Barriers Faced by Mothers in Completion of EPI

Syeda Beenish Bukhari1, Sidra Khalid1*, Shahid Bashir1, Riffat Mehboob2, Humaira Waseem2

1University Institute of Diet and Nutritional Sciences, Faculty of Allied Health Sciences, The University of Lahore, Pakistan

2Research Unit, Faculty of Allied Health Sciences, The University of Lahore, Pakistan

Abstract | Present study was conducted to determine the barriers of immunization among mothers attending Pediatric and Gynecological Department of the Sir Ganga Ram Hospital Lahore. For this, 150 mothers were selected randomly; relevant data were collected through pre-tested questionnaire. Data were tabulated and analyzed with the help of SPSS version 21.0. Results of current study showed that barriers to complete vaccination course were lack of information, myths, un-availability, non-affordability, fear of side effects and fear of lack of safety of vaccination procedure/ dirty needles. Analysis revealed a significant association between maternal education and barriers to complete vaccination course.

Article History

Received: October 11, 2018

Revised: November 23, 2018

Accepted: December 29, 2018

Published: January 23, 2019

Authors’ Contributions

SBB collected the data and reviewed the literature. SK wrote the article. SB designed and supervised the study. RM reviewed the article critically. HW did statistical analysis.

Keywords

Barriers, Mothers, Immunization, Children.

*Corresponding author: Sidra Khalid

sidrakhalid.uaf@gmail.com

To cite this article: Bukhari, S.B., Khalid, S., Bashir, S., Mehboob, R. and Waseem, H., 2019. Barriers faced by mothers in completion of EPI. Punjab Univ. J. Zool., 34(1): 21-25. http://dx.doi.org/10.17582/journal.pujz/2019.34.1.21.25

Introduction

Immunization is a defensive procedure whereby a man is made invulnerable or resistant to an infectious disease, by the administration of a vaccine (Arora, 2018). It is one of the most cost-effective and secure public health interventions in reducing the childhood mortality and morbidity (Mathew G et al., 2017; Shashidhara and Jeyalakshmi 2018). The expanded program on immunization was introduced in 1974 by world health organization (WHO) to give general access to a set of life saving vaccines (Owais et al., 2013; Hu et al., 2018). The national Expanded Program on Immunization (EPI) goals to immunize all children in the range of 0 and 23 months against eight vaccine

preventable diseases that include newborn tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus, hepatitis B, Haemophilus influenza type b (Hib), and measles (Masud et al., 2012). Pakistan’s Expanded Program on Immunization (EPI) plan includes administrating single dose of 0.05ml to 0.1ml of BCG/OPV during childbirth, 3 doses of 0.5ml of DPT/OPV/Hepatitis B antibodies at 6, 10 and 14 weeks of age, and 2 doses of 0.5ml of measles immunization at 9 and 15 months of age (Owais et al., 2011; Tariq K and Tariq R 2018; Khan and Aslam 2017; IHMA 2017). The Expanded Program on Immunization (EPI) in Pakistan every year focuses around 5.8 million children aged under 1 year to ensure against 8 antibody preventable illnesses and 5.9 million pregnant ladies to shield them and their new-born from tetanus through routine vaccination administrations (Rasheed et al., 2014). The maternal immunization provides greater protection to pregnant women and their new-born against infectious diseases during the initial couple of long stretches of life (Vojtek et al., 2018; Perrett and Nolan 2017). Other vaccines used for children and older age people are hepatitis A and B vaccination, Haemophilus influenzae type b, meningococcus, pneumococcus, rotavirus, human papilloma infection and varicella (Okwo-Bele and Cherian 2011). Barriers to complete immunization include poor financial status, lower education level, non-utilization of maternal child health services, missed immunization opportunities and dropped immunization sessions (Sodha and Dietz 2015). Other factors associated with incomplete immunization are little access to services, health staff behavior and practices, trustworthiness of services, false contraindications, parents’ practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs (Favin et al., 2012). Absence of parent awareness and powerless administration also acted as barriers to complete vaccination (Mutua et al., 2017). Cantuária et al. performed a study in 2016 to find the factors associated with incomplete or delayed vaccination across countries. They reasoned that the inoculation status is affected by factors identified with the youngster, parental attitude or knowledge, social context of the family and health care services (Cantuária et al., 2016). Bbaale E in 2013 demonstrated that 50% of youngsters in Uganda were completely vaccinated. Furthermore, 89%, 24%, 52%, and 64% got BCG, DPT, polio and measles immunizations separately. Factors of incomplete vaccination include maternal education, introduction to media, maternal age, occupation, regional and local peculiarities (Bbaale 2013). Rainey et al. conducted a study in 2011 and inferred that the most possible factors of incomplete vaccination were poor access, insufficient antibody supply, wellbeing specialist accessibility and information, missed chance to immunize, vaccinator absent at the booked time for inoculations, place of home (Rainey et al., 2011). Sheikh A in 2013 concluded that the most common primary reason for non-vaccination was lack of information, and the most common secondary reason was religious taboos (Sheikh et al., 2013). Glatman-Freedman A et al. in 2012 revealed that the barriers associated with complete vaccination were parental absence of knowledge regarding benefits of vaccinations, fear of adverse reaction, belief that vaccination is not beneficial or causes harm, absence of motivation, mistrust of health care system and social or cultural pressure against vaccinations (Glatman-Freedman et al., 2012). Negussie A et al. performed a study in 2015 revealed that the barriers to complete vaccination course include child’s birth order, mother’s age, information about immunization benefits and perception of vaccine side effects (Negussie et al., 2015). The current study was conducted to determine the barriers faced by mothers in completion of immunization.

 

Materials and Methods

A cross sectional study was conducted at Pediatric and Gynaecological Department of the Sir Ganga Ram Hospital, Lahore, over a period of 4 months, after obtaining the ethical approval from the The University of Lahore. A total number of 150 mothers having children under five years of age with multigravida were selected through non probability convenient sampling technique. Mothers having children above five years of age and non cooperative mothers were excluded from the study. Data were collected through pre-tested data collection tool (questionnaire/Proforma). Data were tabulated and analyzed with the help of SPSS version 21.0. Frequencies were calculated and Pearson chi-square test was applied to evaluate the association of maternal education with the barriers to complete Expanded Program on Immunization. P-value less than 0.05 was considered to be significant.

 

Results and Discussions

This study reveals that the awareness about EPI among mothers was 99.3%. Similar results were found by Rachna et al, in 2010 also concluded that 85% of mothers were aware about immunization (Rachna et al., 2010). The major source of information about EPI were media (8.7%), relatives (40%), health workers/ medical staff/clinics (49.3%) while remaining (2%) had no known source of information. Kaoje et al, in 2017 demonstrated that the source of information about EPI was from health workers (29.8%), radio (43.8%), television (10.7%), workshops, seminars, training (2.7%), newspaper (1.3%), friends, relatives (11.5%), and lectures from school (0.2%) (Kaoje et al., 2017). Analysis revealed that, 30% mothers were uneducated, 38% were below matric while 32% were above matric. Khan and Aslamin 2017; Ahmad et al. 2017; Legesse and Dechasa in 2015 concluded that all the categories of mother’s education had positive impact on the probability of immunization of children (Khan and Aslamin 2017; Ahmad et al., 2017; Legesse and Dechasa 2015). In current study 68.7% mothers were taking EPI as their prime responsibility while 31.3% mothers just succeeding the society. Favin et al. in 2012 concluded that parents lacking interest and low perceived importance of vaccination for child’s health were the key factors of not vaccinating their children (Favin et al., 2012). Current results concluded that 13.3% mothers were having fear of side effects of EPI. Similar results were shown by Ahmed et al. in 2013, that mothers thought that immunization could cause infertility, fever, deformity, convulsions and diarrhea (Ahmed et al., 2013). Current results showed that 60% of mothers completed the vaccination course (Tetanus Toxoid) during pregnancy. Lambo and Nagulesapillaiin 2012 reported that maternal tetanus is responsible for at least 5% of maternal deaths (Lambo and Nagulesapillai 2012). 65.3% mother were completed the vaccination course of their children while 34.7% stopped EPI course. Mabrouka and Bofarrajin 2011, showed that 81% mothers completely immunized their children and 19% partially immunized them (Mabrouka and Bofarraj, 2011). Out of 34.7% mothers, 24% declared that barriers to complete vaccination course were lack of information, 9.3% had myths, 0.7% had un-availability and 0.7% had non-affordability. Similar results were found by Srivastava and Shankar, in 2017 and Hasan et al. in 2010 showed that the major cause for faire of vaccination was found to be lack of awareness (Srivastava and Shankar, 2017; Hasan et al., 2010)

 

Table 1: Education level of Mother

Sr. No.	Education Level	Frequency	Percentage
1	Uneducated	45	30
2	Under matric	57	38
3	Above matric	48	32
4	Total	150	100

 

Table 1 represents the education level of 150 mothers having children less than five years of age. Among those 30% were uneducated, 38% were under matric and 32% were above matriculation

 

Table 2: Source of information about EPI

Sr. No.	Source of information about EPI	Frequency	Percentage
1	Electronic & Print Media	13	8.7
2	Relatives	60	40
3	Health workers	74	49.3
4	Some other/Unknown source	3	2
5	Total	150	100

 

Table 2 represents the EPI source of information of mothers having children less than five years of age. Among those 13 (8.7%) mothers were aware about EPI through media, 60 (40%) through relatives, 74 (49.9%) through health workers and only 3 (2%) were aware through some other unknown source.

Table 3 represents, 60% mothers have completed their Tetanus Toxoid course during pregnancy while 40% mothers dropped their Tetanus Toxoid course during pregnancy. Out of 60% mothers: 6.7% were uneducated, 26.7% were undermatric while 26.7% were above matric. 65.3% mothers had completed vaccination course of their children and 34.7% mothers dropped EPI. Out of 65.3% mothers: 10.7% were uneducated, 29.3% were undermatric while 25.3% were above matric. There was a strong association between education level of mothers and their status of vaccination of Tetanus Toxoid during pregnancy and a robust association between education level of mothers and the status of vaccination course of their children as well.

 

Table 3: Association between education and status of Tetanus Toxoid course during pregnancy and status of EPI course of children

Education Level	Status of TT course during pregnancy		Total	P-value
	Yes	No
Uneducated	10 (6.7%)	35 (23.3%)	45 (30%)	0.000
Under matric	40 (26.7%)	17 (11.3%)	57 (38%)
Above matric	40 (26.7%)	08 (5.3%)	48 (32%)
Total	90 (60%)	60 (40%)	150 (100%)
Education Level	Status of EPI course of children		Total	P-value
	Yes	No
Uneducated	16 (10.7%)	29 ( 19.3%)	45 (30%)	0.000
Under matric	44 (29.3%)	13 (8.7%)	57 (38%)
Above matric	38 (25.3%)	10 (6.7%)	48 (32%)
Total	98 (65.3%)	52 (34.7%)	150 (100%)

 

Table 4 represents a strong association between education level of mothers and barriers faced to complete vaccination course of their children. Out of 34.7% mothers: 9.3% mothers had not completed vaccination course of their children due to myths, 24% due to lack of information, 0.7% due to unavailability and 0.7% due to non-affordability.

Table 5 represents the association between education level of mothers and fear of side effects of EPI. 20 (13.3%) mothers had a fear of side effects of EPI while 130 (86.7%) mothers had no fear about EPI. Out of 20 (13.3%) mothers: 8.7% were uneducated, 2% were undermatric while 2.7% were above matric.

 

Conclusions

Based on the results of the current study, mother’s awareness, willingness towards immunization and source of information regarding the benefits of immunization significantly affected for completion of recommended immunization within due date and time. Mothers were not aware about the diseases for which their children are being vaccinated. Lack of information and knowledge, myths, un-affordability, un-availability and fear of side effects of vaccination acted as barriers for incomplete immunization.

 

Table 4: Association between education and barriers of incomplete vaccination

Education Level	Barriers of incomplete vaccination course of children					Total	P-value
	Myths	Lack of Information	Un-available	Non- Affordability	Non
Un-educated	9 (6%)	20 (13.3%)	0(0.0%)	0 (0.0%)	16 (10.7%)	45(30%)	0.000
Under matric	2 (1.3%)	10 (6.7%)	0 (0.0%)	1 (0.7%)	44 (29.3%)	57 (38%)
Above matric	3 (2%)	6 (4%)	1 (0.7%)	0 (0.0%)	38 (25.3%)	48 (32%)
Total	14 (9.3%)	36 (24%)	1 (0.7%)	1 (0.7%)	98 (65.3%)	150 (100%)

 

Table 5: Association between education and fear of side effects of EPI

Education Level	Fear of side effects of EPI		Total	P-value
	Yes	No
Uneducated	13 (8.7%)	32 (21.3%)	45 (30%)	0.001
Under matric	03 (2%)	54 (36%)	57 (38%)
Above matric	04 (2.7%)	44 (29.3%)	48 (32%)
Total	20 (13.3%)	130 (86.7%)	150 (100%)

 

References

Ahmad, N.A., Jahis, R., Kuay, L.K., Jamaluddin, R. and Aris, T., 2017. Primary Immunization among Children in Malaysia: Reasons for Incomplete Vaccination. J. Vaccin. Vacc., 8(3):1-8. https://doi.org/10.4172/2157-7560.1000358

Ahmed, S.M., Abd-El Rahman, T.A. and Masoed, E.S., 2013. Mothers’ awareness and knowledge of under five years children regarding immunization in Minia city Egypt. Life Sci. J., 10(4):1224-32.

Arora S., 2018. National Immunization Schedule India: A Review. Research & Reviews: J. Immunol., 7(3):6-10.

Bbaale, E., 2013. Factors influencing childhood immunization in Uganda. J. Hlth. Popul. Nutr., 31(1): 118. https://doi.org/10.3329/jhpn.v31i1.14756

Cantuária Tauil, M., Sato, A.P. and Waldman, E.A., 2016. Factors associated with incomplete or delayed vaccination across countries: a systematic review. Vaccine., 34(24):2635-43. https://doi.org/10.1016/j.vaccine.2016.04.016

Favin, M., Steinglass, R., Fields, R., Banerjee, K. and Sawhney, M., 2012 Why children are not vaccinated: a review of the grey literature. Int. Hlth., 4(4):229-38. https://doi.org/10.1016/j.inhe.2012.07.004

Glatman-Freedman, A. and Nichols, K., 2012. The effect of social determinants on immunization programs. Human Vac. Immunotherap., 8(3):293-301. https://doi.org/10.4161/hv.19003

Hasan, Q., Bosan, A.H. and Bile, K.M., 2010. A review of EPI progress in Pakistan towards achieving coverage targets: present situation and the way forward.

Hu, Y., Chen, Y., Liang, H. and Wang, Y., 2018. Routine vaccination coverage of children aged 1-7 years in Zhejiang province, China. Human Vac. Immunotherap., (accepted).

IHMA (Immunization Handbook for Medical authors). Department of Health and Family Welfare, Government of India. 2017, Available from http://www.nihfw.org/pdf/nchrc-publications/immunihandbook.pdf. Published by Department of Health and Family Welfare, Government of India.

Kaoje, A.U., Yahaya, M., Olayinka, R.M., Hauwau, S., Abubakar, J. and Ambursa, A.H., 2017. Prevalence of vaccine preventable diseases and utilization of routine immunizations services by parents of under-one child in a semi-urban community of Sokoto State, Nigeria. Global J. Med. Pub. Hlth., 6(4):10.

Khan, R.E. and Aslam, I., 2017. Child Immunization in Pakistan: Socio-Institutional and Regional Aspects. Asian J. Econ. Modellin., 5(1):49-56. https://doi.org/10.18488/journal.8/2017.5.1/8.1.49.56

Lambo, J.A. and Nagulesapillai, T., 2012. Neonatal tetanus elimination in Pakistan: progress and challenges. Int. J. Infect. Dis., 16(12): e833-42. https://doi.org/10.1016/j.ijid.2012.07.015

Legesse, E. and Dechasa, W., 2015. An assessment of child immunization coverage and its determinants in Sinana District, Southeast Ethiopia. BMC Pediat., 15(1):31. https://doi.org/10.1186/s12887-015-0345-4

Mabrouka, A. and Bofarraj, M., 2011. Knowledge, attitude and practices of mothers regarding immunization of infants and preschool children at Al-Beida City, Libya 2008. Egypt J. Pediatr. Allergy Immunol., 9(1):29-34.

Mathew, G., Johnson, A.R., Thimmaiah, S., Kumari, R. and Varghese, A., 2017. Barriers to childhood immunisation among women in an urban underprivileged area of Bangalore city, Karnataka, India: a qualitative study. Int. J. Commun. Med. Pub. Hlth., 3: 1525-30

Masud, T. and Navaratne, K.V., 2012. The expanded program on immunization in Pakistan: recommendations for improving performance.

Mutua, M.K., Kimani-Murage, E. and Ettarh, R.R., 2017. Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated? BMC Pub. Hlth., 1: 6-12.

Negussie, A., Kassahun, W., Assegid, S. and Hagan, A.K., 2015. Factors associated with incomplete childhood immunization in Arbegona district, southern Ethiopia: A case–control study. BMC Pub. Hlth., 16(1): 27. https://doi.org/10.1186/s12889-015-2678-1

Okwo-Bele, J.M. and Cherian, T., 2011. The expanded programme on immunization: a lasting legacy of smallpox eradication. Vaccine,. 29: D74-9. https://doi.org/10.1016/j.vaccine.2012.01.080

Owais, A., Hanif, B., Siddiqui, A.R., Agha, A. and Zaidi AK., 2011. Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan. BMC Pub. Hlth., 11(1):239.

Owais, A., Khowaja, A.R., Ali, S.A. and Zaidi, A.K., 2013. Pakistan’s expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage. Vaccine., 31(33):3313-9.https://doi.org/10.1016/j.vaccine.2013.05.015

Perrett, K.P. and Nolan, T.M., 2017. Immunization during pregnancy: impact on the infant. Pediat. Drugs., 19(4): 313-24. https://doi.org/10.1007/s40272-017-0231-7

Rachna, K. and Sheetal, V., 2010. Awareness and knowledge of mothers of under five children regarding immunization in Ahmedabad. Healthline, J. Indian Assoc. Prevent. Soc. Med., 1(1):14-20.

Rainey, J.J., Watkins, M., Ryman, T.K., Sandhu, P., Bo, A. and Banerjee, K., 2011. Reasons related to non-vaccination and under-vaccination of children in low and middle-income countries: findings from a systematic review of the published literature, 1999–2009. Vaccine., 29(46):8215-21. https://doi.org/10.1016/j.vaccine.2011.08.096

Rasheed, M., Akram, U., Asif, N., Ahmed, K., Zafar, S. and Mumtaz, S., 2014. Expanded Programme of immunization (EPI) Status among Children of Factory Workers. JIsb. Med. Dental Coll., 2: 62-.

Shashidhara, Y. and Jeyalakshmi, K., 2018. Vaccination Coverage and Perceived Barriers to Immunization as Identified by Mothers of Under Five Children in Rural Areas of Udupi District, Karnataka, India: A Descriptive Survey. J. Clin. Diagn. Res., 12(8).

Sheikh, A., Iqbal, B., Ehtamam, A., Rahim, M., Shaikh, H.A., Usmani, H.A., Nasir, J., Ali, S., Zaki, M., Wahab, T.A. and Wasim, W., 2013. Reasons for non-vaccination in pediatric patients visiting tertiary care centers in a polio-prone country. Archiv. Pub. Hlth., 71(1):19.

Sodha, S.V. and Dietz, V., 2015. Strengthening routine immunization systems to improve global vaccination coverage. Br. Med. Bull., 113(1): 5-14. https://doi.org/10.1093/bmb/ldv001

Srivastava, A.K. and Shankar, G., 2017. A study of immunization coverage and its determinants among under five children residing in urban field practice area of SN Medical College, Bagalkot, Karnataka, India. Indian J. Forensic Commun. Med. 4(1): 48-52.

Tariq, K. and Tariq, R., 2018. Assessment of children immunization pattern in Children Hospital Lahore, Pakistan. Pak. J. Pharma. Sci., 31(2).

Vojtek, I., Dieussaert, I., Doherty, T.M., Franck, V., Hanssens, L., Miller, J., Bekkat-Berkani, R., Kandeil, W., Prado-Cohrs, D. and Vyse, A., 2018. Maternal immunization: where are we now and how to move forward? Ann. Med., 50(3):193-208. https://doi.org/10.1080/07853890.2017.1421320