Different Reasons for Not Completing Routine Vaccinations Among Jewish and Arab Children in Israel

  • Anat Amit Aharon
  • Haim Nehama
  • Shmuel Rishpon
  • Orna Baron-Epel


Minority communities are at high risk for low childhood vaccination coverage rates. This paper compared the rate of children not fully vaccinated and the reasons for that between Jewish (majority) and Arab (minority) children in Israel. This cross-sectional study screened the medical files of 14,232 children (12,360 Jewish and 1872 Arab), registered at Mother-Child Health Clinics in two large geographical area, to identify children who did not complete the last dose of hepatitis B and DTaP or first dose of MMR vaccines. We compared the reasons for not completing the vaccine schedule registered by the nurses between Jewish and Arab children. We identified 1052 children who did not complete at least one of the vaccines: 975 Jewish children and 77 Arab children. Four causal categories were identified: medical reasons, parental decision, parental behaviour, and organizational reasons. Multinomial logistic regression analysis was performed to analyze the reasons for not completing the vaccination protocol. Arab children compared to Jewish children were more likely not to complete the vaccination protocol due to medical reasons (OR 3.81, CI 1.53–9.49) and less likely due to the reason parental decision (OR 0.35, CI 0.13–0.96). Therefore, patterns of reasons for not completing vaccinations vary, depending on population. Interventions to reduce the number of children not fully vaccinated should be tailored to the specific population.

Key words

Minority community Child vaccinations Reasons for non-vaccination 


Authors’ Contributions

Conceptualization: Anat Amit Aharon, Haim Nehama, Shmuel Rishpon, Orna Baron-Epel. Data curation: Anat Amit Aharon, Shmuel Rishpon, Orna Baron-Epel. Formal analysis: Anat Amit Aharon. Funding acquisition: Orna Baron-Epel, Shmuel Rishpon, Haim Nehama. Investigation: Anat Amit Aharon. Methodology: Anat Amit Aharon, Haim Nehama, Shmuel Rishpon, Orna Baron-Epel. Project administration: Anat Amit Aharon. Supervision: Orna Baron-Epel, Shmuel Rishpon. Validation: Anat Amit Aharon, Orna Baron-Epel, Shmuel Rishpon. Writing—original draft: Anat Amit Aharon, Orna Baron-Epel. Writing—review and editing: Anat Amit Aharon, Orna Baron-Epel, Shmuel Rishpon, Haim Nehama.

Funding Information

This work was supported by the Israel National Institute for Health Policy Research, under Grant number 2012/149/R.

Compliance with Ethical Standards

The study was approved by the Ethics Committee for Studies with Human Participants at the University of Haifa (approved no. 032/12).

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Kang Y. Vaccination coverage among children aged 19-35 months - United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(43):1171–7.CrossRefGoogle Scholar
  2. 2.
    Forster AS, Rockliffe L, Chorley AJ, Marlow LAV, Bedford H, Smith SG, et al. Ethnicity-specific factors influencing childhood immunisation decisions among Black and Asian minority ethnic groups in the UK: a systematic review of qualitative research. J Epidemiol Community Health. 2017;71(6):544–9.CrossRefGoogle Scholar
  3. 3.
    Danis K, Georgakopoulou T, Stavrou T, Laggas D, Panagiotopoulos T. Predictors of childhood vaccination uptake: a cross-sectional study in Greece. Procedia Vaccinol. 2010;2(1):86–91.CrossRefGoogle Scholar
  4. 4.
    Harmsen IA, Ruiter RAC, Paulussen TGW, Mollema L, Kok G, de Melker HE. Factors that influence vaccination decision-making by parents who visit an anthroposophical child welfare center: a focus group study. Adv Prev Med. 2012;2012:175694.CrossRefGoogle Scholar
  5. 5.
    Ruijs WLM, Hautvast JLA, van Ansem WJC, Akkermans RP, van’t Spijker K, Hulscher MEJL, et al. Measuring vaccination coverage in a hard to reach minority. Eur J Pub Health. 2012;22(3):359–64.CrossRefGoogle Scholar
  6. 6.
    Muscat M. Who gets measles in Europe? J Infect Dis. 2011;204(Suppl 1):S353–65.CrossRefGoogle Scholar
  7. 7.
    C B S. statistic annual for Israel. Central Bureau Statistics [Internet]. 2019 Jun; Available from:הירחון-הסטטיסטי-לישראל%2D%2D-יולי-2019.aspx. Accessed 13 Aug 2019
  8. 8.
    C B S. IMMUNIZATION COVERAGE OF TWO-YEAR-OLDS. Statistical annual for Israel [Internet]. 2013; Available from:חיסונים. Accessed 13 Aug 2019
  9. 9.
    Muhsen K, Abed El-Hai R, Amit-Aharon A, Nehama H, Gondia M, Davidovitch N, et al. Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services. Vaccine. 2012;30(12):2109–15.CrossRefGoogle Scholar
  10. 10.
    Belmaker I, Dukhan L, Elgrici M, Yosef Y, Shahar-Rotberg L. Reduction of vaccine-preventable communicable diseases in a Bedouin population: summary of a community-based intervention programme. Lancet. 2006;367(9515):987–91.CrossRefGoogle Scholar
  11. 11.
    Yitshak-Sade M, Davidovitch N, Novack L, Grotto I. Ethnicity and immunization coverage among schools in Israel. Ethn Health. 2016;21(5):439–51.CrossRefGoogle Scholar
  12. 12.
    Vaysblay E. The national imunization in Israel [Internet]. Knesset Israel: center of research; 2008 Jan [cited 2019 Oct 8]. Available from:
  13. 13.
    Field A. Discovering statistics using IBM SPSS statistics. 4th ed. London: SAGE Publications Ltd; 2013.Google Scholar
  14. 14.
    Wagner KS, van Wijgerden JCJ, Andrews N, Goulden K, White JM. Childhood vaccination coverage by ethnicity within London between 2006/2007 and 2010/2011. Arch Dis Child. 2014;99(4):348–53.CrossRefGoogle Scholar
  15. 15.
    Elran B, Yaari S, Glazer Y, Honovich M, Grotto I, Anis E. Parents’ perceptions of childhood immunization in Israel: information and concerns. Vaccine. 2018;36(52):8062–8.CrossRefGoogle Scholar
  16. 16.
    Stein-Zamir C, Israeli A. Age-appropriate versus up-to-date coverage of routine childhood vaccinations among young children in Israel. Hum Vaccin Immunother. 2017;13(9):2102–10.CrossRefGoogle Scholar
  17. 17.
    Poland GA, Jacobson RM. Understanding those who do not understand: a brief review of the anti-vaccine movement. Vaccine. 2001;19(17-19):2440–5.CrossRefGoogle Scholar
  18. 18.
    Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine. 2014;32(19):2150–9.CrossRefGoogle Scholar
  19. 19.
    Velan B, Boyko V, Lerner-Geva L, Ziv A, Yagar Y, Kaplan G. Individualism, acceptance and differentiation as attitude traits in the public’s response to vaccination. Hum Vaccin Immunother. 2012;8(9):1272–82.CrossRefGoogle Scholar
  20. 20.
    Baron-Epel O, Kaplan G, Weinstein R, Green MS. Extreme and acquiescence bias in a bi-ethnic population. Eur J Pub Health. 2010;20(5):543–8.CrossRefGoogle Scholar
  21. 21.
    Soskolne V, Marie S, Manor O. Beliefs, recommendations and intentions are important explanatory factors of mammography screening behavior among Muslim Arab women in Israel. Health Educ Res. 2007;22(5):665–76.CrossRefGoogle Scholar
  22. 22.
    Ben Natan M, Kabha S, Yehia M, Hamza O. Factors that influence Israeli Muslim Arab parents’ intention to vaccinate their children against influenza. J Pediatr Nurs. 2016;31(3):293–8.CrossRefGoogle Scholar
  23. 23.
    Sarid O, Shraga Y, Tzvikal G, Pereg H. Influence of ethnic cultural background of mothers and their beliefs on health on childhood vaccine behavior. Social security [Internet]. 2015 Feb; 96:112–87. Available from: Accessed 20 Oct 2019
  24. 24.
    Glatman-Freedman A, Nichols K. The effect of social determinants on immunization programs. Hum Vaccin Immunother. 2012;8(3):293–301.CrossRefGoogle Scholar
  25. 25.
    Danis K, Georgakopoulou T, Stavrou T, Laggas D, Panagiotopoulos T. Socioeconomic factors play a more important role in childhood vaccination coverage than parental perceptions: a cross-sectional study in Greece. Vaccine. 2010;28(7):1861–9.CrossRefGoogle Scholar
  26. 26.
    Brown KF, Kroll JS, Hudson MJ, Ramsay M, Green J, Long SJ, et al. Factors underlying parental decisions about combination childhood vaccinations including MMR: a systematic review. Vaccine. 2010;28(26):4235–48.CrossRefGoogle Scholar
  27. 27.
    Dubé E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications. Expert Rev Vaccines. 2015;14(1):99–117.CrossRefGoogle Scholar
  28. 28.
    Amit Aharon A, Nehama H, Rishpon S, Baron-Epel O. Reasons why parents do not comply with recommended pediatric vaccines. The Israel national institute for health policy research; 2013 [cited 2019 Oct 19]. Available from: http://file:///C:/Users/anat/Downloads/The 205th International Jerusalem-Program and book of abstracts 6 2013 CoverS.pdf. Accessed 19 Oct 2019.Google Scholar
  29. 29.
    Luman ET, Shaw KM, Stokley SK. Compliance with vaccination recommendations for U.S. children. Am J Prev Med. 2008;34(6):463–70.CrossRefGoogle Scholar
  30. 30.
    Song BJ, Katial RK. Update on side effects from common vaccines. Curr Allergy Asthma Rep. 2004;4(6):447–53.CrossRefGoogle Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2019

Authors and Affiliations

  1. 1.Sackler Faculty of Medicine, Nursing DepartmentTel-Aviv UniversityTel-AvivIsrael
  2. 2.Public Health DepartmentTel Aviv-Yafo MunicipalityIsrael
  3. 3.Ministry of Health and School of Public Health, Faculty of Welfare and Health StudiesHaifa UniversityHaifaIsrael
  4. 4.School of Public Health, Faculty of Welfare and Health StudiesHaifa UniversityHaifaIsrael

Personalised recommendations