IMPLEMENTATION AND ROLE OF HEALTH EDUCATION PROGRAM IN IMPROVING THE KNOWELEGE ABOUT VACCINATION AMONG THE MOTHERS OF UNDER FIVE YEARS OLD CHILDREN IN ERBIL GOVERNORATE

IMPLEMENTATION AND ROLE OF HEALTH EDUCATION PROGRAM IN IMPROVING THE KNOWELEGE ABOUT VACCINATION AMONG THE MOTHERS OF UNDER FIVE YEARS OLD CHILDREN IN ERBIL GOVERNORATE

*Farqad Ahmed Jawad 1, Namir Ghanim Al-Tawil 2*

1. Department of community medicine, College of Medicine, Hawler Medical University, Erbil Kurdistan- Iraq;
2. Department of community medicine, College of Medicine, Hawler Medical University, Erbil Kurdistan- Iraq. Email: [email protected].

Corresponding author: Farqad Ahmed Jawad

 E-mail: [email protected].

ORCID  :

ABSTRACT

Parents' attitudes and degree of information surrounding child immunization may have an impact on how they practice. Deficiency of information about vaccinations, low levels of awareness or unfavorable attitudes about vaccinations, and false beliefs or rumors about the safety of vaccinations is major barriers to achieving high vaccination rates in children. To assess the level of knowledge about immunization among parents and to assess the role of an educational program in improving the knowledge of a selected group of parents with low level of knowledge. A quasi-experimental study (pre and post educational program) was carried out on 50 women who were selected from urban and rural areas of Erbil governorate, Kurdistan, Iraq to participate in the educational program. The questionnaire was developed by the researcher. The data were analyzed by SPSS, version 26, software. A p-value of ≤ 0.05 was considered, statistically significant. Chi square test of association (or Fisher’s exact test) was used to compare proportions. The majority (88.6%) of the mothers mentioned that family, mother, or mother-in-law are the source of first information about vaccination. Mothers in Erbil governorate had medium knowledge score before the program. There was development in the knowledge level of them after the implementation of health education program and all of them had high knowledge after the program. There was improvement in the knowledge level of them after the implementation of health education program, and all of them had high knowledge after the program therefore, consistent health education sessions and reminders among mothers will solve the problems of immunization.

Keywords: Health education, Immunization, under five children, Erbil governorate..

Received: 4 March 2023, Revise Date: 29 April 2023 Accepted:10  May 2023, Available online: 28 July 2023

INTRODUCTION

A vaccine is an immune-biological agent that aids in preventing a certain disease and encourages the creation of antibodies (UIP, 2015; Park, 2015). All individuals gain from illness inhibition through vaccination, which has a favorable impact on social, economic, and healthiness outcomes at the international, governmental, and local levels. Immunization is a low-cost, life-saving measure that guards against avoidable illnesses, impairments, and fatalities (Zaffran, 2014). By directly lowering the number of children dying from preventable causes or indirectly by lowering the prevalence of other infectious diseases, immunization and other related interventions will significantly aid in the achievement of the Millennium Development Goals (MDGs), which will ultimately lead to improved population health and a reduction in poverty (Zaffran, 2014).

More than ten millions children in little- and middle-income nations die before turning five each year. Most of them pass away because they lack access to efficient interventions that would combat common and preventable babyhood diseases (Lee, 2003). To provide the best defense against illnesses, kids should receive all advised immunizations at advised ages (Chris-Otubor et al. 2015; Joseph et al. 2015). A child's quality of life would be improved if they were given the right immunizations, which would also greatly lower the costs of disease treatment and disease rates (Fad et al. 2017). Parents' attitudes and degree of information surrounding child immunization may have an impact on how they practice (ALAmri et al. 2018). Lack of awareness or information about vaccinations, low levels of awareness or negative attitudes about vaccinations, and false beliefs or rumors about the safety of vaccinations are major barriers to reaching high vaccination rates in children (Hu et al. 2016; Ramadan et al. 2016; Birhanu et al. 2016). Objectives: To assess the level of knowledge about immunization among parents and to assess the role of an educational program in improving the knowledge of a selected group of parents with low level of knowledge.

METHODS

 A cross-sectional descriptive study design (household survey) was carried out during May 15, 2021 - September 1, 2023. Data collection started on Aug 18, 2021 and ended on Dec 27, 2021.In addition to that, a quasi-experimental study (pre and post educational program) was carried out during the period February 2, 2022 - May 31, 2022. Before collecting data, necessary approvals and official permissions were obtained from presidency of Hawler Medical University, ethical agreement was being taken from the ethics committee of the college of medicine, general security of Erbil governorate, and general directorate of health- Erbil. Oral consent was taken from the mothers before starting the interview and health education program. In a previous study of the authors (which was done to find out the immunization coverage); Multi stage cluster sampling method was carried out to collect 1025 women. There are six municipalities in Erbil city, three of them were selected using simple random sampling by Excel, accordingly municipalities number 3, 4, and 5 had been selected, and then five quarters were selected from each municipality, so the total randomly selected quarters were 15, as follows: Khanzad, Sarwaran Havalan, Manara, Mamostayan, Khabat, Mufty ronaky street, Gullan, Hawler new, Briaty, Safeen3, Andazyaran, Zankoo, Azady, Rasty, and Ronaky. Rural areas that had been visited by the researcher during the household survey were as follows: Kore, Babishtian Soran, Garota, Spekrah, Pongeena, Hujaran, Seberan, Kani qurzalla, Dosara jabar, Dosara fatih, Yaramja, Kardarash Zab, Qalamortic, Si garka, and Jajnikan Abu bakir. For the health education program, a convenience sample of 50 women was selected out of the 1025 women, 30 women were selected conveniently from rural areas, and 20 women were taken from urban areas, More women were taken from rural areas as the proportion of defaulters was more in the rural areas. The researcher (with the help of a translator) discussed with the parents the role of vaccines in preventing communicable diseases, their safety and effectiveness in preventing disease, and encouraged the mothers to adhere to the vaccination schedule. A booklet made by the researcher, was distributed to the above-mentioned mothers in Kurdish language. It included pictures and information about the vaccination process and communicable diseases in order to educate the parents about these topics, hence protecting the baby’s health and improving the immunity system of the child. Re-assessment of knowledge was carried out three months after the educational program.

The Knowledge part of the questionnaire consisted of 45 items that begins with the routes of administration of vaccines to the child (injection route, oral route) and finally to the sources of information about vaccination (television, internet and social media, friends, neighbors, health personnel, family, mother, mother-in-law, and others ), and the reasons of dropout in those who are defaulters from immunization like (unaware of need for immunization, unaware of need to return for second and third dose of the same vaccine, fear of side effects of the vaccines, wrong idea about the contraindication of immunization, place/time of immunization are unknown, illness of the child, mother is too busy, inconvenient time, place of immunization is too far to go, family problems including illness of the mother, long waiting time due to overcrowding in health center, postponed until another time, no faith in immunization, rumors, and others). Frequencies, Percents, arithmetic mean, and standard deviation were calculated; figures and tables, Pie charts, and Bar charts were used for graphical presentation.

Statistical analysis:

The statistical package for social sciences (SPSS, version 26) was used for data entry and analysis. Chi square test of association was used to compare proportions. When the expected frequencies of more than 20% of the cells of the table were less than 5, Fisher’s exact test was used (instead of the Chi square test).  A non-parametric test (Wilcoxon signed rank test) was used to compare the median knowledge scores before and after the educational program. A p value of ≤ 0.05 was considered as statistically significant.

RESULTS

Almost all of the mothers knew that the vaccines can be given by injection (99%) and oral route (98.9%), and 92.2% knew that the vaccines are effective in preventing diseases as presented in Table 1. It is evident in the table that 94.1% of the mothers identified that the first dose of vaccine should be given at birth. The majority (81.1%) of the mothers knew that regular rounds or campaigns are advantageous for increasing the vaccination coverage, and 80.1% of them believe that there is a need for these campaigns even if the child had completed his/her scheduled immunizations. The majority (80.2%) of the women knew that repeated vaccinations of poliomyelitis during campaigns do not lead to vaccine over dose. Regarding the contraindications of vaccine administration, only (12.4%) of the mothers recognized that the vaccine can be given to a child suffering from diarrhea, (80.4%) of the mothers believe that the vaccine cannot be given to a child with high fever, (18.7%) of the mothers believe that the vaccine can be given to a child with common cold or mild flu, and (68.2%) of the mothers believe that vaccines cannot be given to children with malnutrition. Around two thirds (65.1%) of the mothers distinguished that the child can eat or drink 30 minutes after administration of oral vaccine. Less than half (39.3%) of the mothers knew that low birth weight children should not be immunized, and the majority (93.2%) of them knew that the vaccine doses (not only one jab) are important to protect child's health. Regarding the adverse reactions after immunization, 96.4% of the mothers knew that fever may occur, and 87.9% of them knew that swelling and redness at the site of injection are possible adverse effects. The main reasons for dropout were as follows: child’s illness (86.7%), unawareness of need of immunization (83.5%), and unawareness of need to repeat for 2nd or 3rd dose (81.9%). The other reasons are presented in the table. Regarding the reasons for parents to vaccinate their children, the largest proportion (94.6%) of the sample mentioned that the reason is to protect their children from diseases (Table 1).

Table 1: The knowledge about the vaccination (N=1025):

*Correct answer is ‘Yes’.   **Correct answer is ‘No’

Regarding to knowledge score of the whole sample of mothers before the implementation of health education program, 83.4% of them with high knowledge score, and 13.8%, 2.8% of them with medium and low level of knowledge respectively

Figure 1: Knowledge score categories of mothers (of the whole sample) before the educational program.

Regarding the foundation of first information about vaccines, the majority (88.6%) of the mothers mentioned that family, mother, or mother-in-law are the source of first information, while 47.6% mentioned the internet as the first source. Other sources are presented in Table 2.

Table 2:  Source of first information about vaccination as mentioned by the mothers.

The median of the total knowledge score was 17 before the health education program, which increased significantly to 19 after the implementation of the health education program (p < 0.001) (Table 3).

Table 3: knowledge score before & after health educational program (n = 50).

Fifty women were involved in the educational program. Six (12%) of them had medium knowledge score before the program. There was significant improvement after the program, where it is evident in Figure 2 that none of the women had medium knowledge and all of them had high knowledge after the program (Figure 2).

Note: p value is not applicable Figure 2: knowledge before and after the educational program.

DISCUSSION

The knowledge about vaccination

The majority of the mothers had high knowledge about vaccination. This could be related to the wide spread of the vaccination units in the primary health care centers, and the health education programs in these centers that emphasizes the meaning and safety of the vaccines, in addition to the role of friends and social media. Almost all of the women knew the routes of vaccine administration (injection and oral routes). This high percentage is simply because of the previous experience of the mothers observing their children during getting the vaccine. The majority (92.2%) of the mothers knew that the vaccines are effective in preventing diseases. This result coincides with the result of Almutairi et al (2021) in Saudi Arabia, where most of the mothers (90.1%) knew that the vaccination can prevent infectious diseases. This result disagrees with the study’s result of Verulava et al (2020) in Georgia, where they discovered that just 58% of participants were supporting immunization as a mean of illness prevention. The majority (94.1%) of the mothers identified that the first dose of vaccine must be given at delivery. This result is in agreement to the study’s result of Almutairi et al (2021) in Saudi Arabia, where almost all (98.5%) of the mothers knew that the vaccination is important for children from the first day of birth.  The majority (81.1%) of the mothers knew that regular rounds or campaigns are valuable for increasing vaccination coverage, and 80.1% of them believe that there is a need to these campaigns even if the child had completed his/her scheduled immunizations. In addition to that, the majority (80.2%) of the women knew that repeated vaccinations of poliomyelitis during campaigns do not lead to vaccine over dose. This coincides with the outcome of Olajide et al (2014) in Nigeria. They found that 72.5% of respondents recognized that Polio vaccine given at several times can defend a child. Regarding the contraindications of vaccine administration, only 12.4% of the mothers knew that the vaccine can be given to a child suffering from diarrhea, while a higher percentage (45.4%) was detected by Almutairi et al (2021) in Saudi Arabia. On the other hand, 80.4% and 68.2% of the mothers believe that the vaccine cannot be given to a child with fever, and malnutrition respectively. These proportions are more than the study’s result of Almutairi et al (2021) in Saudi Arabia, they found that more than half (54.6%) of the mothers identified that fever and malnutrition are contraindications to vaccination. Only 18.7% of the mothers believe that the vaccine can be given to a child with common cold or mild flu. This percentage was higher than what was reported by Thomas et al (2015) in Nigeria, they found that only 3.2% of mothers knew that the child with cold can be vaccinated. Around two thirds (65.1%) of the mothers knew that the child can eat or drink 30 minutes after administration of oral vaccine, while Jawad and Al-Janabi (2019) in their study in Baghdad demonstrated that 85.2% of the mothers knew about the ability of the baby to eat or drink within half an hour after administration of polio drops. More than one third (39.3%) of the mothers knew that low birth weight children should not be immunized, compared with 94% in a study done in Baghdad (Jawad and Al-Janabi, 2019). The majority (93.2%) of mothers knew that several doses of the vaccine are important to protect kids’ health. Regarding the adverse reactions after immunization, 96.4% of the mothers knew that fever may occur. This outcome is in contract with a study accomplished in Saudi Arabia where they found that 85.9% of the mothers knew that fever and pains are due to some vaccinations (Almutairi et al. 2021). The majority (87.9%) of mothers knew that swelling and redness at the site of injection are possible adverse effects after getting immunized.  This result powerfully agrees with the result of Almutairi et al (2021) in Saudi Arabia, they found that 88.3% of the mothers knew that swelling and pain are possible adverse reactions to vaccination. The majority (83.5%) of mothers knew the unawareness of need of immunization is a reason for dropout from immunizations. This result is incompatible with a study done in Bangladesh, they found that 25% of the mothers mentioned the unawareness of need for further immunization is one of the reasons of dropout from immunization (Rahman et al., 2012). Unregularly/cancelled EPI sessions, fear of side effects, mothers' poor knowledge of the advantages of complete vaccination, mothers' lack of knowledge about EPI sessions, geographical barriers, etc. are all factors that contribute to the low complete immunization coverage in Bangladesh's rural, difficult -to-reach hilly areas (Uddin et al.,2010). Regarding to ‘unawareness of the importance of  second or third dose as a cause for dropout. The majority (81.9%) of the mothers agree to this cause, compared with 83.6% obtained in a study done in Baghdad (Jawad and Al-Janabi, 2019). The majority (75.9%) of mothers agreed that ‘fear from side effects’ is one of the reasons of dropout. This result disagrees with the result of a study done in Jordan that demonstrated that 29.2% of the mothers think that the vaccines cause side effects (Masadeh et al., 2014). Mothers in Bangladesh stated that despite the fact that side effects like fever, redness, and rash are frequent and typically go away on their own in a day or two, they were still reluctant to vaccinate their children (Rahman et al., 2012). Armenian parents frequently cite concern over adverse reactions as a reason for not vaccinating their kids (UNICEF and WHO, 2006). In some instances, parents opted not to vaccinate their newer children if an older sibling or colleague's child had unkind effects. In certain records, it is said that adverse reactions become a problem when fathers or mothers-in-law grow offended and reject to let additional immunization (Favin et al., 2012). This discomfort might or might not be sufficient to prevent under vaccination, depending on other circumstances. Better health worker communication, such as informing caregivers about the side effects, what to expect, and what to do, according to several mothers, might eliminate this issue (Favin et al., 2012). The majority (75.4%) of the mothers knew that ‘misconception about vaccination’ is a reason for dropout. This result is different from the study result of Babitha and Suresh (2020) in India where none of the mothers didn’t consider this reason as a cause for partial immunizations. The majority (70 %) of the mothers believe that not knowing the place and time of immunization is considered as a reason for dropout, compared with 80% of women in a study done in Baghdad (Jawad and Al-Janabi, 2019). The majority (86.7%) of the mothers knew that the child’s illness is one of the reasons for dropout. This result is higher than the study’s result done in India where 36.7 % of mothers demonstrated this reason as cause for partial immunizations (Babitha and Suresh, 2020). A numeral of worries and myths, including those that say underweight children shouldn't be immunized and that unwell kids shouldn't have immunizations. They also say that kids shouldn't receive numerous vaccinations in the same visit. The most typical fake contraindication, which is reported in Pakistan (WHO and EPI, 1987). Health professionals give rational explanations for why they won't vaccinate unwell children: they worry that the vaccination will be responsible if the child's health get worse, and they say they're just following the mother's wishes. Nurses in Kenya said that they wanted to examine the scientific proof about the security of vaccinating unwell children (Qidwai et al., 2007). Most of the mothers would not immunize their child if child was having slight upper respiratory tract infection and would not immunize their child if child had fever (Mahalingam et al., 2014). An evaluation of mothers' vaccination knowledge revealed a substantial difference between urban and rural moms in terms of the value of vaccination as well as the age at which the immunization schedule should begin and end. To achieve nationwide immunization coverage of 100%, particularly in rural regions, these gaps must be corrected (Mahalingam et al., 2014). After learning more about vaccination, the majority of women in both urban and rural settings supposed that vaccinations were safe. However, a significant number of mothers in both urban and rural settings would postpone immunizing their child in the event of a simple childhood illness (Mahalingam et al., 2014). The majority (73.2%) of the mothers knew that being too busy is one of the reasons for dropout. This outcome is inconsistent with a study done in India were 8.9 % of mothers mentioned that being busy is a reason for partial immunizations (Babitha and Suresh, 2020). The majority (72%) of the mothers mentioned that ‘inconvenient time’ is a reason for dropout. This result is incompatible with a study done in India where none of the mothers considered ‘inconvenient time of immunization’ as a reason for partial immunizations (Babitha and Suresh, 2020). More than two thirds (69.7%) of the mothers mentioned that remote place of immunization is a reason for dropout, compared with 0% in an Indian study (Babitha and Suresh, 2020). Mother illness is one of the reasons for dropout as stated by the majority (70.8%) of the mothers. This result is inconsistent with the study’s result of Babitha and Suresh (2020) in India where none of the mothers mentioned the above reason. More than two thirds (69.4%) of mothers knew that long waiting time due to overcrowding in health center is one of the reasons of dropout from vaccinations. This outcome is like to the study’s result of Jawad and Al-Janabi (2019) in Baghdad who demonstrated that 62.9% of the mothers agreed with this reason. The majority (78.0%) of mothers mentioned that postponing the time of vaccination to another day is one of the reasons of dropout, compared with 31.6% reported in an Indian study (Babitha and Suresh, 2020). The majority of the mothers considered ‘no faith in immunization and rumors’ (74.3%, 74.1% respectively) are reasons of dropout from vaccinations. This outcome was inconsistent with the study’s outcome done in India who demonstrated that none of the mothers believe in this reason (Babitha and Suresh, 2020). Many women in Syria thought that the polio vaccine rendered their children paralyzed. Some individuals in Ethiopia thought that vaccinations could result in sterility, paralysis, abscesses, and illnesses like HIV/AIDS, or that they were being utilized as test subjects for particular medical treatments (Bisrat, 2008). Regarding to the reasons for parents to vaccinate their children, the largest proportion (94.6%) of the sample mentioned that the reason is to protect their children from diseases. This result strongly agrees with a study done in Saudi Arabia, they found that 98.5% of the mothers knew even the healthy child needs vaccinations to prevent the diseases and 97.3% of mothers recognized that the vaccines save children well (Almutairi et al. 2021). Another study done in Jordan they found that 70.7% of the mothers believed that the vaccines can protect their children against the spreading of contagious diseases. While more than two thirds (66.6%) of the mothers use other behaviors to defend the kids from infection (Masadeh et al., 2014).

Knowledge score before the health educational program: In this study, mothers’ knowledge about vaccination was assessed by asking mothers to identify the name of vaccines and the compliance to the mandatory vaccines according to the National Vaccination Program. The majority of the mothers (71%) were aware about the name of the given vaccine, this coincides with the result of a studies done in El Salvador and Nigeria (Suarez-Castaneda et al., 2014; Umeh and Ahaneku, 2013 respectively). While in another study conducted in India, it was said that women must be confident in the safety of vaccines and that myths must be eradicated. The failure of mothers to name or recognize illnesses other than poliomyelitis suggests that health education must be prioritized to improve understanding of the entire program (Mahalingam et al., 2014).

Regarding the foundation of first information about vaccines: more than half (50.7%) of the mothers mentioned that TV is the source of information about vaccines. This result is inconsistent with the result of Jawad and Al-Janabi (2019) in Baghdad, they stated that 77.1% of the mothers depend on the same source (TV) for information about vaccination. For the second basis of first information about vaccines, 47.6% of women were depending on internet and social media. This result is incompatible with the study results of Tabacchi et al (2017) in southern Italy; they mentioned that the main information source on vaccination was 17.6%, 24.1% for internet, and mass media respectively. Regarding to friends , neighbors as a sources for first information, 55.3% and 61.8% of the mothers respectively agree .This study is incompatible with the results of Coates et al (2013) in Angola, they stated that (33%) of friends and neighbors were the source of information. More than two thirds (67.1%) of the mothers mentioned the health personnel are the first source of information about vaccines. This result is disagrees with the result of Tabacchi et al (2017) in southern Italy, they mentioned that 12.5% of the respondents depending on health care workers for information on vaccination. The majority (88.6%) of the mothers mentioned that family, mother, or mother-in-law are the source of first information. This result doesn’t coincide with the study’s result of Riccò et al (2017); they stated that 8.4% of participants recalled relatives as the source of information. Mothers who got their information about vaccination from medical staff, posters/brochures offered by the medical center had higher vaccination knowledge/attitude scores compared with those who got the information from TV-radio-internet websites, and family members and friends or neighbors (Masadeh et al., 2014).

Health education program:

According to a study, misunderstandings, a lack of knowledge, and a lack of faith in the healthcare system all contribute to an increase in vaccine reluctance. This claim was supported by evidence showing how ineffective vaccination education programs reduced vaccination readiness. (Leask, 2011). According to this study, several students who opposed mandatory vaccination talked about enhancing patient education and interpreting information about vaccinations (Harmsen et al., 2013). Parents' desire for additional vaccination-related knowledge is one of the causes of vaccine reluctance. Knowing both the advantages and disadvantages of each vaccine can help them make educated decisions about their child's healthcare (Harmsen et al., 2013). A third of parents said they lacked access to enough information, and the majority of those parents said they didn't find it easy to communicate with their child's provider (Gust et al., 2005). Many parents want more in-depth information about the drawbacks and advantages of vaccines explained in a factual manner that doesn't seem to be trying to persuade them one way or the other about immunizing their child (Harmsen et al., 2013). Parents can be given access to a variety of print and online resources, including those from the American Academy of Pediatrics and the Centers for Disease Control and Prevention. Parents desire to be able to speak openly with their child's doctor without fear of being judged or attacked (Dubé et al., 2014). Parents would like to be able to question things without feeling judged. One of the most crucial information sources for parents who are making decisions about their children's heath is their doctors (Dubé et al., 2014). In a study conducted by Kennedy et al. (2011) noted that 81.7% of parents said their child’s healthcare provider was one of the most important sources of information. When parents don't receive the information they need from their providers, they go for it elsewhere, where it may be misleading and inaccurate, leading them to make bad decisions for their kids (Fredrickson et al., 2004). Pharmacists and other healthcare professionals will be better equipped to conduct enlightening discussions regarding vaccines if they can comprehend the primary worries parents have about vaccinating their children. They will also be able to give parents the data they require to make the best choices for their children (McKee and Bahannon, 2016). Just like any other parent, parents who are reluctant to vaccinate their children or who refuse vaccinations care about their kids and want to do everything in their power to protect them. In order for families to grasp the advantages of vaccination without feeling attacked or criticized for having questions about their child's healthcare, practitioners must have open and honest talks with their patients and their families (Saada et al., 2015). Parents' views toward immunization have been proven to improve modestly as a result of education and patient time spent with them, but the precise messages or methods that healthcare professionals should employ have not yet been fully uncovered (Williams et al., 2013). Understanding the reasons behind parents' questions can help pharmacists, doctors, nurses, and other healthcare professionals connect with patients on a more personal level and address the topics that matter most to parents. All healthcare professionals should make an effort to be informed on the recommended vaccinations and to comprehend the rationale behind those recommendations. Patients will now have direct access to trustworthy information that will enable them to choose the best course of action for their families. More analysis is needed to determine how professionals can aid parents by properly educating them (McKee and Bahannon, 2016). According to one point of view, the disparities in maternal knowledge across geographical regions are caused by mothers' lack of knowledge about vaccinations administered in hospitals after birth, which is the case today, when all deliveries take place in hospitals or primary healthcare facilities and mothers adhere to the vaccination schedule. Furthermore, we think that mothers' attitudes and immunization practices may be impacted by the knowledge they learn in hospitals or basic healthcare facilities. Furthermore, social media may have a significant (positive or negative) impact on mothers' understanding due to false beliefs or misconceptions about the safety of vaccinations that are spread by the media and Internet (Almutairi et al., 2021).

Limitations of the Study: There was some barriers that interferes with make the interview period and educational session about vaccination with mothers from rural areas due to the nature, and transportation in addition to the distances away from the center, language is the most important barrier that interferes with the study especially in the rural areas because all of them didn’t know the Arabic language therefore the researcher need to translator’s help.

Strengths of the study: Up to the researcher knowledge, this is the first comprehensive survey in Erbil governorate that compares between the knowledge level of mothers in the urban and rural areas before and after the implementation of health education program.

CONCLUSIONS: The mothers in Erbil governorate had medium knowledge score before the program. There was improvement in the knowledge level of them after the implementation of health education program, and all of them had high knowledge after the program therefore, regular health education sessions and reminders among mothers will solve the problems of immunization.

ETHICAL CONSIDRATION COMPLIANCE WITH ETHICAL GIUDELINES

Ethical agreement was being taken from the ethics committee of the college of medicine, general security of Erbil governorate, and general directorate of health- Erbil. Oral consent was taken from the mothers before starting the interview and health education program.

FUNDING:

The effort that is the subject of this article is not supported financially.

AUTHOR’S CONTRIBUTIONS:

Conceptualization; Jawad FA and AL-Tawil NG. A performed of data entry, editing, analysis and interpretation of the results. Writing the methods of the study. Reviewing of literature review about vaccination.

DISCLOSURE STATEMENT: The author did not disclose any possible conflicts of interest(s).

AKNOWLEDGMENT:

The authors would like to thank the participants, parents, Hawler medical university committee and the managers and staff of the general department of Erbil police that cooperated with the researcher.

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