Niger J Paediatr 2020; 47 (2):96 – 102 ORIGINAL

Ese AO CC –BY
Brown VB
Mothers’ knowledge and utilization
Oluwatosin OA of non-routine childhood
immunisation in Ibadan North
Local Government Area, Oyo state,
Nigeria
DOI:http://dx.doi.org/10.4314/njp.v47i2.8
Accepted: 8th April 2020 Abstract: Background: Vaccine- were computed and Chi-square test
preventable-diseases are major was used for investigating associa-
Brown VB ( ) contributors to child mortality in tion between categorical variables
School of Nursing, University Africa. In Nigeria, apart from the at 0.05 level of significance.
College Hospital, Ibadan, Nigeria. routine childhood vaccines that Results: The findings revealed that
Email: [email protected] are provided free by the govern- 62 (56.4%) of the 110 mothers
ment, there are additional lifesav- were aware of non-routine immu-
Ese AO, Oluwatosin OA ing non-routine vaccines like Ro- nisation of which 23 (20.9%) had
Department of Nursing, tavirus, Pneumococcal Conjugate good knowledge about it. Only 23
Faculty of Clinical Sciences, (PCV), Varicella, Cerebrospinal (20.9%) of their children were
College of Medicine, University of meningitis, and Measles, Mumps, immunized with all the non-
Ibadan, Nigeria. Rubella (MMR) vaccines. Until routine vaccines. High income,
2015 when PCV was included in higher level of education and good
. the routine childhood immunisa- knowledge level about non-routine
tion, these five vaccines were immunisation of mothers were
optional and parents paid to im- associated with the utilization of
munize their children with them. all non-routine immunisation
Objective: To assess the level of among their children (p<0.01).
knowledge and utilization of non- Conclusion: Knowledge of moth-
routine immunisations among ers about non-routine immunisa-
mothers. tion was poor and uptake of the
Methodology: A descriptive, cross vaccines among their children low.
-sectional study conducted in Health education to improve moth-
three infant welfare clinics pur- ers’ knowledge and utilization of
posively selected in Ibadan North non-routine immunisation by their
Local Government Area, Oyo children is recommended.
State, Nigeria. Participants were
110 mothers of children aged 6-24 Keywords: Vaccine-preventable-
months. A structured question- diseases, Children, Optional, Im-
naire was used for data collection munisation, Awareness, Uptake,
and analysis done using SPSS Ibadan, Nigeria
version 20.0. Descriptive statistics

Introduction corded in increasing coverage for routine immunisation

(RI)5. RI schedule consisted of Bacillus Calmette-Guerin
Pneumonia and diarrhoea are leading causes of morbid- (BCG) vaccine, Diphtheria, Pertussis and Tetanus (DPT)
ity and mortality among children worldwide1. Similarly, Oral Polio Vaccine (OPV), Hepatitis B vaccine (HBV),
cerebrospinal meningitis, also called epidemic meningo- Measles and Yellow Fever vaccines. The introduction
coccal meningitis, is a major public health problem af- of other vaccines is one of the three objectives of the
fecting tropical countries, particularly in sub-Saharan Global Immunisation Vision and Strategy (GIVS) for
Africa.2. Varicella is associated with a substantial bur- fighting Vaccine Preventable Diseases (VPDs)6. In order
den of morbidity and mortality3. Measles is highly infec- to achieve this objective, in 2012 Nigeria introduced the
tious, potentially fatal and mostly affects children, while Pentavalent Vaccine into its national immunisation
Rubella can lead to severe lifelong disabilities in chil- schedule. The pentavalent vaccine which consists of
dren. Meanwhile, vaccine-preventable diseases (VPDs) Haemophilus influenzae type b (Hib), DPT and HBV
account for 17% of global total under-five mortality per replaced the DPT vaccine. Obviously, some important
year and 22% of child mortality in Nigeria.4 However, non-routine vaccines such as the Rotavirus, Pneumococ-
the best protection against these deadly diseases is cal Conjugate, Varicella, Cerebrospinal meningitis and
through vaccination. Measles, Mumps, Rubella (MMR) vaccines are not part
In Nigeria, some major accomplishments have been re- of routine immunisation that are provided free by the
 97
government. Apart from Pneumococcal Conjugate vac- the time of data collection. The exclusion Criteria were
cine which has been included as part of routine immuni- being mothers with infants less than 6 months, having
sation in Nigeria in recent time, it is optional for parents children above 24 months and not currently attending
to pay a fee in order to immunize their children with the any of the selected infant welfare clinics and not present
non-routine vaccines. at the time of data collection. The estimated population
Non-routine vaccines or optional vaccines are those of mothers who attend infant welfare clinics over the
which are not included in the routine immunisation study period based on the records in the three clinics
schedule and given on an optional basis7. Although the used for the study was 152. The recruitment of the
stated optional vaccines are not included among the rou- mothers as respondents was calculated based on the
tine childhood immunisation in Nigeria, the WHO rec- sample size determined 12 as shown below:
ommended that infants should be vaccinated with 2-3 N
doses of rotavirus vaccine, 1 dose of MMR vaccine and n = 1 + N (e) 2
2-3 doses of Pneumococcal Conjugate vaccine and 1-2 Where,
doses of Varicella vaccine.8,9,10 N = estimated population 152 over the study period
n = required sample size
Mothers play a key role in their children’s vaccination e = level of error tolerance 5%
11
, therefore it is important for them to have adequate 152
knowledge so as to utilize the vaccines for their chil- n= 1 + 152 (0.05)2
dren’s protection. Only few studies have assessed moth- 152
ers’ knowledge and utilization of non-routine immunisa- n= 1.38
tion in Nigeria and in Oyo state in particular. This study n = 110.14~110
was designed to assess the knowledge and utilization of
non-routine immunisation among mothers in selected To adjust for 10% Non –response rate due to nature of
infant welfare clinics in Ibadan North Local Government the population
Area, Oyo state. The findings of the study may help in n
providing baseline information for further intervention n = 1 – NR NR= Non- response rate 10%
studies on non- routine immunisations. 110
n= 1 – 10%
110
n= 0.9
Material and Methods n = 122

This study was a descriptive health facility-based cross- The structured questionnaire utilized for data collection
sectional survey. The study setting was Ibadan North was developed in English after a thorough literature re-
Local Government Area (LGA), which is one of the 33 view. The questionnaire had 48 question items. It was
LGAs in Oyo State, South Western Nigeria. The Local subdivided into three sections. Section A was to collect
Government Area is located approximately on longitude information on demographic data of the respondents,
8°5’ East of the Greenwich meridian and latitude 7°23’ section B considered knowledge of childhood immuni-
North of equators. The Local Government Area also sation including routine and non-routine childhood vac-
houses some tertiary educational institutions such as the cines, and section C considered the utilization of the
University of Ibadan, The Polytechnic Ibadan and sev- routine and non-routine childhood vaccines.
eral private and public secondary and primary schools. Knowledge of respondents in the study were assessed on
The Local Government Area also has one public tertiary five vaccines that were not routinely administered at the
hospital, (University College Hospital), one public sec- time of the study in 2015 namely, Rotavirus vaccine,
ondary hospital (Adeoyo Maternity Hospital) and many Pneumococcal conjugate vaccine (PCV), Cerebrospinal
public Primary Health Centres. The tertiary educational Meningitis (CSM) vaccine, Measles, Mumps, Rubella
institutions also have clinics which provide health care (MMR) vaccine and Varicella vaccine. Knowledge as-
services to the members of their communities. sessment questions included the diseases each vaccine
offers protection against in childhood, the frequency and
A purposive sampling technique was used for selecting timing of administration of each of the vaccines.
three infant welfare clinics in the LGA. The clinics se-
lected for the study consisted of the Institute of Child The respondents were requested to circle the correct
Health, College of Medicine, University of Ibadan, Kola answer for each item. Correct response to each knowl-
Daisi Foundation Primary Health Centre and Adeoyo edge question on non-routine vaccine was scored 1,
Maternity Hospital. The three infant welfare clinics were while the wrong response was scored 0. The total
selected for the study due to the availability of the non- knowledge score a mother obtained was computed,
routine childhood vaccines at these clinics. minimum score obtainable was 0 and the maximum ob-
The target population for this study was mothers having tainable score was 14. Based on the total knowledge
at least one child 6-24 months attending infant welfare score, the levels of mothers’ knowledge for each non-
clinic. Inclusion criteria were being mothers of children routine vaccine were classified into 3 categories good,
between six months and 24 months, currently attending fair and poor. Any mother with a score of 10 (75% cut-
the selected infant welfare clinics and being present at off point) or higher was regarded as having a good
 98
knowledge, mother’s score between 7 and 9 (50-65%) Ethical Review Committee. Written informed consent
was regarded as fair knowledge while any mother who was obtained from all the respondents who voluntarily
scored below 7 (˂50%) was regarded as having poor participated in the study.
knowledge about non-routine immunisation.
Information regarding the children’s non-routine immu-
nisation status was obtained through mothers’ recall and
verified from the immunisation cards. Results
To ensure content and face validity, the questionnaire
was developed after thorough literature review and was One hundred and ten (110) out of the 122 questionnaires
then reviewed by experts for completeness and appropri- administered were retrieved, giving the response rate of
ateness to ensure validity. The reliability of the instru- 90.2%.
ment was assessed using test retest method carried out The mothers’ ages ranged from 18-40 years with a mean
with mothers from the University Health Centre, (SD) of 27.7 ±5.4 years. Only six (5.5%) of the mothers
University of Ibadan. had no formal education, 11 (10%) of them had primary
After obtaining informed written consent from eligible education, 26 (23.6%) had secondary education, while
mothers, data were collected during the clinic hours in 67 (60.9%) had tertiary education. The ages of the chil-
the selected infant welfare clinics. dren in the study ranged from 6-20 months, mean age
+SD was 9.7 months +2.5. Eighty-nine (80.9%) of them
Data Analysis were ≤9 months old, only eight (7.2%) were above 12
months. Seventy-two (65.5%) were male and 38
Data entry was carried out using the IBM SPSS Statis- (34.5%) were females.
tics version 20 software (IBM Corporation, Armonk, Sixty-two mothers (56.4%) were aware of non- routine
NY). Descriptive statistics were computed to describe immunisation, their sources of information about non-
participants' socio-demographic characteristics. Continu- routine immunisation is presented in figure 1. Most
ous variables were summarized using means and stan- (96.8%) of the mothers got the information from post-
dard deviations (SD). Chi-square test was used for in- natal clinic while educational institution was the least
vestigating association between categorical variables of (6.5%) source of information.
interest at 0.05 level of significance. The total knowledge score a mother obtained was com-
puted, minimum score obtainable was 0 and the maxi-
Ethical consideration mum obtainable score was 14. As shown in figure 2,
only 23 (20.9%) mothers in the study had good knowl-
Ethical approval for the study was obtained from the edge about non-routine immunisation.
University of Ibadan/University College Hospital Ibadan

Table 1: Factors Associated with Respondents’ Knowledge of Non- routine Childhood Immunisation
Variable Knowledge Score χ2 p-value
Good Knowledge Fair Knowledge Poor Knowledge Total
Age in years 23.17 .003
≤ 25 1 (3.4%) 2 (6.9%) 37 (92.5%) 40
26-30 9 (23.7) 4 (10.5%) 25 (65.8%9 38
31-35 10 (47.3%) 3 (14.3%) 8 (38.1%) 21
36-40 3 (27.3) 2 (18.2%) 6 (54.5%) 11
Religion 8.49 .092
Christianity 17 (28.8%) 8 (13.6%) 34 (57.6%) 59
Islam 6 (12%) 3 (6%) 42(84.0%) 51
Marital status 8.96 .176
Single 0 (0%) 0 (0%) 4 (100%) 4
Married 21 (20.6%) 10 (9.8%) 71 (69.6%) 102
Separated/Divorced 2 (66.7%) 1 (33.3%) 0 (0%) 3
Widow 0 (0%) 0 (0%) 1(100%) 1
Occupation 62.38 .000
Civil servant 11 (22.4%) 8 (16.3%) 30 (61.2%) 49
Trading/Artisan 10 (24.4%) 2 (4.9%) 29 (70.7%) 41
Housewife 0 (0.0%) 0 (0.0%) 7 (100.0%) 7
Student 0 (0%) 1 (50%) 1 (50%) 2
Health care workers 11 (100%) 0 (0%) 0 (0%) 11
 99
Fig 1: Respondents’ Sources of Information about Non- rou- (12.1%) vaccinated their babies based on doctor’s rec-
tine Immunisation ommendation while 25 (75.8%) claimed they acted
Doctor 5 based on the information they received about the vac-
Source of Information cines from the clinic.
n Nurse/Midwife 29
io
ta
Antenatal Clinic 20
m
r
o
f Postnatal clinic 60
The major barriers perceived by 49 (44.5%) mothers to
In
f their children’s uptake of non- routine immunisations
o Electronic media 42
se were lack of information about the vaccines, 40 (36.4%)
cr Friends/Neighbours 6
u of them perceived inability to afford the vaccine while
o
S Relations 3
21 (19.1%) mothers perceived the vaccines were not
Educational Institution 4
important since their children were healthy.
0 10 20 30 40 50 60 70
Analysis of association between the two most utilized
Frequency non- routine vaccines and some variables about the
mothers /children socio-demographic status revealed a
Figure t 2. Lev els of
* Multiple Responses
100
number of significant findings as shown in table 3. Re-
n garding the factors associated with utilization of all non-
Respondents' e
cr K nowledge routine vaccines, mothers’ level of education was found
e to have significant association as all the 23 mothers who
about NPon-ro 0 utine… vaccinated their children with all the non-routine vac-
Percent

cines had tertiary education in contrast with other moth-

Poor
Fair
Good ers with secondary education and below (p<0.01). Table
Poor
Know
Know
Kn
le dg
ow
le dg
le dg 4 shows other associated factors associated with utiliza-
Know ledge tion of all non-routine vaccines. Mothers’ income and
e e e their level of knowledge about non-routine immunisa-
F air Know ledge tion were found to have significant association with
utilization of all non-routine vaccines (p<0.01).
Poor Fair Good Table 4: Factors Associated with Utilization of all Non-
Knowledge Knowledge Knowledge
routine Vaccine among the Children of Respondents
In this study, a significant association was found be- Variables Received all Non-routine Vaccines
tween higher education of mothers and good knowledge Yes No χ2 P.
about non-routine immunisation as the results showed No. % No. % value
that 23 (34.3%) mothers with tertiary education, had Religion 7.150 .028
good knowledge, 11 (16.4%) had fair knowledge, while Christianity 18 78.3 41 47.1
33 (49.3%) had poor knowledge. Meanwhile, all the 43 Islam 5 21.7 46 52.8
(100%) mothers with secondary education and below Mother’s Income 42.50 .000
had poor knowledge of non-routine vaccines (p<0.001). ₦50,000 and 4 17.4 70 80.5
Also, as presented in table 1, significant associations Below
≥ ₦60,000 - 19 82.5 17 73.9
existed among mothers’ age, occupation and their ₦100,000
knowledge about non-routine immunisation (p<0.05). Gender of Index Child 1.026 .311
Uptake of non-routine immunisation is generally low in Male 13 56.5 59 67.8
the study. Rotavirus and Pneumococcal conjugate vac- Female 10 43.5 28 32.2
cine (PCV) have the highest frequency of uptake as Level of Mother’s Knowledge about Non-routine Immunisation
shown in table 2. Poor Knowledge 0 0 76 87.4 98.72 .000
Fair Knowledge 1 4.3 10 11.5
Table 2: Uptake of Non Routine Vaccines among Children of Good Knowledge 22 95.7 1 1.1
Respondents
Non Routine Vaccines Received Not Received
No. % No. %
Rotavirus vaccine (n=110) 33 30 77 70 **
Pneumococcal conjugate 33 30 77 70 **
vaccine (PCV) (n=110)
Varicella vaccine (n=110) 4 3.6 106 96.4 **
Cerebrospinal meningitis 10 9.1 100 90.9 **
(CSM) (n= 110)
MMR vaccine (n=110) 5 4.5 105 95.5 **
** Multiple Responses

All the 33 (100%) mothers whose children received at

least one of the non-routine vaccines perceived the bene-
fit of the vaccine(s) uptake has been effective for pre-
vention of some childhood diseases, 31 (94%) of them
perceived that it will make their babies healthy, 4
 100
Table 3: Factors Associated with Two Most Utilized Non- Routine Childhood Vaccines
Variables Rotavirus Total χ2 P Pneumococcal Conju- Total χ2 P
Vaccine gate Vaccine received
Received
Mothers’ Education 17.82 .000 17.82 0.000
Secondary and below 3 (7.0%) 43 3 (7.0%) 43
Tertiary Education 30 (44.8%) 67 30 (44.8%) 67
Mothers’ Income 40.59 .000 46.21 0.000
₦50,000 ($140) and Below 8 (10.8%) 74 7 (9.5%) 74
₦60,000 ($165) - ₦100,000 ($280) 23 (67.6%) 34 24 (70.6%) 34
Above ₦100,000 ($280) 2 (100%) 2 2 (100.0%) 2
Gender of Child 0.490 .484 0.490 0.484
Male 20 (27.8%) 72 20 (27.8%) 72
Female 13 (34.2%) 38 13 (34.2% 38

routine immunisation among children was low in the

study. The uptake of Rotavirus and PCV ranked the
highest among the children of participated mothers
Discussion while varicella was the least received vaccine by the
children.
This study assessed the knowledge and utilization/ The main factor for higher utilization rate of Rotavirus
uptake of non- routine (optional/non-obligatory/non- and PCV might be due to the burden and severity of
mandatory) childhood immunisation among nursing diseases prevented by the two vaccines9,10. Also, the use
mothers in Ibadan North Local Government Area of Cerebrospinal meningitis (CSM) vaccines might not
Oyo state. All the mothers in the study were below 45 have been maximum in south western Nigeria as cere-
years of age and majority of them had tertiary education. brospinal meningitis outbreaks occur more in the north-
Majority of the index children of the mothers were nine ern part of Nigeria19,20,21. In addition, as stated by some
months old please note what I said earlier on the babies’ mothers in the study, cost of purchase of the vaccines
ages. may be a major barrier to the uptake of the vaccines.

Just over half of the mothers were aware of non-routine Regarding the uptake of all the non- routine immunisa-
immunisation, this showed that a large proportion of the tion, only about a third of the children whose mothers
mothers were not aware of the non-routine immunisa- participated in the study received all the vaccines. The
tion. Majority of those mothers who were aware got the findings of the study showed that high income, higher
information from post-natal clinic. This indicates the level of education and good knowledge level about non-
need for health care providers to provide adequate infor- routine vaccines were associated with the utilization of
mation for mothers about non-routine immunisation all the vaccines among their children. Previous studies
early especially during ante-natal clinics considering the corroborated that higher education and high income of
deadly childhood diseases the vaccines can prevent. mothers are significantly associated with childhood non-
Providing information about non-routine immunisation routine immunisation uptake22,23. This is another indica-
six weeks after the delivery of a baby may be quite late tion for the implementation of strategy and actions for
in guiding parental decisions about the vaccines. women economic empowerment and access to quality
education in Nigeria.
The findings of the study showed that less than a quarter
of mothers in the study had good knowledge about non- This study had its strength and limitations. In the study
routine immunisation, this finding corroborates the find- setting, studies on non-routine immunisation are scarce,
ings in India where majority of mothers in the studies so this study is one of the few studies on the subject
had poor knowledge regarding optional vaccines13,14. matter. One of the limitations of the study is the fact that
Mothers’ educational level was found to have an asso- the study was conducted in three clinics which limit the
ciation with their knowledge of non-routine immunisa- generalizability of the findings. Also non-routine vac-
tion, as a higher proportion of mothers’ with tertiary cines were not being administered in many health facili-
education had “good knowledge” compared with moth- ties especially at Primary Health Care (PHC) level, so
ers with secondary education or less. This suggests the this study did not involve PHC centers.
need to intensify the advocacy for mothers’ education as
maternal education has been found to be significant in
reducing child mortality and morbidity 15,16,17,18.
Conclusion
Regarding the association between mothers’ occupation
and their knowledge, it is not surprising that the highest In conclusion, this study showed that knowledge of
proportion of mothers who had good knowledge were mothers studied about non-routine immunisation was
health workers. This is an evidence that health workers poor and the uptake of the vaccines among their children
have access to information relevant to their jobs, and was low. Considering the life threatening effects of in-
ultimately may enhance a culture of knowledge sharing fectious diseases in Sub-Saharan Africa and Nigeria and
with health care consumers. Overall the uptake of non- the life-saving benefits of routine and non-routine im-
 101
munisations against the infectious diseases, there is need Africa.
for health care professionals’ especially nurses and mid- Authors contribution
wives to empower mothers with information to improve EAO, BVB and OOA contributed to the concept, design,
their knowledge and utilization of non-routine vaccines. intellectual content, literature search/review, data analy-
It is also important for health care professionals and sis and manuscript preparation.
other stakeholders in child health to advocate for the Conflict of interest: None
reduction in the costs of non-routine vaccines to make Funding: None
them affordable for parents. All these strategies may in
turn reduce the mortality and morbidity associated with
infectious diseases among children in Sub-Saharan

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