Maternal knowledge, attitude, and perception about childhood routine immunization program in Atakumosa-west Local Government Area, Osun State, Southwestern Nigeria

¹African Field Epidemiology Network, Abuja, Nigeria, ²School of Public Health, University of Nevada, Reno, Nevada, USA, ³Centers for Disease Control and Prevention, Atlanta, Georgia, USA, ⁴Epidemiology and Medical Statistics Department, College of Medicine, University of Ibadan, Oduduwa Road, 200132, Ibadan, Nigeria

^&Corresponding author
Elizabeth B. Adedire, African Field Epidemiology Network, Abuja, Nigeria

Introduction    

Immunization remains one of the most important public health interventions and a cost-effective strategy to reduce both the morbidity and mortality associated with vaccine-preventable diseases (VPDs). The World Health Organization (WHO) in 1974 initiated the Expanded Programme of Immunization (EPI), which aims to immunize, and thus protect, children against the following six deadly diseases: childhood tuberculosis, measles, poliomyelitis, diphtheria, pertussis, and tetanus [1]. Since that time, WHO added vaccination against hepatitis B and Haemophilus influenza type b to EPI, currently as pentavalent diphtheria-tetanus-pertussis-Hib-hep B vaccine.

In Nigeria, EPI was introduced in 1979, although RI is provided free of charge, VPDs remain the most common cause of childhood mortality with an estimated 40% death resulting from diseases that can be prevented by vaccination such as pneumonia, measles, and neonatal tetanus [2]. It is estimated that out of the six million children born every year in Nigeria, more than one million fail to complete appropriate vaccinations by their first birthday [3]. Despite a high level of political will demonstrated by government and appreciable contributions made by development partners to boost immunization service delivery, the proportion of children who received all doses of antigens in the EPI program across the states in Nigeria still ranged from 1.4% to 62.4% [4-7]. The Nigeria Demographic and Health Survey (NDHS) 2013 report indicated a slight decline in the proportion of fully-immunized children aged 12-23 months in Osun State from 57.8% in 2008 to 55.3% in 2013 [4]; the WHO target is 80% in all districts. Children in rural areas were 50% less likely to receive full vaccination than those in urban areas, thus contributing to the high morbidity and mortality due to VPDs among children in these areas [4].

The uptake of vaccination services is dependent not only on availability of and accessibility to vaccination services but also other factors including knowledge and attitude of mothers. Studies have shown that understanding the maternal perceptions and knowledge about immunization helps health planners develop effective health education programs and messages [8-10]. While the reasons for low immunization coverage have been proffered in general, mitigation efforts have focused on health system factors, but little attention has been paid to maternal knowledge, perception, beliefs, and practice. Understanding mothers´ knowledge and attitudes towards immunization could guide this aspect of multi-pronged efforts to improve routine immunization coverage.

This study is a part of a larger survey conducted in 2013 that assessed immunization coverage and determinants in Atakumosa-west Local Government Area (Nigeria district level), Osun State, Nigeria [11]. We assessed mothers´ knowledge, attitudes and perceptions on the routine childhood immunization program and examined associations with sociodemographic variables.

Methods     

Study setting

Osun State is located in southwestern region of Nigeria with an estimated population in 2013 of 4,274,858 people, with 17% children under the age of five years [12]. Osun State has a total of 30 Local Government Areas most of which are predominantly rural. There are 736 public health facilities (678 primary, 54 secondary and 4 tertiary facilities) and 359 private health facilities. Over 88% of the public health facilities systematically offer routine immunization services [13].

Study design

The cross-sectional study design included mothers of children aged 12-23 months who have been residing in the study area for at least 24 months. The survey sample size was determined using the methods recommended by the WHO for Immunization Coverage Cluster Survey (2005) for estimating a proportion. The sample size need was 750, assuming a proportion of fully immunized children = 58% [14], precision = ±5%, design effect = 2, and an alpha = 0.05. Atakumosa-west Local Government Area (LGA) was selected randomly from the 30 LGAs in Osun State. A two-stage sampling technique was then used to sample eligible mothers from the LGA. At stage one (selection of clusters), 30 clusters were selected from the available 170 clusters based on probability-proportional-to-size of the population. In stage two (selection of households), 25 households were selected from each of the 30 clusters selected at stage one. The first household in each cluster was selected randomly and subsequent households were selected contiguously on the right until the required number of eligible households for that cluster was achieved. From each selected household, one eligible mother was arbitrarily selected.

Data collection and analysis

Data for the study were collected by 15 trained community health extension workers using a standardized structured and pretested interviewer-administered questionnaire. Data collected include sociodemographic characteristics of mothers and children, knowledge of mothers regarding routine immunization and VPDs; sources of information on the RI program; and the mother´s attitudes toward and perceptions of the program. Data analysis was performed using Microsoft Excel 2007 and SPSS Statistics for Windows, Version 19 (Armonk, NY: IBM Corp.) and analysis accounted for the cluster design using standard survey methods. Univariate data analyses were done to obtain frequencies, means and proportions. Bivariate data analyses were also carried out to identify factors associated with mothers having satisfactory knowledge of the childhood Immunization program.

Study variables

To assess the knowledge of mothers on RI and VPDs, responses were scored using six questions on various aspects of routine immunization. The questions assessed respondent´s ability to state: 1) the correct purpose of immunization; 2) correct age a child should receive second doses of RI vaccinations; 3) age a child should receive the last doses of RI vaccines; 4) total number of visits a child should make to the health facility to receive all recommended doses; 5) at least three symptoms of VPDs; 6) at least three VPDs. Each correct response was scored one point while each wrong response was scored zero. Mothers who scored three points and below were graded as having poor knowledge while those who scored four points and above were graded as having good knowledge. This scoring system is similar to what has been used in a previous study in determining vaccination coverage in Nigeria [15]. To assess the attitudes of mothers, responses were graded on five attitude-related statements on RI using a Likert scale. The scores were then categorized into three groups: agree (strongly agree and agree), neutral (neither agree nor disagree) and disagree (disagree and strongly disagree).

Ethical consideration

Ethical clearance for the study was obtained from the Ethical Review Committee of the Ministry of Health of Osun State. Written informed consent was obtained from each respondent and data were anonymized. Confidentiality of the respondents was assured and maintained during and after the study.

Results     

Sociodemographic characteristics of the mothers

A total of 750 mothers were recruited for the study. The mean age of the mothers was 27.9 years (SD±6.1) and ranged 15-50 years. The majority (73.9%) were Christians and about half (55.3%) completed secondary school education; almost all were married (94.1%) and the highest proportion were traders (43.6%) (Table 1).

Knowledge of mothers on routine immunization and VPDs

Overall, 77.9% of mothers mentioned the correct purpose of immunization, and 85.3%, 70.7% and 93.1% could correctly state the age at which each of the first, second and last doses of vaccine was given to children under one year, respectively. Overall a total of 571 mothers (76.1%) had good knowledge on VPDs and RI (Table 2). Most of the respondents correctly mentioned VPDs including poliomyelitis (81.6%), tuberculosis (75.5%), measles (62.2%) and yellow fever (46.8%). However, some mothers incorrectly mentioned malaria (17.1%), and convulsions (5.1%) as VPDs (Figure 1).

Sources of information on routine immunization program

Overall, 71.9% mothers reported that they had access to RI information in the last twelve months and 498 (66.4%) had heard information on the benefits of routine immunization. The most common source of information reported by mothers was from health facilities; 199 (36.9%), radio programs 157 (29.1%); town criers 92 (17.0%) and television programs 35 (6.4%). Other mentioned sources of information on RI program included religious gatherings 38 (7.0%) and community meetings 14 (2.6%).

Attitudes and perception of mothers towards routine immunization program

A total of 723 mothers (96.4%), stated that immunization is beneficial to children, and 98.5% agreed that childhood vaccines are safe. Most respondents (82.4%) would advise other mothers to take their children for routine immunization. Six hundred and ninety-four (92.6%) confirmed that RI services are provided free of charge. Very few mothers had contrary attitudes that immunization can cause infertility in life (0.9%), that government promotes immunization for its selfish interests (1.2%) and that there are local substitutes for routine immunization (6.4%) (Table 3).

Association between sociodemographic factors and maternal knowledge on RI

Following a bivariate analysis, four factors were significantly associated with having good knowledge on childhood routine immunization program: 1) completing a higher or tertiary educational level (1.9 [1.4 - 2.5]); 2) receiving antenatal care (3.7 [2.0 - 6.7]; 3) delivery of their child at the health facility (1.7 [1.2 - 2.7]); 4) receiving tetanus immunization during pregnancy (4.0 [2.3 - 7.2] (Table 4).

Financial disclosure

The funding for this study was provided by USAID through a cooperative agreement between the Centers for Disease Control and Prevention, Atlanta and AFENET.

Discussion     

This study assessed mothers, knowledge, attitude, and perceptions regarding the routine immunization program for children in one LGA in Osun state. The knowledge of mothers on VPDs and routine immunization in this survey was satisfactory. Overall, more than 70 percent of mothers had good knowledge.

Our findings are similar to a 2006 survey in rural Edo State in southwestern Nigeria that showed 87% of respondents had satisfactory knowledge on routine immunization issues [15]. However, a similar survey conducted in 2010 in Zamfara State in northwest Nigeria, a state with much lower RI coverage in 2008 [14], revealed poor knowledge of mothers on routine immunization [16]. In our study, more than three-quarters of mothers knew the correct purpose of routine immunization, which is to prevent childhood illnesses. This finding is similar to a survey in another setting with higher RI coverage in Ethiopia, that revealed that ~80% of mothers mentioned that vaccination is to prevent childhood disease [17]. More than 80% of the mothers knew the appropriate schedule for immunization in terms of the number of visits to be made to the facilities in order to be fully immunized, the correct age at which the different vaccines are given particularly the correct age of the first and last doses. This is consistent with findings in southwestern Nigeria [15]. About 80% of mothers could mention three or more VPDs correctly, with high proportions readily identifying poliomyelitis, measles and tuberculosis as VPDs, similar to the findings in Zamfara [16]. Although mothers knew the correct routine immunization schedule and the purpose of the RI program, their knowledge on symptoms of individual VPDs was very low, contrary to the findings in Edo [15].

Even though this survey demonstrated positive perceptions of and attitudes about routine immunization. Certain misconceptions and negative beliefs still exist among a small proportion of the respondents. Contrary to findings from a 2010 qualitative study on immunization in Uganda [18], some mothers believe that children can still contract these VPDs whether they are immunized or not. This could potentially influence why some mothers do not take their children for any vaccination. Nonetheless, a much higher proportion would advise other women to take children for immunization as the benefits far outweighs the harm. These findings on providing advice to others are in accordance with a study reported in 2012 in Oyo State, also located in southwest Nigeria [19].

Our study shows that attendance of ANC and delivery at a health care facility was significantly associated with mothers´ knowledge on RI and VPDs; this corroborates with other studies conducted in the south of Nigeria [10,15]. It is important to note that 40% of responding mothers obtained information on the RI program primarily from the health facilities, which highlights the need to train and retrain health care workers on emphasizing the benefits of immunization and educating the mothers on VPDs, including during RI outreach sessions in the communities. One of the strengths of this survey is that it enrolled mothers within the communities thereby eliminating the selection bias that would have resulted if the respondent were drawn from mothers attending health facilities such as in some studies [20,21].

This report has limitations. One major limitation is that significant associations were found but given covariation of some of the factors; the means to address the issues affecting low knowledge and perceptions still require further exploration. The survey was limited to maternal knowledge and attitudes therefore did not explore paternal, family (e.g., other wives) and other potential sources of influencing a mother´s attitude towards routine immunization. These factors have been implicated by other studies in Tanzania and Iraq [22,23]. Likewise, our survey results cannot be considered representative of Osun State, since it only collected data from one of 30 LGAs. Lastly, the most recent Demographic and Health Survey in Nigeria was conducted in 2018 and reported in 2019. The results for receipt of all basic vaccination in Osun state in NDHS 2018 was 33.8%, a marked decline in the >50% full immunization found in the 2008 and 2012 NDHS results [24]. The knowledge and attitudes of women may have changed since that time in Atakumosa-west LGA.

Conclusion     

The findings of this study show overall satisfactory maternal knowledge and positive attitudes and perceptions regarding the childhood RI program. Attendance of antenatal care, health facility delivery of child and higher level of education were positively associated with having good knowledge of the immunization program and VPDs. Future efforts are needed to improve maternal knowledge and address misconceptions that may limit vaccination coverage rates in Osun and other regions of Nigeria and further issues explored on how to enhance knowledge and practices.

Recommendation

Promotion of female education will help to reinforce knowledge of health issues critical to implementing child survival interventions. There is a need to reinforce health education on routine immunization among mothers during all health facility and RI outreach sessions. In addition, there is a need to explore the role of potential influencers inside and outside a household in the low uptake of routine immunization in Osun State.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Elizabeth Adedire designed the study, analyzed the data and drafted the manuscript, Oluwapo Ajayi, Olufemi Ajumobi, Omotayo Bolu and Patrick Nguku guided the design of the study, provided necessary reference materials and reviewed draft manuscript. All authors read and approved the final manuscript.

Acknowledgments     

We acknowledge the technical and logistic support provided by the African Field Epidemiology Network (AFENET) during implementation of this study and development of this manuscript. This study was made possible by the support of the American people through the United States Agency for International Development (USAID). The findings and conclusions in this report are those of the authors and do not necessarily reflect the official position of the funding agencies.

Tables and figures     

Table 1: sociodemographic characteristics of mothers in Osun State immunization knowledge survey, Nigeria, 2013

Table 2: knowledge of mothers on routine immunization and VPDs, Osun State immunization knowledge survey, Nigeria, 2013

Table 3: attitudes and perception of mothers towards routine Immunization Program, Osun State immunization knowledge survey, Nigeria, 2013

Table 4: association between sociodemographic factors and maternal Knowledge on Routine Immunization issues, Osun State immunization knowledge survey, Nigeria, 2013

Figure 1: knowledge of respondents on diseases preventable by vaccine

References