The study evaluated the long-term effects of vaccination on children from birth to 13 years old in Kuwait. The target group of the study was chosen as mothers who could access their children’s records regarding vaccination to provide accurate data findings. Initially, we identified the online groups focused on local communities in Kuwait, and a careful invitation message was shared across emails and WhatsApp to reach out to the potential participants. The invitation messages included a brief introduction, purpose, and importance of the research along with the link for an online questionnaire. The online questionnaire was developed using Google Forms to provide the questions and allow the participants to answer the questions regarding demographic data, health outcomes, and vaccination status. To fill out the questionnaire, clear instructions or guidelines should be provided for each section.

The selection criteria of this study included mothers who had their children’s vaccination certificates and were interested in sharing their opinions voluntarily. A questionnaire link was distributed to mothers through WhatsApp, and emails to collect the data. This approach allowed an efficient collection of data from a diverse group of the population in Kuwait.

In the initial stage, the researcher continued the study by choosing several key segments for the survey within Kuwait. To gather comprehensive data, an online questionnaire was designed for collecting the data regarding the health outcomes and vaccination history of children. In the second stage, the second mail was sent, demonstrating the research background and purpose, that the institutional heads were instructed to send further to all the respective mothers. Therefore, a link was facilitated to a questionnaire where no personally determining details or information was demanded. The researcher pursued to acquire maximum responses from mothers of children aged from 0 to 13 years old by including questions about the demographics of children and mothers, birth history of children, vaccination history, and health outcomes. However, the demographics of children included age and gender, while mothers’ demographics included education, social status, and pregnancy-related factors such as medications and suffering. Furthermore, the age group of 0 - 13-year-old children was chosen as the majority recommended vaccination or immunization was intended to be received. Regarding vaccination history, we collected the details about the partially vaccinated, fully vaccinated, and unvaccinated statuses of a child. In addition, the children’s health was also gathered relevant to the incidence of chronic and acute illnesses and emergency room visits.

Multiple reminders were sent to the participants to encourage their participation. The survey questionnaire contained only “close-ended questions” with single answers or responses, with the goal of developing both completion rates and responses. Moreover, the online survey remained open for four months during the spring of 2024.

Before accessing the online questionnaire link, this study was presented a consent form for participants to ensure that the collected data would be kept as confidential and maintained data anonymity. The participation was entirely voluntary and they could be allowed to withdraw from the questionnaire at any time. However, participants needed to answer for questionnaire, including their demographics, health status of children, and vaccination history of children. The designed questionnaire was expected to take 10 to 15 minutes of time to complete the answers to questions.

Health outcomes: All the mothers were informed to direct on a particular list of above 40 chronic and acute diseases all those factors for that their children suffered from diagnosis by respective physician. Major outcomes contained the vaccine-preventable diseases’ including hepatitis B, polio, tetanus, pertussis, diphtheria, rubella, mumps, and measles. In the survey, other questions contained the application of health procedures and services, hospitalizations, medications used, sick visits to doctors or physicians, social status (married, separated, or divorced), and the education level of the mother. Particularly for the mother, the questions included birth history and pregnancy-related conditions, medications application during pregnancy, and contact with a contrary environment (stated as living near communication tower/electrical tower less than 300 meters).

Vaccination status: Differentiated as fully vaccinated (obtained all suggested age-appropriate vaccines), partially vaccinated (obtained few suggested vaccinations and not all), and unvaccinated (such as no past vaccinations) as investigated by mothers. Such diversifications were made on the segment that the vaccines’ long-term impact would seem more authentic among fully-vaccinated instead of the partially-vaccinated infants and children and absent or rare among the unvaccinated. However, all the mothers were informed to apply their vaccination records of their child to direct the suggested doses and vaccines their children received. Moreover, vaccination dates were not demanded to decrease the inaccurate reporting’s likelihood and ignore the overburdening participants.

The research followed “unadjusted bivariate analysis” applying chi-square tests primarily to analyze the null hypothesis of particularly no relationship between health outcomes and vaccination status, such as health services’ application, medications, physician-diagnosed chronic and acute illnesses, and vaccine-preventable diseases’ prevalence rates. In the majority of analyses, fully and partially vaccinated children and infants were associated together as the group of vaccinated, with all the unvaccinated children and infants as the “control group.” However, the second goal of this research was to ascertain whether any integration is there between health outcomes and vaccination, which stands as significant after measuring for other assumed aspects, such as the socio-demographic variables. In this research, descriptive statistics were measured on all variables to ascertain percentages and frequencies for categorical means and variables for such continuous variables. However, the strength of the relationship between health outcomes and vaccination status was analyzed by applying 95% CI (Confidence Intervals) and OR (Odds Ratios). Odds ratios demonstrate the strength of the relationship between two simultaneously measured categorical variables and are suitable procedures for that association in such cross-sectional research. Finally, adjusted and unadjusted analyses of logistic regression were followed in this research applying SAS (Version 9.4) to ascertain the factors integrated with vaccination adherence and health outcomes.

The information provided the data for 976 children in this study. Table 1 shows the demographic characteristics of respondents (mothers) and children. Mothers mostly held college degrees (61%) and were married (93%). However, the majority of respondents (77.4%) did not have gestational diabetes, pre-eclampsia, or other conditions during their pregnancy. In addition, many of them (74.1%) did not take any medications during pregnancy.

Regarding demographic characteristics of children, many of them (51.2%) were female compared to male (48.8%) ( Table 1 ). They were mostly aged (32.4%) between two and five years old. Based on these findings, this study targeted female children between two to five years old.

Table 2 presents the birth history of children, including the birth type, birth time, and type of feeding in the first three months and health information, including vaccination, emergency visits, sick visits, in the past year, spent nights in the hospital, used medications for fever, antibiotics, allergy, and ADHD, and COVID vaccine status. However, the results depicted that most of the children (69.2%) were born naturally with full-term (88.9%) birth time and mixed-feeding of both breast milk and bottle feeding (43.8%) in the first three months of their birth. The distribution of children for vaccination status was fully vaccinated (73.2%), partially vaccinated (22.7%), and unvaccinated (4.1%). Many children did not take the COVID-19 vaccine (83.7%). Out of them, most children did not have any emergency visits (57.7%) during the past year and did not spend one or more nights (84.6%) at the hospital. The children were mostly had sick visits (64.2%) during the last twelve months. Regarding medications for different health conditions, many children used antibiotics (54.1%) and medicines for fever (84.4%). On the contrary, most of them did not use medications for allergies (64.6%) and ADHD (95.9%) as well.

Vaccinated children were more likely to have been diagnosed than unvaccinated children for different chronic conditions, such as allergic rhinitis (9.9% vs. 7.5%, p = 0.61; OR 1.4, 95% CI: 0.4, 4.5), allergies (16.3% vs. 10%, p = 0.28; OR 1.8, 95% CI: 0.6, 5), and neuro-developmental disorders (0.7% vs. 0%, p = 0.58; OR 1.01, 95% CI: 1, 1.01), autism spectrum (1.2% vs. 0%, p = 0.49; OR 1.01, 95% CI: 1, 1.02), eczema (13.7% vs. 10%, p = 0.51; OR 1.4, 95% CI: 0.5, 4.1), learning disability (2.9% vs. 0%, p = 0.28; OR 1.03, 95% CI: 1.02, 1.04), ADHD (2.9% vs. 2.5%, p = 0.89; OR 1.2, 95% CI: 0.2, 8.8), and any chronic condition (2.8% vs. 0%, p = 0.29; OR 1.03, 95% CI: 1.02, 1.04). On the contrary, unvaccinated children were more likely to be diagnosed with none of these chronic conditions than vaccinated children (80% vs. 65.9%, p = 0.065; OR 0.5, 95% CI: 0.2, 1.1) ( Table 3 ). However, no significant differences were observed for all these conditions, including allergic rhinitis, allergies, neuro-developmental disorders, autism spectrum, ADHD, learning disability, eczema, any chronic conditions, and none of the above.

Figure 1 compares the percentages of chronic diseases between vaccinated and unvaccinated participants. You can see the slight differences between the two groups in different conditions.

Vaccinated children were more likely to be diagnosed with the acute conditions compared to unvaccinated children, such as whooping cough (1.1% vs. 0%, p = 0.511; OR 1.01, 95% CI: 1, 1.02), pneumonia (4.9% vs. 0%, p = 0.151; OR 1.1, 95% CI: 1.04, 1.07), rubella (0.8% vs. 0%, p = 0.557; OR 1.01, 95% CI: 1.0, 1.01), hepatitis A or B (0.4% vs. 0%, p = 0.678; OR 1, 95% CI: 1.0, 1.01), measles (1.3% vs. 0%, p = 0.471; OR 1, 95% CI: 1.0, 1.02), mumps (0.8% vs. 0%, p = 0.557; OR 1, 95% CI: 1.0, 1.01), meningitis (0.1% vs. 0%, p = 0.836; OR 1, 95% CI: 0.99, 1), influenza (28.2% vs. 20%, p = 0.257; OR 1.6, 95% CI: 0.7, 3.5), Rota virus (0.8% vs. 0%, p = 0.583; OR 1, 95% CI: 1.0, 1.01), cancer (0.2% vs. 0%, p = 0.77; OR 1, 95% CI: 0.99, 1.0), chronic fatigue (0.2% vs. 0%, p = 0.77; OR 1, 95% CI: 0.99, 1.0), Crohn’s disease (0.1% vs. 0%, p = 0.836; OR 1, 95% CI: 0.99, 1.0), inflammatory bowel disease (0.5% vs. 0%, p = 0.643; OR 1, 95% CI: 1.0, 1.01), conduct disorder (1.1% vs. 0%, p = 0.511; OR 1.01, 95% CI: 1.01, 1.02), diabetes type 1 or 2 (1% vs. 0%, p = 0.533; OR 1.01, 95% CI: 1.0, 1.02), Rheumatoid arthritis (0.2% vs. 0%, p = 0.77; OR 1, 95% CI: 0.99, 1), obesity (3.4% vs. 0%, p = 0.234; OR 1.04, 95% CI: 1.0, 1.04), seizures (0.3% vs. 0%, p = 0.72; OR 1, 95% CI: 0.99, 1.01), hearing loss (0.3% vs. 0%, p = 0.72; OR 1, 95% CI: 0.99, 1.01), depression (1.3% vs. 0%, p = 0.471; OR 1, 95% CI: 1.0, 1.02), polio (0.3% vs. 0%, p = 0.72; OR 1, 95% CI: 0.99, 1.01), tetanus (0.1% vs. 0%, p = 0.72; OR 1, 95% CI: 0.99, 1.01), and diphtheria (0.1% vs. 0%, p = 0.72; OR 1, 95% CI: 0.99, 1.01). On the contrary, unvaccinated children were more likely to be diagnosed with acute conditions than the vaccinated children for chickenpox (20% vs. 14.8%, p = 0.373; OR 0.7, 95% CI: 0.3, 1.5), otitis media (5% vs. 4.7%, p = 0.93; OR 0.9, 95% CI: 0.2, 4), encephalopathy (2.5% vs. 0.5%, p = 0.119; OR 0.2, 95% CI: 0.02, 1.8), and none of the above (65% vs. 57.9%, p = 0.373; OR 0.7, 95% CI: 0.4, 1.4) ( Table 4 ). Although the vaccinated and unvaccinated children showed likely diagnoses for those mentioned above respective acute conditions, they did not provide significant differences since their p-values were above 0.5. Therefore, no significant differences were found between vaccinated and unvaccinated children under acute conditions.

Figure 2 indicates that there were small differences in the incidence of acute diseases between the two groups, with no statistically significant differences in most cases.

As shown in Table 5 , an intermediate position was taken by partially vaccinated children between fully and not vaccinated children for some chronic health outcomes, such as allergic rhinitis, neuro-developmental disorder, autism spectrum, learning disability, and any chronic condition. Thus, the partially vaccinated group had taken an intermediate position in terms of allergic rhinitis, NDD, learning disability (LD), autism spectrum (ASD), and any chronic condition without any significant differences.

The results show allergic Rhinitis incidence was slightly higher among fully vaccinated (10.4%) than among partially vaccinated (8.6%) and unvaccinated (7.5%).

Overall, Figure 3 indicates that there are some differences in the rates between the different groups, but most of the differences are not large enough to be statistically significant, as shown in Table 5 by the p-values.

Similar to chronic conditions, partially vaccinated children had taken an intermediate position between fully and unvaccinated children for some acute health outcomes but not all health outcomes. They included influenza, Rotavirus, inflammatory bowel disease, conduct disorder, diabetes type 1 or 2, obesity, and depression. However, unvaccinated children were significantly more likely to be diagnosed compared to partially and fully vaccinated children for chickenpox (20% vs. 5.9% vs. 17.7%; p < 0.001) and encephalopathy (2.5% vs. 1.8% vs. 0.1%; p < 0.01). Partially vaccinated children were significantly more likely to be diagnosed than unvaccinated and fully vaccinated children for rheumatoid arthritis (0.9% vs. 0% vs. 0%; p = 0.033), and none of the above (67.6% vs. 65% vs. 54.9%; p < 0.01). Fully vaccinated children were significantly more likely to be diagnosed compared to partially vaccinated and unvaccinated children with influenza (30.1% vs. 22.1% vs. 20%; p = 0.035) ( Table 6 ). Therefore, significant differences in acute health conditions among unvaccinated, partially vaccinated, and fully vaccinated children were found for chickenpox, influenza, rheumatoid arthritis, encephalopathy, and none of the above.

***Significant at 0.001 level; **Significant at 0.01 level; *Significant at 0.05 level.

Figure 4 shows differences in some acute cases between different vaccination statuses, and the statistical significance varies between cases.

This study showed that males were more likely to be diagnosed with chronic conditions for allergic rhinitis (11.6% vs. 8.1%, p = 0.073; OR 1.5, 95% CI: 1, 2.3), allergies (20% vs. 12.5%, p < 0.01; OR 1.7, 95% CI: 1.2, 1.5), autism spectrum (1.5% vs. 0.9%, p = 0.414; OR 1.7, 95% CI: 0.5, 5.7), eczema (13.9% vs. 13.4%, p = 0.816; OR 1, 95% CI: 0.7, 1.5), and ADHD (3.5% vs. 2.2%, p = 0.222; OR 1.6, 95% CI: 0.7, 3.6) among vaccinated children (n = 936; combination of both fully and partially vaccinated groups) ( Table 7 ). On the contrary, females were more likely to be diagnosed than males, but not significantly for some chronic conditions, such as NDD (1.1% vs. 0.4%, p = 0.225; OR 0.4, 95% CI: 0.1, 1.9), learning disability (3.5% vs. 2.3%, p = 0.261; OR 0.6, 95% CI: 0.3, 1.4), any chronic condition (3.5% vs. 2.1%, p = 0.181; OR 0.6, 95% CI: 0.3, 1.3), and none of the above (68.6% vs. 63.4%, p = 0.096; OR 0.8, 95% CI: 0.6, 1.0) ( Table 7 ). The significant differences between male and female groups for chronic outcomes, specifically in terms of allergies, indicate that males were significantly more likely to be diagnosed with allergic chronic conditions compared to females among vaccinated children.

**Significant at 0.01 level.

Figure 5 shows there were some differences between males and females in some chronic health conditions, but the differences were not statistically significant in most cases except for allergies.

In the vaccinated children (n = 936, combination of both fully and partially vaccinated groups), females were significantly more likely to be diagnosed with acute illnesses than males, such as whooping cough (1.8% vs. 0.4%, p = 0.046; OR 0.2, 95% CI: 0.04, 1.1), hepatitis A or B (0.9% vs. 0%, p = 0.039; OR 1, 95% CI: 0.98, 0.99), and inflammatory bowel disease (1.1% vs. 0%, p = 0.021; OR 1, 95% CI: 0.98, 0.99). In the opposite, males were significantly more likely to be diagnosed than females with pneumonia (6.4% vs. 3.3%, p = 0.026; OR 2, 95% CI: 1.1, 3.8) ( Table 8 ). The remaining acute health conditions, such as chickenpox, rubella, otitis media, measles, mumps, meningitis, rotavirus, influenza, chronic fatigue, cancer, chron’s disease, conduct disorder, rheumatoid arthritis, diabetes type 1 or type 2, depression, obesity, hearing loss, seizures, encephalopathy, polio, diphtheria, tetanus, and none of the above were not showed gender differences significantly ( Table 8 ).

*Significant at 0.05 significance level.

Figure 6 shows that there are some noticeable differences between the sexes in some acute cases, but most cases show similar proportions between males and females.

The vaccinated (n = 936; a combination of both partially and fully vaccinated groups) children were significantly more likely to use medications than unvaccinated (n = 40) for allergies (36.5% vs. 10%, p < 0.001; OR 5.2, 95% CI: 1.8, 14.7), antibiotics (55.2% vs. 27.5%, p < 0.001; OR 3.3, 95% CI: 1.6, 6.6), and fever (85.8% vs. 52.5%, p < 0.001; OR 5.5, 95% CI: 2.9, 10.4) ( Table 9 ). Regarding health service applications, vaccinated children were also significantly more likely to have emergency visits in the past year (43.3% vs. 20%, p < 0.01; OR 3.1, 95% CI: 1.4, 6.7) and sick visits in the past 12 months (65.3% vs. 40%, p < 0.01; OR 2.8, 95% CI: 1.5, 5.4). Vaccinated were more likely to have COVID vaccine than unvaccinated children (16.8% vs. 5%, p = 0.048; OR 3.8, 95% CI: 0.9, 1.6). No significant differences were observed between vaccinated and unvaccinated children regarding their living conditions, including living near electrical substations, electrical towers, communication towers, industrial areas, and waste dump areas ( Table 9 ).

***Significant at 0.001 level; **Significant at 0.01 level; *Significant at 0.05 level.

Figure 7 indicates that there is an association between vaccination status and increased use of medicines and health services.

This study aimed to determine the associated factors of vaccination with neurodevelopmental disorders (NDD) by focusing on a particular health outcome and finding out whether it was associated with measured factors significantly after adjustment analysis. NDD was a combined diagnosis of learning disability (LD), autism spectrum (ASD), and ADHD due to the relatively smaller number of children with particular diagnoses. Figure 8 shows the overlap and closer association of these diagnoses for NDD. However, the largest diagnoses group was noted for ADHD (n = 19), LD (n = 19), and ASD (n = 8), with smaller numbers for a combination of three diagnoses, such as ADHD and ASD (n = 5). ADHD, ASD, and LD (n = 3), and ADHD and LD (n = 1) ( Figure 1 ).

In unadjusted logistic regression analyses, the results depicted that factors associated with neuro-development disorders were age of the child (2 to 5 - OR 0.2, 95% CI: 0.1, 1.1; 6 to 9: OR 8.5, 95% CI: 1.9, 7.3; 10 to 13 - OR 0.1, 95% CI: 0.03,

0.6; 13+− OR 0.2, 95% CI: 0.03, 0.7), birth type (OR 0.5, 95% CI: 0.3, 0.8), and mother suffering during pregnancy (gestational diabetes, OR 2.6 95% CI: 1.3, 5.2; pre-eclampsia, OR 1.2, 95% CI: 0.2, 9.7; others, OR 2.0, 95% CI: 0.9, 4.4) ( Table 10 ). These three factors of age, birth type, and mother suffering during pregnancy were associated with the NDD. This study showed that other factors were not associated with NDD, such as vaccination status (vaccinated and not vaccinated), gender (male and female), and birth time (pre-term and full-term).

**Significant at 0.01 level; *Significant at 0.05 level.

Figure 9 shows that some risk factors, such as the child’s age, type of birth, and the mother’s health problems during pregnancy may be more closely linked to the risk of neurodevelopmental disorders.

The significant factors that remained associated with NDD after performing adjustment or logistic regression analysis were age of a child (OR 8.6, 95% CI: 1.9, 38 for 2 to 5 years old; OR 7.9, 95% CI: 1.7, 36.1 for 6 to 9 years old; OR 6.1, 95% CI: 1.3, 28.9 for 10 to 13 years old); birth type (OR 1.8, 95% CI: 1, 3.2 for cesarian); and mother suffering during pregnancy (OR 2.6, 95% CI: 1.3, 5.3 for gestational diabetes) ( Table 11 ). The possibility of an interaction between the factors of age, birth type, mother suffering during pregnancy, and NDD was suggested because of the strong association among them.

*Number of observations used = 976 (NDD = 55 and Not NDD = 921); NS = Not Significant at 0.05 level.

Further, an adjusted model with interaction was validated for the possibility of remaining association of the factors of mother suffering during pregnancy, age, and birth type. The factors like age (OR 5.3, 95% CI: 1.1, 25.3 for 6 to 9 years old) and mother suffering during pregnancy (OR 2.5, 95% CI: 1.2, 5.2 for gestational diabetes). The birth type was not significantly associated with NDD, whereas the interaction of birth type and age was also not associated with NDD ( Table 11 ).

Figure 10 suggests that child age at onset, type of delivery, and maternal gestational diabetes are factors that may be associated with an increased risk of neurodevelopmental disorders.

This study did not show any significant differences in the prevalence of chronic conditions and some significant differences in acute conditions between unvaccinated and vaccinated children, even though they were more likely to have been diagnosed with vaccination. However, chronic conditions included allergies, allergic rhinitis, NDD, autism spectrum, eczema, learning disability, and any chronic condition. In alignment with these results, the study by Hooker & Miller [6] reported that chronic conditions like allergies, eczema, and autism spectrum did not result in any significant difference between unvaccinated and vaccinated children. Another study conducted by Straub et al. [12] also revealed that there was no potential association between the vaccination status of children and certain chronic health outcomes, such as learning disability and NDD.

In contradictory to the previous research by Di Pietrantonj et al. [13] , this study found that no prevalence rates of acute infections were exhibited between vaccinated and unvaccinated children included whooping cough (pertussis), pneumonia, rubella, otitis media, hepatitis A or B, measles, mumps, meningitis, influenza, rotavirus, chronic fatigue, cancer, inflammatory bowel disease, Crohn’s disease, diabetes type 1 or 2, conduct disorder, obesity, seizures, polio, depression, hearing loss, tetanus, and diphtheria, while the influenza increased with vaccination , chickenpox and encephalopathy increased in unvaccinated, and rheumatoid arthritis increased in partially vaccinated all with significant differences. This is inconsistent with the findings of a study by Yoon & Shin [14] , which disclosed that vaccinated children exhibited reduced prevalence rates than unvaccinated children for acute conditions, such as whooping cough, mumps, and measles. Another study by Chung et al. [15] also depicted that vaccines could reduce the incidence of acute conditions like influenza among children compared to unvaccinated status.

This study disclosed that partially vaccinated children occupied an intermediate position between unvaccinated and fully vaccinated children for certain chronic health conditions, including allergic rhinitis, autism spectrum, learning disability, neuro-developmental disorders, and any chronic condition. However, the study did not show any significance for partially, fully, and not vaccinated statuses. These findings are not in agreement with the studies that highlighted children with partial vaccination showed a reduced prevalence of chronic conditions than unvaccinated children [16] . This study did not show any importance for partial vaccination as a crucial factor in reducing the incidence of chronic conditions.

The outcomes of this research revealed that partial vaccination played an intermediate role between unvaccinated and fully vaccinated for certain acute illnesses without any significance, such as conduct disorder, depression, obesity, diabetes type 1 or 2, inflammatory bowel disease, rotavirus, and influenza. Similar to these findings, the study by Mawson & Croft [16] discussed that acute illnesses like inflammatory bowel disease and depression could be diagnosed with partial vaccination than the unvaccinated, not as low as full vaccination. On the other hand, the incidence of rheumatoid arthritis was increased with partial vaccination than with fully vaccinated and unvaccinated children. Consistent with these results, the research by Safary et al. [17] is evident that acute conditions like rheumatoid arthritis could be diagnosed with partial vaccination rather than unvaccinated status. Fully vaccinated children showed an increased prevalence of acute conditions of influenza than the partially and not vaccinated children in this study.

This study proved that males showed a significantly higher prevalence of chronic conditions than females in terms of allergies among vaccinated children. Similarly, Liu & Liu [18] resulted in an increased rate of diagnosis for males compared to females regarding chronic conditions of allergies and allergic rhinitis for vaccinated children. On the other hand, males with vaccination were likely to be diagnosed with acute conditions like pneumonia compared to females with vaccination in this study. In addition, females showed a significant increase in acute illnesses with vaccination than males, including inflammatory bowel disease, hepatitis A or B, and whooping cough. Similarly, the study by Ford et al. [19] , showed a reduced incidence of inflammatory bowel disease for males than females with vaccination status.

This study demonstrated that children who had been vaccinated were much more interested in using medications for allergies, fever, and antibiotics than unvaccinated children. They were also likely to have had sick visits and emergency visits in the past year while interested in having the COVID-19 vaccine. In support of this, Chapman et al. [20] indicated that the children with vaccination were more likely to use the medications for antibiotics and allergies in addition to the sick visits. Moreover, this study did not show any impact of vaccination because of the living conditions of children, such as living nearer to industrial areas, electrical substations, waste dump areas, and communication and electric towers.

One of the aims of this study was to determine the potential association between the vaccination of children and the development of NDD, including autism spectrum, even after using the controlled measurement factors. The factors of age with 2 to 5, 6 to 9, and 10 to 13 years old, cesarian birth type, and mother suffering from gestational diabetes during pregnancy remained associated with NDD significantly after adjustment. In the final adjusted model with interaction (birth type and age), the age of 6 to 9 years old and mothers suffering from gestational diabetes during pregnancy remained associated with NDD.

This study highlighted a possible link between gestational diabetes and an increased risk of neurodevelopmental disorders in children. This is a significant finding, as it mirrors the results of several key studies in the field. Xiang et al. [21] found that children born to mothers with gestational diabetes had a significantly higher risk of developing autism spectrum disorder (ASD). Similarly, Krakowiak et al. [22] observed a higher incidence of autism and other NDDs among children whose mothers had metabolic conditions such as gestational diabetes. Also, Perea et al. [23] investigated the effects of gestational diabetes and found that prenatal exposure to GDM increases the risk of ADHD in offspring, regardless of treatment complexity.

This study found a potential association between caesarean section (C-section) birth and an increased risk of neurodevelopmental disorders (NDD), including autism and ADHD. While this relationship was not statistically significant in some cases, it is consistent with emerging evidence suggesting that mode of delivery can influence a child’s long-term neurodevelopmental health. Several studies support these findings.

Tianyang and others [24] , In their systematic review and meta-analysis of 61 studies comprising more than 20 million deliveries, birth by cesarean delivery was significantly associated with autism spectrum disorder and attention-deficit/hyperactivity disorder.

Curran et al. [25] conducted a systematic review and meta-analysis, concluding that children born by C-section were at an elevated risk of both autism and ADHD.

However, cesarian birth type was no longer associated with NDD, while cesarian birth type combined with age was also not associated with NDD in contrary to the study findings of Zhang et al. [26] .

In summary, age (2 to 5, 6 to 9, 10 to 13, and 13+), cesarian birth type, and mother suffering from gestational diabetes, pre-eclampsia, and others during pregnancy were significantly associated with NDD. Although cesarian birth was significantly associated with ND for unadjusted analysis, it was not strongly associated with NDD in the final adjusted model. In the interaction model, the ages of 6 to 9 years old and the mother suffering from gestational diabetes during pregnancy were strongly associated with NDD. This evidence-based study suggests that the age of 6 to 9 years old and the suffering of the mother from gestational diabetes would play contributing roles in the reduced prevalence of NDD (ADHD, ASD, and learning disability).

The simultaneous examination of these two risk factors—type of birth and maternal health conditions—provides valuable insight in this study. Few studies have explored how these factors interact or compound, but these results suggest that both factors could independently or jointly influence the risk of neurodevelopmental disorders in children. This complexity points to the need for more nuanced research, particularly studies that consider the cumulative effects of birth method and maternal health conditions.

One of the major limitations of the study is the sample size and socio-demographics. The small sample size may not represent the whole Kuwaiti population. To improve the generalizability of data findings for Kuwait, it would be essential to increase the sample size and consider the diverse population, including children from different socio-economic backgrounds and regions across Kuwait. Another limitation is the self-reported data from mothers that would be prone to the possibility of recall bias because the participants may not report correct details about their children’s health issues and vaccination history. This study may affect the accuracy of data due to the misrepresentation of health effects and vaccination status by participants.

This study demonstrated the association between factors like socio-demographics and health conditions but did not fully account for other measured variables. These include genetic factors or healthcare access, which influence the associations between health outcomes and vaccination status. In the future, this study should consider the potential measurement factors with a comprehensive set to improve the data validity and accuracy of study findings.

This study lacks detailed information about the type of vaccines, vaccination times, and deviations from vaccination schedules. However, it included the categorization of vaccination into unvaccinated, fully, and partially vaccinated groups. Future research will assist in overcoming this limitation and provide an analysis of the effects of vaccination schedules and specific vaccines on health outcomes, including chronic and acute illnesses.