Assessment of the knowledge of fathers, uptake of routine immunization, and its associated factors in a rural community of North West Nigeria.

Introduction: Father's involvement is essential for the successful immunization of the child, as man is the head of the family and he takes responsibility for all decisions including health and financial issues. This study aimed to assess the knowledge of fathers, uptake of routine immunization (RI), and its associated factors in a rural community of North West Nigeria. Materials and
Methods: The study was a community-based cross-sectional study conducted among the male heads of households residing in a rural community of Sokoto state. Systematic sampling was used to recruit 276 respondents. Data were obtained using a structured interviewer-administered questionnaire. Data obtained was entered into the IBM Software package and subsequently analyzed. Level of significance was set at 5%.
Results: Only 2.5% and 1.4% of the respondents knew the age measles and yellow fever vaccines were given, respectively. Majority (75.4%) of the respondents' last-born child did not receive bacillus Calmette-Guérin at birth. Only (7.6%) of their last-born child were completely immunized for age. Majority of the respondents that had poor knowledge of RI had no formal education (P = 0.043).
Conclusion: The study reported the knowledge of RI among fathers was poor. Having formal education and perception that children should be allowed to receive RI were correlates of good knowledge and uptake of RI. Parents, fathers, in particular, should be educated on the schedule of RI.

INTRODUCTION

Immunization is globally recognized as one of the most powerful, safe, and cost-effective measures for the prevention/control of some childhood diseases.[1234] Each year, vaccination averts an estimated 2–3 million deaths from diphtheria, tetanus, pertussis, and measles, all life-threatening diseases that disproportionately affect children, approximately 17% of deaths in children under-fives being vaccine preventable.[4] The United Nations General Assembly Special Session sets a goal for full immunization of children who <1-year old at minimum coverage of 90% nationally and 80% in every district or equivalent administrative unit by 2010.[5] Despite this, global vaccine coverage has stalled over the past few years, in 2016 an estimated 19.5 million infants worldwide were not reached with routine immunization (RI) services, about 60% of these children live in 10 countries with Nigeria being one of them.[6] The 2016 Multiple Indicators Cluster Survey/National Immunization Survey Coverage revealed that 77% of children 12–23 months in Nigeria have not received all the RI as recommended in the country's RI Schedule, whereas 40% of children in this age group did not receive any immunization.[6] Some studies have identified deficit human resources, poor health worker attitude, poor community participation,[7] and mothers knowledge and attitude[8] toward RI as some of the reasons for low RI coverage. Factors such as caregiver's knowledge, attitude, and practices are also known to contribute to success or failure of the immunization.[2] Studies have assessed the knowledge[791011] and attitude[7911] of mothers on immunization, however, few studies have assessed that of men. Studies have found fathers involvement essential for the successful immunization of the child[912] as this is consistent with the belief in traditional African society where the interplay of culture, tradition, and religion admits that man is the head of the family and that he takes responsibility for all decisions including health and financial issues.[12] Fathers having good knowledge of RI are likely to encourage their children to assess immunization services. This study thus aimed at assessing the knowledge of fathers, uptake of RI and its associated factors in a rural community of North West Nigeria. The result of this study will provide data on the level of knowledge and acceptance of RI among men, which can subsequently be used by policymakers for the improvement of acceptance of RI services.

MATERIALS AND METHODS

The study was conducted in Kwalkwalawa community of Dundaye ward in Wamakko Local Government area (LGA) of Sokoto state. The study population consisted of all male heads of households residing in the community. Heads of households with children <12 months were excluded from the study. The study design was cross-sectional in nature. Systematic sampling technique was used to recruit 286 respondents following sample size estimation and adjusting for nonresponse. Houses in the community were mapped out, and the house numbering was carried out. A total of 603 houses were enumerated, a sampling interval of 1:2 was arrived out, and the systematic sampling was carried out. The instrument of data collection was administered to the head of households in these houses in the local language (Hausa). The instrument of data collection was a structured questionnaire and had four sections which sought information of respondents' socio-demographic characteristics, knowledge, and uptake of RI. The male head of household was asked questions on the utilization of RI services, assumption made here was that the head of household gives permission to the mother to take the child for RI services. The questionnaire was pretested and necessary adjustments made to it before the commencement of data collection. Temporal stability was assessed by administering the questionnaire to the male head of household in Sokoto south LGA of Sokoto state; the questions were readministered 2 weeks later. This was done to ascertain the correlation between initial response and the second set of responses. Informed verbal consent was obtained from each respondent, permission to conduct this study was obtained from the Research and Ethics Committee of the Sokoto State Ministry of Health. Administered questionnaires were sorted out and entered into the IBM statistical software (International Business Machines, New York, USA) package. Data editing and cleaning were carried out after the data were ascertained clean data analysis commenced. Data were summarized using mean and standard deviation for quantitative variables and frequency and percentages for qualitative variables. Inferential statistics (Chi-square test) were conducted to determine the association between the categorical variables. Informed verbal consent was obtained from each respondent, permission to conduct this study was obtained from the Research and Ethics Committee of the Sokoto State Ministry of Health.

RESULTS

A total of 286 respondents out were recruited for this study, 10 respondents refused to participate, giving response rate of 96.5%. Over one–third of the respondents, 95 (34.4%) were within the age group of 40–49 years. Majority of the respondents 167 (60.5%) had only qur'anic education, whereas only 24 (8.7%) respondents had tertiary education. Majority of the respondents 208 (75.4%) were farmers, and barely half of them 119 (43.1%) had 1–5 number of children, whereas 61 (22.1%) of them had over 10 children. Half of the respondents 138 (50.0%) were in a polygamous relationship [Table 1].

Table 1

Socio-demographic characteristics of respondents

Variables		n (%)
Age group (years)	21-30	42 (15.2)
	31-40	71 (25.7)
	41-50	100 (36.2)
	51-60	43 (15.6)
	61-70	17 (6.2)
	71-80	3 (1.1)
Educational status	None	6 (2.2)
	Quranic	167 (60.5)
	Primary	16 (5.8)
	Secondary	63 (22.8)
	Tertiary	24 (8.7)
Number of children	1-5	119 (43.1)
	6-10	96 (34.8)
	>10	61 (22.1)
Occupation	Civil Servant	12 (4.3)
	Farmer	208 (75.4)
	Trader	56 (20.3)
Nature of family	Polygamous	138 (50)
	Monogamous	138 (50)

Majority of the respondents knew that child RI prevents children from the infectious diseases 221 (80.1%); multi-doses of the same vaccine given at intervals were important for the child immunity 207 (75.0%); more than one vaccine can be given to a child at same time 201 (72.8%); it is important to vaccinate children during immunization campaign 229 (83.0%), and it is important to comply to child's RI schedule 223 (80.8%). However, majority of the respondents did not know when the first dose of a child's immunization is given 222 (80.4%) or the schedule of RI as only 37 (13.4%) knew when the first dose of hepatitis B vaccine is given; 32 (11.6%) knew the number of times a child is given oral polio vaccine during RI; and only a paltry 7 (2.5%) and 4 (1.4%) knew the age measles and yellow fever vaccines were given, respectively [Table 2].

Table 2

Respondents knowledge of Routine Immunization

Variables	Correct responses	In-correct responses
Does child routine immunization prevent children from infectious diseases	221 (80.1)	65 (19.9)
When is the first dose of child routine immunization given	54 (19.6)	222 (80.4)
Most diseases against which children are vaccinated occur during the first year of life	131 (47.5)	145 (52.5)
Multi doses of same vaccine given at intervals are important for child immunity	207 (75.0)	69 (25.0)
Can more than one vaccine be given to a child at same time	201 (72.8)	75 (27.2)
Is it important to vaccinate children during immunization campaign	229 (83.0)	47 (17.0)
Should a child with mild illness be immunized	182 (65.9)	94 (34.1)
Is compliance to child routine immunization schedule important	223 (80.8)	53 (19.2)
First dose of Oral polio vaccine is given at birth	124 (44.9)	152 (55.1)
First dose of Hepatitis b vaccine should be given at birth	37 (13.4)	239 (86.6)
BCG vaccine is given at birth	71 (25.7)	205 (74.3)
How many times should a child be given oral polio vaccine during routine immunization	32 (11.6)	244 (88.4)
How many times should a receive BCG vaccine	76 (27.5)	200 (72.5)
How many times should a child receive Yellow Fever vaccine	66 (23.9)	210 (76.1)
How many times should a child receive Measles vaccine	71 (25.7)	205 (74.3)
At what age is Measles vaccine administered	7 (2.5)	269 (97.5)
At what age is Yellow Fever vaccine administered	4 (1.4)	272 (98.6)
Overall knowledge of Routine immunization	131 (47.5)	145 (52.5)

Majority of the respondents allowed their children received RI 220 (79.7%) and they have indeed taken their children to receive RI 200 (72.5%). However, majority of the respondents' last-born child did not receive OPV 189 (68.5%), bacillus Calmette-Guérin (BCG) 208 (75.4%) at birth, and only 21 (7.6%) of their last-born child were completely immunized for age. Almost all respondents 250 (90.6%) received health education and counseling from the health-care providers before immunizing their children [Table 3].

Table 3

Uptake of Routine Immunization

Variables	Yes n (%)	No n (%)
Do you allow your children receive Routine Immunization?	220 (79.7)	56 (20.3)
Have you or your wife ever taken your child to receive Routine Immunization?	200 (72.5)	76 (27.5)
Did your last born child receive Oral Polio vaccine at birth?	87 (31.5)	189 (68.5)
Did your last born child receive BCG vaccine at birth?	68 (24.6)	208 (75.4)
Is your last born child completely immunized for age?	21 (7.6)	255 (92.4)
Do the Health provide health education and counselling before immunizing the children?	250 (90.6)	26 (9.4)

Majority of the respondents that had poor knowledge of RI had no– formal education (P = 0.043) and were farmers (P = 0.013). Almost all the respondents that had good knowledge of RI felt children should be allowed to receive RI (P < 0.001). All the respondents that had good knowledge of RI knew that RI is beneficial to the health of children (P < 0.001) and believed that children who received RI will be protected against some diseases (P < 0.001) and these were statistically significant [Table 4].

Table 4

Factors associated with Respondents’ knowledge of Routine Immunization

Variables		Knowledge score		Test statistics & P
		Good n (%)	Poor n (%)
Educational status	No- formal	74 (56.5)	99 (68.3)	χ2=4.088, P=0.043
	Formal	57 (43.5)	46 (31.7)
Occupation	Civil servant	9 (6.9)	3 (2.1)	χ2=8.424, P=0.013
	Farmer	89 (67.9)	119 (82.1)
	Trader	33 (25.2)	23 (15.9)
Nature of family	Polygamous	67 (51.5)	71 (49.0)	χ2=0.131, P=0.718
	Monogamous	64 (49.8)	74 (51.0)
Children should be allowed to receive RI	Yes	120 (91.6)	95 (65.5)	χ2=55.166, P=0.000
	No	11 (8.4)	50 (34.5)
RI Is beneficial to health of children	Yes	131 (100)	104 (71.7)	χ2=43.504, P=0.000
	No	0	41 (28.3)
Do you believe that children who receive RI will be protected against some diseases	Yes	131 (100)	98 (67.6)	χ2=51.177, P=0.000
	No	0	47 (32.4)

Majority of the respondents that will not permit RI had no formal education (P < 0.001). Almost all respondents that permitted RI felt children should be allowed to receive RI (P < 0.001), knew that RI is beneficial to the health of children (P < 0.001), and believed that children who received RI will be protected against some diseases (P < 0.001) [Table 5].

Table 5

Factors associated with Respondents uptake of Routine Immunization

Variables		Permit routine immunization		Test statistics & P
		Yes n (%)	No n (%)
Educational status	No- formal	123 (55.9)	50 (89.3)	χ2=21.258, P=0.000
	Formal	97 (44.1)	6 (10.7)
Occupation	Civil servant	12 (5.5)	0	χ2=4.355, P=0.113
	Farmer	161 (73.2)	47 (83.9)
	Trader	47 (21.4)	9 (16.1)
Nature of family	Polygamous	112 (50.9)	26 (46.4)	χ2=0.358, P=0.549
	Monogamous	108 (49.1)	30 (53.6)
Children should be allowed to receive RI	Yes	217 (98.6)	9 (16.1)	χ2=205.132, P=0.000
	No	3 (1.4)	47 (83.9)
RI Is beneficial to health of children	Yes	214 (97.3)	21 (37.5)	χ2=125, P=0.000
	No	6 (2.7)	35 (62.5)
Do you believe that children who receive RI will be protected against some diseases	Yes	217 (98.6)	12 (21.4)	χ2=188.33, P=0.000
	No	3 (1.4)	44 (76.8)

DISCUSSION

This study assessed the knowledge of fathers, uptake of RI and its associated factors in Sokoto, North-western Nigeria. The overall knowledge of RI among fathers was poor, with variations in their responses. Majority of them knew that child RI prevents children from infectious diseases. Radio and television stations in Sokoto often transmit programs to enlighten residents on the importance of RI, this may have contributed to their knowledge. Abubaker et al.[13] in Saudi Arabia and Bernsen et al. in the United Arab Emirates[14] also reported that over 85% of the participants knew the role of childhood vaccination in the prevention of life-threatening diseases. However, only one-fifth of the respondents knew when the first dose of child RI is administered, not knowing when RI is commenced may cause a delay in initiation of RI and delay in initiating RI is a cause of concern. For instance, BCG, oral polio, and hepatitis vaccines should be administered at birth or within the first 2 weeks of life if one wants to get the best result.[15] Most of the fathers knew that it is important to comply with child RI schedule. However, less than one-fourth of them knew the RI schedule. Not knowing the immunization schedule may leads to reduced access to immunization services, reduced immunization coverage, and child immunization dropout.

Majority of the fathers knew that more than one vaccine can be safely administered to a child at the same time. For instance, at 9 months of age, both yellow fever and measles vaccines are administered to a child at the same time. There is no scientific evidence that supports parents' fears about combined vaccines causing immune overload.[16] In contrast, a study by Gellin in 2000, revealed that a quarter of the parents believed that their child's immune system could become weakened as a result of too many immunizations.[17]

Almost all the respondents knew it is important to vaccinate children during the immunization campaign. A large number of children can be reached during immunization campaign that for a variety of reasons never get to be vaccinated during RI or are unable to complete the recommended immunization schedule. This also helps to boost the herd immunity of children against childhood diseases. However, Asiimwe et al. in Uganda, reported that parents/caretakers perceived vaccines used during mass immunization not to be safe either because they are expired or are deliberately contaminated with harmful agents intended to harm their children.[18]

Despite the knowledge gap in the immunization schedule, majority of the fathers allowed their children to receive RI and have indeed taken them to receive it. This is a commendable practice and it will go a long way in not only improving the health-care utilization of their wives and children but also improve the immune status and wellness of their children and family at large. The study also reported that only 7.6% of their last-born children were completely immunized for age. This is very low and implies that the community may not have herd immunity, and as such they may be prone to outbreaks of these vaccine preventable diseases (VPDs).

Factors found to significantly influence the knowledge of fathers on RI were educational status, occupation, and their perception that children should be allowed to receive RI; RI is beneficial, and the believe that children who receive RI will be protected against those specific diseases. Majority of fathers with poor knowledge of RI had no– formal education and were farmers. Educated parents will better understand the educational messages given to them. Moreover, such parents are more likely to comprehend educational messages they receive from various media (radio, television, billboards, and posters). Educational status is also related to the occupation of the people. Those with formal education are more likely to be employed (civil servant, etc.,) living those with no formal education in the informal sectors like subsistence farming. This finding is consistent with previous studies.[1920]

Almost all fathers with good knowledge of RI felt their children should be allowed to receive RI. They could have acquired this knowledge from several media and could have also observed that children vaccinated were immune to various childhood diseases and also have a better quality of life.

All fathers with good knowledge of RI perceived RI to be beneficial to children's health and believe that children who receive it will be protected against some diseases. Successful immunization of children depends highly on parents' existing knowledge and positive attitude. These ranged from individual cognitions to family, social, and system factors. Individuals perceived the benefits of vaccines differently. Nevertheless, these benefits outweigh the risks. These positive perceptions were supported by beliefs about infectious disease threats which can be prevented by vaccinating children, the social and political will to provide potent vaccines for the prevention of childhood diseases in the community.[21]

This study also revealed the factors that significantly influence the permission of children to RI to be the educational status of fathers, the perception that children should be allowed to receive RI, perceived benefits of RI to the health of children, and belief that children who receive RI will be protected against some diseases. Almost all the fathers that did not permit their children to receive RI had no formal education. Education of parents, mothers' in particular, has been found to be associated with the knowledge of when to start immunizations, the frequency of visits and the diseases prevented by each vaccine.[22] This is consistent with that observed by Tadesse et al. in 2009[23] and Jani et al. in 2008 and other researchers that reported that mother's education was a significant predictor of completeness of immunization because the highly educated mother will be more aware of the importance of immunization.[242526]

Education is related to the parents' perception that children should be allowed to receive RI because of its immense benefits– the belief that children who receive RI will be protected against some diseases called VPD. A study by Rasheed Kola in Lagos, South-western Nigeria, reported that willingness of parents to present their children for immunization is significantly affected by the level of education of such parents (P < 0.05). Parents with better or higher education were likely to be willing to present their children for immunization. The study further reported that the opinion about the benefit of immunization is also found to be significantly affected by the respondents' level of education (P < 0.05).[27]

CONCLUSION

The study reported knowledge of RI among fathers was poor, with variations in their responses. Most of them were not aware of the immunization schedule of children, and only a paltry 7.6% of their last children were completely vaccinated. Having formal education, the perception that children should be allowed to receive RI, perceived benefits of RI to the health of children, and believe that children who receive RI will be protected against VPD were correlates of good knowledge and uptake of RI. Parents, fathers, in particular, should be educated on the schedule of RI and the need to ensure children receive all vaccines as and when due.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.