ABSTRACT

Immunization remains one of the most cost-effective public health interventions globally, yet coverage gaps persist, particularly in Sub-Saharan Africa. According to WHO and UNICEF (2024), global childhood immunization coverage stalled in 2023, with 14.5 million children failing to receive even a single dose of the diphtheria-tetanus-pertussis (DTP) vaccine an increase from 13.9 million in 2022. Nigeria bears a disproportionate share of this burden, with an estimated 2.1 million zero-dose children in 2023, the largest population of unvaccinated children in Africa (Gavi, 2024). Health education is widely recognized as a pivotal strategy for bridging immunization knowledge gaps and improving vaccine uptake among caregivers. This study assessed the impact of health education towards compliance of immunization among children aged 0-5 years in Ahoada General Hospital, Rivers State. A descriptive cross-sectional survey design was adopted. Data were collected using structured questionnaires administered to mothers/caregivers attending the immunization clinic at Ahoada General Hospital. The study examined knowledge and perception of vaccine-preventable diseases, sources of immunization information, immunization practices, and factors influencing compliance. Findings revealed that health education significantly improved caregivers' knowledge of vaccine-preventable diseases and increased compliance with immunization schedules. Key factors influencing non-compliance included low maternal education, distance from health facilities, and misinformation. Consistent with Okunlola et al. (2023), literate mothers were significantly more likely to fully vaccinate their children compared to illiterate counterparts. The study recommends intensified health education campaigns, community outreach, and targeted information dissemination to address knowledge gaps and improve immunization coverage in Rivers State.

Keywords: Health Education, Immunization, Compliance, Vaccine-Preventable Diseases, Children 0-5 Years, Rivers State, Nigeria.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Immunization is one of the safest and most effective interventions to prevent disease and early child death. Although about three-quarters of the world’s child population is reached with required vaccines, only a fraction of children in Sub-Saharan Africa receive access to basic immunization in a timely and complete manner. According to data published by the World Health Organization (WHO) and UNICEF (2024), global immunization coverage stalled in 2023, with the number of children who received three doses of the vaccine against diphtheria, tetanus, and pertussis (DTP) a key marker for global immunization coverage remaining at 84%, while 14.5 million children did not receive a single dose, up from 13.9 million in 2022. These figures underscore that global immunization coverage has not yet returned to pre-pandemic 2019 levels (WHO & UNICEF, 2024). In recent years, many countries have employed a growing range of strategies to increase both the provision and utilization of immunization services, consistent with the Immunization Agenda 2030 (IA2030) strategy, which calls for a global effort using combinations of approaches to reach everyone targeted for immunization (Gavi, 2024).

A substantial number of children worldwide do not complete immunization schedules because neither health services nor conventional communication mechanisms regularly reach their communities. Geographic access plays a critical role in delivering equitable essential healthcare services, particularly in low- and middle-income countries (LMICs) where infrastructure and transportation barriers often limit healthcare reach (Medrxiv, 2025). Studies across diverse settings, including Ethiopia, Burkina Faso, Kenya, Uganda, and Nigeria, have consistently found a link between greater distance to healthcare facilities and poorer health outcomes or reduced vaccination rates (Medrxiv, 2025). A pooled analysis of Demographic and Health Surveys conducted between 2019 and 2023 across Sub-Saharan Africa found that over 55% of women of reproductive age face at least one significant barrier to healthcare access, with wealth status, place of residence, and community poverty level all being significant predictors (Barriers to Healthcare Access, 2024). Underserved communities have consistently shown low immunization coverage. Innovative outreach strategies are therefore needed to particularly target children who are excluded or beyond the reach of routine immunization services.

Anti-vaccination information and/or refusal to have children immunized is not a new phenomenon. Historically, populations have rejected immunization due to concerns about vaccine safety as well as political, cultural, and religious reasons. Today, trust and acceptance of immunization face formidable new challenges. Social media platforms have allowed the rapid spread of health misinformation and disinformation, impacting vaccine confidence globally, including in low- and middle-income countries such as Nigeria, Brazil, and Indonesia (IVAC, 2022; Arxiv, 2023). The global anti-vaccine movement and vaccine hesitancy that accelerated during the COVID-19 pandemic show no signs of abating; Americans in October 2023 were less likely to view approved vaccines as safe than they were in 2021 (Boston University, 2024). Research published in BMJ (2024) has provided a roadmap for countering social-media-driven vaccine misinformation, noting that anti-vaccine campaigns have proliferated significantly since the COVID-19 pandemic and target all kinds of vaccines, including childhood vaccines, measles, and others (Behavioural Interventions to Reduce Vaccine Hesitancy, BMJ, 2024). Secondly, increased democratization promotes debates about individual and community rights and choice, making national immunization programs more vulnerable to being questioned in both the developed and developing world.

There remains an ever-widening gap in access to vaccines between developed and developing countries. While more vaccines have become available globally, most developing countries cannot afford newer vaccines, lack well-functioning systems to deliver them, and have inadequate surveillance systems to motivate decision-makers to adequately fund immunization programs (Annals of Global Health, 2023). A study on middle-income countries identified key barriers including unaffordability, lack of technical capacity in forecasting and planning, and limited or unpredictable funding as serious challenges to achieving universal vaccine coverage (Annals of Global Health, 2023). Furthermore, a scoping review of routine childhood immunization barriers in Nigeria documented that despite the proven benefits of immunization, the number of zero-dose and under-immunized children has increased across the African continent, with Nigeria recording the highest burden of missed-dose and zero-dose children on the continent as of 2022–2023, alongside Ethiopia, the Democratic Republic of the Congo, Angola, and Guinea (Preprints.org, 2024).

The induction of immunity by applying vaccines to children is among the most cost-effective health interventions to reduce child mortality, morbidity, and disability in the world (Danso et al., 2023). This is achieved through a routine vaccination schedule for children in Nigeria. According to the National Primary Health Care Development Agency (NPHCDA) and UNICEF Nigeria, the current immunization schedule includes vaccines for tuberculosis (BCG), polio (OPV and IPV), hepatitis B, diphtheria, tetanus, pertussis (DTP), measles, yellow fever, pneumococcal diseases, and others (UNICEF Nigeria, 2024). BCG and OPV0 are administered at birth, while three doses of OPV and pentavalent vaccines which protect against diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type B disease are given at 6, 10, and 14 weeks, and measles vaccine is given at nine months. The NPHCDA continues to update and strengthen Nigeria’s immunization schedule to align with evolving global immunization strategies (NPHCDA, 2023).

Nigeria, like many countries in Africa, is making efforts to strengthen its health system especially routine immunization so as to reduce disease burden from vaccine-preventable diseases (VPDs). The Nigeria Strategy for Immunization and Primary Health Care System Strengthening (NSIPSS) is a 10-year strategy document that defines the country’s plan to achieve a minimum of 80% equitable and sustained national immunization coverage for all antigens by 2028 (Nigeria Zero-Dose Situation Analysis, 2023). Such efforts include provision of the vaccines and personnel through the NPHCDA, private or NGO providers’ contributions, community-based participation, and media engagement. Despite these efforts, Nigeria remains home to an estimated 2.1 million zero-dose children in 2023 the largest population of unvaccinated children on the African continent with 100 local government areas (LGAs) across 18 states accounting for 1.5 million of these children (Gavi, 2024; WHO, 2024).

1.2 Statement of Problem

Death in infancy has been a prevalent issue in the medical and health sector despite efforts through various campaigns and immunization centre establishment. Social, educational, and cultural practices continue to restrict many caregivers particularly women from obtaining basic information on immunization (Olaniyan et al., 2022). A scoping review of routine immunization in Nigeria published in 2024 identified persistent barriers including educational gaps, community-level misinformation, cultural beliefs, and inadequate health infrastructure as key drivers of immunization non-compliance (Preprints.org, 2024). The low routine immunization coverage has favoured the transmission of wild poliovirus and has created immunity gaps that favour the emergence and spread of vaccine-preventable diseases such as measles.

According to the WHO (2024), the persistence of vaccine-preventable diseases in Nigeria can largely be attributed to the under-utilization of available vaccines, and health education knowledge gaps among mothers and caregivers, which underscore low compliance with vaccination schedules. A qualitative study on vaccination decision-making among Nigerian mothers (Tandfonline, 2024) found that vaccine-preventable diseases still account for one-in-eight child deaths before their fifth birthday in Nigeria, one of the ten countries globally where 4.3 million children under five lack complete immunization. A knowledge, attitudes, and practices study conducted in Abuja Municipal Area Council (AMAC) found that while there was generally positive maternal KAP towards immunization, crucial socioeconomic disparities in vaccine knowledge and financial barriers to complete vaccination were identified (medrxiv, 2025). Relative distance of communities to health centres also remains a significant barrier to the completion of immunization schedules, consistent with findings from a pooled analysis of DHS data from Sub-Saharan Africa (2024) which showed that place of residence and community poverty level significantly predict barriers to healthcare access. It is against this backdrop that this study sets out to assess the impact of health education towards compliance of immunization among children 0-5 years in Ahoada General Hospital, Rivers State.

1.3 Research Objectives

The general objective of this research study is to assess the impact of health education towards compliance of immunization among children 0-5 years in Ahoada General Hospital, Rivers State. The specific objectives are stated below:

1. To assess the knowledge and perception of mothers/caregivers on vaccine preventable diseases in children aged 0-5 years in Ahoada General Hospital, Rivers State.

2. To determine the sources of information on immunization among mothers/caregivers that aid compliance with immunization of children aged 0-5 years in Ahoada General Hospital, Rivers State.

3. To determine the mothers/caregivers’ immunization practices based on available health information on immunization.

4. To assess factors that influence the compliance with immunization by mothers of children 0-5 years in Ahoada General Hospital, Rivers State.

1.4 Research Questions

The following research questions were formulated from the research objectives for the study:

1. What are the sources of health information on immunization in Ahoada General Hospital, Rivers State?

2. What is the impact of health education on level of immunization coverage in the study area?

3. What are the socio-demographic factors that influence the compliance of immunization activities by mothers/caregivers of children 0-5 years?

1.5 Scope of the Study

This study was set out to find the impact of health education towards compliance of immunization among children 0-5 years. The research was focused in Ahoada General Hospital, Rivers State.

1.6 Significance of Study

Different studies have shown that knowledge gaps underlie low compliance with vaccination schedules. A scoping review of vaccine series completion in Sub-Saharan Africa covering 53 studies from 20 countries (2000–2023) identified caregiver education level, household wealth status, and knowledge of immunization as among the ten most frequently reported factors associated with vaccine series completion in children aged 12–23 months (Vaccines/MDPI, 2025). Mothers and caregivers are less likely to complete immunization schedules if they are poorly informed about the health implications and need for immunization, logistics (time, date, and place of vaccination), and the appropriate series of vaccines to be followed. A qualitative study on the content and factors influencing health education in immunization clinics across Nigeria found that health talks in most immunization settings are not standardized and that little is known about the topics addressed, how these topics are chosen, and how parents experience these talks a significant knowledge gap that undermines routine immunization compliance (PubMed, 2026). Although knowledge alone is insufficient to create demand, poor knowledge about the need for vaccination and when the next vaccination is due is a consistent indicator of poor compliance (Danso et al., 2023; Okunlola et al., 2023).

Tracking, evaluating, and assessing the type and quality of information received by mothers would provide a vital tool for understanding routine immunization gaps in the study area. A study on maternal health literacy and childhood immunization in North-Central Nigeria (2026) found marked urban-rural disparities, with children in urban areas more likely to be fully immunized (62.5%) than those in rural communities (43.8%), and identified qualitative evidence that family influence and cultural norms significantly modulate how mothers translate knowledge into immunization behaviour (African Journal of Humanities & Contemporary Education Research, 2026). Therefore, it is important to conduct this study to examine the impact of health education towards compliance of immunization among children 0-5 years, as well as their socio-demographic factors. When up-to-date, complete, and scientifically valid health information about vaccines is available, parents are empowered to make informed decisions understanding the risks of non-vaccination, the importance of community immunity, and the actual risks of complications (WHO, 2024). Without this information, many mothers may develop a false sense of security and regard immunizations as unimportant, which continues to fuel the immunization gap in communities like Ahoada, Rivers State.

1.7 Definition of Terms

Health Education: This is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.

Immunization: A process whereby a vaccine is injected or introduced into a child to confer immunity to the child against a specific disease.

Access: The opportunity or right to experience or make use of something.

Information: Definite knowledge acquired or supplied about something or somebody, or the collected facts and data about a specific subject.

Knowledge: A familiarity, awareness, or understanding of someone or something, such as facts, information, description, or skills, which is acquired through experience, education, or learning.

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