Factors influencing low immunization coverage among children below 59 months at Migori

County Referral Hospital

By;
Karoli Atinga Seda
D/UPHRIFT/19051/388

A research dissertation submitted to Kenya Medical Training College in partial fulfillment

of the requirement for award of diploma in Health Records and Information Technology

December, 2020
Declaration
This proposal is my original work and has not been presented in a diploma in any other
institution.

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

Karoli Atinga Seda

D/UPHRIFT/19051/388

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Supervisor's Approval
This proposal has been submitted for review with the approval

Internal supervisor

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

Mr. Victor Otwori

BSc HRIM

3
Acknowledgement
Firstly, I thank God almighty for the strength during the whole period of my study. Special
thanks to all individuals who partially contributed to this work. My gratitude and sincere thanks
are expressed my supervisor Mr. Victor Otwori, for his tireless guidance, encouragement and
counseling through the process of carrying out this study. Am grateful to my parents, family and
friends for their encouragement, support and interest that led to the completion of my research
proposal.

MAY GOD ALMIGHTY BLESS THEM ALL.

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Table of Contents
Declaration ii
Supervisor's Approval iii
Acknowledgement iv
List of Tables vii
List of Figures ix
Abbreviations and Acronyms x
Abstract xii
Chapter One 13
1.0 Introduction 13
1.1 Background of the Study 13
1.2 Problem statement. 15
1.3 Justification 16
1.4 Objectives 17
1.4.1 Broad Objective 17
1.4.2 Specific Objectives 17
1.5 Research Questions 17
1.6 Scope 18
1.7 Limitations 18
Chapter Two 19
2.0 Literature Review 19
2.1 To Determine Mothers’ Knowledge On Immunization Coverage. 19
2.2 To Determine Reasons For Failure For Full Immunization. 22
2.3 To Identify Socio Economic Factors Influencing Acquisition Of Immunization. 23
Chapter Three 25
3.0 Research Methodology 25
3.1 Research Design 25
3.2 Study Area 25
3.3 Study Population 25
3.3.1 Inclusion criteria 25
3.3.2 Exclusion criteria 25
3.4 Variables 25

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 3.4.1 Dependent 25
3.4.2 Independent 26
3.5 Sampling Techniques 26
3.6 Sample Size Determination 26
3.7. Data Collection Instruments. 27
3.8 Data Collection Process 27
3.9 Pilot Testing 27
3.10 Validity 28
3.11 Reliability 28
3.13 Ethical Consideration 28
Chapter Four 29
4.0 Data Analysis, Presentation and Interpretation 29
4.1 Introduction 29
4.2 Demographic Characteristic of the respondents 29
4.2.1. Gender of respondents 29
4.2.2 Age of the respondents 29
4.2.3 Level of education of the respondents. 30
4.2.4 Religion of the Respondents 30
4.2.5 Relationship with the child 31
4.3 Knowledge of the respondents on the programme 31
4.3.1 Awareness on immunization 31
4.3.2 Source of information on immunization 32
4.3.3 Formal education about childhood immunization. 32
4.3.4 Availability of clinic immunization card. 33
4.3.5 Importance of childhood immunization. 33
4.4 Reasons for failure for immunization coverage. 34
4.4.1 Time taken to reach the nearest facility 34
4.4.2 Size of the land of the respondents. 34
4.4.3 Period of time spent on farm and household chores. 35
4.4.4 Number of children of the respondents 35
4.4.5 When is child taken for immunization 36
4.5 Socio-economic factors affecting acquisition of immunization services. 36
4.5.1 Marital status of the respondent 36

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 4.5.2 Types of employment of the respondents 37
4.5.3 Paid for immunization services 37
4.5.4 Amount of money paid for immunization services 38
4.5.5 Mode of transport 38
Chapter Five 39
5.0 Discussion, Conclusion and Recommendations 39
5.1 Discussion of the findings 39
5.1.1 Knowledge of the respondents on the Programme. 39
5.1.2 Reasons for failure for immunization coverage. 39
5.1.3. Socio-economic factors affecting acquisition of bursary funds. 40
5.2 Conclusions 40
5.3 Recommendation 41
5.4 Further Research 41
References 42
Appendices 44
Appendix I: Work Plan 44
Appendix II: The Budget 45
Appendix III: Map of Migori County 46
Appendix IV: Consent Form 47
Appendix V: Questionnaire 48
Appendix VI: Research Permit 53

List of Tables
Table 4.1: Age of the respondents 29
Table 4.2: Source of information on immunization 32
Table 4.3: Availability of clinic immunization card 33

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Table 4.4: Amount of money paid for immunization services 38

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List of Figures
Figure 4.1: Gender of respondents 29
Figure 4.2: Level of education of the respondents 30
Figure 4.3: Religion of the Respondents 30
Figure 4.4: Relationship with the child 31
Figure 4.5: Awareness on immunization 31
Figure 4.6: Formal education about childhood immunization s. 32
Figure 4.8: Time taken to reach the nearest facility 34
Figure 4.9 Size of the land of the respondents. 34
Figure 4.10 Period of time spent on farm and household chores. 35
Figure 4.11 Number of children of the respondents 35
Figure 4.12 When is child taken for immunization 36
Figure 4.13 Marital status of the respondent 36
Figure 4.14 Types of employment of the respondents 37
Figure 4.15 paid for immunization services 37
Figure 4.16 Mode of transport 38

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Abbreviations and Acronyms
BCG: Bacillus Chalmette Guerin
CDC: Centre for Disease Control
DPT: Diphtheria Pertussis Tetanus
EPI: Expanded Program for Immunization
FHI: Family Health International
GAVI: Global Alliance for Vaccine and Immunization
GIV: Global Immunization Vision
HBM: Health Belief Model
Hib: Hemophilus Influenza Vaccine
Hep B: Hepatitis B
IPV: Injectable Polio Vaccine
KDHS: Kenya Demographic Health Survey
KEPI: Kenya Expended Program for Immunization
KNBS: Kenya National Bureau of Statistics
OPV: Oral Polio Vaccine
PCV: Pneumococcal Vaccine
SPSS: Statistical Package for Social Sciences
RTHC: Road to Health Card
UNICEF: United Nation Children Emergency Fund
WHO: World Health Organization

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Definition of terms
Community: Social groups of any size whose members reside in specific locality, share
governments, and often have a common cultural and historical heritage.

Immunization: The process whereby a person is made immune or resistance to an infectious

disease, typically by administration of a vaccine.

Regimen: A regulated course intended to preserve or restore health or to attain some results.

Respondents: Any person taking part in the study.

Vaccine: A biological preparation that provides active acquired immunity to a particular disease.

Vaccination: Administering of antigenic material (vaccine) to stimulate an individual’s immune

system to develop adaptive immunity to a pathogen.

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Abstract
Immunization remains one of the most cost effective and efficient ways of preventing childhood
diseases across the world. Delay in completing immunization schedule as required by the
government puts the children at a risk of contracting the vaccine preventable diseases. The
purpose of this study was to determine factors influencing low immunization coverage among
children below 59 months at Migori County Referral Hospital.The objectives of the study
included; examine the influence of knowledge of mothers/caregivers on immunization coverage,
assess the reasons for failures in full immunization coverage and determine the role of
socioeconomic status of the mother and caretakers influence on immunization coverage. The
findings of the study would help the regional and central governments, policy makers and other
agencies develop regional strategies aimed at improving immunization coverage completion as
stipulated in the EPI guidelines. A cross sectional study design was employed in quantitative
methods that were used in this study. The target population was mothers of children between 1-4
years who have lived in Migori County in the past one year. Simple random sampling technique
was used to collect data from the 80 respondents. Data collected was coded, entered and
analyzed using Microsoft Excel and the results were presented in tables, charts and graphs.
Percentages were also used for interpretation purposes and conclusions. Some of the conclusions
were 70% had no formal education about childhood immunization and negligence and guardian
engagement in work were major causes of partial immunization. It was recommended that
government should create awareness and improve formal education on routine immunization
services offered. The data collected was used by the central and county government to know the
trend of immunization coverage in Migori County and how to improve the trend and make sure
the residents complete the immunization schedule as per the KEPI guidelines.

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 Chapter One
1.0 Introduction

1.1 Background of the Study

Immunization is one of the most cost- effective public health interventions for reducing global
child morbidity, mortality and life time disabilities. It describes the whole process of delivering a
vaccine and immunity. It generates in an individual and population. Vaccine preventable
infectious diseases such as tuberculosis, poliomyelitis, diphtheria, tetanus and measles are the
main causes of morbidity and mortality in children especially in developing countries (UNICEF,
2010). Globally, immunization prevents more than 2.5 million children deaths each year
(WHO,UNICEF,World Bank, 2009). Global public health has greatly improved though
widespread use of vaccines, preventing millions of childhood Hospitalization and death each
year rating immunization as a major public health intervention (CDC, 2011).
(The World Health Organization) WHO in 2012 established the Global Vaccine Action Plan
(GVAP) as a road map to prevent millions of deaths through more equitable access to routinely
recommended vaccines under this plan, countries are hoping to achieve vaccination coverage of
at least 90% nationally and at least 80% in each district by 2020. The aim of the plan includes,
accelerating control of all vaccine – preventable diseases, polio – eradication, and promoting
research and development for the next generation of vaccine (WHO & UNICEF, 2015).
In United States, there is a remarkable achievement in the control of vaccine preventable
diseases resulting in decline in morbidity and mortality associated with vaccine preventable
diseases (CDC, 2011). In Africa, there is a great improvement in the overall immunization
coverage, though at a relatively slower rate (WHO, 2014)). Despite some African countries like
Ghana, Morocco and Gambia have registered success in reaching coverage of over 90% (Ghana
News Agency 2012, (WHO,UNICEF, 2012). In Kenya since the year 1998, introduction of the
immunization programme has led to a continual reduction of vaccine preventable disease
incidence. The introduction of Rotavirus has been associated with 82% reduction in rotavirus
diarrhea cases in vaccinated children in Kenya (Kenya WHO,UNICEF, 2015)

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Even though there are remarkable achievements and improvements in immunization coverage
the agenda still remains largely unfinished with large numbers of children (24 million) remaining
unvaccinated, unreached or under- vaccinated (WHO, UNICEF,World Bank, 2009)

Approximately about 22.4 million infants which is equal to one- fifth of the world’s children are
not immunized against VPDs (vaccine preventable disease) and 70% of these children come 10
countries, Kenya being one of them (Kenya WHO,UNICEF, 2015)
One of the causes of high mortality rates in Kenya are vaccine preventable diseases (Hiskenya,
2012) In Kenya, 20% of the children do not access to immunization each year, one out seven
children die before reaching their 5th birthday from the cause that are vaccine preventable
(CDC,2012). Full Immunization Coverage (FIC) declined nationally from 74 to 73 per cent in
2014 and 2015 respectively and huge decline from 69 per cent in 2016 to 63 per cent in 2017 and
in Migori county approximate 64 per cent of eligible children fully immunized (KNBS, 2015)

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1.2 Problem statement.

Immunization program is a key strategy for prevention of child and neonatal deaths and life time
disabilities. Immunization prevents 2.5 million child deaths each year (WHO,UNICEF,World
Bank, 2009).

Despite the global improvement in vaccine coverage that has seen 84 per cent of the children
around the world receiving this life- saving intervention; 10 million children in low and middle
level countries die before receiving age of five (WHO, 2014)

Full immunization potential has not been achieved in many countries where 22.4 million children
around the world are not fully immunized. Majority of the no fully immunized children 70 per
cent are from 10 countries, Kenya being one of them (WHO and UNICEF, 2013).

Low immunization coverage remains a challenge even in committed country like Kenya which
has an average of 66% and 70% fully immunized children.

In recent years, Kenya has made tremendous progress in reaching every child with life- saving
vaccines. Eight vaccine formulation procured by UNICEF, provided against ten childhood
diseases free of charge in all public health facilities, but too many children still miss out on this
services. For example, in 2016 and 2017, an estimated 852,806 children in Kenya did not receive
vaccines. It is estimated that 1.7 million children born between 2013 and 2017 did not receive all
the scheduled vaccines. This means that 1 in 3 children aged below 5 years in Kenya is at risk of
diseases which can be prevented through vaccinations (UNICEF/NOORANI, 2016)

This study therefore shall aim to identify specific factors influencing low immunization coverage
among children below 60 months at Migori County Referral Hospital as well as ways to reduce
the number of missed opportunities so as to propose recommendations for interventions
strategies therefore raising overall immunization coverage.

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1.3 Justification

Immunization is a basic right as defined by the Constitution of Kenya Children’s Act. Vaccines
are provided free of charge in Kenya through routine immunizations in public health facilities,
outreach sites and vaccination campaigns. Vaccines are a safe and effective way of protecting
children from diseases, including pneumonia and diarrhoea which are responsible for the highest
mortality of children in Kenya.
Immunization coverage in Migori County approximate 64 per cent of eligible children are fully
immunized. This study seeks to determine immunization coverage at Migori County Referral
Hospital by collecting information on immunization status as well as ways to reduce the number
of missed opportunities so as to propose recommendations for interventions strategies therefore
raising overall immunization coverage. The results also provided data for other research studies
on immunization at Migori County Referral Hospital.
The findings from this study could be useful to the Migori County Referral Hospital, MCH clinic
and KEPI in decision on the best approach to use to raise overall immunization coverage.

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1.4 Objectives
1.4.1 Broad Objective
To determine factors influencing low immunization coverage among children below 59 months
at Migori County Referral Hospital

1.4.2 Specific Objectives

i. To determine the mothers’ knowledge on immunization coverage.
ii. To determine reasons for failure for full immunization
iii. To identify socio- economic factors influencing acquisition immunization coverage.

1.5 Research Questions

i. What is the mothers’ knowledge on immunization coverage?
ii. What are the reasons for failure to fully immunize children?

iii. What are the socio-economic factors influencing immunization coverage?

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1.6 Scope

The result of this study was useful in constructing local immunization strategies and programs
aimed at tackling the immunization problem in this region of the country. The results of this
study was also important for the planning, monitoring and supervision of the immunization
services in order to improve immunization completion coverage and the quality of health status
of children in this region. Consequently, the results of this study was also be applicable in
planning and strategizing for immunization programs in different regions of the country with the
same geographic and socio-economic characteristics with the aim of improving immunization
completion by the time the children reach the age of 9 months or as soon as possible thereafter.
It was hoped that the study was important in helping international institutions like WHO and
United Nations Children Fund (UNICEF) reach their targets in the global Immunization Vision
by making them focus their activities in different sub regions of the countries rather than the
whole country alone.

1.7 Limitations
This study had few challenges in including limited resources in terms of money and time. The
course had a pre-determined time-line that must be met to the letter hence to spend a significant
amount of money that was not easy to come by.

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 Chapter Two

2.0 Literature Review

This chapter extensively illustrated the on the knowledge on immunization coverage, the reasons
for failure for full immunization and also socio-economic factors affecting acquisition of
immunization by different children below 60 months.

2.1 To Determine Mothers’ Knowledge On Immunization Coverage.

Knowledge and education are usually interrelated and according to oxford online dictionary
(2016), education is the act or process of imparting or acquiring general knowledge, developing
the powers of reasoning and judgment, and generally of preparing oneself or others intellectually
for mature life. In this context education refers to acquisition of the knowledge by undergoing a
formalized education system while knowledge is the acquaintance with facts, truths, or principles
for example on immunization. Education should therefore enable an individual to acquire enough
information to help in decision making and judgment as far as childhood immunization is
concerned.
Knowledge can also be gathered through experience, and the same should be applicable to
knowledge on Immunization. Mothers who have experienced more than one births should have
gained additional knowledge from dealing with the immunization issues of the first and probably
second born. In a study on age appropriateness of Immunization, mothers with multiple births
were shown to have increased awareness and knowledge on immunization, but this unfortunately
did not translate into complete immunization coverage because of numerous confounding factors
among them lack of time because of commitment looking after the other children etc. (Eun -
Young, K.et.al, 2011). Globally, Studies in different parts of the world have demonstrated that
taking children to the hospital when they are sick and during vaccination visits is the
responsibility of mothers and not fathers, but there may be exceptions for example in cases
where the mothers are absent, ill or there are twins when the fathers can take children to the
hospital including for vaccinations. It is therefore very important for mothers and caretakers to
understand the importance of vaccinations as they are the ones who have the responsibility of
taking children for vaccinations until the process is complete (Antia, D, 2009)

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In Japan, Matsumura noted that education attainment of the mothers/caretakers was found to be
associated with immunization rates while in almost similar study conducted in Istanbul indicated
that immunization rates were higher in parents with higher education than the others with lower
educational levels. The vaccination coverage for children whose mothers had at least primary
education was about 9 times higher than those whose parents had no education. The vaccination
coverage was also affected by educational level of the fathers, where the children of fathers with
less that secondary level of education were 2-3 times more likely to be non-vaccinated
(Awodele,O.,Oreagba, et.al, 2010). Mothers and caregivers showed good knowledge of
immunization benefits and side effects. Being a developed country with good social and health
infrastructures, they either received this information from mass media or family pediatrician.
Their knowledge of side effect did not affect immunization of their children because the benefits
of vaccinations outweighed the associated risks. Mother’s decision to vaccinate their children
was not because it was a mandatory requirement by the authorities but because the mothers knew
the benefits of vaccinations to their children. Supported the results of the study in Sicily where
mothers knew most of the mandatory vaccinations, for example respondents rightly believed that
vaccinations for hepatitis B (87.5%), poliomyelitis (79.9%), tetanus (74.4%), and diphtheria
(66.3%) were required for all infants. However, there were some misconceptions about which
vaccinations were mandatory, and respondents clearly overestimated requirements for their
children. In the same study, about 53.4% of mothers knew about all four mandatory vaccinations
for infants, and the results of the multiple logistic regression analysis also showed that this
knowledge was significantly greater among those with a higher rather than lower education level.
Generally, these results indicate that lack of knowledge on vaccination prevents Italian mothers
from playing an effective role in the eradication of vaccine-preventable diseases in that country.
Unfortunately, only half of the respondents could identify all the mandatory vaccines for infants
and of even greater concern was that only approximately 20% of the mothers interviewed knew
that Pertussis, measles, mumps, and rubella were diseases that are vaccine preventable in
children. Moreover, the mothers' lack of knowledge about vaccinations was supported by the
finding that the main reason for not vaccinating or not completing the vaccination schedule was
that they had not been advised about it (Coniglio.et.al, 2011).

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In North West Bengal a rural area in India with high illiteracy level, knowledge on immunization
was directly related to immunization completion. In some areas like this, parents who are
illiterate with very poor knowledge of immunization are not expected to be serious about
immunization. It was found out that negligence was the major cause for non-immunization while
guardian engagement in other work was the major cause for partial immunization. Mothers were
also not aware of the beneficial effects of vaccinations to their children
(Manna,P.K,Catterjee,K. et.al, 2009)
In Africa, mothers’ knowledge on immunization has a significant bearing on immunization
up-take and completion. Knowledge on when specific vaccines should be administered and the
whole immunization process completed is significant in having a completely protected
population. In a cross sectional study conducted in 10 administrative wards of Nigeria about
14.1% of the mothers knew that vaccination against childhood killer diseases should be
completed at the age of 9 months and only a few mothers, some of whom were employed as
teachers knew the various time points for administering BCG (at birth) and that hepatitis B
vaccines could also be given at birth. In as much as parents and authorities may wish to have
complete immunization for the children, vaccine safety concerns may sometimes come into play.
In this area for instance, parents’ objection and mothers concern about safety of the vaccines was
found to be the major reason (38.8%) for incomplete vaccination among other host of health
system specific issues (Abdulraheem,I. S et.al, 2011).
In Burkina Faso, literacy of the mothers was found to significantly determine vaccine uptake
among children in rural areas. In urban areas, parents who attended school and mother’s
attendance in literacy classes in the rural areas were found to be related to vaccination status, this
also supports findings from other studies. Mothers’ knowledge of the reasons for childhood
immunization and completion of immunization schedule was found to be associated with
complete immunization. To this end, it can be deduced that the knowledge acquired from schools
is important in understanding disease progression, seriousness and curative and preventive
strategies (Mirkuze,W Amare,D. et.al,, 2009)
In Mali there is insufficient information to parents regarding immunization was the major reason
(63.3 % of respondents) for incomplete immunization, this finding supports the findings of a

21
study in Indian slums where mothers lack of knowledge about vaccination was found to be an
independent predictor for incomplete vaccination among children between 12-23 months of age,
(Abdelsalam,H.H.M et.al, 2009)

In Burkina Faso, respondents were asked about specific concerns that prevented them from
participating in vaccination sessions. From 476 respondents, 318 (66.8%) mentioned
communication problems (they did not understand what the health workers wanted; they thought
their child was totally immunized) and 5% (25/476) complained about the organization of
immunization. It can be deduced from this study that the majority of health system related factors
and negative perception of the health system are the major hindrances in immunization
completion in Burkina Faso (Mirkuze,W Amare,D. et.al,, 2009)
In Kenya, Education of mothers is associated with higher chances of their children having been
fully immunized. 85% of children whose mothers had at least secondary education was fully
vaccinated compared to 67% of children whose mothers had no schooling. Also all health care
givers have a responsibility to listen and try to understand patient concern, fears and beliefs
about immunization. These effort will not only help strengthen the bond between the two but will
also help the most effective in persuading the patient to accept vaccination if any argument arises
(CDC, 2012)
In Migori, there are high percentage of home deliveries due to lack of education among the
women and this leads to absences of adequate post-partum visits the missed opportunities on
health messages regarding importance of protecting childhood immnizable disease
(Mukui,S.J,,Mutua,E.M,,et.al,, 2016)

2.2 To Determine Reasons For Failure For Full Immunization.

Globally, Immunization of under –five child and infant against prevention disease is a cost
effective public health intervention to improve the child’s health. Report estimates suggest that
approximately 34 million children are not completely immunized, with almost 98% of them
residing in developed countries. The Partial / non immunized under-five child immunization
within the scheduled time significantly revolve around access to funds to facilitate the whole
process (Kumar,D,Aggarwal,A.et.al,, 2010)

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In Africa, the status of the family influences the health seeking behaviour and hence the child’s
vaccination the wealth index of family measured in terms of land size in acres directly determine
the immunization status of a child. The families with two acres and above of land complied with
immunization scheduled more than their counterparts who owned less than half an acre piece of
land. Education level of the guardian will have a direct impact on the child’s vaccination
compliance since those who attend school will attempt to vaccinate their children, While those
who had post-secondary education complied to the scheduled and within the right time
(Luke,J.S, 2014). In Kenya, there are with several socio –demographic and socio-economic
factors are associated with failure to full immunization coverage among the under –five children
e.g Religion Maternal occupation, Parents education, maternal ages and Ethnicity
(Maina,L.C,Karanja, S. et.at,, 2013). The delivery of vaccines later in the scheduled after the
infant stage of child’s life and achieving 100% complete immunization coverage of under five
children is a great challenge in rural areas of Nyanza e.g. Migori and Western provinces showed
that approximately 79.4% of children 12 to 23 months were fully vaccinated; However,
timeliness of the vaccination process was not accessed (Kawakatsu & Honda,S, 2012)

2.3 To Identify Socio Economic Factors Influencing Acquisition Of Immunization.

Countries with strong economies are bound to have strong health care systems with
economically empowered citizens, a combination that may positively influence immunization
uptake, immunization completion and other preventive modes of disease control. Most of the
countries in the developing worlds and especially in Africa south of Sahara and some parts of
Asia have poor households, weak economies and poor health infrastructures that don’t
adequately support childhood immunization. Household with low socio economic status may
have to give priorities to those requirements that guarantee immediate continued existence for
example food and May not give much attention to preventive methods of disease control like
immunizations but may be reactive to disease situations.
In India, low socioeconomic status in Indian slums was a significant predictor of
non-immunization but not partial immunization. This could be because immunization is
accessible and affordable to everyone irrespective of their socioeconomic status. In the study

23
conducted in a low socio economic region of Nigeria, family monthly income was found to be
strongly associated with immunization completion among children (Antia, D, 2009)
In Africa, families have the fathers as the heads of the households and often the fathers’ income
will dictate the socioeconomic status of the household. In the cross sectional study conducted in
Burkina Faso, demonstrated that children of non-educated fathers among the higher fourth
quartile had better immunization coverage compared to those of non-educated fathers in the
poorer lower quartile in rural setting. Better immunization coverage is not equal to immunization
completion but is a strong indication of the likelihood of complete immunization. This finding
supported the results of many other studies indicating that economic power of the family can be
an important predictor for immunization completion. Profession has sometimes been associated
with immunization completion but this was not evident in this study where there was no
significant difference noticed in immunization coverage between farmers and other professions
(Mungwira,R.G,Zuber,P.L,,et.al,, 2019)
In unmatched case control study conducted in Ethiopia to determine the predictors of defaulting
among mothers of children between 9 and 23 months, monthly family income was found to be an
outstanding and a significant predictor of defaulting immunization as elucidated in other studies,
defaulting of immunization tend to increase the risk of incomplete immunization. In Burkina
Faso, higher socio-economic condition of the parents has also been shown to be associated with
greater probability of the child being vaccinated under a routine vaccination program compared
to vaccination under the mass campaigns (Mirkuze,W Amare,D. et.al,, 2009)
In Kenya, socio – economic factors associated with partial immunization coverage e.g. Religion,
Maternal, occupation and ethnicity. Children born from Christian mothers were found to be 2.49
times to receive vaccination while children born with Muslim mothers were less likely to receive
immunization. Christian mothers tend to follow western culture that includes modern medicine
than Muslim. This is because they mainstream medicine and western culture tends to have
historical ties (Ishmael K. et.al,, 2016)
In Migori the following socio- economic factors are associated with low immunization coverage
e.g. relatively high percentage of home deliveries (45%) and absence of post-partum, poverty,
transport means to immunization facility is foot and the areas with high humidity mothers may

24
find it a challenge reaching the facility while carrying their babies
(Mukui,S.J,,Mutua,E.M,,et.al,, 2016)

Chapter Three

3.0 Research Methodology

This chapter described the research procedure and techniques that were used in the study. It
described research design, target population, sample size and sample selection. It also described
the procedure for application of research instruments, data analysis technique as well as ethical
issues in research

3.1 Research Design

The study design was across-sectional, combining both qualitative and quantitative method of
data collection which this included; listening within the survey questionnaire to find out factors
influencing low immunization coverage among women who have children under five years .

3.2 Study Area

Migori County is a county in the former Nyanza Province of southwestern Kenya. Migori
County is located in western Kenya and borders Homa Bay County (North), Kisii County (North
E) Narok (South East) Tanzania (West and South) and Lake Victoria to the West. The county also
borders Uganda via Migingo Island in Lake Victoria. The capital is Migori its own, which is also
its largest town.

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3.3 Study Population
The study population was made up of mothers/caretakers of children of ages between 1 and 4
years who have lived in Migori County in the last one year of their lives.

3.3.1 Inclusion criteria

Any female or male who had ever taken care of a child less than 5years of age regardless of
religion, social status and physical disability or challenge.

3.3.2 Exclusion criteria

Any female or male who had never taken care of a child less than 5years of age.

3.4 Variables
3.4.1 Dependent
Factors influencing low immunization coverage
3.4.2 Independent
i. Mothers’ knowledge on immunization coverage.
ii. Reasons for failure for full immunization coverage.
iii. Socio- economic factors influencing low immunization coverage.

3.5 Sampling Techniques

Simple random sampling was used to identify factors influencing low immunization coverage
among children below 5 years. The technique was chosen to avoid biasness during selection of
respondents

3.6 Sample Size Determination

It was determined by Fisher’s et al 1998 method. The population of the study is less than 10,000.
The standard formula to be used to get the sample size
n = Z2pq
d2
Where;
n = desired sample size if the target population is greater than 10,000
Z2 = the standard normal deviation normally set at 1.96

26
 P = the proportion in the target estimated to take a particular characteristic. If there is no
reasonable estimate use 0.5
q = 1-p
d =degree of accuracy desired usually set at 0.05
Therefore;
n = Z2pq
d2
n =1.962 × 0.5(1-0.5)
0.052
n = 0.9604
0.0025
=384.16
=384
The standard formula population less than 10,000 was
nf = n/1+ n/N
Where;
nf =desired sample size if the target population is less than 10,000
n = desired sample size if target population is more than 10,000
N = estimated number of healthcare providers (95)
Therefore;
nf = n/ 1+n/N
nf = 384
1+ (250)
100
384
2.50
=78.33
= 80 healthcare providers

27
3.7. Data Collection Instruments.
A structural questionnaire was used to collect data for the research purpose. The questions were
be simplified for easy understanding of the respondents and contain closed ended questions
which helped to identify factors influencing low immunization coverage among children below 5
years.

3.8 Data Collection Process

The data collection period was 4weeks of the month of September, 2020. The researcher
distributed questionnaires to the respondents and were given some time to fill but not allowed to
leave the hospital with them because finding them later on would be a big challenge. After
filling, the respondents returned them back to the researcher.

3.9 Pilot Testing

The questionnaire was pre-tested using 5 mothers from Migori County Referral Hospital who
came for MCH services a week before the beginning of data collection. By doing this the
researcher was able to determine unclear and ambiguous questions which was reworked on or be
removed for effectiveness.

3.10 Validity
Before beginning of the actual study, the research data collection tool was pre-tested in Migori
County Referral Hospital among 5 parents to ascertain its validity in presentation.

3.11 Reliability
To ensure reliability, the research data collection instruments was discussed and certified by the
internal supervisor.
3.12 Data Analysis
Data collected was analyzed manually and electronically using calculators and EXEL. Data was
presented in frequency tables, charts and graphs. Percentages were used for interpretation
purpose.

28
3.13 Ethical Consideration
The authority to conduct the research was obtained from the director of Kenya Medical Training
College(KMTC).Permission to carry out the study was obtained from National Council for
Science and Technology Information(NACOSTI) through authority letter .Consent from the
subject under the study was obtained from the respondents and was treated with confidentiality.

Chapter Four
4.0 Data Analysis, Presentation and Interpretation
4.1 Introduction
The purpose of this study is to present data in a systematic manner. Data was derived from 80
respondents who made 100% of the sample size. Data was tallied, analyzed in figures and
percentages. Calculated and presented in frequency tables, bar graphs and pie charts.

All questionnaires were well answered to satisfaction. Short statements were used to explain the
bar charts, pie charts and tables

29
4.2 Demographic Characteristic of the respondents
4.2.1. Gender of respondents

Figure 4.1: Gender of respondents

According to the figure above, out of 80 respondents who participated in the study 93.75% were
female while 6.25% were male.

4.2.2 Age of the respondents

Age Frequency Percentage
Under 20 years 15 18.75%
20-24 years 28 35%
25-29 years 25 31.25%
30+ years 12 15%
Total 80 100%
Table 4.1: Age of the respondents

With regards to the table above the majority of the respondents (35%) are aged 20-24 years
followed closely with 25-29 years with (31.25%), followed by under with (18.75%) and lastly
by 30 years and above with 15%.

30
4.2.3 Level of education of the respondents.

Figure 4.2: Level of education of the respondents

The figure above shows that majority of the respondents were primary dropouts with (52.5%)
followed by those who reached secondary with (25%), followed by level tertiary level (17.5%)
and lastly (5%) who were high school leavers.

4.2.4 Religion of the Respondents

Figure 4.3: Religion of the Respondents

In the figure above, 36 of the respondents were Protestants, making it the religion with most
respondents followed by catholic with 25 and Muslims having only 19 respondents.

31
4.2.5 Relationship with the child

Figure 4.4: Relationship with the child

With regards to the figure above, the majority of the respondents are mothers with (77.5%),
followed by a tie between caretakers with (12.5%), followed by fathers with (7.5%) and lastly
2.5 % others.

4.3 Knowledge of the respondents on the programme

4.3.1 Awareness on immunization

Figure 4.5: Awareness on immunization

According to the figure above 100 % of the respondents are aware of the immunization services.

32
4.3.2 Source of information on immunization
Source Frequency Percentage
Media 25 31.25%
Hospital 50 62.5%
Community gathering 5 6.25%
Nearby schools 0 0%
Others 0 0%
Total 80 100%

Table 4.2: Source of information on immunization

With regards to the table, majority of the respondents (62.5%) knew had heard the information
from the hospital, followed by media with (31.25%) and community gathering around the
villages with 6.25%.

4.3.3 Formal education about childhood immunization.

Figure 4.6:
Formal
education
about
childhood
immunization
s.
The figure above shows that 70% of the respondents had no formal about childhood
immunization, while 30% of the respondents had formal education about childhood
immunization.

33
4.3.4 Availability of clinic immunization card.
Frequency Percentage
Yes 80 100%
No 0 0%
Total 80 100%

Table 4.3: Availability of clinic immunization card

Figure above shows that 100% of the respondents had the clinic immunization card.

4.3.5 Importance of childhood immunization.

Figure 4.7: Importance of childhood immunization.

With regards to the figure above, majority of the respondents 40% said importance of childhood
immunization is to protect them from fatal disease, 30% mentioned it was a routine, 17.5%
mentioned it introduced diseases to children and 12.5% did not know the importance of
childhood immunization.

34
4.4 Reasons for failure for immunization coverage.
4.4.1 Time taken to reach the nearest facility

Figure 4.8: Time taken to reach the nearest facility

The figure above shows that majority of the respondents 75% took proximity of 30 minutes- 1
hour from home to hospital and the remaining 25% took less than 30 minutes.

4.4.2 Size of the land of the respondents.

Figure 4.9 Size of the land of the respondents.

With regards to the figure above, most of the respondents 65% had more than 2 acres of land
followed by 17.5% had an acre, then 12.5% had a quarter acre and least 5% had two acres.

35
4.4.3 Period of time spent on farm and household chores.

Figure 4.10 Period of time spent on farm and household chores.

Majority of the respondents 81.25% took 4-6 hours on the farm and household chores and
18.75% spent 1-3 hours.

4.4.4 Number of children of the respondents

Figure 4.11 Number of children of the respondents

According to the figure above, shows that most of the respondents 91.25% fell in the range of
1-4 children and the remaining 8.75% fell in 5-9 children.

36
4.4.5 When is child taken for immunization

Figure 4.12 When is child taken for immunization

Majority of the respondents 52.5% took their children for immunization on the indicated TCA
date, followed by 35% during outreaches and finally 12.5% during outbreaks.

4.5 Socio-economic factors affecting acquisition of immunization services.

4.5.1 Marital status of the respondent

Figure 4.13 Marital status of the respondent

The figure above, majority of the respondents 40% were married followed with a tie of 23.75%
between single and Divorced and lastly 12.5%.

37
4.5.2 Types of employment of the respondents

Figure 4.14 Types of employment of the respondents

According to the figure above, 43.75% were subsistence farmers followed by 31.25% others then
18.75% were self-employed and lastly 6.25% had formal employment.

4.5.3 Paid for immunization services

Figure 4.15 paid for immunization services

The study revealed that most of the respondents 90% knew that immunization services were
offered free hence no payment while 10% paid for the services.

38
4.5.4 Amount of money paid for immunization services
Amount Frequency Percentage
50/= 80 100%
100/= 0 0%
200/= 0 0%
500/= 0 0%
Total 80 100%

Table 4.4: Amount of money paid for immunization services

Among the respondents who mentioned that they paid for the immunization coverage, all of
them paid Sh.50/= comfortably from their own income.

4.5.5 Mode of transport

Figure 4.16 Mode of transport

According to the figure above, majority 81.25% were using public vehicle, followed by 12.5%
walked to the facility while 6.25% used public transport in order to access the immunization
services.

39
 Chapter Five
5.0 Discussion, Conclusion and Recommendations
5.1 Discussion of the findings
Out of all the respondents, more than half of the respondents were female while the rest were
male.

Similarly, the majorities of the respondents fell in the age bracket 20-24 years while 30 years and
above had the least respondents.

The respondent’s year of study was found with differences. Primary dropouts were the majority
followed by secondary, followed by tertiary and lastly high school.

The research also discovered that majority of the respondents were followers from protestant
denomination and the least were the Muslims.

In addition to that majority of the respondents were mothers, followed by caretakers, then fathers
and lastly from other people who had relations with the child.

5.1.1 Knowledge of the respondents on the Programme.

The research discovered that almost all of the respondents had heard about the immunization
services that were offered. While most of them received the information from the hospital staff.
This concurs with (Abdulraheem,I. S et.al, 2011)as they stated the main source of information
were the hospital staff.

However, majority of the respondents had no formal information about childhood immunization.
This disagrees with (Awodele,O.,Oreagba, et.al, 2010)) as he started that majority of the
respondents had formal information about childhood immunization.

Majority of the respondents said that they had clinic immunization card. While most of them said
that importance of childhood immunization was that it protected the children from fatal diseases.
This agrees with (BN Tagbo,ND Uleanya,et.al, 2012) who reported that the importance of
childhood immunization was to protect them from fatal diseases.

40
5.1.2 Reasons for failure for immunization coverage.
The research also found out that majority of the respondents took 30 minutes- 1hr from home to
reach the hospital while the rest took less than 30 minutes .This dissents with (Abdulraheem,I. S
et.al, 2011) as they reported that distant trekking involved approximately one and a hour to reach
the nearest hospital.

Findings also found out that more than half of the respondents had more than two acres of land.
While most of the respondents spent more than four hours on farm and household chores. This
corresponds with (Abdulraheem,I. S et.al, 2011). This stated that they had to spend more than
two hours in the farm and household chores.

Consequently, majority of the respondents had four children and below while the rest had more
than five children (KNBS, 2009) started that the average number of children per household in
Kenya was 4.8.

5.1.3. Socio-economic factors affecting acquisition of bursary funds.

Majority of the respondents were single followed by a tie between married and divorced and the
least were widowed. This finding contradicts with (Ngake et al, 2014) as they started that most
of the respondents were married.

Furthermore, most of the respondents were subsistence farmers and least was formally
employed. This disagrees with (BN Tagbo,ND Uleanya,et.al, 2012)) as he started that most of
them were traders.

The research also discovered that most of the respondents did not pay for the immunization
services. While those who paid Ksh.50 comfortably from their income.

Nevertheless, most of the respondents used public transport as mode of transport. This disagrees
with (Abdulraheem,I. S et.al, 2011) which stated that the parents used footing as a mode of
transport due to high cost of transportation.

5.2 Conclusions
This study was carried out to determine factors influencing low immunization coverage among
children below 59 months at Migori County Referral Hospital

41
The findings have revealed that parents had poor knowledge on formal education about
childhood immunization.

The study also established that negligence and guardian engagement in work were major causes
of partial immunization.

5.3 Recommendation
It is recommended that local and national governments should offer formal maternal knowledge
on routine immunization services offered in the facilities.

It was recommended that functional health facilities should be available in every political ward
for easy accessibility to parents and caretakers.

I would recommend that the county governments should create more awareness on the essence of
both young and old mothers who have children who have not been immunized to go for
immunization.

5.4 Further Research

Further research can be done on the effectiveness of formal maternal knowledge on routine
immunization services offered in the facilities.

A study should be carried out on investigating the awareness of immunization services on

parents who have children who are under five years.

42
References

Abdelsalam,H.H.M et.al. (2009). Accurancy of parental reporting of immunization. Clin. Pediatr..,, 43, 83.

Abdulraheem,I. S et.al. (2011). Reasons for incomplete vaccination and factors for missed opportunities
among rural Nigerian children. Public health epidemiol , 3(4), 195-203.

Antia, D. (2009). Inequitable childhood immunization uptake in Nigeria. BMC infectious diseases, 9(1),
181.

Awodele,O.,Oreagba, et.al. (2010). The knowledge and attitude towards childhood immunization
amongst mothers attending in Lagos University Teaching Hospital. Tanzania journal of Health
research, 12(3), 172-177.

BN Tagbo,ND Uleanya,et.al. (2012). Mothers' knowledge,perception and practice of childhood

immunization in Enugu. Nigerian Journal of Paediatrics, 39(3), 90-96.

CDC. (2011). Global immunization strategic framework. 888(232), 6348.

CDC. (2012). Vaccination coverage among children MMWR. 61(33), 647.

Eun - Young, K.et.al. (2011). Related factors of age-appropriate immunizationa among Urban-Rural
children 23-35 months. Yonsei Med. J, 52(1), 104-112.

Hiskenya. (2012). kenya health information system.

Ishmael K. et.al,. (2016). The effect of socio-demographic factors on the utilization of maternal health
care services in Uganda . Union African population studies .

Kawakatsu & Honda,S. (2012). Individual - family & community - level determinats of full vaccination
coverage amongst children aged 12- 23 minths in Western Kenya,Vaccine. 30(52), 7588 - 7593.

Kenya WHO,UNICEF. (2015). Estiamates of immunization coverage.

KNBS. (2015). Kenya demographic and health survey 2014. kenya national bureau of statistics (KNBS).

Kumar,D,Aggarwal,A.et.al,. (2010). Immunization status of children-admitted tp tertiary-care hospital

North India. Journal of health ,population & nutrition, 28(3), 300.

Luke,J.S. (2014). Family factors associated with immunization up-take in children aged between 12-59
months.

Maina,L.C,Karanja, S. et.at,. (2013). Immunization coverage and its determinants amongst chilfren age
12-23 months in a peri - urban area of Kenya. Pan African Medical Journal, 14(1).

Manna,P.K,Catterjee,K. et.al. (2009). Child Immunization coverage of some rural belt in relation to
socio-economic Factors of Jalpaiguri & Darjeeling district of West Benga. Journal of life science,
1(2), 91-95.

Mirkuze,W Amare,D. et.al,. (2009). Predictors of defaulting from completion of childhood immunization
in south ethopia- Acase contro studyl. BMC Public Health, 9, 150.

43
Mukui,S.J,,Mutua,E.M,,et.al,. (2016). Determinants of infants immunization coverage in Migori
County,Nyanza Region,Kenya. Ethopian journal of environmental studies of management., 9(5),
604-612.

Mungwira,R.G,Zuber,P.L,,et.al,. (2019). Economic & Immunization safety surveillance characteristics of

countries implementing no - fault compensention programmes for vaccines injuries. 37(31),
4370 - 4375.

UNICEF. (2010). Expanding immunization coverage.

UNICEF/NOORANI. (2016). Immunization coverage.

WHO & UNICEF. (2015). Estimates of immunization coverage.

WHO. (2014). Immunization supply chain and logistics but essential system for national immunization
programmes.

WHO. (2014). Infant mortality rate ,under - five mortality rate.

WHO and UNICEF. (2013). Estimates of National immunization coverage. Retrieved from United Nations
website: www.un,org/..//pdf/...mdg report 2013

WHO, UNICEF,World Bank. (2009). State of the world's vaccine and immunization. 3rd World health
organization, Gevena .

WHO,UNICEF. (2012). Global immunization coverage data.

WHO,UNICEF,World Bank. (2009). State of the world's vaccine and immunization . 3rd World Health
Organization, Geneva.

44
 Appendices

Appendix I: Work Plan

YEAR 2019 2020

MONTH AND JULY AUG SEP OCT JAN FEB MAR APR MAY
ACTIVITY
Topic Selection

Literature Review

Proposal
Development

Proposal
Submission
Data Collection

Data Analysis
And Dissertation
Writing
Dissertation
Submission

45
Appendix II: The Budget
ITEMS UNIT COST QUANTITY TOTAL COST(Kshs.)

Laptop @35,000 1 Piece 35,000

Pencil @20 5 Pieces 100

Biro Pens @20 5 Pieces 100

Rubber @20 2 pieces 40

Stapling Pins @100 2 pckts 200

Flash @1,500 1 1,500

Modem @1,500 1 1,500

Internet Service 2,500

Typing And 1,000

Photocopy

Questionnaires @100 80 Copies 800

Miscellaneous 5,000

Total 47,470

46
Appendix III: Map of Migori County

47
Appendix IV: Consent Form
My name is Seda Karoli Atinga a student at Kenya Medical Training College Rera Campus. I am
carrying out research on factors influencing low immunization coverage among children below
59 months at Migori County Referral Hospital. Your participation in this study will be highly
appreciated since you are among the sampled respondents believed to have the required
information on this subject. There is no risk associated with the research. You are therefore
requested to respond appropriately to the best of your knowledge and understanding.
Confidentiality will be highly considered and participation is voluntary. You are free to leave
participating anytime you feel you are uncomfortable with the study. Do not write your name nor
sign on the questionnaire. If you have any concern or question about the study as well as any
concern about your rights as a research participant, please contact me on 0719500391 Seda
Karoli or the Research Supervisor Mr. Victor Otwori - 0721424203.

RESEARCH PARTICIPANTS STATEMENT

I have read this consent form and have been given the opportunity to ask any question, I am
satisfied with the answers provided.

A. I accept to participate in the study [ ]

B. I don’t want to participate in the study [ ]

RESEARCHER’S STATEMENT

The participant has read the terms of the study and wishes to be/not to be part of the study.

48
Name: Seda Karoli

Email; seda.atinga16@gmail.com

Signature………………………………….

Date………………………………………….

Appendix V: Questionnaire
Date of Issue…………………………………………
Assurance Statement to the Respondents
I’m A Health Record and Information Student from K.M.T.C Rera Campus Undertaking a Study
on factors influencing low immunization coverage among children below 59 months at Migori
County Referral Hospital. You have been identifying to be one of my respondents, please note
that confidentiality will be highly maintained for any information you will give out. The study
will assist the researcher to fulfill one of the requirements for the Award of Diploma in Health
Records and Information.
Instructions
i. Please note that this study is specifically for learning purpose. Your identity is not
required.
ii. Please Tick [ ] The appropriate answer in the spaces provided
PART A: SOCIO-DEMOGRAPHIC CHARACTERISTICS
1. Gender

Male [ ]

Female [ ]
2. What is your age?
Under 20 years [ ]

49
 20-24 years [ ]
25-29 years [ ]
30years and above [ ]
3. Which is the highest educational level you have attained?
Primary School [ ]
Secondary School [ ]
High School [ ]
College or University [ ]

4. Which is your Religious?

Protestant [ ]

Catholic [ ]

Muslim [ ]

5. What is your relationship with the child?

Mother [ ]

Father [ ]

Caretaker [ ]

Others, Specify -----------------------------------------------------------

PART B: KNOWLEDGE OF RESPONDENT ON THE PROGRAMME.

6. Have you ever heard about immunization?
Yes [ ]
No [ ]
7. If yes, how did you get to know about the immunization coverage?

50
 From Media [ ]

From the Hospital [ ]

From the Community Gathering [ ]

From Nearby School [ ]

Others [ ]

8. Do you have a clinical immunization Card?

Yes [ ]

No [ ]

9. Do you understand the formal education written on the immunization card?

Yes [ ]

No [ ]

10. Do you know any importance of childhood immunization card?

Protection of Fatal diseases [ ]

Introduce disease to children [ ]

It’s a routine [ ]

Don’t know [ ]

PART C: REASONS FOR FAULIRE FOR IMMUNIZATION COVERAGE.

11 How much time do you take to walk to the nearest health facility for vaccination?

Less than 30 minutes [ ]

30minutes – 1 Hour [ ]

51
 More than one hour [ ]

12. What size of land do you own?

Less than a quarter acre [ ]

Quarter Acre [ ]

An Acre [ ]

Two Acres [ ]

Others, specify --------------------------------------------------------------------------------

13. What amount of time do you spend on farm and household chores in a day?

1-3 Hours [ ]

4-6 Hours [ ]

7-9 Hours [ ]

> 10 Hours [ ]

14. How many children do you have in the family?

1-4 Children [ ]

5-9 Children [ ]

10 and Above [ ]

15. When do you take your children for immunization?

On the indicated TCA date [ ]

During outbreaks [ ]

During Outreaches [ ]

Others, Specify ……………………………………………………………

52
SECTION D: SOCIO- ECONOMIC FACTORS INFLUENCING ACQUISITION OF
LOW IMMUNIZATION COVERAGE.
16. What is your marital status?

Single [ ]

Married [ ]

Divorced [ ]

Widowed [ ]

17. What do your parents do for living?

Subsistence Farming (crops and animals) [ ]

Self-Employment [ ]

Formal Employment [ ]

Others specify ……………………………………………..

18.Have you ever paid any amount of money to receive any immunization service?
Yes [ ]

No [ ]

19.If yes, how much did you pay?

50 Shillings [ ]

100 Shillings [ ]

200 Shillings [ ]

500 Shillings [ ]

1000 Shillings [ ]

Others, specify --------------------------------------------------------------------

20. What is the mode of transport used when taking the child for immunization?

53
Footing [ ]

Public Transport [ ]

Private Transport [ ]

THANK YOU FOR PARTICIPATION.

54
Appendix VI: Research Permit

55
56
57