A cross sectional survey on reasons for incomplete vaccination and factors for missed opportunity among rural Nigerian children identified several reasons for poor uptake of routine immunization.98 Parental objection, disagreement or concern about immunization safety (38.8%), long distance walking (17.5%) and long waiting time at health facilities (15.2%) are the most common reasons for poor uptake of routine immunization. Several other studies have demonstrated an association that parental belief about immunization safety is the major reason for incomplete immunization among Nigerian children. Parents objection, disagreement or concern about immunization is also in keeping with a case control study from south Ethiopia.99 Family income is associated with immunization coverage levels, and low family income is also a risk factor for low immunization.100 Parents with low household incomes are more likely to experience barriers, such as transportation or access to health care services that make staying up-to-date on immunization difficult.100
Several studies have demonstrated an association between education status of mothers and missed opportunities for vaccination. Mothers with missed opportunities for vaccination had either primary school education or no formal education. A study on effect of several demographic factors on measles immunization in children of Eastern Turkey showed an association that education of mothers increases the vaccination chances of a child and reduces missed opportunity.101
This significant impact of maternal education on knowledge of immunization has also been observed by some authors.79 A descriptive cross sectional study with a sample size of 200 mothers of children below the age of 2 years on knowledge, perception and beliefs of mothers on routine childhood immunization in a Northern Nigerian village Danbare, similarly noted that mothers with formal education were more likely to be aware of childhood immunization compared to those who had no formal education.102 It could then be inferred that the more educated women are, the more they are likely to immunize their children thus resulting in higher immunization coverage.
Individual, community and systemic factors have been shown to influence the equitable uptake of childhood immunization in Nigeria and other countries in sub-Saharan Africa.103 These
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include vaccine supply, distribution, costs and provider skills104 and individual-level factors are poor understanding of immunization, suspicion, myths and rumours,105 low maternal education
106-107 maternal employment and working outside the home,108 younger maternal age,106 delivery away from a health facility and not possessing an immunization card.109-110 These determine immunization uptake within rural areas of developing countries such as Nigeria. Much less is known about the role of community-level characteristics on rural-urban inequities in childhood immunization.
In addition, residence in the south-south region of Nigeria was associated with significantly lower likelihood of a child receiving full immunization. Because the six geopolitical regions in Nigeria represent different levels of social development and population densities, different economic, religious, and political situations,111 it is not unexpected that these regional differences would influence child immunization campaign effectiveness, a fact reported in a previous study.112 This study showed that children resident in the South-South (or Niger Delta) region of Nigeria had lower likelihood of being fully immunized. This is not an unexpected finding, given that this region is severely economically deprived and is characterized by extensive mangrove forest, lagoons and swamps, stretching over 100km in land. This region is characterized largely by rural hard-to-reach communities, with extensive poverty, as well as poor health care and social infrastructure. It is a region undergoing conflict, with armed militias interfering with vaccination processes, thus preventing vaccination officers from reaching children in remote settlements.112
In other settings, both younger and older age of mothers has been reported to be associated with incomplete immunization.95 The significantly higher likelihood of children of mothers 34 years or older receiving full immunization is consistent with findings from a recent cross-sectional DHS studies from Nigeria113 that assessed the individual-level and community-level explanatory factors associated with child immunization uptake between migrant and non migrant groups from Bangladesh.114 This latter study showed that older mothers were more likely to fully immunize their children than the youngest and oldest age groups, because maternal age may serve as a proxy for the women accumulated knowledge of health care services, which may in turn have a positive influence on acceptance of full immunization of children.
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A comparative ethnographic study with two stage stratified sampling technique and a total sample size of 1600 mothers on the social shaping of childhood vaccination practice in rural and urban Gambia found that mothers in rural Gambia were influenced by their peer networks and organizations like village music groups to attend clinic days as a group.65 In urban settings where this support was lacking, fewer mothers attended the clinic alone. Integration into these social networks encouraged women to go to health facilities and seek immunization. Prior social connection with the clinic staff also led to privileged treatment.65 In northern Nigeria, a positive association was found between perceived social approval of childhood immunization in the community and the uptake of DPT3.115
Surveys have shown that educated women have higher autonomy regarding decision-making and mobility, which facilitate their use of antenatal care.116,117 Maternal autonomy may enable mothers to achieve better health outcomes for their children.118 A community based study on child mortality in India documented the positive externality produced by other local women’s education on childhood immunization and other child health out-comes.119
In a study on the evaluation of primary immunization coverage in migratory versus non-migratory labour population of an urban area in Bhopal city India, associated partial immunization to unawareness and ignorance of mothers to the need for complete immunization and the consequence resulting from non-immunization of their children.35 Similarly a study on the immunization status of under five children in migrants from peri-urban areas of Pune India also observed that for partial and non-immunization in migrants communities showed that unawareness of the parents were 21.8%, and parents who forgot to immunize their children were 23.9%.41 On the other hand, a study on evaluation of primary immunization coverage in an urban area of Bareilly city India using cluster sampling technique found that ignorance (50%) was the main reason for non immunization in non migrants urban area children.27
In the study of community participation and childhood immunization coverage: a comparative study of rural and urban communities of Bayelsa State Nigeria, relocation of some of the respondents in the urban community prevented them from immunizing their children. This was not a problem in rural community, especially because most of the residents were indigenes, and therefore permanent residents of the community.120
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Misperception of routine immunization is widespread in Nigeria. Quantitative research conducted in six states in 2004 revealed that in rural Enugu, minor childhood illnesses are believed to be vaccine-preventable diseases (VPDs), while in rural and urban Kano, same illnesses are listed.80 This is consistent with an earlier mentioned pilot community research in March 2005 in Katsina State Nigeria.81 These misperceptions affect routine immunization negatively.
In Nigeria, the greatest challenge to the acceptance of immunization is a religious one especially among the northern Nigerian Muslims. Generally, the Muslim north has the low immunization coverage, the least being 6% (northwest) and the highest being 44.6% (southeast). In Ekiti State, for example, the northeast and west of Ekiti state, with a stronger Islamic influence, has low immunization coverage and also poor educational attainment. Christians have 24.2%
immunization coverage as compared to only 8.8% for Muslims.121
Over the years Nigeria has received huge quantities of cold chain equipment. Despite this support, much of the cold chain equipment appears to be beyond repair. This is partly due to the focus on polio eradication, which uses freezers. In one zonal store in the northwest region of Nigeria, only one of the three cold rooms was working, with only a single compressor operational. Substantial numbers of solar refrigerators have been bought in the last few years, although, they are expensive ($5,000 each) and may be prone to breakdowns due to lack of the maintenance culture of government owned facilities. At the state level, the cold stores are poorly equipped and badly managed. More than half of the refrigeration equipment is either broken or worn out. In the eight states visited by a team of National Programme on Immunization, 47% of the installed solar fridges were broken and $205,000 worth of solar equipment remained uninstalled.122
The downward trend in the coverage of all the antigens appears to be associated with political problems. In Nigeria, the boycott of polio vaccinations in the three northern states in 2003 created a global health crisis that was political in origin.123,124 These political problems included low government commitment to ensure the fulfillment of EPI policy as well as over-centralization in the administration of EPI at the federal level of governance in Nigeria. The poor coverage of measles between 1998 and 2005 was blamed on vaccine shortages and
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administrative problems, as was the case in 1996, 1999 and 2000 when polio coverage was only 26%, 19% and 26% respectively.125 Some positions offer potential for patronage due to the large payments for NID activities. This has led to political appointments and frequent changes in personnel as some LGA chairmen wish to bestow or repay political favours. Even at the state government level, increased political interference has been reported to be in the appointment of civil servants, also resulting in frequent changes of staff and the appointment of inappropriately qualified staff.125
Another problem and challenges facing immunization programmes in Nigeria is the rejection of selected vaccines/vaccination by parents or religious bodies more especially in the northern part of this country. Fears regarding routine immunization are expressed in many parts of Nigeria.
This is consistent with an earlier mentioned qualitative study in five state in Nigeria.80
Nigeria has a major problem with trust and confidence in the routine immunization programme.81 Mothers have not really come to terms why a healthy child should be immunized like the study by Yola in Kano.88 where they found only 9.2% of mothers who said that they do not have faith in immunization and another 6.7% said they are afraid of adverse effects. However many in Kano and Enugu believe immunization provide at best only partial immunity.80,89
Under the NPI’s the first mandate is to “support the states and local governments in their immunization programmes by supplying vaccines, needles and syringes, cold chain equipment and other things and logistics as may be required for those programmes”. However, the supply of vaccines has always been problematic for Nigeria, primarily because funds were not sufficient and were not released on time. For example in 2001 the whole amount was approved but only 61% was released, the late release of funds (April 2001) meant that vaccine had to be bought on the spot market at inflated prices. In 2002 no funds were released and by March 2003 the funding cycle had only reached the stage of getting the budget approved. NPI did not supply any syringes for Rubella infection in 2005, and the only safety boxes that have been supplied are the limited quantities given by donors for SIAs. Following an assessment in 2003, it was decided that UNICEF would supply vaccines in future.124
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In the last quarter of 2003, UNICEF began supplying vaccines through a procurement services agreement, and this arrangement continues to date. However, it has not solved the problem of vaccine shortages. For example, cerebrospinal meningitis (CSM) vaccine was not supplied in time to allow CSM immunization to take place before the cerebrospinal meningitis season, and some states had to buy their own stocks of CSM using state funds. Measles vaccine also arrived too late to limit the effects of a measles outbreak in the north, and an insufficient quantity of measles vaccine was supplied to Abia.124
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CHAPTER THREE METHODOLOGY 3.1 Study Area
Awka is the capital of Anambra State, and the headquarters of Awka South LGA. It is bounded in the North by Okpuno, South by Nibo and Nise, East by Ndiagu and in the West by Amawbia and Nawfia. It is made up of nine communities, eight political wards and forty seven settlements (Appendix 3). It has a population of 218059 which was based on population of 167,738 recorded in 2006 Nigerian census, using an annual growth rate of 3.5 percent weighed against other variables such as rising life expectancy and declining infant mortality rate.126,127
Awka is famous for its blacksmith and also specialized in wood carving, ivory and arts design.
Altogether Awka has 8 political wards and 33 villages (appendix 4). Immigrants from northern Nigeria, Delta, Enugu State, Cameroun and Ghana now comprise more than 60% of residents in the town.127
The town lies 300metres above sea level in a valley on the plains of Mamu River. Two ridges, both lying in North-South direction, form the major topographical features of the area. Awka is in the tropical rain forest zone, but due to increased deforestation for agriculture and commerce has largely reduced the vegetation to mixed savanna with mean annual rainfall of 1,485.2mm. It has a thick sequence of shale and sand stones formed in the paleocene age which underlies most of the territory. Awka experiences temperatures of 27-30 degrees Celcius between June and December but rises to 32-34 degrees Celcius between January and April with the last few months of the dry season marked by intense heat.128
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Awka town has less than 10% of its roads paved, inadequate water drainage, poor public water supply, garbage dumped on the sides of roads and a non existent public sewage system. Awka market is defined by large rudimentary open air market like most Nigerian cities where everything from basic food produce to clothes, cosmetics and household items are sold. Health facilities include Anambra state university teaching hospital, Regina Caeli Hospital (Catholic owned), Faith hospital (Anglican owned), health centres in every community, many private clinics and maternity homes. Educational facilities include Paul University (Anglican owned), 18 secondary schools (government owned), 42 primary schools (government owned), many private primary, secondary and commercial schools. Federal government presence are Nnamdi Azikiwe University, federal government ministries, departments and agencies, Federal Science and Technical College. Religious denominations and faith groups range from the church missionary society (CMS) of the Anglican Church, Roman Catholic Church, many Pentecostal churches, Muslims and the traditional religions.129
Awka has three maternity and child healthcare centres constructed and equipped by the state government in conjunction with the Bill and Melinda Gates Foundation of the United State of America to improve maternal health and decrease child mortality in the state. There are many completed projects of service delivery in secondary health facilities like the renovation of health care staff quarters, comprehensive health centres in Awka. There is also a refurbished and equipped isolation centre at Anambra state university teaching hospital Awka. The state government in Awka has improved its coverage in routine immunization, quarterly campaign for maternal, newborn and child health and regular distribution of long lasting insecticide treated mosquito net (LLINs) to schools, communities and corporate organization.130
There is a state central pharmaceutical stores at Anambra state university teaching hospital Awka that is renovated and equipped by the state government including an established state quality control and drug information centre. There is also re-establishment of drug revolving fund scheme (DRF) for the initial procurement of required drugs and medical sundries in bulk and stores same at the state central store Awka for purchase by the hospitals.130
The state government with its headquarters in Awka is partnering with Rise Health Corporation of the United State of America to improve the health sub-sector by giving grant in aid to mission hospitals in the spirit of PPP and for sustaining growth and development of the health sub-sector.
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The state government disbursed the sum of =N=447,000,000 to the Catholic, Anglican and Pentecostal missionary health facilities in the first quarter of 2015. There is also the reconstitution of the traditional medicine board, patient and proprietary medicine board and constitution of state emergency management agency (SEMA) in Awka.130
There is a committee in Awka on recertification of health institution in the state to improve the quality of the health care service delivery and eliminate quacks for sanity to prevail in the health system. However due to vertical and horizontal fragmentation in the absence of clearly defined roles and responsibilities led to disorderliness in the management of the affairs of the PHC centres. The state government has passed a bill for Anambra State Primary Health Care Development Agency to strengthen the PHCs to offer basic health of the people.130
Awka has 8 political wards and these are Awka wards1-V111 (Appendix4). Each of these wards has a primary health centre except Awka ward V111 which has a health post. These wards have a number of settlements (Appendix 4)
Sabo Community
Sabon Gari means ‘strangers quarters’ or literally ‘new town’ in the Hausa language, plural Sabon Garuruwa.131 Sabo community in this study is therefore a colloquial term describing the Hausa community living in Awka, while the non-Sabo community includes other residents in the town with the exception of the Hausa community.
The Sabo community are the Hausa communities in Awka. The head of the Sabo community is the Seriki, Alhaji Garuba Haruna. The Sabo communities are mainly in the Awka 1V-V111 with Awka V and Awka V1 selected for the study. The selected wards have the settlements of Umubelle, Umuenechi, Umuogbu, Umuanaga , Umuike, Umuoruka, Umujagwo for Awka V and Amikwo, Obunagu, Udoka housing, Iyiagu Estate, Abuja Estate Phase 11, Ngozika Housing for Awka V1.
Every settlement had at least one place set aside for communal prayers. In the larger settlement, mosques are well attended like the central mosque at Awka V Umuogbu settlement, especially on Fridays when the local administrative and chiefly elites lead the way. One or more pilgrimages to Mecca for oneself or one’s wife provides prestige and respect.129 The Sabo
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communities are mainly cattle rearers, tailor, security personnel, bureau d’change operators, traders in jewelleries and clothes. The selected wards are well delineated and they are between 2km to 3km from local government headquarters in Amawbia111. The settlements are both residential and commercial. The estimated total population of the two wards is 36,259 according to Awka South Local Government area-NPI unit (Appendix4).
Non-Sabo Resident Community
These are the Awka indigenes and other residents in Awka. The non-Sabo resident communities are Awka 1, 11, 111 and V11. Awka 1 and Awka 11 were selected for the study. The selected wards have the settlements of Umuayom, Nkwelle, Umuoramma, Umunoke for Awka 1 and Umuzocha, Amudo, Enu-ifite, Agbani-ifite, Government House, Ekedum Agu Awka and Unizik for Awka 11.
The non-Sabo residents are mainly civil servants, traders, artisans and craftmen. They are mainly Christian of various denominations and few traditional African religions. The settlements are both residential and commercial. These selected wards are well delineated from each other with a distance of 8km to 10km from local government headquarters in Amawbia 111. The estimated total population of the two wards are 47,926 according to Awka South Local Government Area-NPI unit (Appendix 4).