Globally, vaccine-preventable diseases (VPDs) account for nearly 20% of deaths occurring in children  under  five years of age (World Health Organization, 2019). This makes childhood immunization one of the most important public health interventions and a cost-effective strategy that has reduced both the morbidity and mortality associated with infectious diseases in children (Babalola and Olabisi, 2004). Even though immunization is proven to be the most successful and cost-effective public health intervention in reducing childhood morbidity and mortality as it averts 2 to 3 million deaths every year, the global vaccination coverage has remained stalled at 86% since 2010, with no significant changes during the past years (World Health Organization, 2018). Of the estimated 19.5 million infants that were not reached with routine immunization services worldwide in 2016, 60% of them live in 10 countries including Nigeria (National Population Commission, 2014). According to the National Demographic and Health Survey 2018, vaccination coverage in Nigeria has improved over the past 10 years. The percentage of children aged 12-23 months who received all the basic vaccinations increased from 23% in 2008 to 31% in 2018; while the percentage of children who received none of the basic vaccinations declined from 29 to 19% during the same period. Although these trends show improvement in childhood vaccination coverage, they fall short of the Sustainable Development Goal 3, for which the target is achieving more than 90% coverage of all basic vaccinations among children aged 12- 23 months. Vaccination coverage among children aged 12-23 months is highest in Anambra (76%) and lowest in Sokoto (5%), with Ebonyi State having a coverage rate between 34 - 48% (National Population Commission, 2019).

Reports from studies have shown that uptake of immunization services depends not only on the provision of these services but also on knowledge and attitude of mothers, accessibility to immunization services, the density of health workers and the availability of safe needles and syringes (Torun and Bakirci, 2006; Anand and Bamighausen, 2007). Misperceptions of routine immunization, the influence of religion, inadequate cold chain equipment, rejection of routine immunization, health-worker and political factors, attitudes of community stakeholders and members, poor communication, funding constraints, shortage of vaccines and immunization supplies are other factors affecting optimal uptake of routine immunization in Nigeria (Ophori et al., 2014). Frequent communal conflict, difficult terrain, religious belief, lack of political will, and inadequate knowledge and negative attitude toward childhood immunization are frequent hindrances to vaccination in in most cities in Nigeria including Ebonyi State. A good attempt to address these factors may go a long way to improve vaccine utilization and subsequent protection of the children against childhood infectious diseases.

Mothers have an important role to play in child care, so their awareness and involvement are a necessity to implement programs for a child’s wellbeing. Mothers with sufficient  knowledge,  a  favorable  attitude,  and  healthy practices toward a child`s overall development are good assets of our communities and nation. Assessing their knowledge and attitude towards childhood immunizations becomes an important step to understanding and addressing some of the factors that contribute to low uptake of childhood immunization (Vonasek et al., 2016).

Therefore, this present study was carried out to assess the knowledge and attitude of mothers attending immunization clinics in a tertiary hospital in Ebonyi State. The findings obtained may serve as the basis for effective intervention.

This was a cross-sectional descriptive questionnaire-based study that was conducted over 3 months at the Institute of Child Health (ICH) of Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Ebonyi State between August and October 2019. Mothers/caregivers who brought their babies for immunization during the study period and gave consent were recruited and enrolled in the study. Care was taken not to enroll any participant twice since most of them came for the subsequent immunization schedules.

Data were collected with the assistance of trained research assistants who were mainly nurses and resident doctors working in the institute using a standard structured questionnaire adapted from the previous studies (Awodele et al., 2010; Tagbo et al., 2012; Awosan et al., 2018) which had three sections on socio‐demographic characteristics, knowledge on immunization and attitude towards childhood immunization. Knowledge and attitude were assessed using 8 stem questions some of which had multiple responses, resulting in a total of 15 questions. Each correct response was allotted a point. Knowledge was further dichotomized using half (7.5 points) of the maximum score as a cutoff into good (≥7. 6 points) or poor knowledge (≤7. 5 points). The attitude was also determined using 8 questions, each of which had 1 point for a favorable response. It was further categorized into positive (5-8 points) and negative (0-4 points), attitude. Ethical approval was obtained from the Research and Ethical Committee of Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi state while Informed consent was obtained from the participants.

The collected data were coded, entered in an excel sheet, and imported into SPSS software version 23 which was used for the analysis. The data were presented in frequency distribution tables with percentages. Chi-square statistics were used to test for association between the dependent variables (knowledge and attitude of the mothers towards childhood immunization) and independent ones such as socio-demographic characteristics. Multivariate analysis using the Binary Logistics Regression model was applied to determine the predictors of good knowledge of immunization among the mothers. Statistical significance was set at p<0.05.

Socio-demographic characteristics of respondents

Seventy-eight (55.3%) of the respondents were aged ≥40 years. Most of them, 139 (98%) were Christians. A total of 58 (41.1%) have had  1-4  pregnancies while 70 (49.6%) have 1-4 living children. Majority 130 (92.2%) were married. Respondents residing in rural areas constituted 99 (70.2%) of the study population (Table 1).

Knowledge and attitude of mothers’ regarding childhood immunization

All of the respondents had heard about childhood immunization. Health workers were the major source of knowledge for 72 (56.3%) mothers. Fear of general illness 119 (88.1%) was the main driving force for taking their children for vaccination. Only 40  (28.8%)  had  good knowledge of childhood immunization. Positive attitude towards vaccination was seen in 139 (98.6%) (Tables 2 and 3).

A reasonable number of mothers had missed their child's immunization with vaccination centers being far away from their house as the commonest reason. Being busy at the workplace and no available vaccine at vaccination centers also contributed.  Mothers from a rural area with a limited number of health facilities and difficult terrain are likely to be affected here. Also, difficulty in transporting these vaccines to these areas may contribute to its limited availability. These highlighted reasons need to be addressed to ensure compliance with the vaccination schedule. Different researchers have reported husband’s refusal, not remembering vaccination day, unaware of the need  for   vaccination,   lack   of  vaccination  information provided to parents by health workers and a child’s illness as well as the unavailability of vaccines as the commonest reasons for the missing vaccine (Tagbo et al., 2012; Al-lela et al., 2014; Birhanu et al., 2015; Mugada et al., 2017; Awosan et al., 2018). Although some mothers took their babies back for vaccination, many of them did nothing after missing their child’s vaccination. This creates a gap that should be addressed when providing information concerning childhood vaccination to mothers on the importance of catch-up vaccination following missed schedule as this will further strengthen compliance to immunization among mothers.

Despite  many  mothers’  poor  knowledge  of childhood vaccination in this study, they however, demonstrated a very good attitude towards immunization of their children.

This finding aligns with the reports of studies conducted in different parts of the world (Birhanu et al., 2015; Awosan et al., 2018; Ramawat and Goswami, 2018; Adefolalu et al., 2019).

In this study, a significant association was found between age, parity of respondents, educational status, place of residence, and mothers’ knowledge regarding childhood immunization. It is also likely that older mothers and mothers with higher parity had more opportunities for more visits to hospitals and therefore receive more health talks on childhood immunization compared to younger respondents with lower parity levels. Also, those with higher educational levels may understand health talk information on childhood immunization, better than respondents with lower educational attainment. This may explain the reason for the observed significant association between educational level and knowledge of childhood immunization as more than half of respondents in this study either had no formal education or only attained primary level of education. Similarly, most researchers have reported a significant association between maternal education and knowledge of  childhood immunization (Awodele et al., 2010; Birhanu et al., 2015; Dharmalingam et al., 2017; Mugada et al., 2017; Awosan et al., 2018; Ramawat and Goswami, 2018; Adefolalu et al., 2019). Besides, Birhanu et al. (2015), Adefolalu et al. (2019), and Ramavat and Goswami, (2018) noted maternal age and parity was significantly associated with mothers’ knowledge regarding childhood immunization. Our findings are at variance with reports by other researchers (Jose et al., 2013; Vinish, 2016).

Only maternal educational level significantly predicted respondents’ knowledge of childhood immunization. This finding is important in the design and implementation of childhood immunization programs. Thus, measures such as female education, adult literacy programs, health education campaigns, and new or improved immunization campaign delivery methods should be considered for raising immunization uptake in Ebonyi State, Southeast Nigeria.

This study shows that mothers had poor knowledge of childhood  immunization.  For  the few mothers who knew childhood immunization, their major sources of information were from health workers. The maternal educational level predicted good knowledge of childhood immunization. Far vaccination centers and being busy at work contributed to missed vaccination in their children. It is recommended that immunization information should be taken to the doorsteps of mothers, especially at various female gatherings. Optimization of routine immunization sessions should be intensified in every community with the implementation of daily immunization at every fixed post, weekly vaccination for outreach sessions, and monthly vaccination for mobile sessions. Also, the integration of routine immunization with other health services, reducing multiple hospital visits that will disrupt mothers’ busy schedules is advocated. These measures may likely increase immunization awareness as well as improve its uptake in Ebonyi State, southeast Nigeria.

This was a cross-sectional study with small sample size so the findings may not be generalized to the populace. Further research is needed to understand the respondents’ perception of childhood immunization and factors that influence its uptake in Ebonyi State, Nigeria.

The authors have not declared any conflict of interests.