Knowledge, perception and reporting attitudes of adverse events following immunization among parents of infants in rural area, Sri Lanka: a community-based cross-sectional study

Knowledge, perception and reporting attitudes of adverse events following immunization among parents of infants in rural area, Sri Lanka: a community-based cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge, perception and reporting attitudes of adverse events following immunization among parents of infants in rural area, Sri Lanka: a community-based cross-sectional study Teshan Eranda Pragnaratna, Samarappuli Piyasumana, Manjula Priyadarshana, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9288794/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Adverse events following immunization (AEFI) play a critical role in shaping parental confidence and the effectiveness of vaccine safety surveillance systems. Despite the predominantly mild and self-limiting nature of most AEFIs, inadequate awareness and misperceptions may contribute to underreporting and undermine trust in immunization programmes. Evidence on parental knowledge, perception, and reporting practices regarding AEFI in Sri Lanka remains scarce, particularly in rural settings. Methods A community-based cross-sectional study was conducted among parents of infants in the Buttala Medical Officer of Health area, Sri Lanka. A total of 393 participants were selected using systematic random sampling from Public Health Midwife registers. Data were collected using a pre-tested interviewer-administered questionnaire assessing socio-demographic characteristics, knowledge, perception, and reporting attitudes related to AEFI. Knowledge was evaluated using a ten-item scoring system, with scores >6 indicating adequate knowledge. Associations were assessed using chi-square tests, and effect sizes were expressed as odds ratios (OR) with 95% confidence intervals (CI). Results Overall, 73% (n = 287) of participants demonstrated adequate knowledge of AEFI. While awareness of common adverse events was high, knowledge of serious AEFIs remained limited, with only 48.1% (n = 189) identifying severe reactions such as anaphylaxis and convulsions. Adequate knowledge was significantly associated with age ≥30 years (OR = 2.99; 95% CI: 1.90–4.77), higher educational attainment (OR = 2.52; 95% CI: 1.56–4.06), higher household income (OR = 2.12; 95% CI: 1.04–4.35), and infant age ≥6 months (OR = 1.82; 95% CI: 1.16–2.85). Although overall perception towards immunization was highly positive, with 94.9% expressing confidence in the national programme, reporting practices were suboptimal. Among parents who experienced an AEFI, only 56.9% reported the event, while a substantial proportion (43.1%) did not report, often perceiving minor events as insignificant. Conclusion Despite generally favourable levels of knowledge and positive perceptions, critical gaps persist in the recognition of serious AEFIs and in reporting behaviour. The observed disconnect between awareness and reporting highlights the need for targeted risk communication strategies and strengthened community-based reporting systems. Addressing these gaps is essential to improve AEFI surveillance and sustain long-term public confidence in immunization programmes. Adverse events following immunization knowledge perception reporting attitude parents Sri Lanka Introduction Immunization is one of the most effective public health interventions for preventing infectious diseases and reducing morbidity and mortality worldwide. It has contributed substantially to the control and elimination of several vaccine-preventable diseases and continues to play a central role in improving child survival. In addition to providing individual protection, immunization contributes to herd immunity, thereby reducing disease transmission within communities [ 1 ]. Despite these benefits, vaccines may be associated with adverse events following immunization (AEFI), defined as any untoward medical occurrence that follows immunization and does not necessarily have a causal relationship with vaccine administration [ 2 ]. Most AEFIs are mild and self-limiting, such as fever or local reactions; however, rare but serious events, including anaphylaxis and convulsions, may occur. These events can influence parental perception of vaccine safety and affect their confidence in immunization programmes [ 3 ]. Parental knowledge and perception regarding AEFI are critical determinants of health-seeking behaviour and reporting practices. Studies have shown that while caregivers are generally aware of common minor reactions, knowledge of serious AEFIs remains limited [ 4 , 5 ]. In addition, misconceptions and concerns about vaccine safety contribute to vaccine hesitancy and may influence reporting behaviour [ 6 ]. Underreporting of adverse events remains a global challenge, limiting the effectiveness of vaccine safety surveillance systems and delaying identification of potential safety signals [ 7 ]. In the South-East Asian region, immunization programmes have achieved high coverage; however, gaps persist in awareness and reporting of AEFI, particularly in rural communities. Limited access to accurate health information, cultural beliefs, and communication gaps between healthcare providers and caregivers contribute to these challenges [ 5 , 8 ]. Strengthening community awareness and improving communication strategies are therefore essential to enhance vaccine safety monitoring. Sri Lanka has a well-established Expanded Programme on Immunization (EPI) with high coverage and a strong public health infrastructure [ 9 ]. AEFI surveillance is integrated into the national immunization system; however, reporting rates remain relatively low compared to the number of vaccines administered, suggesting possible underreporting [ 7 ]. Although immunization coverage is high, evidence on parental knowledge, perception, and reporting attitudes related to AEFI is limited, particularly in rural settings. Understanding these factors is essential for strengthening AEFI surveillance systems and maintaining public confidence in immunization programmes. Therefore, this study aimed to assess the knowledge, perception, and reporting attitudes regarding adverse events following immunization among parents of infants in a rural area of Sri Lanka. Methods Study design and setting A community-based cross-sectional study was conducted in the Buttala Medical Officer of Health (MOH) area in the Monaragala District of Sri Lanka. The study was carried out from November 2023 to May 2025. Study population The study population consisted of parents of infants residing in the Buttala MOH area for at least six months prior to data collection. Parents with diagnosed psychiatric illness or cognitive impairment and those with acute illnesses at the time of data collection were excluded. Sample size and sampling technique The sample size was calculated using a standard formula for cross-sectional studies, assuming a prevalence of 50% due to lack of prior local estimates, with a 95% confidence level and a margin of error of 5%. After adjusting for a 10% non-response rate, the required sample size was 427. A systematic random sampling method was used. A sampling frame was developed using Birth and Immunization Registers maintained by Public Health Midwives (PHMs) in the study area. All registers were combined into a single list and arranged alphabetically. From a total of 695 eligible participants, the sampling interval ( k ) was calculated. A random starting point was selected using a computer-generated random number, and every k th individual was subsequently selected until the required sample size was achieved. Data collection tool and procedure Data were collected using a pre-tested interviewer-administered questionnaire consisting of four sections: socio-demographic characteristics, knowledge on AEFI, perception related to AEFI, and reporting attitudes. The questionnaire was developed based on literature review and expert consultation. Content and face validity were established through a panel including Consultant Epidemiologists, Medical Officers of Health, a Public Health Nursing Sister, and a Public Health Midwife. The tool was prepared in Sinhala and validated using forward and backward translation. Pre-testing was conducted among 20 parents in a neighbouring MOH area, and necessary modifications were made. Data collectors were trained to ensure standardization. Participants were invited through PHMs and attended data collection sessions at maternal and child health clinics. Interviews were conducted in a private setting, and confidentiality was ensured throughout the process. Measurement of variables Knowledge on AEFI was assessed using a ten-item scoring system, with each correct response assigned one point. Total scores ranged from 0 to 10. A score greater than 6 was considered as adequate knowledge based on expert consensus. Perception and reporting attitudes were assessed using structured questions Data analysis Data were entered into Epi Info and analyzed using the Statistical Package for Social Sciences (SPSS). Descriptive statistics were used to summarize variables using frequencies and percentages. Associations between categorical variables were assessed using the chi-square test. The strength of associations was expressed using odds ratios (OR) with 95% confidence intervals (CI). A p-value of less than 0.05 was considered statistically significant. Ethical considerations Ethical approval was obtained from the Ethics Review Committee of Uva Wellassa University, Sri Lanka. Administrative approval was obtained from the relevant Medical Officer of Health offices. Written informed consent was obtained from all participants prior to data collection. All methods were carried out in accordance with the Declaration of Helsinki. Participation was voluntary, and participants were informed of their right to withdraw at any time without consequences. Confidentiality and anonymity were maintained by using unique identification codes, and data were securely stored. Results Participant characteristics A total of 427 parents were invited to participate in the study, of whom 393 completed the questionnaire, yielding a response rate of 92.0%. The socio-demographic and child characteristics of the participants are presented in Table 1 . Table 1 Socio-demographic and child characteristics of participants (n = 393) Characteristic Number Percentage (%) Age (years) 18–25 68 17.3 26–35 244 62.1 36–45 81 20.6 Gender Female 346 88.0 Male 47 12.0 Educational Level Up to O/L 214 54.5 Up to A/L 72 18.3 Diploma 71 18.1 Degree 36 9.2 Occupation Employed 75 19.1 Unemployed 318 80.9 Monthly income (SLR) ≤25,000 53 13.5 25,001–50,000 278 70.7 ≥50,000 62 15.8 Relationship to child Mother 343 87.3 Other 50 12.7 Infant age <6 months 180 45.8 ≥6 months 213 54.2 The majority of participants were aged 26–35 years (n = 244, 64.1%), followed by 36–45 years (n = 81, 20.1%) and 18–25 years (n = 68, 17.3%). Most participants were female (n = 346, 88.0%) and of Sinhalese ethnicity (n = 386, 98.2%). Nearly all participants were married (n = 376, 95.7%). With regard to socio-economic characteristics, 80.9% (n = 318) were unemployed, and the majority had a monthly income between 25,001–50,000 LKR (n = 278, 70.7%). Most respondents were mothers (n = 343, 87.3%), and more than half of the infants were aged ≥ 6 months (n = 213, 54.2%). The majority of infants did not have congenital diseases (n = 367, 93.4%). Knowledge on adverse events following immunization (AEFI) The overall level of knowledge on AEFI among participants is presented in Table 2 .Awareness of common adverse events following immunization was generally high among participants. A large proportion correctly identified the need to inform healthcare staff when the child had fever, long-term illness, or allergies prior to vaccination (> 90%). Table 2 Level of Knowledge on Adverse Events Following Immunization among Parents Having Infants (n = 393) Level of knowledge Frequency Percentage Adequate 287 73 Inadequate 106 27 However, knowledge of serious adverse events was limited. Only 48.1% (n = 189) of participants correctly identified severe reactions such as anaphylaxis and convulsions as possible AEFIs. Overall, 73.0% (n = 287) of participants were categorized as having adequate knowledge, while 27.0% (n = 106) had inadequate knowledge. Factors associated with knowledge on AEFI The factors associated with adequate knowledge on AEFI are presented in Table 3 .There was a statistically significant association between age and adequacy of knowledge.. Participants aged ≥ 30 years were more likely to have adequate knowledge compared to those aged < 30 years (OR = 2.99; 95% CI: 1.90–4.77; p < 0.001). Table 3 Factors associated with adequate knowledge on AEFI (n = 393) Characteristic Knowledge OR Significance Adeqaute N(%) Inadeqaute N(%) Total N(%) 95%CI Age in years ≥30 185 (82.2) 40 (17.8) 225(100) 2.99 χ²=24.55 <30 102 (60.7) 66 (39.3) 168(100) (1.90–4.77) p = 0.00 Income ≥ 50,000 LKR 52 (83.9) 10 (16.1) 62 (100) 2.12 χ²=0.00 < 50,000 LKR 235 (71.0) 96 (29.0) 331 (100) (1.04–4.35) p = 0.94 Education A/L and above 148 (82.7) 31 (17.3) 179(100) 2.52 χ²=14.83 O/L 140 (65.4) 74 (34.6) 214(100) (1.56–4.06) p = 0.00 Infant age in months ≥ 6 167 (78.4) 46 (21.6) 213 (100) 1.82 χ² = 6.82 <6 120 (66.7) 60 (33.3) 180 (100) (1.16–2.85) p = 0.00 Educational level was also significantly associated with knowledge. Participants with education at Advanced Level or above had higher odds of adequate knowledge compared to those with lower education (OR = 2.52; 95% CI: 1.56–4.06; p < 0.001). Monthly income ≥ 50,000 LKR was significantly associated with adequate knowledge (OR = 2.12; 95% CI: 1.04–4.35; p = 0.036). Infant age ≥ 6 months was also significantly associated with adequate knowledge (OR = 1.82; 95% CI: 1.16–2.85; p = 0.009). No significant associations were observed with sex, ethnicity, marital status, or occupation. Perception towards immunization and AEFI The distribution of perception towards immunization and AEFI among participants is shown in Table 4 .Overall, participants demonstrated a highly positive perception towards immunization. The majority expressed confidence in the national immunization programme (94.9%) and agreed that the benefits of vaccination outweigh the risks (94.1%). Table 4 Distribution of perception towards immunization and AEFI among study participants (n = 393) Statement Agree n (%) No idea n (%) Disagree n (%) Confidence in quality of immunization programme 373 (94.9) 14 (3.6) 6 (1.5) Vaccination protects more than side effects 370 (94.1) 21 (5.3) 2 (0.5) Aware of value and side effects of immunization 355 (90.3) 25 (6.4) 13 (3.3) Avoid immunization due to fear of side effects 46 (11.7) 27 (6.9) 320 (81.4) Avoid next immunization after side effects 48 (12.2) 55 (14.0) 290 (73.8) Need to know side effects from health staff 326 (83.0) 38 (9.7) 29 (7.4) Illness within 3 days due to vaccine 225 (57.3) 91 (23.2) 77 (19.6) Illness within 1 month due to vaccine 57 (14.5) 105 (26.7) 231 (58.8) Immunization for children with chronic illness 215 (54.7) 140 (35.6) 38 (9.7) Reporting side effects improves programme 308 (78.4) 65 (16.5) 20 (5.1) However, some misconceptions were observed. A proportion of participants attributed common childhood illnesses occurring after vaccination to the vaccine itself, indicating gaps in understanding of causality. Reporting attitudes on AEFI The reporting behaviour of adverse events following immunization is presented in Table 5 .Among participants who experienced an adverse event following immunization, only 56.9% reported the event to healthcare staff, while 43.1% did not report. Table 5 Reporting attitude of adverse events following immunization (n = 181) Characteristic Number Percentage (%) Reported AEFI Yes 103 56.9 No 78 43.1 Common AEFI Fever 132 72.9 Redness/swelling 32 17.7 Nodules 11 6.1 Abscess 6 3.3 Fever was the most commonly reported adverse event (72.9%), followed by local reactions such as redness and swelling. A considerable proportion of participants (36.9%) believed that minor adverse events do not require reporting, indicating gaps in reporting practices. Discussion This study assessed the knowledge, perception, and reporting attitudes regarding adverse events following immunization (AEFI) among parents of infants in a rural Sri Lankan setting. The findings demonstrate that although overall knowledge and perception were generally favourable, important gaps persist in awareness of serious AEFIs and in reporting practices. Knowledge on AEFI In the present study, 73% of participants had adequate knowledge on AEFI. This indicates a relatively satisfactory level of awareness at the community level. Similar findings have been reported in studies conducted in India, where a high proportion of mothers were aware of common adverse events such as fever and local reactions [ 10 , 11 ]. However, knowledge of serious AEFIs was limited, with only 48.1% of participants correctly identifying severe reactions such as anaphylaxis and convulsions. This finding is consistent with previous studies, which have shown that awareness of severe AEFIs is considerably lower compared to common minor reactions [ 10 , 12 ]. Limited knowledge of serious adverse events is of concern, as it may delay timely healthcare seeking and appropriate reporting. The present study also demonstrated significant associations between knowledge and socio-demographic factors. Parents aged ≥ 30 years, those with higher educational attainment, and those with higher income were more likely to have adequate knowledge. These findings are consistent with previous literature, which highlights the role of education and socio-economic status in influencing health literacy and awareness of immunization-related issues [ 13 ]. Perception towards immunization and AEFI The study found that parental perception towards immunization was highly positive, with the majority expressing confidence in the national immunization programme and acknowledging the benefits of vaccination. This is consistent with previous findings from Sri Lanka, where positive attitudes towards immunization were observed despite gaps in knowledge [ 14 ]. However, some misconceptions were identified, particularly regarding the attribution of common childhood illnesses to vaccination. Similar concerns have been reported in other settings, where parental perception of vaccine safety is influenced by previous experiences and communication from healthcare providers [ 15 , 16 ]. These misconceptions may contribute to unnecessary anxiety and influence decision-making regarding future vaccinations. Reporting attitudes on AEFI Despite relatively good knowledge and positive perception, reporting practices were suboptimal. Among participants who experienced AEFI, only 56.9% reported the event to healthcare staff. This finding reflects a substantial gap between awareness and reporting behaviour. Underreporting of AEFI is a well-recognized issue globally and has been attributed to factors such as lack of awareness of reporting mechanisms, perceived insignificance of minor events, and limited access to healthcare services [ 17 , 18 ]. In the present study, a considerable proportion of participants believed that minor adverse events do not require reporting, which may explain the observed underreporting. These findings suggest that knowledge alone is insufficient to ensure appropriate reporting behaviour. Perceived severity, attitudes towards healthcare systems, and communication with health workers appear to play a significant role. Public health implications The findings of this study have important implications for strengthening AEFI surveillance systems. Although Sri Lanka has a well-established immunization programme, improving community awareness regarding serious AEFIs and the importance of reporting all adverse events is essential. Targeted health education interventions focusing on recognition of serious AEFIs and appropriate reporting practices should be implemented at the community level. Strengthening communication between healthcare providers and parents, particularly during immunization sessions, may help address misconceptions and improve reporting behaviour. Enhancing community-based reporting mechanisms and promoting active engagement of Public Health Midwives may further improve the completeness of AEFI reporting and contribute to strengthening vaccine safety surveillance systems. Strengths and limitations This study has several strengths. It was conducted in a community setting using a systematic sampling method, which enhances the representativeness of the findings. In addition, focusing on parents of infants minimized recall bias, as immunization events were recent. However, certain limitations should be considered. The cross-sectional design limits the ability to establish causal relationships. Data were collected using self-reported measures, which may be subject to recall and social desirability bias. Furthermore, the study was conducted in a single rural MOH area, which may limit generalizability to other settings. Conclusion This study demonstrated that although parental knowledge and perception regarding adverse events following immunization were generally satisfactory, important gaps remain in awareness of serious AEFIs and in reporting practices. The relatively low reporting of adverse events highlights a disconnect between knowledge and actual reporting behaviour. Strengthening community-level education, particularly on recognition of serious AEFIs and the importance of reporting all adverse events, is essential. Enhancing communication between healthcare providers and parents, along with improving community-based reporting mechanisms, will be crucial to strengthen AEFI surveillance and sustain public confidence in immunization programmes in Sri Lanka. Abbreviations AEFI Adverse Events Following Immunization CI Confidence Interval EPI Expanded Programme on Immunization MOH Medical Officer of Health OR Odds Ratio PHM Public Health Midwife SPSS Statistical Package for Social Sciences Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethics Review Committee of Uva Wellassa University, Sri Lanka. Administrative approval was obtained from the relevant Medical Officer of Health offices. Written informed consent was obtained from all participants prior to data collection. Consent for publication Not applicable. Competing interests The author declares that there are no competing interests. Funding No external funding was received for this study. Author Contribution Teshan Eranda Pragnaratna conceived and designed the study, collected data, performed the statistical analysis, and drafted the manuscript. Samarappuli Piyasumana, Manjula Priyadarshana, Manuri Imalika, and Palika Tennakoon contributed to data collection, study design, data interpretation, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements The author would like to thank the participants of the study and the staff of the Buttala Medical Officer of Health area for their support during data collection Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Lindstrand A, Cherian T, Chang-Blanc D, Feikin D, O’Brien KL, et al. The World Health Organization’s Expanded Programme on Immunization: a review of its achievements and future challenges. Vaccine. 2021;39(Suppl 1):A1–8. World Health Organization. Surveillance of adverse events following immunization. Geneva: WHO; 2018. Clothier HJ, Crawford NW, Russell M, Buttery JP, Wood N. Adverse events following immunisation: the role of surveillance in maintaining confidence in immunisation programs. Vaccine. 2014;32(49):6832–7. Mishra NM, Dhingra S, Adhikari KM. Adverse events following immunization: orchestrated outcome of mothers’ knowledge and behavior on vaccination practices. Int J Community Med Public Health. 2021;8(2):802–6. Datta A, Baidya S, Das S, Mog C, Datta S. Assessment of mother’s knowledge and practices regarding adverse events following immunization of their children in a rural area of Tripura. Natl J Community Med. 2017;8(4):159–63. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy: an overview. Hum Vaccin Immunother. 2013;9(8):1763–73. Hazell L, Shakir SAW. Under-reporting of adverse drug reactions. Drug Saf. 2006;29(5):385–96. Braka F, Asiimwe D, Soud F, Lewis RF, Makumbi I, Gust D. A qualitative analysis of vaccine safety perceptions and concerns among caretakers in Uganda. Matern Child Health J. 2012;16(5):1045–52. Epidemiology Unit, Ministry of Health Sri Lanka. National guidelines on surveillance of adverse events following immunization (AEFI). Colombo: Ministry of Health; 2012. Afolaranmi TO, Hassan ZI, Dagona Z, Abufuce C, Chingle MP, Bupwatda PW. Knowledge of adverse events following immunization, its prevalence and actions of mothers of children aged 0–23 months in a tertiary health institution in Jos, North Central Nigeria. Int J Matern Child Health AIDS. 2020;9(1):95–107. Nnenna TB, Davidson UN, Babatunde OI. Mothers’ knowledge and perception of adverse events following immunization in Enugu, South-East Nigeria. J Vaccines Vaccin. 2013;4:202. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Health Econ. 2010;29(1):1–28. Jayaweera HAMD, Wijesinghe CJ. Maternal knowledge, perceptions and age-appropriate coverage of routine immunization in children under five years in Southern Sri Lanka. Asian J Pharm Nurs Med Sci. 2018;6(1). Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics. 2011;127(Suppl 1):S92–9. Parrella A, Gold M, Marshall H, Braunack-Mayer A, Baghurst P. Parental perspectives of vaccine safety and experience of adverse events following immunisation. Vaccine. 2013;31(16):2067–74. Parrella A, Gold M, Braunack-Mayer A, Baghurst P, Marshall H. Consumer reporting of adverse events following immunization (AEFI): identifying predictors of reporting an AEFI. Hum Vaccin Immunother. 2014;10(3):747–54. Restrepo-Méndez MC, Barros AJD, Wong KLM, Johnson HL, Pariyo G, França GVA, et al. Inequalities in full immunization coverage. Bull World Health Organ. 2016;94(11):794–805. Sanchayan K, Fernandopulle R, Amarasinghe A, Thiyahiny SN, Sri Ranganathan S. Safety of live attenuated Japanese encephalitis vaccine given at age 9 months in the national immunisation programme of Sri Lanka. Ceylon Med J. 2016;61(3):99–105. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9288794","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":622525461,"identity":"e56e168a-ddb4-4c72-884e-010c0ea214b2","order_by":0,"name":"Teshan Eranda Pragnaratna","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYHACNiA+AGIwPgASPHyE1PMgaWE2AAmwkaKFTQJmKV5gz97+7MHHHXfy+WckH6v8mmMnw8bA/PDRDXy28JwxN5x55pnljBtpabdltyUDHcZmbJyDT4tEDps0b9thA4YzZ8xuS25jBmrhYZPGq0X++TPpv0At8mfOfyuW3FZPhBYJBjNpRqAWg+M9bIwftx0mQsuZHDPJ3jPPDAyPtxlLM247zsPGTMAv7O3Hn0n83HHHQO4w88OPP7dV2/OzNz98jE8LGDA2QGhmHjBJSDmyFsYfxKgeBaNgFIyCEQcA3btG01EJofwAAAAASUVORK5CYII=","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":true,"prefix":"","firstName":"Teshan","middleName":"Eranda","lastName":"Pragnaratna","suffix":""},{"id":622525462,"identity":"5adbd30c-a251-4a8a-83f7-0bf385aa79c6","order_by":1,"name":"Samarappuli Piyasumana","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Samarappuli","middleName":"","lastName":"Piyasumana","suffix":""},{"id":622525465,"identity":"ed08570f-34cc-4033-a406-036e63be1adb","order_by":2,"name":"Manjula Priyadarshana","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Manjula","middleName":"","lastName":"Priyadarshana","suffix":""},{"id":622525466,"identity":"ff43d0c6-b4ff-455d-b430-4940b844b5ec","order_by":3,"name":"Manuri Imalika","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Manuri","middleName":"","lastName":"Imalika","suffix":""},{"id":622525467,"identity":"41c2cf9b-cb79-454d-9434-cb88c1d49976","order_by":4,"name":"Palika Tennakoon","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Palika","middleName":"","lastName":"Tennakoon","suffix":""}],"badges":[],"createdAt":"2026-04-01 08:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9288794/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9288794/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108007404,"identity":"579aa74d-1b39-44f4-9bc7-d47a5c3896b5","added_by":"auto","created_at":"2026-04-28 12:59:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":329346,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9288794/v1/0162d32e-f386-473b-ab09-224823cb56bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge, perception and reporting attitudes of adverse events following immunization among parents of infants in rural area, Sri Lanka: a community-based cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eImmunization is one of the most effective public health interventions for preventing infectious diseases and reducing morbidity and mortality worldwide. It has contributed substantially to the control and elimination of several vaccine-preventable diseases and continues to play a central role in improving child survival. In addition to providing individual protection, immunization contributes to herd immunity, thereby reducing disease transmission within communities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these benefits, vaccines may be associated with adverse events following immunization (AEFI), defined as any untoward medical occurrence that follows immunization and does not necessarily have a causal relationship with vaccine administration [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Most AEFIs are mild and self-limiting, such as fever or local reactions; however, rare but serious events, including anaphylaxis and convulsions, may occur. These events can influence parental perception of vaccine safety and affect their confidence in immunization programmes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParental knowledge and perception regarding AEFI are critical determinants of health-seeking behaviour and reporting practices. Studies have shown that while caregivers are generally aware of common minor reactions, knowledge of serious AEFIs remains limited [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, misconceptions and concerns about vaccine safety contribute to vaccine hesitancy and may influence reporting behaviour [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Underreporting of adverse events remains a global challenge, limiting the effectiveness of vaccine safety surveillance systems and delaying identification of potential safety signals [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the South-East Asian region, immunization programmes have achieved high coverage; however, gaps persist in awareness and reporting of AEFI, particularly in rural communities. Limited access to accurate health information, cultural beliefs, and communication gaps between healthcare providers and caregivers contribute to these challenges [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Strengthening community awareness and improving communication strategies are therefore essential to enhance vaccine safety monitoring.\u003c/p\u003e \u003cp\u003eSri Lanka has a well-established Expanded Programme on Immunization (EPI) with high coverage and a strong public health infrastructure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. AEFI surveillance is integrated into the national immunization system; however, reporting rates remain relatively low compared to the number of vaccines administered, suggesting possible underreporting [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although immunization coverage is high, evidence on parental knowledge, perception, and reporting attitudes related to AEFI is limited, particularly in rural settings.\u003c/p\u003e \u003cp\u003eUnderstanding these factors is essential for strengthening AEFI surveillance systems and maintaining public confidence in immunization programmes. Therefore, this study aimed to assess the knowledge, perception, and reporting attitudes regarding adverse events following immunization among parents of infants in a rural area of Sri Lanka.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA community-based cross-sectional study was conducted in the Buttala Medical Officer of Health (MOH) area in the Monaragala District of Sri Lanka. The study was carried out from November 2023 to May 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of parents of infants residing in the Buttala MOH area for at least six months prior to data collection. Parents with diagnosed psychiatric illness or cognitive impairment and those with acute illnesses at the time of data collection were excluded.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling technique\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated using a standard formula for cross-sectional studies, assuming a prevalence of 50% due to lack of prior local estimates, with a 95% confidence level and a margin of error of 5%. After adjusting for a 10% non-response rate, the required sample size was 427.\u003c/p\u003e \u003cp\u003eA systematic random sampling method was used. A sampling frame was developed using Birth and Immunization Registers maintained by Public Health Midwives (PHMs) in the study area. All registers were combined into a single list and arranged alphabetically. From a total of 695 eligible participants, the sampling interval (\u003cem\u003ek\u003c/em\u003e) was calculated. A random starting point was selected using a computer-generated random number, and every \u003cem\u003ek\u003c/em\u003eth individual was subsequently selected until the required sample size was achieved.\u003c/p\u003e\n\u003ch3\u003eData collection tool and procedure\u003c/h3\u003e\n\u003cp\u003eData were collected using a pre-tested interviewer-administered questionnaire consisting of four sections: socio-demographic characteristics, knowledge on AEFI, perception related to AEFI, and reporting attitudes.\u003c/p\u003e \u003cp\u003eThe questionnaire was developed based on literature review and expert consultation. Content and face validity were established through a panel including Consultant Epidemiologists, Medical Officers of Health, a Public Health Nursing Sister, and a Public Health Midwife. The tool was prepared in Sinhala and validated using forward and backward translation.\u003c/p\u003e \u003cp\u003e Pre-testing was conducted among 20 parents in a neighbouring MOH area, and necessary modifications were made. Data collectors were trained to ensure standardization.\u003c/p\u003e \u003cp\u003eParticipants were invited through PHMs and attended data collection sessions at maternal and child health clinics. Interviews were conducted in a private setting, and confidentiality was ensured throughout the process.\u003c/p\u003e\n\u003ch3\u003eMeasurement of variables\u003c/h3\u003e\n\u003cp\u003eKnowledge on AEFI was assessed using a ten-item scoring system, with each correct response assigned one point. Total scores ranged from 0 to 10. A score greater than 6 was considered as adequate knowledge based on expert consensus.\u003c/p\u003e \u003cp\u003ePerception and reporting attitudes were assessed using structured questions\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were entered into Epi Info and analyzed using the Statistical Package for Social Sciences (SPSS).\u003c/p\u003e \u003cp\u003eDescriptive statistics were used to summarize variables using frequencies and percentages. Associations between categorical variables were assessed using the chi-square test. The strength of associations was expressed using odds ratios (OR) with 95% confidence intervals (CI). A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Ethics Review Committee of Uva Wellassa University, Sri Lanka. Administrative approval was obtained from the relevant Medical Officer of Health offices. Written informed consent was obtained from all participants prior to data collection. All methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eParticipation was voluntary, and participants were informed of their right to withdraw at any time without consequences. Confidentiality and anonymity were maintained by using unique identification codes, and data were securely stored.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eA total of 427 parents were invited to participate in the study, of whom 393 completed the questionnaire, yielding a response rate of 92.0%. The socio-demographic and child characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and child characteristics of participants (n\u0026thinsp;=\u0026thinsp;393)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUp to O/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUp to A/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly income (SLR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;25,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25,001\u0026ndash;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship to child\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfant age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe majority of participants were aged 26\u0026ndash;35 years (n\u0026thinsp;=\u0026thinsp;244, 64.1%), followed by 36\u0026ndash;45 years (n\u0026thinsp;=\u0026thinsp;81, 20.1%) and 18\u0026ndash;25 years (n\u0026thinsp;=\u0026thinsp;68, 17.3%). Most participants were female (n\u0026thinsp;=\u0026thinsp;346, 88.0%) and of Sinhalese ethnicity (n\u0026thinsp;=\u0026thinsp;386, 98.2%). Nearly all participants were married (n\u0026thinsp;=\u0026thinsp;376, 95.7%).\u003c/p\u003e \u003cp\u003eWith regard to socio-economic characteristics, 80.9% (n\u0026thinsp;=\u0026thinsp;318) were unemployed, and the majority had a monthly income between 25,001\u0026ndash;50,000 LKR (n\u0026thinsp;=\u0026thinsp;278, 70.7%).\u003c/p\u003e \u003cp\u003eMost respondents were mothers (n\u0026thinsp;=\u0026thinsp;343, 87.3%), and more than half of the infants were aged\u0026thinsp;\u0026ge;\u0026thinsp;6 months (n\u0026thinsp;=\u0026thinsp;213, 54.2%). The majority of infants did not have congenital diseases (n\u0026thinsp;=\u0026thinsp;367, 93.4%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge on adverse events following immunization (AEFI)\u003c/h2\u003e \u003cp\u003eThe overall level of knowledge on AEFI among participants is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.Awareness of common adverse events following immunization was generally high among participants. A large proportion correctly identified the need to inform healthcare staff when the child had fever, long-term illness, or allergies prior to vaccination (\u0026gt;\u0026thinsp;90%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLevel of Knowledge on Adverse Events Following Immunization among Parents Having Infants (n\u0026thinsp;=\u0026thinsp;393)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of knowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, knowledge of serious adverse events was limited. Only 48.1% (n\u0026thinsp;=\u0026thinsp;189) of participants correctly identified severe reactions such as anaphylaxis and convulsions as possible AEFIs.\u003c/p\u003e \u003cp\u003eOverall, 73.0% (n\u0026thinsp;=\u0026thinsp;287) of participants were categorized as having adequate knowledge, while 27.0% (n\u0026thinsp;=\u0026thinsp;106) had inadequate knowledge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with knowledge on AEFI\u003c/h2\u003e \u003cp\u003eThe factors associated with adequate knowledge on AEFI are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.There was a statistically significant association between age and adequacy of knowledge.. Participants aged\u0026thinsp;\u0026ge;\u0026thinsp;30 years were more likely to have adequate knowledge compared to those aged\u0026thinsp;\u0026lt;\u0026thinsp;30 years (OR\u0026thinsp;=\u0026thinsp;2.99; 95% CI: 1.90\u0026ndash;4.77; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with adequate knowledge on AEFI (n\u0026thinsp;=\u0026thinsp;393)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdeqaute\u003c/p\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInadeqaute\u003c/p\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e185 (82.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e225(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;=24.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.90\u0026ndash;4.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 50,000 LKR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;=0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 50,000 LKR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e235 (71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e331 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.04\u0026ndash;4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA/L and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148 (82.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e179(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;=14.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140 (65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e214(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.56\u0026ndash;4.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfant age in months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e167 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e213 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2; = 6.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e180 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.16\u0026ndash;2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEducational level was also significantly associated with knowledge. Participants with education at Advanced Level or above had higher odds of adequate knowledge compared to those with lower education (OR\u0026thinsp;=\u0026thinsp;2.52; 95% CI: 1.56\u0026ndash;4.06; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eMonthly income\u0026thinsp;\u0026ge;\u0026thinsp;50,000 LKR was significantly associated with adequate knowledge (OR\u0026thinsp;=\u0026thinsp;2.12; 95% CI: 1.04\u0026ndash;4.35; p\u0026thinsp;=\u0026thinsp;0.036).\u003c/p\u003e \u003cp\u003eInfant age\u0026thinsp;\u0026ge;\u0026thinsp;6 months was also significantly associated with adequate knowledge (OR\u0026thinsp;=\u0026thinsp;1.82; 95% CI: 1.16\u0026ndash;2.85; p\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003eNo significant associations were observed with sex, ethnicity, marital status, or occupation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePerception towards immunization and AEFI\u003c/h2\u003e \u003cp\u003eThe distribution of perception towards immunization and AEFI among participants is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.Overall, participants demonstrated a highly positive perception towards immunization. The majority expressed confidence in the national immunization programme (94.9%) and agreed that the benefits of vaccination outweigh the risks (94.1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of perception towards immunization and AEFI among study participants (n\u0026thinsp;=\u0026thinsp;393)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo idea n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisagree n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence in quality of immunization programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e373 (94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccination protects more than side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e370 (94.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAware of value and side effects of immunization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e355 (90.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoid immunization due to fear of side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e320 (81.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoid next immunization after side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e290 (73.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed to know side effects from health staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e326 (83.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness within 3 days due to vaccine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e225 (57.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77 (19.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness within 1 month due to vaccine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e231 (58.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmunization for children with chronic illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e140 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReporting side effects improves programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e308 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, some misconceptions were observed. A proportion of participants attributed common childhood illnesses occurring after vaccination to the vaccine itself, indicating gaps in understanding of causality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReporting attitudes on AEFI\u003c/h2\u003e \u003cp\u003eThe reporting behaviour of adverse events following immunization is presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.Among participants who experienced an adverse event following immunization, only 56.9% reported the event to healthcare staff, while 43.1% did not report.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReporting attitude of adverse events following immunization (n\u0026thinsp;=\u0026thinsp;181)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReported AEFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommon AEFI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRedness/swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNodules\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFever was the most commonly reported adverse event (72.9%), followed by local reactions such as redness and swelling.\u003c/p\u003e \u003cp\u003eA considerable proportion of participants (36.9%) believed that minor adverse events do not require reporting, indicating gaps in reporting practices.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the knowledge, perception, and reporting attitudes regarding adverse events following immunization (AEFI) among parents of infants in a rural Sri Lankan setting. The findings demonstrate that although overall knowledge and perception were generally favourable, important gaps persist in awareness of serious AEFIs and in reporting practices.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge on AEFI\u003c/h2\u003e \u003cp\u003eIn the present study, 73% of participants had adequate knowledge on AEFI. This indicates a relatively satisfactory level of awareness at the community level. Similar findings have been reported in studies conducted in India, where a high proportion of mothers were aware of common adverse events such as fever and local reactions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, knowledge of serious AEFIs was limited, with only 48.1% of participants correctly identifying severe reactions such as anaphylaxis and convulsions. This finding is consistent with previous studies, which have shown that awareness of severe AEFIs is considerably lower compared to common minor reactions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Limited knowledge of serious adverse events is of concern, as it may delay timely healthcare seeking and appropriate reporting.\u003c/p\u003e \u003cp\u003eThe present study also demonstrated significant associations between knowledge and socio-demographic factors. Parents aged\u0026thinsp;\u0026ge;\u0026thinsp;30 years, those with higher educational attainment, and those with higher income were more likely to have adequate knowledge. These findings are consistent with previous literature, which highlights the role of education and socio-economic status in influencing health literacy and awareness of immunization-related issues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePerception towards immunization and AEFI\u003c/h2\u003e \u003cp\u003eThe study found that parental perception towards immunization was highly positive, with the majority expressing confidence in the national immunization programme and acknowledging the benefits of vaccination. This is consistent with previous findings from Sri Lanka, where positive attitudes towards immunization were observed despite gaps in knowledge [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, some misconceptions were identified, particularly regarding the attribution of common childhood illnesses to vaccination. Similar concerns have been reported in other settings, where parental perception of vaccine safety is influenced by previous experiences and communication from healthcare providers [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These misconceptions may contribute to unnecessary anxiety and influence decision-making regarding future vaccinations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eReporting attitudes on AEFI\u003c/h2\u003e \u003cp\u003eDespite relatively good knowledge and positive perception, reporting practices were suboptimal. Among participants who experienced AEFI, only 56.9% reported the event to healthcare staff. This finding reflects a substantial gap between awareness and reporting behaviour.\u003c/p\u003e \u003cp\u003eUnderreporting of AEFI is a well-recognized issue globally and has been attributed to factors such as lack of awareness of reporting mechanisms, perceived insignificance of minor events, and limited access to healthcare services [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the present study, a considerable proportion of participants believed that minor adverse events do not require reporting, which may explain the observed underreporting.\u003c/p\u003e \u003cp\u003eThese findings suggest that knowledge alone is insufficient to ensure appropriate reporting behaviour. Perceived severity, attitudes towards healthcare systems, and communication with health workers appear to play a significant role.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePublic health implications\u003c/h2\u003e \u003cp\u003eThe findings of this study have important implications for strengthening AEFI surveillance systems. Although Sri Lanka has a well-established immunization programme, improving community awareness regarding serious AEFIs and the importance of reporting all adverse events is essential.\u003c/p\u003e \u003cp\u003eTargeted health education interventions focusing on recognition of serious AEFIs and appropriate reporting practices should be implemented at the community level. Strengthening communication between healthcare providers and parents, particularly during immunization sessions, may help address misconceptions and improve reporting behaviour.\u003c/p\u003e \u003cp\u003eEnhancing community-based reporting mechanisms and promoting active engagement of Public Health Midwives may further improve the completeness of AEFI reporting and contribute to strengthening vaccine safety surveillance systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. It was conducted in a community setting using a systematic sampling method, which enhances the representativeness of the findings. In addition, focusing on parents of infants minimized recall bias, as immunization events were recent.\u003c/p\u003e \u003cp\u003eHowever, certain limitations should be considered. The cross-sectional design limits the ability to establish causal relationships. Data were collected using self-reported measures, which may be subject to recall and social desirability bias. Furthermore, the study was conducted in a single rural MOH area, which may limit generalizability to other settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that although parental knowledge and perception regarding adverse events following immunization were generally satisfactory, important gaps remain in awareness of serious AEFIs and in reporting practices. The relatively low reporting of adverse events highlights a disconnect between knowledge and actual reporting behaviour.\u003c/p\u003e \u003cp\u003eStrengthening community-level education, particularly on recognition of serious AEFIs and the importance of reporting all adverse events, is essential. Enhancing communication between healthcare providers and parents, along with improving community-based reporting mechanisms, will be crucial to strengthen AEFI surveillance and sustain public confidence in immunization programmes in Sri Lanka.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAEFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdverse Events Following Immunization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExpanded Programme on Immunization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Officer of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Health Midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e Ethical approval was obtained from the Ethics Review Committee of Uva Wellassa University, Sri Lanka. Administrative approval was obtained from the relevant Medical Officer of Health offices. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe author declares that there are no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTeshan Eranda Pragnaratna conceived and designed the study, collected data, performed the statistical analysis, and drafted the manuscript. Samarappuli Piyasumana, Manjula Priyadarshana, Manuri Imalika, and Palika Tennakoon contributed to data collection, study design, data interpretation, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe author would like to thank the participants of the study and the staff of the Buttala Medical Officer of Health area for their support during data collection\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLindstrand A, Cherian T, Chang-Blanc D, Feikin D, O\u0026rsquo;Brien KL, et al. The World Health Organization\u0026rsquo;s Expanded Programme on Immunization: a review of its achievements and future challenges. Vaccine. 2021;39(Suppl 1):A1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Surveillance of adverse events following immunization. Geneva: WHO; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClothier HJ, Crawford NW, Russell M, Buttery JP, Wood N. Adverse events following immunisation: the role of surveillance in maintaining confidence in immunisation programs. Vaccine. 2014;32(49):6832\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra NM, Dhingra S, Adhikari KM. Adverse events following immunization: orchestrated outcome of mothers\u0026rsquo; knowledge and behavior on vaccination practices. Int J Community Med Public Health. 2021;8(2):802\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta A, Baidya S, Das S, Mog C, Datta S. Assessment of mother\u0026rsquo;s knowledge and practices regarding adverse events following immunization of their children in a rural area of Tripura. Natl J Community Med. 2017;8(4):159\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDub\u0026eacute; E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy: an overview. Hum Vaccin Immunother. 2013;9(8):1763\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHazell L, Shakir SAW. Under-reporting of adverse drug reactions. Drug Saf. 2006;29(5):385\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraka F, Asiimwe D, Soud F, Lewis RF, Makumbi I, Gust D. A qualitative analysis of vaccine safety perceptions and concerns among caretakers in Uganda. Matern Child Health J. 2012;16(5):1045\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpidemiology Unit, Ministry of Health Sri Lanka. National guidelines on surveillance of adverse events following immunization (AEFI). Colombo: Ministry of Health; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfolaranmi TO, Hassan ZI, Dagona Z, Abufuce C, Chingle MP, Bupwatda PW. Knowledge of adverse events following immunization, its prevalence and actions of mothers of children aged 0\u0026ndash;23 months in a tertiary health institution in Jos, North Central Nigeria. Int J Matern Child Health AIDS. 2020;9(1):95\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNnenna TB, Davidson UN, Babatunde OI. Mothers\u0026rsquo; knowledge and perception of adverse events following immunization in Enugu, South-East Nigeria. J Vaccines Vaccin. 2013;4:202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Health Econ. 2010;29(1):1\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJayaweera HAMD, Wijesinghe CJ. Maternal knowledge, perceptions and age-appropriate coverage of routine immunization in children under five years in Southern Sri Lanka. Asian J Pharm Nurs Med Sci. 2018;6(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics. 2011;127(Suppl 1):S92\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParrella A, Gold M, Marshall H, Braunack-Mayer A, Baghurst P. Parental perspectives of vaccine safety and experience of adverse events following immunisation. Vaccine. 2013;31(16):2067\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParrella A, Gold M, Braunack-Mayer A, Baghurst P, Marshall H. Consumer reporting of adverse events following immunization (AEFI): identifying predictors of reporting an AEFI. Hum Vaccin Immunother. 2014;10(3):747\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRestrepo-M\u0026eacute;ndez MC, Barros AJD, Wong KLM, Johnson HL, Pariyo G, Fran\u0026ccedil;a GVA, et al. Inequalities in full immunization coverage. Bull World Health Organ. 2016;94(11):794\u0026ndash;805.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanchayan K, Fernandopulle R, Amarasinghe A, Thiyahiny SN, Sri Ranganathan S. Safety of live attenuated Japanese encephalitis vaccine given at age 9 months in the national immunisation programme of Sri Lanka. Ceylon Med J. 2016;61(3):99\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adverse events following immunization, knowledge, perception, reporting attitude, parents, Sri Lanka","lastPublishedDoi":"10.21203/rs.3.rs-9288794/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9288794/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdverse events following immunization (AEFI) play a critical role in shaping parental confidence and the effectiveness of vaccine safety surveillance systems. Despite the predominantly mild and self-limiting nature of most AEFIs, inadequate awareness and misperceptions may contribute to underreporting and undermine trust in immunization programmes. Evidence on parental knowledge, perception, and reporting practices regarding AEFI in Sri Lanka remains scarce, particularly in rural settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA community-based cross-sectional study was conducted among parents of infants in the Buttala Medical Officer of Health area, Sri Lanka. A total of 393 participants were selected using systematic random sampling from Public Health Midwife registers. Data were collected using a pre-tested interviewer-administered questionnaire assessing socio-demographic characteristics, knowledge, perception, and reporting attitudes related to AEFI. Knowledge was evaluated using a ten-item scoring system, with scores \u0026gt;6 indicating adequate knowledge. Associations were assessed using chi-square tests, and effect sizes were expressed as odds ratios (OR) with 95% confidence intervals (CI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 73% (n = 287) of participants demonstrated adequate knowledge of AEFI. While awareness of common adverse events was high, knowledge of serious AEFIs remained limited, with only 48.1% (n = 189) identifying severe reactions such as anaphylaxis and convulsions. Adequate knowledge was significantly associated with age ≥30 years (OR = 2.99; 95% CI: 1.90–4.77), higher educational attainment (OR = 2.52; 95% CI: 1.56–4.06), higher household income (OR = 2.12; 95% CI: 1.04–4.35), and infant age ≥6 months (OR = 1.82; 95% CI: 1.16–2.85).\u003cbr\u003e\nAlthough overall perception towards immunization was highly positive, with 94.9% expressing confidence in the national programme, reporting practices were suboptimal. Among parents who experienced an AEFI, only 56.9% reported the event, while a substantial proportion (43.1%) did not report, often perceiving minor events as insignificant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite generally favourable levels of knowledge and positive perceptions, critical gaps persist in the recognition of serious AEFIs and in reporting behaviour. The observed disconnect between awareness and reporting highlights the need for targeted risk communication strategies and strengthened community-based reporting systems. Addressing these gaps is essential to improve AEFI surveillance and sustain long-term public confidence in immunization programmes.\u003c/p\u003e","manuscriptTitle":"Knowledge, perception and reporting attitudes of adverse events following immunization among parents of infants in rural area, Sri Lanka: a community-based cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 16:10:11","doi":"10.21203/rs.3.rs-9288794/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fb4d909-db22-4d92-acf8-c02d212d6d5d","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T05:10:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 16:10:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9288794","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9288794","identity":"rs-9288794","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}