(o 7 “ •‘THE DEVELOPMENT OF A SCALE FOR PREDICTING MOTHERS COMPLIANCE IN THE EXPANDED PROGRAMME ON IMMUNIZATION (EPI)» BY ADETUNJI HAMED ADEMOLA B.SC, HONS. (HUMAN NUTRITION) IBADAN A dissertation in the Department of PREVENTIVE AND SOCIAL MEDICINE Submitted to the Faculty of Clinical Sciences and Dentistry in partial fulfilment of the requirements for the degree of MASTER OF PUBLIC HEALTH (HEALTH EDUCATION) of the UNIVERSITY OF IBADAN. NIGERIA AUGUST, 1989 UNIVERSITY OF IBADAN LIBRARY DEDICATION With Gratitude to Almighty • Allah the source of Knowledge, this dissertation is dedicated to my dear son, Abdul Hakim Adekola Alani Adetunji whose birth coincinded with the period I gained admission to study for the degree of Master of Public Health. UNIVERSITY OF IBAD N LIBRARY -ii- Abatragt The apparent high drop out rate in Expanded Programme on Immunization (EPI) is constituting a major barrier in the break through of the child survival programme especially in developing countries of the World (Alakija, 1986). This cross-sectional, descriptive and explorative study was carried out in Obokun Local Government Area (LGA), Oyo State of Nigeria between October, 1987 and July, 1988. The study population consists of mothers who attended EPI clinics for their childrerfs immunization under the Expanded Programme on Immunization. Respondents were mothers whose children bad taken the first doses of diphtheria, pertussis, tetanus and Oral polio vaccines (DPT/OPV) between October 1987, and January, 1988. These mothers were classified as compliers if by the end of July, 1988 they had completed the three doses of DPT/OPV schedules. Those who had not completed these three doses were termed non-compliers. Out of 121 mothers used in the study, 65 were compilers while 56 were non-compliers. Data gathering tools used included questionaire to explore demographic, attitudinal and cognitive factors in these mothers UNIVERSITY OF IBADAN LIBRARY -iii- which may affect compliance with EPI appointment schedules. In addition, observational check-list was used to probe into factors which may affect compliance due to clinic settings or arrangements. After analysis of the data, the identified compliance factors were scored to form a predicting scale that can be used to identify those that are likely not to comply with appointment schedules among mothers in EPI Programme so that measures that will make them comply can be instituted from the start. The result showed that the repondents in both compilers and non-compilers were similar in such demographic characteristics as age, marital status and parity They however differ significantly in demographic charateristics such as educational levels, occupation, income and religion. Also, there were more compilers among mothers who attended orthodox form of ante-natal services, those who had institutionalized deliveries and mothers who brought their children to have first contacts of immunization within their six months of lives. i < V * 'S* UNIVERSITY OF IBADAN LIBRARY -iv- The risk factors that can determine non-compliance with appointments in EPI based on the findings of the study are low- educational level, low income, semi-skilled and non-occupation, non attendance of Orthodox ante-natal services in pregnancy, no immunization during pregancy, non-institutionalized deliveries, long distance from home to EPI centres, giving herbs as protection to children, delaying the first immunization till children reached ages six months and lastly religions of mothers in which case muslims can default more than Christians. Based on the findings from the study, it is recommended that the health education approach in EPI be modified to include local communication system for rural women since effective communication is the key to implementation of health education acitvities. In adition future studies should focus on production of predictor scale that will enable the identification of non- compliance among urban/cities mothers. UNIVERSITY OF IBADAN LIBRARY - V - MfHlQW L^piP fr Glory be to God Almighty who has granted me His will to pursue this course. I wish to express my profound gratitude first to my Principal Supervisor Dr. J.£>. Adeniyi who despite his load of deparmental assignments at home and abroad found time to give his critical review of this study especially his untiring efforts to see the work going at difficult stages. My thanks also go to Dr. Dimeji Oladepo my second Supervisor for his thorough supervision and assistances not only on this project but thjbughout the course. He has really motivated me to work hard. I appreciate the encouragement, understanding and patience of my wife Kudirat Adeola Adetunjl for enduring the hardship of the course with me. The supports I received from my parents are also appreciated. I thank the Federal Government who provided me the financial support, for the second year of the course . My gratitude also goes to Dr. (Mrs.) Onadeko for her support and assistance in providing useful references especially during the preparation of my research seminar. UNIVERSITY OF IBADAN LIBRARY -vi- The entire staff members Primary Health Centres Ipetu-Ijesa and Ijeda, Health Clinic Ilase and maternity centre lpetu Ijesa {all in Obokun LGA the site of the study) did everything within their powers to support the study. I thank them all. I also thank those mothers I used for their cooperation. Finally, 1 am grateful to all other persons who contributed in making the work a success especially my friends whose names arc too numerous to mention here. UNIVERSITY OF IBADAN LIBRARY -vii- CKRTIFICATION We certify that this work was carried out by Adetunji Hamed Ademola of the Department of Preventive and Social Medicine, University of Ibadan, Ibadan Nigeria. DR. J.D. ADENIY1, B.A., {IFE), M.P.H. (Chapel Hill), A.R.S.H. (Lond.) Dr. P.H (John Hopkins). Reader/Consultant Department of Preventive and Social Medicine, UNniigveerrisai.ty of Ibadan, SUPERVISOR DR. D1MEJI OLADEPO B.Sc (Hons), M.P.H. PhD. Lecturer Department of Preventive and Social Medicine, University of Ibadan, Ibadan Nigeria. UNIVERSITY OF IBADAN LIBRARY -viii- TABLE OF CONTENTS TITLE PAGE DEDICATION ........................................ i ABSTRACT ................................................. ii ACKNOWLEDGEMENT .......................................... V CERTIFICATION .............................. vii TABLES OF CONTENTS ........................................ viii LIST OF TABLES ............................................ xii LIST OF FIGURES ............................................ xv CHAPTER ONE Introduction ........... 1 CHAPTER TWO Literature Review ................................... 7 EPI in Nigeria . . ;............................ 8 Nature of the problems of EPI target diseases ....... 9 Immunization as a preventive option to EPI diseases .. 13 Vaccination scheduling in EPI ....................... 14 The concept of Compliance ...................... 1 Factors affecting Compliance ....................... 18 UNIVERSITY OF IBADAN LIBRARY -ix- CHAPTER THREE Methodology ......................................... 36 Description of the Study area ...................... 36 Objectives .......................................... 37 Hypothesis .......................................... 38 Research Design .................................... 39 Universe ........................... ................ 40 Selection Procedure ................................. 40 Operational Definitions .................. ........... 41 Instruments for Data collection and Procedure ....... 43 Review of Records ................................... 43 Questionnaire ....................................... 44 Observation ............ 45 Validity and Reliability ............................ 46 Data Analysis ....................................... 4 7 Formation of Compliance Predictor Scale . .......... 47 Test of Effectiveness of compliance Predictor Scale .. 47 Limitations of the Study ............................ 48 CHAPTER FOUR Results .................. .i.......................... 49 Demographic Characteristics ......................... 53 UNIVERSITY OF IBADAN LIBRARY -x- Characteristics related to the immunized children .... 67 Medical history Characteristics ..................... 70 Cognitive Factors and Compliance .................... 80 Attitudinal Factors and Compliance .................. 89 Characteristics due to clinic arrangements and services.. 90 Observation check list result ....................... 103 Formation of Compliance Predictor scale ............. 106 CHAPTER FIVE DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS ........ 113 Discussions .................... 113 Demographic characteristics ........................... 113 Characteristics related to immunized children ......... 116 Medical history characteristics ....................... 117 Cognitive factors and Compliance ...................... 119 Attitudinal Factors and Compliance .................... 122 Characteristics due to clinic arrangements and services. 122 CONCLUSIONS ........................... 124 RECOMMENDATIONS ....................................... 125 REFERENCES ............................................ 129 APPENDIX 1 - Questionnaire . . ....................... 137 UNIVERSITY OF IBADAN LIBRARY -xi- APPENDIX 2 - Summary of Immunization exercise in Obokun LGA, March to September, 1987 ........................ 150 APPENDIX 3 - Checklist for observation at EPI clinics.. 151 UNIVERSITY OF IBADAN LIBRARY -xii- LIST OF TABLES Stratification of area of sample by clinics and their sites ..................................... 42 Distribution of respondents by groups of compliers and non-compliers in the EFI centres ............ SO Compliance status of mothers and their marital status .......................................... S2 Compliance status of mothers and type of family .. 56 cChoimlpdlrieann/cteo tsatla tnuusm boefr m. are those mothers whose children received the first doses of DPT/OPV between October, 1987 and January, 1988 and had completed the 3 doses or all schedules at the end of July, 1988* Non-Compilers: are those mothers whose children received the first doses of DPT/OPV between October 1987 and January 1988 but did not complete the third doses by the end of July, 1988* stratification Procedure Stratified random sampling method was used to select 4 out of 10 EPI static units (centres with permanent EPI stations) in the LGA. Stratification was based on two broad criteria* One is on the status of the centre whether it is a health centre, a health clinic or a maternity centre* The second criterion is where the said EPI centre is located* This could either be in semi-urban or rural towns (see table 1), According to the above stratification, out of the 10 EPI static units in the LGA, 4 are maternity centres, all located in UNIVERSITY OF IBADAN LIBRARY 42 TABLE 1 Stratification of area of sample by Clinic and their sites. MAT ! HEALTH HEALTH SITE CENTRE !1 CENTRE CLINIC TOTAL 1» — SEMI-URBAN 4 1i; 2 0 6 RURAL 0 ii: 2 2 4i TsOsTsA=Ls=:stcs sr4ssxssss |: S3S4CSSSS ssss2:=e: 10 UNIVERSITY OF IBADAN LIBRARY 43 Semi-urban towns, 4 are Primary Health Centres two located in semi-urban towns and the other two in rural towns. There are only two health clinics and the two are located one each in two rural towns. One out of 4 maternity centres was picked randomly, two Primary Health Centres (one each in semi-urban and rural towns) and one health clinic were also randomly picked by ballot (one each in the boxes shown in table 1). Instruments for Data Collection and Procedure In this study, three methods of data collection were used namely: 1. Review of Records 2. Interview using formal questionnaire 3. Observation using observation checklist. Review of Records Baseline data on the EPI clinic attenders was obtained from the 4 chosen EPI clinics. Records reviewed were the cards and register of children who attended the clinics for immunization purpose. Information obtained included the age, sex, home address, the immunization already received by each child and dates of next appointments. The information was supplemented UNIVERSITY OF IBADAN LIBRARY 44 and validated through informal interviews with both groups of mothers used in the study. Questionnaire In order to investigate the relationship of demographic, attitudinal and cognitive factors to compliance status among mothers who complied with the three DPT/OPV EPI schedules and those who did not, same type of questionnaire was used for the home visit interview (appendix 1)- The questionnaire sough t information about the mother^ demographic characteristics, ages of children at first immunization contacts, history of ante-natal services and places where the children were delivered. Other information sought included the mothers beliefs about EPI. In the administration of the questionnaire the author made use of three staff nurses and a ward orderly who are working in the chosen EPI clinics as research assistants. They were already familiar with the areas of the research as well a s with th e m others They were therefore used to assist in tracing the mothers homes. When a house u b b located, the research team introduced themselves to the occupants and asked politely for the particular mother of the child who was immunized at the clinic in that area. UNIVERSITY OF IBADAN LIBRARY 4b Customary greetings were exchanged and the purpose of the visit explained. The conduct of the interview was done exclusively by the author except three occasions where .there was more than one mother in the s house. Interview were conducted in such cases simultaneously by the author and the staff nurses at different locations of such homes. Observation check list tool: The observation check list (appendix 3) sought information about the time spent by the mothers in the EPI clinic during each visit the interactions between them and the health staff in the clinic and whether the vaccines to be used for the children were all available at each clinic day. Training of Research Assistants: Three staff nurses and a ward orderly were used as research assistants during the data gathering of the project. They were told about the objectives of the study and the areas where their assistance would be needed especially in the aspect of tracing the mothers homes. The three staff nurses were trained on the technique of administration of questionnaire in order to minimise observer errors and variations. UNIVERSITY OF IBADAN LIBRARY 46 Validity and Reliability of Data Gathering Instruments In order to ensure reliability of the questionnaire a pre­ test was conducted on ten mothers who attended the EPI clinics chosen (five compilers and five non-compliers). These mothers were later removed from the actual study population. It was as a result of the pre-test that few questions were reframed to remove ambi uities. Examples of such questions were those which their answers required likert scale options where the respondents were asked to "strongly agree" ’don't know’ 'strongly disagree’ or 'disagree'. They were changed to 'agree' 'uncertain' 'disagree' and 'don’t know’. The interview was carried out in respondents own familiar environment which was likely to have enhanced the mothers confidence and as such encouraged them to express their views freely. Administration of questionnaire in translated form to illiterate mothers added to the comprehensiveness and clarity of the tool. During the use of the observation check list, the author tried as much as possible not to allow the health staff or the mothers to have prior knowledge o\f some aspects of what were being observed from them such as the interaction between the UNIVERSITY OF IBADAN LIBRARY 47 health staff and the mothers. This action made what were being observed to appear in their natural form to a large extent. Data Analysis. All the data collected through questionnaire were analysed statistically by the computer. Formation and Testing of Compliance Scale After subjecting the variables that could affect mothers compliance with EPI appointment schedules to chi-square test, the variables that showed associations with compliance with EPI schedules were then assigned arbitrary scores in ascending order of magnitude as they affected compliance positively or negatively. Then, the scored variables became the predictor scale for complicance or non-compliance. The higher the scores the greater the probability that the mother will comply with schedule of appointment and vice versa. Test of effectiveness pf Predictor Scale: The effectiveness of the predictor scale was pilot tested in one of the already used EPI clinics for initial data gathering. Ten mothers were picked randomly and then scored accordingly with the predictor scale in order to predict their compliance or non-compliance with subsequent appointments of DPT/OPV schedules. They were marked 'reported' or 'not reported' as the Cast might UNIVERSITY OF IBADAN LIBRARY 48 be after two appointments. Limitations of the study; Six months may be too small to label mothers non-compliers because they might bring their children later to complete the schedules becoming 'delayed compilers'. In other words, complete EPI defaulters for all the expected vaccination if identified and used solely could have added more quality to the results. Few respondents especially the literates flipped through the six and half pages of the questionnaire and lamented because of its length. The length could have affected the ways such mothers answered the questions in the few questionnaires that were self administered by those mothers. UNIVERSITY OF IBADAN LIBRARY CHAPTER 4 RESULTS The findings of this study are presented under five broad subsections. First, the demographic characteristics of the compilers and non-compliers are described. followed by their responses on the children brought for immunization. The third sub-section compares the two groups knowledge about EPI. Source of information, different schedules in EPI, diseases covered by the programme and other methods that the mothers employed apart from Orthodox immunization. Other areas examined are the beliefs about the efficacy of vaccinations on six killer diseases and opinions about the health staff and clinics arrangements at various places of immunization used. Finally, the last subsection presents the outcome of observation checklist carried out during the clinic sessions. The subsection ends with the result of application of predictor scale formed. UNIVERSITY OF IBADAN LIBRARY 50 TABLE 2 DISTRIBUTION OF RESPONDENTS 3Y GROUP OF COMPLIERS A^P IN TOE EPI CENTFtiBS.'... n" CENTRE COMPLIERS % NGN-COMPLIER % TOTAL % A 14 (21.5) 20 (35.7) 34 (28.1) B 18 (27.7) 12 (21.4) 30 (24.8) C 15 (23.1) 10 (17.9) 25 (20.7) D 18 (27.7) 14 (25.0) 32 (26.4) TOTAL 65 (100) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 51 Fig 2 Compliance status and age of mothers Key Ccmpliers Non - Ccmpliers - 26 '4 - 24 <* Age of mother in years Note! 1 cm represent 2 mothers in 'Y axis' mothers UNIVERSITY OF IBADAN LIBRARY 52 TABLE 3 Compliance status of mothers and their Marital status MARITAL STATUS COMPLIERS NON-COMPL1ER TOTAL SINOLE 7 2 9 MARRIED 58 52 110 DIVIORCED 0 2 2 TsOsTsAsLsrrzs=ss38s SIB6Z533SSSS: 56 121 2 X b 4.46 , df » 2 (p> 0.0S). UNIVERSITY OF IBADAN LIBRARY 53 (a). Demographic Characteristics Demographic variables are used to compare the characteristics of compliers and non-compliers in EPI appointment schedules. The results of 121 mothers used for the study are presented. Of these, 65(53.7%) are compliers while 56(46.3%) are non- compliers (see table 2). Compliance Status and mothers age Figure 2 compares the compliance status and age of mothers. Ages of mothers studied range between less than 15 and above 40 years. More compliers were found in the following age ranges 25 to 29 years, 30 to 34 years and 35 to 39 years, while majority of non-compliers were more in age ranges 15 to 19 years, 20 to 24 years and 40 years and above. In all, the age range with the highest proportion of compliers was 25 to 29 years with 22 (62.9%) compliers and 13 (37,1%) non- compliers as compared to age range 20 to 24 with the highest non-compli.ers 21 (61.8%) * and 13 (38.2%) compliers. The observed differences among the two groups were however not-statistically significant

0.05>. UNIVERSITY OF IBADAN LIBRARY Marital status The marital status of the two groups are compared in table 3. Maioritv of mothers surveyed. 110 (91%). were married, onlv 9 t ' (7 .47*) were single while just 2 (1. %) were divorcees. There is almost equal distribution of compliers 58 (52.7%) and non- compliers 52 (47.3%) among the married mothers. However, of the 9 mothers who were single. 7 (77.8%) were compliers as compared to 2 (22.2%) non-compliers. The two mothers who were divorcees failed to comply with EPI schedules. No statistical difference was feund among the two groups with regards to their marital status

0.05> Compliance Status of mothers and type of Family Table 4 displays the compliance status of respondents and their type of family. Majority of mothers studied. 96 (79.3%) were from monogamous families while 22 (18.2%) were from polygamous families. The result shows that more compliers are found in monogamous families. Out of 96 monogamous mothers. 54 (56.3%) were compliers as against 42 (43.7%) non-compliers. Among the 22 polygamous mothers. 8 (36.4%) and 14 (63.6%) were complierB and non-compliers respectively. UNIVERSI Y OF IBADAN LIBRARY 5 5 Compliance Status and Child Alive/Total births The respondents* compliance status and number of children alive per total births are displayed in tables. Mothers with 100% children alive formed the majority numbering 110 iidth 57 (51*8%) compilers and 53 (48.2%) non-compliers* Out of 8 mothers who had between 50 and 74% children alive, 6 (75%) were oompliers as against 2 (25%) non- compliers* The result showed that the higher the number of dead children per total births, the greater the tendencies of mothers to comply with appointment schedules in EPI, UNIVERSITY OF IBADAN LIBRARY 56 TABLE 4 Compliance status of Mothers arid type of family TYPE OF FAMILY COMPLIERS NON-COMPLIER TOTAL MONOGAMY 54 42 96 POLYGAMY 8 14 22 NO RESP0N1 5E 3 0 3 T3O3T3A3L*3233333*23 65 3*2**353632*2 ."T 22 121 2 X « 5.5 , df * 1 (p> 0.05). 2 2 NOTE : X excludes the * noresponse' values. UNIVERSITY OF IBADAN LIBRARY 5 7 TABLE S COMPLIANCE STATUS OF MOTHE CHILDREN ALIVE PER CHILDREN ALIVE/ TOTAL BIRTHS COMPLIERS NON-COMPLIER TOTAL 50 - 74% alive 6 2 8 75 - 99% " 2 1 3 100% * 57 S3 110 TOTAL 65 56 121 X2 * 2,3 cf ■ 2 (P>0.05) NOTE* No mother had 50% Children alive UNIVERSITY OF IBADAN LIBRARY 58 Fig 3 Educational levels of mothers and compliance Key SCcnpliersNpn Compliers 30 29 -28 •f , 26 24 24 - 22 - |20 19 - 18 - 16 - 14 - 12 _ 10 10 - 8 _5. 4 2 > teacher N.C.E Degreel Edu. HND Educational Levels of mothers Note! I <3m. represent 2 mothers in 'Y axis* of mothers UNIVERSITY OF IBADAN LIBRARY 59 TABLE § Compliance status of Mothers and occupation JOB Compilers Non-compliers TOTAL UNEMPLOYED 14 17 31 PETTY TRADING. 20 24 44 CIVIL SERANTSs 23 1 24 OTHERS 8 14 22 TSOSTSASLSB2SSSSC 3SSBS6533SC8S zzsrata5B6zaszzzzzzsrz 33=1321333 2 X a 21.9, df a 3 (p<0.001) UNIVERSITY OF IBADAN LIBRARY 60 Compliance Status and Mothers education In figure 3, mothers educational levels are compared with their compliance status. Out of 34 mothers who were illiterates, only 10 ( 29.4%) were compilers as against 24 (70.6%) non- compliers. Mothers with primary education were twenty-seven out of which $\(29.6%) were compilers as against 19 (70.4%) non- compliers. The result showed that the higher the educational levels of mothers the better their compliance tendencies in EPI appointment schedules and vice-versa. This is evident from the result showing all the 36 mothers with educational levels above secondary school as compilers. Also, there was a significant difference among the two groups statistically . Therefore, the earlier hypothesis that non-compliance with appointment schedules in EPI among mother is not due to educational level is rejected. Occupation of mothers and compliance status Compliance Status of mothers and their occupation are presented in table 6. Most of the mothers studied were petty traders, 44( 36.4% of total population). Salary earners among the mothers were the most compilers. Out of 24 who claimed to be on monthly salary, 23 (95.8%) were compilers as against one (4.2%) non-complier . The difference observed between the two UNIVERSITY OF IBADAN LIBRARY 61 groups were statistically significant (p<0.0001). Therefore, the hypothesis • • v that occupation of mothers has nothing to do with their EPI appointment compliance is rejected;* Mothers income and their compliance status Results of monthly earnings of mothers are presented in table 7. Thirty-seven mothers had no idea of their monthly earnings. Out of 39 mothers (32.2% of total) who earned monthly income of below N100 21 (53.8%) are non-compliers as compared with 18 (46.2%) compilers. Among the 20 mothers with N200-299 a month, 16 (80%) were compilers while the rest 4 (20%) were non- compliers. All the 11 mothers (9.1% of total population studied) earning N300 and above were complierB. The test of significance showed an association between compliance with appointment schedules and monthly earning (p<0.001>. Cpjnplianse Status of ^Iptherf arjd Religion The religious beliefs of mothers compared with their compliance status is shown in table 8. Christain mothers formed the majority numbering 95 (78.5% of total population) of whom 59 (62.1%) were compliers and 36 (37.9%) non-compliers. Out of 26 Muslims (21.5% of the total population) only 6 ( 23.1%) were compliers with the rest 20 (76.9%) -s non-compliers. From the UNIVERSITY OF IBADAN LIBRARY 62 - result, christain mothers have more tendencies to comply with appointments schedules than Muslims. There was a sta— statistically significant association between compliance and religions (p 0.0001). UNIVERSITY OF IBADAN LIBRARY table z Compliance statue fif mothers and their sonthly earnings MOTHLY EARNING(N) Compilers Non-compliers TOTA] < 100 . 18 21 39 100 - 199 8 6 14 200 - 299 16 4 20 * 300 - 399 7 0 7 * 400 and above 4 0 4 No Idea 12 25 37 TOTAL 65 56 = = =1 2= 1= : 2 X = 22.7, df = 2 (p< 0.05) 2 * NOTE : X excludes the cells with Zero value. UNIVERSITY OF IBADAN LIBRARY 64 TABLE 8 Compliance status of ■others and their relieious beliefb RELIGION Compilers Non-compliers TOTAL ISLAM 6 20 26 CHRISTAINITY 59 36 95 T3O3T3A3L33333333 3333363533333 33333353633333333 121 2 X ■ 10.9, df = 1 (p<0.0001) UNIVERSITY OF IBADAN LIBRARY TABLE 9 Compliance status of mothers and ages of their children at first immunization contact AGE RJ-NGE (MONTH) Compilers Non-compliers TOTAL 21 4 25 - 2 11 2 13 - 3 4 0* 4 - 4 13 8 21 - 5 0* 1* 1 - 6 0* 1* 1 above 6 16 40 56 TOTAL 65 56 121 X2 = 34.8, df = 3 < p< 0.001) * NOTE : X2 excludes cells with values less than 5. UNIVERSITY OF IBADAN LIBRARY iH \ o £6 TABLE 10 COMPLIANCE STATtS OF MOTHERS AHO S5X OF r TH£i»' i'»ftEiitZEdrCHIU>H»5jl SEX OF CHILD COMPLIERS UON~COttPLIERS TOTAL mhE 40 32 72 FEMALE 25 24 49 ........ r.|? TOTAL 65 55 121 X2 - 9.33 4# » 1 P> 0.05 UNIVERSITY OF IBADAN LIBRARY 67 CHARACTERISTICS RELATED TO THE IMMUNIZED CHILDREN Ages of children at first immunization; The mothers compliance status is compared with the ages of their children as at first immunization contacts in table 9. Fifty-six (46.3%) mothers who brought their children for first immunization contacts after the age of 6 months formed the majority. Sixteen (28.6%) of this number are compilers and 40 (71.4%) are non-compliers. However, among the 25 (20.7%) mothers whose children received first doses of immunization before their first month of lives. 21 (84%) are compilers while 4 (16%) are not. The result further showed that more mothers in the compilers group brought their children for immunizatiion before these children reached ages 6 months. Test of significance indicated that ages of children at the time mothers brought them for first immunization contacts are related to compliance with subsequent appointment schedules of EPI (p<0.001>. Sex of children Another child factor considered was the sex of the immunized children and mothers compliance status (see table 10 ). The proportions of male and female children brought by compilers and UNIVERSITY OF IBADAN LIBRARY • 68 - non-compliers were 72 (59%) and 49 (41%) respectively* There were more compilers, 40 (55*6%) as against 32 (44.4%) non—compilers among mothers with male children compared to mothers who brought female children, 25 (51%) compilers versus 24 (49%) non-compliers* No statistical significant difference were found indicating that the compliance status among the two groups of mothers were similar regardless of the sex of their immunized children* UNIVERSITY OF IBADAN LIBRARY table 11 Co«p1lance status and places where Mothers delivered children PLACE OF DELIVERY COMPLIERS NON-COMPL1ERS TOTAL HOME 3 11 14 HEALTH CENTRE 30 6 36 MAT. CENTRE 18 26 44 GOVT. HOSPITAL 8 1 9 PRIVATE HOSPITAL 5 10 IS * CHURCH 1* 2* 3 TsOsTsAsLssBssssssrssag srsac6a5sssEs: 56 121 2 X » 19.2, df = 4 (p<0.001) 2 * NOTE : X did not include church values. UNIVERSITY OF IBADAN LIBRARY 70 Places of Deliveries Table 11 considers the compliance status of mothers and where they delivered their children. Most mothers, 44 (36.4%) claimed to have delivered their children in the maternity centres while only 3 (2.5%) delivered in the church. Out of 14 mothers (11.6%) who delivered children at home, 11 (78.6%) were non- compliers. However, most mothers who delivered their children at health centres and government hospitals were ' compilers. For instance, out of 9 mothers who delivered at government hospitals, only 1 (11.1%) belonged to the non- compliers group. Similarly, of all the 36 mothers (29.8%) who had their deliveries at health centres, 30 (83.3%) and 6 (16.7%) were compilers and non-compliers respectively. Chi-square result showed that there is a relationship between where mothers delivered their children and their compliance status with EPI schedules (p<0.001>. MEDICAL HISTORY CHARACTERISTICS Immunization in Pregnancy Result of information sought from mothers on their immunization status while carrying the pregnancies of their children is presented in table 12. Out of the 73 (60.3%) mothers who had immunization themselves during pregnancy , 19 (26%) did not UNIVERSITY OF IBADAN LIBRARY - 7 1 - comply with schedules for their children delivered from such pregnancy as compared whereas out of the 47 (38.8%) mothers who did not receive immunization in pregnancy 36 (64.3%) were non—compilers. Previous Siblings and EPX history: Another area of consideration was whether mothers immunized their previous children. As presented in table 13, out of the 58 mothers (47.9%) who immunized other children before, 30 (51.7%) were compliers and 28 (48.3%) non- compliers. However, chi-square suggest that previous child immunization experience by mothers does not necessarily influence compliance with future schedules. EPI versus other protections; In table 14, compliance status of mothers were compared on the basis of whether they gave other protective measures to the children besides EPI. Over all, 54 (44.6%) answered ’♦yes" while 65 (53.7%) said they did not give any other form of protection. Out of 54 with "yes” responses, 41 (75.9%) were non—compliers who admitted giving other forms of protention such as native drugs (see table 15) to their children as compared to 13 (24.1%) compliers. The difference between the two groups was significant statistically (pr 0.001). UNIVERSITY OF IBADAN LIBRARY 72 TABLE 12 Compliance status of fjotherB and whether they. received Western immunization in pregnancy. Had immunization in Pregnancy C0MPL1ERS NON-COMPLIERS TOTAL YES 54 19 73 NO 11 36 47 * No response 0* 1* 1 TOTAL 65 56 121 s a e = 8 S S S S 3 S Z C S = S S 3 S 3 I SZ S S S 3 S S S 3 S 2 X > 29.1, df * 1 (p<0.001) * NOTE : X 2 excludes the 'No' response values . UNIVERSITY OF IBADAN LIBRARY 73 TABLE 13 CoMPliance status of Mothers and whether the children i— unized were the first to undergo EPI awong the Mothers other children. 1st CHILD IMMUNIZED COMPLIERS NON-COMPLIERS TOTAL YES 30 28 58 NO 33 27 60 * No response 2* 1* 3 TOTAL 65 56 121 secsaesa: : = = s at = 2 : 2 X = 0.13, df * 1 (p 0.05) 2 * NOTE : X excludes the 'No' response values . UNIVERSITY OF IBADAN LIBRARY TABLE 14 Compliance status of mothers and whether they gave any other forms of protection to children apart from EPI. OTHER PROTECTION WAS GIVEN TO CHILD COMPLIERS NON-COMPLIERS TOTAL YES 13 41 54 NO 50 15 65 * No response 2* 0* 2 TOTAL 65 56 121 a X S B B S Z C B B B B r C S B S a S Z S ZSZS Z B 3 S S Z Z S Z S S B B Z S S S S Z Z S Z azsssss 2 X ■ 23.5, df * 1 (p<0.001) 2 * NOTE : X excludes the ’No’ response values . UNIVERSITY OF IBADAN LIBRARY 75 TABLE 15 Compliance status of mothers and other type of protection given apart from EPI. PROTECTION GIVEN C0MPL1ERS NON-COMPLIERS TOTAL NATIVE DRUGS 4 31 37 ORTHODOX DRUGS 7 1 8 * GOOD FOOD/GOOD HYG. 2 1 3 Nothing 52 21 73 TOTAL 65 56 121 sssssssssaasassrssssB saasssaasss aasaasassasaaaa 2 X * 37.1, df * 1 (p<0.001) 2 * NOTE j X excludes Western drugs and good food/hygiene values. UNIVERSITY OF IBADAN LIBRARY 76 TABLE 16 Distribution of compliance by schedule of immunization received for the children by mothers BCG DPT1/0PV1 DPT2/0PV2 DPT3/0PV3 MEASLES SchecJules received NO X NO X NO X NO X no o C 0 i YES 65 (100) 65 (100) 65 (100) 65 (100) 47 (72.3) P 1 i e r NO 0 (0) 0 (0) 0 (0) 0 (0) 18 (27.7) 8 N c 0 0 n a YES 56 (100) 56 (100) 24 (42.9) 0 (0) 8 (14.3) - P 1 i e r NO 0 (0) 0 (0) 32 (57.1) 56 (0) 48 (85.7) 8 fJ .. . . . . M . . . . . . . . . UNIVERSITY OF IBADAN LIBRARY 7 7 TABLE 1 7 NON—COMPLIERS REASON(S) FOR FAILURE TO COMPLY WITH SCHEDULES REASONS NON—COMPLIERS % No Reasons 19 <33 .a) Child was sick 12 (21.4) Forgot the date 14 (25) Travelled 1 (1.8) Not staying at home most of the time 2 O.h) Feared side-effect 1 (1.8) Child did not need other doses 7 (12.5) TOTAL 56 (100) UNIVERSITY OF IBADAN LIBRARY 7 8 TABLE 1 8 COMPLIANCE STATUS OF MOTHERS AND THEIR KNOWLEDGE OF EPI SCHEDULES KNOWLEDGE OF SCHEDULE COMPLIERS NON-COMPLIERS TOTAL Correct 58 41 9 9 In Correct 7 15 2 2 TOTAL 65 56 121 X* « 4.2 df t (P > 0.05) UNIVERSITY OF IBADAN LIBRARY 79 :iizliance and type of schedule In table 16, proportions and types of EPI schedules ::»plied with or missed by mothers were considered with their compliance status. All mothers 121 (100%) complied with BCG and 2rTl/0PVl, all the 6S compilers (53.7%) complied with DPT2/OPV2 and DPT3/OPV3. Whereas only 24 (19.8%) mothers in non-compliers group complied with DPT2/OPV2 while none of them complied with 2f=T3/0PV3 schedules. Forty-seven (38.8%) mothers from compilers group and 8 (6.6%) from non-compliers group had measles vaccination for their children. Reasons for Non-compliance with schedule When mothers were asked to give reason(s) for their failure to turn up on appointed dates for their childrerfs immunization see table 17) 14 (25%) Non-compliers forgot appointed dates, 12 21.4%) of them alleged that their children were sick* while 7 12.5%) did not realise the importance of taking their children back for repeated dosas. Only 1 (1.8%) mother feared side effect of immunization and 19 (34.2%) gave no reason at all. UNIVERSITY OF IBADAN LIBRARY 80 Cognitive Factors and Compliance (a) Knowledge of gPI schedules. The knowledge of mothers about the number of schedules of immunization were tested and compared with compliance status (see table 18 ). Those who mentioned the five schedules correctly were simply labeled "correct" and those who missed any of the schedules were termed "incorrect". Among the 99 (81. 8%) mothers with "correct " answers, 58 (58.6%) were compilers as compared to 41 (41.4%) Non-compliers. Belief in immunization effectiveness against childhood disease Belief of mothers on the effectiveness of immunization against the childhood diseases were also examined and compared with their compliance status (see table 19). Nearly all mothers, 117 (96.7%) believed that EPI is efficacious against the six killer diseases. A striking result is that all the 56 (100%) Non-compliers had this positive belief. -Che observed differences between the two groups was non-statistically significant (P>o.05). Sources of EPI information and Compliance Sluluu In table 20, the compliance status of mothers was compared with their sources of information about EPI. Majority of mothers 65 (53.7%) with 40 (61.5%)in the compilers group and 25 (38.5%) UNIVERSITY OF IBADAN LIBRARY 81 non-compliers obtained their information through the health workers, followed by radio and television 34 (28.1%) out of which 16 (47.1% were compilers as against 18 (S2.9%) non-compliers. The least source was through the husband (0.8%). Compliance Status and Sickness after Immunization Compliance status of mothers and their children post - BCG illness state was examined (see table 21). Majority of mothers 99 (81.8%) claimed that their children were not ill after the first immunization. Of the 16 (13.2%) mothers who said "Yes", 15 (93.7%) belonged to the group of non-compliers. UNIVERSITY OF IBADAN LIBRARY 82 TABLE 19 COHt»LlA*tC& EK5 OCLlgTS ON Eff'lCACY Of' :*M S ‘'TJEOJi t&kTust ESZ T/iiiO£Z T>*•* »<-»♦• «»? ». > W1 : m m m i m m i m T i m cm m m m r efi cof^Liess % mn~CQmhims % TOTAL % 91SBAMS Yr.s si m . e ) 56 (100) 117(96*7 HO 4 <6*2) 6 <0) 4(3.3) TOTAL 65 (ICO) 56 (46*3) 121(100) UNIVERSITY OF IBADAN LIBRARY 83 TABLE 20 CGKfrLlANCK STATUS OF MOTHERS AND SOURCE OF INFORMATION ABOUT El X SOURCE OF INFORMATION C0MfLIERS<%) NON—COMFLXER3(%) TOTAL (%) Radio/Tel©vision 16 (24.6) 18 (32.1) 34 (28.1) Health Worker 40 (61.4) 25 (44.6) 65 (53.7) Husband 1 (1.5) 0 (0) 1 (0.8) Relative 3 (4.6) 11 (19.6) 14 (11.6) •Neighbour 3 (4.6) 2 (3.6) 5 (4.1) Others 2 (3.1) 0 (0) 2 (1.7) TOTAL 65 (100) 56 (100) 121(100) UNIVERSITY OF IBADAN LIBRARY 34 TABLE 21 COMPLIANCE STATUS OP MOTHERS ND EXPERIENCE OF -SE-R-I-O-U-S -S-IFDIER̂-E'FF-DEQC'sTfS- gIFN. PCPHfI7L'D6REEv-N -A-F-T-ER- -T-H-E ’ fm m nmrnm » .— « » ... i n w i nnw « ■ .....— ■ ...... IMi ■ CHILDREN BECAME SERIOUS SICK AFTER CQMFLIERS % NON-CGHPLIERS % TOTAL % FIRST DOSE YES 1 <1.5) 15 (26.8) 16 (13.2) NO 64 (98.5) 35 (62.3) 99 (81.8) I can»fc remember 0 CO) 6 (10.7) 6 (5.0) TOTAL 65 (100) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 8 5 TABLE 2 2 COMPLIANCE STATUS OF MOTHERS AND THEIR PERCEPTION OF SERIOUSNESS OF DIPHTHERIA DISEASE DIPHTHERIA IS NOT A SERIOUS DISEASE COMPLIERS % NQN- TOTAL %CGMPLIERS % AGREE 0 (0) 2 (3.6) 2 (1.7) UNCERTAIN 2 (3.1) 0 (0) 2 (1.7) DISAGREE £57 (87.7) 54 (96.4) 111 (91 j) DON'T KNOW 6 (9.2) 0 (0) 6 (5.0) TOTAL 65 (100) 56 (100) & UNIVERSITY OF IBADAN LIBRARY ro OO 8$ TABLE 2 3 COMPLIANCE STATUS OF MOTHERS AND THEIR BELIEF... ' W t h e"'£ause riF roL¥dn..r PARALYSIS IN CHILDREN IS CAUSED BY WITCH­ CRAFTS, AS SUCH CANNOT COMPLIERS % NON- TOTAL % BE PREVENTED BY e©&rp)Lii*s % VACCINATION AGREE 2 (3*1) 0 (0) 2(1.7) UNCERTAIN 1 (1.5) 1 (1.8) 2(1.7) DISAGREE 16 (86.2) 51 (91.1) 107(884 DON'T KNOW 6 (9.2) 4 (7.1) 10 (8.1) TOTAL 65 (100) 56 (100) 121(10® UNIVERSITY OF IBADAN LIBRARY 8 7 TABLE 2 4 COMPLIANCE STATUS OF MOTHERS AND THEIR PERCEPTION /'bout the cause of childhood tuberculosis T.B. IN CHILDREN IS CAUSED BY NATIVE MEDICINE NON— AND ITS PREVENTION CAN COMPLIERS% COMPUTERS % TOTAL % ONLY BE BI IT AGREE 0 <0) 1 (1.8) 1 (0.3) UNCERTAIN 4 (6.2) 0 (0) 4 (3.3) DISAGREE 54 (83.0) 52 (92.9) iu->(87.6 1 DON'T KNOW 7 (10.8) 3 (£.$> 10 (8.3) TOTAL 65 (100) 56 (100) 121(100) UNIVERSITY OF IBADAN LIBRARY 88 TABLE 2 5 COMPLIANCE STATUS OF MOTHERS AND THEIR PERCEPTION ABOUT PREVENTION OP MEASLES ONLY NATIVE MEDICINE CAN PREVENT MEASLES COMPLIERS % NON— COMPLIERS TOTAL % AGREE 1 (1.5) 4 (7.1) 5 (4*1) UNCERTAIN 2 (3.1) 3 (5.4) 5 (4.1) DISAGREE 59 (90.8) 49 (87.5) 108(89.3) DON’T KNOW 3 (4.6) 0 (0) 3 (2.5) TOTAL 65 (100) 56 (100) _ 1_2_1_ _(_1_0_0_)_* UNIVERSITY OF IBADAN LIBRARY 89 Attitudlnal Factors Mothers were asked to "agree" or "disagree" with a number of statements which examined their perceptions towards causes and prevention of childhood diseases in EPI as well as their attitudes towards the programme in general. The findings are presented in tables 22 to 27. Most mothers (compliers and non-compliers) disagreed gene­ rally tf£4b the statement that "diphtheria is not a serious childhood disease to warrant immunization". See table 22). This disagreement was more among the non-compliers, 54 (96.4%) as compared to 57 (87.7%) of the compliers. In table 23, both groups of mothers believed that psliomyelitis is not inflicted by the enemies to children. Causes of childhood tuberculosis were also probed into against the erroneous beliefs that it is inflicted through native medicine (see table 24). Majority of these mothers 106 (87.6%) especially the non-compliers 52 (92.9%) believed that T.B. cannot be inflicted through native medicine. Mothers perceptions on the preventive measure for measles were also compared with their compliance status (see table 25). While majority of mothers, 108 (89.3%) disagreed with lhe statement that "only native medicine can prevent measles", the UNIVERSITY OF IBADAN LIBRARY 90 disagreement was higher among the compliers. Furthermore, majority of mothers, 117 (96,7%) consisting of 61 (93.8%) compliers and 56 (100%) non-compliers did not share the opinion that Western immunization makes children to become more prone to sickness (see table 26). In addition, the perception of mothers on whether herbs taking in pregnancy can be enough measure to prevent childhood diseases was also examined (see table 27). One hundred and fifteen mothers (95.9) comprising of 62 (95.4%) compliers and 54 (96.4%) non-compliers did not believe that only herbs taken in pregnancy can prevent all the childhood diseases after births. Characteristics due to clinic arrangements and Services (i) . Distance from home to clinics The compliance status of mothers wa& examined against home distances to EPI clinics (see table 28). More mothers, 68 (56.2%) of which 40 (58.80%) from the compliers group were from homes less than 1 kilometer to the various EPI clinics as compared to 28 41.2%) non-compliers. However, more mothers in the non- compliers group, 15(83.3%) lived In distances of between 1 to 2 kilometres to clinics as compared to 3 (16.7%) compliers. (ii) . Means of transportation to EPI clinics: In table 29, compliance status among mothers are compared UNIVERSITY OF IBADAN LIBRARY 9 1 against means by which they travelled to EPI clinics. Majority of mothers, 84 (69.4%) of which 41 (48.8%) were compilers and 43 (51.2%) were non-compliers trek to the clinics. Among 34 mothers(28.1%) who went by public transport, there were 21 (61.8%) compilers as against 13 (37.2%) non-compliers. The observed differences wasnnot significant statistically (P 0.5). (lii). Mothers perceptions of the clinic staff Mothers were asked whether the health workers listened to them whenever they complained about their children's health (see table 30). Almost all mothers (100% compilers and 98.2% non-compliers) said 'yes'. In addition, all the mothers, 121 (100%) stated that the health workers explained the different schedules of immunization to them and that they also explained the changes that could occur or could be observed in children after receiving immunizations. Fever, mild weakness, and swelling from injection sites were specifically mentioned. As could be seen in table 31, most mothers in both groups, 94 (77.7%) were unanimous in saying that health workers in the immunization centres were not rude except 27 (22.3%) of which 13 (45*2%) and 14 (51.8%) were compilers and non-compliers respectively. In UNIVERSITY OF IBADAN LIBRARY - 3 2 addition most mothers, 108 (89.2%) consisting of 59 (90.6%) compilers and 49 (87.5%) non compilers agreed that the health workers were not hurrying while attending to them during the vaccination sessions. When the mothers were asked whether the health workers in their various EPI clinics were ’always friendly* * sometimes friendly*, *not friendly* or very *friendly*, majority 60 (45.6%) of whom 22 (36.2%) were compilers and 38 (63.3%) non—compliers said the health workers were ‘always ; friendly* to them. All the 6 (5%) mothers who perceived the health workers asbbeing ’unfriendly* were non-compliers. It is a general assumption that satisfied patients will likely comply with the advice they receive from health care provider. As could be seen in table 33, most mothers in the two groups were satisfied with the services received at the EPI centres* However, a more higher level of satisfaction was noticed among the compilers. Among the 52 who said they were very satisfied 43 (82.7%) were compilers as against 9 (17.3%) non-compliers. In table 34, compliance status of mothers was examined in relation to their decisions to participate in future immunization. All the 56 (100%) non-compliers pledged to immuniz UNIVERSITY OF IBADAN LIBRARY 93 their children in future contrary to expectation. However, 3 (4.6%) of the compliers could not decide on the future immunization of their children. UNIVERSITY OF IBADAN LIBRARY 9 4 TABLE 2 6 asskfj^ MOTHERS AND THEIR PERCEPTIONIHHAjNi NATION Of CHILDREN ORTHODOX XMKUNXZATXOft HARKS CHILDREN TO Sg CDHPLX ms %NON- TOT L % MORE SICK JCOMPLI RS AGREE 1 (1*5) 0 (0) 1 (0*3) UNCERTAIN 0 (0) 0 (0) 0 (0) DISAGREE' 61 (93.^) 56 (100) 117 (96.7) DON’T KNQte >3(4*6) 0 (0) 3 (2.5) TOTAL 65 (100) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 9 5 TADLZ 2 7 compliance: statu 3 .->ND THEIR 3SLISPS THAT "heIr^s during DSOUATE 'FOR PRstsMTlN^ ONCE I TAKE HERBS IN PREGNANCY CHILD 13 PROTECTED AGAINST ANY COMPILERS % NGN— TOTAL % DISEASE C< MPLIERS % AGREE 1 (1*5) 2 (3.6) 3 (2.5) UNCERTAIN 1 (1*5) 0 (0) 1 (0.8) DISAGREE 62 <95.50 54 (96.4) 116 (95.9) DON’T KNOW 1 (1.5) 0 (0) 1 C 0 ♦ 8) TOTAL 65 (100) 56 (100) '.1.2.1. .(.1.0.0)- .1 UNIVERSITY OF IBADAN LIBRARY 96 t a b l e 2 8 Compliance status of Mothers and distance frOB thejr hopes tfi EPI Ĉ jinip. i1 1 Home Distance COMPLIERS NON-COMPLIERS TOTAL < 1 Kilcmeter 40 28 68 * 1 - 2 3 IS 18 + 3 - 4 13 4 17 + 5 - 6 4 2 6 + above 6 " 4 1 5 + No response 1 6 7 sTsOoTsAsLsssassaessasstca sssss65aaassa 2rxSSB5=6SSSSSS£Zl =31231SSSBXXZ 2 X = 20.4, df « 1 (p< 0.05) *NOTE; Home Distances 1-2 and 3-4 were merged for values used to 2 calculate X 2 +NOTK: X excludes kilometres 5 and above and 'no response' values. UNIVERSITY OF IBADAN LIBRARY 97 TABLE 29 Conpliance Status of Mothers and seanB of getting to EPI CLINIC Means of getting 1 to clinic COMPLIERS NON-COMPLIERS TOTAL By foot 41 43 84 Public transport 21 13 34 *other means 3 0 3 TOTAL 65 56 121 S B S S S B Z S S S S 3 S 3 S a S S S S B B 3 8 B S B 5 33SS Z S Z 3 S 3 2 X 2 = 2, df *1 (p>O.OS) 2 * NOTE: X excludes other means values. UNIVERSITY OF IBADAN LIBRARY 98 TABLE 30 COMPLIANCE STATUS OF MOTHERS AND THEIR PERCEPTIONS OF HEALTH WORKERS ATTITUDE TO THEM AT.CLINIC SESSIONS HEALTH l ORKERS LISTENED TO MOTHERS WHEN THEY NON- COMPLAINED ON THEIR COMPLIERS % COMPLIERS % TOTAL % CHILDREN'S HEALTH 65 (100) 55 (98.2) 120(99.2) NO 0 (0) 1 (1.8) 1(0.8) TOTAL 6S (100) 56 (100) 121(100) HEALTH WORKERS EXPLAINED SCHEDULES TO MOTHERS YES 65 (100) 56 (100) 120(99.2) NO 0 (0) 0 (0) 1(0.8) TOTAL TOTAL 65 (100) 56 (100) 121(100) UN K j I U J 1 VER iS 1ITY OF I ____iBADAN LIBRARY 9 9 TABLE 3 1 COMPLIANCE STATUS OF MOTHERS AND WHETHER THE HEALTH WORKERS EXPLAINED SIDS—EFFECTS OF IMMUNIZATION AND WHETHER THEY APPEARED RUDE OR IMPATIENT TO MOTHERS AT CLINIC SESSIONS APPEARED HEALTH WORKERS EXPLAINE£ CHARGES TO OBSERVE AFTEF COMPLIERS 9; NON- IMMUNIZATION TO MOTHERS COMPLIERS TOTAL % % YES 65 (100) 55 (98.2) 120(99.2) NO 0 (0) 1 (1.8) KC.8) TOTAL 65 (100) 56 (100) 121(100) HEALTH WORKERS WERE RUDE TO MOTHERS YES 13 (20) 14 (25.0) 27(22.3) NO 52 (80) 42 (75,0) 94(77.7) TOTAL 65 (100) 56 (100) 121(100) HELLTH WORKERS APPEARED HURRIED YES 6 (9.2) 7 (12.5) 13(10.7) NO 56 (90.8) 49 (87.5) 108(89.3) TOTAL 65 (100) 56 (46.3) 121(100) UNIVERSITY OF IBADAN LIBRARY 1 0 0 TABLE 3 2 COMPLIANCE STATUS OF MOTHERS NO WHETHER THE HEALTH WORKERS AT THE CLINICS WERE FRIENDLY TO MOTHERS AND THEIR CHILDREN MOTHERS PERCEPTION OF NQN- THE HEALTH WORKERS COMPLIERS % COMPLIERS % TOTAL % ALWAYS FRIENDLY 22 (33.8) 38 (67.9) 60 (49.6) SOMETIMES FRIENDLY 4 (6.2) 1 (1.8) 5 (4.1) | NOT FRIENDLY 0 (0) 6 (10.7) 6 (5.0) VERY FRIENDLY 33 (58.5) 11 (19.&V 49 (40.5) NO RESPONSE 1 (1.5) 0 (0) 1 (0.8) TOTAL 65 (100) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 101 TABLE 3 3 COMPLIANCE STATUS OF MOTHERS AND THEIR LEVELS OF SATISFACTIONWITtiTHE EPI CLINICS SERVICES LEVELS OF SATISFACTIOf^ NON- OF MOTHERS COMPLIERS % 1COMPLIERS % TOTAL % NOT SATISFIED 1 (1.5) 0 (0) 1 (0.8) SATISFIED 18 (27.7) 46 (82.1) 64 (53.0) FAIRLY SATISFIED 2 (3.1) 1 (1.8) 3 (2.4) VERY SATISFIED 43 (66.2) 9 (l4. |> 52 (43.0) NO RESPONSE 1 (1.5) 0 (0) 1 (0.8) TOTAL 65 TlOO) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 102 TABLE 3 4 COMPLIANCE STATUS OF MOTHERS AND THEIR FUTURE DECISIONS ON IMMUNIZATION I WILL IMMUNIZE MY NON- CHILDREN IN FUTURE COMPLIERS % COMPLISRS TQTAL %% YES 62 (95.4) 56 (100) 118 (97.5) I CAN’T DECIDE NOW 3 (4,5) 0 (0) 3 (2.5) TOTAL 65 (100) 56 (100) 121 (100) UNIVERSITY OF IBADAN LIBRARY 103 OBSERVATION CHECKLIST RESULT From what was observed, none of the four clinics selected for the study have a standardized system of giving health talks. The discussion topics were usually unplanned and diffused rather than specific. Another, crucial finding was that mothers waiting time were excessively and unnecessarily prolonged. Time range spent by mothers was between 7.30 a.m. to 1.30 p.m. (6 hours) with mean hours of approximately two and half hours. The EPI health staff do not normally start clinic sessions until most mothers who came early enough started to frown and reflect ’unhappiness’ in their faces. The early attenders would start to arrive as from 7.30 a.m. whereas the earliest time the clinic session would start was 10.00 a.m. - a difference of two and half hours. It was also observed that most of the health staff serving at EPI clinics were temporarily assigned to the clinics. In addition the nursing staff are assigned daily to the immunization clinics without prior information..The system precipitated by shortage of staff did not give room for continuity of relationship with the mothers. Also, it -usually took the assigned staff between 30 minutes and one hour to orient themselves to the clinic sessions. UNIVERSITY OF IBADAN LIBRARY 104 Furthermore, the officers in charge of vaccine distribution to the EP1 Clinics (who Usually belonged to LGA council staff) also contributed to mothers long waiting time as vaccines do not reach the clinic until about il.00 a.m. On two occasions the observer recorded none supply of vaccines to the clinic. On these two occasions, mothers were sent back home without immunization for their children. No efforts were made to track down the defaulters even though the EPI baby tracking slip (see fig L̂) was available. Lack of vehicles for home visits and shortage of staff to go round were observed to be major handicaps preventing the tracing of the defaulters. UNIVERSITY OF IBADAN LIBRARY 105 Fig. A Baby tracking slip. BABY TRACKING SLIP E. P. I. Please bring your child................................ To................................. Health Centre/Clinic On....................At.............................. REMEMBER: Your Baby Needs 5 visits To The Clinic in order to complete ALL the doses of Vaccination and become fully protected. Ask The Nurse when In Doubt. UNIVERSITY OF IBADAN LIBRARY 106 FORMATION OF COMPLIANCE PREDICTOR SCALE In Summary, results showed significant associations between compliance and the following variables viz educational level (P< 0 .001), occupation (P<0.001), monthly earnings (P<0.001) distance from home to clinic$(P<0.OS), ages of children at first immunization contacts (P<0.001, Places where mother delivered (P<0.001, whether mother received Western ante-natal services (P<0.001), whether mother received immunization in Pregnancy (P<0.05), whether mother gave child other protection like herbs (P<0.001) and mothers religion (P<0.001). Compliance Predictor Scale The predictor scale of compliance is displayed in figure The ten variables that showed associations with compliance were simply given arbitrary scores ranging from zero to six according to their association with compliance (whether enhancing compliance or not). On educational levels, illiterate mother scores zero while another with HND/Degree certificate will score six. Mother who is unemployed is zero, a semi-skilled mother scores one, a petty trader two and salary earner scores the highest which is three. The monthly earning scores range from zero for no earning to five UNIVERSITY OF IBADAN LIBRARY 107 for any mother earning N400 and above. Next to be scored is the age of child when receiving the first contact of immunization. A child brought after the age 6 months scores zero for the mother while other marks run from one for less than 6 months to six for a child under one month of age. Any mother who attended institutionalized ante-natal services and received immunization in pregnancy will score one mark each for the two acts whereas another one who did not will be scored zero each. Place where mother delivered the child brought for EPI is also scored ranging from zero for home to S for government hospital. If a mother gave other protection like herbs to child, the mark for that is zero whereas mother who did not will have one full mark. Distance from home to EPI clinic less than one kilometer scores one and if above one kilometer it is zero. And lastly, a Christian mother will earn one mark and another who is a muslira will score zero in the scale. based on the above arbitrary scpres, compliance predictor scale thus consists of two zones vizn-onc nompliance zone for any mother whose total scores after interaction falls below IS marks from the 30 total obtainable and compliance zone for mother whose total marks is above 15. UNIVERSITY OF IBADAN LIBRARY 108 Simply put, any mother who is participating in EF1 in rural areas and falls within non-compliance zone will not be likely to A. comply with schedule whereas another who falls within a compliance zone is likely to comply. UNIVERSITY OF IBADAN LIBRARY Fie.5 Compliance Predictor Scale Educational levels of mother Mother attended Western Illiterate ante-natal0 Primarv No 01 Yes 1 Secondary 2 Technical 3 Teacher Training 4 Mother received immunizationin Pregnancy NCE/OND/Equivalent 5 HND/Degree 6 No 0 Yes 1 Occupation of Mother Place where mother delivered Unemployed 0 Semi-skilled Home1 0 Petty trading 2 Church 1Private Hosp. Gisil Servant 23 Mat. Centre 3 Health centre/ clinic 4 M o n t h l y Earning of Mother Govt. Hosp. 5 No earning 0 <: N100 1 Mother gave child other N100-N199 2 Protection (Herb) N200-N299 3 Yes 0 N300-N399 4 No 1 N400 and above 5 Mother’s home to EPI Long (above 1 Clinic0 Short (below 1 km ) 1 Child’s age at 1st Immunization Contact Above 6 months 0 6 months Mothers religion1 5 months 2 4 months 3 Islam 0 3 months 4 Christianitv 1 . - 2 months 5 >0 - 1 month 6 0 A non compliance V/ zone- 15 ^ compliance ! zone 30 \y' UNIVERSITY OF IBADAN LIBRARY 110 TABLE 35 Distribution ofif 10 Mothers used for pilot testing of the~~gffecthiveness of compliance predictor scale ao.cordiijng to scores based on the scale Educational Occupation Imthly Child's Attended Received Place Gave other Distance Religion Total Prediction of Mothers level (6) (3) i arning age at 1st Western inunization delivered protection fro« hose (1) out would-be (S) contact (6) antenatal(1) in preg. (1) (5) (1) to clinic(l) of '30' coapliers 1 1 2 3 4 1 0 0 1 1 1 14 No 2 2 3 2 4 1 1 4 1 1 0 19 Yes 3 4 3 3 2 1 1 2 1 0 1 18 Yes 4 3 1 1 3 1 1 2 1 0 1 14 No 5 1 0 0 6 1 0 1 0 0 1 10 No 6 6 3 3 6 1 1 4 1 0 1 26 Yes 7 5 3 4 6 1 1 3 1 1 1 26 Yes 8 3 2 1 4 0 0 0 0 1 1 12 No 9 5 3 5 6 1 1 3 1 1 0 26 Yes 10 h 3 5 6 1 0 2 0 0 0 22 Yes UNIVERSITY OF IBADAN LIBRARY Ill TABLE 36 Would-be compilers and non-compliers after 3DPT/OPV appointment schedules would-be would-be compilers Non-compliers Reported as Total scheduled No % No % No % 4 (66.7) 1 (25) 5 (50) Yes NO 2 (33.3) 3 (75) 5 (50) Total 6 (100) 4 (100) 10 (100) Bssczsssass: UNIVERSITY OF IBADAN LIBRARY 112 Result of Application of Compliance Scale: Tables 35 and 36 show the result of the pilot test of compliance prediction scale. In table 35, the distribution of 10 mothers used for the test of effectiveness of compliance scale is displayed according to their total scores* Pour mothers had a total score of below 15 each and they were marked would-be non—compilers* The remaining six mothers on the other hand had total scores above 15 each forming would be compilers* After three months, four out of the six mothers categorized as would be compilers actually complied, they reported for the 3DPT/OPV immunizations for their children (see table 36)* The remaining two, failed to turn up as scheduled* Also among the four mothers in the category of would-be non—compilers, one reported at the three appointment days* The other three missed two appointments each* The above result showed that the scale formulated can predict mothers compliance in semi-urban or rural setting* This is because it has been able to predict atleast 4 out of 6 would-be compilers end three out of 4 would-be non-compliers* UNIVERSITY OF IBADAN LIBRARY CHAPTER FIVE DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS In this chapter, the implications of this study are discussed. This discussion follows the same arrangement as the results and as such grouped into five broad areas. DISCUSSION. Demographic Characteristic (i). Socio-economic Status: Income and education have been shown by various studies (Glasser, . , (1958), Cassel, (1963) and Winkelstein, W. : > 1 ) and Grahams, (1959), to be related to better participation in free-polio vaccine programme. A positive association of education, income and occupational status have also been reported with preventive dental visits (Rosenfield, and Donebedian, 1958, Yan Kaner, 1961 and Kegeles, 1963). In the present study, strong associations were found between compliance and educational levels of mothers, their occupation as well as monthly earnings. Higher compliance in mothers of high socio-economic status (measured by their monthly income, educational levels and occupation) suggests that mothers in this category apart from UNIVERSITY OF IBADAN LIBRARY 114 having high education, will probably be salary earners who have better access to journals, pamphlets, write-ups and radio/television where information about EPI could be correctly gained than mothers in low socio-economic group who are likely to be illiterates or with very low educational levels, without job and little or no income. Such category of mothers may possibly not be able to read or afford radio/television sets and will depend on incomplete information either from neighbour or other not well-informed individuals. (ii) . Mothers age. Even though there is no significant association statistically between the ages of mothers and their compliance status, mothers in age groups 20-24 years and 40 yearB and above need to be watched because they formed the age groups where there were more non-compliers. (iii) . Marital Status: Also, marital status is among the demographic characteristics without strong association with compliance. However, divorcee mothers who come to clinic may not likely comply because none of the two (1.7%) of such mothers who came to clinic used for the study was a compiler. If this finding is interpreted as reflecting a low degree of family cohesiveness, UNIVERSITY OF IBADAN LIBRARY 115 — therefore it agreed with a study conducted elsewhere by White et al., (1976) where family disorganisation was found to be an important barrier to providing comprehensive medical care to poor urban families. However, Winger, et al., (1968) studying the relationship of family organisation to utilization of pediatric emergency services, found no relationship between utilization of health services and family organization. They speculated that in any such families, there may be hidden sources of stability to enable parents to manage adequately their childrens health problems. (iv) . ReJ.4gj.9n: The higher compliance of Christian mothers with EPI schedules than their muslim counterparts relate to the higher number of Christian respondents in the study. In addition, it is .because majority of muslim mothers in the area are traders who move from one place to the other in search of their trading articles thereby causing 20 (35.7%) of them not to comply as against 6 (9.2%) who complied. (v) . Compliance status and parity.- It is always expected that mothers with many children will find it difficult to comply because of many responsibilities attached to child-bearing with consequent neglect of preventive UNIVERSITY OF IBADAN LIBRARY 116 medical services. However, this hypothesis failed to hold in this study probattfy because high parity in developing areas of the world such as Nigeria does not necessarily mean that all the children are alive. In Nigeria for instance, the infant mortality rate is extremely high (110/1000) compared to developed countries such as United States of America or Sweden with infants mortality rates of 11/1000 and 7/1000 respectively (World Dev. Report, 1986). It is not uncommon to find a woman who has given births ten times, but has only two of them alive. As could be seen from the result In table 5 the higher the number of alive children per total births the lower the mother’s tendency to comply with the schedules and vice-\'ersa. (b) Characteristics related to Immunized Children: (i) Age of child at 1st immunisation contacts: The strong association between compliance status of mothers and ages of children at first immunization contacts agree with expectation* Statistically significant association (P 0.05) showed probably that mothers who reported early enough according to schedules might have come from among educated categories who have correct information about EPI during pregnancy and at deliveries. (ii) . Places of child delivery/mothers ante—natal services: Also, in the study, there was statistical association UNIVERSITY OF IBADAN LIBRARY 117 between compliance and places where the mothers delivered the immunized children (P<0.001). Mothers who delivered ul government hospitals and health centres complied more than those who delivered at home or private clinics. One is not surprised non-compliance of those mothers who delivered at home, this is because un-institutionalized deliveries showed that mothers themselves have not been well informed or motivated to use available health services not to talk of using preventive services for the children. The same reason would hold for most mothers 47 (38.8%) in the non-compliers group who did not receive tetanus toxoid vaccination during pregnancy. These mothers might have picked wrong information about EPI from other sources because they did not have institutionalized ante-natal services or deliveries where such information could be obtained. (c). Medical History Characteristics (i). Giving other Protection to Children.- Majority of those mothers who gave either herbs or any other protection to their children apart from EPI did not comply with schedules. They were 41 (73.2%) out of 56 non-compliers. This group of mothers might probably be satisfied and sure that at least they have protected their children. The association of UNIVERSITY OF IBADAN LIBRARY 118 giving other protection and compliance is statistically significant (P<0.001). Mothers in this group need to be closely monitored when they first appear at EPI clinics and probably educated that even though herbs may be good, ' EPI deals with specific diseases which can further help the children who already had herbs. Mothers Compliance and EPI Schedules: The fact that compliance decreased as schedules progressed in this study substantiates the earlier findings on default rates in EPI carried out elsewhere. For instance, similar result was obtained in an intensive immunization programme in a region in Ghana whereby 63% coverage was achieved in the first dB&e of OPV but only 22% for the 2nd do.s# and 11% for the third dose WHO, 1979). Reasons for non-compliance Twenty-five percent of mothers (14) who defaulted said they 'forgot dates’ of appointments while 12 (21.4%) claimed that their children were sick (see table 17). One may not be too surprised to find such reasons as these. They are related to lack of appropriate communication as was earlier documented by Hertz and Stamps, (1977). It may also reflect inadequate utilization of appropriate local media for the purpose of UNIVERSITY OF IBADAN LIBRARY 119 informing mothers on future immunization schedule dates as well as other health education/information relevant to immunization. For example next appointment dates are usually written at the back of immunization cards (figure 6) which are given to both literate and illiterate mothers to take home. (d). Cognitive factors and Compliance Knowledge of EPI Schedules; The finding of this study showed that 41 (73.2%) of the 56 non-compliers had good knowledge of EPI schedules. Surprisingly, this did not help them to comply. Health knowledge is expected to positively influence the attitudes and beliefs of the recipient towards taking appropriate measure regarding his health. This also show that acquisition of knowledge alone may not necessarily lead to practice. Though these mothers demonstrated that they have acquired some knowledge, yet they have not been keeping their appointment days. It is probably that certain barriers were yet to be removed from these mothers through a more efficient health education approach as suggested by Soladoye, (1980). UNIVERSITY OF IBADAN LIBRARY 120 Mothers beliefs in Efficacy of EPI It was anticipated that mothers who believed in the efficacy of vaccines in EPI against target disease would comply with appointment schedule. The finding is however in line with the Null hypothesis set at the beginning of this study that compliance to EPI schedule is not due to lack of belief in the efficacy of EPI vaccination on those 6 killer diseases. Sources of information to mothers about EPI The most common source of information about EPI to mothers in this study was through health workers at various EPI clinics (see table 20). Out of 65 (53.7%) whose source of information was through this medium, there were <40 (61.5%) compilers. This study agrees with the earlier study by a group of medical students ('B' Group, 1986) at Igbo-ora, a rural town in Nigeria where it was discovered that 91.3% of their study population of mothers heard about EPI through the clinics and that the mothers in this category had higher proportion of children (47.0%) with full immunization schedule. UNIVERSITY OF IBADAN LIBRARY EPI appointment Card showing schedules where next appointment is given 1. 2 . 3. 4. IMMUNIZATION SCHEDULE Vacgiae Age of Child B.C.G......................... At Birth Oral polio 1st Dose........... Two Months D.P.T. 1st Dose............... Two Months Oral polio 2nd Dose.................. Three Months D.P.T. 2nd Dose...................... Three Months Oral polio 3rd Dose............Four Months D.P.T. 3rd Dose................Four Months Measls........................ Nine Months UNIVERSITY OF IBADAN LIBRARY 122 (e) . Attitudinal Factors (i). Fear of Side-Effect of Immunization: One may not be too surprised to find 15 (26.9%) non-compliers out of 16 mothers who claimed that their children became seriously sick after the first immunization schedule. It is probable that those mothers feared a repeat situation where their healthy babies receiving what is regarded as preventive medication suddenly become sick after receiving injections. Lola Adekunke (1975) also discovered the same even among elite* parents in Bodija area (a peripheral area of Ibadan, Nigeria) in her study of impediments to immunization coverage. Generally, side effects of drugs have been documented to be associated with non-compliance (Soladoye, 1980). (f) . Characteristics due to Clinic arrangement and Services (i). Distance of Mothers from home to EPI Clinic According to expectation, distance showed strong association with compliance (P<0.05). Mothers who lived at a distance of less than one kilometer to the clinics were found mostly among the compilers 40(61.52) compilers as against 28 (50%) non-compliers (see table 28). To substantiate the view that; availability of health services may not necessarily lead to use of such services, those UNIVERSITY OF IBADAN LIBRARY 1 2 3 who went to EPI by foot complied more than those who went by any other means* In table 29, out of 65 compilers, 41 (63*1%) went by Foot* This means, that health facility should not only be available, but it should also be accessible — put within reach of people it is meant for (Ademuwagun, 1986), Mothers perception of the Clinic Staff? Studies have shown that personality and manner of physician as well as the quality of the doctor patient relation or health worker - client relation do influence compliance (Francis, et al, 1969), In the present study, it was found that friendliness or warmth on the part of the health workers at EPI Clinics surveyed (as perceived by mothers) did not itself result in increased compliance* However, where the mothers stated that the health workers were not friendly, there was a noticeable reduction in the compliance behaviour (see table 32). This finding is supporting by Francis et al (1969), Compliance and Client Satisfaction A crucial finding is the extent to which compliance is influenced by the mothers satisfaction* Although high satisfaction does not necessarily imply total compliance with EPI appointment schedule, there was certainly an impressive association between the two* It has been suggested that a patient/client who UNIVERSITY OF IBADAN LIBRARY 1 2 4 cooperated with health care providers in the course of relationship do have the feeling of satisfaction with himself that may be reflected on to the health provider and medical consultation (Francis et al, 1969). Even though it is not yet proved, the much more lifeely explanation seems to be that client/patient who is satisfied with the health care provider behaviour and services would be more apt to carry out the medical advice than one who was unimpressed and thought that his needs are not met by such visit* CONCLUSIONS Fran the results of the study, many factors are found associating with non-compliance of mothers with appointment schedules in EPI* Among these factors are low—socio-economic status measured by income, educational level and occupation* Others include distance between homes to EPI centres, uninstitutionalized ante-natal services, none taking of immunization by mothers in pregnancy, and delivering children at homes or church* Mothers who brought children for first immunization after ages of six months may also not comply with schedule so also for those who gave their children other protection. Lastly muslims are likely to default than Christians UNIVERSITY OF IBADAN LIBRARY 125 will do. All these factors should be given adequate attention to minimise defaults in EPI. The studv also recalled other factors that affected compliance not due to mothers faults. The factors included inadequate supply of vaccines on clinic days, excessive waste of mother time at clinic session and deficiencies in health education methods in EPI. All these factors can be removed with appropriate planning and job consciousness by the health care providers responsible for EPI. In order to improve compliance in EPI schedules especially among the rural dwellers, a predictor scale has been produced with the studv for use in EPI centres to enable the staff responsible for immunization identifv those would-be defaulters and give them extra attention right from the first visits to make them complv with subsequent appointments. The scale can also serve as a guide for future studies for production of predictor scale for mothers in the cities/urban centres participating in EPI. RECOMMENDATIONS Two broad areas of recommendations are presented to round up this studv. One focuses attention on improvement in appointment schedules of immunization in rural areas like Obokun LGA where UNIVERSITY OF IBADAN LIBRARY 126 the study took place. The other is in relation to health education components of EPI in general. 1. Integration of EPI to other health services may contribute to vaccination coverage•when children are brought to health centres for treatment, for example, they can be vaccinated at the same time. Continuing immunization services could increase coverage and reduce drop out rates. 2. How to communicate the concept of immunization of healthy children to prevent an illness that might or might not occur later is one of the most difficult problems faced in promoting immunization. Therefore, health workers concerned with EPI in rural settings should adopt communication whereby local experiences will be used for the mothers. For instance health workers can compare immunization to using an umbrella to protect against rain. If a person out doors sees that rain is likely to fall and wants to stay dry, before the rain begins, he picks a banana leaf which he will use as an umbrella. If such person could wait until the rain starts, he may be wet by it. In the same manner, if a person waits until children became ill before having them vaccinated, they will not have the protection. This type of system using local examples increased four-fold the UNIVERSITY OF IBADAN LIBRARY 127 number of children brought- for immunization in Kenya as reported by Were, (1985). 3. Formalised Health Education needed in EF1 should be emphasized and possibly the health staff in charge of the immunization be trained on approach to health education. This will enable them to explain to mothers the basic information needed to motivate the parents so that they will be told: (i) that it is important to have children vaccinated (ii) that children need specific and repeated vaccinations on a definite schedule, and (iii) that side effects of vaccines are normal and rarely serious. 4. Present design of vaccination card is effective for literate mothers only. Illiterate mothers are unable to tell from the cards which vaccinations their children had received, how many doles had been given, or how many were still needed. Thus the cards are not reminding parents to turn up when the next schedule is ripe. Studies have shown that mothers recognized vaccines by the way they were administered i.e. either orally, or injected in the arm or buttock. A small booklet of six pages each depicts a UNIVERSITY OF IBADAN LIBRARY 128 particular type of vaccine administered in particular type of vaccine being administered in picture form is recommended. This has been effectively employed in Hunduras (William, et al., 1984). 5. Future studies may wish to explore how compliance in cities and urban centres mothers would be predicted to for a comparison of this work. 6. Where this study took place and like in many other areas in the rural settings, people patronize private health institutions than they do to government established ones. It will go a long way in improving coverage as well as reducing drop outs if registered private clinics could have regular supply of vaccines so that mothers who have more confidence in such institutions will have their children vaccinated in them. UNIVERSITY OF IBADAN LIBRARY 129 REFERENCES Abramson J.H; Mayet F.G; and Majola C.C (1961): What is wrong with me? A study of the views of African and Indian patients in a Durban Hospital. South African Wed, Journal 35 j_ £90 - 694. Ademuwagun Z.A (1986): MPH Health education Lecture notes. 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UNIVERSITY OF IBADAN LIBRARY WHO (1979a): Trial of BfG vaccines in South India for tuberculoaiB prevention: First report. Bulletin of the WHO 5/ (5); 819 - 32/' WHO (1979b): EP1 Carbon weeily Epidemiological Record 54 (13): 97 -98. WHO (1981a): EPI: Levelopment of the programme, 1978-1980 Ivory Coast. weekly Epidemiological Record 56 (43): 341 - 34.3 . WHO (1981b): Tuberculosis control: a world review weekly Epidemiologies,1 Record 56 (50) 393 - 396. WHO (1982a): Expanded Programme on Immunization: Prevention of neonatal tetanus. Weekly Epidemiological Record S3 (37): 137- 142. WHO (1984a) : Guidelines for the investigation and conr ,ol o f outbreak: of EPI target diseases. Geneva. Pg.80 (Mimao). WHO (1987 b) : EPI: Missed immunization opportunities. Pakistan Weekly Epidemiological Record 59 (44) 341 - 342. WHO ( 1 9H.5a) ; EPI: Pregress and evaluation report by the Director General. Geneva Pg 20 (E/7/27) WHO (1935b) :EPI: R„* appraisal of early OPV and DPT. Weeklr Epidamclogical Record 60 (37): 284 - 285. WHO (1986a) : Reported annual incdence of dishtneris measles, pertussis, poliomyelites, tetanus anl tuberculosis (1974 -1984) geneva. (Unpublished). World Development Report(1986): World Bank Publication Oxford University Press. Yankaner A. (1961)* 7. Stuciy of Periodic School Medical Examinations., IV Educational Aspects. Am. J. Publ. Health 51:1532. UNIVERSITY OF IBADAN LIBRARY 137 APPEDXX 1 QUESTIONNAIRE INTERVIEW SCHEDULE FOR MOTHERS WHO ATTENDED EPI CENTRES FOR THEIR CHILDREN IMMUNIZATION PLACE .......................................... LANGUAGE ............................ SERIAL NO SECTION A INFORMATION ABOUT THE MOTHER (Please tick ( ) or write the number of your choice as appropriate in the opposite boxes) 1. Age last birth day in years or year !--------! of birth (e.g. 1940) ! ! 2. Marital Status 1. Single 2. Married 3. Divorced 4. Separated 5. Widowed 6. Never married 3. If married, What type of family? 1. Monogamous 2. Polygamous UNIVERSITY OF IBADAN LIBRARY 138 4. If Polygamous what is your rank among other wives of your husband? 1. 1st wife 2. 2nd wife 3. 3rd wife 4. 4th and above 1. No of children ....... 2. No alive ....... 3. No dead ....... 6. What type of job do you do? 1. Unemployed 2. Petty trading 3. Salaried work 4. Student 5. Other (specify) ....... 7. What is your educational level? 1. Illiterate 2. Primary School 3. Attended Arabic School 4. Secondary School Education 5. Teacher Training Education 6. NCE Holder 7. University Degree 8. Other (specify) ........... 8. About; bow much do you earn or say do you get from your trade in a month? ....... 9. How many male children do you have? .. 10. How many female children do you have? UNIVERSITY OF IBADAN LIBRARY 139 11. What is the actual distance of your home to the (where you immunized your child)? EPI clinic 12. How do you get to the EPI Clinic? 1. By foot 2. By public transport 3. By private vehicle 4. Other (specify) 13. How much do you spend in bringing your immunization on each day? child for 14. Who provides the said money for transport? 1. Self 2. Husband 3. Relatives 4. Other (specify) 15. What is your relegion? 1. Islam 2. Christianity 3. Traditional religion 4. Other (specify) UNIVERSITY OF IBADAN LIBRARY 140 SECTION B INFORMATION ABOUT THE CHILD YOU IMMUNIZED LAST AT THE EFI CLINIC 16. What is the age of the child when you first took him/her to EFI clinic for immunization? 17. Sex of the child 1. Male 2. Female 18. Rank of the child among your other children. 1. 1st born 2. 2nd born 3. 3rd born 4. 4th born 5. 5th born and above 19. Where did you deliver the child? 1. At home 2. Government Health Centre 3. Maternity Centre 4. Government Hospital 5. Private Hospital/Clinic 6. Spiritual Church 7. Native Healer's House 8. Other (specify) ........... UNIVERSITY OF IBADAN LIBRARY 141 20. Before the birth of the child, did you receive antenatal care from hospital/health centre /clinic? 1. Yes 2. No 21 . Where do you normally deliver your baby? 1. At home 2. Government health centre/hospital 3. Maternity Centre |--------; 4. Private Hospital ! | 5. Spiritual Church !-------- ! 6. Native healer's house 7. Other (specify) ..................... 22. Have you done any other thing to protect the child against illnesss apart from EPI programme? 1 . 2. No 3.1 don’t know 23. If yes to question '22' above, specify what you have done 24. Did you receive any form of immunization during the child’s pregnancy? 1. Yes 2. No 9.1 don’t know 25. pIsr ogrhaem/mseh?e your first child to be immunized through EPI 1. Yes 2. No 9.1 don't know 26. Which of the following EPI schedule has the child received? UNIVERSITY OF IBADAN LIBRARY 142 1 .BCG 1. Yes ; i__i ii --- : i 2 . no :i --- :i i *i 9.1 don' t know i___i i i l1 t « i li 1 i1 2.1st DPT/OPV 1. Yes i: --- : i 2 . No !--- ! 9.1 don' t know 1 i 1i ti ii l l ll 11 1 il i i 1 ll i1 ii 3.2nd DPT/OPV 1. Yes :i --- : i 2 . No 1! --- ;1 9.1 don' t know 1 • 11 ti •i 1 1 1 1 1 1 li ii i “ » t i 4.3rd DPT/OPV 1. Yes : l ( it --- : 2 . 9.1 don' t know 1 i ii i1 l1 ii ii il li 5.Mealses 1. Yes ;t --- ! i 2 . No i --- !1 9.1 don' t know i___ i1 »i ___ »i 1l ___ 1 t1 I1 i 27. State the reason(s) for missing the immunization which the child did not receive in 'Q 26' above schedule 28. Which of the following diseases is very common with the children in your area? 1.Diphtheria 1. Yes 2. N o ---- 9.1 don't know 2.Pertusis 1. Yes 2. N o ---- 9.1 don't know 3.Tetanus 1. Yes 2. N o ---- 9.1 don't know 4.Poiomyelitis 1. Yes 2. N o ---- 9.1 don’t know 5.Measles 1. Yes 2. N o ---- 9.1 don't know 6.Tuberculossis 1. Yes 2. N o ---- 9.1 don't know UNIVERSITY OF IBADAN LIBRARY 11 1 1 1 1 1 11 11 I 2o 143 29. Do you think the child can be immunized against the following diseases? 1. Yes 2. No 9.1 don't know 1. Diphtheria 2. Pertussi 3. Tetanus 4. Poliomyelitis 5. Measles 6. Tuberculosis 30. How many times were you turned back without having your chid immunized at the EPI clinic you attended? 31. Did your child become seriously sick after the first immunization schedule? 1. Yes 2. No 9.1 don't know SECTION C KNOWLEDGE OF MOTHER ABOUT EPI 32. By what means did you ger to know abou EPI? 1. Radio/TV 2. Newspapers/Magazine 3. Health Worker 4. Husband 5. Relative 6. Neighbour 7. Other (specify) .............. 33. How many schedule of immunization is your child supposed to take before completing his/her immunization? UNIVERSITY OF IBADAN LIBRARY 144 34. Were you told about the ages for different EPI schedule? 1. Yes 2. NO 9.1 don't know 35. In your opinion, do you consider modern immunization of children enough preventive measure against childhood diseases covered by EPI? 9.1 don't know 36. If ‘no’ to question 35 above, whatelse can one do to prevent tetanus in children. 37. What else can one do to prevent childhood tuberculosis? 38. What else can one do to prevent Poliomyelitis in children? 39. What else can one do to prevent diphtheria in children? UNIVERSITY OF IBADAN LIBRARY £0 11 11 11 11 i! 1 1 1 1 145 40. What else can one do to prevent mealses in children? 41. What else can one do to prevent whooping cough in children? UNIVERSITY OF IBADAN LIBRARY 146 SECTION D BELIEF/IMPRESSION OF MOTHERS ABOUT EPI (Please check the opposite column for each question or statement according to your degree of agreement or disagreement and tick (