Acceptability of Reminders for Immunization Appointments via Mobile Devices by Mothers in Ilorin, Nigeria: A Cross-sectional Study.
Traditionally in Nigeria, the time of appointment for the next vaccine of the baby is recorded on the immunization card, with the expectation that the caregiver would remember to check the date of the next scheduled immunization and bring the child as and when due. The immunization schedule has a time interval between four and 25 weeks for the various vaccines. Missed opportunities for vaccinating a child could occur because the mother forgets the date or is not available to keep the scheduled appointment for immunization. (2, 5, 6) Therefore, there may be a need to provide reminders to caregivers about the scheduled immunization appointment before the due date, with prompting to keep the appointment, which could be done via the use of telephones. Indeed, some studies have shown that immunization reminders have been effective in increasing childhood immunization rates. (7-10) The use of mobile communication technology is a fast-growing sector of the communications industry in developing countries including Nigeria. (11) Thus, the telephone may be used for the reminders.
Deployment of reminders as a means of improving vaccination coverage requires the participation and cooperation of the caregiver. Thus, the objectives of the study were to identify the willingness of mothers to receive reminders for immunization appointments, as well as the factors associated with willingness of mothers in Ilorin, Nigeria to receive reminders.
This descriptive, cross-sectional study was conducted at the two public hospitals, owned and run by the state, located in Ilorin West Local Government Area, Ilorin, Kwara State. Ilorin is the capital city of Kwara State, situated in the North Central geopolitical zone of Nigeria, with a population of 854 737 according to the 2006 census. The inhabitants belong mainly to the Yoruba, Fulani, Nupe, and Kanuri tribes.
Each hospital has an immunization unit that gives vaccinations on working days and attends to an average of 80 newborns every month. Other services offered at the immunization unit include nutrition and general health education.
The formula used for estimating the minimum sample size required for the study was "n = ([z.sup.2]pq)/[d.sup.2]" where "p" (the percentage of the study phenomena in population) was estimated at 62.6% from a previous study, (12) and an observed difference of 5% or more taken as being significant. Therefore the minimum sample size calculated was 360. However, a total of 526 mother-child pairs were recruited.
Mothers/caregivers bringing their newborn for their first set of vaccines, who had a contact telephone number (personal/spouse), and who gave their consent to be enrolled in the study were included. Those with no contact telephone number, refused to give consent, or whose babies had already received the first group of vaccines were excluded from the study.
Ethical approval was obtained from the Ethical Board of the Kwara State Ministry of Health. The participants gave their informed verbal consent.
Purposive sampling of every mother-child pair who fit the inclusion criteria was done, and the mother-child pairs were recruited over four months (15 August to 15 December 2016) as part of another study. Two research assistants deployed a semi-structured interview-based questionnaire. The sociodemographic details of each child brought for vaccination was recorded. The parents occupation was grouped into five categories according to Oyedeji: (I) professionals, owners of large business; (II) secondary school teachers, owners of medium-sized business; (Ill) artisans, primary school teacher, clerks; (IV) petty traders, laborers; and (V) students, unemployed, housewives. (13) Questions were asked about antenatal care (ANC) history, such as the location and number of visits. The delivery details of the infant, including date and place of birth, were also recorded. Previous vaccination for a child and whether it was completed was also noted. Responses on the ownership of a phone by the mother or father, as well as willingness to have the phone number recorded for reminders, were noted and recorded if applicable. The mother's opinion about whether she would want a reminder for subsequent vaccines was sought and recorded. Responses to reasons for either wanting or not wanting reminders were also recorded. If mother answered in the affirmative, answers on the type of reminder, and the preferred language for communication were sought.
Data was analyzed using SPSS Statistics (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Continuous variables were expressed as the mean and standard deviation (SD) and categorical variables as number and percentage. After the generation of frequency tables and simple proportions, the chi-square test was used to identify significant differences for categorical variables. Variables with a p-value less than 0.050 on bivariate analysis were included in the binomial logistic regression model to identify factors that predicted willingness to receive reminders. A p-value of less than 0.050 was considered statistically significant.
The mean age of all mothers recruited was 28.5 [+ or -] 4.8 years, and the age range of mothers recruited was between 17 years and 45 years old. Of the 526 children enrolled, 267 (50.7%) were male, and 259 (49.2%) were female. Islam was the religion of 380 (72.2%) mothers, and 146 (27.7%) mothers were Christians. The major occupation of the mothers and fathers were artisans accounting for 318 (60.4%) and 257 (48.8%) of participants, respectively. Ten (1.9%) mothers were single, and 516 (98.0%) mothers were married. Other sociodemographic features are shown in Table 1. The majority of mothers had AN C and delivery at a government-owned facility (n = 421, 80.0% and n = 420, 79.8%, respectively). Most mothers (41.6%) had one child, with a decrease in the proportion recorded with an increasing number of children [Table 1].
Previous immunization experience was recorded for 299 (56.8%) mothers while 227 (43.1%) mothers had no experience taking a child for immunization. Information about the NPI schedule on the number of visits and the infant's age at each visit was identified correctly by 273 (51.9%) mothers and wrongly by 253 (48.0%) mothers.
Four hundred and eighty-eight (92.7%) mothers had a personal phone. Of the 488 mothers who had a personal phone, 484willingly provided their phone number while four provided only the phone number of their spouse. All (100%) fathers had a phone, and the mothers willingly provided the phone numbers of the 526 fathers.
A positive response on willingness to receive reminders for immunization visits was given by 363 (69.0%) mothers and a negative response by 163 (30.9%) mothers. Forgetfulness of the date of the next scheduled visit was the main reason mothers opted for reminders. Of the 163 who opted out of receiving reminders, 73 (44.7) reported that they would remember the date of the next scheduled visit given verbally by the healthcare worker while 90 (55.2%) reported they would check the immunization card for the date of the next visit.
Of the 363 mothers who were willing to receive reminders, 189 (52.0%) chose text messages as the preferred reminder type, while 174 (47.9%) mothers preferred phone calls. English was the preferred language for reminders for 194 (53.4%) mothers while the remaining mothers preferred their native language. A total of 206 (56.7%) mothers were willing to pay for the reminders.
On bivariate analysis, the educational level of parents, maternal occupation, number of children in the family, previous immunization experience, knowledge of the immunization schedule, and place of ANC and delivery were factors significantly associated with the acceptance of reminders [Table 2].
The multivariate logistic regression model of these factors had a goodness of fit measure which was statistically significant (chi-square = 68.013, df= 10, p < 0.001) with an R-square of 17.1. Table 3 shows mothers with children less than or equal to four in number had a three-fold increased odds of wanting reminders. Postsecondary education and ANC in a hospital increased the odds of wanting reminders by two- and eight-fold, respectively. The chances of those not willing to receive reminders were increased in mothers with group III occupation compared to those with group IV and V occupational class.
The current study found that 93% of the mothers owned a phone, and all had access to a phone in the household. This finding is similar to the proportion of maternal phone ownership of 92.6% and 100% access reported in Benin, (12) but lower than that reported in Ibadan (14) (98.9%) and Lagos (98%). (15) All mothers in the study were willing to provide contact information (either their own or spouses) as reported in previous studies. (12, 14-16) Contact details are needed for reminders, and thus the fact that mothers were willing to provide the contact details would be of aid in utilizing reminders to improve vaccination coverage.
Most mothers (69.0%) responded positively to accepting immunization reminders, which is slightly higher than the value of 62.6% reported in Benin, (12) but lower than that reported from Lagos (15) and Ibadan (14) (77.0% and 95.1%, respectively). Mothers who were not willing to receive reminders believed that the appointment date provided on the vaccination card would serve as a sufficient reminder thus buttressing the importance of the vaccination card. The finding of a majority preference for text messages compared to phone calls in the current study differs from the findings reported in Benin, Lagos, and Ibadan where phone calls were preferred. (12, 14, 15) The majority preference for text messages may be supported by the fact that majority of the mothers had at least a secondary school level education and would be able to read the text messages.
Postsecondary maternal education was an important maternal household characteristic that determined the mothers' willingness to accept reminders. Studies have identified maternal educational level as an important determinant of reminders for immunization. (12, 14) This earlier finding supports the current study findings for maternal education but differs from the paternal education finding, which was not significant.
Typically, the mother takes the child for immunization (as demonstrated by 100% maternal presentation at immunization clinic); therefore, an educated mother is better able to understand the information provided on vaccination, which is needed to ensure complete immunization status. Indeed, the role of maternal education in completion of child immunization is important as reported previously. (1, 17-19)
ANC attendance was a significant predictor of mothers who were willing to receive reminders. This finding may be attributable to the health education (including the benefits of immunization) provided by the healthcare worker (usually nurses) during ANC visits. The health talk, reinforced at all ANC visits, serves as a source of information, especially to first-time mothers, who may lack or have inadequate knowledge about childhood immunization. This current study finding can be supported by studies that have reported ANC as an accessible source of information on immunization, (20, 21) as well as a determinant of complete childhood immunization. (3, 22) Therefore, improvement in maternal access to health care services during pregnancy and delivery may be a step towards improving vaccination uptake.
Total number of children and previous immunization experience were important predictors of willingness to receive reminders as mothers who had no previous experience and fewer (< 4) children were more likely to be willing to receive reminders than mothers with previous immunization experience and had five or more children. Reasons for this finding could probably be attributed to lack of confidence and also fear of failure to remember an appointment on the part of the mother with no previous immunization experience and fewer children. Also, this is supported by the findings of the current study of a higher proportion of mothers who could not correctly identify the NPI schedule being willing to receive reminders. An earlier study had reported mothers with fewer children as being more willing to receive reminders. (12)
Mothers who were students or housewives were more likely to want reminders compared to those who worked as artisans, junior clerks, or primary school teachers. This finding is similar to the reports from Benin. (12) The fact that the former group of mothers wanted reminders may be attributable to the fact that they may have limited experience with taking a child for immunization and are yet to develop confidence in childrearing. This could be adduced from the fact that majority of these unemployed mothers were also mothers with only one or two children. Thus, they would benefit from the reminders prompting them to take the children for vaccination. Indeed, an earlier Nigerian study had identified unemployed mothers as those likely to complete the immunization of their children. (17)
Mothers have ready access to mobile phones, and most are willing to receive reminders about immunization appointments. Determinants of maternal willingness to receive reminders include mothers with less than four children, postsecondary education, and ANC attendance. Program planners should consider utilizing reminders as a strategy to increase the immunization uptake as accessibility to contact details will make it feasible.
Received: 1 May 2017
Accepted: 26 September 2017
The authors declared no conflicts of interest. No funding was received for this study.
The authors are grateful to Dr. MJ Mohammed of Adewole Cottage Hospital, and the nurses in the immunization units of General Hospital, and Adewole Cottage Hospital, Ilorin for the support and cooperation rendered during the collection of data.
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Rasheedat Mobolaji Ibraheem  * and Moshood Adebayo Akintola 
 Department of Paediatrics and Child Health, University of Ilorin and University of Ilorin Teaching Hospital, Ilorin, Nigeria.
 Department of Paediatrics, General Hospital, Ilorin, Nigeria.
TABLE 1: Household, antenatal, and delivery characteristics of the mother-child pairs recruited in the study. Variable Frequency, Percentage, Cumulative, n % % Mothers' occupation I 11 2.0 2.1 II 57 10.8 12.9 III 318 60.4 73.4 IV 22 4.1 77.6 V 118 22.4 100 Mothers' education level None/primary 8 1.5 1.5 Secondary 186 35.3 36.9 Postsecondary 332 63.1 100 Fathers' occupation I 74 14.0 14.1 II 163 30.9 45.1 III 257 48.8 93.9 IV 8 1.5 95.4 V 24 4.5 100 Fathers' education level None/primary 3 0.5 0.6 Secondary 126 23.9 24.6 Postsecondary 397 75.4 100 Mothers' monthly income, Nigerian Naira 0-18000 229 43.5 43.5 18001-50000 120 22.8 66.3 50 001- 28 5.3 71.7 100 000 >100 000 2 0.3 72.1 Not stated 147 27.9 100 Fathers' monthly income, Nigerian Naira 0-18000 18 3.4 3.4 18 001-50 000 98 18.6 22.0 50 001- 64 12.1 34.2 100 000 > 100 000 13 2.4 36.7 Not stated 333 63.3 100 Place of ANC Government 421 80.0 80.0 hospital Private hospital 71 13.4 93.5 None 34 6.5 100 Place of delivery Home 24 4.4 4.6 Traditional 5 0.9 5.5 birth attendants Private hospital 58 11.0 16.5 Government 420 79.8 96.4 hospital Place of delivery Faith home 19 3.6 100 Number of children One 219 41.6 41.6 Two 140 26.6 68.3 Three 89 16.9 85.2 Four 57 10.8 96.0 Five 21 3.9 100 ANC: antenatal care; I: professionals, owners of large business; II: secondary school teachers, owners of medium-sized business; III: artisan, primary school teacher, clerks; IV: petty traders, laborers; V: students, unemployed, housewives. TABLE 2: Factors associated with willingness to receive immunization reminders. Variables Willing to [X.sup.2] p-value receive reminder Yes No n = 363 n = 163 Sex of child Male 181 86 0.378 0.539 Female 182 77 Religion Islam 262 118 0.003 0.959 Christianity 101 45 Occupational group of mother I and II 50 18 20.614 0.001 III 197 121 IV and V 116 24 Maternal education None/primary/ 110 84 21.781 0.001 secondary Postsecondary 253 79 Occupational group of father I and II 171 66 4.288 0.117 III 167 90 IV and V 25 7 Paternal education level None/primary/ 77 52 6.944 0.008 secondary Postsecondary 286 111 Maternal age group, years [greater than 18 6 1.675 0.433 or equal to] 20 21-35 320 141 > 35 25 16 Marital status Single/separated 8 2 FET 0.731 Married 355 161 Number of children 1-2 268 93 21.312 0.001 3-4 88 56 5 7 14 Previous immunization experience Yes 184 115 18.092 0.001 No 179 48 Knows NPI schedule Correct 169 104 13.404 0.001 Wrong 194 59 ANC attendance None 11 23 22.842 0.001 Yes 352 140 Place of delivery Outside hospital 27 21 4.022 0.045 In hospital 336 142 [X.sup.2] : chi-square. FET: Fisher's exact test; NPI: National Programme on Immunization; ANC: antenatal care. TABLE 3: Binomial logistic regression analysis of factors associated with maternal willingness to receive reminders for immunization appointments. Variables B (#) p-value OR (95% CI) Previous immunization experience None 0.441 0.217 1.554 (0.772-3.129) Yes * Maternal education level Postsecondary 0.672 0.004 1.958 (1.232-3.111) Secondary */ Primary/None Paternal education level Postsecondary -0.057 0.826 0.945 (0.570-1.566) Secondary */ Primary/None Occupation classification mother Group I, II -0.503 0.177 0.622 (0.291-1.256) Group III -0.700 0.010 0.506 (0.291-0.847) Group * IV V Number of children 1-2 1.245 0.016 3.474 (1.258-9.596) 3-4 1.124 0.029 3.077 (1.123-8.433) > 5 * ANC attendance Yes 2.126 0.001 8.381 (2.495-28.170) None * Place of delivery In a hospital -0.954 0.071 0.383 (0.136-1.079) Out of a hospital * Knows NPI schedule Yes -0.161 0.638 0.851 (0.436-1.663) No * * Reference category; #Estimated logistic co-efficient. OR: odds ratio; 95% CI = 95% confidence interval; NPI: National Programme on Immunization; I:professionals, owners of large business; II: secondary school teachers, owners of medium-sized business; III: artisan, primary school teacher, clerks; IV: petty traders, laborers; V: students, unemployed, housewives.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Ibraheem, Rasheedat Mobolaji; Akintola, Moshood Adebayo|
|Publication:||Oman Medical Journal|
|Date:||Nov 1, 2017|
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