Ethiopian Journal of Environmental Studies & Management 9(5): 604 – 612, 2016. ISSN:1998-0507 doi: http://dx.doi.org/10.4314/ejesm.v9i5.7 Submitted: May 08, 2016 Accepted: September 14, 2016

DETERMINANTS OF INFANT IMMUNIZATION COVERAGE IN COUNTY, NYANZA REGION,

MUKUI, S.J., 1 MUTUA, E.M., 1 GITONGA, M.M., 1 CHEPTUM, J.J., 1 NDAMBUKI, J.M.1 AND KOIMA, W. 2 1 School of Health Sciences, Dedan Kimathi University of Technology, P.O Box 657 – 10100, , Kenya 2 Department of Research,Training Management and Community Linkages, Dedan Kimathi University of Technology, P.O Box 657 – 10100, Nyeri, Kenya

Abstract The main objective of this study was to examine determinants of infant immunization coverage in ; Nyanza. Migori-Nyanza is the regions of disparities that continue to register low rates of immunization coverage in Kenya. The coverage rate was measured against Kenya’s and World Health Organization target percent for achieving herd immunity and improved child survival. Immunization coverage rates are accepted as an indicator of the performance and adequacy of a Country’s Health Service Systems. A descriptive study of 446 households sampling units was conducted in January 2013. The households were randomly selected from four demand areas. Methods of data collection were: interviewer administered questionnaires, key informant interviews and homogeneous focus group discussions. Respondents were mothers aged 19- 45 years with a child less than five years of age. The results indicated that fully immunized infants were 70%; a fully immunized infant was one who received one dose of BCG, four doses of Oral Polio Vaccine (OPV), three pentavalents, and one dose of measles vaccine before reaching one year of age. The results further indicated that:- 80% of infants had their birth polio and Bacillus- Calmette Guerin (BCG) within the first two weeks of life, 78% 3 rd pentavalent and 4 th polio at 14 weeks of life and 77% measles at 9 months. Measles and third dose of pentavalent immunizations are used as indicators of a fully immunized child. The determinants of immunization coverage that were identified from the study included: means of transport to health facilities, religious affiliation, home delivery and not attending postnatal clinics, mothers’ lack of knowledge on dangers of childhood diseases and hostile attitudes shown by service providers to the mothers. In conclusion there was under coverage of immunization in the region. The recommendation was that the health service providers need to in- cooperate both outreach and mobile immunization services into their current static module.

Key Words: Immunization coverage, Infant mortality, immunization Indicators, Migori , Kenya

Introduction element and is considered the most cost- Millions of children die globally from effective preventive health service for vaccine preventable diseases. children. According to UNICEF (2010), Immunization is a primary health care immunization of children against vaccine

*Corresponding Author: Mukui, S.J. 604 Email: [email protected]

Determinants of Infant Immunization Coverage in Migori County ...... MUKUI et al. preventable diseases has made impressive According to KNBS office, (Migori contribution to reducing child deaths. 2013), the under- one year (infants) Overall Immunization averts an estimated comprised of 1.1% of the total population 2-3 million deaths of children in all age of 917,170 people (2009 census. groups every year (WHO, 2012). Infant Therefore in the county’s integrated immunization has been regarded as one development plan2013-2017, there was a of the most important achievements of need to increase immunization coverage public health as well as an effective in order to reduce child mortality as strategy of reducing child mortality rates. enshrined in millennium development It has also been documented that goal number four. This reason was the immunization coverage is a key measure genesis of the partnership between of immunization system performance Migori County, College of the Rockies (WHO, 2013). Immunization coverage and Dedan Kimathi University of levels and trends are also used to monitor Technology. the performance of immunization The main objective of this study was services locally and internationally therefore to examine determinants of (WHO, 2010). Infant and child mortality infant immunization coverage in Migori rates are key indicators of a child well County; Nyanza with the view of being, child survival interventions and establishing interventions towards more broadly a Country’s health status. addressing the same as part of the Good health is a pre-requisite for socio- Maternal Access and Infant Survival for economic development. Immunization Health Advancement (MAISHA) Project. coverage rates are accepted as an The aim of the project is to improve indicator of the performance and maternal and infant service delivery adequacy of a Country’s Health Service through retraining of staff on essential Systems. emergency obstetric care and the Kenya’s immunization coverage community health workers on target of children under 5 years is 90% strengthening immunization services (KDHS 2009), this is the level required to among other basic services at the reach herd immunity and interrupt community level. The project is a joint community transmission for all vaccine venture between the College of Rockies preventable diseases. However there are in Canada and Dedan Kimathi University regional disparities with Nyanza of Technology- Kenya. continuing to register low rates of coverage which is lower than the Methods National figures and increase child Description of Study Area mortality rates (KDHS 2008-2009). The study was done in Migori Documented evidence by research such County; confined to households in four as the Kenya National Bureau of demand areas namely: Ondong’, Statistics (KNBS 2011) multiple Ogwedhi in Suba East, Nyamaraga and indicator cluster survey report in Nyanza Godkwer in Suba West. Migori County is Province showed that the percentage of a County in the of fully immunized children was 70%. South-Western Kenya which is found between latitude 0° 24 ʹ and 0° 40 ʹʹ S and 605

Ethiopian Journal of Environmental Studies and Management Vol. 9 no.5 2016 longitude 34° and 34° 50 ʹʹ East. The respondents were mothers in their county has an altitude varying between reproductive age (15-49 years) and with 1140m above sea level at the shores of children less than five years of age. Data in Nyatike Sub-county to was obtained using a combination of 4625m sea level in Uriri Sub-county. The verbal responses to structured questions, high altitude area has several undulating immunization records and recall when the hills and plains stretching for about 20- records were not available. Qualitative 70km. data was obtained through Key informant The county has an inland equatorial interviews and homogenous male and climate modified by the effects of female focus group discussions using an altitude, relief and the influence of the interview guide. Key Informant large body of water of Lake Victoria. The Interviews (KII) with healthcare annual rainfall averages between 700 and administrators was also conducted on 1,800 mm. The Lake shore division factors affecting immunization coverage experiences unreliable and poorly in the demand areas using an interview distributed rainfall. Temperatures show guide. To ensure quality data was mean minimum of 24 0C and maximum of obtained supervisors ensured the 31 0C, with high humidity and a potential questionnaires were completed fully evaporation of 1800 to 2000 mm per before enumerators left the field. year. The study was conducted to generate Study Design and Data Collection baseline information for the Maternal A total of 446 households were Access and Infant Survival for Health randomly selected in four demand areas Advancement (MAISHA) project. This namely: - Ondong’, Ogwedhi in Suba was a DFATD funded project East, Nyamaraga and Godkwer in Suba implemented through the Dedan Kimathi West. Ethical standards were observed University of Technology (DeKUT) and by having the proposal approved by the College of the Rockies, Canada Kenyatta University research board and the collaboration (COTR). National Council for Science and Research Data Analysis (Kenya).Also informed consent from After data collection, cleaning was respondents was obtained before they were done both at the field and centrally before engaged in the interviews. entry onto a computer programme was A two stage sampling technique of done. Descriptive and inferential probability random sampling was used; statistics were used for data analysis population proportionate to size and using Stata version 11. Pearson’s Chi- simple random. A cross- sectional Square was used to determine descriptive survey design was used in associations between immunization which both quantitative and qualitative coverage and identified variables methods of data collection were used. (determinants). Using 95 % confidence The questionnaire administered method level, a value that was <0.05 was was used to collect quantitative data considered to be associated and a value because it made face to face interview that was >0.05 was considered not to be easy. The 446 sampled households were associated. surveyed in January 2013. The

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Determinants of Infant Immunization Coverage in Migori County ...... MUKUI et al.

Results between mother’s occupation and General Characteristics immunization coverage. The reproductive age concentration Overall Immunization Coverage was between 18-35 years and there was The results indicated that the fully no significant association between immunized children in the County were maternal age and child immunization 70%; a fully immunized child was one coverage. The highest level of education who got measles vaccine at or above nine a majority of the mothers had primary months in addition to the three education (80%). Inferential statistics did pentavalents and four oral polios. This not show significant association between finding showed under coverage because mothers level of education and this was below Kenya’s National target immunization coverage. The surveyed coverage of 90% and at least 80% mothers were mainly self employed coverage for Counties. Figure 1 (Full (42.2%) and housewives 51.47%); again Immunization Coverage) illustrates the there was no significant association percentage of the County’s coverage.

Figure 2: Immunization Coverage

The results from the survey further weeks; 58.8 (207) % had been given 3 rd indicated the distribution of the coverage pentavalent and 4 th polio at 14 weeks of as follows: 80% of the children under life and 76.9 % (254) for measles at 9 five years had been given birth polio and months. Measles and third dose of Bacillus-Calmette Guerin (BCG) within pentavalent immunizations are used as the first two weeks of life; 60.3% had indicator of a child’s full immunization; received first pentavalent and second 76.9% is therefore below Kenya’s polio at 6 weeks of life; 60.7% (224) had National target coverage of 90%, and at had 2 nd pentavalent and 3 rd polio at 10 least 80% in each County. Figure 2 below

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(Distribution of Vaccine Coverage) coverage of the primary immunizations. indicates percentage distribution

Figure 3: Vaccine Coverage

Immunization Determinants coverage. There was a significant Means of Transport association between full immunization of The findings from quantitative a child and home deliveries, P-Value = methods indicated means of transport to 0.024. In this regard the mothers who immunization sites as one of the delivered at home did not get their determinants of immunization coverage. children fully immunized. One of the The commonest means of transport was mothers in the focus group discussion on foot (88%); inferential statistics had this to say to this effect “ home showed there was a significant deliveries are preferred because the association between a child’s traditional birth attendants are friendly immunization coverage and mothers and so we don’t use other services as means of transport to the immunization required because we shy away from the site (P-Value=0.044). health service providers” (FGD Nearly half of the mothers in their participant ); Figure 3 below (Place of reproductive age (15-49 years) delivered Last Delivery) illustrates the percentages their babies at home (45%). Home of home and health facility deliveries. delivery also determined immunization

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De terminants of Infant Immunization Coverage in Migori County ...... MUKUI et al.

Figure 4: Place of Last Delivery.

Religion child; P-Value= 0.023. Seventy four The results also indicated that percent (74%) of mothers attended religion was a determinant of postnatal clinic. immunization. The religion that many of Qualitative Analysis the mothers ascribed to was protestant The qualitative data from key (68.9%). The findings indicated a informant interviews revealed that lack of significant association between religious knowledge on dangers of childhood affiliation and full immunization of a immunizable diseases, inadequate child, P-Value = 0.001. Table 1 below; immunization health messages to (Distribution of Religious Affiliation) mothers, immunization clinic defaults illustrates the distribution of religious and negative attitudes by staff towards affiliation. mothers determined immunization coverage. Some of the key informants Distribution of Religious Affiliation had this to say, “There is incomplete Religion Frequency Percent immunization of infants, mothers default Catholic 81 18.37 after BCG & 1 st polio”. (KII -Facility in- Protestant 304 68.93 charge). Muslim 2 0.45 “Mothers are ignorant of immunization Others 54 12.24 schedule and there is low turn up for Total 441 100.00 hospital delivery” (KII- Facility in- charge). Postnatal Clinic Attendance The mothers had this to say, “ The The other identified determinant was immunization services offered are very not attending postnatal services. There poor and the staff have negative attitude was also a significant association towards us (clients), staff ignore patients between uptake of postnatal clinic and do not pay attention to our health attendance and full immunization of a 609

Ethiopian Journal of Environmental Studies and Management Vol. 9 no.5 2016 needs and concerns”. (FGD woman immunization sites while carrying their participant). babies. This finding is similar to that of Owino et.al (2009) in their study on Discussion factors influencing immunization Use of immunization is a key strategy coverage in Mathare Valley . for improving child survival whereas a They also identified means of transport low rate of immunization coverage is and distance to immunization indicative of poor health status. Despite a facilities as determinants of well-established and supported Kenya immunization coverage. Expanded Programme on Immunization There is evidence from WHO (KEPI), immunization coverage in /UNICEF (2013) that children in poor Migori County is still low (70%); a households are deprived of their rights in reverse of gains made to positively many ways, including immunization influence child survival and achievement services. The topographic information of millennium development goal number and occupation tallies from the survey four. This is evidenced by the regions’ indicate that poverty index in many high infant mortality rate of 95 deaths per households is high. These factors are 1000 live births and the under fives 149 likely to contribute to low immunization deaths per 1000 live births. The national coverage. Poverty deprives a human infant mortality rate is 52 deaths per 1000 being of essential elements of dignified births (KHDS 2008-2009). livelihood such as basic education. Due to relatively high percentage of home deliveries (45%) and absence of Conclusion adequate post-partum visits the mothers The overall immunization coverage is miss opportunities to have their infants below the National and County targets. immunized which in turn contribute to The challenges mothers face to meet their low immunization coverage. In addition obligation of taking their children for the mothers suffer missed opportunities immunization included: means of on health messages regarding importance transport, religion, not attending postnatal of protecting a child against childhood services, lack of information on dangers immunizable diseases. The background of childhood vaccine preventable information indicates that the topography diseases and delivering at home. of the area facilitates poverty since Increasing immunization coverage and economic opportunities are limited. This achieving the national target in Migori back ground plays a role in determinants County depends therefore upon of immunization in regard to accessibility empowering women through education, and utilization. The mother’s means of economic activities and strengthened transport to the immunization facility was post-partum visits for infant an associated determinant to immunization. immunization coverage. Since the The health care service providers commonest means was on foot and the need to incorporate both outreach and area experiences high humidity mothers mobile immunization services into the may find it a challenge reaching the current static module so as to reach the un- reached mothers and their infants. 610

Determinants of Infant Immunization Coverage in Migori County ...... MUKUI et al.

Further exploration on the significant Development (DFATD) Canada for association between religion and funding the MAISHA project. immunization coverage is recommended. 2. College of the Rockies Kranbrook This is in view of the fact that 68.9% of Canada for collaboration and linkage the mothers were Protestants. to DFATD 3. Dedan Kimathi University of Acknowledgements Technology (DeKUT) management.

The authors would like to acknowledge 4. Ministry of Health (MOH) Migori the immense contributions made by the County for hospitality and assistance following: in household survey guide.

1. Canadian Government, Department 5. Homabay Kenya Medical Training of Foreign Affairs, Trade and Centre (KMTC) for data enumeration

MAP OF MIGORI COUNTY: County Administrative and Political Units.

Source: KNBS, 2012

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