Influences of Cultural Factors on Vaccination Practices Among Parents Prior to School Age: A Systematic Review and Meta-Analysis

"Understanding the cultural influences on parents in Saudi Arabia regarding adherence to childhood vaccination programs is crucial for the health and safety of the whole society."

Despite the Kingdom of Saudi Arabia (KSA)'s mandatory vaccination policy for children in school, delayed immunisations are considered missed opportunities, leaving children vulnerable to preventable diseases. Vaccine hesitancy, defined as a delay in accepting or refusing vaccines, arises from various factors, including misinformation and sociocultural beliefs. This study explores the impact of cultural factors on parents' attitudes toward vaccinating children before school age in KSA.

The literature review that has been conducted for this paper focused specifically on culture. The term 'culture' has been used widely in different disciplines; here, it is understood as all-encompassing notion that encapsulates worldviews and social structures that can include, among other things, social, legal, philosophical, familial, religious, and economic considerations.

A systematic review and meta-analysis were conducted on cross-sectional and interventional studies, resulting in 30 articles that examined cultural factors influencing childhood vaccination in Saudi Arabia. An interpretative synthesis was created using Leininger's Sunrise Enabler Model (see Table 1 in the paper).

The researchers identified seven key themes:
 

1. Economic and political aspects: As indicated by vaccination delays, the government's mandatory vaccination policy has not solved the issue of timely immunisation from birth to seven years of age, despite the legal necessity that has resulted in high vaccination coverage. According to one article in the review, researchers emphasised the need to carry out more studies to address the impact on the health system when access to health care in rural regions remains an issue.
2. Saudi cultural values, beliefs, traditions, and norms: Saudis seeking medical attention or routine vaccinations are not discouraged from doing so by their Islamic beliefs. Thus, it has been emphasised that other cultural factors, rather than the Islamic faith, affect preschoolers' delayed immunisation schedules in the KSA. Some parents refuse vaccinations due to cultural beliefs and belief systems; instead, they seek advice from traditional healers and wait for orders from dependable family members.
3. The socio-cultural position of women in family and society: Saudi Arabian society is marked by significant gender segregation across various settings, including government agencies, entertainment venues, and educational institutions. Social standards have several negative effects on the health of Saudi women and children and may discourage them from visiting medical facilities for treatment. These explanations are typically linked to the idea that male guardians are the ones who make decisions about their health. Even though women were permitted to drive in 2018 due to changes in the legislation, certain families may continue to uphold outdated customs, beliefs, and social mores that prohibit women from traveling around society, including to medical facilities, without a male guardian.
4. The impact of religious and philosophical factors on Saudi Arabia's health practices: According to Alfahl and Alharbi (2017), parental religious background may have an impact on a child's normal immunisation schedule in the KSA. Islam supports vaccinations, since they improve children's health and serve as a preventive tool against sickness. However, certain leaders' ignorance and misunderstandings regarding health rights and their opposing views of Islam provide the wrong picture of the religion's actual teaching.
5. Knowledge and education levels of Saudi parents toward vaccinating preschool children: There are gaps in the particular understanding of some vaccinations, even with the high immunisation rate and appropriate information. Compared to those in rural areas, urban residents are more informed and have more optimistic views. Furthermore, studies show that parents with less education than a university degree are linked to a higher risk of vaccine delays compared to parents with a university degree.
6. Technological influences: Social media and the internet are effective channels in Saudi society for disseminating health-related information, particularly those on child vaccinations. However, anti-vaccination social activists in the KSA use social media to instruct people on how to extract vaccine ingredients using traditional herbal therapy. This method may be potent enough to draw the ingredients out of the injection site and counteract the intended effects of the vaccine. Parents' attitudes and opinions have been greatly impacted by the widespread social media claims concerning failing immunisation efforts in the KSA.
7. Knowledge gaps among healthcare providers: Notably, parents greatly trust healthcare professionals to offer advice, making them important stakeholders in immunisation programmes. Health workers such as doctors and nurses should spread the word about how important it is to get immunisations on time. Their lack of understanding may be the root of ongoing doubts about the safety of specific vaccinations, particularly when they are unable to address queries and worries regarding the advantages and disadvantages of vaccinations.

The pooled cultural factors were analysed using random-effects meta-analysis, and the researchers conducted meta-regression studies to explore the effects of relevant variables. The meta-analysis revealed significant associations between parental age, education level, and the number of children with vaccination compliance. Parents aged 30-40 or over 40, those with higher education levels, and those with more than 4 children were more likely to be compliant. Nevertheless, parental occupation did not exhibit a significant association with vaccination compliance.

Reflecting on the findings, the researchers suggest that, to close the gaps resulting from problems with vaccination perception and safety concerns in the KSA, educational initiatives are required. They recommend development of parent awareness programmes that emphasise the value of vaccinations and that educate medical professionals so they can inform parents with confidence about the necessity of vaccinating their children in accordance with the advised schedule.

To improve child vaccine adherence rates, the intervention's tactics should also consider the components of effective communication. Reducing vaccination-related anxieties and addressing vaccine hesitancy issues require accurate information from the appropriate source. Participants' levels of trust in doctors and the KSA's Ministry of Health were found to be high. Therefore, the problem of delays may be resolved if the Ministry of Health (MOH) and the healthcare providers work together to raise awareness.

It is also recommended that healthcare professionals actively engage in awareness campaigns, utilising diverse technological platforms to spread genuine messages and encourage adherence to immunisation regimens. Smartphone applications that promote vaccination adherence can be utilised as instructional resources and reminders to improve vaccine adherence.

Per the researchers, further research is required to examine health system accessibility in Saudi Arabia's rural areas to address the issue of children's vaccinations being delayed. Furthermore, this study emphasises the need for more research to examine the socio-cultural elements pertaining to social media, religion, and healthcare access that may be influencing the occurrence of this issue.

In conclusion, the findings highlight the importance of tailoring public health strategies to address specific cultural nuances and promote vaccination adherence. The researchers argue that intensifying efforts to study and attend to the cultural dimensions of health-seeking behaviours may help resolve safety concerns and guarantee adherence to immunisation schedules - not just in Saudi Arabia but in other nations with comparable sociocultural issues.