A logistic regression was performed to ascertain the effects of type of marriage, highest educational qualification, spouse highest educational qualification and occupation on the likelihood of respondent’s uptake of routine immunization. The logistic regression model showed, X2 = 28.627; p< 0.000; df = 4. The model explained 12.9% (Nagelkerke R2) of the variance in uptake of routine immunization and correctly classified 88.2% of cases. Sensitivity was 76.7%, specificity was 38.8%, positive predictive value was 90.2% and negative predictive value was 18.4%. Of the four predictor variables only one was statistically significantly associated with the outcome: highest educational qualification (as shown in Table 11). Mothers with higher educational qualification were associated with good uptake of routine immunization than mothers with lower educational qualification. Overall model significance was poor.
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Table XI: Logistic Regression of Likelihood of Uptake of Routine Immunization with Relevant Predictors
95% CI for EXP (B)
Model properties Predictor
variables
Odds ratio
p-value
df Lower Upper NR square
HL test
Chi-square (X2)
Overall model significance Type of
marriage
1.282 0.465 1 0.401 1.518 0.129 0.018 28.627 Poor**
Highest educational qualification Spouse highest educational qualification
0.316 1.073
0.000 0.805
1 1
0.183 0.612
0.546 1.881
Occupation 0.910 0.841 1 0.364 2.278
NR=Negelkerke R square; HL= Hosmer Lemeshow test; *= considered good due to non significant value of HL
lxxxv 4.2 FOCUS GROUP DISCUSSION RESULTS:
The themes were generated from the quantitative instrument for further explanation of the participants’ responses in the questionnaire survey. The themes generated in these qualitative interviews in the two communities overlapped and were presented in a thematic content analysis involving open coding of the participant’s words and generation of an analytic schema. The themes generated include:
What do you think is the best time to go for immunization?
Do you think immunization card is important for immunization?
What is your reasons for immunizing your children?
Have you experienced any ill health after immunizing your children?
What could prevent you from going for immunization?
How do you overcome this so that you do not miss immunization?
lxxxvi Table XII: FOCUS GROUP DISCUSSION RESULT Themes generated Participant’s words
*MnSC: mothers nth Sabo community;
*MnNC: mother nth non-Sabo community.
Analytic schema
What do you think is the best time to go for immunization?
“I do not know when is the best time to go for immunization, but for me I can only go for immunization when my husband tell me to go because he is the one to give me transportation money.” M4SC.
Poor knowledge and lack of maternal autonomy.
“Health workers told us that immunization should start on the first day of birth, but I have never immunized any of my children on the first day because I deliver with operation and nobody to help me.” M6NC.
Good knowledge and poor family support.
“There is no particular time as long as you immunize the baby, what of those who do not immunize and still nothing happened to their babies.” M1NC.
Poor knowledge and poor attitude.
“I am grateful to the health workers where I delivered because they won’t let you go if the baby is not immunized.” M8SC.
Good knowledge and good health policy.
Do you think immunization card is important for immunization?
“I think it is for my personal record so that I can show the child when he grows
up.”M3NC.
Poor knowledge and ignorance
“Health workers demand for it and will not immunize the child if you don’t come with it.”M9SC.
Poor knowledge and good health policy.
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“It is to know the next appointment for my child and also it will help me take my child for immunization by my sister assuming I am unable to go because of my work.”
M10NC.
Good knowledge and good attitude.
“It was part of the requirements from health workers that you must come with your immunization card each time you come for immunization.”M7SC.
Poor knowledge and good health policy.
What is your reasons for immunizing your children?
“My husband and I decided to immunized our children because we noticed that many children who were not immunized were usually ill and don’t look healthy.”M1SC.
Good attitude and personal experience.
“I don’t really have any reason but I think it is an opportunity for government to do business because I don’t know what they would gain from us. If they care for us let them make delivery free.”M9NC.
Poor knowledge and poor attitude.
“It is very useful for preventing diseases in children like polio because children who had polio vaccines did not develop
polio.”M2SC.
Good knowledge and good attitude.
“We are very grateful to government because the number of children with polio have reduced with immunization.”M4NC.
Good knowledge and good attitude.
Have you experienced any ill health in you child after immunization?
“Immunization caused my child ulcer at the injection site on the arm and it caused my husband a lot of money to treat and because of that we did not complete her
immunization.”M6SC.
Poor knowledge, poor attitude and poor uptake with shortage of food security..
“My children used to have fever and vomiting sometimes and will also refuse food after immunization.”M8NC.
Poor knowledge, poor attitude and bad experience.
“I have never experienced any harmful effect, health workers give us paracetamol to give our child after immunization.”M3SC
Good knowledge, good attitude and good health policy.
“There is no serious harmful effect of immunization except sometimes you have the child have fever, diarrhea or vomiting for a short period.”M5NC
Good knowledge with health challenge.
What could prevent you from going for
immunization?
“I do not go for immunization when my child is ill or on native medication.”M10SC.
Poor attitude and poor uptake.
“My child will not go for immunization when I am ill, because I do not have
Poor uptake and lack of family support.
lxxxviii anybody to take my child for immunization.”M5SC
“My husband must give his consent before I can go for immunization, because he warned me the day I went for immunization without his consent and the child developed fever the next day.” M2NC.
Poor uptake and lack of maternal autonomy.
“It is costly, I spend =N=200 on transportation to immunization centre.”M7NC.
Poor uptake due to financial constraint.
How do you overcome this so that you do miss immunization
“I will treat my child first before continuing with immunization.”M10SC.
Home visits by health workers.
“I pray that I will not fall sick anytime my child is due for immunization.”M5SC.
Home visits and divine farvour.
“I think government should also talk to our spouses about immunization.”M2NC
Government should creat more awareness for spouses.
“I don’t know, except if the health workers will reimburse me the money.”M7NC
More health facilities in hard to reach communities.
MnSC: mother nth sabon community, MnNC: mother nth non-sabon community.
CHAPTER FIVE 5.1 DISCUSSION
This comparative study assessed and compared maternal knowledge, attitude and uptake of routine immunization in ‘Sabo’ and ‘non-Sabo’ communities in Awka town of Anambra state.
It also determined the possible reasons affecting routine immunization at the community level in
‘Sabo’ and ‘non-Sabo’ communities in Awka town of Anambra state. A total of four hundred and twenty (420) respondents, consisting of two hundred and ten (210) women in Sabo community and two hundred and ten (210) women from non-Sabo community were studied. The commonest age group in both Sabo community (44.7%) and non- Sabo community (49.5%) were 30-39 years while the least age group in both Sabo community (0.0%) and non- Sabo community (100.0%) was <20 years. The mean age group in Sabo community was 32.54 ± 7.35 compared to
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the mean age group in non- Sabo community which was 32.64 ± 6.88. The difference was not statistically significant P = 0.125.
Christianity was the commonest religion in non- Sabo community where every respondent was a Christian (100.0%) and none was a Muslim (0.0%) compared to Sabo community where both Christians (23.6%) and Muslims (100.0%) participated in the study. The difference was statistically significant p = 0.000. The highest educational qualification in the Sabo community was secondary education (44.9%) with no qualification in tertiary education (0.0%) compared to the highest educational qualification in the non-Sabo community were secondary education was (55.1%) and tertiary education (100.0%) was the highest educational qualification. The commonest educational qualification were secondary education in both Sabo community (44.9%) and non-Sabo community (55.1%). The difference was statistically significant p = 0.000.
The respondents in Sabo community who knew immunization was commenced at birth was (38.6%) compared to the respondents in non-Sabo community (61.4%) who knew immunization was commenced at birth. The difference was statistically significant p = 0.000. The respondents in Sabo community who go for immunization with immunization card to know the next appointment was (51.9%) compared to the respondents in non-Sabo community (48.1%) who go for immunization with immunization card to know the next appointment. The difference was statistically significant p = 0.000. The respondents in the non-Sabo community who knew the purpose of immunization was to prevent diseases was (66.3%) compared to the respondents in Sabo community (33.2%) who knew the purpose of immunization was to prevent diseases. The difference was statistically significant p = 0.000.
Non-Sabo respondents were better aware of vaccine preventable diseases as (3.8%) mentioned five VPDs, (33.8%) mentioned four VPDs and (49.5%) mentioned three VPDs compared to Sabo respondents who could not mention up to five VPDs but mentioned only four VPDs (1.0%) and three VPDs (19.5%). The difference was statistically significant p = 0.000. This is related to the level of enlightenment of routine immunization of mothers by health workers in Sabo community where migrant mothers had less knowledge of routine immunization. This is consistent with the study done on immunization of children in rural area of north Kashmir, that mothers had good knowledge about importance of vaccination but their knowledge about VPDs
xc
was limited.69 It is also consistent with many other studies like the study done on impact of national immunization days on polio related knowledge and practice of urban women in Bangladesh.70 Only 2% of mothers knew about protective role of BCG. Health workers were the main source of information (88%). Similar findings were seen in other studies where paramedics were seen as the main source of information.71 A quantitative research conducted in six states on community and systematic factors affecting the uptake of immunization in Nigeria in 2004 reveals that incorrect knowledge was a factor81. In rural Enugu, diarrhea, fever, convulsion, vomiting and malaria were believed to be vaccine preventable diseases (VPDs), while in rural and urban Kano, malaria, teething problems, vomiting, convulsion and pneumonia were listed.82 Respondents in Sabo community who waited for consent from spouse before they go for immunization was (53.1%) compared to the respondents in non-Sabo community (48.9%) who waited for consent from spouse before they go for immunization. The difference was statistically significant p = 0.000. This lack of women’s autonomy was more in Sabo community as they depended on their spouse for transportation fare to immunization centres and many of them were illiterates and petty traders/ self employed. Two studies on the dimensions of women’s autonomy and the influence of maternal health care utilization in a North Indian city116 and another study on women’s autonomy in India and Pakistan117 have shown that educated women have higher autonomy regarding decision-making and mobility, which facilitate their use of antenatal care.118,119 Maternal autonomy may enable mothers to achieve better health outcomes for their children.120 A community based study on child mortality in India documented the positive externality produced by other local women’s education on childhood immunization and other child health out-comes.121
The respondents in Sabo community (95.6%) who delivered at home were more compared to respondents in non- Sabo community (4.4%) who delivered at home, the difference was statistically significant p = 0.000. Also few respondents in Sabo community (19.6%) go for immunization with immunization card compared with more of the respondents in non-Sabo community (80.4%) who go for immunization with immunization card. The difference was statistically significant p = 0.000. The respondents in Sabo community (89.8%) had less uptake of routine immunization compared with respondents in non- Sabo community (10.2%) with few poor uptake of routine immunization. The difference was statistically significant p = 0.000. This
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is in keeping with the NDHS 2013 which showed that widespread inequities persisted in immunization coverage to the disadvantage of children of mothers in the lowest socio-economic quintile, parents with no education, and parents residing in rural areas, especially in the Northern regions.5 This is consistent with the study on inequitable childhood immunization uptake in Nigeria which showed that living in a community with low proportion of mothers with hospital delivery was associated with lower likelihood of full immunization.95 This association is in line with expectations, given that timely access to maternal healthcare (hospital delivery) is one of the most important preventive measures against maternal and child health outcomes.97,98 Community hospital delivery is also an indication of the quality of care received by the mother and infant during delivery, and associated with the higher likelihood of full immunization.
Child illness was the commonest possible reason for incomplete immunization in Sabo community (58.1%) compared to non-Sabo community (41.9%). The difference was statistically significant p = 0.000. Unavailability of vaccines was a less possible reason for incomplete immunization in Sabo community (25.6%) compared to non- Sabo community (74.4%). The difference was statistically significant p = 0.000. Others were vaccinators absent and fear of adverse effect. This is contrary with the study on vaccine preventable diseases and immunizations where 91% of the mothers did not know any contra indications for immunization.138 However it was consistent with 12% of 185 children who had not been immunized at the health facility due to child illness. Minor illnesses in the family (fever, headache) had also been related with the non completion of immunization program.138Also the study in Nigeria showed the poor coverage of measles between 1998 and 2005 was blamed on vaccine shortages and administrative problems, as was the case in 1996, 1999 and 2000 when polio coverage was only 26%, 19% and 26% respectively.125
Another study also was in keeping with the fear of adverse effect of immunization where parents or religious bodies, more especially in the northern part of this country, had fear of adverse effect regarding routine immunization.80 Fathers of partially immunized children in Muslim rural communities in Lagos State perceive hidden motives linked with attempts by Non-governmental Organizations (NGOs) sponsored by unknown enemies in developed countries to reduce the local population and increase mortality rates among Nigerians.80 This belief in a secret immunization agenda was prevalent in Jigawa, Kano and Yobe States, where many believe
xcii
activities were fuelled by Western countries determined to impose population control on local Muslim communities,as in the study of Yola.88
Maternal knowledge of routine immunization showed that majority of the respondents with good knowledge were in the age group of 30- 39years with more respondents in non- Sabo community (55.0%) compared to Sabo community (45.0%). The difference was statistically significant p = 0.001. This is consistent with findings from a recent cross-sectional DHS studies from Nigeria113that significantly showed higher likelihood of children of mothers 34 years or older receiving full immunization. Another study between migrant and non migrant groups from Bangladesh, also showed that older mothers were more likely to fully immunize their children than the youngest and oldest age groups.116 This is because maternal age may serve as a proxy for the women‘s accumulated knowledge of health care services, which may in turn have a positive influence on acceptance of full immunization of children.
Majority of the respondents with good knowledge were the married women with more respondents in Sabo community (53.0%) compared to non- Sabo community (47.0%). The difference was statistically significant p = 0.000. A logistic regression is also in keeping that married women in Sabo community had 14.070 times higher odds of good knowledge of routine immunization than married women in non- Sabo community.
Women in monogamous marriages were the most knowledgeable in routine immunization with more respondents in non- Sabo community (59.0%) compared to Sabo community (41.0%). The difference was statistically significant p = 0.027. This is similar to the study done in south west Nigeria were married mothers had good knowledge of routine immunization, more especially women in monogamous marriages. This knowledge was good (98.1%) and majority (65.7%) said their awareness were from routine antenatal clinics.139 Also another study done in 2012 in southwest Nigeria found that children of monogamous families were twice more likely to complete immunization than those from polygamous homes and children of the 1st and 2nd birth order than those of 3rd order and above. This may be related to socioeconomic and domestic pressures of a large family due to time pressures and cost of transportation for each child, especially if health care facilities were not in close proximity.140
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The women and their spouses with secondary school education were the most knowledgeable in routine immunization with good knowledge more in respondents in non- Sabo community (55.0%) compared to Sabo community respondents (45.0%). Logistic regression model also found that mothers with higher educational qualification was associated with good uptake of routine immunization than mothers with lower educational qualification. This is in keeping with a facility based cross sectional descriptive study in Enugu Nigeria where up to (90.0%) of mothers in the study had at least secondary education and about half of that number had tertiary education.79 This however, explained why they had good knowledge of the reasons for immunization and the killer diseases protected against by immunization. It also showed in the same study that most of the mothers with secondary and tertiary education had knowledge of the reasons for immunization and the killer diseases protected against by immunization.79 They were also more likely to take their children to immunization centres for immunization at the appropriate age and more likely to accept immunization during immunization campaign.
Maternal attitude towards routine immunization showed that majority of the respondents with good attitude towards routine immunization were in the age group of 30- 39years with more respondents in non- Sabo community (55.0%) compared to Sabo community (45.0%). The difference was statistically significant p = 0.001 Majority of the respondents with good attitude towards routine immunization were the married women with more respondents in Sabo community (53.0%) compared to non- Sabo community (47.0%). The difference was statistically significant p = 0.000. Women in monogamous marriages had better attitude towards routine immunization with more respondents in non- Sabo community (59.0%) compared to Sabo community (41.0%). The difference was statistically insignificant p = 0.474. This is in contrary to the child immunization cluster survey by Yola where lack of confidence and trust in routine immunization appear to be relatively common in many parts of Nigeria. This report found (9.2%) expressed no faith in immunization while (6.7%) expressed fear of side effects.89
The women and their spouses with secondary school education had better attitude towards routine immunization with more of the respondents in non- Sabo community (55.0%) compared to Sabo community respondents (45.0%). The difference was statistically insignificant p = 0.053.
This is contrary to the study in Katsina State Nigeria which revealed an uncertainty as to the reasons why a healthy infant should receive an injection. This is due to the difficulty in
xciv
understanding the link between preventive health care and good health.86 Women that are self employed had good attitude towards routine immunization with more of the respondents from Sabo community (66.0%) compared to non- Sabo community (34.0). The difference was statistically significant p = 0.053. Though a study on migration in India found unemployment related reasons for not immunizing children. The self employed mothers who were financially independent showed positive attitude towards routine immunization.61
Uptake of routine immunization showed that majority of the respondents with good uptake were in the age group of 30- 39years with more respondents in non- Sabo community (55.0%) compared to Sabo community (45.0%). The difference was statistically insignificant p = 0.295.
The Sabo community had (100.0%) Muslims and (24.0%) Christians with good uptake compared with the respondents in non- Sabo community with (0.0%) Muslim and (76.0%) Christians with good uptake. The difference was statistically significant p = 0.010. This is consistent with the study in Ekiti State, Nigeria, where the northeast and northwest of Ekiti state, with a stronger Islamic influence, had low immunization coverage and also poor educational attainment.
Christians have 24.2% immunization coverage as compared to only 8.8% for Muslims.123 This is in keeping with the Nigerian demographic and health survey 2013 in which the Hausa/Fulani ethnic which were dominantly Muslims especially the group in the northwest had low uptake of routine immunization of 6% compared to the Igbo/other ethnic group in the southeast which were dominantly Christians had 44.6% uptake of routine immunization.5
However some studies had shown that integration into social network encouraged good uptake of routine immunization by mothers as in the study done in rural and urban Gambia where prior social network improved uptake of routine immunization.65 Another study in northern Nigeria found a positive association in social network with the Hausa/Fulani ethnic group on maternal uptake of routine immunization.115This is consistent with study in Ado-Ekiti where the Christians had 24.2% uptake of routine immunization compared to Muslims with 8.8% uptake of routine immunization121.
A qualitative study in five states of Nigeria found an association with low uptake of routine immunization with the fear that immunization was determined to impose population control by causing infertility on Muslim communities by the Western developed countries.80This is consistent with the study conducted in 12 LGAs of Kano state where poor knowledge and
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attitude contributed to increased poor uptake of routine immunization with 9.2% of respondents (mothers aged 15-49) expressed ‘no faith in immunization’, while 6.7% expressed ‘fear of side reactions.’89 The Sabo community are the migrant Hausa/Fulani ethnic group in Awka who had low utilization of health facilities in their host community which resulted in poor uptake of routine immunization. This is in keeping with the study where most of the migrant women were delivered at home without making use of health facility thus resulting in poor uptake of routine immunization.37
Non-Sabo community had 0.031 times lower odds of good uptake of routine immunization than the Sabo community. This reiterates the widespread inequities persistent in immunization coverage to the disadvantage of children of mothers in low socio-economic quintile. The Sabo community were the migrant community from the northern regions with low immunization uptake. This is consistent with the survey by the Nigerian Institute of Social and Economic Research (NISER) were children of mothers' from the Igbo ethnic group had more than twice the likelihood of receiving full immunization compared to children of Hausa/Fulani/Kanuri mothers.93 This is due to the fact that not only that ethnic differences in Nigeria reflect differences in social identity, attitudes and health-seeking behavior of mothers, also showed disparities in socio-economic position.93 There is a behavioural influence on the uptake of routine immunization on Sabo community 79.0% compared to the low proportion of children 10.0% fully vaccinated in the northwest of Nigeria.5 This is in keeping with the study on migration in India where uptake of routine immunization is low among migrants and lowest among the recently migrated population.61
In the FGDs the schematic analysis showed the respondents in both Sabo and non-Sabo communities had good knowledge, attitude and uptake of routine immunization in response to some of the generated themes and also had poor knowledge, attitude and uptake of routine immunization to others. Lack of maternal autonomy, bad personal experiences, lack of family support, ignorance and financial constraint were some of the observations associated with poor knowledge, attitude and uptake of routine immunization. Good health policy, good personal experience have been associated with good knowledge, attitude and uptake of routine immunization.
xcvi
Some of the measures observed to improve immunization coverage are more health talks, home visits by health workers, creation of awareness of routine immunization and set up of more health facilities especially in hard to reach areas. This finding collaborates the quantitative finding of this study where majority of the sampled women got information from health workers because they delivered in health facilities where they were informed on uptake of routine immunization through health talks and home visits by health workers. As a result mothers showed compliance to health worker’s instructions and also trust in government health facilities for vaccinating their children. This finding suggests a unique opportunity to improve the knowledge of mothers by improving the knowledge of health workers via regular trainings and awareness programmes. The study also showed that 53.1% of mothers in Sabo community and 46.9% of mothers in non- Sabo community did not take decisions regarding immunizing their children without the consent of their spouses.
Generally this study reveals that overall knowledge and attitude towards routine immunization was good in both Sabo and non-Sabo communities, but the overall uptake of routine immunization was poor in the Sabo community. This study is contrary to the usual beliefs that the knowledge and attitude of the Sabo community would be poor due to the following characteristics that are known to influence immunization like ethnicity, religion, highest educational qualification and migration that have national impact on immunization. This means there is acculturization of the Sabo community by their host community, though the issue of uptake in the Sabo community is still poor and this needs to be addressed.