Gates Open Res Gates Open Research 2572-4754 F1000 Research Limited London, UK 10.12688/gatesopenres.15135.1 Research Article Articles 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]

 Omobowale Mofeyisara O. Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9988-500X a 1 Amodu Folakemi A. Conceptualization Investigation Project Administration Resources Supervision Writing – Review & Editing https://orcid.org/0009-0000-3429-4682 1 Falase Olugbenga S. Data Curation Formal Analysis Methodology Writing – Original Draft Preparation 2 Olajide Taiwo H. Formal Analysis Methodology Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9548-9587 1 Amodu Olukemi K. Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Review & Editing 1 Institute of Child Health, University of Ibadan, Ibadan, Oyo, Nigeria Department of Sociology, Lead City University, Ibadan, Oyo, Nigeria feyisarat@yahoo.com

No competing interests were disclosed.

 31 5 2024 2024 8 48 13 5 2024 Copyright: © 2024 Omobowale MO et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

Contextualizing childhood immunization in the context of working mothers can boost coverage and completion. This study examines how informal working mothers perceive post-day-one routine immunization, and vaccines not covered under the National Program on Immunization (NPI), immunization schedules, timing, and duration.

 Methods

The study was conducted in Ibadan, Nigeria and involved 1,044 quantitative and 73 qualitative samples of working nursing mothers. A mixed methods approach was used, including a semi-structured questionnaire to gather immunization experiences. Data were analyzed using descriptive statistics, chi-square test for proportions, and t-test for means (p<0.05), while qualitative data were subjected to content analysis.

 Results

The average age of mothers participating in this study was 31.39 years. The mean age of mothers at their first childbirth within the study group was 24.12 years. A significant majority of these mothers (95%) are married. Around three-quarters of women in this population ensured immediate immunization for their infants after birth, but less than a third achieved the complete age-specific vaccination series due to livelihood related causes, long waiting time spent in conventional immunization clinic. Around 40% of interviewed mothers vaccinated their children up to the third DPT dose, and just over 30% achieved full vaccination. Many informal working mothers, have concerning practice of adding 'supplements' to their children's immunization, driven by a lack of sufficient information about the vaccines. Some mothers also seemed unaware of these specialized vaccines.

 Conclusions

Promoting complete immunization requires more than just raising awareness about childhood vaccinations but close and quick immunization service delivery is required. It is crucial for mothers to possess comprehensive knowledge about the mechanics and operation of immunization. Achieving this understanding could involve translating vaccine names and functions into indigenous terms, enhancing clarity and comprehension. Furthermore, a firm grasp of the immunization schedule significantly contributes to successful immunization completion.

 Post-day one immunization Working mothers Drop-off rate Ibadan Gates Foundation OPP1217235 This work was supported by the Gates Foundation [OPP1217235]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 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.

Educational attainment of working mothers.
Highest level of education
Educational attainment Frequency Percent Cumulative Percent
No education 37 3.7 3.8
Others 4 .4 4.2
Quranic school uncompleted 2 .2 4.4
Quranic school completed 1 .1 4.5
Primary uncompleted 4 .4 4.9
Primary completed 72 7.2 12.1
Secondary uncompleted 111 11.1 23.3
Secondary completed 536 53.8 77.0
Tertiary uncompleted 49 4.9 81.9
Tertiary completed 180 18.1 100.0
Total 996 100.0

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 14 th 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.

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

The table depicts the distribution of the timing when newborns received that first vaccination in the population. About half of the population were not vaccinated at day zero and as much as one-fifth of the population got their first vaccine at above two weeks of age.

Childhood immunization completion rate and drop-off rate among working mothers by Market region stratification.
Population Stratification Summary Statistics
Completion at 14 weeks Completion at 9 Months Drop off rate Total Population
Market Population Urban 42.57% 33.95% 41.55% 863
Rural 26.80% 20.99% 53.3% 181
General Population 39.81% 31.7% 43% 1044

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.

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:

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:

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:

Confirming the above statement, a mother also opined that:

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:

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:

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:

Yet another working mother noted that:

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:

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:

Likewise, another working mother said:

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:

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.

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:

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:

Correspondingly, a working woman who is completely unaware of special vaccines also explained that:

However a woman was able to get one of the special vaccines for her children in order to prevent diseases.

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 line 1 . 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:

While referring to the lecture received by health workers, a mother stated the specific times given to her on the immunization schedule as:

Similarly, another woman explained the immunization schedule as starting from:

In addition, an informal mother emphasized the immunization schedule with personal experience:

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:

Different from the unknown woman, another working mother makes use of any available moment to immunize her child as explained thus:

Another woman emphasized that:

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:

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:

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:

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:

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:

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.

 Data availability Underlying data

Due to ethical constrains to protect the privacy of the participants, the raw qualitative data containing identifiable information has not been made publicly available. However, access to the data can be made under specific documented request that must confirm that the data will not be made public or misused through the corresponding author.

The underlying quantitative data can be found below:

Harvard Dataverse: "Standard baseline result for working mothers in Ibadan SHEVACCS", https://doi.org/10.7910/DVN/EHQBQL ( Omobowale, 2024).

 Extended data

Harvard Dataverse: "Standard baseline result for working mothers in Ibadan SHEVACCS", https://doi.org/10.7910/DVN/EHQBQL ( Omobowale, 2024).

This project contains the following extended data:

consent for informal mothers.docx

participants general info page sample.docx

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

1 As at January 2022, a dose of rota virus vaccine is 7500 Naira (18.7$)

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Int J Infect Dis. 2012;16(2):e136–e145. 22197748 10.1016/j.ijid.2011.11.004 Anyene BC : Routine immunization in Nigeria: the role of politics, religion and cultural practices. African Journal of Health Economics. 2014;03(1):01–09. Reference Source Asim M Mahmood B Sohail MM : Infant health care practices in Pakistan: a systematic review. The Professional Medical Journal. 2015;22(08):978–988. 10.29309/TPMJ/2015.22.08.1142 Brounéus K : In-depth interviewing Understanding Peace Reasearch: Methods and Challenges. 2011;130–45. Reference Source Chido-Amajuoyi OG Wonodi C Mantey D : Prevalence and correlates of never vaccinated Nigerian children, aged 1–5 years. Vaccine. 2018;36(46):6953–6960. 30337173 10.1016/j.vaccine.2018.10.006 Ekwebelem OC Nnorom-Dike OV Aborode AT : Eradication of wild poliovirus in Nigeria: lessons learnt. Public Health Pract (Oxf). 2021;2: 100144. 36101607 10.1016/j.puhip.2021.100144 9461633 Fatiregun AA Okoro AO : Maternal determinants of complete child immunization among children aged 12–23 months in a southern district of Nigeria. Vaccine. 2012;30(4):730–736. 22137878 10.1016/j.vaccine.2011.11.082 Hailu S Astatkie A Johansson KA : Low immunization coverage in Wonago district, southern Ethiopia: a community-based cross-sectional study. PLoS One. 2019;14(7): e0220144. 31339939 10.1371/journal.pone.0220144 6655723 Hilton S Petticrew M Hunt K : ‘Combined vaccines are like a sudden onslaught to the body’s immune system’: parental concerns about vaccine ‘overload’ and ‘immune-vulnerability’. Vaccines. 2006;24(20):4321–7. 16581162 10.1016/j.vaccine.2006.03.003 Ijarotimi IT Fatireun AA Adebiyi OA : Urban-rural differences in immunisation status and associated demographic factors among children 12–59 months in a southwestern state, Nigeria. PLoS One. 2018;13(11): e0206086. 30395617 10.1371/journal.pone.0206086 6218029 Korn L Böhm R Meierf NW : Vaccination as a social contract. Proc Natl Acad Sci U S A. 2020;117(26):14890–14899. 32541033 10.1073/pnas.1919666117 7334515 McGavin ZA Wagner AL Carlson BF : Childhood full and under-vaccination in Nigeria, 2013. Vaccine. 2018;36(48):7294–7299. 30340882 10.1016/j.vaccine.2018.10.043 Miles MB Huberman AM : Qualitative data analysis: an expanded sourcebook.sage,1994. Reference Source Mugada V Chandrabhotla S Kaja DS : Knowledge towards childhood immunization among mothers & reasons for incomplete immunization. J App Pharm Sci. 2017;7(10):157–161. 10.7324/JAPS.2017.71023 Mutiu A Yahaya A Baban B : Immunization, primary healthcare system and efficient service delivery in Nigeria. International Journal of Recent Innovations in Academic Research. 2019;3(12):11–38. Reference Source National Population Commission (NPC) Nigeria and ICF Macro: Nigerian Demographic and Health Survey (NDHS) 2013. 2014. Reference Source Nigeria Population Commission: Nigeria demographic and health survey 2018. NPC, ICF,2018. Reference Source Obiajunwa PO Olaogun AA : Childhood immunization coverage in south west Nigeria. Sudanese J Public Health. 2013;8(3):94–98. Reference Source Oladepo O Dipeolu IO Oladunni O : Nigerian rural mothers’ knowledge of routine childhood immunizations and attitudes about use of reminder text messages for promoting timely completion. J Public Health Policy. 2019;40(4):459–477. 31427672 10.1057/s41271-019-00180-7 7771534 Oladokun RE Adedokun BO Lawoyin TO : Children not receiving adequate immunization in Ibadan, Nigeria: what reasons and beliefs do their mothers have? Niger J Clin Pract. 2010;13(2):173–8. 20499751 Oladokun RE Lawoyin TO Adedokun BO : Immunization status and its determinants among children of female traders in Ibadan, south-western Nigeria. Afr J Med Med Sci. 2009;38(1):9–15. 19722422 Oleribe O Kumar V Awosika-Olumo A : Individual and socioeconomic factors associated with childhood immunization coverage in Nigeria. Pan Afr Med J. 2017;26: 220. 28690734 10.11604/pamj.2017.26.220.11453 5491752 Omobowale AO : Social capital and AJỌ system among working class traders in Ibadan, Nigeria. J Labor Soc. 2011;14(3):333–346. 10.1111/j.1743-4580.2011.00344.x Omobowale MO : Class, gender, sexuality, and leadership in Bodija market, Ibadan, Nigeria. J Anthropol Res. 2019;75(2):235–251. 10.1086/702708 Omobowale AO Oyelade OK Omobowale MO : Contextual reflections on COVID-19 and informal workers in Nigeria. Int J Sociol Soc Policy. 2020;40(9/10):1041–1057. 10.1108/IJSSP-05-2020-0150 Omobowale MO : "You will not mourn your children": spirituality and child health in Ibadan urban markets. J Relig Health. 2021;60(1):406–419. 32436036 10.1007/s10943-020-01032-5 Omobowale MO : Standard baseline result for working mothers in Ibadan SHEVACCS. Harvard Dataverse, V1. [Dataset].2024. http://www.doi.org/10.7910/DVN/EHQBQL Ophori EA Tula MY Azih AV : Current trends of immunization in Nigeria: prospect and challenges. Trop Med Health. 2014;42(2):67–75. 25237283 10.2149/tmh.2013-13 4139536 Tade O : ‘My husband is living like a dead person’: explaining women portage labour in Ibadan urban market. African Identities. 2022;20(3):225–236. 10.1080/14725843.2020.1813550 Tagbo BN Uleanya ND Nwokoye IC : Mothers’ knowledge, perception and practice of childhood immunization in Enugu. Niger J Paed. 2012;39(3):90–96. 10.4314/njp.v39i3.1 World Health Organization Africa (WHO): Seventy seven percent (77%) of children 12 – 23 months in Nigeria did not receive all routine immunization – Survey findings. 2017. Reference Source 10.21956/gatesopenres.16473.r37382 Reviewer response for version 1 Jain Monica 1 Referee International Initiative for Impact Evaluation, Washington, District of Columbia, USA

Competing interests: No competing interests were disclosed.

 3 9 2024 Copyright: © 2024 Jain M 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The study has an important objective of understanding of informal working mothers 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. My main comments are as follows:

The paper needs major editing as there is a significant repetition in different sections of the papers and correction in errors leave some sentences hanging and make it difficult to follow authors’ reasoning.

Methods - Which software was used for doing the process coding and content analysis?

Methods – While authors mention that that markets were randomly selected, they do not mention the criteria of selection of women within the markets.

The authors mention – ‘’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.’’ What is the role of the market leaders and significant others in the study design, data and analysis?

Statistical analysis – In table 3 – What is general population being referred to? Is it an average of urban and rural population?

Statistical analysis - In figure 1 – the number of PCV or OPV vaccination is not visible.

It would be useful to provide a rationale for understanding the uptake of ‘’special vaccines’’ not under NPI? Also, what vaccines are under this ‘’special vaccines’’ category?

In one part of the paper authors mention ‘’the factors contributing to incomplete immunization rate among mothers, which are the cost of special vaccines, such as Rotavirus.’’ If the vaccines are not part of the national immunization schedule, should they be included in estimation of immunization completion rate? Are these vaccines used in calculating childhood immunization completion rate and drop-off rate in Table 3? If not, then it may be useful to differentiate between the immunization completion rates under the NPI schedule and those with special vaccines.

Can the authors shed more light on the ‘’supplements’’ that they have mentioned in the paper? Why are these supplements important to discuss in relation to immunization uptake?

The results based on qualitative data contain too many similar quotes. Removing similar quotes will improve readability of the paper.

Authors mention – ‘’In some cases, many of them despite being married, still remained “breadwinners” in their families’’. It is not clear what the authors are suggesting about roles of women and their work status and after marriage.

Authors mention – ‘’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).’’ Are the authors implying that childhood immunization is embedded in the culture so much so that it is mandatory for mothers to immunize their children? Please clarify the argument being made here and its implication.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Public health policy with specialization in immunization of children.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.21956/gatesopenres.16473.r37387 Reviewer response for version 1 Ibrahim Olayinka 1 2 Referee https://orcid.org/0000-0002-2621-6593 University of Ilorin Teaching Hospital,, Ilorin, Nigeria Pediatrics, University of Global Health Equity, Kigali, Kigali, Rwanda

Competing interests: No competing interests were disclosed.

 22 7 2024 Copyright: © 2024 Ibrahim O 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Re: Contextualizing post day-one childhood immunization in-take

drop-off rate in Nigeria: An assessment of working mothers in

Ibadan

Comments

Title “Contextualizing post day-one childhood immunization in-take

drop-off rate in Nigeria: An assessment of working mothers in

Ibadan”  This title is too technical for general audience and a bit confusing, what is post day-one childhood immunization? Is after birth? Is first dose irrespective of date vaccine is received? The phrase is unclear? This should be modified. Immunization is an important, and audience go beyond medical personnel's. Also, be specific. add informal working mother: Typical understanding of a working mothers in Nigeria refers to those in formal sector, and also, include country? Not everyone knows Ibadan Globally

Abstract

Aims: “perceive post-day-one routine immunization” –this manuscript did not access post one day routine immunization but rather mothers’ perception and knowledge of immunization along with other itemized aims.

Methods

“ working nursing mothers” qualify it further: informal working nursing mothers.

Results:  Average age (mean) should be presented along the standard deviation. “The mean age of mothers at their first childbirth within the study group was 24.12 years” delete, it is not adding any information

Results

A “significant majority” of these mothers 95%) are married—delete significant

“ livelihood related causes” include the related causes? Though I find it difficult to locate in the manuscript

Conclusion

“ It is crucial for mothers to possess comprehensive knowledge about the mechanics and

operation of immunization” ?difficult to discern this the manuscript

Introduction

Unduly long with most concept repeated; this should be reduce and preferably about half of the current number of pages.

Methods

When was this data collected???

“A total of 1,044 (quantitative samples)” ? How is this sample size derived? Provide the details,

The qualitative sample is adequate.

“Immunization record assessment” how was this done? Provide the details.

“Health workers in the selected study sites” were they part of the qualitative vs quantitative? I did see their findings in the results.

What informed the sampling of 13 markets? How were the1,044 mothers recruited across these markets?

“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”

I guess this was the quantitative arm of the study, kindly specify

Also, this too  generic, give details of how each variable was handled. Indeed, there was no a single inferential statistics?

Results

All the mean should be accompanied with their respective standard deviations

“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” difficult to understand while the mean age of the mother and mean age at first childbirth? Look more of tautology??? The most important- age of the children of the mothers’ recruited is missing, which will guide in the interpretation of the data?

“The majority of mothers (53.8%)” In science 53% is not majority? Rather report as about half of the mothers

“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” These information are incomplete and yet there is no reference Table??? Besides, most of the information was not subjected to statistical analysis? What is there relevance

“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%)”- you can not use completion rate rate for 14 th week because it is not the end point, similar observation for 9 months- kindly revise and use drop off rate.

“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” you cannot make this conclusion without inferential statistics,-cursory look is insufficient.

Table 1: provide the details of “others” as footnote

“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” Delete…you can not have a prose repetition of a Table

 “About 48 mothers” humans are countable noun and can not be about?

Table 2: Present column one in days for consistency and need for clarity does within first week include day zero, does within second week include preceding days

Table 3: Insert n? percent's alone does not convey the true meanings? Delete completion rate, you can specify drop rate at 14 weeks, at 9 months? Nothing like completion rate- it gives impression as if it is satisfactory . Delete the footnote, besides it was a wrong interpretation.

Figure 1: Again the completion rate is confusing? This figure should n somewhere?

“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” ? birth dose vaccines are equally important (hepatitis B, Polio and BCG?

“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” It would have been good to also find out why don’t know the names? Are their local names for these vaccines?

“supplements’ this term needs to be defined? Supplement may mean different things to different people.

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” Partly it is not their faulty, if they were not told ? efforts should be made to teach the mothers the corresponding local names for these vaccines if there is any?

iko ahubi (coarse cough)? Am not sure the correct interpretation/translation is coarse cough -rather cough with post-tussive vomiting/pertussis),

“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)” am not sure when this data was collected but you should discuss with current NPI schedules, Rota Virus is now part of our routine immunization and PCV has already been part of pentavalent.

“Rotavirus is very low as shown that only a 7.5% rate had been completed (Table 2).? I can not see this in Table 2???

“ Mothers/caregivers’ knowledge of routine childhood immunization and vaccination status in children aged, 12-23 months in Ilorin, Nigeria; SO Ariyibi, AI Ojuawo, RM Ibraheem, FM Afolayan, OR Ibrahim African Health Sciences 23 (4), 582-591

Above article may be relevant for your discussion.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Pediatric Infectious disease, General Pediatrics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References : Mothers/caregivers' knowledge of routine childhood immunization and vaccination status in children aged, 12-23 months in Ilorin, Nigeria. Afr Health Sci .2023;23(4) : 10.4314/ahs.v23i4.61 582-591 38974273 10.4314/ahs.v23i4.61 omobowale mofeyisara Institute of Child Health, University of Ibadan, Ibadan, Oyo, Nigeria

Competing interests: No competing interests were disclosed.

 4 9 2024

Dear Reviewer,

Thank you for your insightful review. All suggestions have been examined and used in the improvement of the manuscript.

 10.21956/gatesopenres.16473.r37252 Reviewer response for version 1 Olomofe Charles 1 Referee https://orcid.org/0000-0002-5046-0449 East Tennessee State University, Johnson City, Tennessee, USA

Competing interests: No competing interests were disclosed.

 17 7 2024 Copyright: © 2024 Olomofe C 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

I have a few comments on the research.

METHODS SECTION

Every research carries risk. I would rather say the risk is minimal. What about the data that was collected? If it gets into the wrong hands, that is a risk!

Conducting an interviewer-administered questionnaire for 1,044 persons is huge. Did you make use of research assistants? If yes, you need to mention it here.

Moreover, which language was this questionnaire administered? Was Yoruba language employed at any point? If yes, was a back translations done?

Can you expound on this (sequential mixed method) more? Any sampling technique used?

Any particular reason or justification why only women within markets were considered? Working mothers in the title of your research is a broad group and it would be great to know why you scoped only market women.

DISCUSSION SECTION

There is no conclusion in this manuscript. What important messages are you leaving your readers with?

Similarly, no mention of the strengths and limitations of your work in this manuscript. Are there things you would have done differently had it been the circumstances were different

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Infectious disease epidemiology and vaccine research

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

omobowale mofeyisara Institute of Child Health, University of Ibadan, Ibadan, Oyo, Nigeria

Competing interests: No competing Interest declared

 4 9 2024

Reviewer comment: 1. Every research carries risk. I would rather say the risk is minimal. What about the data that was collected? If it gets into the wrong hands, that is a risk!:     

Author response: The participants in this study were not exposed to any serious know risk. The research team employed various means of protection to minimize risk.

Reviewer comment: 2. Conducting an interviewer-administered questionnaire for 1,044 persons is huge. Did you make use of research assistants? If yes, you need to mention it here: 

Author response: Yes. Trained research assistants were employed on the project to assist in data collection. 

Reviewer comment: 3. Can you expound on this (sequential mixed method) more?: Sequential mixed method here implies timing in collection of the data. The phasing of how data were collected. Any sampling technique used?: 

Author response: Explanatory Sequential Design detailing two phase design,  where quantitative data is collected and analyzed first, then qualitative data were also collected and analyzed based on the quantitative results.

Reviewer comment: 4. Any particular reason or justification why only women within markets were considered? Working mothers in the title of your research is a broad group and it would be great to know why you scoped only market women:

Author response: Working mothers have limited or no time to attend the available immunization centers because of the time-consuming age-long practices of traditional immunization centers, which can result in loss of time, wages and in some instances source of livelihood for these mothers. These partly culminate to low demand for childhood vaccination in addition, many working mothers in the informal sectors like the local markets miss out on community household’ immunization programmes due to the long hours they spend in the market and also because of the inconvenience of leaving their wares to attend immunization centers, and there are limited studies in Nigeria on mothers on informal economic space  and childhood immunization in particular, thus this study was carried out.

DISCUSSION SECTION

Reviewer comment: 5. There is no conclusion in this manuscript. What important messages are you leaving your readers with?:

Author response:  Conclusively, working mothers’ awareness and knowledge about childhood immunization is not contextualize in practice thus leading to incomplete understanding and interpretation of vaccine and vaccination.

Reviewer comment: 6.Similarly, no mention of the strengths and limitations of your work in this manuscript. Are there things you would have done differently had it been the circumstances were different:  

Author response: This study contribute to the discourse on childhood immunization by identifying socio-cultural, socio-economic and day-to-day taken for granted  determinants that affect post-day one immunization among the study population, however, the study is limited in that the sample cannot be generalized for the whole of Nigeria or West Africa and the data that were collected represent western part of Nigeria. The study recommends further National studies.