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EFFECTS OF SOCIOECONOMIC AND GEOGRAPHICAL FACTORS IN

THE UTILISATION OF IMMUNISATION SERVICES IN THREE

SELECTED LOCAL GOVERNMENT AREAS OF ANAMBRA STATE,

NIGERIA.

Submitted by

DR NJELITA CHUKWUDI UCHENNA

(PGD/MPH/05/45394)

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

MASTER OF PUBLIC HEALTH

DEPARTMENT OF COMMUNITY MEDICINE

FACULTY OF MEDICAL SCIENCES

UNIVERSITY OF NIGERIA

SUPERVISOR: PROF CHIKA ONWASIGWE




MAY 2009

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EFFECTS OF SOCIOECONOMIC AND GEOGRAPHICAL FACTORS IN THE

UTILISATION OF IMMUNISATION SERVICES IN THREE SELECTED LOCAL

GOVERNMENT AREAS OF ANAMBRA STATE, NIGERIA.

Submitted by

DR NJELITA CHUKWUDI UCHENNA

(PGD/MPH/05/45394)

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

MASTER OF PUBLIC HEALTH




SUPERVISOR: PROF CHIKA ONWASIGWE




MAY 2009

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DECLARATION

I hereby declare that the study reported herein was done by me and any assistance

received is also acknowledged and that I have not previously submitted this

dissertation in part or in full for any examination or publication.

--------------------------------------

DR CHUKWUDI NJELITA




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CERTIFICATION

I hereby certify that the work for this dissertation, “socioeconomic and geographical

differentials in the utilisation of immunisation services in three selected Local

Government Areas of Anambra state, Nigeria”.

Submitted by

Dr Njelita Chukwudi Uchenna

Was supervised by me

--------------------------

Prof Chika Onwasigwe

Dept of Community Medicine

University of Nigeria

----------------------------------------

Prof M. N. Aghaji

Head of Department of Community Medicine

University of Nigeria

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DEDICATION

I wish to dedicate this project to the children who receive their immunisations at the

various primary Health Care Centers in Njikoka L. G. A. where I work as Medical

Officer of Health.

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TABLE OF CONTENTS

Title page…………………………………..…………….1

Declaration……………………………………………….2

Certification ……………………………………….…... 3

Dedication …………………………………...................4

Table of contents………………………………….………5

List of Acronyms…………………………………………7

Definition of terms ……………………………………….9

List of Tables…………………………………………….10

Acknowledgement ……………………………….….…...11

Abstract ………………………………….……..…..…….12

CHAPTER ONE: INTRODUCTION

1.1 Background of the study………………………...14

1.2 Statement of the problem……………………......15

1.3 Rational for the study ……………………………17

1.4 Objectives of the study…………………………..18

CHAPTER TWO: LITERATURE REVIEW

2.1 A review of the immunization activities

in Anambra state .……………….………….……..19

2.2 Factor that affect utilisation of

Immunisation services ……………………………20

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CHAPTER THREE: MATERIALS AND METHODS

3.1 Study Area……………………………………………26

3.2 Study Population…………………………………..…28

3.3 Study design …………………………………………28

3.4 Sample size estimation ………………………………28

3.5 Inclusion criteria …………………………………….29

3.6 Sampling technique ………………………………….29

3.7 Data collection ……………………………………….29

3.8 Data analysis …………………………………………30

3.9 Limitations …………………………………………..30

3.10 Ethical considerations ………………………………30

CHAPTER FOUR: RESULTS ………………………….31

CHAPTER FIVE: DISCUSSION ……………………….44

5.1 Conclusion ……………………………………………46

5.2 Recommendation ……………………………………..46

Reference ………………………………………………..47

Questionnaire ……………………………………………49

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LIST OF ACRONYMS

BCG Baccille Calmette-Guerin

DPT Diphtheria-Pertussis-Tetanus

DFID Department for International Development

EPI Expanded Programme on Immunisation

FMOH Federal Ministry of Health

FGD Focus Group Discussion

FOS Federal Office of Statistics

IDI In-depth Interview

IPC Interpersonal Communication

IPDs Immunisation Plus Days

LGA Local Government Area

LID Local Immunisation Day

MICS Multiple Indicator Composite Survey

MOEP Ministry of Economic Planning

MOH Medical Officer of Health

MOH&SS Ministry of Health and Social Services

NGO Non-Governmental Organisation

NICS National Immunisation Coverage Survey

NID National Immunisation Day

NPC National Population Commission

NPI National Programme on Immunisation

OPV Oral Polio Vaccine

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ORT Oral Re-hydration Therapy

PEI Polio Eradication Initiative

PHC Primary Health Care

PLA Participatory Learning and Action Approach

RI Routine Immunisation

TBAs Traditional Birth Attendants

UCI Universal Childhood Immunisation

UNICEF United Nations Children’s Fund

USP United States Pharmacopoeia Convention, Inc

VHWs Village Health Workers

WHO World Health Organisation

WPV Wild Polio Virus

FIC Fully Immunised Child/Children

FMoH Federal Ministry of Health

FOMWAN Federation of Muslim Women’s Organisations

GAVI Global Alliance for Vaccines & Immunisation

HBV Hepatitis B Vaccine

ICC Inter-agency Co-ordination Committee

ICHCS Integrated Child Health Cluster Survey

IMR Infant Mortality Rate

M&E Monitoring & Evaluation

NAFDAC National Agency for Food & Drugs’ Administration & Control

NC/CE National Co-ordinator/Chief Executive (NPI)

NDHS Nigeria Demographic & Health Survey

NICS Nigeria Immunisation Coverage Survey

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NID National Immunisation Day/s

NPHCDA National Primary Health Care Development Agency

PAFA Population Activities’ Fund Agency

PATHS Partnership for Transforming Health Systems

PSVD Private Sector Vaccine Distributor

PTF Petroleum Trust Fund

SIA Supplemental Immunisation Activities

SMoH State Ministry of Health

SMoLG State Ministry of Local Government

SNID Sub-national Immunisation Day/s

TT Tetanus Toxoid

VPD Vaccine-preventable Disease/s

UN United Nations

UNDP United Nations’ Development Programme

UNICEF United Nations’ Children’s Fund

USAID United States’ Agency for International Development

WHO World Health Organisation

YF Yellow Fever

ZSDO Zonal State Desk Officer (NPI)

DEFINITION OF TERMS

1. Immunisation Coverage: The proportion of eligible children who have actually

received a particular immunisation.

2. Fully Immunised: A child who has received all the immunisations due to him

from birth to his present age.

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LIST OF TABLES

Table 1: Socio-demographic characteristics of respondents 31

Table 2: Attitudes to immunization 33

Table 3: Factors that prevent taking the child to the immunization centre 34

Table 4: Problems that discourage going back to an immunization centre after a 35

Previous visit

Table 5: Amount paid for immunization in one visit 36

Table 6: Utilization of immunization services in relation to age 38

Table 7: Utilization of immunization services in relation to educational level 39

Table 8: Utilization of immunization services in relation to marital status 40

Table 9: Utilization of immunization services in relation to occupation 41

Table 10: Utilization of immunization services in relation to husband’s occupation 42

Table 11: Utilization of immunization services in relation to geographical location 43

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ACKNOWLEDGEMENTS

I appreciate the assistance given to me by my supervisor Professor Chika Onwasigwe

in the prompt review of every stage of this research up to its final presentation.

Thanks to the Community Health Extension Workers in the local government system

of Anambra State for their co-operation in the data collection.

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ABSTRACT

Objective: This survey studied the socio-economic factors that affect the uptake of

immunisation services in three selected Local Government Areas of Anambra State.

Materials and Methods: The study was a cross-sectional descriptive study.

Multistage sampling was done in which three LGAs were selected from the state;

these L.G.As are Njikoka, Ogbaru and Aguata. Four wards from each of these LGAs

were also selected. A research assistant was blindfolded and he randomly pointed a

number on the table of random numbers and the number was ‘3’. Every third house

was, therefore, entered in each ward to enquire for eligible respondents.

Only women of child bearing age who were present in the study area at the time of the

study were interviewed. Data collection instrument used is a semi-structured, pre-

tested, interviewer administered questionnaire. Research assistants were recruited

from the primary health centers in the selected wards.

Findings: As much as 53.7% of respondents knew that every child needs

immunization, while 55.1%, 35.1% and 18.2% believed that immunization should be

missed in the event of diarrhea, yellowness of the eyes and fever respectively. Up to

39.3% of women with only primary education missed their immunisation sessions

while 30% of women with tertiary education missed it. Only 23.5% of mothers who

are public/civil servants missed immunisation while 42.6% of mothers who are

farmers missed it. As high as 42% of women in Ogbaru (with very bad terrain) missed

immunisation while 23% of women in Njikoka (semi-urban) missed immunisation.

The study showed no correlation between the mother’s educational level and whether

she missed her child’s immunisation. This does not agree with the finding of National

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Immunisation Coverage Survey (NICS) 2003;

there was a positive correlation

between mothers’ education and the fully immunised child: nationally 31.1% of

children of mothers with secondary education are fully immunised; the figure for

children of mothers with no education is 3.9%.3 The possible reason why this survey

varied from a previous study in 2003 is that public enlightenment campaigns on

immunisation have been so elaborately utilised in Anambra State that the importance

of immunisation is presently equally known to the illiterate as the literate.

Conclusion: The statistical significance of these compared variables shows that

occupation and geographical location significantly affect utilisation of immunisation

services in Anambra State, therefore, health education promotion and programming

must take into consideration such factors.

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CHAPTER ONE

Introduction

1.1 Background of the study

In 1979 Nigeria’s Expanded Programme on Immunization (EPI) was initiated, and

was placed within the Department of Public Health and Communicable Disease

Control of the Federal Ministry of Health (FMOH) 1

. It was re-launched in 1984 due

to poor coverage.2

In 1996 it became the National Programme on Immunisation (NPI),

launched by the then First Lady, Mrs Abacha. Following a review of EPI, Decree 12

of 1997 created NPI as a parastatal. NPI has a sole responsibility of supervising and

enhancing routine and supplemental immunisations in Nigeria. 2

Routine immunisation (RI) is provided largely through the public health system, with

significant variations between the 36 States and Federal Capital Territory (FCT);

private or NGO providers are the source of up to one-third of RI in Anambra state.3

Public sector provision is by health staff based at facilities run by the 21 Local

Government Areas (LGAs) who have a Primary Health Care Coordinator (PHCC), a

Local Immunisation Officer and a Cold Chain Officer. These staff members are under

the control of the Head of Local Govt Administration and are employees of the State

Government (Ministry of Local Government and Local Government Service

Commission).

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Routine immunisations are done at the fixed posts in the health centres, health posts,

General hospitals and tertiary health facilities in the State. Supplemental

immunisations in the State are aimed at boosting the immunisation coverage and

mopping up missed opportunities.2 It also becomes imperative in epidemics.

2 These

supplemental immunisations are achieved through National Immunisation Days

(NIDs), Local Immunisation Days (LIDs), Immunisation Plus Days (IPDs) and Child

Health Week. 2

1.2 STATEMENT OF THE RESEARCH PROBLEM

Since they were first introduced in 1956, immunization activities in Nigeria have been

characterised by intermittent successes and failures.1 The expanded programme on

immunisation (EPI) introduced in 1979 with the aim of providing immunisation

services to children aged 0 – 23 months, experienced some initial success. However, a

few years after the programme started, it became obvious that it was no longer

achieving its stated objectives and had to be re-launched in 1984. 2

As a result of concerted efforts of the Federal Ministry of Health, State agencies, and

International Organisations, Nigeria attained universal childhood immunisation (UCI)

with 81.5 percent coverage for all antigens in 1990. 2

The success was not to last long

and by 1996, immunisation coverage had declined substantially to less than 30

percent for DPT3 and 21 percent for the three doses of oral poliovirus vaccine

(OPV).2 The situation has become even worse since then despite considerable donor

and Federal Government efforts to improve the provision and promotion of

immunisation services.

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Today, coverage rates for the various childhood vaccines in Nigeria are among the

lowest in the world.3 Nigeria is now considered the greatest threat to the global

eradication of polio and there is an urgent need to address the problems facing

immunisation activities in the country and increase coverage.3

Research in other parts of the world has shown that social factors, economic factors,

community and systemic factors affect immunisation coverage. These factors are

potentially modifiable.

Anambra State, centrally located in the south eastern zone of the Federal Republic of

Nigeria is not immune to the catalogue of problems facing immunisation uptake in

Nigeria. Since the mid-1990s, Anambra State has continued to witness fluctuations in

immunisation coverage for all vaccine-preventable diseases and this has had grave

consequences on children’s health and survival. Data from the 2003 National

Immunisation Coverage Survey reveal a very gloomy picture with only 12.7 percent

of children aged 12-23 months receiving full immunisation service. Of great

significance and concern is the emerging status of Nigeria as the country with the

highest number of Wild Polioviruses (WPV) in the world. Increased widespread

transmission of the WPV was reported in the highly endemic States of Kano, Katsina,

Jigawa, Kaduna and Bauchi, while a fresh outbreak of WPV was confirmed in Kebbi.

Of epidemiological importance to Anambra State is the recent incident of WPV

outbreak in the neighbouring state of Enugu.

Against this background, the goal of this study is to provide data that would assist

programme staff and policy makers to design strategic interventions to improve

immunisation coverage in Anambra State in particular and Nigeria in general.

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1.3 RATIONAL FOR THE STUDY

Routine immunization against DPT, measles, polio and TB is proven to be one of the

most cost-effective interventions for reducing childhood illness and mortality,

especially with the addition of other vaccines such as CSM and yellow fever in

endemic areas and TT injections for pregnant women1 and yet national coverage in

Nigeria for full immunization is less than 13%, one of the lowest rates in the world,

even lower than many countries in conflict, such as DRC.4 Some states in northern

Nigeria have coverage rates below 1%, and the average for the whole North West

Zone is just 4%. These coverage figures are much worse than in the neighbouring

countries of Benin, Niger, Chad and Cameroon. Both the Nigeria Demographic and

Health Survey (NDHS 2003), conducted by the National Population Commission, and

the Nigeria Immunization Coverage Survey (NICS 2003), conducted by the National

Programme on Immunization (NPI), provide the same irrefutable evidence.8 Nigeria’s

performance on routine immunization has continued to decline since the high point

achieved around 1990.

Vaccine-preventable deaths

In Nigeria, one child in five dies before its fifth birthday.8 This represented about

872,000 childhood deaths in 2002. Vaccine-preventable diseases (VPDs) account for

about 22% of deaths,4 therefore over 200,000 children a year are dying needlessly of

VPDs. Various well meaning researchers have conducted credible studies with a view

to unravelling the root cause of this decline in immunisation uptake. This research

study in three selected Local Government Areas in Anambra State is at discovering

the possible local causes of this decline in immunisation uptake in Anambra State.

The result of this research is meant to inform the health policy makers of the state on

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areas of hence enhance rational resource allocation. The public will benefit from this

research as the result when published will show statistically the state of immunisation

activities in these selected LGAs.

1.4 OBJECTIVES OF THE STUDY

General Objective

The general objective of this study is to identify socioeconomic and geographical

factors which affect the utilisation of immunisation services in Anambra State.

Specific Objectives

The specific objectives of the study are to:

1. Identify the social, economic and geographical pattern of people requiring

immunisation services in Anambra State.

2. Assess the effect of social, economic and geographical factors on

immunisation uptake.

3. Identify factors hindering or fostering immunisation in the state.

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CHAPTER TWO

LITERATURE REVIEW

2.1 A REVIEW OF IMMUNISATION ACTIVITIES IN ANAMBRA STATE.

Immunisation remains one of the cheapest and most cost effective means of protecting

the masses from vaccine preventable diseases.1 It has been widely employed in the

prevention and control of epidemic and endemic diseases in Nigeria since 1956.1

National Programme on Immunisation is the parastatal saddled with the responsibility

of immunisation in Nigeria.1

Another parastatal, the National Primary Health Care

Development Agency (NPHCDA), has responsibilities in immunisation. The

Anambra State office of the NPI oversees immunisation activities in the state. Routine

Immunisation (RI) is the major focus of the NPI.1 It has a schedule in Nigeria for the

full immunisation of every child before the age of one. Nigeria’s immunization

schedule contains tetanus toxoid (TT), BCG, Hepatitis B vaccine (HBV), OPV, DPT,

measles, cerebro-spinal meningitis vaccine (CSM) for types A and C, and yellow

fever (YF). 1

CSM is administered in an annual campaign in susceptible areas in the

north of Nigeria, to age groups which vary according to the quantity of vaccine

supplied.

Apart from the RI, the NPI employs supplemental immunisation to enhance

immunisation coverage. This is seen in the Polio Eradication Initiative (PEI). National

activities for polio eradication started in 1996, and the global effort to eradicate polio

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has made PEI National Immunisation Days (NIDs) and Sub-NIDs the main focus of

NPI’s attention since 1998.

“One of the problems with NIDs is that it tends to undermine the importance of the

routine immunization. The publicity given to NIDs usually makes the routine look

like it is non-existent. However, recently RI has received some attention in Nigeria

through the series of trainings of health workers in RI by European Union Partnership

to Reinforce Immunisation Efficiency (EU-PRIME) in 18 states of the federation

including Anambra state. Cases of polio genetically linked to the wild polio virus is

endemic in Nigeria. This has recently been discovered in Enugu State which is a close

neighbour to Anambra state.4 This WPV has been found not only in 13 African

countries but also in Indonesia and Yemen. 4

In spite of the considerable efforts that

have been put into immunisation programme in Nigeria, immunisation uptake remains

generally low in the country, especially in the northern states. Each year, thousands of

children die or are maimed for life as a result of diseases that are preventable through

immunisation. Preliminary results from the 2003 Demographic and Health Survey

(DHS) revealed a DPT3 coverage rate of 21% among children aged 12 – 23 months.

Moreover, Nigeria remains one of the few reservoirs of polio around the world. Data

for 2003 shows that with 347 cases, Nigeria has the highest number of children

paralysed by the poliovirus.

2.2 FACTORS THAT AFFECT UTILISATION OF IMMUNISATION

SERVICES.

In 2004 survey on the individual and community factors affecting the uptake of

immunization in four northern and two southern states of Nigeria, a total of 7200

respondents, mostly women with under-5 children, were interviewed. One finding

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from the survey is that there is a strong correlation between household poverty level

(measured in terms of the socio-economic status of the household) and the prevalence

of full immunization.5 The paper also explored the mediating role of mother's

decision-making power in this relationship. It was deduced that the stronger the

mothers decision-making power, the higher the likelihood of full immunisation. The

woman's decision-making power was measured through a set of questions that

assessed the woman's contribution to specific household decisions.5

This study by Babalola showed that poverty is likely to distract parents from placing

high premium on disease prevention as is the case in immunisation. This must be due

to the pressure on the family scarce resources hence giving the men and women no

chance to think about essentials like immunisation. This study clearly showed that the

lower the socio-economic class, the less likelihood for full immunisation. Furthermore,

the study showed that spousal communication around child immunization

significantly is a function of education, socio-economic status and exposure to

immunization-related information on the media or through community sources.

Specifically, spousal communication increases steadily with the woman’s education

such that the women least likely to report discussion with their spouse are the

illiterates. Exposure to immunization related information is associated with increased

spousal communication, indicating that the information obtained served as a point for

discussion about immunization among spouses.

In a study of the effects of geographical differentials in the utilisation of immunisation

services, Jegede et al x rayed the accessibility of information on immunisation to

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Nigeria women.6 A random sample of 1,554 women of reproductive age who have

given birth to, at least one child in the last five years in the south-east Zone of Nigeria

were recruited for the study. Their responses indicated limited access to information

in the rural areas than the urban areas. For those who have received information in the

urban areas, their major sources of information are electronic media (television and

radio), whereas the main sources of information in the rural areas were health workers,

traditional rulers, friends and neighbours. These sources differed by place of residence,

age, level of education and occupation of mothers. Data showed that respondents from

urban areas utilise immunisation better than those in the rural areas. Thus, it is

concluded that access to health information may be influenced by geographical

location and social class, therefore, health education promotion and programming

must take into consideration such factors.6

Elsewhere, a study done by Christopher Oluwadare on the social determinants of

routine immunisation in Ekiti State of Nigeria in 2005 concluded that the biggest

factor affecting uptake of immunisation appears to be whether a family lives in a rural

area or a town. This rural/urban factor is linked directly to the availability of services.

Most rural areas are without a sitting qualified nurse or senior health officer and most

are left to the least skilled assistants. Access to central supply of vaccines is hindered

by poor commitment to the service, non release of financial support and bad road

networks. Other rural people must travel considerable distances to urban health

facilities to access routine immunisation offered on specific days. Although many

health workers claimed to carry out ‘outreach’ for routine immunisation to rural areas,

there was no evidence of it.7

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Public health specialists see immunisation as one of the most accessible primary

health interventions. In many countries routine immunisation coverage for the poorest

group is lower than for higher income groups, but the disparity is less marked than for

other health interventions.8

In Nigeria widespread differences persist in immunisation

coverage. The child of parents in the lowest socio-economic quartile is nearly 12

times less likely to be immunised than children of parents in the highest. There is a

positive correlation between mothers’ level of education and the fully immunised

child: nationally 31.1% of children of mothers with secondary education are fully

immunised; the figure for children of mothers with no education is 3.9%. Children in

rural areas, especially in the north, are particularly disadvantaged.

The NICS (2003) states that nationally 7% of rural children and 25% of urban

children have been fully immunised. Full immunisation coverage is less than 13%

nationally, and below 4% in the North West Zone.8

Among the population as a whole,

only 70% of Nigerians had access to health care of any description (public, private,

traditional; primary, secondary, tertiary) in 2001. This figure is lower in rural areas.9

Barrier to equitable routine immunisation access and uptake remains a challenge to

many Nigerians.9 Barriers may be gender-linked (e.g. women not wishing to see a

male health worker; women not being given permission to visit a health facility with

their child); financial (e.g. inability to pay for transport, vaccine and/or syringes);

physical (e.g. terrain and amount of time needed to trek to the nearest health facility).

There may be opportunity costs (e.g. time taken out from wage labour).9

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Incorrect knowledge as to the preventive role of routine immunisation is widespread

in Nigeria. Quantitative research conducted in six States in 2004 reveals that in rural

Enugu, diarrhoea, fever, convulsion, vomiting and malaria are believed to be vaccine-

preventable diseases (VPDs), while in rural and urban Kano, malaria, teething

problems, vomiting, convulsion and pneumonia are listed.10

During pilot community

research in March 2005 a number of immunisation decision-makers and caregivers in

Katsina State stated that polio immunisation is all that is required: once a child has

received its polio ‘drops’, it is immunised against any childhood illness, including

those for which there is no vaccine available, e.g. acute respiratory infection.11

Those

least likely to demonstrate high levels of correct knowledge include people who do

not use public facilities for the treatment of common illnesses, those who lack easy

access to public health facilities, and illiterates.13

Many decision-makers and caregivers reject routine immunisation due to rumour,

incorrect information, and fear. The National Immunisation Coverage Survey 2003

report describes such perceptions as ‘wrong ideas’: this is an inadequate interpretation.

Attempts to increase coverage must seek to understand people’s attitudes and the

influence of these on behaviour. Fears regarding routine immunisation are expressed

in many parts of Nigeria. Fathers of partially immunised children in Muslim rural

communities in Lagos State see hidden motives, linked with attempts by NGOs

sponsored by unknown enemies in developed countries, to reduce the local population

and increase mortality rates among Nigerians.3 Belief in a secret immunisation agenda

is resonant in Jigawa, Kano and Yobe States, where many believe activities are

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fuelled by Western countries determined to impose population control on local

Muslim communities.10, 13

Confusion remains high in Katsina, with several issues emerging: not only lack of

correct knowledge, but uncertainty as to the reasons why a healthy infant should

receive an injection. Understanding the links between preventive health care and good

health is often weak; as a result, there is growing fear of the possibility of infection

and disease.13

Other factors contributing to rejection of routine immunisation include an apparently

deep-rooted suspicion in Kano State of western-style health services, dating from the

1980s. These suspicions link to national population policy: some northerners continue

to see routine immunisation as a means of fertility control. The situation is said to

have been exacerbated by drug trials by an American company, apparently conducted

without proper ethical standards and approval, which led to children’s deaths.12

Lack of confidence and trust in routine immunisation as effective health interventions

appear to be relatively common in many parts of Nigeria.13

A 2003 study in Kano

State found that 9.2% of respondents (mothers aged 15-49) had ‘no faith in

immunisation’, while 6.7% expressed ‘fear of side reactions’.14

For many,

immunisation is seen to provide at best only partial immunity, e.g. in Kano and

Enugu.10

The widespread misconception that immunisation can prevent all childhood

illnesses reduces trust: when, as it must, immunisation fails to give such protection,

faith is lost in immunisation as an intervention, for any or all diseases.

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CHAPTER THREE

MATERIALS AND METHODS

3.1 STUDY AREA

The area for this study is three Local Governments in Anambra State; Njikoka,

Aguata and Ogbaru. Anambra State is in the south-eastern zone of Nigeria. Anambra

people are predominantly of the Igbo tribe. It is in the rain forest region. The state has

total population estimated at 5 million. There are 21 local governments in the state

with Awka as the state capital. There are urban, semi-urban and rural LGAs in the

state. For the purpose of this study, three LGAs have been selected.

1. NJIKOKA LGA

Njikoka Local Government Area was created in 1976 and it is one of the twenty one

LGAs in Anambra state with headquarters at Abagana. It is bound in the North by

Awka North LGA and Awka South LGA and in the South by Dunukofia LGA. It has

a target population for routine immunization for children under the age of one and

pregnant women as 6,276 and 7,845 respectively and a total population of 156,895

from the 2006 census. It is classified as semi urban LGA of the state and is occupied

by mostly Igbos. They are predominantly traders. The indigenes are mainly Christians

with Roman Catholic and Anglican adherents dominating others. Njikoka Local

Government Area is made up of 7 districts, 18 political wards and 93 settlements.

There are 22 health facilities that provide routine immunization in Njikoka LGA.8

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2. PROFILE OF OGBARU LGA

Ogbaru LGA is one of the twenty-one LGAs in Anambra State with its headquarters

at Atani. It has a population of 133,066. It is one of the largest LGA in the state

tapering towards the Okpoko end in the north and broadening towards the Ogwu-

Aniocha and Ogwu-Ikpele communities in the south. The River Niger covers the

whole North West and south west of the LGA. It shares boundaries with Onitsha

South, Idemili North, Ekwusigo and Ihiala LGAs in the northeast and southeast areas

of the LGA. The LGA is bound in the south by Delta and Rivers states. There are

twenty-eight health facilities in Ogbaru LGA. They all provide routine immunization.

Generally the LGA has a very bad terrain throughout the year that worsens during the

rainy season when River Niger overflows its banks and blocks the only major link

road (Onitsha-Atani road) that traverses the LGA. The Igbos are the dominant tribe in

the LGA. The inhabitants are predominantly yam and vegetable farmers and

fishermen. There are twelve health districts and sixteen political wards in Ogbaru

LGA. The wards are Atani 1 and 11; Iyiowa/Odekpe/Ohita; Akili Ozizor;

Ochuche/Ogbakuba/Amiyi/Umuzu; Umunankwo/Mputu; Ossomala; Akili

Ogidi/Obeagwe; Ogwu-Ikpele; Ogwuaniocha; Okpoko1, 11,111,1V,Vand V1.8

3. PROFILE OF AGUATA LGA

Aguata LGA is one of the largest and oldest LGA in Anambra State. It is located at

the northern part of Anambra State. It is bound in the north by Orumba North; in the

south by Akokwa in Abia state; and at the east by Orumba South. The people of

Aguata LGA are predominantly Christians. They are mainly farmers, traders and civil

servants. Aguata LGA has areas of thick forests, erosion sites and gullies around

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Umuchu, Igboukwu, and Ora-Eri communities. The indigenes are mostly Igbo

speaking people. It has twenty districts and fourteen autonomous communities with

forty-two health facilities that provide routine immunization. They are: Ekwulobia,

Isuofia, Igboukwu, Ora-Eri, Ikenga, Umuona, Ezinifite, Amesi,Achina,

Aguluezechukwu, Nkpologwu, Umuchu, Uga and Akpo. Aguata LGA has twenty-one

districts with seven health centers and fifteen health posts. Routine immunizations are

carried out at these facilities. Aguata LGA has a population of about 163,301 and

routine immunization population (0-11mths) of 6,532.

3.2 STUDY POPULATION

The study population is women of child bearing age. A sample of this population was

studied.

3.3 STUDY DESIGN

It is a cross-sectional descriptive study.

3.4 SAMPLE SIZE ESTIMATION

n = z2pq

15

d2

Where,

n = the minimum sample size

z = standard normal deviate (1.96) at confidence level of 95%.

p = proportion of women of child bearing age in

- 29 -

Anambra State. (22% = 0.22). 1

q = 1.0 – p = 1- 0.22 = 0.78

d = degree of accuracy desired. (0.05)

Therefore,

n = 1.96 x 1.96 x 0.22 x 0.78

0.05 x 0.05

n = 0.6592

0.0025

n = 263.68 (approx. 264)

3.5 INCLUSION CRITERIA

The study was of women, who were of child bearing age and were in Anambra State

at the time of this study,

3.6 SAMPLING TECHNIQUE

Multistage sampling technique was used.16

Anambra State is the study area. Three

LGAs were selected from the state by simple random sampling. Four wards from each

of these LGAs were also selected by simple random sampling. A research assistant

was blindfolded and he randomly pointed a number on the table of random numbers

and ‘3’ was picked, therefore, every third house was entered in search of eligible

respondents. At the village square of the selected wards, a coca-cola bottle was spun

on the ground to randomly determine the direction to be followed by the data

collectors. The questionnaires were equally distributed in the three LGAs

3.7 DATA COLLECTION

Data collection instrument used is a structured, pre-tested, interviewer administered

questionnaire. The questionnaire was validated by pre-testing it in a small survey of

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20 respondents conducted in Urum, Awka North L.G.A. Data collectors who were

recruited from the primary health centers in the selected wards were thoroughly

trained in the meanings of all the terms in the questionnaire. The data from the pre-

test did not form part of the study.

3.8 DATA ANALYSIS

Data collected were entered into computer and analysed using the SPSS version 13.

The relevant means and standard deviations were calculated. The confidence limit of

this study is 95%; therefore the hypothesis was tested at 0.05 level of significance.

Chi-square test was also done to ascertain the significance levels between proportions.

3.9 LIMITATIONS

The limitation we had was that we were in short supply of funds for transporting the

interviewers around throughout the period of the research.

3.10 ETHICAL CONSIDERATIONS

Ethical clearance was obtained from the Health Research Ethics Committee of the

University of Nigeria Teaching Hospital Ituku-Ozalla. Verbal consent was obtained

from respondents before the administration of questionnaires.

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CHAPTER FOUR

RESULTS

300 questionnaires were distributed but 285 were appropriately filled and returned

from the field, therefore the response rate was (285/300 X 100%) = 95%

Table 1: Socio-demographic characteristics of respondents

Characteristic Frequency (n = 285) Percent Age group (years):

15 – 19 24 8.4

20 – 24 56 19.5

25 – 29 66 23.2

30 – 34 64 22.5

35 – 39 43 15.1

≥ 40 32 11.3

Educational level:

Primary school 28 9.8

Secondary attempted 42 14.7

Secondary completed 126 44.3

Tertiary attempted 49 17.2

Tertiary completed 40 14.0

Marital status:

Married 241 84.5

Divorced 23 8.1

Single 15 5.3

Widowed 6 2.1

Occupation:

Public / civil servant 132 46.3

Trader 127 44.6

Farmer 26 9.1

Husband’s occupation:

Public / civil servant 160 56.1

Trader 110 38.6

Farmer 15 5.3

Mean age of respondents = 29.6 years, standard deviation = 7.3 years

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The mean age of the respondents was 29.6 years with standard deviation of 7.3 years

and most fell within the age range of 25-34 years, followed by 20-24 while 15-19 year

age range has the least number of respondents. The modal educational level of

respondents was secondary completed. Women of child bearing age in Anambra State

were predominantly literate. Most of them were literate with over 90% having

attended a minimum of secondary education. 9.1% of them were farmers while 46.3%

and 44.6% of them were public/civil servants and traders respectively.

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Table 2: Knowledge/Conception to immunization

Knowledge/Conception Frequency (n = 285) Percent

Every child needs immunization 153 53.7

A child’s immunization should be

missed if there is:

Diarrhoea 157 55.1

Yellowness of the eyes 100 35.1

Fever 52 18.2

Findings on correct knowledge of immunization revealed that 53.7% knew that every

child needs immunization. While 46.3%, believed that immunization should be

missed in the event of diarrhea, yellowness of the eyes or fever. There were multiple

entries. This shows that more that half of the population surveyed had the right

attitude towards immunisation.

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Table 3: Factors that mostly prevent taking the child to the immunization centre

Factor Frequency Percent

Husband’s decision 115 40.4

Lacks knowledge of the need for

immunisation 111 38.9

Bad roads 28 9.8

Long distance 14 4.9

Religious belief 13 4.6

Others 4 1.4

Total 285 100.0

There was a very high dependence on the decision of the husbands for a child’s

immunisation. This is shown in Table 3 where 40.4% of the women would see

husband’s decision as the commonest reason for missing an immunisation session.

Lack of knowledge of the need for immunisation is viewed by 38.9% as the most

deterring factor as they don’t know why, where and when they should get immunised.

- 35 -

Table 4: Problems that discourage going back to an immunization centre after a

previous visit

Problem Frequency (n 285) Percent

Health workers’ attitude 119 41.8

Long waiting time at the health

facility 104 36.5

Long distance 51 17.9

Immunization charges 15 5.3

Unavailability of vaccines 4 1.4

Table 4 shows that the most frequent reason for not going back to an immunisation

centre after a previous visit was health workers’ attitude. This is followed by the long

waiting time at the centre.

- 36 -

Table 5: Amount paid for immunization in one visit

Amount in Naira Frequency (n 285) Percent

< 200 59 20.7

200 – 500 223 78.2

> 500 3 1.1

Total 285 100.0

Table 5 shows that most of the women (78.2%) paid between 200 and 500 Naira in

one immunisation visit.

- 37 -

Fig 1: Utilization of immunization services

Above is a pie chart which shows that 68.1% of the respondents did not miss their

immunisation at any time.

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Table 6: Utilization of immunization services in relation to age

Age group (years) Missed

immunization

Did not miss

immunization

Total (%)

Frequency (%) Frequency (%)

< 30 42 (28.8) 104 (71.2) 146 (100.0)

≥ 30 49 (35.3) 90 (64.7) 139 (100.0)

Total 91 (31.9) 194 (68.1) 285 (100.0)

χ2 = 1.378, df = 1, p = 0.240 (not statistically significant)

This table compares two age groups of the respondents; below 30years and above 30

years with compliance to immunisation. The chi square test shows that there is no

significant association between the two variables.

- 39 -

Table 7: Utilization of immunization services in relation to educational level

Educational level Missed

immunization

Did not miss

immunization

χ2 p-value


Primary school (n = 28) 11 (39.3) 17 (60.7) 0.773 0.379

Secondary attempted (n =

42) 18 (42.9)

24 (57.1) 2.706 0.100

Secondary completed (n =

126) 33 (26.2)

93 (73.8) 3.423 0.064

Tertiary attempted (n =

49) 17 (34.7)

32 (65.3) 0.208 0.648

Tertiary completed (n =

40) 12 (30.0)

28 (70.0) 0.080 0.778

Total (n = 285) 91 (31.9) 194 (68.1)


This table compares the educational level of the respondents with compliance to

immunisation. Women who completed their secondary education and those who had

tertiary education fared better in immunising their children, although there was no

statistically significant difference among the various educational levels.

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Table 8: Utilization of immunization services in relation to marital status

Marital status Missed

immunization

Did not miss

immunization

χ2 p-value


Married (n = 241) 75 (31.1) 166 (68.9) 1.131 0.287

Divorced (n = 23) 9 (39.1) 14 (60.9) 0.597 0.440

Single (n = 15) 4 (26.7) 11 (73.3) 0.027 0.869Y

Widowed (n = 6) 3 (50.0) 3 (50.0) 0.267 0.065Y

Total (n = 285) 91 (31.9) 194 (68.1)

Y = Yates correction


This table compares the marital status of the respondents with compliance to

immunisation. The table shows that marital status does not affect compliance to

immunisation. There were no significant variations in compliance among the various

groups.

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Table 9: Utilization of immunization services in relation to occupation

Occupation Missed

immunization

Did not miss

immunization

χ2 p-value


Public / civil servant (n =

132) 31 (23.5)

101 (76.5) 8.086 0.005*

Trader (n = 127) 48 (37.8) 79 (62.2) 3.626 0.057

Farmer (n = 26) 12 (46.2) 14 (53.8) 2.663 0.103

Total (n = 285) 91 (31.9) 194 (68.1)

*Statistically significant

χ2 = 8.762, df = 2, p = 0.013 (statistically significant)

Table 9 compares the occupation of the respondents and their compliance to

immunisation. The table shows that occupation affects compliance to immunisation.

Farmers were more likely to miss immunisation appointments than traders and traders

more than public/civil servants. This association was tested using the Chi square and

it showed statistical significance.

- 42 -

Table 10: Utilization of immunization services in relation to husband’s occupation

Occupation Missed

immunization

Did not miss

immunization

χ2 p-value


Public / civil servant (n =

160) 55 (34.4)

105 (65.6) 1.004 0.316

Trader (n = 110) 30 (27.3) 80 (72.7) 1.788 0.181

Farmer (n = 15) 6 (40.0) 9 (60.0) 0.474 0.491

Total (n = 285) 91 (31.9) 194 (68.1)


This table compares the occupation of the respondent’s husband and their compliance

to immunisation. The table shows that Husband’s occupation does not affect

compliance to immunisation. There were no significant variations in compliance

among the various groups.

- 43 -

Table 11: Utilization of immunization services in relation to geographical location

(LGA)

LGA Missed

immunization

Did not miss

immunization

χ2 p-value


Njikoka (n = 100) 23 (23.0) 77 (77.0) 5.652 0.017

Ogbaru (n = 100) 42 (42.0) 58 (58.0) 7.188 0.007

Aguata (n = 85) 26 (30.6) 59 (69.4) 0.100 0.751

Total (n = 285) 91 (31.9) 194 (68.1)

χ2 = 8.405, df = 2, p = 0.015 (statistically significant)

This table compares the geographical location of the respondents and their

compliance to immunisation. The table shows that geographical location affects

compliance to immunisation. Ogbaru women were more likely to miss immunisation

appointments than Aguata women and Aguata women more than Njikoka women.

This association was tested using the Chi square and it showed statistical significance

- 44 -

CHAPTER FIVE

DISCUSSION

The study was conducted on the socio-economic and geographical differentials in the

utilization of immunization services in Anambra State of Nigeria. A total of three

local government areas were studied under the following socio-demographic

parameters; age group, educational level, marital status, occupation and husband’s

occupation.

Findings from this study showed that the husbands’ decision (40.4%) was the factor

that most often prevented a child’s immunisation. This showed the role of the husband

in the Igbo family system. Critical decisions in a family are usually the sole

responsibility of the husband. There are, however, some variations in cases where the

woman is well educated or the bread winner of the family. In 2004 survey on the

individual and community factors affecting the uptake of immunization in four

northern and two southern states of Nigeria, a total of 7200 respondents, mostly

women with under-5 children, were interviewed. The paper explored the mediating

role of mother's decision-making power in this relationship. It was deduced that the

stronger the mothers decision-making power, the higher the likelihood of full

immunisation. The woman's decision-making power was measured through a set of

questions that assessed the woman's contribution to specific household decisions.5

The study showed no correlation between the mother’s educational level and whether

she missed her child’s immunisation. This does not agree with the finding of National

- 45 -

Immunisation Coverage Survey (NICS) 2003;

there was a positive correlation

between mothers’ education and the fully immunised child: nationally 31.1% of

children of mothers with secondary education are fully immunised; the figure for

children of mothers with no education is 3.9%.3 The possible reason why this survey

varied from a previous study in 2003 is that public enlightenment campaigns on

immunisation have been so elaborately utilised in Anambra State that the importance

of immunisation is presently equally known to the illiterate as the literate.

Only 23.5% of mothers who are public/civil servants missed immunisation while

42.6% of mothers who are farmers missed it. An association was found between the

respondent’s occupation and completeness of their child’s immunisation. This is

comparable with the study by Babalola in 2004 on the individual and community

factors affecting the uptake of immunization in four northern and two southern states

of Nigeria, One finding from the survey is that there is a strong association between

household poverty level (measured in terms of the socio-economic status of the

household) and the prevalence of full immunization.5 This study by Babalola showed

that poverty is likely to distract parents from placing high premium on disease

prevention as is the case in immunisation. This must be due to the pressure on the

family scarce resources hence giving the men and women no chance to think about

essentials like immunisation. This study clearly showed that the lower the socio-

economic class, the less likelihood for full immunisation.

This study showed that 23% of the respondents in Njikoka Local Government, a semi-

urban L.G.A missed immunisation while 42% of respondents in Ogbaru, a

predominantly rural L.G.A. with difficult terrain missed immunisation. The study

- 46 -

showed a association between geographical location and likelihood for full

immunisation. This agrees with a previous study done by Christopher Oluwadare on

the social determinants of routine immunisation in Ekiti State of Nigeria in 2005 in

which he concluded that the biggest factor affecting uptake of immunisation appears

to be whether a family lives in a rural area or a town. This rural/urban factor is linked

directly to the availability of services.7

5.1 CONCLUSIONS

Husband’s decision is the most important factor that prevents a child’s

immunisation.

Health workers’ attitude is the biggest factor that deters mothers from going

back for further immunisation after an initial immunisation session.

Educational level has no association with adherence to immunisation schedule

in Anambra State unlike elsewhere.

Mother’s occupation has a direct association with adherence to immunisation

schedule

Geographical location has direct association with adherence to immunisation

schedule. People in urban areas are more likely to be fully immunised than

people in rural areas.

5.2 RECOMMENDATIONS

A more detailed study should be done to analyse the husband decision

factor as it affects immunisation of a child.

Further study should be carried out on the effect of educational level

on immunisation in Anambra State.

- 47 -

REFERENCES

1. National Programme on Immunisation (NPI). Basic Guide for Routine

Immunization service providers, 2nd edition, Abuja, Amana publishers, 2004.

2. Awosika A. Boosting Routine Immunization in Nigeria: issues and proposed

action points, power point presentation developed by NPI and BASICS, Abuja,

September 2000.

3. National Programme on Immunisation (NPI). National Immunisation coverage

survey, Abuja, 2003.

4. World Health Organisation (WHO). Global Summary on immunization,

www.who.int/vaccines/globalsummary/immunization/countryprofileresult.cfm

(accessed 20th March 2009)

5. Babalola S O. Poverty and immunization coverage in Nigeria: the mediating

role of mothers’ decision making power, a presentation at the 133rd annual

meeting and exposition of American Public Health Association10th – 14th

December 2005, Philadelphia, PA, 2005.

6. Jegede A S, Idemudia E, Madu S N. Factors affecting access to health

information among Nigerian nursing mothers. Research for Development,

2004 vol 6 pg 15.

7. Oluwadare C. The social determinants of routine immunization in Ekiti State

Nigeria, department of sociology, University of Ado Ekiti, Ado Ekiti, Nigeria.

2005, vol 3 pg 20.

8. National population commission (NPC). Nigeria demographic and health

survey 2003, Abuja, 2004.

- 48 -

9. United Nations’ Development Programme (UNDP). Human development

Report, New York, 2004.

10. Babalola S, Aina O. Community and systemic factors affecting the uptake of

immunization in Nigeria: A qualitative study in five states, Abuja, 2004.

11. Brieger W R, Salami K K, Ogunlade B P. Catchment area planning and

action: Documentation of the community-based approach in Nigeria,

Arlington, Va, BASICS II for USAID, 2004.

12. Brieger W R. The polio epidemic in Nigeria; a public health emergency,

2004. www.nigeriavillagesquare1.com (accessed on 15th April 2009).

13. Babalola S. and Adewuyi. Addendum to existing qualitative and quantitative

immunization survey. Health-link international for PATHS, London & Abuja,

2005.

14. Yola A W. Report on Child Immunization Clusters Survey (CICS)

conducted in 12 LGs of Kano State, BASICS II, Lagos, 2003.

15. Araoye M O. Research methodology with statistics for health and social

sciences. Ilorin Nigeria, NATHADEX publishers, 2004.

16. Onwasigwe C. Principles and methods of epidemiology, Enugu Nigeria,

Institute for Development Studies UNEC, 2004.

- 49 -

QUESTIONNAIRE ON SOCIOECONOMIC AND GEOGRAPHICAL

DIFFERENTIALS IN THE UTILISATION OF IMMUNISATION SERVICES

IN ANAMBRA STATE

This is an academic research project by Dr Njelita Chukwudi, an MPH student of

University of Nigeria, Enugu Campus.

Questionnaire No: ---------------------------

Date: ---------------------------

Name of interviewer: ---------------------------

LGA: ---------------------------

This questionnaire is intended to obtain information on the socio-economic and

geographical differentials in the utilisation of immunisation services in Anambra state.

Your responses to the questions will be treated as confidential. Thank you for your

co-operation.

BIODATA

1. Sex: 1) Male……….. 2) Female………….

2. How old are you? …………

3. What is your level of education?

1) No formal education………….

2) Primary School ……………….

3) Secondary Attempted…………

4) Secondary Completed…………

5) Tertiary Attempted ……………

6) Tertiary Completed …………...

4. What is your marital status?

1) Single ………………

- 50 -

2) Married …………….

3) Divorced ……………

4) Widow ……………...

5. Do you think every child really needs immunisation?

(1) YES ……. (2) NO ………

6. Has your child missed any immunisation so far?

(1) Yes…..… (2) No ………

7. Do you think a child’s immunisation appointment should be missed due to any of

these?

1) fever

2) diarrhoea

3) yellow eyes

8. What is your occupation?

1) Farmer…………

2) Trader …………

3) Public/Civil Servant ………

4) Others, please specify …….

9. What is your husband’s occupation?

1) Farmer…………

2) Trader …………

3) Public/Civil Servant ………

4) Others, please specify …….

- 51 -

10. What factors deter you from taking your child to the immunisation centre?

1) long distance

2) Bad road

3) Husband’s decision

4) Religious belief

5) Lack of information

6) Others, please specify ………………………..

11. How much money do you spend for immunisation

in one visit.

1) Less than 200

2) Between 200 and 500

3) above 500

12. What problems discourage you from going back to an

immunization centre after your previous visit to the place.

1) Immunisation charges

2) Health workers’ attitude

3) Unavailability of vaccines

4) Long waiting time at the health facilities.

5) Long distance

6) Others, please specify ………………………..

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