Niger J Paed 2014; 41 (4): 375 - 382

ORIGINAL

Fatiregun AA

Clients’ satisfaction with

Ossai EN

immunisation services in the urban

and rural primary health centres

of a South-Eastern State in Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i4,17

Accepted: 6th August 2014

Abstract Objectives: To deter-

and the availability of vaccines in

mine clients’ satisfaction with

the rural area (35.3%). The major-

Fatiregun AA (

)

immunisation services in the ur-

ity of clients in the urban (84.5%)

World Health Organization State Office

ban and rural primary health cen-

and rural areas (94.3%) were truly

Ondo State Primary Health Care Board

tres of a South-eastern state in

satisfied with the immunisation

Akure, Ondo State, Nigeria.

E-mail: fatireguna@who.int,

Nigeria

services. A long waiting time and

akinfati@yahoo.com,

Methods: A three-stage sampling

uncomfortable waiting areas were

fatireguna@gmail.com

method was used to select 800

the major sources of dissatisfaction

clients who presented with their

among the clients. Factors that

Ossai EN

children/wards to 18 of the 440

were associated with the clients’

Department of Community Medicine,

primary health centres. Exit inter-

true satisfaction with immunisa-

University of Nigeria Teaching

views were conducted using an

tion services included being a cli-

Hospital Ituku-Ozalla, Enugu.

adapted,

semi-structured

ques-

ent in an urban area (adjusted odds

tionnaire. A composite index of

ratio (AOR)=0.2, 95% confidence

satisfaction with immunisation

interval (CI): 0.1-0.4), being mar-

services, denoted as true satisfac-

ried, (AOR=33.5, 95% CI: 12.7-

tion, was assessed as the propor-

88.1), being of the Igbo ethnic

tion of clients who reported being

nationality (AOR=14.9, 95% CI:

satisfied with the immunisation

3.9-57.4),

being

a

Christian

services received on the day of

(AOR=21.1, 95% CI: 2.9-154.6),

data collection, who were ready

and being in close proximity to the

to use the health centre again for

health centres (AOR=2.6, 95% CI:

immunisation services, and who

1.5-4.4).

were willing to recommend the

Conclusion: The

waiting time

health centre to others for the

needs to be reduced and the physi-

same services.

cal conditions of the waiting area

Findings: The mean age of the

need to be improved to reduce the

clients was 28.9±4.5 and 26.7±5.1

clients’ dissatisfaction with the

years old in the urban and rural

services, particularly in urban

areas, respectively. The main

areas.

reasons why the clients chose the

primary health centres for immu-

Keywords: Clients’ satisfaction,

nisation services were because of

immunisation, primary health cen-

their proximity to the health

tres, urban and rural, Enugu State.

centres in the urban area (34.3%)

Introduction

has been shown to determine adherence to treatment

and, thus, follow-up measures, and good adherence

likely leads to positive health outcomes . It has been

8

Immunisation saves more lives than any other public

health intervention, except possibly improvements in

established that vaccine coverage is always high in areas

where the primary health centres function adequately .

6

sanitation and a safe water supply . However, the level

1-6

of immunisation coverage in Nigeria is very low, as only

Furthermore, it has been identified that promoting client

23% of children between the ages of 12-23 months are

-oriented health services should be based on identified

determinants of client satisfaction in various cultures .

9

fully immunised and 29% of children do not receive any

vaccinations . High dropouts from poor functioning

7

Additionally, economists believe that health care

health centres and poor attitudes of service providers are

consumers are in favour of high-quality care, even if

such care results in increased costs

10,11

factors that may be responsible for this low immunisa-

.

tion rate . Clients’ satisfaction with the received care

5,6

376

In south-east Nigeria, the level of immunisation cover-

Sample Size Determination

age is 43%, which is the highest coverage among the

geo-political zones in the country; however, a child in

The minimum sample size for the study was determined

south-east Nigeria is more likely to have received no

by the formula used to compare two independent pro-

portions.

15

vaccinations compared with another child in other geo-

From a study in India, 93.9% of the respon-

political zones because of the fear of side effects . Good

7

dents were truly satisfied with the immunisation services

interaction between parents and health care providers

in an urban area, which was the average proportion of

will help allay these fears and, thus, improve the immu-

the fully and partially immunised clients who were satis-

fied,

16

nisation coverage in south-east Nigeria and in Nigeria as

while 95.9% of the respondents in a community-

a whole. In addition, a child in an urban area in Nigeria

based study in Nigeria were satisfied with immunisation

services in a rural area.

11

is more than twice as likely to be fully immunised as a

A total of 400 clients were

child in the rural area . Therefore, this study was con-

7

estimated for each group based on a type 1 error ( α ) of

ducted to determine clients’ satisfaction with immunisa-

0.05 in a two-sided test and a power of 0.8.

tion services in the urban and rural primary health cen-

tres of a south-eastern state in Nigeria.

Sampling Technique

A three-stage sampling technique was used. In the first

stage, a simple random sampling technique by balloting

Methods

was used to select three local government areas in each

Setting

of the urban and rural areas of the state. In the second

stage, three health centres in each of six local govern-

The study area is Enugu State, which is in the south-east

ment areas were randomly selected by balloting. In the

geo-political zone of Nigeria. It is composed of 17 local

third stage, we used the systematic random sampling

government areas (5 of which are designated as urban

technique to select the clients as they presented to the

and 12 of which are designated as rural) and 291 politi-

immunisation/infants’ welfare clinic on each day of data

cal wards, with a population of 4,881,500 people within

collection. We used the average attendance at the health

a total area of 7,618 sq. km . Its capital, Enugu, was the

12

centres for immunisation services of the last six months

headquarters of the former East-Central State and the

as the population in the sampling frame (2000 in the

defunct Eastern Region. The major occupations are trad-

urban area and 1600 in the rural area), and by dividing

ing and formal employment in the urban areas and pri-

this population by the sample size of 400 in each group,

marily subsistence farming and animal pasturing in the

we sampled one out of every five individuals in the ur-

rural areas. The inhabitants are mostly Igbo with a mix-

ban area and one out of every four individuals in the

ture of other tribes and are predominantly Christians.

rural area. The index client was selected among the first

five clients in the urban area and the first four clients in

Enugu State operates the District Health System, which

the rural area by a simple random sampling method

consists of seven district hospitals (Awgu, Udi, Enugu

through balloting using the health facility register of

Ezike, Agbani, Nsukka, Isi Uzo, and Enugu Metropolis),

clients on each day of data collection. To ensure that a

440 primary health care facilities, 40 cottage hospitals,

client was not selected twice, there was a register for all

two specialist hospitals, two teaching hospitals, and 384

of the clients who had been included in the study, and

mission/private hospitals and clinics.

13

All of the pri-

this register was cross-checked by the research assistants

mary health centres in Enugu State offer free immunisa-

before a new client was included.

tion services.

14

Study Instrument

Study Design

The study instrument was a validated, semi-structured

The study employed a cross-sectional, analytical design

questionnaire. The questionnaire was adapted from the

and compared clients’ satisfaction with the immunisa-

protocol of the Addis Ababa University KABP Study on

Immunisation: Exit Interview Questionnaire,

17,18

tion services in the urban and rural primary health cen-

with

tres of Enugu State.

slight modifications to suit some unique aspects of the

study area.

Study Participants

Data Collection Method

The study population consisted of clients who presented

with their children/wards to receive immunisation ser-

The validated, semi-structured questionnaire was admin-

vices at the primary health centres selected for the study

istered to the clients by trained research assistants. Re-

in August 2013. Immunisation/infant welfare clinics of

spondents were assured that all of the information pro-

the selected health centres were the client recruitment

vided in the questionnaire was confidential. Addition-

locations. A minimum of two immunisation visits quali-

ally, we did not obtain any identifying information from

fied the client for inclusion in the study.

the participants. Participation in the study was volun-

tary, and participants were assured that there would be

no victimisation of clients who refused to participate or

who decided to withdraw from the study after providing

377

consent. Ethical approval for the study was obtained

decision to immunise their child, a significantly higher

from the Research and Ethics Committee of the Univer-

proportion of clients in the rural (55.8%) compared with

sity of Nigeria Teaching Hospital, Ituku Ozalla, Enugu.

the urban (49.5%) areas reported that both parents were

Clients were required to sign or provide a thumbprint on

involved in the decision. The main reason for utilising

the written informed consent form before the interview,

the primary health centres for immunisation services by

and the nature of the study, its relevance, and the level

clients in the urban area was proximity (34.3%), while

of their participation were thoroughly explained to them.

in the rural area, the main reason was the availability of

the vaccines (35.3%).

Outcome Measure

Table 1: Socio-demographic characteristics of clients of

The outcome measure of the study was the satisfaction

immunisation services in the urban and rural primary health

index, corresponding to the clients’ true satisfaction with

centers of Enugu State, August 2013.

Variable

Urban

Rural

χ

2

immunisation services. It was assessed as the proportion

p value

{n=400}

(n=400)

of clients who were satisfied with the vaccination ser-

N (%)

N (%)

vices received at the primary health centres on the day

Age of clients

6.447

a

of data collection, who were willing to use the health

Mean ±SD (years)

28.9±4.5

26.7±5.1

<0.001

Age groups in years

centres again for vaccination services, and who were

<20

7 (1.8)

32 (8.0)

48.073

<0.001

willing to recommend the health centres to others for the

20 – 24

58 (14.5)

111 (27.8)

same services.

25 – 29

163 (40.8)

133 (33.3)

30– 34

110 (27.5)

94 (23.5)

≥ 35

62 (15.5)

30 (7.5)

Data Analysis

Age of index child

0.782

a

Mean ± SD (months)

3.9±3.3

3.7±2.9

0.435

The analysis was performed using SPSS statistical soft-

Age group in months

≤ 12

391 (97.8)

395 (98.8)

1.163

0.281

ware, version 15 (SPSS Inc., Chicago, IL). Frequency

>12

,9 (2.3)

5 (1.3)

tables and cross-tabulations were generated, and signifi-

Relationship of client to child

cance was indicated by a p-value of less than 0.05. We

Mother

390(97.5)

392 (98.0)

1.382

0.501

compared the socio-demographic characteristics of the

Father

5 (1.3)

6 (1.5)

Female guardian

5 (1.3)

2 (0.5)

clients, their sources of information on immunisation,

Position of index child

the place of delivery of the children who presented to

1

109 (27.3)

103 (25.8)

3.041

0.219

the centres for immunisation, and the reasons why the

2 – 4

257 (64.3)

248 (62.0)

≥ 5

34 (8.5)

49 (12.3)

primary health centres were chosen for vaccination ser-

Marital status

vices. We also compared the true satisfaction of the cli-

13.346

b

Married, currently living with

390(97.5)

371 (92.8)

0.001

ents with immunisation services in the urban and rural

spouse.

Married, not living with spouse

0 (0)

5 (0.6)

primary health centres. Multivariate analysis using bi-

Never married

10 (2.5)

24 (6.0)

nary logistic regression was used to determine the fac-

Religion

tors predictive of the true satisfaction of the clients with

Christian

399 (99.8)

393 (98.3)

4.712

0.095

Others

c

immunisation services. Variables that had a p-value of

1 (0.2)

7 (1.8)

Ethnic group

less than 0.2 in the bivariate analysis were entered into

Igbo

391 (97.8)

394 (98.5)

0.611

0.434

the logistic regression model to determine the predictors

Others

d

9 (2.3)

6 (1.5)

of the clients’ true satisfaction with immunisation ser-

Education of mother of index

child

vices. A logistic regression model was fitted for both the

No formal education

1 (0.3)

3 (0.8)

37.257

<0.001

urban and rural areas. The results are reported using

Primary education

30 (7.5)

49 (12.3)

adjusted odds ratios (AOR) and 95% confidence inter-

Secondary education

255 (63.8)

301 (75.3)

Post secondary education

114 (28.5)

47 (11.8)

vals (CI).

Occupation of mother

Self employed

211 (52.8)

238 (59.5)

8.360

0.015

Unemployed/housewife

130 (32.5)

128 (32.0)

Salaried employment

59 (14.8)

34 (8.5)

n= 390 N (%) n= 371 N (%)

Results

Education of father of index child

No formal education

2 (0.5)

18 (4.9)

40.256

<0.001

Table 1 shows the socio-demographic characteristics of

Primary education

31 (7.9)

47 (12.7)

the clients who received immunisation services. The

Secondary education

223 (57.2)

241 (65.0)

Post secondaryrducation

134 (34.4)

65 (17.5)

mean ages of the clients in the urban and rural areas

Occupation of father

were 28.9±4.5 and 26.7±5.1 years, respectively. The

Self employed

269 69.0)

298 (80.3)

13.069

0.001

majority of the mothers of the children who visited the

Salaried employment

116 (29.7)

69 (18.6)

Unemployed

5 (1.3)

4 (1.1)

urban (63.8%) and rural (75.3%) primary health centres

Socio-economic status

n=400 N (%)

n=400 N (%)

for immunisation services had secondary education.

Least poor

157 (39.3)

45 (11.3)

152.982 <0.001

The poor

121 (30.3)

84 (21.0)

Table 2 shows the sources of information regarding the

Very poor

86 (21.5)

107 (26.8)

Poorest

36 (9.0)

164 (41.0)

immunisation activities of the clients. Most participants

in the urban (91.3%) and rural (92.8%) areas reported

a

student t test

health workers as their source of information. Regarding

b

Likelihood ratio

c

the question of which family member makes the

Islam and traditional African religion

d

Yoruba, Hausa and the minority tribes

378

Table 2 : Sources of information and decision about child

statistically significant (p=0.420). The major reason for

immunisation, by clients in the urban and rural primary health

the clients’ intention to use the primary health centres

centers of Enugu State, August 2013

again for immunisation services and to recommend the

Variable

Urban

Rural

χ 2

p value

health centres to others in the two study areas was re-

(n=400)

(n=400)

N (%)

N (%)

lated to the health workers; specifically, the health work-

ers were reported to be well trained, friendly, and of-

Obtaining information about immunisationa

Health workers

365 (91.3)

371 (92.8)

0.611

0.434

fered good services. A significantly higher proportion of

Friend

298 (74.5)

275 (68.8)

3.254

0.071

the respondents who utilised the rural health centres

Neighbour

248 (62.0)

262 (65.5)

1.060

0.303

(94.3%) were truly satisfied with the immunisation ser-

Radio

236 (59.0)

180 (45.0)

15.705 <0.001

vices received compared with those in the urban health

Television

213 (53.3)

139 (34.8)

27.780 <0.001

Church leaders

195 (48.8)

169 (42.3)

3.408

0.065

centres (84.5%).

Newspaper

76 (19.0)

42 (10.5)

11.492

0.001

Community leaders

47 (11.8)

72 (18.0)

6.170

0.013

Table 3: Clients’ satisfaction with immunisation services in

Traditional birth atten-

38 (9.5)

68 (17.0)

9.787

0.002

the urban and rural primary health centers of Enugu State,

dants

August 2013

Variable

Urban

Rural

χ

2

Political leaders

31 (7.8)

37 (9.3)

0.579

0.447

p value

Decision about child immunization

(n=400)

(n=400)

Both parents

198 (49.5)

223 (55.8)

14.510

0.001

N (%)

N (%)

Mother alone

184 (46.0)

175 (43.8)

Satisfied with vaccination

Father alone

18 (4.5)

2 (0.5)

services

Weight of baby checked

Yes

348 (87.0)

380 (95.0)

15.629

<0.001

Yes

238 (59.5)

263 (65.8)

3.338

0.069

No

52 (13.0)

20 (5.0)

a

No

162 (40.5)

137 (34.3)

Reason for not being satisfied

n=52 N

n= 20 N

(%)

(%)

Estimated distance of client residence to health center

Waiting time too log

39 (75.0)

11 (55.0)

6.102

0.014

< 1 kilometer from home

251 (62.8)

278 (69.5)

32.243 <0.001

Waiting area uncomfortable

22 (42.3)

13 (65.0)

1.861

0.173

1- 5 kilometer from

108 (27.1)

118 (29.5)

Vaccination area unclean

24 (46.1)

4 (20.0)

5.565

0.018

home

Vaccine provider unfriendly

13 (25.0)

5 (25.0)

0.051

0.822

>5 kilometer from home

4 1(10.5)

4 (1.0)

Injection equipment not clean

1 (1.9)

3 (15.0)

FT

0.076

Reason for choosing the health center for immunisation

Will use health center again for

n=400

n=400

Proximity

137 (34.3)

110 (27.5)

5.448

0.142

vaccination

Availability of vaccine

119 (29.8)

141 (35.3)

Yes

395 (98.8)

398 (99.5)

FT

0.451

Health worker related

115 (28.8)

124 (31.0)

No

5 (1.3)

2 (0.5)

factors

Reason to use health center

n=395 N

n= 398 N

Service is free

29 (7.3)

25 (6.3)

again

(%)

(%)

Health worker related factors

171 (43.3)

164 (41.2)

0.569

0.904

a

Multiple responses

Proximity

117 (29.6)

125 (31.4)

Availability of vaccines

76 (19.2)

80 (20.1)

Table 3 shows the clients’ satisfaction with the immuni-

Service is free

31 (7.8)

29 (7.3)

sation services in the urban and rural primary health

Will recommend the health

n=400 N

n=400 N

center to others

(%)

(%)

centres. The majority of the clients using the immunisa-

Yes

389 (97.3)

399 (99.8)

8.460

0.004

tion services in the urban and rural health centres re-

No

11 (2.8)

1 (0.3)

ported satisfaction with the services that they received

Reason to recommend the

n=389 N

n=399 N

health center to others

(%)

(%)

(87.0% and 95.0%, respectively), and the difference in

Health worker related factor

185 (47.6)

185 (46.4)

2.036

0.565

the proportion was found to be statistically significant

Availability of vaccines

107 (27.5)

103 (25.8)

(p<0.001). The major reason for dissatisfaction among

Proximity

68 (17.5)

70 (17.5)

the urban respondents who reported dissatisfaction was

Service is free

29 (7.5)

41 (10.3

the long waiting time (39/52, 75.0%), while the major

Difficulties in use of HC for

n=400 N

n=400 N

vaccination

(%)

(%)

reason for the rural respondents was that the waiting

No difficulty

355 (88.8)

369 (92.3)

2.850

0.091

area was uncomfortable (13/20, 65.0%). A slightly

Difficulty

45 (11.3)

31 (7.8)

higher proportion of the rural (99.5%) than the urban

Difficulties encountered

n=45 N

n=31 N

(%)

(%)

(98.8%) respondents responded that they would be will-

Waiting area uncomfortable

26 (57.8)

15 (48.4)

0.652

0.420

ing to utilise the health centres again for immunisation

Waiting time long

19 (42.2)

16 (51.6)

services. This result was not found to be statistically

Overall “True satisfaction with

n=400 N

n=400 N

Immunisation” services

(%)

(%)

significant (p=0.451). A higher proportion of the rural

Yes

338 (84.5)

377 (94.3)

20.021

<0.001

(99.8%) than the urban (97.3%) respondents stated that

No

62 (15.5)

23 (5.8)

they would recommend the health centres to friends,

neighbours, and relatives for immunisation services, and

a

multiple responses encouraged

FT Fishers exact test

this difference was found to be statistically significant

(p=0.004). Comparable proportions of the clients in the

Table 4 shows the factors that affect the true satisfaction

two groups (88.8% in urban vs. 92.3% in rural) experi-

of the clients who utilised immunisation services.

enced no difficulty in the use of the primary health cen-

Among all of the clients who used the immunisation

tres for immunisation services. In the urban health cen-

services in the study area, the location, marital status,

tres, the major difficulty experienced by the clients was

ethnic group, religion, occupation of the index child’s

that the waiting area was uncomfortable, while in the

mother, socio-economic status, and estimated distance

rural area, the major complaint was that the waiting time

from the clients’ homes to the health centres showed a

was too long. This difference in the proportion of com-

statistically significant association with the clients’ true

plaints between the two groups was also not found to be

satisfaction with immunisation services.

379

Table 4: Factors affecting clients true satisfaction with

(91.3%) and rural (92.8%) health centres. This result

immunisation services in the study area, August 2013

was expected, as the health workers are the individuals

Variable

True satis-

Not

p-value

Adjusted Odds

most involved in the national immunisation programme.

faction with

satisfied

on

Ratio (95% confi-

immunisa-

N (%)

bivari-

dence interval)

This result is similar to the finding in a study in

ate

on multivariate

tion ser-

analysis

analysis

Al-Beida City, Libya, that focused on the knowledge,

vices

N (%)

attitudes, and practices of mothers regarding the immu-

nisation of infants and pre-school children, as this study

Location

showed that the majority of the respondents received

Urban

338 (84.5)

62 (15.5)

<0.001

0.2(0.1-0.4)

Rural

377 (94.3)

23 (5.8)

1

information concerning immunisation from paramedical

workers . In a qualitative study on the knowledge, atti-

19

Age category

< 30 years

444 (88.1)

60 (11.9)

0.154

0.8(0.4-1.5)

tudes, and perceptions of the respondents regarding im-

≥ 30 years

271 (91.6)

25 (8.4)

No of living children

munisation and diarrhoea performed in six districts in

≤ 2

382 (88.0)

52 (12.0)

0.275

NA

Malawi, it was also observed that the health workers

≥ 2

333 (91.0)

33 (9.0)

were the main source of information for clients concern-

Marital status

ing immunisation,

20, 21

and in a community-based study

Married, currently

696 (91.5)

65 (8.5)

<0.001

33.5(12.7-88.1

living with spouse

on the patronage of the national programme on immuni-

Married, not living

19 (48.7)

20 (51.3)

1

sation in selected local government areas of Oyo State,

with spouse/Never

married.

Nigeria, the health workers were noted as the greatest

source of information on immunisation activities . It is

22

Ethnic group

Igbo

710 (90.4)

75 (9.6)

<0.001

14.9(3.9-57.4)

also somewhat interesting that immunisation services

Others

a

5 (33.3)

10 (66.7)

1

have attracted the attention of the clergy, as 48.8% of

Religion

Christianity

711 (89.8)

81 (10.2)

<0.001

21.2(2.9-154.6)

the clients in the urban and 42.3% in the rural areas re-

Others

b

4 (50.0)

4 (50.0)

1

ceived information on immunisation from the church

Education of mother

leaders.

Primary education

76 (91.6)

7 (8.4)

0.494

NA

and below

Secondary education

639 (89.1)

78 (10.9)

Regarding the question of which family member makes

and above

the decision about immunising the child, a higher pro-

Occupation of mother

Unemployed/ house-

228 (88.4)

30 (11.6)

0.043

1.6(0.7-3.5)

portion of the clients in the urban and rural health cen-

wife

tres perceived that it is a joint decision of both the father

Self employed

410 (91.3)

39 (8.7)

1.9(0.9-3.8)

and mother. This result is, however, in contrast to the

Salaried employment

77 (82.8)

16 (10.6

1

Socio economic status

findings from a community-based study on the maternal

High socio-economic

353 (86.7)

54 (13.3)

0.014

0.6(0.3-1.1)

determinants of complete child immunisation among

status

children between the ages of 12-23 months in a southern

Low socio-economic

362 (92.1)

31 (7.9)

1

status

district of Nigeria, in which the major decision regard-

Education of father

ing immunisation was made by the mothers alone,

Primary education

92 (93.9)

6 (6.1)

0.357

NA

closely followed by the fathers . This result reveals that

23

and below

Secondary education

604 (91.1)

(8.9)

in the present study, the entire family is involved in is-

and above

sues pertaining to immunisation, as demonstrated by the

Occupation of father

proportion of mothers who brought their children to the

Self employed

522 (92.1)

45 (7.9)

0.313

NA

Salariedemployment

165 (89.2)

20 (10.8)

immunisation centres. One cannot detach this family

Unemployed

9 (100.0)

0 (0.0)

interest in immunisation from the increased awareness

Decision on immunisation

of the importance of immunisation, particularly during

Both parents

375 (89.1)

46 (10.9)

0.771

NA

the polio eradication campaigns that made it possible for

Either parent

340 (89,7)

39 (10.3)

Distance from home to health center (estimated)

vaccinators to visit homes, schools, and churches to im-

≤ 1kilometer

489 (92.4)

40 (7.6)

<0.001

2.6(1.5-4.4)

munise children. The massive media campaigns and the

>1 kilometer

226 (83.4)

45 (16.6)

1

gory pictures of the paralysing effects of the disease may

Place of delivery of child

have perhaps facilitated the involvement of both parents

Private health facility

354 (88.5)

46 (11.5)

0.862

NA

Public health facility

284 (90.4)

30 (9.6)

in matters concerning immunisation. The involvement

Traditional birth

54 (90.0)

6 (10.0)

of the family, particularly fathers, may have helped to

attendant

make immunisation services a top family priority in the

Home

23 (88.5)

3 (11.5)

Relationship of client to child

study area. It is hoped that the involvement of the family

Mother

701 (89.6)

81 (10.4)

0.106

0.6(0.2-2.4)

and the community in other sensitive health issues, such

Others

c

14 (77.8)

4 (22.2)

1

as child health in Nigeria, through increased awareness

will help improve the high under-five mortality rate in

a

Yoruba, Hausa, minority tribes

b

Nigeria. Similarly, in a study on the maternal determi-

Islam, traditional religion

c

Father, guardian

nants of complete child immunisation among children

between the ages of 12-23 months in a district in south-

ern Nigeria, it was found that the decision regarding

immunisation by both parents was a significant factor

Discussion

that affected the completion of the immunisation sched-

ule by the children

24-30

.

The health workers were the main source of information

regarding immunisation for the clients in the urban

380

The high proportions of clients who were truly satisfied

public health facilities. Close proximity of the health

are relevant, as client satisfaction with immunisation

centres may also support the immunisation programme,

services is directly related to the completion of the chil-

thus enhancing the satisfaction of clients with services.

dren’s immunisation schedule,

31-35

which in turn greatly

Ethnicity and religious affiliations also increase the

contributes to the reduction of vaccine-preventable dis-

probability of client satisfaction with immunisation ser-

eases. Regarding the reason for not being satisfied, the

36

vices. Two variables, namely, occupation of the mother

majority of the dissatisfied clients in the urban primary

and socio-economic status of the clients, were signifi-

health centres believed that the waiting time was too

cant in the bivariate analysis but not in the binary logis-

long, while in the rural area, the major reason was that

tic regression. It may be assumed that these variables

the waiting area was uncomfortable. In a study per-

were confounders to the significant variables identified

formed in Kansas City, a lack of information from the

by the multivariate analysis.

vaccine providers was identified as the major reason for

dissatisfaction . This difference in the reason for being

33

An important limitation of this study was that there was

dissatisfied with immunisation services provided in the

no qualitative assessment of the views and expectations

two study areas may be attributed to cultural differences,

of the clients of the immunisation services regarding the

the perception of childhood immunisation, and the cli-

factors that best determine their satisfaction with the

ents’ rights in the two regions. The fact that clients rely

immunisation services in the primary health centres.

on the primary health centres for the provision of immu-

However, while qualitative methods would have permit-

nisation services and that the country’s administrative

ted the clients to fully disclose their feelings in greater

structure also favours the use of primary health centres

depth than the quantitative data collection method, it

for immunisation services may be responsible for the

also has low external validity compared with the quanti-

proportion of the respondents who were willing to use

tative method, which would limit the application of the

the health centres again for immunisation and who were

findings to the population from which the sample was

also willing to recommend the health centres to their

drawn. A well-defined sampling process and the use of

friends, relatives, and neighbours for the same purpose.

extensive interviews by trained research assistants, as

Health worker-related factors, including the fact that

were performed in this study, provided results that could

they were well trained and friendly and offered good

be generalised to clients of immunisation services in the

services, were the major reasons why the clients were

primary health centres with a significant degree of confi-

willing to use the health centres again and also recom-

dence. It is also noteworthy that the presence of inter-

mend the health centres to others for immunisation ser-

viewers in the primary health centres on the day of vac-

vices in the urban and rural primary health centres.

cination could have introduced bias into the study.

These results may indicate a good client-provider inter-

Although adequate measures were taken to explain the

action associated with immunisation services in the

relevance of the study to the clients, this effort may not

study area, and the results are very significant, as the

have prevented the clients from perceiving the inter-

attitude of the health workers and their relationships

views to be an audit process by any of the various

with the mothers have been found to play prominent

government agencies, and as a result, they may have

roles in the demand and acceptance of vaccinations .

34

responded in favour of the health facilities out of fear of

indicting the health workers. This possibility is very

Our study suggests that being a client in a rural area

significant, as the focus of this study was immunisation

increases the probability of being satisfied with immuni-

services, and the study indicated that the clients prefer

sation services. This may be as a result of fulfilled ex-

the use of primary health centres for such services.

pectations on the part of the clients in rural areas, as the

primary health centres are the predominant health facili-

ties and the country’s administrative structure supports

the provision of immunisation services at primary health

centres. Additionally, the majority of the clients in the

Conclusion

rural area prefer the primary health centres for immuni-

sation services based on the fact that vaccines are always

Most clients were satisfied with the immunisation ser-

available, which may have influenced their satisfaction

vices in urban and rural primary health centres, which

with the services. The clients who were married were

could be attributed to good client-provider relationships.

found to be more satisfied based on logistic regression

However, the waiting time needs to be reduced, and the

analysis, which could be a result of the support from

physical conditions of the waiting area in the health cen-

their spouses and family stability. Clients who lived

tres also need to be improved to reduce client dissatis-

closer to the health centres were also found to have a

faction with the services.

higher probability of being satisfied with immunisation

services, which could be attributed to the fact that they

view such closeness as a form of welfare service from

Conflict of interest: None

the government because primary health centres are

Funding: None

381

References

1.

Lucas AO, Gilles HM. Short Text-

15. Taofeek I. Research Methodology

25. Oladokun RE, Adedokun BO,

book of Public Health Medicine

and Dissertation Writing for

Lawoyin TO. Children not receiv-

for the Tropics. 4 ed. London:

th

Health and Allied Health Profes-

ing adequate immunisation in

sionals. 1 ed. Abuja: Cress

st

Bookpower, 2003.

Ibadan, Nigeria: What factors and

2.

Obionu CN. Primary Health Care

Global Link Ltd. 2009.

beliefs do their mothers have?

for developing countries. 2 ed.

nd

16. Nath B, Singh JV, Awastha S,

Niger J Clin Pract 2010;13(2):173

Enugu: Delta Publications, 2007

Bhushan V, Singh SK, Kumar V.

-8.

3.

Greenwood B, Salisbury D, Hill

Client satisfaction with Immunisa-

26. Federal Ministry of Health.

A. Vaccines and Global Health.

tion services in urban slums of

(FMOH). & National Primary

Philos Trans R Soc Lond B Biol

Lucknow district. Indian J Pedi-

Health Care Development Agency.

Sci 2011, 12;366(1579):2733-42.

atr, 2009;76(5), p.479-83.

(NPHCDA). Comprehensive EPI

4.

Bloom DE, Canning D, Weston

17. WHO/AFRO/EPI. Mid-Level

multi-year plan, 2011-2015.

M. The value of vaccination.

Management Course for EPI Man-

Abuja, Nigeria, 2011.

World Economics, 2005;6(3):15-

agers. Block VII: Monitoring and

27.

National Programme on Immuni-

39.

Evaluation Modules, Module 23.

sation (NPI). Report of the Federal

5.

Fatiregun AA, Etukiren EE. De-

Conducting Assessment of the

Republic of Nigeria Immunisation

terminants of uptake of third doses

Immunisation Programme 2004.

Coverage Survey, 2003. Abuja

of oral polio and DTP vaccines in

18. Udonwa NE, Gyuse AN, Eto-

Nigeria, 2004.2

the Ibadan North Local Govern-

kidem AJ, Ogaji DST. Clients

28. National Programme on Immuni-

ment Area of Nigeria. Int. Health

views, perception and satisfaction

sation (NPI). Report of the Federal

2014 : ihu027v1-ihu027.

with Immunisation services at

Republic of Nigeria Immunisation

6.

WHO, UNICEF, World Bank.

Primary Health Care facilities in

Coverage Survey, 2006. Abuja

State of the world’s vaccines and

Calabar, South-south Nigeria.

Nigeria, 2007.

immunisation. 3 edition. Geneva.

rd

Asian Pacific J Trop Med 2010;3

29. Ehiri JE, Oyo-Ita AE, Anyanwu

WHO, 2009.

(4):298-301.

EC, Meremikwu MM, Ikpeme

7.

National Population Commission

19. Bofarraj MAM. Knowledge, atti-

MB. Quality of child health ser-

(NPC) (Nigeria) & ICF Macro.

tude and practices of mothers re-

vices in primary health care facili-

Nigeria, Demographic and Health

garding immunisation of infants

ties in south-east Nigeria. Child

Survey, 2008. Abuja. Nigeria.

and preschool children at Al-Beida

Care, Health Dev 2005;31(2):181-

NPC and ICF Macro, 2009.

City, Libya 2008. Egypt J

191.

8.

Sachdeva S, Datta U. Study of

Peadiatr Allergy Immunol 2011;9

30. Banerjee B. A qualitative analysis

client movement availing immuni-

(1):29-34.

of maternal and child health ser-

sation services in urban govern-

20. Munthali AC, Mvula P. Knowl-

vices of an urban health centre, by

ment dispensaries. Biomed Res

edge, attitudes and perceptions

assessing client perception in

2010;21(1):107-9.

study on immunisations and diar-

terms of awareness, satisfaction

9.

Aldana JM, Piechulek H, al-Sabir

rhoea. Available at www. unma-

and service utilization. Indian J

A. Client satisfaction and quality

lawi.org/2012/Malawi/KAP.

Community Med 2003;28(4):186.

of health care in rural Bangladesh.

Accessed 4 November 2013.

31.

Abdulraheem IS, Onajole AT,

Bull World Health Organ 2001;79

21. Tagbo BN, Uleanya ND,

Jimoh AAG, Oladipo AR. Reasons

(6):512-7.

Nwokoye IC, Eze JC, Omotowo

for incomplete vaccination and

10. Gibson L, Alilio M, Heggen-

IB. Mothers’ knowledge, percep-

factors for missed opportunities

hougen K. Community satisfaction

tion and practice of childhood

among rural Nigerian children.

with primary health care services,

immunization in Enugu. Niger J

Journal of Public Health and Epi-

an evaluation undertaken in the

Paed 2012;39 (3):90 – 96.


demiology 2011;3(4):194-203.

Morogoro region of Tanzania. Soc.

22. Oyerinde OO. National pro-

32.

Patro BK, Kumar RK, Goswani

Sci Med, 1994;39:767 – 80.

gramme on immunisation patron-

A, Nongkynrih B, Pandav CS.

11. Uzochukwu BSC, Onwujekwe

age in selected local government

Community perception and client

OE, Akpala CO. Community satis-

areas of Oyo state. Available at

satisfaction about primary health

faction with the quality of mater-

www.unilorin.edu.ng/journals/

care services in an urban resettle-

nal and child health services in

education. Accessed 14 December

ment colony of New Delhi. Indian

Southeast Nigeria. East Afr Med J

2013.

J Community Med, 2008;33

2004;81:293-9.

23. Fatiregun AA, Okoro AO. Mater-

(4):250-4.

12. Federal Republic of Nigeria.

nal determinants of complete child

33. Weddle G, Jackson MA. Parental

(FRN). Official Gazette. Lagos.

immunisation among children

satisfaction with vaccination ser-

Nigeria. 2007.

aged 12-23 months in a southern

vices. Poster/abstract section. Pro-

13. Enugu State Ministry of Health.

district of Nigeria. Vaccine

grammatic adjustments to improve

(MOH). Planning, Research and

2012;30:730-6.

vaccine coverage. ID Week. Ad-

Statistics Department. Enugu.

24. National Programme on Immuni-

vancing science, improving care.

Nigeria, 2012.

sation. (NPI). Knowledge, percep-

San Diego, CA. Available at

14. Enugu State Ministry of Health.

tion and beliefs about childhood

www.idweek.org. Assessed 7 Sep-

(MOH). Policy Brief on Free Ma-

immunization and attitude towards

tember, 2013.

ternal and Child Health Care Ser-

uptake of poliomyelitis immuniza-

vices in Enugu State. Enugu. Ni-

tion in Northern Niigeria. Study

geria, 2007.

Report 2006. Available at

www.comminit.com/polio/node.

Accessed 9th September, 2013.

382

34.

Expanded Programme on Immu-

35. Manjunath U, Pareek RP. Mater-

36. Perry H, Nurami S, Quaiyum MA,

nisation. (EPI). The Social Science

nal knowledge and perceptions

Jinnah SA, Sharma A. Barriers to

and Immunisation Research Pro-

about the routine immunisation

Immunisation among women and

ject, Wkly Epidemiol Rec,

programme: A study in a semi-

children living in slums of Zone 3

1998;73:285-8.

urban area in Rajasthan. Indian J

of Dhaka City, Bangladesh: A

Med Sci, 2003;57:158-63.

Qualitative Assessment. Interna-

tional Center for Diarrhoeal Dis-

ease Research, Bangladesh. Work-

ing paper no.166, 2007.