ASSESSMENT OF MOTHERS’ BEHAVIOUR IN THE PREVENTION OF

CHILDHOOD DISEASES THROUGH IMMUNIZATION IN KATSINA

METROPOLIS, KATSINA STATE

BY

ABDULAZIZ ABUBAKAR
MAAUN/21/PH/10003

SUBMITTED TO THE DEPARTMENT OF PUBLIC HEALTH, MARYAM

ABACHA AMERICAN UNIVERSITY, NIGER. IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE AWARD OF BARCHELOR OF SCIENCE IN
PUBLIC HEALTH

OCTOBER, 2023
i
 DECLARATION

I wish to declare that this research work titled Assessment of Mothers’ Behavior in the

Prevention of Childhood Diseases through Immunization in Katsina Metropolis” has been

conducted by me in the Department of Public Health under the supervision of Dr. Abdullahi

Ibrahim Kankia. The information derived from the literature was duly acknowledged in the

text and a list of references provided.

_____________________________ ____________________________
Sign Date

Abdulaziz Abubakar
MAAUN/21/PH/10003

ii
 CERTIFICATION

This is to certify that this Research Project on “Assessment of Mothers’ Behavior in the

Prevention of Childhood Diseases through Immunization in Katsina Metropolis” has

been formally approved as a meeting the requirement for the award of BSc. Public

Health.

_____________________________ ____________________________
Sign Date

Project Supervisor
Dr. Abdullahi Ibrahim Kankia

_____________________________ ____________________________
Sign Date

Project Coordinator

_____________________________ ____________________________
Sign Date

HOD (Public Health Dept.)

Malam Abba Jidda

iii
 DEDICATION

This work is dedicated to Almighty Allah for his abundant grace and mercy on me during

this my academic pursuit and to my parents, Alhaji Abubakar M. Zauro and Hadiza Sani

Zauro; also to my wonderful siblings for all their support, encouragement and care.

iv
 ACKNOWLEDGEMENTS

My profound appreciation goes to my father Alhaji Abubakar M. Zauro, the man who

worked hard all to see me succeed, the man who fulfills my needs and wishes without

any complaints, the man who always believes in me and shows a sense of confidence in

me. I am forever grateful.

To my mother Hadiza Sani Zauro thank u for your unconditional love, prayers and

support, I’m extremely grateful to for the caring and sacrifices for educating and

preparing me for my future. I am very much thankful.

To my siblings Farida Abubakar Zauro, Rashida Abubakar Zauro, Ubaida Abubakar

Zauro, Ridwan Abubakar Zauro, Ibrahim Abubakar Zauro and my Tom Maryam

Abubakar Zauro thanks for the love, caring and valuable prayers.

My special thanks goes to my friends Sadiq Aminu Rima, Abdulmumin Abubakar,

Aminu Jafar, Ismail Khalifa Ismail, Aliyu Mallam, Buhari Kabir Bawa, Hauwau Labaran,

Khadija Chika, Muhammad Almustapha, Muhammad Ahmad Jabo, Ahmad Murtala and

the rest for always staying true. I feel so grateful that we’re friends forever and ever.

v
 ABSTRACT

This study investigated mothers’ behaviour in prevention of childhood diseases in

Katsina Metropolis, Katsina State. Sixty (60) child bearing mothers were randomly
selected from the five autonomous communities of Katsina Metropolis. The study's
specific objectives are: Firstly, to examine the socio-demographic characteristics of
mothers with children under the age of five in the study area. Secondly, to gauge the
mothers' knowledge regarding routine immunization for children under five. Thirdly, to
assess the attitudes and behaviors of mothers towards childhood routine immunization.
Lastly, to investigate the impact of mothers' socio-demographic characteristics on the
immunization status of children within Katsina Metropolis. Questionnaires were
distributed to three hundred (300) child bearing mothers from which information
pertinent to immunization were elicited. Data were subjected to descriptive survey and
chi-square analysis using Genstata Statistical Package (GSP) version 18. Statistical
results showed 87% coverage of immunization where majority 137 (52.5%) of the
mothers were aware that immunization is a vaccine that prevent communicable diseases.
A higher number of them, 106 (40.6%) correctly mentioned the rightful time for
immunization. The most source of immunization information for the mothers was radio
102 (39.1%). This helped the women to start immunization at the rightful time at birth
132 (50.6%) with significant association (P<0.001). However, majority 191 (73, 2%)
ensured completion of previous child immunization. Highest proportion of the
respondents (52.9%) practice infant immunization always by expanded programme on
immunization card and ensured availability of EPI card during immunization (75.5%)
and adherence to immunization schedule (67.4%). Moreover, Religion (40.8%) was the
highest barrier to immunization. In furtherance, age had strong association on
awareness of immunization (X2=28.35), DF=4, P<0.001) where those within the age
bracket of 30-35 years were more aware of immunization. Marital status and gender of
baby also had strong influence on adherence to immunization. Similarly, family monthly
income had strong relationship (X2=33.63, DF=6, P<0.001) with onset of child
vaccination. Therefore, it is important that healthcare workers double their effects in
awareness of immunization especially in churches and other religions gathering.

vi
 TABLE OF CONTENTS

Title Page
Cover Page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables ix
CHAPTER ONE: INTRODUCTION 1
1.1 Background of the Study 1
1.2 Statement of the Problems 5
1.3 Aims and Objectives of the Study 6
1.4 Research Questions 7
1.5 Research Hypothesis 7
1.6 Significance of the Study 8
1.7 Scope of the Study 8
1.8 Operational Definitions of Terms 9
CHAPTER TWO: LITERATURE REVIEW 10
2.1 Conceptual Framework 10
2.2 Childhood Diseases 12
2.2.1 Pneumonia 13
2.2.2 Malaria 14
2.2.3 Diarrhea 16
2.2.4 Vaccine Preventable Diseases 18
2.3 Concept of Immunization 20
2.4 Immunization in Nigeria 22
2.4.1 The National Programme on Immunization (NPI) 23
2.5 Factors Affecting Routine Immunization in Nigeria 24
2.5.1 Misperceptions of Routine Immunization 25
2.5.2 Influence of Religion 25
2.5.3 Inadequate Cold Chain Equipment 25

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2.5.4 Political Problems 26
2.5.5 Rejection of Routine Immunization 26
2.5.5.1 Fear and Confusion 26
2.5.5.2 Low Confidence and Lack of Trust 26
2.5.5.3 Shortage of Vaccines and Immunization Supplies 27
2.6 Socio-demographic Factors Influencing Adoption of Immunization Services 27
2.7 Empirical Studies 29
2.8 Theoretical Framework 30
CHAPTER THREE: RESEARCH METHODOLOGY 32
3.1 Study Design 32
3.2 Area of Study 32
3.3 Study Population 32
3.4 Sample size and Sampling Methods 32
3.4.1 Sample Size 32
3.4.2 Sampling Methods 33
3.5 Instruments for Data Collection 33
3.6 Validity of the Instrument 34
3.7 Reliability of the Instrument 34
3.8 Method of Data Collection 34
3.9 Method of Data Analysis 34
CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION 35
4.1 Socio-Demographic Characteristics of the Respondents 35
4.2 Mothers’ Knowledge on Immunization 36
4.3 Practice of Immunization among Mothers 38
4.4 Influence of Demographic Characteristics on Immunization 40
4.5 Influence of Family Monthly Income on Onset of Child Vaccination 41
4.6 Discussion of Findings 41
CHAPTER FIVE: SUMMARY, CONCLUSION & RECOMMENDATIONS 44
5.1 Summary 44
5.2 Conclusions 45
5.3 Recommendations 47
References 48
Appendix I 57

viii
 LIST OF TABLES

Table 1: Immunization Schedule for Vaccines used in Nigeria 21

Table 2: Socio-demographical characteristics of the respondents 36
Table 3: Mothers’ knowledge on immunization 37
Table 4: Practice of Immunization among Mothers 38
Table 5: Influence of demographic characteristics on immunization 40
Table 6: Influence of family monthly income on onset of child Vaccination 41

CHAPTER ONE

ix
 INTRODUCTION

1.1 Background of the Study

Childhood disease is an unpleasant condition that affects children, with the potential of

temporarily or permanently maiming them, or leading to their ultimately death.

Childhood immunization is the initiation of immunity through application of vaccine

(WHO, 2008). It is considered important for improving child survival (UNICEF, 2013).

According to World Health Organization-WHO (2007), immunization is a process of

administering special medicine(s) into a person’s body to make the body resist certain

vaccine preventable diseases. Azubike and Nkanginieme, (2007) suggested that

immunization may be active or passive and confers some protection or immunity to the

recipient. Onuzuluike, (2008) posited that active immunization is a deliberate stimulation

of the body’s defenses against a specific harmful germ or bacteria. Obionu, (2007) opined

that it is the most powerful cost-effective means of preventing some deadly diseases of

childhood and the best practical community-based health measure known today for

protecting children against the major killer diseases.

Ghulam, (2008) listed the benefits of immunization to include partial or complete

protection against the consequences of infection for the vaccinated person, as well as

overall benefits to society as a whole. It also includes protection from symptomatic

illness, improved quality of life and productivity, and prevention of death. Societal

benefits include creation and maintenance of herd immunity against communicable

diseases, prevention of disease outbreaks, and reduction in health-care-related costs. Herd

immunity results when a vaccine not only prevents the vaccinated person from

contracting the disease but also prevents him from spreading or transmitting the disease

x
to others. This will cause the prevalence of the organism in the entire population to

decline. This is because as Jekel, et al, (2007) and Ibezimako (2008) observed, when

some vaccines are given, they not only provide the immunized person with some level of

individual immunity to a specific disease but also reduce or prevent the shedding (spread)

of infectious organisms from an immunized person to others.

Currently, Nigeria is among the ten countries in the world with vaccine coverage rates

below 50% (WHO, 2010), having been persistently below 40% since 1997 (WHO, 2008).

Efforts to prevent childhood diseases dated back as far as 1979 when the Federal

Government established the Expanded Programme on Immunization (EPI) in 1979. In

1997, this programme was renamed the National Programme on Immunization (NPI) and

was charged with the responsibility of effectively controlling, through immunization and

provision of vaccines, preventable diseases by the end of 2005 and 2015 as target years

(NPI, 2007). The realization of these goals faced many setbacks as more than half of the

children aged 12 to 23 months in 2004 were not vaccinated and the ratio of unimmunized

children against each of the diseases was inconsistent (Onwu, 2007). Nigeria operates the

immunization schedule of the EPI 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, three doses of hepatitis B at birth, at six weeks

of age, and at 14 weeks of age and measles vaccine at nine months of age (Federal

Ministry of Health, 1995; WHO, 2010). 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 (Luman et al; 2009). However, for

maximum protection against vaccine-preventable diseases, a child should receive all

xi
immunizations within recommended intervals (Glauber, 2008). Receipt of vaccines at

recommended ages and intervals ensures that the child is adequately protected from target

diseases at all times.

In spite of these huge resources being expended, surprisingly has not resulted to

significant increase in immunization coverage in the country. CDC (2007) argued that

despite recent success in reducing health inequities in immunization rates in young

children among some communities and ethnic groups, immunization rates remain below

optimal levels (Smith and Stevenson, 2008; Wooten et al., 2007). Among the reasons for

slow progress in attaining the goal for reduction in child mortality in Nigeria are the

inequitable access to immunization services, deficient vaccine supplies and equipment

(Lambo, 2005). Also, individual, community and systemic factors affect the equitable

uptake of childhood immunization in Nigeria, as in other countries in sub-Saharan Africa

(UNICEF, 2009).

Moreover, it has been documented that vaccination demands and acceptance depend

largely on a number of factors that are quite broad and complex. Some studies attributed

acceptability of immunization to the kind of relationship that exists between the

vaccinators and mothers, stressing on the attitude of the health care providers when being

approached by mothers for their children vaccination (EPI, 2007; Streefland et al., 2008).

Unfortunately, some children miss vaccination opportunity as a result of the parents’

misperception on the competence of some of the vaccinators (EPI, 2007; Streefland et al.,

2008; Nichter, 2009). In addition, parental knowledge, attitude and practice to childhood

immunization have been reported by researchers to play a key role in immunization

coverage (Anand and Barnighausen, 2007; Rehman et al., 2007; Wang et al., 2007). In

xii
developing nations where illiteracy level is still on the high side, immunization coverage

has been documented to be significantly affected by parental knowledge and attitude on

childhood immunization (Odusanyaet al., 2008; Chhabra et al., 2007; Manjunath and

Pareek, 2009; Nisar et al., 2010).

Even in a population where high immunization coverage is reported, an assessment of

maternal knowledge, attitude and behaviour on childhood immunization is believed to

improve service delivery and further facilitates coverage (Gust et al., 2008).

Kaliyaperumal, (2014) asserted that mothers' knowledge, attitude and practice play an

important role in achieving complete immunization before first birthday of the child,

Data on mothers' knowledge, attitudes, and behaviour towards vaccination of infants are

not scarce in Nigeria in general and southeastern Nigeria in particular. Such information

is urgently needed, since the reasons for noncompliance with or non-delivery of

vaccinations to eligible children on schedule and the factors that may affect immunization

rates need to be identified and addressed in order to prevent these diseases and improve

the quality of life of these children.

1.2 Statement of the Problems

Low immunization coverage against preventable childhood illness constitutes a major

public health concern word wide. It was reported in the NDHS (2007) that widespread

inequities persist in immunization coverage to the disadvantage of children of parents in

the lowest socioeconomic quintile, parents with no education, and parents residing in

rural areas, especially in the Northern regions. Babalola and Aina, (2008) also noted that

inequitable access to routine immunization in Nigeria has also been attributed to fear and

confusion. As reported by WHO (2014), 22.4 million children were incompletely

xiii
vaccinated at 12 months of age and remained at risk for vaccine preventable morbidity

and mortality. The result was more disturbing when it revealed that more than half of all

incompletely vaccinated children live in India (32%), Nigeria (14%), and Indonesia (7%).

Vaccines are one of the best and most cost effective public health interventions known to

man. Nigeria is an important country in the immunization world. Nigeria is a large

country with high child mortality and low immunization coverage rates. Of the 6 million

Nigerian children born every year, more than 1 million fail to get fully vaccinated by

their first birthday (IVAC 2012). Current coverage rates for the various childhood

vaccines in Nigeria are among the lowest in the world (Babalola and Aina, 2008). Among

the problems encountered today in the expanded program on immunization is the failure

to reach an acceptable level of immunization coverage to the population. Although

childhood vaccination is a major tool in the primary prevention of some infectious

diseases, there is some reluctance in a proportion of the population. Factor for low

vaccination coverage can be broadly divided into health system on one side and clients

perspectives. On the other, Semali (2009) has noted poverty, education, cultural beliefs

variables were important determinants of vaccination coverage to the population.

According to WHO estimates in 2000, measles accounted for approximately 777, 000

deaths worldwide, of which around 60% occurred in sub-Saharan Africa (Arevshatian et

al.,2007), Many developing countries have the ability to make vaccines widely available

and where they have not, the reasons are well understood (Kris, 2007). Reasons as to why

parents do not take their children for vaccination are not well known. Sometimes parents

may perceive a visit to a clinic and receiving injections as actions taken only when

someone is ill, not when a child is perceived to be healthy (Hodder, 2007).

xiv
1.3 Aims and Objectives of the Study

The major aim of this study is to assess mothers’ behaviour in prevention of childhood

diseases through immunization in Katsina Metropolis. However, the Specific objectives

of the study:

1. To determine the socio-demographical characteristics of mothers of under- fives

(childhood) in the study area

2. To assess the level of knowledge on routine immunization among the mothers of

children (under five) population

3. To determine the attitude and behaviour of childhood routine immunization by the

mothers of target children

4. To assess the effect of socio-demographical characteristics of mothers on the

immunization status of children in Katsina Metropolis.

1.4 Research Questions

1. What are the socio-demographical characteristics of mothers of under- fives

(childhood)?

2. What is the level of knowledge on routine immunization among the mothers of

children (under five) population?

3. What is the attitude and behaviour of childhood routine immunization by the

mothers of target children?

4. What is the effect of socio-demographical characteristics of mothers on the

immunization status of children in Katsina Metropolis?

1.5 Research Hypothesis

xv
Ho: there is no association between behaviour of mothers and socio-demographical

variables on prevention of childhood diseases through immunization.

1.6 Significance of the Study

This study is significant in various ways, especially to health system planners, the health

personnel involved in rendering routine immunization system (RIS) to mothers, non-

governmental health agencies, health educators and mothers adopting immunization

services and infants for routine immunization. It is expected that the findings of the study

may reveal the RIS that are available for adoption by mothers in Katsina Metropolis. This

may help the health system planners to plan for the provision of the unavailable ones. The

present study findings may also show which of the available RIS are adopted by mothers

for their children in Katsina Metropolis and the extent of adoption for each of the RIS by

mothers in the study. This may sensitize mothers to go for their adoption. The findings

regarding the extent of adoption of the routine immunization services by the mothers may

help health educators, and other health personnel engaged in RIS provision in Katsina

Metropolis to plan on how to intensify improvement strategies particularly through health

education for the mothers in Katsina Metropolis on the need for proper adoption of

routine immunization services for their children especially for the ones that their rates of

adoption are low.

Furthermore, the findings will also be useful to such governmental agencies as UNICEF

and WHO, and non-governmental agencies, who have interest in promoting the adoption

of RIS by mothers as they could use the findings to evaluate the success of immunization

so far and to plan strategies to improve adoption of RIS by mothers in the area of study.

In the present study, data have been generated on the socio-demographic correlates of

xvi
mothers who adopt RIS in Katsina Metropolis. The findings may equally reveal whether

mother’s age, educational status, marital status, parity, religious status, occupation and

location are significant predictors of the adoption of RIS by the mothers in this study.

This knowledge may help health educators and RIS providers to adjust their teaching and

give attention to all mothers adopting RIS in Katsina Metropolis irrespective of their age,

educational status, marital status, parity, religious status and location in other to improve

the adoption of RIS by these mothers.

1.7 Scope of the Study

This study focuses on the assessment of behaviours of mothers with children of less than

five years of age, in the prevention of childhood diseases through immunization in

selected primary health centres in Katsina Metropolis, Katsina state.

1.8 Operational Definitions of Terms

1. Vaccine: A preparation of weakened or attenuated bacteria or viruses that can be

injected to confer immunity to a specific disease.

2. Vaccine Preventable Disease (VPDs): Refers to disease that can be prevented by

routine vaccination

3. Fully Vaccinated Children: Minors between the ages of 0-18 who are up to date on

the immunization schedule recommended by the CDC and/or their personal

pediatrician: Diphtheria, Tetanus, Pertussis (DTaP) (5 doses), Hepatitis A (HepA) (2

doses), Hepatitis B (HepB) (3 doses), Inactivated Poliovirus (3-4doses), Measles,

Mumps, Rubella (MMR) (2doses), Meningococcal (1 dose). (CDC, 2008c and CDC,

2008d).

xvii
4. Partially Vaccinated Children: Minors who have begun the series of vaccinations,

but are not up to date on their recommended immunization schedule. (Smith, et

al.,2008)

5. Unvaccinated Children: Minors who have “received no vaccinations”. (Smith, et-al.

2008)

6. Assessment: It is the organized systematic and continuous process of collecting data

from mother of under five children regarding vaccination.

7. Knowledge: It denotes the awareness or information that the mothers possess

regarding vaccination.

8. Behaviour: “The way in which one acts or conducts oneself, especially towards

others”. (Lindberg, 2009).

9. Belief: “An acceptance that a statement is true or that something exists”. (Lindberg,

2009)

10. Attitude: Refers to opinion of mothers towards vaccination.

11. Mothers: Mothers of under five children attending the immunization clinics.

xviii
 CHAPTER TWO

LITERATURE REVIEW

2.1 Conceptual Framework

To understand the relationship between the availability of the vaccination services

(supply by the health care system) and the active utilization of the vaccination services

(demand for vaccines by parents), four frameworks were identified, including: i) Mosley

and Chen (Mosley and Chen2003, 140-145); ii) Conceptual Framework for Social

Determinants of Health (Solar and Irwin 2007); iii) Conceptual Framework for Health

Research System (Pang et al. 2007) and iv) Andersen and Aday “behaviour model and

access to health care” framework (Andersen, 2009). These frameworks were evaluated

for their relevance to the study objectives and simplicity of use. Based on the criteria, the

Andersen and Aday framework was selected to assess the immunization coverage in

Pakistan. It identifies the determinants of a health outcome as a series of variables

incorporating the

1) Environment, 2) population characteristics and 3) health behavior of the population

under investigation. According to the authors the components of the framework interact

at different levels directly and/or through a series of interconnected associations. The

health care system can be an independent predictor of health status and consumer

satisfaction and also interact with population characteristics. Whereas population

predisposing characteristics can act as direct as well as intermediate predictors of health

outcomes. The health status of a population can be an enabling resource as healthy people

use more health services and the perceived health status can directly determine personal

health practices and use of health services. Three components of the framework are not

xix
modeled because variables from the PDHS data set were not available to enable modeling

with accuracy. We assume unknown risk across all levels for these three left out

components. The components not included in modeling are i) population need, both

perceived and prescribed, for immunization services, ii) personal health practices of the

population and iii) perceived health outcomes. Consumer satisfaction with public health

services for the treatment of a sick child (fever, diarrhea and pneumonia) is collected by

the PDHS 2006-07 but not for immunization services. The components of the framework

are described below and the variables proposed for use are given in

Environment: The framework presents the environment which includes the 1) health

care system, 2) General external environment in which the study population lives.

The general external environment can also include the political, social and economic

factors and events that shape the movement of individuals and communities as well as

uptake of services by them.

Population Characteristics: According to the framework several factors influence and

determine the uptake of health services by a population which are: 1) predisposing

characteristics of the population like the socioeconomic characteristics, 2) enabling

resources available to the population to access medical care/services and 3) need for

health services by the population. The population’s need for health care services are both

i) perceived needs by the population and ii) prescribed need by health care providers. The

perceived health care needs are formed by the health education and messages

disseminated to the population and their awareness regarding a health condition. The

prescribed need for health care services is directed by health providers, education,

training, health protocols and policies.

xx
Health behaviour: The framework addresses health behaviours of a population by

investigating: 1) personal health practices and 2) use of health services. The former

includes variables like diet, exercise and self-care and the later involves use of formal

health care services.

Outcomes: According to the framework three different outcomes can be evaluated

through health services research, including: 1) perceived health status; 2) evaluated health

status; and 3) patient satisfaction. The outcome for my research will be an evaluated

health status identified as vaccination status and the DTP vaccine schedule initiation and

completion among children 12 –23 months of age and UTD among children 36-52 weeks

of age in Pakistan. I propose to use these outcomes as these have been documented in the

PDHS both by observing the vaccination card and the verbal confirmation by mothers.

Analytic limitations of the data set: The DHS data are specifically from a cross

sectional survey to record health and demographic distributions of the population and less

emphasis is placed on the health systems related data. The DHS also specifically collects

data on maternal and child health but it does not elaborate on the knowledge, attitudes

and practices (KAP) of the parents regarding immunizations, and collects little or no data

on the quality of care of the public health system providing the immunization services.

As several variables identified by the conceptual framework were not available in the

PDHS data set their association could not be evaluated with the health outcome.

2.2 Childhood Diseases

Children, due to their fragile nature, have been found to be more susceptible to a host of

diseases, and may die due to these attacks if not managed properly and timely (WHO,

2008). In a bid to achieve the desired level of existence without diseases, various attempts

xxi
have been made to find better ways of managing diseases that have proved difficult or

impossible to eradicate. One of such efforts at coping with the prevalence of diseases is in

studying the etiology of various diseases, their mode of transmission, and the best

conditions within which they thrive. According to WHO (2010), four million children

under the age of five die each year from three preventable causes: diarrhea, malaria or

pneumonia. In placing these diseases in categories according to their prevalence among

children worldwide, the highest ranking diseases affecting children include Acute

Respiratory Infections (ARI), diarrhea, malaria and vaccine preventable diseases (WHO,

2008). Some of these are examined further.

2.2.1 Pneumonia

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are

made up of small sacs called alveoli, which is filled with air when a healthy person

breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid,

which makes breathing painful and limits oxygen intake. Pneumonia affects children and

adults everywhere, but is most prevalent in sub-Saharan Africa, of which Nigeria is

located. Pneumonia is the number one killer of children under age five, and kills an

estimated 1.6 million children every year accounting for 18% of all deaths of children

under five years old worldwide (Leo, 2010). According to UNICEF and WHO (2008),

one child dies from pneumonia every 15seconds, 5,500 children every day, two million

children every year. Pneumonia is considered to be more deadly than malaria and

diarrhea, and is one of the fastest killers among children indeed as reported by Johnson

(2010); a severe attack of the disease could kill a child in just four hours.

xxii
The symptoms of pneumonia include: difficult breathing, cough, fever, chills, loss of

appetite and wheezing. When pneumonia becomes severe, children may experience lower

chest wall in drawing, where their chests move in or retract during inhalation (in a

healthy person, the chest expands during inhalation). Infants may be unable to feed or

drink and may also experience unconsciousness, hypothermia and convulsions. Leo,

(2010) describes some environmental factors such as poverty, illiteracy, poor living

conditions, design of houses, overcrowding, personal hygiene, exposure to polluted air,

and some underlying medical conditions such as measles, increases a child’s

susceptibility to pneumonia. Medical practitioners have discovered a vaccine against

pneumonia, called the PCV, and encourage its administration to all children under five

years old, to prevent infection. Early detection of the ailment However, has been found to

drastically reduce the mortality rate, particularly among children.

2.2.2 Malaria

Over 40% of the world’s children live in malaria-endemic countries. Each year,

approximately300 to 500 million malaria infections lead to over one million deaths, of

which over 75% occur in African children under the age of 5 years. The rapid spread of

resistance to antimalarial drugs, coupled with widespread poverty, weak health

infrastructure, and, in some countries, civil unrest, means that mortality from malaria in

Africa continues to rise (UNICEF, 2010). In Nigeria, malaria caused 24% deaths in

children below the age of 5 in the year 2000 (WHO, 2008). It is reported to claim the life

of one child, every 30 seconds (RBM, 2009). The disease thus kills an unacceptable

number of African children each year, and blights the life of many millions more. High

levels of malaria endemicity and inadequate access to treatment facilities help make

xxiii
malaria a prominent killer of children, accounting for an estimated 25%–30% of

mortality in children under five, or an estimated 300,000 deaths each year in Nigeria

(George et-al., 2008). What these figures indicate is that malaria still kills more people

than HIV/AIDS. Yet, this is a disease that can be eradicated by eradicating mosquitoes.

African scientists are said to have been working to develop a malaria vaccine.

According to George et-al., (2008), vaccines may have helped in the prevention of polio,

tuberculosis, and tetanus, but, in the case of malaria, it would have been better and

cheaper to kill mosquitoes than seek malaria vaccines. Munthali, (2009) undertook a

study on the management of Malaria in Under-Five Children in a Rural Malawian

Village. He carried out in depth interviews with the mothers of children under five years

old that reside in the village, and discovered that there were factors that caused delays in

the proper treatment of malaria in children. Some of these factors included distance to

health centres, unavailability of medication and medical personnel in health centres,

superstitious beliefs and drug abuse, such as the use of antipyretics on the event of fever

occurrence. Unfortunately, malaria deteriorates very fast and can kill in a couple of hours.

The longer the delay, the higher the risk of death, especially in children. Olasehinde et

al., (2010) carried out studies to determine the prevalence of malaria parasite infection

among children in Ota, Southwestern Nigeria between April and December 2008.

Structured Questionnaires were distributed among 267 parents and caregivers of children

to ascertain the age, sex, drugs or insecticides used in prevention or management of

malaria and the state of health of the subjects. Overall, 215 (80.5%) of the 267 children

investigated were found to have malaria infection. Age group (0-5years) had the highest

frequency rate of 84.7%. Children of illiterates from suburb villages had the highest mean

xxiv
parasite density of 850 with78.1% prevalence rate. 20% of the children were given local

herbs and 22% used orthodox medicine as prophylaxis. Only 18% used insecticide

treated mosquito nets while 24% of the parents spray insecticides to prevent mosquito

bites. Various beliefs trail the occurrence of malaria in children. One of such beliefs is

that undernutrition is a triggering factor of the disease in children. Deribrew et al., (2010)

in his community based study in Ethiopia, attempted to correlate the occurrence of

malaria in children under five years old with under nutrition in children. A total of 2410

under-five children were included for anthropometric measurement and blood

investigation for the diagnosis of malaria, between February to March 2009.The

nutritional status of children was determined using the International Reference Population

defined by the U.S National Centre for Health Statistics (NCHS). Data were entered into

computer, and analyzed using SPSS-12 software. The statistical tests showed that there is

no correlation between under nutrition and the occurrence of malaria in children.

2.2.3 Diarrhea

According to UNICEF (2010), diarrhea is the second largest killer of children, causing as

many as 17% of the deaths of those under the age of five. This is largely a result of

unsafe water and poor hygiene. About 4 billion cases of diarrhea are thus reported each

year and results in the deaths of 1.7 million people, most of who are children under the

age of five (UNICEF, 2010). Diarrhea is defined as having loose or watery stools at least

three times per day, or more frequently than normal for an individual (UNICEF/WHO,

2009). Though most episodes of childhood diarrhea are mild, acute cases can lead to

significant fluid loss and dehydration, which may result in death or other severe

consequences if fluids are not replaced at the first sign of diarrhea. About 46% of deaths

xxv
due to diarrhea occur in Africa alone, and Nigeria happens to record mortality cases due

to diarrhea, at a staggering figure of 151,700 annually (UNICEF/WHO,2009). Children

with poor nutritional status and overall health, as well as those exposed to poor

environmental conditions, are more susceptible to severe diarrhea and dehydration than

healthy children. Children are also at greater risk than adults of life-threatening

dehydration since water constitutes a greater proportion of children’s bodyweight. Young

children use more water over the course of a day given their higher metabolic rates, and

their kidneys are less able to conserve water compared to older children and adults.

Reducing childhood diarrhea requires interventions to make children healthier and less

likely to develop infections that lead to diarrhea; clean environments that are less likely to

transmit disease; and the support of communities and caregivers in consistently

reinforcing healthy behaviours and practices over time. El Samani et al., (2007) studied

on the predictors of diarrhea in children under five in Sudan. They collected data on 445

children under the age of 5 and categorized them according to their weight for age. A

strong association between malnutrition and diarrhea was observed. It was also

discovered that undernourished children had close to twice the risk of diarrhea of well-

nourished children. The study also revealed that the risk of diarrhea was higher in female

children, probably due to the preference of male children. The risk of diarrhea also

decreased with older and more educated mothers. Gascon et al., (2010) studied the

prevalence of diarrhea in children under five year’s old in Ifakara, Tanzania. Data was

collected on a total of 103 children suffering from acute diarrhea, with watery stool

presentation at least 24 hours to the time information was collected.

xxvi
Conditional logistic regression was used to evaluate how the risk of having a case of

disease varied for different risk factors and pathogens. The analysis was performed using

Stata statistical software, and the results showed that the larger the number of siblings,

the higher the risk of diarrhea infection. Also, lesser distance to water source, open

latrines and children below six months that were not exclusively breast fed were

associated with a higher risk of diarrhea. Girma et al., (2008) studied the environmental

determinant of diarrhea infection among under five children in Western Ethiopia. A

community based study was conducted, and data was collected randomly between

October 15 and November 26 from four hundred and seven mothers/caregivers of

children less than five years of age. Structured and pre-tested questionnaire, were used

for data collection, and the information was entered into a computer, edited and analyzed

using SPSS for windows version. The results showed that a number of risk factors

including distance from drinking water sources, availability & ownership of the latrine,

refuse disposal, the presence of feces around the pit-hole and presence or absence of pit-

hole cover & feces seen in the compound was significantly associated with under-five

childhood diarrhea morbidity. Some cases of diarrhea are prolonged, with the child

continuously passing loose and watery stool for a period over seven days. Many children

in this critical state end up adding to mortality figures if not managed with utmost care.

2.2.4 Vaccine Preventable Diseases

Vaccine-preventable diseases (VPD) are responsible for severe rates of morbidity and

mortality in Africa (Omer et al., 2009). In Sub Saharan Africa, in spite of the availability

of appropriate vaccines for routine use on infants, vaccine-preventable diseases are highly

endemic throughout sub-Saharan Africa (Attai, 2010). The commonest VPD’s include

xxvii
Poliomyelitis, Measles, Diphtheria, Tuberculosis, Yellow fever, meningitis, tetanus and

Hepatitis. Immunization is the process of conferring increased resistance to an infectious

disease by a means other than experiencing the natural infection (Awodele et al, 2010).

Childhood immunization is an act of inducing immunity to a child by applying a vaccine

that almost guarantees protection from many major diseases (UNICEF, 2010). These

vaccinations can be administered either as injectable, or orally as mouth drop. In Nigeria,

over two million deaths are delayed through immunization each year (WHO, 2007). In

spite of the effort to get children immunized in Nigeria, over one million children still die

annually from preventable diseases, making the country one of the least successful of

African countries in achieving improvements in child survival during the past four

decades (Ngowu, et al., 2008).

There are many factors that contribute to the status of unimmunized children in Nigeria.

Previous studies have shown that uptake of vaccination services is dependent not only on

provision of these services but also on other factors such as knowledge of mothers

(Awodele et al., 2010), misinformation of parents (Buhari, 2010); availability of trained

health workers (Kabir, 2007), availability of safe needles and syringes and a host of other

reasons, such as inadequate monitoring and supervision, inadequate immunization centres

and sessions. An effort to address these factors is of great importance in order to improve

vaccine utilization, increase the number of immunized children and subsequent protection

of the children against childhood infectious diseases, thus giving a better chance of a

child to survive to adulthood. A lot of effort has been put in place by the Nigerian health

sector to publicize the importance of immunization to the health of children, but a quite a

number of mothers still lack the education on the individual vaccines and their functions.

xxviii
2.3 Concept of Immunization

Immunization, as defined by the World Health Organization (WHO), is the process of

making a person immune to infectious diseases through the administration of vaccines,

which stimulate the body's immune system to protect against future infections (WHO,

2013). Immunity refers to having sufficient biological defenses to prevent infectious

diseases or unwanted biological invasions (Gherardi, 2009). Immunization plays a crucial

role in disease prevention and is one of the most successful and cost-effective public

health interventions, having prevented more deaths globally than any other health

intervention (Awosika, 2012).

The WHO Expanded Programme of Immunization (EPI), initiated in 1974, aimed to

reduce mortality from major vaccine-preventable infectious diseases such as measles,

polio, diphtheria, pertussis, tetanus, and tuberculosis. It has prevented over 20 million

deaths worldwide and achieved a global immunization coverage rate of more than 80%

(Vandelaer et al., 2008). Ongoing research seeks to improve the safety and efficacy of

vaccines and develop new vaccines for diseases like malaria and HIV.

However, disparities in access to immunization persist, with many underserved

populations lacking access to vaccines. Universal immunization was a goal set by WHO

to achieve health for all by 2000, and while progress has been made, challenges in

reaching all children with vaccines remain (Mphahlele et al., 2008). Routine childhood

immunization is a cornerstone of preventive primary health care, actively stimulating a

child's immune system to develop immunity. This process often requires multiple doses,

and various routes of administration, including oral, intramuscular, intradermal, or

subcutaneous injections, depending on the vaccine.

xxix
Combining vaccines is a strategic process that considers factors like the current

immunization schedule, compatibility of vaccine components, safety, efficacy, and route

of administration. Combination vaccines, such as two-in-one or three-in-one

formulations, have been successful in simplifying vaccine administration and increasing

acceptance (Yeh et al., 2007). Immunization efforts are expanding to include adolescents,

who may receive boosters of childhood vaccines to enhance individual protection and

herd immunity (Finn et al., 2011).

Misinformation and misconceptions, even among healthcare workers, can lead to delayed

or missed immunizations. Proper storage and handling of vaccines are critical to

maintaining their effectiveness, with temperature control being a key concern. Healthcare

workers must be well-informed about vaccines, catch-up schedules, and when to seek

expert advice in special circumstances to ensure safe and effective immunization (Finn et

al., 2011).

Table 1 Immunization Schedule for Vaccines used in Nigeria

xxx
2.4. Immunization in Nigeria

Following the formulation and launching of EPI by WHO in 1974, Nigeria officially

launched the Expanded Programme on Immunization (EPI) in 1979 as one of the

component of the Primary Health care with the following objectives (Obionu, 2008):

 To achieve 80% immunization coverage of the target population by the year 1990

and midterm goal of 60% by 1987.

 To reduce by 1990 by at least 50% the incidence of the target diseases i.e.

Tuberculosis (TB), Diphtheria, Pertussis, Tetanus, Polio and Measles, through

immunization and other preventive measures.

 To establish an efficient system of surveillance and program monitoring activities

to ensure reliable and systematic procurement of vaccines.

 To foster inter sectoral cooperation and community involvement and participation

in these activities at all levels, and therefore enhance the ability of the program to

sustain itself effectively.

The implementation of this program started in all states of the Federal Republic of

Nigeria between 1979 and 1982. Initial components of the national EPI were TB,

Diphtheria, Pertussis, Tetanus, and Poliomyelitis and Measles. Yellow fever and

Hepatitis B were included several years later. The program recorded initial significant

success but declines in uptake of the services were quickly observed. With concerted

efforts of the Federal Government, state agencies and international Organization between

1983 and 1984, a new strategy was developed and pre- tested in 1984 in Owo Local

Government Area of Ondo State which led to Nigeria attaining UCI in 1991 (PHC/EPI

Coverage Survey, 1991). Based on the success at Owo, a national plan was developed

xxxi
which resulted in the launching of the revised EPI in 1986 with the following strategies

adopted (Ransom-Kuti et al., 2007).

 Decrease in the reliance on electricity to maintain the cold chain and increase use

of cold boxes.

 Involvement of other sectors mobilizing local, political and religious leaders to

mobilize community members.

 Use of ancillary facilities to increase accessibility.

 Intense health education using the media.

The general objective of the revised EPI in 1986 was to achieve 80% coverage of the

target children population and reduce the mortality due to the vaccine preventable

diseases by 50% by the end of 1990. But since the mid – 1990s, Nigeria has continued to

witness fluctuations in immunization coverage for all vaccine – preventable diseases. The

Federal Ministry of Health set – up a technical committee with the aim of reversing the

trend by developing a 5 year plan (1994 - 1998) with the aim of meeting the mid – decade

goals, which included:

 Achieving 80% EPI coverage.

 Reducing in measles mortality by 95% and morbidity by 90%.

 Immunizing of 90% of women in reproductive age with Tetanus toxoid as an

effort towards reaching elimination of Tetanus by 1995.

 Full integration of yellow fever immunization into EPI.

2.5 Factors Affecting Routine Immunization in Nigeria

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

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

in Katsina. As aresult, 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 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 programs. At the

family/community level there is a low demand for immunization due to a lack of

understanding of its value (Feilden, 2007). Some of these problems are briefly discussed

below;

2.5.1 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’, itis

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

available, e.g. acute respiratory infection (Feilden, 2007). Those least likely to

demonstrate high levels of correct knowledge include people who do not use public

xxxiii
facilities for the treatment of common illnesses, those who lack easy access to public

health facilities, and illiterates (Oluwadare, 2009).

2.5.2 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). (Ankrah and Nwaigwe, 2007).

2.5.3 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

(Yahya, 2007)

.2.5.4 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 (Kaufmann and

Feldbaum, 2009; FBA. 2009). These political problems included low government

xxxiv
commitment to ensure the fulfillment of EPI policy as well as over-centralization in the

administration of EPI at the federal level of governance in Nigeria. 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 (Babalola and Adewuyi, 2009).

2.5.5 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;

2.5.5.1 Fear and confusion

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

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 immunized

children in Muslim rural communities in Lagos State see 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. Belief in a secret immunization agenda is prevalent in Jigawa, Kano and Yobe

States, where many believe activities are fueled by Western countries determined to

impose population control on local Muslim communities (Feilden, 2007; Yola, 2008).

2.5.5.2 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 (Babalola and Adewuyi, 2009).

xxxv
A 2003 study in Kano State found that 9.2% of respondents (mothers’ aged15–49)

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 Kanoand Enugu

(Feilden, 2007; Brieger et al., 2008). 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.

2.5.5.3 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 maybe 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

2.6 Socio-demographic Factors Influencing Adoption of Immunization Services

Socio-demographic variables significantly impact a mother's adoption of immunization,

encompassing factors in family, ethnicity, and health care provider-related categories

(Ghulam, 2008). Family factors include educational status, age, marital status,

occupation, economic status, and family size (parity). Ethnic and minority factors involve

culture, religion, and location, which can lead to fears and misconceptions about

immunization. Health care provider-related factors encompass access to health care,

missed opportunities, and prohibitive fees.

Age can affect the adoption of health behavior, as young mothers may lack experience

and support, potentially leading to challenges in immunization (Akinsola, 2009).

xxxvi
Educational status plays a critical role, with educated mothers being more likely to

understand the importance of immunization, as it correlates with the child's and

community's health (Akinsola, 2009). Lower education may hinder a mother's

understanding of immunization schedules and decision-making. The socio-economic

status of a mother also influences her adoption of services, with lower socio-economic

classes being more likely to lack awareness of health issues, especially if the mother is

uneducated (Akinsola, 2009). Ojinnaka (2008) suggests that socio-economic status is

strongly associated with immunization, mediated through factors related to poverty, such

as uneducated mothers, low-income parents, and large families. The poor may face

difficulties in accessing and utilizing health services, including immunization, due to

financial and transportation barriers.

Religious beliefs can influence health-seeking behavior, with some beliefs promoting

health while others may hinder it (Akinsola, 2009). Religious affiliation may deter

mothers from seeking and utilizing health services, and some religious beliefs may limit

interaction with male health workers (WHO, 2007).

The location of the mother from a health care facility is another crucial factor affecting

health behavior, considering elements like distance, access, service frequency, and

reliability (WHO, 2007). Mothers may encounter financial barriers or physical barriers

related to terrain or transportation when trying to access immunization services. These

factors collectively impact a mother's decision to immunize her child.

xxxvii
2.7 Empirical Studies

Several studies have investigated the factors that influence the adoption of immunization

services by mothers. These studies have highlighted a range of socio-demographic and

access-related factors that impact immunization rates:

Matsuda (2010) found that mothers with higher levels of education were more likely to

have their children immunized. Educational status was significantly related to

immunization use, with mothers with higher education reporting higher immunization

rates.

Morrow et al. (2007) conducted a study on access to immunization services in urban

Virginia and identified several access-related problems. The most common barriers

included clinic-waiting time and difficulty obtaining timely appointments. Other

problems included taking time off work, transportation issues, and office hours that did

not align with mothers' schedules.

The same study by Morrow et al. found that household factors associated with hindered

access to immunization included having a greater number of children, single parenthood,

lack of education beyond high school, teenage motherhood, African-American ethnicity,

and loss of the child's immunization card. Not being in the Women, Infants, and Children

(WIC) program, longer clinic waiting times, and transportation problems were also

associated with under-immunization.

Ojinnaka (2008) conducted a study in an urban slum and found that fear of side effects,

ignorance, and a lack of belief in the benefits of immunization were contributing factors

to under-immunization. Younger mothers tended to utilize immunization services more

xxxviii
than older ones. The number of children in the family was positively correlated with the

level of under-immunization.

Torun and Bakirci (2009) investigated vaccination coverage and reasons for non-

vaccination in Istanbul. They found that lack of knowledge about immunization, paternal

and maternal levels of education, and parental income influenced whether children were

completely vaccinated or not. In some cases, non-vaccination was due to logistical issues,

such as being unable to reach a health center in a village or health staff not opening a vial

for only one child (missed opportunities).

The Department of Community Medicine (2005) conducted a study in urban settlements

in Papua New Guinea and found that maternal education was positively associated with

knowledge of when to start childhood immunization. This knowledge was in turn

positively associated with actual immunization practices. Maternal education was also

associated with the ability of mothers to name vaccine-preventable diseases (VPDs).

A study conducted in Papua New Guinea revealed that lack of money for transportation,

indifference about attending immunization clinics, and the sickness of the child were

some of the barriers that hindered immunization.

These studies collectively highlight the importance of addressing socio-demographic

factors, access barriers, and knowledge gaps to improve immunization rates and protect

children from vaccine-preventable diseases.

2.9 Theoretical Framework

The theoretical framework for this study was the social learning theory (SLT) and self-

efficacy (SE). The SLT has been in use since the 1950s; however, it was later redefined

by Bandura (2007) in addressing SE. The SLT theory deals with the cognitive, emotional,

xxxix
and behaviour as aspects for understanding change in behaviour. The SLT is also

pertinent to changing human behaviour and human development. The SLT centers on

individuals learning from one another. People can learn new information and behaviours

by observing other people (Chavis, 2012). The SLT was chosen because an individual’s

action is revealed in his/her cognitive activities, which are centered on human

development. The SLT and SE theories can be used to examine children’s health,

maternal characteristics, and understanding of health care practices and how maternal

developmental stages influences immunization practices. The ability to adhere to

maternal responsibilities such, as completing childhood immunization series on time, can

lead to increased childhood immunization rates. These concepts are important in the SLT

and SE practices. Mothers should be educated on the importance of timely completion of

childhood immunization series and be provided with information based on their

individual needs.

xl
 CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Study Design

The study adopted a cross-sectional survey design which was used to accomplish the

purpose of the study. Eboh (2008) posited that the cross-sectional design can be

employed to study the physical characteristics of people, behaviour of people as well as

the knowledge, attitudes, beliefs and opinions that help to explain behaviour, events and

practices that occurred or are occurring in the population.

3.2 Area of Study

Katsina is a Local Government Area and the state capital of Katsina State in northern

Nigeria. Katsina is located some 260 kilometers (160 mi) east of the city of Sokoto and

135 kilometers (84 mi) northwest of Kano, close to the border with Niger. In 2016,

Katsina is estimated population was 429,000. The city is the centre of an agricultural

region producing groundnuts, cotton, hides, millet and guinea corn. People of the city

are predominantly Muslims, and Hausa Fulani ethnic group.

3.3 Study Population

Katsina Metropolis has a population density of 1,591,879, both indigenes and non-

indigenes. The population of the study comprises of mothers with children less than five

years of age in the local government area.

3.4 Sample size and Sampling Methods

3.4.1 Sample Size

Sample size was calculated based on UNAIDS (2010) report that 18% of children were

fully immunized at age of 10-12 months.

xli
n=
Where n = sample size
Z = confidence interval (1.96)
P= proportion of the target population estimated to the characteristics from previous
studies (0.18)
q = 1-p
d= Degree of accuracy set as 0.05

n=

= = = 227
Assuming anticipated 85% response rate and to compensate for attribution, the sample

size used was adjusted as follows:

227/0.85= 267

Therefore, a sampling size of 300 child bearing mothers drawn from five communities in

Katsina Metropolis was used for the study.

3.4.2 Sampling Methods

Simple random sampling method was employed in selecting sixty (60) child bearing

mothers each from the five autonomous communities in Katsina Metropolis for the study.

A total of three hundred (300) child bearing mothers were used for the study.

3.5 Instruments for Data Collection

The standard questionnaire for the EPI surveys (Training for mid-level manager, 1991)

was modified to adapt it for self-administration and to reflect the Italian vaccination

schedule and the likely reasons for not being vaccinated. Questions focusing on mothers'

demographic and socio-economic features, characteristics of the study child, knowledge

about vaccine-preventable diseases for infants, attitudes towards immunization

programmes, and immunization histories were also included. The questionnaire adopted a

face-validated method used in a study in a low-resource urban setting by Ochola, (2008).

xlii
3.6 Validity of the Instrument

The questionnaire was revised by research supervisor and the recommended

modifications to specific items were done to suit the study objectives. The questionnaire

was subjected to a pre-test before its use in actual data collection.

3.7 Reliability of the Instrument

A sample of the questionnaire was printed and distributed to 15 childbearing mothers in

different communities within the primary healthcare centres. This was repeated on

another immunization date and the result so far collated having it compared with the

former for consistency.

3.8 Method of Data Collection

Multistage sampling method was used to select the 300 respondents. The 24 communities

in the area were categorized into five zones. Out of these zones, one major primary health

centre was chosen by simple random sampling. Data collection for this study was done in

October 2017. Sixty (60) child bearing mothers were drawn from each of the five

autonomous communities selected. All the mothers selected to participate in the study

were met at each of the five primary health centres. The visit was done on scheduled

immunization day using questionnaire.

3.9 Method of Data Analysis

Statistical product and service solutions (SPSS) software package version (20) was used

for data analysis. Descriptive statistics including frequency, distribution, mean, and

standard deviation were used to describe different characteristics. Chi-Square test was

used to test the significance of results. P-value of less than 0.05 was considered as

denoting statistical significance.

xliii
 CHAPTER FOUR

DATA ANALYSIS AND PRESENTATION

4.1 Socio-Demographic Characteristics of the Respondents

Table 1: depicts the result of the socio-demographic characteristics of the respondents

where majority 88 (29.3%) of the respondents are within age bracket of 30-35 years.

Many of them 243 (81%) are married compared to those that are separated or divorced 34

(11.3) and never married 23 (7.7%). Numerous proportion of them 291 (97%) are

Christians that have a nuclear type of family 276 (92%) most of them 132 (44%) earn

N21000-50000 as monthly income while majority 198 (66) of them have more than one

child. In addition, most of them 262 (87.3%) of them gave birth through normal process.

The gender of the last child is mostly female 173 (57.7%) who are mostly 123 (41%) the

second issue. In furtherance, majority 199 (66.3%) of them use short birth interval.

Table 1 Socio-demographical characteristics of the respondents

Variables Frequency Percentage
Age
Less than 20 39 13
25 - 30 yrs 76 25.3
30–35 88 29.3
35–40 67 22.3
Above 40 30 10
Total 300 100
Marital status
Never married 23 7.7
Married 243 81
Separated/divorced 34 11.3
Total 300 100
Religion
Christian 291 97
Muslim 4 1.3
Traditional 5 1.7
Total 300 100

xliv
Type of family
Nuclear 276 92
Extended 24 8
Total 300 100
Family monthly income
<N20,000 101 33.7
N21000-50000 132 44
N51000-100000 23 7.7
>N100000 44 14.7
Total 300 100
Parity
Primipara 102 34
Multipara 198 66
Total 300 100
Type of delivery
Normal 262 87.3
Minor Operation 23 7.7
LSCS 15 5
Total 300 100
Gender of baby
Male 127 42.3
Female 173 57.7
Total 300 100
Child's birth order
First 91 30.3
Second 123 41
Third or more 86 28.7
Total 300 100
Birth interval
Short birth interval 199 66.3
Long birth interval 101 33.7
Total 300 100

4.2 Mothers’ Knowledge on Immunization

Table 2: shows the result of mothers' knowledge on immunization. It was shown that

majority of the respondents 158 (52.7%) know immunization as a vaccine used in

preventing diseases. Large number of the mother 137 (52.5%) immunize their child for

the reason of preventing communicable diseases. However, most of the 194 (74.3%)

xlv
perceived immunizations as been harmful. Majority 169 (64.8%) of them know the

correct age a child should be immunized. Table 4.2 also showed that majority 10.9

(41.8%) of them see fever as a majority symptom of immunization compared to other

symptoms of immunization. However, many 102 (39.1%) of them heard about

immunization from radio compared to other medium of communication.

Fig 3 displayed the awareness of immunization among the participant where majority

(87%) are aware of immunization.

Fig 4 depicts the result of the vaccine preventable disease known by the respondents

where majority (19%) of them know measles as the prominent vaccine preventable

disease.

Table 2 Mothers’ knowledge on immunization

Variables Frequency Percentage

Immunization is
A drug given to children 46 15.3
A vaccine to prevent diseases 158 52.7
Improve children immune 44 14.7
It’s an injection 13 4.3
Don’t know 39 13
Total 300 100
Reasons for immunization
For good health 60 23
For child development 25 9.6
Prevent communicable diseases 137 52.5
Don’t know 39 14.9
Total 261 100
Vaccines harmful
Yes 67 25.7
No 194 74.3
Total 261 100
Age a child should be immunized
Correct 169 64.8
Incorrect 70 26.8
Don’t know 22 8.4
Total 261 100
Infants should start vaccination program

xlvi
Just after birth 106 40.6
After one month 85 32.6
Don’t know 70 26.8
Total 261 100
Symptoms of immunization
Fever 109 41.8
Body Pain 55 21.1
Rash 12 4.6
Body weakness 54 20.7
Body swelling 21 8
Diarrhea 10 3.8
Total 261 100
Means of awareness
Radio 102 39.1
Television 44 16.9
News paper 31 11.9
Friends 44 16.9
School 3 1.1
Health workers 10 3.8
Community leaders 23 8.8
Symposium/lecture 4 1.5
Total 261 100

4.3 Practice of Immunization among Mothers

Table 3: presents the result of the practice of immunization among the mothers studied. It

was shown that majority of them 231 (88.5%) confirm BCG vaccination by looking at the

presence of BCG Scar unlike 30 (11.5%) that don’t know. Most 132 (50.6%) started

vaccination of their child at birth. Moreover, majority 191 (73.2%) of them previously

immunized their children with significant association (P<0.001). In addition, most 169

(64.8%) of them ensured the completion of immunization. With regards to distance of

health care centre from house, most 113 (43.3%) of them live far from the primary health

centre. Majority 173 (66.3%) of the participants see fever as major sign after

immunization with significant association (p<0.001). numerous proportions of them 206

(78.9%) inform doctor or healthcare workers of the signs seen in their child after

xlvii
immunization. However, majority 191 (73.2%) of them reported that doctors provided

medicine for the fever with significant association.

Table 3 Practice of Immunization among Mothers

Variables Frequency Percentage
Confirming BCG vaccination
By looking the presence of BCG scar 231 88.5
Don’t know 30 11.5
Total 261 100
X2 154.79 p < 0.001
Started vaccination for child
At birth 132 50.6
others 101 38.7
Don’t know 28 10.7
Total 261 100
X2 65.54 p < 0.001
Previous children immunized
Yes 191 73.2
No 70 26.8
Total 261 100
X2 56.1 p < 0.001
Their immunization was complete
Yes 92 35.2
No 169 64.8
Total 261 100
X2 22.72 p < 0.001
Distance of house and primary health centre
Very near 19 7.3
Near 75 28.7
Far 113 43.3
Very far 54 20.7
Total 261 100
X2 71.12 p < 0.001
Signs seen
Pain 38 14.6
Fever 173 66.3
Swelling 13 5
Rash 23 8.8
Others(vomiting) 14 5.3
Total 261 100
X2 357.14 p < 0.001
Inform doctor/healthcare workers
Yes 206 78.9
No 55 21.1

xlviii
Total 261 100
X2 87.36 p < 0.001
Reaction of doctor
Provide medicine for illness 191 73.2
Provide treatment for illness 70 26.8
Total 261 100
X2 56.1 p < 0.001

4.4 Influence of Demographic Characteristics on Immunization

Table 4 shows the influence of selected demographic characteristics on awareness of

immunization. It was revealed that age, marital status and gender of baby head strong

association with awareness of immunization. However, with regards to age, majority 82

(93.2%) of the respondents who are in 30-35 years bracket are aware of immunization

compared to other age brackets. However, with regards marital status, those that are

married 142 (69.6%) adhered more to immunization than the other marital statuses. Table

4.4 further showed that with regard to gender of the baby, female children adherence to

immunization schedule is skewed to female gender with significant association

(X2=54.57, >F=1, P<0.001).

Table 4 Influence of demographic characteristics on immunization

Awareness of immunization
Age Yes No Total
Less than 20 24(61.5%) 15(38.5%) 39
25 - 30 yrs 65(85.5%) 11(24.5%) 76
30–35 82(93.2%) 6(6.8%) 88
35–40 62(92.5%) 5(7.5%) 67
Above 40 28(93.3%) 2(6.7%) 30
Overall Chi-square 28.35 4 d.f. p < 0.001
Adhering to immunization schedule
Marital status
Never married 21(72.4%) 8(27.6%) 29
Married 142(69.6%) 62(30.4%) 204
separated/divorced 13(46.4%) 15(63.6%) 28
Overall Chi-square 6.39 2 d.f p = 0.041

xlix
 Adhering to immunization schedule
Gender of baby
Male 39(42.4%) 53(57.6%) 92
Female 137(81.1%) 32(28.9%) 169
Overall Chi-square 54.57 1 d.f. p < 0.001

4.5 Influence of Family Monthly Income on Onset of Child Vaccination

Table 5 presents the association of family monthly income on onset of child vaccination

where there was a significant (X2=33.63, DF∑6.,) association between family income of

the mothers and onset of child vaccination. It was revealed that majority 46 (45.5%) 65

(69.9%) of the respondents who start vaccination at birth earn <20-50000 per month.

Whereas those that start vaccination at other times earn N51000-100000 (91.3%) and

>N100000 (47.7%) per month (table 4.5).

Table 5 Influence of family monthly income on onset of child vaccination

Started vaccination for child
Family monthly
income At birth Others Don’t know Total
<N20,000 46(45.5%) 43(64.5%) 12(%) 101
N21000-50000 65(69.9%) 22(30.1%) 6(%) 93
N51000-100000 2(8.7%) 15(91.3%) 6(%) 23
>N100000 19(43.2%) 21(47.7%) 4(9.1%) 44
Overall Chi-square 33.63 6 d.f. p < 0.001

4.6 Discussion of Findings

The findings in this research highlights various factors related to a mother's behavior,

knowledge, and practices regarding childhood immunization, as well as the influence of

socio-demographic factors. In terms of knowledge and awareness, a significant portion of

the respondents demonstrated knowledge of immunization as a preventive measure

against communicable diseases. Most participants correctly identified the recommended

time to start immunization and vaccination programs. Additionally, media outlets,

l
particularly radio and TV, played a crucial role in providing information about

immunization to mothers.

Regarding the practice of immunization, many mothers initiated vaccination at birth and

completed the immunization schedule, despite facing challenges such as long distances to

the primary health center. Notably, the walking time to the health facility was a factor

associated with completing child immunization.

Utilization of EPI cards was also examined, with more than half of the respondents

consistently using the EPI card for infant immunization. Availability of the EPI card

during immunization and adherence to the immunization schedule were also relatively

high among the participants.

Barriers to immunization were identified, with a significant barrier being the belief that

immunization goes against one's religion. Religious restrictions, such as some Muslim

women not wishing to see male health workers, were seen as potential barriers to

immunization. Other barriers included the lack of money for transportation and

indifference about attending immunization clinics.

The study also explored the influence of socio-demographic factors. It found that age had

a significant association with awareness of immunization, with mothers in the age bracket

of 30-35 years being more aware. Teenage mothers and single mothers were less likely to

present their children for immunization, possibly due to their lack of experience and

support. Marital status was associated with adherence to the immunization schedule, with

married mothers having more support and resources. Additionally, the gender of the baby

was associated with adherence to the immunization schedule, with female children

having higher privilege. Family monthly income strongly influenced the onset of child

li
vaccination, with mothers in the higher income bracket starting immunization at the

recommended time.

In conclusion, the findings in this study indicate that knowledge and awareness of

immunization are important factors in immunization practices. However, various socio-

demographic factors and barriers can influence a mother's decision to immunize her

child. These findings emphasize the need for tailored interventions that address specific

barriers, such as religious beliefs and socio-economic factors, to improve immunization

rates and protect children from vaccine-preventable diseases.

lii
 CHAPTER FIVE

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

5.1 Summary

This study investigated mothers’ behaviour in prevention of childhood diseases in

Katsina Metropolis, Katsina State. Chapter one of this research provides an overview of

the research, beginning with a background of the study. It highlights the significance of

studying childhood diseases and immunization in Nigeria, a country facing numerous

health challenges. The statement of the problems articulates the issues related to

immunization and child health. The chapter establishes aims and objectives, research

questions, and research hypotheses that will guide the investigation. It also defines the

scope and operational terms to clarify the focus of the study.

Chapter two delves into the theoretical and contextual framework of the study. It explores

childhood diseases, with a specific focus on pneumonia, malaria, diarrhea, and vaccine-

preventable diseases. The concept of immunization and its implementation in Nigeria,

including the National Programme on Immunization, is discussed. The chapter also

explores the factors affecting routine immunization in Nigeria, including misperceptions,

religion, cold chain equipment, political issues, and public acceptance issues. Socio-

demographic factors influencing the adoption of immunization services are examined,

along with empirical studies and a theoretical framework to provide a comprehensive

background for the research.

Chapter three outlines the research methodology adopted for the study. It discusses the

study design, the area of study, the study population, and the sample size and sampling

methods employed. Instruments for data collection, their validity and reliability, are

liii
detailed. The chapter explains the method of data collection and data analysis, ensuring a

clear understanding of the research process.

Chapter four presents the results of the study. It starts by examining the socio-

demographic characteristics of the respondents, followed by an analysis of mothers'

knowledge on immunization and their practices. The chapter also explores how

demographic characteristics and family monthly income influence child vaccination. The

findings are discussed, providing insights into the state of immunization among mothers.

Lastly, Chapter five summarizes the key findings and conclusions drawn from the

research. It offers a concise overview of the research outcomes, including the impact of

socio-demographic factors on immunization practices. The chapter then concludes by

presenting recommendations to address the challenges identified. These

recommendations aim to improve immunization services and child health in Nigeria,

based on the research findings, thereby contributing to the broader healthcare landscape

in the country.

5.2 Conclusions

Immunization is one aspect of preventive medicine which gives protection to susceptible

individuals from vaccine preventable infectious disease by administration of a modified

infectious agent. This study assessed mothers’ behaviour in prevention of childhood

diseases through immunization in Katsina Metropolis, Katsina state. Simple random

method was employed in selecting sixty (60) child bearing mothers each from the five

autonomous communities of Katsina Metropolis. Overall, a total of three hundred

mothers were used in the study in which questionnaire was used in eliciting pertinent

information for the study. Data were subjected to descriptive and chi-square analysis

liv
using Genstat-Statistical Package (GSP) version 18. Result of the study showed 87%

coverage of immunization where majority of the respondent were aware that

immunization is a vaccine that prevents communicable disease. Most of them correctly

mentioned the rightful time for immunization. This knowledge are mostly acquired from

radio broadcasting. Most of the mothers started immunization at the rightful time after

birth and ensured the complete immunization of their previous children.

Additionally, the study revealed highest proportion of the respondents practicing infant

immunization always by EPI card and ensured availability of EPI card during

immunization and adherence to immunization schedule. However, religion was the

highest barrier to immunization in the study area. Among the socio-demographic

characteristics, age has strong influence on immunization awareness where those within

30-35 years age bracket are more aware of immunization that other age brackets. Also,

marital status recorded significant association (X2=6.39, DF=2, P=0.041) with adherence

to immunization schedule. In addition, the study further showed strong association

X2=54.57., DF=1; P<0.0001) between gender of baby and adherence to immunization

schedule, in that, female children received more privilege to immunization schedule then

their male counterpart.

Finally, the study revealed that family monthly income had strong association (X2=33.63,

DF=6, P<0.001) with onset of child vaccination where majority of the mothers who earn

N21000-500000 start child immunization at birth which is the rightful period for

commencing vaccination.

lv
5.3 Recommendations

Based on the outcome of the research work, the following were recommended.

- Sufficient information about child vaccination and vaccine preventable diseases

should be provided to mothers especially by healthcare workers for them to make

an informal choice on whether to vaccinate their children or not.

- Healthcare workers should ensure that mothers are comfortable with the language

used during their communications. The use of translators who know the local

language can be employed where applicable to ensure smooth communication.

- The major barrier to immunization was religion therefore healthcare workers

should double their efforts in awareness of immunization by taking advantage of

churches and other religious gathering.

- Similar studies should be conducted in various LGAs published and the result

forwarded for comparison.

lvi
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APPENDIX I

DEPARTMENT OF PUBLIC HEALTH, MARYAM ABACHA AMERICAN

UNIVERSITY, NIGER

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 QUESTIONNAIRE ON THE ASSESSMENT OF MOTHERS’ BEHAVIOUR IN

THE PREVENTION OF CHILDHOOD DISEASES THROUGH

IMMUNIZATION IN KATSINA METROPOLIS

Dear respondent,

I wish to solicit with you to respond to the attached questionnaire, I am a postgraduate

student in the department of public health embarking on a research based on “Assessment

of Mothers’ Behavior in the Prevention of Childhood Diseases through Immunization in

Katsina Metropolis.” This Research work is for the award of Bachelor of Science in

Public Health (B.Sc. Public Health) and is basically for academic purpose. I would be

very grateful with your utmost response, as it will be treated confidentially.

Thanks for your anticipation.

Yours Sincerely

Abdulaziz Abubakar

RESEARCH QUESTIONS
INSTRUCTION: Please tick √ where necessary
SECTION A: SOCIO-DEMOGRAPHICAL CHARACTERISTICS OF THE
RESPONDENTS

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Age
Less than 20 25 - 30yrs 30–35 35–40 Above 40
What is your current marital status?
Never married Married Living together Not living together
What is your religion?
Muslim Christian Traditional
What is your type of family?
Nuclear Extended
Education completed
Illiterate Elementary school Senior high school Tertiary
What is your family monthly income
<N20,000 N21000-50000 N51000-100000
>N100000
Employment status
Full house wife Trader Farming Working class
Parity
Primipara Multipara
Type of delivery
Normal Minor Operation LSCS
Place of delivery
Traditional birth attendant Health centre Hospital
Gender of baby
Male Female
Child's birth order
First Second Third or more
Birth interval
Short birth interval Long birth interval
SECTION B: MOTHERS’ KNOWLEDGE ON IMMUNIZATION
AWARENESS OF IMMUNIZATION
Yes No
What do you know about it?
A drug given to children A vaccine to prevent diseases Improve
children immune It’s an injection Don’t know
Reasons for immunization
For good health For child development Prevent communicable diseases
Don’t know
VPDs known
Tuberculosis Diphtheria Whooping cough Tetanus
Measles Yellow fever Hepatitis B Meningitis
Poliomyelitis Others
Are vaccines harmful?
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Yes No Don’t know
What age should a child be immunized
Correct Incorrect Don’t know
Infants should start vaccination program
Just after birth After one month Don’t know
Can children with fever be immunize
Yes No Not sure
Symptoms of immunization
Fever Body Pain Rash Body weakness Body
swelling
Diarrhea
Means of awareness
Radio Television News paper Friends School
Health workers Community leaders Symposium/lecture

SECTION C: BEHAVIORAL PRACTICE OF IMMUNIZATION AMONG

MOTHERS
ADHERING TO IMMUNIZATION SCHEDULE
Yes No
Confirming BCG vaccination
By looking the presence of BCG scar Don’t know
Availability of EPI card during immunization
Yes No
Infant immunization practice always by EPI card
Yes No
When you started vaccination for child
At birth others Don’t know
Were previous children immunized?
Yes No
Was their immunization complete?
Yes No
If no, why
It’s against my religion Attitude of the health workers Cultural belief
Afraid Lack of interest in it Far-distance of health centre
Absents of health workers Time constraint
Distance of house and primary health centre
Very near Near Far Very far
If yes, was any side effect noticed
Yes No
If yes, which were seen
Pain Fever Swelling Rash Others (vomiting)
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Did you inform doctor/healthcare workers?
Yes No
If yes, what was done?
Provide medicine for illness Provide treatment for illness

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