|ORIGINAL RESEARCH REPORT
|Year : 2019 | Volume
| Issue : 1 | Page : 7-14
Maternal knowledge, attitude and compliance regarding immunization of under five children in Primary Health Care centres in Ikorodu Local Government Area, Lagos State
Oluwatoyosi Adetola Adefolalu, Oluchi Joan Kanma-Okafor, Mobolanle Rashidat Balogun
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idiaraba, Lagos, Nigeria
|Date of Web Publication||14-Feb-2019|
Dr. Oluchi Joan Kanma-Okafor
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idiaraba, Lagos
Source of Support: None, Conflict of Interest: None
Introduction: Immunization is one of the most successful and cost-effective public health interventions, saving the lives of 3 million children annually. One-third of the deaths among under-fives are preventable by vaccines. This study aimed to assess the knowledge, attitude, and compliance of mothers regarding immunization of under-five children in Ikorodu Local Government Area, Lagos State. Subjects and Methods: A cross-sectional descriptive study was carried out among 250 mothers of under-five children at health centers in Ikorodu selected by multistage sampling. An interviewer-administered questionnaire was used as the survey tool. Data were analyzed using Expanded Program on Immunization – Info Version 126.96.36.199. P < 0.05 was considered statistically significant. Results: All respondents were aware of immunization, more than half (72%) of them had good knowledge about the immunization of under-five children, all the mothers (100%) had a positive attitude toward immunization and a majority (86.4%) of the respondents had fully immunized their children. There was a statistically significant association between the mother's age, occupation, level of education, nature of the family and the level knowledge of the respondents. There was also a statistically significant association between the mothers' age and occupation and their compliance with the immunization of their children. Conclusion: Most mothers had good knowledge, a positive attitude and good practice towards immunization. Maternal age, education, and hence their occupation were important factors for good knowledge and practice towards childhood immunization. The education of women, thus delaying marriage, remains a key factor in ensuring child survival through immunization.
Keywords: Ikorodu, immunization, measles, mothers, under-five
|How to cite this article:|
Adefolalu OA, Kanma-Okafor OJ, Balogun MR. Maternal knowledge, attitude and compliance regarding immunization of under five children in Primary Health Care centres in Ikorodu Local Government Area, Lagos State. J Clin Sci 2019;16:7-14
|How to cite this URL:|
Adefolalu OA, Kanma-Okafor OJ, Balogun MR. Maternal knowledge, attitude and compliance regarding immunization of under five children in Primary Health Care centres in Ikorodu Local Government Area, Lagos State. J Clin Sci [serial online] 2019 [cited 2019 Mar 23];16:7-14. Available from: http://www.jcsjournal.org/text.asp?2019/16/1/7/252276
| Introduction|| |
Immunization is the process whereby a person is offered protection from or is made resistant to an infectious disease, typically by the administration of a vaccine. Vaccines act by stimulating the body's immune system to protect the person against subsequent infections or diseases. Immunization is regarded as one of the most successful and cost-effective public health interventions which averts about 3 million deaths annually and has the potential, if coverage improves, of saving the lives of an additional 1.5 million children annually.
Vaccines can protect more children than most other strategies. Almost one-third of deaths among children under-five are preventable by vaccines, yet every 20 seconds, a child dies from a vaccine-preventable disease. In 2012, nearly one in five infants worldwide, 22.6 million children, missed out on the basic vaccines needed to stay healthy. Many children in remote rural regions and impoverished areas of cities in developing countries are not being vaccinated. More than 70% of the world's unimmunized children live in only 10 countries, mainly in Africa and Asia.
As part of the child survival programs, the Expanded Program on Immunization (EPI) was created in 1974 by the WHO with UNICEF and Rotary International as partners. The EPI was created with the purpose of expanding immunization services beyond smallpox to the following six preventable diseases: diphtheria, measles, pertussis, poliomyelitis, tetanus, and tuberculosis. Immunization can be routine or supplemental (taking the form of immunization campaigns). Routine immunization refers to the nationally scheduled regular administration of vaccine dosages to infants at specified ages. Children are usually taken to the health facility by their parents or caregivers to receive age-appropriate doses of antigens. In most developing countries, immunization is carried out on specific days of the week to reduce vaccine wastage since the vaccines are supplied in multi-dose vials to reduce cost. The main aim of routine immunization is to deliver a complete scheduled number of doses of potent vaccines in a timely, safe and effective way to all children and women, ultimately inducing immunity against the targeted diseases.
Vaccine-preventable diseases contribute significantly to under-five mortality. Maternal and neonatal tetanus, measles, and rubella can be prevented by vaccines, but they continue to afflict children around the world. Measles, a virus that attacks the respiratory tract, is one of the most contagious diseases known. In 2013, as high as about 84% of children around the world were reported as immunized against measles. However, 367 children worldwide die from measles daily despite the availability of a safe, effective, and affordable vaccine.
The EPI has increased the level of immunization of the world's children from 5% to 80% in 30 years. Although efforts at immunization have yielded highly beneficial results with most developed countries having a coverage of over 90%, the situation is quite different for developing countries especially in Africa where vaccine-preventable diseases (VPDs) contribute significantly to under-five mortality.
Nigeria like many other countries in Africa is making efforts to strengthen its health system so as to achieve adequate routine immunization to reduce the burden of VPDs. Factors, such as lack of political will, lack of motivation, poor level of education and awareness and poor infrastructure, have been contributed to the low level of immunization coverage in Nigeria. Other factors associated with poor immunization coverage in resource-limited countries, as depicted in a multi-level analysis involving 24 African countries, including high community illiteracy rates, high country fertility rates and living in urban areas. At the individual level, however, the low level of immunization can be linked to the poorest households, uneducated parents, parents with no access to the media and/or with low health-seeking behaviors. In Nigeria, immunization coverage is still low. Nigeria recorded an abysmal national routine immunization coverage of 12% in 2003 and 36% in 2006. In 2009, Nigeria accounted for about 3.5 million (14%) of the 23.2 million children worldwide who did not receive three doses of diphtheria, tetanus toxoids and pertussis (DPT) vaccine during their 1st year of life. Despite the improvement in global immunization coverage, about 16% of the worlds' children had not completed the 3-dose DTP-3) series by 2013. The estimated 2013 global DTP-3 coverage among children aged <12 months, which is a key indicator of immunization program performance was 75% in the World Health Organization (WHO) African Region and 84% worldwide. In 2013, approximately 6.2 million children under the age of five died worldwide, and 3 million of these deaths occurred in Sub-Saharan Africa. In 2009, WHO estimated that if global vaccine coverage increased to 90% by 2015, then approximately two million deaths of children under the age of five would be prevented. However, due to the EPI, childhood immunization coverage in the WHO African Region is improving, even if still sub-optimal in many areas.
Surveying the knowledge and attitudes toward childhood immunizations (KATCI) is an important first step toward understanding the factors that influence vaccine nonacceptance in particular settings. Strategies need to be developed to improve vaccine coverage rates aided by the understanding of the relationship between KATCI and actually vaccinating children adequately. This study is aimed at determining the knowledge, attitude, and compliance regarding immunization of under-five children among mothers at Primary Health Care centers (PHCs) in Ikorodu Local Government Area, Lagos State, Nigeria and to demonstrate the association between maternal KATCI and the full, on-time vaccination status of their under-five children.
| Subjects and Methods|| |
A cross-sectional descriptive study design was used to determine the knowledge, attitude, and practice of mothers of children under 5 years of age toward immunization of under-five children in Ikorodu Local Government Area (LGA) of Lagos. The study population comprised 250 mothers of under-five children attending the Baiyeku, Igbogbo and Ikorodu PHCs in Ikorodu LGA. A multistage sampling technique was used to select the participants. In Stage 1, 3 PHCs (Ikorodu PHC, Igbogbo PHC, and Baiyeku PHC) out of 25 PHCs in Ikorodu LGA, were selected by simple random sampling using balloting. In Stage 2, for the selection of respondents, 83 respondents were selected from Baiyeku PHC and Igbogbo PHC each while 84 participants were selected from Ikorodu PHC. Each consecutive mother attending the immunization clinic was included in the study until the required sample size of 83 or 84 participants per PHC was achieved. Data were collected using a pretested, semi-structured, interviewer-administered questionnaire. Data analysis was done using EPI INFO version 188.8.131.52 statistical software. The Chi-square test was used to test for associations between categorical variables. The level of significance was set at 5% (P ≤ 0.05).
The items of knowledge examined were on the childhood diseases preventable by immunization, (including polio, diphtheria, pertussis, tetanus, measles, hepatitis B, chicken pox), the vaccines given to babies at birth (including BCG vaccine, oral polio vaccine [OPV], hepatitis B vaccine, the frequency and route of administration of vaccines (including through injections or oral drops). The overall knowledge was scored on a scale of 0–20; a score of 0–10 being poor knowledge about the immunization of under-five children and a score of 11–20 being good knowledge about the immunization of under-five children.
The respondents' attitude toward childhood immunization was examined using the following items; whether childhood immunization is necessary or essential, if children should be given immunization if at the appropriate ages, if local herbs are considered suitable substitutes for immunization, if they considered immunization to be necessary only for the healthy/sick, well breastfed/poorly breastfed, well-fed/poorly fed, female/male, firstborn/lastborn child, if they considered that the fathers should be involved in the immunization of their children and what they considered as barriers to immunization such as the long distances to immunization centers. The attitude of the mothers toward the immunization of under-five children was scored on a scale of 0-10; a score of 0–5 being negative while a score of 6–10 was considered positive. The scores for both knowledge and attitude were split at the median. Age-appropriate immunization compliance was determined using the questionnaire which matched each vaccine with the appropriate age of the child following the current immunization schedule in Nigeria.
Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital. Permission was obtained from each Chief Nursing Officer at the Baiyeku, Igbogbo and Ikorodu PHCs to conduct the study at their respective facilities. A written informed consent was obtained from each participant before the commencement of data collection for the study. The respondents at each PHC were not coerced or given incentives to participate. All the information provided by the respondents were treated with strict confidentiality.
| Results|| |
[Table 1] shows the mean age of the respondents as 30.96 years with a standard deviation of 5.67 years. The modal age was 26-30 years (32.8%). The majority (95.6%) of the mothers were married, 78% were in monogamous families, and 63.6% were Christians. Most (73.6%) of the mothers were Yoruba, 17.6% were Igbo, 3.2% were Hausa, while 5.6% of the mothers accounted for other tribes such as Edo and Efik. Less than half of the mothers (41.6%) had tertiary education while about half (51.2%) of the mothers had secondary education.
More than half of the index children were females (57.6%) while the other 42.4% were males. About a quarter (24.0%) of the children were delivered at the general hospital while 40.0% were delivered at private hospitals, 22.8% were delivered at primary health care centers. The rest were delivered at home, at the church/mosque and by traditional birth attendants.
All the respondents (100%) had heard about immunization [Table 2] and the most common source of information was the antenatal clinic (46.8%) followed by healthcare workers (29.6%), the media (17.6%) and family members (6.0%). Nevertheless, the BCG vaccine was correctly identified by the majority (86.4%) of the respondents as one of the vaccines administered at birth. A small proportion (14.8%) of the respondents erroneously identified the measles vaccine as one of the vaccines administered at birth. Majority of the respondents correctly identified the use of injections and oral drops as methods of administering vaccines to under-five children.(83.2% and 77.6%, respectively) [Table 2]. The most frequently identified VPDs were polio, yellow fever, and measles. Erroneously identified as being vaccine-preventable were the Human Immunodeficiency virus infection (7.6%) and malaria (26.0%) [Figure 1].
Regarding the attitude of the respondents toward childhood immunization [Table 3], majority (98.8%) of the respondents agreed that childhood immunization was necessary. A large proportion (92.8%) of the respondents agreed that local herbs did not serve as substitutes for immunization. Majority (99.6%) of the respondents were of the opinion that children should be taken to the health facility for immunization at the appropriate ages. Almost half (44%) of the respondents strongly held the opinion that not all sick children should be prevented from being immunized. Some (3.6%) of the respondents felt that a well-breastfed baby should not be immunized as immunization was needed only for those children who are not well fed.
A large proportion of the respondents (72.0%) had an overall good knowledge about the immunization of under-five children, while all the respondents (100%) had an overall positive attitude towards the immunization of under-five children [Figure 2]. The majority (86.4%) of the respondents indicated from their responses that they had immunized their child (the index child) completely or up-to-date. A minority (4.4%) of the respondents did not have their children's immunization cards in their possession, whether with them at the time of interview or kept elsewhere. Out of the 250 mothers, 226 had more than one child. A minority (10%) of them had not fully immunized their older children. The majority (94.4%) of the respondents involved their husbands in the immunization of their children [Figure 2].
|Figure 2: Respondents' overall knowledge, overall attitude, and practice related to childhood immunization|
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According to [Table 4], there was a statistically significant association between the mothers' age and knowledge. The older the mother, the better the level knowledge about childhood immunization. There was also a statistically significant association between the level of knowledge of the respondents about childhood immunization and the mothers' level of education, their occupation and the nature of their family. On the other hand, there was no statistically significant association between the knowledge of the respondents about under-five immunization and their marital status, their tribe, and their religion.
|Table 4: Association of respondent's sociodemographic characteristics by knowledge and immunization status of index child|
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The association between the mothers' age and immunizing their last children fully or up-to-date showed a statistical significance. The older the mother, the better their practices towards immunizing their children fully or up-to-date. This could be linked to their knowledge about immunization gained over the previous years of motherhood. There was also a statistically significant association between occupation and the practice of mothers immunizing their children fully or up-to-date. There was no statistically significant association between marital status, tribe, religion, level of education, nature of family, and the practice of mothers immunizing their children fully or up-to-date [Table 4].
| Discussion|| |
This study was carried out among mothers of children under 5 years in Ikorodu Local Government Area, Lagos, with the aim to determine their level of knowledge, assess their attitude and practice toward the immunization of under-five children. The mean age of the respondents was 30.96 years, and the modal age was 26–30 years.
The respondents were all (100%) aware of immunization of under-five children. This is similar to studies carried out in Democratic Republic of Congo, Oyo state, Kosofe LGA and Lagos University Teaching Hospital where 99.8%, 99%, 98%, and 93.8% of the respondents, respectively, had heard about immunization of under-five children.,,, This may be due to the fact that childhood immunization being such an important intervention capable of preventing debilitating diseases to children, public enlightenment on the subject has been intensive and sustained.
The most common source of information about the immunization of under-five children was at the antenatal clinics (46.8%). This is similar to a study carried out in Oyo state where the most common source of information was also at the antenatal clinics (65.7%). This is, however, contrary to studies carried out in Karachi Pakistan, North India, Saudi Arabia and Bangladesh where 62.2%, 52.0%, 88%, 77%, and 80.18% of the respondents, respectively stated that the commonest source of information about the immunization of under-five children was through health workers at other hospital visits other than antenatal clinics.,,,, This is also contrary to a study carried out in Egypt where the television (54.6%) was the most common source of information about immunization of under-five children. The findings of another study in keeping with this study are in Rishikesh where almost all the respondents (96%) reported that their source of information regarding immunization is the healthcare personnel. Other sources of information on immunization were the healthcare workers, the media, and family members.
In this study, the respondents most commonly named polio and yellow fever as VPDs. A majority (82.8%) of the respondents correctly identified polio as one of the VPDs. This is congruent with a study carried out in Uganda where 81.3% of the respondents identified polio as one of the VPDs, as well as measles (77.5%) while 8.6% of women thought that malaria was vaccine preventable. More than half (55.6%) of the respondents in this study correctly also identified tuberculosis as one of the vaccine-preventable diseases. This is contrary to a study conducted in Karachi Pakistan where less than half (40.4%) of the respondents were able to state tuberculosis as a vaccine-preventable disease. Other VPDs correctly identified by respondents in this study include yellow fever (64.0%), measles (63.6%), and hepatitis B (55.2%). This is similar to findings from a study conducted in Enugu where 93.4% of the respondents were able to mention at least two VPDs correctly. High proportions were also found in a study in Egypt where measles, tuberculosis, polio, diphtheria/pertussis/tetanus, and hepatitis B were the diseases identified as VPDs (91.7%, 84.8%, 97.7%, 77.8% and 57.2%, respectively). In a study in Addis Ababa, 56% could name more than one diseases that could be prevented by immunization while 20.5% could name none. In another study in India, only 11.61% could name two or more diseases that could be prevented by immunization, and 61.2% could not name even one.
On the other hand, less than half of the respondents could correctly identify tetanus (48.8%), diphtheria (40.8%), and pertussis (32.8%) as VPDs. This is similar to a study carried out in Kosofe where less than half (36%) of the respondents did not know that there was a vaccine, DPT, that prevented diphtheria, pertussis, and tetanus in children. Furthermore, in this study, malaria and HIV were erroneously identified as VPDs (26.0% and 7.6%, respectively). This can be compared to studies in Democratic Republic of Congo where malaria as well as diarrhea were identified by respondents as vaccine-preventable and as EPI-targeted diseases though the proportions of respondents stating these were much lower (3.0% and 3.9%, respectively), in Oyo state where 41.3% of the respondents erroneously believed immunization prevented HIV, 84.6% holding the same opinion for diarrhea and in Uganda where 8.6% of the respondents thought malaria was a vaccine-preventable disease.,,
The routes of administering vaccines to under-five children were correctly identified by large proportions of respondents (injections 83.2% and oral drops 77.6%, respectively). This contrasted sharply with what obtained in Kaduna State, Nigeria where only 4.8% of the mothers knew the correct route of administering the vaccine.
The respondents mostly (98.8%) believed that immunizing children was necessary for disease prevention. This was similar to what was found in Addis Ababa where 96% of the respondents opined that diseases could be prevented by immunization, but much better than in Karnakata, India, where 65.16% of the respondents were of the opinion that diseases could be prevented by immunization. A large proportion (92.8%) of the respondents agreed that local herbs did not serve as substitutes for immunization. Majority (99.6%) supported that children should be taken for immunization at the appropriately scheduled ages. In a study in Kaduna Nigeria 65% of the respondents knew vaccination protects against VPD and should be completed within 12 months of age. However, in another study, only 29.98% of the respondents were of the opinion that it was important to give all the doses of immunization as scheduled.
Regarding which child should or should not take immunization, in this study almost half of the mothers held the opinion that some but not all sick children should be prevented from being immunized. A small proportion (3.6%) of them considered immunization to be for the unwell child hence healthy, and well-breastfed babies were not to be immunized as immunization was needed only for those children who were not well fed. More respondents (24%) of those in Kaduna believed that only sick children take immunization.
A large proportion of the respondents (72%) had good knowledge about the immunization of under-five children as was also found in Jos, Nigeria where the proportion of respondents with good knowledge was almost 90%. In the study among mothers of under-fives in Rishikesh, 50% had moderately adequate knowledge and 32% showed adequate knowledge while 18% had inadequate knowledge regarding immunization. There, in Rishikesh, a high proportion (90%) had a favorable attitude toward immunization. This is similar to the findings of this study where all the respondents (100%) showed a positive attitude. This is a sharp contrast with the findings of the study in Addis Ababa where only about half of the respondents had a positive attitude toward immunization.
Over 85.0% of the respondents had immunized their index child up-to-date. A high proportion of complete immunization (72.2%) was also found in Imala, Ogun State. On the contrary, in another study in Indonesia, only 32% of the children were fully immunized. In Ethiopia, the prevalence of fully immunized children was also low (24.3%). Under 5% of the respondents did not have their children's immunization cards. This is a slight improvement from the findings of an earlier study in Lagos where 16.3% of the mothers did not have the immunization cards of their children. In Rishikesh, it was found that as high as 28% of the rural mothers of under-five children did not possess a vaccination card.
Majority (94.4%) of the respondents involved their husbands in the immunization of their children. This is much higher than was found in Mangalore, India, where the decision-maker in the house regarding immunization of the children was less commonly the father (55.3%), followed by the joint decision of the father and the mother (26%).
The mothers' knowledge about childhood immunization was significantly associated with the mothers' age, level of education, occupation and the nature of the family. Among women in Addis Ababa it was found that maternal education (adjusted odd ratio [AOR] =1.781, 95% confidence interval [CI] =1.035, 3.065), respondents who had infants aged from 3 to 9 months (AOR = 1.947, 95% CI = 1.051, 3.607), 9–12 months (AOR = 2.305, 95% CI = 1.216, 4.371) and having more than one child (AOR = 1.560, 95% CI = 1.087, 2.238) were the factors significantly associated with the knowledge of mothers regarding immunization of infants. Another study in Vhembe District, Limpopo found, in contrast, that most mothers had knowledge about immunization regardless of their level of education and occupational status.
There was a statistically significant association between the mothers' age and immunizing their last children fully or up-to-date. The older the mothers, the better their practice of immunizing their children completely. This could be linked to the fact that they had received a lot of information over the years as mothers hence their better practice. The occupation of the mother also showed a statistically significant association with the practice of mothers immunizing their children fully/up-to-date. Higher proportions of mothers who were able to fully immunize their children were found among those who were formally employed. This could be due to their better understanding of the benefits of complete immunization as formal jobs require a higher level of education. Among mothers in Addis Ababa maternal education (AOR = 1.781, 95% CI: 1.035, 3.065), respondents who had infants <9 months of age (AOR = 1.947, 95% CI: 1.051, 3.607), 9–12 months of age (AOR = 2.305, 95% CI: 1.216, 4.371) and having more than one child (AOR = 1.560, 95% CI: 1.087, 2.238) were significantly associated with knowledge of mothers regarding childhood immunization.
| Conclusion|| |
All of the respondents had heard about the immunization of under-five children, and the majority of the respondents showed good knowledge about the immunization of under-fives. Mothers with at least a secondary level of education had good knowledge and exhibited better practice toward childhood immunization than mothers who had either a primary level of education or no formal education at all. All the respondents had a positive attitude towards the immunization of under-five children irrespective of age, marital status, tribe, religion, occupation, level of education, and nature of the family. The knowledge of under-five immunization was associated with the mothers' age, level of education, occupation and the nature of the family while maternal age and occupation showed a statistically significant association with the practice of immunization. It is thus recommended that health education and talks at immunization centers on the benefit of each vaccine should be intensified in order to improve mothers' knowledge about childhood immunization. The government and policymakers should ensure and monitor the education of the girl child.
Limitations to the study
Respondents with older children had to recall their immunization experiences sometimes over 10 years earlier.
Because the mothers were routine clinic attendees, many could not show immunization cards to support the claim that the index child had an immunization card.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]