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Omer Qutaiba B Allela*
Clinical Pharmacy Department, College of Pharmacy, University of Duhok, Duhok, Kurdistan Region, Iraq
*Correspondence: Omer Qutaiba B Allela, Clinical Pharmacy Department, College of Pharmacy, University of Duhok, Iraq, Email: [email protected]

Citation: Allela OQB. Knowledge and Attitude of Immunization among Iium Pharmacy Students. J Basic Clin Pharma 2017;8:S65-S69.

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Background and Aim: This study sought to explore International Islamic University Malaysia (IIUM) third-year pharmacy students’ knowledge and attitudes regarding immunization using a questionnaire. Method: A crosssectional prospective survey was carried out among 89 students to obtain demographic data. Other data were collected using knowledge and attitude immunization questionnaires consisting of twenty questions related to knowledge and five questions related to attitude and practice. The final questionnaire was subsequently discussed among specialist pharmacists who are experts in this field and who judged the face and content validity of the questionnaire. Descriptive statistics were used and internal consistency was tested using Cronbach’s alpha coefficient. Results: Employing the recommended scoring method, the mean+standard deviation of the knowledge and attitude scores was 11.7614 ± 3.30445. Cronbach’s alpha test for internal consistency was 0.582 for the 25 items in the knowledge and attitude questionnaire. Conclusion: The study concluded that the knowledge and attitude immunization questionnaire appears to be reliable and valid for measuring knowledge, attitude, and practices among third-year pharmacy students at IIUM. It can be used in future research as it was suitable to determine the knowledge and attitudes regarding immunization among pharmacy students.


Knowledge; attitude; immunization; pharmacy students


The World Health Organisation (WHO) states that many children die all over the world especially in developing nations due to measles, hepatitis B, Haemophilia influenza, whooping cough (pertussis), tetanus, diphtheria and polio.[1] Children have a low level of immunity due to an undeveloped immune system. Therefore, children are more prone to microbial infection. Children need to be immunised at a certain age, in order to ensure that they have a good ability to fight against infection.

Immunization is one of the public health programmes that prevent disease in society. Vaccination is the most common technique used in immunization. It entails the administration of a vaccine into the human body in order to stimulate an individual’s immune system against bacteria, viruses, parasites and fungi. Vaccines are defined as biological preparation intended to produce immunity against a disease by exciting the production of antibodies. Vaccines are safe and effective; however, adverse reactions may develop following a vaccine and the process of immunization itself.[2]

In certain cases, adverse effects and misconceptions about vaccines cause some parents to reject the vaccination programme. Hence, the role of health care providers is very important in determining the decision making of parents regarding vaccination. According to Philip et al., ‘5.7% of parents thought that vaccines were not safe, and 21.5% said that their decision to vaccinate their children was not influenced by a health care provider. Meanwhile, parents who influenced by the health care providers were twice as likely to state positively that vaccines were safe for children. In order to overcome this rejection, the health care providers need to follow the guidelines to communicate with parents who refuse to vaccinate their children.[3] They should respect and listen to the parent’s decision and, at the same time, help them to have the right information by providing knowledge about the risks and benefits of vaccines. Philip et al. stated that medical professionals should provide best practices such as lessening the pain, reducing the number of injections per visit and professional advice to increase parents’ confidence.

Pharmacists have long been recognised in clinical practice as one of the most trusted and accessible health care providers.[4] They have a unique position and role in order to promote vaccinations. There are six practices that can be done by pharmacists, including reviewing history and screening, patient counselling, documentation, formulary management, administrative measures, and public education.[5] Thus, in order to provide excellent practice, pharmacists need to be knowledgeable, up-to-date and understand many issues related to vaccines like different types of formulary and side effects including all the controversial issues, for example: halal vaccine and non-halal vaccine. In short, currently the immunity level of a community is highly dependent and influenced by health care providers especially pharmacists. Pharmacy students who will be health care providers should have high knowledge and good attitudes regarding immunization so that they can improve parents’ understanding of vaccines. After all, the parents will decide whether to vaccinate their children or not.


Development of the questionnaire

The questionnaires were developed in English to maintain consistency of questions that were adapted from previous research.[6-21] There were a total of 25 questions on knowledge and attitude regarding immunization among IIUM pharmacy students. No additional questions were added. Overall, 20 questions concerned knowledge and the remaining 5 questions were about attitude.

Data collection

The questionnaire consisted of two parts: part A and part B. The first part (part A) covered demographic data including student’s personal data, family data, parent’s education and family income data. The second part (part B) consisted of the knowledge and attitude questionnaire (20 questions on knowledge and 5 questions on attitude). This prospective study was carried out with third year IIUM pharmacy students. The questionnaire forms were intended to be filled out by 90 students. However, only 89 complete forms were collected and analysed. Data collection was done within a day and students that attended class on that particular day answered the questionnaires. The questionnaires were distributed among third year IIUM pharmacy students in a class during recess time. They were given enough time to answer the questionnaires related to their knowledge and attitude towards immunisation. The questionnaires were in English.

Validation study

The final questionnaire was subsequently discussed among specialist pharmacists who are experts in this field and who judged the face and content validity of the questionnaire.

Statistical analysis

Microsoft Excel was used to tabulate the data, which were further analysed using Statistical Package for Social Sciences (SPSS) 20 for Windows. The percentages and frequencies of available students, gender, state of origin, demographic distribution, fathers and mother’s education and family income (categorical variables) were evaluated. Means and standard deviations were calculated for age, number of preschool children in the family, number of siblings, student order in family and knowledge and attitude scores (continuous variables). In order to assess knowledge, attitudes and practices, the following scores were used: 1=yes; 0=no or not sure. Overall mean and median scores were calculated for each student and statement. The maximum possible score was 25. Discrete data were analysed using the Kruskal-Wallis and Mann-Whitney tests for non-parametric distribution. P-values<0.05 were considered significant. In order to test reliability, the internal consistency and corrected item-total correlations were assessed using Cronbach’s alpha.


Demographic data

A total of 89 students were analysed. The majority of students were female (70.8%) and most students were 22 years old (80.9%). A majority of students lived in urban areas (66.3%). About 20.2% (n=18) were from the state of Selangor [Table 1]. The remaining variables are described in Tables 2 and 3.

Parameter (n=89) Frequency %
Gender Male
Age 21
Demographic Distribution Urban
State of origin Perlis
Pulau Pinang
Kuala Lumpur

Table 1: Demographics data of students

Parameter   Frequency Percent
Preschool children 0.00 85 95.5
  1.00 1 1.1
  3.00 1 1.1
  4.00 2 2.2
Siblings number 1.00 1 1.1
  2.00 2 2.2
  3.00 18 20.2
  4.00 12 13.5
  5.00 29 32.6
  6.00 12 13.5
  7.00 6 6.7
  8.00 5 5.6
  9.00 2 2.2
  10.00 2 2.2
Father education Primary 5 5.6
  Secondary 33 37.1
  Undergraduate 51 57.3
Mother education Primary 6 6.7
  Secondary 47 52.8
  Undergraduate 36 40.4
Family income <1000 7 7.9
  1000-2000 12 13.5
  2001-3000 11 12.4
  3001-4000 17 19.1
  >4001 42 47.2

Table 2: Family data

Scale Cronbach α Mean SD Median Maximum Minimum
KAP total 0.582 11.7614 3.30445 11.00 20.00 3.00

Table 3: Cronbach alpha and descriptive statistics


The mean ± standard deviation of knowledge and attitude scores was 11.7614 ± 3.30445. Cronbach’s alpha test for internal consistency was 0.582 for the 25 items in the questionnaire. The item-total correlations are shown in Tables 4 and 5. Questions 15, 17 and 19 had the lowest corrected item-total correlation value among 25 questions. When these three questions were eliminated, Cronbach’s alpha increased to 0.599.

Item-Total Statistics
  Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item-Total Correlation Cronbach's Alpha if Item Deleted
Q1 11.0114 10.448 0.100 0.581
Q2 11.1136 9.964 0.239 0.563
Q3 11.3750 9.455 0.406 0.538
Q4 11.2045 9.843 0.264 0.559
Q5 11.0114 10.126 0.218 0.567
Q6 11.4659 10.229 0.164 0.574
Q7 10.8636 10.901 -0.037 0.591
Q8 11.2045 10.325 0.107 0.582
Q9 11.4886 9.678 0.373 0.546
Q10 11.2500 10.236 0.134 0.578
Q11 11.4205 9.833 0.287 0.556
Q12 11.3864 10.516 0.053 0.589
Q13 11.4205 9.580 0.377 0.544
Q14 11.4205 9.925 0.256 0.561
Q15 11.6364 10.924 -0.052 0.594
Q16 11.1023 10.047 0.214 0.567
Q17 11.6477 11.058 -0.113 0.599
Q18 11.2386 10.529 0.042 0.591
Q19 11.6364 10.993 -0.083 0.597
Q20 11.5568 10.411 0.132 0.577
Q21 11.6136 10.424 0.160 0.574
Q22 11.3636 10.073 0.193 0.570
Q23 10.9545 10.251 0.201 0.569
Q24 10.9886 10.011 0.274 0.560
Q25 10.8977 10.185 0.279 0.562

Table 4: Reliability test of 25 questions of knowledge and attitude scale

Question Correct answer (%) Incorrect answer (%)
1. A vaccine is a medical treatment in which dangerous viruses and bacteria are killed or modified and then put into your body. 74.16 25.84
2. Active immunization is a killed or weakened form of disease-causing agent. 65.17 34.83
3. Passive immunization is an antibody from someone who was infected with the disease. 38.20 61.80
4. Vaccines have not substantially changed the incidence of any major infectious disease 56.18 43.82
5. Vaccines actually cause more disease than they prevent 75.28 24.72
6. Vaccines are amongst the most effective and least costly forms of medical treatment. 29.21 70.79
7. The reason vaccines are given regularly to children is that they result in lifelong protection from several serious diseases. 89.89 10.11
8. Vaccination is for all age. 56.18 43.82
9. initiation of potential routine immunization schedule should be on the first day 26.97 73.03
10. Vaccines should never be given to infants under 1 year of age 51.69 48.31
11. Children younger than 2 years received more than 70% of immunization doses. 33.71 66.29
12. BCG is the first immunization dose against TB 37.08 62.92
13. Vaccine needed to be stored at temperature more than 8'C and do not freeze. 34.83 65.17
14. The product should be used within 72 hours of the seal broken. 33.71 66.29
15. Vaccines is harmful 12.36 87.64
16. The risk of a few adverse reactions to vaccines is acceptable if the majority of the population is protected against infectious disease 65.17 34.83
17. Fever is one of the important contraindication in child immunization 11.24 88.76
18. If the child receives extra immunization, it is more effective and safer. 52.81 47.19
19. If child receive immunization dose before appropriate time for immunization, this dose will be repeated. 12.36 87.64
20. The CDC recommended that all adult receive annul(annual) influenza vaccination 21.35 78.65
21. Is it possible to get influenza from the influenza vaccine? 15.73 84.27
22. Influenza vaccine is safe for children 6 months to 18 years and adult 40.45 59.55
23. Vaccines are necessary 79.78 20.22
24. Are you in favour of vaccination in general? 76.40 23.60
25. Will you recommend vaccination to others? 85.39 14.61

Table 5: The list of questionnaires with its percentage values

Multivariate analysis

The level of knowledge among the students was positively associated with their attitude towards immunisation. Based on the Kruskal-Wallis test, Students’ scores in knowledge and attitude towards immunisation were highest when the fathers’ education level was high (p=0.009). Meanwhile, other parameters were not significant in determining the students’ knowledge and attitude scores.


The questionnaire was developed to evaluate knowledge and attitude of third year pharmacy students in IIUM. The questionnaire was developed by adapting previous questionnaires with consideration of the target sample group. It had two types of continuous questions, with 25 items for knowledge and attitudes. The reliability of the knowledge and attitude questionnaire was verified using Cronbach’s alpha to measure the internal consistency and the validity of the questionnaire was determined. Cronbach’s alpha was used to estimate the proportion of variance that is systematic or consistent in a set of test scores.[22] Cronbach’s alpha is a test for reliability that requires only a single test administration to provide a unique estimate of reliability for a given test. It also provides the average value of the reliability coefficient that would be obtained for all possible combinations of items when split into two half-tests.[23] In other words, the value of Cronbach’s alpha determines whether the instrument used will always elicit consistent and reliable responses even if the questions were replaced with other similar questions for the same respondent. It ranges between 0 and 1 and the coefficient which is closer to 1.0 has the tendency for greater internal consistency of the item in the scale although this value is dependent on the number of items in the scale. The questionnaire had an internal consistency of 0.582. Scale scores are considered acceptably reliable for group comparisons with internal consistency estimates above 0.7.[17] However, according to study in 2011, they were still considered sufficient because the internal consistency was greater than 0.5.[17]

However, Cronbach’s alpha cannot provide a reliability estimate for single items. The Cronbach’s alpha coefficient for the questionnaire developed in this report marginally passed the acceptable criteria which is above 0.5 but still a poor value, indicating possible higher risk for error when analysing data.[24] Moreover, possible improvement can be achieved using a Likert scale approach and increasing the length of the test or number of questionnaires. When identifying the independent variables that affect the dependable variables – the knowledge and attitude of pharmacy students on immunisation, extensive reading constructed for a few possible variables including age, ethnicity, location (rural or urban), state origin, parent’s education and family income. The sample (third year students) taken from the population (IIUM Kulliyah of Pharmacy), were born between 1989 to 1991.

The results showed no significant (p>0.05) relationships between gender, age of respondent, location (rural or urban), mother’s education, family income and knowledge and attitude towards vaccination. However, there was a significant (p<0.05) relationship between father’s education and knowledge and attitude towards vaccination. The documented immunisation schedule for children under 18 years old includes the frequency and intensity of the government’s effort to improve overall health. Statistics have shown a steady decline in the infant and children mortality rate since 1970. The Malaysia millennium development goal (MDG) targeted a two-thirds reduction of child mortality between 1990 and 2015 from both urban and rural areas of all ethnicities and dispersed equally between all states. However, there are no available studies that specifically focussed on immunisation and vaccination in Malaysia but rather reported on general health. In addition, research conducted by Angellilo et al. found that parent’s (especially mother’s) awareness towards mandatory vaccination for infants (poliomyelitis, tetanus, diphtheria and hepatitis B) is affected by higher education level and older age at child’s birth. Subsequently, the variables mentioned indirectly impacted the level of exposure of the respondent which later should influence the degree of knowledge and attitude.[25]

The mean ± standard deviation level of knowledge and attitude of third year pharmacy students was 11.7614 ± 3.30445 which is considered low. This is because third year pharmacy students do not receive formal education on vaccination topics. Therefore, students are unaware of its importance, possible side effects, schedule, and storage condition. Apart from that, they are not exposed to their future role of pharmacist as a health care provider. Environment factors such as family education as well as media promotions are also crucial in increasing student’s knowledge.

The knowledge and attitude score of third year IIUM students is low which can be linked to insufficient formal exposure to the subject. The findings are similar to other studies which show extraordinarily poor mean knowledge.[26] Low level of knowledge can result in low acceptance of vaccinations. In some studies, lack of knowledge is the main reason for not being vaccinated.[27,28] This is contradicted in a study which showed knowledge did not contribute to acceptance of vaccination compared to cost and safety concerns.[29]

On the other hand, some studies showed high level of knowledge and attitude scores among students towards vaccination.[30] In another study, mean score of knowledge and attitude was high but there was a low correlation between knowledge and attitudes towards acceptance of vaccinations.[31] Negative attitudes will develop with inadequate knowledge of vaccinations, including its purposes, functions and side effects. Anti-vaccination attitudes will develop if the knowledge of vaccination is based on informal knowledge.[22] A study measuring vaccination acceptance among college students in Canada revealed that they need tools to personalise information because if it is absent, they are not able to apply the knowledge to benefit their health.[32] In both studies, lack of valid sources of knowledge cause negative attitudes towards vaccination. Almost all studies concluded that formal education is important to increase level of vaccination awareness in students.


The sample size used in this study was small and restricted to third year pharmacy students.


Based on the data analysis, father’s level of education has an important role in the respondent’s knowledge and attitude towards immunisation. The reasons behind this are rather bleak such as being responsible as a leader of the household to provide the best accommodation which also involves consent and support of immunisation programme, known or informed of risk including disease mortality in children with or without immunisation and consistent or adherent in completing the immunisation schedule. Due to the fact that the study only assessed a single sample, the assessment should not rule out other variables as contributing factors.