ANALYSIS ON THE KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING

IMMUNIZATION OF UNDER-FIVE CHILDREN AMONG MOTHERS

ATTENDING ANTENATAL CLINIC (ANC) AT MADONNA UNIVERSITY
TEACHING HOSPITAL IN ELELE, RIVERS STATE

DEPARTMENT OF NURSING SCIENCE

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF STUDY

Immunization is a modern miracle, it has saved millions of lives worldwide and its

origin dates back ancient Greece. In the 14 th century the Chinese discovered and used a

primitive form of vaccination called variolation. The aim was to prevent small pox by

exposing healthy people to tissue from the scabs caused by the disease this is the first

recorded attempt at vaccination1.

The British physician Dr. Edward Jenner in 1796 discovered vaccination in its

modern form and proved to the scientific community that it worked. He was considered the

founder of vaccinology in the west after he inoculated a 13year old boy with vaccine of a

virus (cow pox) and demonstrated immunity to small pox. By 1798, the first small pox

vaccine was developed2

Immunization is the most effective method of preventing infectious diseases 3.

Widespread immunity due to vaccination is largely responsible for the worldwide eradication

of smallpox and the restrictions of disease such as polio, measles and tetanus4.

Generally immunization involves stimulating immune responses with infectious

agents, i.e. priming the immune system with an immunogen with the intention of creating
1
specific resistance to an infectious disease. Simply put, a process by which an individual’s

immune system becomes fortified against an agent.

Immunization is done through various techniques, most commonly vaccination and is

definitely less risky and an easier way of being immune to a particular disease than risking a

milder form of the disease itself. They are important for both adult and children because of

the protection it confers. Immunization not only confers immunity but helps in developing

child’s immune system. Immunization could be passive or active.

Active immunization can occur naturally or artificially. Naturally occurring active

immunization is when a person comes in contact with an organism. The immune system

essentially creates antibodies against the microbe, making it more efficient in the next

exposure. Artificially active immunization is where the microbe or part of it are injected into

the person before they are able to take it naturally.

Passive immunization is where pre synthesized elements of the immune system are

transferred to a person so that the body does not need these elements itself. It can occur

physiologically, transferred from mother to foetus during pregnancy. Passive immunity can

also be artificial and it’s administered by injection especially if a recent outbreak of a disease

has occurred5.

Immunization can prevent infectious diseases in an individual, restrict the spread of

diseases and may ultimately eradicate the disease in the community. It represents the

remarkably successful and cost effective means of reducing infectious diseases and thereby

decreasing the morbidity and mortality in infants and children6.

According to an estimation made by WHO, vaccination annually prevents 2-3 million

deaths of children from diphtheria, tetanus, pertussis and measles, a million alone due to

2
measles vaccination in particular. It is believed that an additional 1.5 million deaths will be

avoided if global vaccination coverage improves6.

1.2 STATEMENT OF THE PROBLEM

The global burden constituted by vaccine preventable disease is immense. Worldwide

about 2.5 million children die every year from vaccine preventable infectious disease mainly

in Africa and Asia among children less than 5 years old. In the year 2000, measles alone

resulted in 777,000 deaths and 2 million disabilities 7-8. Financial commitment towards

immunization would amount to an estimate of 3 billion dollars per year in the next 10years

with UNICEF investing 56% of its health funds7.

According to WHO 1.5 million children under the age of 5 died from vaccine

preventable diseases in 2008 reported globally9. Every year more than 10 million children in

low and middle income countries die before they reach their fifth birthdays. Most die because

they do not access effective interventions that would combat common and preventable

childhood illnesses10. Vaccine preventable diseases remain the most common cause of

childhood mortality with an estimated three million deaths each year11.

Four countries in the world were reported to have endemic poliomyelitis with Nigeria

being one of them. Others include India, Pakistan and Afghanistan. Presently Polio remains

endemic in only two countries- Pakistan and Afghanistan. The deaths and disabilities

resulting from this vaccine preventable disease is quite high is these countries12.

3
 Vaccine preventable diseases remain one of the major causes of illnesses and deaths

among children in Nigeria and this country is one of the few remaining countries in the world

where polio is still endemic. The WHO Global Polio Eradication initiative 2005 Annual

Report cited uncontrolled transmission of poliovirus in northern Nigeria and identified the

states of Bauchi, Kaduna, Jigawa, Kano and Kastina as the greatest threat to the global

eradication of Polio. Nigeria accounts for half of the deaths from Measles in Africa, the

highest prevalence of circulating wild poliovirus in the world and the country is among the

ten countries in the world with vaccine coverage rates below 50 percent, having been

persistently below 40 percent since 1997 13. In Nigeria, one child in five dies before its fifth

birthday and vaccine preventable disease account for 22 percent of deaths14.

Immunization coverage in Nigeria as well as other developing countries is low. As

part of the Child Survival Programme, the EPI (Expanded Programme on Immunization) was

created in 1974 by WHO and UNICEF and the Rotary International as partners. Since it’s

launching over sixty countries have adopted the programme and others are being constantly

added to the list. All of whom are laying emphasis on EPI as a building block for Primary

Health Care. Its aim is assisting all nations to carry out immunization of their 0-2 year child

population against vaccine preventable communicable and dangerous diseases of childhood.

The attempt by the Nigerian government to make the program come alive by renaming it as

NPI has been met with certain challenges due to lack of community participation, lack of

motivation by mother and vaccine availability.15

1.3 JUSTIFICATION

There is dearth of data on the Knowledge, attitude and practice (KAP) of

immunization among mothers of under 5 children in Nigeria. This can be attributed to the

4
many barriers against immunization, including misinformation about vaccines, their adverse

effect, vaccine preventable diseases and disease development after administration of

vaccines.16-18Inadequate or complete lack of knowledge about the contraindications of

vaccines also leads to many immunization errors.19

Certain mothers are of the opinion that ill-health is associated with vaccine

administration. As a result, the slightest illness however mild is considered a reason for not

giving their children up to date vaccination.19-21

Proper information and appropriate awareness regarding immunization will improve

mothers’ perception about the benefits of vaccines and help enhance their attitude towards

immunizing their children as well as ensure that they are up to date with the immunization

schedule21. Hence, there will be reduction in the incidence of infectious diseases especially

the vaccine preventable ones, giving children the chance for good health, ability to grow well,

go to school and improvement in their life prospect.

This study has not been done in MUTH, Elele. If for any reason the knowledge and

attitude is deficient in this area following this study, then substantial measures can be

recommended to ensure that mothers of under five children are appropriately enlightened

about immunization and where there are difficulties in uptake of the vaccines, proper

investigations can be carried out to ascertain the reasons, so appropriate interventions can be

put in place.

1.4 SCOPE OF STUDY

The study was not limited to assessing the knowledge, attitude and practice regarding

immunization of under five children among mothers attending antenatal clinic in MUTH, but

also to determine the factors and reasons why these children are not being immunized with

5
the available vaccines and assessment of the children who are up to date with their

immunization schedule. The research was done within the confinements of the hospital with

the mothers being the direct point of contact.

1.5 OBJECTIVES

1.5.1 GENERAL OBJECTIVES

The aim of this study was to determine the knowledge, attitude and practice regarding

immunization of under-five children among mothers attending antenatal clinic (ANC) at

Madonna University Teaching Hospital in Elele, Rivers State.

1.5.2 SPECIFIC OBJECTIVES

1. To determine the knowledge regarding immunization among mothers of under-five

children attending ANC at MUTH.

2. To determine the attitude towards immunization among mothers of under five children

attending ANC at MUTH.

3. To assess the level of utilization of immunization by mothers of under five children

attending ANC at MUTH.

4. To determine factors /reasons affecting utilization of immunization by mothers of under

five children attending ANC at MUTH.

6
 CHAPTER TWO

LITERATURE REVIEW

2.1 OVERVIEW

Immunization is one of the most effective interventions to prevent major illnesses that

contribute to child mortality in the country particularly in an environment where

malnourished children, overcrowding, poverty and illiteracy reign.22

Immunization has made an enormous contribution to public health, including the

eradication of one dreaded disease, small pox and elimination of poliomyelitis from all but a

handful of countries.23 In addition to other child care services, it ensures that the new born

child, grows with good health through infancy, preschool, school and adolescent period to a

healthy adult with healthy children.24

Millions of childhood deaths are averted annually through vaccination against

diphtheria, tetanus, pertussis and measles. However, vaccine-preventable diseases are still

7
responsible for about 25% of the 10 million deaths occurring annually among children under

five years of age.23

With the availability of new vaccines and further improvement in vaccination

coverage, a much larger proportion of children can now be protected against a broader range

of infectious diseases. Thus making vaccines one of the basic means of achieving the health

related United Nations Millennium Development Goals (MDG), especially MDG4 25 that calls

for reduction in the under-five mortality rate by 2015.26

The 58th World Health Assembly in 2005 recognised the role that immunization can

play in reducing under five mortality, welcomed the Global Immunization Vision and

Strategy (GIVS) 2006-2015 developed by WHO and UNICEF as a framework for

strengthening national immunization programmes. The goals of GIVS is to reduce illnesses

and deaths due to vaccine preventable diseases by at least two third by 2015 or earlier.27, 28

The task force on immunization in Africa (TFI), recognized from the onset the need

for high vaccination coverage to counter the disproportionate burden from vaccine

preventable diseases in African Region, and therefore set challenging goals for 2001-2005.

These goals aimed to ensure that immunisation performance of the African Region’s caught

up with other regions performance.29

BRIEF HISTORY OF IMMUNIZATION IN NIGERIA.

Immunization started in Nigeria in 1956 prior to the small pox eradication campaign.

The Expanded program on immunization (EPI) responsible for routine delivering of

immunization started in 1970 (USAID). Since then, The Federal Government of Nigeria

continued to place high priority on immunization and implementation with the aim of

providing immunization services to all children below 24 months of age against the

8
childhood killer diseases such as tuberculosis, whooping cough, poliomyelitis, diphtheria and

measles 30.

Following her partnership to the World Health Assembly, Nigeria adopted the World

Health Assembly Resolution (WHAR) and United Nation General Assembly Special Session

goals for all countries to achieve by 2005 and this lead to the development of certain policies

to be undertaken by the EPI as stated specifically by the Federal ministry of health. The

policies included; strengthening of immunisation system, accelerated disease control(that is

reduced incidence of measles and reduced cases of acute flaccid paralysis associated with

poliovirus by 2004 ), innovations (which involves introduction of new vaccines like vitamin

A and hepatitis B in the NPI and vaccination coverage not less than 80%). This policies has

not recorded 100% success, though enormous progress has been made31.

VACCINE AND VACCINATION

Vaccines are preparations of killed microorganisms, living attenuated organisms that

are administered to produce or artificially increase immunity to a particular disease. They are

special preparations of antigenic materials that can be used to stimulate the development of

antibodies and thus confer active immunity against specific number of diseases. Many

vaccines are produced by culturing bacteria or viruses under conditions that lead to a loss of

their virulence but not their antigenic nature32.

Vaccination is the administration of antigenic material (vaccine) to stimulate an

individual’s immune system to develop adaptive immunity to a pathogen. When a sufficiently

large percentage of population has been vaccinated, this results in herd immunity33.

Immunization is what happens when one has been vaccinated and simply a process by

which an individual’s immune system becomes fortified against an agent or a particular

disease5.

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TYPES OF VACCINES

-Live attenuated vaccine; derived from disease causing viruses or bacteria that have been

weakened under laboratory condition but still maintain their antigenic nature. However, they

can cause little or no disease. This provides lifelong immunity except for oral polio vaccine

that requires multiple doses. Examples are measles, yellow fever, BCG and OPV.

-Inactivated vaccines; are produced by growing viruses or bacteria and then inactivating it

with heat or chemicals. This requires multiple doses and are not as effective as live vaccines.

Examples are IPV, Pertussis, diphtheria, tetanus, hemophilus influenza type B.

-Recombinant vaccine; are produced by inserting the genetic material from a disease causing

organism. An example is hepatitis B vaccine6.

A number of other vaccine’s strategies are still under experimental investigation. Example

DNA vaccination.

MECHANISM OF ACTION

Once vaccines are introduced, they provide the body with harmless copies of the

antigen (antigens are portions of the surface of a bacterium or virus that the immune system

recognises as foreign and plays a role in causing disease by allowing that microorganism

attach itself to cells). As soon as the antigen is detected by the immune system, the B

lymphocytes of WBC creates antibody designed to be attached to the antigen.

If a true infection of same disease should occur, many copies of the antibody are

produced and these antibodies attach to their target thus blocking the activity of the virus

directly and hence fight the infection. In addition, the antibodies also makes it much easier

for other components of the immune system particularly the phagocytes to recognise and

destroy the invading agent.

10
 The immune system once exposed to a particular disease (bacterial or viral), will

recognise it and retains immunity to that disease for years, decade or even a life time 6.

VACCINE PREVENTABLE DISEASES.

Vaccine preventable diseases are infectious diseases for which an effective preventive

vaccine exists. They are diseases that are preventable using particular vaccines. The most

serious vaccine preventable diseases targeted by WHO are diphtheria, hemophilus influenza

serotype B, hepatitis B, measles, pertussis, poliomyelitis, rubella, tetanus, tuberculosis and

yellow fever infections13.The WHO has licenced vaccines available to prevent or contribute

to the prevention and control of about 25 vaccine preventable diseases34.

Death following a vaccine preventable disease is described as a vaccine preventable

death34. Vaccine preventable deaths are usually caused by failure to obtain the vaccine in a

timely manner. This may be due to financial constraints, lack of access to vaccines, severe

allergies, damaged immune system and in addition, absence of vaccines which are not

routinely received by residents of a particular country because the vaccine preventable

disease is uncommon in that country making them vulnerable if exposed to the disease35, 3

NATIONAL IMMUNIZATION PROGRAMME.

A national immunization program is the organizational component of ministries of

health charged with preventing diseases disabilities, and death from vaccine preventable

disease in children and adult. The national program on immunization is used interchangeably

with the expanded programme on immunization EPI that originally focused on preventing

diseases in children.

All countries have a National Immunization Programme to protect the population

against vaccine preventable diseases. The NPI core function is to ensure for safe storage,

handling, delivering and administration of vaccines that are effective and of high quality 37.

11
ROUTINE IMMUNIZATION SCHEDULE

According to the NPI, routine immunization of children is carried out using the

following vaccines, with the recent recommended immunization schedule.

Vaccines Age Number of dose Route of administration

BCG At birth 1 Intradermal

OPV 1 Oral

Hepatitis B 1 Intramuscular

Pentavalent vaccines At 6,10,and 14 3 Intramuscularly

1,2,3 weeks respectively

OPV 1,2,3 3 Oral

PCV At 6,10,and 14 3 Intramuscularly

weeks

Rota virus vaccine At 6 and 10 weeks 2 Oral

Measles At 9months 1 Subcutaneously

Yellow fever At 9months 1 Subcutaneously

Vitamin A At 9 and 15 2 Oral

12
 months

According to the Nigeria Federal ministry of Health definition, a child is considered fully

vaccinated if he or she has received a BCG vaccination against tuberculosis; 3 doses DPT to

prevent diphtheria, pertussis and tetanus with the inclusion of hepatitis B and hemophilus

influenza type B to make it pentavalent vaccine; at least 3 doses of polio vaccine; one dose of

measles and one dose of yellow fever vaccine.

These vaccination should be received during the 1st year of life, over the course of five

visits including the dose given at birth. Following this schedule, children aged 12-23 months

would have completed their immunization and be fully immunized. To keep track of the

administration of these immunizations, Nigeria also provided mothers with a health card on

which each dose received is recorded38, 39.

Recently three other vaccines have been added, i.e. the pneumococcal conjugate

vaccine, rota virus vaccine and vitamin A.

2.2 EMPIRICAL STUDIES

Worldwide studies report that successful immunization of children depends highly on

the mothers existing knowledge and positive attitude towards immunization. Individuals

perceived the benefits of vaccines as outweighing the risks. These positive perceptions were

supported by aspects of the social environment, including beliefs about infectious disease

threats, ideas of social responsibility, high levels of declared trust in authorities, a willingness

to conform and a strong sense of societal responsibility40.

13
2.2.1 KNOWLEDGE OF IMMUNIZATION

According to UNICEF, vaccine coverage is calculated as the percentage of persons in

the target age group who received a vaccine dose by a given age. Estimated Global DPT3

coverage amongst infants aged less than 12 months in 2012 was 83% from 72% in the WHO

African region to 97% in the western pacific. Amongst all incompletely vaccinated children

nearly 10million received one DPT dose but failed to complete the 3 dose series; however

56% never received the first DPT41.

Factors associated with under vaccination might differ from those associated with

non-vaccination. Mother’s attitude and knowledge about immunization appear to play a role

in non-vaccination of children42.

In a study in Enugu town, Nigeria. Mothers of varying age, occupation and socio

economic background were involved, 81.2% mentioned the prevention of major killer

diseases as the reason for immunization, and 17.4% said that children are immunized to

prevent or treat all diseases. About 93.7% of mothers were able to mention at least two major

killer diseases correctly. It was found that most mothers accepted immunization more in

immunization centres than during immunization campaign for reasons based on confidence of

the health personnel43.

In Northern Nigeria, a study showed that 1 in 500 mothers interviewed believed that

measles is prevented by immunization, 16% believed that it was caused by evil spirits,

witchcrafts and heat, 25% have never heard of immunization, 27% said they did not believe

in immunization, 4% were not allowed to go for immunization by their husband44.

In a study done in Ogbo-ora, Oyo state, Nigeria, it was found that majority of the

mothers interviewed (65.7%) got their awareness of immunization at the antenatal clinics.

14
General awareness (98.1%) was gotten from several sources. This can be attributed to a more

enlightened society that emerged with passage of time45.

Another study carried out in Kosofe LGA of Lagos state, Nigeria showed that

majority (83.3%) of mothers knew that immunization protects against infectious diseases.

This finding is slightly better than what was reported in a study conducted among mothers

dwelling in urban areas of New Zealand where about 78.5% of the respondents interviewed

knew what immunization does (Petousis- Harris, 2002). Odusanya et al 2008, Chhabra et al,

2007: stated that the ``parental knowledge on immunization contributes largely to

immunization coverage’’.46

In California, USA it was reported that most mothers were aware of immunization,

thereby leading to optimal utilization. The coverage however largely influenced by

government integration of it into schools.47

2.2.2 ATTITUDE TOWARDS IMMUNIZATION

Attitude is a feeling or way of thinking that affects a person’s behaviour 48. As related

to Immunization, it could be positive or negative, and it goes a long way to influence the

decisions made by mothers towards immunizing their children.

In Lagos, Nigeria, a study showed that most respondents were convinced that

immunization is necessary for their children and were ready to ensure immunization of their

children not minding the cost. They also believed they could advice their fellow women to

take their children for immunization. Only a few (1.5%) thought immunization can cause

HIV/AIDS. The overall attitude was very good.49

15
 In Borno, Nigeria, a study done revealed that the level of acceptance as being very

high and majority of the respondents indicated that they do not only accept the programme

but also present their children for immunization. This studies generally shows a good attitude

towards immunization of children and this improves the number of children that are likely to

be immunized.50

A study done in Ethiopia, reported that98% of the respondents had favourable attitude

towards immunization of infants.51A similar study done in Congo showed that 93.8% had

positive attitude towards children immunization.52

In India, a study done in Rajasthan shows that 88.6% of the study participants

expressed a favourable attitude towards the program, with 100% of mothers of fully

immunized, 86.5% of the partially immunized, and 61.3% of the not immunized children

showing favourable attitudes.53

In a study in Nairobi, Kenya it was discovered that participants who rated

immunization services as being very good (86.7%) were 2.2 times more likely to receive full

immunization compared to ones whose mothers had just good opinions about immunization.54

2.2.3 PRACTICE AND DETERMINANTS OF IMMUNIZATION UTILIZATION

Practice of immunization is greatly influenced by knowledge and attitude towards the

program, coupled with this are various limitations which may reduce access to immunization

services by the community. An assessment of these limitations is necessary in improving the

state of immunization of children within Nigeria.

A research done in Nigeria, recorded that less than half (32%) of the mothers

completed routine immunization schedules for their children by the age of nine months.

16
Various reasons were attributed to mothers not completing the immunization of their children

of which parent’s objections, disagreement or concern about immunization had the highest

percentage (38.8%). Others includes long distance walking (17.5%), long waiting time at the

health facility (17.5%), lack of money (10.6%), absence of personnel at the health facility

(5.4%), child ill health at the time of immunization (3.6%), lack of vaccine on the

appointment day (3.5%), lack of information on the day of the immunization (2.5%),

forgetting the day of the immunization (1.5%) and other reasons. The study was done in rural

areas of Nigeria with attitude towards immunization having the highest influence on their

practice.55

A worldwide review of why children are not vaccinated revealed that distance of

travel, poor health staff motivation and attitude, lack of logistics and resources false

contraindications failure to use all opportunities unreliability of vaccination program,

inappropriate and limited service hours, waiting time, informal illegal charges and indirect

costs, fear of side effects, lack of parental knowledge as part of the most mentioned key

factors limiting the immunization of children.56

A study in Southwest Nigeria revealed that 76.9% of children were fully immunized,

99.6% of respondents agreed that their culture permits immunization. Also 99.6% said their

husbands support it. About 46.1% attributed the reason for not completing immunization due

to a long waiting time on queue, in addition to paying for vaccines (20.2%) and traveling a

long distance (17.7%). 45

A study done in Bangladesh associated increase in full vaccination rate with higher

level of education of the mother. Distance from health facility, parity, mother’s age, mass

media, children's sex were also significantly associated with full vaccination 57. In Pilani

India, a study showed that literacy rate appearjed not to have a negative influence on

immunization.58

17
 In Mozambique, a study showed a good rating in practice of immunization in the area,

but despite this the reasons given by the respondents for not taking children for immunization

include, unawareness that the child was due for another vaccine i.e. insufficient knowledge,

loss of immunization card, child was ill, migration of parents up country, service charge and

shortage of vaccines at the health facilities.59

A study on immunization coverage rate done in Gambia showed a rate of 73% for

Measles, 86% for BCG, 79% for 3 doses of DPT and 52% for full immunization coverage

and was influenced by area of residence and ethnicity.60

CHAPTER THREE

METHODOLOGY

3.1 STUDY AREA

The study area was Madonna University Teaching Hospital (MUTH). MUTH is

located in Elele town Ikwere local government area of Rivers state, Nigeria. It is a private

tertiary health care facility located along the Owerri-Portharcourt express way with latitude of

6.20N and longitude of 700N. It is bounded by the catholic prayer ministry (CPM) and

Madonna University, Elele campus.

The type of persons seen in MUTH include health workers (such as doctors, nurses,

laboratory scientist, pharmacist) auxiliary nurses, hospital cleaners, lecturers, medical

18
students and other student offering health related courses. Majority of these persons are

Christians of different denominations.

The teaching hospital is made up of ten departments which includes the obstetrics and

gynaecology, ophthalmology, dental, psychiatric, radiology, surgical, medical, paediatric, and

physiotherapy departments; it has 26 wards – obstetrics and gynaecology wards, medical

ward, surgical ward, private ward, psychiatric ward, paediatrics ward. It also has the GOPD,

SOPD, MOPD, a pharmacy, a provision store, immunization unit, a medical laboratory and 2

restaurants.

3.2 STUDY POPULATION

The study population comprised of all mothers who had children under five years of

age irrespective of their status who are attending antenatal clinic of MUTH. The population

of women who attended clinic from 2014 to the month of August 2016 was obtained and it

was discovered that on average about 210 women usually come for antenatal visit within 3

months.

3.3 STUDY DESIGN

This is a descriptive cross sectional study that was carried out within a period of three

months, (which lasted Between September 2016 to December 2016), using a semi structured

questionnaire.

19
3.4 INCLUSION AND EXCLUSION CRITERIA

-INCLUSION CRITERIA

*The respondents were women who registered for antenatal clinic in MUTH.

*The respondents should have children under five years of age.

-EXCLUSION CRITERIA

*Women who do not have under – five children

*Women not attending antenatal clinics.

*Women attending antenatal clinic but are pregnant for the first time.

3.5 SAMPLE SIZE CALCULATION

Sampling size was calculated using the Cochrane formula for descriptive studies in

population >1000061.

N=Z2pq
d2

Z= the standard normal deviate which is equal to 1.96

d =the degree of accuracy usually 0.05

p = prevalence of the parameter of interest elsewhere.

q = 1-p

Where

20
Z = 1.96

d = 0.05

p = 52% = 0.52. (From a study done Gambia with full immunization coverage of 52%).60

q = 1-0.52= 0.48

(1.962)*0.52*0.48 = 0.9590 = 383.6

0.052 0.0025
For population <10000 we use the Cochrane correction formula61.

nf = n/ (1+n/N)

Where,

nf = Sample size when population is less than 10000

n = Sample size when population is greater than 10000

N = Estimated population size

N= 210
n=383.6
383.6 = 383.6 = 383.6 = 135.6
(1+383.6/210) 1+ 1.83 2.83
nf = 136 (approx.)

However to increase the power of study with 10% risk of attrition, the population studied was
136*0.1= 13.6
= 136+13.6= 149.6.
= 150 (approx.)

3.6 SAMPLING METHOD.

21
 Sampling method used was Systematic Random Sampling of the women attending

Antenatal. The numbers given to the women attending ANC for the week was used. A sample

interval was gotten by dividing the total number of women who attended ANC for that week

by 15 (Target sample for each week of ANC attendance). A total of 15 samples were

collected each week.

I.e. Sampling interval = population size for the week/ target sample size for a week.

180 samples were collected and analysed.

3.7 DATA COLLECTION METHOD

Data collection was done using a semi-structured questionnaire (Appendix I).

Research assistants helped in administering questionnaires to the uneducated. The

respondents were enlightened about the topic and the questionnaires administered to those

who were willing to comply. The questionnaire was divided into 4 section:

SECTION A: Comprised of socio-demographic data of the respondents

SECTION B: This assessed the knowledge regarding immunization of under 5 children. The

knowledge score was got using 10 selected questions from this section. For each correct

answer a score of 1 was awarded and for an incorrect answer a score of 0. The total score was

added for each of the respondents and a total score of 7-10 was considered as an excellent

knowledge score. With 5 and 6 a good score, 0-4 a poor score.

SECTION C: This was used to assess the attitude towards immunization of under 5 children.

Five selected questions from this section was used to assess their attitude score. This was

done for each of the respondents. Each correct answer earned 1 point and incorrect answers 0

22
points. A total score of 4-5 was considered to be an excellent score, a score of 3 a good score

and 0-2 was taken to be a poor attitude score.

SECTION D: This assessed the practice of immunization among mothers with under 5

children. Five questions were selected and used to assess the practice score. Correct answers

score a point each and incorrect answers to the questions zero points. The total score of 4-5

was considered to be an excellent score with 3 a good score and 0-2 a poor score.

3.8 DATA ANALYSIS

Collected data was analyzed using the software Statistical Package for the Social

Sciences (SPSS) version 20: IBM, USA. Frequencies and Percentages were presented in

tables. Chi-square test was used to determine association between variables and statistical

significance was set at p= 0.05.

3.9 ETHICAL APPROVAL

Approval of the project was got from.

1. The Department of community medicine, Madonna University, Elele.

2. The Office of the Chief Medical Director, Madonna University Teaching Hospital, Elele.

3. The Head of Obstetrics Department, Madonna University Teaching Hospital, Elele.

4. Informed consent from respondents

3.10 ASSISTANCE USED

The help of the following was employed for the study

23
1. An Interviewer for better communication

2. Auxiliary Nurses, obstetrics department MUTH

3. Nurses, Obstetrics department MUTH

3.11 LIMITATIONS

1. Corporation of respondents: We had convince them of the confidentiality of their

responses to the questionnaire and explain the purpose of the research.

2. Misinterpretation of questionnaire: Questions that seem difficult where explained and

simplified by the interviewers whenever required.

3. Communication barriers: An interpreter was used when necessary to assist the

respondents.

4. False information by respondents: Some of the responses such as Age, marital status and

parity where cross checked with the respondents’ anti natal folders with the aid of the

Obstetric nurses.

3.12 SCHEDULE OF ACTIVITIES

Activity Time Responsible personnel

Proposal Writing 20/08/16-20/09/16 Researchers

Data Collection October 2016 - Researchers

January
2017

Data Analysis February – April Researchers and

2017 Supervisor

24
Final Report October 2017 Researchers and
Writing Supervisor

CHAPTER FOUR
RESULTS
SOCIODEMOGRAPHY
TABLE 1A:
FREQUENCY PERCENTAGE (%)
AGE (IN YEARS)
<20 2 1.1
21 – 25 39 21.7
26 – 30 91 50.6
31 – 35 34 18.9
36 – 40 11 6.1
>41 3 1.7

25
 TOTAL 180 100

RELIGION
CHRISTIAN 176 97.8
MUSLIM 4 2.2
TOTAL 180 100

TRIBE
IGBO 101 56.1
HAUSA 1 0.6
YORUBA 7 3.9
IKWERE 48 26.7
OTHERS 23 12.8
TOTAL 180 100

OCCUPATION
CIVIL SERVANT 45 25.0
BUISNESS WOMAN 83 46.1
PETTY TRADER 13 7.2
FARMER 1 0.6
CLERGY 5 2.8
OTHERS 33 18.3
TOTAL 180 100

MARITAL STATUS
SINGLE 4 2.2
MARRIED 175 97.2
DIVORCED 1 0.6
TOTAL 180 100

FAMILY TYPE
MONOGAMOUS 156 86.7
POLYGAMOUS 22 13.3
TOTAL 180 100
Table 1A shows that a total number of 180 mothers were analysed. The age range of 26 to 30

years had the highest percentage (50.6%). Christians (97.8%) were more than Muslims

(2.2%). Most of them belong to the Igbo and Ikwere tribe, 56.1% and 26.7% respectively.

Majority were business women (46.1%), 25.0% were civil servants and 18.3% were of other

professions. Ninety seven point two percent (97.2%) of the mothers were married with

majority into the monogamous family type (86.7%) and 13.3% into the polygamous family

type.

26
TABLE 1B:
EDUCATIONAL STATUS FREQUENCY PERCENTAGE
NO FORMAL EDUCATION 6 3.3
COMPLETED PRIMARY 13 7.2
COMPLETED SECONDARY 88 48.9
COMPLETED TERTIARY 73 40.6
TOTAL 180 100

HUSBAND EDUCATION
STATUS
NO FORMAL EDUCATION 1 0.6
COMPLETED PRIMARY 6 3.3
COMPLETED SECONDARY 74 41.1

27
 COMPLETED TERTIARY 96 53.3
NO RESPONSE 3 1.7
TOTAL 180 100

Table 1B shows that Eighty nine point five percent of mothers have completed at least

secondary level of education and 53.3% of their husbands completed tertiary level of

education.

KNOWLEDGE
TABLE 2: RESPONDENTS’ GENERAL KNOWLEDGE ON IMMUNIZATION
VARIABLE FREQUENCY PERCENTAGE (%)
HAVE YOU HEARD ABOUT
IMMUNIZATION?
YES 178 98.9
NO 2 1.1

SOURCE OF KNOWLEDGE
ON

28
 IMMUNIZATION(MULTIPLE
RESPONSES)
A FRIEND 16 8.9
TELEVISION 25 13.9
RADIO 16 8.9
PARENTS 16 8.9
LECTURERS 11 6.1
HEALTH WORKERS 87 48.3
DOCTORS 48 26.7
ANTENATAL CARE 65 36.1

RESPONDENTS
KNOWLEDGE ON HOW
IMMUIZATION IS
ADMINISTERED(MULTIPLE
RESPONSES)
THROUGH INJECTION 172 95.6
ORAL DROPS 114 63.3
THROUGH FOOD 4 2.2
BY PRAYING 1 0.6

Table 2 shows that 98.9% of respondents had heard of immunization. The source of

knowledge for many of the mothers was from the health workers (48.3%), 36.1% got to know

through ANC, 26.7% knew through the doctors as against 13.9%, 8.9% and 8.9% whose

sources of knowledge were through television, radio and friend respectively. Most of the

mothers (95.6%) correctly identified that immunization is administered through injection and

63.3% through oral drops with 2.2% and 0.6% wrongly stating food and by praying

respectively.

29
TABLE 3: REPONDENTS’ KNOWLEDGE ON WHO ADMINISTERS VACCINES
AND WHERE IT CAN BE DONE
VARIABLE FREQUENCY PERCENTAGE (%)
RESPONDENTS’
KNOWLEDGE REGARDING
WHERE IMMUNIZATION IS
DONE(MULTIPLE
RESPONSES)
IN CHURCH 15 8.3
IN MOSQUE 3 1.7
AT HOSPITALS 177 98.3
WITH TBA 2 1.1
HOME 29 16.1

30
 RESPONDENTS’
KNOWLEDGE REGARDING
WHO ADMINISTERS
IMMUNIZATION(MULTIPLE
RESPONSES)
HEALTH WORKERS 39 49.4
PASTORS 3 1.7
NURSES 127 70.6
IMAMS 1 0.6
LAWYERS 1 0.6

Table 3 shows that majority of the respondents (98.3%) indicated that immunization is done

in hospitals, 16.1% indicated immunization can be done at home. Most of the mothers 70.6%

indicated that immunization is performed by the nurses and 49.4% indicated it’s done by the

health worker.

TABLE 4: RESPONDENTS’ KNOWLEDGE ON VACCINE PREVENTABLE

DISEASES
VARIABLES FREQUENCY PERCENTAGE (%)
RESPONDENTS’
KNOWLEDGE
REGARDING WHICH
DISEASE VACCINES
CAN PREVENT
(MULTIPLE
RESPONSES)
MEASLES 151 83.3
POLIO 145 80.5
CHICKEN POX 117 65.0

31
 TUBERCULOSIS 108 60.0
YELLOW FEVER 104 57.8
HEPATIS 80 44.4
PERTUSIS 57 31.7
DIPHTHERIA 49 27.2

RESPONDENTS’
KNOWLEDGE
REGARDING VACCINE
FAILURE.
CAN VACCINES FAIL?
YES 37 20.6
NO 143 79.4
REASONS WHY
VACCINES CAN FAIL
IF YES WHY?
NOT PROPERLY 14 37.8
ADMINISTERED
EXPIRED 10 27.0
I DON’T KNOW 4 10.8
POOR STORAGE 4 10.8
FAKE 3 8.1
NOT COMPLIANT TO 1 2.7
SCHEDULE
WEAK CHILDREN 1 2.7

RESPONDENTS’
KNOWLEDGE
REGARDING DISEASE
PREVENTION BY
VACCINATION.
YES 175 97.2
NO 5 2.8

Table 4 shows a greater percentage of the respondents are aware that immunization can

prevent measles, polio and yellow fever (83.3%, 80.5% and 57.8% respectively). Sixty five

percent (65.0%), sixty percent (60.0%) of the respondents think vaccines can prevent chicken

pox and tuberculosis respectively. A good number of mothers (79.4%) think vaccine cannot

fail while 20.6% stated that vaccine can fail. Most of their reasons were if the vaccine is

expired (27.0%) and if not properly administered (37.8%). Almost all the respondents 97.2%

indicated that vaccines can prevent the occurrence of diseases in an individual.

32
TABLE 5: FREQUENCY OF VACCINE ADMINISTRATION
ARE ALL VACCINES
GIVEN AT ONCE? FREQUENCY PERCENTAGE (%)
YES 55 30.6
NO 125 69.5

Table 5 shows frequency of vaccine administration. Most of the mothers (69.0%) correctly

indicated that not all vaccines are given once and 30.6% indicated that all vaccines are given

once.

33
TABLE 6: RECIPIENTS OF VACCINE (MULTIPLE RESPONSES)
WHO SHOULD
RECEIVE A VACCINE? FREQUENCY PERCENTAGE (%)
ONLY CHILDREN 48 26.7
ONLY ADULTS 2 1.1
ONLY GIRLS 3 1.7
ONLY BOYS 4 2.2
ALL 131 72.7

34
Table 6 shows that majority of the respondents 72.7% indicated that every person is eligible

for vaccination. Twenty six point seven percent (26.7%) indicated that only children should

be vaccinated.

TABLE 7: KNOWLEDGE SCORE QUESTIONS

QUESTIONS CORRECT ANSWER %

Have you heard about immunization 98.9
Immunization is performed by health worker 49.9
Immunization is performed by nurses 70.6
Immunization administered through injection 95.6
Immunization administered through oral drops 66.3
Can vaccine prevent disease in an individual 97.2

35
 Is immunization done in church 91.7
Is immunization done in a hospital 98.3
Is immunization done at home 16.1
Can vaccine fail 20.1

Table 7 shows the questions that where analysed to get the knowledge score with the

percentage of correct answers of the respondents.

TABLE 8: RESPONDENTS’ SCORE ON KNOWLEDGE REGARDING

VACCINATION
NUMBER OF
GRADE SCORE RESPONDENTS PERCENTAGE
Excellent 7-10 117 65%
Good 5-6 61 33.9%
Poor 0-4 2 1.11%

36
Table 8 shows the level of knowledge of respondents. Most of the respondents had either an

excellent knowledge score (65%) or a good knowledge score (33.9 %.). The knowledge score

of each of the respondents was gotten from the number of correct answers they indicated

from table 7 with each correct answer scoring one.

ATTITUDE

TABLE 9: ATTITUDE OF RESPONDENTS TOWARDS IMMUNIZATION

VARIABLES FREQUENCY PERCENTAGE(%)
IS IMMUNIZATION
IMPORTANT?
YES 178 98.9

37
 NO 0 0.0
I’M NOT SURE 2 1.1

DO YOU BELIEVE
VACCINES CAN KILL?
YES 19 10.5
NO 161 89.4

WILL YOU IMMUNIZE

ALL YOUR CHILDREN?
YES 180 100
NO 0 0.0

WILL YOU ADVICE

OTHERS TO IMMUNIZE
THEIR CHILDREN?
YES 179 99.4
NO 1 0.6

Table 9 shows majority of the respondents believe immunization is important (98.9%).

Eighty nine point four percent (89.4%) of respondents indicated that vaccines are not

harmful. All the respondents had positive attitude towards immunizing their children under

5years of age and almost all the respondents’ (99.4%) will advise others to immunize their

children below 5 years of age.

38
TABLE 10: ATTITUDE OF RESPONDENTS’ FAMILY AND FRIENDS
TOWARDS IMMUNIZATION
VARIABLE FREQUENCY PERCENTAGE (%)
DOES YOUR HUSBAND
SUPPORT
IMMUNIZATION?
YES 174 96.7
NO 2 1.1
NO RESPONSE 4 2.2

39
 IF NO WHY?
MAKES CHILDREN SICK 2 100

DO YOUR PARENTS
SUPPORT
IMMUNIZATION?
YES 180 100
NO 0 0.0

DOES YOUR INLAW

SUPPORT
IMMUNIZATION?
YES 176 97.8
NO 4 2.2
IF NO WHY
CHILDREN DON’T NEED 1 25.0
IT
NO REASON 3 75.0

HAVE YOU EVER BEEN

TOLD NOT TO
IMMUNIZE YOUR
CHILD?
YES 17 9.4
NO 163 90.6
IF YES, BY WHO?
A FRIEND 11 64.7
HEALTH WORKER 2 11.8
GRAND PARENTS 1 5.8
HUSBAND 2 11.8
NEIGHBOURS 1 5.8

Table 10 shows that ninety six point seven percent (96.7%) of husbands showed good attitude

towards immunization. All parents of respondents (100%) are in support of immunization.

Most of the in-laws 97.8% are positive towards immunization with 2.2% not in support. Most

of the respondents did not give reasons why their in-laws do not support immunization. Few

of the respondents (9.4%) have been told not to immunize their children by friends (64.7%),

health worker (11.8%), grandparents (5.8%), husbands (11.8%), and by neighbours (5.8%).

40
TABLE 11: ATTITUDE SCORE QUESTIONS

QUESTIONS CORRECT ANSWER %

Will you immunize all your children? 100%
Will you advice others to immunize their children? 99.4%
Do you think immunizing your child can help in preventing some 99.4%
diseases?
Is immunization important? 98.4%
Do you believe vaccines can kill 89.4%

41
Table 11 shows attitude score questions and the percentage of correct answers given by
respondents

TABLE 12: RESPONDENTS’ SCORE ON ATITUDE REGARDING

IMMUNIZATION
NUMBER OF
GRADE SCORE RESPODENTS PERCENTAGE(%)
Excellent 4-5 179 99.4
Good 3 1 0.6
Poor 0-2 0 0.0

Table 12 shows that ninety nine point four percent (99.4%) had an excellent score in their

attitude regarding immunization. The attitude score of each of the respondents was gotten

42
from the number of correct answers they indicated from table 11 with each correct answer

scoring one.

PRACTICE

TABLE 13: IMMUNIZATION OF RESPONDENTS DURING PREGNANCY

HAVE YOU EVER BEEN
IMMUNIZED DURING
PREGNANCY FREQUENCY PERCENTAGE (%)
YES 165 91.7
NO 15 8.3

43
Table 13 shows that majority of the respondents 91.7% were immunized in previous

pregnancy.

TABLE 14: IMMUNIZATION OF CHILDREN BELOW 5 YEARS OF AGE

WAS YOUR
CHILD/CHILDREN
BELOW FIVE YEARS
IMMUNIZED? FREQUENCY PERCENTAGE (%)
YES 171 95.0
NO 9 5.0

44
Table 14 shows that ninety five percent of respondents immunized their children below 5

years of age, while the remaining 5% did not.

TABLE 15: PLACE OF DELIVERY OF LAST CHILD AND IMMUNIZATION AT

BIRTH
VARIABLE FREQUENCY PERCENTAGE (%)
WHERE DID YOU
DELIVER YOUR LAST
CHILD?
HOSPITAL 148 82.2
MATERNITY 20 11.1
TBA 12 6.7
CHURCH 0 0.0

45
 WAS YOUR LAST
CHILD IMMUNIZED AT
BIRTH?
YES 150 83.3
NO 30 16.7

Table 15 shows that most of the respondents (82.2%) had their last delivery in a hospital, as

against 11.1% and 6.7% of them who delivered in the maternity centre and with the TBA

respectively. Greater percentage of the mothers, 83.3%, immunized their children at birth.

TABLE 16: HEALTH CENTRE RENDERING IMMUNIZATION AROUND

RESPONDENTS AND PLACE OF IMMUNIZATON OF LAST CHILD.
VARIABLE FREQUENCY PERCENTAGE (%)
HEALTH CENTRE
RENDERING
IMMUNIZATION
AROUND YOU?
YES 161 89.4
NO 19 10.6

46
 WHERE WAS YOUR
LAST CHILD
IMMUNIZED?
HOME 7 3.9
HOSPITAL 146 81.1
HEALTH CENTRE 26 14.4
OTHERS 1 0.6

Table 16 shows that majority 89.4%, had health centres that render immunization around

them. Most of the respondents 81.1%, immunized their last child in a hospital; few of them

14.4% in the health centre.

TABLE 17: COMPLETION OF IMMUNIZATION OF LAST CHILD AND

INFLUENCING FACTORS
VARIABLES FREQUENCY PERCENTAGE (%)
DID YOU COMPLETE
THE IMMUNIZATION
OF YOUR LAST CHILD?
YES 161 89.4
NO 19 10.6
IF NO, WHY?
NEGLIGENCE 13 68.4

47
 INADEQUATE 2 10.5
KNOWLEDGE
DISTANCE 2 10.5
FEAR OF PAALYSIS 1 5.3
RELOCATION 1 5.3

DO YOU HAVE
IMMUNIZATION
CARD?
YES 166 92.2
NO 14 7.8

HOW DO YOU KNOW

IT’S TIME FOR
IMMUNIZATION?
IMMUNIZATION CARD 169 93.9
PHONE CALL 2 1.1
HOME VISIT 9 5.0

Table 17 shows that eighty nine point four percent (89.4%) of mothers completed the

immunization of their last child. The remaining 10.5% did not. Reasons for not completing

the immunization of their child include; distance10.5%, relocation 5.3%, fear of paralysis

5.3%, inadequate knowledge 10.6%, and negligence 68.4%. Almost all the respondent 92.2%

had immunization card for their children. Immunization card 93.9%, was the major means

used in remembering the scheduled time for the next vaccination.

48
TABLE 18: RESPONDENTS’ PRACTICE SCORE QUESTIONS
QUESTIONS C0RRECT
ANSWER %
DO YOU HAVE IMMUNIZATION CARD? 92.2
HAVE YOU EVER BEEN IMMUNIZED DURING 91.7
PREGNANCY?
DID YOU COMPLETE IMMUNIZATION OF YOUR LAST 89.4
CHILD?
WERE YOUR CHILDREN IMMUNIZED T BIRTH? 83.3
WHERE DID YOU DELIVER YOUR LAST CHILD? 82.2

49
Table 18 shows respondents’ practice score and the percentage of correct answers given by
the respondent.

TABLE 19: RESPONDENTS’ PRACTISE SCORE OF IMMUNIZATION

NO OF PERCENTAGE
GRADE SCORE RESPODENTS (%)
Excellent 4-5 160 88.9
Good 3 10 5.6
Poor 0-2 3 5.6

50
Table 19 shows that eighty eight point nine percent (88.9%) had excellent practice on

immunization. The practice score of each of the respondents was gotten from the number of

correct answers they indicated from table 18 with each correct answer scoring one.

TABLE 20: ASSOCIATION BETWEEN EDUCATIONAL STATUS OF

RESPONDENTS AND THEIR AWARENESS THAT IMMUNIZING
YOUR CHILD CAN HELP PREVENT DISEASES
DO YOU THINK CHI P-VALUE
IMMUNIZING YOUR SQUARE
CHILD CAN HELP
PREVENT DISEASE?
YES NO

51
 EDUCATIO NO FORMAL 5 1 29.162 0.000
N STATUS EDUCATION 83.3% 16.7%
COMPLETED 13 0
PRIMARY 100.0% 0.0%
COMPLETED 88 0
SECONDARY 100.0% 0.0%
COMPLETED 73 0
TERTIARY 100.0% 0.0%

Table 20 shows that the educational status of the respondents had an effect on their awareness

that immunizing their children can help prevent diseases with the P value of 0.000. This is

statistically significant as the P value is less than 0.05.

TABLE 21: ASSOCIATION BETWEEN OWNING AN IMMUNIZATION CARD

AND RESPONDENTS’ COMPLETION OF IMMUNIZATION OF
THEIR LAST CHILD
DID YOU COMPLETE CHI P-VALUE
THE IMMUNIZATION SQUARE
OF YOUR LAST
CHILD?
YES NO
DO YOU HAVE YES 151 12 27.015 0.000
IMMUNIZATION 92.6% 7.4%

52
 CARD? NO 6 7
46.2 53.8%
TOTAL 157 19
89.2 10.8

Table 21 shows that the association between owning an immunization card and complete

immunization of respondents’ children is significant with a P value of 0.000.

TABLE 22: ASSOCIATION BETWEEN RESPONDENTS’ EDUCATION LEVEL

AND THEIR AWARENESS OF IMMUNIZATION
HAVE YOU HEARD CHI P-VALUE
OF IMMUNIZATION? SQUARE
YES NO
EDUCATIONAL NO FORMAL 6 0 2.114 0.549
STATUS EDUCATION 100.0% 0.0%
COMPLETED 13 0
PRIMARY 100.0% 0.0%

53
 COMPLETED 86 2
SECONDARY 97.7% 2.3%
COMPLETED 73 0
TERTIARY 100.0% 0.0%

Table 22 shows that educational status is not statistically significant for their awareness of

immunization.

TABLE 23: ASSOCIATION BETWEEN IMPORTANCE OF IMMUNIZATION

AND COMPLETION OF IMMUNIZATION OF RESPONDENTS’
LAST CHILD
DID YOU COMPLETE CHI P-VALUE
IMMUNIZATION OF SQUARE
YOUR LAST CHILD?
YES NO
IS YES 156 18 3.229 0.072

54
 IMMUNIZATION 89.7% 10.3%
IMPORTANT
I AM NOT 1 1
SURE 50.0% 50.0%

Table 23 shows that Immunization importance is not statistically significant to the completion

of immunization of their last children by the respondent.

TABLE 24: ASSOCIATION BETWEEN THE AVAILABILITY OF HEALTH

CARE CENTRE CLOSE TO RESPONDENTS AND COMPLETION OF
IMMUNIZATION THEIR LAST CHILD
DID YOU COMPLETE CHI P-VALUE
IMMUNIZATION OF SQUARE
YOUR LAST CHILD?
YES NO
DO YOU HAVE YES 142 16 0.718 0.397

55
 A HEALTH 89.9% 10.1%
CENTRE THAT NO 15 3
RENDERS 83.3% 16.7%
IMMUNIZATION
AROUND YOU

Table 24 shows that the presence of health centre that renders immunization around

respondents is not statistically significant for the completion of immunization of their last

children. The P value is 0.397 which is greater than 0.05.

TABLE 25: ASSOCIATION BETWEEN THE EDUCATIONAL STATUS AND

PLACE OF DELIVERY OF RESPONDENTS’ LAST CHILD
WHERE DID YOU DELIVER CHI P-
YOUR LAST CHILD? SQUAR VALUE
HOSPITAL MATERNITY TBA E

EDUCATIO NO FORMAL 5 1 0 4.421 0.620

NAL EDUCATION 83.3% 16.7% 0.00
STATUS %

56
 COMPLETED 10 1 2
PRIMARY 76.9% 7.7% 15.4
%
COMPLETE 71 9 6
SECONDARY 82.9% 10.5% 7.0%

COMPLETED 62 9 2
TERTIARY 82.9% 12.3% 2.7%

Table 25 shows that the educational status of respondents does not significantly influence the

place of delivery of their last child.

TABLE 26: ASSOCIATION BETWEEN PLACE OF DELIVERY OF

RESPONDENTS’ LAST CHILD AND IMMUNIZATION OF CHILD

AT BIRTH

WAS YOUR CHILD CHI P-VALUE

IMMUNIZED AT SQAURE
BIRTH?
YES NO

57
 WHERE HOSPITAL 131 13 23.099 0.000
DID YOU
DELIVER 91% 9.0%
YOUR
MATERNITY 14 5
LAST
CHILD? 73.7% 26.3%

TBA 4 6

40.0% 60.0%

Table 26 shows that the place of delivery of respondents’ last child had a significant

association with their immunization at birth. This is statistically significant with a P value of

0.000 which is less than 0.05.

TABLE 27: ASSOCIATION BETWEEN EDUCATIONAL STATUS OF

RESPONDENTS AND THEIR KNOWLEDGE SCORE

KNOWLEDGE SCORE CHI P-

SQUARE VALUE

7-10 5-6 0-4

EDUCATIONAL NO FORMAL 2 4 0

58
 STATUS EDUCATION 66.7% 5.309 0.505

33.3% 0.0%

COMPLETED 11 2 0

PRIMARY 84.6% 15.4% 0.0%

COMPLETED 58 29 1

SECONDARY 65.8% 33.0% 1.1%

COMPLETED 46 26 1

TERTIARY 63.0% 35.6% 1.4%

Table 27 shows that the association between respondents’ educational status and knowledge

score is not statistically significant.

TABLE 28: ASSOCIATION BETWEEN THE RESPONDENTS LEVEL OF

EDUCATION AND THEIR ATTITUDE SCORE

ATTITUDE SCORE CHI P

SQUARE VALUE
4-5 3 0-2

EDUCATIONAL NO FORMAL 6 0 0
STATUS
EDUCATION

59
 100% 0.0% 0.0% 12.918 0.05

COMPLETED 12 1 0

PRIMARY 92.3% 7.7% 0.0%

COMPLETED 88 0 0

SECONDARY 100% 0.0% 0.0%

COMPLETED 73 0 0

TERTIARY 100.0% 0.0% 0.0%

Table 28 shows a statistically significant association between educational status of

respondents and their attitude score. The P-value is 0.05.

KNOWLEDGE SCORE CHI P-

SQUARE VALUE
7-10 5-6 0-4

YES 103 53 1

60
 DID YOU 65.6% 33.8% 0.6% 3.232 0.199

COMPLETE
NO 12 6 1
THE
63.2% 31.6% 5.3%
IMMUNIZATION

OF YOUR LAST

CHILD

TABLE 29 ASSOCIATION BETWEEN KNOWLEDGE SCORE AND

COMPLETION OF IMMUNIZATION OF LAST CHILD

Table 29 shows the association between knowledge score of respondents and completion of

immunization of their last child. The p value is 0.199 which is not statistically significant.

CHAPTER FIVE
DISCUSSION

61
 Immunization has made a significant impact on global public health and its

importance in prevention of certain diseases in children cannot be overemphasized. However,

to achieve maximum benefit, immunization coverage should reach certain levels for different

diseases. Achieving this requires effort on provision of immunization services and also

optimum utilization of these services by the target population. The main target of childhood

immunization are mothers of under five children and there’s a need for them to be

sufficiently aware of the benefits and have a good attitude towards immunization services.

In the study, most of the mothers were within the age groups 21-25, 26-30 and 31-35

(21.7%, 50.6% and 18.9% respectively), majority of them are Christians (97.8%). A large

number of the mothers are Igbo by tribe (56.1%), Ikwere (26.7%), Yoruba (3.9%) Hausa

(0.6%) and other tribes taking the remaining 12.8%. They are mostly business women, civil

servants and petty traders with the married proportion dominating 97.2%. Up to 40.6% of the

women have completed tertiary level of education, the rest have a majority of them who have

completed secondary level 48.9%, 7.2% have completed just primary and a minority with no

formal education.

5.1 KNOWLEDGE OF IMMUNIZATION

The study showed that 98.9% of mothers attending antenatal care had heard about

immunization, most of their knowledge source was from health workers, antenatal clinic and

62
doctors (48.3%,36.1% and 26.7%) respectively, this is similar to a study conducted by

Adeyinka45 where most of the mothers source of knowledge was from the antenatal clinic

(65.7%) and health workers(19.2%). Generally this indicates that mothers of under five

children get informed about immunization mostly from or around the hospital environment.

Other sources of immunization are quite low with information from friends, parents and radio

taking 8.9% each and television 13.9%.

In our study, knowledge about vaccine preventable diseases was encouraging because

a large number of mothers knew that vaccines could prevent measles (83.3%), polio (80.5%),

chickenpox (65.0%), tuberculosis (60%), yellow fever (57.8%), hepatitis B (44.4%), pertussis

(31.7%) and diphtheria (27.2%). In comparism to a study done by Abidoye et al46 where

mothers knowledge of the vaccine preventable diseases was for measles(73.5%),

polio(85.5%), tuberculosis(89.5%), yellow fever(71.0%), hepatitis B (42.0%) pertussis and

diphtheria(78.5%). This showed that the respondents had a good knowledge about the

vaccine preventable diseases.

A knowledge score based on selected questions from the questionnaire showed that

65% had an excellent knowledge and 33.9% had a good knowledge of immunization. This

result was similar to a study done by Tagbo B.N in Enugu where 82% of respondents knew

that immunization helped to prevent major killer diseases 43. The reason may be due to the fact

that most mothers had attained secondary and tertiary level of education (48.9% and 40.6%

respectively). This effect of maternal education was also noted in a work done in Enugu on

Mothers knowledge, perception and practice of immunization 43, though a cross tabulation of

the association between mothers education level and the knowledge score wasn’t significant

with a p-value of 0.505. In addition to this, most of their sources of knowledge was from

63
health care officers and ante natal clinic, it stands to reason that they would have been given a

good orientation about immunization and its importance to their children.

The setbacks to adequate knowledge include the fact that only a few percentage of

mothers could properly identify that immunization can be done at home (16.1%), with most

indicating it can be done in hospitals (98.3%). Also a majority of them believed vaccines

can’t fail (79.4%) with a low proportion being able to identify diphtheria, pertussis and

hepatitis B (27.2%, 31.7%, 44.4% respectively) as diseases vaccines can prevent.

5.2 ATTITUDE TOWARDS IMMUNIZATION

Attitude is one of the major determinants of practice of immunization. Immunization

services need to be accepted and generally considered important for maximum utilization of

these services.

In our study, most mothers 98.9% felt immunization is important to the health of their

children while 1.11% where not sure immunization is important. This is similar to a study

done by D. Adeyinka in south west Nigeria where 99.4% of the mothers thought their

children should be immunised45. Majority of the respondents also indicated they will

immunize all their children and further advice other mothers to also take their children for

immunization.

Attitude towards immunization is greatly influenced by support of immunization by

close relatives and friends. With a good support from their husbands, parents and in-laws the

respondents showed a positive attitude towards immunizing their children. Generally 99.4%

of mother had an excellent attitude towards immunisation this is in contrast to a study in

64
Borno state where respondents believed that immunization was a means through which the

government try to control their birth rate50.

Despite the positive attitude, a number of the mothers (9.4% of respondents) have

been advised not to immunize their children mostly by friends (64.7%), health workers and

husbands (11.8% each), neighbours and grandparents (5.8% each).

A cross tabulation showed educational status had a significant association with the

attitude of the respondents with a p-value of 0.05. The high level of education may be

responsible for the excellent attitude of majority of the women. In addition to this, the study

was conducted among a group who are receptive towards hospital services (Antenatal Care),

this may also contribute to their positive attitude towards immunization.

5.3 UTILIZATION OF IMMUNIZATION AND ITS DETERMINANTS

Majority of the mothers indicated that they immunized their children below five years

of age (95%). A large proportion also had a good practice of immunization during pregnancy

with tetanus toxoid vaccine (91.7%).

With regards to place of immunization we noted that majority of the mothers got their

children immunized at hospitals (81.1%), with home visits having the lowest frequency

(3.9%). This low frequency may point out to the inadequacy of supplemental vaccination

programs and campaigns around this region. This in comparism to the work by B.N.Tagbo et

al in Enugu, southeast Nigeria in which there was a high proportion of vaccinated children

among mothers who delivered in primary and tertiary health centres as compared to maternity

homes64. This shows the great influence Hospitals have on immunization.

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 Immunization at birth of children serves as an important channel through which

mothers are initiated into the practice of routine immunization of their children and the place

of birth goes a long way to determine this. In our study we noticed a significant association

between these two variables with a p-value of 0.000 with most of the women who delivered

in hospitals understandably practicing immunization at birth as compared to those who

delivered with a traditional birth attendant. The same association was noticed in a study done

by Tabgo B.N on Vaccination Coverage and its Determinants in Children Aged 11-23

Months in Enugu state64.

Initiation and completion of immunization in our environment is influenced by a great

number of factors. These factors consequent of the general deterrents such as poverty,

ignorance and inadequate government participation in immunization programs often lead to

suboptimal utilization of immunization services. Most of the respondents confirmed the

presence of a centre rendering immunization around them (89.4%), despite this not all

mothers completed the immunization of their children who are under five(10.6%) . This is

similar with a work done by D. Adeyinka, where about 76.9% of the children were fully

immunized45. The knowledge score of the respondents in the study did not have a significant

association with completing the immunization of their children below 5 years of age with a P

value of 0.199 (Table 29).

A cross tabulation of the association between mothers completing the immunization of

their children and the presence of an immunization centre close to their residence wasn’t

significant with a p-value of 0.397. Various reasons were given as to why they failed to do so

with reference to table 17 which include negligence 68.4%, inadequate knowledge 10.6%,

distance 10.5%, relocation 5.3% and fear of paralysis 5.3%. Comparing with a work done on

the Reasons for incomplete vaccination and factors for missed opportunities among rural

Nigerian children which recorded that less than half (32%) of the mothers completed routine

66
immunization schedules for their children by the age of 9 months. With various reasons,

though parents objections, disagreement or concern about immunization had the highest

percentage (38.8%), others such as long distance walking (17.5%), long waiting time at the

health facility (17.5%), lack of money (10.6%), absence of personnel at the health facility

(5.4%), child Ill health at the time of immunization (3.6%), lack of vaccine on the

appointment day (3.5%), lack of information on the day of the immunization (2.5%),

forgetting the day of the immunization (1.5%) and others reasons, 55 this shows a similar trend

and points out the inadequacy of the government in tackling deterrents to immunization.

A significant association was also seen between mothers owning immunization cards

for their children and completing immunization of their children with a p-value of 0.000.

Table 21 Shows that mothers who have immunization cards for their children are more likely

to complete their immunization. It was also noted in the study that a large proportion of the

respondents know of the right time to take their children for immunization through

immunization cards (93.9%), home visits (5%) with phone calls taking just 1.1%.

The practice of immunization in the study was satisfactory with majority of the

women falling under an excellent practice score 88.89%. Five point fifty six percent (5.56%)

fall had a good practice score while poor practice had a percentage of 5.56%. This is similar

to a work done by O.J Odia in Kosofe Lagos state which had an excellent immunization

practice score of 88.1%.63

67
 CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 CONCLUSION

Immunization of under five children is mainly dependent on their mothers. In our

study, we did not just focus on assessing the knowledge, attitude and practice of

immunization of under five children among the mothers but also the determinants of their

practice.

The knowledge, attitude and practice of immunization of under five children in these

women was relatively high. High maternal education as well as a good knowledge and

attitude towards immunization of children was found to be great contributors to the adequate

utilisation of immunization services. The negative contributors in the study include

negligence, ignorance and distance to immunization centres.

Although the percentage of mothers who completed immunization of their children

was high, there’s still room for improvement as a stronger political will in addition to a

general improvement of health care services could bring about a better result.

6.2 RECOMMENDATIONS

We recommend there should be an increase in amount of materials on immunization

posted on social media, radio and television shows held to further enlighten the general

public about the importance of immunization.

The government should also work with health personnel to set up supplementary

vaccination programmes and campaign and also train more health personnel so the rural

communities can be reached.

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 Initiation of a well-financed mobile health care service which will include

immunization in hospitals to serve as a means to help remind mothers via calls and text

messages when it’s time for immunization of their children.

The government should also organise talks on immunization at the community level

to help educate mothers the communities who have refuse to immunise their children.

69
 REFERENCES

1. National Health Service (NHS). “The history of vaccination 2016”. Available

from www.nhs.uk/conditions/vaccinations/pages/the-history-of-vaccination.aspx.

Accessed August 2016.

2. The University of Auckland. “The history of vaccines 2015”. Available from

www.immune.org.nz/vaccines/vaccine-development. Accessed August 2016.

3. Bruce Gellin. “Vaccine and infectious diseases, putting risk into perspective”.

American Medical association briefing on microbial threat. National press club

Washington DC 2000. Available from

www.iaomt.org/testfoundaton/lifesaver.htm. Accessed August 2016.

4. World health organization (WHO). “Global vaccine action plan 2011-2020

(Geneva 2012)”. Available from

www.who.int/immunization/global_vaccine_action_plan/en. Assessed August

2016.

5. YOBOT. “Immunization”. Wikipedia the free encyclopaedia (2016). Available

from https://en.m.wikipedia.org/wiki/Immunization. Accessed august 2016.

6. Edina Iroha. “Vaccines and Immunization” In: Azubike J.C, Nkanginieme K.E

(eds.). Paediatrics and Child Health in a Tropical region. 2nd Edition. Owerri,

Nigeria: Africa educational service; 2007. p.28.

7. United Nations Children Fund (UNICEF). “Global measles deaths drop by 74 per

cent”. Joint press release 2008. Available from

www.unicef.orf/media/media_46751-html. Assessed August 2016.

8. World Health Organization/United Nations Children Fund (WHO/UNICEF).

“Global Immunization Vision and Strategy (GIVS) 2006-2015” (Geneva 2005).

Available from http://whqlibdoc.who.int/hq/2005/who. Accessed August 2016.

70
9. World Health Organization (WHO). “Immunization coverage” 2014. Available

from www.whoint/mediacentre/facsheets/fs378/en. Assessed august 2016.

10. Lee J.W. “Child Survival, a global health challenge”. The Lancet. July 2003; 362

(9380):262. Available from www.thelancet.com/journals/lancet/article/p11so140-

6736(03)14006-8/abstract. Accessed August 2016.

11. Odusanya O.O, Alufohai E.F, Meurice P.F, Ahonkha V.I. “Determinants of

vaccination coverage in Rural Nigeria”. BMC public health. 2008; 8:381. DOI:

10.1186/1471-2458-8-281. Accessed on August 2016.

12. World Health Organization (WHO). “Removes Nigeria from Polio endemic list”.

Geneva/New York September 2015. Available from

http://www.who.int/mediacenter/news/releases/2015/nigeria-polio/en/. Accessed

August 2016.

13. Schimmer B, Ihekweazu C. “Polio Eradication and Measles Immunization in

Nigeria”. The Lancet. 2006; 6(2):63-65. DOI: http://dx.doi.org/10.1016/s1473-

3099(06)70358-9. Accessed August 2016.

14. Fielden Battersby Health System Analyst. “The state of routine immunization

services in Nigeria and reasons for current problem”. FBA Health Systems

Analysts. 2005: 1-4. Available from

www.phfn.org/resources/Immunisation/2005%20State_of_Immunization_in_Nige

ria.pdf. Accessed August 2016.

15. Tagbo B.N, Onwuasigwe C. “Missed Immunization opportunities among children

in Enugu”. Nigerian Journal of Paediatrics. 2005; 32(4): 73-76. Available from

http://www.ajol.info. Accessed August 2016.

71
16. Gellin B.G, Malback E.W, Marcus E.K. “Do parents understand immunization, a

national telephone survey”. American academy of paediatrics journal. 2000;

5(106). Available from http://pediatrics.aappublications.org/content/106/5/1099.

Accessed August 2016.

17. Ritvo P, Irving J, Klain N, Wilson K, Brown L, Bremner K et al. “A Canadian

national survey of attitudes and knowledge regarding preventive vaccines”.

Journal of Immune based therapies and vaccines. 2003; 1(1): 3-9. Available from

www.jibtherapies.biomedcental.com/articles/10.1186/1476-8518-1-3. Accessed

August 2016.

18. Sporton R.K, Francis S.A. “Choosing not to immunize; are parents making

informed decision?” Family Practice Journal. 2001; 2(18): 181-188. Available

from http://fampra.oxfordjournals.org. Accessed August 2016.

19. Richard A, Sheridan J. “Reasons for delayed compliance with childhood

vaccination schedule and some failing of computerized vaccination registers”.

Australia New Zealand Public Health Journal. 1999; 23(3): 315-317. Available

from

www.onlinelibrary.wiley.com.com/doi/10.111/azph.1999.23.issue-3/issuetoc.

Accessed August 2016.

20. Salsberry P, Nickel J, Mitch R, Pamela J.S, Jennie T.N. “Why aren’t pre-schoolers

immunized? A comparison of mothers and providers perceptions of barriers of

immunization”. Community Health Nursing. 1993; 10(4): 213-224. Available

from www.tandfonlince.com/toc/hchc20/10/4?nav=toclist . Accessed August

2016

72
21. Hall JA, Roter D.L, Katz N.R. “Meta-analysis of correlates of provider behaviour

in medical encounters”. Medical Care Journal. 1998; 26(7):657-675. Available

from www.mcbi.nlm.nih.gov. Accessed August 2016.

22. Pande R.P and Yazbeck A.S. “Wealth gender and regional inequalities in

immunization in India”. Soc Sci Med. 2003; 57(11)2075-2088. Available from

www.ncbi.nlm.nih.gov/pubmed/14512239. Accessed August 2016.

23. World Health Organization (WHO). “Challenges in global immunization and the

global immunization vision and strategy 2006-2015”. Weekly epidemiological

records. 2006; 81(19):189-196. Available from

www.who.int/wer/206/wer8119.pdf. Accessed august 8th 2016.

24. Obionu C.N. Primary Health Care. 2nd Edition. Enugu, Nigeria. Evanseenio

printing and publishing; 2007.

25. United Nations (UN). “United Nations development project”. Millennium

development goals September 2000. Available from

www.unmilleniumproject.org/goals/indx.htm. Accessed august 2016.

26. United Nations Children Fund (UNICEF). “The state of the world’s children”.

UNICEF 2005. Available from www.unicef.org/SOWC06/. Accessed August

2016.

27. World health organization (WHO) and United Nations Children Fund (UNICEF).

“GIVZ-global immunization vision and strategy 2006-2015”. 2005. Available

from www.who.int/vaccine-document/DOCSPDF05/GIVS-final-EN.pdf.

Accessed August 2016.

73
28. Philippe D, Jean-Marie O.B, Thomas C. “Global Immunization: status, progress

challenges and future”. BMC International Health and Human Rights. 2009; 9(1):

S2 doi: 10.1186/1472-698X-9-S1-S2. Accessed August 2016.

29. L Arevshantian, C.J Clements, S.K Lwanga, A.O Misore. “An evaluation of infant

immunisation in Africa: is a transformation in progress?” World Health

Organization (WHO) Epidemiology. 1998. Available from

www.who.int/bulletin/volumes/85/6/06-031526/en/. Accessed August 2016.

30. World Health Organization (WHO)/United nations Children Fund (UNICEF).

“State of the world, vaccine and immunization by October 2010”. WHO/UNICEF

1996. Available from www.who.int/vaccine. Accessed August 2016.

31. Obioha E.E, Ajala A.S, Motobo T.A. “Analysis of the performance of the

expanded programme on immunization (EPI) for four killer diseases under the

military and civilian regimes in Nigeria, 1995-1999”. Ethno med. 2010;4(1):43-

52. Available from https://wwww.krepublishers.cm/02-journals/S-EM/EM.

Accessed August 2016.

32. Oxford concise medical dictionary. 6th Edition, 2003. Page 723

33. Fiore AE, Bridges CD, Cox N.J. “Seasonal influenza vaccine”. Journal of Current

topics in microbiology and immunology. 2009; 333:43-82. Available from

https://www.ncbi.nlm.nih.gov Doi: 10.1007/978-3-540-92165. Accessed August

2016.

34. Anonymous. “Vaccine-preventable diseases”. Wikipedia the free encyclopaedia

2016. Available from https://en.m.wikipedia.org/wiki/vaccine-

preventable_diseases. Accessed August 2016.

74
35. Public Health Agency of Canada. Canadian Immunization guide 2016. Available

from http://www.canada.ca/en/public-health/services/canadian-immunization-

guide.html. Accessed August 2016.

36. Immunization Action Coalition (IAC). “Vaccine preventable diseases: yellow

fever 2011”. Available from http://www.immunize.org/vis/vis_yellow_fever.asp.

Accessed August 2016.

37. World Health Organization (WHO). “Vaccine Safety basic e-learning course

2013”. Available from

http://www.who.int/vaccine_safety/initiative/tech_support/basic/en. Accessed

August 2016.

38. Ophori E.A, Tula M.Y, Azih A.Y, Okojio R, Ikpo P.E. “Current trends of

immunization in Nigeria: Prospect and challenges”. Tropical medicine and Health.

2014; 42(2): 67-75. Available from

http://www.ncbi.nlm.nih.goo/pmc/articles/PMC4139536/. Accessed August 2016.

39. Doctor H.V, Bairagi R, Findley S.E, Helringer S, Dahir T. “Northern Nigeria

Material, new-born and child health program: selected analysis from population

based survey”. The Open Demography Journal. 2011;4: 11-21. Available from

www.academiccommons.columbia.edu/catalog/ac:179354. Accessed August

2016.

40. Briss P.A, Rodewald L.E, Hinman A.R. “Reviews of evidence regarding

interventions to improve vaccination coverage in children, adolescents and adults.

The Task Force on Community Preventive Services”. American Journal of

Preventive Medicine. 2000; 18(1): 97-140. Available from www.ajolonline.org.

Accessed August 2016.

75
41. United Nations Children Fund/ World Health Organization (UNICEF/WHO).

“Expanded Programme on Immunization (EPI) Coverage”. October Joint Press

Release-UNICEF Geneva 2011. Available from

www.unicef.org/media/46751.html. Accessed August 2016.

42. Baker L.D, Dang T.M, Diaz R. “Perception of Barrier to Immunization among

parents of Hmong origin California”. American Journal of Public Health. 2010;

100(5): 839-845. Available from www.ncbi.nlm.nih.gov. Accessed August 2016.

43. Tagbo B.N, Uleanya N.D, Nwokoye I.C, Omotawo I.B. “Mothers Knowledge,

Perception and Practice of Childhood Immunization in Enugu”. Nigerian Journal

of Paediatrics. 2012; 39(3). Available from www.ajolonline.org. Accessed August

2016.

44. Ambe J.P, Omotara B.A, Mandu B.M. “Perception, Beliefs and Practices of

Mothers in Suburban and Rural areas towards Measles Vaccination in Northern

Nigeria”. Tropical Doctor Journal. 2001; 31(2): 89-90. Available from

www.ncbi.n/m.nih.gov. Accessed August 2016.

45. Adeyinka D.A, Oladimeji O, Adeyinka F.E, Aimakhu C. “Uptake of childhood

immunization among mothers of under five in south-western Nigeria”. The

internal journal of epidemiology. 2008:7(2). Available from

www.ispub.com/ije/7/2/3255. Accessed August 2016.

46. A.O Abidoye, K.A Odeyemi. “Knowledge, attitude and practice of mothers to

childhood immunization in Kosofe LGA of Lagos state Nigeria”. International

journal of Basic, Applied and Innovative Research. 2013:2(4):66-72.Available

from www.ajol.info/index.php/ijbair/article/view/104907. Accessed August 2016.

76
47. Fong N.P, Banv H, Seo W. “Awareness and acceptance of Vaccination elements.

Annals of the Academy of Medicine”. 1990; 44(2): 94-124. Available from

www.annals.edu.sg. Accessed August 2016.

48. Merriam-Webster dictionary. Attitude. Merriam Webster Online Dictionary.

Available from http://www.merriam-webster.com/dictionary/attitude. Accessed

August 2016.

49. Awodele.O, Oreagbu I.A, Akinyede .D.F, Dolapo D.C. “The knowledge and

attitude towards childhood immunization among mothers attending ANC in

LUTH. Nigeria”. Tanzania journal of health research. 2010; 12(3). Available from

https://www.ajol.info/index.php/thrb/article/view/511112. Accessed August 2016.

50. Babatungi A.O, Tamunoibuomi F.O, Samuel O.E, Omieza B, Eric G.

“Assessment of knowledge, attitude and practice of stakeholders towards

immunization in Borno state, Nigeria: A qualitative approach”. Community

medicine and health education journal. 2012; 2(9). Available from

www.omniscience.org. Accessed August 2016.

51. Shiferaw Birhanu, Aderaw Anteneh, Yezabnesh Kibie, Ayalew Jejaw.

“Knowledge, Attitude and Practice of mothers towards immunization of infants in

health centres at Addis Ababa, Ethiopia”. American journal of health research.

2016; 4(1):6-17. Available from www.sciencepublishinggroup.com. Accessed

August 2016.

52. Mapatano MA. “Immunization related knowledge, attitude and practice of

mothers in Kinshasa, Democratic Republic of the Congo”. Journal of South Africa

Academy of family Physicians. 2008; 50(2): 60. Available from

http://www.safpj.co.za/index.php/safpj/article/view798. Accessed August 2016.

77
53. Indian paediatrics. “Awareness, utilization and cost of newer childhood vaccines

in a lower and middle class urban population of Vellore town India”. India

paediatrics. 1999; 36: 954-955. Available from

http://indianpaediatrics.net/sep18.htm. Accessed August 2016.

54. Owino L.O, Irimu G,Olenja J, Meme J.S.” Factors influencing immunization

coverage in mathare valley, Nairobi”. East Africa medical journal. 2009; 6(7):

323-329. Available on http://www.ncbi/n/m.nih.gov/pubmed/20499781. Accessed

August 2016.

55. Abdulraheem I.S, Onajole A.T, Jimoh A.G, Oladipo R.A. “Reasons for

incomplete vaccination and factors for missed opportunity among rural Nigerian

children”. Journal of Public health and Epidemiology. 2011;3(4):194-203.

Available from www.academicjournals.org. Accessed August 2016.

56. Michael F, Robert S, Monika S. “Why children are not vaccinated: a review of the

grey literature”. International health Journal. 2012; 4(4):229-238. Available from

www.sciencedirect.com/science/article/piti/s1876341312000496. Accessed

August 2016.

57. Bugvi A.S, Zakar R, RahatR, Zarkar M.Z, Nasrulla M, Manaar R, Fischer F.

“Factors associated with non-utilization of child immunization in Pakistan:

evidence from the demographic and health survey 2006-2007”. PBM Public

health. 2014; 14:232. DOI 10.1186/14171-2458-14-232. Available from

www.ncbi.nlm.nih.gov/pubmed/24602254. Accessed August 2016.

58. Manjunath U, Pareek R.P. “Maternal knowledge and perception about the routine

programme-a study in semi-urban area in Rajasthan”. India journal of Medical

science. 2003; 57(4):158-163. Available from

www.ncbi.nlm.nih.gov/pubmed/14510348. Accessed August 2016.

78
59. Jani J.V, De Schactht C, Jani I.V, Bjunne G. “Risk factors for incomplete

vaccination and missed opportunity for immunization in rural Mozambique”.

BMC public Health. 2008; 8:161 Doi: 101186/1471-2458-8-161. Available from

www.ncbi.nlm.nih.gov/pubmed/18485194. Accessed August 2016.

60. Payne S, Townsend J, Momodou J, Lowe Jallow Y, Kampmann B. “Achieving

comprehensive childhood immunization: and analysis of obstacles and

opportunities in Gambia”. Health policy plan. 2014; 29(2): 193-203. Available

from https://www.ncbi.nlm.nih.gov/pubmed/23426974. Accessed August 2016.

61. Cochran WG. Sampling technique. Iowa State university press. 1997;3:27

62. Nisar N, Mirza M, Qadri M.H. “Knowledge, Attitude and Practices of mothers

regarding immunization of one year old child at Mawatch Goth, Keari Town,

Karachi”. Pakistan Journal of Medical Sciences. 2010; 26(1). Available from

www.pjms.com.pk/issues/janmar2010/abstract/article38.html. Accessed January

2017.

63. OJ Odia, IP Okafor, AA Roberts. “Knowledge, attitude and practice of childhood

immunization among mothers of under-fives in Kosofe Local Council

Development Area, Lagos State”. Journal of Community Medicine and Primary

Health Care 2015; 27(1):55-63. Available from

www.ajol.info/index.php/jcmphc/issue/view/14252. Accessed January 2017.

64. Tagbo B.N, Eke C.N, Omotowo B.I, Onwuasigwe C.N, Onyeka E.D, Mildred

U.O. “Vaccination Coverage and its Determinants in Children Aged 11-23 months

in an Urban district of Nigeria”. World Journal of Vaccines 2014;4(4). Available

from www.scirp.org/journal/PaperInformation.aspx?paperID=50711 Accessed

January 2017.

79
80