Drivers Influencing Childhood Immunization-Related Behaviours in Kyrgyzstan

"The family, family doctor, and paediatricians play a very important role in the decision to vaccinate a child. Parents who rate their communication with their paediatrician as positive and perceive the doctor as responsive are more likely to vaccinate their child." - Dr Sanja Matovic-Miljanovic, head of the research team



Kyrgyzstan is facing a problem of low population awareness of routine vaccination benefits and safety, as well as the shortage of health personnel. Commissioned by the United Nations Children's Fund (UNICEF) Regional Office for Europe and Central Asia (ECARO), this report provides an overview of the factors influencing people's childhood immunisation-related choices and practices in Kyrgyzstan. "Understanding the drivers influencing people's immunization-related choices and practices is expected to enable government and decision makers to obtain insights into barriers and drivers to vaccination in priority target groups and enable them to design evidence-based interventions for high and equitable vaccination uptake."



The research detailed in the paper drew on the Behavioural Drivers Model (BDM). As a transtheoretical model, the adapted BDM used here applies a broad perspective and a comprehensive framework for analysis, including psychological, sociological and environmental levels of behavioural drivers (BDs).



Two cross-sectional studies were conducted through the collaborative research network of the Euro Health Group (EHG) team, the UNICEF country office in Kyrgyzstan and the Rebicon team, under the supervision of UNICEF ECARO. In September and October 2022, the research team used computer-assisted personal interviewing (CAPI) with 1,000 adult parents/caregivers of children under five and 400 healthcare workers (HCWs) in Kyrgyzstan. In designing the questionnaire, international standards and best practices, UNICEF and World Health Organization (WHO) behavioural insights (BI) guidance and protocols, and lessons learned from similar work done by UNICEF, WHO, and other partners were followed.



Key findings from the survey of parents/caregivers:

• The majority of parents/caregivers reported they had vaccinated their child on time according to the vaccination calendar (96.8%, n=866). About 8% of parents and caregivers intentionally refused all or some of the recommended vaccines.
• Overall, parents'/caregivers' attitudes towards vaccine efficacy and vaccine safety were positive, and they estimated the risk of the diseases against which children are vaccinated to be moderately high. However, one barriers to vaccination is parents' lack of confidence in the safety of vaccines, despite the fact that more than 77% of parents believe they are safe.
• Parents/caregivers expressed a moderately high level of trust in societal factors, with the family and family physician being the most trusted sources for most parents.
• The parents surveyed had an average level of factual knowledge about vaccines.
• Almost all parents/caregivers claimed (98.9%, n= 986) that as parents they have a high responsibility to protect their children from any harm, while one quarter of them (25.7%, n=255) were afraid that they might harm their child by vaccinating them. Almost one fifth of parents/caregivers (18.9%, n=187) reported that they personally know someone whose child had a serious adverse reaction to a vaccine.
• Parents/caregivers who participated in this study had moderately low level of alternative health beliefs and worldviews.
• Most of the surveyed parents/caregivers believed that healthcare providers (97.5%, n=967), national health authorities (93.6%, n=905), and government representatives (91.6%, n=877) had positive attitudes towards childhood vaccination. Most believed that healthcare providers (94.8%, n=936), national health authorities (92%, n=894), government representatives (89%, n=845), and family members (85.3%, n=852) think it is important to vaccinate their children.
• The majority of parents/caregivers ranked family members (85.6%, n=856) and healthcare providers (71.5%, n=715) as the most influential social agents in the decision to vaccinate the child. Other parents/caregivers (54.2%; n=542), community members (54.2%, n=542), religious leaders (54.0%, n=540), and local leaders (43.9%, n=439) were perceived by the majority of parents/caregivers as least influential on their vaccination intentions.
• Parents/caregivers assessed communication with their child's paediatricians as high-quality, and the vast majority of them followed the vaccine recommendations given by their child's paediatrician.
• Parents/caregivers did not, on average, consider themselves lacking information about vaccines and vaccination. However, some parents noted that the lack of information about vaccines made it difficult for them to make a decision. The majority of them reported that their most frequently used sources of information about vaccines were their family physicians (86.2%, n=862) and family members (67.2%, n=670). The least used sources of information were national TV channels (15.8%, n=158) and religious leaders (14.2%, n=139). Parents/caregivers reported few structural barriers to vaccination.
• Considering psychological drivers significantly associated with parental vaccine behaviour, parents/caregivers who perceive vaccine as more safe were more likely to timely vaccinate their child (odds ratio (OR)=3.17, p<0.01), whereas parents/caregivers who were more inclined to the alternative health beliefs were less likely to timely vaccinate their child (OR=0.53, p<0.01).
• Among the sociological drivers that significantly influenced parents' vaccination behaviour, those who perceived that their family members thought vaccines were extremely important for their child's health were more likely to be vaccine accepting (OR=5.23, p<0.05) than those who perceived that their family members thought vaccines were not important at all. Parents/caregivers who believed that their friends thought that childhood vaccination was moderately important (OR=1.59, p<0.01), extremely important (1.94, p<0.01), or even were neutral (OR=1.41, p<0.01) were also more likely to be vaccine accepting than those who think that their friends considered childhood vaccination not being important at all.
• Parents who rated communication with their child's paediatrician/family physician as more responsive (OR=2.83; p<0.001) were more likely to be vaccine accepting.
• In terms of environmental drivers significantly influencing parental vaccine behaviour, parents/caregivers who perceived to a greater extent that there is a lack of information about childhood vaccination were less likely to timely vaccinate their child (OR=0.60, p<0.001). In addition, parents/caregivers who more frequently follow information regarding childhood vaccination given by their family physician (OR=1.48, p<0.001) and healthcare professionals in media (OR=1.39, p<0.01), and less frequently follow information given by religious leaders (OR=0.67, p<0.001) were more likely to timely vaccinate the child.

Key findings from the survey of HCWs:

• The vast majority of HCWs surveyed believed that it was important vaccinate their child (99%, n=205). 74% of HCWs surveyed said they always persuade parents to vaccinate their child, and almost 95% provide additional information if the parent is unsure.
• HCWs showed highly positive attitudes towards vaccine efficacy, moderately positive attitudes towards vaccine safety, and perceived danger of vaccine-preventable diseases as moderately high.
• HCWs demonstrated high level of societal trust. Colleagues (84.9%, n=339), continuing medical education (86.4%, n=345), national (83.7%, n=329) and international scientific conferences (82%, n=319), publications and guidelines from national (79.8%, n=317) and international organisations (75.9%, n=299), government (77.4%, n=308), national (77.4%, n=302) and international scientific literature (74.2%, n=288) were the most trusted sources of vaccine-related information for the majority. Public media and social networks were rated as the least trustworthy, with 54.5% (n=216), and 34.1% (n=135) respectively.
• A small minority of physicians (6.2%, n=8) and nurses/technicians (3%, n=8) denied feeling responsible for their patients' parents' decisions regarding vaccination, while almost all physicians (99.3%, n=129) and nurses/technicians (99.3%%, n=268) agreed that it is their duty to advise parents to vaccinate their children.
• The majority of HCWs surveyed believed that national health authorities (98%, n=389), their colleagues (98%, n=391), members of their family (97.3%, n=389) and the government (96.4%, n=382) had positive attitudes towards vaccination. The majority believed that their colleagues (98.6%, n=201), members of their family (97.6%, n=202), national health authorities (97.1%, n=200), and the government (96.1%, n=197) thought it was moderately or extremely important to get their child vaccinated.
• Family members (74.4%, n=154) and personal attitudes towards vaccination (73.4%, n=152) were considered to have the greatest influence on vaccination intentions.
• Among the socio-demographic characteristics that significantly predicted vaccination behaviour, vaccine promotion behaviour was more prominent among HCWs who self-identified as Muslim compared to those with no religion.
• HCWs who manifested higher level of societal trust and put more trust in information provided by colleagues were more likely to engage in vaccine promotion behaviour. HCWs who perceived vaccine preventable diseases as less dangerous and who put more trust in information from social networks were more likely to express vaccine hesitancy.
• HCWs who had very positive general attitudes towards vaccination were more likely to engage in vaccine promotion behaviours compared to HCWs who had neutral attitudes. Also, HCWs who perceived their friends' attitudes towards vaccination as very positive were more likely to promote childhood vaccination than HCWs who perceived their friends' attitudes towards vaccination as neutral or somewhat positive.

Recommendations that are derived directly from the findings and conclusions of this research are outlined in the report. In summary, a multi-component strategy to promote vaccination is needed, consisting of:

• campaigns to educate parents/caregivers about vaccination, focusing on vaccine safety and the risks of vaccine-preventable diseases, preferably led by healthcare providers;
• vaccine promotion interventions that focus more on urban areas of Kyrgyzstan, where negative attitudes and vaccine hesitancy among parents/caregivers are more prominent;
• dialogue-based interventions that address specific concerns and fears of parents through direct communication;
• education of HCWs to increase their vaccine-related knowledge through formal and informal communication channels;
• hands-on-training for HCWs to develop their communication skills and empower them to advocate for vaccination;
• community engagement and a participatory approach in the design and implementation of culturally sensitive and context-appropriate immunization strategies; and
• provision of information that is targeted to families as the decision-making units.