Determinants of maternal adherence to child vaccination in jordan: A cross-sectional study (2025)

Children’s vaccination is a cornerstone of public health efforts worldwide and plays a pivotal role in the prevention of infectious diseases for which an effective vaccine is available, also called vaccine-preventable diseases (VPDs)¹. It is considered the most efficient and cost-effective way to protect the health and well-being of children and, by extension, the entire community¹. Vaccination programs significantly contribute to reducing the prevalence of life-threatening illnesses, leading to increased life expectancy and improved quality of life for millions of people globally².

In the past few years, the COVID-19 pandemic has led to negative consequences, as demonstrated by a significant decrease in children’s vaccination coverage^3,4. In 2020 and 2021, the COVID-19 pandemic strained healthcare systems and led to setbacks in vaccinations. For example, in 2022, approximately 22million children missed their first measles vaccine dose, an increase from 19million in 2019¹. Additionally, the US reported an outbreak of measles in a total of 1486 patients between 2019 and 2023⁵. This alarming outbreak necessitates global attention to vaccination adherence in children.

Parents’ reluctance, refusal, and delays in adhering to regular childhood immunizations are major contributing factors to a substantial population of children who remain unvaccinated or inadequately vaccinated^6,7. However, investigations of parental adherence or hesitancy are needed to provide children with the necessary vaccination programs. Mothers are widely acknowledged as the primary caregivers for most children; therefore, their knowledge, attitudes, and adherence to children’s vaccinations demand comprehensive evaluation⁸. Exploring this issue plays a pivotal role in developing effective strategies to promote immunization and enhance overall child well-being⁸. In turn, mothers who cooperate and adhere to completing children’s vaccinations avoid VPDs in children and reduce the likelihood of vaccine failure⁹.

Many factors can contribute to mothers’ adherence to vaccination programs. For example, Ali et al. (2020) conducted a study in southern Sudan revealing that illiteracy, maternal age, and poverty are the main contributors to poor child vaccination adherence¹⁰. Also, Zeng et al. (2019) suggested that maternal age, education, and income affect mothers’ knowledge about childhood vaccination in China¹¹. Additionally, they found that higher education and the mother’s occupation strongly promoted parents’ willingness to vaccinate their children.

In conclusion, the contextual factors contributing to adherence and/or lack of adherence to vaccination programs require thorough investigation, especially in low- and middle-income countries (e.g., Jordan)¹². Knowing what affects mothers’ adherence to vaccination can inform decision makers in developing efficient and effective strategies to enhance adherence to vaccination programs. This study, therefore, aimed to identify the factors contributing to mothers’ adherence to children’s vaccination by investigating sociodemographic factors in addition to mothers’ knowledge and attitudes scores.

Study design and setting

This study utilized a cross-sectional analytical design supported by quantitative data from mothers’ perspectives. Descriptive, comparative, and correlation analyses were employed to determine the influence of demographic and personal variables on mothers’ adherence to children’s vaccination. The use of a cross-sectional design is appropriate because it provides a “snapshot” of a population at a single point in time, which is useful for understanding the prevalence and correlations of certain characteristics, conditions, or behaviors through the conduction of the study within a specific time frame across the entire sample¹³. This study was conducted in Jordan, and the survey instrument was disseminated digitally using popular social media platforms such as Facebook, Instagram, and WhatsApp. This approach was strategically employed to maximize the likelihood of obtaining an optimal response rate.

Sampling procedures.

The study was conducted using a self-reported online questionnaire between May and July 2023. The eligibility criteria included being a mother, with a minimum age of 18 years, and having at least one child at the age of 12 years or younger. A total of 533 mothers participated in the study. The sample was confirmed to be sufficient through G*power post hoc analysis.

Instruments.

The questionnaire included a sociodemographic section that was developed for the purpose of this study and included questions on mothers’ age, location of residence, educational level, job status, working/studying in a medical field, monthly household income level, number of children, and ability to obtain knowledge and information to manage health concerns (ability to access health information). The second Sect.(24 items) pertains to mothers’ knowledge, attitudes, and adherence to their children’s vaccination. This section was developed based on previous literature, such as that of Almutairi et al.‘s (2021) study¹⁴. Specifically, 12 items were used to collect data on the knowledge variable (such as the importance of VPD vaccinations, vaccination timings, and possible adverse events), for which the minimum possible total score was zero and the maximum possible total score was 24. The responses can be either yes or no coded as 0 for the incorrect response and 2 for the correct response. For the attitude score, six items were identified, and the total score ranged between six and 30. The participant can score their responses on a 5-item Likert scale ranging from 1: strongly disagree to 5: strongly agree. Adherence was measured using six items with a possible range of 6–18 for the total score. The items can be rated as 1: never, 2: sometimes, or 3: always.

Validity and reliability.

The face validity of the instrument was well ascertained by offering it to a panel of healthcare experts in the field of pediatrics. This panel evaluated the linguistic and contextual formulation of the items. Their comments and recommendations were incorporated to refine the final version of the questionnaire. Additionally, a pilot study of 20 participants was conducted to ensure the reliability of the study using Cronbach’s alpha, resulting in a coefficient of 0.77, demonstrating the instrument’s reliability according to Louangrath and Sutanapong (2018)¹⁵. To elaborate, the knowledge, attitude, and adherence sections had reliability coefficients of 0.70, 0.89, and 0.61, respectively.

The questionnaire was designed on Google Forms and was consistently released weekly from May to July 2023. The introduction of the questionnaire featured a cover letter outlining the study’s primary objectives within the context of children’s vaccination in Jordan. Additionally, it included a clear affirmation of the researcher’s commitment to confidentiality. The questionnaire was structurally organized with two mandatory questions to ensure adherence to the study participation requirements. The initial question sought confirmation from respondents that they were older than 18 years and had at least one child aged 12 years or younger. The second question focused on obtaining voluntary consent, emphasizing the option to terminate the response at one’s discretion.

Upon completing the questionnaire, participants were given the choice to provide an email address for receiving information on their children’s vaccinations. Following the conclusion of the data collection process, participants received a link directing them to the Ministry of Health’s comprehensive vaccination booklet, encompassing a summary of information on childhood vaccines in Jordan¹⁶. This authoritative guide provides essential details on both mandatory and optional vaccines available in Jordan, accurately explaining their respective significance, contraindications, circumstances warranting vaccination postponement, and wealth of information pertinent to the vaccination domain. This gesture aimed to express gratitude for participants’ involvement and enhance awareness regarding children’s vaccination.

Data analysis

The data were analyzed using the Statistical Package for the Social Sciences version 26 (SPSS v.26). Descriptive analyses (frequency, percentage, mean, and standard deviation) were performed to obtain a general overview of the study participants and the study variables. Then, tests of variance (one sample t-test and one-way ANOVA) and correlation (Pearson r correlation) were performed to identify differences in participants’ adherence scores according to the possible contributing factors. Comparisons necessitating further delineation (for variables with more than two categories) were subsequently performed via the Scheffe post hoc test.

A total of 533 mothers participated in this study, Table1. The highest percentage of them resided in Amman, the capital of Jordan (44.7%), had a diploma or a bachelor’s degree (68.1%), were unemployed (58.2%), did not work or study in a medical field (71.9%), had a household monthly income of 500–1000 JD (equivalent to 700–1400 USD), and had two to three children (51.4%). Physicians and healthcare centers were the two main sources of vaccine-related information for mothers in this study. The mothers’ ages ranged between 19 and 55 years, with an average of 33 years. On a zero-to-ten scale, mothers’ reports of their ability to access and understand health-related information ranged from one to ten, with an average of 7.6 (SD = 2.03). The mothers’ knowledge, attitudes, and adherence mean scores were 20.9 (SD = 1.98), 22.07 (SD = 6.94), and 14.89 (SD = 1.13), respectively.

After conducting the descriptive analyses of the study variables, tests of variance and correlation were performed to determine the differences in adherence scores according to the other study variables. Table (2) shows the results of these analyses. The findings revealed significant differences in mothers’ adherence to vaccination programs according to six factors: income, education, job status, working or studying in a medical field, and ability to access and understand health information. Mothers who worked demonstrated significantly greater adherence scores than those who did not work (M = 15.05, SD = 1.24 vs. M = 14.77, SD = 1.02). Similarly, mothers who studied or worked in a medical field showed significantly greater adherence to vaccination (M = 15.27, SD = 1.15 vs. M = 14.74, SD = 1.08). Significant positive correlations were noted between the adherence score and the scores for mothers’ knowledge and ability to access and understand health information.

More specifically, for differences in adherence scores based on income and educational levels, the Scheffe post hoc test was performed to compare the factors influencing mothers’ adherence to children’s vaccinations. The results revealed that higher levels of education and income were associated with higher adherence scores. Tables2 and 3 provide a detailed overview of the results.

Table2 shows that the 75 participants who had postgraduate degrees had an average adherence score of 15.28 (SD = 1.3); the 363 participants who had diplomas or BSc degrees had an average adherence score of 14.89 (SD = 1.10); and the 95 participants who did not have a graduate degree had a mean of 14.58 (SD = 0.97). One-way analysis of variance (Table4) revealed that the effect of education was significant, F (2,530) = 5.71, p < 0.01.

Post hoc analyses using the Scheffe post hoc criterion for significance indicated that the average adherence score was significantly greater among mothers who had postgraduate degrees than among those in the other two educational categories and that adherence was significantly greater among diploma or BSc holders than among those with secondary or high school education (Table3).

With respect to income level, mothers in the highest household monthly income category, more than JD1000 (USD750), reported significantly greater adherence scores than mothers in the other two income categories (Tables2 and 3). Nevertheless, no significant differences were demonstrated between other pairs of income categories.

The results demonstrated a commendable level of maternal knowledge in Jordan regarding children’s vaccinations. Mothers’ substantial knowledge about children’s vaccinations in Jordan underscores a well-informed community that values and comprehends the medical aspects of vaccinations. These findings are consistent with those of a previous study conducted in Romania ¹⁷ and, to some extent, consistent with those of a previous study conducted in Pakistan, which showed that parents are mostly aware of the importance of vaccination but lack sufficient knowledge on vaccination timing¹⁸. It is worth mentioning that the above-mentioned study was conducted among participants from a different cultural background and used a different set of questions that may vary from the items used in the current study which may yield inconsistencies in the findings. On the other hand, a study in Sudan reported a limited grasp of maternal knowledge about child vaccination¹⁹. These variations in findings shed light on the importance of considering other factors that may contribute to shaping vaccination knowledge as well as practices considering the cultural background and demographical variables.

Maternal attitudes toward children’s vaccinations in Jordan portray a highly positive and medically informed perspective. This is evident through their strong agreement on the benefits of vaccination, as they recognize the crucial role of vaccination in bolstering immunity against diseases. A high mean score for attitudes signifies a community dedicated to protecting children’s health, informed by a thorough understanding of the benefits, safety, and public health implications of immunization. These results agreed with the observations of Balbir Singh et al. (2019), who demonstrated that approximately 89% of mothers believe that vaccination is more beneficial than harmful and that most mothers agree that vaccines are safe for use²⁰. However, the findings of Mohammed and Al-Zahrani (2021) yielded a moderate extent of maternal attitudes toward child vaccinations in Sudan; therefore, these findings diverged from the findings of the present study¹⁹.

Regarding maternal adherence to children’s vaccinations in Jordan, the study’s results reflect a high commitment to medical practices related to disease prevention and child health. The consistently high adherence score shows their dedication to ensuring their children’s immunization against preventable diseases by vaccination, which is consistent with the findings of Abor et al.²¹. Our study findings confirmed the influence of demographic characteristics on maternal adherence to children’s vaccinations in Jordan. The disparities are based on their job status and whether they work in the medical field; these findings are consistent with those of Almutairi et al. (2021)¹⁴. Compared with unemployed mothers, employed mothers had significantly greater mean scores for vaccination adherence, suggesting that employment might provide greater access to healthcare services and resources for adhering to vaccination schedules. Moreover, mothers working in the medical field exhibit significantly greater vaccination adherence, indicating the impact of healthcare professionals’ knowledge and role modeling in prioritizing vaccinations for their children due to their understanding of vaccine benefits and risks. The study indicated that education and income levels play crucial roles, which is partially different from the findings of Balbir Singh et al. (2019)²⁰. These findings highlight the need for targeted health education programs and equitable access to vaccines, emphasizing the role of education and financial resources in shaping vaccination behaviors among mothers in Jordan.

The analysis indicated significant differences in vaccination adherence based on mothers’ educational backgrounds. Mothers with higher educational attainment, particularly those with postgraduate education, demonstrated distinctive vaccination adherence compared to those with secondary, high school, diploma, or BSc education. Hence, mothers with postgraduate studies display more favorable adherence to vaccination practices, which may have resulted from the advanced education that equipped them with the knowledge and critical thinking skills needed to engage in their children’s health. This was confirmed by Kaufman et al. (2018), who reported that education affects mothers’ intentions and practices related to vaccinating their children²². On the other hand, higher-income mothers tend to exhibit greater vaccination adherence, which may be attributed to improved access to healthcare resources, including information and facilities. This highlights the role of financial stability in overcoming barriers to vaccination. Conversely, lower-income mothers face challenges accessing vaccines and healthcare services, leading to delayed or missed vaccinations.

The results also showed that there was a positive correlation between mothers’ knowledge and adherence to vaccination but a nonsignificant correlation between attitude and adherence. This emphasizes the need for continuous and consistent education for caregivers to yield valid adherence to timely and comprehensive vaccination. Similarly, Seal et al. (2023) conducted a randomized controlled trial to measure the effect of knowledge on maternal attitudes toward and adherence to child vaccination²³. The study revealed that improving knowledge significantly affected adherence, while attitude did not significantly change.

Moreover, our study revealed a significant positive correlation between mothers’ ability to access and understand health information and their adherence to vaccination. This can be interpreted as mothers with a greater ability to access and understand health information being better equipped to interpret medical information, navigate healthcare resources, and critically assess vaccination benefits and risks. There is a lack of research investigating this topic, which adds value to the current research. Clear and accessible communication strategies are essential for addressing disparities in knowledge based on mothers’ ability to access and understand health information, as they enable mothers to make informed choices.

Based on the findings of this study, several recommendations can be made. First, developing and implementing tailored health education campaigns that focus on addressing knowledge gaps that target mothers with low income and educational levels. Second, a robust monitoring and evaluation system should be established to continuously assess the impact of vaccination programs and initiatives. We need to regularly collect data on vaccination coverage and the barriers faced to refine strategies and ensure their effectiveness. Third, the popularity of social media platforms should be leveraged to disseminate accurate information about vaccinations. Collaborate with influencers and health professionals to create engaging and informative content that can reach a wider audience. Finally, ongoing training should be provided for healthcare professionals to ensure that they are equipped with the latest vaccination-related information and communication skills. This approach will enhance their ability to address parental concerns and provide evidence-based guidance.

Certain limitations should be acknowledged. This study adopted a cross-sectional design. Therefore, future longitudinal studies could track the evolution of these concepts over time or the response to changing health communication practices. The study relied on self-report surveys, which may be subject to bias. Another limitation is the use of social media in data collection which may lead to sampling bias. Social media users may not be representative of the general population, as they often differ in terms of demographics, behavior, and opinions. Moreover, some demographics may be interlinked requiring attention to possible confounding factors in future studies. Future research could incorporate mixed methods that involve combining surveys and in-depth interviews. Moreover, the scope of this study was limited to Jordan; thus, replications of this study are encouraged to encompass a wider variety of geographic regions and cultural settings to provide a more comprehensive understanding of the topic.

This study contributes significantly to the understanding of mothers’ adherence to children’s vaccinations in Jordan. The impact of employment, education, and income on vaccine adherence highlights the diverse nature of health behaviors and suggests areas for targeted interventions. Our findings mirror the worldwide consensus emphasizing the importance of immunization while also demonstrating distinct local differences. The significant link between knowledge and adherence necessitates continuous education and easily accessible information to guarantee that all children receive timely and thorough vaccines. To raise awareness about vaccinations, respondents who took part in the study and chose to receive information about vaccination were sent a weblink that included a pamphlet on the vaccines available in Jordan.

To build on this, we propose several recommendations: we advocate customizing health education programs for mothers from diverse backgrounds, with lower incomes and education levels, establishing accurate and dynamic vaccination monitoring systems, and utilizing social media to spread valid vaccination information. Healthcare workers must also be equipped with up-to-date knowledge and communication skills to successfully address parental concerns.

While our study offers useful insights, it also paves the way for future research. The study relies on self-report surveys of mothers, which may be subject to recall bias or social desirability bias. Future research could incorporate objective measures of vaccination coverage and verification to enhance data accuracy through structured interviews supported by qualitative data. Regarding the increasing role of technology, investigating the impact of digital health solutions, such as mobile apps or SMS reminders, on vaccination-related behaviors could provide valuable insights into enhancing vaccination coverage. Moreover, future research should explore the evolving landscape of vaccination attitudes and practices through longitudinal studies and expand the geographical scope to capture a broader cultural spectrum. By continuing to explore and address these critical factors, we can strive toward a future where every child is protected and every mother is empowered with the knowledge and resources to make informed health decisions.

Authors and Affiliations

1. Deputy Manager, Center of Excellence and Innovation Projects; Associate Professor, Department of Community and Mental Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan

   Wafa’a F. Ta’an

2. MSc graduate, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan

   Rand A. Al-rashdan

3. MSc Graduate, Department of Community and Mental Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

   Rawan M. Shatnawi

4. MSc Graduate, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan

   Aseel Ai-zenati

5. Department of Paramedicine, Monash University, Clayton, VIC, 3800, Australia

   Brett Williams

6. Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan

   Tareq L. Mukattash

Contributions

Author contributions: Study design: WFT, RAA, RMS, BW, AA, TLM; Data collection: WFT, RAA; Data analysis: WFT, RAA, TLM; Study supervision: WFT, RAA, RMS, BW, TLM; Manuscript writing: WFT, RAA, RMS, BW, AA, TLM; Critical revisions for important intellectual content: WFT, RAA, RMS, BW, AA, TLM.

Corresponding author

Correspondence to Wafa’a F. Ta’an.

Competing interests

The authors declare no competing interests.

Ethical considerations

Prior to the conduction of the study, ethical approval was obtained from the Institutional Review Board at Jordan University of Science and Technology (ID: 20230501). The study adhered to the Declaration of Helsinki; participants were offered a cover letter that appeared upon starting the questionnaire with a brief description of the study’s purpose and an explanation that there are no foreseeable risks to participating. Informed consent was obtained from all participants. Participation was voluntary and participants had the right to withdraw from the study at any time without penalty.

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