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Perceived barriers of migrants and refugees to vaccinate their children against Measles and polio: a study in Iran



This study examined the perceived barriers of migrants and refugees to vaccinating their children against measles and polio in Iran.


First, an instrument was developed and validated through several steps. Next, 1,067 parents who had not vaccinated their children against polio and measles or had delayed receiving any dose of these two vaccines until the age of 15 were selected from 16 provinces and completed the instrument. Finally, the data were analyzed.


The results of the explanatory factor analysis showed that the perceived barriers affecting vaccination against polio and measles vaccines were categorized into five factors: low knowledge, negative attitude, communication challenges, lack of participation in vaccination programs, and problems related to migration and refugees. Additionally, the results indicated a significant difference in the mean score of perceived barriers based on participants’ level of education, economic status, and nationality.


The identified barriers may provide a perspective for developing effective efforts in this area. Interventions should focus on parents with low education and poor economic status.


Global vaccine programs have prioritized the eradication and elimination of two specific diseases: poliomyelitis and measles [1,2,3]. Despite the extensive efforts of most countries to eliminate these diseases by increasing immunization coverage in children, there are several challenges to achieving this objective [4,5,6]. One of the challenges is the immunity gap between refugee and migrant children compared to non-migrant children born in host countries [7,8,9]. Children from migrant families are at a higher risk for certain vaccine-preventable diseases [10].

The increasing public health concern of parental reluctance towards recommended childhood vaccines is influenced by various factors at the individual, vaccine, and environmental levels [11]. Many studies have evaluated the barriers to national program vaccination in refugees and migrants, regardless of the specific age group and vaccine type [12,13,14]. However, limited studies have documented the personal perceived barriers and perspectives of refugee and migrant parents regarding the uptake of childhood vaccines such as measles and polio. Different reasons have been mentioned for the low coverage of measles or polio vaccination among migrant children. Literature indicates that parents’ negative attitudes towards polio and fear of the vaccine, as well as concerns about the safety and side effects of the measles vaccine, are among the factors contributing to the failure of vaccination programs against these two diseases [15,16,17]. Hu et al. found that living in a single-child family and having a parent who was unaware of the measles supplementary immunization activity or had low trust in the government-administered measles campaign were reasons for low levels of measles vaccination coverage among migrant children compared to all eligible children in Beijing [18]. In another study, Hu et al. found that several factors influenced the receipt of the first and second doses of measles vaccines among migrant children in East China. These factors included being unaware of the necessity for measles vaccination and its schedule, misunderstanding the side effects of the vaccine, and the child being sick during the recommended vaccination period [19]. Khowaja et al. demonstrated that fear of sterility, lack of faith in the polio vaccine, scepticism about polio supplementary immunization activities, and fear that the vaccine might contain religiously forbidden ingredients were reasons for refusing polio vaccination among Pashtuns in Karachi [20].

Iran has been hosting millions of documented and undocumented refugees for the past four decades [21]. This country is at risk of a polio reemergence as it accommodates approximately 2.5 million Afghan refugees, while neighboring countries Afghanistan and Pakistan continue to experience incidents of wild poliovirus cases [4]. In 2022, 214 cases of measles infection were reported in Iran, half of which were non-Iranians [22]. Despite the fact that Iran’s primary healthcare network provides free access and free-of-charge to a majority of healthcare services, including immunization, for refugees and migrants, including undocumented migrants [21], there remains a significant and unidentified population of migrants and undocumented refugees residing in Iran with low participation in vaccination programs [23]. The evidence indicates that migrant and refugee children have lower immunization rates compared to Iranian-born individuals. The prevalence of partial immunization in non-Iranian children was reported to be six times higher than in Iranian children (11.9% vs. 2%) [9].

Considering the importance of gaining a better understanding of the determinants of parental vaccine hesitancy, vaccine uptake, barriers, and demand issues in migrant and refugee groups in each country [24], the present study was conducted. The objective of the study was to determine the perceived barriers of parents of migrants and refugees to vaccinating their children against measles and polio in Iran.


Data resources and participants

This cross-sectional study was conducted in Iran from October 2022 to April 2023. A total of 1,067 parents of migrant and refugee children were selected from 16 provinces of Iran, including Tehran, Markazi, Ghom, Sistan and Baluchistan, Fars, Khuzestan, Kerman, Alborz, Esfahan, Khorasan Razavi, South Khorasan, Semnan, Bushehr, Hormozghan, and Qazvin. These provinces were chosen as they have large numbers of migrants and refugees, making them particularly relevant to the study. The inclusion criteria were: (a) Immigration from other countries to Iran, (b) Parents whose children under the age of 15 had not yet received measles or polio vaccinations, (c) Parents whose children under the age of 15 had experienced at least a delay in receiving the measles or polio vaccine, and (d) Willingness to participate.

In the present study, accessing samples for random sampling was challenging due to several factors. These factors include the residence of some refugees and migrants in the suburbs and remote areas, as well as their lack of a residence permit and fear of going to healthcare centers. Therefore, an available sampling method was used. This method is often employed when the population of interest is difficult to reach or access. In the study, health workers from each province collaborated with health liaisons for non-Iranian nationals in cities and villages, as well as the SINA and SIB, to identify eligible parents for participation.

It is important to mention that in Iran, the two most commonly used information systems for recording public health services provided to the population are the integrated health record system, known as the “SIB,” and the integrated information record system, known as the “SINA.” The primary objectives of these systems are to facilitate the efficient distribution of health services, establish the necessary requirements for the referral system, evaluate the accuracy of public health data, and ultimately enhance the quality of healthcare services. These systems have been implemented in primary healthcare facilities across Iran and are utilized to record all health-related data collected during the delivery of primary healthcare services to the population. Health information of refugees and migrants is recorded in these systems, just like the health information of Iranian nationals [25,26,27].


Outcome variable

The primary outcome variable for this study was the perceived barriers of migrants and refugees to vaccinating their children against measles and polio. These barriers were assessed using a 30-item instrument (developed in the present study) consisting of five subscales. Each subscale included a different number of items: low knowledge (5 items), negative attitude (5 items), communication challenges (5 items), lack of participation in vaccination programs (5 items), and problems related to migration and refugees (5 items).

Independent variables

The independent variables included demographic characteristics, including education level (illiterate, < 12th grade, and ≥ 12th grade), sex (male or female), occupation status (employee, self-employed, casual laborer, household duties, and retired), language (Dari, Pashto, Tajik, Uzbek, Arabic, and Ordo), nationality (Afghanistan, Pakistan, Iraq, and others), age (years), length of stay in Iran (years), marital status (single or married), self-reported economic status (weak, moderate, good), and the geographic location of residence (city or town, village, and suburbs). These variables were self-reported using a questionnaire.

Sample size calculation to assess perceived barriers

The sample size was calculated using the formula (n = Z 1−α/2 pq/d2), resulting in 1,067 people. In this formula, a confidence interval of 95%, p = 0.5, and d = 0.03 were considered.

To decrease the chance of missing data, a web-based questionnaire was used (developed in where the option to require an answer to each question was set. Therefore, there was no missing data in the present study. Additionally, the questionnaires were completed by face-to-face interview method for participants.

Stages of developing the instrument

In the present study, researchers developed an instrument to gather information on perceived barriers of migrants and refugees to vaccinating their children against measles and polio. Firstly, item generation (n = 40 items) was carried out based on a literature review and 15 face-to-face interviews with health liaisons for non-Iranian nationals and five health workers. Next, several tests were conducted to measure the validity and reliability of the developed instrument. The findings of each test are reported in the following section.

Quantitative and qualitative content validity

A panel of six experts in public health and infectious diseases evaluated the quantitative and qualitative content validities of the instrument items. They assessed the Content Validity Index (CVI) and Content Validity Ratio (CVR) of each item [28, 29]. The CVR formula is calculated based on the level of agreement among the experts who evaluate an item as essential [28]. The panelists rated the necessity of the items using a three-point rating scale: essential, useful but not essential, and not necessary. The CVI was calculated by dividing the number of experts who assessed an item as essential or very relevant by their total number. Additionally, the relevance of the items was assessed using a four-point rating scale ranging from not relevant to very relevant.

Face validity

The developed instrument underwent qualitative and quantitative face validity assessment by ten health liaisons for non-Iranian nationals. They evaluated the relevance, ambiguity, and difficulty of the items. Based on their opinions, minor wording errors were edited. The impact score of each item was measured at this stage, with an impact score of ≥ 1.5 considered acceptable [30].

KMO and Bartlett’s test and factor analysis

Exploratory Factor Analysis (EFA) using the orthogonal varimax rotation procedure was conducted for the proposed research model. Four hundred parents of migrant and refugee children who met the inclusion criteria completed the instrument (Table 1). To assess the sample adequacy and the appropriateness of the factor analysis model, we performed the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity using SPSS on the instrument. The final list of items in each subscale included in the proposed research model was selected based on commonality indexes above the threshold of 0.4. Additionally, a latent root criterion of 1.0 was used for factor extraction [24, 25].

Convergent validity

Based on the data of 400 parents in the EFA assessment stage, the convergent validity of the subscales was measured by Average Variance Extracted (AVE). To establish convergent validity, the constructs’ AVE should exceed 0.50 and be less than Composite Reliability (CR) [31]. The convergent validity of the instrument was measured using Excel software.

Cronbach’s alpha

To assess the internal consistency of the instrument’s five subscales, we used Cronbach’s alpha based on the data of 100 parents of migrant and refugee children. An estimate of Cronbach’s alpha (≥ 0.70) was considered satisfactory [32].

Statistical analyses

The Kolmogorov-Smirnov test was used to verify the normality of the data. Multiple linear regression (forward method) was used to examine the relationship between perceived barriers and demographic variables in the participants. Post-hoc comparisons were performed using Tukey’s honestly significant difference (HSD) test among various groups based on occupation status, education level, economic status, nationality, and language. The participants’ general characteristics were analyzed using descriptive statistics such as frequency, percentage, mean, and standard deviation. The statistical analysis was conducted using SPSS version 13.0, and a significance level of P < 0.05 was considered statistically significant.


The results of the validation of the instrument

Quantitative and qualitative content validity

After calculating CVI and CVR, eleven items were eliminated at this stage because they had a CVI score of less than 0.79 and a CVR score of less than 0.99. Additionally, two items were edited based on suggestions from an expert panel to clarify ambiguity in their wording (qualitative content analysis).

Face validity

After measuring quantitative face validity, four items that did not have an impact score of ≥ 1.5 were deleted.

KMO and Bartlett’s test and factor analysis

Table 1 presents the demographic characteristics of the participants in EFA. In this study, the KMO was 0.871, and the Bartlett’s test of sphericity was significant (= 3615.445, df = 562, p < 0.0001), indicating that the data were suitable for factor analysis. Eigenvalues of all subscales were > 1, confirming the suitability of the data for factor analysis [31, 33]. Table 2 displays the factor load of each item. At this stage, one item was deleted. EFA revealed that 25 items could be categorized into five factors: low knowledge, negative attitude, communication challenges, low participation in vaccination programs, and problems related to migration to another country.

Table 1 Demographic information of the participants
Table 2 The results of explanatory factor analysis (n = 400), Cronbach’s alpha (n = 100), ICC (n = 30) and AVE and AR (n = 400)

Convergent validity

The convergent validity of all subscales was considered acceptable (CR > 0.60 and AVE > 0.50) [31], confirming convergent validity. The AVE and CR of all subscales are reported in Table 2.

Cronbach’s alpha

In this study, Cronbach’s alpha of the developed instrument subscales was the range of 0.70–0.843 (Table 2).

Final instrument and scaling

The final 25-item instrument consists of five subscales, with 5 items each: low knowledge, negative attitude, communication challenges, lack of participation in vaccination programs, and problems related to migration and refugees. Table 3 displays the statements used to measure each variable. All items were scored on a Likert scale ranging from 1 (completely disagree) to 5 (completely agree).

The results of measuring perceived barriers and their subscales

Demographic characteristics of the participants

The participants had a mean age of 31.84 (SD = 9.391) years old and had lived in Iran for an average of 12.74 (SD = 11.463) years. Table 1 displays other demographic characteristics of the participants.

The results of the simple regression analysis indicated that all demographic variables, except for the age of the parents, were significant at a level of 0.2, making them candidates for multiple linear regression. The findings of the multiple linear regression (forward method) revealed that education level, nationality, and self-reported economic status variables were significant predictors of perceived barriers to vaccination of children against polio and measles (R2 = 0.060, F = 9.579, p < 0.001) (Table 3). Increasing one unit in the education level and self-reported economic status variable led to a decrease in perceived barriers to vaccination of children against polio and measles by 0.101 and 0.179, respectively (Table 3). The results of the HSD test indicated that illiterate participants had higher perceived barriers compared to other participants. According to the HSD test results, participants with a good economic status had fewer overall perceived barriers to measles/polio vaccination for their children than participants with poor (p < 0.001) and moderate (p = 0.014) economic status. Refugees and migrants from other nationalities had more perceived barriers to measles/polio vaccination for their children than migrants and refugees from Afghanistan (p < 0.001) and Pakistan (p = 0.001).

Table 3 Multiple linear regression model results to investigate demographic factors affecting perceived barriers to vaccination of children against polio and measles (n = 1067)

Perceived barriers of migrant and refugee parents to vaccinate their children against Measles and polio

The mean score of perceived barriers and its five subscales is presented in Table 4.

Table 4 The mean score of perceived barriers to vaccination of children against polio and measles and its 5 subscales (n = 1,067)


The findings of the current study indicate that a lack of awareness regarding polio and measles vaccines is a hindrance to the timely vaccination or non-vaccination of measles and polio among refugee and migrant children in Iran. This observation aligns with the findings of Shafique et al., who found that insufficient knowledge about polio vaccination among individuals was a key factor contributing to the ineffectiveness of Pakistan’s polio eradication program [15]. The significance of immunization knowledge among refugees and migrants was underscored in two studies conducted by Hussain et al. and Abdi et al. [23, 34]. In contrast to our findings, Mishra et al. demonstrated that the awareness of polio vaccination among a sample of Indian mothers was 100%, whereas knowledge about measles vaccination was reported at 83% [35]. Habib et al. demonstrated that there was a considerable level of awareness regarding polio and its immunization among females in Pakistan [36]. From the findings of the studies, it can be concluded that parents of migrant and refugee children possess lower knowledge regarding measles and polio vaccines compared to non-migrant parents in each country. This may be attributed to factors such as lower literacy, language and communication barriers, and limited access to training opportunities in migrants and refugees [8]. As such, the health system in Iran should prioritize raising awareness and knowledge of polio and measles vaccinations among parents of refugees and migrants through targeted campaigns and educational initiatives.

An unfavorable attitude towards polio and measles vaccines was identified as the second barrier that may influence vaccine uptake for children. The findings of Habib et al. were consistent with the results of the present study. According to their report, misperceptions surrounding the polio vaccine resulted in the rejection of both polio vaccines and routine immunizations among females in Pakistan [36]. Shafique et al. found that individuals’ unfavorable attitude towards polio vaccination was one of the main reasons for the failure of Pakistan’s polio eradication program [13]. In another study, Singh and Chawla found that the attitude regarding the measles vaccine was not favorable in women with children under the age of five in an urban slum area of Aligarh [37].

Contrary to our findings, Hussain et al. identified that 96.85% of their participants endorsed the necessity of immunizing children. Despite parents’ insufficient knowledge regarding their children’s immunization, their attitudes towards it remained positive, as highlighted in their study [34]. In another study, Mollema et al. reported that most parents in the Netherlands had a positive attitude towards childhood vaccination, although some had doubts [38]. The reason for the contradiction between the findings of past studies in the field of attitudes towards measles and polio vaccines may be attributed to differences in the target population and geographical area where these studies were conducted. It is essential to conduct periodic needs assessments to identify the requirements of all population groups, such as refugees and migrants, in each society and design suitable interventions accordingly. It is recommended to implement collaborative educational programs, such as peer education, to enhance the positive attitude of refugee and migrant parents towards measles and polio vaccines in Iran.

Communication challenges and low parental participation in vaccination programs have been identified as two primary barriers that can influence the uptake of polio and measles vaccines for children. Common rumors about the possibility of paralysis in children and other negative consequences after receiving the polio and measles vaccines, a lack of trust in the recommendations of Iranian health providers, and living in the outskirts of cities and remote areas have been recognized as challenges that contribute to the delay or non-vaccination of children against measles and polio among the study participants. To the best of our knowledge, most previous studies have identified communication and participation factors as influential factors in the vaccination rate of polio and measles in children. For example, SteelFisher et al. found that increasing trust in vaccinators, providing accurate information about poliovirus transmission, spreading positive messages to counter rumors, and fostering community support for polio vaccination could potentially strengthen caregivers’ commitment to polio vaccinations in Afghanistan [39]. The findings of a study conducted in Sudan indicated that exposure to anti-vaccination information messages or materials and doubts about the effectiveness of the measles vaccine were two significant factors contributing to parental hesitancy regarding the vaccine. The study also concluded that investing in vaccines and addressing accessibility issues could serve as effective interventions for enhancing measles vaccine acceptance and, consequently, improving measles vaccine coverage [16]. Kashyap et al. found that the parent-provider relationship, weak interpersonal communication skills of health workers, social media, and lack of trust may influence parents’ reluctance to vaccinate their children against infectious diseases [40].

In the present study, a small number of participants reported that they had not been invited to participate in the implementation of polio and measles vaccination programs for children of migrants and refugees. While community involvement has a positive effect on health, especially when supported by robust organizational and community procedures [41], consistent with our findings, Itimi et al. showed that childhood immunization coverage was attributed to improved mobilization and participation in the delivery of immunization services [42]. In Iran’s health system, non-Iranian volunteers participate as health liaisons for non-Iranian nationals. They transmit information and follow up on cases of vaccination delays among migrants and refugees in all parts of the country, including suburbs and remote areas. Since some non-Iranian migrants and refugees place more trust in these contacts due to shared language and culture, the health system should take steps to empower these individuals on childhood vaccination and address rumors regarding the vaccine. This empowerment will strengthen their role as intermediaries between the health system and migrants and refugees. It is necessary to provide training for this group on the positive effects of community participation on childhood vaccination coverage, as well as strategies for increasing it.

One of the barriers influencing polio and measles vaccination rates was the problems related to migration. Some of the reported challenges faced by participants included regular changes in the geographical area of residence, unfamiliarity with Iran, lack of birth certificates, and absence of the child’s previous vaccination card. These problems have been reported in previous studies. For example, Assi et al. and Azizi et al. found that the absence of fixed addresses among refugees made it more challenging to deliver primary and secondary healthcare services to them [43,14]. In another study, Hu et al. found that immigration status had an effect on polio and measles vaccination coverage in Zhejiang province, China [44]. The literature has shown that migrants and refugees are a hard-to-reach population for vaccination due to various factors, including geographical distance, transient lifestyles, discrimination by healthcare providers, insufficient vaccination systems, conflicts, and legal restrictions. These barriers limit their access to healthcare and make it challenging to track their vaccination status, leading to missed opportunities for vaccination [45]. When planning to increase vaccination coverage in migrant and refugee children, special attention should be paid to immigration-related problems such as not having a vaccination card, frequent changes of residence, unfamiliarity with the destination country, and more. It is crucial to integrate refugees and migrants into each country’s health system by incorporating them into immunization policies, planning, and service delivery.

The findings showed that there were significant difference between the mean score of perceived barriers according to the participants’ level of education and economic status. Previous studies have consistently identified an association between socioeconomic status and the acceptance of polio and measles vaccination. For example, Shafique et al. found that participants with higher education and better financial status had a greater knowledge about polio vaccination [15]. This finding has been confirmed by the results of studies conducted by Alagsam [46], Kantner et al. [47], Hu et al. [44], and Hossain et al. [48]. To achieve full coverage of measles and polio vaccines among refugees and migrants in Iran, it is crucial to prioritize parents with low education or income levels. Specific vaccination strategies should be implemented to enhance access to these communities.

This study represents the first national-level survey conducted on barriers to vaccinating children against polio and measles among a sample of migrants and refugees in Iran. Despite this, the study has limitations. One limitation is the lack of access to all sub-groups of migrants and refugees, particularly those residing in remote and inaccessible areas or those without permission to stay in Iran. Additionally, there may be subgroups that frequently change their addresses. As a result, Iran’s health system faces additional challenges in reaching these populations. Therefore, it is important to note that these findings may not be generalizable to the entire population of refugees and migrants in Iran. Another limitation of the present study was the inability to evaluate the test-retest reliability of the questionnaire due to problems accessing the participants and changes in their residence between the two visits required to complete the questionnaire. Another limitation of the study is its focus solely on examining the personal perspectives of parents regarding their barriers to child vaccination. Future studies should consider investigating the role of other factors, such as structural factors, in relation to measles and polio vaccination coverage among children of refugees and migrants. Overall, these limitations highlight the need for further research and a comprehensive approach to address the barriers to vaccination among refugees and migrants in Iran.


This study contributed to a better understanding of the barriers to delayed or non-vaccination of measles and polio for children of refugees and migrants in Iran. The findings of this study suggest that, despite free access and no charge for immunization of children of refugees and migrants, low knowledge, negative attitudes, low participation in vaccination programs, communication challenges, and problems related to migration are recognized as barriers to vaccinating children of refugees and migrants against polio and measles in Iran. These results can provide insights for researchers and policymakers at various levels in developing tailored and targeted programs for caregivers of refugee and migrant children, taking into consideration the barriers to vaccinating children as a whole.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Please contact the corresponding author for the data requests.



Content Validity Index


Content Validity Ratio


Kaiser-Meyer-Olkin test


Explanatory Factor Analysis


  1. World Health Organization (WHO). (2020). Global Vaccine Action Plan 2011–2020. Retrieved from

  2. Sadrizadeh B, Zahraei SM. Poliomyelitis eradication in Iran: opportunities and challenges. J Compr Pediatr. 2013;4(2):91–2.

    Article  Google Scholar 

  3. Orenstein WA, Cairns L, Hinman A, Nkowane B, Olivé JM, Reingold AL. Measles and Rubella Global Strategic Plan 2012–2020 midterm review report: background and summary. Vaccine. 2018;36(1):A35–A42.

    Article  PubMed  Google Scholar 

  4. Razavi SM, Mardani M, Salamati P. Eradication of Polio in the world; Iran is at risk for reemerging of Polio: a review of the literature. Arc Clin Infec Dis. 2016;11(4):e36867.

    Google Scholar 

  5. Cutts FT, Lessler J, Metcalf CJ. Measles elimination: progress, challenges and implications for rubella control. Expert Rev Vaccines. 2013;12(8):917–32.

    Article  CAS  PubMed  Google Scholar 

  6. Zahraei SM, Gouya MM, Azad TM, Soltanshahi R, Sabouri A, Naouri B, Alexander JP Jr. Successful control and impending elimination of measles in the Islamic Republic of Iran. J Infect Dis. 2011;204 (Suppl 1):S305–11.

    Article  Google Scholar 

  7. Moller SP, Hjern A, Andersen AM, Norredam M. Differences in uptake of immunisations and health examinations among refugee children compared to Danish-born children: a cohort study. Eur J Pediatr. 2016;175(4):539–49.

    Article  CAS  PubMed  Google Scholar 

  8. Kaji A, Parker DM, Chu CS, Thayatkawin W, Suelaor J, Charatrueangrongkun R, et al. Immunization coverage in migrant school children along the Thailand-Myanmar border. J Immigr Minor Health. 2016;18(5):1038–45.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Zahraei SM, Eshrati B, Gouya MM, Mohammadbeigi A, Kamran A. Is there still an immunity gap in high-level national immunization coverage. Iran? Arch Iran Med. 2014;17(10):698–701.

    PubMed  Google Scholar 

  10. Lopalco PL. Access and barriers to childhood immunization among migrant populations. In: Rosano A, editor. Access to primary care and preventative health services of migrants. SpringerBriefs in Public Health. Cham: Springer; 2018.

    Google Scholar 

  11. Gowda C, Dempsey AF. The rise (and fall?) Of parental vaccine hesitancy. Hum Vaccin Immunother. 2013;9(8):1755–62.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ozaras R, Leblebicioglu H, Sunbul M, Tabak F, Balkan II, Yemisen M, Sencan I, Ozturk R. The Syrian conflict and infectious Diseases. Expert Rev Anti Infect Ther. 2016;14(6):547–55.

    Article  CAS  PubMed  Google Scholar 

  13. Abdi I, Menzies R, Seale H. Barriers and facilitators of immunisation in refugees and migrants in Australia: an east-african case study. Vaccine. 2019;37(44):6724–9.

    Article  PubMed  Google Scholar 

  14. Azizi N, Delgoshaei B, Aryankhesal A. Barriers and facilitators of providing primary health care to Afghan refugees: a qualitative study from the perspective of health care providers. Med J Islam Repub Iran. 2021;35:1.

    PubMed  PubMed Central  Google Scholar 

  15. Shafique F, Hassan MU, Nayab H, Asim N, Akbar N, Shafi N, et al. Attitude and perception towards vaccination against Poliomyelitis in Peshawar, Pakistan. Rev Saude Publica. 2021;55:104.

    Article  PubMed  Google Scholar 

  16. Sabahelzain MM, Moukhyer M, Bosma H, van den Borne B. Determinants of Measles vaccine hesitancy among Sudanese parents in Khartoum state, Sudan: a cross-sectional study. Vaccines. 2022;10:6.

    Article  CAS  Google Scholar 

  17. Ezezika O, Mengistu M, Opoku E, Farheen A, Chauhan A, Barrett K. What are the barriers and facilitators to polio vaccination and eradication programs? A systematic review. PLOS Glob Public Health. 2022;2(11):e0001283.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Xiaojiang H, Chen SXB. Zhihong Sa. Gaps in the 2010 Measles SIA coverage among migrant children in Beijing: evidence from a parental survey. Vaccine. 2012;30(39):5721–5.

    Article  Google Scholar 

  19. Hu Y, Li Q, Luo S, Lou L, Qi X, Xie S. Timeliness vaccination of Measles containing vaccine and barriers to vaccination among migrant children in East China. PLoS ONE. 2013;8(8):e73264.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Khowaja AR, Khan SA, Nizam N, Omer SB, Zaidi A. Parental perceptions surrounding polio and self-reported non-participation in polio supplementary immunization activities in Karachi, Pakistan: a mixed methods study. Bull World Health Organ. 2012;90(11):822–30.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kiani MM, Khanjankhani K, Takbiri A, Takian A. Refugees and sustainable health development in Iran. Arch Iran Med. 2021;24(1):27–34.

    Article  PubMed  Google Scholar 

  22. UNICEF. UNICEF supports the measles vaccination campaign for Afghan refugee children in Iran 23 January 2023.

  23. Khazaei S, Nematollahi S, Ayubi E, Ahmadi-Pishkuhi M, Immigrants. Potential menace for Measles elimination target in Iran. Int J Pediatr. 2016;4(6):1975–6.

    Google Scholar 

  24. Mipatrini D, Stefanelli P, Severoni S, Rezza G. Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence. Pathog Glob Health. 2017;111(2):59–68.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Bitaraf S, Janani L, Hajebi A, Motevalian SA. Information system success of the Iranian integrated health record system based on the clinical information system success model. Med J Islam Repub Iran. 2022;36:25.

    PubMed  PubMed Central  Google Scholar 

  26. Rangraz Jeddi F, Nabovati E, Bigham R, Khajouei R. Usability evaluation of a comprehensive national health information system: a heuristic evaluation. Inf Med Unlocked. 2020;19:100332.

    Article  Google Scholar 

  27. Meraji M, Farkhani EM, Ramezanghorbani N, Azghandi AF, Mahmoodian SS. Challenges of the Integrated Information System (SINA) in Maternity Care. Res Sq. 2022.

    Article  Google Scholar 

  28. Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975;28:563–75.

    Article  Google Scholar 

  29. Polit DF, Beck CT. Nursing research: principles and methods. LWW. (2004).

  30. Abbasi A, Araban M, Heidari Z, Alidosti M, Zamani-Alavijeh F. Development and psychometric evaluation of waste separation beliefs and behaviors scale among female students of medical sciences university based on the extended parallel process model. Environ Health Prev Med. 2020;16(1):12.

    Article  Google Scholar 

  31. Hajizadeh E, Asghari M. Statistical methods and analysies in health and biosciences a research methodological approach. Tehran: Jahade Daneshgahi Publications. 2011: 395–410.

  32. Cronbach L. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297–334.

    Article  Google Scholar 

  33. Wang J, Wang X. Structural equation modeling: application using Mplus. Chichester: John Wiley & Sons; 2012. pp. 17–23.

    Book  Google Scholar 

  34. Hussain A, Zahid A, Malik M, Ansari M, Vaismoradi M, Aslam A, Hayat K, Gajdács M, Jamshed S. Assessment of parents’ perceptions of childhood immunization: a cross-sectional study from Pakistan. Child (Basel). 2021;4(11):1007.

    Google Scholar 

  35. Mishra S, Pathak A, Bansal M. Assessment of knowledge and awareness regarding immunization among the mothers of under five children attending immunization clinic of a tertiary care hospital. J Evol Med Dent Sci. 2016;5(2):103–5.

    Article  Google Scholar 

  36. Mishra S, Pathak A, Bansal M. Assessment of knowledge and awareness regarding immunization among the mothers of under five children attending immunization clinic of a tertiary care hospital. J Evolution Med Dent Sci.

  37. Habib MA, Tabassum F, Hussain I, Khan TJ, Syed N, Shaheen F, Soofi SB, Bhutta ZA. Exploring knowledge and perceptions of polio Disease and its immunization in Polio high-risk areas of Pakistan. Vaccines (Basel). 2023;11(7):1206.

    Article  PubMed  Google Scholar 

  38. Singh S, Chawla U. Knowledge, attitudes and practices about Measles among mothers in Urban Slum Area of District Aligarh. Int J Infect Dis. 2008;12(suppl 1):E438.

    Article  Google Scholar 

  39. Mollema L, Wijers N, Hahné SJ, van der Klis FR, Boshuizen HC, de Melker HE. Participation in and attitude towards the national immunization program in the Netherlands: data from population-based questionnaires. BMC Public Health. 2012;12:57.

    Article  PubMed  PubMed Central  Google Scholar 

  40. SteelFisher GK, Blendon RJ, Guirguis S, Lodge W 2nd, Caporello H, Petit V, Coleman M, Williams MR, Parwiz SM, Corkum M, Gardner S, Ben-Porath EN. Understanding threats to Polio vaccine commitment among caregivers in high-priority areas of Afghanistan: a polling study. Lancet Infect Dis. 2017;17(11):1172–9.

  41. Kashyap A, Shrivastava S, Krishnatray P. Vaccine hesitancy: the growing parent–provider divide. Asia Pac Media Educ. 2019;29(2):259–78.

    Google Scholar 

  42. Haldane V, Chuah FLH, Srivastava A, Singh SR, Koh GCH, Seng CK, et al. Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes. PLoS ONE. 2019;14(5):e0216112.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Itimi K, Dienye PO, Ordinioha B. Community participation and childhood immunization coverage: a comparative study of rural and urban communities of Bayelsa State, south-south Nigeria. Niger Med J. 2012;53(1):21–5.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Hu Y, Chen Y, Wang Y, Liang H, Lv H. Age-appropriate vaccination coverage and its determinants for the polio containing vaccine 1–3 and measles-containing vaccine doses in Zhejiang Province, China: a community-based cross-sectional study. Hum Vaccin Immunother. 2020;16(9):2257–64.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ozawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY. Defining hard-to-reach populations for vaccination. Vaccine. 2019;37(37):5525–34.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Alagsam EH, Alshehri AA. Knowledge, attitude, and practice of parents on childhood immunization schedule in Saudi Arabia. IJMDC. 2019;3(5):457–61.

    Article  Google Scholar 

  47. Kantner AC, van Wees SH, Olsson EMG, Ziaei S. Factors associated with Measles vaccination status in children under the age of three years in a post-soviet context: a cross-sectional study using the DHS VII in Armenia. BMC Public Health. 2021;21:552.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Hossain MM, Sobhan MA, Rahman A, Flora SS, Irin ZS. Trends and determinants of vaccination among children aged 06–59 months in Bangladesh: country representative survey from 1993 to 2014. BMC Public Health. 2021;21(1):1578.

    Article  PubMed  PubMed Central  Google Scholar 

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We appreciate the parents involved in the study for their cooperation.


This study was supported by UNICEF, Iran.

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Authors and Affiliations



ContributionsTD, FR, AN, HF, AK and HR contributed to the design of the study and interpretation of data and prepared the manuscript. MG, AN, FR, and AK were involved in the data collection and drafting of the manuscript. All authors read and approved the final manuscript.All authors reviewed the manuscript.

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Correspondence to Tahereh Dehdari.

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The study was approved by the ethics committee of Iran University of Medical Sciences, Tehran, Iran (Ethical Approval Code: IR.IUMS.REC.1401.920). All participants were informed about the study objectives and the voluntary nature of their participation. Also, a consent form was obtained from them.

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The authors declare no competing interests.

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Nasiri, A., Farshidi, H., Rezaei, F. et al. Perceived barriers of migrants and refugees to vaccinate their children against Measles and polio: a study in Iran. Int J Equity Health 22, 253 (2023).

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