ORIGINAL

Niger J Paed 2014; 41 (1):38 –42

Sadoh AE

Okungbowa E

Nigerian mothers opinion of

reminder/recall for immunization

DOI:http://dx.doi.org/10.4314/njp.v41i1,7

Accepted: 23th June 2013

Abstract Introduction:

mothers should be reminded about

immunization appointments of

their children. Of those who dis-

agreed, most agreed that mothers

who forget/did not keep appoint-

ments could be reminded. More

mothers 126(70.8%) favoured

reminders compared to recalls 52

(29.2%) There was no significant

difference in the proportion of

mothers who preferred telephone

calls and those who preferred text

messages. Those with post secon-

dary education were more likely to

prefer text messages.

Conclusion: The mothers studied

are favourably disposed to receipt

of reminder/ recalls for their chil-

dren’s immunization appoint-

ments. There is good access to

telephones among the study popu-

lation enough to support the use of

this technology for a reminder /

recall intervention but the use of

text messages may be limited by

literacy.

Reminder/recall interventions

have been shown to improve im-

munization coverage. The percep-

tion of mothers/caregivers may

influence the outcome of such

interventions. The attitude of

Nigerian mothers to reminders/

recalls using cell phones was

evaluated.

(

)

Sadoh AE

Okungbowa E

Institute Of Child Health,

University Of Benin,

Pmb 1154

Benin City, Nigeria.

Email: Ayebosadoh@Yahoo.Com

Methods: This was

a cross-

sectional observational study car-

ried out (August to October 2012)

on mothers attending the child

welfare clinic of the Institute of

Child Health, University of Benin,

Benin City. The instrument was

an interviewer administered ques-

tionnaire which sought informa-

tion on respondents’ access to

phones, their ability to read,

perception and preference with

regard to reminders/ recalls.

Results: All 203 mothers had

access to a phone although 188

(

92.6%) currently owned a phone.

Majority of the mothers 163

80.3%) could read. Of the 203

mothers 127(62.6%) agreed that

(

Key words: Reminder, Recall,

Nigerian, Mothers

Introduction

letters, ₀postcards, telephone calls, autodialers, and

1

emails. A systematic review noted that the use of pa-

Immunization is among the most cost effective public

health interventions The immunization coverage in Ni-

tient reminder/recall interventions resulted in improve-

ment in immunization rates irrespective of baseline im-

munization rates, patient a₁g₀e, setting or vaccination type

in 33(80%) of 41 studies. The same review also noted

that telephone reminder/recall interventions we₁r₀e more

effective than the other forms of reminder/recall.

1

geria is below the 90% target of the World Health Or-

2

ganization. This low coverage is contributed to by the

weak routine immunization programme amongst other

3

reasons. The recent reports of clusters of diphtheria in

various parts of Nigeria including an epidemic in Borno

state as well as the measles epidemic in the northern

states of Nigeria empha₄s_-i₈ze the need for strengthening

of routine immunization.

For a reminder recall intervention to be effective there

must be a means of tracking the children so that children

due for immunizations, those overdue and those under-

immunized can be identified. In Nigeria although immu-

nizations are recorded on cards that are kept by the par-

ents many facilities do not keep immunization registers

that can help identify incompletely immunized children.

Few studies have evaluated the potential for tracking. In

one such study it was concluded that Community Health

Extension Workers had the potential for identifying un-

Various strategies have been employed to improve im-

munization coverage in developed countries. One of

such strategies as stipulated in the standards of immuni-

zation practices is the use of reminder/recall interven-

9

tions. Reminders are utilized to remind parents of an

appointment while recall is used when the immunization

9

11

is overdue. Different types of reminders and recalls

der-immunized children in their communities. This

approach may however, not be effective due to the

1

0

have been used in various studies. These include

3

9

dearth of health care workers in Nigeria.

phone. A respondent was considered to have access if

the respondent had an op₂ portunity to utilize or derive

1

The introduction of Global System for Mobile Commu-

nications (GSM) to Nigeria has greatly improved access

to telephones in both urban and rural areas. In a report in

benefits from the phone. Respondents were also asked

if they could read. The respondents were asked to agree

or disagree with whether parents/ caregivers should be

reminded about their child’s immunization appointment.

For those who neither agreed or disagreed they had the

option of “not sure” For those who disagreed they were

asked to agree or disagree with whether the parents/

caregivers should be reminded if they failed to keep the

child’s immunization appointment. Respondents were

also asked to state the frequency of reminder/recalls,

when the reminder/recall should be sent and the pre-

ferred type of reminder.

2

011, 60% of respondents owned a phone/had access to

12

a phone. The availability of phones could allow for the

use of these phones in interventions to raise immuniza-

tion coverage. In view of this there is a need to examine

the factors that could affect the utility of cell phones in a

reminder/recall intervention to improve immunization

rates in Nigeria.

One of the factors that may determine the effectiveness

of a reminder/recall intervention is the perception of the

targeted population. In a study on parents’ opinion about

use of text messaging for immunization reminders, the

authors noted that their findings provided a greater

Responses were recorded as simple percentages while

association between variables was tested using Chi

square and Fishers Exact tests as appropriate.

understanding of imm₃unization communication from the

1

parents’ perspective. They also opined that their find-

ings provide a basis for further research and text

messaging interventions that could address adherence to

childhood immunization schedule. In a study, in Lagos

the willingness of mothers₄to receive text message

Results

Two hundred and three mothers were studied. The socio

demographic data of the mothers is shown in table 1.

The mean age of the mothers was 30.51±5.07 years with

a range of 18 to 45 years. An equal proportion of moth-

ers 38.9% had secondary and post secondary education.

Majority of the mothers 63(31.5%) had one child each.

1

reminders was evaluated. It was found that while 77%

were willing to receive text messages, 67% preferred

telephone reminders. In that study it was also found that

having post secondary education, being currently mar-

ried and being a Christian were positive predictors of

willingness to receive text messages. The findings in

that study may not be extrapolated to Nigeria as a whole

as the population studied was largely urban and highly

educated which is not representative of the country as a

whole.

Of the 203 mothers 188(92.6%) currently owned a

phone. All 15 who did not own a phone had access to a

phone thus total access was 100%. Majority of the moth-

ers 163(80.3%) could read. Most 197(97.0%) of

spouses/partners of the respondents could read. Of the

40 mothers who could not read 4(10%) of their spouses/

partners could also not read. Thus overall, 4/203(2.0%)

of the families represented could not read.

The Institute of Child Health (ICH), University of Be-

nin, Benin City runs a child welfare clinic where a regis-

ter of the children immunized in the facility is kept. The

immunizations received and dates of next appointment

are noted. This study evaluated the perception of moth-

ers about reminders/recalls prior to a planned introduc-

tion of this service.

0f the 203 mothers, 127(62.6%) agreed that mothers

should be reminded about immunization appointments

of their children while 72(35.5%) disagreed and 3(1.5%)

were unsure. Those who disagreed opined that a mother

should never forget the child’s immunization appoint-

ment. Of these 72 however 63(87.5%) agreed that a

mother could be reminded (that is get a recall) if she

forgets the appointment but 7(9.2%) still disagreed

while 2(2.8%) were unsure. Thus overall, 190(93.6%)

mothers agreed on the need for reminders

Methodology

Ethical approval for the study was obtained from the

ethics and research committee of the College of Medical

Sciences, University of Benin, Benin City. The study

was cross-sectional and was carried out between August

and October 2012. A convenience sample of 203 moth-

ers was interviewed using an interviewer administered

questionnaire. Mothers who brought at least one child

for immunization were included in the study. Those who

did not come with any child or did not give consent

were excluded. Verbal consent was obtained from the

mothers after an explanation of the purpose and proce-

dure of the study. The questionnaire sought information

on the age of the respondent, her educational level and

number of children. Respondents were asked if they

owned a phone and if they did not if they had access to a

(either reminder (127) or recall (63)).

4

0

Table 1: Characteristics of the mothers studied

between maternal age and level of education and choice

of reminder/recall is shown on table 3. Level of educa-

tion was significantly associated with the choice of re-

minder/recall. P=0.003. Mothers who had post secon-

dary education were more likely to prefer text messages

than those with either primary or secondary education.

Age was not significantly associated with preference

Characteristic

n

%

Age

≤

24

26

59

72

35

8

13.0

29.5

36.0

17.5

4.0

2

3

5-29

0-34

5-39

≥40

Level of education

Nil

Table 3: Association between maternal age, maternal level of

education and preferred type of reminder/recall and

3

1.5

Primary

42

79

20.7

38.9

Variable

Preferred Reminder/ Text Message

pvalue

Secondary

Post secondary

Number of children

1

Recall Telephone Call

N

%

N

%

Maternal Age (years)

63

111

20

31.5

55.5

13.0

<

>

34

35

72

21

55.0

56.8

59

16

45.0

43.2

2

-4

1.0000

0.0003

≥5

Level of education

Nil/Primary

Secondary

30

38

26

75.0

55.9

36.1

10

30

46

25.0

44.1

63.9

Table 2 shows the association between maternal occupa-

tion, number of children, level of education and attitude

towards reminder/recalls. Mothers with one child were

more likely to agree that mothers should be reminded

about immunization appointments compared to mothers

with two or more children. P=0.02. Mothers who were

unemployed were also more likely to agree that mothers

should be reminded about immunization appointments.

p=0.03

Tertiary

Discussion

This study confirms the improved access to phones in

Nigeria. Majority of the mothers owned a phone while

all mothers had access to the benefits of a phone. This

implies that it would be feasible to use a telephone based

intervention in the population s₁t₄udied. This is similar to

findings from Lagos in Nigeria.

Table 2: Association between some variables and attitude of

mothers to reminder/ recall

Parameter

Agrees on need Disagrees on need pvalue

for RR N % for RR N %

Telephone reminders can either be text messages or tele-

phone calls. The use of the former is dependent on the

recipient’s ability to read and comprehend. In this study

almost 20% of the mothers could not read. However

when the ability of the couple (mother and spouse/

partner) was combined only 2% of the studied group

was unable to read. Previous studies have shown that

parental education is a significant determinant of immu-

nization uptake with children of less ed₁₅u_,₁c₆ated parents

Maternal occupation

Unemployed

Employed

18

107 61.1

85.7

3

68

14.3

38.9

0.03

0.99

0.02

Level of Education

Nil

0

0.0

64.3

64.1

64.9

2

100.0

35.7

35.9

35.1

Primary

Secondary

27

50

15

28

27

Post secondary 50

Number of Children

being more likely to be undervaccinated.

The utiliza-

1

48

63

78.7

57.8

53.8

13

46

12

21.3

42.2

46.2

tion of an intervention that is based on the literacy of

parents may thus exclude the most vulnerable groups.

This may be a limitation of the use of text messages in

this population of mothers.

2

-4

≥5

14

Of those who agreed that mothers could be reminded

about immunization appointments (including those who

felt such reminders should be if the mother forgets) 126

The attitudinal disposition of the studied mothers sug-

gests that they are highly motivated mothers who be-

lieve that a mother should not forget her child’s immuni-

zation appointment. This attitudinal disposition is differ-

ent from that of Lagos mothers of whom 25% reporte₁d₄

having missed a prior immunization appointment.

Thus, the Lagos mothers seemed more favourably

disposed to reminders with 77% of those studied report-

ing their willingness to receive text messages. In this

study however the respondents who felt mothers should

not forget immunization appointments were favourably

disposed to reminders for mothers who forget or miss

immunization appointments. Thus overall majority of

the studied mothers were favourably disposed to immu-

nization reminders/recalls.

(

recalls.

70.8%) preferred reminders while 52(29.2%) favoured

As to the number of reminder/recalls majority 104

(

58.1%) felt one reminder/recall was adequate while 56

31.3%) and 19(10.6%) preferred two and three

reminder/recalls respectively. As to when such

reminder/recall should be sent 82(45.8%) preferred a

week before the due date, 43(24.0%) preferred a day

before the due date, 20(9.4%) a day after the due date

while 34(14.6%)

preferred a day before the next possible appointment.

Of the 180 who responded to the question on preferred

type of reminder/recall 94(52.2%) preferred telephone

calls while 86(47.8%) preferred text messages. No

mother preferred the use of email. The association

Unemployed mothers and mothers with only one child

4

1

were more likely to agree on the need for reminders

compared to employed mothers and those with two or

more children. It would have been expected that these

mothers would be less likely to favour reminders since

they have more time. Perhaps mothers with two or more

children having had previous experience with immuni-

zation appointments feel more confident about the han-

dling of their children’s immunization hence their less

favourable attitude. It is not clear as to why employed

mothers would be unfavourably disposed to reminders.

a week before the appointment day compare to a day

before the appointment. This is in contrast to findings in

Lagos in which more mothers preferred receipt of re-

minders on the day before the₁i₄mmunization appoint-

ment compared to a week before.

The choice of type of reminder showed that although

more mothers preferred telephone calls it was not

significantly more than those who preferred text mes-

sages. The proportion preferring telephone calls in this

study was however lower than that in Lagos but higher

than that found in a cross-sectional survey of nationally

representative sample of pa₁r₄e_,n₁₉ts of children 0-17 years

Even if forgetting appointments may not be a significant

contributor to undervaccination among the mothers

studied, it is important to note that while improving

vaccination coverage is an important goal of an immuni-

zation programme, timeliness of receipt of immuniza-

tions is also important. Epidemics could result from the

temporary build up of susce₇ptible children due to delays

of age in the United States.

In this study those with

post secondary education were more likely to prefer text

messages than those with either primary or secondary

education. This may be due to their better literacy. Text

messages have the advantage of the recipient being able

to see the message repeatedly at a later time unlike the

telephone call which may be missed if the mother is

busy and a mother may equally forget that she had a

telephone call reminding her of her child’s immuniza-

tion appointment.

1

in receipt of immunization. Such delays can be

prevented by the use of reminder/ recall interventions.

Previous studies have shown that many₁N₈ igerian chil-

dren do not receive their vaccines on time.

More mothers preferred reminders compared to recalls.

This may be because reminders are proactive and allows

the mother clear her schedule to accommodate the im-

munization appointment. Recalls on the other hand tends

to highlight a failing on the part of the mother. Remind-

ers may be more useful in improving timeliness of re-

ceipt of immunizations compared to recalls. Although

majority of the mothers felt that one reminder/recall was

sufficient a significant proportion suggested multiple

reminders/recalls. A systematic review of the literature

found that multipl₀e reminders were more effective than

Conclusion

In conclusion mothers in Benin City have a positive

perception of reminders/recalls for immunization. The

finding that there was adequate access to cell phones in

the study population could allow for the use of re-

minder/recall interventions. Programme planners would

need to be flexible and provide reminder/ recalls based

on parental preferences for type of reminder and timing

of reminders.

1

single reminders. Most of the reviewed studies were

however from developed countries and may not reflect

realities in a developing country.

With regards to the preferred time for receipt of remind-

ers more mothers (42.8%) preferred receiving reminders

Conflict of interest: None

Funding: None

References

4

5

6

.

Fajolu IB, Temiye EO, Egri-

7. Epicentre Diphtheria outbreak

investigation, Kimba village ,

1

.

World Health Organization. Chal-

lenges in global immunization and

the global immunization vision and

strategy 2006-2015. Weekly Epide-

miol Rec 2006;19:190-4

Okwaji TC. Sporadic emergence

of probable cases of diphtheria

Niger J Paed 2009;36:87-90

Sadoh AE, Okhakhu A, Omuemu

V, Lofor PV, Oviawe O. Diphthe-

ria in Nigeria: Is there resurgence?

Ann Biomed Sc 2010;

Oyeyemi BO, Suleiman BM, Aje-

tomobi A, I brahim A. A report on

two clusters of diphtheria outbreak

involving three contiguous local

government areas in Katsina state.

Abstract 013 presented at Annual

General and Scientific conference

of the Paediatric Association of

Nigeria. Niger J Paed 2011; 38:10

Borno state, Nigeria. Available at

http://www.epicentre.msf.org/en/

diphtheria-outbreak-investigation-

th

nigeria Accessed 5 September

2

3

.

Centre for Disease Control. Global

routine vaccination coverage,

2012

8. Reliefweb.Vaccine suspicion ag-

gravates measles outbreak in Nige-

ria. Available at http://

reliefweb.int/report/Nigeria/

vaccine-suspicion-aggravates-

measles-outbreak-nigeria Last

accessed 27th April 2013

2

011. MMWR 2012;61:883-885

Stokes-Prindle C, Wonodi C, Aina

M, Oni G, Olukowi T, Pate MA,

Privo-Dumm L, Levine O. Land-

scape analysis of routine immuni-

zation in Nigeria: identifying barri-

ers and prioritizing interventions.

Available at http://www.jhsph.edu/

research/centers-and-institutes/

ivac/projects/nigeria/IVAC-

9. George P. Immunization practices:

In Behrman RE, Kliegman RM,

Jensen HB editors. Nelson text-

book of paediatrics. WB Saunders

-64

Landscape-Analysis-Routine-

Immunization-Nigeria-

th

company, publishers. 16 ed. 2000

th

Whitepaper.pdf Accessed 29

April 2013

4

2

1

0. Szilagyi NP, Bordley C, Vann JC,

Chelminski A, Kraus RM, Mar-

golis PA et al. Effect of reminder/

recall interventions on immuniza-

tion rates. A review. JAMA

14. Balogun MR, Sekoni AO, Okafor

JP, Odukoya OO, Ezeiru SS,

Ogunnowo BF, Campbell PC.

Access to information technology

and willingness to receive text

message reminders for childhood

immunization among mothers

attending a tertiary facility in La-

gos, Nigeria SAJCH 2012;6:76-80

15. Rammohan A, Awofeso N, Fer-

nandez RC. Paternal education

status significantly influences in-

fants’ meas3es vaccination uptake,

independent of maternal education

status. BMC Public Health

2012;12:336 Available at http://

www.biomedcentral.com/1471-

2458/12/336 Accessed 16th No-

vember 2012

16. Wiysonge CS, Uthman OA,

Ndumbe PM,Hussey GD. Individ-

ual and contextual factors associ-

ated with low childhood immuni-

zation coverage in sub-Saharan

Africa: a multilevel analysis. PLoS

ONE2012;7:e37905 doi:10.1371/

journal.pone.0037905

17. Luman ET, Barker LE, Shaw KM

et al. Timeliness of childhood vac-

cinations in the United States.

JAMA 2005; 293:1204-1211

18. Sadoh AE Eregie CO. Timeliness

and completion rate of immuniza-

tion among Nigerian children at-

tending a clinic-based immuniza-

tion service. J Health Popul Nutr

2009;27:391-5

19. Clark SJ, Butchart A, Kennedy A,

Dombkowski KJ. Parents’ experi-

ences with and preferences for

immunization reminder/recall tech-

nologies. Pediatrics 2011;128

(5):e1100-e1105 DOI:10.1542/

peds.2011-0270

2

000;284:1821-1827

1. Sadoh AE, Odunvbun ME, Ony-

iriuka AN, Enabudoso E, Okolo

AA, Okpere EE. Tracking immuni-

zation in Nigeria; a community

based approach. J Med Biomed Res

2

011; 10:92-99

2. National Bureau of Statistics, Ni-

geria. 2011 Annual socio-

economic report: Access to ICT.

Available at www.nigeriastat.

th

gov.ng Accessed 13 February

2

012

3. Ahlers-Schimdt CR, Chesser AK,

Paschal AM, Hart TA, Williams

KS,Yaghmai V, Shah-Haque S.

Parent opinions about use of text

messaging for immunization re-

minders. J Med Internet Res

2

012;14:e83 doi:10.2196/

jmir.1976