TABLE OF CONTENTS

Title Page        –           –           –           –           –           –           –           –           –           i

Certification    –           –           –           –           –           –           –           –           –           ii

Dedication      –           –           –           –           –           –           –           –           –           iii

Acknowledgement             –           –           –           –           –           –           iv

Table of Contents       –           –           –           –           –           –           –           –           v

List of Tables –  –           –           –           –           –           –           –           viii

Abstract          –           –           –           –           –           –           –           –           –           x

CHAPTER ONE: INTRODUCTION

Background to the Study       –           –           –           –           –           –           –           1

Statement of the Problem            –           –           –           –           –           9

Purpose of the Study  –       –           –           –           –           –           11

Research Questions –  –       –           –           –           –           –           –           12

Hypotheses –   –         –           –           –           –           –           –           –           13

Significance of the Study        –           –           –           –           –           13

Scope of the Study     –           –           –           –           –           –           –         –            15

Operational Definition of Terms –        –           –           –           –           15

CHAPTER TWO: LITERATURE REVIEW

Conceptual Review         –           –           –           –           –           –           18

• Concept of Routine Immunization     – –           –                       21
• Routine Immunization Targeted Diseases the Immunization Schedules-      24
• Immunization Uptake:Benefits   –           –                       27
• Consequences of Lack/Low Routine Immunization Uptake-           28
• Need for Improvement of Routine Immunization Uptake   –           29
• Strategies for Improvement of Uptake of Immunization Services 30
• Reminders and Recalls                 –           –           –           32
• Benefits of Reminders and Recalls    –    –           –           32
• Benefits of Improving Immunization Uptake Rate    –                       34

Theoretical Review     –          –           –           –           –           –           35

• The Health Belief Model (HBM)       –           –           –           –                       35
• Application of the Theory to the Study             –           –           37

Empirical Studies        –              –           –           –           –           –           38

Summary of Literature Review –        – –           –           –           –           46

CHAPTER THREE – RESEARCH METHOD

Research Design         –    –           –           –           –           –           –           48

Area of Study –           –            –           –           –           –           –           49

Population for the Study        –           –           –           –           –           50

Sample                               –           –           –           –           –           –           –           51

Inclusion Criteria           –           –           –           –           –           –           51

Sampling Procedure    –           –           –           –           –           –           52

Instrument for Data Collection           – –           –           –           –           53

Validity of the Instrument      –       –           –           –           –           54

Reliability of the Instrument   –        –           –           –           –           –           54

Ethical Consideration –           –          –           –           –           –           55

Procedure for Data Collection          –           –           –           –           55

Pre-Intervention Data –                   –           –           –           –           55

Experimental Group–Intervention      –          –           –           –           56

Control Group –           –             –           –           –           –           –           57

Post Test         –           –           –           –           –           –           –           –           –           57

Methods of Data Analysis      –           –       –           –           –           –           58

CHAPTER FOUR: PRESENTATION OF RESULTS

Summary of Major Findings                                                              74

CHAPTER FIVE: DISCUSSION OF FINDINGS

Discussion       –                 –           –           –           –           –           77

Implications of the Study       –                   –           –           –           84

Limitations           –           –           –           –           –           87

Suggestions for Further Study          –           –           –           –           88

Summary of the Study              –           –           –           –           –           88

Conclusion      –        –           –           –           –           –           –           91

 Recommendations      –           –           –           –           –           –           93

References      –             –           –           –           –           –           94

Appendices     –                 –           –           –           –           –           –           100

LIST OF TABLES

Table 1:  Summary of WHO position papers- recommended routine immunization for children    –           –           –           –           –           24

Table 2: Nigeria’s Childhood Routine Immunization Schedule   –           25

Table 3: 2 x 2 Factorial Quasi Experimental Design           –           48

Table 4: Demographic Characteristics of Respondents        –           60

Table 5: Pre and Post Intervention Rate of Immunization Uptake in the

Experimental  Groups –           –           –           –           –           –           –           61

Table 6: Rate of Completion of the Three Scheduled Immunization Appointments by Mothers in the Experimental Groups   –           –           63

Table 7: Pre and Post Intervention Rate of Immunization Uptake in the Control Groups    –           –           –           –           –           –           –           –           65

Table 8: Rate of Completion of the Three Scheduled Immunization Appointments by Mothers in the Control Groups —           –           –           67

Table 9: Comparison between the Post-intervention Rates of Uptake of the Experimental and Control Groups Controlling their Rates of Uptake Pre-Intervention          –           –           –           –           –           –           –           68

Table 10: Comparison between the Post-intervention Rates of Immunization Uptake of the Experimental and Control Groups in the Urban Community Controlling their Rates of Immunization Uptake Pre-Intervention -69

Table 11: Comparison between the Post-intervention Rates of Immunization Uptake of the Experimental and Control Groups in the Rural Community Controlling their Rates of Immunization Pre-Intervention –         –           70

Table 12: Comparison between the post-intervention rates of immunization uptake of the Experimental Groups’ In the Rural and Urban Locations Controlling their Pre-intervention immunization rates –    –           71

Table 13: Comparison between Post-intervention Immunization Uptake Rates of the Experimental and Control groups in the Rural and Urban Locations Controlling their Pre-Intervention Immunization Rates    –           72

Table 14: Comparison between the Post-intervention Immunizations Rates of Uptake of the Control Groups in the Rural and Urban Locations Controlling their Pre-Intervention Immunization Uptake Rate –       –           73

ABSTRACT

The need to improve uptake of routine immunizations by mothers using reminder and recall strategies so as to prevent childhood vaccine-preventable diseases is a global public health concern. Globally, about 1.5 million children still die yearly from vaccine-preventable diseases. In Nigeria, 62.8% children are not immunized while 36.4% of children were partially immunized due to poor uptake. The Taraba State W.H.O. reports for 2011-2014 showed hat uptake of routine immunization was less then 50% in 14 out of the 16 L.G.As as about 87.5% of mothers missed their routine immunization appointments. Previous empirical studies have found that reminding and recalling mothers for their immunization appointments improve their rate of immunization uptake but no such studies have been done in Taraba State. The study was designed to find the efficacy of telephone call reminders and recalls in improving uptake of routine immunization services in Taraba State. Five objectives were formulated, five corresponding research questions posed and five hypotheses postulated for verification. A quasi-experimental research design was used for the study.  The instruments for data collection were two pre and post-intervention immunization checklists. Reliability test yielded a co-efficient index of 0.72. The population was 1000 while the sample size was 100 mothers of 0-1 year olds coming for routine immunization at the time of the study. Data was analyzed using descriptive statistics, the McNemar’s test and ANCOVA. The major results of the study were that: the total mean rate of uptake for the scheduled visits for the three antigens by the experimental groups pre-intervention was 1.50+0.71 and 2.74+0.44 post-intervention and for the control groups pre-intervention, it was 1.74+0.53 and 1.98+0.62 post intervention; there was a significant  difference between the pre and post-intervention uptake of the experimental groups; there was no statistically significant difference between the rate of uptake of majority of the antigens by the control groups in the pre- and post-invention periods; there was a significant difference in the rates of uptake between the experimental and control groups; there was no significant difference between the uptake of the experimental groups in the rural and urban locations; there were no significant difference between the rate of uptake of the experimental and control groups in the rural and urban locations. Recommendations were that effective current communication strategies like telephone calls used to remind and recall mothers to ensure improvement in uptake of routine immunization services in both rural and urban locations.

CHAPTER ONE

INTRODUCTION

Background to the Study

The need to use immunization reminders and recalls for mothers to ensure continued uptake of routine immunization of their infants cannot be over-emphasized. It has been found that immunization reminder and recall system is one of the effective ways of improving immunization uptake rates (Brown, Oluwatosin&Ogundeji, 2015). Immunization has been defined by the Centre for Disease Control (CDC, 2014) as “an act of introducing a vaccine into the body through vaccination to produce immunity to a specific disease. Schuchat& Bell (2008) posited that immunization is aimed at producing immunity to specific diseases and improving control of vaccine preventable communicable diseases thereby preventing their spread. Immunization can also be defined as the use of vaccines through immunization programmes to enable the body to develop immunity so as to resist vaccine-preventable infections and prevent their spread.

There are various types of immunization. These have been identified by Hamm (2015) as including adult immunization, travel immunization, influenza immunization and routine childhood immunization. Routine childhood immunization according to UNICEF (2015) is one of the most cost-effective public health interventions to date against vaccine-preventable diseases (VPDs) as it averts about 2-3 million deaths and disability of children each year. Castillo (2013) also stated that approximately 29 per cent of deaths of under-5 children are preventable through routine immunization. The vaccine-preventable diseases targeted by routine immunization according to Antai (2012), include infantile tuberculosis, diphtheria, pertussis (whooping cough), poliomyelitis, pneumococcal diseases, rotavirus, vitamin A deficiency, measles, yellow fever and cerebro-spinal meningitis.

 However, Offit (2014) observed that approximately 1.5 million children still die each year from vaccine-preventable diseases. Also CDC (2013) hinted that polio is still paralyzing children in several African countries and that more than 350,000 cases of measles were reported from around the world in 2011.  Balogun, Sekoni, Okafor, Odukoya et al (2012) observed that about 22 per cent of under-five mortality is still caused by vaccine-preventable diseases in Nigeria even close to the end of the 2015 deadline set aside for the achievement of the fourth Millennium Development Goals (MDGs).The possible reasons for the continued prevalence of VPDs as observed by Gilbert (2012) could be that some vaccines used for immunization are less effective and some communicable diseases are unlikely to be controlled by immunization because of pathogen, host or population characteristics. He also observed that some parents could be complacent and this may culminate in low uptake of immunization by them.

The aim of using vaccination routine immunization to avert VPDs may be difficult to achieve if mothers are complacent about their children’s immunization or they do not present their children for immunization which may make their uptake of routine immunization services low. For instance, UNICEF (2013) observed that out of five infants worldwide, nearly 20 per cent still do not receive the three life-saving doses of diphtheria, tetanus and pertussis vaccine due to lack of adequate uptake of vaccines by mothers for their children and this could make the unreached children defenseless against these killer vaccine-preventable diseases. Also, the World Health Organization (WHO, 2015) observed that in 2013, an estimated 21.8 million infants worldwide did not complete their routine immunizations and 21.6million children in the same age group had not been presented to receive the single dose of measles-containing vaccine due to low uptake of immunization services by mothers. UNICEF (2013) stated that one out of every five infants worldwide still did not receive their complete recommended routine immunization doses in a series. Referring to Taraba State, Ophori (2011) observed that their OPV3 uptake rate was the lowest in the country in 2010 (18.75 per cent). This was collaborated by the yearly routine immunization report for the past four (4) years which revealed that majority of the children (87.5 per cent) who started the immunization schedule did not finish them as shown by the high drop-out rates and that majority of the LGAs performed poorly with regards to uptake of immunization services by mothers. This study conceptualizes a poorly-performing LGA as one that their immunization uptake is below 80 per cent.

Uptake of immunization as defined by Oladimeji, Adeyinka and Aimakhu (2008) is “the percentage of the target population that has been vaccinated according to the recommended immunization schedule. It is synonymous with coverage level and level of use of a vaccine by a proportion of the target population in an immunization programme. Referring to the pentavalent vaccine as an example of immunization uptake, Antai (2009) said that uptake would be the percentage of children in the target population who receive the first dose (penta 1) and those who continue to receive up to the third dose (penta 3) in a series. According to him, this is particularly useful as it shows continuity of use. Immunization programs are usually instituted in such ways as to encourage and ensure a continuous uptake of the relevant recommended vaccines. For instance, the World Health Organization (WHO) had initiated and advised the adoption of immunization schedules an aim of ensuring continuous vaccine uptake rates and reduce the impact of vaccine-preventable diseases (Antai, 2009).The routine immunization schedule in Nigeria according to the National Primary Health Care Development Agency – NPHCDA (2014) requires that a mother visits an immunization clinic seven (7) consecutive times and at various intervals of time for her child to be fully immunized. The WHO (2014) stated that following the immunization schedule,  a child under one year should receive BacilleCalmette Guerin (BCG), oral polio vaccine(OPV0) and Hepatitis (Hep0) at birth or within 2 weeks of delivery, OPV1 and Pentavalent 1(penta 1) at 6 weeks, OPV2 and Penta 2 at 10 weeks, OPV3 and Penta 3 at 14 weeks, Vitamin A (first dose) at 6months,  Measles(first dose), Yellow fever and Conjugate A Cerebro- Spinal Meningitis (CSM) vaccines at 9 months and Measles 2 and Vitamin A (2^nd dose) at 12 months. As there are recommended scheduled intervals for routine immunization vaccines to be given, Offit (2014) suggested that to maintain reductions in morbidity and mortality from VPDs, there may be a need to consider the timing and spacing of vaccine doses according to the schedule to ensure continued and appropriate uptake of vaccines. This is because according to him, the right dose of vaccines given at the right interval through the right route generates the optimal immune response. Brown, Oluwatosin and Ogundeji (2015) also added that children could be exposed to the risk of VPDs if they received their routine immunizations untimely or if the schedule is not followed to ensure maximal uptake. 

Routine immunization uptake in Nigeria is far from optimal and not equitable (Antai, 2009). According to him, it could be the reason why Nigeria still accounts for half of the deaths from measles in Africa and has the highest prevalence of circulating wild polio virus (WPV) in the world. Ophori, Tula, Azih, Okojie and Ikpo (2014) added that Nigeria has witnessed gradual but consistent reduction in immunization coverage and is among the ten countries in the world that has an immunization uptake rate below the internationally recommended 80 per cent. Dube, Laberge, Guay, Bramadat et al (2013) added that lack of proper uptake of immunization could pose a threat to herd immunity thereby creating room for vaccine-preventable diseases to persist in or return to communities that have inadequate immunization uptake rates. Continued immunization uptake during childhood has been observed by Harvey, Reissland and Mason (2013) to be reliant on mothers’/parental decision-making and subsequent regular attendance to vaccination clinics. Failure to keep to routine immunization schedules or not continuing to attend immunization appointments by mothers has been observed byBalogun, Sekoni, Okafor, Odukoya, Ezeiru, Ogunnowo and Campbell (2012) to have remained a challenge for uptake of RIS globally as their children may be partially immunized or not immunized. For instance, Abdulraheem, Onajole, Jimoh and Oladipo (2011) observed that 62.8 percent of children in Nigeria were not fully immunized and that 33.4 per cent had missed immunization opportunities while36.4 per cent were partially or incorrectly immunized because of problems of uptake. Also, Henry, Bairagi, Finley, Helleringer and Dahir (2011) posited that only about 5.1 percent of all children in Nigeria had received the three recommended doses of polio and many missed the third dose of the pentavalent vaccines probably because they were not presented for their scheduled routine immunizations at the right times by their mothers. These mothers could lack information and ignorant about the right timing and schedules for immunization of their children or they may be complacent and may forget their children’s immunization schedules and may need to be communicated about their children’s scheduled immunization dates. For instance, Abdulraheen et al (2011) found that 2.5 per cent of mothers whose children had partial or incomplete immunization lacked information of the immunization days and they suggested that there is a need to explore effective information strategies that will help ensure that eligible children receive all the needed and recommended vaccines at the appropriate times so as to become fully immunized and to improve the routine immunization uptake rates.

Since previous studies have linked problems of immunization uptake to problems with communication and information to mothers about immunization, Esamgbedo (2012) therefore suggested that it may be necessary to utilize existing information technology and communication (ICT) tools to communicate and relay information especially about immunization appointments to mothers as they could have some efficacy with regards to their immunization uptake rates. Palavuzlar (2011) defined efficacy as the ability of something, e.g. a medicine to produce the intended or desired results. This means that it is the event which follows immediately after an antecedent or cause and could be referred to as the result or consequence or outcome. He also posited that it is synonymous with effectiveness. Williams, Woodward, Majeed and Saxena (2011) posited that communicating with mothers and caregivers about immunization of their children may be effective in improving immunization uptake rates.

Previous studies have also shown that communicating with mothers through reminder systems could have a strong positive effect on demand for immunizations. NaikandJarosz, (2015)found that adopting improvement strategies like the reminder and recall systems especially for preventive care like routine immunization was effective in provision of systematic care and in reduction of missed appointments. Harvey, Reissland and Mason (2015) therefore suggested that since continued uptake of immunization relied on parental or caregivers’ decisions-making for continued attendance at immunization clinics, it could be necessary to adopt improvement strategies targeted at parents like the reminders and recalls.

Litt (2015) defines reminders and recalls as messages to patients or their caregivers stating that recommended immunizations are due soon (reminders) or past due (recall).  Reminders and recalls may be necessary for parental/mothers decision-making about attendance to immunization appointments. This is because they may have some efficacy in improving their uptake of immunization. The efficacy of reminders and recalls in the context of this study refers to the power or ability of reminders and recalls to produce desired consequences, results or outcome of improving the uptake of routine immunization services by the mothers that will be used for this study. For instance, Balogun et al (2012) found that the use of innovative approaches through use of new information technologies like mobile phone reminders helped to reach to 20 per cent of the children that were previously being missed for routine immunization services (RIS). Also, Tieney, Yusuf, McMahon, Rusinak, Brien, Massondi and Lieu (2013) found that reminders and recalls information sent by telephone were effective in increasing full child immunization rates and improving uptake of RIS. Brown, Oluwatosin and Ogundeji (2015) also found that the use of mobile phone technology to remind and recall mothers for their children’s immunization dates aided their compliance with and adherence to immunization guidelines. For this study, the efficacy of mobile telephone call reminders and recalls for mothers in terms of improvement in uptake will be interpreted as increase in the proportions of the children of these mothers that were immunized at 6 weeks , at 10 weeks and at14 weeks with penta 1, penta 2 penta 3 and polio 1, polio 2,  polio 3  compared with their pre-intervention  measure or cut –off mark that will be elicited from the immunization registers when they immunized their last child for the series of the pentavalent and polio vaccines. The choice of intending to use mobile telephone calls as reminders and recalls is that although Nigeria is a developing country, the use of mobile phone technology is high. Brown, Oluwatosin and Ogundeji (2015) observed that almost everybody both in the urban and rural areas use mobile phones to communicate information and important messages. This study will be experimental in nature and the mothers who come for uptake of routine immunization services for their children in both the urban and rural settings will be used as subjects.  Since previous studies have found that RIS uptake is low in Nigeria and have recommended improvement of the immunization uptake in Nigeria using communication strategies like reminder and recall systems, identifying the effects or eff