CHAPTER TWO

Literature Review and theoretical frame work

2.1 Introduction

2.1.1 Concept of Immunization

Immunisation is a process whereby children are made immune or resistant to an infectious

disease, typically by the administration of a vaccine. The administration of vaccines is called

vaccination which refers to the administration of antigenic materials to produce immunity to

a disease. The purpose of vaccine immunisation of children is to fortify the immune system

against agents known as immunogens (any substance or organism that provokes an immune

response [produces immunity] when introduced into the body). Immunisation was launched

to prevent six killer diseases including polio, diphtheria, tuberculosis, pertussis (whooping

cough), measles and tetanus during the first year of life of children. Immunization of children

against serious communicable diseases is the most cost effective strategy to decrease overall

morbidity and mortality among children (Boëlle, 2007). Immunisation programme is put in

place as a strategy to realize the developmental goals of government to ensure a healthy

society. However, in a situation wherein the immunisation programme is not nicely executed,

either by cause of corruption on the part of healthcare workers, government officials or bad

policies, it is probable to revel in the challenges of development (Adejumo & Oluwabunmi,

2014; Edoho, 2011).

Nursing Mothers’ Knowledge, Attitudes and Practice on Immunisation Health before wealth

is an adage that can effortlessly be understood by way of searching on the hyperlinks between

ill-health and development. With this statement, Edoho (2011) averred that it is very vital to

know that good health (using immunisation services) boosts labour productiveness,

educational attainment and income generation, and so reduces poverty. To achieve this

greatness, there is a need to prioritise the practice of immunisation through increased

awareness for nursing mothers to avail their children of vaccination. Importantly, sufficient

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information on the modus operandi and the consistent practice of immunisation could

adequately lead to healthy life on the part of individuals and the country at large. However, it

appears that some nursing mothers lack sufficient information on the importance of

immunisation to the health of their children, themselves and the country. Siddiqi et al (2015)

revealed that most of the emphasis on information about immunization is on the "when and

where" with very little on the "what is it". As a result, most mothers have a poor

understanding of immunization, do not know which diseases are prevented by which vaccines

or how many doses of each are needed. A lack of knowledge is a significant barrier to

childhood immunization practice, in addition to a lack of health facilities, low literacy level,

lack of commitment among health workers, and rough terrain (Abdulraheem et al., 2012).

Well, his appears like some nursing mothers are never told, or never learn the names of the

vaccinations they are being asked to accept for their children. The knowledge of nursing

mothers on immunization is a public health intervention and plays a vital role in childcare

which can greatly reduce mortality and morbidity globally. Falade and Bankole (2014)

posited that mothers’ ability to have the right knowledge enhances their practice and attitude

towards immunization. Family caregivers’ inadequate knowledge of vaccine-preventable

diseases may have led to misconceptions about the risk of diseases to children. However, it is

still very possible that parents who possess adequate information on immunisation may still

fail to get their children vaccinated. It is on this note that Abdulraheem et al (2012), revealed

that poor immunization rates might be due to mothers not knowing the benefits of vaccine-

preventable diseases, and being illiterate. Mothers' knowledge plays an important role in

achieving complete immunization before the first birthday of the child. In other words, the

success or failure of the immunization program is dependent upon children's parental

knowledge of the modus operandi of immunisation services.

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2.1.2 Knowledge, Attitude, and Practice

Studies provide information about the people's awareness of certain topics, their feelings and

their practices. Relative to other child survival measures, very few "knowledge, attitude, and

practice" (KAP) studies have been done on immunization (Siddiqi et al., 2010). It appears,

however, that most people in developing countries do have some knowledge about

immunization, but this knowledge is only partial and quite superficial. As an indication that

some parents lack sufficient information on immunisation, Siddiqi et al (2010), observed that

many mothers are not aware that the red liquid given orally is polio vaccine; which they may

assume to be a vitamin. Accordingly, mothers generally do not know how many vaccines or

doses their child has left, and some say a child needs to be taken to get vaccines every month

until five years old. Many mothers have information concerning immunization with some

showing positive attitudes toward it but have not had their children vaccinated. On this

assertion, Falade and Bankole (2014) revealed in their study that despite past campaigns and

communication from health workers, mothers interviewed lacked understanding as to how

vaccines work and had received absolutely no information on the subject. It can be said that

the level of parents’ awareness on immunisation has increased over the years but still needs

the effort to inform every member of society on the implications of not immunizing their

children and its influence on individual and societal development. Parents are the primary

health decision-makers for their children, their knowledge and practices regarding

immunization, in general, have a great impact on not only the immunization status of their

children but also on the stability of society. It is no doubt that sufficient knowledge, positive

attitudes and adequate practice of immunisation are a bridge to the success of preventing

vaccine preventable diseases as well as multiplying immunisation coverage, although, these

are sometimes influenced by decision-makers in every household. It is on this note that

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Opeyemi and Akintoye (2014) concluded that, routine immunisation decision-maker makes

the final choice as to whether a child gets fully immunised. Accordingly, the adequate

practice of immunisation by nursing mothers can result in development in the medical sector,

educational and political institutions, among others. Siddiqi et al. (2010) asseverated that the

partial and superficial knowledge about immunization in many countries has resulted in many

misperceptions, leading to poor practice, disinclining parents to have their children

immunized. The mind-set of most mothers to immunization services is fine and is predicated

on the efficacy of the vaccine to protect in opposition to disorder; there has been a negative

mind-set toward polio immunization amongst mothers who accept it as true that it includes

anti-fertility agents (Renne, 2016). The huge amount of conflicting vaccine-safety

information and misinformation on the internet can negatively influence mothers’ decisions

on immunising their children. Where mothers are misinformed, they may develop attitudes by

believing that immunization is for curing diseases only and not for prevention. This helps

explain why, in Honduras, many mothers knew of immunization and had a positive attitude

toward immunization, but had not adequately practised it by getting their children vaccinated

(Streefland, 2013). He further argued that some of these mothers believe immunization has a

curative rather than preventive function, and even those who mentioned prevention did not

know what this concept means. In Nigeria, it is believed among some nursing mothers that

healthy children do not need immunization. It is sometimes said that they (mothers) do not

see why they should expose a healthy child to fever and other complications. This

misperception is an extension of traditional Yoruba beliefs in which ideas about the

prevention of illness run parallel with ideas about cure (Ayebo & Charles, 2009). Mothers'

knowledge, attitude and practice play an important role in achieving complete immunization

before the first birthday of the child. The previous parent factors are also contributing to the

success or failure of immunization programs, knowledge attitude, and practice studies

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provide information about the people’s awareness of certain topics, their feelings and their

practices. Parental level of income and education are significantly associated with negative

attitudes to immunisation practice. According to Streefland (2013), 72% of parents with high-

level concern responded that the risk of a child getting a disease was their primary reason for

having their child immunized, while 17% listed state laws requiring immunizations for

school/day-care entry. He further stressed that more importantly, black parents were more

likely than white parents to have negative attitudes toward immunizations and their child's

healthcare provider. Despite the notable improvement, still, around three million children are

permanently disabled each year by vaccine-preventable diseases (Abdulraheem et al, 2012).

Similarly, in areas with astronomical coverage, it is valuable to allow clear-cut attitudes and

behaviours toward immunizations in sequence to progress healthcare services and keep in

good condition from top to bottom coverage proportion. The use of immunisation services by

nursing mothers is important to economic growth and a healthy nation. Akintoye and

Opeyemi (2014) argue that when children are promptly and adequately vaccinated, they grow

to be strong and healthy. This will increase the expenditures of a country on health care to

improve the health status of its citizens. More resources are put into immunisation

programmes and other health programmes that are good for healthy citizens and nations.

Successful vaccination of children against vaccine-preventable diseases is a component of

human capital. WHO (2021) reported that failure to utilise immunisation services as

projected, either due to poor awareness or negative attitude, results in children’s poor health.

By implication, this reduces both the quality and quantity of labour supply and results in low

levels of human capital accumulation. In simple parlance, poor attention to vaccinating every

new-born baby is tantamount to low growth and poor health outcomes. Adequate use of

immunisation services by children through the help of their parents significantly relates to

development because it results in good health, prevents diseases, and enables both parents

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and the country to save resources for better use. Increased parents’ knowledge on and regular

practice of immunisation leads to the improved health status of the citizens and reduces the

financial burden of health challenges. Improved use of immunisation services by mothers

increases the quantity and the efficiency of labour, reduces lost time spent on illness,

increases the intensity of work from a given quantity of labour, boosts investment in human

capital, increases the return to investing in human capital (Abdulraheem et al, 2012; Adejumo

& Oluwabunmi, 2014; WHO 2021).

2.1.3 Factors influencing Knowledge and uptake of Routine Immunization in Nigeria

Immunization is a proven tool for controlling and eliminating the life-threatening infectious

diseases among children. In most developed countries, immunization programs have had

dramatic success in reducing morbidity and mortality rate significantly. Although the children

received immunization free of charge, the immunization status in developing countries did

not achieve the immunization targets of the WHO. (WHO, 2016) The factors and barriers that

influence the immunization program include child demographic factors, family factors and

other factors. Purpose: It was to evaluate immunization completeness among children

younger than 2 years, demographic characteristics and familial data associated with

immunization rates and the reasons of immunization incompleteness as reported by the

mothers attending PHC centers in Basrah.

Immunization rates in northern Nigeria are some of the lowest in the world. According to the

2003 National Immunization Schedule the percentage of fully immunized infants in the

targeted states was less than 1% in Jigawa, 1.5% in Yobe, 1.6% in Zamfara and 8.3% in

Katsina. As a result, thousands of children are victims of vaccine-preventable diseases.

There are several reasons for these low rates. Firstly, primary health care services are highly

ineffective and have deteriorated due to the lack of investment in personnel, facilities and

drugs, as well as poor management of existing resources. There is also a lack of confidence

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and trust by the public in the health services resulting from the poor state of facilities and low

standards of delivery. These problems have been exacerbated by “vertical” interventions

undertaken by outside agencies which undermined the capacity of the local service providers

to implement sustainable programmes. At the family/community level there is a low demand

for immunization due to a lack of understanding of its value (World Health Organization,

2020). Some of these problems are briefly discussed below;

1. Misperceptions of routine immunization

Incorrect knowledge as to the preventive role of routine immunization is widespread in

Nigeria. Quantitative research conducted in six states in 2004 reveals that in rural Enugu,

diarrhoea, fever, convulsion, vomiting and malaria are believed to be vaccine-preventable

diseases (VPDs), while in rural and urban Kano, malaria, teething problems, vomiting,

convulsion and pneumonia are listed. During pilot community research in March 2005, a

number of immunization decision-makers and caregivers in Katsina state stated that only

polio immunization is required that once a child has received its polio ‘drops’, it is

immunised against all childhood illnesses, including those for which there is no vaccine

available, e.g. acute respiratory infection (Kerksiek, 2009). Those least likely to demonstrate

high levels of correct knowledge include people who do not use public facilities for the

treatment of common illnesses, those who lack easy access to public health facilities, and

illiterates (Meissner, 2004).

2. Influence of religion

In Nigeria, the greatest challenge to the acceptance of immunization is a religious one

especially among the northern Nigerian Muslims. Generally, the Muslim north has the low

immunization coverage, the least being 6% (northwest) and the highest being 44.6%

(southeast).

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In Ekiti state (southwest), for example, the northeast and west of Ekiti, with a stronger

Islamic influence, has low immunization coverage and also poor educational attainment.

Christians have 24.2% immunization coverage as compared to only 8.8% for Muslims

(Orenstein, 2020).

3. Inadequate cold chain equipment

Over the years Nigeria has received huge quantities of cold chain equipment. Despite this

support, much of the cold chain appears to be beyond repair. This is partly due to the focus on

polio eradication, which uses freezers. In one zonal store, only one of the three cold rooms

was working, with only a single compressor operational. Substantial numbers of solar

refrigerators have been bought in the last few years; although, a useful addition these are

expensive ($5,000 each) and prone to breakdowns. At the state level, the cold stores are

poorly equipped and badly managed. More than half of the refrigeration equipment is either

broken or worn out. In the eight states visited, 47% of the installed solar fridges were broken

and $205,000 worth of solar equipment remained uninstalled (Mastny, 2019)

4. Political problems

The downward trend in the coverage of all the antigens appears to be associated with political

problems. In Nigeria, the boycott of polio vaccinations in the three northern states in 2003

created a global health crisis that was political in origin (Epstein, 2011)

These political problems included low government commitment to ensure the fulfilment of

EPI policy as well as over-centralization in the administration of EPI at the federal level of

governance in Nigeria. The poor coverage of measles between 1998 and 2005 was blamed on

vaccine shortages and administrative problems, as was the case in 1996, 2019 and 2020 when

polio coverage was only 26%, 19% and 26% respectively (Ajala, 2022). Some positions offer

potential for patronage due to the large payments for NID activities. This has led to political

appointments and frequent changes in personnel as some LGA chairmen wish to bestow or

8
repay political favours. Even at the state government level, increased political interference

has been reported to be in the appointment of civil servants, also resulting in frequent changes

of staff and the appointment of inappropriately qualified staff (Central Bank of Nigeria

(CBN) Annual Reports and Statement of Accounts, 2021).

5. Rejection of routine immunization

Another problem and challenges facing immunization programmes in Nigeria is the rejection

of selected vaccines/vaccination by parents or religious bodies more especially in the

northern part of this country. The reasons for such rejection are outlined below;

a) Fear and confusion

Many decision-makers and caregivers reject routine immunization due to rumour, incorrect

information, and fear. Attempts to increase coverage must include awareness of people’s

attitudes and the influence of these on behaviour. Fears regarding routine immunization are

expressed in many parts of Nigeria. Fathers of partially immunised children in Muslim rural

communities in Lagos State see hidden motives linked with attempts by non-governmental

organisations (NGOs) sponsored by unknown enemies in developed countries to reduce the

local population and increase mortality rates among Nigerians. Belief in a secret

immunization agenda is prevalent in Jigawa, Kano and Yobe States, where many believe

activities are fuelled by Western countries determined to impose population control on local

Muslim communities (UNICEF, 2016)

b) Low confidence and lack of trust

Lack of confidence and trust in routine immunization as effective health interventions

appears to be relatively common in many parts of Nigeria (Doctor, 2011). A 2003 study in

Kano State found that 9.2% of respondents (mothers aged 15–49) evinced ‘no faith in

immunization’, while 6.7% expressed ‘fear of side effects’. For many, immunization is seen

to provide at best only partial immunity, e.g. in Kano and Enugu NPI/UNICEF march,

9
(2003). The widespread misconception that immunization can prevent all childhood illnesses

reduces trust because when, as it must, immunization fails to give such protection, faith is lost

in immunization as an intervention, for any and all diseases.

6. Shortage of vaccines and immunization supplies

Under the NPI’s the first mandate is to “support the states and local governments in their

immunization programmes by supplying vaccines, needles and syringes, cold chain

equipment and other things and logistics as may be required for those programmes”.

However, the supply of vaccines has always been problematic for Nigeria, primarily because

funds were not sufficient and were not released on time. For example in 2021 the whole

amount was approved but only 61% was released, the late release of funds (April 2021)

meant that vaccine had to be bought on the spot market at inflated prices. In 2022 no funds

were released and by March 2003 the funding cycle had only reached the stage of getting the

budget approved. NPI did not supply any syringes for Rubella infection in 2005, and the only

safety boxes that have been supplied are the limited quantities given by donors for SIAs.

Following an assessment in 2003, it was decided that UNICEF would supply vaccines in

future. In the last quarter of 2003, UNICEF began supplying vaccines through a procurement

services agreement, and this arrangement continues to date. However, it has not solved the

problem of vaccine shortages. For example, cerebrospinal meningititis (CSM) vaccine was

not supplied in time to allow CSM immunization to take place before the cerebro-spinal

meningitis season, and some states had to buy their own stocks of CSM using state funds.

Measles vaccine also arrived too late to limit the effects of a measles outbreak in the north,

and an insufficient quantity of measles vaccine was supplied to Abia (WHO, 2007).

2.1.4 Perceived Benefits of Routine Immunization

Key benefits include the good health and survival of children. Another is the cost-saving

benefit of immunization from a lower incidence of disease and less frequent visits to the

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hospital. In 2004, parents in both Lagos and Enugu stated that immunization reduces

mortality and morbidity, helps to minimise the anxiety associated with rearing children, and

helps to maximise use of time and money.

Whether or not people take up the offer of a vaccine, for themselves or their children, can be

a ‘default’ or a proactive decision, influenced by a range of factors.

Benefits

For individuals, the most direct benefit of vaccination is the protection from infection and

disease for themselves and the people they are close to, and the knowledge of having such

protection. Where vaccination reduces transmission of disease, individuals might value the

opportunity to help protect others in their wider network or community. In some cases,

particular groups are offered a vaccine that offers more protection to others than to

themselves. For example, a vaccine is offered in pregnancy that can give the baby immunity

against whooping cough, and all children are offered vaccines against rubella which poses

more serious risks in pregnancy, and against mumps which can reduce sperm count and

fertility. Taking part in collective efforts to prevent diseases as a wider public good might

also be considered a benefit to individuals. (Centre for Global Development, 2005)

Risks and uncertainty

The risk of diseases and their effects are key factors in motivating vaccination uptake.

However, real and perceived risks are also key factors motivating people to reject the offer of

vaccination. Though a high degree of safety and efficacy is required before vaccines are

approved and offered in the wider population, some risks and individual variation in

responses to vaccines remain, as is recognised in the UK by the existence of a Vaccine

Damage Payment Scheme for individuals who have become severely disabled as a result of

vaccination.

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How people understand and interpret risks, for example of side effects that are rare but

severe, can vary. Incidents that coincide with vaccination, but where the causality is not

immediately clear, can also cause concerns that linger even after evidence that the

vaccination was not responsible has emerged. (World Health Organization, 2009)

Information and influences

Where people source or receive information about vaccines and the framing or accessibility

of this information can be a significant factor in their decision about whether or not to take

them up.

Studies have found that people who received information about diseases and vaccines from

official sources, particularly healthcare professionals or others in community support roles,

were more likely to think vaccines were safe and to be vaccinated. The extent to which this

information is tailored to communities might be important: for example, whether such

information is provided in accessible formats; or translated into minority languages

However, recent studies have found that relying on mainstream media for news is generally

associated with positive attitudes to vaccines. The extent to which stories are being reported

by specialist medical or science journalists might have an impact on how vaccine stories are

covered in non-specialist media.

The internet, social media platforms, and messaging applications have enabled rapid global

sharing of vaccine-related content, including public health information and views. Social

media encourages private users to actively participate in creating and circulating influential

messaging. This can help to inform users, but can also contribute to rapid distribution

of misinformation or contradictory messages, including between friends, family, or members

of a community. Internet trolls and bots have been found to promote negative and polarised

messages around vaccination as a way to incite political discord, or as clickbait to distribute

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malware or commercial content. Research has shown that exposure to misinformation on

social media can cause confusion and anxiety about vaccines and lead people to delay or

refuse vaccination. (Odusanya, 2008)

Trust

A global survey of vaccine confidence levels found that higher levels of vaccine uptake in 43

countries were associated with trusting healthcare workers more than family, friends or other

non-medical sources for medical and health advice.

Levels of trust can vary across different groups in society. For example, recent studies of

vaccine intentions in an ethnically diverse community in the UK with high levels of

deprivation found that there was a general lack of trust in the Government and the local

council, but strong levels of trust of the NHS, local hospitals and schools. Given that most

vaccines are delivered by GPs or nurses, trust in primary care might be particularly important.

(Edward, 2020)

Other values and attitudes

Social norms might be significant in affecting people’s decisions, for example in

communities where vaccination is seen as the normal thing to do. Religious and philosophical

beliefs and values can also influence decisions, for instance, through obligations to protect

life or ideas around the purity of the body. Some are concerned that processes or materials in,

or involved in the production of, some vaccines might conflict with their diet, personal values

or religious teachings. (Obioha, 2010)

2.1.3 Types of immunization

The standard measure of vaccination coverage is the percentage of children who have

received the requisite number of vaccine doses irrespective of the age at receipt of the

vaccine (Green, 2004). However, to achieve maximal protection against vaccine-preventable

13
diseases, a child should receive all immunizations within recommended intervals (Babalola,

2004). Receipt of vaccines at recommended ages and intervals ensures that the child is

adequately protected from target diseases at all times.

Nigeria operates the immunization schedule of the Expanded Programme on Immunization

which prescribes five visits to receive one dose of Bacille Calmette Guerin (BCG), four doses

of oral polio vaccine, three doses of diphtheria, pertussis and tetanus vaccine, and one dose of

measles vaccine (National Population Commission (NPC) [Nigeria] and ICF Macro, 2008).

According to the National Programme on Immunization (2003), routine immunization of

children in Nigeria is carried out using the following vaccines;

• BCG ( Bacilli Calmette Guerin)—at birth or as soon as possible after birth

• OPV (Oral Polio Vaccine)—at birth and at 6, 10, and 14 weeks of age

• DPT (Diphtheria, pertusis, tetanus)—at 6, 10, and 14 weeks of age

• Hepatitis B—at birth, 6 and 14 weeks

• Measles—at 9 months of age

• Yellow Fever—at 9 months of age

• Vitamin A—at 9 months and 15 months of age

According to the Nigerian Federal Ministry of Health definition, a child is considered fully

vaccinated if he or she has received a BCG vaccination against tuberculosis; three doses of

DPT to prevent diphtheria, pertussis (whooping cough), and tetanus; at least three doses of

polio vaccine; and one dose of measles vaccine. All these vaccinations should be received

during the first year of life, over the course of five visits, including the doses delivered at

birth. According to this schedule, children aged 12–23 months would have completed their

immunizations and be fully immunised. To keep track of the delivery of these immunizations,

Nigeria also provides parents or guardians with a health card on which each dose is recorded.

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2.1.4 Prevalence of child killer disease

Infant mortality is defined as the death of a live born child between the day of birth and span

of 12months United Nation International Children Fund (UNICEF), 2008). The mortality rate

among infants is the measure of probability of children dying before reaching the age of one

year. Child mortality includes deaths that occur at ages 1 to 5 years. The reduction of infant

and child mortality is a worldwide target and one of the most important key indices among

Sustainable Development Goals (SDGs) of reducing nfant and under-five child mortality

rates by two-thirds from the 1990 levels by 2015 (Desta, 2011). Asa result of this, in October

2008, the Nigerian government’s National Health Insurance Scheme

(NHIS) launched a pilot health project, titled the NHIS/SDG Maternal and Child Health

Project(Bello and Joseph, 2014). The Project focuses on reducing maternal and child

mortality and is assisted by the World Bank’s Heavily Indebted Poor Countries Initiative

funds (HIPC). Cases of infant and child mortality are largely under-reported and seldom

documented in developing countries (Nigeria inclusive). Survival efforts can be effective

only if they are based on accurate information of the cause of morbidity (Abhulimhen and

Iyoha, 2012).The environment where the child is born and raised is increasingly becoming so

unhealthy so that the life of the child is continually threatened by diseases. Another factor

that is affecting the survival of infants and children has been identified to be the increasing

devastating effect of Human Immunodeficiency Virus / Acquire Immune deficiency

Syndrome (HIV/AIDS). This threat has become a major concern affecting the lives of

families and thereby reducing the survival chances of the child (Baingana and Bos, 2009).

Many countries have shown considerable progress in tackling child mortality rate and it has

been more than halved in Northern Africa, Eastern Asia, Western Asia, Latin America the

Caribbean and Europe. It has placed them on track to achieving the (SDG) in contrast to

many countries with unacceptably high rates of child mortality. Sub-Saharan Africa which

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accounts for 1/5th of the population of children under 5years, also accounts for half (8.8

million) of deaths in 2008indicating insufficient progress to meet the SDG 2020 target world

health organization (WHO, 2014). Smith (2010), posited that infant and child mortality rate is

high in Sub-Saharan Africa. Despite the region having only one fifth of the world’s infants

population, it harbors half of childhood deaths globally. Worldwide, mortality in children

younger than 5 years has dropped from 11.9 million deaths in1990 to 7.7 million in 2010.

About 33.0 percent of deaths of children younger than 5 years occur in South Asia and 49.6%

occur in Sub-Sahara Africa with less than one (1) percent of deaths occurring in high income

countries (Rajaratnam, Tran, Lopez, andMurray, 2010). In Nigeria, an examination of

mortality levels across three successive five-year periods show that under-five mortality

decreased from 199 deaths per 1,000 births during the middle to late 1990s (1993-1998) to

157 deaths per 1,000births in the middle part of this decade (2003-2008) and 128 deaths per

1, 000 births in 2013 (NPC and ICF Macro, 2013). Infant mortality rates have remained

steady at 75 deaths per 1,000 births for2019 and 2008 while under-five mortality rates show

increase between 2019 and 2008. Under-five mortality rates increased from 140 deaths per

1,000live births in 2019 to 157 deaths in 2008 (Buwembo, 2010). Socio-demographic and

economic factors play important roles in determining child survival all over the world

(Shawky and Milaat, 2011). For instance mothers’ education has an implicit effect on the

health of children (Abuqamar, Coomansand Louckx, 2011). Early marriage has also been

identified in several studies to have affected both the socioeconomic condition and infant

mortality(Othman and Saadat, 2009).

2.2 Theoretical Framework:

Health Belief Model The HB1M indicates that a person's perception of personal danger of an

illness or ailment or perception of the effectiveness of positive health behaviour or action,

16
chances are high that the person will keep to health-seeking behaviours, including the taking

of children for vaccination. HBM, as a model, is composed of six constructs which

encompass perceived susceptibility, perceived severity, perceived benefits, perceived

barriers, self-efficacy, and cues to action; all explain caregivers’ perceptions in the direction

of immunization of their children as well other health behaviours. This involves an

individual’s perception of susceptibility, perception of the severity of disease as well as the

perception of barriers, benefits and taking action to prevent diseases (Gabriel, Hoch &

Cramer, 2019). The explanation for the constructs is briefly done below:

i. Perceived susceptibility - This refers to a person's subjective perception of the danger of

contracting an infection or disease. There is a wide variant in a person's emotions of private

vulnerability to an illness or ailment.

ii. Perceived severity - This refers to a person's feelings on the seriousness of contracting a

particular disease or disorder most especially when left untreated if contracted. There is a

wide version of a person's feelings while evaluating the severity of diseases, and regularly, a

person considers the implication of leaving them untreated or the contraction to include

death, disability, loss of family members, poor social relationships.

iii. Perceived benefits - This refers to someone's belief in the effectiveness of various

approaches and strategies available to lessen the risk of illness or ailment, including therapy.

The course of taking action to stop or cure infection or sickness is predicated on attention and

evaluation of both perceived susceptibility and perceived benefit. This implies that

individuals would receive the recommended health action if it is perceived beneficial.

iv. Perceived barriers - This refers to someone's feelings at the obstacles to acting a

recommended health action. There is a huge variant in a person's emotions of obstacles, or

impediments, which lead to a price/advantage analysis. People try to weigh the effectiveness

17
of healthcare services in terms of side-effects, convenience, timing, cost, pain, among others

before seeking any healthcare.

v. Cue to action - This is the stimulus needed to trigger the decision-making process to

accept a recommended health action. These cues can be internal (e.g., chest pains, wheezing,

etc.) or external (e.g., advice from others, illness of family member, newspaper article, etc.).

vi. Self-efficacy - This refers to the level of a person's confidence in his or her ability to

successfully perform a behaviour. This construct was added to the model most recently in the

mid-1980. Self-efficacy is a construct in many behavioural theories as it directly relates to

whether a person performs the desired behaviour. It is essential to understand the knowledge,

attitudes and practice of caregivers who have children at risk of vaccine-preventable diseases

with the use of all constructs of the model. Using the constructs of the health belief model

like perceived susceptibility, severity, benefits, and barrier among parents, immunisation

practice will be welcomed and celebrated by most parents if they perceive it beneficial to the

health of their children. This goes in line with the results of Idris (2014), who indicated that

individuals who took flu shots in the past, perceived a higher level of benefits from the

vaccine and lower barriers to getting the vaccination than those who did not get vaccinated.

This theory stresses that for Nigeria to successfully develop, the issue of immunisation must

be taken into cognisance. This action will make it possible for the government to reduce child

mortality and prevent all sorts of vaccine preventable diseases, most especially when the

behaviours of mothers are influenced through adequate information on the benefits of

vaccines. The awareness of nursing mothers can be enhanced through mass campaigns and

education. To achieve development in Nigeria, HBM has shown that there is a need to

prioritise immunisation practice by addressing the barriers causing poor awareness and

practice. All actors in the social system must develop positive attitudes towards the

programme. Should any of these actors, mostly mothers, fail to develop positive attitudes and

18
access adequate information on the benefits of vaccination, child mortality may increase,

immunisation practice may decrease and the economy of Nigeria may as well be affected.

These consequences will certainly slow down development because it will divert the attention

of all stakeholders to addressing health challenges instead of galvanising the economy

through various developmental activities and projects. This theory was justified on the basis

that child health constitutes one of the main indicators of development of a country and child

mortality is one of the most used measures of child health. Also, childhood mortality is a

fundamental measurement of a country's level of socioeconomic and demographic

development, and quality of life, especially of families (Opeyemi & Akintoye, 2014). This

makes immunisation a development issue. Given the important roles of parents towards child

immunisation in Nigeria, this study contributes to the existing body of knowledge on the

influence of parental knowledge, attitude and the practice of immunisation on development. It

specifically contributes to development studies through understanding how the relationship

between the aforementioned variables can help in achieving the United Nation’s Sustainable

Development Goals (SDGs) to end preventable deaths of underfive children by 2030. This

theory is straightforward and intuitively appealing to health service providers. There is a

substantial amount of research literature on the HBM. The fact that HBM has its strengths for

providing an understanding of how the knowledge, attitude and practice of immunisation by

nursing mothers can influence national development, is not free from criticisms. The theory

was criticised for not accounting for a person's attitudes, beliefs, or other individual

determinants that dictate a person's acceptance of health behaviour. It does not take into

account behaviours that are habitual and thus may inform the decision-making process to

accept a recommended action (e.g., immunisation). It does not take into account behaviours

that are performed for non-health-related reasons such as social acceptability. It does not

account for environmental or economic factors that may prohibit or promote the

19
recommended action. It assumes that everyone has access to equal amounts of information on

illness or disease. It assumes that cues to action are widely prevalent in encouraging people to

act and that "health" actions are the main goal in the decision-making process.

2.3 Empirical review

2.3.1 Knowledge and uptake of immunization

In a study “Awareness, knowledge, risk perception and uptake of maternal vaccination in

rural communities of Ebonyi State, Nigeria” by (Ugochukwu Chinyem Madubueze, 2022)

asserted that knowledge and uptake of maternal vaccination has been reported to be low in

low- and middle-income countries. The Objectives of the study include, To determine the

knowledge, uptake and determinants of uptake of maternal vaccination among women of

child-bearing age.

A cross sectional study was done among 607 women of childbearing age selected from rural

communities in Ebonyi State using multi-staged sampling technique. A pretested, interviewer

administered questionnaire was used. The proportion of maternal vaccination uptake and

predictors of uptake was determined at 5% level of significant using multiple logistic

regression model. Results shows that Most of the respondents (39.9%) were in the 15–24

years age group. Only 1.3% and 41.5% were knowledgeable and had received any form of

maternal vaccines respectively. The main reasons adduced for non-receipt of the vaccine was

lack of information (65.8%) and not being pregnant (23.5%). Pregnancy was the predictor for

uptake of maternal vaccine among the study population.

The study concluded that There was low level of knowledge and uptake of maternal vaccine

among rural women and a myth that the vaccine is only given when pregnant. This calls for

increase targeted enlightenment of rural women on maternal vaccine in order to improve

uptake.

2.3.2 factors influencing knowledge and uptake of immunization

20
Factors Affecting Completion of Childhood Immunization in North West Nigeria by (Sule

Abdullahim 2022), reported that North West Nigeria has the lowest vaccination rate of the

geopolitical regions of the country. The purpose of this cross-sectional study was to examine

associations between the parents’/caregivers’ biological, cultural, and socioeconomic factors

and the completion or non-completion of routine immunization schedules. Andersen’s

behavioral model provided the framework for the study. Data were obtained from the 2013

National Demographic Health Survey. Descriptive statistics were calculated for all variables.

Chi square tests were used for categorical predictor variables, simple logistic regression

models were used for the age variable, and multiple linear regression models were used for

the biological, cultural, and socioeconomic variables to assess the relative importance of

factors within each category. Findings indicated a statistically significant association between

4 factors (education, wealth index, religious affiliation, and cost of health care) and

completion of immunization schedules. Findings may be used to improve the likelihood of

immunization of children in North West Nigeria and reduce the levels of childhood morbidity

and mortality. Policy makers and immunization programmers can strengthen social services

such as women’s education, income generation, especially in the agricultural sector and other

culturally sensitive interventions with community collaboration to bring the required social

change.

2.3.3 Types of immunization in Nigeria

Determinants of vaccination coverage in rural Nigeria by (Olumuyiwa, 2008) stated that

Childhood immunization is a cost effective public health strategy. Expanded Programme on

Immunisation (EPI) services have been provided in a rural Nigerian community (Sabongidda-

Ora, Edo State) at no cost to the community since 1998 through a privately financed

vaccination project (private public partnership). The objective of this survey was to assess

vaccination coverage and its determinants in this rural community in Nigeria. A cross-

21
sectional survey was conducted in September 2016, which included the use of interviewer-

administered questionnaire to assess knowledge of mothers of children aged 12–23 months

and vaccination coverage. Survey participants were selected following the World Health

Organization's (WHO) immunization coverage cluster survey design. Vaccination coverage

was assessed by vaccination card and maternal history. A child was said to be fully

immunized if he or she had received all of the following vaccines: a dose of Bacille Calmette

Guerin (BCG), three doses of oral polio (OPV), three doses of diphtheria, pertussis and

tetanus (DPT), three doses of hepatitis B (HB) and one dose of measles by the time he or she

was enrolled in the survey, i.e. between the ages of 12–23 months. Knowledge of the mothers

was graded as satisfactory if mothers had at least a score of 3 out of a maximum of 5 points.

Logistic regression was performed to identify determinants of full immunization status.

Findings from the study revealed that ‘Three hundred and thirty-nine mothers and 339

children (each mother had one eligible child) were included in the survey. Most of the

mothers (99.1%) had very positive attitudes to immunization and > 55% were generally

knowledgeable about symptoms of vaccine preventable diseases except for difficulty in

breathing (as symptom of diphtheria). Two hundred and ninety-five mothers (87.0%) had a

satisfactory level of knowledge and stated that there are two types of immunization namely;

active and passive immunisation. Vaccination coverage against all the seven childhood

vaccine preventable diseases was 61.9% although it was significantly higher (p = 0.002)

amongst those who had a vaccination card (131/188, 69.7%) than in those assessed by

maternal history (79/151, 52.3%). Multiple logistic regression showed that mothers'

knowledge of immunization (p = 0.006) and vaccination at a privately funded health facility

(p < 0.001) were significantly correlated with the rate of full immunization.

2.3.4 Prevalence Of Childhood Killer Diseases In Nigeria

22
Analysis of Infant and Child Mortality Rates in Kaduna State-Nigeria” a research study

carried out by (Jumbo, Ogbole, Mangbon, 2018) asserted that Infant and child mortality rate

in Kaduna State is a major concern as the State recorded 88 deaths per 1,000 live births and

179 deaths per 1,000 live births in 2010. The aimed of this study is to analyze infant and child

mortality rates in Kaduna state, Nigeria. Data from the hospitals in three Local Government

Areas purposively selected from 2005 to 2014 were analyzed to assess the rates of infant and

child mortality. A total of four hundred (400) copies of semi structured questionnaire were

administered using purposive sampling technique, of which 386 were found useful for

analysis. The data were analyzed using descriptive statistics, and regression analysis using

SPSS 20.0 version. The descriptive statistics showed that 66.3% of the respondents are

between the ages of 20 and 34 years, 36.8% are Hausa/Fulani. Malaria was discovered to be

the major cause of under-five deaths with 30.1%. The level of under-five mortality in Kaduna

State has remained high since the past 10 years with an estimated under-five mortality rate of

163/1,000 live births. Logistic regression revealed that distance from the health facility had

the most significant correlation(0.379), followed by age at first marriage (0.138), age of

mother (0.118), marital status (0.064), level of education(0.064) and length of breast feeding

contribute (0.054). On the basis of the findings, the study recommends that programme

interventions need to focus on mothers with low socioeconomic status

23
 CHAPTER THREE
METHODOLOGY
3.0 INTRODUCTION

This chapter represents the research design, area of the study, population of study, sample
and sample technique, instrument for data collection, validity and reliability of the
instrument, procedure for data collection, method of data analysis and ethical considerations.

3.1 RESEARCH DESIGN

The research design used for this study is descriptive study which is used so as to explain the
knowledge and uptake of immunization among residents of zaria, Kaduna State.

3.2 RESEARCH SETTING

Zaria, formerly Zazzau, or Zegzeg, historic kingdom, traditional emirate, and local

government council in Kaduna State, northern Nigeria, with its headquarters at Zaria (q.v.) city.

The kingdom is traditionally said to date from the 11th century, when King Gunguma founded it

as one of the original Hausa Bakwai (Seven True Hausa States). As the southernmost state of the

seven, it had the function of capturing slaves for all Hausa Bakwai, especially for the northern

markets of Kano and Katsina. Camel caravans from the Sahara travelled south to Zazzau to

exchange salt for slaves, cloth, leather, and grain. Islām was introduced about 1456, and there

24
were Muslim Hausa rulers in the early 16th century. Muḥammad I Askia, a warrior leader of the

Songhai Empire, conquered Zazzau c. 1512; the results of that conquest were recorded by the

traveller Leo Africanus.

Later in the century, Zazzau’s ruler Queen Amina enlarged her domain by numerous

conquests, including those of the Nupe and the Jukun kingdoms; even the powerful states of

Kano and Katsina were required to pay tribute. By the end of the century, however, Zazzau—

renamed Zaria—came under the control of Kororofa (Kwararafa), the Jukun kingdom centred

near Ibi to the southeast. Shortly after the decline of Kororofa, Zaria was forced to become a

tributary state (c. 1734–1804) of the Bornu kingdom to the northeast.

In 1804 the Muslim Hausa ruler of Zaria pledged allegiance to Usman dan Fodio, the

Fulani Muslim leader who was conducting the great jihād (“holy war”) in northern Nigeria. This

resulted in a Fulani becoming ruler of Zaria in 1808. Zaria emirate was created in 1835, retaining

some of its old vassal states (including Keffi, Nasarawa, Jemaa, and Lapai to the south); it was

governed by a representative of the sultan at Sokoto (216 mi northwest of Zaria city), as well as

the local emir.

Zaria’s fortunes declined in the late 19th century; the critical blow was the loss in 1899 of

Birnin Gwari (a town and Hausa chiefdom 63 mi west of Zaria city) to Kontagora (an emirate to

the southwest). In 1901 Zaria sought British protection against slave raids by Kontagora. After

the murder in 1902 of Captain Moloney, the British resident at Keffi (154 mi south), by the Zaria

magaji (“representative”), the British stripped the emirate of most of its vassal states.

Zaria remains, however, one of Nigeria’s largest (about 12,750 sq mi [33,000 sq km])

traditional emirates. A savanna area, it is one of the nation’s leading producers of cotton for

export. Other significant cash crops include tobacco, peanuts (groundnuts), shea nuts, soybeans,

sugarcane (which is processed locally into brown sugar), and ginger. Sorghum, millet, and

cowpeas are the staple foods; cattle, chickens, goats, guinea fowl, and sheep are raised for meat.

25
Tin mining has long been important in the south, at the western edge of the Jos Plateau. The

population is an ethnic mix in which Muslim Hausa and Fulani people predominate.

3.3 TARGET POPULATION

The target population for this study are women (Nursing Mothers) residing in Zaria
Metropolis.

3.4 SAMPLE SIZE

The sample size for this study is five hundred (500) respondents, from the target population.
This was obtained through Ofoegbu (2014) which stated that In determining the sample size,
the population in a few hundred 20% Sample could be used and if the population in a several
thousand than 5% less could be used A total of 5000 eligible respondents were selected from
the community. This was determined using sample size determination formula

N = Total sample size X 50%

100
Were N = Sample Size
Percentage to be used is 50%

N = 500 X 50 %
100 = 250
3.5 SAMPLING TECHNIQUES

A simple random sampling technique was used, these was done to provide equal opportunity
for the participant to be chosen for the study

Inclusive criteria:

The study involve nursing mothers within zaria and gave their consent by receiving and
accepting to fill the questionnaire.

Exclusive Criteria:

All those that refuse to participate in the research were not included.

3.5 INSTRUMENT FOR DATA COLLECTION

Data for this study was collected by the use of a well-structured which was designed to elicit
information regarding knowledge and uptake of immunization among residents of zaria local
Government Area, Kaduna State it consist of four (4) Sections; section A, B, C and D

26
Section A: Deals with socio demographic data of respondents

Section B: Assess knowledge and uptake of immunization

Section C: Factors influencing knowledge and uptake of immunization

Section D: Types of immunization available in zaria.

Section E: Prevalence of Childhood killer disease in zaria

3.6 VALIDITY OF THE INSTRUMENT

The instrument (Questionnaire) will be evaluated by the project supervisor face and content
validity. Necessary correction were made to ensure that the questions were valid to achieve
the objectives of the study.

3.7 RELIABILITY OF THE RESEARCH INSTRUMENT

Reliability of the instrument (questionnaire) will be established by test re-test technique, a
pilot study involving (10) ten nursing mothers in ABUTH Tudun Wada Zaria and will be
conducted twice to measure the consistency of the instrument. First and second results if
agreed with each other and when the real research work repeated, it measured what was
expected.

3.7 METHOD OF DATA COLLECTION

This study was based on primary sources of data, consisting of real data generated from
responses by questionnaire, which was shared and answered. Respondents confidentiality was
ensured and questionnaire was distributed among available nursing mothers and collected
hand to hand by the researcher.

3.8 METHOD OF DATA ANALYSIS

Quantitative analysis method was used. This involves the use of frequency, distribution tables
and percentages, figures which include bar charts and pie charts. To summarize the general
data. The technique would be used due to its simplicity for data analysis using the fomular
below

F 100
P= X
T 1

Where

P = Percentage %

27
T = Total Number of Respondents

F = Frequency

3.10 ETHICAL CONSIDERATION

- Consent letter was obtained from the , the letter involve was given to the community
heads within thestudy area as well as the stake holders district head) which in turn
granted permission for the research to be carried out.
- Respect for the dignity and the confidentiality of respondent were ensured
- Informed consent was sought out from the respondents before the research was
carried out.
- Any form of misleading information, as well as representation of primary data
findings in a biased way was avoided.
- There was no falsification of data or information from the data collected

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