SUDANESE JOURNAL OF PAEDIATRICS
2020; Vol 20, Issue No. 2
Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan
Almigdad Hayder Mohammed Ali (1), Mohamed Ahmed Abdullah (1), Fadwa Mohammed Saad (2), Haidar Abu Ahmed Mohamed (2)
(1) Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
(2) Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
Almigdad Hayder Mohammed Ali
Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan.
Email: Almigdad.h.m [at] gmail.com
Received: 14 April 2020 | Accepted: 26 April 2020
How to cite this article:
Ali AHM, Abdullah MA, Saad FM, Mohamed HA. Immunisation of children under five years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudan J Paediatr. 2020;20(2):152–162.
© 2020 SUDANESE JOURNAL OF PAEDIATRICS
Mothers are the major role players with regard to their children’s immunisation. The aim of this study is to assess the knowledge, attitude and practice of mothers of children below 5 years of age with regard to immunisation in Northern State, Sudan. This was a cross-sectional survey which was conducted in three villages in 2016. All mothers having at least one child below the age of 5 years were included. Data were collected by interviews using a self-structured questionnaire. Descriptive statistics were displayed and chi-square test was used to assess associations. A total of 127 mothers of 191 children were included. The mean knowledge score about the names of vaccines/diseases prevented was 3.47 out of 10. The most correctly named vaccines by the mothers were measles (87.4%) and polio (86.6%), whereas the least ones were hepatitis (7.1%) and diphtheria (8.7%). The majority (99.2%) of the mothers had a positive attitude. The mean knowledge score about the timing of doses was 4.12 out of 5. The most correctly timed dose by the mothers was the dose at 6 weeks ‘dose 1’ (96.1%) and the least one was the dose at birth ‘dose 0’ (60.6%). About half (48.7%) of the children were completely immunised, 46% were only missing their ‘dose 0’, mostly because of closed vaccination units on the day of birth (73.6%), and 5.3% were incompletely immunised. Hospital delivery, availability of vaccination card and good socioeconomic status were associated with complete immunisation status, with p-values equal to 0.00, 0.00 and 0.03, respectively. Educating mothers about immunisation, increasing the days of immunisation and providing outreach services for home-delivered newborns are important interventions to increase the immunisation coverage.
Children; Under 5 years; Immunisation; Mothers; Sudan.
Immunisation is one of the most cost-effective health investments worldwide . The World Health Organisation (WHO) launched the expanded programme on immunisation (EPI) in 1974 with the aim of immunising children throughout the world. The programme uses proven strategies, like outreach services, to ensure delivery of vaccines even to the most hard-to-reach and vulnerable populations. The worldwide implementation of this programme has resulted in more than 100 million infants being immunised each year, saving 2–3 million lives annually .
In Sudan, the EPI was established in 1976 in few states, but eventually expanded geographically to cover the whole country. Currently, through collaboration between the Sudanese Federal Ministry of Health, the WHO, the United Nations Children’s Fund and the Global Alliance for Vaccines and Immunisation (GAVI), the programme is considered as one of the leading immunisation programmes in Africa .
Since 2001, under GAVI’s support, Sudan has been introducing additional vaccines to its immunisation schedule, including hepatitis B (HepB), Haemophilus influenzae type b (Hib) and pneumococcal vaccine, and was the first GAVI-eligible country in Africa to introduce rotavirus vaccine and meningococcal vaccine (MenAfriVac), in 2011 and 2016, respectively [4–6]. Currently, the programme offers seven routine vaccines: Bacillus Calmette Guerin (BCG), oral polio vaccine (OPV), pentavalent vaccine (DTP/HepB/HiB), rotavirus vaccine, pneumococcal vaccine (PCV), measles vaccine and meningococcal vaccine. These vaccines are administered in five doses from the day of birth to the age of 9 months (Annex 1). The programme implements global initiatives such as the eradication of poliomyelitis, and elimination of measles and neonatal tetanus . All EPI services in Sudan are provided for free.
In addition to its accomplishments and on-going improvements, EPI faces a lot of operational and social challenges. Many developing countries have inadequate cold chains—meaning the optimal temperature control for the transport, storage and handling of vaccines—or they are not able to manage vaccine stocks effectively, leading to insufficient vaccine supply to immunise all children . Remote locations and weak health services are also adding to the problem. In a study in Nyala locality in Southern Darfur State, Sudan, children from urban areas were more likely to complete their immunisation schedule than those from rural areas . Maternal factors, as mothers are considered to be the primary care givers of their children, have also been elaborated in many studies. Illiteracy, poverty and other sociodemographic factors affect their knowledge, attitude and practice with regard to their children’s immunisation. This was shown in two studies conducted in Sudan, in Khartoum State and in River Nile State, which reported that children of highly educated mothers were more likely to be correctly vaccinated than the children of illiterate mothers [9,10].
The aforementioned operational and social challenges are both present in Northern State. Being the largest state in Sudan, with 36% of its population living below poverty line and 83% living in rural areas , this state represents a suitable area to study these factors.
The aim of this study is to assess mothers’ knowledge, attitude and practice regarding their children’s immunisations and to identify the factors associated with non-immunisation in one of the localities in Dongola area, Northern State, Sudan.
MATERIALS AND METHODS
Study design and setting
This was a cross-sectional, community-based study conducted in Northern State, Sudan. Three villages in the Dongola province were randomly selected, which were Alseir, Hamid Narti and Altoraa. The total coverage of mothers having at least one child below 5 years of age who were residing in one of the three villages was done, and a total 127 mothers of 191 children were included.
Data collection, scoring, data entry and analysis
The data were collected by interviews using a self-structured questionnaire. Data on immunisation status were verified from the vaccination card, when available.
A 21-item questionnaire was developed after surveying the available literature. These questions were selected and modified to suit the Sudanese context and vaccination schedule. The questionnaire contained four sections: sociodemographic and background variables (9 items), knowledge (5 items), attitude (4 items) and practice (3 items). The attitude section involved the mothers’ opinion on safety and importance of immunisation, whether they are responsible for immunising their children and whether they recommend the children’s immunisation to fellow mothers. The practice section involved the immunisation status of the child and causes of incomplete immunisation.
Four scores were developed: socioeconomic status (SES), knowledge about the names of the vaccines/disease prevented, knowledge about the timing of vaccination doses and attitude. Each response was given a certain number depending on the number of responses. The total for each of the four scores was calculated separately and then classified into categories after identifying the suitable cut-off points (Annex 2).
The data were entered and analysed using the Statistical Package for Social Sciences ver22. Descriptive statistics in the form of frequencies, percentages and tables were displayed. The chi-squared test was used to assess associations between categorical variables. A p-value less than 0.05 at a confidence level of 95% was considered to be significant.
A total of 127 mothers of 191 children were included. Most of them (59.1%) were in the age group of 25–34 years and 50.4% had a low SES (Table 1).
Knowledge about the names of vaccines/diseases prevented
The most correctly named vaccines (Figure 1) were measles (87.4%) and polio (86.6%), whereas the least correctly named were hepatitis (7.1%) and diphtheria (8.7%). The mean knowledge score about the names of vaccines/diseases prevented was 3.5 (SD = 1.5, minimum 0 and maximum 9). All mothers (100%) thought that vaccines will protect their children from the diseases.
Knowledge of mothers of children about the timing of doses
The mean knowledge score about the timing of doses (Figure 2) was 4.1 ± 1.2 (minimum 0 and maximum 5). The most correctly named dose timing was the timing of ‘dose 1’ (96.1%), whereas the least one was that of ‘dose 0’ (60.6%).
Regarding mothers’ sources of information about children’s immunisation (Figure 3), the main source of information was the healthcare worker (57.9%), followed by older family members (10.3%) and media (9.5%).
Of all the sociodemographic and background variables, only the age of older mothers was found to be associated with better knowledge about the names of vaccines/diseases prevented (p = 0.03).
Attitude of mothers towards immunisation
An overwhelming majority (99.2%) of the mothers had a positive attitude, and 98.4% of the mothers reported that they will recommend immunisation for others. All (100%) of them said they are totally responsible for immunisation of their children, 98.4% thought that immunisation is important and 99.2% thought it was safe for their children.
Practice of mothers regarding immunisation
From a total of 191 children, 48.7% were fully immunised since birth, 46% were only missing ‘dose 0’ and 5.3% were incompletely immunised. Data on children’s immunisation status, place of delivery and availability of vaccination card are summarised in Table 2. Data were missing for one participant regarding the availability of the vaccination card, eight for place of delivery and two for vaccination status.
With regard to the place of vaccination, 83.5% of mothers immunised their children in the hospital, 7.1% in the health centre, whereas 8.7% were mixed: sometimes in hospital and other times in the health centre. A few (0.8%) had their children vaccinated at home by a healthcare worker only for ‘dose 0’, while the following doses were administered in the hospital. Closed vaccination unit at date of birth was the most common cause for not being fully immunised (73.6%; Figure 4).
Table 1. Sociodemographic and background characteristics of mothers of children below 5 years in Northern State, Sudan (n = 127).
Figure 1. Knowledge of mothers of children below 5 years about the names of vaccines/diseases prevented (n = 127). BCG = Bacillus Calmette Guerin; OPV = oral polio vaccine; PCV = pneumococcal vaccine (PCV).
Figure 2. Knowledge of mothers of children below 5 years about timing of immunisation doses (n = 127)
Figure 3. Mothers’ main source of information about immunisation of their children below 5 years of age (n = 127).
When the mothers were asked about their satisfaction regarding the information given by the vaccinator about diseases prevented by the vaccines, vaccination doses, side effects of the vaccines and importance of vaccination card, 58.9% of them were totally satisfied, 16.9% were satisfied, 10.5% were somewhat satisfied and 13.7% were not satisfied at all.
Table 2. Availability of vaccination card, place of delivery and immunisation status of the children below 5 years (n = 191).
Figure 4. Causes of incomplete immunisation for children below 5 years (n = 95).
FACTORS AFFECTING THE IMMUNISATION OF THE CHILDREN BELOW 5 YEARS
Mother’s better socioeconomic status (p value = 0.03) and availability of the vaccination card (p value = 0.00) were associated with the complete immunisation status of the child. Mothers who delivered in a health facility were more likely to immunise their children than those who delivered at home (p value = 0.00). None of the mothers (0%) who had delivered at home had her first child fully vaccinated since birth. Other factors studied were not associated with the immunisation status of the children. All the studied factors with their corresponding p values are summarised in Table 3.
This study included 127 mothers of 191 children below 5 years of age. Mothers were found to have good knowledge about the timing of doses but poor knowledge about the names of the vaccines/prevented diseases. This may be attributed to the healthcare workers paying more attention to informing the mothers the time in which they are supposed to bring their children to immunisation and not necessarily educating them to know the names of the vaccines/prevented diseases. The most common prevented vaccines/diseases to be mentioned were measles (87.4%) and polio (86.6%). This may be attributed to the fact that measles vaccine is administered alone as the last dose of the Sudanese immunisation schedule, and the mother will be told that this is the first measles’ dose and she should bring her child back for the booster dose when the baby reaches 18 months of age. This result is consistent with that of a study conducted in Nigeria and another one in Ghana, where measles vaccine was the most common and the second most common vaccine to be mentioned, respectively [12,13]. Good knowledge about polio was also consistent with the results of a study conducted in India, which also showed good knowledge about polio but poor knowledge about other vaccine-preventable diseases .
Table 3. Significance of the studied factors affecting the immunisation status of children below 5 years (n = 191).
The least prevented vaccines/diseases to be mentioned were hepatitis (7.1%), diphtheria (8.7%) and meningitis (9.4%). The three vaccines are included in the pentavaccine (Annex 1), and the fact that they are under the umbrella of the name of pentavaccine could be the cause of the poor knowledge about them.
Although the knowledge about the timing of doses was good, the timing of ‘dose 0’ was only mentioned by 60.6% of the mothers, making it the least dose to be mentioned. This may be due to two main findings in this study. The first is the percentage of mothers who deliver at home, which reached 9.8% of mothers. Once they deliver their child, they do not get out of their houses until they complete their puerperium period (about 40 days). So, by the time they show up to the vaccination unit, it will already be the timing of ‘dose 1’. The second finding is that vaccination units open only 2 days a week. So, even children who are delivered at the health facility (90.2%) will miss ‘dose 0’ if they were delivered on a day other than Sunday or Wednesday because the mother will be discharged home and will not return until she completes the puerperium period.
The main source of information about vaccinations was the healthcare worker. This was also the case in a study from India, which showed that the paramedics were the main source of information for immunised children and community leaders for unimmunised children . Although being the main source of information, many mothers reported that the healthcare workers only give information about the side effects of the injection (e.g., pain, redness and swelling on the site of the injection), how to deal with these side effects (e.g., applying ice bags) and the timing of the next dose, rather than giving a proper health education covering the importance, diseases prevented and possible side effects of the vaccine itself. Therefore, they concentrate more on the practice of these mothers rather than concentrating on their knowledge. The problem in this approach is that it leaves them vulnerable to misbeliefs. In fact, this was the case in some of these mothers. One of these mothers – who had a negative attitude towards immunisation – reported that vaccines cause tympanic membrane rupture and impotence in males, and reduce modesty in females. Another one said that the vaccination programme is a foreign project that aims at causing harm to Sudanese children in the future. Both of them had these misbeliefs from members of their community. Surprisingly, the misbelief of vaccines being a cause of impotence was also recorded by Gidado et al. , where 14% of mothers believed that immunisation can cause infertility later in the life of children. Further adding to these misbeliefs, few mothers argued that vaccines are not important because their parents were not vaccinated and they are quiet well now, so there is no need for them to get their children vaccinated. These cases show that neglecting proper health education that covers all aspects of vaccination will open the doors for misbeliefs that will later affect the attitude and practice of these mothers towards immunisation of their children. This can be overcome not only by improving health education through healthcare providers, but also through incorporating immunisation-related educational materials in the school curriculum of current students who are going to be parents in the near future.
Effective communication is particularly needed to achieve vaccination coverage in hard-to-reach populations and to build trust in vaccines among those who question them. The quality of the interaction between healthcare workers and caregivers is decisive to ensure completion of the vaccination schedule. The use of different types of media (e.g., television and radio) in immunisation campaigns and collaboration with influential community leaders can positively increase immunisation coverage in both rural and urban areas. On the other hand, poor or inadequate information-sharing by healthcare providers results in high dropout rates and caregivers’ negative attitudes towards immunisation services .
Home delivery and the opening of vaccination units for only 2 days a week affected the immunisation status of the children. The percentage of children who were fully vaccinated since birth was only 48.7%, keeping in mind that a considerable number of these fully immunised children achieved this required immunisation status because they were delivered in the hospitals located in the city of Dongola (the capital of Northern State), which has open vaccination units all days throughout the week. Children who were only missing ‘dose 0’ were 46%. According to healthcare workers, the missed ‘dose 0’ of these children was usually compensated by adding the BCG vaccine to ‘dose 1’ and giving only three doses of OPV instead of the four scheduled OPV doses. This reflects a major defect in ‘dose 0’. However, simple interventions, like increasing vaccination days and developing outreach immunisation services for home-delivered newborns, will solve the issue of ‘dose 0’ for both hospital and home-delivered children. These interventions can increase the percentage of completely immunised children to around 90% (by adding the 46% who are only missing ‘dose 0’ to the 48.7% who are already fully immunised). This will also decrease the load on Alseir hospital and the two other health centres on vaccination days and, hence, will give the healthcare workers a good opportunity to provide proper health education about immunisation to these mothers. Such interventions were previously proven to be effective in other developing countries. In Pakistan, a simple educational intervention designed for low-literate populations improved DPT-3/HepB vaccine completion rates by 39% . Also, in Ghana, a home-visiting strategy in a town resulted in a rise in coverage from 38% to 91% .
Certain factors were found to be associated with the good immunisation status of those children. These factors were delivery in a health facility, available vaccination card and mother’s good socioeconomic status. Similar results were found in other studies conducted at the local, regional and international levels. In Ethiopia, good immunisation status was significantly associated with delivery in a health facility . Another study from Bangladesh linked poor immunisation status with low socioeconomic status .
In Sudan, same results regarding the effect of mother’s education—an important determinant of the socioeconomic status—were found in previous studies. In Shendi and Almatamma localities, educated mothers were more likely to have their children immunised than mothers who had no education . Also, in Khartoum, mothers with intermediate, secondary, university and higher education were 1.99 times more likely to report correct vaccination of their children than those with no schooling or with primary schooling .
The findings of this study suggest that increasing vaccination days in vaccination units and providing outreach immunisation services for home-delivered newborns are two important interventions to be considered. They will increase immunisation coverage for both hospital and home-delivered children. Training healthcare workers on delivering a high-quality health education for mothers is also an important intervention that will help clarify and combat the wrong beliefs and taboos surrounding immunisation in Sudan, which in turn will increase mothers’ compliance and, hence, immunisation coverage.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest.
Ethical approval was obtained from the Department of Community Medicine, Faculty of Medicine, University of Khartoum. Informed consent was obtained from all the participants in this study.
Annex 1. Sudanese immunisation schedule as of 2016, showing timing of doses of each vaccine [BCG vaccine, OPV, Pentavaccine [DTP/HepB/Hib] rotavirus vaccine, PCV, measles vaccine and meningococcal vaccine].
Annex 2. Method of scoring.
Socioeconomic status scoring: The socioeconomic status was assessed by using three variables: mother’s educational level, mother’s occupation and family income per month. Each response was given a score from 1 to 4 and the total score was calculated for each questionnaire. A total score of 3–5 was considered as low SES, 6–7 as middle SES and 8–10 as high SES.
Mothers’ knowledge scoring: Two knowledge scores were developed: one for knowledge about the names of the vaccines/disease prevented and the other was for knowledge about the timings of vaccination doses. The score of the knowledge about names of vaccines/disease prevented ranged from 0 to 10. The participant can name either the name of the vaccine (e.g., BCG) or the disease prevented by the vaccine (e.g., tuberculosis). If the participant names pentavaccine, she will be asked to name the diseases prevented by it. The participant will score 10 if she names the 10 vaccines/disease prevented in the Sudanese immunisation schedule (Annex 1). Meningococcal vaccine was not included, as this research was conducted before the vaccine was introduced into the Sudanese immunisation schedule.
The score of knowledge about timing of doses ranged from 0 to 5. The participant will score 5 if she names the five timings of the vaccination doses in the Sudanese immunisation schedule (Annex 1). Timing of the booster dose of measles (at 18 months of age) was excluded from this scoring.
Both scores were further categorised into three categories for further analyses and presentation. Regarding the score of vaccines’ names, 0–3 was categorised as poor, 4–6 as moderate and 7–10 as good, whereas in the score of timings of doses, 0–1 was categorised as low, 2–3 as moderate and 4–5 as good.
Attitude of mothers towards immunisation: Four elements were studied to determine the attitude of mothers towards immunisation. The score ranged from 0 to 4. The participants who scored 0–2 were categorised as having a negative attitude and those who scored 3–4 were categorised as having a positive attitude.
|How to Cite this Article|
Ali AHM, Abdullah MA, Saad FM, Mohamed HAA. Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudan J Paed. 2020; 20(2): 152-162. doi:10.24911/SJP.106-1586870453
Ali AHM, Abdullah MA, Saad FM, Mohamed HAA. Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. http://www.sudanjp.com/?mno=99231 [Access: October 29, 2020]. doi:10.24911/SJP.106-1586870453
AMA (American Medical Association) Style
Ali AHM, Abdullah MA, Saad FM, Mohamed HAA. Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudan J Paed. 2020; 20(2): 152-162. doi:10.24911/SJP.106-1586870453
Ali AHM, Abdullah MA, Saad FM, Mohamed HAA. Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudan J Paed. (2020), [cited October 29, 2020]; 20(2): 152-162. doi:10.24911/SJP.106-1586870453
Ali, A. H. M., Abdullah, . M. A., Saad, . F. M. & Mohamed, . H. A. A. (2020) Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudan J Paed, 20 (2), 152-162. doi:10.24911/SJP.106-1586870453
Ali, Almigdad Hayder Mohammed, Mohamed Ahmed Abdullah, Fadwa Mohammed Saad, and Haider Abu Ahmed Mohamed. 2020. Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudanese Journal of Paediatrics, 20 (2), 152-162. doi:10.24911/SJP.106-1586870453
Ali, Almigdad Hayder Mohammed, Mohamed Ahmed Abdullah, Fadwa Mohammed Saad, and Haider Abu Ahmed Mohamed. "Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan." Sudanese Journal of Paediatrics 20 (2020), 152-162. doi:10.24911/SJP.106-1586870453
MLA (The Modern Language Association) Style
Ali, Almigdad Hayder Mohammed, Mohamed Ahmed Abdullah, Fadwa Mohammed Saad, and Haider Abu Ahmed Mohamed. "Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan." Sudanese Journal of Paediatrics 20.2 (2020), 152-162. Print. doi:10.24911/SJP.106-1586870453
APA (American Psychological Association) Style
Ali, A. H. M., Abdullah, . M. A., Saad, . F. M. & Mohamed, . H. A. A. (2020) Immunisation of children under 5 years: mothers’ knowledge, attitude and practice in Alseir locality, Northern State, Sudan. Sudanese Journal of Paediatrics, 20 (2), 152-162. doi:10.24911/SJP.106-1586870453