A research proposal submitted to Debre Brehan university research coordinating office on assessment of mothers practice towards child vaccination and its associated factors with child vaccination in

Debre Brehan town

Principal Investigator

Endale Melesse (M.Sc.)

Debre Brehan, Ethiopia.

October, 2010.

A research proposal submitted to Debre Brehan university research coordinating office on assessment of mothers practice towards child vaccination and its associated factors with child vaccination in

Debre Brehan town

Team Members

1. Tesfa Dejenie (B.Sc.)

2. Yohannes Gebireegzeabher (B.Sc.)

3. Sisay Mulugeta (B.Sc.)

Debre Brehan, Ethiopia.

October, 2010.

Table of content PageTable of content------------------------------------------------------------------------------------I

List of abbreviation-------------------------------------------------------------------------------III Abstract---------------------------------------------------------------------------------------------1

1. Introduction-------------------------------------------------------------------------------------2

1.1. Back ground---------------------------------------------------------------------------2

2. Statement of the problem---------------------------------------------------------------------33. Literature review-------------------------------------------------------------------------------4

4. Significance of the study-----------------------------------------------------------------------5

5. Objective of the study--------------------------------------------------------------------------6

5.1. General objectives--------------------------------------------------------------------6

5.2. Specific objectives--------------------------------------------------------------------6

6. Methodology--------------------------------------------------------------------------------------6

6.1 study area----------------------------------------------------------------------------6

6.2 study design------------------------------------------------------------------------6

6.3 study period-------------------------------------------------------------------------6

6.4 study population--------------------------------------------------------------------6

6.5 source population------------------------------------------------------------------6

6.6 sampling unit------------------------------------------------------------------------6

6.7 study unit-----------------------------------------------------------------------------7

6.8 study variable------------------------------------------------------------------------7

6.8.1. Independent variables-------------------------------------------------------7

6.8.2. Dependent variables---------------------------------------------------------7

6.9. Inclusion and exclusion criteria--------------------------------------------------------7

6.9.1. Inclusion criteria--------------------------------------------------------------7

6.9.2. Exclusion criteria-------------------------------------------------------------7

6.10. Sampling technique and sampling size determination----------------------------7

6.11. Data collection tools and procedures------------------------------------------------8 6.12. Data quality assurance-----------------------------------------------------------------86.13. Data processing and analysis---------------------------------------------------------8 6.14. Operational definition of terms-------------------------------------------------------9

7. Dissemination of result----------------------------------------------------------------------------9

I

8. Ethical consideration-------------------------------------------------------------------------------9

9. Action plan------------------------------------------------------------------------------------------10

10. Budget proposal-----------------------------------------------------------------------------------11

11. Reference-------------------------------------------------------------------------------------------1412. Annex------------------------------------------------------------------------------------------------16

12.1. Questionnaire----------------------------------------------------------------------------17

II

List of abbreviation

AEFI: Adverse effect following immunizationBCG; Bacillus calmette GuerinBSC: Bachlore of science

DTP: diphtheriatetanuspertussisEFY: Ethiopian fiscal yearEPI: Expanded program of immunizationFMOH: Federal Ministry of HealthGAVI: Global alliance Vaccine and Immunization

Heb: Hepatitis type b

Hib: Homophiles influenza type b

HSDP: Health sector development programIMR: Infant mortality rateMCH: Maternal and Child HealthMDG: millennium development goal

MPH: Master of Public HealthNGO: Non-governmental organizationNPW: Non pregnant womenOPV: Oral Polio Vaccine

PEI: Polio Eradication Initiative

PI: Principal Investigator

PW: Pregnant womenRED: Reaching every districtRHB: Regional health BureauSOS: Sustainable outreach serviceTT: Tetanus toxoid Vaccine

UN: United NationsUNICEF: United Nations children fundURTI: upper respiratory tract infectionV.P.D: vaccine preventable diseasesWCBA: Women child bearing AgeWHO: world health organization

IIIABSTRACT

Introduction: Infant and under five mortality rates in Ethiopia is among the highest in the world. About 472,000 children die each year before their fifth birth days. The highest proportion for childhood deaths is due to Vaccine preventable diseases. EPI program encompass multiple activities to be conducted by different bodies at different level of organization and health sectors. EPI was started in Ethiopia in 1980 with the aim of reducing morbidity and mortality of children and mothers from vaccine preventable diseases. During the inception of EPI the objective was to increase immunization coverage by 10 % annually but this target has not been realized even after two decades because of factors such as poor health infrastructure, low number of trained manpower, high turnover of staff and lack of donor funding.Objective: To assess knowledge, attitude and practice of mothers towards immunization in Debre Brehan district/ town, North Shoa administrative zone, Amhara region, Ethiopia. Methodology: A descriptive community based cross sectional survey will be undertaken to assess Knowledge, Attitude, and Practice among mothers of Debre Brehan town towards immunization from November to January 2003. A multi stage sampling technique will be used to select samples from the general population. By considering 5% non-response rat, the total sample size will be 845. From the total 9 kebeles in the town 4 of them will be selected by lottery method. A structured questionnaire composed of closed-ended questions will be administered to the respondents to collect the quantitative data. Qualitative data will be collected by observation by using check list. Data collectors will approach by introducing him/her self and interview the selected respondents after informed consent obtained. The data collectors will be recruited depending on the criteria, the one who has Bachelor of Science in nursing and above, and both female and male applicants will be accepted. The data gathered through the structured questionnaire will be entered to EPI- INFO version 6 and SPSS version 16 a statistically packed soft ware for analysis. Qualitative data will be analyzed and presented by descriptive statement.Expected result: 80% of the sample mothers have good knowledge, 80% of the sample mother have good attitude, and 75% of the sample mother have good practice of immunization. Budget summary: This proposal will require a total of 20,642.50 Ethiopian birr with personnel cost of 12,600.00, equipment and supplies cost of 3,460.00, transportation and communication cost of 480.00, training /Refreshments cost of 1,410.00, and contingency (10%) of 2,692.50.1. Introduction1.1. Back ground Infant immunization is considered essential for improving infant and child survival. In 1974 when the world health organization (WHO) launched the Expanded program of immunization (EPI), the program was based on the belief that most countries already had some elements of nation immunization activities which could be successfully expanded if the program become a national priority with the commitment from the government to provide managerial manpower and fund to provide service to at least 85% of the target population .i.e. children under four years. Because of differences in epidemiological factors the common childhood diseases targeted for vaccination in Expanded Program on Immunization (EPI) are vary in different countries around the world. WHO recommended targeted diseases, and also adopted in Ethiopia are measles, pertussis (whooping cough), tuberculosis, tetanus, poliomyelitis and diphtheria. (1)

Recently Hepatitis B virus and Homophiles Influenza type b are included in EPI program in Ethiopia. (2)

EPI was started in Ethiopia in 1980 with the aim of reducing morbidity and mortality of children and mothers from vaccine preventable diseases. During the inception of EPI the objective was to increase immunization coverage by 10 % annually but this target has not been realized even after two decades because of factors such as poor health infrastructure, low number of trained manpower, high turnover of staff and lack of donor funding. The same factors still affect the program today. The target group when the program started were children under two years of age until it changed to one year in 1986 to be in line with the global immunization target. (3, 4)

Ethiopia has developed a health policy in 1993 and revised EPI policy in 1997. The national EPI policy recommends that health workers should use every opportunity to immunize eligible children according to the recommended schedule. The policy says children who are hospitalized should be immunized as soon as their general condition improve and at least before discharge from hospital. An individual with known or asymptomatic HIV infection should receive all EPI vaccine at as early age as possible.

Patients with overt AIDS should receive all vaccine except BCG and yellow fever. EPI service should be routinely available preferably on daily bases in all facilities (Governmental, NGO and private).The policy also state about the need to screen and assess status of children and women at every contact prior to giving antigens. The program strategies of EPI are directed for increasing immunization coverage, to reduce missed opportunities/ defaulters, increasing the quality of immunization service, improve public awareness and community participation, to sustain high immunization coverage and disease Eradication/control/Elimination strategies.One of the strategy to combat vaccine preventable disease is immunization , 2001 EFY national report showed that the immunization coverage of DPT3,measle and fully vaccinated has reached to 72.6%,64.9%,and 52.5% respectively and in Oromia region the coverage was 74.4% 81.8% and 51.0 % respectively. (5)

The Polio Eradication Initiative (PEI) is a global program with the target of a polio free world by the year 2005. Ethiopia has achieved tremendous progress in its Polio Eradication Initiative activities since it commended in 1996. To achieve the Millennium Development Goal (MDG) of reducing child deaths by two-thirds in 2015, Ethiopia has adopt strategies such as Sustainable outreach service (SOS) and Reaching every district (RED) that focus on identifying bottlenecks and developing community ownership of the services in order to improve routine immunization services and increase coverage. (6)The immunization program is funded primarily by partners and government; vaccine cost by UNICEF, salary by government, cold chain equipment, transport equipment, social mobilization and some operational cost by WHO, UNICEF and other development partner. In terms of health financing and budget provisions, the government has taken steps to reallocate resource from curative to preventive care targeting the rural population. So the involvement of stakeholders/partners is important for strengthening immunization service and the achievement of high coverage.

Ethiopia is using different strategies and innovations to increase the national EPI coverage throughout the country to benefit from it in reducing child and infant mortality that is one of the millennium development goals of 2015 but still national EPI coverage is low. During the years 2001-2002 there was an increasing trend in EPI coverage where the national coverage based on DPT3 reached 70% and after wards the coverage began to decline to 65 % in 2003/4. (7) Currently, EPI policy guideline has revised in 2007,the countrys immunization effort move from developmental phase focusing on coverage to a phase that concentrates on disease control and eradication and this showed that the country commitment for strengthening immunization service and sustaining high immunization coverage. (13)

Reaching every district (RED) is a multi-faceted approach with the goal of reaching >80% DTP3 coverage in every district in >80% of developing countries by 2005. This goal is referred to as the "80/80 goal". It is the accepted approach to achieve a sustained and equitable access to good quality immunization services and accelerate progress towards achieving the 80/80 goal. This approach means reaching every child in every district with quality immunization services. The main components of reaching every district (RED) include re-establishing outreach vaccination, supportive supervision, linking communities and services, monitoring for action, and planning and management of resources. The comprehensive approach for immunization are increase and monitor vaccination coverage, improve health system service delivery and management, decrease drop-out rate, improve logistics system, promote positive behaviors in support of immunization, improve epidemiological surveillance System, increase supervision process review and follow-up , maximize cost-effectiveness, improve inter-agency coordination. (7, 15)2. Statement of the problem About 472,000 Ethiopian children die each year before their fifth birthdays. This make under five mortality rate bout 140/1000 with variations among the regions from 114 to 233/1000 .This tragic fact places Ethiopia sixth among the countries of the world in terms of the absolute number of child deaths. Among the cause of mortality, vaccine preventable diseases are the major ones (2).

Every year more than 10 million children in low- middle-income countries die before they reach their fifth birthdays. Most die because they do not access effective interventions that would combat common and preventable childhood illnesses (3).

A 2001 vaccine-preventable diseases estimate of WHO showed that the greatest burden of disease in Sub-Saharan Africa were deaths of pertussis, tetanus, and measles which account 58 percent, 41 percent, 59 percent, and 80 percent respectively. East Asia and the Pacific have the greatest burden from hepatitis B with 62 percent of deaths worldwide. South Asia also experienced a high disease burden particularly for tetanus and measles (11).In 2007, A total of 24.3 million infants not immunized DPT3, from which Africa account 7.3%, South East Asian account 11.5% ,Europe account 0.4%, Western pacific and Eastern Mediterranean account 1.95 each and America account 1.1% (12).

Ethiopia has an estimated population of approximately 76 million. Although infant mortality rate (IMR) has declined from 97/1000 in 2000 to 77/1000 in 2005, it is still among the highest in the world. From a total under five deaths in Ethiopia 28% is due to pneumonia, 25% due to neonatal condition 20% each due to malaria and diarrhea, 4% due to measles and the rest by other. Yet there is effective low cost intervention to prevent two/third of these deaths of every 100 children in Ethiopia (14). EPI is essential for improving infant and child survival although the coverage can be improved by increasing KAP of the population. In Debre Brehan town there are health facilities that give service to the community including child vaccination. There are 1 hospital, 1 health center, 4 health post, 1 pharmacy, 1 higher clinic, 7 medium clinic, 8 low level clinic, 2 special clinic and 4 drug store which are both governmental and non-governmental. According the 2002 annual woreda health bereau report, the coverage of child vaccination is 56.3% BCG, 51% Penta3, 57.7% Penta2, 51% OPV3, 41.5% measles. 43.9% of childrens are fully immunized. 3. Literature review A survey conducted in China about KAP towards Vaccine preventable disease the result shows that the level of immunization knowledge among parents was positively associated with attitude and practice of immunization. Immunization coverage was 89.3% in the high stratum in 63.8% in the low stratum service area (28).

In Africa, a serious 30 cluster immunization coverage survey was undertaken as a survey of KAP among parents result of the survey showed 90% of population begins immunization but 30% drop out. The survey conducted in Ethiopia and the weighted national immunization coverage assessed by card plus history for children aged 12-23 months vaccinated before the age of one year was BCG 83.4%, DPT1 84.3%, DPT3 66.0% ,measles 54.3%, and fully immunized children 49.9% . A community based cross sectional survey in Ziway town eastern showa shows 53% of children was fully immunized, 19 % was defaulters and the rest were totally non-immunized. The reasons for defaulters were inconvenience of vaccination time, child sickness and lack of information about the need for repeated vaccination (30).

April 1995 in Gonder and surrounding villages in West Ethiopia cluster sampling was conducted to assess immunization coverage in area and problem associated with vaccination delivery. Among the sample children 47.4% fully immunized while 30% were not immunized at all. The reason given for not immunizing children were lack of knowledge 39.7% social problem 38.7% various obstacles 22% such as child sickness and health institution related problems (31).

A cross sectional community based study was carried out in Jimma town South west Ethiopia to determine reason for defaulting from expanded program of immunization (EPI) using structured questionnaire in March 1997. A total of 376 children aged 12 to 23 months and their mothers were covered in study. Out of total 376 children 46.5% were fully immunized, 53.5% were defaulters. The reason given by mothers for not completing vaccination were missed appointments time (48.8%) mothers and no enough time (25.9%) and child was sick (23.4%) maternal age, neonatal care , parity, education knowledge about vaccine preventable disease and immunization. Another study in Jimma town shows higher acceptance of immunization by mothers who have been educated to above 6 grade and the higher of educational status the higher rate of completing the vaccination schedule and the relation between occupation and child immunization were government employee was the first to fully immunize their child that is i.e. 94% and the least was house made that is 50% the reason for this might be government employee could have access to know the benefit of immunization from their passed education and daily activities but house maids might have lack of education & economy. Also the study had been identified factors associated with non immunization and defaulters was illiteracy, lack of knowledge about EPI target diseases attitude of mothers were 45.6% said very useful, 54.1% said useful and the rest 0.3% said not useful (32). Currently a great consideration have given for immunization, the result have been under expected. The aim of this study will be to assess the obstacles in relation to the mother KAP to child immunization. 4. Significance of the studyThe highest proportion for child hood death is due to vaccine preventable disease (2). The service with the provision of health message to the population about the vaccine is the first to increase the EPI coverage. Non- immunization was associated with low socioeconomic status, maternal illiteracy and lack of mothers knowledge on vaccination as recommended by the expanded program on immunization (23).

The problem of management of intersectional co-ordination and lack of public awareness of the purpose and importance of immunization persisted (25). Lack of information about the childs immunization status, complexities of immunization schedules, misconception regarding multiple vaccine contradiction and inadequate emphasis to parent about the importance of the timely completion of immunization are factors that affect immunization (25). Lack of community participation was also found to be crucial constraining factors (26). However, the two principle problems in the way of achieving effective immunization for all children are lack of awareness and lack of knowledge. Miss information about immunization is amongst the most serious traits to the success of immunization program. Some examples of rumors are: Vaccines are contraceptives to population or to limit the size of certain ethnic group, Vaccines are contaminated by HIV , and Children are ding after receiving vaccines.

The consequence of rumors can be serious and if not unchecked those can drawback the EPI program (21).

This study helps to detect mothers KAP towards the eight types of vaccination, common defects of mothers for not vaccinate their child. The result could be help to plan for child immunization based health education to the community, and better practice among mothers who have poor practice to immunize their children. In addition the study will used as literature for others (individual, group, organization both governmental and non-governmental) who wants to intervene based on the result obtained or who wants to do further study to answer question that are not answered by this study.5. Objective of the study 5.1. General Objectives

To assess practice of mothers towards child vaccination and its associated factors with child vaccination in Debre Brehan district/ town, North Shoa administrative zone, Amhara region, Ethiopia. 5.2. Specific objectives

To assess the practice of mother to vaccinate their children in Debre Brehan town.

To determine the associated factors towards child vaccination in Debre Brehan town.6. Methodology and material 6.1. Study Area

The study will be conducted in Debre Brehan district/ town, North Shoa administrative zone, Amhara region, Ethiopia. The district has 9 administrative kebeles. The district / Debre Brehan town is located at 130 km North of Addis Ababa, capital city of Ethiopia. Based on the 2007 population and housing census, the total population size of the district estimated to be 72,097. The number of married couples/ households in the district is estimated to be 16,767. According to the information obtained from District Health Office; in the district there are 1 hospital, 1 health center, 18 clinics and 4 health posts which render health services for the community. In most of the health facilities including health posts immunization in service and outreach service is available for who need the service.

6.2. Study design

A descriptive community based cross sectional survey will be undertaken to assess practice of mothers towards child vaccination and its associated factors with child vaccination in Debre Brehan district/ town.6.3. Study period

From November to January 2003.

6.4. Source population

All mothers between the age of 15-49 years old in Debre Brehan town.6.5. Study population

All mothers between the age of 15-49 years old in the selected sample kebeles.6.6. Sampling unit

Household in the selected cluster.

6.7. Study unit

Individual mother with the age between 15-49 years.

6.8. Study variable 6.8.1. Independent variables

Age

Sex

Occupation

Educational status

Monthly income

BCG scar

6.8.2. Dependent variables

KnowledgeAttitudepractice

6.9. Inclusion and Exclusion criteria

6.9.1. Inclusion criteria Mothers in selected kebeles.

Mothers with age 15-49 year.

Mothers who can able to communicate without difficulty.

6.9.2. Exclusion criteria

Mothers with age 49 years.

Mothers cant able to communicate easily.

Mothers of other kebeles of the town.

6.10. Sampling technique and Sampling size determinationA multi stage sampling technique will be used to obtain the total sample size of respondent. The total sample size to be calculated based on the assumption below. Z (Confidence level) = 95%, which have 1.96 value.

P (Proportion of Secuss) =50%, because it is unknown.

d (Margin of error) = 5%,

p (Proportion of failurity) =1-P Design effect = 2

= = 384 n = 384*2, with design effect of 2. By considering 5% non-response rat, the total sample size will be 845. From the total 9 kebeles in the town 60%of them (5 kebeles) will be selected by lottery method. From those kebeles households are selected proportionally until we meet the total sample. The first house hold will be obtained by using sharp dot pencil with closed eye on the sample frame. Every Kth house hold will be included in the sample. K is calculated by dividing the total number of house hold by the sample house hold.Schematic presentation of sampling

6.11. Data collection Tools and ProceduresA structured questionnaire composed of closed-ended questions will be administered to the respondents to collect the quantitative data. Qualitative data will be collected by observation by using check list. The questionnaire is prepared in English and it will be translated in to Amharic language for appropriate and easiness in interviewing the study subjects as they are Amharic language speakers. The Amharic version will again be translated back to English to check the consistency of meaning. Translation of questionnaire will be done by language experts in both cases. The questions included in the questionnaire are prepared depending on review of different related literatures and variables identified to be measured.

Data collectors will approach by introducing him/her self and interview the selected respondents after informed consent obtained. A household will be revisited for two more times if the study the next subject not available on the first visit and if not be found during the revisit, household will be considered. Incase there is no eligible mother in the household the next household is taken as a sample.

6.12. Data quality assuranceThe data collectors will be recruited depending on the criteria, the one who has Bachelor of Science in nursing and above, and both female and male applicants will be accepted. Training will be given on the basic technique of interviewing. The issue of confidentiality and privacy will be stressed during the training session and they will practice on pre-testing of the questionnaire after their training.

The data collectors will be supervised daily by supervisors who are qualified in masters of public health. The filled questionnaires will be checked daily by the supervisors and principal investigator. If there is any problem the solution will be given daily by discussing with the supervisors and the data collector. Data quality will also be maintained by Cross checking the filled questionnaire by repeating the interview on a randomly selected households from which that data collected. Different methods of handling missed data will be used. Moreover, a pretest of questionnaire will be conducted on 30 mothers age 15-49 years to assess its completeness in providing the information needed for the study in the area that will be out of selected kebeles.

6.13. Data processing and analysis

The data gathered through the structured questionnaire will be entered to EPI- INFO version 6 and SPSS version 16 a statistically packed soft ware for analysis. Also the data will be checked and cleaned for its completeness and errors in data entering. All the data obtained from the study population will be entered, cleaned and analyzed by the investigator. The result will be presented by using tables, charts, and graphs. Qualitative data will be analyzed and presented by descriptive statement. 6.14. Operational definition Satisfactory knowledge those mothers who answers >80% of the knowledge questions.

Un Satisfactory knowledge those mothers who answers < 60% of the knowledge questions.

Good attitude those mothers who answers >75% of the attitude questions.

Poor attitude those mothers who answers 70% of the practice questions.

Poor practice-those mothers who answers Five 6. Other/specify_____________6. Have you ever seen side effect of a vaccine while childrens have vaccinated?

1. Yes 2. No

7. If Yes for Q. No 7 describe

1. Fever 2. Swelling, pain, readiness at the site of injection 3. Rash4. Loss of apatite 5. Other /specify/_____________

8. Does the provider told you about the importance of immunization?

1. Yes 2. No

9. Do you have a card that you immunize your child?

1. Yes 2. No

10. If your answer is No for Q No 2, why?

1. Not given by health professional 2. Teared by children 3. Other (Specify)_________

9. Do you have any idea how the service can be improved? Check lists for direct observationScheduleImmunization given

BCGPolioPentavalentMeasles

OPV0OPV1OPV2OPV3DPT-HIB-HBV1DPT-HIB-HBV2DPT-HIB-HBV3

BCG scare Present Not PresentTHANK YOU!

Name of Interviewer_______________________ Date______________ Sign_________

Name of supervisor________________________Date______________Sign__________ Debre Brehan Town

Kebele-1

Kebele-2

Kebele-3

Kebele-4

Kebele-5

Kebele-6

Kebele-7

Kebele-8

Kebele-9

Kebele-9

Kebele-4

Kebele-2

Kebele-8

Kebele-6

Household

26

_1349469485.unknown

_1349469962.unknown