KNOWLEDGE AND PRACTICE OF IMMUNIZATION CHILDREN UNDER FIVE

YEARS AMONG WOMEN ATTENDING HEALTH CENTRES IN UMUAHIA SOUTH

L.G.A

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 ABSTRACT

Knowledge and practice of nursing mother's towards immunization of children under five years
among women attending health centres in Umuahia South L.G.A of Abia State. The design uesd
was descriptive survey. A population of 355 women were used and sample size of 188 respondents
were selected using Taro Yamani formula. Questionnaires were used as instrument for data
collection. Convenience sampling techniques was also used in the selection of respondents. Data
collected were analyzed using statistical package for social science and frequency tables and
percentages. Findings showed that mother's are knowledgeable about childhood immunization with
130(69.5%) while the remaining 58(30.9%) had little knowledge about immunization. Parents who
accepted to have fully immunized their children were 92(50.5%) while 93(49.5%) partly or neither
immunized their children. Based on the findings, the researcher made recommendations thus: there
should be comparative teaching of parents about immunization using media mobilization, laws that
compel parents to immunize their children should be put in made among others.
Key Words: Knowledge, Practice, Immunization.

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 TABLE OF CONTENTS
Title Page i
Declaration Page ii
Certification Page iii
Dedication iv
Acknowledgement v
Abstract vi
Table of Contents vii
CHAPTER ONE: INTRODUCTION
Background to the Study 1
Statement of the Problem 4
General Objectives 4
Research Questions 4
Significance of the Study 5
Scope of Study 5
Operational Definition of Terms 6
CHAPTER TWO: LITERATURE REVIEW
Conceptual Review 7
Theoretical Review 12
Empirical Review 16
Summary of Literature Review 20
CHAPTER THREE: RESEARCH METHODOLOGY
Research Design 21
Area of study 21
Target Population 22
Sampling and Sampling Techniques 23
Instrument of Data Collection 23
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Validity of Instrument 24
Reliability of the Instrument 24
Ethical Consideration 24
Method of Data Collection 24
Method of Data Analysis 25
CHAPTER FOUR: DATA ANALYSIS
Socio-demographic Data 26
CHAPTER FIVE: DISCUSSION OF FINDINGS
Highlight of Findings 30

Conclusion 31

Nursing Implications 31

Recommendation 32

Limitations of the Study 32

Suggestions for Further Studies 33

References 34

Appendix I 36
Appendix II 37
Appendix III 38

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 CHAPTER ONE

INTRODUCTION

Background of the Study

The World Health Organization (WHO, 2013) defined immunization as the process whereby a

person is made resistant to an infectious disease, typically by administration of a vaccine.

Vaccination is a means of producing immunity against pathogens, such as viruses and bacteria, by

the administration of live, killed, or attenuated antigens (the vaccine) that stimulate the body to

produce antibodies against the more dangerous forms. (Sarfaraz et al, 2017) Vaccination has

eradicated diseases such as smallpox worldwide and also prevents other diseases such as cholera,

polio, diphtheria, tetanus, and typhoid fever. Vaccines work by stimulating the body ’s own

immune system to protect the person against subsequent infection or disease. It is one of the most

cost-effective health interventions; with proven strategies that make it accessible to even the most

hard-to-reach and vulnerable populations (WHO, 2013)

Gains (2017) described immunization as the most successful and cost-effective public health

intervention of the 20th century in terms of number of deaths averted per year. In the developing

world, it does not only prevent about 3 million child deaths per year but also has the potential to

avert additional 2 million deaths if immunization programs are expanded and fully implemented

(USAID, 2011) Childhood immunization has been reported by Zangene, et al (2011) to indirectly

prevent infectious diseases in adults through herd immunity.

They noted that the use of the pneumococcal protein conjugate vaccine among children reduced

the total number of invasive pneumococcal disease (IPD) cases and resulted in a 38% decrease

in the rate of IPD among non-vaccinated elderly adults through herd immunity.

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According to Tagbo, et al (2012), there are two types of immunization, namely:

1. Routine immunization and

2. Supplemental (immunization campaign).

Routine immunization refers to the nationally scheduled and regular administration of vaccine

dosages to infants at specified ages. The main aim of routine immunization is to deliver a

complete number of doses of potent vaccines in a timely, safe and effective way to all children

and women (USAID, 2011), ultimately producing immunity against said ailments (Manjunath

and Pareeth, 2013). If properly implemented, the result of routine immunization will be a drastic

reduction in the burden of childhood vaccine preventable diseases (Sanford, 2012).

Supplemental immunization - also known as immunization campaign - is organized

occasionally by governments for the purposes of catch-up immunization, disease

eradication/elimination and to avert epidemics (Tagbo et al, 2012).

For example, immunization campaigns against polio have yielded positive results worldwide.

According to Obregon et al (2009) immunization campaigns have reduced global polio cases

from 350,000 in 1988 to 1643 in 2009 (>99% reduction), and measles cases from 871,000 in

1999 to 454,000 in 2004 (48% reduction). According to a 2012 Trans Aid report, some parents

accept routine immunization but reject immunization campaigns while others reject both due to

ignorance. Despite the success of expanded program on immunization (EPI), such as

eradication of small pox, and global lowering of incidence of polio by 99%, Zangene et al

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 (2011) report that many vaccine-preventable diseases remain prevalent, especially in

developing countries such as Nigeria.

Vaccine preventable diseases are known to account for approximately 22% of child deaths in

Nigeria, amounting to over 200,000 deaths per year (USAID). However, according to Tagbo et al

(2012), in Nigeria, as in some other third world countries, immunization coverage is low. Nigeria

recorded an abysmal national routine immunization coverage of 12% in 2003, and 36% in 2006

(Tagbo et al, 2012). In

2009, Nigeria accounted for about 3.5 million (14%) of the 23.2 million children worldwide who

did not receive 3 doses of DPT vaccine during the first year of life (WHO, 2013) This not only

impedes disease control, but may consequently diminish public support for vaccination, which

may lead to a resurgence of vaccine preventable diseases.

In Nigeria, universal childhood routine immunization is provided free of charge as in some

countries of the world. Routine immunization is a key strategy in the polio eradication program,

both in Nigeria and globally (WHO, 2017) A study reported by Tagbo et al (2012) in Colorado

demonstrated that children exempted from routine immunization were twenty-two times more

likely to acquire measles and almost six times more likely to acquire pertussis than vaccinated

children. The primary site for acquiring infection usually, being their schools. The fact that

immunization is not 100% effective, implies that the choice of some parents not to immunize

their children significantly increases the risk of infection for other children who are immunized

(Sanford, 2012). This is because a small proportion of vaccinated children would not be

protected since sub-optimal immunization coverage reduces herd immunity.

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There have been signs of improvements in in child immunization. The Government has taken

many measures to improve immunization and to eradicate vaccine preventable diseases such as

polio. In the case of polio, 2007 was the year with the lowest polio incidence since 2002 and the

lowest incidence ever of type 1polio, the most virulent of all polio viruses. Yet Njidda et al have

opined that Nigeria is not likely to achieve the health related Millennium Development Goals.

(Njidda et al 2017)

Statement of Problem

In the last decade, child immunization activities, oral polio immunization in particular has been

shrouded in controversies (Njida et al, 2017). This has resulted in cases of resistance, rejection

and outright or active opposition of supplemental immunization activities. Parents are critical

and major players in deciding for or against health activities that target children. Therefore, the

attitudes of parents are an important factor behind the acceptance or rejection of immunization.

The aim of the current study is therefore to assess the knowledge and practice of nursing

mothers towards immunization of children under 5 years among women attending health

centers in Umuahia South LGA, Abia state.

General Objectives

The general objective of study is to: assess the knowledge and practice of nursing mothers

towards immunization of children under five years among women attending health centers in

Umuahia South LGA of Abia State

Specific objectives are to:

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 1. Assess the level of knowledge of childhood immunization among mothers with

children under the age of five years in Umuahia South LGA.

2. Assess utilization of childhood immunization by mothers of children under the age of 5

in Umuahia South LGA.

Research questions

1. What do mothers of children under the age of 5 years in Umuahia South LGA

know about immunization

2. What are their practice towards the Immunization of their children aged 0-5 years?

Significance of the Study

Findings of this study will reveal factors associated with the attitude of nursing mothers towards

immunization of children under five years among women attending health centers in Umuahia

South LGA of Abia State. It will also help to increase immunization uptake through creation of

awareness.

Other benefits of the study include:

To the Health Sector: The knowledge gained from this research can be used in improving

health education towards immunization in the country.

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It can also help to identify appropriate strategies to reach mothers who are resistant to

immunization

It may provide input to healthcare planners to address other factors including the role of fathers and

religious beliefs.

To the Community: by improving the rate of immunization, we can also improve the defenses of

our society at large against such killer diseases such as polio, measles, and yellow fever.

To the Nation: It will also play a small but significant role in helping to achieve the nation’s

millennial development goal by increasing herd immunity against illnesses.

Scope of the study

This study is delimited to the knowledge and practice of nursing mothers towards immunization

of children under five years among women attending health centers in Umuahia South LGA of

Abia State. The researcher will investigate the factors behind their compliance and the

demographic characteristics of women who need help in accepting childhood immunization

services.

Information for this study was obtained from mothers of children under five years attending

health centers in Umuahia South LGA of Abia State. The findings of the study may not be

generalizable regarding the knowledge and practice of mothers in Nigeria towards

immunization of children under the age of two due to the limited geographical area of the

sample population. However, the information gathered from the study is useful to understand

the knowledge and practice of nursing mothers toward immunization of their infants.

Operational Definition
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 Immunity: is the state of having sufficient biological defense to avoid infection, disease, or other

unwanted biological invasion.

Knowledge: awareness of a particular fact or situation

Practice: the actual application of an idea, belief or method

Immunization: a process whereby a person is made resistant to a disease

Herd Immunity: resistance to the spread of disease within a population as a result of a

sufficiently high proportion of the population being immune to the disease

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 CHAPTER TWO

LITERATURE REVIEW

This chapter deals with the review of relevant literature as it relates to childhood

immunization. It is presented and discussed under the following headings:

 Conceptual review

 Theoretical review

 Empirical review

 Summary of reviewed literature

CONCEPTUAL REVIEW

Immunization is defined by American Academy of Pediatricians as the process whereby a person

is made immune or resistant to an infectious disease, typically by the administration of a vaccine.

Vaccines stimulate the body’s own immune system to protect the person against subsequent

infection or disease. The World Bank (2018) asserted that when viewed globally, vaccines are the
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most cost-effective medical intervention for controlling and eliminating life threatening infectious

disease and is estimated to avert over 2 million deaths each year. It is one of the most cost-

effective health investments, with proven strategies that make it accessible to even the most hard-

to-reach and vulnerable populations. Immunizations have reduced childhood vaccine preventable

disease incidence by 98-100%. Continued vaccine preventable disease control depends on high

immunization coverage.

Before the introduction of vaccines, reports Silverstein M. (2009) people could only become

immune to an infectious disease by contracting the disease and surviving it. Smallpox (variola)

was prevented in this way by inoculation, which produced a milder effect than the natural

disease. The first clear reference to smallpox inoculation was made by the Chinese author Wan

Quan (1499, 1582) in his Douzhen xinfa published in (1549). In China, powdered smallpox

scabs were blown up the noses of the healthy. The patients would then develop a mild case of

the disease and from then on were immune to it. The technique did have a 0.5, 2.0% mortality

rate, but that was considerably less than the 20, 30% mortality rate of the disease itself. Two

reports on the Chinese practice of inoculation were received by the Royal Society in London in

1700; one by Dr. Martin Lister who received a report by an employee of the East India

Company stationed in China and another by Clopton Havers. In 1798 Edward Jenner introduced

inoculation with cowpox (smallpox vaccine), a much safer procedure. This procedure, referred

to as vaccination, gradually replaced smallpox inoculation, now called variolation to distinguish

it from vaccination. Until the 1880s vaccine/vaccination referred only to smallpox, but Louis

Pasteur develop immunization methods for chicken cholera and anthrax in animals and for

human rabies, and suggested that the terms vaccine/vaccination should be extended to cover the

new procedures. This can cause confusion if care is not taken to specify which vaccine is used
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e.g. measles vaccine or influenza vaccine. Toxoids against diphtheria and tetanus were

introduced in the early 1890s; the Bacillus Camette- Guérin (BCG) (against tuberculosis) in

1927; the Salk polio vaccine in 1955; and vaccines against measles and mumps in the 1960s.

(Njidda et al, 2017)

Commonly used vaccines

Routine vaccination is now provided in all developing countries against measles, polio,

diphtheria, tetanus, pertussis and tuberculosis (Linkins, 2016). Immunization against hepatitis B

is now recommended by WHO for all nations, and currently is offered to infants in 147 of 192

WHO Members States. Immunization against Haemophilus influenza type b (Hib) is

recommended where resources permit its use and the burden of disease is established; it is

provided in 89 countries (only in selected parts of two of those countries). Yellow fever vaccine

is offered is about two-thirds of the nations at risk for yellow fever outbreaks. Routine

immunization against rubella is provided in 111 countries. (Njidda et al, 2017)

In most countries; Nigeria, Canada and the USA inclusive, vaccines against the following diseases

are considered routine; diphtheria, tetanus (lockjaw), pertussis (whooping cough), poliomyelitis,

rubella (German measles), measles (red measles), mumps, hepatitis B and Haemophilus influenza

type b disease. These vaccines except oral polio are given by needle injections, in common

practice; hepatitis B vaccine is given alone.

Six vaccines are recommended for children between birth and 6 months of age. They can

prevent the 8 common childhood infectious diseases. Children will also get at least one booster

dose of most of these vaccines when they are older.

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Table 1 National routine immunization schedule

Age Vaccine Organism

At birth BCG, OPV0, HEP B0 -

6 Weeks OPV1, Penta1, PCV1 -

10 Weeks OPV2, Penta2, PCV2 -

14 Weeks OPV3, Penta3, PCV3 -

9 Months Measles, Yellow Fever -

Adapted from National Primary Healthcare Development Agency.

Legend:

• BCG: Bacillus Calmette-Guerin.

• OPV: Oral Polio Vaccine

• PCV: Pneumococcal Vaccine

• Penta (Pentavalent): Diphtheria, Tetanus & Pertussis (DPT); Hepatitis B (HepBV);

and Haemophilus influenza type B(Hib)

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Routine immunization schedule in Nigeria stipulates that infants should be vaccinated with the

following vaccines: a dose of Bacillus Calmette-Guerin (BCG) vaccine at birth (or as soon as

possible); three doses of Pentavalent vaccine at 6, 10 and 14 weeks of age; at least three doses of

oral polio vaccine (OPV) - at birth, and at 6, 10 and 14 weeks of age; and one dose of measles

vaccine at 9 months of age. (Njidda et al, 2017)

The benefits and risks of childhood immunization

Babies are born with a certain amount of natural protection against disease, which comes in the

form of antibodies they get from their mothers. However, the natural protection does not last past

the first year of life and young children are at risk for diseases that can be serious, and even fatal.

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(Center for Disease Control, 2010) Vaccines are safe, and the benefits of immunization far

outweigh the risks.

Many youngsters or children do sometimes have some swelling or tenderness at the spot where

the vaccine is injected, and some may also develop a mild fever, but these reactions are minor and

temporary (Njidda et al, 2017) Serious side effects such as severe allergic reactions can occur, but

are extremely rare, and occurs in less than once per million doses of vaccines. On the other hand,

the diseases that vaccines fight pose serious threats. Diseases such as polio, diphtheria, measles,

and whooping cough can lead to paralysis, pneumonia, choking, brain damage, heart problems,

and even death in children who are not protected by immunization (AAP, 2015)

Adverse events following immunization (AEFI) are surrounded by a variety of myths.

Unfoundedly, reports Lieberman (2013) vaccines have been blamed for supposed relationships

with a number of chronic conditions for which etiologies remain unknown. Hornig, Biese, and

Bauman (2012) report allegations that occurrences as neurologic disorders diabetes mellitus and

mental illness are associated with hepatitis B. Vaccine Autism is also linked to mumps, measles

and rubella (MMR) vaccines and convulsions or seizures with measles vaccine.

Hornig et al (2013) looked for measles virus in the guts of 25 children with both autism and

gastrointestinal disorders, and another 13 children with the same gastrointestinal disorders but no

autism. The virus was detected in one child from each group. This study provides strong evidence

against association of autism with persistent measles virus RNA in the gastrointestinal tract or with

measles, mumps and rubella (MMR) vaccine exposure.

Njidda et al reveal that the underpinning factor behind the polio controversy in Nigeria are

conspiracy theories speculating that polio vaccine is a western (American) strategy to introduce
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residual contraception in children to reduce Nigerian population or induce future sterility or

infertility. Ironically, Njidda et al relate, virtually all medicines, nutritional supplements and

health products are directly or indirectly discovered, manufactured and marketed by the same

western world and are consumed by Nigerians without inducing infertility. Obviously then, they

concluded, vaccines which are expensive to manufacture and deliver would not be used to

achieve such purported mischief against Nigerians.

Theoretical Review

The Health Belief Model

The health belief model (HBM) is a social psychological health behavior change model

developed to explain and predict health-related behaviors, particularly in regard to the uptake of

health services (Siddique et al, 2016) The HBM theoretical constructs originate from theories in

Cognitive Psychology (Glanz K, 2016) In early twentieth century, cognitive theorists believed

that reinforcements operated by affecting expectations rather than by affecting behavior

straightly. Glanz proposed that behavior is a function of the degree to which people value a

result, and their evaluation of the expectation that a certain action will lead to that result. In

terms of the health-related behaviors, the value is avoiding sickness. The expectation is that a

certain health action could prevent the condition for which people consider they might be at risk.

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Perceived susceptibility

Perceived susceptibility refers to subjective assessment of risk of developing a health problem

(Glanz, Barbara, and Rimmer, 2018) The HBM predicts that individuals who perceive that

they are susceptible to a particular health problem will engage in behaviors to reduce their risk

of developing the health problem.[3] Individuals with low perceived susceptibility may deny

that they are at risk for contracting a particular illness. Others may acknowledge the

possibility that they could develop the illness, but believe it is unlikely. Individuals who

believe they are at low risk of developing an illness are more likely to engage in unhealthy, or

risky, behaviors. Individuals who perceive a high risk that they will be personally affected by

a particular health problem are more likely to engage in behaviors to decrease their risk of

developing the condition.

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The combination of perceived severity and perceived susceptibility is referred to as perceived

threat. Perceived severity and perceived susceptibility to a given health condition depend on

knowledge about the condition. The HBM predicts that higher perceived threat leads to a higher

likelihood of engagement in health-promoting behaviors.

Perceived severity

Perceived severity refers to the subjective assessment of the severity of a health problem and its

potential consequences. The HBM proposes that individuals who perceive a given health problem

as serious are more likely to engage in behaviors to prevent the health problem from occurring (or

reduce its severity). Perceived seriousness encompasses beliefs about the disease itself (e.g.,

whether it is life- threatening or may cause disability or pain) as well as broader impacts of the

disease on functioning in work and social roles. For instance, an individual may perceive that

influenza is not medically serious, but if he or she perceives that there would be serious financial

consequences as a result of being absent from work for several days, then he or she may perceive

influenza to be a particularly serious condition.

Perceived benefits

Health-related behaviors are also influenced by the perceived benefits of taking action. Perceived

benefits refer to an individual's assessment of the value or efficacy of engaging in a health-

promoting behavior to decrease risk of disease. If an individual believes that a particular action

will reduce susceptibility to a health problem or decrease its seriousness, then he or she is likely to

engage in that behavior regardless of objective facts regarding the effectiveness of the action. For

example, individuals who believe that wearing sunscreen prevents skin cancer are more likely to
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wear sunscreen than individuals who believe that wearing sunscreen will not prevent the

occurrence of skin cancer.

Perceived barriers

Health-related behaviors are also a function of perceived barriers to taking action. Perceived

barriers refer to an individual's assessment of the obstacles to behavior change. Even if an

individual perceives a health condition as threatening and believes that a particular action will

effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior.

In other words, the perceived benefits must outweigh the perceived barriers in order for behavior

change to occur. Perceived barriers to taking action include the perceived inconvenience, expense,

danger (e.g., side effects of a medical procedure) and discomfort (e.g., pain, emotional upset)

involved in engaging in the behavior. For instance, lack of access to affordable health care and the

perception that a flu vaccine shot will cause significant pain may act as barriers to receiving the

flu vaccine. In a study conducted by Latoya (2012) about the breast and cervical cancer screening

among Hispanic women, perceived barriers, like fear of cancer, embarrassment, fatalistic views of

cancer and language, was proved to impede screening.

Cues to action

The HBM posits that a cue, or trigger, is necessary for prompting engagement in health-

promoting behaviors (Carpenter, 2014) Cues to action can be internal or external. Physiological

cues (e.g., pain, symptoms) are an example of internal cues to action. External cues include

events or information from close others, the media, or health care providers promoting

engagement in health-related behaviors.

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Examples of cues to action include a reminder postcard from a dentist, the illness of a friend or

family member, and product health warning labels. The intensity of cues needed to prompt action

varies between individuals by perceived susceptibility, seriousness, benefits, and barriers. For

example, individuals who believe they are at high risk for a serious illness and who have an

established relationship with a primary care doctor may be easily persuaded to get screened for

the illness after seeing a public service announcement, whereas individuals who believe they are

at low risk for the same illness and also do not have reliable access to health care may require

more intense external cues in order to get screened.

Applications

The HBM has been used to develop effective interventions to change health-related behaviors by

targeting various aspects of the model's key constructs. Carpenter (2010) opines that interventions

based on the HBM may be used to increase perceived seriousness of a health condition by

providing education about prevalence and incidence of disease, individualized risk, and

information about the consequences of disease (e.g., medical, financial, and social consequences).

Interventions may also aim to alter the cost-benefit analysis of engaging in a health-promoting

behavior (such as immunization) by providing information about the efficacy of various

behaviors like immunization to reduce risk of disease.

Interventions can be aimed at the individual level (i.e. health educating mothers on the value of

immunization) or the societal level (e.g. through legislation promoting immunization, mass

media campaign and engaging religious and cultural organizations).

Empirical Review

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Manner, Chatterjee, and Debasis (2009) in a cross-sectional study conducted in two districts of

South Bengal, India from December 2006 to March 2008 revealed that the knowledge of the

parents about immunization was very poor and the literacy of the parents was also poor. Thus

the study indicated that the knowledge about immunization is directly related to education.

Parents with higher education got the higher score while parents with lower education got lower

scores.

In a study about Beliefs about Immunization and Childrens Health among Child bearing Mothers in

Nepal, (Matsuda, 2012) reported: When asked Why did you get your children immunized? 78.9%

of the subjects answered To prevent my children from getting diseases. Additionally, 11.9% of the

mothers responded I had my children immunized to keep them healthy and full of immunity

power, while 5.9% indicated that immunization was important to help eliminate any

concerns about communicable diseases. In response to the final open-ended question What is

the biggest barrier to immunizing your children? 32.5% of the sample stated that there were

no barriers to immunization, 31.6% of the sample noted that lack of knowledge about

immunization was a significant barrier, and 11.1% of the sample indicated that lack of

transportation was the biggest barrier to getting their children immunized.

A comparative study of mothers knowledge of children immunization before and after mass

media health education conducted in Egypt by El-Shazly (2009) made up of study groups I: 250

mothers not exposed to mass media, group II: 150 exposed to mass media and group III: 100

primigravida exposed to mass media.

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All attended the same clinic to vaccinate their children. The mean score of knowledge increased

with higher levels of education in groups I, II and III. The group with unsatisfactory knowledge

had the highest percentage of completion of immunization in both groups I and II (62.9% and

100% respectively). Mothers with satisfactory knowledge among those completing the schedule

were significantly higher in group II 87.9%) than in group I (46.2%). In group II, 73.5% of

mothers had very good knowledge and completed the schedule compared to 60% in group I.

Sarfaraz et al (2017) in a study assessing the knowledge, attitude and perception (KAP) of

mothers regarding immunization conducted an interventional study was conducted on 103

mothers for a period of six months in a tertiary care teaching hospital in Karnataka, India. During

this period, 103 mothers who met the inclusion criteria were enrolled in the study. The

knowledge, attitude and perception of mothers towards immunization was analyzed using a

structured KAP questionnaire. In post-intervention study the mothers were counseled on

immunization using study materials like patient information leaflet, personal conversation with

mothers to explain and clear their doubts about vaccines, smart phones and other media (like

newspaper and television) to educate them in order to enhance their knowledge, attitude and

perception towards vaccination.

After the counseling period, the post- intervention KAP questionnaire was given and again scores

were collected for 103 mothers. Comparison of pre and post- intervention scores showed that

mother’s knowledge is improved after counseling. Educational status of mothers indicated that out

of total 103 mothers, 77 (74.75%) mothers were uneducated which was the main reason for lack

of knowledge regarding immunization because most of them did not know about the diseases for

which their child is being immunized and many mothers did not know the timings of vaccination.

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Adisa, et al (2016) in a study aimed at determining the perception and uptake of childhood

immunization among mothers of under-five children surveyed 320 mothers of under-five

children attending post-natal Clinics in Osogbo, South Western Nigeria. Using a pre-tested semi-

structured interviewer administered questionnaire, data was collected which shows that poverty

is a major factor that can influence the level of immunization uptake of mothers of under-five

children. Another factor responsible for level of immunization uptake in this study was long

waiting time in the health facility. Nevertheless, this study shows a high level of fully

immunized children.

Ndida, et al (2017) conducted a study describing parents perceptions of the benefits of child

immunization, risks of lack of

immunization and sources of information on child immunization in Maiduguri. The instrument for

data collection was a modified Likert type Gains of Immunization Rating List (GIRL). Items on

the list are dimensions of benefits of child immunization covering; child health, intellectual/

academic, socio-economic, and family/community benefits of child immunization. The sample is

made up of six hundred (600) (male and female) parents having child aged five (5) years and

below. They concluded that parents in Maiduguri are significantly aware of benefits of child

immunization and the risks of its lack. Sources of immunization information used in Maiduguri

also seem to be adequate. Most parents strongly, agreed that:

1. Compulsory immunization certification by legislation.

2. Demand for full immunization certificate as personal documents.

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 3. Worship place long term and strategic orientation of the Nigerian

population.

4. Mass campaigns for immunizations at special festivals (Salah, Christmas etc).

5. Special outreach, projects and education on paternal roles in family and child

health.

Should be adopted as methods of increasing immunization uptake.

Enwonwu, et al (2018) conducted a survey on perception of childhood immunization among

mothers of under-five children in Onitsha, Anambra State. A total of 300 mothers were

interviewed. Majority 285 (95.0%) of mothers had vaccinated their children against tuberculosis

(received BCG), the remaining 5% were mothers of newborns who were about to receive BCG on

the day of interview. More than 90% of mothers of those that received BCG said that their

children had BCG scar. The uptake of immunization decreased gradually with increasing age of

the child, fewer mothers reported immunizing their children against measles and yellow fever

than polio, tuberculosis, diphtheria, pertussis and tetanus. All the mothers 300 (100%) were aware

of immunization and they all got informed about immunization during their antenatal clinic visits.

All the mothers were of the opinion that immunization was for all children, irrespective of sex,

birth order, feeding status and health status. All the mothers interviewed (100 %) got their

awareness of immunization at the antenatal clinics. Some others had churches and media as

additional sources of information. In their study, all the mothers believed that immunization was

to stop children from getting the deadly preventable diseases and none of them believed that

vaccines contained contraceptives.

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Summary of Reviewed Literature

Literature pertaining to the immunization of children by nursing mothers was reviewed under the

following: Conceptual review explaining the benefits and relative risks of immunization. A

theoretical review of related theories was discussed, including the epidemiologic triangle model

and the health benefit model. The empirical review considered previous works on the factors

affecting attitude of mothers toward immunization of their children, of which levels of education

are found to be key. Also, a relationship between knowledge and attitude (and therefore, practice)

was also discerned. The review of literature further showed that there was a dearth of studies on

the attitude of mothers toward immunization of children under the age of five years in the area of

study being Umuahia South LGA and Abia state as a whole. Hence this study intends to bridge

the gap.

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 CHAPTER

THREE

METHODOLOGY

This chapter is discussed under the following subheadings:

1. Research design,

2. Area of study,

3. Target population,

4. Sample size,

5. Inclusion criteria,

6. Instrument for data collection,

7. Validity of instrument,

8. Reliability of instrument,

9. Ethical considerations,

10. Method of data collection and

11. Method of data analysis.

Research Design

The study adopted a cross-sectional descriptive design. Cross sectional design

provides a snapshot of the outcome and the characteristics associated with it at a

specific point in time. It focuses on studying and drawing inferences from existing

differences between people, subjects, or phenomena. Cross-sectional descriptive

XXVIII
design was adopted for this study because it entails collecting data at and

concerning one point in time, the groups concerned are selected purposefully based

on their inclusion in the target population, can use a large number of subjects and

cover a wide geographic area.

Area of study

The area of study is Umuahia South L.G.A of Abia State. Umuahia South LGA is

located in central Abia State, South eastern Nigeria. It consists of the city of

Umuahia-Ibeku, located in Ibeku clan, and several rural and suburban communities

in Ibeku and Ohuhu clans. Its administrative headquarters is at Umuahia Ibeku.

Umuahia is located along the road that lies between Port Harcourt in the south and

Enugu in the South. .

Target population

The population for this study were women of childbearing age who had children

under five years, attending health centers in Umuahia South LGA (Town).

Basically, five health centres were chosen with bias to accessibility and the

population of women attending them for antenatal and postnatal services. They

were a total number of 355 target population from which the sample size was

drawn

The health centres studied on are as follows:

XXIX
1. Primary Health center Ubakala, Umuahia South LGA.

2. Health center Old Umuahia, Umuahia South LGA.

3. Primary Health Center Alaoji, Umuahia South LGA.

4. Primary Health center Amakama, Umuahia South LGA.

5. Primary Health center Ahiaukwu Umuahia South LGA.

Sample Size

The Taro Yamani formula (1967) was used to determine the sample size for the

quantitative data, thus; n= N

1+N(e)2

Where; n = sample size

N = population size

e = significance/ precision level which is usually given as 0.05

Therefore, sample size is calculated thus;

n = 355

XXX
 e = 0.05

n= n = 355 355 = 188

1+355(0.05)2 355(0.0025)

Therefore, sample size (n) is 188

Sampling Technique

Multi-stage sampling was used to draw out populations for the study. In the first

stage, 5 health centres were chosen. Then respondents were randomly selected

using convenient sampling method among women of childbearing age attending

these centres

Inclusion criteria:

1. Women of childbearing age with children

2. Such women who volunteered to participate in the study.

Instrument for data collection

XXXI
 Data were collected using an interviewer administered questionnaire developed

and pre-tested by the investigator. The content of the questionnaire was based on

literature reviewed. The questions were formulated according to the research

objectives stated.

Section A: Is concerned with the respondents demographic data.

Section B contained items designed to elicit knowledge and practice of

mothers towards immunization of children under five years among women of

child bearing age in Umuahia South LGA.

Validity of Instrument:

The questionnaire was submitted to the researcher’s supervisor for validation. The

items were scrutinized and modifications were made where possible. All the inputs

were used to effect corrections in the final copy of the questionnaire which was

presented to the supervisor before use.

Reliability of Instrument:

An instrument is said to be reliable when it consistently gives the same result when

used more than once. The reliability of the questionnaire was tested using test-retest

method and the answers were consistent, it was used to establish reliability

Ethical Consideration

XXXII
 Permission was taken from the charge nurse at each of the health facilities to be

used. Respondents consent was also obtained and the need for the study explained

to them to gain their co-operation, confidentiality and anonymity of information was

guaranteed. Respondents were not forced to participate in the study and were not

prevented from backing out if they wanted.

Method of data collection

Written permission to carry out, the study was obtained from the charge nurse. Data

was collected in from women meeting the inclusion criteria. Participants had the

questions explained to them by the researcher.

Method of data analysis:

Data analysis was done with the statistical Package for Social Sciences. The data

collected was analyzed using frequency table, converted to percentages and pie

charts. The results obtained was presented in appropriate table, figures and bar

charts for easy understanding.

XXXIII
XXXIV
 CHAPTER FOUR

PRESENTATION OF RESULTS

This chapter presents the results of the data analysis on Knowledge and Practice of

mothers towards immunization of children under age five among women of child

bearing age in Umuahia South LGA. One hundred and eighty-eight (188)

questionnaires were distributed to the respondents; all of the questionnaires were

filled correctly and returned giving the return rate of (100%). This is because

questionnaires were administered in an interview format.

Table 1: Demographic information of Respondents

Age Response Percentage%

15-19 26 13.83

20-24 43 22.87

25-29 86 45.74

30-34 20 10.64

>35 13 6.92

Total 188 100%

Marital status.

Single 148 78.72

Widow 8 4.26

XXXV
Divorced 20 6.38

Total 188 100%

Number of children

1-3 70 37.23

4-5 93 49.47

>6 25 13.30

Total 188 100%

Data obtained Shows that, majority of respondents falls between ages of 24-29years

86(45.74); followed by 20-24years 43(22.87) while 30-34 years are 26(13.83); 15-19

years are 20(10.64) and above 35 years 13(6.92) respectively.

Majority of respondents are married 148(78.72). Single are 8 (4.07%), widow

12(2.71) and divorced are 20(4.53).

And 78 (41.48) parents are having 1 - 3 children, 58 (30.85) parents have 4 - 6

children and 52(27.6) of responding mothers had 6 or more children

Objective One: Access the knowledge of nursing mother's towards immunization in

Umuahia South LGA towards immunization

Table 2: on knowledge of mothers on child immunization in Umuahia South, L.G.A.

XXXVI
Benefits of child immunization Strongly Agree Agree Disagree Strongly
Disagree

Increases child survival 59(33.70) 69(36.00) 19(10.60) 37(19.70)

Makes Children look & live 63(34.60) 73(36.90) 19(10.60) 39(17.90)

healthier

Reduces disease spread. 58(33.50) 72(36.70) 18(10.20) 37(19.70)

Makes child grow normal 61(34.20) 72(36.70) 19(10.60) 38(18.60)

Reduces hospital attendance 60(33.90) 69(36.00) 21(10.90) 40(19.20)

Helps healthful adulthood 56(33.00) 74(37.10) 23(11.30) 38(18.60)

Parents are significantly aware of the benefit of child immunization. The most valued

benefit is that immunization Makes Children look and live healthier (n= 136, 71.5%)

while vaccines being cheaper than treatment is the least (n= 127, 69.4%).

Table 3: Dangers of lack of child immunization

Dangers of lack of child Strongly Agree Disagree Strongly

immunization? Agree Disagree

Blindness and physical deformity 72(36.70) 61(34.20) 19(10.60) 38(18.60)

Mental and intellectual disability 69(36.00) 60(33.90) 21(10.90) 40(19.20)

XXXVII
Frequent child sicknesses 74(37.10) 56(33.00) 23(11.30) 38(18.60)

High chances of childhood death 56(33.00) 74(37.10) 38(18.60) 23(11.30)

Parents are also significantly aware of the dangers of lack of child immunization. The

most strongly accepted danger is that lack of immunization causes Frequent child

sicknesses (n=74, 71.5%) while High chances of childhood death is the least accepted

danger (n= 127, 69.4%).

Objective Two: Assess utilization of childhood immunization by mothers of children

under the age of 5 in Umuahia South LGA

Table 4: Utilization of Immunization by nursing mother's

Immunization of children Response Percentage%

Fully immunized. 95 50.5

Partly immunized. 73 38.8

Others. 20 10.7

Total. 188 100%

XXXVIII
Only 95(50.5) Parents accepted to have fully immunized their children. The

remaining 93(49.5%) parents immunized their child in part or not at all.

XXXIX
 CHAPTER FIVE

DISCUSSION OF FINDINGS

The discussion of the findings is presented in this chapter. Discussion was done

based on the objectives set for the study. Also the limitation of the study, implication

of the findings, recommendations and suggestions for further studies were all

presented.

This study assessed the attitude of nursing mothers towards immunization of

children under 5 years among women attending health centers in Umuahia South

LGA, Abia state. The women in this study were between ages of 30-34years

86(19.46) and were mostly married.

Objective One: Access the knowledge of immunization of mothers of children

under age 5 in Umuahia South LGA towards immunization.

In response to the question, What would you identify as the benefits of

immunization? the survey revealed that most parents are significantly aware of the

benefits of child immunization. The most valued benefit is that immunization Makes

Children look and live healthier (n= 136, 71.5%) while vaccines being cheaper than

treatment is the least (n= 127, 69.4%). On the other hand, concerning the dangers of

not immunizing a child, the study reveals that parents are also significantly aware of

the dangers of lack of child immunization. The most strongly accepted danger is that

lack of immunization causes Frequent child sicknesses (n= 74, 71.5%) while High

chances of childhood death is the least accepted danger (n= 127, 69.4%).

XL
Objective Two: Assess utilization of childhood immunization by mothers of children

under the age of 5 in Umuahia South LGA

Investigation by the researcher shows that 95(50.5) Parents accepted to have fully

immunized their children. The remaining 93(49.5%) parents immunized their child in

part or not at all.

The above findings correlate with that by Tagbo, et al (2012) on mothers ’ knowledge,

perception and practice of routine and campaign immunization in Enugu. Most

mothers studied had good knowledge and positive perception and practice of

immunization. However, the immunization rejection rate was high for the south

eastern region of Nigeria where it is often assumed that non-compliance is not a

problem.

In contrast, however, Enwonwu, et al 2018 revealed in a survey on perception of

childhood immunization among mothers of under-five children in Onitsha, Anambra

State that out of a total of 300 mothers interviewed, majority 285 (95.0%) of

mothers had vaccinated their children against tuberculosis (received BCG), the

remaining 5% were mothers of newborns who were about to receive BCG on the day

of interview. More than 90% of mothers of those that received BCG said that their

children had BCG scar. However, the uptake of immunization decreased gradually

with increasing age of the child, with fewer mothers having reported immunizing

their children against measles and yellow fever than polio, tuberculosis, diphtheria,

pertussis and tetanus.

XLI
Conclusion

A majority of interviewed women demonstrated positive attitude immunization of

children under the age of five but most of them don ’t complete the immunization

schedule as indicated.

Nursing implications

Having identified that parents are significantly aware of the benefits and risks of

child immunization, there is the need for Nurse-Midwives to use these identified

media of information sources for long term and strategic parents ’ education and

counseling. The intensification of community education, mobilization and advocacy

capitalizing on what parents know and the limit of or extent to which they are useful

towards acceptance and use of child health services need to be done.

Recommendations

1. There is need for comparative teaching of parents especially fathers and media

mobilization on benefits and risks and the gross gains of immunization over

and above its dangers.

2. Community values such as religious and ethnic gatherings can be harnessed

and as a strong means of creating awareness and in-depth knowledge on all

XLII
 matters that relate to health policy generation and participatory

implementation in collaboration with individuals, families and community.

3. Laws that compel parents to immunize their Children should be put in made

4. The certification of complete immunization as personal documents like

indigenization certificate, birth certificate could be valuable for ensuring child

protection with vaccines.

5. To increase immunization acceptance should be made part of the community ’s

common health practices, vaccines should be readily available in primary

health care facilities more than periodic and supplemental campaigns.

Limitations of the study

There were some limitations in the course of this study which include:

Geographic limitations: This research is limited to data obtained in Umuahia South

LGA of Abia State and therefore may not be generalized to other areas of the state

or the country at large

Scope of study: This study is delimited to dealing with subjects related to the

objectives of the study, and therefore does not cover all the possible aspects and

angles of the issues.

Suggestions for further studies.

The scope of this study was limited to only one local government area, similar

studies can be conducted using a wider population for example the entire state and

other locations in Nigeria.

XLIII
XLIV
 REFERENCES

American Association of Pediatricians (2015) Children immunization support

program. Information for providers and parents.

Austin, Latoya T. Breast and Cervical Cancer Screening in Hispanic Women: a

Literature Review Using the Health Belief Model. Women ’s Health Issues
12.3 (2012): 122–128.

Carpenter, Christopher J. (2010). "A meta-analysis of the effectiveness of health belief

model variables in predicting behavior". Health Communication. 25 (8):
661,669. doi:10.1080/10410236.2010.521906. PMID 21153982

Center for disease control and prevention. (CDC) Principles of Epidemiology in Public
Health Practice, Third Edition: An Introduction to Applied Epidemiology and
Biostatistics

Center for disease control and prevention. (CDC) Your Baby’s first vaccines; what you
need to know; Department of health and human services; vaccine information
statement (Interim) 42 U.S.C; 2010

Gains S. Vaccination is the best protection. American academy of pediatrics healthy

children’s magazine. Last updated 31/05/2017. Available at

XLV
 http://www.healthychildren.org/English/safety-prevention/immunization
Accessed 31/05/2020.

Glanz, Karen (July 2015). Health behavior: theory, research, and practice.

Rimer, Barbara K., Viswanath, K. (Kasisomayajula) (Fifth ed.). San Francisco, CA.
ISBN 9781118629055. OCLC 904400161.

Glanz, Karen; Barbara K. Rimer; K. Viswanath (2008). Health behavior and

healtheducation: theory, research, and practice (PDF) (4th ed.). San
Francisco, CA: Jossey Bass. pp. 45-51. ISBN 978-0787996147.

Hornig M, Biese T, Bauman ML. Lack of association between measles virus vaccine
and autism with enteropathy: a case control stud. Plos One. 2012; 3(9):
e3140.

Lieberman JM. Myths regarding immunizations; Monograph to: An ounce of

prevention: Communicating the benefits and risks of vaccines to parent;
2013.

Linkins support for immunization registries among parents of vaccinated school aged
children: A case control study. BMC Public health. 2016; 6:236.

Manjunath U, Pareek RP. Maternal Knowledge and Perception about the Routine
Immunization Programme a Study in a Semi-Urban Area in Rajasthan. Ind J
Med Sci 2013; 57: 158-163.

Njidda UM, Kever RT, Lola N, et al. Assessment of parents’ knowledge towards the
benefits of child immunization in Maiduguri, Borno State,

Nigeria. Nurse Care Open Access J. 2017;3(2):226‒239. DOI:

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 10.15406/ncoaj.2017.03.00067

Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M. Achieving polio

eradication: a review of health communication evidence and lessons learned
in India and Pakistan. Bull WHO 2009; 87: 624-630.

Sanford RK. Vaccine Adverse Events: Separating Myth from Reality. Am Fam Phy
2012; 66: 2110-2113

Sarfaraz Md, Athira A, Thotamsetty LMD, Ravilla SA, Nadikudi N, Doddayya H.

Assessment of knowledge, attitude and perception among mothers towards
immunization in a tertiary care teaching hospital. Int J Community Med
Public Health 2017; 4:3429-35.

Schmiege, S.J., Aiken, L.S., Sander, J.L. and Gerend, M.A. (2007) Osteoporosis
prevention among young women: psychological models of calcium
consumption and weight bearing exercise, Health Psychology, 26, 57787.

Siddiqui, Taranum Ruba; Ghazal, Saima; Bibi, Safia; Ahmed, Waquaruddin; Sajjad,
Shaimuna Fareeha (2016-11-10). "Use of the Health Belief Model for the
Assessment of Public Knowledge and Household Preventive Practices in
Karachi, Pakistan, a Dengue-Endemic City". PLOS Neglected

Silverstein, Arthur M. (2009). A History of Immunology (2nd ed.). Academic Press. p.

293. ISBN 9780080919461...

Tagbo BW, Uleanya ND, Nwokoye IC, Eze JC, Omotowo IB. Mothers knowledge,
perception and practice of childhood immunization in Enugu. Nigerian
Journal of Pediatrics. 2012; 39(3): 17-22

The World Bank group. Nigeria; Improving Primary Health Care Delivery Evidence.
Nigeria; 2018

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WHO. Towards Universal Coverage of basic Health Services: Contribution to Routine
Immunization in Nigeria. Abuja, Nigeria: Interim Report; 2005.

APPENDIX 1

TO WHOM IT MAY CONCERN

LETTER OF INTRODUCTION

The bearer, Owasi Faith Chiamaka, is a final year student of the Department of
Nursing Science of Abia State University, Uturu.

She is conducting a research on Knowledge and Practice of Immunization Children

Under five years among Women attending Health Centres in Umuahia South L.G.A as
the part for the award of a Registered Public Health Nursing (RPHN) certificate.

This is to request your kind cooperation to facilitate access to information and other
necessary assistance.

XLVIII
Thanks for your co-operation

............................ ..............................

Mrs. Onyekachi-Chigbu A.C Dr. Mrs Emeonye

O.P

(Supervisor). (Head of
Department)

XLIX
L
 APPENDIX II

ETHICAL CLEARANCE

Department of Nursing Sciences,

Faculty of Health Sciences,
Abia State University,
P.M.B. 2000,
Uturu, Abia State.
The Eze,
Federal Medical Community,
Umuahia,
Abia State.

Sir,

APPLICATION FOR ETHICAL CLEARANCE

I humbly apply for ethical clearance to carry out a study on "Knowledge and Practice
of Immunization Children Under five years among Women attending Health Centres
in Umuahia South L.G.A .

Thank you for your anticipated co-operation.

Yours Faithfully,

Owasi Faith
Chiamaka

LI
 APPENDIX III

Department of Nursing Science,

Faculty of Health Science,
Abia State University,
P.M.B. 2000,
Uturu, Abia State.

The Chief Matron,

Federal Medical Health Centre,
Umuahia
Abia State

Dear Ma,

APPLICATION FOR PERMISSION TO COLLECT DATA

I write to apply for the permission for collection of data on my study on "Knowledge
and Practice of Immunization Children Under five years among Women attending
Health Centres in Umuahia South L.G.A
Thank you for your anticipated co-operation.

Yours
Faithfully,

Owasi
Faith Chiamaka

LII
 APPENDIX IV

QUESTIONNAIRE

Knowledge and Practice of Nursing Mother's towards Immunization of children under

Five years among Women attending Health Centres in Umuahia South L.G.A

Section A

Demographic characteristics of Respondents

Age

15-19. 20-24 25-29 30-34. >34

Marital status

Married Widow Divorced. Single

Number of children

1-3 4-5. >6

Section B

Knowledge about Immunization

Increases child survival

Strongly agree. Agree Disagree Strongly disagree

LIII
Makes look healthier

Strongly agree Agree Disagree Strongly disagree

Reduces spread of disease

Strongly agree Agree Disagree. Strongly disagree

Makes Child grow normal

Strongly agree Agree Disagree Strongly disagree

Reduces hospital attendance

Strongly agree Agree Disagree Strongly disagree

Helps healthful Adulthood

Strongly agree Agree Disagree. Strongly disagree

Saves family money and resources

Strongly agree Agree Disagree Strongly disagree

Dangers of lack of Immunization

Blindness and physical deformity

Strongly agree Agree Disagree. Strongly disagree

Mental and intellectual disability

Strongly agree Agree. Disagree Strongly disagree

LIV
Frequently child sickness

Strongly agree Agree Disagree Strongly disagree

High chances of childhood death

Strongly agree Agree Disagree Strongly disagree

Utilization of Immunization

Fully immunized Yes No

Partly immunized Yes No

Others Yes No

LV