Maternal Healthcare-seeking Behaviour and Timely Childhood Vaccination in Low- Resource Agricultural Areas of Nigeria

doi:10.21203/rs.3.rs-5014410/v1

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Research Article

Maternal Healthcare-seeking Behaviour and Timely Childhood Vaccination in Low- Resource Agricultural Areas of Nigeria

https://doi.org/10.21203/rs.3.rs-5014410/v1

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Background

Maternal healthcare-seeking behavior is a key determinant of childhood vaccination rates. Understanding this behavior among mothers makes improving vaccination rates and reducing preventable disease incidence possible. Maternal Healthcare-seeking Behavior (MHB) in rural Nigeria is low, with high maternal mortality. Empirical evidence linking MHB to the vaccination of children is limited; therefore, the effect of maternal health-care-seeking behaviour on the timely immunization of children in low-resource agricultural areas in Nigeria was investigated.

Method

Secondary data sourced from the 2018 National Demographic Health Survey were utilized in this study. Information on vaccines collected by the children, prenatal care, timing of first ante-natal, number of ante-natal visits during pregnancy, assisted by a skilled attendant, and post-natal care by mothers was extracted from 2,751 women with under-five children. It was analyzed using descriptive statistics, multiple correspondence analysis, and an extended ordered logit model.

Results

Women in rural Nigeria seek the use of maternal healthcare facilities moderately with a mean value of 0.54 while most (55.85%) of the children are unimmunized. The MHB and husband’s education improved partial vaccination in children, while the husband’s education and mother's full employment in agriculture improved the child’s full vaccination status.

Conclusion

It was concluded that MHB improved child vaccination status in low-resource areas in Nigeria. Therefore, policies to facilitate better use of maternal healthcare facilities should be formulated and upheld. The government should also try to create mini health centers in major markets across states where pregnant mothers can have their antenatal care and vaccines can as well be administered to children. Also, implementing programs and policies to improve child vaccination in low-resource areas in Nigeria should be considered.

Healthcare-seeking

Child vaccination

Healthcare facilities

Agricultural area

Nigeria

Nigeria's routine immunization schedule stipulates that infants should be vaccinated with the following vaccines: a dose of Bacillus Calmette-Guerin (BCG) vaccine at birth (or as soon as possible); three doses of Pentavalent {DPT, Hep B and Hib} vaccine at 6, 10 and 14 weeks of age; at least three doses of oral Polio vaccine (OPV) – at birth, and 6, 10 and 14 weeks of age; and one dose of Measles vaccine at 9 months of age. However, the country's immunization program has been characterized by intermittent failures and successes since its initial introduction in 1956. The immunization program was again re-introduced as the Expanded Programme on Immunization (EPI) in 1979 to provide immunization services to children aged 23 months and younger. Following repeated and limited initial success, the immunization program was re-launched in 1984. The EPI program was re-visited and re-named the National Programme on Immunization (NPI) in 1995.

Maternal health encompasses the health of women during pregnancy, childbirth, and the postpartum period. The study of [1] and [2] opined that maternal health influences child immunization as vaccines given to pregnant women can provide antibodies to the baby, offering protection during the first few months of life before the baby can receive their vaccines. Also, ensuring that mothers receive continuous care from pregnancy through the postpartum period increases the likelihood that their children will receive timely immunizations. This established that a relationship exists between the use of healthcare facilities in mothers and the immunization status of children.

During the periods between birth and age five, children are vulnerable to diseases, illness, and death. From one month to five years of age, the main causes of death are pneumonia, diarrhoea, malaria, measles, and HIV [3]. The preventive measure at the childhood stage is child immunization, which is the complete course of injections administered to children soon after birth till 5 years old. It produces antibodies inside the body against specific diseases. These diseases take several precious lives all over the world, especially in low-income countries like African and South Asian countries.

Child mortality has fallen significantly in many low-income countries; however, sub-Saharan Africa continues to experience the slowest fall in mortality rate among children [4]. According to the United Nations Children's Fund [5], the under-five mortality rate (U5MR) in sub-Saharan Africa fell from 99 deaths per 1,000 live births in 2000 to 74 deaths per 1,000 live births in 2021 which represents a decline of 25%. However, globally in low-income countries; the average newborn mortality rate was 27 deaths to 1,000 births while in high-income countries it was 3 deaths to 1,000 births. According to [6] data, it is estimated that 5.2 million children under the age of five died in 2019 and more than half of those deaths occurred in sub-Sahara Africa. Six countries - India, Nigeria, China, Pakistan, the Democratic Republic of Congo, and Ethiopia - account for half of worldwide childhood deaths [7]. Currently, [7] established that Nigeria recorded an estimated average of 858,000 under-five deaths in 2019 and so became the world’s highest contributor to under-5 deaths for the Sustainable Developmental Goal 3 to be achieved, the under-5 mortality rate must reduce to 25 per 1000 live births.

Globally, about 23 million children under the age of one did not receive basic vaccines which is the highest since 2009, over 60% of these children live in Nigeria and nine other countries [8]. According to [8], only 23% of children in Nigeria receive all the recommended vaccines which means that nearly 1 in 4 Nigerian children receive all of the recommended vaccines, with 36% receiving them in urban areas and only 14% in low-resource agricultural areas in rural areas, which puts the children at risk of preventable diseases.

Households in low-resource agricultural areas earn income directly from agriculture, this directly influences their ability to purchase and gain access to food, water, land, and health-related services which in turn determine their overall health status. A child who is not immunized is predisposed to diseases and vulnerable to death. As a result, the time available to the mother to attend to other healthy children is limited and this also renders her less productive as one of the major sources of labour in the household. All these consequently limit productivity, and affect livelihood and income generated. Generally, a sick child affects a mother’s ability to fully participate in the labour force which will enhance sustainable development and for mothers to have a balanced family and a work life, good health is essential for all members of the households.

Policymakers will find it helpful to plan developmental programs for low-resource agricultural areas and the health sector if they have an awareness of the relationships, and interactions, that exist between maternal healthcare-seeking behavior and the immunization status of the child. Furthermore, such a study will provide the basis to invest in health capital, especially maternal and child health. Regrettably, although extensive studies existed on child immunization in Nigeria, including patterns of uptake as well as determinants [9];[10] and [11] there is a dearth of knowledge and limited empirical evidence that links maternal health care-seeking behaviour to child immunization status. Therefore, maternal healthcare-seeking behaviour and child immunization status is an important gap in knowledge that will direct knowledge generation and policy recommendations that will enhance the attainment of the sustainable development goals (SDGs) 3- good health and well-being were investigated in this study. From the aforementioned, the central research question is “How does maternal healthcare-seeking behavior influence the immunization status of children in low-resource agricultural areas in rural Nigeria? The specific questions to be answered by the study are: (i)What is the level of maternal healthcare-seeking behaviour? (ii) What is the immunization status of children in the households? (iii) What is the effect of maternal healthcare-seeking behaviour on child immunization status?

Scope of the Study

The study focused on agricultural households in low-resource regions across Nigeria. Located in West Africa, Nigeria, officially known as the Federal Republic of Nigeria, lies between the Sahel region to the north and the Gulf of Guinea to the south, within the Atlantic Ocean. Covering an area of 923,769 square kilometers (356,669 square miles) and with a population exceeding 230 million, Nigeria is bordered by Niger, Chad, Cameroon, and Benin. The country operates as a federal republic and is divided into 36 states, plus the Federal Capital Territory, where the capital city, Abuja, is situated. Geographically, Nigeria spans latitudes 4° to 14° north and longitudes 2° to 15° east. It is organized into six geopolitical zones: North West, North East, North Central, South West, South East, and South South.

Source and Type of Data

To achieve the objectives of the study, data from the 2018 National Demographic Health Survey (DHS) for Nigeria was utilized. The DHS dataset encompasses a sample ranging from 5,000 to 30,000 households nationwide. This dataset not only provides national estimates but also includes data on key indicators across regions, the six geopolitical zones, states, and the Federal Capital Territory (FCT). Questionnaires were distributed to collect information from households, including men and women, which was then analyzed to extract crucial national indicators. The dataset proved adequate for addressing the primary research questions due to its comprehensive nature and adaptability for various research and assessment purposes. It contains extensive demographic, nutritional, and health information.

For the survey, a representative sample of 42,000 households was initially selected. Ultimately, data was collected from 40,427 households, 41,821 women, and 13,311 men, including 23,403 rural households. However, following data cleaning and sorting, the number of rural households was reduced to 6,514. Given that this study focuses on mothers with children under five in low-resource agricultural areas, the final sample of 6,514 rural households was utilized. Further, these rural households were categorized into agricultural (2,751) and non-agricultural (3,763) households based on the employment status of the household head. Consequently, the study specifically analyzed data from 2,751 women with children under five in low-resource agricultural areas in rural Nigeria.

Analytical Techniques

Multiple Correspondence Analysis (MCA)

Multiple Correspondence Analysis (MCA) was employed to consolidate various indicators of maternal healthcare-seeking behavior into a comprehensive index. In this analysis, a lower weighted average across all indicators signifies a lower level of maternal healthcare-seeking behavior, whereas a higher weighted average reflects a higher level of maternal healthcare-seeking behavior. The formula used for this calculation is provided below.

Z = PBQT (1)

Where;

Z is the contingency table of the data

P is the indicator matrix of the rows

B is the Burt matrix

Q is the indicator matrix of the columns

The equation for MCA can be interpreted as follows the contingency table is decomposed into a product of three matrices. The first matrix, P, is a matrix of row scores. The second matrix, B, is a matrix of column scores. The third matrix, Q, is a matrix of row-column correlations. The row scores and column scores can be used to visualize the data in a biplot. The biplot is a scatterplot that shows the rows and columns of the contingency table. The rows and columns are connected by lines that show the correlations between them. MCA is an effective method for examining relationships between categorical variables. It helps uncover underlying patterns within the data and enables visualization through a biplot, allowing for a clearer understanding of data structures. Table 1 shows the six indicators of maternal healthcare-seeking behaviour that were adopted for this study as earlier used by [12] to develop the Maternal Healthcare-seeking Behaviour Index (MHSB).

Table 1

Maternal healthcare-seeking behaviour indicators /variables
S/N	Indicators	Definition of indicators	Modalities
1	Pre-natal care	Women who received care before pregnancy i.e. family planning, fertility tests, etc.	Yes, No
2	Timing of first ante-natal	Pregnant women are first-trimester antenatal starters and those who are not	Yes, No
3	Number of ante-natal visits during pregnancy	Total number of antenatal visits to the health facility before delivery	≥ 4 = 1, $\:<$ 4 = 0
4	Place of delivery	Women in pregnancy who gave birth at medical facilities and those who delivered in other homes.	Yes, No
5	Assisted by a skilled attendant	Pregnant women who were assisted by a skilled birth attendant during delivery and those assisted by others.	Yes, No
6	Post-natal care	Women who received care immediately after delivery till 6 weeks after from a trained professional and those who do not	Yes, No

Descriptive Statistics

Descriptive Statistics were used to profile the immunization status of under-five children. This includes frequencies, tables, and percentages. The various vaccines used by the children were used to describe immunization status of the children as shown in Table 3. Children were described as partially immunized (when a dose of any of the vaccines is skipped), fully immunized (when all the doses of the vaccines are received), and unimmunized (when all the doses of the vaccines are not received/when oral polio vaccine only is received). This approach follows [13].

Table 3

Routine Immunization in Nigeria according to the National Program on Immunization (NPI)
Vaccines	Schedule	Fully Immunized	Unimmunized	Partially immunized
Bacillius Calmette Guerin (BCG) Hepatitis B OPV 0	At birth
PENTA (DPT, Hep B and Hib) (3 doses)	6,10,14th weeks
Oral Polio Vaccine (3 doses)	6,10,14th weeks
Oral Polio inactive	14th week
Measles	9 months

*Partially immunized is when a dose of any of the vaccines is skipped.

*Fully immunized is when all the doses of the vaccines are received.

*Unimmunized is when all the doses of the vaccines are not received/when oral polio inactive vaccine only is received.

Extended Ordered Probit Regression Model

The Extended Ordered Probit Regression Model was employed to examine the impact of maternal healthcare utilization on child immunization status. This model is appropriate as it handles endogenous covariates, nonrandom treatment assignment, endogenous sample selection, and can be applied to panel or grouped data. The model is formulated as follows:

$$\:yi=vh\:\:\:iff\:\:\:{k}_{h-1}<{X}_{i}\:\beta\:+\:\:{Ԑ}_{i}\le\:\:{K}_{h}\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\left(2\right)\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:$$

The limits on the unobserved $\:{{\epsilon\:}}_{\text{i}}$ based on the observed values of$\:\:{y}_{i}$ and$\:\:{X}_{i}$

$\:{l}_{1i}={c}_{i(h-1)}\:\:\:\:\:\:\:\:$ if $\:{y}_{i}=$ $\:{v}_{h}\:$ (3)

$\:{u}_{1i}=$ $\:{c}_{ih}\:$ if $\:{y}_{i}=$ $\:{v}_{h}$ (4)

the log-likelihood is written as

1nL$\:={\sum\:}_{I=1}^{N}{w}_{i}ln{ɸ}_{i}$($\:{l}_{1i}$, $\:{v}_{1i}$,1) (5)

The conditional probabilities of success can be written For h = 1,……, H as;

Pr ($\:{y}_{i}$=$\:{v}_{h}$/$\:{X}_{i}$) = $\:{ɸ}_{i}$($\:{c}_{i(h-1)}$,$\:\:{c}_{ih}\:$, 1) (6)

Y=

Y= $\:{K}_{h}\:+{X}_{1}+{X}_{2}\:+{X}_{3}+{X}_{4}\dots\:\dots\:\dots\:.\:\:{X}_{N}+£\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\left(7\right)\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:$

Y₁ = = Child Immunization (0-unimmunized, 1- partially immunized, 2- fully immunized)

Child’s Characteristics

X₁₌ Age of the child ( In months)

X₂ =Child’s sex. (1 if male and 0, otherwise)

X₃ =Child’s birth weight (in kg)

X₄=Child’s age square (in months)

X₅ = Total children (Numbers)

X₆ = Birth order (Number)

Mother’s Characteristics

Y₀= Maternal health care utilisation index

X₇= Mother’s educational status (1 if formal, 0= otherwise).

X₈ = Mother’s age at first birth (years)

X₉ = Mother’s occupation (0= Agriculture part–time, 1= agriculture full-time.)

X₁₀ = Media exposure (1=exposed, 0=otherwise)

Household’s Characteristics

X₁₁ = Household size (persons)

X₁₂ = Family wealth index

X₁₃ = Sex of household head. (1 if male, 0 if otherwise)

X₁₄= Husband’s educational status (1= formal, 0= no formal)

N₁₅ = Husband’s age (years)

Region of Residence

X₁₆= 1 if Northcentral, 0 if otherwise

X₁₇= 1 if Northeast, 0 if otherwise

X₁₈=1 if Northwest, 0 if otherwise

X₁₉ =1 if Southeast, 0 if otherwise

X₂₀ =1 if South-south, 0 if otherwise

X₂₁ =1 if Southwest, 0 if otherwise

Mother’s Socio-economic Characteristics

Table 4 presents an overview of the socioeconomic characteristics of mothers. The data reveals that 65.4% of the mothers engaged in occupations beyond agriculture, while only 34.57% were exclusively employed in the agricultural sector. This indicates that most mothers worked in other fields, such as sales and administrative roles. Less than 1% of the mothers were between the ages of 33 and 45 years, whereas 54.12% were between 12 and 18 years old at their first childbirth. On average, mothers gave birth for the first time at 18.54 years of age. This suggests that a significant proportion of the mothers were young women, who might lack adequate childcare knowledge. The low educational attainment among Nigerian women, which often results in limited employment opportunities, could contribute to their early age at first childbirth. Furthermore, the prevalence of early marriage among young girls in rural areas likely influences the age at which they first give birth. These findings are consistent with the reports by [14] and [15].

Additionally, 40.35% of the mothers had received formal education, while 59.65% had not. Previous studies, including those by [16], [14], [17], [15], and [18], have reported that women in rural areas often have limited formal education. This lack of education among women in low-resource agricultural areas in rural Nigeria is often attributed to cultural practices and religious beliefs. Moreover, 64.16% of the mothers were identified as Muslims, a finding consistent with [19], which noted that a significant number of rural women in Nigeria, particularly in the Northern regions, are Muslim.

Table 4

Distribution of mothers by socio-economics characteristics
Characteristics	Frequency	Percentage (%)
Occupation of mothers
Agriculture part-time	1800	65.43
Agriculture full-time	951	34.57
Age of mothers at first birth
12–18	1599	58.12
19–25	992	36.06
26–32	143	5.20
33–45	17	0.62
Mean	18.54	-
Standard deviation	3.791	-
Education of mothers
No formal education	1641	59.65
Formal education	1110	40.35
Religion
Christianity	959	34.86
Islamic	1765	64.16
Traditionalist	17	0.62
Others	10	0.36

Source: Computed from NDHS, 2018

Socio-economic Characteristics of Households

Table 5 reveals that 44.82% of the husbands in the households had no formal education, while 55.18% had received formal education. Nearly half (43.44%) of the household heads were aged between 36 and 45 years, and 12.00% were over 55 years old. The average age of household heads was 43.66 ± 9.92 years, indicating they were generally in their prime earning years. This finding aligns with the study by [20], which suggests that heads of rural households are typically at an economically productive age.

In terms of household leadership, only 5.85% were headed by women, while 94.15% were led by men. This supports the observation made by [21], [22], [23], and [16] that men predominantly head households in rural Nigeria. Regionally, the Northwest accounts for 30.61% of the households, compared to 9.38% in the Southwest. Additionally, 3.2% of households had more than fifteen members, while 51.84% had between six and ten members, with an average household size of 8.30 ± 3.64. This is consistent with findings from [24], [16], and [25], which reported large household sizes in low-resource rural areas of Nigeria.

Table 5

Distribution of households by socio-economics characteristics
Characteristics	Frequency	Percentage (%)
Education of husbands
No formal education	1233	44.82
Formal education	1518	55.18
Age of household head ≤ 25 26–35 36–45 46–55 ≥ 55 Mean Standard deviation Sex of household head Male Female Zones North central Northeast Northwest Southeast South south Southwest Household size 1–5 6–10 11–15 > 15	63 514 1195 649 330 43.66 9.916 2590 161 424 798 842 156 273 258 655 1426 582 88	2.29 18.68 43.44 23.59 12 - - 94.15 5.85 15.41 29.01 30.61 5.67 9.92 9.38 23.81 51.84 21.16 3.20
Mean	8.30	-
Standard deviation	3.642	-

Source: Compilation for NDHS, 2018

Children’s Socio-economics Characteristics

The children's socioeconomic characteristics are presented in Table 6. According to the results, 32.45% of the children were between the ages of 10 and 18 months, and about 18% were between the ages of 28 and 35 months. The youngsters were 15.93 ± 9.64 months old on average. According to birth order, 90.66% of the children were third or later born, while 2.60% were first born. The average order of birth was 6 ± 2.603.

Also, there were roughly 51.47% male and 48.53% female among the children. Furthermore, 2.15% of the newborns weighed 2.5 kg or less, whereas approximately 84.05% of the infants were not weighed at delivery. As children who were born weighing less than 2.5kg were considered ineligible to begin the immunization program, this suggests that a small proportion of the children may have missed out on vaccinations due to low birth weight. This is probably one of the causes of the high proportion of children living in low-resource areas who were not immunized

Table 6

Distribution of children by socio-economics characteristics
Characteristics	Frequency	Percentage (%)
Child’s age(months) 0–9 10–18 19–27 28–35 Mean Standard deviation Birth order 1 2 ≥ 3 Mean Standard deviation Child sex Male Female Childbirth weight (Kg) ≤ 2.5 2.6-5.00 > 5.00 Not weighted	779 880 546 507 15.93 9.641 69 188 2494 6.0 2.60 1416 1335 59 375 5 2312	28.72 32.45 20.13 18.69 - - 2.51 6.83 90.66 - - 51.47 48.53 2.15 13.63 0.18 84.05

Source: Compilation from NDHS, 2018

Maternal Health Care Seeking Behaviour Variables across the Households

Table 7 presents the measures of maternal healthcare-seeking behavior among mothers in low-resource agricultural areas in rural Nigeria. The data shows that only 12.58% of mothers accessed prenatal care at healthcare facilities, while 12.65% did not receive any prenatal care. This indicates that a significant proportion of mothers in these areas opt for non-traditional locations for prenatal care. Additionally, 23.26% of mothers started prenatal care during the first trimester, whereas 76.74% began care later. This suggests that many expectant mothers did not follow the World Health Organization's recommendation to start prenatal care in the first trimester, a finding consistent with [26], which reported that young rural women often lack early antenatal care.

Regarding the frequency of antenatal visits, 76.26% of mothers attended four or more visits during their pregnancy, while nearly a quarter (23.74%) did not meet the World Health Organization's recommended minimum of four visits. On average, mothers had 4.99 ± 3.07 antenatal visits. This suggests that while most mothers did receive antenatal care, there remains room for improvement, as highlighted by [27], which noted substandard antenatal care services in Nigeria.

In terms of delivery assistance, 52.96% of mothers received skilled labor assistance, while approximately 47.04% had unskilled labor support during delivery. This implies that a notable proportion of mothers gave birth with the aid of unskilled personnel. Consequently, 69.43% of mothers delivered at home, compared to 30.57% who gave birth in a hospital. This finding aligns with previous research indicating that home births are common among Nigerian mothers, as noted by [28]. Additionally, only 17% of mothers received postnatal care, as defined by the World Health Organization, leaving 82.22% without such care. This mirrors findings from [29], which reported low postnatal care rates among mothers in Swaziland.

Table 7

Distribution of mothers by maternal health care seeking variables
Indicators	Frequency	Percentage
Prenatal care
None	348	12.65
Others	2057	74.77
Healthcare facility	346	12.58
Timing of Ante-natal care
Later	2111	76.74
First Trimester	640	23.26
Number of Ante-natal care
< 4(No)	653	23.74
≥ 4(Yes)	2098	76.26
Mean	4.99	-
Standard deviation	3.074	-
Assisted During Delivery
Others	1294	47.04
Skilled birth attendants	1457	52.96
Place of Delivery
Others	1910	69.43
Health Facility	841	30.57
Post-natal Care
No	2262	82.22
Yes	849	17.78

Source: Compilation from NDHS, 2018

Levels of Maternal Healthcare-seeking Behaviour of Mothers in the Households

The result in Table 8 shows the maternal healthcare-seeking behaviour of mothers. A little above a quarter (26.94%) of mothers within households were low seekers of maternal healthcare facilities while 33.99% were high seekers of maternal healthcare facilities. A low level of maternal healthcare-seeking behaviour in low-resource areas was reported by [30]; [31]. Close to half of the mothers (39.08%) were moderate seekers of maternal healthcare facilities. The mean level of maternal healthcare-seeking behaviour was 0.5381 ± 0.232. Having a high proportion of mothers as low seekers of maternal health care facilities in an agricultural household means the mothers are vulnerable to complications before, during, and after pregnancy, when there is any health-related issue, their productivity is affected as there will be a shortage in the available labour source.

Table 8

Distribution of Mothers by Levels of Maternal Health Care Seeking Behaviour
Levels	Frequency	Percentage (%)
Low	741	26.94
Moderate	1075	39.08
High	935	33.99
Mean	2.071
Standard Deviation	0.778

Source: Compilation from NDHS, 2018

Vaccine Collection across Children in Households

The distribution of children within the households by scheduled vaccines in Table 9 reveals that 69.57% of the children, did not receive BCG at birth while 30.43% did. The result also shows that 77.83% of the children did not receive the hepatitis B vaccine and Polio vaccine administered at birth, a larger proportion (78.70%) of the children in the households did not receive it. This implies that many of the children in agricultural households in rural Nigeria did not receive the vaccines scheduled for children at birth (BCG, Hepatitis B, and polio 0). Low BCG vaccine coverage among children was earlier reported by [32] and [33].

Furthermore, 61.43% of the children did not receive polio1 vaccine at 6th week. A higher proportion (72.81%) of the children missed PENTA 1 vaccine scheduled for the 6th week. Polio 2 vaccine that was to be taken by the 10th week in children, 67.76% of the children within the households did not receive it. This means that most of the children in low-resource agricultural areas of Nigeria did not receive the Polio 2 vaccine. This is like the report of [34] who reported that hundreds of thousands of children continue to be missed during the oral polio vaccine in Nigeria.

A large proportion (79.17%) of the children did not receive the PENTA 2 vaccine as of when due. This implies that a higher proportion of the children missed the vaccine scheduled for the 10th week. The result also shows that 16.74% of the children in the households received Polio 3 vaccine at week 14, which invariably means a higher proportion (83.06%) did not receive it. PENTA 3 vaccine was only received by 13.63% of the children in the households, leaving about 86.37% of the children out. In the 14th week when the Polio inactive vaccine was to be received, it was shown from the result that 79.83% of the children in the households did not receive it. This implies that out of the vaccines scheduled for the 14th week in children, the PENTA 3 vaccine was skipped mostly by children.

The measles vaccine is scheduled for the 9th month in children, 78.19% of the children in agricultural households in rural Nigeria did not receive the vaccine. [35] reported a low coverage of measles antigen among children. Across all the vaccines, children in low-resource agricultural areas in Nigeria missed out on the majority; however, the PENTA 3 vaccine was mainly skipped, Immunization coverage for the pentavalent vaccine is still below the recommended global goal of 90% as earlier reported by [36] while most of the children received polio 1 vaccine. The implication is that children in low-resource agricultural areas in Nigeria are vulnerable to diseases as the vaccines to develop antibodies that help the body fight the diseases have been skipped so, the time available to the mother to take care of other healthy children is limited. Also, the mother and the sick child/children will not add up to the labour source available to the household for that production period, which impacts productivity and income adversely

Table 9

Distribution of children by scheduled vaccines
Scheduled Time	Vaccines	Freq.	Percent (%)
At birth	BCG
	No	1914	69.57
	Yes	837	30.43
	Hepatitis B
	No	2141	77.83
	Yes	610	22.17
	Polio o
	No	2165	78.70
	Yes	586	21.30
6 weeks	Polio 1
	No	1690	61.43
	Yes	1061	38.57
	Penta 1
	No	2003	72.81
	Yes	748	27.19
10 weeks	Polio 2
	No	1864	67.76
	Yes	887	32.24
	Penta 2
	No	2178	79.17
	Yes	573	20.83
14 weeks	Polio 3
	No	2285	83.06
	Yes	466	16.94
	Penta 3
	No	2373	86.37
	Yes	375	13.63
	Inactive Polio
	No	2176	79.83
	Yes	555	20.17
9months	Measles
	No	2168	78.19
	Yes	583	21.19

Source: Compilation from NDHS, 2018

Immunization Status of Children

Immunization status of children in the low-resource agricultural areas in Nigeria as seen in Table 10 shows that 55.83% of children in the households were unimmunized (meaning they had not received any of the vaccines scheduled), while 5.00% of the children were fully immunized. This implies that most of the children in low-resource areas in Nigeria did not receive any of the vaccines at the due time. This report is in line with the report of the National Primary Health Care Developmental Agency [37] that there were over four million unimmunized children in Nigeria even though improvement in child health measured by immunization status was earlier reported by [38]. The mean of child immunization status in the households was 1.493 ± 0.594. Having a good number of children unimmunized in the household implies that more of the children will be vulnerable to disease outbreaks and attacks which might eventually lead to a state of morbidity or mortality.

Table 10

Distribution of children by immunization status
Categories of child immunization	Frequency	Percentage (%)
Unimmunized	1536	55.83
Partially immunized	1073	39.00
Fully immunized	142	5.16
Mean	1.4933	-
Standard deviation	0.5944	-

Source: Compilation from NDHS, 2018

Effect of Maternal Healthcare Seeking Behaviour on Child Immunization Status

The result from Table 11 reveals that maternal healthcare-seeking behaviour index, husband’s educational status, age at first birth, wealth index, and child’s age square affect child immunization status among low-resource agricultural areas in Nigeria. It implies that an increase in the maternal healthcare-seeking behaviour index increased the probability of children with a better-immunized status in the households (s = 1.636, p < 0.1). Seeking maternal health care facilities by the mother (delivering in a health care facility and having postnatal care) invariably means the child will receive BCG at birth and receive the vaccines scheduled for the 6th week. This guarantees that the child will be partially immunized and will be immune to some diseases which help to keep them healthy and eventually add up to labour sources in the agricultural household in the future.

The husband’s formal education is one of the determinants of the child's immunization status (s = 0.224, p < 0.01). This implies that mothers with husbands with formal education relative to those without formal education will increase the probability of fully immunized status in children in the household. Formal education in husbands enlightens them on the benefits the children will derive by being immunized, desiring a good level of health for their children will necessitate having them immunized against diseases. The result was corroborated, by the findings of [39].

Furthermore, the age of mothers at first birth was a determinant of the child’s immunization status (s = 0.088, p < 0.01). This implies that an increase in the age of mothers at first birth will lead to a higher likelihood of having an improved immunization status of children in the household. A higher proportion of the mothers were teenagers at birth who knew little about childcare and management. As women age, their level of maturity improves and they better care for their children’s health, so, an increase in the mother’s age at birth will more likely make mothers see reasons to adopt practices that will improve the health and wellbeing of their children. [40] established that the odds of completing immunization are higher among younger mothers.

The extended ordered log-odds estimate compared the household size on child immunization status, given that the other variables were constant. The results showed that household size was a determinant of child immunization status (s = 0.0831, p < 0.5). This implies that an increase in household size in agricultural households will more likely improve the immunization status of the children. Every addition of a person to an agricultural household is invariably an addition to income; an increase in income inflow will increase the affordability of basic health facilities within the household. [39] established from their findings that household size is significant in the immunization status of children.

Furthermore, the result reveals that child age square determines child immunization status (s = -0.0018, p < 0.5). An increase in child age square will more likely lead to a decrease in the probability of an improved immunized status of children in the households. The vaccines are age-bound in children, so doubling their current age will likely make them overshoot the designated age for vaccine collection.

Additionally, the total number of children among mothers who were seekers of maternal healthcare facilities determines child immunization status (s = 0.008, p < 0.01). Also, formal education of mothers seeking maternal healthcare facilities influences child immunization status (s = 0.076, p < 0.01). The result further shows that the age of mothers at first birth among mothers seeking maternal healthcare facilities affects child immunization status among mothers in low-resource agricultural areas in Nigeria (s = -0.0103, p < 0.01).

Also, mother’s occupation among mothers seeking maternal health care facilities was a determinant of child immunization status (s = -0.065, p < 0.01). This implies that an increase in mothers fully engaged in agriculture relative to those partially engaged in agriculture will less likely improve the immunization status of the children. Additionally, Media exposure among mothers using maternal healthcare facilities influences child immunization status (s = -0.039, p < 0.01). Lastly, among mothers with maternal healthcare-seeking behaviour, the household’s wealth index significantly influences child immunization status (s= -0.062, p < 0.01). This implies that an increase in household wealth is less likely to improve the immunization status of children in low-resource agricultural areas in Nigeria.

Table 11

Distribution of children by the effects of maternal healthcare-seeking behaviour on immunization status
Variables	Coefficient	Std. Error	Z-value
Child immunization category
Maternal healthcare-seeking behaviour index	1.6355***	0.3911	4.18
Husband’s education
Formal	0.2243***	0.0516	4.34
Age of mother at first birth	0.0879***	0.0368	2.39
Sex of household head
Female	-0.1095	0.0867	-1.26
Child sex
Female	0.0658	0.0954	0.69
Household size	-0.0080	0.0069	-1.16
Wealth index	0.0831**	0.0390	2.13
Birth weight	-0.000	9.90e-06	-1.11
age	-0.0015	0.0022	-0.67
age square	-0.0018**	0.0009	-2.11
Maternal healthcare-seeking behaviour
Total children	0.0076***	0.0018	4.20
Mother’s education
Formal	-0.0759***	0.0108	-7.02
Mother’s age at first birth	-0.0103***	0.0012	-0.11
Mother’s occupation
Agriculture full-time	-0.0652***	0.0088	-7.39
Media exposure
Exposed	-0.0389***	0.0068	-5.68
Household size	0.0016	0.0013	1.19
Wealth index	-0.0615***	0.0045	-13.63
Cut 1	2.023	0.5028
Cut 2	3.430	0.478
Corr (e. maternal health care utilization, e. child immunization category	-0.3358***	0.0885	-3.79
Number of observations	2712
Log pseudo likelihood	-2075.54
Wald chi²(10)	38.65
Prob > chi²	0.0000

Source: Compilation from NDHS, 2018

Marginal Effects of Maternal Health Care Utilisation on Child Immunization Status

The marginal effect estimation of the effect of maternal health care utilisation on child immunization status in low-resource agricultural areas in Nigeria is presented in Table 12. The result shows a 1% increase in maternal health care utilisation index significantly increased partially immunized status in children (s = 0.042, p < 0.01). Also, a 1% increase in the husband’s formal educational status will decrease unimmunized status in children (s= -0.093, p < 0.01), increase partial immunized status in children (s = 0.068, p < 0.01), and increase fully immunized status in children (s = 0.025, p < 0.01). This implies that an increase in the husband’s formal education will improve the immunization status of children. Furthermore, a 1% increase in a child’s age square will increase unimmunied status in children (s = 0.0008, p < 0.5) decrease partially (s = -0.0005, p < 0.5), and decrease fully immunized status in children (s= -0.0002, p < 0.5) respectively.

Additionally, a 1% increase in the number of total children among mothers seeking maternal healthcare facilities will lead to a decrease in unimmunized (s = -0,047, p < 0.01), partially immunized (s= -0.035, p < 0.01) and fully immunized (s = -0.013, p < 0.01) status in children respectively. Similarly, a 1% increase in mothers who are fully engaged in agriculture among mothers with maternal healthcare-seeking behaviour will increase unimmunized status in children (s = 0.041, p < 0.01), decrease partially immunized status (s = -0.029, p < 0.01) and increase fully immunized (s = 0.011, p < 0.01) status in children. This implies that having mothers fully engaged in agriculture using maternal healthcare facilities, will improve the immunization status of children by increasing the chances of having many more children fully immunized

Furthermore, a 1% increase in formal education among mothers who seek maternal health care facilities will lead to an increase in unimmunized status in children (s = 0.047, p < 0.01), a decrease in partially immunized status (s = -0.035, p < 0.01) and decrease in fully immunized status (s= -0.013, p < 0.01). Lastly, a 1% increase in the level of exposure of mothers among those seeking maternal health care facilities will increase unimmunized status (s = 0.024, p < 0.01), decrease partially immunized status (s = -0.018, p < 0.01) and decrease fully immunized status (s = 0.007, p < 0.01) in children.

Table 12

Distribution of children by the marginal effect of maternal health care seeking behaviour on the immunization status of children
Variables	Unimmunized	Partially immunized	Fully immunized
Child immunization category
Maternal healthcare-seeking behavior index	-0.0576	0.0421*	-0.0156
Husband’s education level
Formal	-0.0928***	0.0681***	0.0247***
Mother’s age at first birth	0.0301	0.0220	0.0081
household head Sex
Female	-0.0274	0.0197	0.0077
Wealth index	0.0037	-0.0027	-0.0010
Household size	0.0024	-0.0017	-0.0006
Child sex
Female	-0.0113	0.0082	0.0030
Childbirth weight(kg)	4.57e-06	-3.34e-06	-1.23e-06
Child age (months)	0.0006	-0.0005	-0.0001
Child age square (month)	0.0008**	-0.0005**	-0.0002**
Maternal healthcare-seeking behaviour
Total children	-0.0471***	-0.0346***	-0.0125***
Mother’s occupation
Agriculture full-time	0.0405***	-0.0298***	0.0107***
Mother’s educational level
Formal	0.0471***	-0.0346***	-0.0125***
Media exposure
Exposed	0.0242***	-0.0177***	-0.0065***

Source: Compilation from NDHS, 2018

Profiling of Levels of Maternal Health Care Seeking Behaviour across Child Socio-economics Characteristics

Table 13

outlines the levels of maternal healthcare-seeking behavior among mothers in low-resource agricultural areas in Nigeria, categorized by child socio-economic characteristics. The data reveals that 32.24% of mothers who infrequently used maternal healthcare facilities had children aged between 0 and 9 months. Additionally, about 51.96% of these mothers were caring for male children. It was also noted that mothers with children who were third-born or later were more likely to be low seekers of maternal healthcare services. This suggests that these more experienced mothers may feel they have sufficient knowledge to manage their health and their children’s health before, during, and after delivery. This finding is supported by [31], which reported that birth order influences maternal healthcare utilization in rural areas. Furthermore, the results indicate that 55.87% of mothers who were infrequent users of maternal healthcare services had children who were not weighed at birth. This points to the likelihood that these births did not occur in healthcare facilities, as such births would typically include weight measurements. This underscores the prevalent underuse of maternal healthcare services among mothers in these areas. There were significant differences (p < 0.01) in maternal healthcare-seeking behavior based on the child’s age, birth order, and birth weight. However, no significant differences were observed based on the child’s sex among mothers in low-resource agricultural areas of Nigeria.
Characteristics	Low		Moderate		High
	Freq.	Percent (%)	Freq.	Percent (%)	Freq.	Percent (%)
Child’s age (months)
0–9	237	32.24	308	29.33	234	25.24
10–18	190	25.85	347	33.05	343	37.00
19–27	190	25.85	148	14.10	208	22.44
28–35	118	16.05	247	23.52	142	15.32
${\chi ^2}$	78.56***
Sex of child
Male	385	51.96	556	51.72	475	50.80
Female	356	48.04	519	48.28	460	49.20
${\chi ^2}$	1.27s
Birth order
1	31	4.18	17	1.58	21	2.25
2	76	10.26	69	6.42	44	4.60
≥ 3	634	85.56	989	92.00	871	93.16
${\chi ^2}$	38.76***
Birth weight
< 2.5	73	9.85	7	0.65	0	0.00
2.6-5.0	270	34.44	83	7.72	22	2.35
> 5	5	0.67	0	0.00	0	0.00
Not weighted	414	55.87	985	91.62	913	97.64
${\chi ^2}$	1.3e + 03***

Table 13: Distribution of mothers by levels of maternal healthcare-seeking behaviour across child’s characteristics

Source: Compilation from NDHS, 2018

Profiling Child Immunization Status across Socio-demographic Characteristics of Children

Profiling child immunization status across child’s socio-demographic characteristics in Table 14 reveals that 32.66% of the unimmunized children were between age 10-18months within the households, while a few proportions (18.53%) of them were between ages 28-38months. This implies that most of the unimmunized children in low-resource agricultural areas in Nigeria were between 10–18 months, at that age, they were supposed to have received a good number of the scheduled vaccines. (they were expected to be partially immunized at that timeframe). A similar result was obtained by [35] and [41] that a child’s age is strongly related to child immunization status in Ethiopia There was no significant difference in child immunization status across the child’s age.

The result further showed that 89.97% of the unimmunized children were 3rd born and above while 2.73% who were 1st born were found to be unimmunized This implies that many of the unimmunized children were from experienced mothers who were currently nursing children who were 3rd born and above. This is in line with the report of [42] who opined that fully immunized status in children decreases with an increase in the number of children. There was no significant difference in child immunization status across the child’s birth order.

A majority (52.18%) of the male children in the household were unimmunized compared to the 47.85% of female children unimmunized This implies that more male children were unimmunized than female children in low-resource agricultural areas in Nigeria. This is contrary to [35] reports which earlier documented that girls were less likely to be up to date with their immunization status at any given age compared with boys because of inequalities in girl’s access to health care facilities. Considering the child’s weight at birth, 83.79% of the unimmunized children were not weighed at birth, while 2.34% whose birth weight was less than 2.5kg at birth were unimmunized. A child whose birth weight is less than 2.5 kg is said to have low birth weight clinically and so, unfit to start the immunization scheme. This implies that the immunization status of a child in the household is influenced by birth weight and many of the unimmunized children were not weighed at birth. There was a significant difference (p < 0.5) in child immunization status across the child’s birth weight.

Table 14

Distribution of children by immunization status across child socio-economics characteristics
Variables	Unimmunized		Partially Immunized		Fully Immunized
	Freq.	Percent (%)	Freq.	Percent (%)	Freq.	Percent (%)
Child’s age (months)
0–9	429	28.26	317	29.91	85	24.82
10–18	492	32.66	349	32.83	40	28.37
19–27	312	20.65	198	18.68	36	25.53
28–35	280	18.53	197	18.58	30	21.28
${\chi ^2}$	6.04
Birth order
1	42	2.73	25	2.83	2	1.41
2	112	7.29	67	6.24	9	6.34
> 3	1382	89.97	981	91.43	131	22.25
${\chi ^2}$	2.39
Sex of child
Male	901	52.15	536	49.35	79	55.63
Female	735	47.85	537	50.05	63	44.37
${\chi ^2}$	2.26
Child’s birth weight(kg)
< 2.5	36	2.34	21	1.96	2	1.41
2.6-5.0	213	13.87	138	12.86	24	16.90
> 5	0	0.00	5	0.47	0	0.00
Not weighted	1287	83.79	909	84.72	116	81.69
${\chi ^2}$	72.03**

Source: Compilation from NDHS, 2018

Child Immunization Status and Indicators of Maternal Healthcare-Seeking Behaviour

Table 15 shows the distribution of maternal healthcare-seeking behaviour variables across child immunization status among agricultural households in rural Nigeria. Many (73.24%) of the unimmunized children were from mothers who had prenatal care in other places apart from healthcare facilities whereas 13.87% of mothers of the unimmunized children used healthcare facilities for their prenatal care. This implies that more of the unimmunized children were raised by mothers who had prenatal care in other places apart from healthcare facilities. The findings of [43] align with this report.

The findings further reveal that 76.50% of the mothers with unimmunized children started ante-natal care later than the first trimester while 23.50% started in the first trimester as recommended by the WHO. This implies that many of the mothers who start ante-natal care in the later trimester raised the highest proportion of unimmunized children. This is corroborated by the findings of [44] that mothers in Imo state Nigeria who had ante-natal care had a higher likelihood of having their children fully immunized compared to those who did not. However, [45] reported that ante-natal care attendance is not related to fully immunized status in children. There was a significant difference (p < 0.01) between the timing of ante-natal care across the child’s immunization status.

The majority (77.54%) of the mothers with unimmunized children had 4 or more antenatal care visits during pregnancy while 22.46% of them did not meet up with the 4 minimal number of antenatal care visits as recommended by WHO. There was a significant difference (p < 0.01) between the number of antenatal care visits across the child’s immunization status. Most (69.27%) of the unimmunized children had mothers who delivered in other places besides healthcare facilities. This implies that a higher proportion of the unimmunized children were raised by mothers who had other homes apart from healthcare facilities as places of delivery. This report aligns with the findings of [46] that mothers in Senegal who delivered in healthcare facilities were less likely to raise unimmunized children.

Lack of maternal healthcare-seeking behaviour on assisted during delivery was predominant among mothers of unimmunized children as 55.97% of the unimmunized children were raised by mothers who were not assisted during delivery by skilled healthcare personnel. There was a significant difference(p < 0.01) between the place of delivery and the child’s immunization status.

The highest proportion of the unimmunized children had mothers who had no post-natal care. Most (79.10%) of the unimmunized children had mothers who did not receive post-natal care after delivery while 20.90% of their mothers had post-natal care. This implies that unimmunized children came mostly from mothers who did not receive post-natal care. The report of [47] supported this finding. There was a significant difference between post-natal care usage across children’s immunization status.

Table 15

Distribution of children by immunization status across maternal healthcare-seeking behaviour variables
Variables		Unimmunized									Partially immunized							Fully immunized
Prenatal Care		Frequency	Percentage								Frequency				Percentage			Frequency			Percentage
None		198	12.89								144				13.32			6			4.23
Others		1,125	73.24								809				75.40			123			86.62
Health facility		213	13.87								120				11.18			13			9.16
${\chi ^2}$		16.755***
Timing of ante-natal visit
Later		1,175			76.50						842				78.47			94			66.20
First trimester		361			23.50						231				21.53			48			33.80
${\chi ^2}$		10.69***
Number of ante-natal
< 4 (No)		345		22.46							287				26.75			21			14.79
≥ 4 (Yes)		1,191		77.54							786				73.25			121			85.21
${\chi ^2}$		13.03***
Place of delivery
Others		1,064					69.27					752		70.08				94			66.20
Health Facilities		472					30.73					321		29.92				48			33.80
${\chi ^2}$		0.93
Assisted during delivery
Others		676						44.01		582			54.24				36			25.35
Skilled birth attendance		860						55.97		491			45.76				106			74.65
${\chi ^2}$		54.80***
Post-natal care
No	1215					79.10			933				86.95			114			80.28
Yes	321					20.90			140				13.05			28			19.72
${\chi ^2}$	27.03***

Source: Compilation from NDHS, 2018

Recommendation and Policy Implication

Based on the findings from the study, it was established that the low level of maternal healthcare-seeking behaviour was high among mothers in low-resource agricultural areas in Nigeria. The study affirmed that maternal healthcare-seeking behaviour improves the immunization status of children in low-resource agricultural areas in Nigeria. Furthermore, it was established from the study that more children were unimmunized than those who were either partially or fully immunized. The findings further stress the need for the government to enhance the immunization status of children by increasing awareness of the need for mothers to seek healthcare facilities before, during, and after pregnancy. Furthermore, the government should try to create mini health centers in major markets across states where pregnant mothers can have their ante-natal care, vaccines can be administered to children and first aid services can also be provided. Also, the government must put in place programs to improve the livelihood and welfare of households in low-resource agricultural areas at large.

Clinical trial number: not applicable.

Ethics approval and consent to participate

Not Applicable

Consent for publication

All authors gave consent to the publication of this study

Availability of Data and Material

The data sets generated and analysed during the current study are available in the Demographic and Health Survey (DHS) Program https://dhsprogram.com/data/dataset/Nigeria_Standard-DHS_2018.cfm?flag=1

Competing Interest

The authors declare that they have no competing interests

Funding

The research did not enjoy funding from any source

Authors contributions

MV and KK conceptualized and designed the study, MB sorted and analyzed the data, MV and KK drafted the manuscript, and MB revised the manuscript. All authors read and approved the manuscript.

Acknowledgment

Not applicable

Authors’ Information

Adejoorin Mobolaji Victoria, e-mail add: [email protected], Affiliated with the University of Ibadan, Ibadan, Nigeria.

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No competing interests reported.

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Editorial decision: Revision requested
06 Sep, 2024
Editor assigned by journal
05 Sep, 2024
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05 Sep, 2024
First submitted to journal
01 Sep, 2024

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Maternal Healthcare-seeking Behaviour and Timely Childhood Vaccination in Low- Resource Agricultural Areas of Nigeria

Status:

Version 1

Abstract

Background

Method

Results

Conclusion

Background

Method

Scope of the Study

Source and Type of Data

Analytical Techniques

Multiple Correspondence Analysis (MCA)

Descriptive Statistics

Extended Ordered Probit Regression Model

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Results

Mother’s Socio-economic Characteristics

Source: Computed from NDHS, 2018

Socio-economic Characteristics of Households

Source: Compilation for NDHS, 2018

Children’s Socio-economics Characteristics

Source: Compilation from NDHS, 2018

Maternal Health Care Seeking Behaviour Variables across the Households

Source: Compilation from NDHS, 2018

Levels of Maternal Healthcare-seeking Behaviour of Mothers in the Households

Source: Compilation from NDHS, 2018

Vaccine Collection across Children in Households

Source: Compilation from NDHS, 2018

Immunization Status of Children

Source: Compilation from NDHS, 2018

Effect of Maternal Healthcare Seeking Behaviour on Child Immunization Status

Source: Compilation from NDHS, 2018

Marginal Effects of Maternal Health Care Utilisation on Child Immunization Status

Source: Compilation from NDHS, 2018

Discussion and Conclusion

Profiling of Levels of Maternal Health Care Seeking Behaviour across Child Socio-economics Characteristics

Source: Compilation from NDHS, 2018

Profiling Child Immunization Status across Socio-demographic Characteristics of Children

Source: Compilation from NDHS, 2018

Source: Compilation from NDHS, 2018

Recommendation and Policy Implication

Declarations

References

Additional Declarations

Status:

Version 1