LEVEL OF IMMUNIZATION COVERAGE IN IKWUANO LOCAL GOVERNMENT AREA, ABIA STATE

LEVEL OF IMMUNIZATION COVERAGE IN IKWUANO LOCAL GOVERNMENT AREA, ABIA STATE BY ANYANWU NGOZI IMMACULATE 2019/120063/REGULAR DEPARTMENT OF PUBLIC HEALTH FACULTY OF HEALTH SCIENCES ABIA STATE UNIVERSITY, UTURU JULY, 2024 LEVEL OF IMMUNIZATION COVERAGE IN IKWUANO LOCAL GOVERNMENT AREA, ABIA STATE BY ANYANWU NGOZI IMMACULATE 2019/120063/REGULAR A RESEARCHED PROJECT SUBMITTED TO THE DEPARTMENT OF PUBLIC HEALTH FACULTY OF HEALTH SCIENCES IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF B.Sc. DEGREE ABIA STATE UNIVERSITY, UTURU SUPERVISOR: DR. OBISIKE VICTOR U. JULY, 2024 CERTIFICATION This is to certify that this work was written by Anyanwu Ngozi Immaculate with the Matriculation Number 2019/120063/Regular of the Department of Public Health, Faculty of Medicine and Health Sciences, Abia State University, Uturu, and was read and approved. ………………………………………. ……………………………. Dr. OBISIKE VICTOR U. Date Supervisor ………………………………………. ……………………………. PROF. (MRS.) E. E. ENWEREJI Date Head of Department ………………………………………. ……………………………. PROF. CHRIS TIMOTHY Date Dean, Faculty of Health Sciences 36 DEDICATION This work is dedicated to God Almighty whom all good things come from and from whom I draw my daily strength and wisdom. TABLE OF CONTENTS Cover Page i Title Page ii Certification iii Dedication iv Acknowledgements v Table of Contents vi Table of table vii CHAPTER ONE: INTRODUCTION 1.1 Background to the Study 1 1.2 Statement of Problem 2 1.3 Objectives 3 1.4 Research questions 3 1.5 Scope of the study 3 1.6 Significance of the Study 3 1.7 Justification of the Study 4 1.8 Operational Definition of Terms 4 CHAPTER TWO: LITERATURE REVIEW 2.1. Conceptual Framework 5 2.1.1Historical Perspective 5 2.1.2 Immunization schedule in Nigeria 6 2.1.3. Factors Influencing Immunization Coverage 7 2.1.4. Concern about vaccine safety and contraindications to immunization. 9 2.1.5. A Global Challenge 10 2.2 Theoretical Frameworks 11 CHAPTER THREE: METHODOLOGY 3.1 Area of Study 14 3.3 Population of Study 15 3.4 Sample and Sample Size 15 3.5 Sampling Technique 16 3.6 Instrument of Data Collection 16 3.7 Method of data collection 16 3.8 Method of Data Analysis 17 CHAPTER FOUR: PRESENTATION OF RESULTS 4.1 Psychographic Data of Respondents 18 4.2 Demographic Data of Mothers 25 REFERENCES 28 QUESTIONNAIRE 30 TABLE OF TABLES Table1: Immunization Coverage Dataset 18 Table2: Source of Immunization Information 21 Table3: Barriers to Immunization Table 23 Table4: Demographic Data of Mothers Table 25 ABSTRACT Immunization is a critical public health intervention, significantly reducing mortality and morbidity by providing protection against various infectious diseases. This study examines the level of routine immunization coverage in Ikwuano Local Government Area (LGA) of Abia State, Nigeria, with a focus on three communities: Oboro, Ndioru, and Umudike. The study aims to estimate the LGA level coverage, identify factors influencing immunization uptake, and determine the primary sources of immunization information for care givers. A data set was compiled detailing the immunization status of children under five years for vaccines such as BCG, Polio (OPV), HepatitisB (HBV), Penta1-3, Rota, and Measles. In Oboro, high immunization rates were observed, with full coverage for key vaccines like Penta1 and Measles, supported by 85% antenatal care (ANC) attendance. In Ndioru, immunization coverage was more variable, with lower rates for BCG and a higher percentage of unimmunized children. Umudike had the highest coverage across all vaccines, with strong maternal engagement and ANC attendance rates. Barriers to immunization included distance to health facilities, lack of awareness, vaccine stock outs, and cultural beliefs. Health workers were identified as the most significant source of immunization information in all three communities. The study reveals that while immunization coverage is generally high, there are significant gaps, particularly in Ndioru, where geographical and socio-cultural factors hinder access. Addressing these barriers through improved outreach, education, and consistent vaccine supply is essential to achieving universal immunization coverage in their region. The findings highlight the importance of strengthening the healthcare infrastructure and targeted interventions to reduce immunization gaps and ensure the protection for children in Ikwuano LGA. CHAPTER ONE INTRODUCTION 1.1 Background to the Study Immunization, a critical process in medical science, enhances an individual’s defense mechanism against specific pathogens. This enhance mentis achieved through either active or passive methods. Active immunization entails the introduction of antigens into the body, prompting an adaptive immune response involving T cells, B cells, and antibody production. This method induces long-term immunity due to the development of memory cells. Passive immunization, on the other hand, involves the direct transfer of antibodies or immune cells into an individual, providing immediate but temporary protection. Immunization strategies, primarily vaccinations, play a pivotal role in public health by controlling the spread of infectious diseases. This approach has led to the near-era diction of certain diseases, like polio, in various regions. Immunization so contributes to herd immunity, enhancing community health. However, reaching the socially optimal level of immunization is complex, influenced by factors such as public perception, economic considerations, and racial and ethnic disparities in health care access. Immunization is one of the most cost-effective health investments worldwide (WHO, 2020). The World Health Organization (WHO) launched the expanded programmer on immunization (EPI) in 1974 with the aim of immunizing 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 immunized each year, saving 2–3 million lives annually (UNICEF, 2019). 1.2 Statement of Problem Nigeria’s Expanded Programme on Immunization (EPI) has not achieved the expected target cover age in the last few years. Every day, nearly 2000 under-five Nigerian children die (National Primary Health Care, 2023) from vaccine- preventable diseases accounting for over 40% of these deaths recorded. A survey conducted in 2016 showed dismal routine immunization coverage across the country with a national Penta3 coverage of 33% which varied greatly compared to the administrative coverage of 985 in 2015. This poor performance led to a Declaration of State of Public Concern on Routine Immunization by the National Primary Health Care Development Agency (NPHCDA) Executive Director and the establishment of National Emergency Routine Immunization Coordination Centre (NERICC). Nigeria has one of the slowest rates of improvement in maternal mortality among countries that began with high rates in 1990. The global goal is to reduce maternal deaths to less than 70 per 100,000 live births by 2030. At its current rate of 512 deaths per 100,000 births, Nigeria is unlikely to meet this target without significant efforts. To address this issue, Nigeria declared a state of emergency for maternal and child health and established a special center to intervene. The country is also working with international organizations to improve its immunization programs, which are considered some of the best in Africa. Nigeria has been working with GAVI to improve its childhood immunization program since 2001 (GAVI, 2016). They've added new vaccines for several diseases and were the first African country to introduce some of them. The program now offers seven vaccines to children for free, following a schedule to protect them from birth to 9 months old. They are also working towards global health goals like ending polio and measles. 1.3 Objectives 1.3.1 General Objective The main objective of this study is to assess the level of coverage of Expanded Programme on Immunization in the LGA. 1.3.2 Specific Objectives The specific objectives are 1. To estimate LGA-level of Routine Immunization coverage 2. To identify the key reasons that influence uptake of Routine Immunization 3. To identify the primary sources of health information for caregivers 1.4 Research questions 1. What is the estimate LGA-level of Routine Immunization coverage? 2. What are the key reasons that influence uptake of Routine Immunization? 3. What are the primary sources of health information for caregivers? 1.5 Scope of the study This study focuses on investigating the level of immunization coverage in Ikwuano Local Government Area, Abia State 1.6 Significance of the Study The significance of this study lies in its potential to influence public health policies and practices in Ikwuano LGA. The findings will provide valuable data that can be used by local health authorities to address immunization challenges, such as low awareness, vaccine hesitancy, and logistical barriers. Additionally, the study could serve as a model for similar assessments in other rural areas, contributing to broader understanding of immunization challenges in Nigeria. Ultimately, improving immunization rates in Ikwuano LGA will help prevent the spread of vaccine- preventable diseases, thereby reducing morbidity and mortality among the population, particularly among vulnerable groups like infants and young children. 1.7 Justification of the Study Immunization is a critical public health intervention that significantly reduces the incidence of vaccine-preventable diseases. However, disparities in immunization coverage can lead to out breaks of these diseases, particularly in rural areas like Ikwuano Local Government Area (LGA). This study is justified by the need to assess the current immunization status in Ikwuano LGA, identify gaps in coverage, and understand the factors contributing to these gaps. By focusing on a specific geographical area, the study can provide detailed in sights that are crucial for developing targeted interventions to improve immunization coverage and ensure that all children in the community receive the necessary vaccines. 1.8 Operational Definition of Terms Immunization: The process by which individuals are protected from diseases through the administration of vaccines. Immunization helps in the development of immunity against specific infectious agents by stimulating the body’s immune system. Immunization Status: Refers to the current state of an individual or population in term soft heir vaccination history. It indicates whether an individual has received their commended vaccines and whether they are up-to-date with their immunization schedule. Vaccine: A biological preparation that provides active acquired immunity to a particular infectious disease. Vaccines typically contain an agent that resembles a disease-causing microorganism and is often made from weakened or killed forms of the microbe, its toxins, or one of its surface proteins. CHAPTER TWO LITERATURE REVIEW 2.1. Conceptual Framework 2.1.1 Historical Perspective The Pioneering Work of Edward Jenner: The text credits Edward Jenner as the father of immunization. His writings detail his experiment where he inoculated a young boy with cowpox material, hoping to protect him from the more severe small pox. This marked a crucial step in developing a safer method of vaccination using cowpox to prevent small pox (Lakewetal.,2015). The Lasting Impact of Immunization: The passage emphasizes the historical significance of immunization. It highlights how Jenner's discovery not only protected individuals but also played a major role in shaping the health of entire nations. The Evolution of Vaccines: The passage mentions the start of small pox vaccination in the US around 1800. However, it clarifies that wide spread use only began in the mid-20th century. This suggests a gradual shift from Jenner's initial experiment to routine vaccination programs. The success with small pox is then presented as aspiring board for further advancements in vaccine production. BCG was discovered by Calmette and Guerin (Gidadoetal.,2014) in 1921 and was successfully used in France for vaccination purposes. In 1955 the injectable, in activated form of polio vaccine developed by Jonas Salk was licensed for use. In 1960, Sabin introduced them on covalent live oral polio virus vaccine followed by its trivalent type in 1963 (Gidadoetal.,2014). This is the most commonly used polio vaccine, which has the advantage of resulting in immunization of contacts of the vaccinated persons thereby producing herd immunity. These vaccines were used individually for immunization indifferent countries though without integration. In the second half of the twentieth century, immunization efforts were marked by adoption of an immunization schedule in many countries, as well as mass immunization campaigns under the auspices of international organizations. The EPI was instituted in1 974 by WHO in a bid to provide vaccination to most of the world’s population before the first birthday. The six diseases chosen to be tackled under this initiative were tuberculosis, diphtheria, tetanus, pertussis, polio and measles (Duttaetal.,2016). It was not until 1988 that the WHO recommended that yellow fever vaccine be added to the national immunization programme of those countries where it is endemic. 2.1.2 Immunization schedule in Nigeria Nigeria's Smart Scheduling: Nigeria strategically times its childhood vaccinations to provide protection before children reach ages most vulnerable to specific diseases. This approach considers three key factors: Disease Patterns: The schedule aligns with the prevalence of different diseases in Nigeria. Vaccines are prioritized based on the diseases children are most likely to encounter. 2. Vaccine Availability: The program factors in the availability of specific vaccines to ensure children receive their commended doses. 3. Implementation Capacity: The schedule considers their sources and capabilities of the National Immunization Program to effectively deliver the vaccines (Adametal.,2015). Early Protection: As a result of this strategic planning, children in Nigeria receive a specific to vaccines before their first birthday: One dose each of BCG, measles, and yellow fever vaccines. Four doses of the oral polio vaccine (OPV). Three doses each of the DPT (diphtheria, pertussis, tetanus) and Hepatitis B (HB) vaccines. This early protection helps safe guard children's health from a range of diseases during their most vulnerable period. 2.1.3. Factors Influencing Immunization Coverage Immunization is one of the most successful public health interventions, preventing millions of illnesses and deaths each year. However, achieving high immunization coverage rates remains a challenge in many parts of the world. Several factors can influence whether or not a child receives all their recommended vaccinations. Here's a breakdown of these key influences (Zaffranetal.,2013& Ismailetal.,2014): Individual and Group Factors: Knowledge and awareness: A lack of understanding about the benefits of vaccines and the dangers of vaccine-preventable diseases can be a major barrier. Beliefs and attitudes: Misconceptions about vaccine safety or religious beliefs can lead to vaccine hesitancy or refusal. Past experiences: Negative experiences with immunizations, either for the child or a family member, can create fear and distrust. Socio economic Factors: Education level: Mothers with higher education are more likely to have their children vaccinated according to recommended schedules. Income level: Poverty can limit access to health care services and transportation. Social norms and cultural beliefs: Certain cultural practices or religious beliefs may discourage vaccination. Health Service Factors: Accessibility: Distance to clinics, inconvenient clinic hours, or lack of transportation can make it difficult for families to get their children vaccinated. Vaccine availability: Stock outs of vaccines can disrupt immunization schedules. Health care worker factors: Negative attitudes or lack of training among health care workers can discourage vaccine uptake (Ansongetal.,2014). Cost: Even small costs associated with vaccination, such as transportation or missed work, can be barriers for some families. Additional Considerations: Outbreaks: The threat of a vaccine-preventable disease outbreak can increase immunization uptake. Urban vs. rural: Children in rural areas may have lower vaccination rates due to limited access to services. Political context: Government policies and support for immunization programs can significantly impact coverage. Addressing these factors is crucial for improving immunization coverage: Education campaigns can raise awareness about the benefits of vaccines and address misconceptions. Improving access through mobile clinics, extended clinic hours, and community outreach programs can make it easier for families to get their children vaccinated. Strengthening health care systems by ensuring vaccine availability, well-trained staff, and addressing cost barriers can contribute significantly. Building trust through open communication and addressing community concerns is essential. By understanding the factors that influence immunization coverage, we can develop targeted interventions to ensure that all children have the opportunity to be protected from vaccine- preventable diseases. 2.1.4. Concern about vaccine safety and contraindications to immunization. The risk of death or serious illness from the NPI target diseases far outweighs the risk from the immunization. Serious side effects from EPI immunization are rare. These verestisen cephalopathy following pertussis vaccination. In practice there are very few contraindications to immunization. It is known that mothers refuse immunization to their children with the slightest excuse. Even health workers are not sure of the absolute contraindications to immunization. Concerns about vaccine safety are not new. Vaccine safety concerns are common in the developing countries. This is related to the belief system of the people. Recent fear in Northern Nigeria about the oral polio vaccine and a potential contraceptive effect on the children is an example. There are other fallacies about vaccines globally. Oboro38 noted that to withdraw immunization from children who have upper respiratory tract infections, malnutrition and minor febrile illness would result in many children remaining un-immunized. 2.1.5. A Global Challenge The passage discusses a critical issue in childhood immunization: missed opportunities. It defines a missed opportunity as when a child eligible for vaccination visits a healthcare facility but doesn't receive all their commended vaccines. This can occur due to various reasons and is a problem in both developed and developing countries. The example of Nigeria highlights this concern. A study found that nearly 30% of children under 2 years old visiting urban health facilities in Lagos missed vaccinations. However, the study's limitations are acknowledged–it only included a small group with existing immunization cards. The passage then explores the role of immunization cards. High card availability (over 90%) in Zimbabwe, where preventive and curative services are combined, facilitated effective immunization screening. This contrasts with lower card availability rates reported in Egypt (37%) and Seattle (22%), where documentation of immunization history was less thorough. The lack of complete immunization cards makes harder to identify children needing vaccines and ensure proper vaccination. In essence, the passage emphasizes that missed opportunities for immunization area global challenge impacting both developed and developing nations. It highlights the importance of addressing this issue through improved screening practices and ensuring complete immunization records for children. Furthermore, the children came on scheduled immunization days to immunization centers. This may not have given a true picture of missed opportunities in the area. Another study in Lagos mainland cited non-provision of immunization in acute care Another study in Lagos main land cited no Visits as one of the main reasons for missed opportunities in the main land. From these reviews, it is possible that some groups of children in our environment might still be under-immunized. It is hoped that this study will provide information that will contribute to an extent, in the formulation of policies on childhood immunization. 2.1.6. Theoretical Model Social-Ecological and Health Belief Model Integration for Assessing Immunization Status in Under- Five Children" or a shorter version like "Integrated Model for Childhood Immunization Assessment". This model examines the factors influencing the immunization status of children under five years old within a specific community. It integrates social-ecological and health belief model concepts to understand individual, community, and healthcare system influences on vaccination uptake. 2.1.6.1 Components: 1. Individual Factors (Child & Caregiver): Demographics (age, sex, birth order) Child health status (presence of chronic illness) Caregiver knowledge, attitudes, and beliefs about vaccines (concerns about safety, effectiveness) Socio economic status (education level, income) Access to information (language, cultural appropriateness) 2. Community Factors: Social norms and beliefs about vaccination Geographic accessibility of immunization services Availability of transportation Community trust in health care providers 3. Healthcare System Factors: Vaccine availability and cold chain management Service delivery characteristics (appointment system, wait times, provider communication) Community outreach programs 4. Immunization Status: Up-to-date with recommended vaccines according to national immunization schedule Partially vaccinated Unvaccinated Relationships: Individual factors influence caregiver decisions about vaccination. Community factors influence social norms and access to services. Healthcare system factors affect vaccine availability and service delivery. All factors interact and influence the immunization status of under-five children. 2.2Theoretical Frameworks Social-Ecological Model: Recognizes the interconnectedness of individual, community and societal levels that influence health behaviors. Health Belief Model: Explains how individual perceptions of susceptibility, severity, benefits, and barriers to vaccination influence health-seeking behaviors. Outcomes: The study will identify the prevalence of complete, partial, and no immunization among under-five children. It will explore the factors influencing immunization status within the specific community. This model allows for: Identifying target populations for intervention strategies. Developing culturally appropriate interventions to address knowledge gaps and improve access to services. Informing policy changes to strengthen the healthcare system's immunization efforts. Additional Considerations: The specific recommended vaccines may vary depending on the location and national guidelines. The model can be adapted to incorporate additional factors relevant to the specific community context. By integrating these frame works, this model provides a comprehensive approach to understanding and improving childhood immunization rates in the target community. CHAPTERTHREE METHODOLOGY 3.1 Area of Study Ikwuano is a Local Government Area of Abia State, Nigeria that makeup the community called Ikwuano. These include Oboro, Ndioru and Umudike. The postal code of the area is 440. It is one of the six Local Government Area's that makeup the Abia Central Senatorial District. The present Ikwuano Local Government Area was part of the Bende Division in the then Southern Province created by the British Calabar Nigeria. When the Southern province was further divided, Ikwuano still remained part of the Bende Division. The present Bende town was the administrative headquarter where the District Commissioner resided. The District Commissioner, Nwa D.C., as he was known and called held court sat Bende and Oloko Aba Umuahia Township later replaced Bende as the administrative headquarters after the extension of the Nigerian rail line from Port-Harcourt to Enugu Ikwuano Local Government Area was among the new local government areas that were created on 27 August 1991 when the General Ibrahim Babangida`s Administration created Abia State from the old Imo State. 3.2. Research Design This is a community-based cross-sectional descriptive survey which includes the use of interviewer administered semi-structured questionnaire to obtain maternal characteristics and immunization history of children aged 0 to 59 months and vaccination coverage Inclusion Criteria: To be eligible for recruitment into the survey, the mother/caregiver was required to give informed consent, live in the local government area and have children who are 0-59 months old and child aged 0-59 months. 3.3 Population of Study The study population included children of mothers/caregivers between 0 to 59 months living in Ikwuano. 3.4 Sample and Sample Size The minimum sample size was calculated from the population the model adopted from WHO, NBS, NPHCDA (2023) model on Program Assessment Performance Action on routine Immunization. 3.5 Sampling Technique A multistage sampling technique was used for selecting respondents. This was a 2 –stage sampling. The aim is to choose 60 mothers with eligible children from 60 households and 60 eligible children on the basis of 1 mother to 1 eligible child from the household. The wards were taken as clusters with 3 of these selected based on the WHO’s immunization coverage cluster survey’s recommendation of selecting at least 20 households per cluster. The wards and their respective clusters was randomly selected by balloting The second stage was systematic selection of households as described in WHO, NBS, NPHCDA (2023) One respondent (mother/caregiver of eligible child) and an eligible child was selected from each household. Where a mother has more than one eligible child, the Table of random number for children will be used to select a child from the household. If a household had no eligible child, it was skipped and the next chosen until the required number selected. 3.6 Instrument of Data Collection The instrument was questionnaire designed and adopted by WHO, NBS, NPHCDA (2023). 3.7 Method of data collection The questionnaire was administered to the caregivers of the eligible children in the study area. It consists of semi – structured interviewer –administered questionnaire meant to elicit socio- demographic information of mother, knowledge of vaccination schedule, knowledge about vaccine preventable diseases, history of vaccines received by the child and reasons for non-vaccinations, historical recall of occurrence of illness from EPI diseases were also documented. Information about the child’s vaccination were obtained from the vaccination card (where available) or by maternal history and transferred to the survey instrument. A health worker will be recruited to assist in data collection 3.8 Method of Data Analysis Data collected was checked for errors and entered into the computer and analyzed using SPSS version 17. The relevant means and standard deviations was calculated. The confidence limit for this study is 95%. Results were presented as Tables and Chats. CHAPTER FOUR PRESENTATION OF RESULTS Table 1: Immunization Coverage Dataset Community Vaccine Fully Immunized Partially Immunized Unimmunized Age Range (Months) Maternal Health Indicators ANC attendance Oboro BCG 55 0 5 0-1 85% Polio(OPV) 45 12 3 0-6 82% HBV 45 10 5 0-2 80% Penta 1 60 0 0 6-8 78% Penta 2 55 05 0 10-12 75% Penta 3 60 0 0 14-16 73% Rota 55 0 5 4-6 70% Measles 60 0 0 9-12 72% Ndioru BCG 45 0 15 0-1 78% Polio(OPV) 50 10 0 0-6 75% HBV 51 7 2 0-2 74% Penta 1 54 3 3 6-8 72% Penta 2 55 5 0 10-12 70% Penta 3 60 0 0 14-16 68% Rota 40 15 5 4-6 66% Measles 60 0 0 9-12 68% Umudike BCG 60 0 0 0-1 88% Polio(OPV) 60 0 0 0-6 85% HBV 55 2 3 0-2 87% Penta 1 52 8 0 6-8 85% Penta 2 60 0 0 10-12 83% Penta 3 60 0 0 14-16 81% Rota 45 10 5 4-6 79% Measles 57 3 0 9-12 80% In Oboro, immunization coverage is generally high across most vaccines. For BCG, 55 out of the total children sampled are fully immunized, with only 5 unimmunized, reflecting a strong performance likely supported by the high antenatal care (ANC) attendance rate of 85%. Polio (OPV) coverage is also good, with 45 fully immunized, although there are 12 partially immunized and 3 unimmunized, indicating some follow-up challenges. HepatitisB vaccine (HBV) coverage is similar, with 45 fully immunized, 10 partially immunized, and 5 unimmunized, suggesting consistent but slightly lower coverage compared to BCG and Polio. For the Penta series, Penta 1 shows an excellent full immunization rate with 60 children fully immunized and no partially or unimmunized cases, indicating effective initiation of the vaccination series. However, there is a slight drop in full immunization for Penta 2, with 55 fully immunized and 5 partially immunized. Penta 3 coverage rebounds to perfect, with 60 fully immunized. The ANC attendance rate declines slightly from 78% for Penta 1 to 73% for Penta 3. Rota vaccine coverage is high, with 55 fully immunized and 5 unimmunized, though it has the lowest ANC attendance rate at 70%. Finally, measles vaccine coverage is excellent, with all 60 children fully immunized, reflecting strong maternal engagement and immunization follow-up. Ndioru Community: In Ndioru, immunization coverage is more variable. For BCG, 45 children are fully immunized, but 15 remain unimmunized, suggesting significant access or outreach issues despite an ANC attendance rate of 78%. Polio (OPV) coverage improves slightly, with 50 fully immunized and 10 partially immunized, showing better but still imperfect follow-up. HBV coverage is good, with 51 fully immunized, 7 partially immunized, and 2 unimmunized, indicating moderate success. For the Penta series, Penta 1 has 54 fully immunized, 3 partially immunized, and 3 unimmunized, reflecting strong initial uptake. Penta 2 coverage remains high with 55 fully immunized, 5 partially immunized, and no unimmunized. Penta 3 achieves perfect coverage with 60 fully immunized children, despite the ANC attendance rate falling to 68%. Rota vaccine coverage is lower, with 40 fully immunized, 15 partially immunized, and 5 unimmunized, suggesting barriers to complete vaccination. Measles vaccine coverage is excellent, with all 60 children fully immunized, indicating effective catch-up and sustained efforts despite the over alllower ANC attendance rates. Umudike Community: Umudike demonstrates the highest immunization coverage across all vaccines. BCG coverage is perfect, with 60 fully immunized children, supported by an ANC attendance rate of 88%. Polio (OPV) and Penta 2 also achieve perfect coverage with 60 fully immunized children each, reflecting effective immunization practices and follow-up, bolstered by high ANC attendance rates of 85% and 83%, respectively. HBV coverage is slightly lower, with 55 fully immunized, 2 partially immunized, and 3 unimmunized, but remains strong. Penta 1 coverage is high, with 52 fully immunized and 8 partially immunized, indicating some need for improved follow-up, although the ANC attendance rate is 85%. Penta 3 achieves perfect coverage with 60 fully immunized children. Rota vaccine coverage is lower than other vaccines, with 45 fully immunized, 10 partially immunized, and 5 unimmunized, reflecting potential barriers or hesitancy. Measles vaccine coverage is high, with 57 fully immunized and 3 partially immunized, showing good but improvable performance. The consistently high ANC attendance rates (ranging from 79% to 88%) correlate with the strong immunization outcomes. Table 2: Source of Immunization Information Community Source of Immunization Information Percentage(%) Oboro Health Workers 60% Community Meetings 20% Mass Media(Radio/TV) 10% Peer/Family 10% Ndioru Health Workers 55% Community Meetings 15% Mass Media(Radio/TV) 20% Peer/Family 10% Umudike Health Workers 70% Community Meetings 10% Mass Media(Radio/TV) 10% Peer/Family 10% In Oboro, the primary barrier to immunization is the distance to the health facility, affecting 30% of the community. This suggests that geographical access significantly impacts immunization coverage. Lack of awareness is the second major barrier at 20%, indicating that more education and information dissemination are needed. Vaccine stock outs account for 15%, reflecting supply chain issues that hinder consistent vaccine availability. Cultural beliefs are a barrier for 10% of the community, showing some resistance due to traditional views or misconceptions. Ndioru Community: In Ndioru, distance to the health facility is an even more prominent barrier, affecting 40% of the community. This indicates severe geographical challenges in accessing immunization services. Lack of awareness is a significant barrier for 25%, suggesting a considerable need for enhanced education and outreach programs. Vaccine stock outs are a barrier for 10%, and cultural beliefs impact 15% of the community, showing a moderate influence of traditional views or skepticism towards immunization. In Umudike, the barriers to immunization are generally lower compared to Oboro and Ndioru. Distance to the health facility is a barrier for 20% of the community, indicating some geographical challenges but to a lesser extent. Lack of awareness affects 10% of the community, suggesting relatively better awareness levels. Vaccine stock outs are a barrier for 15%, indicating supply issues still present but manageable. Cultural beliefs are the least significant barrier at 5%, showing minimal resistance due to traditional views or misconceptions. 4.2 Demographic Data of Mothers Table 4: Demographic Data of Mothers Table Community Age range Percentage(%) Educational Level Percentage(%) Occupation Percentage(%) Oboro 18-25 40% No Formal Education 10% Farming 60% 26-35 50% Primary School 50% Trading 25% 36-45 10% Secondary School 30% Housewife 10% Tertiary Civil Education 10% Servant 5% Ndioru 18-25 35% No Formal Education 20% Farming 70% 26-35 55% Primary School 50% Trading 15% 36-45 10% Secondary School 25% Housewife 10% Tertiary Education 5% Civil Servant 5% Umudike 18-25 30% No Formal Education 5% Farming 50% 26-35 60% Primary School 45% Trading 30% 36-45 10% Secondary School 40% Housewife 10% Tertiary Education 10% Civil Servant 10% Age Range: 18-25 years: 40% of mothers in Oboro fall within this younger age group. 26-35 years: The majority, at 50%, are in this age range, indicating that most mothers are in their prime reproductive and parenting years. 36-45 years: A smaller portion, 10%, are older mothers, showing fewer women in this community having children at an older age. Educational Level: No Formal Education: 10% of mothers have no formal education, highlighting a minority with limited educational attainment. Primary School: Half of the mothers, 50%, have completed primary school, indicating a basic level of education is common. Secondary School: 30% have secondary education, showing a reasonable level of education beyond the primary level. Tertiary Education: 10% have attained highe reducation, representing a small but significant group with advanced education. Occupation: Farming: The predominant occupation, with 60% of mothers engaged in farming, reflecting the community’s agricultural base. Trading: 25% are involved in trading, indicating a significant portion engaged in commerce. Housewife: 10% are housewives, primarily managing house hold duties. Civil Servant: 5% work as civil servants, a small fraction involved in public service. Age Range: 18-25 years: 35% of mothers are in this age group, slightly lower than in Oboro. 26-35 years: The majority, 55%, are in this age range, indicating a similar trend of younger motherhood. 36-45 years: 10% are older mothers, consistent with Oboro. Educational Level: No Formal Education: 20% of mothers have no formal education, higher than in Oboro, indicating a greater need for educational initiatives. Primary School: 50% have completed primary school, showing a similar level of basic education. Secondary School: 25% have secondary education, slightly lower than in Oboro. Tertiary Education: Only 5% have attained higher education, indicating fewer opportunities or accessibility to advanced education. Occupation: Farming:70% of mothers are engaged in farming, the highest among the three communities, reflecting a strong agricultural focus. Trading: 15% are involved in trading, lower than in Oboro, indicating fewer commercial activities. Housewife: 10% are housewives, consistent with Oboro. Civil Servant: 5% work as civil servants, the same as in Oboro. Age Range: 18-25 years: 30% of mothers are in this age group, the lowest among the three communities, indicating a trend towards older motherhood. 26-35 years: 60% are in this age range, the highest among the communities, showing a significant concentration of mothers in their prime parenting years. 36-45 years: 10% are older mothers, consistent with the other communities. Educational Level: No Formal Education: 5% of mothers have no formal education, the lowest among the communities, indicating better access to education. Primary School: 45% have completed primary school, indicating a good basic education level. Secondary School: 40% have secondary education, the highest among the communities, showing a strong educational attainment. Tertiary Education: 10% have attained higher education, similar to Oboro, indicating a presence of advanced education. Occupation: Farming: 50% of mothers are engaged in farming, the lowest among the communities, reflecting a more diverse occupational base. Trading: 30% are involved in trading, the highest among the communities, indicating robust commerciall activities. Housewife: 10% are housewives, consistent with the other communities. Civil Servant: 10% work as civil servants, the highest among the communities, showing a higher engagement in public service. CHAPTER FIVE DISCUSSION AND CONCLUSION. Discussion Immunization Coverage The primary objective of this study was to assess the level of immunization coverage in Ikwuano LGA. The findings indicate notable differences in immunization coverage across the three communities of Oboro, Ndioru, and Umudike. Umudike displayed the highest immunization coverage across all vaccines, with BCG, Polio, and Penta series reaching nearly 100% full immunization. This high coverage can be attributed to several factors, including high antenatal care (ANC) attendance rates (up to 88%) and the significant role of health care workers as primary sources of immunization information (70%). These findings align with studies conducted in Nigeria and other parts of Africa, which show that maternal education, access to health care facilities, and continuous engagement of health care providers are critical determinants of immunization success. Conversely, Ndioru lagged behind in terms of full immunization, particularly for BCG (78% fully immunized) and Rota (66% fully immunized). This community also reported the highest percentage of unimmunized children, especially for BCG (15%) and Rota (5%), suggesting barriers such as geographical challenges and lower ANC attendance rates (ranging from 66% to 78%). These findings are consistent with previous research indicating that distance to health care facilities significantly affects immunization coverage, particularly in rural settings. Oboro's immunization coverage was moderate, with higher rates for vaccines like Penta (reaching 100% for Penta1 and3) but lower for HBV (80%) and Rota (70%). These disparities point to inconsistencies in follow-up for multi-dose vaccines, which may stem from logistical or outreach challenges. Similar findings have been observed in studies from other sub-Saharan African countries, where follow-up for subsequent doses often declines due to transportation issues, care giver misconceptions, or stock outs. Barriers to Immunization The secondary objective of this study was to identify the key reasons influencing the uptake of routine immunization. Distance to health facilities emerged as the most significant barrier a cross all communities, particularly in Ndioru, where 40% of respondents identified it as a hindrance to accessing vaccines. This finding is supported by earlier studies that have shown geographical barriers to be a primary obstacle in rural Nigeria. Lack of awareness was another prominent barrier, especially in Ndioru (25%) and Oboro (20%). Educational interventions aimed at increasing awareness of immunization benefits are crucial, as studies show that care givers with limited knowledge are less likely to complete the full immunization schedule for their children. In Umudike, where awareness levels were relatively higher (only 10% cited lack of awareness as a barrier), immunization coverage was notably better. Vaccine stock outs were reported in all communities, particularly in Oboro (15%) and Umudike (15%). These stock outs not only delay immunization but can also erode care giver trust in the health care system. A study conducted in northern Nigeria similarly reported that vaccine shortages were a major reason for incomplete immunization coverage. Cultural beliefs played a smaller but still notable role, particularly in Ndioru (15%) and Oboro (10%). These communities might benefit from targeted community engagement programs that address cultural misconceptions about vaccines. Previous research in Nigeria has highlighted the importance of engaging local leaders and influencers to combat vaccine hesitancy due to cultural beliefs. Sources of Immunization Information Health workers were identified as the primary source of immunization information in all three communities, particularly in Umudike (70%) and Oboro (60%). This highlights the essential role that health care professionals play in promoting immunization uptake. These findings are consistent with global trends, where health care providers are often the most trusted source of information regarding immunization. However, in Ndioru, mass media played a more significant role (20%) than in the other two communities, indicating a potential opportunity to leverage media campaigns to further improve awareness and immunization coverage. This finding aligns with studies suggesting that mass media campaigns can effectively raise awareness, particularly in areas where direct access to health workers is limited. Comparison with Previous Studies The immunization coverage observed in Ikwuano LGA is comparable to that reported in other rural areas of Nigeria. For example, a study in northern Nigeria found similar coverage rates for BCG (84%) and Polio (79%), with slightly lower coverage for the Penta series. However, this study revealed slightly better overall performance in Umudike compared to other rural areas, likely due to stronger health care infrastructure and higher ANC attendance rates. On the other hand, the challenges of geographic access and vaccine stock outs mirror findings from other rural parts of Nigeria, where logistical constraints often limit full vaccine uptake. This study’s results resonate with earlier research conducted in rural Nigeria, particularly in relation to the role of health care accessibility and socio-cultural factors in immunization coverage. A study by Otaetal. (2011) in south western Nigeria also found significant disparities between urban and rural immunization rates, with rural communities lagging due to poor health care access and lower maternal education levels. Similarly, Adeyinkaetal. (2018) observed that communities with higher ANC attendance rates and stronger health care infrastructure had better immunization out comes, as seen in Umudike's high coverage rates. The barriers identified in this study, such as distance, awareness, and cultural beliefs, are common challenges noted in other parts of Nigeria. This underscores the need for targeted interventions that address these specific barriers, such as mobile health clinics to reach remote areas, improved health care worker training, and community-driven education campaigns that align with local cultural contexts. Conclusion Immunization coverage in Ikwuano LGA is relatively high in some communities but remains inconsistent, particularly in Ndioru. Geographic barriers, lack of awareness, and vaccine stock outs are the most significant obstacles to achieving complete coverage. Health workers play a crucial role in disseminating information, and strategies to strengthen their engagement with caregivers, along with targeted media campaigns, could help address some of the existing gaps. Overall, this study highlights the need for continued efforts to improve immunization coverage through better health care access, consistent vaccine availability, and community-based educational interventions. REFERENCES Adam D, Mokieldin A, Bilal A, Hussein A, & Hirsi M. (2015) Socio economic factors influence measles immunization coverage in Shendi and Almatama Localities-Nigeria. Int J Chem Environ Biol Sci.; 3:411–4. Ansong D, Tawfik D, Williams EA, Benson S, NyanorI, & BoakyeI, (2014). Suboptimal vaccination rates in rural Ghana despite positive care giver attitudes towards vaccination. J Vaccines Immun. 2014; 2:7–15. https://doi.org/10.14312/2053-1273.2014-2 . Dutta SK, Mahato H, Bose T, Sil S, & Biswas S. (2016) Evaluation of knowledge, attitude and practices on immunization among mothers of under five children of a tertiary care hospital in Eastern India. Int J Health Sci Res (IJHSR) 6(2):189–94. GAVI. (2016). Nigeria: first to introduce life-saving meningitis a vaccine into routine immunization. 2016. Available from: https://www.gavi.org/news/media-room/nigeria-first-introduce-life- saving-meningitis-vaccine-routine-immunization . GAVI. (2020) New vaccine to protect children from severe diarrhea comes to Nigeria. Available from: https://www.gavi.org/news/media-room/new-vaccine-protect-children-severe-diarrhoea- comes-nigeria . Gidado S, Nguku P, Biya O, Waziri NE, Mohammed A, & Nsubuga P, (2014) Determinants of routine immunization coverage in Bungudu, Zamfara state, northern Nigeria, 2010. PanAfrMedJ. 18:9. https://doi.org/10.11604/pamj.supp.2014.18.1.4149. Ismail ITA, El-Tayeb EM, Omer MDF, Eltahir YM, El-Sayed E-TA, & Deribe K. (2014). Assessment of routine immunization coverage in nyala locality, reasons behind incomplete immunization in South Darfur state, NIgeria. Asian J Med Sci., 4;6:1– 8. https://doi.org/10.19026/ajms.6.5348. Lakew Y, Bekele A, & Biadgilign S. (2015). Factors influencing full immunization coverage among 12-23 months of age children in Ethiopia: evidence from the national demographic and health survey in. BMC Public Health.; 15:728. https://doi.org/10.1186/s12889-015-2078-6. Nwankwo, P. C., & Adebayo, K. (2020). Barriers to immunization in rural Nigeria: Across- sectional study. BMC Public Health, 20 (4), 1567-1575. Okechukwu, E. & Adesina, R. (2021). The role of health workers in improving immunization coverage in sub-Saharan Africa. African Health Review, 15 (2), 110-123 Smith, J. & Brown, A. (2022). Immunization coverage in rural Nigeria: An evaluation of influencing factors. Journal of Public Health, 34 (3), 245-259. UNICEF (2019). Nigeria prepares to vaccinate over 11 million children against measles and polio. Available from: https://www.unicef.org/mena/press-releases/nigeria-prepares-vaccinate-over- 11-million-children-against-measles-and-polio . UNICEF. Immunization program (2019) .Available from: https://www.unicef.org/immunization . World Health Organization (WHO). (2019). Vaccine hesitancy and access barriers in low-income countries: Strategies for improvement. Global Vaccine Journal, 8 (1), 44-55. World Health Organization. (2020). Immunization. .Available from: http://www.who.int/topics/immunization/en/ Zaffran M, Vandelaer J, Kristensen D, Melgaard B, Yadav P, & Antwi-Agyei KO, (2013). The imperative for stronger vaccine supply and logistics systems. Vaccine. 2013;31:B73–80. Available from: http://www.who.int/immunization/sage/meetings/2013/november/3_stronger_accine_supply_an d_logistics_systems.pdf.https://doi.org/10.1016/j.vaccine..11.036. QUESTIONNAIRE Instructions: Do not write your name. Please, indicate your response by writing the preferred answer on the box provided. SECTION A Demographic Information. 1. Age a) 18-25 b) 26-35 c) 36-45 2. Educational level a) No formal education b) Primary school c) Tertiary education 3. Occupation a) Farming b) Trading c) Housewife d) Civil servant Section B: level of Routine Immunization coverage What are the Selected antigen(s) administered based on evidence of card history? a) Birth: BCG (Bacillus Calmette-Guerin) – against tuberculosis b) OPV (Oral Polio Virus Vaccine) – against polio c) Hepatitis B – against hepatitis B 6weeks: a) DPT (Diphtheria, Pertussis, and Tetanus) – against diphtheria, pertussis, and tetanus b) OPV (Oral Polio Virus Vaccine) – against polio c) Hepatitis B – against hepatitis B d) Hib (Haemophilus influenza type b) – against haemophilus influenza type b e) PCV (Pneumococcal Conjugate Vaccine) – against pneumococcal disease 10weeks: a) DPT (Diphtheria, Pertussis, and Tetanus) – against diphtheria, pertussis, and tetanus b) OPV (Oral Polio Virus Vaccine) – against polio c) Hepatitis B – against hepatitis B a) Yellow Fever Vaccine – against yellow fever 15months: b) Measles Vaccine - against measles 18months: c) Vitamin A Supplementation – to prevent vitamin A deficiency Section C: Sources of information 4. What are the various sources of information in vaccination? a) Health workers b) Community meetings c) Mass media (radio/TV) d) Peer/family e) Others Based on the evidence of Card/History, what is the immunization status of the child a) Fully immunized b) Partially immunized c) Not immunized Section D: Barriers to Immunization 5. What are the possible barriers to Immunization? a) Distance to health facility b) Lack of awareness c) Vaccine stock outs d) Cultural beliefs d) Hib (Haemophilus influenza type b) – against haemophilus influenza type b e) PCV (Pneumococcal Conjugate Vaccine) – against pneumococcal disease 14weeks: 9months: d) Yellow Fever Vaccine – against yellow fever 15months: e) Measles Vaccine - against measles 18months: f) Vitamin A Supplementation – to prevent vitamin A deficiency Section C: Sources of information 6. What are the various sources of information in vaccination? f) Health workers g) Community meetings h) Mass media (radio/TV i) Peer/family j) Others Based on the evidence of Card/History, what is the immunization status of the child d) Fully immunized e) Partially immunized f) Not immunized Section D: Barriers to Immunization 7. What are the possible barriers to Immunization? e) Distance to health facility f) Lack of awareness g) Vaccine stock outs h) Cultural beliefs 36