DETERMINANTS OF MALARIA VACCINE UPTAKE AMONG CHILDREN BELOW

TWO YEARS IN KABONDO KASIPUL SUB COUNTY, HOMA COUNTY

BY

BEATRICE OSANGA ACHIENG

MPH/PH/6015/2020

A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH
DEGREE IN HEALTH PROMOTION MASENO UNIVERISTY

JANUARY 2023
 ABSTRACT
Malaria is an acute febrile illness caused by Plasmodium parasites, which is spread to people
through the bites of infected female Anopheles mosquitoes. Kenya introduced the Malaria
vaccine (RTS,S/AS01) into routine childhood immunization in 8 counties and 26 Sub Counties
on the 13th September 2019, through the Malaria Vaccine Implementation Program (MVIP),
namely Busia, Kisumu, Vihiga, Bungoma, Siaya, Migori, Homa Bay and Kakamega Counties.
According to the MVIP report for July 2022, nationally, the cumulative uptake of the vaccine
was with RTS,S I at 84%, RTS,S II at 79%, RTS,S III, at 71% and RTS,S IV at 35% for the
fourth dose. Even though Homa bay falls in the fifth position with RTS,S I, 83%, RTS,S II
79%, RTS,S III, 68% RTS,S 1V 27 % and performing better than Vihiga and Migori Counties
the dropout rate is higher than the cumulative national dropout rate that is between dose1 and 2
at 11% and between dose 1 and 3 at 20%. The national dropout rate is 8% between dose 1 and 2
and 15% for dose 1 and 3. Kasipul Kabondo further contributes to this high dropout rate with
RTS,S I, at 78%, RTS,S II at 77%%, RTS,S III, at 62% and RTS,S IV at 30% . This study
seeks to determine the factors that contributed to the low uptake of this vaccine. The main
objective will be the determinants of the uptake of malaria vaccine among children below two
years in Kasipul Kabondo Sub County, Homa Bay County. The specific objectives shall be; To
determine the socio demographic characteristics of the caregivers of children below two years in
Kabondo Kasipul Sub County, To assess the individual health seeking behaviour of caregivers of
children below two years in Kabondo Kasipul Sub County, To determine the socio cultural
factors of care givers of children below two years in Kasipul Kabondo Sub County and to
Establish the influence of health systems factors on the uptake of malaria vaccine among
children below two years in Kabondo Kasipul Sub County. This will be a cross sectional survey
study that will be conducted using questionnaire for quantitative data and Key Informant
Interviews from five health care workers, 12 Community Health Extension Worker (CHEW) and
4 Community Health volunteers randomly selected for qualitative data, and targeting care givers
of children below two years in Kasipul Kabondo Sub County. A total of 410 respondents as
determined by (Fisher et, al., 1999) formula from the 883 children aged 8 to18 months who
received the four doses of malaria vaccine in Kasipul Kabondo Sub County shall be recruited for
this study. Descriptive statistics will be used to analyze socio-demographic variables. Chi-square
tests will be used to analyze associations of the categorical variables. Logistic regression will be
used to find out the association between predictor and outcome variables. The findings of this
study may contribute to policy on reducing and even eliminating avoidable malaria deaths
among children below two years, while at the same time may provide the national and Homa
Bay County governments with the much needed data for resource allocation on programs that
support malaria eradications.
Candidate:
Osanga Beatrice Achieng
Adm No: Mph/Ph/6015/2014 Signature________________ Date ___________
Proposed Supervisors
1. Dr. Peter Omemo Signature ………………… Date ……………
2.

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Contents
ABSTRACT....................................................................................................................................2
LIST OF FIGURES.........................................................................................................................5
ABBREVIATIONS AND ACRONYMS........................................................................................6
DEFINITION OF OPERATIONAL TERMS.................................................................................7
DECLARATION.............................................................................................................................8
CHAPPER ONE: INTRODUCTION..............................................................................................9
1.1 INTRODUCTION.................................................................................................................9
1.1 Background information........................................................................................................9
1.2 Statement of the problem RTS,S/AS01 malaria vaccine.....................................................11
1.3 OBJECTIVES......................................................................................................................12
1.3.1 Broad objectives............................................................................................................12
1.3.2 Specific Objectives........................................................................................................12
1.4 Research questions...........................................................................................................12
1.5 Significance of the study......................................................................................................13
CHAPTER TWO: LITERATURE REVIEW................................................................................14
2.0 Introduction..........................................................................................................................14
2.1 Socio Demographic Factors.................................................................................................14
2.2 Health Seeking Behavior.....................................................................................................16
2.3 Socio Cultural Factors..........................................................................................................18
2.4 Influence of health systems factors......................................................................................21
2.5 Summary.............................................................................................................................24
2.6 The Conceptual Framework.................................................................................................24
Figure 2.1: Conceptual Framework...........................................................................................26
CHAPTER THREE: RESEARCH METHODOLOGY...............................................................27
3.1 Study area.............................................................................................................................27
3.2 Study population..................................................................................................................27
3.2.1. Inclusion criteria...........................................................................................................28
3.2.2 Exclusion criteria...........................................................................................................28
3.3 Study design.........................................................................................................................28
3.4 Sample size determination and Sampling procedure...........................................................28

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 3.5.1 Sampling size determination.........................................................................................28
3.4.2 Sampling procedure.......................................................................................................29
3.5 Data collection instruments..................................................................................................30
3.5.1 Questionnaire.................................................................................................................30
3.5.2 Key informant interviews (KIIs)...................................................................................30
3.6 Data collection procedure....................................................................................................31
3.6.1 Questionnaire.................................................................................................................31
3.6.2 Key informant interview...............................................................................................31
3.7 Pre testing.............................................................................................................................31
3.8 Validity and reliability.........................................................................................................32
3.8.1 Validity..........................................................................................................................32
3.8.2 Reliability......................................................................................................................32
3.9 Measurement of variables....................................................................................................33
3.9.1 Independent Variables...................................................................................................33
3.9.4. Health system factors...................................................................................................34
3.9.2 Dependent variable........................................................................................................35
3.10 Data management and analysis..........................................................................................35
3.10.1 Quantitative Data.........................................................................................................35
3.10.2 Qualitative data............................................................................................................36
3.11 Ethical considerations........................................................................................................36
REFERENCES..............................................................................................................................37
APPENDIX I: MAP OF KASIPUL KABONDO SUB COUNTY...............................................45
.......................................................................................................................................................45
APPENDIX II: CONSENT FORM...............................................................................................46
APPENDIX III A: QUESTIONNAIRE TO THE STUDY IN KASIPUL KABONDO SUB
COUNTY.......................................................................................................................................47
APPENDIX 111 B: IMMUNIZATION SCHEDULE CHECK-LIST.........................................53
APPENDIX IV: SEMI STRUCTURED QUESTIONNAIRE (HEALTH CARE PROVIDERS)55
APPENDIX V: WORK PLAN......................................................................................................56
APPENDIX VI: BUDGET............................................................................................................57

LIST OF FIGURES
2.1 Conceptual framework……………………………………………………………………

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4.1 Map of Kasipul Kabondo Sub County……………………………………………………
ABBREVIATIONS AND ACRONYMS

BCG Bacillus Calmette Guerin

CDC Centre for Disease control and prevention

DVI Division of Vaccine and Immunization

DHS Demographic Health Survey

EPI Expanded Programme on Immunization

GIVS Global Immunization Vision and Strategy

GVAP The Global Vaccine Action Plan

KEPI Kenya Expanded Programme on Immunization

KEMRI Kenya Medical and Research Institute

KNBS Kenya National Bureau of Statistics

KDHS Kenya Demographic and Health Survey

MCH Maternal and Child Health.

MDGs Millennium Development Goals

MTT Maternal Tetanus Toxoid

MVIP Malaria Vaccine Implementation Program

RTS,S Is a recombinant protein-based malaria vaccine and represents its composition.

The 'R' stands for the central repeat region of Plasmodium (P) falciparum
circumsporozoite protein (CSP); the 'T' for the T-cell epitopes of the CSP; and the
'S' for hepatitis B surface antigen (HBsAg),
SDGs Sustainable Development Goals
UNICEF United Nations Children’s Fund
WHO World Health Organization

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 DEFINITION OF OPERATIONAL TERMS
Determinants are the many factors combined together to affect the health of individuals and
communities, usually influenced by their circumstances and environment.

Malaria is an acute febrile illness caused by Plasmodium parasites, which are spread to people
through the bites of infected female Anopheles mosquitoes

Malaria vaccine/ Mosquirix/ RTS,S/AS01, or simply RTS,S is a recombinant protein-based

malaria vaccine and represents its composition. The 'R' stands for the central repeat region of
Plasmodium (P) falciparum circumsporozoite protein (CSP); the 'T' for the T-cell epitopes of the
CSP; and the 'S' for hepatitis B surface antigen (HBsAg),

Mothers and care givers: These are people who attended to the needs of children on a day to
day basis and could be the children’s mothers or somebody else.

Socio demographic characteristics of the caregivers/guardians. These are factors that

primarily influence decision-making on whether to seek care, rather than affecting whether care
givers reach a facility. Examples are Maternal age, level of education and marital status.

Individual health seeking behavior is any action or inaction undertaken by individuals who
perceive themselves to have a health problem or to be ill for the purpose of finding an
appropriate remedy. It also encompasses activities undertaken to maintain good health to prevent
ill health, as well as dealing with any departure from a good state of health. Examples are
obstetric factors, Obstetric factors, maternal attitude and self-efficacy and maternal knowledge,

Socio cultural factors such as religion/ culture, are those factors that are concerned with the
social networks of individuals. Examples are religion, house hold wealth and mother’s
autonomy are

Influence of health system factors describe the factors associated health systems that
determine the process of delivering vaccine and vaccine related services to it beneficiaries.
Examples are accessibility and distance from the facility health workers attitude and availability
of supplies.

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 DECLARATION

This research proposal is my original work and has not been presented for the award of
any Diploma or Degree in any University.

Osanga Beatrice Achieng

Signature……………………………... Date………………………………………

This research proposal has been submitted for examination with my approval as the
University Supervisor.

Dr. Peter Omemo, PhD

Department of Public Health

Signature………………………………… Date…………………………………

Department of Biological Sciences

Maseno University

Signature………………………………… Date…………………………………

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viii
 CHAPPER ONE: INTRODUCTION
1.1 INTRODUCTION

This chapter discusses the background information of the study to include the definition of terms
that is malaria and the malaria vaccine, the historical back ground on malaria prevention, theory
on which the study is pegged, the operational indicators and the epidemiological distribution of
malaria, globally, regionally and locally.

1.1 Background information

Malaria is an acute febrile illness caused by Plasmodium parasites, which are spread to people
through the bites of infected female Anopheles mosquitoes (CDC, 2018). Determinants are the
many factors combined together to affect the health of individuals and communities, usually
influenced by their circumstances and environment (WHO,2022). Malaria vaccine, Mosquirix,
RTS,S/AS01, or simply RTS,S is a recombinant protein-based malaria vaccine and represents
its composition. The 'R' stands for the central repeat region of Plasmodium ( P) falciparum
circumsporozoite protein (CSP); the 'T' for the T-cell epitopes of the CSP; and the 'S'
for hepatitis B surface antigen (HBsAg), ( WHO,2021),

Historically, the prevention of malaria that was associated with the understanding of malaria
parasites began in 1880 with the discovery of the parasites in the blood of malaria patients by
Alphonse Laveran (Celli A, 1933). The discovery of the role of mosquitoes in the transmission
of malaria provided malariologists with a new weapon against this ancient disease. Over the next
decades, different interventions were put in place to prevent the spread of malaria, most of which
are still in place to date (Bruce-Chwatt LJ, 1988). In recognition of malaria’s global importance,
Millennium Development Goal no. 6 aimed to combat HIV/AIDS, malaria and other diseases by
2015 (WHO,2000), and the United Nations Sustainable Development Goal no.3, to ensure
healthy lives and promote well-being for all at all ages, targets a 90% reduction in malaria
incidence and

mortality by 2030 (WHO, 2018).

1
Theoretically, this study is hinged on ecological model of human development. The theory
postulates that behavior has multiple levels of influences, often including intrapersonal
(biological, psychological), interpersonal (social, cultural), organizational, community, physical
environmental, and policy. Ecological models are believed to provide comprehensive
frameworks for understanding the multiple and interacting determinants of health behaviors.
More importantly, ecological models can be used to develop comprehensive intervention
approaches that systematically target mechanisms of change at each level of influence
(Bronfenbrenner, 1994). This behavior change is needed for malaria prevention strategies,
especially the uptake of the malaria vaccine

Operational indicators which determine the uptake of childhood vaccination have been
documented as: Socio demographic characteristics of the caregivers/guardians. These included:
Maternal age, level of education and marital status ( Mohameed F et al., 2020). These
primarily influence decision-making on whether to seek care, rather than affecting whether care
givers reach a facility (Celik et al., 2000). Individual health seeking behavior such as obstetric
factors, Obstetric factors, maternal attitude and self-efficacy and maternal knowledge, is any
action or inaction undertaken by individuals who perceive themselves to have a health problem
or to be ill for the purpose of finding an appropriate remedy (Olenja J, 2004). It also
encompasses activities undertaken to maintain good health to prevent ill health, as well as
dealing with any departure from a good state of health (MacKian S. A, 2003). Socio cultural
factors such as religion/ culture, house hold wealth and mother’s autonomy are those factors that
is concerned with the social networks of individuals (CDC, 2020). Influence of health system
factors such as accessibility and distance from the facility health workers attitude and availability
of supplies (Sharma S.K, 2007). These describe the factors associated health systems that
determine the process of delivering vaccine and vaccine related services to it beneficiaries
(Tadesse H. et al., 2009).

According to (WHO,2020) report, nearly half of the world's population was at risk of malaria in
2020: Approximately 30600 children under the age of 5 died that year due to malaria, and
approximately two thirds of these deaths occurred in the African region (World Malaria Report,

2
2021). This same report revealed that there were 241 million cases of malaria in 2020 compared
to 227 million cases in 2019 and 211 million in 2018 (World Malaria Report, 2021). Out of
this, over 30% of all the confirmed cases were children below the age of 5 years. The estimated
number of malaria deaths stood at 627 000 in 2020 – an increase of 696 000 deaths in 2019 and
721,000 in 2018. (World Malaria Report, 2021)

Sub Saharan Africa continues to carry a disproportionately high share of the global malaria
burden. In 2020 the Region was home to 55% of all malaria cases and 96% of deaths during this
period (WHO, 2020). Children under 5 years of age accounted for about 77% of all malaria
deaths in the region that is 840,000 in 2018, 534,000 in 2019 and 602,000 in 2020 attributed to
disruptions due to covid 19 (WHO, 2020)

In Kenya, malaria remains a major public health burden and accounts for an estimated 13 to 15
% of outpatient consultations. Malaria transmission and infection risk in Kenya are mainly
determined by altitude, rainfall patterns and temperature, leading to considerable variation in
malaria prevalence by season and across geographic zones. Approximately 70% of the
population is at risk of malaria, including 13 million people in endemic areas and another19
million in highland epidemic prone and seasonal transmission (Kenya Malaria Strategy, 2021)
People in endemic estimated 3.5 million new cases and 10,700 deaths were attributed to Malaria.
Pregnant women and their newborns are particularly vulnerable to Malaria due to their low
immunity levels. (Kenya Malaria strategy, 2021).

1.2 Statement of the problem RTS,S/AS01 malaria vaccine

Kenya introduced the Malaria vaccine (RTS,S/AS01) into routine childhood immunization in 8
counties and 26 Sub Counties on the 13th September 2019, through the Malaria Vaccine
Implementation Program (MVIP), namely Busia, Kisumu, Vihiga, Bungoma, Siaya, Migori,
Homa Bay and Kakamega Counties. According to the MVIP report for July 2022, nationally, the
cumulative uptake of the vaccine was with RTS,S I at 84%, RTS,S II at 79%, RTS,S III, at 71%
and RTS,S IV at 35% for the fourth dose. Busia is so far the best performing county in terms of
vaccine uptake, with RTS,S I at 95%, RTS,S II at 89% , RTS,S III at 81 % and RTS,S IV at
31% followed by Siaya with RTS,S I, at 79%, RTS, S at 71% RTS, S and 40%. The worst
performing counties are, Migori at 74%, RTS,S 1,RTS,S II and 39% RTS,S IV.68% 65% RTS,S

3
II, 57%RTS,S III and 31% RTS,S IV. This is followed by Vihiga County at 74% RTS,S I, 69%
RTS,S II, 68% RTS,S III and 39% RTS,S IV. Even though Homa bay falls in the fifth position
with RTS,S I, 83%, RTS,S II 79%, RTS,S III, 68% RTS,S 1V 27 % and performing better
than Vihiga and Migori Counties the dropout rate is higher than the cumulative national dropout
rate that is between dose1 and 2 at 11% and between dose 1 and 3 at 20%. The national dropout
rate is 8% between dose 1 and 2 and 15% for dose 1 and 3. Kasipul Kabondo further contributes
to this high dropout rate with RTS,S I, at 78%, RTS,S II at 77%%, RTS,S III, at 62% and
RTS,S IV at 30% as compared to Homa Bay town Sub County at RTS,S I, at 93%, RTS,S II, at
93%, RTS,S III, at 78% and RTS,S IV at 30% . In fact, Homa bay and Migori Counties had to
be supported to conduct outreach vaccination programs to bridge this dropout rate. This
therefore calls for the need to investigate what could have contributed to the low uptake and the
drop in the subsequent doses. This is a noble course and its success would be a break through
towards malaria eradication globally. Therefore, a detailed study on the Determinants of the
uptake of Malaria Vaccine among children below 2 years in Kasipul Kabondo Sub County would
be a big step towards this a achievement

1.3 OBJECTIVES
1.3.1 Broad objectives
Determinants of malaria vaccine uptake among the children below 2 years in Kabondo Kasipul
Sub County in Homa bay County.

1.3.2 Specific Objectives

1. To determine the socio demographic characteristics of the caregivers of children below
two years in Kabondo Kasipul Sub County.
2. To assess the individual health seeking behaviour of caregivers of children below two
years in Kabondo Kasipul Sub County.
3. To determine the socio cultural factors of care givers of children below two years in
Kasipul Kabondo Sub County.
4. Establish the influence of health systems factors on the uptake of malaria vaccine among
children below two years in Kabondo Kasipul Sub County.
1.4 Research questions

4
 1. What are the socio demographic characteristics of the caregivers of children below two
years in Kabondo Kasipul Sub County?
2. What are the individual health behaviors of caregivers associated with the uptake of
malaria vaccine among children below two years in Kabondo Kasipul Sub County?
3. What are the socio cultural factors associated with the uptake of malaria vaccine among
children below two years in Kasipul Kabondo Sub County.
4. What are the health systems factors influencing the uptake of malaria vaccine among the
children below two years in Kabondo Kasipul Sub County?

1.5 Significance of the study

The WHO Global technical strategy for malaria 2016–2030, updated in 2021, provides a
technical framework for all malaria-endemic countries. It is intended to guide and support
regional and country programs as they work towards malaria control and elimination. The
strategy sets ambitious but achievable global targets, including: reducing malaria case incidence
by at least 90% by 2030, reducing malaria mortality rates by at least 90% by 2030, eliminating
malaria in at least 35 countries by 2030, preventing a resurgence of malaria in all countries that
are malaria-free.

Guided by this strategy, the Global Malaria Programme coordinates the WHO’s global efforts to
control and eliminate malaria by: setting, communicating and promoting the adoption of
evidence-based norms, standards, policies, technical strategies and guidelines; keeping
independent score of global progress; developing approaches for capacity building, systems
strengthening, and surveillance; and identifying threats to malaria control and elimination as well
as new areas for action. This study may also add to the existing literature, since currently very
scanty literature exists on malaria vaccine.

The study may support government in areas of policy on the use of malaria vaccine in the
prevention, control and elimination, while at the same time help the health workers understand
what they need to improve and increase the uptake

5
 CHAPTER TWO: LITERATURE REVIEW
2.0 Introduction
This chapter discusses the detailed literature review, on the determinants of the uptake of malaria
vaccine in Kasipul Kabondo Sub County, Homa bay County. These factors are; socio
demographic factors, to include, maternal age, maternal education, and marital status. Individual
Health seeking behavior to include, Obstetric factors, Maternal/caregivers Knowledge, Maternal/
caregivers attitude and self-efficacy, Maternal outcome expectations. Socio Cultural factors to
include Religious beliefs, Cultural beliefs, Economic conditions and Father’s attitude. Health
facility factors to include; Accessibility of the health facility, Quality of immunization services,
Provider/ client relationship and Availability of supplies.

2.1 Socio Demographic Factors

Socio demographic factors are personal characteristics, which include, age, level of education
and marital status. These factors primarily influence decision-making on whether to seek care,
rather than affecting whether care givers reach a facility (Celik et al., 2000). One could
conceptually distinguish the care givers own motivation to use services from whether they can
act on their wishes. Immunization uptake is therefore dependent on parents making an active
decision to have their child immunized. Generally, childhood immunizations are indicated for
children too young to have any input into the decision-making process, so parents tend to be the
target audience for promotional communications, (Looijimans van dAl et al., 2010). The study
therefore, would wish to give recommendations to policy makers on the need to increase the
awareness through health education and information to family members about the need to
complete immunization for all children in order to prevent childhood deaths and life-long
disability and at the same time address the socio demographic challenges to the uptake of

childhood vaccination.

6
Ahmad (2020) while analyzing the 2015 Afghanistan Demographic and Health Survey found
mother’s age seems to have a significant impact to immunization uptake for children aged 12-23
months in Afghanistan. Women under 16 years of age in Indonesia were less likely to use any
health care than older women. (Reynold H et al., 2006). This is because younger mothers are
often unable to make their own decisions; they must discuss decisions with family members.
Older mothers are more likely to have experience regarding raising children and more likely to
be knowledgeable about children’s health (Reynold H et al., 2006). A similar study on maternal
age was revealed to be a factor influencing childhood immunization uptake in a case-control
study conducted in Ethiopia that involved 548 children aged between 12 to 23 months, in which
mothers over 19 years of age were approximately 10 times more likely to have their children
fully immunized compared to mothers under 19 years of age (Negussie A et al., 2015). This may
be due to knowledge gained over time on the importance of immunization by mothers over 19 
years of age, combined with the negative impact on children due to lack of immunization.

A study by (Girmay, 2019) revealed that maternal education was a predictor of childhood
immunization status. The role of maternal education as an important predictor of immunization
uptake has also been stated by other studies in Zimbabwe (Mukungwa T, 2015), Uganda (Bbaale
E, 2013), and Ethiopia (Ayano B, 2015, Animau et al., 2014) .This is due to the contribution of
education, changes in attitudes, traditions and beliefs, increased autonomy, and decision-making
which could directly enhance a health seeking behavior of the mothers. Apart from maternal
education, mothers’ good knowledge of immunization programs increased the odds of their
children being vaccinated in the district. Research evidence from Nigeria (Adedire E et al., 2013)
and Southern and North Western Ethiopia reached this similar conclusion (Debie A et al., 2014,
Animau et al., 2014, Ayano B et al., 2015) This might be due to mothers having a better
understanding of Vaccine Preventable Diseases (VPDs), immunization schedules, and awareness
about a reason for vaccination, which might increase their motivation to immunize their children.

According to Miriam Webster Dictionary, Marital status is the distinct options that describe a
person's relationship with a significant other. Married, single, divorced, and widowed are
examples. A study in Kenya on Determinants of uptake of immunization services among
children aged below 12 months in Aldai Sub-County, Nandi County, revealed that the uptake of
immunization is influenced by the marital status of the care giver (Kemboi DK, 2014). The

7
probit model results of this study revealed that married care givers are more likely to have their
children fully immunized compared to unmarried care givers. This could point towards the
influence of a spouse in adhering to vaccination schedule (Kemboi DK, 2014). This is also
supported by a study on the Socio-Cultural Factors Associated with Incomplete Routine
Immunization of Children in Amach Sub-County, Uganda which revealed that marital status was
significantly associated with incomplete routine immunization. This is in agreement with studies
conducted in Ghana by (Anokye 2018, Mekonnen et al. 2019, Zida, et al.,2019, and Landoh et
al. 2016). The reason why the unmarried were less likely to complete routine immunization of
their children could be because of the low awareness among unmarried young women, fear to
meet the nurses, and feeling of shame to meet older married women.
2.2 Health Seeking Behavior
Healthcare seeking behavior has been defined as, "any action or inaction undertaken by
individuals who perceive themselves to have a health problem or to be ill for the purpose of
finding an appropriate remedy" (Olenja J, 2004). Worldwide, and most especially in developing
countries, discussion of vaccination demand is often reduced to narrow issues of knowledge,
services and education. Missing is a deeper understanding of the mothers health seeking behavior
that influences its acceptance, use and effectiveness. (Bisiriyu L et al., 2014). Maternal health
seeking behavior has a huge impact not only on lives of mothers, but also on the lives of their
children. (Lashman, 2006). The study therefore seeks to recommend to the policy makers the
importance of going beyond the normal factors to the maternal individual health seeking
behavior in order to improve childhood vaccination in Homa bay County.

A study on the Influence of socio-demographic factors on coverage of full vaccination among

children aged 12–23 months in India concluded that the full vaccination coverage was higher
among the children whose mothers had four or more ANC visits, delivered at the health facility
and had PNC visit than those who had no ANC visit, and delivered at home and no PNC visit
(Islam T et al.,2016) The findings of this study was consistent with other studies conducted in
Afghanistan, Zimbabwe, Ethiopia, Senegal, Indonesia for ANC visit, (Tamirat K et al, 2019,
Girmay A et al., 2019, Mbengue M et al.,2017, Farzard F et al., 2017, Mkungwa T, 2015).
Zimbabwe, Ethiopia, Senegal, Indonesia for the place of delivery (Tamirat K et al, 2019,
Girmay A et al., 2019, Mbengue M et al., 2017, Farzard F et al., 2017,Mkungwa T et al., 2015),
and Ethiopia, Papua New Guinea for PNC visit. (Bundu et al., 2020, Lakew Y et al.,2017). This

8
may be due to easy accessibility of ANC services which subsequently increase maternal and
child health care, and prior knowledge about vaccination which they further transfer toward their
child health care, (Tamirat K et al, 2019, Girmay A et al., 2019, Mbengue M et al., 2017,
Farzard F et al., 2017,Mkungwa T. 2015). Babies delivered at health facility provided an instant
initial dose of vaccination and prescribed instruction for vaccination by health professional
increase vaccination coverage, ( Efendi F et al., 2020, Mukungwa T. 201) and PNC checkup
creates awareness to the mother about the vaccination of children. A similar study also revealed
that maternal tetanus toxoid (MTT) vaccine was also noted to be a factor influencing childhood
immunization uptake. Mothers who received at least one dose of the MTT vaccine were three
times more likely to have their children fully immunized compared with mothers who did not
receive any dose of the MTT vaccine (Adedire E et al., 2016, Mohamud A et al., 2014). This
could be attributed to the knowledge that mothers may have obtained regarding the benefit of
childhood immunization uptake during the MTT vaccination in their health Centre (Adedire E et
al., 2014).

Attitude as explained by Oxford Dictionary is a settled way of thinking or feeling about

something and involves the mindset, and feeling. On the other hand, Psychologist Albert
Bandura has defined self-efficacy as people's beliefs in their capabilities to exercise control over
their own functioning and over events that affect their lives. One's sense of self-efficacy can
provide the foundation for motivation, well-being, and personal accomplishment (Bandura A,
1977). In Nigeria, the poor attitude of mothers accounted for 16% of the reasons for poor
childhood immunization uptake (Gunala R et al., 2016). Among 248 defaulting mothers in
Ibadan, Nigeria, more than half of this group reported that the reason for defaulting was that they
considered childhood immunization to be a waste of time (Oladokun R et al., 2010-13). The
children whose mothers had a positive perception towards vaccine side effects, were twice more
likely to be fully immunized compared with children whose mothers had a negative perception
towards vaccine side effects (Negussie et al., 2015). Many studies also reported that fear of
vaccine side effects influenced immunization uptake, (Ekure E et al., 2013, Gunala R et al.,
2016, Kio et al., 2016). Mothers who lacked confidence in vaccine safety, were less likely to
have their children immunized (Oladokun R et al., 2010-13). Mothers with a good perception on

9
immunization were three times more likely to have their children fully immunized compared
with mothers with a poor perception on immunization (Taiwo l et al., 2017).

A study on the determinants of full vaccination among children aged 12-23 months in Katheka
Kai location, Machakos County, Kenya concluded that Knowledge on immunization related
issues was found be satisfactory among the respondents as slightly more than half could mention
at least three childhood vaccines and more and at least three and more childhood diseases
prevented through immunization (Kioko T. 2020). Having knowledge and information regarding
children immunization acts as a motivator for mothers to vaccinate their children (Kioko T,
2020). Similar findings were made in a study conducted in Mathare slums Nairobi that maternal
knowledge and attitude contributed to increased children immunization, (Kamau & Esamai,
2001). In other studies, parents held reservations towards the associated side effects of vaccines.
Others expressed a total distrust of immunization programs and vaccines (Obasoha P et al., 2018,
Babirye J et al., 2011, Babalola S, 2011, Kagone M et al.,2018, Braka F et al.,2012, Ambe J et
al., 2001,Jani J et al., 2008). This is in line with previous review of Influenza Vaccine hesitancy,
which pointed out that, a lack of confidence due to low perceived effectiveness of the vaccine
was a hindrance to vaccine uptake (Schmed P et al., 2017). Another review outlined similar
beliefs, including concerns about side effects, uncertainty toward vaccine safety, and belief in
anti-vaccine theories (Wilson L et al., 2018). Thus health education programs targeting these
groups are critical in increasing vaccines acceptance, therefore immunization programs should
intensify public sensitization on vaccines safety and promote effective mechanisms of addressing
parents’ concerns. Healthcare workers should develop approaches that acknowledge parental
concerns and respectfully try to correct their misconceptions

2.3 Socio Cultural Factors

These are factors concerned with the arrangement of the surrounding and the way the community
is designed in a way that can affect the life of the individuals and the communities. The study
seeks to bring to the attention of policy makers the fact that these factors can promote or create
barriers for immunization uptake (CDC, 2020). National decisions on the use of a new
intervention require strong supportive data to best facilitate its timely and systematic uptake. It is
critical to gain an understanding of the socio-cultural environment prior to introduction of a
possible malaria vaccine, and other new vaccinations, as in the past it has taken up to two

10
decades for some vaccines to be available to communities in developing countries (WHO, 2015,
Baleta A et al., 2012, Oria P et al., 2013). Vaccine safety concerns must be addressed with
special focus on male parents, local religious and traditional leaders.

A study in India concluded that full vaccination coverage was higher and lower among the
children belonging to other religions and Islamic religion respectively than those belonging to
Hindu religion. (Islam T et al., 2016). While prior studies in Zimbabwe, Papua New Guinea, and
Tamil Nadu ascertain that religions have no significant influence on children’s full vaccination
coverage (WHO, 2012), Mukungwa T et al., 2019, Murhekar M et al., 2017) . Among the
Muslims, due to lack of awareness and belief on immunization, the full vaccination coverage was
lower among their children. The result is similar to the other study conducted in rural Vellore of
Tamil Nadu, India. (Francis M et al., 2009).This might be due to lack of educational and health
care awareness and lack of belief in vaccination because most of the Tribes are still untouchable.
A similar study in Mozambique revealed religious factors to be one of the social factors
influencing childhood immunization uptake (Jani J et al., 2008). Mothers who considered
immunization as unacceptable in their religion were less likely to have their children fully
immunized compared with mothers who did not consider immunization as unacceptable in their
religion (Jani J et al., 2008). Lack of adequate involvement by religious and traditional leaders in
immunization activities was found to be a reason for immunization failure in Borno State,
Nigeria (Omatara A et al., 2012). In Nigeria, cultural beliefs against immunization are found to
be destructive towards childhood immunization uptake (Duru C et al., 2016, Tadesse H et al.,
2009). This could probably be due to the circulation of false information via the use of either
family or religious networks towards vaccines. For example, beliefs that vaccines were
composed of anti-fertility drugs and therefore could destroy the eggs of females and cause
damage to the reproductive system (Tadesse H et al., 2009, Jegedde A et al., 2007). Traditional
and religious leaders are highly respected and are generally regarded and accepted as the
custodians of traditions entrusted to them to provide traditional guidance to their respective
communities. Therefore, their involvement in immunization activities will help increase
immunization acceptance and uptake since the community trust their views on various matters
(Omatara A et al., 2017)

11
A study on factors contributing to the uptake of childhood vaccination in Somalia discovered that
the Galkayo District is a Muslim patriarchal community in which men are the decision-makers.
In Muslim culture, women are not permitted contact with non-related men. Participants
questioned the rationale for having female social mobilizers targeting mothers for childhood
vaccination when fathers make the final decisions (Mohamed F A et al., 2022). A similar
research in Ethiopia showed that lack of paternal involvement in immunization leads to vaccine
refusal (Zewdie A et al., 2016). Child healthcare decision-making by mothers play a significant
role in full immunization coverage, with the child more likely to be fully immunized if the
mother was the decision-maker. (Olembo O et al., 2017). This might be due to more awareness
of the mothers for their child’s health than the fathers. Therefore, the mothers’ autonomy is
essential for their child’s immunization. However, an earlier study showed that if the parents
jointly decided on healthcare decision, their children were often fully immunized (Olembo O et
al., 2017). Thus, there is a need to disseminate information about women autonomy in making
healthcare decisions about their children to increase full immunization coverage. Based on the
findings, community-based behavior change programme that targets parents might be helpful for
developing awareness for their childhood immunization. A study carried out in Cambodia
suggested that women’s decision-making power and autonomy were relevant to maternal and
child health outcomes (Forder JA, 2002). It is important to carefully consider the social contexts
during program design and implementation for child immunization. There is a serious need to
effectively address socio-cultural contexts by involving the entire community, and not only
target mothers and female caregivers. At the same time, women need to be empowered to
overcome their financial challenges in taking their children to vaccination centers

Household wealth is a significant determinant of vaccine inequity with children in richer

households more likely to be fully immunized than children in poorer households, even though
vaccines are provided free-of-charge in public facilities in Kenya (Kiptoo E, 2015). This is
consistent with previous studies which found that the poorest households face both financial and
non-financial barriers to accessing immunization services ( Calhourn L et al.,2014, Tugumisirije
F et al., 2012, Ismael T et al., 2014). The barriers include transportation cost to access the public
facilities, childcare cost for other children, and the opportunity cost of taking time off work. New
approaches for delivering immunization services to reduce the travel time, such as constructing

12
new health facilities in underserved areas or introducing community health worker models that
operate on a localized level will facilitate improved access to immunization services (Bruce T et
al., 2019). (Donfouet, 2019) while seeking to unravel the causes of unequal distribution of
vaccination services among young ones of ages above 12 months and less than 2 years in Kenya,
Ghana and Ivory Coast by use of demographic and health surveys and multiple indicator cluster
surveys 16 found out that vaccination inequalities tend to favor those economically able
households basing on the fact they are more knowledgeable about the positive outcomes of
vaccines and have increased access to the facilities thus increasing their demand compared to
their counterparts in the lower wealth quintile (Donfouet, 2019). The findings of this study tends
to register similar results when it comes to inequalities on economic empowerment with a cross-
sectional study seeking to establish the determinants of immunization coverage of children aged
12-59 months in Indonesia that showed poverty as one of the determinants stating that children
who were born from poor families had decreased chances of being immunized as well as those
who had no medical cover and those who came from families where parents had no or minimal
exposure to media (Herliana and Douiri,2017).

2.4 Influence of health systems factors

This describes the factors associated health systems that determine the process of delivering
vaccine and vaccine related services to it beneficiaries. These include accessibility of the health
facility, Quality of immunization services, Provider/ caregiver relationship an availability of
supplies (Tadesse H. et al., 2009, Obasoha P.E, et al., 2018, Malonde O. et al., 2019). An
important supply-side limitation Information on childhood vaccination is urgently needed in
Homa Bay County where coverage remains inadequate. The study would wish to recommend to
the Policy makers on the crucial need to build public trust and confidence in vaccine safety and
effectiveness. It is necessary to understand, therefore, not only the factors that drive trust, but
also the local perceptions of risks and benefits within different community contexts. Health
workers must remain accountable for any misrepresentations, whether intended or otherwise. It is
critical that health workers are given appropriate training and support to address operational field
challenges. The creation of trained community imbedded health workers is one way of better
educating individuals and communities about the importance of childhood vaccination in Homa
bay County.

13
Various studies have attributed uptake of immunization services to environmental and health
system factors establishing that these factors include to distance to the health facility. In India,
Rup (2008) while seeking to determine what affects coverage of immunization in relation to
children in across-sectional study in Assam India found that children born in families residing
within a 2 kilometer radius tend to comply with the immunization schedule unlike their peers
living outside the 2 kilometer. Similar results are reported by (Logullo,2008) case-control and
explanatory study on factors affecting compliance with measles vaccination schedule in a
Brazilian City attributing accessibility to healthcare facilities as having the ability to increase
uptake of vaccines. In Zimbabwe, (Mukungwa T, 2015) in across-sectional study on
determinants of immunization coverage affecting under 5 s found that distance to a vaccinating
facility has a significant contribution to vaccine uptake by stating that children with caretakers
who reported having no issue with access to a vaccinating facility had an increased likelihood of
having their children fully vaccinated as opposed to those who reported to have an issue with the
distance to the hospital. (Mukungwa T, 2015). Therefore, policy should target divisions with
low immunization coverage with an innovative immunization approach that addresses both
supply-side and demand-side barriers. For instance, households that are located away from or
have difficulty in accessing immunization services, especially in hilly areas, might benefit from
outreach programme or mobile immunization strategies.

The quality of the vaccine provider and client relationship was also found to be a predictor for
childhood immunization uptake in Tanzania among 380 participants. Mothers who had a positive
perception towards quality of vaccine provider and client relationship were twice more likely to
have their children fully immunized compared to mothers who had a negative perception towards
quality of vaccine provider and client relationship (Chambongo P et al., 2016). This could
probably be due to the way vaccine providers behave which may either enhance or discourage
mothers from taking their children for vaccinations (Chambongo P et al., 2016). A similar study
in Nigeria revealed that Health service factors were key drivers of immunization utilization.
Health workforce shortage was a frequently mentioned problem which hindered immunization
service delivery in both wards—though to a lesser extent in the semi-rural Ipara which is more
likely to attract and retain health workers than Ilara. (Tadesse H et al., 2009).Other studies also
noted that due to staff limitation, only one staff often conducted immunization sessions in the

14
catchment population (Tadesse H. et al., 2009, Malonde O. et al., 2019, Tefera AY et al., 2018,
Ishmael IT et al., 2014). Similarly providers’ hostility and rude attitudes to mothers were also a
reported immunization barrier in this review (Nolna S.K et al., 2018), (Zewdie A, et al., 2016),
(Swartz N.G et al., 2009). Increased financial resources would enable countries to equip and
upgrade existing health facilities and to increase their numbers. Targeted resources may motivate
and enable staff deployed in remote areas for effective outreach activities to maximize coverage
of immunization. This findings reflect a review (conducted in sub-Saharan countries) focus on
children and youth which noted that poorly organized services can cause delays and increase
costs for beneficiaries (Sullivan J e al., 2017). A coordinated National Immunization Program
can rationalize services, thus improve immunization uptake and regulating healthcare providers.

Vaccine stock-outs have been known to cause a pose to delivery of immunization services with
children missing out on their stipulated vaccines as per the vaccine schedules. In Kenya BCG
and
pentavalent vaccines stock out has been more prevalent (Kiptoo E, 2015). This is as stated by
(Lyndo, 2017) while looking at vaccine stock-outs around the world. This has the potential of
discouraging caregivers from taking their children for immunization services thus affecting
uptake of immunization services.(Babirye, 2012) while conducting a cross sectional study to
assess how time lines of vaccines affects vaccination services in Kampala Uganda found out that
inadequate supply of vaccines to immunizing facilities had a significant impact on uptake of
vaccination. In Nigeria, Vaccine shortages at health facility level and difficulties of transporting
vaccines were commonly reported to significantly hinder immunization services (Tadesse H. et
al., 2009), (Malonde O. et al., 2019). Common to both wards was the irregularities associated
with the availability of vaccines for routine immunization in the health facilities—a common
finding in other Nigerian studies ( Siriwardena A et al., 2002, Nuttall D , 2003, Looijmans – van
dA I et al., 2010), and usually as a result of logistical problems rather than stock out. The
restricted vaccine opening policy (use of multi-dose vials and the limited time for their use) was
noted as a barrier (Pertet A.M. et al., 2018), (Kagone M. et al., 2018), (Tadesse T. et al., 2017).
This finding disagreed with previous systematic review conducted in middle- and low -income
countries. It indicated that the main factors that impede vaccination uptake and coverage were
associated with healthcare system (Raieney J J et al., 2011). Some healthcare system related

15
strategies could be realistically to designed and implemented in a range of settings, such as
training of health workers to reduce missed opportunities, improve communication, and remove
barriers by enhancing outreach services while at the same time coming up with single dose
vaccine vials.

2.5 Summary
Immunization is a strong pillar of community health, as it is a cost-effective intervention to
prevent illness and disability, and saves millions of lives every year and also a key to achieving
the Sustainable Development goals (SDGs). Vaccination coverage remains an important
indicator of child health outcomes in virtually all countries. Improving vaccination coverage by
ensuring that all children born in or out of a healthcare set up are vaccinated remains a desire of
most nations due to the undesirable health outcomes of non-immunized children The studies
have not mentioned utilization of the newly introduced vaccines which have played a key role in
reducing morbidities related to vaccine preventable diseases among under five children and these
include; pneumococcal vaccines, rotavirus and malaria vaccines. This study intends to determine
the uptake of the newly introduced malaria vaccine in malaria endemic Kasipul Kabondo Sub
County.

2.6 The Conceptual Framework

This framework considers a person’s related factors as well as health facility factors. The person
related factors include various factors that may influence care givers choice of place to seek
immunization services. The independent variables are those variables that stand alone and isn't
changed by the other variables in the study. They include socio demographic characteristics on
one hand include: maternal age, marital status, woman’s education. These reflect an individual’s
own influence to seek immunization services. Individual health seeking behaviour on the other
hand include: Obstetric factors and maternal attitude and efficacy and maternal health
knowledge. These reflect both individual and community attitude and their influence on the
decision to seek child immunization services. Maternal/ care givers socio cultural factors include,
religious/cultural beliefs, economic status and mother’s autonomy. It is critical to gain an
understanding of the socio-cultural environment prior to introduction of a possible malaria
vaccine, and other vaccinations, as in the past it has taken up to two decades for some vaccines
to be available to communities in developing countries. Finally, the influence of health systems

16
 factors on the uptake of malaria vaccine will include: Accessibility of the health facility,
Provider caregiver relationship and availability of supplies. These reflect the operations of the
prevailing systems and their influence on the uptake of malaria vaccine among the children
below two years. The dependent variable is the variable being tested and measured in a study. In
this study, the dependent variable is the uptake of malaria vaccine among the children below two
years in Kasipul Kabondo Sub County. On the other hand, is the intervening variable which
affects the relationship between independent variable and a dependent variable. In this study, the
intervening variable will be government policy which is the back bone for the implementation of
all the government policies in any country.

INDEPENDENT VARIABLES INTERVENING VARIABLES DEPENDENT VARIABLES

Socio Demographic Factors

Maternal/caregivers age

Level of education

Marital status

Individual health seeking behavior

Obstetric factors

Educational
Maternal/ Factors attitude and self-
caregivers
efficacy

Maternal/caregivers Knowledge
Uptake of
malaria
Government policies
vaccine
among
Socio cultural factors children
below two
 Religious /Cultural beliefs
years in
 Economic conditions Kasipul
 Mothers autonomy Kabondo Sub
County
17

Health System Factors

Accessibility of the health facility
Availability of supplies

Figure 2.1: Conceptual Framework on Determinants of malaria vaccine uptake among children
below 2 years in Kasipul Kabondo Sub County, Homa bay County.

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Study area
Kabondo Kasipul Sub County is one of the eight (8) sub-counties that make up Homa Bay
County. It is made up of four wards which form the political representation units, namely: 
Kokwanyo-Kakelo, Kojwach, Kabondo East, and Kabondo West. It is made up of two Divisions
of Kabondo and East Kasipul. It consist of 11 locations and 23 sub-locations a. The Sub County
is divided into two main relief regions namely the lowlands towards the Lake Victoria basin and
the highlands bordering Kisii and Nyamira Counties. The Sub County lies between 1,160 -1,220
m above sea level.  It is characterized by hills including; Gangre, Nyabondo, Olak, Ongoro,
Dudi, Kimori, Adega, Rateng, Oogo, Kimondi, Okombo, Komala and Atela.  It has a number of
rivers which originate mainly from Kisii and Nyamira highlands namely; Miriu, Nyamwaga,
Awach Pala, Awach Othoro, Anyona, Awach Kadongo, Opilu, Awach Ogera and Orue.
Kabondo Kasipul has 2 waterfalls namely; Odino and Atemo Falls.

Kabondo Kasipul lies within longitudes 34.85 North, 0.44 degrees East and latitudes 0° 20’
South and 0° 50’ South. It is bordered by seven (7) sub counties, namely; Sigowet/Soin to the
East, North Mugirango and West Mugirango to the South East, Kitutu Chache North to the
South, Kasipul to the West,  Karachuonyo to North West, and Nyakach to the North. The
Constituency covers a total area of 249.80 km2.

18
The main Wetlands in the Sub County include; Nyamwaga, Luanda, Pundo Lando and Tala. The
constituency has the following gazetted forests; Kasewe, Kamondi, Kawuor and Anuoyo in
Kakang’utu west. It also has dams which include; Kokise in Kodhoch, Kagero in Ramula, and
Anuoyo in Kakang’utu west. The Sub County also has a man-made lake called Odino-Nyandolo.
It is characterized by a range of mineral-rich soils, predominantly of red-clay to loamy types thus
making it suitable for variety of agricultural activities. The total population is 345654, of whom
12.80 % are children below 5 years.

3.2 Study population

The study population will consist of caregivers of children aged below 9 to 18 months from
Kabondo Kasipul Sub- County who attended child welfare clinics and meets the inclusion
criteria upon consenting. In 2021). This population was 1,949 (KNBS, 2021)

3.2.1. Inclusion criteria

1. Care givers of children aged 9 to 18 months from Kasipul Kabondo Sub County
2. Caregivers of children aged 9 to 18 months from Kasipul Kabondo Sub County who
holds child welfare clinic card
3. Caregivers of children age 9 to 18 months from Kasipul Kabondo who will consent to
participate in the study

3.2.2 Exclusion criteria

Caregivers of Children from Kasipul Kabondo Sub-County who are mentally incapacitated.

3.3 Study design

A cross sectional study design shall be adopted for this study using both qualitative and
quantitative data approaches in order to collect information about respondent’s attitudes opinions
and behaviours with respect to these study objectives.

3.4 Sample size determination and Sampling procedure

3.5.1 Sampling size determination

19
By July 2022, 883 children aged 9- 18 months had received malaria vaccination in Kasipul
Kabondo Sub County. According to MVIP monthly data bulletin the percentage of malaria
vaccine uptake in Homa Bay County to which Kasipul Kabondo Sub County is part was at 51%.
To estimate a minimum sample size that would allow for any significant statistical association
between the independent variable and outcome variable to be detected. It is upon this assumption
that Fisher et al., 1999 Standard formula was used to determine sample size as follows:

Z ² pq
n=
d²

Where

N = Minimum sample size

Z = statistic for 95% level of confidence and its value is 1.96

P = Estimated malaria vaccine coverage of children aged 12 -23 months in Homa Bay County of
which Kasipul Kabondo is part at 51%

D = Absolute precision at 5% Level of Significance i.e. 0.05

Q = 1-p

(1.96)²(0.51)(0.49)
Hence¿
(0.05) ²

=373 respondents

There will be 10 % non-respondent rate that is, (10/373) x100 = 37

Therefore 373+37 = 410 respondents

3.4.2 Sampling procedure

Stratified sampling technique proportionate to size will be used in selecting participants from the
4 wards which will serve as strata since there are differences in the characteristics of the wards.
Therefore employing stratified sampling technique will ensure that all locations are represented
in the sample. It will also allow comparison to be made across the wards. In determining the
proportionate sample size for each ward, the formula below will be used:

20
A=yz,A=yz,

where A is the sampling fraction, ‘y’ is the sample size  =  410, and ‘z’ is the 2022 monthly
target coverage for malaria vaccines in Kabondo Kasipul which is 347. The sampling fraction
will be applied to the monthly target of each ward to determine the sample size for each location.

Systematic sampling will then be used to select respondents from each stratum. A sampling
frame will be constructed using the Child Welfare Clinic (CWC) registers at the various health
facilities. The CWC registers contain the official records of each vaccinated child in a particular
health facility. The frame will contain the names of children who were be eligible for the first 3
doses of the malaria vaccine by December 2021, for each ward. A sampling interval will be
determined for each sampling frame using the formula:

K=Nn,K=Nn,

where K  =  sampling interval, N  =  the number of children in the sampling frame, and n  = 
sample size for the ward. Simple random sampling will be used to select the first sample by
writing the names of the children from one to the sampling interval, folded and mixed up in a
bowl. One piece of paper will be selected and the name on the paper will represent the first
sample. Subsequent samples will be drawn by adding the sampling interval to the number of the
first drawn sample until all samples required for the ward has been drawn. The
parents/caregivers of the selected children will be contacted and those who agree to be part of the
study will be interviewed

3.5 Data collection instruments

3.5.1 Questionnaire
Primary data will be collected using questionnaire from the respondents. (Appendix III).The
questionnaire will be structured to provide the respondents with easy- to fill-in data. The
Instrument will contain both open and close ended questions, and will consist of two sections,
that is section one will contain the bio- data of the respondent, while section two will focus on
the study variables. Secondary data will be obtained from relevant sources that will be available
to the researcher using a check list.

21
3.5.2 Key informant interviews (KIIs)

Stratified sampling technique will be used to identify Key informant interviews (KIIs). Health
workers, community health works and community health Extension workers will be selected as
per the 4 wards in the sub county. There after purposive sampling will be used to identify the
respondents according to their knowledge in teenage sexual and reproductive health required by
the researcher and willingness to participate in the interview.

These will be obtained from the 4 administrative wards respectively. A total of five health
workers, 12 community health extension workers and 3 community health workers will be
interviewed on the factors associated with the uptake of malaria vaccine in the sub county.

3.6 Data collection procedure

3.6.1 Questionnaire

Eligible mothers will be given numbers, (for example W1, W2, Wn.,,,).During this visit, the
purpose of the study as well as the sampling procedures will be adequately explained to each
caregiver. The care giver will then be allowed up to one week to discuss their participation in
the study with their partners and /significant others on their willingness to participate in the
study. All the selected caregivers will be re-contacted via phone after one week. Finally, all the
care givers who will consent to participate in the study will be interviewed individually at their
place of choice. There will be 10% non-response rate for those who declines to participate in the
study

3.6.2 Key informant interview

This procedure will be carried out before the actual interviews by the Principal investigator and
the first contact will be made to discuss the possibility of participating in the study. Convenient
time and venue for the interview will also be agreed upon. After the identification of the

22
participants, the scheduled interviews will be conducted at the place of choice of the Key
Informants. The purpose, scope of the study and the procedures to be used in data collection,
risks, benefits and how the results will be used will be communicated to the participants before
the interviews are carried out. The possibility of using a recording device will also be mentioned
to the informants and their consent sought. The interview will be based on an earlier prepared
guide.

3.7 Pre testing

The questionnaire will be pre tested Ndhiwa Sub County Sub-County which has a similar
population to test for clarity, validity and reliability of the research instrument before the actual
study. This will be done at 10% of the target population who met the study inclusion criteria and
will be done in one location different from the one randomly selected for the study to avoid
recruiting the same respondents. The principal investigator will closely monitor the research
assistants during data collection to ensure that will be collected from participants as scheduled.
Administered questionnaire and key informant interviews will be checked daily for completeness
and accuracy to ensure internal consistency. Data analysis will be done to check the
appropriateness of the data collection tools and the identified gaps and overlaps will be rectified
before the actual study.

3.8 Validity and reliability

3.8.1 Validity
Validity of instruments will be ensured through the use of a well- designed and pretested
questionnaire together with well-trained research assistants. Content Validity Ratio, or CVR
formula will be used to establish the validity of the research. The formula will be based on
ratings from a group of experts in the field related to the subject at hand. This will involve
assembling a group of experts, whose task it will be to rate the research instruments. Their
answers can be "essential," "useful" or "not necessary." Group size will be between five and ten,
since the more opinions received, the more accurate the determination will be. Finally, tallying
the number of "essential" ratings for the instruments will be done. The formula therefore will be:

CVR = [(E - (N / 2)) / (N / 2)]

Whereby:

23
(N) Represents the total number of experts

(E) Represents the number who rated the object as essential CVR can measure between -1.0
and 1.0. The closer to 1.0 the CVR is, the more essential the instrument is considered to be.
Conversely, the closer to -1.0 the CVR is, the more non-essential it is Interpret the results. CVR
can measure between -1.0 and 1.0. The closer to 1.0 the CVR is, the more essential the object is
considered to be. Conversely, the closer to -1.0 the CVR is, the more non-essential it is (C. H.
Lawshe, 1975)

3.8.2 Reliability

Various data quality measures will be adopted for this study. First research questions will be
designed to ensure that consistent results will be achieved. The field manual for the research
team will be prepared to ensure no stressful moments in terms of number of interviewers per day
and payment mode. Guidelines will also be prepared on how to ask questions and how to record
the answers provided.

Chronbach’sa coefficient will be used to measure internal consistency reliability. And a value of
0.7 or greater is believed to indicate satisfactory reliability and suggest that a set of items is
measuring a common dimension as per the formula below:

⌊
K
( K −1 ) (
⌋∗⌊ 1− )
∑ of itemvariance ⌋
total scale variance

Where K = No. of items.

Range is between 0 and 1

Source: (Landis and Koch, 1977)

3.9 Measurement of variables

3.9.1 Independent Variables

3.9.1.1 Socio Demographic characteristics

Socio demographic characteristics of the caregivers/guardians. These primarily influence

decision-making on whether to seek care, rather than affecting whether care givers reach a

24
facility. These will comprise data and information on age of the mother, maternal education and
marital status of mothers and care givers of children below 2 years in Kasipul Kabondo Sub
County.

Age will be defined as the number of completed years since birth and will be determined using
the reported age.

Maternal education shall be defined as a complex process aimed at enabling women to obtain
knowledge, skills and emotional support so that they can take care of themselves and their child
during pregnancy, child birth and post-partum period.

Marital status shall be defined as the distinct options that describe a person's relationship with a
significant other. Married, single, divorced, and widowed are examples

3. 9.1.2 Individual health seeking behavior

Individual health seeking behavior is any action or inaction undertaken by individuals who
perceive themselves to have a health problem or to be ill for the purpose of finding an
appropriate remedy. This shall include obstetric factors, maternal knowledge, maternal attitude
and self-efficacy of the mothers and caregivers of children below 2 years in Kasipul Kabondo
Sub County.

Attitude shall be defined as a way of thinking or feeling about something which involves the
mindset, and feeling. On the other hand, maternal self-efficacy shall be defined as an
individual’s beliefs in their capabilities to exercise control over their own functioning and over
events that affect their lives.

Obstetric factors shall be defined as the past experiences of pregnancy, labour and child birth,
together with any immunization services received during these periods.

Maternal knowledge shall be defined that which enables women to know more about their health
issues and take appropriate steps towards enhancing their health status

3.9.1.3 Socio cultural factors

25
Socio cultural factors such as religion/ culture, mother’s autonomy are those factors that are
concerned with the social networks of individuals. They shall include, Religion and culture,
women autonomy and house hold wealth of mothers and care givers of children below 2 years in
Kasipul Kabondo Sub County.

Religion shall be defined as the belief in and worship of a super human power or powers
especially a God or gods. Culture shall be defined as the ideas, norms and social behavior of a
particular people or society.

Women autonomy shall be defined as the capacity to and conditions to freely make decisions
impacting their lives

House hold wealth shall be defined as the difference between the value of a house holds assets
and the value of its liabilities

3.9.4. Health system factors

Influence of health system factors describe the factors that determine the process of delivering
vaccine and vaccine related services to it beneficiaries. They shall include accessibility and
distance from the facility health workers attitude and availability of supplies.

Distance from the health facility shall be defined as space between the care givers place of
residence and the health facility.

Health worker/client relationship shall be defined as the attitude of the care giver towards the
health provider on one hand and the attitude of the provider towards the care giver on the other
hand.

Availability of supplies shall be defined as in any time, the amount of vaccines and other
commodities needed shall be adequate.

3.9.2 Dependent variable

Uptake of malaria Vaccine

26
This shall be defined as the making use of the available malaria vaccine among the children
below 2 years in Kasipul Kabondo Sub County. It shall be measured through the uptake of the
first second third anf fourth doses of the vaccine against the set targets both nationally and per
county.

3.10 Data management and analysis

3.10.1 Quantitative Data
All study participants will receive a unique participant identification number that will be
recorded on the questionnaire. Collected data from the study will be thoroughly checked and
validated for accuracy and completeness. Data captured in questionnaires will be double entered
into an Ms Excel database, data cleaning done in Epi info version 7, after which data will be
imported to SPSS version 20 for analysis. The data will be stored in pass word flash disks/CD
ROMs for backup before and after analysis. Data on the questionnaire will be secured under lock
and key while electronically stored data will be password protected.

Frequency distribution, percentages and proportions will be used to analyze socio demographics
of the respondents. Correlation co-efficient will be used to establish relationship between
individual health seeking behavior and the influence of health system factors and the uptake of
malaria vaccine among the children below 2yearsin Kasipul Kabondo Sub County. Qualitative
analysis using emerging themes will be used to analyze individual behavior, and Chi square will
be used to assess the associations between socio cultural factors and the uptake of malaria
vaccine below two years in Kasipul Kabondo Sub County. Data will be presented in the final
research report in form of bar charts, frequency tables and pie charts, which will reflect the
answers recorded from the respondents.

3.10.2 Qualitative data

The audio taped data from KIIs will be transcribed into full text and translated to English where
the local language will be used as a media of communication during the interviews. To ensure
accuracy of the translation, the information will be retranslated and checked by the researcher.
The notes taken during the interviews and the transcribed data will be typed on an Ms Word
document and saved in flash disks as back up. The notes will be read and re-read before sorting.
Data analysis will be done manually, coding the responses into themes. These will then be

27
analyzed through content analysis to derive themes relevant to answer the research questions.
These themes will then be categorized and summarized according to how they were discussed.
3.11 Ethical considerations
The study will seek permission from School of Graduate Studies and ethical approval from
Maseno University Research and Ethics Committee (MUERC) respectively. Authorization will
also be sought from Kasipul Kabondo Sub-County Commissioner as well as the Medical Officer
of Health, from where data will be collected prior to the study. Sensitization meetings with chiefs
and village elders will be held to get permission to access the homesteads. The objectives of the
study will be explained and permission sought to carry out the study in the villages. Data
collection will emphasize on issues of confidentiality and privacy by restricting access to the
information collected and coding of questionnaires. Care givers who meet study requirements
and sign the consent/assent forms, will be enrolled into the study. Each study participant will be
informed about voluntary participation in the study. Their right to decline or withdraw any time
from participating in the study without feeling constrained will be explained. Respondents will
be assured of the confidentiality on the information given. Respondents will further be assured
that no person-identifiers would be used for publication. All information about the respondents
will be handled with utmost confidentiality and only used for intended purpose.

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APPENDIX I: MAP OF KASIPUL KABONDO SUB COUNTY

36
APPENDIX II: CONSENT FORM

37
1.0 Identification

Date of the interview: _________________ Interview number: _________________

Respondents name (optional) _____________________________________________

1.1 Introduction

My name is__________________, a Post graduate student undertaking Masters in Public Health

at Maseno University. I am carrying out a study whose aim is to investigate the Determinants of
malaria vaccine uptake in Kasipul Kabondo Sub County, Homa Bay County.

1.2 Benefits

The information from this study will be strictly for learning purposes. It may also be used by the
Ministry of Health both at the county and National level and other stake holders to improve
Adolescent Sexual and reproductive health in general.

1.3 Basis of Participation

Your participation in this study is purely voluntary. You will need about 10 minutes to respond
to the questions. The information will be given to the Researcher and will be treated with utmost
confidentiality. Your sincere and true response will contribute to the achievement of the aim of
this study

Would you be willing to contribute?

_____________________________________________________
(Signature of the respondent certifying that informed consent has been given verbally)
_____________________________________________________
(Signature of interviewer certifying that informed consent has been given verbally by the
respondent)
APPENDIX III A: QUESTIONNAIRE TO THE STUDY IN KASIPUL KABONDO SUB
COUNTY
A: SOCIO DEMOGRAPHIC CHARACTERISTICS OF THE MOTHER/CAREGIVER.

38
 1) 10-14
2) 14-18
1 How old are you currently
3) 18-24
4) 24-34
5) AB0VE 35
1. Primary
2. Secondary
2 What is your highest level of education completed?
3. Tertiary

(fill in ‘99’ if the respondent cannot recall) 4. University

5. Never
1. Single
2. Monogamous
3. Marital status
3. Polygamous
4. Seperated
5. Divorcee

B: INDIVIDUAL HEALTH SEEKING BEHAVIOUR OF THE MOTHER/CAREGIVER

4. Did you attend Ante natal clinic Yes………………………….

NO………………………….

39
 If Yes, How many times………………….
Briefly explain the services you
received’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’
IfNo,Why?Briefly
explain…………………………………..
5. Did you receive Tetanus toxoid injection Yes/ No
If Yes, how any doses……………………
What is your feeling about the tetanus injection
………………………………………………
Does it have any influence on your decision to
have your children immunized? Briefly explain
………………………………………………
………………………………………………
………………………………………………..
6. Have you ever heard of child hood Yes/No
immunization? If Yes, How did you get the
information……………………………………
………………………………………………
…...........
7. What are some of the Childhood vaccines ………………………………………………
available. Kindly name some of them ………………………………………………
………………………………………………

8. Yes/No
Do you know some of the diseases prevented If Yes, name some of them
by Vaccination? 1.
2.
3.
4.
YES/NO/DON’T KNOW
Do vaccines have side effects? If Yes, what are some of them? Briefly

40
9. What are some of the side effects of the explain……………………………....................
malaria vaccine ...........................................................................
..........................................................................

10. Would the mentioned side effects stop you Briefly explain
from having your child immunized? ………………………………………………
……………………………………………….
……………………………………………….
11. Has your any of your children missed any of YES/NO/ DO NOT KNOW
the vaccines? If Yes, which ones……………………………
………………………………………………..
……………………………………………….
………………………………………………..

12. Is there a problem associated failure to Yes/NO/DO NOT KNOW

complete childhood vaccinations If Yes, What are some of them?
Briefly explain………………………………
………………………………………………
………………………………………………
13. What is your attitude towards childhood Briefly
immunization in general explain…………………………………………
……………………………………………….
……………………………………………….
13. Would you encourage other mothers to take ………………………………………………
their children for vaccination? …………………………………………….

C: SOCIO CULTURAL FACTORS OF THE MOTHERS/CAREGIVERS

14. What is your Religion 1. Christian

41
 2. Muslim
3. Hindu
4. Other (Specify)
15. Briefly
What are some of your religious beliefs explain…………………………………………
about child hood immunization ………………………………………………
……………………………………………..

16. Yes/NO
Do you need to seek permission from your Briefly
Religious leaders to access immunization explain…………………………………………
services ? ………………………………………………
…………………………………………….

1. Farmer
2. Artisan
17. What is your occupation 3. Trader
. 4. Formal employment
Beloow 5000
5000-10000
18. What is your average monthly income
10,000 -20,000
Above 20,000
19. Who makes decisions on whether to seek Briefly explain……………………………….
immunization services
……………………………………………….

………………………………………………
………………………………………………

42
D: INFORMATION ON FACILITY BASED FACTORS

20. What is the level of your facility 1.County/ Sub County Hospital
2.Health centre
3. Dispensary
4.Private hospital
21. Who attended to you during your visit for 1.Doctor
immunization 2.Nurse/ Midwife
3.Clinical Officer
4.Other (specify)
22. How long did you take to reach the health facility in 1………..hours
which you delivered? 2 ………Minutes
1.Walking
23. What was your mode of transport to the facility in 2. Bicycle/motor cycle
which you delivered? 3.Public transport
4. Private vehicle
24. How long did you take to receive immunization 1…………….Hours
services at this health facility? 2…………….Minutes
25. How would you rate the quality of services in the ...................................................
health facility in which you received the immunization ...................................................
services? (Briefly explain ...................................................
26. Could you briefly comment on the staff attitude in this ...................................................
health facility? ...................................................

27. What are some of the instructions given to you after 1. Side effects
the immunization services 2. When to come back to the facility
3. Next appointment

28. Were the vaccines available Yes/No

Briefly

43
 explain…………………………………
…………………………………………

29. Would you recommend another mother to seek YES or NO

immunization services in this particular health
facility?
30. If YES, Why? ...........................................................................................................
If NO, Why? ..............................................................................................................

APPENDIX 111 B: IMMUNIZATION SCHEDULE CHECK-LIST

Do you have the child’s immunization card? 1 Yes…2 No.. if no terminate interview

DATE

SEX (Male/F)

BCG Date

Source

44
OPV BIRTH Date

Source

Penta Date
1/OPV1/Pneumococcal1/
Rota 1 Source

Penta 2/OPV 2/ Date

Pneumococcal 2/Rota 2
Source

Penta 3/OPV 3/ Date

Pneumococcal 3
Source

VTAMIN A Date

Source

RTS,S 1 Date

Source

RTS, S 2 Date

Source

RTS,S 3 Date

Source

RTS,S 4 Date

Source

MR 1 Date

Source

MR 2 Date

Source

Immunization Coverage Not immunization

Partially immunization

45
 Fully immunization

APPENDIX IV: SEMI STRUCTURED QUESTIONNAIRE (HEALTH CARE

PROVIDERS)

Key informant Interviews to be conducted in the Health Facilities in Kasipul Kabondo Sub
County.

Topics of the Interview

1. What is the population and the population served by this facility?

46
 2. What is your target or immunization services in this facility?
3. What is your coverage against the targets?
4. What are some of the challenges towards achieving the targets
5. What is the average age of mothers and caregivers seeking immunization
6. What percentage are married?
7. What percentage have gone through formal education?
8. What is the relationship between mothers who attended ANC services ad those seeking
immunization services?
9. Are mothers aware of the available immunization services?
10. What are their sources of information?
11. What role does religion play in immunization coverage?
12. Who makes decisions on childhood immunizations in this community?
13. How far are the distance to the nearest health faciltity?
14. What is the relationship between the health care providers and the caregivers?
15. Have you experienced vaccine stock outs?
16. What are the challenges experienced in childhood immunization services in general?

APPENDIX V: WORK PLAN

MONTHS (YEAR 2023) JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP

Activity

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Literature review

Piloting of tools

Data collection

Data entry and analysis

Report writing and

submission of first draft

Submission of final copy of

the report

APPENDIX VI: BUDGET

No. Items Quantity Price (Ksh.) Total (Ksh.)
1 Ball Pens 1 Packet 250 250
2 Photocopy papers 10 reams 550 5500
3 Foolscaps 1 ream 300 300

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4 Printer 1 peace 7,000 7,000
5 Toner 1 Cartridge 3,000 3,000
6 Field notebooks 3 pieces 50 150
7 Folders 2 pieces 150 300
8 Files 4 pieces 240 960

9 Stapler 1 piece 300 300

10 Paper punch 1 piece 250 250
11 Staple pins 2 boxes 50 100
12 Travelling expenses 60 days 1,000 60,000
13 Research assistance & supervisors allowance 10 5,000 50,000
14 Training expenses 14,000 14,000
15 Contingencies ( 20% ) 20,500
Grand Total 135,650

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50