Attitude of mothers towards immunization of their children

Introduction

Immunization is one of the most powerful and cost effective of all primary healthcare interventions. Immunization prevents debilitating illness and disability and saves millions of lives every year. It is also key to achieving Millennium Development Goal Four (MDG 4) (World Health Organisation [WHO], 2011). Despite the evidence-based successes in reducing vaccine-preventable diseases (VPDs) morbidity and mortality, routine childhood immunization compliance in Nigeria is suboptimal.

The immunization completion rate was 10% among children aged 9-12 months and 53% among children aged 12-23 months according to the Nigeria National Immunization Coverage Survey (NICS) conducted in 2010 (National Primary Health Care Development Agency [NPHCDA], 2010). This rate is well below the 90% level recommended by the World Health Organization (WHO) for the sustained control of vaccine-preventable diseases (VPDs).

According to NPHCDA (2010), Nigeria´s routine immunization schedule requires that infants be vaccinated with the following vaccines: a dose of Bacillus Calmette-Guerin (BCG) vaccine at birth (or the first week of life); three doses of diphtheria, pertussis and tetanus (DPT) vaccine at 6, 10 and 14 weeks of age; at least four doses of oral polio vaccine (OPV) – at birth, 6, 10 and 14 weeks of age; and one dose of measles vaccine at nine months of age.

In 2004, hepatitis B vaccines were included in the country’s schedule, recommending the receipt of three doses of hepatitis B (hepB) vaccine at birth, 6 and 14 weeks of age. In May 2012, the Nigerian government introduced the pentavalent vaccine, which is a combination of five vaccines-in-one that prevents diphtheria, tetanus, whooping cough, hepatitis B and haemophilus influenza type B, in a single dose (WHO, 2012). Instead of children taking different vaccines at different times, the pentavalent vaccine is administered in three doses between the ages of 6 weeks and 14 weeks at an interval of 4 weeks. The pentavalent vaccine replaced the DPT vaccine administered at 6, 10, and 14 weeks and HBV administered at birth, 6 and 14 weeks.

In the year 2012, World Health Organisation (WHO) introduced the pneumococcal conjugate vaccine (PCV) and added it to the routine infant immunization schedule; which is aimed towards the prevention of diseases like pneumonia and pneumococcal disease. Inactivated polio vaccine (IPV) was also introduced in 2012. With the introduction of the pentavalent vaccine Nigeria’s expanded program on immunization now has a new schedule as follows: antigens BCG, OPV0, hepB0 (at birth) OPV (3 doses), pentavalent (3 doses), measles and yellow fever.

Okpukpara (2007) stated that parental attitude and knowledge regarding immunization services in Nigeria is still abysmally low, stressing that parents have negative beliefs about childhood killer diseases and immunization programmes. In the light of this he stressed that for the immunization programme to be successful in Nigeria, parental attitudes and beliefs about vaccines are an important factor.

Definition of immunization

Immunization as defined by WHO (2011) is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. The vaccines stimulate the body’s own immune system to protect the person against subsequent infection or disease. In addition, immunization is referred to as a proven tool for controlling and eliminating life-threatening infectious diseases and is estimated to avert between 2 and 3 million deaths each year.

Hornby (2010) described immunization as is the process by which an individual’s immune system becomes fortified against an agent (known as the immunogen). During immunization the system is exposed to molecules that are foreign to the body, called non-self, it will orchestrate an immune response, and it will also develop the ability to quickly respond to a subsequent encounter because of immunological memory. This is a function of the adaptive immune system. Therefore, by exposing an animal to an immunogen in a controlled way, its body can learn to protect itself (Park, 2007).

Immunization is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations. It has clearly defined target groups; it can be delivered effectively through outreach activities; and vaccination does not require any major lifestyle change (Babalola & Adewuyi, 2015).

Types of immunity

The Centre for Disease Control and Prevention (2010) stated that immunization can be achieved in an active or passive manner: vaccination is an active form of immunization.

1.  Active immunization: Active immunization can occur naturally when a person comes in contact with, for example, a microbe. The immune system will eventually create antibodies and other defenses against the microbe. The next time, the immune response against this microbe can be very efficient; this is the case in many of the childhood infections that a person only contracts once, but then is immune. Artificial active immunization is where the microbe, or parts of it, are injected into the person before they are able to take it in naturally. If whole microbes are used, they are pre-treated. Their effectiveness depends on the immune system’s ability to replicate and elicits a response similar to natural infection. It is usually effective with a single dose. Examples of live, attenuated vaccines include measles, mumps, rubella, MMR, yellow fever, varicella, rotavirus, and influenza
2. Passive immunization: Passive immunization is where pre-synthesized elements of the immune system are transferred to a person so that the body does not need to produce these elements itself. Currently, antibodies can be used for passive immunization. This method of immunization begins to work very quickly, but it is short lasting, because the antibodies are naturally broken down, and if there are no B cells to produce more antibodies, they will disappear. Passive immunization occurs physiologically, when antibodies are transferred from mother to foetus during pregnancy, to protect the foetus before and shortly after birth. Artificial passive immunization is normally administered by injection and is used if there has been a recent outbreak of a particular disease or as an emergency treatment for toxicity, as in for tetanus.

The advent of immunization worldwide is a landmark achievement toward the prevention of children against being infected with the six killer diseases vis-à-vis tuberculosis, poliomyelitis, measles, diphtheria, pertussis (whooping cough), and hepatitis B. It is an age-long practice that date several decades ago. The Federal Ministry of Health (FMOH) places to place high priority on immunization which is demonstrated by the national consciousness and ownership for immunization charged with the mandate to effectively control vaccine preventable disease through immunization and the provision of vaccines (FMOH, 2010).

In order to eradicate these targeted diseases, the development of 10 years strategic plan has been carried out by WHO from 1995 –2004 to achieve the following:

• routine immunization coverage for all National Programme on Immunization (NPI) target disease in all local government areas by 80%.
• reduction of measles morbidity by 90% and mortality by 95%;
• control of yellow fever;
• control of hepatitis B;
• control of cerebrospinal meningitis (CSM);
• elimination of neonatal tetanus (NNT) and vitamin A deficiency; and
• eradication of poliomyelitis

Osakwe (2008) described immunization as one of the major ways employed in preventing disease. He stressed that high survival of children these days is due to immunization. Ama (2013) also defined immunization as the process of making a person immune to a particular disease. While Akubue (2010) considered immunization as a process which confers immunity against a specific disease. He further emphasized that immunization is achieved by vaccination which is the process of givingvaccine which may be inactivated or attenuated viruses or bacteria toxoid.

The above literature has recognized and identified immunization as mechanism of defense against infection. This explains the reason why it has globally been accepted and adopted for protection and survival of the people especially children. On this ground, Ibada Elume has equally adopted same idea to immunize her people especially children. Considering this, the researcher deemed it imperative and appropriate to find out the attitude of the mothers towards this programme in the community to see the level of progress.

Demographic factors associated with immunization attitude

There are some unique determinants that are associated with towards immunization of a particular group of people. Some of the determinants as identified by NPHCDA (2010) include:

·        Household living conditions

·        Parental education

·        Religious and cultural factors

·        Migration

·        War and civil unrest

·        Traditional healers

·        Program accessibility

Household living conditions

Several studies found an association between living conditions and immunization attitude. In rapidly growing slum, access to health care services in general and immunizations in particular are limited, contributing to a large burden of infectious diseases and spread of infections to other communities. These observations suggest that families that possess better housing are more likely to have their children immunized (Cutts, 2011).

Household income plays a major role in access to care, as many indirect costs associated with immunizations, such as transportation to clinics, are more tolerable for households with higher incomes. In this regard, a cross-sectional study conducted in Delhi, India, demonstrated that a secure and salaried job held by the head of household was associated with higher probability of children being immunized. These findings indicate that poor living conditions are associated not only with reduced immunization rates, but also with increased incidence of disease, which in turn raises the overall burden placed on an existing poor health care infrastructure (Kusuma, Kumari, Pandav & Gupta, 2010).

Parental education

Parental education in general, and about immunization in particular, was described in multiple studies to be associated with higher child immunization rates, suggesting that education of parents plays a significant role in this regard. Maternal education as well as parents’ knowledge about immunization is associated with full immunization of their children. Lack of education can potentially lead to misconceptions about vaccines. In this regard, a study conducted in Uganda found that reduced participation in National Immunization Day for polio was due, to concerns that vaccines may cause malaria or contain contraceptives (King, Mann & Boone, 2010).

Religious and cultural factors

Religious and cultural factors have been shown to affect immunization rates among different populations. Differences in religious affiliation were found to be associated with differences in immunization rates in a study conducted in Nigeria, where immunization rate was 66% among Christians but only 32% among Muslims. Lower immunization rates among certain religious groups could be due to several factors such as respect for their religious leaders’ opinions. In this regard, certain religious leaders have cited vaccinations as a sin against God (Antai, 2009).

Migration

Belonging to a community has a strong positive association with full immunization coverage. In this regard, war related migration is associated with poor immunization attitude. Low immunization coverage among migrant groups can lead to disease outbreaks which affect both the immigrant population as well as the host country. Most of these outbreaks occurred in post-conflict circumstances, where immunization status, nutrition, living conditions and refugee movements contributed to the transmission, illness and death from the disease. The migration of children between Burkina Faso and Cote D’Ivoire was found to contribute to a measles outbreak in Burkina Faso which occurred despite supplementary measles vaccination given to children in Burkina Faso shortly before the outbreak (Kouadio, Kamigaki & Oshitani, 2010).

War and civil unrest

War and civil unrest have a deleterious effect on the physical and mental health of individuals within a population, including the prevalence of vaccine preventable diseases and the success of vaccination programs. As an example, a high prevalence of Hepatitis B was found in populations of internally displaced persons due to war in countries such as Pakistan, especially in rural environments. Such populations have multiple risk factors for Hepatitis B as well as other vaccine preventable diseases, and are in great need of effective vaccination programs (Centre for Disease Control and Prevention [CDC], 2010).

However, war and civil unrest have a negative impact on the infrastructure necessary to deliver effective health services, including clean water, sanitation and electric power supply to allow proper cold chain capacity. In addition to destruction of transportation systems as a result of war, destruction of communication systems such as radio and telephone networks impacts vaccination programs due to an inability to inform the population of National Immunization Days as well as vaccine and medical staff availability. The consequences of war also present a challenge to vaccination program surveillance, as measuring vaccination coverage and other health related metrics becomes difficult in the face of communication and transportation systems malfunction. Thus, in areas stricken by continual civil unrest and war, such as the Sudan, the scarce and unreliable relief efforts, including vaccination, contribute to high prevalence of disease(CDC, 2010)

Traditional healers

Traditional healers often serve as primary health care providers in developing countries and mothers use their services for paediatric care to various degrees. Traditional medicine may include herbal, spiritual or religious practices. A study done in Haiti found that the use of traditional healers by mothers was negatively associated with the vaccination rates of their children. Furthermore, in a study done in Pakistan, the use of traditional healers was found to be a risk factor for under-5 mortality (D’souza & Bryant, 2009).

Program accessibility

Accessibility to immunization programs was shown to have an impact on their utilization by various populations. A study conducted in Yemen demonstrated that longer geographical distance and longer driving time were associated with lower childhood immunization rates. A study conducted in a poor district in Kenya showed that immunization rate ratios of the pentavalent vaccine decreased with each kilometre of distance from vaccine clinics to homes. In this regard, a study conducted in Burkina Faso demonstrated that mortality of children under five years of age increased by 50% when the walking distance to healthcare facilities was longer than four hours and a study conducted in Pakistan showed that proximity to government healthcare centres led to increase in children’s immunization coverage. Another study conducted among the Bedouin Arabs in southern Israel, many of whom have lived a nomadic lifestyle away from Maternal and Child Centres, and are thus similar to populations in low-income countries, demonstrated low infant immunization coverage prior to the establishment of a population-specific intervention program (Schoeps, Gabrysch, Niamba, Sié & Becher, 2011).

Methods of improving immunization coverage

According to Abdulraheem (2011), ensuring participation in immunization requires multifaceted efforts which among other strategies include:

1. Training of health workers: Adequate training of health worker will help them to understand the perception of mothers towards immunization and be able to provide them with appropriate information on the importance of immunization to their children.
2. Government incentives: In year 2004 the Australian government called for drastic action to raise child immunization coverage rate. Some of these actions include giving cash to mothers and doctors and free fast-food vouchers to children as incentives to comply with the recommended vaccination schedule (Sadoh & Okungbowa, 2014).
3. Provision of immunization service posts: Robinson, Steven and Maluku (2007) indicated that over the last ten years, Indonesia has achieved high coverage rate through attendance at routine immunization clinics throughout most parts of the countries using the Posyandu (or integrated service post).
4. Creating adequate awareness: Government should ensure adequate awareness by liaising with people who command some influence in the community. For example, teachers should be employed to disseminate immunization information. This is because the teachers are often the best educated people in the village and are respected as village leaders who provide reliable advice to children and adults alike, they remarked. With this school children can also be targeted to take health education message about immunization to their mothers (Robinson et al., 2007).
5. Community participation: Freyen, Martin and Mbakukyemo (2013) strongly recommended the concept of community participation to be used widely in primary health care programmes. They stressed that the more the community participate, the more its health workers, have to share decision-making and responsibility with it. For this reason, the community becomes an important partner of the health workers at all levels, they noted. They further explained that the way health workers understand the concept of community participation is therefore crucial since they are the key intermediaries between the bodies who influence health policies and the target populations.

Empirical studies on immunization attitude

Adeyinka, Oladimeji, Folasade and Chris (2009) in their descriptive cross sectional household survey of perception of mothers with children under 5 years of age to immunization in Igbo-ora, Oyo state carried out a cluster sampling of mothers. Their aim was to determine the awareness, attitude of mother under five toward immunization and proportion of children fully immunized. The sample size of 124 was obtained. Out of the women sampled, almost all the women interviewed (99%) were aware of the immunization with 65.7% obtaining information at antenatal clinics. They further stressed that a good proportion of children age 12 to 33 months were fully partially immunized and 0.7% were not fully immunized. They contended that majority had good attitudes to immunization with 84.5% having attitude scores of 75% and above.

Immunization of the children was not significantly associated with the socio-demographic characteristic at 5% level of significance difference. The reason reported for not completing immunization include long waiting on queues (46.1%), payment at private clinics (20.2%) and distance (17.7%). Based on the researchers’ findings, the following recommendations were made;

• The role of antenatal clinic as a source of awareness should further be strengthened by training more health care workers since majority of the respondents got informed about immunization in the antenatal clinic,
• The training of more health care workers will also ease the burden of long waiting hours spend at immunization centres,
• There should be creation of more immunization centres to solve the problem of travelling long distances to immunization centres,

Bhuiya, Bhuiya and Chowdhury (2015) conducted a study on the factors affecting acceptance of immunization among children in rural Bangladesh. The aim of the study was to identify the factors affecting acceptance of immunization among children. The researchers in their works attempt to identify the role of health programme related to variables in relation to acceptance of immunization in Bangladesh. The sample of the study was a total of 8,467 ever married women aged under 50 years who were interviewed. The findings revealed that acceptance of immunization was greater for children whose community was more frequented by the health workers, and that the frequency of visits mat small differences among children of mother with higher primary level of education have important policy implications.

The importance of mass media campaigns was reflected in the positive relationship of immunization and possession of radio. The effects of health workers’ visits and exposure to radio were found to be reinforced by each other. That the effect of mother’s independent mobility on acceptance of immunization and its dependence on education, household economic condition, and possession of a radio has raised some important issued. That the fact that independent mobility did not matter for those who were either from poor households or illiterate implied that such mobility has different meanings for literate and illiterate, for rich and poor.

Kabir (2016) in his report of the study of knowledge, perception and beliefs about childhood immunization and attitude toward uptake of poliomyelitis immunization in Northern Nigeria which was commissioned by NPI. The aim was to examine knowledge, attitude and perceptions regarding vaccination in 11 states in Northern Nigeria namely Kaduna, Zamfara, Kano, Katsina, Sokoto, Kebbi, Jigawa, Bauchi, Yobe, Borno and Adamawa. Specifically, these parameters included awareness of the protective properties of vaccines; reasons for acceptance of poliomyelitis immunization; reasons for rejection of polio vaccines, and reasons for poor uptake or rejection of immunization. According to the researcher, an estimated 68.9 million people reside in this northern part of the country. In the researcher’ sample, one urban and one and two rural LGAs were selected randomly from each state.

The author findings however revealed that the majority of respondents were aware of common childhood illness and their preventive measures; the attitude of most mothers/caregivers towards immunization services is positive and relies on efficacy of the vaccine to protect against diseases; there was poor attitude towards polio immunization among respondents who believe that it contain fertility agents; decision-making on immunization of child lies predominantly on the father; and if polio vaccination was rejected it was because of rumour; frequency of rounds, non-payment of charges, and the priority accorded to preference to more severe diseases.

Conceptual framework

In this context, immunization attitude in the present study refers to the belief, which predisposes mothers to react positively or negatively towards immunization programme. It is the way mothers feel, whether they take immunization exercise seriously or otherwise. Immunization attitude is the extent to which mothers are predisposed to the exercise of immunization of their children against the six killer diseases -vis tuberculosis, polio, measles, diphtheria, pertussis (whooping cough), and hepatitis B. Immunization attitude has a tendency to influence or determine practice (Kabir, 2016).

Immunization protects individuals immunized by helping the body fight germs by producing substances to combat them. Once it does, the immune system “remembers” the germ and can fight it again. Vaccines contain germs that have been killed or weakened. When given to a healthy person, the vaccine triggers the immune system to respond and thus build immunity.

Table 2.1: Immunization schedule chart

Note

Interdermal: Into the skin

Intramuscular: Into a muscle

Subcutaneous: Under the skin

(Source: Babalola & Adewuyi, 2015).

References

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