Introduction:
With over two million children dying annually from vaccine-preventable diseases, many developing nations are still a long distance away from achieving the Sustainable Development Goals (SDG). This scenario is largely caused by factors mitigating against the acceptance and utilization of childhood vaccination in the low- and middle-income countries. (1-5)
In Nigeria, over the last three decades, after an initial drop from 29% in 1990 to 13% in 2003, the national percentage of children aged 12-23 months who received all the basic vaccinations has steadily improved, through 23% in 2008, 25% in 2013 to 31% in 2018. (6) Although the increasing coverage is commendable, tremendous public health efforts are still needed if the nation must meet the third SDG, which targets universal vaccination coverage for children in that age group. (7)
Previous studies have shown that childhood vaccination coverage is modulated by interplay of factors ranging from supply/provision of the vaccines, accessibility, to utilization by mothers. Each of these components is determined by other variables which have a causal or casual influence on the final coverage figures depending on the location and population studied. (1,8-10) However, one factor that merits further exploration is the contribution from migrant communities. Threats to the health of individuals and whole societies could follow the huge disparities in the vaccination coverage between host communities and the immigrants. (11) A direct consequence of suboptimal vaccination coverage is lowered herd immunity, which will result in perpetuation of vaccine-preventable diseases within the affected community. (9)
In this 21st century global village and with about one billion people moving within and without national boundaries, the effects of migration on health and health services must come to the front burners. (12) Immigrants and migrant populations tend to underutilize health care services across the world, creating a chasm of inequalities between them and their indigenous neighbours in terms of access to essential healthcare, including immunization. (13,14) The modifiers of their decision to use pertinent health care include socio-economic status, level of awareness, perception of the service including myths, knowledge of the programme, attitude of the care providers, and health care setting. When these immigrants form communities or ethnic minorities, more complex variables like power relations, healthcare-seeking behaviours, status hierarchies (or caste system) and politics are introduced. Since these migrant communities are non-homogenous across different regions, it would be worthwhile to explore the factors shaping these health disparities/inequalities among individual migrant groups. (15-18)
Migrant Ebira families within Ekiti State make up such a population. A 2009 study revealed that although the population of Ebiras in Ekiti State is on the increase, the immunization coverage amongst their communities is very low. (19) Being from the northern parts of Nigeria where immunization coverage is abysmally low (for example, it is 5% in Sokoto, one of the biggest states in Nigeria), (6) it is possible that similar poor statistics will be observed amongst them. With the percentage of completely immunized children in Ekiti State standing at 41.1%, (6) a steady increase in the cohort of non-immunized or partially immunized migrant children will further reduce the less-than-average coverage statistics of the State. However, data highlighting the utilization of immunization among the Ebira communities in Ekiti State are sparse. In other to complement public health strategies aimed at eliminating barriers to vaccine uptake and increasing coverage in Ekiti State specifically, and Nigeria as a whole, this study focused on the experiences of Ebira mothers with regards to childhood immunization.
Methods
This cross-sectional survey adopted a mixed method design to explore the experiences of Ebira mothers within the context of childhood vaccination in Ekiti State. A combination of quantitative research and explorative in-depth interviews was employed to obtain the data between September and October, 2019.
Ado-Ekiti, the study location, is the capital city of Ekiti State in southwest Nigeria, with a human population of 308,621 [20]. It has fifteen Ebira communities, the largest number in the State, thus its suitability as the study location was purposive. The Ebira people are indigenous to Kogi, Kwara and Nassarawa states in northern Nigeria. Since they are predominantly farmers and traders, they migrate to parts of the nation where they can find adequate land and favourable climate for their agricultural vocation. Most of their communes are on the outskirts of urban cities, with little influence from technological advances like electricity, transportation, and communication. Basic health centres located close to some of the communities meet their health needs, including childhood immunization. Also, on National immunization campaign days, they are targeted for supplemental and catch-up vaccinations.
Data from the unit of the National Population Commission domiciled within the health facility serving the communities revealed that there were 2287 households with Ebira women who have children less than 2 years of age. Using an error margin of 5% at 95% confidence level, a standard normal deviate of 1.96, vaccination coverage rate of 61.9% (1) from a previous study in southern rural Nigeria, 362 respondents would be needed for the survey. Ethical approval for the survey was obtained from Ekiti State Ministry of Health.
There are fifteen established Ebira communities in the local government area studied. In order to ensure comprehensiveness, the three largest communities were selected in the first stage of the multi-staged sampling. The next stage of selecting the households for the survey was done by dividing the total number of households containing eligible women by the required sample size. Thus, households were selected by adding the calculated kth interval (2287/362 ≈ 6), taking the first house in each community as the start-off point, till the sample required was obtained. Then, the eligible women in each selected household were interviewed. If there were more than one eligible mother, one of them was selected by simple random sampling. Only Ebira mothers who had children under 2 years, who had lived in the community for at least 12 months before the time of the survey and who gave consent for the study were eligible.
The study instrument, a semi-structured questionnaire adapted from the Nigeria Demographic and Health Survey, (21) was used to obtain the quantitative data. It had five sections: Section A required information regarding the socio-demographic characteristics of the respondents; Section B considered the respondents' awareness and knowledge of routine immunization, while Section C focused on their acceptance and utilization of childhood immunization. Sections D and E respectively explored the factors affecting routine immunization utilization and mothers' reasons for underutilization where it existed.
The instrument was pre-tested using twenty women in a smaller Ebira community. For the purpose of this study, utilization was regarded as successful use of routine immunization, which follows the current National Programme on Immunization (NPI) schedule in Nigeria: Bacille Calmette Guerin (BCG), Oral Polio Vaccine 0 (OPV0), and Hepatitis B vaccine 1 (HBV1) at birth; three doses of pentavalent vaccine [containing Diphtheria, Pertussis, Tetanus (DPT), HBV and Haemophilus influenza type b (Hi-b)] and oral polio vaccines at 6, 10 and 14 weeks; measles, and yellow fever at 9 months. Acceptance of immunization referred to the act of receiving childhood immunization with satisfaction, believing in it without any form of doubt.
The primary outcome of interest was utilization of routine childhood immunization among the Ebira women. The responses to the questions on knowledge were assigned a numerical value of +1 for each correct answer, and 0 for the wrong responses. Good knowledge described scores ≥ 70% of the total, 50-69% fair knowledge, and < 50% poor knowledge.
The qualitative research was conducted within the same communities, but with a different set of respondents. This involved in-depth interviews (IDI) with twenty participants spread across the communities. They included key informants: three male community leaders/heads, one patent medicine seller, one trainee traditional birth attendant, and three married men with children; other participants of the IDI were twelve mothers of varying ages until data saturation was obtained. The interviews were conducted by one of the authors (OFB) with the help of trained assistants in the common Yoruba language. They took place within the premises of the respondents' homes to create a conducive environment and ensure privacy. The IDI followed a semi-structured guide: interviewer and the project objectives were introduced to each respondent, and consent for a recorded interview was obtained; demographic details were obtained, and the questions on awareness, acceptance, utilization, myths and dangers of immunization were asked to provide further insights into the topic and deepen the quantitative component. The recordings were listened to repeatedly by three groups of researchers and research assistants. The key themes and responses were documented by each group, and the results compared to ensure accurate transcription. The results were then triangulated with those of the quantitative data to present the findings in a meaningful manner.
The validly completed questionnaires were entered into and analyzed using the Statistical Software for the Social Sciences (SPSS) version 20. After ascertaining data accuracy and completeness, simple frequency counts and percentage distribution tables of socio-demographic and immunization-related characteristics of the respondents and reasons for underutilization of immunization were generated. The association between maternal acceptance and utilization of immunization with their characteristics was tested using Pearson's Chi-square test (and Fisher's exact test where necessary). Also, odds ratios were used as appropriate, with the 95% confidence interval. The level of significance was set at p < 0.05.
Results
The analyses were based on 361 women. One questionnaire was excluded because it was incorrectly filled. The mean age of the women was 30.88±7.36 years.
| Table 1: Socio-demographic characteristics of the respondents |
Characteristics |
Frequency |
Percentage |
Age (years) |
≤ 19 |
3 |
0.8 |
20-29 |
161 |
44.6 |
30-39 |
138 |
38.2 |
≥ 40 |
59 |
16.3 |
Parity |
1 |
53 |
14.7 |
2-4 |
252 |
69.8 |
≥ 5 |
56 |
15.5 |
Marital Status |
Single |
21 |
5.8 |
Married |
319 |
88.4 |
Widowed |
4 |
1.1 |
Separated |
17 |
4.7 |
Religion |
Christianity |
55 |
15.2 |
Islam |
306 |
84.8 |
Occupation |
Unemployed |
19 |
5.3 |
Unskilled |
313 |
86.7 |
Semi-skilled |
22 |
6.1 |
Skilled/Professional |
7 |
1.9 |
Level of Education |
No formal |
52 |
14.4 |
Primary |
131 |
36.3 |
Secondary |
165 |
45.7 |
Tertiary |
13 |
3.6 |
Monthly Income (Naira) |
≤ 19,999 |
219 |
60.7 |
20,000-39,999 |
97 |
26.9 |
40,000-59,999 |
32 |
8.9 |
≥ 60,000 |
13 |
3.6 |
Table 1 displayed the socio-demographic characteristics of the respondents. Three (0.8%) of the respondents were teenagers, while 59 (16.3%) were aged 40 and above. Primiparous women accounted for 53 (14.7%), and grandmultiparous women made up 56 (15.5%) of the respondents. Majority of the women, 319 (88.4%) and 306 (84.8%), were married and of the Islamic faith respectively. Nineteen (5.3%) of the women who participated in the survey were unemployed, and only 13 (3.6%) had tertiary education. Low-income earners made up 219 (60.7%) of the respondents.
| Table 2: Immunization-related characteristics of the respondents, n = 357 |
Characteristics |
Frequency |
Percentage |
Acceptance of Childhood Immunization |
Yes |
353 |
98.9 |
No |
4 |
1.1 |
Completed Baby's Immunization |
Yes |
328 |
91.9 |
No |
29 |
8.1 |
Sources of Awareness |
Radio & Television |
100 |
28 |
Bill boards |
26 |
7.3 |
Town crier/announcer |
5 |
1.4 |
Healthcare practitioners |
226 |
63.3 |
Possession of a Vaccination Card/Record |
Yes |
350 |
98 |
No |
7 |
2 |
Child Immunized at Birth? |
Yes |
344 |
96.4 |
No |
13 |
3.6 |
Visits Government Facilities for the Routine Immunization |
Yes |
346 |
96.9 |
No |
11 |
3.1 |
Does Husband Support Immunizing Their Children? |
Yes |
340 |
95.2 |
No |
17 |
4.8 |
Any Health Facility Close to Her Residence? |
Yes (<3 kilometres) |
271 |
75.9 |
No (≥ 3 kilometres) |
86 |
24.1 |
Reasons for Non-Completion of Childhood Immunization, N = 29 |
Travelled out of the community |
9 |
31 |
Lack of support from the husband/financial constraints |
6 |
20.7 |
Forgetfulness/lost card |
4 |
13.8 |
Fear of side effects |
4 |
13.8 |
Mother too busy |
2 |
6.9 |
Mother lacks faith in immunization |
2 |
6.9 |
'I was sick' |
1 |
3.4 |
'My child was sick' |
1 |
3.4 |
Four out of the 361 respondents were not aware of childhood immunization. Among the respondents who were aware of immunization, four (1.1%) did not accept childhood immunization, while 328 (91.9%) utilized childhood immunization. Of the 357 (98.9%) women who were aware of childhood immunization, the majority, 226 (63.3%), were informed by health care workers. Seven (2%) women did not possess a vaccination record for their children, 13 (3.6%) women did not obtain immunization for their children at birth, while eleven (3.1%) waited for immunization campaign days before vaccinating their children. Also, 17 (4.8%) had husbands who did not support/agree with the immunization of their children. Regarding the proximity of the health facilities to the respondents' homes, 271 (75.9%) lived close to a health facility (Table 2).
| Table 3: Association between socio-demographic factors and respondents' acceptance of childhood immunization |
Variables |
Accepts immunization |
χ2 |
Odds Ratio (95% C. I.) |
p-value |
| |
Yes |
No |
|
|
|
| |
n (%) |
n (%) |
|
|
|
Age |
≤ 19 |
2(66.7) |
1(33.3) |
29.241 |
|
<0.001* |
20-29 |
159(99.4) |
1(0.6) |
|
|
|
30-39 |
135(98.5) |
2(1.54) |
|
|
|
≥ 40 |
57(100) |
0(0) |
|
|
|
Parity |
1 |
52(98.1) |
1(1.9) |
0.749 |
|
0.688 |
2-4 |
247(99.2) |
2(0.8) |
|
|
|
≥ 5 |
54(98.2) |
1(1.8) |
|
|
|
Religion |
Christianity |
53(98.1) |
1(1.9) |
0.307 |
0.530(0.054-5.192) |
0.483a |
Islam |
300(99) |
3(1) |
|
|
|
Marital Status |
Single |
41(100) |
0(0) |
0.525 |
1.013(1.000-1.026) |
0.469 |
Married |
312(98.7) |
4(1.3) |
|
|
|
Educational Level |
No formal |
50(98) |
1(2) |
0.626 |
|
0.891 |
Primary |
128(99.2) |
1(0.8) |
|
|
|
Secondary |
162(98.8) |
2(1.2) |
|
|
|
Tertiary |
13(100) |
0(0) |
|
|
|
Occupation |
Unemployed |
18(94.7) |
1(5.3) |
3.334 |
|
0.343 |
Unskilled |
306(99) |
3(1) |
|
|
|
Semi-skilled |
22(100) |
0(0) |
|
|
|
Skilled |
7(100) |
0(0) |
|
|
|
Income (Naira) |
≤19,999 |
215(99.5) |
1(0.5) |
4.747 |
|
0.191 |
20,000-39,999 |
94(96.9) |
3(3.1) |
|
|
|
40,000-59,999 |
32(100) |
0(0) |
|
|
|
60,000 and above |
12(100) |
0(0) |
|
|
|
Birth Place |
Medical facilities |
266(99.3) |
2(0.7) |
2.534 |
|
0.282 |
Church/TBA |
20(100) |
0(0) |
|
|
|
Home |
67(97.1) |
2(2.9) |
|
|
|
Husband Accepts/Supports |
Yes |
340(100) |
0(0) |
80.907 |
1.308(1.005-1.702) |
<0.001* |
No |
13(76.5) |
4(23.5) |
|
|
|
*significant at p <0.05; TBA: Traditional birth attendant; C.I.: Confidence interval; aFisher's exact |
From Table 3, teenagers were significantly less likely to accept immunization for their children compared with other age groups (p <0.001). Also, women whose husbands supported childhood immunization were more likely to be acceptors of immunization (100% versus 76.5%, p < 0.001).
| Table 4: Factors affecting utilization of routine immunization by the respondents, n = 357 |
Factors |
Utilization of immunization |
χ2 |
Odds Ratio (95% C.I.) |
p-value |
| |
Yes - n (%) |
No -n (%) |
|
|
|
Age (years) |
≤ 19 |
2(66.7) |
1(33.3) |
6.101 |
|
0.107 |
20-29 |
150(93.8) |
10(6.2) |
|
|
|
30-39 |
127(92.7) |
10(7.3) |
|
|
|
≥ 40 |
49(86) |
8(14) |
|
|
|
Religion |
Christianity |
50(92.6) |
4(7.4) |
0.044 |
1.12(0.38-3.37) |
1.000a |
Islam |
278(91.7) |
25(8.3) |
|
|
|
Educational Level |
No formal |
45(88.2) |
6(11.8) |
2.088 |
|
0.554 |
Primary |
119(92.2) |
10(7.8) |
|
|
|
Secondary |
151(92.1) |
13(7.9) |
|
|
|
Tertiary |
13(100) |
0(0) |
|
|
|
Marital Status |
Single |
40(97.6) |
1(2.4) |
2.005 |
3.89(0.515-29.371) |
0.227a |
Married |
288(91.1) |
28(8.9) |
|
|
|
Occupation |
Unemployed |
17(89.5) |
2(10.5) |
0.881 |
|
0.830 |
Unskilled |
284(91.9) |
25(8.1) |
|
|
|
Semi-skilled |
21(95.5) |
1(4.5) |
|
|
|
Skilled |
6(85.7) |
1(14.3) |
|
|
|
Income (Naira) |
≤19,999 |
207(95.8) |
9(4.2) |
14.352 |
|
0.002* |
20,000-39,999 |
83(85.6) |
14(14.4) |
|
|
|
40,000-59,999 |
29(90.6) |
3(9.4) |
|
|
|
60,000 and above |
9(75) |
3(25) |
|
|
|
Parity |
1 |
48(90.6) |
5(9.4) |
2.244 |
|
0.326 |
2-4 |
232(93.2) |
17(6.8) |
|
|
|
≥ 5 |
48(87.3) |
7(12.7) |
|
|
|
Husband Agrees/Supports |
Yes |
319(93.8) |
21(6.2) |
36.257 |
13.503(4.726-38.576) |
<0.001* |
No |
9(52.9) |
8(47.1) |
|
|
|
Birth Place |
Medical facilities |
250(93.3) |
18(6.7) |
8.374 |
|
0.015* |
Church/TBA |
15(75) |
5(25) |
|
|
|
Home |
63(91.3) |
6(8.7) |
|
|
|
Knows Time To Start |
Correct |
289(93.8) |
19(6.2) |
11.485 |
3.900(1.691-8.994) |
0.001* |
Wrong |
39(79.6) |
10(20.4) |
|
|
|
Knows Time To Stop |
Correct |
291(94.5) |
17(5.5) |
20.384 |
5.552(2.459-12.534) |
<0.001* |
Wrong |
37(75.5) |
12(24.5) |
|
|
|
Knows Vaccine At Birth |
Correct |
155(98.7) |
2(1.3) |
17.616 |
12.095(2.830-51.697) |
<0.001* |
Wrong |
173(86.5) |
27(13.5) |
|
|
|
Has Vaccination Card |
Yes |
328(93.7) |
22(6.3) |
80.756 |
|
<0.001*a |
No |
0(0) |
7(100) |
|
|
|
Commenced Immunization At Birth |
Yes |
320(93) |
24(7) |
16.638 |
8.333(2.530-27.443) |
<0.001* |
No |
8(61.5) |
5(38.5) |
|
|
|
Accepts Childhood Vaccination |
Yes |
328(92.9) |
25(7.1) |
45.754 |
|
<0.001*a |
No |
0(0) |
4(100) |
|
|
|
Facility-Based Vaccination |
Yes |
324(93.6) |
22(6.4) |
46.864 |
25.773(7.009-94.772) |
<0.001* |
No |
4(36.4) |
7(63.6) |
|
|
|
Knowledge |
Good |
143(99.3) |
1(0.7) |
43.654 |
|
<0.001* |
Fair |
175(89.7) |
20(10.3) |
|
|
|
Poor |
10(55.6) |
8(44.4) |
|
|
|
Facility Close To Residence |
Yes |
254(93.7) |
17(6.3) |
5.160 |
2.423(1.107-5.301) |
0.024* |
No |
74(86) |
12(14) |
|
|
|
Source Of Information |
Radio/Television |
93(93) |
7(7) |
14.553 |
|
0.002* |
Bill-board |
19(73.1) |
7(26.9) |
|
|
|
Town announcer |
4(80) |
1(20) |
|
|
|
Health worker |
212(93.8) |
14(6.2) |
|
|
|
*significant at p <0.05; TBA: Traditional birth attendant; C.I.: Confidence interval; aFisher's exact test |
In Table 4, factors that were associated with poor utilization of immunization were explored. Women whose husbands did not agree with or support childhood immunization were more likely to have their children incompletely immunized (47.1% versus 6.2%, p < 0.001). Other factors that were associated with poor utilization included non-acceptance of childhood immunization by the mother (100% versus 7.1%, p < 0.001), obtaining vaccination only during national campaign periods [instead of facility-based vaccination] (63.6% versus 6.4%, p < 0.001), not commencing immunization at birth (38.5% versus 7%, p < 0.001), not possessing a vaccination card (100% versus 6.3%, p < 0.001), and having no health centre close to their residence (14% versus 6.3%, p = 0.023). Respondents who gave birth in a medical facility (p = 0.015), with a low monthly income (p = 0.002), and who heard about childhood immunization from health workers (p = 0.002) were more likely to completely immunize their children. Utilization was significantly more likely to be incomplete in women who did not know the correct time of commencing (20.4% versus 6.2%, p = 0.001) or concluding (24.5% versus 5.5%, p < 0.001) the immunization schedule.
Discussion
Although the immunization coverage of children between 12 and 23 years in Ekiti State is above the national average, there is still much room for improvement. Every contributor to core welfare indicators must be explored in order to achieve the target of ensuring healthy lives and promotion of well-being in people of all ages. (22) Migration and health are closely interwoven and vital to sustainable development, thus the input of health statistics from migrant communities cannot be overlooked.
Our study was conducted in a highly immunization-aware migrant population, most of whom heard about childhood immunization from health workers during pregnancy and supplementary immunization campaigns. This is similar to findings in other studies from southern Nigeria, (1,9,10,19,23) and was corroborated by the interviews of the women and key informants:
I know about immunization. Children are vaccinated from birth till nine months when they will complete it. All my children have been immunized. (Mother of four, Muslim, Primary School leaver. Petty trader)
I know about immunization. It helps to prevent diseases in children. (25-year old businesswoman, Muslim, obtained National Diploma from the Polytechnic)
I am aware of childhood immunization; all our three children have completed their immunization. (30-year old Male, Muslim, Bricklayer, Educated up to Junior High School)
I knew about immunization from the officials conducting the immunization campaigns who came to the community. (Male, Community Head, Muslim)
We found that teenagers had the least likelihood of accepting immunization than the older age groups. This finding, which has also been observed by other authors (23) may be due to a number of factors. Firstly, they are likely to have lower educational attainment by virtue of their ages, and thus be less informed about immunization. Secondly, they may lack social support from a partner with resultant financial constraints. Thirdly, they may not be comfortable sitting with older women in designated health facilities, and thus prefer the covert scenario of the immunization campaign days with officials on
'house-to-house' visits. Fourthly, if it is culturally unacceptable for an Ebira teenager to be a mother, they could be stigmatized. This latter reason may lead to pregnancy denial, avoidance of health facilities for antenatal care, and possible home delivery, culminating in diminished exposure to correct information about immunization.
Ebira women in the lowest wealth quartile were most likely to complete their immunization schedule. Other studies have shown instead that low monthly income is a risk factor for incomplete vaccination due to barriers from transportation costs and essential healthcare bills. (5,24-26) However, among these non-native farm or migrant settlements, most of the low-income earners will work within the communities, thus creating more time for them to attend immunization clinics. More skilled workers in the higher wealth quartiles will generally be occupied outside of the communes, and frequently be unavailable for clinics. This was highlighted by the fact that nine (31%) of the women with incompletely immunized children missed the opportunities because they travelled out of their communities.
Immunization for children is well received in our community. I have also vaccinated all my children completely and was able to keep the clinic appointment. (Local hair stylist who works from home, Monthly income #2,500 [$7]).
I am aware of childhood immunization, and I have completely immunized all my children with support from my husband. It is beneficial to children indeed. I followed up on the appointment I was given for the various vaccinations. (Female who sells local corn-drink in the community, Monthly income #3,500 [$9.70])
Having a supportive spouse was the second most influential determinant of immunization utilization from this study, after centre-based vaccination. Oluwadare, (9) in his study of social determinants of routine immunization in Ekiti State, observed that the indigenous Yoruba women would generally settle the bills for immunization and participate in decision-making regarding childhood immunization as their levels of education and income appreciated. (27) However, this was not the case among the Muslim Ebira and Fulani migrants. During their focused group discussions, the men and women agreed that the women should seek the spouses' permission before taking the children for immunization. This will ensure that they receive the nods of their husbands for the hours spent outside the home at the clinics, and also get the financial support for the transportation to the clinics. (9)
I have no objections to the use of immunization for my children. I and my wife accept it wholeheartedly. I believe there are no side effects or negative outcomes from vaccinating the children, and they have completed their immunization. (29-year old Bricklayer, Male. Muslim)
I am aware of childhood immunization, and I support that my wife should get it for our children. All our three children have completed their immunization. (30-year old Male, Muslim, Bricklayer)
Women who gave birth in maternity centres owned by a church or traditional birth attendant were least likely to utilize immunization. Traditional birth attendants have been known to perpetuate a negative attitude in women towards medical facilities for their own social and economic interests. (28,29) If this is extended to immunization, it might create a significant barrier to utilization of immunization amongst Ebira women.
Correct knowledge about immunization led to an increased uptake among the population studied. Mothers who knew when to start, when to conclude and could describe the immunization given immediately after childbirth were more likely to completely immunize their children. Studies from both urban and rural areas have shown that the more knowledgeable mothers were about immunization, the greater the utilization. (30,31) Scaling up information dissemination regarding immunization, especially in the local dialect, will positively influence utilization.
Possession of a vaccination card was associated with increased uptake of immunization from this study. Higher rates of immunization coverage have also been reported among women who possessed immunization records for their children in another southern Nigerian study. (1) This may be due to the fact that the cards serve as a reminder for the immunization schedule. More than one-in-ten women in this study gave forgetfulness/loss of their child's vaccination card as the reason for incomplete immunization.
In the index study, mothers who visited the health facilities to obtain immunization for their children were at least 25 times more likely to fully immunize their children than those who only waited for the national immunization campaign days. Also, more mothers completed their children's immunization schedule when they lived close enough to a health facility. Some of the migrant communities are situated in not-too-easy to access locations. Immunization campaigns may fail to hold for a long time due to lack of refrigerators (to maintain the cold chain) and all-terrain vehicles, suboptimal financial support for the project and workers, and poor road networks. (9) The result is that children miss their vaccines when due. This was corroborated by a mother during an interview:
The timing of commencing the immunization varies: for example, those who give birth in the hospital are given immediately; but when people give birth at home, they need to take their children to the health facility, and this may take some days before they start the process. Also, the immunization officers come to the community to ask for women who just gave birth for the vaccination of their babies. After I waited for them for some days without seeing them, I decided to go to the health facility for the immunization about two weeks after delivery. (21-year old apprentice Traditional Birth Attendant).
Another reason for non-utilization was the fear of side effects and the mothers' lack of faith in immunization.
I believe that the government will not offer something harmful to its citizens. Concerning the side effects that people talk about, I personally feel that the vaccines are not harmful. However, it may be that the way it was administered could lead to the weakness of the leg, but many people do not understand this. (35-year old Father of two, 5 years & one-and-half years, Muslim, Carpenter, Secondary School leaver)
Some people refuse to allow their children to be immunized because they say they have never practiced it before. Others say they will not take it because they heard that in some homes, children were known to have died at night after immunization. (Male, Community Head, Muslim)
Ten years ago, it was reported that some communities of Muslim settlers from north central Nigeria were encountered in Ekiti State who had little or even no knowledge of immunization, and that most of the typically remote rural settlements had not immunized their children against any of the childhood diseases. (9) The picture appears brighter now with the results from this study. Although the strides towards achieving beyond 90% immunization coverage in Ekiti State appear to be slow, the target can still be met if steady steps are taken in the right direction. Some developing countries are still taking giant strides towards achieving this goal. For example, a study from rural Mozambique reported coverage of 71%. (32) To be more impactful, these
'slow and steady steps' that have brought Ekiti State thus far should now include public health strategies that are premised on an understanding of the socio-cultural peculiarities of its migrant communities. (33,34) Some of the key informants (community leaders) also hinted on measures they employed to increase immunization utilization among their Ebira women:
Whenever the officials conducting the immunization campaigns come to the community, children are brought to them for the immunization. Truly, some parents are reluctant to allow their children to be vaccinated, but we usually encourage the parents to bring out their children for vaccination. We do this through the information we give them during the mosque service on Fridays. I support childhood immunization because it has helped to eliminate the incidence of convulsions which we have noticed in our community before. In the past, we could have up to eight children dying per month, but as we have persistently encouraged them to participate in the immunization programme of the government, things are better now. We even tell those who refuse to participate to leave our commune, because once their children suffer from a disease, they will spread to the others. (Muslim cleric and Community Leader)
Some people who were influenced by the ideologies of the Hausa migrants also refused to allow their children to be vaccinated. But, after explaining the benefits to them, they are now accepting to vaccinate their children. (Community Chief)
These strategies of information dissemination through a religious medium and grass root advocacy could be further improved upon to scale up immunization uptake amongst all Ebira communes, just as was done against girl-child discrimination by Islamic clerics in Azerbaijan. (35)
A limitation to this study is its self-reported evidence of immunization utilization among the Ebira mothers, with its attendant possibility of over- and under-reporting. However, the bias was partly mitigated by the use of both quantitative and qualitative data. Further research should address this issue and also evaluate uptake of individual vaccines and ascertain specific reasons for dropping out.
In conclusion, we found that Ebira teenagers were least likely to accept childhood immunization. However, contrary to many studies among relatively affluent and native communities, Ebira women in the highest wealth quartile were least likely to completely immunize their children. Other determinants of utilization include spousal support, knowledge of the women about immunization, distance between their homes and the health facilities, having their babies delivered in a health facility, and obtaining vaccination in a centre rather than waiting for immunization campaign programmes. Ekiti State has made progress in reaching the remote communes of migrant Ebira, but steady steps including co-opting community leaders and religious clerics as strong advocates for childhood immunization amongst the Ebira populace, could still complement public health interventions towards achieving universal coverage.
Acknowledgement
The authors acknowledge the contributions of the Head of Nursing Unit in the Local Government Primary Health Care Development Agency, and the Community Leaders of the Ebira communities used in the survey.
Conflict of Interest: The authors declare that there are no competing interests regarding this work.
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