio-demographic and socio-economic status Items Knowledge Low Medium High No. (%) No. (%) No. (%) P-value Mothers age groups <22 22 (18) 22 (8.9) 3 (7.5) 0.001 22-26 39 (32) 63 (25) 5 (13) 27-31 27 (22) 76 (31) 9 (23) 32-36 21 (17) 42 (17) 2 (5) 37-41 8 (6.7) 41 (16) 21 (53) 42+ 4 (3.1) 5 (2) 0 (0) Education levels of mothers Primary 24 (20) 19 (7.6) 1 (2.5) 0.001 Intermediate 24 (20) 45 (18) 3 (7.5) Secondary 31 (26) 51 (22) 9 (23) Institute &college 41 (34) 112 (45) 12 (30) Postgraduate 1 (0.8) 22 (8.8) 15 (38) Occupation of mother Unemployed 14 (12) 25 (10) 2 (5) 0.001 Unskilled 85 (70) 112 (45) 11 (28) Professional 20 (16) 87 (35) 12 (30) High professional 2 (1.4) 25 (10) 15 (38) Immigration statue Migrant 38 (30) 63 (25) 9 (23) 0.378 Resident 83 (70) 186 (75) 31 (78) Monthly family income Sufficient for daily needs 25 (24) 122 (49) 10 (25) 0.165 Insufficient for daily needs 42 (35) 113 (11) 7 (18) Exceed for daily needs 48 (40) 33 (13) 10 (2.5) Socio-economic status of mothers Low 48 (40) 44 (18) 5 (13) <0.001 Medium 55 (46) 111 (45) 9 (23) High 18 (15) 94 (38) 26 (65) Table 5: Association between mothers’ attitude with their socio-demographic and socio- economic status Items Attitude P-value Medium High No. (%) No. (%) Mothers age group 17-21 5 (18.5) 42 (11) 0.116 22-26 6 (22.2) 101 (26.4) 27-31 3 (11.1) 109 (28.5) 32-36 8 (29.7) 57 (14.9) 37-41 5 (18.5) 65 (17) 42+ 0 (0) 9 (2.2) Total 27 (100) 383 (100) Educational levels of mother Primary 2 (7.4) 42 (11) 0.064 Intermediate 9 (33.3) 63 (16.4) Secondary 6 (22.1) 85 (22.2) Institute &college 10 (37) 155 (40.5) Postgraduate 0 (0) 38 (9.9) Occupation of mothers Unemployed 5 (18.5) 36 (9.3) 0.024 Unskilled 17 (63) 191 (49.9) Professional 5 (18.5) 114 (29.8) High professional 0 (0) 42 (11) Immigration statue Migrant 9 (33.3) 101 (26.4) 0.43 Resident 18 (66.7) 282 (73.6) Monthly family in- come Sufficient for daily needs 10 (37) 147 (38.3) 0.65 Insufficient for daily needs 9 (33.2) 100 (26.1) Exceed daily needs 4 (14.8) 46 (12) Socio-economic stat- ues of mothers Low 7 (25.9) 90 (23.5) 0.083 https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 58 Erbil Journal of Nursing & Midwifery Table 6: Data related to number of missed opportunity Number of missed opportunity n=(410) (%) 1 Item 78 (19) 2 Items 24 (5.9) 3 Items 11 (2.7) 4 Items 13 (3.1) Total 126 (30.7) No missed opportunity 284 (69.3) Total 410 (100) Table 7: Barriers of incomplete immunization Barriers Yes No No. (%) No. (%) Domestic work 60 (14.6) 350 (85.4) Corona virus 57 (13.9) 353 (87.3) Quarantine 5 (1.2) 405 (98.8) Mother was too busy 178 (43.4) 232 (56.6) There is no risk of infection 13 (3.2) 397 (96.8) The vaccine was not available 18 (4.4) 392 (95.6) The time for vaccination was not convenient 88 (21.5) 322 (78.5) The child was not vaccinated because of illness 82 (20) 328 (80) Was not aware for need of immunization 78 (19) 332 (81) mother does not have information about the need for second and third dose 17 (4.1) 393 (95.9) Distrust in the vaccination 45 (11) 365 (89) Fear of side effect after vaccination 55 (13.4) 355 (86.6) Mother health state 118 (21.8) 292 (71.2) Social engagements 26 (6.3) 384 (93.7) Traveling 41 (10) 369 (900 Complications from previous injections 28 (6.8) 382 (93.2) Long distance trekking/walking 35 (8.5) 375 (91.5) Long waiting time 16 (3.9) 394 (96.1) Lack of financial reasons 49 (12) 361 (88) Child sickness 117 (28.5) 293 (71.5) https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article al., indicated that mothers with a medium level of knowledge about immunizations were associated with medium or high lev- els of income, and a high level of knowledge was associated with comple- tion of higher education and higher income [7].The present study found that mothers working in professional occupations had high attitudes regarding immunizations. A 2019 cross-sectional study carried out in Malaysia of 200 postnatal mothers report- ed a statistically significant association be- tween mothers’ occupations and their atti- tudes regarding vaccination [15]. The pre- sent study shows that around one-third of mothers in the sample have missed oppor- tunities for vaccinating their children. The main barriers to not giving immunization were that mothers were busy and their children were sick at vaccination. A 2020 study in Mogadishu, Somalia, report that full vaccination of children under five years were very low. Older marital status of caregivers, low educational background of fathers, low monthly income, premature birth, younger age of children, vaccine un- availability at health centers, cost un- affordability, mothers who were given their births in home, low level of knowledge of caregiver, low levels of atti- tude, and level of low practice on immun- ization were found to be the main barriers to full immunization coverage [8]. The re- sults of a systematic study carried out in Sub-Saharan Africa indicated that gender, beliefs, and socio-culture factors of com- munities that the parents live play a role in parents’ decision to vaccinate their chil- dren [9]. There were statistically significant associa- tions between mothers’ age and vaccination knowledge, mothers’ know ledge and The present study shows a statistically significant association between mothers’ age and levels of knowledge regarding vaccination. Increasing age was associat- ed with increased knowledge. In con- trast, a study in Saudi Arabia by Almutairi et al., reported no significant association between mothers’ age and knowledge regarding vaccination. The differences may be related to the width of age cate- gories, which were not fixed in all levels in the study [10]. The present study shows an association between an in- creased level of mothers’ education and an increased level of knowledge. The output of the present study agrees with a 2016 study by Faris et al., which report- ed a significant association between mothers’ knowledge and their education- al levels [11]. Another study indicated that a high level of knowledge was asso- ciated with completing higher education and higher income [12]. In the present study, there was an association between mothers’ knowledge and occupation. In contrast with a study by Almutairi et al., there was no evidence of an association between mothers’ knowledge and occu- pation. The differences may be related to the classification jobs between both studies and differences related to cul- ture. The present study indicated no as- sociation between income and mothers’ knowledge regarding vaccination. The present study shows that increased occu- pational classes were associated with knowledge classes. Findings from Almu- tairi et al. indicated no evidence of an association between mothers’ level knowledge and mothers’ occupation type [9]. The current study indicated that an increase in mothers' knowledge was as- sociated with an increase in socioeco- nomic status. A study by Kyprianidou et 59 Erbil Journal of Nursing & Midwifery DISCUSSION Conclusion https://doi.org/10.15218/ejnm.2022.06 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [9] Almutairi WM., Alsharif F., Khamis F., Sallam L., Sharif L., Alsufyani A., et al Assessment of Mothers’ Knowledge, Attitudes, and Practic- es Regarding Childhood Vaccination during the First Five Years of Life in Saudi Arabia. Nurses. Repots. 2021, 11, 506–516. [10] Ramadan HA, Soliman SM, El-Kader RG. Knowledge, attitude and practice of mothers toward children's obligatory vaccination. Journal of Nursing and Health Science. 2016 Jul;5(4):22-8. [11] Mahalingam S, Soori A, Ram P, Achappa B, Chowta M, Madi D. Knowledge, attitude and perceptions of mothers with children under five years of age about vaccination in Man- galore, India. Asian Journal of Medical Sci- ences. 2014 May 16;5(4):52-7. [12] Singh J, Deepti SS, Mahajan S, Lal M, Singh T, Neki NS. Assessment of Socio-demographic factors affecting Immunization status of chil- dren of age 0-2 years in Slums of Amritsar city. International Journal of Current Re- search in PubMed Science. 2018;4(3):17-25. [13] Gul S, Khalil R. Immunisation knowledge and practices among mothers attending a paedi- atric clinic in Karachi, Pakistan. International Journal of Advances in Medicine. 2016 Jul;3 (3):656-1. [14] Awosan KJ, Ibrahim MT, Yunusa EU, Isah BA, Raji MO, Abubakar N. Knowledge, Attitude and Compliance with Full Immunization of Children Against Vaccine Preventable Dis- eases among Pregnant Mothers in Sokoto, Nigeria. International Journal Contemp Med Research. 2018; 5(6):F10-6. [15] Umeh CA, Ahaneku HP. The impact of declin- ing vaccination coverage on measles control: a case study of Abia state Nigeria. Pan Afri- can Medical Journal. 2013; 15(1). [16] Al-Lela, O. Q. B., Bahari, M. B., Al-Qazaz, H. K., Salih, M. R., Jamshed, S. Q., & Elkalmi, R. M. Are parents' knowledge and practice re- garding immunization related to pediatrics’ immunization compliance? a mixed method study. BMC Pediatrics, 2014. 14(1), 1-7. [17] Hasan BA. Malocclusion and orthodontic treatment need and demand among 13-18 years students in Erbil city. Ph.D. thesis, col- lege of Dentistry Hawler Medical University, Erbil, Iraq. (2010) educational levels, and mothers' atti- tudes and occupation. Around one-third of the sample have missed the oppor- tunity of provided immunizations; among them, the highest percentages were rec- orded in mothers who were busy or their infants sick at the time of immunizations. No conflict of interest. [1] Chris-Otubor GO, Dangiwa DA, Ior LD, and Anukam NC. Assessment of knowledge, attitudes and practices of mothers in Jos North regarding immunization. IOSR Jour- nal Of Pharmacy. 2015 Jun; 5(6):34-45. [2] Bergin N, Murtagh J, Philip RK. 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