Vaccination is one of the most cost-effective and successful primary public health interventions that has managed to control and eradicate previously devastating infectious disease outbreaks around the world [1-2]. Despite this, vaccination hesitancy remains a global phenomenon [3-4] and a major public health concern as high vaccination rates are crucial to achieve collective immunity and a decrease in transmission rates [1]. In 2019, the World Health Organization (WHO) announced that vaccine hesitancy is one of the top ten threats to global health [5]. Parental vaccination hesitancy is on the rise [6], placing physicians at the forefront to counsel hesitant parents. The Arab region is no exception to this, as vaccination hesitancy and refusal were reported in several countries throughout the literature [7].

Rotavirus (RV) vaccination uptake is currently one of many vaccination efforts that are challenged by several implementation barriers despite the virus being one of the leading causes of gastroenteritis and child mortality at the global level [8]. Globally, it is estimated that RV infections have caused 37% of all diarrhea-associated hospitalizations and more than a quarter of a million deaths annually [9]. In 2009, WHO recommended to include and prioritize RV vaccination within all national immunization programs (NIP) as part of a global comprehensive approach to prevent diarrheal diseases or reduce their severity [10]. In the Arab region, RV remains a persistent public health threat resulting in significant health and economic impacts throughout the years, with poor monitoring and national surveillance systems in place [11-15]. Countries that implemented vaccination programs against RV recorded a significant decrease in associated infections and hospitalization rates [16].              

Identified barriers for RV vaccination uptake are numerous and vary according to the local context. These often include the high costs of vaccination and perceived low cost-effectiveness, concerns about vaccine safety and effectiveness, low perceived risk and severity of RV infections, and inadequate provision of information or recommendations to children’s parents [8-9,17-18].

In Lebanon, the RV vaccine was only introduced to the Ministry of Public Health’s (MoPH) NIP in 2022 [19]. Prior to that, two oral vaccines, introduced in 2006 and 2009 were made available in the private sector [20, 21]. National epidemiological studies showed a strong burden of RV infections in children under the age of 5 requiring hospitalization. In 2013, 43% of deaths from diarrhea in children under the age of 5 were attributed to RV infections [22]. Even though there were no identified studies assessing vaccination coverage and uptake, it can be deduced that vaccination rates are suboptimal as most hospitalized children with RV gastroenteritis were not vaccinated. Since RV vaccination was shown to be effective, with vaccinated children experiencing less severe symptoms and lower hospitalization duration than non-vaccinated children [15,20-21,23-24], it is important to promote its uptake within the NIP to decrease the burden of disease and improve health outcomes of children and to launch national surveillance systems to identify infection and vaccination rates.

There is currently a lack of information on Lebanese parents’ knowledge, attitude, and practice (KAP) regarding RV vaccination. This information will contribute to the implementation of effective strategies for increasing vaccination uptake by providing a clearer picture of the current context-specific barriers and situation in Lebanon. As such, this study aims to better understand Lebanese parents’ KAP regarding RV vaccination given the magnitude of the disease among children and the reported promising effectiveness of vaccination practices.

This study and its findings are part of a larger study that investigated the KAP of Lebanese parents regarding immunization in general with a focus on selected vaccines, including the RV vaccine.

Study Design and Population

This was a cross-sectional survey conducted between the months of April and November 2017. The questionnaire was developed by the research team after review of the literature for similar surveys [25-27]. The questionnaire consisted of fifty questions that assess KAP of school children’s parents towards vaccination. It was first developed in English, translated and adapted to Arabic, then piloted for face validity on 15 parents to assess clarity, acceptability, and length. No modifications were required after the piloting process. A list of public and private schools in the Greater Beirut area was obtained from the Lebanese Ministry of Education. Four schools (two private and two public) were then chosen randomly from the list through a computer-generated sequence. The schools selected were from different districts, ensuring the representation of different socio-demographic populations. We secured approval of the questionnaire from the Lebanese Ministry of Education and the involved schools’ administration prior to its use. Parents included in the study were Lebanese with a child aged 3 to 18 years attending one of the selected schools. Based on previously conducted similar studies [28-29] and due to feasibility purposes, and for logistical reasons, a convenient sample of 400 parents was deemed appropriate for this study.

Data Collection

The questionnaire was distributed to the eligible students enrolled in both private and public schools alongside written instructions for parents to fill and return it with the student in a sealed envelope. The completed questionnaires were retrieved after two weeks by the research team.

Statistical Data Analysis

The questionnaire consisted of three main sections: knowledge, attitude, and practice/behavior (S1 Appendix). The knowledge section included three themes pertaining to efficacy (four questions about vaccine effectiveness and importance), safety (eleven questions about vaccination risks and benefits), and general knowledge (six questions assessing overall understanding of vaccination and its importance) (S2 Appendix). Regarding attitude, three themes were included addressing parents’ reasons to vaccinate their children (three questions), trust in vaccination, healthcare providers, and the national vaccine schedule (six questions), as well as their hesitancy to vaccinate (five questions). Finally, there were three questions about practice, asking if parents gave their children the RV vaccine, and if not, the reasons behind their refusal (S2 Appendix). Knowledge and attitude questions that were answered through a 5-point Likert-scale were converted to a score over 100. Questions were given a full score of 100 for “strongly agree,” 75 for “agree,” 50 for “undecided,” 25 for “disagree,” and 0 for “strongly disagree” (S1 Appendix).

We analyzed response data collected from parents in both public and private schools (S1 File) using the IBM - Statistical Package for Social Sciences (SPSS) version 23. A Chi-square test was performed to determine the presence of a statistically significant relationship between RV vaccination uptake and categorical variables. An independent samples t-test was also performed to determine statistical significance with continuous variables. A p-value less than 0.05 was used to indicate that a statistically significant difference was observed. Statistical results were reported as average mean with standard deviation and absolute value with percentage (%) for continuous and categorical values respectively.

Ethical Considerations

The research team received approval from the American University of Beirut Institutional Review Board, the Ministry of Public Health, the Ministry of Education, and the selected school administrations before proceeding with the study. Questionnaires were sent out and received in a sealed envelope to protect parents’ confidentiality.  The questionnaire did not include any identifying data and was completely anonymous. Additionally, a consent form was included on the first page of the questionnaire informing parents about the purpose of the study, its voluntary nature, and researcher and IRB contact information. Parents were also informed that by completing the survey and sending it back, they are consenting to participate in the study. Study data was stored on a password protected laptop with access limited to the research team.

Demographics

Sociodemographic data and its relationship to RV vaccination are presented in Table 1. The results were also stratified and analyzed for public versus private schools in Table 1 in S3 Appendix. The overall response rate from the intended 400 sample size was 76.5% (306 responses) out of which 221 respondents answered the 

RV questions. These were divided as 64.3% (142 responses) from private schools and 35.8% (79 responses) from public schools. Most of the questionnaires were filled by the children’s mothers aged between 30 and 50 years. Out of all the respondents, 54.8% (121) reported that they did not vaccinate their children against the RV.

Vaccinated children were more likely to be younger (mean age 9.4±3.6) than non-vaccinated children (mean age 12.89±2.7). Children who were not vaccinated against RV were more likely to be females (p-value = 0.01), in middle school (p-value <0.0001), and the second child or more of their parents (p-value= 0.01).

Table 1: Demographic Characteristics of Study Participants

Both parents’ age and education were significantly different between vaccinated and non-vaccinated children with p-values < 0.005. A higher level of education was associated with a higher proportion of RV vaccination uptake, whereas older parents above the age of 50 were less likely to vaccinate their children. Additionally, households with lower incomes were less likely to vaccinate their children (p-value <0.0001) as 56.5% (48 responses) of all non-vaccinated children were from households   with an   income less than 1000$ per month.

Knowledge

The association between knowledge and RV vaccination is presented in Table 2. Out of the 221 respondents, 100 (45.3%) reported vaccinating their children against the RV vaccine, out of which 89.0% (89 responses) were from private schools and 11.0% (11 responses) were from public schools (S3 Appendix). Four questions evaluated parents’ perceived vaccine efficacy. There was a significant difference in the answers of two questions. Parents who vaccinated their children were more likely to believe that vaccination is important for the health of others in the community (87.37±17.35, p-value = 0.034). Parents who did not vaccinate their children were more likely to believe that vaccinations are given for the purpose of preventing diseases which are not serious (58.76±30.49, p-value = 0.013). There was no significant difference between the two groups regarding barriers for vaccination uptake (p-value for vaccination barriers > 0.05). However, parents of children who did not get vaccinated in public schools reported cost as the most common barrier (57.6% of respondents) while accessibility was reported to be the major barrier in private   schools  (78.0% of respondents)    (S3 Appendix).

Table 2: Association Between Parental Knowledge and Rotavirus Vaccine Acceptance

According to most responses (97.8% in those who vaccinated their children and 95.3% in those who did not), the physician was reported to be the primary source of information about vaccination for parents (Fig 1A). Additionally, parents of children who were not vaccinated were more likely to perceive Short Message Services (SMS) as an appropriate source for vaccination awareness (p-value = 0.009) while those who did vaccinate their children were more likely to perceive physicians, the internet, and pamphlets as means to raise awareness (p-value = 0.001, 0.03, and 0.009, respectively).

Figure 1: Association Between Practice Behaviors and Influenza Vaccine Comparing Between Those Who Vaccinated Their Children (Yes) Vs. Those Who Did Not (No)

        In the private schools, parents who did not vaccinate their children were significantly more likely to believe that vaccines may cause conditions such as learning disabilities, autism, diabetes, sudden infant death syndrome, and other chronic diseases when compared with those who did vaccinate their children (S3 Appendix). This observation was not noted for parents in public schools, as there were no significant differences between vaccinating and non-vaccinating parents (S3 Appendix). Additionally, parents of non-vaccinated children were more likely to believe that healthy children did not need vaccination (p-value < 0.0001), that it is better to develop natural immunity by getting the disease rather than by vaccination (p-value < 0.0001), and that vaccination can weaken the immune system (p-value = 0.002). On the other hand, parents who vaccinated their children were more likely to believe that vaccines are effective in preventing rotavirus infection and its complications (p-value < 0.0001), that it is better to develop natural immunity by getting sick (p value= 0.012) and that new vaccines carry more risk than older ones (p value= 0.039).

Attitude

Table 3 presents the association between attitude, trust, and RV vaccine. Parents who had their children receive the RV vaccination were more likely to give their children all the recommended vaccines (p-value = 0.039) and follow their physicians’ recommendations for vaccination (p-value < 0.0001). On the other hand, non-vaccinated children’s parents were more likely to be concerned about vaccination side effects such as fever and pain (p-value = 0.001) and its lack of effectiveness in preventing disease (p-value = 0.045). Non-vaccinating parents were also more   likely    to report   satisfaction  with the vaccination program offered by the Ministry of Public Health (p-value = 0.031) and by the administration of vaccines by healthcare personnel other than the child’s pediatrician, such as a nurse, medical student, or resident (p-value = 0.003).

Table 3: Association Between Attitude, Trust, and Rotavirus Vaccine

When investigating possible reasons for non-vaccination, parents who reported not having their child vaccinated for RV were more likely to believe that alternative methods such as hygiene and better nutrition can be sufficient to prevent infections in their children (p-value < 0.0001). These parents were also more likely to report that their children receive mandatory vaccines only to comply with school admission requirements rather than due to trust in the vaccine or healthcare providers.

Practice

Only 4.2% (4 responses) of parents who vaccinated their children against RV reported delaying or refusing vaccination in the past, compared to 29.2% (33 responses) of those who had not vaccinated their children (p-value < 0.0001) (Fig 1B). Vaccinating parents were also more likely to follow pediatrician recommendations and administer all recommended vaccines to their children (89%) compared to non-vaccinating parents (67.8%) (Fig 1C).

Table 4 shows the reasons reported by parents for not vaccinating their children against RV. The most commonly cited reason was the lack of recommendation by the pediatrician (55%), followed by missing the appropriate timeframe for administration (17.6%), and the vaccine being too expensive (16.0%).

Table 4: Reason for not Vaccinating Against Rotavirus (Percentage of Total Rotavirus Respondents)

Data available for 131 respondents

This study employed a cross-sectional approach to assess rotavirus (RV) vaccination practices among Lebanese parents with children in both private and public schools. It explored the differences in knowledge, attitude, and practices (KAP) between vaccinating and non-vaccinating parents. RV infections remain highly prevalent in Lebanon, ranking as the third leading cause of diarrhea [30]. Although the RV vaccine is now officially included in the Ministry of Public Health’s (MoPH) National Immunization Program (NIP), limited data exist regarding parental KAP toward this vaccine. Considering the critical influence of parental KAP on national vaccine uptake and the development of targeted interventions [9,31], this study provides valuable insights that contribute to both national and global literature on vaccine acceptance [32-39].

The findings reveal that only 45.3% of Lebanese parents who completed the RV vaccination section reported vaccinating their children against RV. Although no national data currently assess RV vaccination rates in Lebanon, this result aligns with previous epidemiological studies identifying low RV vaccine coverage among hospitalized children with gastroenteritis [20-21,30]. One potential explanation for the low uptake is that the RV vaccine was not previously part of the Lebanese NIP, potentially exacerbating the national burden of disease. RV vaccination remains the only effective means to prevent severe RV infection and its complications [22]. Similar trends of low vaccination coverage have been reported in countries such as Italy [9], India [40], and Turkey [41], while higher uptake has been documented in the United States (71–75%), Canada (84%), and Qatar (93%) [42-44]. Importantly, countries that included RV vaccination in their national programs have observed both improved coverage and decreased hospitalization rates due to RV gastroenteritis [45].

In this study, parents who vaccinated their children were more likely to have higher educational attainment and household income, findings that are consistent with a 2018 systematic review identifying these factors as key facilitators of RV vaccine uptake [17]. Other studies conducted in various contexts also confirm that low income is a significant barrier to vaccination [46-48]. It is worth noting that the RV vaccine in Lebanon was previously available only through the private sector, leading to financial barriers for many parents. This is supported by findings from Ontario, Canada, where no association was found between family income and RV vaccine uptake due to a publicly funded universal immunization program [17]. Furthermore, higher parental education levels have consistently been associated with better knowledge of vaccine benefits and greater ability to access healthcare services [46,49-50].

This study highlights the pivotal role of pediatricians in influencing vaccination decisions. More than 95% of respondents reported relying on pediatricians for vaccine-related information, reflecting a strong trust in healthcare professionals. Notably, 55% of non-vaccinating parents cited the absence of pediatrician recommendation as the primary reason for not vaccinating their child. This aligns with findings from a multinational study where healthcare provider recommendation was the strongest predictor of RV vaccine uptake [51]. In Italy, parents were 25 times more likely to vaccinate their children when pediatricians served as their main source of information [9]. Similar patterns have been observed in Germany and Japan, where pediatricians are considered the most influential figures in parental vaccination decisions [46,52]. Furthermore, 57% of parents in this study cited lack of awareness as a major barrier, emphasizing the need for effective communication from healthcare providers. The second most common reason for not vaccinating was missing the recommended timeframe, likely due to communication gaps between parents and healthcare professionals.

Financial barriers were also prominent, with 58.8% of parents—particularly those with children in public schools—citing cost as a reason for not vaccinating. In contrast, availability was the most frequently reported barrier among parents in private schools. This disparity reflects underlying socioeconomic differences and supports the MoPH’s decision to provide the RV vaccine free of charge under the NIP. Previous studies have also identified cost as a major impediment to vaccine uptake [17,38,50]. This is especially concerning in the Lebanese context, where the financial burden of hospitalization and treatment for RV-related illness may be unaffordable for many families—a finding echoed in other studies assessing RV vaccine barriers [53].

Additionally, non-vaccinating parents were more likely to express concerns about the safety and effectiveness of the RV vaccine. This aligns with earlier research indicating that perceived vaccine risks and doubts about efficacy are key drivers of vaccine hesitancy [17,46,50,54]. Although sources of information were relatively similar between vaccinating and non-vaccinating parents, differences in attitudes may stem from several factors, including inadequate communication from healthcare providers, varying personal beliefs and values, community influence, perceived disease severity, and levels of trust in the healthcare system.

Based on this study’s findings, several significant factors were identified which may have influenced Lebanese parents’ decision-making process regarding the vaccination of their children against RV.

These included limited vaccine accessibility and availability, inadequate information on RV vaccination, inadequate physician recommendations, low socioeconomic family status, and concerns about vaccination safety and effectiveness. These findings should help guide the planning and implementation of any vaccination initiatives, programs, or strategies as they highlight areas to address to increase vaccination uptake. Increasing RV vaccination rates is expected to decrease infection and hospitalization rates, given the burden of the disease and the vaccine effectiveness reported in previous epidemiological studies. Pediatricians should be educated and empowered to strongly recommend the RV vaccine to Lebanese parents given the role they play as a main source of information influencing parents’ vaccination decisions. It is also crucial to target and reach low-income families and those who are unable to afford the vaccine cost through well thought-out and planned activities, as their children are more likely to be affected by severe RV infections and their associated costs. The current decision to publicly fund the vaccine through the NIP will hopefully result in better vaccination uptake in this group. However, decision makers must be cautious and continuously ensure that vaccination efforts are covering wide segments of the Lebanese society.

Although our findings suggest that vaccine hesitancy is not the only reason for Lebanese parents not to vaccinate their children, it is still a significant driver for low vaccination uptake. It is then crucial to deliver relevant and convincing information through appropriate channels and combat misinformation to help hesitant parents make an informed decision regarding vaccinating their children.

These results are based on a questionnaire administered in 2017, which provided valuable insights on the status of RV vaccination and parents’ KAP towards it prior to its inclusion in the NIP in 2022. Future studies can make use of this data and investigate the impact that the Ministry’s decision had on parents’ knowledge, attitude, and perceived willingness to vaccinate their children as well as the subsequent effect on vaccination coverage rates. The study did have a few limitations as it only included schools from the Greater Beirut area, so the results are not generalizable to the whole Lebanese population in terms of KAP and vaccination rates. Additionally, 25% of vaccinating parents in private schools had children enrolled in preschool, while public schools do not offer preschool programs. Also, this study included only school children above the age of three, as such the rates of vaccinations may be different in the younger population.

This study employed a cross-sectional survey to assess Lebanese parents' KAP towards children’s vaccines and analyze the difference between parents who had vaccinated their children against RV and those who did not. There was a significant association between non-vaccination and lower income and education levels as well as higher vaccine hesitancy scores. The main barriers for vaccination were financial and the lack of awareness about available vaccines. Our results emphasize the significant role of pediatricians, who were identified as the primary source of information for parents. Notably, the most cited reason for the decision not to vaccinate against RV was the absence of a recommendation from pediatricians. More efforts should be invested in raising awareness about RV vaccination, empowering pediatricians to recommend it, and making it accessible for the most vulnerable populations. Continuous monitoring of KAP is crucial, and future studies should aim at recruiting larger, more representative samples and evaluating the MoPH’s decision to include RV vaccination in the NIP on parents’ attitudes and practices towards RV vaccination.

The authors would like to thank the general director of the ministry of education, the school’s directors, the parents, and their children for their cooperation.

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