CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Despite its importance in promoting public health and reducing illness, vaccination is still a
contentious issue in today's culture. The development of vaccines has led to the near
eradication of diseases that once caused significant morbidity and mortality (Nithya et
al,2023). Immunization is a means of preventing vaccine preventable diseases and mortality
among children less than 5 years of age, and still mothers and caregivers find it hard to
complete them
children immunization schedule thereby endangering the lives of these children.
Immunization,
defined as the process that makes a person immune or resistant to an infectious disease,
typically by the administration of a vaccine, is one of the most effective interventions in
contemporary public health practice (WHO, 2020, UNICEF 2020). Several cost–benefit
analyses have consistently placed immunization as one of the most cost-effective health
interventions with huge direct and societal benefits (Orenstein & Ahmed, 2019). According
to Zhou, et al. 2019, immunization saves about 2–3million lives every year, and has
successfully led to the elimination of several vaccine preventable diseases in some high-
income countries, including polio, diphtheria, and Pertusis, (Greenwood; 2019: Orenstein &
Ahmed, 2019). Indeed, childhood immunization has had a remarkable impact on child
morbidity and mortality worldwide with immense positive multiplier effects on the larger
communities (Zhou et al., 2019, Greenwood; 2019, Orenstein & Ahmed, 2019). Nigeria is
one of the 10 countries (Angola, Brazil, the Democratic Republic of the Congo, Ethiopia,
India, Indonesia, Mexico, Nigeria, Pakistan, and the Philippines) that account for over 60% of
the children who did not get PENTA 3 in 2019. PENTA 3 coverage is used as an indicator of
how well countries are providing routine immunization (RI) services WHO, (2020).
Reaching Every Ward (REW), an approach developed in 2002 by the World Health
Organization (WHO) and partners, provides a framework for strengthening National
Immunization Programmes (WHO, 2019). To improve Immunization coverage, Nigeria
adopted the REW strategy in 2005. The REW strategy focuses on RI in health facilities and
outreaches, including components such as improved access for under-served and hard-to-
reach areas; support supervision; monitoring and use of data for action; community
mobilization and improving community links with service delivery. These community

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linkages include the Ward Development Committee (WDC)-linked to primary health care
including immunization at ward level; and the Social Mobilization Committee (SMC),
focused specifically on immunization at local government level. The Levels of morbidity and
mortality from vaccine-preventable diseases have decreased in recent years due to
administration of childhood vaccinations. Every year, vaccination effectively prevents about
2–3 million child deaths. Nonetheless it is also estimated that vaccine-preventable diseases
are still responsible for 1.5 million deaths each year among children under 5 Years of age.
Previous studies have demonstrated that vaccination has a positive impact on the control of
communicable diseases and decreases the number of disability- adjusted life years (DALYs)
rates, (WHO, 2019)
In Nigeria, the EPI was initiated in 1978. It is one of the main sub-components of the Basic
Package of Health Services (BPHS) under the main component of child health and
immunization. The EPI services are provided from the Health Sub-Center (HSC) level to the
Provincial Hospital (PH) level. Vaccination is provided at all public health facilities free of
charge. The number of health facilities that provide vaccination services has increased from
1,575 in 2015 to 2,926 in 2018 (WHO, 2017). Nonetheless, 2.5 million deaths per year are
still caused by vaccine-preventable diseases, and approximately 1.5 million of them are
among children under 5 years of age in developing countries, (UNICEF, 2021). Vaccine-
preventable diseases including tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal
tetanus, hepatitis B, pneumonia due to Haemophilus Influenzae, and measles are among the
main killers of children under 5 years of age in developing countries (Meleko et al., 2020).
Nigeria is taking part in the global fight against these diseases by implementing BCG, OPV,
Pentavalent, and measles vaccines. As Stipulated by Meleko et al., (2021), despite the
improvements in vaccination services over the past 40 years and the increased number of
health facilities that provide vaccination services, the vaccination coverage in Nigeria has
remained low due non-compliancy of the nursing mothers. A study by Farzard et al., (2019),
that used the Nigeria Health Survey dataset revealed that full vaccination coverage was only
59%. Outbreaks of vaccine-preventable diseases still have a seasonal pattern in Nigeria.
Understanding factors that influence vaccination coverage is important to increase the
vaccination coverage rate. Numerous investigations have found that the factors influencing
vaccination coverage among children include sex of child, place of birth, maternal and
paternal education, maternal and paternal occupation, and numbers of Ante-Natal care (ANC)
visits, household characteristics, sociocultural factors and socio-demographic factors.
Evidence from reviewed literatures could not affirm that nursing mothers’ non-complacency
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is a major factor for non-immunization of children in Nigeria. However, there is a dearth of
empirical data about the context of improving nursing mother’s complacency. This study
therefore will assess the factors responsible for non-completion of expanded program on
immunization among nursing mothers attending general hospital in Nasarawa State Nigeria.
1.2 Statement of Problem
In Nigeria, the Expanded programme on immunization (EPI) was developed based on the
WHO’s guidelines. A child is considered fully vaccinated if he or she has received bacille
Calmette-Guerin (BCG) vaccination against tuberculosis; three doses of vaccine to prevent
diphtheria, pertussis, and tetanus; at least three doses of polio vaccines; a dose of measles
vaccine; and a yellow fever vaccine before the first birthday (NCPN & ICF Macro, 2014).
The North Central region of Nigeria has the lowest vaccination completion compared to the
other five geopolitical regions of the country, as evidenced by 52% of children fully
immunized in the South East and South West compared to only 10% in the North West.
Despite the North central region being ranked second in terms of availability of public health
resources such as health facilities and Primary Health Care workers (Health Reform
Foundation of Nigeria, there is lower coverage of all antigens in the region compared to other
regions in the country (NPCN & ICF MACRO, 2014). Several small-sample hospitals-based
studies have been conducted in Nigeria on non-completion of expanded programme on
immunizations; however, there is a paucity of data from community-based studies with
appropriate sampling technique and large sample size in the North central region (Gidado et
al., 2014). There are also data gaps on the association between the nursing mother’s cultural
factors such as their ability to take decisions independently, religious affiliation, and
tribe/ethnicity, and the non-completion of routine immunization schedules. The current study
also addressed the association between the
nursing mothers’ place of residence (rural/urban), distance from the immunization routine
service point, the cost of transport, session plan, and cost of immunization services, and the
non-completion of expanded programme on immunization. Findings may provide a better
understand of the factors that is responsible on how nursing mothers make health decisions
for and about their children in the context of diseases with high levels of morbidity and
mortality.
1.3 Aim and Objectives
The study aims to assess the factors responsible for non-completion of expanded program on
immunization among nursing mothers attending general hospital in Nasarawa State Nigeria.
The specific Objectives are to;
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 i. identify the socio-demographic factors associated with non-compliance to
immunization regimens among children under the age of 5.
ii. determine the impact of parental knowledge and attitudes towards immunization on
compliance rates.
iii. examine the role of access to healthcare services and immunization programs in
influencing compliance.
iv. investigate the effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance.
v. assess the influence of cultural and religious beliefs on immunization non-
compliance.
vi. evaluate the relationship between healthcare provider-patient communication and
immunization compliance
1.4 Research Hypothesis
H0: There is no significant relationship between the Socio-demographic characteristics and
immunization non-completion rates.
H1: There is significant difference between health system factors and Immunization non-
completion rates
H2: There is significant between the constraint faced by nursing mothers and non-completion
of expanded programs on immunization.
1.5 Research Questions
1. What are the socio-demographic factors associated with non-compliance to immunization
regimens among children under 5?
2. How do parental knowledge and attitudes towards immunization impact compliance rates?
3. What are the roles of access to healthcare services and immunization programs in
influencing compliance?
4. What are the effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance?
5 What are the influence of cultural and religious beliefs on immunization non-compliance?
6. What is the relationship between healthcare provider-patient communication and
immunization compliance?
1.6 Significance of the Study
Using the data from the 2013 NDHS, factors that may be responsible for non-completion of
an expanded program on immunization among nursing mothers attending general hospitals in
Nasarawa State Nigeria will be examined. Factors included socioeconomic (income levels
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and educational level of respondents), biological (age, sex), and cultural (ability to take
decisions independently, religious affiliation, tribe/ethnicity). Finding may be used to develop
social mobilization interventions to target nursing mothers, religious leaders, and other
stakeholders who have the potential to improve access to and utilization of health services
and promote positive health outcomes in the completion of expanded programme on
immunization schedules and reduction of infant/childhood morbidity and mortality.
Identifying the association between nursing mothers’ independence of decision-making,
socioeconomic or cultural and biological characteristics, and the way of using expanded
programmes on immunization services may influence completion of immunization schedules
of children in the Nasarawa state with its multireligious and multitribal populations. Findings
will help policymakers in modifying population specific interventions to improve access and
utilization of health services and immunization schedules. The improvement in the
completion of immunization schedules will reduce infant/childhood morbidity and mortality.
The Nasarawa State has been lacking in data on the factors that is responsible non-
compliance of expanded programme on immunization schedules when compared with other
states of Nigeria. The NDHS data had not been used for analysis of this nature, and this study
presented an opportunity to analyze these factors. Findings may be used to raise awareness of
the factors responsible for non-completion immunization schedules in the Nasarawa State.

1.7 Scope and Delimitations

This study addressed factors responsible for non-completion of expanded program on
immunization among nursing mothers attending general hospitals in Nasarawa State Nigeria.
The findings from this study will be generalizable to the population of the entire Nasarawa
state because the sample will comprise of most populated LG.
1.8 Operation Definition of Terms
1. Non-completion: This refers to the act of not finishing or completing a task/ project,
or failing to meet deadline.
2. Expanded program: This refers to a program or initiative that has been broadened or
enlarged in scope, scale or coverage
3. Immunization: This is the process of making a person or animal resistant to a
specific disease, usually by administering a vaccine.
4. Nursing mothers: This is a woman who is breastfeeding her child.

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 CHAPTER TWO

LITERATURE REVIEW

2.1 Concept of Immunization

Immunization has become a vital part of public health and disease prevention, and yet, it
remains a controversial topic in our society today. Diseases that were once responsible for
significant morbidity and mortality have now become all but eradicated, thanks to the
introduction of vaccines. Immunization has contributed to increased life expectancy and
improved quality of life. (Denstefano et al, 2019, Gageur et al, 2019 and Liebowitz, 2022).

The first vaccine is credited to Edward Jenner, who in 1796 inoculated a 13-year-old boy
with the virus responsible for cowpox, and he demonstrated immunity to smallpox. The first
smallpox vaccine was created in 1798 using that premise. Over the following centuries, and
leading up to the present day, vaccine technology has improved, and vaccines to many
illnesses have been developed. In 1979, global eradication of smallpox was achieved thanks
to immunization (Schrick, et al, 2017, Bidgood, 2019).

The World Health Organization has made lifelong immunization a priority, including it as a
core to the 2030 Sustainable Development Goals. In fact, in 2012, the World Health
Assembly adopted the Global Vaccine Action Plan, which aims to prevent millions of deaths
by 2020 by increasing access to and utilization of vaccines throughout all parts of the world.
The first milestone this action plan hopes to achieve is the worldwide eradication of polio.

A vaccine is a pharmacologic compound that improves a person's immunity to a particular

disease. When a disease-causing bacterium or virus invades the human body, the immune
system recognizes the material as foreign, usually by detecting specific protein portions of the
invading organism, known as antigens. Vaccines contain a form of the disease-causing agent,
whether it be a weakened or killed form of the microbe itself, an inactivated version of its
toxins, or a protein from the surface of the microbe. By introducing a form of the agent, the
vaccine presents the antigen to the immune system, allowing it to recognize the antigen as
foreign and develop antibodies and memory T-lymphocytes against those antigens. This

6
allows a more rapid and robust immune response should the body be exposed to the organism
in the future. In the absence of vaccination, the first exposure to the natural organism may
prove fatal before the immune system can mount a sufficient immune response (Jacob et al,
2024).

2.1.1 Types of immunization

Immunization can be achieved actively or passively:

1. Active immunization
When someone comes into contact with anything, like a microorganism, active immunization
may happen naturally. Eventually, the immune system will produce antibodies and other
antimicrobial defenses. In many childhood infections that a person only encounters once, but
then becomes immune to, the immune response against this bacterium can be quite effective
the next time. In artificial active immunization, the microbe or its components are injected
into the subject before their bodies can naturally absorb them. When using entire
microorganisms, they are first pre-treated.

2. Passive immunization
In passive immunization, immune system components that have already been synthesized are
given to a person so that they won't have to be produced by their own body. Antibodies can
currently be used for passive immunization. The effects of this form of immunization start to
take effect almost immediately, but they are only temporary because the antibodies are
naturally broken down, and if there are no B cells to create additional antibodies, they will
eventually disappear (Nithya et al,2023).

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 Fig. 2.1: Types of immunity.

2.1.2 Anatomy and Physiology

Vaccines affect the immune system, primarily through B-lymphocytes and T-lymphocytes.
Before exposure, the immune system contains B-Lymphocytes and T-Lymphocytes, each
with the potential to respond to a unique antigen. In addition, many antigens require a
combined response of both B-Lymphocytes and T-Lymphocytes. This form of immunity is
termed T-cell-dependent. Less commonly, an antigen causes stimulation of B-Lymphocytes
and antibody production without the help of T-lymphocytes. This form of immunity is termed
T-cell-independent.

The vaccine introduces the antigen to begin the process, which stimulates the initiation of the
immune response. Initially, the foreign material is phagocytized and broken down by
macrophages. Then, the resultant peptides created by the breakdown of the protein material
are sent to the surface of the macrophage cell, where it is displayed. These antigens are
displayed by molecules called Major Histocompatibility Complexes, which exist in two
forms: I or II (MHC-I or MHC-II). The presentation of the antigen stimulates the secretion of
several inflammatory mediators, including cytokines and various interferons, which stimulate
a further response.

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In T-cell-dependent immunity, so-called T-helper cells recognize the antigen and stimulate
the corresponding B-lymphocytes to proliferate and produce antibodies. As the B-
lymphocytes proliferate, they also differentiate into antibody-forming plasma cells. The
antibodies produced have various functions, the most important of which include those which
inactivate soluble protein toxins (antitoxins), those which facilitate intracellular digestion of
bacteria by damaging the bacterial membrane (lysins), those that prevent reproduction of
pathogenic viruses (neutralizing antibodies), and those that prevent bacterial adhesion to
mucosal surfaces (antiadhesion). In response to vaccines, the first antibodies produced are
primarily IgM, with a gradual switch to IgG in the following weeks. Vaccines can be
classified as live attenuated vaccines, killed or inactivated vaccines, subunits, or toxoids
(tetanus) (Ignatova and Antonov, 2018).

2.1.3 Vaccines

A vaccination is a pharmacologic substance that raises a person's resistance to a certain

disease. When a disease-causing bacterium or virus enters the body of a person, the immune
system detects the material as foreign. Typically, it does this by identifying particular protein
components of the invader, known as antigens. Whether it be a weakened or destroyed
version of the microbe itself, an inactivated version of its toxins, or a protein from the germ's
surface, vaccines contain a form of the disease-causing agent. The vaccination exposes the
antigen to the immune system in the form of the agent, enabling it to identify the antigen as
foreign and produce antibodies and memory T-lymphocytes against those antigens. Should
the body come into contact with the organism again in the future, this enables a quicker and
more effective immunological response. Without immunization, the initial encounter with the
natural organism could be lethal before the immune system can establish a powerful enough
defense. (Denstefano et al, 2019, Gageur et al, 2019, Bidgood, 2019).

2.1.4 Types of vaccines

 Inactivated vaccines
 Live-attenuated vaccines
 Messenger RNA (mRNA) vaccines
 Subunit, recombinant, polysaccharide, and conjugate vaccines
 Toxoid vaccines  Viral vector vaccines
2.1.5 Adverse events of immunization

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Adverse reactions to immunizations might be moderate, severe, common, or extremely
uncommon. They may happen as a result of the immunization, establishing a causal link
between the event and immunization, or they could happen by coincidence following
immunization, establishing a coincidental link between the event and immunization. Adverse
events following immunization can be classified as:

 Vaccine response
o Product-related
o Quality defect-related
o Error-related
 Immunization anxiety-related responses
 Coincidental events
1. Vaccine responses
a. Common, Mild vaccine responses
As the immune system reacts to the vaccine, there are observable local or systemic signs.
Around the injection site, local reactions may include discomfort, redness, and/or edoema.
Systemic reactions can include symptoms including fever, headache, exhaustion, irritability,
or feeling generally ill. Mild vaccine reactions typically appear quickly after vaccination and
disappear on their own within a few days without needing any special care. The onset of
minor reactions to intravenous live vaccines may take a week or longer, but they also go
away on their own without needing any special care. Some people find that managing their
symptoms, such as applying a cold, moist cloth to an uncomfortable injection site, taking a
nap, or taking a mild analgesic to ease pain from fever or injection site reactions, makes them
feel better (Nithya et al,2023).

b. Rare, Severe vaccine responses

These reactions also take place as a result of the immune system reacting to the vaccine.
They consist of reactions like a severe allergic reaction (anaphylaxis) to a vaccine
component, or a low platelet count (thrombocytopenia), febrile seizures, HHE (hypotonic,
hyporesponsive (episode), or protracted howling. Since anaphylaxis is treatable, it rarely
poses a threat to life. Other severe reactions are rare to have long-term effects and may or
may not need therapy to help them resolve. Immunization Anxiety-Related responses When
receiving a vaccine, anyone may experience tension or anxiety, especially if the shot is
administered intravenously. These emotions may be so slight for some people that they are
not aware of them, yet they may be so strong for others. When receiving an immunization
10
anxiety symptom may include children holding their breath with or without a momentary loss
of consciousness, vomiting, breathing too quickly (hyperventilation), feeling dizzy or
lightheaded, tingling in the hands or mouth, fainting, or convulsing. These symptoms are not
exclusive to vaccinations and could appear in a variety of other anxiety-related
circumstances. Once the anxiety has subsided, they will resolve themselves. These are also
referred to as immunization-related stress reactions (ISRR). c. Coincidental events

These occurrences bear no connection to vaccinations at all. They happen by accident after
immunization and would probably have happened even if the immunization hadn't been
administered. Lifelong medical issues arise. Some have an impact on people at any point in
their lives. Others are merely observed, diagnosed, or treated more frequently, or are simply
seen more frequently, in certain age groups. Parents and medical experts may easily see and
keep a close eye on an infant's or young child's growth and development. The majority of
immunizations are given to children while they are young so they can establish defenses
against diseases that can be prevented. Additionally, any congenital or developmental
disorders are frequently discovered at this age. It is probable that one or more of these events
will occur after immunization since numerous children are immunized at a stage in their
development when congenital or developmental abnormalities are likely to be identified. This
could give the impression that ailments or recently discovered disorders are related to
immunization when they are not. (Nithya et al,2023).

2. Indications
Childhood vaccinations are indicated for the prevention of a multitude of viral and bacterial
infections and their sequelae. Specific vaccination recommendations for children vary by
region, as exposure to diseases varies by region.

Current recommendations for adult vaccination include a yearly influenza vaccine and
tetanus-diphtheria every ten years, with tetanus-diphtheria-acellular-pertussis at least once in
adulthood. The addition of acellular pertussis once during adulthood is intended to prevent
the transmission of whooping cough to young children or those unable to be vaccinated. For
those adults born after 1956 who didn't receive measles, mumps, rubella vaccinations, or
varicella vaccination as children, these vaccinations are recommended in adulthood. Human
papillomavirus, hepatitis A, and hepatitis B vaccines are also recommended in adulthood.
The meningococcal vaccine is recommended for adults at high-risk, such as those living in
close quarters (college students living in dorms, military personnel living in barracks).

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Pneumococcal vaccination is also recommended for high-risk adults, such as those with pre-
existing pulmonary diseases like chronic obstructive pulmonary disease (COPD) (Ignatova
and Antonov, 2018).

Passive immunization is indicated in patients who cannot form antibodies, such as those
immunocompromised. It is also indicated when the disease may develop before active
immunity can develop antibodies, such as in a patient exposed to rabies. In this instance, the
patient may develop rabies before active immunization effectively creates antibodies.
(Murthy, 2022). COVID-19 vaccination is advised in ages > 6 months, regardless of a
history of SARS-CoV-2 infection. This includes recommendations that include people with
protracted post-COVID-19 symptoms (Brannock,2022).

2.2 Expanded Program on Immunization

The World Health Organization (WHO) started the global effort to use vaccination as a
public health intervention in 1974 when it launched the EPI. Since then, immunization has
remained one of the most cost-effective public health interventions for reducing global child
morbidity and mortality (Machingaidze, Wiysonge, & Hussey, 2015). The EPI program is a
blueprint of how to manage the technical and managerial functions required to routinely
vaccinate children with a limited number of vaccines, providing protection against diphtheria,
tetanus, whooping cough, measles, polio, and tuberculosis, and to prevent maternal and
neonatal tetanus by vaccinating women of childbearing age with tetanus toxoid (Shen, Fields,
& McQuestion, 2014). The original intent of EPI was to deliver multiple vaccines to all
children through a simple schedule of child health visits (Shen, Fields, & McQuestion, 2014).
This was challenging because at that time the health systems in most poor and developing
countries were frail and in some cases nonexistent (Shen, Fields, & McQuestion, 2014).
Vaccine coverage levels were less than 5%, until around 1990 when most of the poor
countries had institutionalized immunization programs based on the EPI blueprint, and by
1991, the global target of vaccinating 80% of the world’s children was declared to have been
met, likely saving millions of lives (Shen, Fields, & McQuestion, 2014). These successes
were attributed to the building of the capacities and capabilities of these countries through the
EPI blueprint that was developed at the inception of the program (Shen et al., 2014).

The cost of vaccination in the developing world has grown from less than one United States
Dollar (USD) in 2001 to about $21 for boys and $35 for girls in 2014, as increasingly
expensive vaccines are being introduced into national immunization programs, and vaccines

12
for girls, such human papillomavirus vaccines, are being introduced more widely (Shen,
Fields, & McQuestion, 2014).To address these and other challenges, additional efforts are
needed to strengthen critical components of RI: policy, standards, and guidelines;
governance, organization, and management; human resources; vaccine, cold chain, and
logistics management; service delivery; communication and community partnerships; data
generation and use; and sustainable financing, though these may not affect the rates of
vaccination among boys and girls (Shen et al., 2014). Countries are expected to ad0apt the
available WHO global-level policies, standards, and guidelines to develop their own
structures to provide overall guidance to their countries’ immunization activities. In the
majority of nations, the national program of immunization provides leadership and a wide
range of other functions as part of its role in building strong governance, organization, and
management (Shen et al., 2014). There is a growing need for a highly trained health
workforce as a result of the increasing complexity of immunization services caused in part by
the rising number of vaccines given to a child and the growing populations of children who
require these services. The quality of the health workforce has become more critical in the
face of the increasing cost of vaccines, making competent handling and oversight of limited
and expensive stocks a key issue. Despite the growing demand for skills in the health 31
workforce, the same basic method of vaccination training is still in use that was in place 30
years ago (Shen et al., 2014). Vaccines, cold chain, and logistics management have become
increasingly important with the growing number of new vaccines for disease prevention,
eradication of existing outbreaks, and frequent mass campaigns that require additional storage
equipment, finance, and expertise in the management of the entire system. Communication
and community partnerships are central to the EPI activities and the use of immunization
services, especially to enlighten and mobilize the community to support immunization (Shen,
Fields, & McQuestion, 2014). In practice, this requires the support of the health workforce
and other trustworthy persons to ensure that parents or caregivers are kept informed of where
and when, as well as how many times, they are required to bring children for vaccination.
Health personnel remains the most cited source of health information including key details
about immunization. (Shen, Fields, & McQuestion, 2014). The role of quality data in guiding
policymakers to make informed programmatic decisions cannot be overemphasized. Data are
usually obtained from vaccine coverage reports, either by periodic population-based surveys
such as NDHS and Mixed Indicator Cluster Surveys, or by routine administrative reports
(Shen et al., 2014).

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2.3 Nigerian Immunization and Vaccine Development

Nigeria introduced EPI in 1978 with the aim of providing routine immunization to children
under two years of age, and saw some initial but recurrent successes with the highest level in
the early 1990s, when Nigeria achieved childhood immunization coverage of 81.5% (Ophori,
Tula, Azih, Okojie, & Ikpo, 2014). However, since that period of success, Nigeria has seen
slow but sure and consistent falls in immunization coverage. By 1996, national coverage had
dropped to less than 30% for all antigens and decreased further to 12.9% in 2003, which was
also consistent with the 2003 national immunization coverage survey findings. The
downward fall in coverage of all antigens seems to have been linked with poor government
political will and commitment resulting in failure of the fulfillment of EPI policies as
reflected in over-centralization in the management of EPI at the federal level of governance
and vaccine shortages and other administrative problems (Ophori et al., 2014). The
government came up with a program to revitalize and sustain the immunization system in
1999, in synergy with the polio eradication program, leading to the establishment of the
National Program on Immunization (NPI). The focus of the NPI is on providing support to
the states and LGAs in the implementation of immunization programs (WHO Regional
Office for Africa, n.d.) In Nigeria, WHO is providing technical support to authorities at
federal, state, local government, and ward levels in the strengthening and implementation of
the Reaching Every Ward (REW) strategy (WHO Regional Office for Africa, n.d.). This
followed the signing of a memorandum of understanding between WHO and the Government
of Nigeria, under which WHO will provide technical support for health workers at all levels.
The support of WHO, along with other development partners, has greatly contributed to
increased access and utilization of routine immunization services in the form of improved
coverage (WHO Regional Office for Africa, n.d.). In a study in Bungudu, Zamfara state,
North West Nigeria (Gidado et al., 2014), on determinants of routine immunization coverage,
it was found that five factors were significantly associated with full immunization coverage;
these included satisfactory level of knowledge on RI, having at least secondary education,
receiving ante-natal care (ANC), having received information on RI 12 months preceding the
study, and delivery 35 at health facility by mothers. Among these factors, having a
satisfactory level of knowledge on RI and at least attaining secondary education were the
only independent determinants of full immunization after performing logistic regression
(Gidado et al., 2014). However, it was also the case that this study, through community-
based, was limited by geographical scope and acknowledged the fact that if it had been

14
conducted even in the entire state, the result could have been different; hence the result
cannot be generalized to the North West zone. Additionally this study did not take into
account the role of socioeconomic status (place of residence, closeness to the routine
immunization services, income levels, and educational level of respondents) of
parents/caregivers, apart from their level of education, their biological characteristics (age,
sex, parity, birth order), cultural factors (ability to take decision independently, religious
affiliation, and tribe/ethnicity), place of residence (rural/urban), distance and cost of
transport, session plan and cost of immunization services. Abdulraheem and Onajole (2011)
looked at the reasons for incomplete vaccination and factors for missed opportunities among
rural Nigerian children in Awe Nasarawa state. They found that the major reasons for
noncompletion of vaccination among rural children were the concerns among parents on the
safety of the immunization, long distance walk to the service point, and long waiting time at
health facilities (Abdulraheem & Onajole, 2011). However, Abdulraheem and Onajole did
not find any significant differences with respect to vaccination completeness due to factors
such as mothers’ age, marital status, schooling level and gender of the child, though one of
the 36 limitations of the study was the fact that the sample population was from a
homogenous rural community and participants were mainly poor women and children. This
might have resulted in an underestimation of the role of socio-demographic factors such as
educational levels, gender and marital status (Abdulraheem & Onajole, 2011). Again, this
study also lacked geographical spread and the sample size was not representative and can
only apply to the community where the study was conducted. Rahji and Ndikom (2013)
conducted a similar study in Ibadan, during which they attempted to identify factors
influencing compliance with the immunization regimen among nursing mothers in Moniya
Community. They found the health workers’ attitude, long waiting for time, and cost of
immunization were factors hindering compliance with immunization schedules (Rahji &
Ndikom, 2013). Age, occupation, education, religion and time spent at the centers also were
found to have a significant relationship with compliance with immunization regimen (Rahji
& Ndikom, 2013). Finally, Tagbo et al. (2014) conducted a hospital study in Enugu on
vaccination coverage and its determinants in children aged 11 - 23 months in an urban district
of Nigeria concluded that vaccination coverage was associated with high maternal education,
government employment, delivery of a child in a government hospital, and knowledge of the
age at which a child should start and complete routine vaccinations were independent
predictors of high vaccination coverage. One of the limitations of this study was that it was

15
hospital-based, and was only conducted in an urban setting and so cannot be a complete
reflection of what is happening at the community level.

2.4 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 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
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 (Ophori et al, 2014). 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 (Ophori et al, 2014). 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.

2. Influence of religion

16
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).

In Ekiti state (southwest), for example, the northeast and west of Ekiti, with a stronger
Islamic influence, have low immunization coverage and also poor educational attainment.
Christians have 24.2% immunization coverage as compared to only 8.8% for
Muslims(Ophori et al, 2014).

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 (Ophori et al, 2014).

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.These political problems included
low government 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. The
poor coverage of measles between 1998 and 2005 was blamed on vaccine shortages and
administrative problems, as was the case in 1996, 1999, and 2000 when polio coverage was
only 26%, 19% and 26% respectively. 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 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 (Ophori et al, 2014).

17
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 rumor, incorrect
information, and fear. Attempts to increase coverage must include awareness of people’s
attitudes and the influence of these on behavior. 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 (Ophori et al, 2014).

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. 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 (Ophori et al, 2014). 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

18
funds were not sufficient and were not released on time. For example, in 2001 the whole
amount was approved but only 61% was released, the late release of funds (April 2001)
meant that vaccine had to be bought on the spot market at inflated prices. In 2002 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 (Ophori et al, 2014).

2.4 Education Level of Parents/Caregivers

In a study in peri-urban area of Kenya on immunization coverage and its determinants

among children aged 12-23 months, maternal education was found to be one of the factors
that were significantly associated with immunization coverage (Maina, Karanja, & Kombich,
2013), this finding was corroborated by similar studies in Bungudu LGA of Zamfara State
Nigeria (Gidado et al., 2014), a study of correlate of complete immunization in East African
countries (Canavan, Sipsma, Kassie, & Bradley, 2014), and Uganda on the factors
influencing childhood immunization that indicate possessing at least a secondary education
remained as single independent determinant of full immunization coverage (Bbaale, 2015),
and Angola on factors associated with vaccination coverage in children < 5 years (Tagbo et
al., 2014; De Oliveira, Martinez, & Rocha, 2014, Tagbo et al., 2014). These findings were in
contrast to Etana and Deressa’s (2012) study on factors associated with complete
immunization coverage in children aged 12-23 months in Ambo Woreda, Central Ethiopia in
which they found that mother’s educational status had no significant association with the
completion of immunization among children 12-23 months. In Kaptembwo, the proportion of
fully immunized children of mothers/guardians who had accomplished secondary school
education and above was 81.6% which is higher than those who had accomplished primary
school education (76.7%) and even those with no formal education (42.9%) (Maina et al.,
2013). Prior studies have also revealed a significant association between immunization

19
coverage and living in an area with high levels of maternal/guardian education (Maina et al.,
2013). The literature that attributes 38 maternal educational level as a predictor of full
immunization coverage attributes this to changes that accompany maternal education, such as
attitudes, traditions, and beliefs, increased autonomy and control over household resources,
which enhance health care seeking and demand childhood immunization (Bbaale, 2015). In
addition, higher education will increase parental awareness, especially on health issues and
facilitate individual’s increased access to services, information, and the capacities to interact
with professionals and health care services in contrast, belonging to less educated groups with
limited social inclusion, hence lacks basic information and increases the likelihood of not
keeping to the vaccination scheme (De Oliveira et al., 2014).

2.5 Income Level of Parents/Caregivers

The level of family income has been associated with immunization coverage by many;
however, there are various studies that looked at the role of parents/mother’s income level in
relation to the completion of immunization schedules in different countries and communities.
And the findings from these studies have shown various scenarios that have left some gaps in
the literature. In a study on the factors influencing compliance with immunization regimen
among mothers in Moniya Community Ibadan, Nigeria (Rahji & Ndikom, 2013), and similar
study on the reasons for incomplete vaccination and factors for missed opportunities among
rural Nigerian children indicates that children of parents of lower socioeconomic background
have reported poor completion of their immunization regimen than children of parents of
higher socioeconomic background (Abdulraheem & Onajole, 2011). This is consistent with
the findings in a study on the factors influencing full immunization coverage among 12-13 39
months in Ethiopia, using 2011 DHS data as evidence, which shows that children of the
wealthy families are more likely to complete their immunization regimen that their
counterpart from the poor families (Lakew, Bekele, & Biadgilign, 2015). While children of
mothers in the lower socioeconomic cadres in their working places are more likely not to
complete their immunizations, since they need to seek permissions to be away from their
places of work, hence making it more difficult to take their children for complete
immunization (Antai, 2009). In a similar study on a nationwide register-based study on
human papillomavirus (HPV) vaccine uptake in the school-based immunization program in
Norway to find if the parental education and income matter, it was found that overall
maternal income is positively associated with HPV vaccine initiation, while education was
negatively associated with initiation of HPV vaccination (Bbaale, 2015). Paternal income and

20
education showed similar, but weaker, associations. The association with parental education
was restricted to girls with low-income parents. More than 94% of all girls who initiate the
HPV-vaccination series complete the schedule and receive all three doses as recommended.
Parental socioeconomic status had little influence on completion of the three-dose series
(Bbaale, 2015). However, in Uganda, the finding was in contrast to the findings of the studies
in Nigeria. While in Nigeria, mothers’/parents’ income is significant in the completion of an
immunization regimen, this was not significant in influencing completion of immunization
regimen in Uganda for the simple fact that immunization is universal in Uganda (Bbaale,
2015). Though Bbaale (2015) acknowledged the fact that similar 40 literature suggests the
significance of wealth or income in completion immunization schedule, no literature reviews
included studies in the North central geopolitical zone, which is distinctly different from all
these study areas, socioeconomically, culturally, and educationally, hence the need for data to
fill in this gap.

2.8 Delivery in a Health Facility

The role of health institutional delivery and its association with complete immunization
coverage was reported in a study on the factors associated with complete immunization
coverage in children aged 12–23 months in Ambo Woreda, Central Ethiopia (Etana &
Deressa, 2012). The findings indicated that children delivered at health facilities were more
likely to complete their immunization schedule than children delivered at home. This is also
corroborated by a study on correlates of complete childhood vaccination in East African
countries (Canavan et al., 2014; Lakew et al., 2015), that found the increased likelihood of
complete vaccination status associated with getting a check-up within 2 months of birth in
Burundi, Kenya, and Uganda, although not in the other countries (Canavan et al., 2014;
Lakew et al., 2015). The explanation was that mothers that gave birth to the health facilities
are more likely to be closer to the health facilities and their children might receive the first
dose of vaccination after birth. In addition to its close relationship with the facility of
delivery, there is statistically significance association between complete childhood
immunization coverage and mothers’ utilization of antenatal care (ANC) services during
pregnancy. Children born of mothers with a history of ANC follow-ups were observed to
have 2.1 times likelihood of 41 completing their immunization schedules than those with no
history of ANC follow-ups (Lakew et al., 2015).

2.9 Knowledge of Parents/Mothers of Immunization Services

21
Studies in many communities in Nigeria and other African countries have suggested that
satisfactory maternal knowledge of immunization services is an independent determinant of
immunization coverage. In a study in Bungudu LGA of Zamfara state (Gidado et al., 2014),
on the determinants of routine immunization coverage, it was found that maternal knowledge
of the benefit and schedule of immunization services has a positive influence on the mother’s
decision to get her child fully immunized (Abdulraheem & Onajole, 2011; Gidado et al.,
2014). This finding is consistent with the Ethiopian study which found that lack of awareness
about immunization contributes to low coverage, and children of mothers that knew the age
at which vaccination starts and finished are more likely to complete immunization compare to
their counterparts whose mothers have no knowledge of the schedule of immunization
services (Etana & Deressa, 2012).

2.10 Distance of Parents/Caregivers From immunization -Providing Facilities

Distance from a health facility was found to be an important predictor of full immunization;
this is because it has an implication in accessing the health facilities where the services are
offered. There are reports of studies that show that mothers that are domicile near where a
health facility providing RI services is within a one-kilometer radius from their residence are
more likely to fully immunize their children than those living in areas where there are no
health facilities providing immunization service close to them (Rahman & Obaida-Nasrin,
2010). Similar studies in developing countries suggest that walking or traveling time and
distance are key factors that influence the utilization of healthcare services (Rahman &
Obaida-Nasrin, 2010). In a study on the reasons for incomplete vaccination and factors for
missed opportunities among rural children in Awe LGA of Nasarawa state Nigeria, found that
long walking distances, as well as long waiting time at the facility, are key factors associated
with poor completion of RI schedules (Abdulraheem & Onajole, 2011). Despite all the
findings above there are still gaps in the literature as it affects the North central region of this
country, these studies were not representative of the region, while Abdul Raheem study was
in the North Central region that may have some similarities with the North central region, his
study can only be generalized in Nasarawa state because it is not representative enough to be
generalized to the entire Nigerian population. While the NDHS 2013 data is very
representative and have adequate sample size as well randomization for the result to
generalize on all the states, hence the need for this study to close this gap in the literature.

2.10 Role of Religious/Ethnic Affiliation of Parents/Mothers in Completion of

immunization schedules.

22
There are many studies and documentations that discuss the role played by the religious
affiliations of the caregivers or mothers in ensuring their children complete immunization
schedules before their first birthday. Many of these studies were either conducted outside
Nigeria or in the southern part of the country leaving the northern region where North West
region belongs with little or no information of the subject matter. In a study on Ojo Local
Government Area, Lagos State, Nigeria, Oyefara (2014) found that in addition to 43 other
personal characteristics of women, religious affiliation, and ethnic background were
statistically associated with full immunization status of their children. These findings were
consistent with studies on the effect of maternal and provider characteristics on up to-date
immunization status aged 19 to 35 months, among Hispanics which is attributed to their
strong cultural emphasis on the well-being of their children which strengthen their awareness
on preventive care leading to high immunization coverage among the Hispanics (Kim,
Frimpong, Rivers, & Kronenfeld, 2007).

2.11 Role of Women’s Autonomy in Completion of Immunization Schedule

The term women’s autonomy has been described by many researchers as the ability of a
woman to take an independent decision about the family that either affects her or her children
without any interference from the family. The word autonomy is used interchangeably with
volitional control and empowerment. Bharati (2014) also reported similar definitions of
women’s autonomy by several researchers. According to Bharati, (2014) defined autonomy
as the opportunities for women to receive education and to work outside the home, while
Bharati (2014) quoted Miles-Doan who defined autonomy as a woman’s position within
household power relations such as her bargaining power. He also defined autonomy as
control over the household and societal resources. Finally, Bharati (2014, quoted Jejeeboy
and Sathar who stated that autonomy entails five interconnected elements, such as knowledge
or experience acquired; decision-making power; physical autonomy which includes ability to
go out freely without seeking permission based on need; emotional independence and
economic and social sovereignty which includes right to use and control over resources. The
overlapping of the definitions and concept of women’s autonomy has brought researchers
recently, to begin to investigate the role of women autonomy on the status of their own health
as well as the health of their children (Bharati, 2014). In a study on the impact of women’s
autonomy, on their children’s nutritional and immunization status as measured by the
women’s decision-making power through four main parameters of decision making on her
own health care, large household purchase, going to relatives or friend’s house and spending

23
the husband’s earning (Bharati, 2014). These decision-making controls are directly or
indirectly associated with the socioeconomic characteristics of the household and cultural
conditions of the society, this is consistent with similar findings from another study in India
and Nepal (Bharati, 2014; Desai & Johnson, 2002). Bharati (2014) also found that the
proportion of independent decision making of women is very small when compared to the
joint decision making with their husband, while the proportion of women who could not take
any decision independently is very high among the Indian women (Bharati, 2014). Similarly,
urban women have more decision-making powers as compared to their rural counterparts,
while literate women have more autonomy than illiterate women, but on the use of husband’s
money, the illiterate women have almost twice the autonomy their counterparts that are more
educated (Bharati, 2014). These findings on the impact of women’s autonomy on the health
of their children as reported by Bharati, (2014) are consistent with findings from another
study in India and Nepal on women’s decision making and child health. Familial and social
hierarchies, in which they found that women autonomy increases their use of emergency care
or 45 preventive health care services including children’s immunization and can influence
even women that have less decision-making authority. While even women that are high
powered when living in communities where women have fewer decision-making powers may
have their powers significantly curtailed (Bharati, 2014). As a fall out of this effect, even
doctors may refuse to treat emergency patients based on the sole decision of women in a
highly male-controlled society (Bharati, 2014; Desai & Johnson, 2002). Similarly, Ebot
(2015) and Singh, Haney, and Olorunsaiye (2013) found a positive relationship between
women’s autonomy and children’s health outcomes including immunization status. These
studies were mainly conducted in the Asian continent with few or little studies in the sub-
Saharan Africa and Nigeria in particular and even in Nigeria the data were mainly from the
southern part of the country which is entirely distinct from the northern part of the country
were North West region is located. The urgent need to understand the impact of women’s
autonomy on the children’s immunization and their overall health status cannot be over-
emphasized, hence the need for this study to fill in this literature gap.

2.12 Role of Maternal Age and Parity, Child’s Sex, and Birth Order in Completion of
Immunization Schedule

In a study on maternal determinants of immunization status of children aged 12- 23 months in

urban slums of Varanasi, India (Awasthi, Pandey, Singh, Kumar, & Singh, 2015), and a
similar study on the factors affecting acceptance of complete immunization coverage of

24
children under five years in rural Bangladesh (Rahman & Obaida-Nasrin,2010), both found
that maternal age, maternal employment status, maternal education, parity of mother, were
the most important factors influencing complete immunization. They found that mothers with
lower parity were more likely to have fully immunized children than mothers with higher
parity with more children who may not have self-motivation to provide care for the most
recent child. The study in rural Bangladesh (Rahman & Obaida-Nasrin, 2010), also found that
age of the mother is statistically significant and that middle age mothers are more likely to get
their children fully immunized than older women, this could be due to their accumulated
knowledge of modern medicine and repeated messages on the importance of immunization
services. The study (Rahman & Obaida-Nasrin, 2010), also found that sex discrimination
plays a role in immunization coverage, with male children more likely to be fully immunized
than females and mothers having received TT injection were also found to be one of the
significant predictors of full immunization coverage for children (Rahman & Obaida Nasrin,
2010). In contrast to the findings in these studies above, in a study on factors associated with
vaccination coverage in children < 5 years in Angola, De Oliveira et al. (2014) showed no sex
differences in vaccination coverage, and is also in line with a study conducted in Sao Luís,
MA, Northeastern Brazil, in 2006, on factors associated with incomplete basic vaccination
schedules. Again, these studies examined similar problems in regions of the world other than
Nigeria; hence the need to understand the impact of these characteristics in relation to the
completion of immunization schedule especially in North central Nigeria where all health
parameters are poorer compared to other regions in Nigeria.

2.13 Attitudes, Motivation, Performance, and Competence of Health Staff

Health staff who deal with mothers in an unfavorable, rude, and sometimes abusive manner
were found to be associated with the mother’s refusal for bringing children for vaccination or
refusal to return to complete vaccination schedules even when they had already begun the
schedule in Ethiopia, Zimbabwe, Niger, Kenya, Bangladesh, West Africa, Uganda, Benin,
Nigeria and Syria (Favin, Steinglass, Fields, Banerjee, & Sawhney, 2012). There were many
reports of health workers screaming at mothers who forgot to bring their children’s
immunization record cards, missed scheduled appointments, or children being dressed in a
dirty cloth or presented as malnourished (Favin et al., 2012).

25
2.5 Theoretical Framework

2.5.1 Andersen’s behavioral model

Andersen’s behavioral model was created to empirically test hypotheses about inequality of
access to health services in the United States (Trochim, 2016). The Andersen model
addresses the concern that some populations, specifically people from ethnic minority groups,
people who live in inner cities, and people who live in rural areas, who receive less health
care provision than the rest of the population. Andersen’s model views access to services as a
result of decisions made by individuals, which are constrained by their position in society and
the availability of health care services. The Andersen model is useful because of its flexibility
in allowing researchers to choose independent variables related to their specific hypotheses,
such as hypotheses regarding social inequalities. According to Phillips et al. (2018) the
Andersen model has become one of the most widely used frameworks to predict health care
use since its inception more than 40 years ago.

The Andersen model encompasses three sets of predictive characteristics or factors:

predisposing, enabling, and need factors. The predisposing factors are based on the argument
that a family’s tendency to use health services can be predicted from a set of personal
characteristics that precede the disease and are categorized into the family composition,
social structure, and health beliefs. Specific variables include age, sex, family size, ethnicity,
and social class. These indicate the position of the family in a society, which could influence
family members’ lifestyle and physical and social environments.

The Andersen model assumes that a sequence of factors determines the utilization of health
services and explains the differences in the utilization of health care services behavior, which
are bio-social and demographic. In the context of this study, the Andersen model implies that
biological characteristics (age, sex, parity, and birth order), socioeconomic characteristics
(place of residence, closeness to the RI services, income levels, and educational level of
respondents) and cultural factors (ability to take decisions independently, religious affiliation,
and tribe/ethnicity) will predispose some parents/caregivers to use or not use immunization
services. At the level of the community, these factors will also depend on the influence of
aggregate communal values, cultural and societal beliefs, and political or organizational
viewpoint. There is usually an expectation of approved behavior in different societies based
on religion or tribe from parents/caregivers, and this expectation is expected to shape the
attitudes of caregivers/parents toward health care system/immunization services utilization.

26
Caregivers/parents who have a positive attitude toward RI services and who believe in its
effectiveness/usefulness are more likely to utilize immunization services and complete the
schedules. The enabling factors are based on the argument that even when the family has a
predisposition to use health services, there must be financial enabling factors at the individual
and family/community level to enable them to access/afford the services. Such enabling
factors may include material resources such as income or family resources, having health
insurance, and the availability of affordable health services. Where a person does not have the
ability to access/afford the services, a predisposition alone will not translate into utilization.
For a health service to be utilized, there must first be a need for the service. There are two
types of need factor: illness variables and response variables. Not only must the family
recognize that there is a sickness or disease, but they must also respond appropriately to
access services by professionals.

2.5.2 The Health Belief Model (HBM)

This theory was originally developed to explain the failure of participation in tuberculosis
screenings, and it is still considered to be salient for use with one-time behaviors, such as
vaccination (Gargano, et al, 2014). However, additional research indicates that alternative
theories, such as the Theory of Reasoned Action (TRA), may also be appropriate for
understanding vaccination behavior. We have successfully employed a framework using
HBM and TRA in a previous school-based intervention to increase the uptake of influenza
vaccine among middle- and high-school students (Gargano, et al, 2014). An illustration of the
conceptual framework used to guide our intervention for the current study. In this study, we
designed our educational intervention materials to target the six major constructs from HBM,
including attitudes toward perceived threat of disease perceived susceptibility and
(2) perceived severity], attitudes regarding perceived expectations of vaccination
[(3) perceived benefits and (4) perceived barriers], (5) cues to action to vaccinate, and
(6) self-efficacy for obtaining vaccinations against HPV, influenza, tetanus, diphtheria,
pertussis, and meningococcal disease.

2.6 Empirical Review

2.6.1 Routine immunization of infants in Nigeria

According to WHO (2010), schedules are provided for immunization of children. These calls
for all children to receive one dose of BCG vaccine, 3 doses of Pentavalent vaccine, 4 doses
of OPV, and one dose of measles vaccine before the first birthday. Nigeria is part of the

27
countries with HBsAg carriage rates of 2% or more, universal infant immunization with HB
vaccine is recommended. Countries with a lower HBV prevalence may consider
immunization of all adolescents as an addition or alternative to infant immunization.
According to Mojoyinola and Olaleye (2013), Nigeria currently operates the immunization
schedule of the expanded programme on immunization which prescribe five visit such as
follows; at birth the child receives one dose of Bacilli Calmate Guarine (BCG), first dose of
oral polio vaccine (OPV1) and first dose of hepatitis B vaccine (HBV0). At second Visit
which is six weeks the child receives OPV1, Pentavalent 1 (this contains Diptheria, Pertussis,
Tetanus vaccine – DPT +Hepatitis B Vaccine – HBV + Hemophilus influenza type b vaccine
– Hib.) and first dose of pneumococcal conjugate vaccine (PCV1). At 10+ weeks which is the
third visit, the child receives OPV2, pentavalent 2, and PCV2. At 14 weeks the child receives
OPV3, Pentavalent 3, PCV3 and the last visit at 9 months the child receives one dose of
measles, one dose of yellow fever and first dose of vitamin A. At 15 months the child gets the
second dose of vitamin A (The Health Team, 2012). The following are the specific
immunization according to when it is given:

• BCG – At birth or as soon as possible after birth

• OPV – At birth and at 6, 10, and 14 weeks of age

• Pentavalent Vaccine – At 6, 10 and 14 weeks of age

• PCV - At 6, 10 and 14 weeks of age

• Yellow fever vaccine Vitamin A1 and Measles – At 9

months of age.

• Vitamin A2 – At 15 months of age.

2.4.6.2 National immunization coverage survey

Immunization is coordinated by the National Programme on Immunization (NPI), a

parastatal of the Federal Ministry of Health in collaboration with the State Ministries of
Health and local government health centres, UNICEF and WHO. It was established by the
Federal Government of Nigeria in 1997 (Folliden, 2005). Nigeria has 774 local government
areas subdivided into 5,450 districts, within which there are villages and 9,555 wards. These
vast areas are expected to be covered for immunization programmes. Previously, the

28
programme was co-ordinated by Expanded Programme on Immunization with multinational
donor agencies.

According to Folliden (2015), immunization coverage in Nigeria has become a major

challenge in the context of child survival strategy, and the Nigerian immunization coverage is
far below some countries in conflict. The DPT3 immunization coverage varied from 5% in
1984 to 29% in 2000 with peak coverage of 57% attained in 1990. A dramatic decline to 28%
was observed in 2001. A target of 95% immunization coverage against vaccine preventable
diseases is necessary for sustained control of vaccine preventable diseases. The national
average for children who received all the basic immunization was 25 percent which was very
low given that A World Fit for Children goal is to ensure full Immunization of children less
than one year of age at 90 percent nationally, with at least 80 percent coverage in each state.
Even among states that had coverage above the national average, none was able to reach this
target of 80 percent coverage in all basic immunization (NDHS, 2013).

World Health Organization argues that drop-out rate of more than 10% is not acceptable and
is dangerous for any country. The national immunization coverage reported in 2003 was
12.7% indicating further decline from 28% reported in 2001.Sources of immunization in
2003 were as follows: government 75.6%, private 8.4%, non-governmental agencies 1.7%.
Reasons for non-immunization were non availability of vaccines, distant and unknown
immunization sites, fear of adverse reactions from vaccines, rumours, lack of trust in
immunization and mother not having time for immunization. Folliden (2015) has it that about
23% of children was fully immunized in 2008, while those without any immunization was
29%. The Fully immunized children were highest in south-eastern zone (43%) and least in
north-western zone (6%). Significant variations were noted between urban and rural areas,
with more coverage observed among urban population (38% versus 16% respectively).
UNICEF reported coverage of 69% for DPT3 in 2010 but insisted Nigeria must intensify her
campaign, as some states had poor coverage (World Health Organization 2011).

NPI has been faced with the challenge of storage, distribution of vaccines, monitoring and
evaluation of immunization activities, along with the submission of its annual report on
immunization coverage to WHO. It was reported that cold chain facilities at the state levels
were poorly equipped and managed, with over half of the refrigerators being worn-out in
2005. Collaboration of staff at different levels has also been a major challenge. Migration was
implicated as a risk factor for non-immunized affected children. Outbreaks of poliomyelitis

29
were reported in Europe and were linked to importation from endemic countries (Antai,
2010).

From 2006 to 2010, Nigeria nearly tripled the proportion of children covered by routine
immunization, according to the National Immunization Coverage Survey (NICS), conducted
in October 2010. The increase took place against the backdrop of aggressive Supplementary
immunization campaigns to eradicate polio. The results of the 2010 NICS indicate that 52%
of Nigerian children aged 12-23 months are reported to be fully immu0nized, compared with
just 18% in 2006. In 2003, when the first baseline study was undertaken, the corresponding
figure stood at just 13%.

The NICS aims to estimate the levels of immunization coverage at national, regional and
state levels. The survey is regarded by the Nigerian Government and international partners as
the most accurate measure of routine immunization services, providing important insights
into community and individual attitudes towards immunization. More than 19,000 households
in selected settlements of every state were visited in October 2010 by trained representatives
of an independent research company. Coverage was determined by vaccination card and the
child's history as recounted by the family at 52 weeks of age. Coverage of DPT3 – a
measurement of the number of children who are fully protected against three killer diseases
Diphtheria, Pertussis and Tetanus and the most common measurement of basic routine
services – increased nationally from 25% in 2006 to 68% in the 2010 study. Advances were
recorded in all regions of the country. The national average distribution of children between
12 - 23 months who received all basic immunization and those who did not receive as at 2013
was 25 percent. This is very low given that A World Fit for Children goal is to ensure full
Immunization of children less than one year of age at 90 percent nationally, with at least 80
percent coverage in each state. No state was able to reach this target of 80 percent coverage in
all basic immunization (State of Nigerian children report 2015).

According to NDHS (2013) between year 2008 and 2013, almost one in four children does
not receive any routine immunization. Overall, 25 percent of children age 12-23 months were
fully vaccinated at the time of the survey. This represents a 9 percent increase from the figure
reported in the 2008 NDHS and is nearly double the figure reported in 2003. Twenty-one
percent of eligible children received no vaccination at all. While this figure represents a 28
percent improvement over that recorded in the 2008 NDHS. As for coverage of specific
vaccines among children age 12-23 months, 51 percent had received the BCG vaccine, and

30
42 percent had received the measles vaccine. While 51 percent received the first dose of the
DPT vaccine, only 38 percent went on to receive the third dose, reflecting a dropout rate of
25 percent. Although only 47 percent of children received their commended polio 0 dose at
birth, 77 percent received the first dose, 70 percent received the second dose, and 54 percent
received the third dose. The wide difference in DPT and OPV coverage is accounted for by
the national and subnational immunization day campaigns during which the polio vaccine is
administered. Overall, only 21 percent of children age 12- 23 months had received all of the
recommended vaccinations before their first birthday, this is by far very low compare with
WHO target of at least 80% NDHS (2013).

2.6.3 Factors influencing childhood immunization compliance/noncompliance in

Nigeria

Supply of vaccine has been the main reason attributed to be the problem of low vaccination in
Nigeria (Jegede and Owumi, 2013). Also, problems of finance, procurement, cold chain
maintenance and weak or collapsed primary health care system were indicated in the reports
(FBA, 2015). Demand for vaccination was considered to be mere knowledge and education
issues (Omar, 2009; Ogilvie, Anderson, Marra, McNeil, and Pielak, 2010). Furthermore,
Jegede and Owumi (2013) stated that culture of the people could also have effect on
childhood immunization uptake. Tarrant and Gregory (2013) also stated that, childhood
immunization uptake is adversely influenced by factors that include parental misperceptions,
vaccine side-effects, negative outcomes from vaccination, and health-care system barriers.

Also, barriers to immunization could be grouped into systems barriers (e.g., those involving
the organization of the health care system and economics), health care provider barriers (e.g.,
inadequate clinician knowledge about vaccines and contraindications to their use), and parent
or patient barriers (e.g., fear of immunization related adverse events) (Kimmel, Burns, Wolfe
and Zimmerman, 2017). Kimmel, Burns, Wolfe and Zimmerman (2017) also stated that
logistical barriers are another challenge that militates against immunization uptake. Logistic
barriers faced by health care providers include the cost of immunizations, vaccine storage or
capacity, and lack of access to patients' prior immunization records. Vaccines with stringent
storage requirements, such as varicella vaccine or live attenuated influenza vaccine, may
present a challenge and fragmentation of patient care makes it more likely that providers will
not have complete immunization records for patients currently in their care (Kimmel et al.,
2017). WHO (2010) drew attention to the behavioral factors of parents especially nursing

31
mothers as major factors influencing immunization compliance. Furthermore, parent socio-
demographic characteristics such as education on the issues of vaccination/immunization,
occupation, among others were also important (Babatsikou et al., 2010).

Also, Mojoyinola and Olaleye (2012) stated that the psychological factor of mothers such as
their attitudes to immunization, knowledge about immunization are major factors to be
considered influencing immunization compliance. Furthermore, physical factors such as
location of immunization services/access to immunization centres/distance to immunization
services are major factors that may affect the success of immunization processes (Mojoyinola
and Olaleye, 2012). In addition, health care provider barriers such as inadequate clinician
knowledge about vaccines and contraindications to their use, lack of care or negligence,
insulting individuals who come for one hospital services or the other, among health providers
also constitute major issues to be considered in the study of immunization compliance.

CHAPTER THREE
METHODOLOGY
3.1 Introduction
Methodology is the science of method and procedure used in any given analysis or activity. It
is a set of principles, which are adopted to specify how to reach a particular conclusion or
achieve a given objective. According to Ndiyo (2015), research methodology enables

32
researchers to focus their thought and action on their investigation and improve or maximize
their chances of reasoned conclusion, as objectively as possible. Ololube (2016) defined
research methodology as the process of arriving at dependable solutions to problems through
the planned and systematic collection, analysis, and interpretation of data. It is the most
important tool for advancing knowledge, promoting progress, and enabling man to relate
more effectively to his environment, accomplish his purposes and resolve his conflicts.
Hence, this chapter will explain the methods used by the researcher in the study. This will
enable the researcher to draw inference concerning the effects of non-completion of expanded
programme on immunization among the nursing mothers attending general hospitals in
Nasarawa State.
.
3.2 Research Design
A community-based cross-sectional study will be conducted in three selected LGA in
Nasarawa state which are Keana, Wamba and Keffi out of the thirteen Local Government.
3.3 Research Setting
This study will be carried out in three selected LGA, from the three senatorial zones in
Nasarawa State. Since the research focus on general hospitals, six general hospitals will be
selected situated in the study area.
3.4 Population of the Study
The total target population will comprise of the nursing mothers attending general hospitals
with children under age 5 in the selected study area.
3.5 Sampling Size
Multi-stage cluster sampling technique will be used to collect data in four stages. At the first
stage, a local government area will be randomly selected from each of the 3 senatorial zones
of Nassarawa state. At the second stage, two general hospitals will be selected from each
selected local government areas (Keana, Wamba and Keffi) using simple random sampling.
At the third stage, registered nursing mothers will be randomly selected from the sampled
general hospitals after nursing mothers listing in the hospitals. From each of the 6 selected
general hospitals, 67 nursing mothers of children under 5 years will be randomly selected and
recruit for interview.
3.6 Sampling Techniques
This study will be carried out in selected general hospitals, in three senatorial zone of
Nasarawa State. The WHO EPI systematic sampling techniques will be used to select nursing

33
mothers of children under 5 years from the three selected Local Governments included in the
study.
3.7 Instrument and Data Collection

Quantitative data will be collected with well-structured Interviewer Administered

Questionnaire (IAQ) adapted from UNICEF (2018). For the qualitative survey, Focus Group
Discussions (FGDs) will be conducted with health care providers and the nursing mothers
(completer and non-completer) by use of an FGD guide. Instruments will be interpreted to
common local language (Hausa) to elicit appropriate responses. Nursing mothers’ non-
completion will be assessing based on the vaccines a nursing mothers immunized her child
and is categorized into three as thus; completely immunized, partially immunized and not
immunized. Non-completion of immunization or otherwise will determined by the child’s
immunization card and/or mothers recall of child being immunized.

3.8 Validity and Reliability Test

The research instrument will be subjected to face, and content validation. The research
instrument will be given to experts in the faculty of medical sciences at Ladoke Akintola
University Ogbomosho, Oyo State for validation. It would be checked whether or not the
items were clearly stated, adequate, and suitable for eliciting the desired responses from the
respondents. Necessary corrections as suggested by the experts will thereafter be effected.
The reliability of the instrument will be determined by a test re-test method.

3.9 Method of Data Analysis

The data collected will be scrutinize for completeness, missing value, and inconsistencies
before entry into the excel spread sheet. The data will be code and enter in statistical
software. Descriptive statistics will be used to analyze data using tables, bar charts and pie
charts by presenting results in simple frequencies. Confidence interval was set at 95% and
odd ratios for completion of immunization were generated. Likely hood ratio and
multinomial logistic regression test were used to test the effects of the socio-demographic
characteristics of the nursing mothers, their children and the health facility with the three
categories of the dependent variables (completely immunized, partially immunized and
unimmunized). Analysis tools such as chi-square test will be used to determine the level of
association between selected independents and dependents variables at P value<0.0

34
 CHAPTER FOUR
RESULTS AND DISCUSSION
Table 4.1: Sociodemographic characteristics of the respondents

35
Sixty-seven questionnaires were given out and all were retrieved, which makes a response
rate of 100%. As shown in table 64.1% of the children were males while 35.8% were
females. Of the respondents that were interviewed, 14.9% of their children were within 0-1
years of age, 37.3% were between the ages of 2 and 3 years, 22.3% were between the ages of
3 -4 years while 17.9 % were for ages between 4-5. The majority (50.7%) of the mothers has
no formal education, while 19.4% primary level of education, secondary education level
14.9% and (7.4%) has tertiary education. Also, majority 82.1% are married while 17.9% of
them are divorced. 37.3% of the households had a family size of 3 to 4 while 44.7% of the
households had a family size above 5. Also, findings show that 80.5% of the respondents had
their child delivery at the provided health facility, while 19.4% of the mothers delivered at
home. Furthermore, parent’s average income varies where 34.3 % has their monthly income
between 15000- 30000, while 29.8 % stands within 41000- 50000
Table 4.1: Sociodemographic characteristics of the respondents (n=67)
Variables Frequency Percentage (%) Mean
Child’s Age (year)
0-1 10 14.9
2-3 25 37.3
3-4 15 22.3
4-5 12 17.9
Child’s Sex
Male 43 64.1
Female 24 35.8
Marital status of the parents
Single - -
Married 55 82.1
Divorced 12 17.9
Widow - -
Mother’s Education level
No formal Education 34 50.7
Primary Education 13 19.4
Secondary Education 10 14.9
Tertiary Education 5 7.4
Father’s Education level
No formal Education 44 65.6
Primary Education 23 34.3
Secondary Education -
Tertiary Education -
Household size (No of
person)
-0 - -
1-2 12 17.9
3-4 25 37.3
5 above 30 44.7
Place of birth
Health Facility 54 80.5
Home 13 19.4
Birth order of the child

36
0 - -
1 16 28.3
2 13 19.4
3 38 56.7
Parent’s Average
monthly income (₦)
15000- 30000 23 34.3
31000 - 40000 14 20.8
41000- 50000 20 29.8
51000 above 10 14.9

4.2 The impact of parental knowledge and attitudes towards immunization on

compliance rates.
When respondents were asked the impact of parental knowledge and attitudes towards
immunization on compliance rates, all (100%) Parents' perceived benefits of immunization,
(97.0%) are willing to accept vaccines for their child and (95.5%) of the parents' perceived
risks or side effects of immunization. On the other hand, (89.5%) of the Parents are not
concerns or doubts about vaccine safety or effectiveness all (85.0%) don’t know that parents
understood vaccine safety and side effects (see Table 4.2). The overall interpretation points to
clarify that parents had knowledge and better attitudes towards immunization.

Table 4.2: The impact of parental knowledge and attitudes towards immunization on
compliance rates.
Variables Yes No
Freq (%) Freq (%)
1. Do parents understanding the specific vaccines, diseases, 25 (37.3)
42 (62.6%)
and benefits of immunization?
2. Are they aware of recommended immunization schedules? 12 (17.9) 55 (82.0)
3 Do parents understand vaccine safety and side effects? 10 (14.9) 57 (85.0)
4 Do they understand of how vaccines prevent diseases? 15 (22.3) 52 (77.6)

5 Are they willing to accept vaccines for their child? 65 (97.0) 2 (2.9)

6 Parents' concerns or doubts about vaccine safety or 7 (10.4) 60 (89.5)

effectiveness.
8 Parents' perceived benefits of immunization. 67 (100) -

9 Parents' perceived risks or side effects of immunization. 64 (95.5) 3 (4.4)

37
4.3 The role of access to healthcare services and immunization programs in
influencing compliance.
67.1% of the parents were domiciled near the health facility, while 59.7% indicate high Cost
of health services, insurance coverage however, in terms of consistent supply of
recommended vaccines showed 41.7% level of consistent, while (100%) indicate that parents
don’t have access to transportation and accommodations for people with disabilities,
accommodations for missed appointments or delayed vaccinations, Strength of providers'
recommendations for immunization and Adequacy of resources (e.g., funding, personnel) for
immunization programs respectively.

Table 4.3: The role of access to healthcare services and immunization programs in
influencing compliance.
S/N Variables High Medium Low
Freq (%) Freq Freq
(%) (%)
1. Distance to nearest health facility 45 (67.1) 17 5 (7.4)
(25.3)
2. Cost of health services, insurance coverage 40 (59.7) 10 16 (23.8)
(14.9)
3 Language, cultural competency of healthcare providers 3 (4.4) 10 54 (80.5)
(14.6)
4 Consistent supply of recommended vaccines 24 (35.8) 28 15 (22.3)
(41.7)
5 Availability of transportation, accommodations for - - 67 (100)
people with disabilities
6 Effectiveness of vaccine delivery systems 12 (17.9) 18 37 (55.2)
(26.8)
7 Accommodations for missed appointments or delayed - - 67 (100)
vaccinations
8 Effectiveness of reminders for upcoming vaccinations - 15 52 (77.6)
(22.3)
9 Quality of communication between providers and 23 (34.3) 24 20 (29.8)
patients (35.8)
10 Strength of providers' recommendations for - - 67 (100)
immunization
11 Adequacy of resources (e.g., funding, personnel) for - - 67 (100)

38
 immunization programs
12 Quality of immunization program monitoring and 5 (7.4) 15 37 (55.2)
evaluation (22.3)
13 Effectiveness of health system infrastructure 35 (52.2) 15 50 (74.6)
(22.3)

4.4 The effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance.
When asked about the effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance, 52.2% of respondents seriously agree that the high cost of
vaccinations or transportation was a barrier, while 67.1% of respondents said the lack of time
or inconvenience was also a major barrier on immunization compliance. However, in terms
of language barriers, 82.0% seriously perceived language difficulties or lack of interpreters
was also and hindrances and (88.0%) perceived difficulty with scheduling or reminders.
Those that seriously disagree with the high cost of vaccinations or transportation compared to
7.4% of those that responded seriously agree high cost of vaccinations or transportation. Cost
of health care vaccinations or transportation are barriers immunization compliance of
children among parents.

Table 4.4: The effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance.

S/N Variables SA A N D SD

Freq Freq Freq Freq Freq

(%) (%) (%) (%) (%)

1 High cost of vaccinations or 35 10 5 (7.4) 10 5 (7.4)

transportation (52.2) (14.9) (14.9)

2 Lack of time or inconvenience 45 - - 10 13

(67.1) (14.9) (19.4)

3 Perceived difficulty accessing 34 12 10 6 (8.9) 5 (7.4)

healthcare facilities or providers (50.7) (17.9) (14.9)
Perceived language difficulties or
4 55 7 5 (7.4) - -
lack of interpreters
(82.0) (10.44)
5 (7.4)
5 Fear of needles, pain, or side 10 15 15 27
effects (14.9) (22.3) (22.3) (40.2)

39
 6 Perceived lack of understanding 34 10 12 1 (1.4) -
about vaccines or immunization (50.7) (14.9) (17.9)

7 Perceived lack of trust in 13 26 13 10 5 (7.4)

healthcare providers or vaccines (19.4) (38.8) (19.4) (14.9)

8 Difficulty with scheduling or 59 7 1 (1.4) - -

reminders (88.0) (10.4)

9 Perceived social or peer pressure 10 15 13 17 25

against immunization (14.9) (22.3) (19.4) (25.3) (37.3)

10 Healthcare provider biases or - 13 21 14 19

judgmental attitudes towards (19.4) (31.4) (20.8) (28.3)
breastfeeding mothers

11 Inadequate privacy or facilities for 35 21 9 (13.4) 1 (1.4) 1 (1.4)

breastfeeding in healthcare (52.2) (31.3)
settings

12 Prioritizing work or other 44 7 6 (8.9) 5 (7.4) 5 (7.4)

responsibilities over immunization (65.6) (10.4)
appointments
SA= strongly agree, A= agree, N =neutral, D= disagree, SA= strongly disagree.

4.5 The influence of cultural and religious beliefs on immunization non compliance

As shown in table 4.5 below, (32.8%) beliefs about traditional medicine or healing practices
were fully immunized, while (67.1%) never beliefs about traditional medicine or healing
practices were fully immunized. On the other hand, (97.3%) understanding of health
information and immunization benefits and (80.2%) Support from family, friends, or
community members. Table 4.5 further rated factors on the scale of 1 to 5, the findings
indicate (35.8%) High Level of commitment to religious beliefs or practices and
Interpretations of religious texts regarding immunization on a scale of 3 compared to other
factors.

40
Table 4.5: The influence of cultural and religious beliefs on immunization non
compliance
Variables Yes NO 1 2 3 4 5
(%) (%)
Beliefs about traditional medicine 22 45(67.1) 10 15 25 10 7
or healing practices (32.8) (14.9 (22.3) (37.3) (14.9 (10.44)
) )
Beliefs about vaccine safety, 43 24 25 23 7 9 3
efficacy, or side effects (64.1) (35.2) (37.3 (34.3) (10.4) (13.4 (4.47)
) )
Beliefs about disease prevention or 55 12 - - - -- 67
treatment (82.0) (17.9) (100)
Beliefs about childhood illnesses or 67 - 10 12 10 10 25
their severity (100) (14.9 (17.9) (14.9) (14.9 (37.3)
) )
Beliefs about immunization 10 57 6 9 22 18 12
conflicting with religious teachings (14.9) (85.0) (8.9) (13.4) (32.8) (26.8 (17.9)
)
Beliefs about faith or prayer being 21 46 14 17 22 27 34
sufficient for healing (31.3) (68.6) (20.8 (25.3) (32.8) (40.2 (50.7)
) )
Beliefs about health outcomes being 34 33 12 10 12 23 10
determined by divine will (50.7) (49.2) (17.9 (14.9) (17.9) (34.3 (14.9)
) )
Interpretations of religious texts 13 54 15 13 24 10 7
regarding immunization (19.4) (80.5) (22.3 (19.4) (35.8) (14.9 (10.4)
) )
Influence of religious leaders on 25 42 14 21 18 16
immunization decisions (37.3) (62.6) (20.8 (31.2) (26.8) (23.8 16
) ) (23.8)
Support from family, friends, or 54 13 12 10 12 23 10
community members (80.5) (19.4) (17.9 (14.9) (17.9) (34.3 (14.9)
) )
Quality of communication between 50 17 14 17 22 27 34
providers and patients (74.6) (25.3) (20.8 (25.3) (32.8) (40.2 (50.7)
) )
Understanding of health 65 2 (2.9) 6 9 22 18 12
information and immunization (97.0) (8.9) (13.4) (32.8) (26.8 (17.9)
benefits )
High Level of commitment to 45 22 15 13 24 10 7
religious beliefs or practices (67.1) (32.8) (22.3 (22.3) (35.8) (14.9 (10.4)
) )
High Level of cultural assimilation 32 35 12 10 12 23 10
or integration (47.7) (52.2) (17.9 (14.9) (17.9) (34.3 (14.9)
) )

41
4.6 The Relationship between healthcare provider-patient communication and
immunization compliance

As shown in table 4.6, the relationship between healthcare provider-patient communication

and immunization compliance, (100 %) stated the relationship on Provider's ability to
communicate in patients' preferred language, Patient satisfaction with immunization services
respectively while (80.2%) stated the relationship on Timeliness of vaccinations and (52.2%)
stated the relationship that Provider's ability to clearly explain immunization benefits and
risks.

Table 4.6: The Relationship between healthcare provider-patient communication and

immunization compliance
S/N Variables High Medium Low
Freq Freq Freq
(%) (%) (%)
1. Provider's ability to clearly explain immunization 39 15 (22.3) 13
benefits and risks (52.2) (19.4)
2. Active listening to patient concerns and questions 54 13 (19.4) -
(80.5)
3 Provider's emotional support and empathy towards patients 40 20 (29.8) 7 (10.4)
(59.7)
4 Provider's involvement of patients in immunization 38 17 (25.3) 12
decisions
(56.7) (17.9)
5 Provider's understanding and respect for patients' cultural 32 (47.7) 13
beliefs 22
(19.4)
(32.8)
6 Provider's ability to communicate in patients' preferred 67 - -
language
(100)
7 Provider's non-verbal cues, such as body language and tone 6 (67) - -
8 Patient's prior immunization experiences 34 30 (44.7) 3 (4.47)
(50.7)
9 Patient satisfaction with immunization services 67 - -
(100)
10 Timeliness of vaccinations 54 10 (1.4) 3
(80.5) (4.47)
11 Vaccination completion rate 55 10 (1.4) 2 (2.9)
(82.0)
12 Up-to-date immunization status_ 55 10 (1.4) 2 (2.9)

42
 (82.0)

Discussion

Compared to other studies on immunization, this study is unique as it collected qualitative

data from parents, community leaders, health care workers and religious clerics. This was
done to elicit responses on reasons for the persistence in the low completion rate of routine
immunization despite the efforts by government and other agencies. The study revealed that
majority of the surveyed respondents stated that immunization prevents children from
diseases and disabilities. Most of the respondents demonstrated a high knowledge of routine
immunization. The high number of respondents with low knowledge poses as a challenge to
action on childhood immunization program. Government findings corroborated the
observation that women have a fair knowledge of routine immunization. However, the less
knowledgeable parents who incidentally are men claim they support the women. Recent
advocacy for men’s better involvement in reproductive and child health makes demands for
efforts to increase men’s knowledge in these areas in order to be more supportive.
It was observed that the health care centres and media are the major sources of knowledge of
routine immunization to respondents. This corroborates the findings of the government
participants who stated that the health care workers, children immunization cards and the
media are the major sources of knowledge of routine immunization to parents. This places a
question on the adequacy of health education provided to mothers in particular during
antenatal care and the mass media. This finding validates the study conducted by Abdul
Raheem (2011). Hence, there is the need to consistently evaluate the content and modalities
of the education on immunization provided to women.

With the observation that more than half of the surveyed parents resides near health facility.
The low completion rate also related to high Cost of health services and insurance coverage
however the low to average level of education and knowledge of routine immunization
amongst the respondents which validates the findings of the NDHS 2013. However, the result
showed that (100%) indicate that parents don’t have access to transportation and
accommodations for people with disabilities, accommodations for missed appointments or
delayed vaccinations, Strength of providers' recommendations for immunization and
Adequacy of resources (e.g., funding, personnel) for immunization programs respectively.
The findings are much higher when compared with the average in Northern Nigeria were
only about 10% of the children in the region have access to the routine vaccines. It however
contradicts findings of study conducted to assess the completion and compliance of childhood
vaccination in the United States which showed that an estimated 70% of children completed
all the recommended six doses of vaccines by 24 months of age (Odusanya et al 2018). From
the FGD, there is a general notion that parents comply but this is contrary to the quantitative
data. Hence there is need of regular feedback to the people on the level of performance about
the rate of parental compliance.
From the study, high cost of vaccinations or transportation, lack of time or inconvenience and
language difficulties or lack of interpreters were a major barrier in completion the child’s
immunization. This was aligned with previous findings, that problems of finance,
procurement, cold chain maintenance and weak or collapsed primary health care system were
indicated in the reports (FBA, 2005). Demand for vaccination was considered to be mere
knowledge and education issues (Omar, 2009; Ogilvie, Anderson, Marra, McNeil, and Pielak,
2010). Furthermore, Jegede and Owumi (2013) stated that culture of the people could also
have effect on childhood immunization uptake. Tarrant and Gregory (2003) also stated that,
43
childhood immunization compliance is adversely influenced by factors that include parental
misperceptions, vaccine side-effects, negative outcomes from vaccination, and health-care
system barriers. Also, barriers to immunization could be grouped into systems barriers (e.g.,
those involving the organization of the health care system and economics), health care
provider barriers (e.g., inadequate clinician knowledge about vaccines and contraindications
to their use), and parent or patient barriers (e.g., fear of immunization related adverse events)
(Kimmel, Burns, Wolfe and Zimmerman, 2007). Kimmel, Burns, Wolfe and Zimmerman
(2007) also stated that logistical barriers are another challenge that militates against
immunization uptake. Logistic barriers faced by health care providers include the cost of
immunizations, vaccine storage or capacity, and lack of access to patients' prior immunization
records. Vaccines with stringent storage requirements, such as varicella vaccine or live
attenuated influenza vaccine, may present a challenge and fragmentation of patient care
makes it more likely that providers will not have complete immunization records for patients
currently in their care (Kimmel et al., 2007). Studies such as those of Luman, et al. (2003)
and Kim, Frimpong et al. (2006) have shown that some of the factors influencing
immunization compliance are young age of parents, low level of parental education, birth
order of the child (which are socio-demographic characteristics of parents), financial barriers
such as low family income. Also, Swennen et al., (2001); Zucs et al. (2004) and O'Connor
and Bramlett (2008) have also revealed that, the lack of health insurance and gaps in the
relevant infrastructures such as lack of periodic primary health care access, or decreased
availability of health care facilities are major factors militating against immunization
compliance. WHO (2010) drew attention to the behavioural factors of parents especially
nursing mothers as major factors influencing immunization compliance. Furthermore, parent
socio-demographic characteristics such as education on the issues of
vaccination/immunization, occupation, among others were also important (Babatsikou et al.,
2010). Also, Mojoyinola and Olaleye (2012) stated that the psychological factor of mothers
such as their attitudes to immunization, knowledge about immunization are major factors to
be considered influencing immunization compliance. Furthermore, physical factors such as
location of immunization services/access to immunization centres/distance to immunization
services are major factors that may affect the success of immunization processes (Mojoyinola
andOlaleye, 2012). In addition, health care provider barriers such as inadequate clinician
knowledge about vaccines and contraindications to their use, lack of care or negligence,
insulting individuals who come for one hospital services or the other, among health providers
also constitute major issues to be considered in the study of immunization compliance.

Based on a systematic review conducted by (Wiysonge et al., 2022), different factors were
found to influence under-five childhood immunization uptake among parents in Africa.
Immunization health education intervention among pregnant women, would hopefully
improve childhood immunization uptake in African countries with poor coverage rates, (Ireye
et al., 2019). The present study has demonstrated strong relationship between healthcare
provider-patient communication and immunization compliance.
In this present study, it was discovered that the Provider's ability to communicate in patients'
preferred language, Patient satisfaction with immunization services were associated with
immunization non compliances. These was contrary to previous studies that revealed some
relationship between full immunization and factors such as age of mother, means of
transportation to nearby health facility, mother’s wealth status, mother’s educational
background, Migration, cultural and economic factors, vaccines stock out, healthcare system
and facility utilization as one of the factors influencing dropout rate of child’s immunization,
(Afolabi et al, 2021). This corroborated with similar findings of another study carried out
Central Ethiopia. The study also showed that a child born to a mother who lacks knowledge

44
on immunization schedule was likely not to receive full immunization compared to the one
born to a mother with knowledge on immunization schedule. Studies done earlier have
indicated a significant relationship between immunization coverage and knowledge of
immunization schedule. In a recent study conducted by Yeung et al., (2021), it was revealed
that Socio-cultural factors have impacted negatively on immunization coverage, significance
is Nomadic lifestyle that was mentioned as an obstacle to Immunization. The mothers may be
willing to have their children immunized but may not be within reach of any health facility
during that particular period of time when the caregiver may be on the move and the outreach
services are rare. A similar study reveals that a child born to a family that practices nomadic
lifestyle are 11 more times likely not to have their child fully vaccinated, (Yeung et al.,
2021).

From this present study over 19.5% of children delivered at home having not received full
immunization, the place of birth was found to be one of the factors that influence full
immunization. The results indicate that a child delivered in a health facility more likely to
receive full immunization compared to one delivered at home. Distance to health facilities,
was associated with non-completion of the recommended vaccination series. The study found
out that those in close proximity to the health facility are times more likely to have their
children fully vaccinated. This finding is consistent with the findings of previous studies that
have associated distance to the nearest service delivery point with full immunization,
(Tadesse , Deribew &, Woldie, 2019). Other studies have also found similar relationships
between the place of birth of the child and immunization status, (Hussein & McCaw-Binns,
2021). This study revealed that a child born to a family that earns less than N5,000 per month
are likely not to be fully immunized compared to one born to a family who earns more. Other
investigators have also found similar associations between level of income and full
immunization, (Michael et al., 2019). The health workers not giving the parents the next
appointment date, poor sitting orders, not respecting first come, first served, no sitting areas,
due to poor infrastructure in the facilities and vaccines stock out. Similar findings was also
reported in Nigeria by fatiregun et al., (2019), where about tenth of the children were not
vaccinated because of stock out of vaccine .The implication of frequent non- availability of
vaccines during sessions and vaccines stock outs in PHCs are delayed vaccination, dropout
rates and incomplete vaccination children. , most reasons for non-compliances to scheduled
immunization in this study was lack of time, this was also the most reported reasons given for
immunization dropout rates in a similar studies in Benin City by Sadoh et al., (2019) . The
lack of transportation available to the facilities facilitated by logistics, like transportation,
healthcare workers not motivated, poor distribution networks, health workers may be owed
salaries , this reduces their motivation, other reasons may be inabilities of the health workers
to forecast vaccine needs of the health facilities properly, since there was no report of vaccine
shortage at that time in the country during the period of study, waiting time and not giving
next appointment dates were the other reasons giving for immunization dropout rates. The
prevalence of immunization non compliances in this present study was reported in similar
findings of study conducted in Anambra state Nigeria, where noncompliance rates for
immunization was given as 16% (Rima , 2019) , the 16% noted in the study is low compared
to 28% and 39% reported in Benin City , Edo state, Nigeria.(Uwaibi & Omokhua, 2021).The
study has discovered a suboptimal rate in immunization coverage in Nasarawa state and this
will be similar in other state, to improve vaccine coverage and reduce non -compliance rate,
interventional programs must be utilize, appropriate vaccine should be supplied, and
healthcare workers must know how to forecast vaccine stock balance and report appropriately
when there is vaccine stock out before their next session of immunization. Uwaibi &
Omokhua, (2021)

45
 CHAPTER FIVE
CONCLUSION AND RECONMMENDATION
5.1 Conclusion
Based on the findings of this study, it is now glaring that among diseases preventive measures
known to man, immunization stands out as important and effective way of protecting people
from disease especially among children, (Babatsikou et al., 2010). It is interesting to note that
we now have immunization against some disease that was causing major public health
challenges in the past, an example is polio. However, despite the availability of vaccines to
tackle preventable childhood diseases, they remain endemic in the sub-Saharan region (Antai
2010). So many factors have been associated with low immunization up take and completion
thereby contributing to high childhood mortality and high childhood morbidity. Factors such
as physical factors, psychological factors, health related factors, level of education of the
mother etc. it is worthy of note that mothers play a key role in ensuring their children gets
immunized. Numerous studies have shown that childhood immunization is a major tool in
reducing the skyrocketing childhood mortality and morbidity rate in Nigeria. It is only
expedient for the governments and decision makers to intensify effort on effectiveness of the
programme.
5.2 Recommendation
Based on the findings of this studies in non-compliance to immunization regimens among
children under age 5 the following are recommended
1) Basic education for the nursing mothers: Studies have shown that childhood immunization
noncompliance is high among illiterate mothers, while children of mothers with basic
education showed the highest coverage. This calls for urgent need for the government to set
goals and implement policies which will aim at reducing the number of illiterate persons and
ensure education for all in Nigeria.
2) Religious approach: There is no official religion in Nigeria. Therefore, Citizen are at
liberty to worship at will. To increase the non-compliance to immunization regimens among
children under age 5, the religious leaders need to be carried along. Non-immunization status
of children was associated with Muslim religion which limit access to immunization centers.

46
Health education of religious leaders at worship centers will go a long way influencing a
positive change regarding immunization
3) Economic approach: Research has shown that income of parents is a major factor
influencing immunization compliance as they miss immunization schedule due to lack of
finance. Despite the effort by the government to subsidized childhood immunization, it is no
news that majority of health workers at various primary health centers and places where
immunizations are given still demand money from mothers all over the nation before
immunizing their children. Health care personnel caught demanding money or any illegal pay
before immunization is given should be seen as a saboteur of a good will from by the
government and should be severely sanctioned. A tax force could be set up by Government at
local level to monitor immunization exercise and to bring immunization services to their door
steps.

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LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY

OPEN AND DISTANCE LEARNING CENTRE
OGBOMOSHO, OYO STATE.
FACULTY OF MEDICAL SCIENCE
DEPARTMENT OF NURSING SCIENCE
TOPIC:
FACTORS RESPONSIBLE FOR NON-COMPLETION OF EXPANDED
PROGRAMS ON IMMUNIZATION AMONG NURSING MOTHERS ATTENDING
GENERAL HOSPITALS IN NASARAWA STATE NIGERIA.

This Research Questionnaire, in which OCHE, KATE ENOCHE a 500-level student of the
above-mentioned department is seeking your participation is fully for academic purposes to
obtain information on the above project topic. You are assured of absolute confidentiality of
any view expressed concerning this research. I therefore request that you give adequate
information accurately.

Thank you for your co-operation.

52
Please tick [√] your most preferred choice(s) on a question.

Section A
1. Socio-demographic factors associated with non-compliance to immunization regimens
among children under age 5.
1) Age: ___________________________ (Years)
2) Sex: Male ( ) Female ( )
3) Mother’s age_______________________(Years)
3) Marital status of the parents: Married ( ) Divorced ( ) Separated ( )
4) Mother’s education level: No formal Education ( ) Primary Education ( ) Qur'anic
Education ( ) Secondary Education ( ) Tertiary Education ( )
5) Father’s education level: No formal Education ( ) Primary Education ( ) Qur'anic
Education ( ) Secondary Education ( ) Tertiary Education ( )
6) Place of birth: Health facility ( ) Home ( )
Birth order of the child __________________

8) Household Size (no person) _____________________

9) Average monthly income (₦): _________________________
Section B: The impact of parental knowledge and attitudes towards immunization on
compliance rates.
S/N Variables Yes No

1. Do parents understanding the specific vaccines, diseases, and

benefits of immunization?
2. Are they aware of recommended immunization schedules?
3 Do parents understand vaccine safety and side effects?

4 Do they understand of how vaccines prevent diseases?

5 Are you willing to accept vaccines for your child?

6 Parents' concerns or doubts about vaccine safety or

effectiveness.
8 Parents' perceived benefits of immunization.

9 Parents' perceived risks or side effects of immunization.

53
Section C: The role of access to healthcare services and immunization programs in
influencing compliance.

S/N Variables High Medium Low

1. Distance to nearest health facility

2. Cost of health services, insurance coverage

3 Language, cultural competency of healthcare providers

4 Consistent supply of recommended vaccines

5 Availability of transportation, accommodations for
people with disabilities
6 Effectiveness of vaccine delivery systems

7 Accommodations for missed appointments or delayed

vaccinations
8 Effectiveness of reminders for upcoming vaccinations

9 Quality of communication between providers and

patients
10 Strength of providers' recommendations for
immunization
11 Adequacy of resources (e.g., funding, personnel) for
immunization programs
12 Quality of immunization program monitoring and
evaluation
13 Effectiveness of health system infrastructure

Section D: The effect of perceived barriers (e.g., cost, transportation, waiting time) on
immunization compliance.

S/N Variables SA A N D SD

1 High cost of vaccinations or

transportation

2 Lack of time or inconvenience

54
 3 Perceived difficulty accessing
healthcare facilities or providers
Perceived language difficulties or
4
lack of interpreters

5 Fear of needles, pain, or side effects

6 Perceived lack of understanding

about vaccines or immunization

7 Perceived lack of trust in healthcare

providers or vaccines

8 Difficulty with scheduling or

reminders

9 Perceived social or peer pressure

against immunization

10 Healthcare provider biases or

judgmental attitudes towards
breastfeeding mothers

11 Inadequate privacy or facilities for

breastfeeding in healthcare settings

12 Prioritizing work or other

responsibilities over immunization
appointments
SA= strongly agree, A= agree, N =neutral, D= disagree, SA= strongly disagree.

Section E: The influence of cultural and religious beliefs on immunization non-

compliance

What is the influence of cultural and religious beliefs on immunization, indicate your level of
use on a 5-point rating scale?
Variables Yes NO 1 2 3 4 5

55
 Beliefs about traditional medicine or healing
practices

Beliefs about vaccine safety, efficacy, or

side effects
Beliefs about disease prevention or
treatment
Beliefs about childhood illnesses or their
severity

Beliefs about immunization conflicting with

religious teachings
Beliefs about faith or prayer being sufficient
for healing
Beliefs about health outcomes being
determined by divine will
Interpretations of religious texts regarding
immunization
Influence of religious leaders on
immunization decisions
Support from family, friends, or community
members
Quality of communication between
providers and patients
Understanding of health information and
immunization benefits
High Level of commitment to religious
beliefs or practices
High Level of cultural assimilation or
integration

Section F: The Relationship between healthcare provider-patient communication and

immunization compliance
S/N Variables High Medium Low

1. Provider's ability to clearly explain immunization

benefits and risks
2. Active listening to patient concerns and questions

3 Provider's emotional support and empathy towards patients

4 Provider's involvement of patients in immunization

decisions
5 Provider's understanding and respect for patients' cultural
beliefs
6 Provider's ability to communicate in patients' preferred
language
7 Provider's non-verbal cues, such as body language and tone

56
8 Patient's prior immunization experiences

9 Patient satisfaction with immunization services

10 Timeliness of vaccinations

11 Vaccination completion rate

12 Up-to-date immunization status_

57