Chapter One

1.1 Background of the Study

The eradication of smallpox and the imminent demise of polio are clear reminders of the power
of vaccination in dealing with the scourge of communicable diseases in the developing world.
The World Health Organization’s (WHO) Expanded Program for Immunization (EPI), which is
focused on the six major diseases of childhood (diphtheria, pertussis, tetanus, polio, measles, and
tuberculosis), succeeded in dramatically raising immunization coverage in developing countries
from 5% in the 1970s to more than 80% of the birth cohort in the 1990s (Almaghaslah, Alsayari
& Kandasamy, 2021).

Although it must be admitted that not all 80% were fully immunized, it is estimated that this
effort saved two to three million lives per year. A report from the U.S. National Institute of
Allergy and Infectious Diseases (NIAID) stated that the twentieth century witnessed a revolution
in immunology, microbiology, molecular biology, biotechnology, and vaccinology and saw the
introduction of vaccines that led to the reduction or elimination of 21 infectious diseases
(Ecarnot & Maggi, 2019). The development of improved vaccines and new vaccines against a
variety of infectious diseases such as hepatitis B, bacterial meningitis, pneumonia, typhoid, and
varicella are examples that have been added to the armory. More importantly, these advances in
the biomedical sciences have provided novel approaches to future vaccines hitherto
unimaginable (e.g. DNA vaccines, edible vaccines, and therapeutic vaccines) (El-Elimat &
AbuAlSamen, 2018).

Despite these impressive achievements, significant problems and challenges remain. The
fragility of achievements by many developing countries is well illustrated by the impact of
economic crises in various parts of the world in the 1990s (Favin, Hickler & Kanagat, 2018).
Clearly, the wider implementation of the currently available vaccines against the major diseases
that cause significant mortality and morbidity in the developing countries (e.g. hepatitis B,
Haemophilus influenzae type b (Hib) meningitis, typhoid fever, and rotavirus) is a key challenge
(Harvey & Reissland, 2018).

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Many of these vaccines have been licensed for more than 10 years, have been proven safe and
efficacious, have been offered at low prices and yet have not been introduced as part of national
mass immunization programs in many developing countries (Favin, Hickler & Kanagat, 2018).
In the face of economic difficulties, maintaining current immunization coverage is a major
challenge for many governments. Political commitment to maintaining vaccination infrastructure
in the face of competing priorities, and continued affordability of vaccines, needs to be
maintained (Khubchandani, 2017).

1.2 Statement of the Problem

Despite the significant progress made in global vaccination efforts, low-income communities
continue to face challenges in achieving optimal vaccine coverage rates. Understanding the
knowledge and practices of the general public towards vaccination in these communities is
crucial for developing targeted interventions to address gaps and improve vaccine uptake.
Clearly, the wider implementation of the currently available vaccines against the major diseases
that cause significant mortality and morbidity in the developing countries (e.g. hepatitis B,
Haemophilus influenzae type b (Hib) meningitis, typhoid fever, and rotavirus) is a key challenge
(El-Elimat & AbuAlSamen, 2018).

Many of these vaccines have been licensed for more than 10 years, have been proven safe and
efficacious, have been offered at low prices and yet have not been introduced as part of national
mass immunization programs in many developing regions. In the face of economic difficulties,
maintaining current immunization coverage is a major challenge for many governments
(Naderifar, Goli & Ghaljaie, 2019). Political commitment to maintaining vaccination
infrastructure in the face of competing priorities, and continued affordability of vaccines, needs
to be maintained (Ozawa, Clark & Portnoy, 2018).

This study aims to determine the knowledge and practices of Vaccination among Pregnant
women attending antenatal care services in Ibeku Umuahia North Local Government Area, Abia
State, Nigeria. Pregnant women may face economic, geographical, and logistical barriers that
limit their access to vaccination services. These barriers may include financial constraints,

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limited healthcare infrastructure, lack of transportation, and insufficient awareness of available
vaccination programs.
By addressing these key problem areas, this research aims to provide valuable insights into the
knowledge and practices of vaccination among pregnant women attending antenatal care services
in Ibeku Umuahia North Local Government Area, Abia State.

1.3 Objectives of the Study

General Objective
The General Objective of this study will be to determine the Knowledge and Practices of
vaccination among pregnant women attending antenatal care services in Ibeku Umuahia North
Local Government Area, Abia State.

Specific Objectives

1. To determine the socio demographic characteristics of pregnant women attending

antenatal care services in Ibeku Umuahia North Local Government Area, Abia State.
2. To determine the knowledge of vaccination among pregnant women attending
antenatal care services in Ibeku Umuahia North Local Government Area, Abia State.

3. To explore the cultural and social factors that influence vaccination practices in Ibeku
Umuahia North Local Government Area, Abia state.
4. To identify the barriers to vaccine accessibility and utilization in Ibeku Umuahia
North Local Government Area, Abia state.
5. To access the practices of vaccination among pregnant women attending antenatal
care services in Ibeku Umuahia North Local Government Area, Abia state.
1.4 Research Questions
1. What is the socio demographic characteristics of respondents in Ibeku Umuahia
North Local Government, Abia state?
2. What is the knowledge of vaccination among pregnant women attending antenatal
care services in Ibeku Umuahia North Local Government Area, Abia state?

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 3. What are the cultural and social factors that influence vaccination practices in Ibeku
Umuahia North Local Government Area, Abia state?
4. What are the barriers to vaccine accessibility and utilization in Ibeku Umuahia North
Local Government Area, Abia state?
5. What are the practices of vaccination among pregnant women attending antenatal
care services in Ibeku Umuahia North Local Government Area, Abia state?

1.5 Scope of the study

The study will be among pregnant women attending antenatal care services in Ibeku Umuahia
North Local Government Area, Abia state on the knowledge and practices of vaccination.

1.6 Significance of the study

The research on the Knowledge and practices of Vaccination among Pregnant women attending
antenatal care services in Ibeku Umuahia North Local Government Area, Abia state will have
significant implications which include:

Bridging the Knowledge Gap: The study will contribute to filling the knowledge gap
regarding vaccination practices and knowledge among Pregnant women attending
antenatal care services in Ibeku Umuahia North Local Government Area, Abia state. By
assessing the knowledge levels of Pregnant women, the research will provide valuable
insights into the specific areas of misinformation or lack of awareness that can be
targeted for educational interventions. This knowledge can help bridge the gap between
misconceptions and accurate information about vaccinations, empowering individuals to
make informed decisions regarding their health.
Informing Vaccination Strategies: Understanding the unique challenges faced by
pregnant women towards vaccination is essential for designing effective vaccination
strategies. The research will provide evidence-based recommendations to healthcare
providers, policymakers, and community leaders, enabling them to develop targeted
interventions to improve vaccine uptake, accessibility, and coverage rates. These
strategies can contribute to reducing health disparities and improving overall public
health outcomes.

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 Building Trust and Confidence: Vaccine hesitancy often stems from mistrust in
healthcare systems, government initiatives, and cultural factors. By examining the level
of trust and confidence in vaccinations among Pregnant women, the study can shed light
on the factors influencing public perception and trust-building measures. This
understanding will assist in developing communication strategies and interventions that
foster trust, address concerns, and enhance confidence in vaccination programs.
Promoting Equity in Healthcare: Most Pregnant women often face disparities in
healthcare access and outcomes. This research will contribute to promoting equity in
healthcare delivery. Findings from the study can inform policy recommendations aimed
at reducing barriers to vaccination access, and protection against vaccine-preventable
diseases.
Replicability and Scalability: The study's findings and recommendations can be adapted
and scaled up to address vaccination knowledge and practices among Pregnant women,
contributing to broader public health initiatives and efforts to achieve universal
immunization coverage.

Overall, this study's significance lies in its potential to contribute to improved vaccination
knowledge, practices, and access among Pregnant women, specifically focusing in Ibeku
Umuahia North Local Government Area, Abia state. The outcomes can inform targeted
interventions, policies, and strategies to address barriers, reduce vaccine hesitancy, and enhance
public health outcomes, ultimately leading to healthier and more resilient communities.

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 Chapter Two
Literature Review
This literature review will be done under the following categories; Conceptual framework,
Emperical review and Theoretical framework

2.0 Conceptual Framework

2.1 Concept of Vaccination
Vaccination is a simple, safe, and effective way of protecting the body against harmful diseases,
before one comes in contact with them. Vaccination uses the body’s natural defense to build
resistance to specific infections and makes the immune system stronger (Liu & Liu, 2018). The
word “vaccine” originates from the Latin Variolae vaccinae (cowpox), which Edward Jenner
demonstrated in 1798 could prevent smallpox in humans (Harvey, Reissland, 2018). Today the
term ‘vaccine’ applies to all biological preparations, produced from living organisms, that
enhances immunity against disease and either prevent (prophylactic vaccines) or, in some cases,
treat disease (therapeutic vaccines). Vaccines are administered in liquid form, either by injection,
by oral, or by intranasal routes (Liu & Liu, 2018). Vaccines are composed of either the entire
disease-causing microorganism or some of its components.
They may be constructed in several ways:
From living organisms that have been weakened, usually from cultivation under sub-optimal
conditions (also called attenuation), or from genetic modification, which has the effect of
reducing their ability to cause disease

From whole organisms that have been inactivated by chemical, thermal or other means

From components of the disease-causing organism, such as specific proteins and

polysaccharides, or nucleic acids

From inactivated toxins of toxin-producing bacteria;

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 From the linkage (conjugation) of polysaccharides to proteins (this increases the
effectiveness of polysaccharide vaccines in young children)

2.1.1 Constituents of a Vaccine

In addition to the bulk antigen that goes into a vaccine, vaccines are formulated (mixed) with
other fluids (such as water or saline), additives or preservatives, and sometimes adjuvants.
Collectively, these ingredients are known as the excipients. These ensure the quality and potency
of the vaccine over its shelf-life (Naderifar, Goli & Ghaljaie, 2019). Vaccines are always
formulated so as to be both safe and immunogenic when injected into humans. Vaccines are
usually formulated as liquids, but may be freeze-dried (lyophilized) for reconstitution
immediately prior to the time of injection. Preservatives ensure the sterility of the vaccine over
the period of its shelf-life. Preservatives may be used to prevent contamination of multi-dose
containers: when a first dose of vaccine is extracted from a multi-dose container, a preservative
will protect the remaining product from any bacteria that may be introduced into the container.
Or, in some cases, preservatives may be added during manufacture to prevent microbial
contamination (Phillips, Dieleman & Lim, 2019).

Preservatives used in vaccines are non-toxic in the amounts used and do not diminish the
potency of vaccines. But not all preservatives can be used in all vaccines. Some preservatives
will alter the nature of some vaccine antigens. Although there is no evidence of harm caused by
any preservative, vaccines in the US and Europe have, for the most part, been free of thimerosal
(or contain only trace quantities) for several years now (Qattan, Alshareef & Alsharqi, 2021),
and some newer vaccines may not contain any preservative. In addition to preservatives, some
vaccines contain adjuvants. Adjuvants enhance the immune effect of the vaccine antigen, but do
not themselves act as antigens. Aluminum salts are the most commonly used adjuvant for
vaccines. Adjuvanted vaccines may have a slightly higher rate of adverse reactions, including
pain at the injection site, malaise and fever (Shadish, Cook & Campbell, 2022).

2.1.2 The Mechanism of Vaccine

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When inactivated or weakened disease-causing microorganisms enter the body, they initiate an
immune response. This response mimics the body’s natural response to infection. But unlike
disease-causing organisms, vaccines are made of components that have limited ability, or are
completely unable, to cause disease. The components of the disease-causing organisms or the
vaccine components that trigger the immune response are known as “antigens” (Naderifar, Goli
& Ghaljaie, 2019). These antigens trigger the production of “antibodies” by the immune
system. Antibodies bind to corresponding antigens and induce their destruction by other immune
cells. The induced immune response to either a disease-causing organism or to a vaccine
configures the body’s immune cells to be capable of quickly recognizing, reacting to, and
subduing the relevant disease-causing organism (Phillips, Dieleman & Lim, 2019).

When the body’s immune system is subsequently exposed to a same disease-causing organism,
the immune system will contain and eliminate the infection before it can cause harm to the body.
The effectiveness and the duration of the protective effect of a vaccine depend both on the nature
of the vaccine constituents and on the manner in which they are processed by the immune system
Some disease-causing organisms, such as influenza, change from year to year, requiring annual
immunization against new circulating strains (Phillips, Beard & Macartney, 2018). In very
young children, the immune system is immature and less capable of developing memory. In this
age group, duration of protection can be very short-lived for polysaccharide antigens (Polack &
Thomas, 2020).

2.1.3 Impact of Vaccine on Diseases

Vaccines have one of the greatest impacts on public health. Their impact on reducing human
mortality is second only to the provision of safe drinking water. Vaccines are provided to
individuals to protect them from disease, but they play an even greater role in protecting entire
populations from exposure to infectious diseases. Vaccine-preventable diseases that were once
prevalent in industrialized countries have virtually disappeared where vaccination has been
implemented. In the 20th century, vaccines have reduced the morbidity from vaccine preventable
diseases by as much as 89 – 100%. The prevention of disease has had an enormous impact on
economic development by limiting the costs of curative care and saving billions of dollars in
countries where diseases have been well controlled or eliminated.

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 Two factors contribute to the ability of a vaccine to control or eliminate a disease and they are:
• the effectiveness of the vaccine; and
• the level of vaccination coverage achieved in a given population. These vary slightly from one
country to another, but everywhere they are used licensed vaccines are considered highly
effective at preventing disease
2.1.4 Efficacy of Vaccines
Vaccine efficacy is the reduction in incidence of a disease amongst those who have been
vaccinated relative to the incidence in the unvaccinated. Because biologicals are inherently
variable, individuals do not respond identically to vaccines. Vaccines may fail to induce
immunity in a few individuals. But the most effective vaccines induce a protective immune
response in > 95% of individuals. If a high level of vaccination coverage is achieved with an
effective vaccine, disease transmission can be interrupted (Qattan, Alshareef & Alsharqi, 2021).
When disease transmission is interrupted, even those individuals who were not vaccinated, or
who were vaccinated and did not develop immunity, will be protected from disease. This effect
is known as herd immunity. Smallpox was eradicated by achieving sufficient immunization
coverage to prevent transmission of disease to unvaccinated non-immunes (susceptible) (Ozawa,
Clark & Portnoy, 2018).

2.1.5 How Safe are Vaccines?

The benefits of vaccination are indisputable. Immunization has had one of the greatest impacts
on health, second only to clean drinking water. Vaccines prevent death, illness and / or disability.
But because of the immune reactions that they induce, vaccines can cause some discomfort. The
vast majority of adverse effects associated with vaccines are minor and transient. These are
typically pain at the injection site, or mild fever (Krejcie & Morgan, 2018). More serious
adverse effects occur rarely. Some serious adverse effects may be so rare that they occur only
once in millions of vaccine doses delivered, and some serious adverse events may occur so rarely
that their risk cannot be accurately assessed (Mathieu, Ritchie & Ortiz-Ospina, 2021). Some
individuals may be sensitive to some components or trace elements in some vaccines, such as
eggs, antibiotics, or gelatin. Otherwise, the cause of rare or very rare adverse events is usually
unknown. It is believed that rare and very rare adverse effects are associated with individual
differences in immune responses (Naderifar, Goli & Ghaljaie, 2019).

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2.1.6 Factors Affecting Vaccination.
2.1.61 Socio-cultural Perspectives on Vaccination
Vaccination programs differ culturally, because they adjust to their environment, being
permeated by social and cultural influences (Naderifar, Goli & Ghaljaie, 2019). Identification
of factors that may impact the success of vaccination and identification of acceptable and
convenient sites for vaccine delivery, reliable sources for information about the vaccine, e.g.
health clinic personnel and community health volunteers, should be considered for successful
vaccination programs (Mathieu, Ritchie & Ortiz-Ospina, 2021). Studies have showed that
vaccination coverage is hampered by difficulty in accessing medical care, costs, complex
transport, and by users’ characteristics, such as low education, parental knowledge, attitude and
family poverty (Krejcie & Morgan, 2018).

Public opinions about vaccination include varied and deep-seated beliefs, due to the tension
between divergent cultural viewpoints and value systems. Several key cultural perspectives on
vaccination stem from individual rights and public health stances toward vaccination, various
religious standpoints and vaccine objections, and suspicion and mistrust of vaccines among
different U.S. and global cultures and communities (Naderifar, Goli & Ghaljaie, 2019).

2.1.7 Individual Versus Public Health Stances

Many countries require their citizens to receive certain immunizations. In the United States, state
laws dictate mandatory vaccinations, such as those required for children to enter school
(Khubchandani, 2017). Controversies over the efficacy, safety, and morality of compulsory
immunization stem from the longstanding tension between two, sometimes divergent, goals:
protecting individual liberties and safeguarding the public’s health (Phillips, Beard &
Macartney, 2018). Individual versus public health priorities were first argued in the U.S.
Supreme Court more than 100 years ago. In Jacobson versus Massachusetts, a Cambridge

10
resident refused to be vaccinated for smallpox, because he believed the law violated his right to
care for his own body how he knew best. The Court rejected Jacobson’s challenge. This seminal
1905 ruling has served as the foundation for state actions to limit individual liberties to protect
the public’s health (Shadish, Cook & Campbell, 2022).

2.1.8 Religious Perspectives and Vaccine Objections

Certain religions and belief systems promote alternative perspectives toward vaccination.
Religious objections to vaccines are generally based on the ethical dilemmas associated with
using human tissue cells to create vaccines, and beliefs that the body is sacred, should not receive
certain chemicals or blood or tissues from animals, and should be healed by God or natural
means. For example, the Catholic Church recognizes the value of vaccines and the importance of
protecting individual and community health. It asserts, however, that its members should seek
alternatives to vaccines made using cell lines derived from aborted fetuses (Polack & Thomas,
2020).

2.1.9 Suspicion and Mistrust of Vaccines

Suspicion and apprehension about vaccination are common, particularly among several specific
disenfranchised communities in the United States and internationally. For these communities,
suspicion is best understood in a social and historical context of inequality and mistrust. For
example, several studies have found that the legacy of racism in medicine and the Tuskegee
Syphilis Study, a clinical trial conducted with African Americans denied appropriate treatment
opportunities, are key factors underlying African Americans’ distrust of medical and public
health interventions, including vaccination (Polack & Thomas, 2020).

Internationally, in parts of Asia and Africa, mistrust of vaccines is often tied to “Western plot”
theories, which suggest that vaccines are ploys to sterilize or infect non-Western communities
(Phillips, Beard & Macartney, 2018). Suspicion has existed for different infections and vaccines
over the past 20 years. For example, in Cameroon in 1990, rumors and fears that public health
officials were administering various childhood vaccines to sterilize women thwarted the
country’s immunization efforts (Mathieu, Ritchie & Ortiz-Ospina, 2021). Similarly, in Tanzania
in the mid 1990s, a missionary raised concerns about tetanus immunizations, sparking

11
sterilization rumors and halting the campaign (Qattan, Alshareef & Alsharqi, 2021). And in
2005, measles vaccine suspicions led to decreased vaccination rates and increased infections in
Nigeria (Phillips, Dieleman & Lim, 2019).

2.1.10 Community Influence

Community participation in promoting and sustaining health was championed in the Declaration
of Alma Ata on Primary Health Care; which stated – “the people have the right and duty to
participate individually and collectively in the planning and implementation of their health care”
(Qattan, Alshareef & Alsharqi, 2021). Community perception and their participation in
vaccination programs aids as a positive reinforcement in parental perception. Parental concern
regarding vaccine safety occurs within the context of the community and may be shared by other
parents in the same community (Khubchandani, 2017).

2.1.11 Socio-economic Status

Mother's occupation and that of her partner are important in the attainment of full childhood
immunization. Children whose parents held white-collar jobs were more advantaged compared to
those in agriculture, blue-collar jobs, and services/sales (Phillips, Beard & Macartney, 2018). In
general, the immunization coverage is lowest among poor populations and in peripheral areas
mainly due to inability to afford transportation to bring the child to immunization clinics
(Streefland, Liu & Reissland 2018). One study showed parents of low socio-economic status
(low annual income, low level of education) were less likely to be up-to-date with newer
vaccines and hence their children were less likely to be vaccinated with these vaccines (Ozawa,
Clark & Portnoy, 2018).

A study conducted in the United States showed that children from low socio-economic
background and low paternal education level were less likely to be vaccinated as the parents
were less up-to-date with the vaccines (Shadish, Cook & Campbell, 2022). Similarly, children of
mothers having an asset score above the poorest had complete DPT immunization status by 9
months of age in Bangladesh (Harvey, Reissland, 2018). On the other hand, children born to

12
mothers of higher socio and economic status were more likely to be fully vaccinated (Snilstveit,
Vojtkova & Bhavsar, 2018). Likewise, another study showed that mothers with a better socio-
economic status, such as having occupations and a stable income improved the fully
immunization coverage (Higgins, Thomas, & Chandler, 2020).

2.1.12 Barriers to Vaccine Accessibility and Utilization

These barriers include:

Family Structure and Support

The major findings of a study conducted in Uganda showed that the supportive or non-supportive
role of significant others influenced the involvement or non-involvement of parents in childhood
immunization (Krejcie & Morgan, 2018). Similarly, reasons for unintentional missed
vaccinations shown by a study were forgetting appointment, lack of time after mother returns
from work or having other children commitments (Mathieu, Ritchie & Ortiz-Ospina, 2021). A
qualitative survey conducted in Transkei community in Eastren Cape showed that one of the
main reasons for not bringing their children to immunization clinics were unavailability of care
taker to either bring the child to the clinic or for the care of other children at home, mother
pregnant/mother unable to walk to the clinic or elderly care taker not able to walk to the clinic
(Krejcie & Morgan, 2018). This shows that family support is a vital aspect which helps in better
uptake of vaccination.

Health Education

Mass media might play an important role in shifting the public’s perception of vaccination
(Reluga, 2019). Exposure to the media is significantly associated with childhood immunization.
This can be attributed to the sensitization messages that parents receive through media to get
their children immunized (Ozawa, Clark & Portnoy, 2018). Advice given to mothers at health
facilities during immunization services was assessed in one study and participants who recalled
having been advised on the next date of growth monitoring had children who were three times
more likely to receive full immunization (Krejcie & Morgan, 2018). Similarly, in one study,

13
community members pointed to a lack of information about particular vaccines, vaccination
scheduling and times of services as one of the most common constraints to having a child
vaccinated (Qattan, Alshareef & Alsharqi, 2021).

Trust on Vaccinator

Likewise, maternal trust on vaccinators and the attitude of vaccinators towards the recipients is
another factor that wheels the uptake of vaccines. A study which looked at the factors governing
maternal decision making regarding their infants vaccination showed that mothers who had open
27 and trusting relationship with their pediatricians were more likely to accept vaccination
compared to the ones whose pediatricians could not address the maternal concerns and give
adequate time and knowledge regarding vaccination to the mothers (Naderifar, Goli & Ghaljaie,
2019). In such instances, they were more likely to be steered to alternative forms of medicine
like homeopathy and reject vaccinations (Qattan, Alshareef & Alsharqi, 2021). Another study
showed that health care provider can positively influence the parents towards vaccinating their
children especially when the parents are concerned about vaccine safety by building a trusting
and respectful relationship with the parents (Polack & Thomas, 2020).

Gender Based Difference

Gender discrimination is an important factor which guides the uptake of vaccination. A study
conducted in India showed that girls were less likely to be fully immunized compared to boys
(Phillips, Beard & Macartney, 2018). Similarly, another study, also conducted in India, showed
that the proportion of boys fully immunized was higher than girls (Polack, & Thomas, 2020).
Similarly, one study conducted in Nepal showed that female children were more likely to
dropout compared to male children (Snilstveit, Vojtkova & Bhavsar, 2018). In a study
conducted in migrant population in China, boys showed higher up to date immunization rate than
girls. It indicated son preference toward immunization services in migrant children in China
(Shadish, Cook & Campbell, 2022).

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 Religion

Religion and spirituality are integral components of socio-demographics (rural culture) and
influence perceived vulnerability to infection and perceived severity to infection (Khubchandani,
2017). Religious leaders are highly esteemed, and their authority can convince members of their
congregations to accept or reject vaccination (WHO, 2021). A WHO report from polio endemic
region in Nigeria states that only a total of 16% children were adequately vaccinated in that
region; the main reason being that the community was predominantly of Muslim background and
believed that polio drops were used as a tool for causing sterility in the children and had been
shunned by community leaders (WHO, 2021).

2.2 Theoretical Framework

2.2.1 Health Belief Model

A suitable theoretical framework for the research on the knowledge and practices of Vaccination
among Pregnant women attending antenatal care services in Ibeku Umuahia North Local
Government Area, Abia state, could be the Health Belief Model (HBM).
The Health Belief Model is a widely used theoretical framework in health behavior research that
seeks to understand and predict individuals' health-related behaviors. It consists of several key
constructs that can be applied to the context of vaccination in low-income communities:

Perceived Susceptibility: This construct explores individuals' beliefs about their

vulnerability to vaccine-preventable diseases. Assessing the perceived susceptibility to
diseases among Pregnant women in Ibeku Umuahia North Local Government Area, Abia
state can help understand the level of awareness and concern about the potential health risks
associated with not being vaccinated.

Perceived Severity: This construct examines individuals' perceptions of the seriousness of

vaccine-preventable diseases. Investigating the perceived severity of such diseases within

15
 Ibeku Umuahia North Local Government Area can provide insights into how community
members evaluate the potential consequences of not receiving vaccinations, thereby
influencing their decision-making processes.

Perceived Benefits: This construct focuses on individuals' beliefs about the positive
outcomes of receiving vaccines. Understanding the perceived benefits of vaccinations among
Pregnant women can help identify factors that motivate individuals to seek vaccination and
emphasize the advantages of immunization.

Perceived Barriers: This construct explores the obstacles individuals perceive in accessing
and utilizing vaccination services. Examining the perceived barriers to vaccination among
Pregnant women such as financial constraints, lack of transportation, or limited healthcare
infrastructure, can inform interventions aimed at addressing these specific challenges.

Cues to Action: This construct encompasses external factors that prompt individuals to
take action towards vaccination. Identifying the cues to action within the community,
such as healthcare provider recommendations, community leaders' influence, or social
support networks, can assist in designing effective communication strategies and
interventions that leverage these cues.

Self-Efficacy: This construct refers to individuals' confidence in their ability to take

action and overcome barriers to vaccination. Assessing the level of self-efficacy among
Pregnant women can help identify factors that may enhance or hinder individuals'
confidence in accessing and utilizing vaccination services.

By employing the Health Belief Model, the research can provide a theoretical framework for
understanding the factors that influence vaccination knowledge, practices, and access among
Pregnant women in Ibeku. This framework can guide data collection, analysis, and the
development of targeted interventions that address the specific beliefs, perceptions, and barriers
identified within the community, ultimately improving vaccine acceptance and coverage rates.

2.3 Empirical Review

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Some meritorious woks conducted during the course of this research includes “Vaccine equity in
low and middle income countries: a systematic review and meta-analysis” by Phillips, Dieleman
and Lim, (2019), they postulated that Evidence to date has shown that inequality in health, and
vaccination coverage in particular, can have ramifications to wider society. However, whilst
individual studies have sought to characterize these heterogeneities in immunization coverage at
national level, few have taken a broad and quantitative view of the contributing factors to
heterogeneity in immunization coverage and impact, i.e. the number of cases, deaths, and
disability-adjusted life years averted. This systematic review aims to highlight these geographic,
demographic, and sociodemographic characteristics through a qualitative and quantitative
approach, vital to prioritize and optimize vaccination policies. A systematic review of two
databases was undertaken using search terms and keywords to identify studies examining factors
on immunization inequality and heterogeneity in vaccination coverage. Inclusion criteria were
applied independently by two researchers. Studies including data on key characteristics of
interest were further analyzed through a meta-analysis to produce a pooled estimate of the risk
ratio using a random effects model for that characteristic. One hundred and eight studies were
included in this review. We found that inequalities in wealth, education, and geographic access
can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were
not significantly different in terms of full vaccination status compared to urban areas but noted
considerable heterogeneity between countries. We found that females were 3% (95%CI[1%,
5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children
whose mothers had no formal education were 27% (95%CI[16%,36%]) less likely to be fully
vaccinated than those whose mother had primary level, or above, education (Phillips, Dieleman
& Lim, 2019).

Another already literature reviewed during the course of this research is Improving routine
childhood immunization outcomes in low-income and middle-income countries: an evidence gap
map by Naderifar, Goli & Ghaljaie, (2019), they had it to say that many LMICs struggle with
last-mile connectivity, limited supply of health personnel, difficulty training health personnel
with relatively low literacy/skill levels and lack of reliable monitoring and surveillance systems
to provide reliable up-to-date data to improve targeting of immunization programs. Behavioral,
social and practical constraints faced by caregivers include caregivers’ and communities’

17
concerns about vaccine safety, lack of knowledge about the recommended schedule, fear of
adverse events following immunization, poor quality and reliability of immunization services
and difficulty accessing health services. developed an intervention–outcome matrix with 38
interventions and 43 outcomes. We searched academic databases and grey literature sources for
relevant impact evaluations (IEs) and systematic reviews (SRs). Search results were screened on
title/abstract. Those included on title/abstract were retrieved for full review. Studies meeting the
eligibility criteria were included and data were extracted for each included study. All screening
and data extraction was done by two independent reviewers. We analyzed these data to identify
trends in the geographic distribution of evidence, the concentration of evidence across
intervention and outcome categories, and attention to vulnerable populations in the literature. We
identified 309 studies, comprising 226 completed IEs, 58 completed SRs, 24 ongoing IEs and 1
ongoing SR. Evidence from IEs is heavily concentrated in a handful of countries in sub-Saharan
Africa and South Asia. Among interventions, the most frequently evaluated are those related to
education and material incentives for caregivers or health workers. There are gaps in the study of
non-material incentives and outreach to vulnerable populations. Among outcomes, those related
to vaccine coverage and health are well covered. However, evidence on intermediate outcomes
related to health system capacity or barriers faced by caregivers is much more limited.

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 Chapter Three
Research Methodology

3.1 Area of study

The research will be carried out in Ibeku Umuahia North Local Government Area, Abia state.
Ibeku is a Community located in Umuahia North Local Government Area made up of seven
clans namely Osaa, Amaforo, Ndume, Afaraukwu, Emede, Isieke and Afaranta. The people of
Ibeku speak Igbo, one of the three dominant Nigerian languages. It has a dense population of
about 5200 persons who are majorly Christians predominantly Christians from Catholic,
Anglicans, Presbyterians and Methodists denominations, but denominations such as Assemblies
of God have increased in number. The people of Ibeku are a historically hardworking people and
their festivity is only generally accepted at the end of the calendar year known as new yam
festival which represents farming, and hard-work. They are also involved in trading and
exchange of goods and services.

3.2 Research Design

The study will adopt a cross-sectional descriptive design. A well-structured questionnaire will be
used to collect data. This design is concerned with the present and tells how people feel or react
to changes under investigation. The purpose why this design will be chosen is to present a
picture of the situation as it naturally occurs. This design allows the researcher to look at
numerous things at once as it takes place at a particular spot.

3.3 Population of Study:

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The population of the study will comprise of all pregnant women attending antenatal care
services in Ibeku Umuahia North Local Government, Abia state.

3.4 Sample Size Determination

The researcher will use Cochrane formula to determine the sample size
no = Z2pq
e2
Where P is sample Proportion
Z is the confidence level
Q is the estimate of Variance
e is the margin of error/precision level

Z = 1.96 at 95% Confidence level

P = 0.5 (Maximum variability)
Q = (1-p) = 1-0.5= 0.5
e = 0.52

n = (1.96)2 (0.5) x (0.5) = 385

(0.5)2

3.5 Sampling Technique

Given the diverse groups within the population, a combination of sampling techniques will be
employed:
 Stratified Sampling: will be used to select all groups (inmates of different security
levels, and different job roles among staff).
 Random Sampling: Simple Random sampling via the use of ballot papers will be used to
select respondents within each stratum to minimize bias.

3.6 Instrument for Data Collection

Data collection will be through a structured questionnaire constructed by the researcher. It will
be based on extensive literature review on the knowledge and practices of vaccination among

20
pregnant women attending antenatal care services in Ibeku Umuahia North Local Government
Area, Abia State. The questionnaire will be made up of open and closed ended questions. The
questionnaire will be divided into different sections. Section A will comprise of the
sociodemographic characteristics of respondents while section B will comprise of the knowledge
of vaccination among respondents and Section C will capture the barriers to vaccination
practices.

3.6.1 Validity of Instrument

Validity will be done by giving the questionnaire to the researcher’s supervisor who will make
the necessary and appropriate corrections and these corrections will be effected by the researcher
before the questionnaire is distributed for reliability test.

3.7. Reliability of the Instrument

For the reliability of the instrument, the instrument will be pretested using 10- 15 pregnant
women attending antenatal in a different Primary health care service other than the study.

3.8 Ethical Clearance

An ethical clearance letter will be obtained from Abia State University Ethical Committee. An
informed consent will be sorted among the chief Matron of the selected Primary health care
Centre. Respondents consent will also be obtained and the need for the study explained to them
to gain their co-operation. Confidentiality and anonymity of information will be guaranteed, the
respondents will not be forced to participate against their will and any who wish to back out will
be allowed to do so.

3.9 Method of Data Collection

The pretested questionnaire will be distributed to the respondents with the help of the research
assistant. The questionnaire will be collected immediately after filling it on the spot.

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3.10 Method of Data Analysis
Data will be cleaned, coded and entered into the system using Statistical Package for Social
Science (SPSS) version 25.0. Data analyzed will be presented in tables and charts.

3.11 Work Plan

The researcher has a work plan of printing a good number of questionnaires in view which will
be used to share to the respondents to access their opinions on the knowledge and practices of
vaccination among pregnant women attending antenatal care services in Ibeku Umuahia North
Local Government Area, Abia state. Meanwhile, the researcher would get a letter from the
Department of Public Health, Abia State University Uturu endorsing her to be a final year
student of public health who is on a Final Year research in partial fulfillment for the award of the
degree Bachelor of Science Degree in Public Health (Bsc in Public Health). The letter would be
taken to the community and given to the authorities in order to enable the researcher carry on
with her research.

3.12 Estimated Budget

The researcher would need a lot of finances to print relevant materials needed for the study. As
well as this, money will be used to produce the questionnaire and also for transportation purpose
for the period the study will be carried out. A total amount of 50, 000 naira will be spent during
the course of this research.

ITEM AMOUNT
Transportation N 15,000

Printing of Materials N 20, 000

Logistics N15,000

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