Introduction
The incidence of measles has spiked in recent times despite the efforts to its eradication using a highly effective measles vaccine. Vaccine coverage and underreporting of cases are the major challenges to this effort.
Aim
This study was designed to assess the parental knowledge of measles, attitude to measles vaccine and practice of case notification in a rural area in Enugu Nigeria.
Materials and Methods
A descriptive cross-divtional study was carried out during a house to house campaign on measles in Ogwuagor (a rural area in Enugu, with frequent cases of measles like symptoms) between June to November 2019. A pre-tested self/interviewer’s administered questionnaire was used to assess the knowledge of measles while Parental Attitude on Childhood Vaccine (PACV) questions were adopted and used to assess the attitude of parents to the measles vaccine. The participants were parents of at least one child of above 12 months of age. The findings and scores were analysed using IBM SPSS Statistic software for windows (SPSS statistical software V.21 (IBM Corp. 2019). The age of the respondents was grouped, and the simple mean obtained. The associations of variables; number of children, level of education and last antenatal care with respect to knowledge and attitude were analysed using Chi-square and p<0.05 was regarded as statistically significant.
Results
Out of 652 households in the area, 213 were assessed. One hundred and ninety three (90.6%) expressed knowledge above average about measles and measles vaccine. The score was higher among mothers who had at least three children in their household (p=0.518), tertiary education (p=0.706) and their last antenatal care in a hospital (p=0.774). Majority of the participants had good knowledge about symptoms, transmission and prevention of measles. Only about half, 114 (53.5%) knew the complication of measles. All the respondents had a positive attitude to the measles vaccine. Forty seven (22.1%) of the respondents delayed having their child get a measles shot while 31 (14.6) had concern on the efficacy of the vaccine. Forty-eight 22.5% were concerned about the side-effects of the measles vaccine. The delays having their child get a measles shot, concern on the efficacy of the vaccine, and concern about the side-effects of the measles vaccine observed were significant (p=0.0001, 0.0001, 0.0001, respectively) among parents of more than two children.
Conclusion
There was adequate knowledge on measles symptoms, transmission and prevention but poor knowledge of the complication. Their attitudes on the measles vaccine were generally good however, the expression of delays having their child get a measles shot, concern on the efficacy of the vaccine, and concern about the side-effects of the measles vaccine were significant among parents of more than two children. Also, few measles cases were treated in hospital. There is a need to educate parents on the complication of measles and the importance of early hospital presentation of suspected cases for confirmation and prompt management. This will help to prevent complications and community transmission.
Introduction
In recent times and in many parts of the world especially among nations with a history of elimination, the burden of measles has increased in worrisome proportion despite the vaccine availability and efficiency [1-4]. There is no doubt on the potency of the vaccine because through vaccination the world had considered the disease as another target for potential eradication until recently [5]. Vaccine coverage and issues about vaccine confidence, and the proper storage of the vaccine are some of the factors contributing to the increasing incidence [2,6].
In 2018, the UK lost the measles elimination status they achieved just a year before [3]. And since then the incidence of the disease has increased exponentially. The reason for this setback has been attributed to incomplete vaccine coverage [7]. Since measles virus is highly contagious, small populations of people who are not immunised are seriously at risk when the virus is introduced from endemic regions. It is becoming difficult to achieve 95% coverage essential for herd immunity because of gradual hesitance on vaccine [8]. This is informed by negative information about vaccines and low/no report of the vaccine preventable diseases. The situation is similar in most other developed countries [4,9].
In Nigeria, poor coverage as a result of difficult to access areas such as rural and crisis-ridden areas have been the major bottleneck [10,11]. Those areas lack a good network of roads and power supply for vaccine storage [12-14]. Health workers through the intervention of the Government are improving entrance and bridging the gap [15,16]. More is expected since the outbreak so far as reported in the first half of 2019 has reached over 700% [17]. Many are still under reported and undiagnosed [18,19]. It is believed that some suspected measles cases are not reported, especially those in the rural area; where it is often managed at home [20,21].
Knowledge about measles has improved among the rural dwellers. Also, is their vaccination practice generally owing to house to house vaccination strategies adopted by many states in Nigeria [22]. There is paucity of data on the issues consigning vaccine belief and confidence which many have reported determine uptake [23,24]. This construct is introduced with intention that it will form the bases to check the changes in attitude about vaccine [23-25]. In Nigeria, there is no aware validated tool to assess the vaccine confidence or hesitance. Even though the confidence is generally reported to be high in the country apart from a few religious and cultural myths, there is a need to have the knowledge of the baseline attitude toward vaccines which will serve as a reference for future evaluation [26].
This study was designed to add to other critical assessment of the knowledge about measles and confidence of measles vaccine among parents, as they are crucial to inform public health policy on measles elimination and formulating a framework approach to further prevent vaccine preventable disease.
Materials and Methods
Study design: This study was a descriptive cross-sectional questionnaire based survey conducted at Ogwuagor, a rural area in Abakpa, Enugu State Nigeriat, from June to November 2019. Present study was done to assess the knowledge about measles, vaccine hesitancy and practice of case reporting among the population during a house to house campaign on measles education and prevention. [Table/Fig-1]. An ethical approval was sought for and granted by the local Government Ethical Committee. Also, consent to the study was given by each participant and those that declined consent were not denied the training on measles knowledge and prevention. The area has approximately 652 houses and a population of 2500 with about 45% constituting of children [27]. Ogwuagor was selected among the twelve rural areas in Abakpa by simple random sampling. The targeted respondents were parents of at least one child of above 12 months of age. Parents whose last child was above five years were excluded from the study. Three hundred and eleven households met the criteria and were included. Each household had at least one family unit. A minimum sample size of 151 parents was estimated using Leslie Fischer’s formula for sample size calculation with 95% confidence interval, a margin of error of 4.5% and a 91.3% prevalence of non-hospital presentation of measles cases as obtained in similar study [28]. The 311 household were interviewed but only 225 respondents granted consent after explaining the aims and objectives of the study to them.
Ogwuagor, Enugu Nigeria (sourced from google map).
The study team consisted of the author, immunisation campaign officers and trained research assistants.
Data collection and management: A 33-item self/assistant administered questionnaire, designed to measure demographics, knowledge about measles, parents’ attitude on measles vaccine and practice of measles vaccination was used. The questionnaire comprised of four domain questions. The first domain contained seven questions on the socio-demographical characteristics of the respondents. The second domain was designed to assess the knowledge of measles. The questions (eight in number) in this domain were adapted by the authors from extensive literature review and were also critiqued and corrected by academics who were involved in measles surveillance [28-30]. The questions centered cause, transmission, symptoms, prevention, and complications of measles. The third domain was designed to assess attitude to measles vaccine. The questions (fifteen in number) were adopted from ‘Parent Attitudes about Childhood Vaccines’ since no available local validated questions on attitude was available [31-33]. The last domain was designed to assess the practice of measles vaccination and hospital presentation of measles cases for confirmation and prompt treatment. The questionnaire was translated to Igbo language and back-translated to ensure that the original meaning of the questions was retained.
Pilot study was done on 34 parents to ensure face validity. This also helped to assess the feasibility of the studies and validate the questionnaire in terms of the logistics of the data collection, the clarity of the questions and the time cost (8-10 minutes) to complete the questionnaire. The questionnaires were analysed by community physician consultants to ensure the validity of the questions. Cronbach’s alpha showed the questionnaire to reach acceptable reliability, α=0.78.
Scores on knowledge were calculated by scoring correct response as 1 and scoring incorrect as 0. All ‘I don’t know’ responses were discarded. Total of 12 respondents responded ‘I don’t know’ in either one or more question and they were all removed bringing the total number of valid participants to 213. A scale cut of less than 50% correct responses was regarded less than average, and 50% or more correct responses was regarded as above average.
Statistical Analysis
The findings and scores were analysed using IBM SPSS Statistic software for windows (SPSS statistical software V.21 (IBM Corp. 2019). The age of the respondents was measured using simple means and grouped and other variables were described using simple proportion. The association of the scores with respect to number of children, last antenatal care and level of education were measured using Chi-square.
Scores on the attitude domain were calculated according to ‘Parent Attitudes about Childhood Vaccines’ survey scoring guide [31-33]. The association of their response to questions; ‘have you ever delayed having your child get a shot’, ‘How concerned are you that your child might have a serious side-effect from a shot’ and; ‘How concerned are you that a shot might not prevent the disease’ with respect to the number of children, last antenatal care and level of education were measured using Chi-square. The p-value <0.05 was regarded as statistically significant.
Results
Characteristics of the participants: All the participants were females with the mean age of 28.79 years SD 5.3. They all had formal education, 68 (31.9%) and 4 (1.9%) of which attained tertiary education and postgraduate education, respectively. Majority of them were married. Twenty two (10.3%) had one child only while 62 (29.1%) had at least four children in their household. The last antenatal care and delivery was attended in a Traditional Birth Attendant (TBA) home in 107 (50.2%) of the participants. Little above half, one hundred and twenty one, 56.8%), were Christian of Roman Catholic denomination. Trading occupation was predominant by 95 (44.6%) followed by house wife with 58 (27.2%) [Table/Fig-2].
Characteristics of study participants.
| Characteristics | n (%) |
|---|
| Parent age (Years) |
| 18-29 | 117 (58.9) |
| ≥30 | 96 (45.1) |
| Parent’s marital status |
| Single | 3 (1.4) |
| Married | 209 (98.1) |
| Divorced | 1 (0.5) |
| Parent education |
| No formal education | 0 (0) |
| Primary school | 21 (9.9) |
| Secondary school | 120 (56.3) |
| Tertiary education | 68 (31.9) |
| Masters/PhD | 4 (1.9) |
| Number of children in household |
| 1 | 22 (10.3) |
| 2 | 70 (32.9) |
| 3 | 59 (27.7) |
| ≥4 | 62 (29.1) |
| Religion |
| Roman catholic | 121 (56.8) |
| Protestant | 76 (35.7) |
| Muslim | 15 (7.0) |
| Tradition religion | 1 (0.5) |
| Occupation |
| Farmer | 8 (3.8) |
| Trader | 95 (44.6) |
| Civil servants | 52 (24.4) |
| House wife | 58 (27.2) |
| Last antenatal care |
| Hospital | 100 (46.9) |
| Traditional birth attendants | 107 (50.2) |
| None* | 6 (2.3) |
*denotes people who delivered at home
Knowledge about measles and measles vaccine: Out of the 213 participants, 193 (90.6%) expressed knowledge above average about measles and measles vaccine [Table/Fig-3]. The score was higher among mothers who had at least three children in their household (p=0.518), tertiary education (p=0.706) and their last antenatal care in a hospital (p=0.774). Almost all the participants, 206 (96.7), knew the symptoms of measles as severe fever and rash but only about half, 114 (53.5%) knew the complication of measles. Although 177 (83.1%) participants knew that it is a childhood killer. Nearly all the respondents, 196 (92.0), knew the contagiousness of the disease but about half of the participants could tell the etiology. One hundred and ninety-four (91.1%) respondents answered that measles is preventable by vaccine but 59 (27.7%) could not remember the immunisation schedule for measles.
Knowledge of participant about measles and measles vaccination.
| Items | Response | n (%) |
|---|
| Measles is a viral infection | Yes | 127 (59.6) |
| No | 86 (40.4) |
| Don’t know | 0 (0) |
| Measles is a childhood killer | Yes | 177 (83.1) |
| No | 36 (16.9) |
| Don’t know | 0 (0) |
| Is measles contagious | Yes | 196 (92.0) |
| No | 17 (8.0) |
| Don’t know | 0 (0) |
| Measles causes severe fever | Yes | 206 (96.7) |
| No | 7 (3.3) |
| Don’t know | 0 (0) |
| Measles causes rash | Yes | 204 (95.8) |
| No | 9 (4.2) |
| Don’t know | 0 (0) |
| Pneumonia and unconsciousness are the most severe complications | Yes | 114 (53.5) |
| No | 99 (46.5) |
| Don’t know | 0 (0) |
| Measles is preventable by measles vaccine | Yes | 194 (91.1) |
| No | 19 (8.9) |
| Don’t know | 0 (0) |
| Are you aware of the schedule for measles vaccination? | Yes | 154 (72.3) |
| No | 59 (27.7) |
| Don’t know | 0 (0.0) |
Parent attitudes about childhood vaccines: Generally, 132 (62%) participants had zero hesitance to measles vaccine. None recorded up to hesitant range [Table/Fig-4]. Although, some specific questions are peculiar in the pattern of answers: the question, ‘have you ever delayed having your child get a shot’; 47 (22.1%) were in affirmative and they were higher among the respondents who had at least three children (p=0.0001). They were also more among those who attended secondary school and below, and those who attended their last antenatal care in TBA’s homes but the differences were not significant. The question ‘How concerned are you that your child might have a serious side-effect from a shot’; 31 (14.6) expressed concern. Those expressed concern were significantly more among the respondents with more than three children in their household. They were also more among those who attended secondary school and below, and those who attended their last antenatal care in TBA’s homes but the differences were not significant. The third question that attracted hesitant response was; ‘How concerned are you that a shot might not prevent the disease’; 48 (22.5%) expressed concern. Those expressed concern were also significantly more among the respondents with more than three children in their household. They were also more among those who attended secondary school and below, and those who attended their last antenatal care in TBA’s homes but the differences were not significant [Table/Fig-5].
Participants response to parent attitudes about childhood vaccines questions.
| Item | Parent response | n (%) |
|---|
| Have you ever delayed having your child get a shot for reasons other than illness or allergy? | Yes | 47 (22.1) |
| No | 166 (77.9) |
| Don’t know | 0 (0) |
| Have you ever decided not to have your child get a shot for reasons other than illness or allergy? | Yes | 0 (0) |
| No | 213 (100) |
| Don’t know | 0 (0) |
| If you had another infant today, would you want him/her to get all there commended shots? | Yes | 212 (99.5) |
| No | 0 (0) |
| Don’t know | 1 (0.5) |
| How sure are you that following the recommended shot schedule is a good idea for your child? | 0-5 days | 0 (0) |
| 6-7 days | 0 (0) |
| 8-10 days | 213 (100) |
| Children get more shots than are good for them | Agree | 1 (0.5) |
| Disagree | 212 (99.5) |
| Not sure | 0 (0) |
| I believe that many of the illnesses shots prevent are severe. | Agree | 213 (0) |
| Disagree | 0 (0) |
| Not sure | 0 (0) |
| It is better for my child to develop immunity by getting sick than to get as hot | Agree | 0 (0) |
| Disagree | 213 (100) |
| Not sure | 0 (0) |
| It is better for children to get fewer vaccines at the same time. | Agree | 34 (16) |
| Disagree | 178 (83.6) |
| Not sure | 1 (0.5) |
| How concerned are you that your child might have a serious side-effect from a shot? | Concerned | 31 (14.6) |
| Not Concerned | 177 (83.1) |
| Not sure | 5 (2.3) |
| How concerned are you that any one of the childhood shots might not be safe? | Concerned | 7 (3.3) |
| Not Concerned | 200 (93.9) |
| Not sure | 6 (2.8) |
| How concerned are you that a shot might not prevent the disease? | Concerned | 48 (22.5) |
| Not concerned | 165 (77.5) |
| Not sure | 0 (0) |
| Overall, how hesitant about childhood shots would you consider yourself to be? | Hesitant | 0 (0) |
| Not hesitant | 213 (100) |
| Not sure | 0 (0) |
| I trust the information I receive about shots | Agree | 213 (100) |
| Disagree | 0 (0) |
| Not sure | 0 (0) |
| I am able to openly discuss my concerns about shots with my child’s doctor. | Agree | 213 (100) |
| Disagree | 0 (0) |
| Not sure | 0 (0) |
| All things considered how much do you trust your child’s doctor? | 0-5 | 0 (0) |
| 6-7 | 2 (0.9) |
| 8-10 | 211 (99.1) |
Association between number of children, educational status, last antenatal care and total score on knowledge, and PACV questions.
| Items | Number of children | Educational status | Last antenatal care |
|---|
| Two children and below n (%) | Three children and above n (%) | Secondary and below n (%) | Tertiary and above n (%) | Hospital n (%) | TBA n (%) |
|---|
| Total knowledge score |
| Below 50% | 10 (50) | 10 (50) | 14 (70) | 6 (30) | 10 (50) | 10 (50) |
| Above 50% | 82 (42.5) | 111 (57.5) | 127 (65.8) | 66 (34.1) | 90 (46.6) | 103 (53.4) |
| Total | 92 (43.2) | 121 (56.8) | 141 (66.2) | 72 (33.8) | 100 (46.9) | 113 (53.1) |
| p-value | 0.518* | 0.706* | 0.774* |
| PACV 3 |
| Yes | 6 (12.8) | 41 (87.2) | 30 (63.8) | 17 (36.2) | 25 (53.2) | 22 (46.8) |
| No | 86 (51.8) | 80 (48.2) | 111 (66.9) | 55 (33.1) | 88 (53.0) | 78 (47) |
| Total | 92 (43.2) | 121 (56.8) | 141 (66.2) | 72 (33.8) | 113 (53.1) | 100 (46.9) |
| p-value | 0.0001** | 0.698* | 0.983* |
| PACV 10 |
| Concerned | 2 (5.6) | 34 (94.4) | 25 (69.4) | 11 (30.6) | 24 (66.7) | 12 (33.3) |
| Not concerned | 90 (50.8) | 87 (49.2) | 116 (65.5) | 61 (34.5) | 89 (50.3) | 88 (49.7) |
| Total | 92 (43.2) | 121 (56.8) | 141 (66.2) | 72 (33.2) | 113 (53.1) | 100 (46.9) |
| p-value | 0.0001** | 0.651* | 0.073* |
| PACV 12 |
| Concerned | 4 (8.3) | 44 (91.7) | 29 (60.4) | 19 (39.6) | 28 (58.3) | 20 (41.7) |
| Not concerned | 88 (53.3) | 77 (46.7) | 112 (67.9) | 53 (32.1) | 85 (51.5) | 80 (48.5) |
| Total | 92 (43.2) | 121 (56.8) | 141 (66.2) | 72 (33.2) | 113 (53.1) | 100 (46.9) |
| p-value | 0.0001** | 0.336* | 0.405* |
PACV: Parent attitudes about childhood vaccines; PACV 3: Have you ever delayed having your child get a shot for reasons other than illness or allergy? PACV 10: How concerned are you that your child might have a serious side-effect from a shot? PACV 12: How concerned are you that a shot might not prevent the disease? Chi-square with p<0.05* statistically significant; p<0.001** statistically highly significant
Practice and hospital presentation of measles cases: Majority, 197 (92.5) immunised their children against measles. One hundred and six (92%) respondents have seen a patient with measles-like symptoms and 117 (54.9%) stated that the case they witnessed was not managed at home.
Discussion
The incidence of measles is increasing globally, despite the effectiveness of measles vaccines. The reasons for the increase are attributed to negative beliefs on measles vaccines and poor vaccine coverage, especially in the developing countries. In most rural areas measles cases are under reported owing to poor hospital presentations and home management of measles suspected illnesses.
The study revealed that all the respondents were females mostly within the age range of 23-34 years. This is in consensus with the prevailing reports and studies in Nigeria and other African countries [34,35]. One of such studies, a population and development review shows an increasing trend in the age of women at their first marriage in Africa [35]. In southern Nigeria, the principle reason is formal education; many women wait to graduate from at least secondary school before marriage, as also shown in this study. This educational achievement allows them to delay marriage to their second decade of life [36]. Although, women in the rural area usually do not proceed beyond secondary school because of the economic requirement, gender preference, marriage and high level of unemployment in Nigeria even among highly educated sects [37,38]. Women are often saddled with the responsibility of caring for the children in rural areas [39]. This responsibility which is enormous is their sole duty, as most of them do not attempt searching for any other job or career [40,41]. Some undertake minor trading activities around the household as evident in this study, to enable them ensure that their children are close to them [39]. There is also high patronisation of the TBAs in the area [42-44]. This is highly due to belief and closeness of these centers to the rural dwellers [44]. Government and some NGO’s have trained (especially on risk identification and early referral) and supported the TBA to reduce maternal and child mortality, since it is difficult to stop women from patronising them [45,46]. The low hospital choice for antenatal, has also contributed to lack of family planning knowledge and practice as evident in the proportion of mothers with more than three children observed in this study despite the prevailing economic reality in the most rural areas in Nigeria [47,48].
Awareness of measles has improved in the rural area in Enugu owing to a series of campaigns and mobilisations organised by the ministry of health and non-governmental organisation [49]. Most of these sensitisations are on the symptoms, transmission and vaccine prevention especially in recent time of supplementary immunisation [50]. The outcome of these campaigns showed from the response of the participants, as the majority has adequate knowledge about measles. Their level of education, the number of the children they have and the place they seek antenatal care did not affect their level of knowledge about measles. This is in support of most findings and could be explained by the fact that measles is an old and common infection [29,51]. Also, the campaign about measles gets to the glass root. It also shows that the house to house campaign has yielded tremendous results and everyone is aware of measles irrespective of their status. The result also shows that there is higher awareness about the symptoms, transmission and prevention but low knowledge about the complication which many believe has more impact on the uptake of the vaccine [51,52]. In a study done to assess the reason behind the negative attitude towards vaccines in the UK, it was observed that people go for vaccines that prevent serious and complicated illness than less complicated ones [53]. This is important since mortality as a result of the complications is still high in Nigeria because of malnutrition and late hospital presentation [54]. In another study, low knowledge of the complication has been attributed to one of the causes of home management of measles and measles-like illnesses [54].
In this study, the parental attitude about measles vaccine is very high on the positive scale. This is in agreement with the study done using the Global Vaccine Confidence Scale (GVCS) (no available publication on parental attitude in Nigeria that made use of the tool used for in this study) [55]. In southern Nigeria, there has been consistent positive belief on the efficiency of vaccine in preventing vaccine preventable diseases especially in rural areas where the parents rely on the information from the health officers [56]. There has not been any reported myth or cultural disposition against childhood vaccines generally unlike in the northern part of the country where such negative beliefs have led to difficulty in sustaining a polio free nation [57]. In rural areas, the majority of the parents utilises the health centers and TBAs for ANC services where the importance of childhood immunisation is emphasised. By this means, negative belief about vaccines is minimised unlike in urban communities with diverse sources of information pertaining child’s care [15]. As obtained in this study, parents with more than two children are likely to delay measles vaccination and express concern about the efficacy of the shot. They also are more worried about the side-effects. These concerns may not immediately translate to hesitance, but when persist, and spread in the community; it could affect the stand of the parents on vaccines.
Measles is one of the notifiable diseases [19]. The symptoms are classical but there are other differentials necessitating prompt diagnosis in health centers to prevent community transmission and complications [58]. This study observed that many children with suspected measles were managed at home. This supports the findings that the disease is under reported [54,58]. Many have reported the frequent management of measles at home using herbs in many parts of Nigeria [59]. For instance a study done in Ibadan observed that the majority (91.3%) of caregivers whose children had measles gave home treatment, while 24 (8.7%) sought treatment from health facilities alone. This practice will affect confirmation and notification of cases for appropriate action such as targeted immunisation.
Limitation(s)
The study was intended to capture the response of both male and female parents but unfortunately, most males decline consent and referred the interviewers to their wives. Four males that gave consent filled the questionnaires, but their response was discarded because they contained a lot of “I don’t know” answers. This study will therefore represent the opinion of the female parents and will stand as basis for future studies and comparison. Another limitation of this study is its inability to access the reasons why parents prefer managing measle cases at home.
Conclusion(s)
The study revealed poor knowledge on the complication of measles, which is crucial for appropriate actions towards measles prevention. The attitude of parents to measles vaccination was generally adequate, the more children a parent has, the likelihood of developing negative attitude or hesitant to measles vaccination. It also showed that few suspected measles cases were managed in the hospital hence, reducing reported prevalence of measles. There is a need to educate parents on the complication of measles and the importance of early hospital presentation of suspected cases for confirmation and prompt management. This will help to prevent complications and community transmission.
*denotes people who delivered at homePACV: Parent attitudes about childhood vaccines; PACV 3: Have you ever delayed having your child get a shot for reasons other than illness or allergy? PACV 10: How concerned are you that your child might have a serious side-effect from a shot? PACV 12: How concerned are you that a shot might not prevent the disease? Chi-square with p<0.05* statistically significant; p<0.001** statistically highly significant
[1]. WHO | Measles-Global situation [Internet]. WHO. [cited 2020 May 12]. Available from: http://www.who.int/csr/don/26-november-2019-measles-global_situation/en/ [Google Scholar]
[2]. WHO | New measles surveillance data for 2019 [Internet]. [cited 2020 May 12]. Available from: https://www.who.int/immunisation/newsroom/measles-data-2019/en [Google Scholar]
[3]. Robert A, Funk S, Kucharski AJ, The measles crisis in Europe-the need for a joined-up approach The Lancet 2019 393(10185):203310.1016/S0140-6736(19)31039-6 [Google Scholar] [CrossRef]
[4]. Zimmerman LA, Muscat M, Singh S, Mamou MB, Jankovic D, Datta S, Progress toward measles elimination-European Region, 2009-2018 Morbidity and Mortality Weekly Report 2019 68(17):39610.15585/mmwr.mm6817a431048675 [Google Scholar] [CrossRef] [PubMed]
[5]. Bankamp B, Hickman C, Icenogle JP, Rota PA, Successes and challenges for preventing measles, mumps and rubella by vaccination Curr Opin Virol 2019 34:110-16.10.1016/j.coviro.2019.01.00230852425 [Google Scholar] [CrossRef] [PubMed]
[6]. Thielmann A, Puth MT, Weltermann B, Visual inspection of vaccine storage conditions in general practices: A study of 75 vaccine refrigerators PloS One 2019 14(12):e022576410.1371/journal.pone.022576431794585 [Google Scholar] [CrossRef] [PubMed]
[7]. Peck M, Global Routine Vaccination Coverage, 2018 MMWR Morb Mortal Wkly Rep [Internet] 2019 [cited 2020 May 12] :68Available from: https://www.cdc.gov/mmwr/volumes/68/wr/mm6842a1.htm10.15585/mmwr.mm6842a131647786 [Google Scholar] [CrossRef] [PubMed]
[8]. WHO | Improving vaccination demand and addressing hesitancy [Internet]. WHO. [cited 2020 May 12]. Available from: http://www.who.int/immunisation/programmes_systems/vaccine_hesitancy/en/ [Google Scholar]
[9]. Wood JG, Heywood AE, Menzies RI, McIntyre PB, MacIntyre CR, Predicting localised measles outbreak potential in Australia Vaccine 2015 33(9):1176-81.10.1016/j.vaccine.2014.12.07125620247 [Google Scholar] [CrossRef] [PubMed]
[10]. Adeloye D, Jacobs W, Amuta AO, Ogundipe O, Mosaku O, Gadanya MA, Coverage and determinants of childhood immunisation in Nigeria: A systematic review and meta-analysis Vaccine 2017 35(22):2871-81.10.1016/j.vaccine.2017.04.03428438406 [Google Scholar] [CrossRef] [PubMed]
[11]. Gunnala R, Ogbuanu IU, Adegoke OJ, Scobie HM, Uba BV, Wannemuehler KA, Routine vaccination coverage in northern nigeria: Results from 40 district-level cluster surveys, 2014-2015 PloS One 2016 11(12):e016783510.1371/journal.pone.016783527936077 [Google Scholar] [CrossRef] [PubMed]
[12]. Eze NC, Reasons for missed immunisation among caregivers of infants in rural communities of Abakaliki in southeast Nigeria Asian J Res Med Pharm Sci 2018 5(3):01-06.10.9734/AJRIMPS/2018/44950 [Google Scholar] [CrossRef]
[13]. Eze NC, Reasons for Childhood Immunisation Drop-out in Rural Health Facilities in Abakaliki, Nigeria Asian J Immunol 2018 1(1):01-06.10.9734/AJRIMPS/2018/44950 [Google Scholar] [CrossRef]
[14]. Obanewa OA, Newell ML, The role of place of residency in childhood immunisation coverage in Nigeria: Analysis of data from three DHS rounds 2003-2013 BMC Public Health 2020 20(1):12310.1186/s12889-020-8170-631996184 [Google Scholar] [CrossRef] [PubMed]
[15]. Antai D, Rural-urban inequities in childhood immunisation in Nigeria: The role of community contexts African Journal of Primary Health Care & Family Medicine 2011 3(1):23810.4102/phcfm.v3i1.2384565435 [Google Scholar] [CrossRef] [PubMed]
[16]. Fatiregun AA, Adebowale AS, Ayoka RO, Fagbamigbe AF, Assessing full immunisation coverage using lot quality assurance sampling in urban and rural districts of southwest Nigeria Trans R Soc Trop Med Hyg 2013 107(11):731-40.10.1093/trstmh/trt07924062523 [Google Scholar] [CrossRef] [PubMed]
[17]. Mahase E, Measles cases rise 300% globally in first few months of 2019 BMJ: British Medical Journal (Online) 2019 365:l181010.1136/bmj.l181030992273 [Google Scholar] [CrossRef] [PubMed]
[18]. Obagha C, Gidado S, Uba B, Ajisegiri S, Nguku P, Bamidele F, Surveillance data analysis on Measles cases, Anambra State, Nigeria, 2011-2016 Int J Infect Dis 2018 73:266-67.10.1016/j.ijid.2018.04.4022 [Google Scholar] [CrossRef]
[19]. Anetor GO, Improving the alignment of measles notification in Nigeria with response activities (Measles Immunisation): An Overview from 2012-2016 Tropical Journal of Health Sciences 2018 25(4):01-06. [Google Scholar]
[20]. Burden of measles in Nigeria: A five-year review of casebased surveillance data, 2012-2016 [Internet]. [cited 2020 May 12]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445333/ [Google Scholar]
[21]. Ezeoke UE, Nwobi EA, Ekwueme OC, Tagbo B, Aronu E, Uwaezuoke S, Pattern of health seeking behaviour of mothers for common childhood illnesses in Enugu metropolis south east zone Nigeria Niger J Clin Pract [Internet] 2010 [cited 2020 May 12] 13(1)Available from: https://www.ajol.info/index.php/njcp/article/view/53183 [Google Scholar]
[22]. Tagbo BN, Uleanya ND, Nwokoye IC, Eze JC, Omotowo IB, Mothers’ knowledge, perception and practice of childhood immunisation in Enugu Niger J Paediatr 2012 39(3):90-96.10.4314/njp.v39i3.1 [Google Scholar] [CrossRef]
[23]. Ogundele OA, Ogundele T, Beloved O, Vaccine hesitancy in Nigeria: Contributing factors-way forward Niger J Gen Pract 2020 18(1):110.4103/NJGP.NJGP_28_19 [Google Scholar] [CrossRef]
[24]. Marti M, Cola M de, MacDonald NE, Dumolard L, Duclos P, Assessments of global drivers of vaccine hesitancy in 2014-Looking beyond safety concerns PLoS ONE [Internet] 2017 [cited 2020 May 13] 12(3)Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5332020/10.1371/journal.pone.017231028249006 [Google Scholar] [CrossRef] [PubMed]
[25]. Dubé E, Gagnon D, Nickels E, Jeram S, Schuster M, Mapping vaccine hesitancy-Country-specific characteristics of a global phenomenon Vaccine 2014 32(49):6649-54.10.1016/j.vaccine.2014.09.03925280436 [Google Scholar] [CrossRef] [PubMed]
[26]. Lane S, MacDonald NE, Marti M, Dumolard L, Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015-2017 Vaccine 2018 36(26):3861-67.10.1016/j.vaccine.2018.03.063 [Google Scholar] [CrossRef]
[27]. Nigeria Census-Nigeria Data Portal [Internet]. [cited 2020 Jul 30]. Available from: https://nigeria.opendataforafrica.org/xspplpb/nigeria-census [Google Scholar]
[28]. Uchendu O, Ige O, Adeyera O, Knowledge and home treatment of measles infection by caregivers of children under five in a low-income urban community, Nigeria African Journal of Primary Health Care & Family Medicine 2019 11(1):01-03.10.4102/phcfm.v11i1.174431038337 [Google Scholar] [CrossRef] [PubMed]
[29]. Singh S, Chawla U, Knowledge, attitudes and practices about measles among mothers in urban slum area of district Aligarh, UP Int J Infect Dis 2008 12:e43810.1016/j.ijid.2008.05.1269 [Google Scholar] [CrossRef]
[30]. Khowaja AR, Sheikh S, Saleem AF, Zaidi AK, Parental awareness and coverage of mass measles vaccination drive 2011: Cross-sectional survey in the metropolitan city of Karachi, Pakistan APJPH 2015 27(2):NP2749-56.10.1177/101053951246656723165488 [Google Scholar] [CrossRef] [PubMed]
[31]. Opel DJ, Mangione-Smith R, Taylor JA, Korfiatis C, Wiese C, Catz S, Development of a survey to identify vaccine-hesitant parents: The parent attitudes about childhood vaccines survey Hum Vaccin 2011 7(4):419-25.10.4161/hv.7.4.1412021389777 [Google Scholar] [CrossRef] [PubMed]
[32]. Opel DJ, Taylor JA, Mangione-Smith R, Solomon C, Zhao C, Catz S, Validity and reliability of a survey to identify vaccine-hesitant parents Vaccine 2011 29(38):6598-605.10.1016/j.vaccine.2011.06.11521763384 [Google Scholar] [CrossRef] [PubMed]
[33]. Opel DJ, Taylor JA, Zhou C, Catz S, Myaing M, Mangione-Smith R, The relationship between parent attitudes about childhood vaccines survey scores and future child immunisation status: A validation study JAMA Pediatr 2013 167(11):1065-71.10.1001/jamapediatrics.2013.248324061681 [Google Scholar] [CrossRef] [PubMed]
[34]. Wusu O, Adedokun OA, Gender revolution prospects in nigeria: Implications for marriage timing and fertility Afr Sociol Rev Afr Sociol 2017 21(2):58-80. [Google Scholar]
[35]. Hertrich V, Trends in age at marriage and the onset of fertility transition in sub-Saharan Africa Popul Dev Rev 2017 43:112-37.10.1111/padr.12043 [Google Scholar] [CrossRef]
[36]. Burroway R, Hargrove A, Education is the antidote: Individual-and community-level effects of maternal education on child immunisations in Nigeria Soc Sci Med 2018 213:63-71.10.1016/j.socscimed.2018.07.03630059899 [Google Scholar] [CrossRef] [PubMed]
[37]. Babatunde R, Omoniwa A, Ukemenam M, Gender analysis of educational inequality among rural children of school-age in Kwara State, Nigeria Agric Sci Technol 2019 11(3):1313-8820.10.15547/ast.2019.03.046 [Google Scholar] [CrossRef]
[38]. Nwarukweh CO, Towards combating the ills of the present day Nigeri Humanit J 2018 (4):67-74.10.32620/gch.2018.4.08 [Google Scholar] [CrossRef]
[39]. Uyanga J, Rural-urban differences in child care and breastfeeding behaviour in southeastern Nigeria Soc Sci Med [D] 1980 14(1):23-29.10.1016/0160-8002(80)90028-3 [Google Scholar] [CrossRef]
[40]. Omadjohwoefe OS, Gender role differentiation and social mobility of women in Nigeria J Soc Sci 2011 27(1):67-74.10.1080/09718923.2011.11892907 [Google Scholar] [CrossRef]
[41]. Iyiola O, Azuh DE, Women entrepreneurs as small-medium enterprise (SME) operators and their roles in socio-economic development in Ota, Nigeria International Journal of Economics, Business and Finance 2014 2(1):01-10. [Google Scholar]
[42]. Nwangwu CC, Edeh AJ, Okenwa WO, An Audit of Cesarean Sections in a rural private Hospital in Enugu, Nigeria IOSR-JDMS 2019 18(9):38-44. [Google Scholar]
[43]. Nkwo PO, Poor availability of skilled birth attendants in Nigeria: A case study of Enugu state primary health care system Ann Med Health Sci Res 2015 5(1):20-25.10.4103/2141-9248.14977825745571 [Google Scholar] [CrossRef] [PubMed]
[44]. Titaley CR, Hunter CL, Dibley MJ, Heywood P, Why do some women still prefer traditional birth attendants and home delivery?: A qualitative study on delivery care services in West Java Province, Indonesia BMC Pregnancy Childbirth 2010 10(1):4310.1186/1471-2393-10-4320701762 [Google Scholar] [CrossRef] [PubMed]
[45]. Una A, Ogbonnaya L, Obionu C, Omeje K, Obi E, Training of traditional birth attendants on prevention of mother to child transmission of HIV: Effect on their knowledge and delivery of prevention of mother to child transmission of HIV services in Igbagu, Ebonyi State Nigeria Arch Curr Res Int 2017 8(2):01-12.10.9734/ACRI/2017/34390 [Google Scholar] [CrossRef]
[46]. Ohaja M, Murphy-Lawless J, Unilateral collaboration: The practices and understandings of traditional birth attendants in southeastern Nigeria Women Birth 2017 30(4):e165-71.10.1016/j.wombi.2016.11.00427889258 [Google Scholar] [CrossRef] [PubMed]
[47]. Abed SN, Salim ID, Al-Sarray AAHM, Comparative study of Knowledge, Attitude and Practices of family planning among traditional birth attendants, trained and untrained in Wassit governorate J Pharm Sci Res 2018 10(4):824-29. [Google Scholar]
[48]. Garces A, McClure EM, Espinoza L, Saleem S, Figueroa L, Bucher S, Traditional birth attendants and birth outcomes in low-middle income countries: A review In Seminars in perinatology 2019 43(5)WB Saunders:247-51.10.1053/j.semperi.2019.03.01330981470 [Google Scholar] [CrossRef] [PubMed]
[49]. Measles Immunisation: Enugu govt targets 500,000 children [Internet]. NPHCDA. 2018 [cited 2020 May 26]. Available from: http://nphcda.gov.ng/measles-immunisation-enugu-govt-targets-500000-children/ [Google Scholar]
[50]. Nigeria launches campaign to protect more than 28 million children against Measles and Meningitis [Internet]. WHO| Regional Office for Africa. [cited 2020 May 26]. Available from: https://www.afro.who.int/news/nigeria-launches-campaign-protect-more-28-million-children-against-measles-and-meningitis [Google Scholar]
[51]. Gaczkowska A, Mertens B, Reckendrees B, Wortberg S, Pott E, Knowledge, attitude, and practice concerning measles vaccination. Approaches for national vaccination education Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 2013 56(9):1270-78.10.1007/s00103-013-1791-523990089 [Google Scholar] [CrossRef] [PubMed]
[52]. Saleh JE, Trends of measles in Nigeria: A systematic review Sahel Medical Journal 2016 19(1):510.4103/1118-8561.18188724598724 [Google Scholar] [CrossRef] [PubMed]
[53]. Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P, Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012 Vaccine 2014 32(19):2150-59. [Google Scholar]
[54]. WHO supports Government to mitigate measles, rubella outbreaks nationwide [Internet]. WHO | Regional Office for Africa. [cited 2020 May 26]. Available from: https://www.afro.who.int/news/who-supports-government-mitigate-measles-rubella-outbreaks-nationwide [Google Scholar]
[55]. Larson HJ, Schulz WS, Tucker JD, Smith DM, Measuring vaccine confidence: introducing a global vaccine confidence index PLoS Currents 2015 710.1371/currents.outbreaks.ce0f6177bc97332602a8e3fe7d7f7cc4 [Google Scholar] [CrossRef]
[56]. Etokidem AJ, Nsan E, Ndifon W, Myths and misconceptions as barriers to uptake of immunisation services in Nigeria J Vac [Internet] [cited 2020 May 26] [Google Scholar]
[57]. WHO | Measles [Internet]. WHO. [cited 2020 May 26]. Available from: http://www.who.int/immunisation/diseases/measles/en/ [Google Scholar]
[58]. Nigeria: Measles Outbreak-Oct 2016 [Internet]. ReliefWeb. [cited 2020 May 26]. Available from: https://reliefweb.int/disaster/ep-2016-000126-nga [Google Scholar]
[59]. Sonibare M, Moody J, Adesanya E, Use of medicinal plants for the treatment of measles in Nigeria J Ethnopharmacol 2009 122(2):268-72.10.1016/j.jep.2009.01.00419168120 [Google Scholar] [CrossRef] [PubMed]