Nigerian rural mothers’ knowledge of routine childhood immunizations and attitudes about use of reminder text messages for promoting timely completion

Study setting: The study team conducted a cross-sectional survey in six randomly selected states and the Federal Capital Territory (FCT) in Nigeria (a total of 7 sites).

Study population: The primary study population consisted of mothers of children attending immunization clinics. The target population was mothers with children aged 0–2 months who attended immunization clinics during the study period.

Study team: Our team consists of the authors with assistance from three sorts of colleagues. The authors conceptualized the research idea, administered the project, managed software and the data, prepared the manuscript, and supervised the enroled facility health workers and two sorts of Research Assistants (Field Research Assistants/FRAs and Technical Research Assistants/TRAs) who performed the tasks we describe below.

Study design: We employed Multi-Stage sampling. First, the authors randomly selected one state from each of Nigeria’s six geo-political zones through drawing lots, yielding: 1. North-Central—Benue; 2. North-East—Bauchi; 3. North-West—Katsina; 4. South-East—Abia; 5. South–South—Bayelsa; 6. South-West—Ondo). Also, the authors intentionally selected the FCT as the seventh study area.

Second, we listed all rural Local Government Areas (LGAs: administrative county or district with representatives elected by those who live there) in each selected State and the FCT. Third, based on the routine immunization data from the LGAs, we categorized all the rural LGAs into “high” (80% or more) and “low” (under 40%) routine immunization coverage areas. From the list of LGAs with low immunization coverage, we randomly selected two LGAs by drawing lots. Fourth, we identified all the health facilities with routine immunization services in the selected LGAs and enroled consenting mothers who met the inclusion criteria in the clinics.

Few if any studies have been conducted on the effects of using SMS text messages to remind mothers to keep all appointments and complete five basic routine immunizations on time. The expected levels of each are little known. This study is the baseline component of a quasi-experimental study; thus, we calculated sample size using the formula adopted from Kirkwood and Sterne [13] and Lwanga and Lemeshow [14]. We obtained a sample size of 166 for each LGA but increased it to 250 to adjust for attrition. Thus, our total sample consisted of 3500 eligible mothers for all 14 LGAs in all the six geopolitical zones and the FCT.

Data collection

The study team employed a mix of methods and data tools. We used a Focus Group Discussion (FGD) guide to explore these mothers’ perceptions about childhood immunization schedules, beliefs about immunization, and its benefits; misconceptions, inhibiting factors influencing uptake, and opinions on the use of mobile phone SMS messaging for facilitating mothers’ appointment keeping and completion with all immunizations. Field Research Assistants (FRAs) conducted a total of 28 FGDs. We used a validated interviewer-administered semi-structured questionnaire with sections on mothers’ socio-demographics, knowledge about vaccine-preventable diseases, and immunizations required for infants, usage of mobile phone, and readiness to adopt mobile phone SMS for promoting mothers’ appointment keeping and assuring infants receive all immunizations.

FRAs recruited mothers seeking immunization for infants at the Primary Healthcare Centres. The Matron/Nurse on duty during the immunization clinic introduced the FRAs to the mothers, informed them of our mission and the purpose of the study. The FRAs established rapport with the mothers and briefed them about the study’s ethical considerations that appeared on the consent form in their local languages (Hausa, Igbo, and Yoruba). FRAs gave each mother a copy. Mothers willing to participate eventually signed the informed consent forms given by FRAs, most by thumb-printing. A few gave verbal consent only, expressing scepticism about signing any document (based on fear from previous experience that the government might use such signed documents to enrol them in future additional taxation). The FRAs interviewed the mothers following the semi-structured questionnaire.

Ethical considerations

The Research and Ethics Committees of the University of Ibadan/University College Hospital (UI/EC/17/0561) approved the study.

Analysis

Technical Research Assistants (TRAs) transcribed qualitative information from voice recorders and handwritten notes, word-processed, edited, and entered it into the computer using Atlas Ti, followed by content analysis. The authors and the TRAs reviewed completed questionnaires for random and systematic errors, and made corrections. TRAs cleaned and coded data prior to entry, using Statistical Package for Social Sciences (SPSS) version 21.0. We scored the knowledge items measured on a 25-point scale as “Knowledge scores” (KS) < 13 and ≥ 13 and then categorized as “poor” and “good”, respectively. We measured attitude towards immunization items using a 7-point attitude scale, and classified attitude scores (AC scores) < 4 and ≥ 4 as “negative” and “positive”, respectively. Data analysis used descriptive statistics with mean, standard deviation, median, and range generated. We present the findings in tables.

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