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J Public Health
DOI 10.1007/s10389-011-0411-9
ORIGINAL ARTICLE
Development of a questionnaire on knowledge, attitude
and practice about immunization among Iraqi parents
Omer Qutaiba B. Al-lela & Mohd Baidi Bahari &
Mustafa G. Al-abbassi & Amena Y. Basher
Received: 13 October 2010 / Accepted: 2 March 2011
# Springer-Verlag 2011
Abstract
Aim To test the reliability and validity of the translated
version of the knowledge, attitude and practice (KAP)
questionnaire on immunization among Arabic parents.
Method A cross-sectional prospective survey was carried
out among 53 parents to obtain demographic data of
immunized children. Other data were collected using
translated KAP immunization questionnaires consisting of
ten questions related to knowledge and ten questions related
to attitude and practice. Descriptive statistics were used,
and reliability was tested for internal consistency using
Cronbach’s alpha coefficient.
Results Employing the recommended scoring method, the
mean±standard deviation of the KAP scores was 13.226±
3.01. Good internal consistency was found (Cronbach’s
alpha=0.735); the test-retest reliability value was 0.812 (p<
0.001). For validity, known-groups validity was used, and
three pharmacist specialists judged the face and content
validity of the questionnaire. The level of immunization
Approval This study was approved by the Ministry of Health (Iraq).
O. Q. B. Al-lela (*)
School of Pharmaceutical Sciences, Universiti Sains Malaysia,
11800, Pulau Pinang, Malaysia
e-mail: omarallela@yahoo.com
M. B. Bahari
School of Pharmaceutical Sciences, Universiti Sains Malaysia,
11800, Pulau Pinang, Malaysia
M. G. Al-abbassi
Pharmacy College, Al-Mustansaria University,
Baghdad, Iraq
A. Y. Basher
Advance Medical and Dental Institute, Universiti Sains Malaysia,
11800, Pulau Pinang, Malaysia
knowledge among parents was positively associated with
the attitude and practices of immunization.
Conclusion The study concluded that the translated KAP
immunization questionnaire appears to be reliable and valid
for measuring the knowledge, attitude and practices among
Arab parents and that it can be used in future research.
Keywords Reliability . Validity . Knowledge . Attitude .
Practice . Questionnaire
Introduction
The development and use of immunizations (vaccination)
against infectious agents is important and a successful step
towards disease prevention (Mell et al. 2005). It is
important that vaccines are administered at an age when a
child can develop a proper immune response and before
significant exposure to natural infections. The immuniza-
tion schedule in Iraq is as follows: Bacillus of Calmette and
Guerin (BCG) at birth; diphtheria, tetanus and pertussis
(DTP) at 2, 4, 6 and 18 months and 4–6 years; hepatitis B
(HepB) at birth, 2 and 6 months; measles at 9 months;
measles, mumps and rubella (MMR) at 15 months and 4–
6 years; and the oral polio vaccine (OPV) at birth, 2, 4, 6
and 18 months and 4–6 years. Child immunization in Iraq is
not mandatory, but is given free of charge by the
government (Ministry of Health-Republic of Iraq. Immuni-
zation profile report 2008; WHO 2008).
Despite the successes of immunization in children, the
system is imperfect because many children remain unim-
munized. The World Health Organization (WHO) plays an
important role in improving and developing the immuniza-
tion programs in the Middle Eastern countries. Based on the
WHO assessment and estimates of the Ministry of Health of

Iraq in 2008, 79–93% and 64–98%, respectively, of
children under 2 years old have been immunized in Iraq
(Ministry of Health-Republic of Iraq. Immunization profile
report 2008; WHO 2008)
Parents’ knowledge, attitude and practices regarding
immunization in general can potentially affect the
immunization or vaccination status of children (Orenstein
et al. 1990; Szilagyi et al. 1994). Identifying family and
provider system characteristics and their influence on the
immunization status of children is important in assessing
the potential risks in maintaining protection against
diseases.
Although much has been published in the international
literature on parents’ knowledge, attitudes and practices
regarding child vaccination (Adhikari et al. 2006; Anjum et
al. 2004; Impicciatore et al. 2000; Shah et al. 1991), no
such studies have been reported in Iraq. This study was
carried out to describe the knowledge, attitudes and
practices about vaccines and immunization practices among
Iraqi parents.
Objectives
The main objectives of this paper were to develop an
instrument to measure immunization KAP among Iraqi
parent samples, to translate the developed instrument into
an Arabic version, and to determine the reliability and
validity of KAP questionnaire or instrument.
Methods
Development of the questionnaire
The questionnaire was originally developed in the English
language to maintain the consistency of the questions
adapted from the references (Qidwai et al. 2007; Zhang et
al. 1999). Additional questions were added to cover the
objectives of this research. As one of the researchers could
not understand Arabic, the additional questions were also
written in English. The KAP questionnaire on immuniza-
tion consisted of 20 questions: 10 on knowledge and 10
about attitudes and practices.
Translation
The questionnaire was translated into Arabic according to
the procedures and guidelines recommended by Guillemin
and Beaton (Beaton et al. 2000; Guillemin et al. 1993).
In the first step, two different translators who could
speak both English and Arabic, but whose native language
was Arabic, translated the questionnaire from English into
J Public Health
Arabic. In order to enhance the quality of the translation,
one of the two translators was the first author of this study,
whereas the other did not know the aims of this
questionnaire. One of the researchers, who is Arabian-
Iraqi, reviewed the two primary versions and compared
them to the original; then, the first report or first version of
the questionnaire was prepared.
The second step involved the reverse translation of the
questionnaire from the first version of the Arabic question-
naire into English. The reverse translation was carried out
by another two translators who were fluent in both English
and Arabic but who did not know the aims of this
questionnaire. The result of the reverse translation was
compared to the original English questionnaire and the
second report was prepared. Repeated discussions between
all of the translators and the Iraqi researchers were carried
out in order to ensure the accuracy of the questionnaire.
The final stage involved pilot testing of the questionnaire
using eight Iraqi parents who completed the questionnaire
and commented on the questions. These eight individuals
were not included in the study. The researchers discussed
the first report and the second report, and the parents’
comments and necessary amendments were made. The final
version of the Arabic KAP Questionnaire on Immunization
was completed and made available for the reliability and
validity study.
Data collection
The data collection form consisted of three parts. The first
part contained demographic data, pediatric history, family
data and the immunization provider’s data. The second part
was related to the pediatric immunization schedule obtained
from the pediatric vaccination card. Part three consisted of
the KAP Questionnaire (10 questions on knowledge and 10
questions on attitude and practice).
The study was a pilot study and was carried out
among 53 Iraqi parents who attended general health
clinics. The recommended sample size for the pilot study
was fewer than 100 subjects (Rattray and Jones 2007).
However, there were only 53 parents who fulfilled the
study criteria (having children born between 1 January
2003 and 31 June 2008 to ensure completeness of the
immunization histories) and who attended the clinic
during the data collection period (5 days). All subjects
provided written consent forms before participation. The
data included demographic information and immunization
histories for Iraqi children. The immunization data were
extracted retrospectively from the immunization cards of
the children.
For part three, the parents of the children were
interviewed and given a translated questionnaire related to
their knowledge, attitudes and practices concerning child-
J Public Health

hood immunization. The interview was conducted in Arabic Table 1 Demographics data of pediatric subjects
by the researcher. Parameters (n=53) Frequency %

Validation study Weight ≥2,500 g 43 81.1

<2,500 g 10 18.9
The final questionnaire was subsequently discussed among Gender Male 32 60.4
three specialist pharmacists who are experts in this field and Female 21 39.6
who judged the face and content validity of the question- Ethnic group Arabic 50 94.3
naire. In addition, known-groups validity was used (Al Kurdish 3 5.7
Qazaz et al. 2010). Birth place General hospital 21 39.6
Maternity hospital 26 49.1
Statistical analysis Maternity home 3 5.7
Home 3 5.7
The data were tabulated using Microsoft Excel and
analyzed using the Statistical Package for Social Sciences
SPSS 15 for Windows. We evaluated the percentages and
frequencies of available child, family and provider charac- naire, 0.677 for the ten items in the knowledge questions
teristics (categorical variables), and means and standard and 0.540 for the ten items in the attitude and practice
deviations were calculated for age, family size and KAP questions (Table 4).
scores (continuous variables). In order to assess knowledge, The item-total correlations are presented in Table 5.
attitudes and practices, we used the following scores: 1, Three questions, 10, 16 and 19, have the lowest corrected
yes; 0, no; 0, don’t know. Overall mean and median scores item-total correlation value among 20 questions. When
were calculated for each parent and statement. The these three questions were eliminated, Cronbach’s alpha
maximum possible score was 20, in the case that 100% of increased to 0.801 (Rattray and Jones 2007).
the respondents replied “yes” to the statements. Discrete
data were analyzed using the Kruskal-Wallis and Mann-
Whitney tests for non-parametric distribution. P-values<
0.05 were considered significant. In order to test reliability, Table 2 Family data
the internal consistency and corrected item-total correla- Parameters Frequency %
tions were assessed using Cronbach’s alpha. Spearman’s
rank correlation coefficient was used to obtain test-retest Father’s education (years) <13 years 0 0
reliability values and to determine known-groups validity 13–18 years 6 11.3
(Rattray and Jones 2007). >18 years 47 88.7
Mother’s education (years) <13 years 0 0
13–18 years 10 18.9
Results >18 years 43 81.1
Mother’s age at birth (years) ≤19 years 2 3.8
Demographic data 20–29 years 36 67.9
>29 years 15 28.3
A total of 53 parents and 53 child subjects were analyzed. The Mother’s ethnic group Arabic 50 94.3
majority of children were male (32, 60.4%) with a mean age of Kurdish 3 5.7
60.3 months. Of the pediatric subjects, 81.1% (n=43) were Marital status Married 53 100
born weighing more than 2,500 g, and 18.9% were born Separated 0 0
weighing less than 2,500 g. About 5.7% (n=3) were Kurdish Preschool number 1 22 41.5
and 94.3% (n=50) were Arabic (Table 1). Tables 2 and 3 2–3 31 58.5
present the distribution of family and immunization system >3 0 0
characteristics of the sample, respectively. Child order 1st 28 52.8
>1st 25 47.2
Reliability Family income (USD $) < $400 0 0
$401–1,000 11 20.8
The mean±standard deviation of the KAP scores was $1,001–2,000 30 56.6
13.226±3.01. Cronbach’s alpha test of internal consis- > $2,000 12 22.6
tency was 0.735 for the 20 items in the KAP question-
 J Public Health

Table 3 Immunization
providers Parameters Frequency %

Number of providers* 1 36 67.9

>1
Provider's facility type* Private clinic
Public clinic
Government hospital
Private clinic and public clinic
*Refers to the institution pro- Private clinic and government hospital
viding the immunizations to the Public clinic and government hospital
children
17 32.1
2 3.8
29 54.7
5 9.4
8 15.2
5 9.4
4 7.5

We investigated the test-retest reliability with an interval
of 2 weeks for the parents of 12 immunized children. The
correlation coefficient was 0.821 (p<0.001), showing
satisfactory reliability and stability.
Validity
Known-groups validity was used. The Spearman’s rho
correlation test showed a significant positive correlation
between KAP scores and normal dose frequency (0.305; p≥
0.001), whereas there was a significant negative correlation
between KAP scores and missed dose frequency (−0.210;
p≥0.001). Table 6 shows the correlation between scale
scores and immunization dose types. As hypothesized, the
parents who reported having adequate KAP also reported
more normal pediatric immunization doses than missed
immunization doses, while parents who reported having
inadequate KAP also reported more missed immunization
doses than normal pediatric immunization doses. Or, in
other words, when a parent’s KAP scores increased, there
was an increase in normal dose frequency and a decrease in
missed dose frequency.
Multivariate analysis
The level of knowledge among the parents was positive-
ly associated with their attitude to and practices of
immunization (Spearman’s rank correlation coefficient
0.543, p<0.001).
A significant difference was found in knowledge scores
among provider facility types (p = 0.002), where the
parents’ knowledge was greatest when the children were
immunized in private and public clinics. A significant
difference was also found in knowledge scores among
pediatric birthplace groups (p=0.006), where the parents’
knowledge was greatest when the children were born in
maternity hospitals. (Table 7).
The study also found significant differences in attitude and
practice scores between provider facility types (p=0.012),
pediatric birthplaces (p<0.001), number of preschool children
(p=0.042) and family income (p=0.035). The parents’
attitude and practice scores were highest when the children
were immunized in a private clinic, were born in maternity
hospitals, had two to three preschool siblings, and when the
family income was more than $2,000 USD (Table 8).
Discussion
This was the first study to use a translated and validated
immunization questionnaire instrument for measuring the
immunization knowledge, attitudes and practices of Iraqi
parents.
The translation of the original English KAP questions was
carried out in accordance with the standard procedures detailed
in the translation guidelines (Beaton et al. 2000; Guillemin et
al. 1993). The original KAP questions were developed and
validated, making it relatively simple and practical to use
among the Iraqi population. The questionnaire consists of 20
items (10 items for knowledge, 10 items for attitude and
practice) that are suitable for assessing general immunization
knowledge, attitudes and practices in studies assessing the

Table 4 Cronbach alpha and

descriptive statistics Scale Cronbach α Mean SD Median Maximum minimum

KAP total 0.735 13.226 3.01 13 18 8

Knowledge 0.677 6.320 1.847 7 10 4
Attitude and practice 0.540 6.905 1.632 6 10 4
J Public Health

Table 5 Reliability test of 20

questions of the KAP scale Question no. Corrected item-total correlation Cronbach's alpha if item deleted

Q1 0.253 0.730
Q2 0.201 0.736
Q3 0.701 0.685
Q4 0.493 0.709
Q5 0.253 0.704
Q6 0.345 0.622
Q7 0.330 0.723
Q8 0.610 0.688
Q9 0.384 0.717
Q10 0.069 0.801
Q11 0.453 0.701
Q12 0.346 0.652
Q13 0.465 0.692
Q14 0.337 0.721
Q15 0.597 0.694
Q16 0.029 0.746
Q17 0.480 0.707
Q18 0.301 0.724
Q19 0.047 0.747
Q20 0.283 0.726

immunization KAP. In comparison, other studies used fewer
questions (Qidwai et al. 2007; Zhang et al. 1999); however,
they measured a narrower scope.
After translation of the instrument, the reliability and
validity of the newly translated version were proven to have
been maintained. The reliability of the KAP questionnaire
was confirmed using measures of internal consistency and
the test-retest, and the validity was examined. The KAP
scale scores were considered sufficiently reliable for group
comparisons when internal consistency estimates exceeded
0.7 (Nunnally et al. 1967). When the 20-item KAP
questionnaire was divided into two parts, the first part
consisted of ten items of knowledge questions and the
second part consisted of ten items of attitude and practice
questions. These two separated parts gave an internal
consistency of less than 0.7, but they were still considered
reliable because the internal consistency was more than 0.5
Table 6 Normal dose and missed dose correlation with KAP scores
(known-groups or construct validity)
Dose types Spearman rho correlation (P value) KAP scores
Normal dose 0.305 (<0.001)*
Missed dose -0.210 (<0.001)*
*Significant, P-value<0.05
(Wood et al. 1995). Our study among Iraqi parents showed
that the 20 questions of the KAP had good internal
consistency and good test-retest reliability.
This study found that the parents’ knowledge level was
positively correlated with their attitude and practice level;
this is consistent with a study in China (Zhang et al. 1999).
This shows that parents who have adequate knowledge
about their child’s immunization also have positive attitudes
and practices towards immunization. This study also found
significant differences in knowledge scores and attitude and
practice scores between provider facility types and pediatric
birthplaces, but no significant differences were found
among the number of providers, child order groups,
education of the father and mother, or the age of the
mothers at childbirth. A lack of knowledge may influence
the risk of immunization errors, as was found in a study in
the USA (Feikema et al. 2000) that showed a significant
difference in extra-immunization errors between provider
facility types and the number of providers. This study also
found a significant difference in attitude and practice scores
between the number of preschool children and family
income. A study by Bobo et al. (1993) found that mothers
who had a lower level of education, a lower income and
more children tended to have under-immunized children.
Therefore, there is concern for families with a greater
number of preschool children and a lower income who may
have a greater risk of immunization errors.
 J Public Health

Table 7 Knowledge scores differences between groups of the study population

Variable group Knowledge scores mean Knowledge scores median P value

Provider facility type 0.002*

Private clinic 6.0 6.0
Public clinic 5.66 5.0
Government hospital 5.73 6.0
Private clinic and public clinic 6.73 7.0
Private clinic and government hospital 5.65 5.0
Public clinic and government hospital 5.65 6.0
Birth place 0.006*
General hospital 5.48 5.0
Maternity hospital 5.98 6.0
Maternity home 5.18 4.0
Home 5.5 5.0

*Significant, P-value<0.05

Limitations Conclusions

The sample of parents in this study was smaller than This translated KAP questionnaire instrument possessed
samples used in previous studies, and the samples were satisfactory reliability and validity. It appears to be a
obtained from a single site. reliable questionnaire for objectively measuring the knowl-

Table 8 Attitude and practice

score differences between Variable group Attitude and practice scores Attitude and practice scores P value
groups of the study population mean median

Preschool child number 0.042*

1 6.86 6.0
2–3 6.29 6.0
>3 6.58 5.0
Family income (USD) 0.035*
<400 6.62 6.0
401–1,000 6.4 6.0
1,001–2,000 6.31 6.0
>2,000 7.39 7.0
Provider facility type 0.012*
Private clinic 8.4 9.0
Public clinic 6.46 6.0
Government hospital 6.41 6.0
Private clinic and public clinic 6.86 7.0
Private clinic and government 6.34 6.0
hospital
Public clinic and government 6.37 7.0
hospital
Birth place <0.001*
General hospital 5.96 6.0
Maternity hospital 6.78 7.0
Maternity home 7.45 7.5
Home 6.5 6.0
*Significant, P-value<0.05
J Public Health
edge, attitudes and practices of child immunization among
Arabic parents.
Acknowledgments I would like to thanks the Universiti Sains
Malaysia (USM) for its support in undertaking this work through the
USM fellowship program. I also wish to thank Mr. Harith K. Al-
Qazaz (PhD student) for his recommendations and cooperation.
Conflict of interest This study is part of the first author’s PhD study
and was not supported by any sponsoring body. Therefore, the authors
declare that they have no conflicts of interest.
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