Vaccination Attitudes in the Adult Population of Kazakhstan: A Nationally Representative Cross-Sectional Study

Background/Objectives: Vaccine hesitancy remains a significant public health challenge worldwide, yet nationally representative data from Central Asia are scarce. Evidence on the multidimensional structure of vaccination attitudes and their social patterning in Kazakhstan is limited. The study aimed to assess the distribution of anti-vaccination attitudes among adults in Kazakhstan and to examine their associations with socio-demographic, behavioural, clinical, and territorial characteristics. Methods: We conducted a cross-sectional, nationally representative survey of adults aged 18-69 years across all 17 regions of Kazakhstan between May and October 2025 (n = 6712). A multistage, stratified cluster sampling design was applied, and analyses incorporated sampling weights and design-based corrections. Vaccination attitudes were measured using the 12-item Vaccination Attitudes Examination (VAX) scale, comprising four subscales: mistrust of vaccine benefit, worries about unforeseen future effects, concerns about commercial profiteering, and preference for natural immunity. Internal consistency and confirmatory factor analysis were performed. Design-adjusted linear regression models were used to identify factors independently associated with each subscale and the overall VAX score. Results: The weighted mean overall VAX score was 3.70 (95% CI 3.67-3.73) on a 1-6 scale. The highest scores were observed for worries about unforeseen future effects (4.12; 95% CI 4.10-4.14), followed by preference for natural immunity (3.93; 95% CI 3.87-3.98), concerns about commercial profiteering (3.49; 95% CI 3.45-3.52), and mistrust of vaccine benefit (3.27; 95% CI 3.23-3.31). Internal consistency was high for the overall scale (Cronbach's α = 0.861), and the four-factor structure demonstrated acceptable fit (CFI = 0.965; TLI = 0.952; RMSEA = 0.071). In multivariable design-adjusted models, age showed a generally consistent gradient, with lower scores in younger groups and the clearest differences observed among the youngest respondents. Married/cohabiting respondents had lower adjusted scores than single respondents across all subscales and for the overall VAX score. Men had lower adjusted worries scores than women, but sex was not independently associated with the overall VAX score. Diabetes was associated with higher adjusted mistrust, concerns about commercial profiteering, and overall VAX score, but not with worries or preference for natural immunity. Territorial differences were domain-specific: urban residence was associated with lower mistrust and higher worries, while macro-region was significant at the factor level only for worries. Conclusions: Anti-vaccination attitudes in Kazakhstan exhibit a multidimensional structure and clear socio-demographic patterning. Concerns about long-term safety were the most prominent attitudinal domain, whereas mistrust of vaccine benefit was comparatively less pronounced. Territorial differences were domain-specific rather than uniform, supporting the need for targeted communication strategies tailored to specific attitudinal domains and population subgroups.