TABLE
OF CONTENTS
Title
Page – – – – – – – – – i
Certification
– – – – – – – – – ii
Dedication – – – – – – – – – iii
Acknowledgement – – – – – – iv
Table
of Contents – – – – – – – – v
List of Tables – – – – – – – – viii
Abstract – – – – – – – – – x
CHAPTER ONE:
INTRODUCTION
Background to the Study – – – – – – – 1
Statement of the Problem – – – – – 9
Purpose of the Study – – – – – – 11
Research Questions – – – – – – – – 12
Hypotheses – – – – – – – – – 13
Significance of the Study – – – – – 13
Scope of the Study – – – – – – – – 15
Operational Definition of Terms – – – – – 15
CHAPTER TWO: LITERATURE
REVIEW
Conceptual Review – – – – – – 18
- Concept of Routine Immunization – – – 21
- Routine Immunization Targeted Diseases the Immunization Schedules- 24
- Immunization Uptake:Benefits – – 27
- Consequences of Lack/Low Routine Immunization Uptake- 28
- Need for Improvement of Routine Immunization Uptake – 29
- Strategies for Improvement of Uptake of Immunization Services 30
- Reminders and Recalls – – – 32
- Benefits of Reminders and Recalls – – – 32
- Benefits of Improving Immunization Uptake Rate – 34
Theoretical Review – – – – – – 35
- The Health Belief Model (HBM) – – – – 35
- Application of the Theory to the Study – – 37
Empirical Studies – – – – – – 38
Summary of Literature Review – – – – – – 46
CHAPTER THREE –
RESEARCH METHOD
Research Design – – – – – – – 48
Area of Study – – – – – – – 49
Population for the Study – – – – – 50
Sample – – – – – – – 51
Inclusion Criteria – – – – – – 51
Sampling Procedure – – – – – – 52
Instrument for Data Collection – – – – – 53
Validity of the Instrument – – – – – 54
Reliability of the Instrument – – – – – – 54
Ethical Consideration – – – – – – 55
Procedure for Data Collection – – – – 55
Pre-Intervention Data – – – – – 55
Experimental Group–Intervention – – – – 56
Control Group – – – – – – – 57
Post Test – – – – – – – – – 57
Methods of Data Analysis – – – – – – 58
CHAPTER
FOUR: PRESENTATION OF RESULTS
Summary of Major Findings 74
CHAPTER
FIVE: DISCUSSION OF FINDINGS
Discussion – – – – – – 77
Implications of the Study – – – – 84
Limitations – – – – – 87
Suggestions for Further Study – – – – 88
Summary of the Study – – – – – 88
Conclusion – – – – – – – 91
Recommendations – – – – – – 93
References – – – – – – 94
Appendices – – – – – – – 100
LIST
OF TABLES
Table 1: Summary of WHO position papers- recommended routine immunization for children – – – – – 24
Table 2: Nigeria’s Childhood Routine Immunization Schedule – 25
Table 3: 2 x 2 Factorial Quasi Experimental Design – 48
Table 4: Demographic Characteristics of Respondents – 60
Table
5: Pre and Post Intervention Rate of Immunization Uptake in the
Experimental
Groups – – – – – – – 61
Table 6: Rate of Completion of the Three Scheduled Immunization Appointments by Mothers in the Experimental Groups – – 63
Table
7: Pre and Post Intervention Rate of Immunization Uptake in the Control Groups – – – – – – – – 65
Table 8: Rate of Completion of the Three Scheduled Immunization Appointments by Mothers in the Control Groups — – – 67
Table
9: Comparison between the Post-intervention Rates of Uptake of the Experimental
and Control Groups Controlling their Rates of Uptake Pre-Intervention – – – – – – – 68
Table 10: Comparison between the Post-intervention Rates of Immunization Uptake of the Experimental and Control Groups in the Urban Community Controlling their Rates of Immunization Uptake Pre-Intervention -69
Table 11: Comparison between the Post-intervention Rates of Immunization Uptake of the Experimental and Control Groups in the Rural Community Controlling their Rates of Immunization Pre-Intervention – – 70
Table 12: Comparison between the post-intervention rates of immunization uptake of the Experimental Groups’ In the Rural and Urban Locations Controlling their Pre-intervention immunization rates – – 71
Table 13: Comparison between Post-intervention Immunization
Uptake Rates of the Experimental and Control groups in the Rural
and Urban Locations Controlling their Pre-Intervention
Immunization Rates – 72
Table 14: Comparison between the Post-intervention Immunizations Rates of Uptake of the Control Groups in the Rural and Urban Locations Controlling their Pre-Intervention Immunization Uptake Rate – – 73
ABSTRACT
The
need to improve uptake of routine immunizations by mothers using reminder and
recall strategies so as to prevent childhood vaccine-preventable diseases is a
global public health concern. Globally, about 1.5 million children still die
yearly from vaccine-preventable diseases. In Nigeria, 62.8% children are not
immunized while 36.4% of children were partially immunized due to poor uptake.
The Taraba State W.H.O. reports for 2011-2014 showed hat uptake of routine
immunization was less then 50% in 14 out of the 16 L.G.As as about 87.5% of
mothers missed their routine immunization appointments. Previous empirical
studies have found that reminding and recalling mothers for their immunization
appointments improve their rate of immunization uptake but no such studies have
been done in Taraba State. The study was designed to find the efficacy of
telephone call reminders and recalls in improving uptake of routine
immunization services in Taraba State. Five objectives were formulated, five
corresponding research questions posed and five hypotheses postulated for
verification. A quasi-experimental research design was used for the study. The instruments for data collection were two
pre and post-intervention immunization checklists. Reliability test yielded a
co-efficient index of 0.72. The population was 1000 while the sample size was
100 mothers of 0-1 year olds coming for routine immunization at the time of the
study. Data was analyzed using descriptive statistics, the McNemar’s test and
ANCOVA. The major results of the study were that: the total mean rate of uptake
for the scheduled visits for the three antigens by the experimental groups pre-intervention
was 1.50+0.71 and 2.74+0.44 post-intervention and for the control
groups pre-intervention, it was 1.74+0.53 and 1.98+0.62 post
intervention; there was a significant
difference between the pre and post-intervention uptake of the experimental
groups; there was no statistically significant difference between the rate of
uptake of majority of the antigens by the control groups in the pre- and
post-invention periods; there was a significant difference in the rates of
uptake between the experimental and control groups; there was no significant
difference between the uptake of the experimental groups in the rural and urban
locations; there were no significant difference between the rate of uptake of
the experimental and control groups in the rural and urban locations.
Recommendations were that effective current communication strategies like
telephone calls used to remind and recall mothers to ensure improvement in
uptake of routine immunization services in both rural and urban locations.
CHAPTER
ONE
INTRODUCTION
Background
to the Study
The need to use immunization reminders
and recalls for mothers to ensure continued uptake of routine immunization of
their infants cannot be over-emphasized. It has been found that immunization
reminder and recall system is one of the effective ways of improving
immunization uptake rates (Brown, Oluwatosin&Ogundeji, 2015). Immunization
has been defined by the Centre for Disease Control (CDC, 2014) as “an act of
introducing a vaccine into the body through vaccination to produce immunity to
a specific disease. Schuchat& Bell (2008) posited that immunization is
aimed at producing immunity to specific diseases and improving control of
vaccine preventable communicable diseases thereby preventing their spread.
Immunization can also be defined as the use of vaccines through immunization
programmes to enable the body to develop immunity so as to resist
vaccine-preventable infections and prevent their spread.
There are various types of immunization.
These have been identified by Hamm (2015) as including adult immunization,
travel immunization, influenza immunization and routine childhood immunization.
Routine childhood immunization according to UNICEF (2015) is one of the most
cost-effective public health interventions to date against vaccine-preventable
diseases (VPDs) as it averts about 2-3 million deaths and disability of
children each year. Castillo (2013) also stated that approximately 29 per cent
of deaths of under-5 children are preventable through routine immunization. The
vaccine-preventable diseases targeted by routine immunization according to
Antai (2012), include infantile tuberculosis, diphtheria, pertussis (whooping
cough), poliomyelitis, pneumococcal diseases, rotavirus, vitamin A deficiency,
measles, yellow fever and cerebro-spinal meningitis.
However, Offit (2014) observed that
approximately 1.5 million children still die each year from vaccine-preventable
diseases. Also CDC (2013) hinted that polio is still paralyzing children in
several African countries and that more than 350,000 cases of measles were
reported from around the world in 2011.
Balogun, Sekoni, Okafor, Odukoya et al (2012) observed that about 22 per
cent of under-five mortality is still caused by vaccine-preventable diseases in
Nigeria even close to the end of the 2015 deadline set aside for the
achievement of the fourth Millennium Development Goals (MDGs).The possible
reasons for the continued prevalence of VPDs as observed by Gilbert (2012)
could be that some vaccines used for immunization are less effective and some
communicable diseases are unlikely to be controlled by immunization because of
pathogen, host or population characteristics. He also observed that some
parents could be complacent and this may culminate in low uptake of
immunization by them.
The aim of using vaccination routine
immunization to avert VPDs may be difficult to achieve if mothers are
complacent about their children’s immunization or they do not present their
children for immunization which may make their uptake of routine immunization
services low. For instance, UNICEF (2013) observed that out of five infants
worldwide, nearly 20 per cent still do not receive the three life-saving doses
of diphtheria, tetanus and pertussis vaccine due to lack of adequate uptake of
vaccines by mothers for their children and this could make the unreached
children defenseless against these killer vaccine-preventable diseases. Also,
the World Health Organization (WHO, 2015) observed that in 2013, an estimated
21.8 million infants worldwide did not complete their routine immunizations and
21.6million children in the same age group had not been presented to receive
the single dose of measles-containing vaccine due to low uptake of immunization
services by mothers. UNICEF (2013) stated that one out of every five infants
worldwide still did not receive their complete recommended routine immunization
doses in a series. Referring to Taraba State, Ophori (2011) observed that their
OPV3 uptake rate was the lowest in the country in 2010 (18.75 per cent). This
was collaborated by the yearly routine immunization report for the past four
(4) years which revealed that majority of the children (87.5 per cent) who
started the immunization schedule did not finish them as shown by the high
drop-out rates and that majority of the LGAs performed poorly with regards to
uptake of immunization services by mothers. This study conceptualizes a
poorly-performing LGA as one that their immunization uptake is below 80 per
cent.
Uptake of immunization as defined by
Oladimeji, Adeyinka and Aimakhu (2008) is “the percentage of the target
population that has been vaccinated according to the recommended immunization
schedule. It is synonymous with coverage level and level of use of a vaccine by
a proportion of the target population in an immunization programme. Referring
to the pentavalent vaccine as an example of immunization uptake, Antai (2009)
said that uptake would be the percentage of children in the target population
who receive the first dose (penta 1) and those who continue to receive up to
the third dose (penta 3) in a series. According to him, this is particularly
useful as it shows continuity of use. Immunization programs are usually
instituted in such ways as to encourage and ensure a continuous uptake of the
relevant recommended vaccines. For instance, the World Health Organization
(WHO) had initiated and advised the adoption of immunization schedules an aim
of ensuring continuous vaccine uptake rates and reduce the impact of
vaccine-preventable diseases (Antai, 2009).The routine immunization schedule in
Nigeria according to the National Primary Health Care Development Agency –
NPHCDA (2014) requires that a mother visits an immunization clinic seven (7)
consecutive times and at various intervals of time for her child to be fully
immunized. The WHO (2014) stated that following the immunization schedule, a child under one year should receive
BacilleCalmette Guerin (BCG), oral polio vaccine(OPV0) and Hepatitis (Hep0) at
birth or within 2 weeks of delivery, OPV1 and Pentavalent 1(penta 1) at 6
weeks, OPV2 and Penta 2 at 10 weeks, OPV3 and Penta 3 at 14 weeks, Vitamin A
(first dose) at 6months, Measles(first
dose), Yellow fever and Conjugate A Cerebro- Spinal Meningitis (CSM) vaccines
at 9 months and Measles 2 and Vitamin A (2nd dose) at 12 months. As
there are recommended scheduled intervals for routine immunization vaccines to
be given, Offit (2014) suggested that to maintain reductions in morbidity and
mortality from VPDs, there may be a need to consider the timing and spacing of
vaccine doses according to the schedule to ensure continued and appropriate
uptake of vaccines. This is because according to him, the right dose of
vaccines given at the right interval through the right route generates the
optimal immune response. Brown, Oluwatosin and Ogundeji (2015) also added that
children could be exposed to the risk of VPDs if they received their routine
immunizations untimely or if the schedule is not followed to ensure maximal
uptake.
Routine immunization uptake in Nigeria
is far from optimal and not equitable (Antai, 2009). According to him, it could
be the reason why Nigeria still accounts for half of the deaths from measles in
Africa and has the highest prevalence of circulating wild polio virus (WPV) in
the world. Ophori, Tula, Azih, Okojie and Ikpo (2014) added that Nigeria has
witnessed gradual but consistent reduction in immunization coverage and is
among the ten countries in the world that has an immunization uptake rate below
the internationally recommended 80 per cent. Dube, Laberge, Guay, Bramadat et
al (2013) added that lack of proper uptake of immunization could pose a threat
to herd immunity thereby creating room for vaccine-preventable diseases to
persist in or return to communities that have inadequate immunization uptake
rates. Continued immunization uptake during childhood has been observed by
Harvey, Reissland and Mason (2013) to be reliant on mothers’/parental
decision-making and subsequent regular attendance to vaccination clinics.
Failure to keep to routine immunization schedules or not continuing to attend
immunization appointments by mothers has been observed byBalogun, Sekoni,
Okafor, Odukoya, Ezeiru, Ogunnowo and Campbell (2012) to have remained a
challenge for uptake of RIS globally as their children may be partially
immunized or not immunized. For instance, Abdulraheem, Onajole, Jimoh and
Oladipo (2011) observed that 62.8 percent of children in Nigeria were not fully
immunized and that 33.4 per cent had missed immunization opportunities
while36.4 per cent were partially or incorrectly immunized because of problems
of uptake. Also, Henry, Bairagi, Finley, Helleringer and Dahir (2011) posited
that only about 5.1 percent of all children in Nigeria had received the three
recommended doses of polio and many missed the third dose of the pentavalent
vaccines probably because they were not presented for their scheduled routine
immunizations at the right times by their mothers. These mothers could lack
information and ignorant about the right timing and schedules for immunization
of their children or they may be complacent and may forget their children’s
immunization schedules and may need to be communicated about their children’s
scheduled immunization dates. For instance, Abdulraheen et al (2011) found that
2.5 per cent of mothers whose children had partial or incomplete immunization
lacked information of the immunization days and they suggested that there is a
need to explore effective information strategies that will help ensure that
eligible children receive all the needed and recommended vaccines at the
appropriate times so as to become fully immunized and to improve the routine
immunization uptake rates.
Since previous studies have linked
problems of immunization uptake to problems with communication and information
to mothers about immunization, Esamgbedo (2012) therefore suggested that it may
be necessary to utilize existing information technology and communication (ICT)
tools to communicate and relay information especially about immunization
appointments to mothers as they could have some efficacy with regards to their
immunization uptake rates. Palavuzlar (2011) defined efficacy as the ability of
something, e.g. a medicine to produce the intended or desired results. This
means that it is the event which follows immediately after an antecedent or
cause and could be referred to as the result or consequence or outcome. He also
posited that it is synonymous with effectiveness. Williams, Woodward, Majeed
and Saxena (2011) posited that communicating with mothers and caregivers about
immunization of their children may be effective in improving immunization
uptake rates.
Previous studies have also shown that
communicating with mothers through reminder systems could have a strong
positive effect on demand for immunizations. NaikandJarosz, (2015)found that
adopting improvement strategies like the reminder and recall systems especially
for preventive care like routine immunization was effective in provision of
systematic care and in reduction of missed appointments. Harvey, Reissland and
Mason (2015) therefore suggested that since continued uptake of immunization
relied on parental or caregivers’ decisions-making for continued attendance at
immunization clinics, it could be necessary to adopt improvement strategies
targeted at parents like the reminders and recalls.
Litt (2015) defines reminders and
recalls as messages to patients or their caregivers stating that recommended
immunizations are due soon (reminders) or past due (recall). Reminders and recalls may be necessary for parental/mothers
decision-making about attendance to immunization appointments. This is because
they may have some efficacy in improving their uptake of immunization. The
efficacy of reminders and recalls in the context of this study refers to the
power or ability of reminders and recalls to produce desired consequences,
results or outcome of improving the uptake of routine immunization services by
the mothers that will be used for this study. For instance, Balogun et al
(2012) found that the use of innovative approaches through use of new
information technologies like mobile phone reminders helped to reach to 20 per
cent of the children that were previously being missed for routine immunization
services (RIS). Also, Tieney, Yusuf, McMahon, Rusinak, Brien, Massondi and Lieu
(2013) found that reminders and recalls information sent by telephone were
effective in increasing full child immunization rates and improving uptake of
RIS. Brown, Oluwatosin and Ogundeji (2015) also found that the use of mobile
phone technology to remind and recall mothers for their children’s immunization
dates aided their compliance with and adherence to immunization guidelines. For
this study, the efficacy of mobile telephone call reminders and recalls for
mothers in terms of improvement in uptake will be interpreted as increase in
the proportions of the children of these mothers that were immunized at 6 weeks
, at 10 weeks and at14 weeks with penta 1, penta 2 penta 3 and polio 1, polio
2, polio 3 compared with their pre-intervention measure or cut –off mark that will be
elicited from the immunization registers when they immunized their last child
for the series of the pentavalent and polio vaccines. The choice of intending
to use mobile telephone calls as reminders and recalls is that although Nigeria
is a developing country, the use of mobile phone technology is high. Brown,
Oluwatosin and Ogundeji (2015) observed that almost everybody both in the urban
and rural areas use mobile phones to communicate information and important
messages. This study will be experimental in nature and the mothers who come
for uptake of routine immunization services for their children in both the
urban and rural settings will be used as subjects. Since previous studies have found that RIS
uptake is low in Nigeria and have recommended improvement of the immunization
uptake in Nigeria using communication strategies like reminder and recall
systems, identifying the effects or eff
