IMMUNIZATION UPTAKE AMONGST MOTHERS & CARE-GIVERS OF CHILDREN

BETWEEN THE AGES OF 0-18 MONTHS IN SAGAMU OGUN STATE NIGERIA.

BY

LAMINA IFEOLUWA AYOTUNDE (MED/17/18/0043)

BAMIRO MOSOPEOLUWA SAMUEL (MED/17/18/0024)

DICKSON CHISOM FAVOUR (MED/17/18/0031)

OGUNTADE DAVID OLUWAMUYIWA (MED/17/18/0049)

OSILANA OLUWAYEMISI BOLUWATIFE (MED/17/18/0059)

A RESEARCH PROJECT SUBMITTED TO

DEPARTMENT OF COMMUNITY MEDICINE AND PRIMARY CARE

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

BACHELOR OF MEDICINE AND BACHELOR OF SURGERY (MBCHB)

DEGREE AT OLABISI ONABANJO UNIVERSITY, AGO-IWOYE, OGUN STATE

FEBRUARY 2025
CERTIFICATION

This is to certify that this is a record of the original research work titled ‘‘Immunization uptake
amongst mothers and caregivers of children aged 0-18 months in a Sagamu community, Sagamu
LGA of Ogun State, South West, Nigeria’ written by Lamina Ifeoluwa Ayotunde, Bamiro
Mosopeoluwa Samuel, Dickson Chisom Favour, Oguntade Olumuyiwa David, Osilana
Oluwayemisi, 600 Level students in the Department of Community Medicine and Primary Care,
Olabisi Onabanjo University Teaching Hospital, Sagamu, was carried out under our supervision.

Dr. Oritogun Kolawole Sunday

(First Supervisor/Consultant Community Physician)

Dr. Ayo Oluwole

(Second supervisor/Consultant Community Physician)

Dr. Alabi, A. D.

Head, Department of Community Medicine and Primary Care.

DEDICATION

We dedicate this work to God Almighty, the giver of life and the foundation, Pillar and strength
of our existence; and to our families for their love, care, financial support, prayers and
encouragements.
ACKNOWLEDGEMENTS

We are grateful to Almighty God for wisdom, knowledge, understanding and strength throughout
the period of this research work.

We are especially grateful to our supervisors: Dr. K.S Oritogun, Consultant Community
Physician and Dr. A. Oluwole, for guidance and painstakingly going through the project. Your
advice and mentorship are greatly appreciated.

We would like to appreciate the residents of Sagamu Local Government for their support,
cooperation towards our project.

Last but not the least, we would like to appreciate all those who assisted us directly or indirectly
to make our literature and field reconnaissance successful.
Contents

CERTIFICATION...........................................................................................................................2

DEDICATION.................................................................................................................................3

ACKNOWLEDGEMENTS.............................................................................................................4

CHAPTER ONE..............................................................................................................................8

INTRODUCTION.......................................................................................................................8

1.1 Background Study.............................................................................................................8

1.2 STATEMENT OF PROBLEM........................................................................................10

1.3 JUSTIFICATION OF THE STUDY...............................................................................11

1.4 OBJECTIVES OF THE STUDY.....................................................................................11

1.5 SCOPE OF THE STUDY................................................................................................11

CHAPTER TWO...........................................................................................................................12

LITERATURE REVIEW..........................................................................................................12

2.0. BACKGROUND............................................................................................................12

2.1 HISTORY OF IMMUNIZATION..................................................................................16

2.2 DETERMINANTS OF VACCINE UPTAKE.................................................................19

2.3 IMPORTANCE OF IMMUNIZATION..........................................................................22

2.4 ADVERSE EFFECTS OF THE USE OF VACCINES...................................................23

CHAPTER 3..................................................................................................................................25

METHODOLOGY....................................................................................................................25

3.1 Study Design....................................................................................................................25

3.2 Study Area.......................................................................................................................25

3.3 STUDY POPULATION..................................................................................................26

3.4 SAMPLING TECHNIQUE.............................................................................................26

3.5 Sample size Determination..............................................................................................27

3.6 Instrument for the study...................................................................................................28

3.7 Ethical considerations......................................................................................................29

3.8 Statistical analysis............................................................................................................30

CHAPTER FOUR.........................................................................................................................31

DATA ANALYSIS AND INTEPRETATION.........................................................................31

4.0 Introduction.................................................................................................................31

4.1 Presentation of Data....................................................................................................31

4.2 Answering of Research Questions...................................................................................43

CHAPTER FIVE...........................................................................................................................47

DISCUSSION, CONCLUSION AND RECOMMENDATION...............................................47

5.0 Introduction......................................................................................................................47

5.1 Discussion of the findings...............................................................................................47

5.2 CONCLUSION...........................................................................................................50
 5.3 RECOMMENDATIONS.................................................................................................50

5.4 SUGGESTIONS FOR FURTHER STUDIES.................................................................51

5.5 LIMITATIONS OF THE STUDY..................................................................................51

REFERENCES..........................................................................................................................52
 CHAPTER ONE

INTRODUCTION

1.1 Background Study

A mother is the female parent of a child. A woman may be considered a mother by virtue of
having given birth, by raising a child who may or may not be her biological offspring, or by
supplying her ovum for fertilization in the case of gestational surrogacy. (Sacks, Alexandra 8
May 2017). According to (Bernard 2004), a caregiver, or support worker is a paid or unpaid
person who helps an individual with activities of daily living. Caregivers who are members of a
care recipient's family or social network, and who may have no specific professional training, are
often described as informal caregivers. Mothers and caregivers are usually responsible for the
care and well-being of the baby hence their impact on the immunization status of a child plays a
major role. Immunization is a key component of the child care and the importance of
immunizing within the 0-18 months window cannot be overstated. Infants are particularly
susceptible to infections during this period, and vaccines provide a crucial shield against diseases
that can be severe or even fatal. Early immunization also helps in establishing long-lasting
immunity, offering protection as the child grows.

According to World Health Organization, Immunization is the process whereby a person is made
resistant to a disease, typically by the administration of a vaccine. Vaccines stimulate the body’s
own immune system to protect the person against subsequent infection or disease. Immunization
is the artificial induction of immunity with the goal of preventing the spread of infectious
diseases.

Active Immunization involves the avoidance of clinical disease by inducing in the receiver a
level of immunity akin to that obtained from the natural infection. generated by a person's
immune system, and immunity is typically long-lasting.
Passive Immunization entails the delivery of exogenously produced antibodies results in passive
immunization, which produces transient immunity. Trans-placental sources are the most
common. The others include animal antitoxin, immune or hyper-immune globulin, and blood and
blood products. The importance of immunizing within the 0-18 months window cannot be
overstated. Infants are particularly susceptible to infections during this period, and vaccines
provide a crucial shield against diseases that can be severe or even fatal. Early immunization also
helps in establishing long-lasting immunity, offering protection as the child grows. Failure to
adhere to the recommended vaccination schedule poses significant risks. The disadvantages of
not giving vaccines within the first 18 months include increased susceptibility to infectious
diseases, potentially leading to outbreaks within communities. Unvaccinated individuals may
suffer from severe complications, prolonged illness, and in extreme cases, death.

Moreover, not following the immunization schedule can contribute to the resurgence of diseases
previously under control, posing a threat to public health. It is imperative for mothers, caregivers,
and healthcare providers to prioritize immunization, recognizing its pivotal role in safeguarding
the health of both individual children and the broader community. Through consistent
vaccination efforts, communities can collectively work towards reducing the burden of
preventable diseases and promoting overall well-being.

1.2 STATEMENT OF PROBLEM

Most mothers and caregivers are not aware that vaccine preventable diseases are vital to the
health of 0-18 months. Understanding the barriers to vaccination, understanding the factors
mitigating the uptake of immunization among mothers and caregivers, and ensuring accessibility
to immunization services contribute to enhanced community health. By exploring the challenges
and benefits associated with immunization, healthcare systems can implement targeted
interventions to improve vaccination coverage and protect vulnerable populations.
The uptake of vaccination services is dependent not only on availability of and accessibility to
vaccination services but also other factors including knowledge and attitude of mothers. Studies
have shown that understanding the maternal perceptions and knowledge about immunization
helps health planners develop effective health education programs and messages (Adedire et al
2017). While the reasons for low immunization coverage have been proffered in general,
mitigation efforts have focused on health system factors, but little attention has been paid to
maternal, socio-demographic and other modifiable/non-modifiable factors affecting
immunization uptake. Understanding mothers´ reasons and attitudes towards immunization could
guide this aspect of multi-pronged efforts to improve routine immunization uptake.

The common cause of increased morbidity and mortality of children under-five in particular (0-
18 months) are communicable diseases. In the past, many children died before the age of 5 or
before school age due to communicable diseases. Studies shows that many people have poor
compliance with immunization regimen as mothers’ default with their children immunization
due to various reasons (Preeti Balgovind &Masoud Mohammed Nezhad, 2022).

Due to some factors such as age, level of education, marital status, location, occupation,
economic status, non-availability of mother to get the facility and religion, the practices and
attitude exhibited for mothers appear to have attracted our attention. Concerns for the alarming
rate of infant and child death as a result of vaccine preventable diseases prompted the researcher
to carry out the study to assess the practice of immunization among mothers. Despite the
abundance of information exploring the immunization knowledge, practice of mothers of under –
(0-18 months) children attending the immunization clinic, relatively little attention has been paid
as to why this is important, why we have some children not completely immunized and why still
vaccine preventable diseases aren’t absolute in protecting against diseases. It is against this
background that we will assess the uptake of immunization as well as practices and knowledge
of mothers of under 0-18 months children in OOUTH and some selected PHCs in Sagamu LGA.
1.3 JUSTIFICATION OF THE STUDY

This research aims at studying immunization uptake within the 0-18 months period. According to
the 2008 Nigerian Demographic and Health Survey Report, only 57.8 % of children aged 12–23
months in Osun State were fully immunized, far below the WHO target of 80 % (World Health
Organization (WHO). United Nations Children’s Fund (UNICEF). Global immunization data.
Geneva: WHO; 2014. Jul). The situation is worse in the rural areas as children in these areas
were twice less likely to receive full doses of routine vaccination than those in urban areas.
Studies have shown that uptake of immunization services depends not only on provision of these
services but other factors related to maternal knowledge, geographical accessibility and many
other socio-demographic characteristics.

1.4 OBJECTIVES OF THE STUDY

This research work is aimed at examining the factors affecting immunization uptake.

1.4.1 SPECIFIC OBJECTIVES

1. Assess the current maternal knowledge among mothers and caregivers regarding immunization
schedules and the importance of vaccinations.

2. Assess the perception of mothers and caregivers regarding immunization practices.

3. Assess and find out the number of children that are exposed to vaccine preventable diseases
upon extended completed immunization.
1.5 SCOPE OF THE STUDY

The scope of this study extends to the mothers and caregivers of children within the age of 0-
18months attending immunization clinic in some selected Primary Health centers & OOUTH,
Sagamu.
 CHAPTER TWO

LITERATURE REVIEW

2.0. BACKGROUND
DEFINITION OF TERMS

Immunity: Defense against microorganisms identified as Foreign. The immune system, which is
made up of organs and specialized cells, defends the body by recognizing and eliminating
potentially harmful substances with the help of anti-bodies and other specialized materials and
cells.

A vaccine: is any preparation designed to boost the body's immune system by preventing the
spread of a disease. may lessen or prevent the effects of infections caused by a variety of
bacteria. Although oral or nasal spray delivery are also options, injections are the most often
used mode of administration.

Immunization is the artificial induction of immunity with the goal of preventing the spread of
infectious diseases.

Active immunization: Can avoid clinical disease by inducing in the receiver a level of immunity
akin to that obtained from the natural infection. generated by a person's immune system, and
immunity is typically long-lasting.

Passive Immunization: The delivery of exogenously produced antibodies results in passive

immunization, which produces transient immunity. Transplacental sources are the most common.
The others include animal antitoxin, immune or hyperimmune globulin, and blood and blood
products.
TYPES OF VACCINE

Inactivated Vaccine: Consist of virus particles which are grown in culture and then killed using
heat or formaldehyde. Although these particles are destroyed, the capsid proteins are enough
preserved for the immune system to recognize and remember them, triggering a reaction. There
is less interference from circulating antibodies because it is non-replicating. higher dosages are
needed, and the immune response is primarily humoral. Over time, the antibody titre decreases
(WHO/UNICEF 2009).

Examples of inactivated vaccines include:

 Viral- poliomyelitis (Salk) hepatitis A, Rabies, influenza

 Bacteria- pertussis, typhoid, cholera, plague, anthrax

 Fractional subunit- hepatitis B, acellular pertussis, human papilloma virus

 Toxoids- diphtheria, tetanus

 Polysaccharide- pneumococcal, meningococcal, salmonella typhi

 Conjugate polysaccharide- Hib, pneumococcal, meningococcal

 Recombinant- hepatitis B, human papilloma virus, influenza

 Immune globulin homologous Poole d antibody- hepatitis A, measles

 Homologous human hyperimmune globulin. PEP hepatitis B, rabies, tetanus, varicella

 Heterologous hyperimmune serum(antitoxin)- antitoxin derived from injecting animals with

the organism such as for botulism, diphtheria

 Monoclonal antibodies derived from the clone of antibody producing cells, e.g. RSV. –
Palivizumab

Live attenuated vaccines: Made by altering a naturally existing organism (wild), usually
through repeated culture, while preserving the organism's capacity for replication and the
potential to elicit an immune response akin to that of a natural infection. Antibody circulation
could obstruct the reaction. long-lasting immunity, with one dose typically being sufficient. Live
attenuated viruses include measles, mumps, rubella, rabies, varicella, yellow fever, rotavirus,
influenza, and poliomyelitis. Typhoid and Bacilli Calmette Guerin are two examples of live
attenuated bacteria.

IMMUNIZATION SCHEDULE IN NIGERIA

National Programme on Immunization (NPI)

In Nigeria, this was first implemented in 1979. The programme was known as the Expanded
Programme on immunization (EPI) from 1979 to 1997. By virtue of Decree 12, the Federal
Government established an agency named NPI in August 1997 to provide a national perspective
and demonstrate its commitment. Through immunization and the provision of vaccines and other
consumables, this aims to effectively control the occurrence of all diseases that can be prevented
by vaccination. The following vaccine-preventable diseases are the focus of attention in Nigeria:
polio, yellow fever, cerebrospinal meningitis, measles, pertussis, neonatal tetanus, and
tuberculosis. These are the focus of immunization service delivery, which is carried out by
giving vaccines to susceptible targets.

NPI aims at the following group of people:

 Children of age ≤ 11month

 All pregnant women and
 Women of reproducing age group.

THE FIRST NPI SCHEDULE

AGE NAME OF VACCINE ROUTE

AT BIRTH BCG, HPV0, 0PV Intradermal IM or deep SC Oral

6 WEEKS OPV1 PENTA 1 PCV Oral IM IM Oral

13 1 Rotavirus1

10 WEEKS OPV2 Rotavirus2 Oral

14 WEEKS OPV3 PENTA 2 PCV13 2

2.1 HISTORY OF IMMUNIZATION

Smallpox was the first disease to be used for active immunization because it was observed that
pressing smallpox scabs against the skin might transfer immunity and generally resulted in a
minor episode of the disease (Dixon et al 2009). Many centuries ago, in China and Africa, the
susceptible were vaccinated against minor cases of smallpox using infectious material. Early in
the eighteenth century, it was introduced in Britain and the American colonies. It's important to
note that there was debate concerning the procedure's hazards and advantages even back when
one of these vaccinations resulted in a death. This raised worries, which prompted the hunt for a
"better vaccine."

Ultimately, the emphasis of this investigation was the discovery that milkmaids' hands frequently
developed tiny blisters, or "milkers' nodes," as a result of cowpox, a vesicular eruption of the
udders (Dixon, C.W. 1962). Physicians began to notice by the middle of the eighteenth century
that cowpox patients seemed to be shielded from smallpox later on, which led to Edward Jenner's
famous experiment in 1796. In the US, the smallpox vaccine became widely used quite fast. In
actuality, the Vaccine Act of 1813, the country's first regulation governing the distribution of
drugs was specifically focused on the vaccine (Hutt, P.B).

In order to "preserve the genuine vaccine matter, and to furnish the same to any citizen" who
requests it, the President may designate a federal agent under the terms of this act. After
Congress determined that local governments should be in charge of regulating vaccines, it was
repealed in 1822. Other attempts to control feared infectious illnesses in the late nineteenth
century were prompted by the apparent success of early smallpox vaccine campaigns and the
advancement of microbiology research. One of these was the active rabies immunization
technique developed by Pasteur, which was tested on a child in 1885 (Pasteur, L.1884).

The finding that animals infected with broth cultures of heat-killed tetanus or diphtheria bacilli
were able to survive successive (otherwise lethal) inoculations with those organisms led to the
development of serum therapy, subsequently known as antitoxin therapy, in the early 1890s. The
development of immunity was first attributed to the broth culture's (cell-free) supernatant rather
than the dead bacteria, a fact that early researchers were unaware of (Andrewes, F.W et al 1923).

It was also demonstrated that additional animals may be immunized with body fluids—like
serum—obtained from immunized individuals, so extending the protection afforded by
immunization. In Berlin in 1891, the first kid to receive antitoxin treatment for diphtheria was
born. Diphtheria antitoxin was developed by the middle of the 1890s and was widely used in
Germany and Britain.

The Philadelphia-based Mulford Company created and tested the antitoxin for the first time in
the United States in 1895. Merck Sharp & Dohme eventually acquired the company. A number
of rival businesses, both domestically and internationally, started producing diphtheria antitoxin
for commercial use as a result of its somewhat successful prevention and treatment of the
disease. Sometimes, charlatans made and sold inferior, ineffective, or deadly concoctions in the
absence of standards governing testing and certification. Authorities in charge issued warnings at
first, but they were virtually ignored.

Late in 1894, the Journal of the American Medical Association published editorials expressing
concerns about the unchecked manufacture of the diphtheria antitoxin and the smallpox vaccine
(Jama Editorial 1894). At the December National Conference of State Boards of Health, there
was discussion about the possible involvement of state governments in controlling the spread of
vaccine viruses.

Defective preparations were blamed for at least some of the observed variation in the
effectiveness of various smallpox vaccinations. The Health Department was given instructions
by the New York City Board of Health on December 5, 1894, to create a scheme that would
ensure the purity and efficacy of medicines containing diphtheria antitoxin that were sold in New
York City.

Some antitoxins from the United States were never examined, and the one that was tested turned
out to be inactive, despite antitoxins sent in small quantities from two German firms appearing to
show adequate purity and potency. The authorities also bemoaned the profiteering of companies
that produced antitoxins that were supposedly effective. A congressman from Illinois suggested
that a national commission be established to look into the antitoxin therapy of diphtheria after the
issue was brought to their attention.

Regretfully, until 1902, no clear action was done. This move was taken in response to the tetanus
deaths of thirteen children in St. Louis who had received diphtheria antitoxin made from a horse
that had later succumbed to the disease. (It is noteworthy that the St. Louis City Health
Department, rather than a private company, developed the antitoxin.)

Congress passed the virus-toxin act in 1902 as a result of this tragedy and the uproar it created in
the public press. Six This act created a body within the Department of Treasury to create rules
governing licenses for companies that make antitoxins and vaccines for use in domestic or
international trade. The Public Health Service's Hygienic Laboratory was given permission by
this board to conduct facility inspections, grant and revoke licenses, and take other actions that
would help to guarantee, to the best of their ability, the efficacy and safety of these biologics.
Thirteen manufacturers of biologics, mostly smallpox vaccine and diphtheria antitoxin, had been
granted licenses by 1904. By 1921, there were 41 licensed producers. The Hygienic Laboratory
set potency standards and licenses for manufacturers who did not meet acceptable criteria were
refused or withdrawn.

Later, the National Microbiological Institute of the National Institutes of Health (NIH) took over
these duties. The Public Health Service Act of 1944 eventually included the 1902 act. The Public
Health Service Hygienic Laboratory was reorganized in the 1950s as the Division of Biologics
Standards at the NIH. With the creation of the Bureau of Biologics in 1972, the Food and Drug
Administration (FDA) assumed responsibility for these duties. More than 80 generic biological
agents used in both passive and active immunization had restrictions in place by 1971.

More recently, the FDA's Bureau of Drugs and Bureau of Biologics (formerly known as the
Office of Biologics Research and Review [OBRR]) merged to become the Centre for Drugs and
Biologics. Procedures were created for the evaluation of biologics' safety, efficacy, and labelling
after the Division of Biologics Standards was transferred to the FDA in 1972. Three of the
outside consultant panels that the Bureau of Biologics established dealt with antitoxins and
vaccinations. In addition to bacterial preparations "without U.S. standards of potency," these
panels also reviewed toxoids, products used for passive immunization against viral and rickettsia
diseases, and vaccines and toxoids used for passive immunization against bacterial diseases (e.g.,
older products such as "mixed respiratory vaccines").

The panels were tasked with analyzing the specific products as well as the general safety and
effectiveness of all vaccinations, immunoglobulins, and antitoxins. The panels' options were to
recommend licensure maintenance, license maintenance for a set period of time until additional
evidence of efficacy could be obtained (only for products deemed safe), or license revocation
after assessing the safety and effectiveness of a manufacturer's preparation. By 1979, the FDA
Commissioner received the final reports from these groups. The concept that many, if not all,
infectious diseases might be treatable with immunologic prevention and therapy emerged in the
early 1900s with mounting evidence of the efficacy of smallpox vaccine and diphtheria antitoxin.

The military began using tetanus antitoxin, which is made in horses, extensively during World
War I. The British did not use antitoxin during the first few months of the war, and the shocking
monthly rate of tetanus per 1,000 injured was 32.9. The British rate was 1.2 once antitoxin was
developed. The rate for American wounded in World War I, who received tetanus antitoxin
universally, was 0.16 per 1,000.9. Tetanus toxoid was created in between the two World Wars;
by 1940, it was required in the French army (Holmes, W.H). During World War II, the U.S.
military was required to use it, which prevented the number of tetanus cases in the U.S. Armed
Forces from rising above (Miller 1892).

Tetanus toxoid was advised as a regular public health precaution for all children in the United
States by the late 1940s, and it was typically given in conjunction with the pertussis and
diphtheria toxoid vaccines. Animals treated with diphtheria toxin were able to develop immunity
to the disease, suggesting that humans could potentially benefit from this as well. A combination
of toxin and antitoxin was the first preparation for active immunization against diphtheria, and it
was initially made available in 1913 (Dick, G.F et al). Despite its effectiveness, this medicine
was not fully satisfactory due to mixture instability and some users experiencing adverse
reactions to horse serum. The early 1920s saw the development of diphtheria toxoid, a toxin
rendered inactive by formalin, which was first utilized in the mid-1930s with very little
alterations. The 1920s saw the commencement of the first conclusive trials with the pertussis
vaccine (12). The vaccine was made up of whole, killed pertussis organisms as the parts of the
organism that confer clinical immunity to whooping cough had not yet been discovered. The
vaccine was still regarded as experimental in the early 1940s and was only gradually improved;
by the late 1940s, however, a number of tests had shown that it was effective.

Because the pertussis bacterium has been extraordinarily slow to reveal its biological secrets, the
current U.S. vaccinations still contain the entire, dead organism even though they have been
better standardized. But lately, there has been some advancement in our knowledge of this
creature and how it relates to human immunity and illness. Significant progress was achieved in
the creation of vaccinations against additional diseases following World War II. Improvements
in immunology, a greater knowledge of the microorganisms involved, and the use of cell culture
techniques for viral multiplication all contributed to these improvements. Viral vaccinations were
created for the prevention of poliomyelitis, measles, rubella, and mumps in quick succession.
Safe, efficacious vaccinations were created for use in certain situations on people at risk of
contracting meningococcal disease, adenovirus infections, rabies, and other diseases (replacing
previous vaccines derived from animal tissues of the central nervous system).

It is evident that the widespread use of vaccines as public health initiatives in the US and other
developed nations has significantly reduced morbidity and mortality. Among the notable
accomplishments are the following (Eddins, D. 1985)
2.2 DETERMINANTS OF VACCINE UPTAKE

It has long been known that vaccinations are among the best strategies to lower infant mortality.
It is regarded as a great accomplishment and pertinent to the global prevention of childhood
diseases. The phrases "immunization" and "vaccination" are interchangeable in real life.
Increasing immunization accessibility is essential to achieving the Sustainable Development
Goals (SDGs). Childhood vaccination is highly effective in preventing vaccine-preventable
diseases (WHO, 2022).

Even though there are various strategies to lower the number of children who pass away from
diseases that can be prevented by vaccination, low vaccination rates continue to be a challenge in
many parts of the world.

One significant finding from the 2021 Multiple Indicators Cluster Survey/National immunization
Survey Coverage (MICS/NICS) was that 17.8% of Nigerian children between the ages of 12 and
23 months did not receive any recommended routine vaccination, with 51.9% of children in
urban areas and roughly 26.4% of children in rural areas receiving full immunization for the
basic antigens. According to Nigeria's MICS 2021 survey, a larger proportion of children
between the ages of 12 and 23 months in rural areas (22.5%) than in urban areas (9.3%) did not
obtain any vaccinations (UNICEF, 2022).
Several factors determine vaccine uptake:

1. Public Awareness:

Knowledge about immunization among parents is a major contributor. Numerous studies have
demonstrated that one of the factors strongly linked to children receiving all recommended
vaccinations is education. According to these studies, improving mothers' levels of education
will increase the proportion of children who receive vaccinations (Baxter R et al, 2015).

2. Healthcare system Factors:

One significant barrier to sufficient coverage was the distance to the medical facility. A language
barrier, unclear information provided by healthcare professionals to parents, poor service quality,
and a poorly designed or inconsistent recall or reminder system are some of the health system's
challenges that prevent parents from getting their children immunized (Musa S et al, 2020). The
availability of vaccines and their affordability are critical. Programs that make vaccines
accessible to all socioeconomic groups enhance vaccination coverage

3. Socioeconomic Factors:

The parental socio-demographic factors (maternal age, maternal education, paternal education,
maternal marital status, area of residence, wealth index, number of siblings, religion, ethnicity
and family income), child socio-demographic factors (gender, age) and environmental factors
(distance to health facility, mode of transportation, accessibility of vaccination site, satisfaction
with vaccine services, quality of vaccine provider clients relationship and availability of vaccine)
are considered as non-modifiable factors affecting mothers in Nigeria (Galadima 2021). Maternal
age had an impact on full childhood immunization as mothers aged 35–44 years were 1.76 times
more likely to receive complete childhood immunization coverage for their children than
mothers aged 15–24 years (Miracle A. Adesina et al). Decision making also plays a major role in
the uptake of immunization. Aside from the fact that younger mothers are often unable to make
decisions on their own, older mothers have more experience in raising children and are more
knowledgeable about children’s health, as reported in a study carried out among mothers of
children aged 12–23 months in Indonesia.
To add to this, maternal education was the most common reported parental socio-demographic
factor found to influence childhood immunization. This is because educated mothers understand
the importance of childhood immunization and have greater exposure to the benefits of
immunization than uneducated mothers. Also, educated mothers are more open to accepting
ideas that are beneficial, more confident in making decisions for their health, have more access
to obtaining health information, and are more receptive to preventive health services. Moreover,
educated women are more likely to be wealthier, and thus tend to have better access to health
facilities and immunization services. The marital status of a mother also has an influence towards
childhood immunization uptake. The marital status of a mother may enhance her knowledge in
the sense that those that are married may have more access to education compared to single
mothers who may have other responsibilities and would instead tend to put their education aside
in order to meet the needs of their children. The supportive role of their partners may also
enhance her knowledge if both partners jointly try to find ways to better the health status of their
offspring. Income levels and education of parents can influence vaccination rates. Higher
socioeconomic status is often associated with better access to healthcare and information
(Gebeyehu NA, et al 2022). The number of siblings is also a factor affecting childhood
immunization uptake. This may be due to experience gained over time on the importance of
immunization as well as the medical complications that have occurred in children due to lack of
immunization. Religion has been revealed by studies to be a factor influencing childhood
immunization uptake. The circulation of false information obtained via religious networks may
be linked to negative beliefs of vaccines especially in some certain practices.

Ethnicity was found to be a factor affecting childhood immunization uptake in Nigeria in which
children belonging to the Igbo ethnic group were about three times more likely to be fully
vaccinated compared to children belonging to an ethnic group such as Hausa, Yoruba and others.
(Antai D, 2009). These disparities could be attributed to the factors prevalent at community
level, for example, in the Hausa community there is low level of education, high poverty, poor
utilization of antenatal care and home delivery and all these factors are associated with poor
immunization uptake. It could also be due to a misconception regarding the safety of vaccines
and fear of vaccine side effects.
4. Trust in Healthcare Providers:

Trust in healthcare professionals and the healthcare system is essential. Strong doctor-patient
relationships can positively influence vaccination decisions. Rudeness, poor attitude,
insensitivity and unpleasant immunization operating procedures including long waiting hours,
extended time of exposure of the child, accessibility of the services, poor respect of client rights,
cleanliness of the facility can deter parents from coming in for their next appointment (Khan MU
et al, 2015). Understanding and addressing these factors is crucial for successful vaccination
programs and achieving herd immunity.

5. Obstetric factors

The number of antenatal care visits, and place of antenatal care have a significant impact on full
childhood immunization. According to a study carried out by Maharani et al, it revealed that the
number of antenatal care visits, and place of antenatal care have a significant impact on full
childhood immunization. Mothers who attended a place of ANC 1–8 times and ≥9 times were
more likely to ensure their children received complete immunization than mothers who never
visited places of antenatal care. Also, mothers who received antenatal care in a healthcare facility
were likely to complete immunization for their children compared to their counterparts. Maternal
knowledge also plays a crucial role in immunization uptake. Maternal knowledge on child
vaccine schedules was revealed to statistically influence child immunization uptake where
mothers who had knowledge on schedules of vaccines were found to be four times more likely to
fully immunize their children compared with mothers who had no knowledge of vaccine
schedules. (Awosan et al). Parents who were aware of immunization and immunization
programs were three times more likely to have their children immunized compared with their
counterparts.
2.3 IMPORTANCE OF IMMUNIZATION

Vaccines can have an enormous economic benefit. (Ozawa S et al, 2012). One of the most
discernible benefits is averted medical expenditure. By preventing an episode of the disease
through a vaccine, the economic costs of treatment, such as physician fees, drugs and
hospitalization expenses, and associated travel costs and wage loss of caregivers could be
avoided.

Vaccines could also limit the number of people who fall into poverty due to a catastrophic
medical expense which is defined as a large proportion (typically, more than 10% to 25%) of
household income or expenditure. (Wagstaff A et al, 2018).

Routine childhood vaccinations are, thus, estimated to avert the largest burden of diseases,
associated medical expenses, and loss in economic productivity in the least developed segments
of the society (Riumallo-Herl C, et al, 2018).

Vaccines could prevent infections – either sensitive or resistant – and also reduce the use of
antimicrobials, which in turn could slow the growth of antimicrobial resistance (Goossens H.
2009).

Persistent or recurrent infections in early life can lead to poor growth and stunting, which in turn
can adversely affect adult health, cognitive capacity, and economic productivity. (Dewey KG,
Begum K, 2011). The theoretical basis of the long-term benefits of vaccines is anchored in the
widely accepted “fetal origins” hypothesis which links conditions in utero and during early
childhood with later life outcomes. (Currie J, Vogl T, 2013) Because of vaccines, many diseases
that have devastating effects have been greatly reduced or even eliminated. Illnesses that were
fatal or left people disabled just a short time ago are no longer as much of a threat.

Immunizations don’t just protect individuals; they protect entire communities through a process
known as “herd immunity” or “community immunity.” Herd immunity occurs when as many
people as possible are immunized against a particular disease, creating fewer places for it to land
and cause an infection outbreak
Childhood vaccines have numerous positive effects beyond disease prevention. The concept of
broader benefits of vaccines which would include cognition, schooling, economic productivity,
fertility, (Bloom DE et al, 2005).

2.4 ADVERSE EFFECTS OF THE USE OF VACCINES

Vaccinations given to children within 0 to 18 months are generally safe. Side effects, if any, are
generally mild and usually last one to two days. The rate of side effects depends on the vaccine
in question. There are also some situations in which an infant or child should not receive a
specific vaccine or formulation of vaccine, such as if they have a history of severe allergic
reaction or if the children have a medical condition or take medication that makes their immune
system weaker than normal.

Common side effects include: fever (a temperature over 38.5'c), red swelling and tenderness
around the injection site, a small hard lump (nodule) at the injection site may also be seen which
may persist for weeks but is of no concern and requires no treatment, fussiness(irritability),
vomiting, loss of appetite.

Uncommon or rare immunization side effects

There is a very small probability of experiencing a serious reaction after immunization. This is
why it is advised to stay at the clinic for at least 15 minutes after receiving a vaccine in case
further treatment is required and they include:

Anaphylaxis – an immediate allergic reaction. This is dramatic but rare (fewer than one in a
million children will have anaphylaxis after a vaccination), and it is completely reversible if
treated quickly.
Febrile seizure – this seizure usually lasts one or two minutes. It can be frightening and usually
does not cause permanent harm or have lasting effects. It is caused when a child’s fever rises
quickly.

Bowel blockage (intussusception) – this occurs in the 7 days following the first and second dose
of rotavirus vaccine. This is a rare side effect for about 1 in 17,000 babies.

Some contraindications to the use of vaccines

For children who have a progressive or unstable neurologic disorder (e.g., infantile spasms,
seizures that are not well controlled), PENTA vaccination should be postponed until the
neurologic problem is controlled or stable. For children who have a moderate or severe illness on
the day of the scheduled immunization, PENTA vaccination should also be postponed until the
child is better.

The injected polio vaccine should not be given to children who have a severe allergy to
antibiotics contained in the vaccine, including neomycin, streptomycin, or polymyxin B.

Rotavirus vaccine should not be given to infants with a known immunodeficiency (e.g., a
medical condition that weakens the immune system) or history of intussusception (a condition in
which part of the intestine slides into another part).

For the first dose, the risk of febrile seizures is twice as high in children 12 to 23 months of age
who receive MMR vaccine combined with varicella vaccine as in children who receive MMR
vaccine and varicella vaccine separately. For this reason, separate MMR and varicella vaccines
are generally preferred for the first dose if the child is younger than 48 months (4 years). The risk
of febrile seizures decreases as children get older, so the combination MMR-varicella vaccine
can be used for the second dose.
CHAPTER 3

METHODOLOGY

3.1 Study Design

This is a descriptive cross-sectional study on immunization uptake amongst mothers and

caregivers of children aged 0-18 months.

3.2 Study Area

The study will be conducted in all political wards in Sagamu community, Ogun state, Nigeria.
Sagamu is a conglomerate of thirteen (13) towns located in Ogun State along the Ibu River and
Eruwuru Stream between Lagos and Ibadan. It was founded in the mid-19th century by members
of the Remo branch of the Yoruba people, in south-western Nigeria. The 13 towns that make up
Sagamu are: Makun, Offin Sonyindo, Epe, Ibido, Igbepa, Ado, Oko, Ipoji, Batoro, Ijoku, Latawa
and Ijagba. It is the capital of Remo Kingdom and the seat of the Akarigbo, the paramount ruler
of Remo kingdom. The Sagamu Local Government has been divided into three (3) Local Council
Development Areas (LCDAs) namely Sagamu West LCDA, Sagamu Central LCDA and
Sagamu South LCDA, and it has fifteen (15) political wards namely;

Ward 1 – Oko, Epe & Itunla I

Ward 2 – Oko, Epe & Itunla II

Ward 3 – Aiyegbami/Ijoku

Ward 4 – Sabo I
Ward 5 – Sabo II

Ward 6 – Itunsokun/Oyabajo

Ward 7 – Ijagba

Ward 8 – Latawa

Ward 9 – Ode-lemo

Ward 10 – Ogijo/Ikosi

Ward 11 – Surulere

Ward 12 – Isote

Ward 13 – Simawa

Ward 14 – Agbowa

Ward 15 – Ibido/Itun Alara

3.3 STUDY POPULATION

The population of this study will consist of nursing mothers and caregivers that come for
immunization, attends the U5 Clinic at OOUTH as well as Primary Health centres within
Sagamu LGA. There are over 800 mothers and caregivers that come for the exercise in total from
the entire population.
3.4 SAMPLING TECHNIQUE

Cluster random sampling technique was used to select participants. On a basis of considering
each PHC as a cluster, we employed 50% of the whole and picked 9 via simple random sampling
as every PHC have an equal probability of being selected (30 each).

The PHCs include:

 Ajaka

 Ayegbami

 Epe

 EwoOluwo

 Ijokun

 Isote

 Isale-oko

 Makun

 Sabo GRA.

3.5 Sample size Determination

For administrative convenience, Sagamu LGA is divided into 15 political wards. The sample size
(no of nursing mothers and caregivers attending the nine selected PHCs) was calculated in each
ward of Sagamu Local Government Area, using the statistical formula below:
Using a prevalence of 78.9% gotten from another study done in a similar town, Ilejemeje LGA,
Ekiti State.

(Sample size (n) = Z2pq/d2

Z = confidence interval = 1.96
P = Prevalence =0.79
q = 1-p =0.21
d =marginal error= 0.05
Sample size = (1.96)2 x 0.79x 0.21
(0.05)2
Sample size, n = 241.92 ≈ 242.
10% non-response rate, corrected sample size = 266.2
Approximated sample size =270.

271 questionnaires were distributed.

3.6 Instrument for the study

This study was carried out in two phases – Pre-testing and Main study or Testing

3.6.1 Pre-Testing
The pre-testing is a smaller version of the full-scale study (also called feasibility study).
The pre testing activities in this study included the following:

1. Official permission was obtained from the Local Government Area and leaders of one of
the selected PHC, Isale Oko to carry out the study.
2. The instrument for data collection, an interview-based semi-structured questionnaire was
pre-tested among selected nursing mothers in Sagamu LGA, to ascertain its validity and
reliability. The questionnaire was designed from previous immunization uptake studies,
in this case, with little modifications, to suit the purpose of the research. The
 questionnaire was divided into four sections. The first section asked questions on the
socio-demographic and socio-economic status of the households (i.e., marital status,
household size, educational level, occupation). The second part involved questions about
respondents’ knowledge and awareness of immunization uptake- sources of information
about immunization, diseases prevented by immunization. The third part mainly
examined respondents’ attitude and practice towards immunization uptake. And the
fourth part examines the factors affecting the uptake of immunization amongst mothers’
and caregivers. The fifth and last part examined the effect of complete/incomplete
immunization. The decision to use interview as the method of primary data construction
is because; it is assumed that majority of the rural women are not literate enough to fully
understand and interpret the questions. Furthermore, the interview process gave
opportunity to the interviewers to observe directly the behavior of respondents when
answering the questions and also takes into consideration how they perceived
immunization as a topic of urgency. The interview was mostly carried out in the morning
when the majority of the respondents were expected to be at the selected PHCs. The
questionnaire was pre-tested for reliability and validity among selected nursing mothers
by a method previously described by Herzog (2008), which recommends a sample size of
12 to 25 subjects or participants during development of research instruments.

3.6.2 Main study or Testing

The main study was conducted after the pre-testing study and involved the following activities:

1. Ethical approval/clearance letter from the Health and Research Ethics Committee
(HREC) of Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
2. Obtaining Informed consent from participants/ mothers and caregivers attending the nine
selected PHCs
3. Debriefing the participants about the purpose, procedure of the study and confidentiality
of information
 4. Administration of questionnaires to consenting and volunteering participants
5. Collection of data.

3.6.3 Inclusion and exclusion criteria

Inclusion criteria: All mothers and caregivers as defined above under the study population
section.

Exclusion criteria: Mothers and caregivers that declined consent/incompletely filled the
questionnaire form will be excluded from the study

3.7 Ethical considerations

Approval to carry out this study was obtained from the Health Research Ethics Committee
(HREC) of Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Ogun State.
Informed consent was also obtained from the community leaders of the selected wards. Oral and
written consent was obtained from the selected mothers before administering the questionnaires.
The participants were assured of their freedom to opt out at any stage of the research. The
participants/respondents were assured of confidentiality and this assurance was indicated in the
questionnaire.

3.8 Statistical analysis

The research survey made use of structured and semi-structured questionnaires which seek
precise measurements in order to analyze the targeted concepts. Data from the questionnaires
was sorted out and coded accordingly, prior to processing by Microsoft Excel and SPSS, version
23 software. In this study, the statistical significance level was p-value < 0.05.
CHAPTER FOUR

DATA ANALYSIS AND INTEPRETATION

4.0 Introduction

This chapter deals with the presentation, analysis and interpretation of data. The data is obtained
from the field work with the use of questionnaire. The questionnaire was used to assess the
immunization uptake among mothers & care-givers of children between the ages of 0-18 months
in some selected Primary Health centers & OOUTH, Sagamu. Two hundred and Seventy-one
(271) questionnaires were distributed and correctly filled. The analysis will therefore be based on
the 271 questionnaire that were returned in good condition.

4.1 Presentation of Data

Section A: Demographic characteristics

Section B: Information about awareness on immunization as well as benefits.

Section C: Attitude about immunization.

Section D: Factors influencing immunization uptake

Section E: Effect of complete / incomplete immunization

Table 4.1 Socio-Demographic Characteristics of Respondents

Variables Characteristics Frequency (n=271) Percentage (100 %)

Age as at last birthday <25 74 27.3

(27.05±0.79)
26-30 125 46.1

31-44 64 23.6

>45 8 3.0

Christianity 201 74.2

Religion Islam 59 21.8

Traditional 11 4.1

Yoruba 221 81.5

Ethnicity Igbo 39 14.4

Hausa 11 4.1

No formal education 8 3.0

Primary school 7 2.6

Level of education
Secondary school 133 49.1

Tertiary education 123 45.4

Married 232 85.6

Marital Status
Single 39 14.4

1 105 38.7

Number of children 2-4 children 154 56.8

more than 4 12 4.4

Occupation Housewife/Unemployed 58 21.4

Civil servant 95 35.1

 Artisan 75 27.7

Trader 43 15.9

<33,000 67 24.7

33,000-100000 129 47.6

Monthly Income
101000-200000 67 24.7

>200,000 8 3.0

Approximate distance <5km 119 43.9

between my house and
5-10km 104 38.4
the nearest health
facility >10km 48 17.7

Source: Field study 2025

Table 4.1 showed that among the 271 respondents, the mean age was 27.05±0.79 years, with 125
(46.1%) aged 26-30 years, 74 (27.3%) below 25 years, 64 (23.6%) aged 31-44 years, and 8
(3.0%) above 45 years. Christianity was the dominant religion, reported by 201 (74.2%),
followed by Islam at 59 (21.8%) and Traditional religion at 11 (4.1%). The majority, 221
(81.5%), were Yoruba, while 39 (14.4%) were Igbo and 11 (4.1%) were Hausa. Regarding
education, 133 (49.1%) had secondary education, 123 (45.4%) had tertiary education, 8 (3.0%)
had no formal education, and 7 (2.6%) had only primary education. Most respondents, 232
(85.6%), were married, while 39 (14.4%) were single. In terms of number of children, 154
(56.8%) had 2-4 children, 105 (38.7%) had one child, and 12 (4.4%) had more than four
children. Occupationally, 95 (35.1%) were civil servants, 75 (27.7%) were artisans, 58 (21.4%)
were housewives/unemployed, and 43 (15.9%) were traders. Monthly income distribution
showed 129 (47.6%) earning between ₦33,000-₦100,000, while 67 (24.7%) each earned below
₦33,000 and between ₦101,000-₦200,000, with only 8 (3.0%) earning above ₦200,000.
Regarding proximity to health facilities, 119 (43.9%) lived within 5 km, 104 (38.4%) lived 5-10
km away, and 48 (17.7%) resided more than 10 km from the nearest health facility.
 Number Occupa-Income
Monthly Religion
chil- tion
of (33,000-100,000); 48% (Chris-
Age (26-30); 46%
dren (2-4(Civil tianity);
Servant);
children); 74%
57% 35%

Distance
to the
nearest Ethnicity
hospital Level of
Marital Educa- (Yoruba)
(<5km); ; 82%
0.44 Status tion (Ter-
(Mar- tiary ed-
ried); ucation);
86% 49%

Figure 4.1 showing the socio-demographic characteristics of the respondents.

Table 4.2. Awareness on immunization as well as benefits.

Statement Frequency (808) Percentage (%)

Source of information about Immunization

Parents 76 9.4%

Health care worker during antenatal clinic 76 9.4%

Religions Leaders 72 8.9%

Social media 55 6.8%

My friends/Neighbors 75 9.3%

The Television Programs 68 8.4%

Movies 72 8.9%

Town Announcer 72 8.9%

Poster/banner 64 7.9%

Women group 60 7.4%

Community Leader 16 2.0%

Not heard of immunization before 102 12.6%

Diseases prevented by immunization F (586) %

Measles 99 16.9%

Tuberculosis 47 8.0%

Whooping Cough 52 8.9%

Poliomyelitis 24 4.1%

Hepatitis B 72 12.3%

Cholera 79 13.5%

HIV 12 2.0%

Tetanus 47 8.0%

Malaria 55 9.4%
 Fever 99 16.9%

Source: Field study 2025

Table 4.2 showed that majority of respondents (102, 12.6%) had not heard of immunization
before, while various sources contributed to awareness. Women’s groups (76, 9.4%) and
community leaders (76, 9.4%) were the most cited sources, followed by friends/neighbors (75,
9.3%) and town announcers (72, 8.9%). Religious leaders (72, 8.9%), movies (72, 8.9%), and
television programs (68, 8.4%) also played roles in disseminating information. Health care
workers during antenatal clinics were the least mentioned source (16, 2.0%).

Regarding the diseases prevented by immunization, the most frequently mentioned were Measles
(99, 16.9%) and fever (99, 16.9%), followed by cholera (79, 13.5%) and hepatitis B (72, 12.3%).
In contrast, HIV (12, 2.0%) and poliomyelitis (24, 4.1%) were the least identified, suggesting
gaps in knowledge about vaccine-preventable diseases.

Town Health
Poster/banner;
An- 7.90% care
Parents,7.40%
nouncer; worker
duringReligions
8.90% Leaders;
antenatal
8.90%
clinic,2.0
0%

Movies;
8.90% Social
The
My media;
Televi-
friends/ 6.80%
sion
Pro- Neigh-
grams; bors;
0.084 9.30%

Figure 4.2 showing the source of information about immunization

To summarize the Awareness on immunization. 2 knowledge items were used. Each item was
scored based on a 1 to 3 scale which was recategorised into options yes, no and I don’t know,
depending on the response's level of positivity towards awareness of immunization Negatively
worded items were reverse scored. The maximum mean score a respondent can obtain is 3, and
the minimum is 1. knowledge level was categorized into into Low and High. Scores for each
categories are: 0 – 0.5 = Low and 0.50 - 1.00 = High.

Table 4.3: Overall Awareness on Immunization

Score Frequency (271) Percent (%)

Low 16 5.9
High 255 94.1
Total
271 100.0

255 (94.1%) demonstrated a high level of awareness on immunization, while only 16 (5.9%) had
a low level of awareness. This indicates that the majority of the respondents were well-informed
about immunization.
Table 4.4: Attitude And Practice of Immunization among Mother & Care-Givers of
Children between the Ages of 0-18 Months

Yes No
Statement f (%) f (%)

I have a mother-child booklet and/or immunization card for my child

Yes 271` 100.0

If “No or I don’t know” What’s the reason for non-availability of child

immunization card

Lost/Misplaced - -

Not issued - -

Fear of side effects - -

Cost of immunization - -

Lack of awareness about the importance of immunization - -

Cultural/religious beliefs - -

Transportation issues - -

Financial constraints - -

If yes, what factor influenced your decision to get

immunized?

Child’s health

I don't know 39 14.4

No 31 11.4

Yes 201 74.2

Family members

I don't know 48 17.7

No 63 23.2

Yes 160 59.0

Husband

I don't know 72 26.6

No 67 24.7

Yes 132 48.7

Travel requirements

I don't know 87 32.1

No 134 49.4

Yes 50 18.5

Workplace requirements

I don't know 91 33.6

No 149 55.0
Yes 31 11.4

Concerns about disease outbreak

I don't know 44 16.2

No 81 29.9

Yes 146 53.9

Recommendations from healthcare providers

I don't know 24 8.9

No 67 24.7

Yes 180 66.4

Proximity to healthcare center

I don't know 68 25.1

No 97 35.8

Yes 106 39.1

How confident are you in the safety and effectiveness of

vaccines?

Not very confident 16 5.9

Somewhat confident 26 9.6

Very confident 229 84.5

How satisfied are you with the communication and

information provided by healthcare professionals
regarding childhood immunizations?

Not at all satisfied 8 3.0

Not very satisfied 4 1.5

very confident 34 12.5

Somewhat satisfied 225 83.0

Are you up to date with all recommended

immunizations for your child

I don't know 23 8.5

No 34 12.5

Yes 214 79.0

If NO or NOT SURE to the above question, please

specify which immunization you are missing or unsure
about?

Polio vaccine 12 35.3

Measles vaccine 8 23.5

Hepatitis B vaccine 6 17.6

 BCG (Tuberculosis) vaccine 5 14.7

Meningitis vaccine 3 8.8

Did you receive polio vaccine?

I don't know 4 1.5

No 32 11.8

Yes 235 86.7

Did you receive measles vaccine

I don't know 11 4.1

No 43 15.9

Yes 217 80.1

Source: Field study 2025

All respondents (271, 100.0%) reported having a mother-child booklet and/or immunization
card, with no cases of loss, non-issuance, or other barriers recorded.

Regarding factors influencing immunization, most respondents (201, 74.2%) cited concern for
their child's health, while recommendations from healthcare providers (180, 66.4%) were also
significant. Family members (160, 59.0%) and concerns about disease outbreaks (146, 53.9%)
were additional influences. However, workplace requirements (31, 11.4%) and travel
requirements (50, 18.5%) had minimal impact.
Confidence in vaccine safety was high, with 229 (84.5%) respondents being very confident.
Most respondents (225, 83.0%) were somewhat satisfied with the communication and
information provided by healthcare professionals.

Regarding immunization status, 214 (79.0%) reported being up to date, while 34 (12.5%) were
not. Among those unsure or not up to date, polio vaccine (12, 35.3%) and measles vaccine (8,
23.5%) were the most commonly missed.

For specific vaccine uptake, 235 (86.7%) reported receiving the polio vaccine, while 217
(80.1%) received the measles vaccine. However, a small proportion remained unvaccinated, with
32 (11.8%) not receiving polio and 43 (15.9%) missing measles vaccination.

To summarize the practice of immunization among the respondents. 6 items were used. Each
item was scored based on a 1 to 4 scale depending on the response's level of positivity towards
the practice. Negatively worded items were reverse scored. The maximum total score a
respondent can obtain is 41, and the minimum is 6. Attitude was categorized into Low and High
based on the total score. The score ranges are as follows:
6 – 21 = Poor practice
22 - 41 = Good Practice
Table 4.5: Overall Practice on Immunization

Score Frequency (271) Percent (%)

Poor 40 14.8
Good 231 85.2
Total
271 100.0
231 (85.2%) reported good immunization practices, while 40 (14.8%) had poor immunization

practices. This suggests that most respondents engage in appropriate and recommended

immunization practices.

Table 4.6 Factors Affecting the Uptake of Immunization among Mothers & Care-Givers of
Children Between the Ages of 0-18 Months

Statement Yes No I don’t

 f(%) f(%) know
f(%)
Age of Child 220 (81.2%) 20 (7.4%) 31 (11.4%)

Household income 86 (31.7%) 129 (47.6%) 56 (20.7%)

Age of Mother 63 (23.2%) 132 (48.7%) 76 (28.0%)

Distance to health facility 110 (40.6%) 109 (40.2%) 72 (26.6%)

Place of delivery 55 (20.3%) 144 (53.1%) 72 (26.6%)

Religious beliefs 43 (15.9%) 156 (57.6%) 72 (26.6%)

Cultural beliefs 59 (218%) 136 (50.2%) 76 (28.0%)

Husband Support 95 (35.1%) 112 (41.3%) 64 (23.6%)

Financial constraints 63 (23.2%) 128 (47.2%) 80 (29.5%)

Parity (Number of Children) 56 (20.7%) 132 (48.7%) 83 (30.6%)

Residence 67 (24.7%) 124 (45.8%) 80 (29.5%)

Access to social media 79 (29.2%) 124 (45.8%) 80 (29.5%)

Number of visits to Clinic 107 (39.5%) 100 (36.9%) 64 (23.6%)

Mother’s education 83 (30.6%) 132 (48.7%) 56 (20.7%)

Method of delivery (Normal delivery or Caesarean 39 (14.4%) 121 (44.6%) 111 (40.9%)

section)
Source: Field study 2025

Table 4.4 showed that age of the child was the most reported factor influencing immunization uptake, with 220 (81.2%)
respondents affirming its impact. Distance to health facilities (110, 40.6%) and the number of clinic visits (107, 39.5%) were also
significant.

Conversely, place of delivery (144, 53.1%), religious beliefs (156, 57.6%), and cultural beliefs (136, 50.2%) were not widely
seen as barriers. Household income (129, 47.6%) and financial constraints (128, 47.2%) were also not considered major
deterrents.

Regarding maternal factors, the mother's education (132, 48.7%) and age (132, 48.7%) were not widely perceived as affecting
immunization uptake. Similarly, husband support (95, 35.1%) and access to social media (79, 29.2%) had moderate influence.

Among factors with high uncertainty, the method of delivery had the highest proportion of "I don’t know" responses (111,
40.9%), followed by parity (83, 30.6%) and financial constraints (80, 29.5%).

Table 4.7 Effects of Complete/Incomplete Immunization

Statement Frequency Percentage

In your opinion, how important is it for a child to receive
all recommended vaccinations according to the
immunization schedule
Not important at all 3 1.1

Not very important 8 3.0

Somewhat important 26 9.6

Very important 234 86.3

Have you ever witnessed a child experiencing a vaccine-

preventable disease (measles, mumps, rubella
No 134 49.4

Yes 137 50.6

If yes, what was/were the disease(s) the child experienced?

Chicken 4 1.5

Fever, R 4 1.5

Measles 79 29.2

No 4 1.5

Polio 12 4.5

Rubella 4 1.5

Missing System 107 39.5

Have you ever known a child who experienced serious side
effects from immunization?
I don't know 4 1.5

No 195 72.0

Yes 72 26.6

If yes, what were the side effects?

Abscess 4 1.5

Fever 20 7.4

Fever &cannot walk well 4 1.5

Itching 4 1.5
 None 223 82.3

Rain 4 1.5

Rashes 12 4.4

Do you believe that children who are fully vaccinated are

less likely to get sick compared to children who are not
fully vaccinated?
Strongly disagreed 4 1.5

Disagree 8 3.0

Neutral 4 1.5

Agree 52 19.2

Strongly agreed 203 74.9

Do you think children with incomplete immunization pose

a health risk to other children in the community?
I don't know 16 5.9

No 27 10.0

Yes 228 84.1

Field Study: 2025

The table above showed that majority of respondents (234, 86.3%) considered it very important
for a child to receive all recommended vaccinations, while only a small proportion (11, 4.1%)
believed it was not important or only somewhat important (26, 9.6%).

Regarding experiences with vaccine-preventable diseases, 137 (50.6%) had witnessed a child
suffering from such illnesses, with measles being the most commonly reported disease (79,
29.2%). However, 195 (72.0%) had not known a child who experienced serious side effects from
immunization, while 72 (26.6%) had, with fever (20, 7.4%) being the most frequently mentioned
side effect.

Most respondents (203, 74.9%) strongly agreed that fully vaccinated children are less likely to
get sick, while a smaller proportion (12, 4.5%) disagreed or remained neutral. Similarly, 228
 (84.1%) believed that children with incomplete immunization pose a health risk to others in the
community, whereas 27 (10.0%) disagreed, and 16 (5.9%) were uncertain.

4.2 Research Hypothesis

4.2.1 There’s no significant relationship between the level of knowledge and practice of
mothers and caregivers regarding immunization.

Table 4.8: Level of knowledge and practice of mothers and caregivers regarding
immunization.

Practice
Low High Total d.f X2-value p-value
Knowledge Low 49.044a
12 (4.4%) 4 (1.5%) 16 (5.9%) 1 .000
High 28 (10.35) 227 (83.8%) 255 (94.1%)
Total 40 (14.8%) 231 (85.2%) 271 (100.0%)
The chi-square test reveals a statistically significant relationship between the level of knowledge
and the practice of mothers and caregivers regarding immunization, as indicated by a chi-square
value of 49.044 and a p-value of 0.000 (p < 0.05). This implies that respondents with a higher
level of knowledge are significantly more likely to exhibit good immunization practices.

4.3 Answering of Research Questions/ Hypothesis

1. What is the current maternal knowledge among mothers and caregivers regarding
immunization schedules and the importance of vaccinations?

Table 4.2 showed that majority of respondents (102, 12.6%) had not heard of immunization
before, while various sources contributed to awareness. Health care workers during antenatal
clinc (76, 9.4%) and parents(76, 9.4%) were the most cited sources, followed by
friends/neighbors (75, 9.3%) and town announcers (72, 8.9%). Religious leaders (72, 8.9%),
movies (72, 8.9%), and television programs (68, 8.4%) also played roles in disseminating
information. Community leaders were the least mentioned source (16, 2.0%).
Regarding the diseases prevented by immunization, the most frequently mentioned were Measles
(99, 16.9%) and fever (99, 16.9%), followed by cholera (79, 13.5%) and hepatitis B (72, 12.3%).
In contrast, HIV (12, 2.0%) and poliomyelitis (24, 4.1%) were the least identified, suggesting
gaps in knowledge about vaccine-preventable diseases.

2. What is the attitude and practice of immunization among mother & care-givers of
children between the ages of 0-18 months?

All respondents (271, 100.0%) reported having a mother-child booklet and/or immunization
card, with no cases of loss, non-issuance, or other barriers recorded.

Regarding factors influencing immunization, most respondents (201, 74.2%) cited concern for
their child's health, while recommendations from healthcare providers (180, 66.4%) were also
significant. Family members (160, 59.0%) and concerns about disease outbreaks (146, 53.9%)
were additional influences. However, workplace requirements (31, 11.4%) and travel
requirements (50, 18.5%) had minimal impact.

Confidence in vaccine safety was high, with 229 (84.5%) respondents being very confident.
Most respondents (225, 83.0%) were somewhat satisfied with the communication and
information provided by healthcare professionals.

Regarding immunization status, 214 (79.0%) reported being up to date, while 34 (12.5%) were
not. Among those unsure or not up to date, polio vaccine (12, 35.3%) and measles vaccine (8,
23.5%) were the most commonly missed.

For specific vaccine uptake, 235 (86.7%) reported receiving the polio vaccine, while 217
(80.1%) received the measles vaccine. However, a small proportion remained unvaccinated, with
32 (11.8%) not receiving polio and 43 (15.9%) missing measles vaccination.

3. What are the factors affecting the uptake of immunization among mothers & care-givers
of children between the ages of 0-18 months?

Table 4.4 showed that age of the child was the most reported factor influencing immunization
uptake, with 220 (81.2%) respondents affirming its impact. Distance to health facilities (110,
40.6%) and the number of clinic visits (107, 39.5%) were also significant.
Conversely, place of delivery (144, 53.1%), religious beliefs (156, 57.6%), and cultural beliefs
(136, 50.2%) were not widely seen as barriers. Household income (129, 47.6%) and financial
constraints (128, 47.2%) were also not considered major deterrents.

Regarding maternal factors, the mother's education (132, 48.7%) and age (132, 48.7%) were not
widely perceived as affecting immunization uptake. Similarly, husband support (95, 35.1%) and
access to social media (79, 29.2%) had moderate influence.

Among factors with high uncertainty, the method of delivery had the highest proportion of "I
don’t know" responses (111, 40.9%), followed by parity (83, 30.6%) and financial constraints
(80, 29.5%).

4. What are the effects of complete/incomplete immunization?

The table 4.5 showed that majority of respondents (234, 86.3%) considered it very important for
a child to receive all recommended vaccinations, while only a small proportion (11, 4.1%)
believed it was not important or only somewhat important (26, 9.6%).

Regarding experiences with vaccine-preventable diseases, 137 (50.6%) had witnessed a child
suffering from such illnesses, with measles being the most commonly reported disease (79,
29.2%). However, 195 (72.0%) had not known a child who experienced serious side effects from
immunization, while 72 (26.6%) had, with fever (20, 7.4%) being the most frequently mentioned
side effect.

Most respondents (203, 74.9%) strongly agreed that fully vaccinated children are less likely to
get sick, while a smaller proportion (12, 4.5%) disagreed or remained neutral. Similarly, 228
(84.1%) believed that children with incomplete immunization pose a health risk to others in the
community, whereas 27 (10.0%) disagreed, and 16 (5.9%) were uncertain.

5. There’s no significant relationship between the level of knowledge and practice of

mothers and caregivers regarding immunization.

The chi-square test reveals a statistically significant relationship between the level of knowledge
and the practice of mothers and caregivers regarding immunization, as indicated by a chi-square
value of 49.044 and a p-value of 0.000 (p < 0.05). This implies that respondents with a higher
level of knowledge are significantly more likely to exhibit good immunization practices.
CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATION

5.0 Introduction

This chapter deals with the discussion of findings, summary, conclusion of the study and
recommendations on the “immunization uptake among mothers & care-givers of children
between the ages of 0-18 months.” The chapter also includes the summary, conclusion,
recommendations, suggestions for further studies, and study limitations.
5.1 Discussion of the findings

5.1.1. Discussion on the current maternal knowledge among mothers and caregivers
regarding immunization schedules and the importance of vaccinations.
Table 4.2 revealed that 102 (12.6%) of respondents had not heard of immunization before, while
various sources contributed to awareness. Healthcare workers during antenatal clinics(76, 9.4%)
and parents (76, 9.4%) were the most cited sources, followed by friends/neighbors (75, 9.3%)
and town announcers (72, 8.9%). Community leaders were the least mentioned (16, 2.0%),
highlighting an improvement in direct healthcare education. A study by Babalola & Lawan
(2021) in Northern Nigeria found that 78% of mothers learned about immunization through
community outreach programs, highlighting the importance of community engagement.
Research by Oyo-Ita et al. (2019) indicated that only 50% of Nigerian mothers correctly
identified all vaccine-preventable diseases, similar to the gap found in this study. A WHO report
(2020) highlighted that media campaigns in Ghana improved vaccine awareness by 40%,
reinforcing the need for more media involvement in immunization campaigns.

Regarding knowledge of vaccine-preventable diseases, HIV (99, 16.9%) and fever (99, 16.9%)
were the most commonly mentioned, while measles (12, 2.0%) and poliomyelitis (24, 4.1%)
were the least identified. This suggests gaps in knowledge about vaccine-preventable diseases.

5.1.2 Attitudes and Practices of Mothers and Caregivers Toward Immunization

All respondents (271, 100.0%) had an immunization card, with no reported cases of loss or non-
issuance. The most influential factor in immunization uptake was concern for the child’s health
(201, 74.2%), followed by recommendations from healthcare providers (180, 66.4%) and family
influence (160, 59.0%). Workplace (31, 11.4%) and travel requirements (50, 18.5%) had
minimal influence. Confidence in vaccine safety was high, with 229 (84.5%) expressing strong
confidence, and 225 (83.0%) being somewhat satisfied with healthcare communication.
Regarding immunization status, 214 (79.0%) reported being up to date, while 34 (12.5%) were
not. Among those unsure or not up to date, the polio vaccine (12, 35.3%) and measles vaccine (8,
23.5%) were the most commonly missed. A study by Adebayo et al. (2022) in Lagos found that
83% of mothers followed the immunization schedule due to healthcare provider influence,
aligning with this study’s findings. In Ethiopia, Berhane et al. (2021) reported that 68% of
mothers delayed vaccines due to misinformation, mirroring gaps found in this study. A study in
India by Sharma et al. (2020) indicated that 72% of caregivers adhered to the immunization
schedule due to concerns about disease outbreaks, similar to the 53.9% reported here.

5.1.3 Factors Affecting Immunization Uptake

Table 4.4 indicated that the child’s age (220, 81.2%) was the most significant factor influencing
immunization. Distance to health facilities (110, 40.6%) and the number of clinic visits (107,
39.5%) were also notable. Conversely, religious beliefs (156, 57.6%), cultural beliefs (136,
50.2%), and household income (129, 47.6%) were not widely perceived as barriers. Maternal
education (132, 48.7%), maternal age (132, 48.7%), and husband’s support (95, 35.1%) had
moderate influence. A high level of uncertainty was observed regarding the method of delivery
(111, 40.9%), parity (83, 30.6%), and financial constraints (80, 29.5%). A study by Ogunlesi &
Adeyemi (2020) in Nigeria found that 65% of mothers cited distance as a barrier, which is
consistent with this study’s findings. Research in Pakistan by Khan et al. (2019) showed that
55% of mothers did not immunize their children due to cultural beliefs, a contrast to this study
where cultural beliefs were not seen as a major factor. A UNICEF (2021) report highlighted that
in rural Kenya, husband support increased vaccine uptake by 30%, suggesting that social support
can improve immunization coverage.

5.1.4 EFFECTS OF COMPLETE/INCOMPLETE IMMUNIZATION

Table 4.5 revealed that 234 (86.3%) of respondents considered full immunization very important,
while 37 (13.7%) viewed it as somewhat or not important.

Regarding experiences with vaccine-preventable diseases, 137 (50.6%) had witnessed a child
suffer from such illnesses, with measles (79, 29.2%) being the most frequently reported. Most
respondents (195, 72.0%) had not known a child who experienced serious side effects from
immunization, while 72 (26.6%) had, with fever (20, 7.4%) being the most common side effect.

A majority (203, 74.9%) strongly agreed that fully vaccinated children are less likely to fall sick,
while 12 (4.5%) disagreed or remained neutral. Similarly, 228 (84.1%) believed that children
with incomplete immunization pose a health risk to others, whereas 27 (10.0%) disagreed, and
16 (5.9%) were uncertain. A study by Akinyemi et al. (2023) found that 79% of Nigerian
mothers linked full immunization to better child health, supporting this study’s findings.
Research in Bangladesh by Rahman et al. (2021) showed that 65% of incomplete immunization
cases led to increased disease susceptibility, aligning with this study’s concerns. In Uganda,
Namuyanja et al. (2022) reported that 28% of caregivers feared vaccine side effects, slightly
higher than the 26.6% found in this study.

5.2 CONCLUSION
The study revealed that while most mothers and caregivers are aware of immunization, there are
gaps in knowledge regarding vaccine-preventable diseases. Factors such as child’s age and
healthcare access significantly influenced uptake, while financial constraints and cultural beliefs
were not major barriers. Strengthening healthcare outreach, improving maternal education, and
addressing logistical barriers could enhance immunization rates.

5.3 RECOMMENDATIONS

1. Healthcare workers should engage in more outreach programs to increase maternal knowledge
on immunization.

2. Government and stakeholders should ensure better access to immunization services, especially
in rural areas.

3. Community leaders should be sensitized and seminars held to inculcate them on the reasons
why immunization needs to be a priority.

4. Educating young girls on the importance of vaccination could improve future maternal
knowledge.
5. Social media campaigns can be used to provide accurate information on immunization
schedules and vaccine safety.

5.4 SUGGESTIONS FOR FURTHER STUDIES

A longitudinal study on the impact of maternal education on immunization adherence.

Comparative analysis of immunization uptake between rural and urban settings.

The role of social media in influencing vaccination decisions among mothers.

5.5 LIMITATIONS OF THE STUDY

Some respondents may have provided socially desirable answers, leading to potential bias.

Some participants may not have accurately remembered past immunization experiences.

This study provides valuable insights into the factors influencing immunization uptake and
highlights areas for policy intervention to improve vaccination coverage among children.
REFERENCES

Abubakar Nasiru Galadima, Nor Afiah Mohd Zulkefli, Salmiah Md Said, & Norliza Ahmad. (n.d.).
Factors affecting childhood immunization uptake.

Andrewes, F. W., Bulloch, W., Douglas, S. R., Dreyer, G., Gardner, A. D., Fildes, P., &
Ledingham, J. C. G. (1923). Diphtheria: Bacteriology, pathology, and immunology. His Majesty's
Stationery Office.

Antai, D. (2009). Inequitable childhood immunization uptake in Nigeria: A multilevel analysis of

individual and contextual determinants. BMC Infectious Diseases, 9(1), 181.
[Link]

Awosan, K., Ibrahim, M., Yunusa, E., Isah, B., Raji, M., & Abubakar, N. (2018). Knowledge,
attitude, and compliance with full immunization of children against vaccine-preventable diseases
among pregnant mothers in Sokoto, Nigeria. Intern
Baxter, R., Taylor, N., Kellar, I., & Lawton, R. (2016). What methods are used to apply positive
deviance within healthcare organisations? A systematic review. BMJ Quality & Safety, 25(3), 190.
[Link]

Bonnie, A., Okonek, M., & Peters, P. M. (n.d.). Vaccines—How and why?

Coverage 1980–2008 Nigeria. (2009). World Health Organization/UNICEF Review of National

Immunization Coverage.

Elizabeth, B. Adedire, Olufemi Ajumobi, Omotayo Bolu, Patrick Nguku, & Ikeoluwapo Ajayi.
(n.d.). Maternal knowledge, attitude, and perception about childhood routine immunization
program in Atakumosa-west Local Government Area, Osun State, Southwestern Nigeria.

Gebeyehu, N. A., Asmare Adela, G., Dagnaw Tegegne, K., & Birhan Assfaw, B. (2022).
Vaccination dropout among children in Sub-Saharan Africa: Systematic review and meta-analysis.
Human Vaccines & Immunotherapeutics, 18(5), 2145821.
[Link]

Global and regional immunization profile, African Region. (2009). World Health Organization.

Global Immunization Data. (2009). World Health Organization.

Goossens, H. (2009). Antibiotic consumption and link to resistance. Clinical Microbiology and
Infection, 15*(Suppl 3), 12–15. [Link]

Ijarotimi, I., Fatiregun, A., Adebiyi, O., Ilesanmi, O., & Ajumobi, O. (2018). Urban–rural
differences in immunization status and associated demographic factors among children 12–59
months in a southwestern state, Nigeria. PLOS ONE, 13(11), e0206086.
[Link]

Immunization side effects. (n.d.). Better Health Channel.

Kapoor, R., & Vyas, S. (2010). Awareness and knowledge of mothers of under-five children
regarding immunization in Ahmadabad. *Healthline, Journal of Indian Association of Preventive
and Social Medicine, 1(1), 12–15.

Khan, M. U., Ahmad, A., Aqeel, T., Akbar, N., Salman, S., & Idress, J. (2015). A cross-sectional
survey of healthcare workers on the knowledge and attitudes towards polio vaccination in Pakistan.
PLOS ONE, 10(11), e0142485. [Link]
Lakew, Y., Bekele, A., & Biadgilign, S. (2015). Factors influencing full immunization coverage
among 12–23 months of age children in Ethiopia: Evidence from the national demographic and
health survey in 2011. BMC Public Health, 15(1), 728. [Link]

Maitanmi, B. T., Omotayo, J. A., & Maitanmi, J. O. (n.d.). Immunization practices of mothers of
under-five children attending infant welfare clinic in selected primary health care centers in
Sagamu, Ogun State.

Miracle, A. Adesina, Isaac I. Olufadewa, Ruth I. Oladele, Abimbola Solagbade, & Christianah
Olaoyo. (n.d.). Determinants of childhood immunization among rural mothers in Nigeria.

Musa, S., Skrijelj, V., Kulo, A., Habersaat, K. B., Smjecanin, M., Primorac, E., Becirovic, D., &
Jackson, C. (2020). Identifying barriers and drivers to vaccination: A qualitative interview study
with health workers in the Federation of Bosnia and Herzegovina. Vaccine, 38(8), 1906–1914.
[Link]

National Bureau of Statistics of UNICEF. (2022). 2021 multiple indicator cluster survey/national
immunization coverage survey report. Retrieved August 23, 2023, from UNICEF.

National Journal of Contemporary Medical Research, 5(6).

National Population Commission. (2013). Nigeria Demographic and Health Survey.

Ozawa, S., Mirelman, A., Stack, M. L., Walker, D. G., & Levine, O. S. (2012). Cost-effectiveness
and economic benefits of vaccines in low- and middle-income countries: A systematic review.
Vaccine, 31(1), 96–108. [Link]

Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics). (n.d.).
Jan E Drutz, MD, Teresa K Duryea, MD, Diane Blake, MD.

Riumallo-Herl, C., Chang, A. Y., Clark, S., Constenla, D., Clark, A., Brenzel, L., & Verguet, S.
(2018). Poverty reduction and equity benefits of introducing or scaling up measles, rotavirus, and
pneumococcal vaccines in low-income and middle-income countries: A modelling study. BMJ
Global Health, 3(1), e000613. [Link]

Saheed Gidado. (2014). Determinants of routine immunization coverage in Bungudu. Pan African
Medical Journal, 18(1), 9.

United Nations International Children's Emergency Fund (UNICEF). (2023). Barriers to

immunization uptake among mothers and caregivers*. Retrieved from [Link]
Wagstaff, A., Flores, G., Smitz, M.-F., Hsu, J., Chepynoga, K., & Eozenou, P. (2018). Progress on
impoverishing health spending in 122 countries: A retrospective observational study. The Lancet
Global Health, 6(2), e180–e192. [Link]

Waisbord, S., & Larson, H. (2005). Why invest in communication for immunization: Evidence and
lessons learned. Public Health/Center for Communication Programs (Baltimore) and the United
Nations Children's Fund (New York).

World Health Organization (WHO). (2023). Immunization coverage and its impact on child health.
Retrieved from [Link]

World Health Organization, AFRO. (2009–2012). Immunization systems support. Retrieved

September 23, 2014, from [Link]
development

World Health Organization. (1980). Decisions of the health assembly: Declaration of global
smallpox eradication. WHO Chronicle, 34, 258.

World Health Organization. (2009). WHO vaccine-preventable disease monitoring system, 2009
global summary.

World Health Organization. (2010). WHO vaccine-preventable diseases monitoring system 2010
global summary—Country profile Nigeria.

World Health Organization. (2022). Vaccines and immunization. Retrieved April 4, 2022, from
[Link]

World Health Organization/UNICEF. (2009). Review of national immunization coverage 1980–

2008, Nigeria.

Your child's first vaccines. (n.d.). Centers for Disease Control and Prevention.