Keywords
Post-day one immunization, Working mothers, Drop-off rate, Ibadan
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Omobowale MO, Amodu FA, Falase OS et al. Contextualizing post day-one childhood immunization in-take drop-off rate in Nigeria: An assessment of working mothers in Ibadan [version 1; peer review: 3 approved with reservations]. Gates Open Res 2024, 8:48 (https://doi.org/10.12688/gatesopenres.15135.1)
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Research Article
Contextualizing post day-one childhood immunization in-take drop-off rate in Nigeria: An assessment of working mothers in Ibadan
[version 1; peer review: 3 approved with reservations]
PUBLISHED 31 May 2024
Abstract
Corresponding author:
Mofeyisara O. Omobowale
Competing interests:
No competing interests were disclosed.
Grant information:
This work was supported by the Bill and Melinda Gates Foundation [OPP1217235].
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2024 Omobowale MO et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Omobowale MO, Amodu FA, Falase OS et al. Contextualizing post day-one childhood immunization in-take drop-off rate in Nigeria: An assessment of working mothers in Ibadan [version 1; peer review: 3 approved with reservations]. Gates Open Res 2024, 8:48 (https://doi.org/10.12688/gatesopenres.15135.1)
First published: 31 May 2024, 8:48 (https://doi.org/10.12688/gatesopenres.15135.1)
Latest published: 27 May 2025, 8:48 (https://doi.org/10.12688/gatesopenres.15135.2)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Introduction
Childhood immunization has become an important contributor to the control and management of mortality and vaccine-preventable diseases among children in low-income countries (Abbas et al., 2020; Hilton et al., 2006). Nigeria has developed several strategies for combating vaccine-preventable diseases since 1979 when it adopted the expanded program for immunization (EPI), and these efforts have drastically reduced the rate of under-five morbidity and mortality. This is further evidenced by the country recently attaining a polio-free status (Ekwebelem et al., 2021). However, a low completion rate of immunization coverage and increased drop-off rate are evidence that several factors are militating against arrays of approaches, which low-income countries like Nigeria have deployed to increase immunization coverage (Adedokun et al., 2017).
Nigeria is still plagued with one of the highest rates of under-five mortality in the world (Mutiu et al., 2019), the second largest after Pakistan (Asim et al., 2015). Nigerian 2016 Multiple Indicators Cluster Survey/National Immunization Survey Coverage (MICS/NICS) revealed that 77% of children aged 12–23 months in Nigeria have not received all the routine vaccinations according to the recommendation of the national EPI schedule. In addition, 40% of children in the above age group did not receive any vaccinations, meaning that the 90% national target that has been set by the country was not met. Likewise, 33% of children aged 12 to 23 months received three doses of Penta vaccines, while 31% of children who received Penta 1 vaccines did not complete the three-dose series (Oleribe et al., 2017; WHO, 2017). Overall, the national immunization coverage average is still far from the World Health Organization (WHO) recommended coverage rate (Chido-Amajuoyi et al., 2018; Obiajunwa & Olaogun, 2013; Oleribe et al., 2017). The 2018 NDHS reports show that the percentage of children aged 12–23 months who have received all basic vaccinations was 43.0% in south West Nigeria, while only 34.9% of this age group have received all age-appropriate vaccinations in the region. Individual states have varying levels of vaccine uptake such as Oyo state in the South-Western region with 23.3% coverage in the number of children of all basic vaccinations and 16.6% with all age-appropriate vaccinations. The average immunization coverage of the state is low and puts the region behind the South-South and South-Eastern regions of the country with higher coverage (McGavin et al., 2018).
Surveys, over the years, have revealed factors including but not limited to mother’s educational status, employment status, income, age, marital position, religious inclination, ethnic division, child’s age, birth order and ease of accessing health center to influence the uptake and completion of childhood immunization (Adenike et al., 2017; Mutiu et al., 2019; Omobowale, 2021; Ophori et al., 2014; Tagbo et al., 2012). Similar studies conducted in different locations and populations in the country revealed a largely similar set of factors militating against the uptake and completion of immunization by children all over Nigeria with the factors being stronger determinants among some populations as compared to others (Abdullahi, 2018; Adeloye et al., 2017; Adeyinka, 2012). The variation in the impact of these factors in different population subsets of the country is an indication of the contextual differences in population subsets, which until now remains unexplored. Contextualizing post-day-one childhood immunization among working mothers as a subset of the population encompasses a holistic examination of social interpretations, a trick of perspective, the nature of social/cultural reality, social explanations of knowledge, and interactions regarding childhood immunization as a social/health process in childcare.
Maternal factors play an important role in the access, uptake, and completion of immunization of under-five children, which consequentially affects the immunization coverage rate in the country (Fatiregun & Okoro, 2012). Statistically, children of young mothers (15–24 years), illiterate mothers, mothers who did not attend ante-natal clinics, mothers who delivered at home or maternity homes, mothers who had no access to media, and mothers who had little, or no knowledge of immunization were more likely not to complete or receive any immunization (Adedokun et al., 2017; The National Demographic Health Survey, 2013). Children of mothers who are aware of immunization at birth are 1.9 times more likely to be fully immunized, while children of mothers who had secondary and tertiary education are two times more likely to be fully immunized than those children whose mothers had primary or no formal education (NDHS, 2018). Other important factors that are maternal-related are the level of education, higher income, and easy access to healthcare establishments among others (Fatiregun & Okoro, 2012). Although, several studies have explored factors that are associated with the low vaccine uptake among Nigerian children, which have been attributed to low immunization coverage, nursing mother’s poor knowledge about immunization, and educational status, among other factors (Abdullahi, 2018; Abdulraheem et al., 2011; Antai, 2010; Antai, 2012; Anyene, 2014; Oladepo et al., 2019). The contextual understanding, the interplay between social/cultural interpretations, explanations and interactions that dictates the social reality of mothers (working in the informal sector) in the up-take of childhood immunization beyond first schedule and post day-one in South-Western Nigeria, has however not been explored. The success of completing the immunization exercise is contingent on the contextual experiences and understanding of mothers who value the significance of childhood immunization. Contextualizing childhood immunization will advance appropriate intervention that will help in increasing immunization coverage and completion among working mothers. The proper monitoring of children in the immunization routine activities cannot be detached from the socio-culturally informed understanding of mothers who are the primary caregivers. This study explored the contextual understanding of informal working mothers on post-day-one childhood immunization in different specific areas including the contextual understanding of the concept of immunization, vaccines not under the National Program on Immunization (NPI), immunization schedule and period as well as the timing and duration of the immunization.
Methods
Ethical considerations
Ethical approval was received from both University of Ibadan/UCH Research Ethics Committee (UI/EC/20/0058) on 23/05/2020 and Oyo State Research and Ethics Review Committee (AD 13/479/1777B) on 20/05/2020. During the data collection, the study details, purpose, and participants’ right to privacy were explained to all participants, with the clarification of the right to withdraw at any time from the interview. Informed consents were obtained both verbally and written. The participants in this study were not exposed to any risk that we know of. Their participation in this study cost them nothing invasive, incentives and transportation were provided at every required instant. Participants through the findings and discussions of this study were more enlightened about childhood immunization along with other minor health-related services benefits provided to them.
Study description
A mixed methods approach was adopted for this study to gain a more comprehensive knowledge of the phenomenon studied. The study was conducted in Ibadan, a major city in Oyo state. The city hosts large markets with a huge population of mothers from diverse cultures in Nigeria. A total of 1,044 (quantitative samples) and 73 (qualitative samples) nursing mothers were sampled from both rural and urban markets of Ibadan, using sequential mixed methods study design. A pretested interviewer administered questionnaire, immunization record assessment, and in-depth interviews with mothers and health workers were employed in the study. The eligible study population comprised of all consenting nursing mothers working within the markets who have commenced childhood vaccination, and health workers in the selected study sites. A total number of 1,044 working mothers were sampled from 13 randomly selected markets (Agbeni, Bodija, Gbagi, Oje, Oja Oba, Ojoo, Dugbe, Sango, Mokola, Orita Merin, Bode, Olomi, Ikereku, Olulosin, Ogunranti 2 and Academy) in Ibadan metropolis, Nigeria for the study.
The qualitative data were obtained through unstructured interview guide for in-depth interviews (IDI) with 73 consenting purposively selected working nursing mothers in selected markets. Four IDIs were conducted in all markets except in Bodija, Agbeni and Gbagi markets where 7 IDIs were conducted due to the larger number of Nursing mothers in the markets. The interviews were stopped when saturation was reached. In-depth interviews help deepen knowledge by bringing focused, insightful and improved understanding of the study (Brounéus, 2011). Mothers of children below the age of five years in selected markets were, purposively identified, approached for explanations and consent for participation in the study. Non-consenting mothers were omitted, while all consenting mothers either verbally or written were recruited for the study. However, in all the markets, market leaders and significant others of the mothers had earlier been identified, visited, and carried along from the inception of the study. The in-depth interview focused on nursing informal mothers with children below 5 years of age to sufficiently explore, understand, and contextualize post-day-one childhood immunization narratives, challenges, and possible solutions. Interviews were transcribed, and coded using process coding methods when observable and conceptual action in the data were linked to process codes, intertwined with the dynamics of vaccination time, such as things that emerge, change, occur in particular sequences, or become strategically implemented. Process coding is appropriate for virtually all qualitative studies, particularly for grounded theory research that extracts participant action/interaction and consequences (Miles & Huberman, 1994). The data were also categorized and subjected to content analysis.
Statistical analysis
The dataset was retrieved and analyzed using statistical packages for Social Sciences (SPSS, version 20 windows). Data were represented by numbers, percentages and expressed by mean. Chi-square test was used to observe the difference between the proportions, t-test was applied to observe- the difference between the two means for normally distributed data. A p-value less than 0.05 was considered as significant.
Results
Demographic information of working mothers in Ibadan
The mean age of mothers enrolled in this study was 31.39 years. The mean age of mothers at first childbirth in the study population is 24.12 years. The mean number of days from birth to first vaccination for children of mothers in this study was 1.95 days and the average number of children per mother in our study is 2.43. The majority of mothers (53.8%) completed secondary school. About one-fifth of the study population had tertiary-level education, while more than a third of the population had no form of education. The distribution of educational levels of mothers is presented in Table 1 (Omobowale, 2024). The majority of the mothers (95%) in this study were married while only 43 (4.2%) were single. The majority of mothers (82.9%) that had antenatal care during their pregnancy attended health care facilities for their antenatal services, while 13.6% had their antenatal care in faith homes. About 76% and 16.4% of respondents in this population delivered their last child at a healthcare facility and mission house, respectively. About three-quarters of the women in this population immunized their children immediately after birth. Less than a third of the children in this population had completed the age-specific vaccinations.
Table 1. Educational attainment of working mothers.
Table showing the highest educational attainment by mothers in the study. This table shows 37 of the mothers do not have any form of education, the majority (536) completed secondary school education and 180, making about 18% had tertiary education degrees. About 48 mothers do not disclose their educational status.
More than half of the women vaccinated their children on day zero, while about 22.4% of mothers vaccinated their children within the first week of birth (Table 2). A higher number of mothers in the urban markets completed the immunization schedule for their children till the 14th week (42.57%) and the ninth month (33.95%). Completion rates in Table 3 were visibly lower among children of mothers in the rural market. More than half (53.3%) of the children of mothers in the rural markets dropped off the immunization schedule before they were fully vaccinated. As presented in Figure 1, almost 40% of the mothers interviewed vaccinated their children till the third dose of DPT and just a little above 30% completely vaccinated their children. There was a steady decline in vaccine uptake with the increasing age among children in the Ibadan population as depicted in Figure 1.
Table 2. Age at which children of working mothers started immunization after birth.
| Age | Frequency | Percentage |
|---|---|---|
| Day Zero | 554 | 53.1 |
| Within the first week | 234 | 22.4 |
| Within the second week | 43 | 4.1 |
| Above two weeks | 213 | 20.4 |
| Total | 1044 | 100.0 |
Table 3. Childhood immunization completion rate and drop-off rate among working mothers by Market region stratification.
Table showing the immunization completion and drop-off rates in the population. It is shown that children born to mothers living in the urban settlements are more likely to complete their vaccination and children born to mothers in the rural settlements are more likely to drop off the vaccination schedule.
Figure 1. Age Specific completion rate of each vaccine among children of informal working mothers in Ibadan Nigeria.
The figure shows the progressive decline in the number of children taking their vaccinations as they advance in age. The most vaccine taken in the population is the first dose of Hepatitis B and the lowest taken vaccine is the yellow fever vaccination taken at age 9 months.
Informal working mother’s contextual understanding of childhood immunization
To clarify the understanding of the informal working mothers on childhood immunization, various questions from the perspectives of working mothers were sought, which included their understanding of the reason for childhood immunization. One of the informal working mothers defined immunization as a disease-preventing vaccine to secure the future as thus:
Immunization is those vaccines that we take to prevent diseases that can affect children in the future. It is something like preventing. We take Hepatitis B, Diabetes, Hepatitis B1, and B2, we just collected it (Agbeni Market IDI).
The mother here has a layman understanding of vaccines as prevention but seems not to know some of the vaccines and their functions as she added diabetes to the list of mentioned vaccines. Another working mother whose opinion was generally shared by many mothers explained the importance of childhood immunization from a preventive perspective also:
I know that it prevents paralysis and it is good for a child. It also prevents jedo-jedo (Hepatitis) and diseases like romolapa-romolese (Polio) and yinrun-yinrun (Meningitis) (Agbeni Market IDI).
Post-day-one childhood immunization is an exercise that should be taken seriously. In explaining some of the diseases that post-day-one immunization prevents, a working mother emphasized that a good mother needs to take immunization very seriously by ensuring that all children take it. She said:
Immunization is good and a true mother should make the effort to ensure that she takes it for her children completely, and we can see its work in our children. So, it is very good and necessary (Agbeni Market IDI).
Confirming the above statement, a mother also opined that:
I know that immunization is important for a child and it is something good that parents should take for infants. It prevents diseases such as polio, diarrhea, tuberculosis, and measles (Gbagi Market IDI).
A respondent emphasized the reason and importance of childhood immunization and also as a means of preserving culture and socialization processes because the immunization exercise is a continuous process that is passed from one generation to another:
I know that it’s good because the parents who gave birth to us also immunized us when we were young. So, when we give birth to a child, we need to immunize them also (Gbagi Market IDI).
Obviously, it can be deduced from the narratives above that the informal working mothers have the layman's knowledge of childhood immunization. Most informal working mothers see childhood immunization as an exercise to prevent children from diseases and other ailments, which may affect children. Also, immunization is recognized as a means of preventing children from sudden death and securing their future.
However, in spite of the working mothers’ enlightenment on childhood immunization, some of the mothers do not know the specific vaccines their children receive. Many of them take the vaccines as instructed and on the general assumption that ‘it is good for children’ as adduced by one of the interviewees:
We have been taking it (immunization), we have taken all the ones that the child is supposed to take, and the ones they carry around that they bring to the market, we also take that one. But I don’t know the name of the vaccines, they only said it is good (Agbeni Market IDI).
As a result of inadequate information that exists on the kind of immunization that children receive, it was observed that some working mothers use ‘supplements’ as an addition, a practice, which could be detrimental to the health of the children. A mother emphasized thus:
I don’t know the name of the vaccine when it is not the only one. We also use Babyrex and vitamins for her [the child], and when we go to the clinic, they say that one is for romolapa-romolese (polio) or something like that. Also, I used to hear the advertisement, because they don’t write the name of the vaccine for us, they just write 3 letters, and you know it is only the nurses who know what they mean by that (Agbeni Market IDI).
Yet another working mother noted that:
I don't know the names, but they say some prevent measles, some for polio, yellow fever, and so on. So, all I know is that they prevent those diseases (Bodija Market IDI).
Although the immunization card has a record of the next vaccine to be received, most mothers do not understand the actual vaccine to be received as explained by a working mother thus:
It (Immunization) is good, it is very good for the body. It kills all diseases that are in the body, such as fever, cough, iko ahubi (coarse cough), and iko ahugbe (dry cough). It is good for children, the way they give them in stages is how we take it, and we have the record. They gave us cards. When we were supposed to receive it, we went to the place and they gave us the next date and wrote the next vaccines that we would take on the next appointment. (Bodija IDI Market).
Informal working mothers, in most cases, do not also know and understand the specific vaccines given to their children. While they are aware of when their children were given the previous immunization through the immunization card, in most cases, they are oblivious of the specific vaccine received as well as the functions but rely on the health workers to tell them. A working mother opined that:
When we gave birth after 7 days, they gave the baby at the hand, and buttocks, after that, at the two hands when she was 2 months but I can’t remember the name of the vaccine. It is good to take it. For the 3 months, I don’t know the name of the vaccine. When we get there, the nurses will explain it to us (Bodija Market IDI).
Likewise, another working mother said:
I can’t remember the vaccine that was given to my baby but it is in my baby’s card. They usually write the one that he will receive there, but I can’t really remember. I know BCG and Rotavirus, the one that prevents meningitis, but I don’t know the timing of these vaccines, despite the fact that I have four children (Gbagi Market IDI).
The above presents the contextual understanding of mother's significance of timely and complete vaccination of their children across groups.
Informal working mother’s understanding of vaccines not under NPI
Most informal working mothers are informed about ‘special vaccines’, which are not under the NPI, these are government-approved but not subsidized vaccines. They know that these vaccines exist and are good for children, but the vaccines are not free. There are suggestions that all working mothers should get these vaccines, but, the cost of these vaccines, remains a major problem for most mothers as explained by one of them:
Of all the vaccines, the BCG is very important, the PCV, and the Rotavirus. They are all good. For the Rotavirus, if not that it is expensive for most of the parents, it would have been good for everybody to take it for their children (Gbagi IDI).
A working mother who has been informed but could not afford one of the special vaccines opined that although the vaccines are crucial for the children, the government needs to support parents by subsidizing the cost of the special vaccines.
Yes, there is one that they said is ROTA (Rotavirus), but it is too expensive, and I feel if it is something that is very important the government will subsidize it and it will be free for everybody so I am not bothered about it but some people still go to pay for it and take for their child. Out of a hundred maybe few people will be able to afford that money. So, I did not bother to immunize my child against Rotavirus. I only take the free ones. It is only Rota that I know is not free (Agbeni Market IDI).
An informal working mother who knows more about the functions of the special vaccines talked about the time that a child should get them. She explained that:
So, the vaccines that we are talking about, are what we call special vaccines. The one that stops Igbegburu (Dysentery), there is Meningitis, and different ones are available. Those ones, would not tell you at the clinic that they are available. Like the one for Rotavirus, a child between 6 weeks and 10 weeks, is supposed to receive it. So, some are to be taken after one year, one for 9 years for females (Agbeni Market IDI).
However, some working mothers do not know if there are special vaccines that require any payment. While responding to a question on the special vaccines, a woman surprisingly said:
Is that also an injection [vaccine]? We don’t pay for any vaccine in the place where we take vaccine o, we don’t pay for the vaccine (Agbeni Markets IDI).
Correspondingly, a working woman who is completely unaware of special vaccines also explained that:
They should let us know about it [special vaccines], because I have never heard of it. Even the first one we received was at the local government, the one for three months or six weeks, and after birth before naming. It was at a local government that we received it (Agbeni Market IDI).
However a woman was able to get one of the special vaccines for her children in order to prevent diseases.
I have heard one that prevents meningitis. It is a good vaccine because I got it for my 2nd and 1st child, because of the disease in the area. We are told to get it for them after 1year (Agbeni Market IDI).
The quantitative section of the study also confirms the fact that the completion rate for special vaccines, particularly, Rotavirus is very low as shown that only a 7.5% rate had been completed (Table 2). Clearly, it can be inferred that the available special vaccines are not free, hence, they are unavailable in many immunization clinics and unaffordable to mothers who live barely on and/or below the poverty line1. by the working mothers. What inhibits most mothers from getting their children vaccinated with these special vaccines is the associated cost of the vaccines. Besides, some working mothers do not know that these vaccines exist and they do not have the knowledge of their functions. For the vaccines to be accessed and affordable, the government needs to subsidize them.
Informal working mother’s understanding of immunization schedule and period
Childhood immunization schedules and period guide mothers on when to take their child(ren) for the next immunization appointment. There is no doubt that the immunization schedule and period will be taken seriously based on the contextual understanding of mothers. Even with the immunization card as a reminder, working mothers who are too busy with their daily work or who do not understand the importance of immunization are at risk of missing the next period of immunization. A mother explained how informed she was on the immunization schedule:
Yes, they tell us. When the child is 3 months, they tell us to come for vaccination, then for 6 months, and after 6 months. They [Nurses] tell when to come next whether by 8 months or 9 months and the date for the next appointment is written in our immunization cards so that when you look at it you remember when to go for the next appointment (Agbeni Market IDI).
While referring to the lecture received by health workers, a mother stated the specific times given to her on the immunization schedule as:
At birth, one month, 3 months, 6months, 9months, and 1 year, that was how we were lectured (Agbeni Market IDI).
Similarly, another woman explained the immunization schedule as starting from:
In addition, an informal mother emphasized the immunization schedule with personal experience:
At birth, 2 months, 3 months, 6 months, although the vaccine is given in the child's mouth, 9 months, and 1 year. I know a child is supposed to complete the vaccination at 2 years because when I gave birth to my 2nd child, the schedule was completed at 18 months but for my 1st born, it was completed at 12 months so now I think the vaccination schedule ends at 2 years (Agbeni IDI).
However, a woman who knows that various vaccines exist for the immunization of children but does not know how and when to take them for her child responded:
There are a lot of vaccines like my baby now has taken the vaccines like six times. But I do not know how many vaccines a child should take (Bodija IDI).
Different from the unknown woman, another working mother makes use of any available moment to immunize her child as explained thus:
I take it from any clinic depending on my location at that moment and I sometimes take the child to the father's village, because the healthcare people often come there. Recently, when I came home, I was passing through Ojee, and I came across some set of healthcare persons giving vaccines, and I took my child to them (Agbeni market IDI).
Another woman emphasized that:
On the day I took the first one, if it was after a month or three months, they would have given me the date for my next appointment. So, it’s the date that I bear in mind to go next, so when I get there, if it’s available, fine I will take it, and if it’s not, they will tell me to come the following week (Gbagi market IDI).
However, the schedule and period of immunization make it easy for informal working mothers to know when and where to immunize their child(ren). It serves as a guide as one woman noted:
You know it is always scheduled, so that makes it easier. Just like after giving birth, you get some; there is another one at six weeks, then ten weeks, 14 weeks then, 9 months, 1 year, and the like. One will know how to do it (Agbeni market IDI).
A mother that understands the importance of the immunization period finally concludes that:
Informal working mother’s understanding of the timing and duration of the immunization
On the duration of the vaccine, it was observed that there was no uniform period according to the responses of the informal working mothers. While some believe that the immunization period ranges from birth to 9 months, some mothers agreed to a year, yet some others said it is over a year, and even more. One of the women noted that:
For my firstborn, I stopped collecting immunization for him at one year and six months, but I am still collecting vitamin A, which they put in his mouth (Agbeni market IDI).
It was observed that some groups of working women agreed that immunization starts from birth till 9 months, while some women noted that the duration is between the delivery period and one year. A woman narrated her experience on the immunization period for her children thus:
When we were collecting the vaccine for the older ones, the vaccine used to stop at one year, but for the ones that I gave birth to later, it was one year and 6 months, now they say you can receive for 2 years (Bodija market IDI)
The uncertainty in the duration of the vaccine also persists as explained by a working mother who missed some vaccinations for one of her children earlier but hopes to complete it for others as she explained that:
Ehn, we did not know then, the one that is now 3 years old, if he can still it, I would take him there. The one that is 10 years old, if he can receive it, I would take him there too. There is one that is 8 years old too and one that is 2 years old now, I have said that I would take him to receive it (Bodija market IDI).
Children, at times, may miss the immunization period as a result of a lack of experience on the duration of the vaccine as an interviewee simply said:
A woman who was unsure about the timing and duration of the immunization needs to rely on the information given by the health workers:
Hmm, they used to tell us a lot about it, but there is little I can remember. Although at birth he took one, I think vitamin K. Also, in the fourth month, he took another one, A month after, he took another one again till the sixth month. I think we took a vaccine that cost seven thousand naira in the third month. In the sixth month, he took vitamin A, which was dropped in his mouth to prevent what he will be eating. After that, we went there but they did not give him any vaccine they just asked questions about his body's reaction to food. We were told he would take another vaccine at nine months (Gbagi market IDI).
A woman narrated that the immunization process should be done “Immediately one gives birth to the baby like the second day after birth and getting home, one should go and receive it. In fact, my child had not been named before I started the immunization. I went to the one at nine months yesterday. So, I take it for my child. Then a year and they also said when the child is a year and three months, I should bring him back. They’ve written it on the card (Gbagi market IDI).
Mothers lay importance on receiving the first set of childhood immunizations.
Discussion
The contextual understanding of informal working mothers plays a significant role in childhood immunization uptake in Ibadan. The working mothers in informal spaces represent a unique population that strives to balance multiple needs and tasks including livelihood survival and childcare practices simultaneously (Oladokun et al., 2009; Omobowale, 2021). Mother literacy and religious institution education on immunization are two important factors in achieving optimal childhood immunization in the study population. This corroborates the findings of Ijarotimi et al. (2018) on the immunization status of children and associated demographic factors in Akinyele Local government are of Oyo state, that female literacy and targeting religious institutions may be effective in improving immunization uptake. The majority of mothers in this study were traders, demonstrating that maternal livelihood may also prevent optimal uptake of immunization by children of working mothers in the informal sectors. Many working mothers in the informal space like markets are pressed with demands of sales and profit making in order to sustain their livelihood. In some cases, many of them despite being married, still remained “breadwinners” in their families (Tade, 2022). Some of them are also indebted to serving usury loans especially that of gbomu le lanta. “Usury loans are locally described as owo gb’omulelantan (which literarily means “a loan akin to having one’s breasts on a hot lantern”). In short, a usury loan default worsens the livelihood and economic situation of the loanee” (Omobowale et al., 2020) and thus may affect their abilities to keep immunization schedules of their (Oladokun et al., 2010; Omobowale, 2019).
The report of Obiajunwa & Olaogun (2013) from an urban-rural study on immunization revealed an immunization completion rate of 26.5% (Urban), and 31.7% (Rural) of mothers in our population state their children have completed the age-specific immunization routine at the time of conducting this study. The reason for the marginal difference in the completion rate we reported here could be associated with higher education status and 100% employment status among our study population. We report a completion of 82.6% for BCG, 71.1% for DPT1, 68.4% for DPT2, and 65.7% for DPT3, which were markedly higher than the completion rates reported in a south-eastern population of Nigeria. The 84.3%,75%, 65.9%, 65.6%, and 47.6% completion rates for OPV0, OPV1, OPV2, OPV3, and Measles, respectively, were consistently lower than the reported among the same south-eastern population of Nigeria (Fatiregun & Okoro, 2012). The differential completion rates among the vaccines between the comparison populations are indicative of a yet to be uncovered population-specific reason influencing the vaccine uptake rates in the Nigerian population. The reported completion rate is greater than the reported average for all the geopolitical zones and the national average (McGavin et al., 2018). This difference can be attributed to the higher education, understanding of childhood immunization, and employment of the women in this population which is higher than the national averages. Also supporting the reports of Hailu et al. (2019); Mugada et al. (2017) among others, our study revealed the factors contributing to incomplete immunization rate among mothers, which are the cost of special vaccines, such as Rotavirus, mothers’ forgetfulness of immunization schedule and period, distance to immunization centers and seldom shortage of vaccines.
These women, who mostly work in the informal economy, do so without social benefits like pension, health insurance, or sick leave, rather, they seek micro loans (Omobowale et al., 2020) or develop an ajǫ (a daily/ weekly/ or monthly contributory saving system) system (Omobowale, 2011) to boost their business. Amidst these various survival systems, the informal working mothers must also take cognizance of the health of their children by taking them for immunization, when necessary. Thus, the contextual understanding of these sets of women is germane to the immunization exercise and how such exercise is conceived and practiced. Through the various narratives above, the working mothers, in spite of their various businesses, understand the importance of childhood immunization in the reflection that Immunization is a cost-effective public health policy designed to prevent millions of children from morbidity and mortality (Ahmad et al., 2017). Childhood immunization is understandably perceived as “prevention” from common childhood diseases such as polio, meningitis, hepatitis, and death, thus, it must be taken seriously. Rather than an exercise, childhood immunization is a culture, which should be preserved through the socialization process and passed down from generation to generation. With such a preservation culture, it is mandatory for all mothers to immunize their child(ren).
The contextual understanding of childhood immunization provides detailed information, as well as a broad analysis of how working mothers conceive the immunization process; what immunization is, and how immunization should be done. This is deeper than the awareness and perceived knowledge of mothers on immunization that are mostly examined by scholars. From working a mother’s perspective, the study gives a clearer picture of what immunization means to them [working mothers]. This simply means that it is not enough for working mothers to be aware of and have a knowledge of childhood immunization, which could merely be through information, but how immunization works and functions. In this case, immunization becomes a prosocial action (Korn et al., 2020) that benefits working mothers and their children, on the one hand and society, on the other hand. As revealed, although most the working mothers are aware of the functions of childhood immunization, they are ill-informed of the specific functions of the vaccines given to their children. Most working mothers who immunize their child(ren) do so as a result of the general assumption that immunization cures diseases and prevents children from death. The study also shows how mothers, due to a lack of understanding, use supplements to aid the vaccinations received by their children, which could be detrimental to the health of the children Thus, what is lacking is the contextual understanding and interpretation of the functions of the specific vaccines that children receive and the reaction that such vaccines could cause. It is therefore important to also contextualize vaccine names in the indigenous words or phrases as to drive how to establish an in-depth meaning and function of each vaccine.
Furthermore, understanding the duration/timing of immunization and period plays a significant role in the completion of immunization. As shown, many of the mothers gave different responses in the timing and duration of immunization. Although the majority of the mothers agree that it starts from birth, the ending period for the immunization, however, is yet unknown. The understanding of some mothers is that it ends at 9 months, some say 1 year, yet another set of mothers believe that is 1 year and 6 months and some agreed to 2 years. Of course, variations in the timing and period of immunization will affect the completion rate of immunization, particularly, for working mothers who are striving to make ends meet. In addition, some of the mothers do not know the schedule of each vaccine. Thus, understanding the function of each vaccine and the schedule will invariably help in the successful completion of immunization.
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Omobowale MO, Amodu FA, Falase OS et al. Contextualizing post day-one childhood immunization in-take drop-off rate in Nigeria: An assessment of working mothers in Ibadan [version 1; peer review: 3 approved with reservations]. Gates Open Res 2024, 8:48 (https://doi.org/10.12688/gatesopenres.15135.1)
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