Applied Research and Evaluation
Compliance With Regimens of Existing Vaccines in Orumba North Local Government Area of Anambra State, Nigeria
International Quarterly of Community Health Education 2015, Vol. 35(2) 120–132 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X15569485 qch.sagepub.com
Nkechi Onyeneho1, Ijeoma Igwe1, Ngozi I’Aronu1, and Uzoma Okoye2
Abstract The factors associated with third dose of diphtheria, pertussis and tetanus (DPT3) uptake, a true indicator of compliance with required regimen of vaccines, in Anambra state, Nigeria, were investigated in a cross-sectional survey of 600 mothers (15–49). Being an older mother showed a positive association with compliance. Compliance was more among those who used the government health facilities for their health needs (2 ¼ 12.286, p < .001). Satisfactory experiences with health service influenced compliance (2 ¼ 8.542, p ¼ .002). Those with good perception (30.1%) complied more (2 ¼ 42.572, p < .001). Those who were aware that immunization protects the children against vaccine preventable diseases complied more (2 ¼ 8.735, p ¼ .002). In conclusion, the action-hesitancy model strengthens the Health Belief Model in explaining parents’ attitude to childhood immunization, as experience and perception of the health service influenced uptake more. Health education and campaigns should be directed at factors that would encourage mothers to adopt required behaviours. Keywords child, compliance, diseases, immunization, vaccines, Nigeria
1 2
Department of Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria Department of Social Work, University of Nigeria, Nsukka, Nigeria
Corresponding Author: Nkechi Onyeneho, Department of Sociology/Anthropology, University of Nigeria, Nsukka, Enugu, Nigeria. Email: [email protected]
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Introduction Given the tremendous success of childhood vaccination in preventing disease, disability, and death associated with polio,1 perceived risks from vaccine preventable diseases have diminished.2 However, the perceived risks of vaccination seem to have increased and the value decreased among parents.3,4 Parental attitudes and beliefs about vaccines are an important factor in predicting a child’s immunization status.5 Evidence from various literature suggests that mothers seem to lack sufficient information about immunization.2,6–8 The traditional vaccine information statements, which providers are required by law to provide to parents (National Childhood Vaccine Injury Act of 1986), have been criticized for their high reading level and for containing insufficient information.9 Scientists had relied on their credibility and the weight of the scientific evidence that demonstrated the safety and efficacy of vaccine to convince hesitant parents, who had concerns about vaccine safety or efficacy, to vaccinate their children.10,11 Yet, parents’ concerns about the vaccine persisted and many openly or indirectly keep away from vaccinating their children.11–15 The resurgence of more polio epidemics in countries where previous transmission has been interrupted point to the fact that development of safe and effective vaccines alone was not sufficient to prevent epidemics.2 These realities show that understanding the reasons why parents failed to present their children for vaccination as well as knowing more effective ways of persuading them are germane to successful prevention of epidemics. A number of efforts have been made to explain parents’ failure to get their children vaccinated. From a systematic review of existing literature, Rosenstock et al.11 noted that there were four psychosocial domains that influenced parents’ decisions to vaccinate their children. These domains were listed as “(1) susceptibility—parents’ assessment of their child’s risk of getting polio; (2) seriousness—their assessment of whether polio was a sufficient health concern to warrant vaccination; (3) efficacy and safety—their assessment of whether vaccinating their child can reduce the chance of their child getting polio, and whether the vaccine is safe; and (4) social pressures and convenience—the concerns and influences that facilitated or discouraged their decision to get their child vaccinated”.16 These factors provided the foundation for the celebrated Health Belief Model (HBM) in public health, as a way of explaining why people adopt behaviors that lead to healthy lives.16–24 However, Buturovic-Bradaric25 argued that contrary to the consequentialist models, which guided most studies of decision-making, the action-hesitancy model aimed at articulating a non-consequentialist to address a broad class of decision-making phenomena, including some that have so far been neglected by decision-making literature. According to this model, people strive to make obvious decisions and act without hesitation. When hesitant, they seek new
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information in order to transform the appraisal of their situation in such a way as to make the course of action obvious. In this paradigm, a perception of obviousness of vaccination is manipulated by introduction of irrelevant alternatives into the choice set. Changes in this perception, in turn, affect the stated probability of presenting one’s child for vaccination and willingness to change one’s choice in directions, irrespective of campaigns, consistent with predictions of the action-hesitancy model. The African Regional target is to reach everyone with effective vaccines and surpass the targets of the fourth and fifth Millennium Development Goals by 2015. DPT3 coverage was raised from 5% in 1974 to 74% in 2010 in the regions11–13 By 2012, 81% (27/33) of the countries at risk for yellow fever had introduced the vaccination into expanded programme on immunization (EPI) schedules14 as against 27% (9/33) in 2000.12 All the same, the region’s DPT coverage, and indicator of the success of a country’s immunization programmes, has stagnated at 71%. In Nigeria, it is as low as 41% in 2012, indicating a very low compliance with the required and existing vaccines.26 This article presents results of a study to identify the factors associated with compliance to required regimen of existing vaccine antigens in Anambra state, Nigeria. The conclusion of the study would help in designing programmes to ensure compliance to compliance with immunization recommendation and reach every child with effective vaccines.
Methods Research Design and Setting This study adopted the cross-sectional survey research design in generating data to answer the research questions as well as test the hypotheses. The study is located in Anambra state, one of the 36 states of Nigeria. The state is situated in the southeast geopolitical zone of the country and derives its name from Anambra river which is a tributary of the River Niger. The state lies on a rolling flat land on the eastern plains of the River Niger. It covers an area of 4,416 square kilometres and has typical semitropical rainforest vegetation, a humid climate with a mean temperature of about 870 F and a rainfall of between 152 and 203 cm. Anambra state shares a common border with Enugu state, Imo state, Delta state, and Kogi state. It has an estimated population of 4,418,032 in 2006 with an annual growth rate of 2.8%.27 This is projected to 4,801,235 in 2011. The ratio of men to women is 108 men to every 100 women. Anambra state is made up of 21 local government areas (LGAs) which is further divided into 330 political wards and approximately 1394 communities. There are estimated 717,663 households and 456 health facilities including 21 general hospitals, 232 primary health care centers (PHCs), 189 health posts, 11 comprehensive health centers,
Onyeneho et al.
123
and 3 cottage hospitals. There are also patent medicine vendors scattered in both urban and rural communities. This study however is limited to Orumba North LGA. Going by the 2006 population census, it has a population of 172,405. The 2011 projection gives the LGA a population of 197,932 with a landmass of about 32.4 square kilometres. Orumba North consists of 16 communities namely Ajalli, Amaetiti, Amaopkala, Awa, Awgbu, Nanka, Ndikelionwu, Ndiokpaleke, Ndiokpaleze, Ndiokolo, Ndiukwuenu, Ndiowu, Oko, Okpeze, Omogho, and Ufuma. The choice of Orumba North LGA, a typical rural area, for this study, is because infant and child mortality are higher in the rural areas. For instance, the 2008 Nigeria Demographic and Health Survey (NDHS) found that child mortality in the rural areas was 106/1000 compared to 58/1000 in the urban communities.28 Further, Orumba North LGA is also well known to the researcher. She originates from this LGA and this enhances the feasibility of the study. The major source of income for the people in this area is agriculture, and as a result they produce cassava, yam, palm wine, and raffia. Apart from farming, the people in this area are also traders and very few of them engage in white collar jobs. However, most of the residents of these communities are poor as this affects negatively their state of health and children are at the receiving end of all these.
Participants The target population for this study consists of all mothers of child-bearing age (15–49) in the LGA. This constitutes 22% of the total population.27 Thus, the target population in 2011 is estimated at 43,545. The focus on this segment of the population is justified with the fact that women are closer to their children and are known to be the providers of child health in the household. They have also experienced the problem with access to health care due to a complex of factors.29 Using a 51.9% PHC access rate in the country28 and a confidence interval of 95% with an estimated 4 percentage error margin, a sample size of 599 respondents was computed. The sample size was, however, rounded up to 600 respondents. A multistage cluster sampling procedure, which entails successive selection of community clusters, villages, housing units, and respondents was employed. First, the communities were grouped into two clusters A and B based on their proximity to the tarred “federal” road traversing the LGA. Cluster A is made up of seven communities close to the tarred road, namely Nanka, Oko, Amaokpala, Ndikelionwu, Omogho, Ufuma, and Ajalli. Cluster B is made up of nine communities remote from the tarred road, namely Ndiowu, Ndiokpalaeke, Ndiokpalaeze, Ndiokolo, Awgbu, Okpeze, Ndiukwuenu, Amaetiti, and Awa.
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Two communities are randomly selected from each cluster. Three villages are randomly selected from each of the four chosen communities, making it 12 villages in all. In each chosen village, all the dwelling units or compounds are numbered, out of which a sample of 50 dwelling units are selected using the systematic sampling technique. In each selected dwelling unit, one eligible respondent was selected purposively, taking into account the age and number of children.
Data Collection An interviewer-based questionnaire designed to provide information on the sociodemographic characteristics of the respondents as well as their childrearing experiences was used. The questionnaire also provided data on the women’s use of immunization services.
Data Processing and Analysis The data were processed and analyzed with EPI Info version 6 and SPSS version 19, respectively. Descriptive statistics such as percentages and frequency tables were employed in characterizing the respondents. Correlation analyses were also done using chi-square (2) and the Pearson’s r to illustrate the relationship between certain sociodemographic variables and use of immunization services among the respondents.
Limitations of the Study The main limitation of the study was the absence of health workers in the health centers. Efforts to get health workers in some of the health centers were unsuccessful. The study would have benefited from the views of the health workers on the people’s attitude to child immunization as well as suggestions on how to ensure every child is fully immunized, with existing vaccines against childhood illnesses. It will thus be necessary to suggest another study to cover this gap in information.
Results The women, in this study, were aged between 15 and 49 years with mean age of 35.2 years (35.2 6.96 SD). Christians of all denominations dominated both the samples. Almost 86% (85.7%) of the women enlisted in the study were married and in union. About 7% (6.7%) of the respondents were single. In terms of educational attainment of respondents, 94% have had formal education. About a quarter (26.7%) of the respondents were farmers while another 6% were unemployed. Others were engaged in some form of paid employment. See Table 1 for details.
Onyeneho et al.
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Table 1. Demographic Characteristics of Respondents. Characteristics Age group 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Marital status Married Single Separated/divorced Widowed Occupation Farming Trading Business Artisan Civil servant Unemployed/housewife Education No formal education Primary school Secondary school Tertiary Religious affiliation Catholic Anglican Pentecostal Islam African traditional religion
Frequency (N ¼ 600)
Percentages (100)
5 21 107 156 149 87 75
0.8 3.5 17.8 26 24.8 14.5 12.5
514 40 5 41
85.7 6.7 0.8 6.8
160 209 103 57 35 36
26.7 34.8 17.2 9.5 5.8 6
36 224 273 47
6 40.7 45.5 7.8
252 222 118 3 5
42 37 19.7 0.5 0.8
Over 90% (98.2%) of the respondents had heard about immunization and have ever brought out their children to be immunized against vaccine preventable diseases. Over 70% (77.7%) of the women demonstrated knowledge of the benefits of vaccines for child survival. However, only 19.3% had adequate immunization for the age of their babies at the time of the survey.
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Table 2. Factors Associated With Uptake of Complete Vaccine Antigens for Child Survival. Factor Age
Category
Young mother (15–29) Older mothers (30–49) Marital status Ever married Never married Ever attended school Yes No Work for pay? Yes No Religion Orthodox Christian Others Use health facility Yes No Experience with Satisfied health service Dissatisfied Perception of health service Good (6–12) Poor (0–5) Immunization protects child Yes No Knowledge of immunization Good Poor
Number
% complete antigens
133 467 40 560 564 36 404 196 474 126 491 109 289 311 292 308 466 134 462 138
14.3 20.8 19.3 20 19.1 22.2 20.3 17.3 18.8 21.4 22 7.3 24.2 14.8 30.1 9.1 21.9 10.4 21.9 10.9
2
p
2.792
.058
0.012
.524
0.205
.393
0.736
.228
0.449
.290
12.286
Compliance With Regimens of Existing Vaccines in Orumba North Local Government Area of Anambra State, Nigeria
International Quarterly of Community Health Education 2015, Vol. 35(2) 120–132 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X15569485 qch.sagepub.com
Nkechi Onyeneho1, Ijeoma Igwe1, Ngozi I’Aronu1, and Uzoma Okoye2
Abstract The factors associated with third dose of diphtheria, pertussis and tetanus (DPT3) uptake, a true indicator of compliance with required regimen of vaccines, in Anambra state, Nigeria, were investigated in a cross-sectional survey of 600 mothers (15–49). Being an older mother showed a positive association with compliance. Compliance was more among those who used the government health facilities for their health needs (2 ¼ 12.286, p < .001). Satisfactory experiences with health service influenced compliance (2 ¼ 8.542, p ¼ .002). Those with good perception (30.1%) complied more (2 ¼ 42.572, p < .001). Those who were aware that immunization protects the children against vaccine preventable diseases complied more (2 ¼ 8.735, p ¼ .002). In conclusion, the action-hesitancy model strengthens the Health Belief Model in explaining parents’ attitude to childhood immunization, as experience and perception of the health service influenced uptake more. Health education and campaigns should be directed at factors that would encourage mothers to adopt required behaviours. Keywords child, compliance, diseases, immunization, vaccines, Nigeria
1 2
Department of Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria Department of Social Work, University of Nigeria, Nsukka, Nigeria
Corresponding Author: Nkechi Onyeneho, Department of Sociology/Anthropology, University of Nigeria, Nsukka, Enugu, Nigeria. Email: [email protected]
Onyeneho et al.
121
Introduction Given the tremendous success of childhood vaccination in preventing disease, disability, and death associated with polio,1 perceived risks from vaccine preventable diseases have diminished.2 However, the perceived risks of vaccination seem to have increased and the value decreased among parents.3,4 Parental attitudes and beliefs about vaccines are an important factor in predicting a child’s immunization status.5 Evidence from various literature suggests that mothers seem to lack sufficient information about immunization.2,6–8 The traditional vaccine information statements, which providers are required by law to provide to parents (National Childhood Vaccine Injury Act of 1986), have been criticized for their high reading level and for containing insufficient information.9 Scientists had relied on their credibility and the weight of the scientific evidence that demonstrated the safety and efficacy of vaccine to convince hesitant parents, who had concerns about vaccine safety or efficacy, to vaccinate their children.10,11 Yet, parents’ concerns about the vaccine persisted and many openly or indirectly keep away from vaccinating their children.11–15 The resurgence of more polio epidemics in countries where previous transmission has been interrupted point to the fact that development of safe and effective vaccines alone was not sufficient to prevent epidemics.2 These realities show that understanding the reasons why parents failed to present their children for vaccination as well as knowing more effective ways of persuading them are germane to successful prevention of epidemics. A number of efforts have been made to explain parents’ failure to get their children vaccinated. From a systematic review of existing literature, Rosenstock et al.11 noted that there were four psychosocial domains that influenced parents’ decisions to vaccinate their children. These domains were listed as “(1) susceptibility—parents’ assessment of their child’s risk of getting polio; (2) seriousness—their assessment of whether polio was a sufficient health concern to warrant vaccination; (3) efficacy and safety—their assessment of whether vaccinating their child can reduce the chance of their child getting polio, and whether the vaccine is safe; and (4) social pressures and convenience—the concerns and influences that facilitated or discouraged their decision to get their child vaccinated”.16 These factors provided the foundation for the celebrated Health Belief Model (HBM) in public health, as a way of explaining why people adopt behaviors that lead to healthy lives.16–24 However, Buturovic-Bradaric25 argued that contrary to the consequentialist models, which guided most studies of decision-making, the action-hesitancy model aimed at articulating a non-consequentialist to address a broad class of decision-making phenomena, including some that have so far been neglected by decision-making literature. According to this model, people strive to make obvious decisions and act without hesitation. When hesitant, they seek new
122
International Quarterly of Community Health Education 35(2)
information in order to transform the appraisal of their situation in such a way as to make the course of action obvious. In this paradigm, a perception of obviousness of vaccination is manipulated by introduction of irrelevant alternatives into the choice set. Changes in this perception, in turn, affect the stated probability of presenting one’s child for vaccination and willingness to change one’s choice in directions, irrespective of campaigns, consistent with predictions of the action-hesitancy model. The African Regional target is to reach everyone with effective vaccines and surpass the targets of the fourth and fifth Millennium Development Goals by 2015. DPT3 coverage was raised from 5% in 1974 to 74% in 2010 in the regions11–13 By 2012, 81% (27/33) of the countries at risk for yellow fever had introduced the vaccination into expanded programme on immunization (EPI) schedules14 as against 27% (9/33) in 2000.12 All the same, the region’s DPT coverage, and indicator of the success of a country’s immunization programmes, has stagnated at 71%. In Nigeria, it is as low as 41% in 2012, indicating a very low compliance with the required and existing vaccines.26 This article presents results of a study to identify the factors associated with compliance to required regimen of existing vaccine antigens in Anambra state, Nigeria. The conclusion of the study would help in designing programmes to ensure compliance to compliance with immunization recommendation and reach every child with effective vaccines.
Methods Research Design and Setting This study adopted the cross-sectional survey research design in generating data to answer the research questions as well as test the hypotheses. The study is located in Anambra state, one of the 36 states of Nigeria. The state is situated in the southeast geopolitical zone of the country and derives its name from Anambra river which is a tributary of the River Niger. The state lies on a rolling flat land on the eastern plains of the River Niger. It covers an area of 4,416 square kilometres and has typical semitropical rainforest vegetation, a humid climate with a mean temperature of about 870 F and a rainfall of between 152 and 203 cm. Anambra state shares a common border with Enugu state, Imo state, Delta state, and Kogi state. It has an estimated population of 4,418,032 in 2006 with an annual growth rate of 2.8%.27 This is projected to 4,801,235 in 2011. The ratio of men to women is 108 men to every 100 women. Anambra state is made up of 21 local government areas (LGAs) which is further divided into 330 political wards and approximately 1394 communities. There are estimated 717,663 households and 456 health facilities including 21 general hospitals, 232 primary health care centers (PHCs), 189 health posts, 11 comprehensive health centers,
Onyeneho et al.
123
and 3 cottage hospitals. There are also patent medicine vendors scattered in both urban and rural communities. This study however is limited to Orumba North LGA. Going by the 2006 population census, it has a population of 172,405. The 2011 projection gives the LGA a population of 197,932 with a landmass of about 32.4 square kilometres. Orumba North consists of 16 communities namely Ajalli, Amaetiti, Amaopkala, Awa, Awgbu, Nanka, Ndikelionwu, Ndiokpaleke, Ndiokpaleze, Ndiokolo, Ndiukwuenu, Ndiowu, Oko, Okpeze, Omogho, and Ufuma. The choice of Orumba North LGA, a typical rural area, for this study, is because infant and child mortality are higher in the rural areas. For instance, the 2008 Nigeria Demographic and Health Survey (NDHS) found that child mortality in the rural areas was 106/1000 compared to 58/1000 in the urban communities.28 Further, Orumba North LGA is also well known to the researcher. She originates from this LGA and this enhances the feasibility of the study. The major source of income for the people in this area is agriculture, and as a result they produce cassava, yam, palm wine, and raffia. Apart from farming, the people in this area are also traders and very few of them engage in white collar jobs. However, most of the residents of these communities are poor as this affects negatively their state of health and children are at the receiving end of all these.
Participants The target population for this study consists of all mothers of child-bearing age (15–49) in the LGA. This constitutes 22% of the total population.27 Thus, the target population in 2011 is estimated at 43,545. The focus on this segment of the population is justified with the fact that women are closer to their children and are known to be the providers of child health in the household. They have also experienced the problem with access to health care due to a complex of factors.29 Using a 51.9% PHC access rate in the country28 and a confidence interval of 95% with an estimated 4 percentage error margin, a sample size of 599 respondents was computed. The sample size was, however, rounded up to 600 respondents. A multistage cluster sampling procedure, which entails successive selection of community clusters, villages, housing units, and respondents was employed. First, the communities were grouped into two clusters A and B based on their proximity to the tarred “federal” road traversing the LGA. Cluster A is made up of seven communities close to the tarred road, namely Nanka, Oko, Amaokpala, Ndikelionwu, Omogho, Ufuma, and Ajalli. Cluster B is made up of nine communities remote from the tarred road, namely Ndiowu, Ndiokpalaeke, Ndiokpalaeze, Ndiokolo, Awgbu, Okpeze, Ndiukwuenu, Amaetiti, and Awa.
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Two communities are randomly selected from each cluster. Three villages are randomly selected from each of the four chosen communities, making it 12 villages in all. In each chosen village, all the dwelling units or compounds are numbered, out of which a sample of 50 dwelling units are selected using the systematic sampling technique. In each selected dwelling unit, one eligible respondent was selected purposively, taking into account the age and number of children.
Data Collection An interviewer-based questionnaire designed to provide information on the sociodemographic characteristics of the respondents as well as their childrearing experiences was used. The questionnaire also provided data on the women’s use of immunization services.
Data Processing and Analysis The data were processed and analyzed with EPI Info version 6 and SPSS version 19, respectively. Descriptive statistics such as percentages and frequency tables were employed in characterizing the respondents. Correlation analyses were also done using chi-square (2) and the Pearson’s r to illustrate the relationship between certain sociodemographic variables and use of immunization services among the respondents.
Limitations of the Study The main limitation of the study was the absence of health workers in the health centers. Efforts to get health workers in some of the health centers were unsuccessful. The study would have benefited from the views of the health workers on the people’s attitude to child immunization as well as suggestions on how to ensure every child is fully immunized, with existing vaccines against childhood illnesses. It will thus be necessary to suggest another study to cover this gap in information.
Results The women, in this study, were aged between 15 and 49 years with mean age of 35.2 years (35.2 6.96 SD). Christians of all denominations dominated both the samples. Almost 86% (85.7%) of the women enlisted in the study were married and in union. About 7% (6.7%) of the respondents were single. In terms of educational attainment of respondents, 94% have had formal education. About a quarter (26.7%) of the respondents were farmers while another 6% were unemployed. Others were engaged in some form of paid employment. See Table 1 for details.
Onyeneho et al.
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Table 1. Demographic Characteristics of Respondents. Characteristics Age group 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Marital status Married Single Separated/divorced Widowed Occupation Farming Trading Business Artisan Civil servant Unemployed/housewife Education No formal education Primary school Secondary school Tertiary Religious affiliation Catholic Anglican Pentecostal Islam African traditional religion
Frequency (N ¼ 600)
Percentages (100)
5 21 107 156 149 87 75
0.8 3.5 17.8 26 24.8 14.5 12.5
514 40 5 41
85.7 6.7 0.8 6.8
160 209 103 57 35 36
26.7 34.8 17.2 9.5 5.8 6
36 224 273 47
6 40.7 45.5 7.8
252 222 118 3 5
42 37 19.7 0.5 0.8
Over 90% (98.2%) of the respondents had heard about immunization and have ever brought out their children to be immunized against vaccine preventable diseases. Over 70% (77.7%) of the women demonstrated knowledge of the benefits of vaccines for child survival. However, only 19.3% had adequate immunization for the age of their babies at the time of the survey.
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Table 2. Factors Associated With Uptake of Complete Vaccine Antigens for Child Survival. Factor Age
Category
Young mother (15–29) Older mothers (30–49) Marital status Ever married Never married Ever attended school Yes No Work for pay? Yes No Religion Orthodox Christian Others Use health facility Yes No Experience with Satisfied health service Dissatisfied Perception of health service Good (6–12) Poor (0–5) Immunization protects child Yes No Knowledge of immunization Good Poor
Number
% complete antigens
133 467 40 560 564 36 404 196 474 126 491 109 289 311 292 308 466 134 462 138
14.3 20.8 19.3 20 19.1 22.2 20.3 17.3 18.8 21.4 22 7.3 24.2 14.8 30.1 9.1 21.9 10.4 21.9 10.9
2
p
2.792
.058
0.012
.524
0.205
.393
0.736
.228
0.449
.290
12.286
