College of Nursing

National Taipei University of Nursing and Health Sciences

Master Thesis

Assessing knowledge, attitudes, and practices of mothers regarding

childhood immunization in Papua New Guinea

Jessica Prabon

Advisor: Cheng-Hui Chou, PhD.

June 2020

Acknowledgements

Student life at National Taipei University of Nursing and Health Sciences (NTUNHS)

has come to its very end and I give all the praise and glory to my God who has always been

my pillar during this time. I am and will be forever be grateful to God for this amazing

experience.

I would like to express my sincere gratitude to my advisor, Professor Cheng- Hui

Chou for her dedicated supervision, tireless effort, patience, commitment and time. Without

her supervision I would not be able to complete my thesis. Moreover, a special thanks to

Professor Chieh-Yu Liu and Professor Fang-Yi Lin for their valuable input into this work. In

addition, a special thanks to Stephanie Pfeiffer who really gave her time to edit this work.

A heartfelt gratitude to the faculty and staff of NTUNHS, for all their efforts, made it

possible to attain my degree. Also special thanks to Taiwan Ministry of Education, through

NTUNHS school scholarship, that made it possible for my dream to become a reality, attain

my master’s degree. Also a special thanks to my course mates who supported me in words

and deeds.

Special thanks also to Sandaun Provincial Hospital Management for giving me

permission to conduct research, the staff of Outpatient and Family Health Service who

assisted me in collecting my data, and the participants of the study.

Finally special thanks to my husband, daughter and all my family for their continuous

love and support throughout my study. Their heartwarming support motivated and inspired

me to see this study to its completion.

Abstract

Background: Immunization is the most effective public health measure against infectious

diseases like influenza, measles, polio and rubella. However, in recent years, Papua New

Guinea has had frequent outbreaks of vaccine-preventable diseases, such as measles and

polio. Knowledge Attitudes and Practice studies are tools for investigating factors that

influence mothers’ decisions about getting their children immunized.

Purpose: The purpose of this study was to explore the relationships amongmothers’

knowledge, attitudes and practices relating to childhood immunization, in order to identify

factors that could be targeted by interventions aimed at increasing immunization coverage in

Papua New Guinea.

Methods: This cross-sectional correlation study was conducted with 114 mothers who had

children under age five from July to September 2019. This study used a demographic

questionnaire and the Knowledge, Attitude and Practice questionnaire on immunization.

Results were analyzed using ANOVA, t-test, Pearson’s correlation and hierarchical multiple

linear regression.

Results: Age, number of children, education, and urban or rural residence were significant

factors influencing immunization practice. Overall, results showed that the mothers had fairly

good knowledge and favorable attitudes about vaccination, but poor practice. However, in the

hierarchical multiple linear regressions, only knowledge was found to predict practice.

Conclusion: This study found that mothers’ knowledge about vaccines is one factor that

hinders them from getting their children fully vaccinated. Despite the efforts of health

workers to increase coverage by educating mothers, knowledge remains uneven and not all

children are brought in for vaccination. The findings suggest that, on the one hand, current

efforts to educate mothers about vaccines have not yet been completely successful, and on the

other, that health education alone may not be sufficient.

Keywords: Immunization, Knowledge, Attitudes, Practices, Mothers of children under five

Acronym

BCG: Bacillus Calmette Guerin

DTP: Diphtheria Tetanus Pertussis

CDC: Center of Disease Control

EPI: Expanded Program of Immunization

GAVI: Global Alliance for Vaccines and Immunization

HepB: Hepatitis B

IPV: Inactivated Polio Vaccine

KAP: Knowledge, Attitudes and Practices

NHP: National Health Plan

PCV: Pneumococcal Conjugate Vaccine

PHA: Provincial Health Authority

PNG: Papua New Guinea

SPH: Sandaun Provincial Hospital

UNDP: United Nations Development Program

UNICEF: United Nations Children’s Fund

UN: United Nations

VDP: Vaccine Preventable Disease

WHO: World Health Organization

WSP: West Sepik Province

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Table of contents List of Tables ............................................................................................................................ iii

List of Figures ........................................................................................................................... iv

Chapter I Introduction ............................................................................................................ 1

Section I: Background .......................................................................................................... 1

Section II: Problem statement ............................................................................................... 5

Section III: Study purpose ................................................................................................... 6

Section IV: Research questions ........................................................................................... 6

Section V: Significance of the study .................................................................................... 6

Section I: Introduction of Papua New Guinea ................................................................... 8

Section II: Health System in PNG ....................................................................................... 9

Section III: Under five mortality....................................................................................... 11

Section IV: Expanded Program of Immunization ........................................................... 12

Section V: Relevant studies................................................................................................ 18

2.Knowledge, attitudes and practices of mothers regarding immunization ................. 22

Section VI: Definition of variables .................................................................................... 26

Chapter III: Methodology .....................................................................................................27

Section I: Conceptual Framework .................................................................................... 27

Section II: Research Design ............................................................................................... 28

Section III: Study area and setting ................................................................................... 28

Section IV: Sample size ...................................................................................................... 28

Section V: Sample Selection .............................................................................................. 28

Section VI: Instruments ..................................................................................................... 29

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Section VII: Research ethics and statements .......................................................................31

Section VIII: Data collection procedure ........................................................................... 31

Section IX: Data Analysis .................................................................................................. 31

Chapter IV Results and Discussion ......................................................................................34

Section I Results .................................................................................................................. 34

Section II Discussion........................................................................................................... 45

CHAPTER V Conclusion ......................................................................................................57

Section I Implications for future research ....................................................................... 57

1. Health Policy ................................................................................................................ 57

2. Public Health Education ............................................................................................... 58

3. Nursing Practice............................................................................................................ 58

Section II Recommendations of the study ........................................................................ 58

Section III Limitations of the study .................................................................................. 60

Section IV Conclusion ........................................................................................................ 61

Reference ............................................................................................................................. 61

Appendix I: Consent Form ....................................................................................................73

Appendix II: Instrument .................................................................................................... 74

Appendix IV: Permission Request for Instrument.......................................................... 83

Appendix V: Data Collection Plan .................................................................................... 84

Appendix VI: Approval letter from Sandaun Provincial Hospital ...................................85

Appendix VII: Approval letter and number from MRAC PNG .......................................86

iii

List of Tables

Table 1.1 PNG National Immunization Schedule……………………………………………06

Table 2.1 PNG Immunization Coverage in 2014…………………………………………….14

Table 2.2 Immunization Coverage of Momase Region in 2014 …………………………….15

Table 3.1 Statistical Test for Study………………………………………………………......31

Table 4.1 Socio demographic characteristics of mothers………………………………...36-38

Table 4.2 Immunization knowledge score of mother………………………………………..40

Table 4.3 Immunization attitude scores of mothers………………………………………….41

Table 4.4 Immunization practice scores of mothers…………………………………………41

Table 4.5 Mean scores of mothers KAP regarding immunization…………………………...42

Table 4.6 Linear regression analysis of knowledge and demographic characteristics………43

Table 4.7 Linear regression analysis of attitude and demographic characteristics…………..44

Table 4.8 Linear regression analysis of practice and demographic characteristics………….45

Table 4.9 Correlation between knowledge and attitude and the immunization practice…….46

Table 5 Hierarchical multiple regression analysis summary predicting practice……………47

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List of Figures

Figure 1 Map of Papua New Guinea…………………………………………………...….....11

Figure 2 Research Framework ………………………………………………………………26

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Chapter I Introduction

Section I: Background

Immunization is the most effective public health measure against infectious diseases

like influenza, measles, polio, and rubella. Immunization saves the lives of an estimated 2.5

million children every year (Lakew, Bekele, & Biadgilign, 2015). However, due to under-

vaccination, 1.7 million children under the age of five still die from vaccine-preventable

diseases each year, according the WHO (WHO, 2011). Outbreaks of vaccine-preventable

diseases like polio can lead to complications such as acute flaccid paralysis. This complication

has substantial consequences for the social and economic activities of the families

affected(Quilici, Smith, & Signorelli, 2015). For example, when a child has acute flaccid

paralysis, he or she will not go to school and will be a burden on the family. Furthermore,

developing countries such as Papua New Guinea (PNG) are more affected by outbreaks of

VPDs than developed countries, because their health systems lack resources.

Papua New Guinea, which occupies the eastern side of the island of New Guinea, is

located south of the equator and north of Australia and shares a land border with

Indonesia(AusAid, 2015).The country has a tropical climate, characterized by a rainy season

(October to May) and a dry season (June to September). Overall, PNG experiences a high

yearly average of rainfall and average humidity levels are around 70~90%. It also has beautiful

tropical forests, savannah grass plains, big rivers and deltas, swamps, numerous islands,

lagoons, and atolls to the east and north east of the country. Its weather affects the timing and

intensity of disease outbreaks and climate conditions impact the geographical and seasonal

distributions of infectious disease. Additionally, geography and weather can make it difficult

for health workers to provide vaccinations to people in rural areas.

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Infectious disease is a main factor responsible for the majority of deaths among children

under five around the world. The overall estimated population of Papua New Guinea in 2015

was 7,619,300 (WHO, 2018a). Approximately 40% of PNG’s population consists of children

and adolescents under the age of 15 (AusAid, 2015; National Department of Health, 2010).

Infectious disease is one of the primary causes of death among children under the age of five

in particular (PNG, 2010).

In June 2012 PNG saw the first outbreak of Chikungunya, a fast-spreading infectious

disease, with 1,590 reported cases (Horwood et al., 2013). In late 2013 and 2014, a measles

outbreak spread across the country and into the Solomon Islands and Vanuatu. More than 365

deaths were reported by the end 2014, with a case fatality rate of 0.46% (International

Federation of Red Cross and Red Crescent Societies, 2018). Just three years later, a measles

outbreak occurred again with 57 reported cases, eight of them confirmed by laboratory testing

and two deaths (International Federation of Red Cross and Red Crescent Societies, 2018). The

problem is widespread. A survey of child mortality done in 2015 by searching the WHO,

Centers for Disease Control & Prevention (CDC), the United Nations Children’s Fund

(UNICEF) and the United Nations (UN) websites revealed that each day, 16,000 children die

before reaching their fifth birthday (Khodaee, Khademi, & Saeidi, 2015).

More than 50 countries worldwide have under five mortality of greater than

25 per 1000 live births. Papua New Guinea has an under-five mortality rate of 54.3 per 1000

live births (WHO, 2018a). Although under-five mortality in PNG dropped from 73 per 1000

live births in 2000 to 57.3 per 1000 live births in 2017, it nonetheless missed its 2015 target of

56 per 1000 live births (PNG Govt., 2015). Innovative interventions will be needed to reach

the UN’s Sustainable Development Goals target of less than 25 per 1000 live births by 2030

(Hug et al, 2018). Consequently, the PNG government is prioritizing improving child survival,

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rolling out immunization programs to address the problem of under-vaccination, with the help

of international agencies such as United Nation agencies and major foundations (PNG, 2010).

Therefore, the PNG national immunization schedule recommends that every child

receive vaccines from birth up to 13 years of age. Table 1 displays the National Immunization

Schedule of Papua New Guinea (PNG, 2010) (See Table 1).

Table 1 Papua New Guinea National Immunization Schedule

Vaccine type/age in

month or year

Immunization Schedule

Birth 1m 2m 3m 6m 9m 12m 18m

BCG ✓

Hepatitis B ✓

Oral Polio ✓ ✓

IPV ✓

DTP-HepB B-Hib ✓ ✓ ✓

PCV-13 ✓ ✓ ✓

Measles ✓ ✓

Measles-Rubella ✓

Note. BCG = Bacillus Calmette-Guerin; IPV = Inactivated Polio Vaccine; DTP = Diphtheria

Tetanus Pertussis; PCV = pneumococcal conjugated vaccine

Despite the interventions the government has undertaken, under-five mortality still

has not reached the 2015 target of 56 per 1000 live births(PNG Govt., 2015). Evidence-based

research is a way to make progress on this issue by identifying the contributing factors that

can be targeted for change.

Researchers have indicated that there are numerous factors contributing to low rates of

immunization in PNG. One study done by Namuigi and Phuanukoonnon(2005), revealed that

barriers to childhood immunization in PNG include a limited number of health centers, long

queues, and distance to clinic sites. A later study concurred, attributing low immunization

coverage to factors such as difficult terrain and a lack of health facilities in rural areas(Apeng

4

et al., 2010). Yet another study revealed that children were not immunized due to distance to

clinics and travel expenses (Toikilik et al., 2010). Issues with health services transport and

travel challenges are thus well-documented. This study will focus on parental factors in under

vaccination among children under age five in PNG.

Factors such as mothers’ knowledge are vital for improving immunization coverage.

One problem is partial or incomplete knowledge. For example, a study by Karel (1994), found

that village mothers knew the importance of vaccination but did not know the importance of

completing the multiple vaccinations. Also, knowledge about vaccinations is unevenly

distributed across urban and rural areas. One study demonstrated that 60 percent of urban

mothers in PNG knew the importance of immunization and that it prevents illness, leading to

a 70 percent immunization rate in that area (Namuigi & Phuanukoonnon, 2005). (Toikilik et

al., 2010) found five years later that 29 percent of rural mothers remained unaware of the need

for vaccination. Prior studies have emphasized parental knowledge and attitudes about vaccines

in either urban or rural settings, but have not explored how these relate to actual practices. This

study will focus on knowledge, attitudes, and practices related to vaccination among mothers

of children under the age of five living in rural areas.

Mothers in rural and urban areas should have at least some basic idea about

immunization that will motivate them to bring their children in for vaccination. A study has

revealed that the uptake of immunization is determined by parents’ theoretical or practical

understanding of childhood immunization (Alamri, Horaib, & Alanazi, 2018). Another study

done in Pakistan reported that educating mothers about vaccines and VPD was highly effective

and improving mothers’ information increases the immunization coverage rate (Agboatwalla

& Akram, 1997). These studies advise that higher immunization coverage can be achieved by

educating mothers on immunization.

5

It is essential for health workers to understand mothers’ perceptions about

immunization because her judgment strongly influences whether or not her child will be

immunized. Health workers need to provide health education adapted to rural mothers’ current

level of understanding, in particular (Alamri et al., 2018; Alshammari et al., 2018; Alshehri et

al., 2018; Namuigi & Phuanukoonnon, 2005). Nonetheless, no studies have been done on

mothers’ knowledge, attitudes, and practices relating to childhood immunization in PNG.

Therefore, the aim of this study is to fill the gap by identifying the relationships between

mothers’ knowledge, attitudes, and practices regarding childhood immunization in Papua New

Guinea.

Section II: Problem statement

Low immunization coverage is still a problem in Papua New Guinea (Bauri et al., 2019;

United Nations Children's Fund, 2017; WHO, 2015, 2018b; Yarong& Aipit, 2014).Within the

last eight years, there was an outbreak of measles with a case fatality rate of 0.46% and 367

deaths (International Federation of Red Cross and Red Crescent Societies, 2018). In addition,

a polio outbreak in 2018 resulted in 26 confirmed cases of polio, of which 19 were children

under five years of age (Bauri et al., 2019). In PNG, this issue mostly occurred in rural areas

as well urban settlements who are migrants from rural areas seeking economic opportunity by

which, rural mothers are less educated and children have poor uptake of immunization(Bauri

et al., 2019). Contemporary researchers have been urging health workers to provide health

education tailored to mothers’ understanding (Alamri et al., 2018;Alruwaili et al.,

2018;Habib,Alsubhi, &Saadawi,2018; Namuigi & Phuanukoonnon, 2005). Taking into

account factors such as mothers’ knowledge, attitudes, and practices towards immunization

may help with designing more effective public health campaigns aimed at increasing

immunization rates.

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Section III: Study purpose

The purpose of this study is to explore the relationships among mothers’ knowledge,

attitudes and practices relating to childhood immunization, and to identify the factors that

influence them in Papua New Guinea.

Section IV: Research questions

The questions of this study are:

1. What are the demographic characteristics of mothers with children under age five in Papua

New Guinea?

2. What are the knowledge, attitudes, and practices of mothers regarding childhood

immunization in Papua New Guinea?

3. What are the relationship between mothers’ knowledge, attitude and practices and the

demographic factors of immunization?

4. Which factors are most influential for determining the actual practice of immunization,

when considering demographic characteristics and mothers’ knowledge and attitudes

regarding childhood immunization in Papua New Guinea?

Section V: Significance of the study

The importance of this study is to explore the depth and breadth of mothers’ knowledge,

attitude and practice on childhood immunization in Papua New Guinea. This is for an effective

result of mothers’ knowledge, attitude and practices impacts in the uptake of childhood

immunization.

The findings can be utilized as a strategy to alleviate factors contributing to under

immunization in Papua New Guinea. Health workers should use the findings to improve the

outcome of immunization. Furthermore, this study will add a great deal to literature and public

health and the Ministry of Health in Papua New Guinea, particularly Provincial Health

7

Authorities to draw up health education programs specific to meet mothers’ understanding. In

addition, it will contribute to innumerable articles regarding the mothers’ knowledge, attitude

and practices on childhood immunization in hospital, country and the Western Pacific region.

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Chapter II Literature Review

This chapter will give a brief introduction of Papua New Guinea and its healthcare

system. And in detail, the knowledge, attitude and practices among mothers’ of under 5

children in Papua New Guinea towards childhood immunization, mothers’ related factors,

socio economic demographic with related studies in line with the study.

Section I: Introduction of Papua New Guinea

Papua New Guinea has 22 provinces and it’s capital city is Port Moresby. For

administrative purposes, PNG is divided into four regions: the southern region is

comprised of six provinces; the highlands region consists of seven provinces; the islands

region consists of five provinces and the Momase region is comprised of four provinces.

It is a culturally diverse society with ethnic groups organized as clans speaking more

than 800 native languages. The three most common languages are Tok Pisin, Hiri Motu

and English(PNG NDoH, 2010). English is used as a second or third language in addition

to local indigenous languages and is commonly used in government, business, and in

non-governmental organizations(Aquastat Survey, 2011; AusAid, 2015). This study will

be conducted in the Momase region in West Sepik province. The most common language

there is Tok Pisin. The questionnaires used in this study will be translated from English

into Tok Pisin.

In 2015, the country’s population was estimated at 7,619,300, with similar

proportion of women and men. The population growth rate has been estimated at

3.1%. It has a relatively young population with 2.6% of the population over age 65 and

40% of the population under 15 years old(WHO, 2016).Furthermore, about 89% of the

population live in the rural area and has an average literacy rate of 63.4%, by which men and

women have a literacy rate of 65.06% and 61.77% respectively(WHO, 2018a). Children

9

under the age of five comprised 11.9% of popilation under the age of 15(WHO, 2016). This

study will focus on knowledge, attitudes, and practices among mothers of children under the

age of five.

Figure 2-1 Map of Papua New Guinea(United Nations,2004)

Section II: Health System in PNG

Papua New Guinea has a decentralized health system, whereby under the Provincial

Health Authority Act (2007), the National government bestows the executive powers

to the Provincial Health Authority (PHA) Board to give authorization for both hospital

and rural health services affairs(PNG Govt, 2010). The provincial hospitals are run by

the government while half of the rural health centers and aid posts are under the

churches (Christians constitute 96% of the population). The PHA is already established

In West Sepik and is being established in the other provinces. Both the government and

10

non -governmental agencies are collaborating to execute the National Health Plan,

2011~2020. It is a blueprint for the PNG health system and integrates government

policies with international health initiatives such as the UN Millennium Development

Goals. The National Health Plan, 2011-2020 outlines eight major public healthgoals.This study

contributes to two of them: improving child survival and improving preparednessfor disease

outbreaks(PNG Govt, 2010).

Supplementary to the NHP 2011~2020, new National Health Service Standards

recategorized Papua New Guinea’s health services delivery structure into seven levels, as

listed:Level 1 consists ofaid posts, Level 2 is community health posts, Level 3 is the rural

and urban health centers, Level 4 consists of district hospitals, Level 5 indicates provincial

hospitals, Level 6 refers to regional hospitals, and Level 7 is the referral hospital(WHO, 2018a).

Because of limited length of the study period and difficult transportation into rural areas, this

study will be carried out in Level 3 rural and urban health centers and a Level 5 provincial

hospital,Sandaun Provincial Hospital.

The leading causes of morbidity are communicable diseases including pneumonia,

malaria, tuberculosis, diarrheal diseases, meningitis and increasingly, HIV/AIDS. These

account for 50% of mortality (WHO & NDoH, 2012). Specifically, pneumonia accounted for

30% of child mortality, neonatal conditions for 17%, malaria accounted for 15%, diarrheal

diseases for 12%, and malaria for 7% in 2013. In recent years, regular outbreaks of VPDs have

been occurring in PNG. Polio made a comeback in 2018 (International Federation of Red Cross

and Red Crescent Societies, 2018).

At 13,000 per year, PNG has the highest proportion of child deaths in the entire Pacific

region (Duke, Kado, Auto, Amini, & Gilbert, 2015). The WHO and UNICEF launched the

Regional Child Survival Strategy in 2006 (Jayawardena, Subhi, & Duke, 2012), PNG is one

11

of the six countries(Cambodia, China, Laos,Papua New Guinea, Philippines, and Vietnam)

with the highest mortality burden in the Western Pacific region(Jayawardena et al., 2012). In

response, the PNG government introduced the child health policy in 2009 to address the

problem of high child mortality and the policy has been carried over into the 2011-2020

National Health Plan (Jayawardena et al., 2012).. The child health policy has strengthened

immunization programs in PNG.

Most healthcare spending in PNG does not come from patients themselves, but relies on

government funding (Asian Development Bank, 2012). The government reduced health

spending from over 9 percent of GDP in 2010 to 6.8 percent in 2014(World Bank Group, 2017).

International resources also play a vital role in health financing in PNG(World Bank Group,

2017). The health expenditures on health have increased from PGK 137 million per capita in

2011 to an estimated PGK 257 million per capita in 2015(WHO, 2016). The main recipients

of this increased spending were the National Department of Health and urban hospitals. Rural

health services and public programs did not benefit from the allocated budget increase from

PGK 12 million in 2005 to PGK 64 million in 2012(WHO, 2016).

Section III: Under five mortality

The under- five mortality of children in Papua New Guinea has improved in

recent years, as evidenced by the decline in mortality rates of children under five from 100

per 1,000 live births in 1990 to 57.3 per 1,000 live births in 2017 (WHO & NDoH, 2012),

which is still high compared to the other Western Pacific countries(Duke et al., 2015). The

PNG government is addressing child health problems through improved immunization,

periodic supplementary immunization activities, and the joint UNICEF/WHO child survival

strategy, with the focus on an approach that integrates management of childhood illnesses

(PNG Govt, 2010).

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Section IV: Expanded Program of Immunization

The World Health Organization (WHO) initiated the Expanded Program of

Immunization in 1974 with the intention to vaccinate children around the world (Greenwood,

2014). The program was created with the purpose of expanding immunization services beyond

smallpox to the following six preventable diseases: diphtheria, measles, pertussis, poliomyelitis,

tetanus and tuberculosis (Matapano et al., 2008). Vaccines create immunity by stimulating the

body’s immune system to make its own antibodies, protecting the individual against infection

(Anderson, 2015).Vaccines can be given routinely and alsoin response to outbreaks. Routine

immunization refers to the nationally scheduled administration of vaccines at specific ages.

Parents should take children to clinicswhen they reach the appropriate age for a vaccine. The

WHO recommends that immunization be carried out on specific days of the week to reduce

vaccine wastage, since the vaccines are supplied in multi dose vials to reduce cost. The goal of

routine immunization is to deliver scheduled doses of vaccines in a timely, safe, and effective

way to all children, ultimately inducing immunity against the targeted diseases.

Though efforts at immunization have yielded highly beneficial results and most

developed countries have over 90% coverage, the situation is quite different in developing

countries, especially in Africa and Asia. Like many other countries in the Pacific, Papua New

Guinea is making efforts to strengthen its health system so as to achieve adequate routine

immunization to reduce the burden of VDPs. However, in Papua New Guinea, immunization

coverage is still low.

The low level of immunization coverage in Papua New Guinea may be attributed to factors

such as lack of political will, lack of motivation among the general public and health workers,

poor level of education and awareness, and poor infrastructure().Other factors related to low

immunization coverage could be high illiteracy rates, high fertility rates, and also 89% of the

13

population is living in rural areas with challenging terrain (PNG Govt,2010).

Immunization is a process where an individual is protected from infectious diseases,

by the administration of vaccines, by which it stimulates the body’s immune system to make

its own antibodies to fight against infections(Anderson, 2015). The vaccines defined below

are included in the immunization schedule of PNG.

Bacillus Calmette-Guerin (BCG) is a vaccine used in the prevention of tuberculosis.

It is used in countries with high prevalence of TB in order to prevent childhood tuberculosis,

meningitis, and military tuberculosis (Centers of Disease Control, 2011). BCG vaccine

should be given at birth and the recommended dose is 0.05 ml intra-dermally into the left

upper arm (PNG Pediatric Society, 2016). BCG vaccine is contraindicated to infants of HIV-

positive mothers for whom full assessment of their HIV status has not been completed

(Nuttall & Eley, 2011).Children with HIV are at risk of disseminated BCG disease, meaning

confirmed presence of the bacteria at one or more sites, usually including the vaccine site and

lymph nodes. It has a death rate of over 70% infants infected with HIV.

Hepatitis B vaccine is used to prevent hepatitis B infections which cause liver

disease,which often leads to liver cancer and cirrhosis(Centers for Disease Control and

Prevention, 2018). It should be given at birth and every month for the following three months

as part of the five-in-one vaccine, Pentavalent. The recommended dosage is 0.5ml

intramuscularly into the right thigh(PNG Pediatric Society, 2016). However, it should not be

administered when a child has fever exceeding 38degree Celsius.

Pentavalent vaccines provide protection against five diseases: diphtheria, tetanus,

pertussis (DTP), hepatitis B and Hemophilus influenza type b(UNICEF, 2015).Hepatitis B

vaccine had previously been added to the DTP (diphtheria, tetanus, pertussis) combination

vaccine (DTP-HepB), which has now been replaced by the pentavalent version that includes

influenza. The pentavalent vaccine is administered in a three-dose schedule. The chosen route

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is intramuscularly into the right thigh. It also should not be given if a child has a fever

exceeding 38 degree Celsius.

Polio vaccine protects children from infection with the polio virus. It is mainly spread

by person-to-person contact and also through the consumption of food or drink products that

are contaminated with fecal matter of an infected person(CDC, 2015c). Most people who get

polio have no symptoms and recover, but others develop paralysis. It can lead to permanent

disability and even death. Some countries have done away with the oral polio vaccine and are

only using injected inactivated polio vaccine, which covers all three types of the polio virus.

PNG is still using the oral polio vaccine and introduced the inactivated polio vaccine in 2015.

Inactivated polio vaccine was not introduced to replace the oral polio vaccine(Expanded

Immunization Programme, 2014). The oral polio vaccine is administered sublingually at one,

two, and three months of age, while the IPV is given intramuscularly into the right thigh at

three months of age together with the oral polio vaccine(PNG Pediatric Society, 2016).

The pneumococcal conjugate vaccine protects against 13 types of pneumococcal

bacteria(CDC, 2015b). It is routinely given at one month of age, then again one month after

the first dose, and again one month after the second dose. The recommended dose is 0.5ml

intramuscularly into the left thigh(PNG Pediatric Society, 2016). It is contraindicated for

children with fever above 38degrees Celsius.

The measles and measles-rubella vaccine are used in the prevention of measles and

rubella(CDC, 2015a) They are viral diseases that have serious consequences. Measles causes

symptoms that can include fever, cough, runny nose, and red watery eyes, commonly

followed by a rash that covers the whole body. While the rubella virus causes fever, sore

throat, rash, headaches and eye irritation. It can lead to ear infections, diarrhea and

pneumonia. It is contagious and can easily spread from person to person. The recommended

15

dose is 0.5ml and it is administered subcutaneously into the right upper arm and is given at

6months, 9months and 18months of age (PNG Pediatric Society, 2016).

Table 2.1 PNG Immunization coverage of children under the age of five in 2014

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Note: BCG=Bacillus Calmette Guerin; OPV=Oral Polio Vaccine; the Pentavent vaccine is

comprised of diphtheria, tetanus, pertussis, hepatitis B and Hemophilus Influenza vaccine

(Arava, 2015)

This diagram clearly shows that the immunization coverage in PNG is still below

80%, which can possibly lead to outbreaks and reemergence of diseases(Bauri et al.,

2019).Of all the four regions in PNG, the Momase region has the lowest immunization

coverage. Therefore, this study was carried out in one of the provinces of the Momase region.

Table 3 shows the immunization coverage rates in the Momase region (See Table 3).

17

Table 2.2 Immunization coverage of children under five in Momase region in 2014

Note: BCG= Bacillus Calmette Guerin; OPV= Oral Polio Vaccine; pentavent comprises

of diphtheria, tetanus, pertussis, hepatitis B and hemophilus influenza type B

(Arava, 2015)

From this diagram, it can be seen that West Sepik Province (WSP) has the lowest

immunization coverage in the Momase region, making it the focus of this study. Low

immunization coverage puts a population at risk of having VPD outbreaks, as demonstrated

by the two measles outbreaks that occurred in PNG in 2013~2014 and 2017, both of which

started in WSP.

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Section V: Relevant studies

1.Socioeconomic demographic factors of mothers

The socio-demographic characteristics used in this study include age, number of

children, education level and income, source of information, marital status, transport,

decision-making power, and place of residence.

1.1. Age

Age affects many things, such as a person’s perspective and conduct, their level of

maturity, range of life experience, and their ability to make decisions; thus, mothers’ age can

influence their knowledge, attitudes, and practices regarding vaccination. A study in Yemen

revealed that parents ages 30 years or younger had significantly lower knowledge scores

compared to older parents (Bamatraf& Jawass, 2018).Similarly, a study in the United Arab

Emirates demonstrated that older mothers are less likely to have good knowledge about

childhood immunization(Bersen et al., 2011).However, a study in India showed that there was

no statistical difference in mothers’ knowledge according to age(Dharmalingam, Raghupathy,

Sowmiya, Amudharaj, & Jehangir, 2017). This could mean that, in some contexts, age does

not have much impact on mothers’ knowledge about vaccination.

1.2. Number of children

In general, having more children means more experience and results in better

practices regarding childhood immunization. For example, a study in Saudi Arabia revealed

that having more children resulted in having significantly better KAP scores (Alshehri et al.,

2018). A different study in Saudi Arabia likewise found that having more children was

associated with better KAP scores (Habib et al., 2018).It can be concluded that mothers

having more children have a lot of experience, resulting in positive practices regarding

childhood vaccination.

19

1.3. Education level

Parental education in general and about vaccines in particular has been found in

numerous studies to be related with higher immunization rates, suggesting that parents’

education level plays a significant role in this regard. In a study done in India, the use of health

care services as well as full immunization of children was associated with maternal education

level (Kusuma, Kumari, Pandav, & Gupta, 2010). In a study in Pakistan, immunization of

children was associated with maternal education about vaccination(Mitchell et al.,

2009).Moreover, a study in Guinea Bissau revealed that women and men who have had access

to higher education tend to have better general health knowledge (King.R, Mann.V, &

Boone.P.D, 2010), demonstrating the influence education has on health behaviors including

childhood immunization.

1.4. Income

Income refers to money received on a regular basis for work that can be used to provide

for the child’s basic needs, such as paying for transportation to bring the child to the clinic.

Studies tracking the association between income and immunization have yielded mixed results

in different regions and countries. For example, a study in Uganda revealed that income was

not associated with full vaccination status (Vonasek et al., 2006). In contrast, a study done in

Iraq showed that family’s economic status was positively associated with the uptake of

immunization (Quaitaba et al, 2015). The results of these studies differ, in part, because they

were done in countries with different health systems and different levels of economic

development, which may influence the results.

1.5. Source of information

Sources of information about vaccination include health workers and other people,

media such as pamphlets or TV programs, and clinics and hospitals. A study done in Papua

New Guinea found that participants’ health information came mostly from health workers

20

(Toikilik et al, 2010). Similarly, a study in Egypt revealed that health workers were the main

source of information related to vaccination (Ramadan et al., 2016). These findings

demonstrate that parents often get their knowledge about immunization from health workers.

1.6. Marital Status

For the purposes of this study, marital status is defined as married, single, divorced or

widowed. Marital status can have an impact on mothers’ KAP regarding immunization. One

study done in Nigeria found that married women had significantly higher knowledge of

immunization than separated, single, or divorced women (Chris-Otubor, et al, 2015). Another

study from Nigeria revealed no significant difference regarding the practice of immunization

among mothers of different marital statuses (Kanma-Okafor, et al, 2019). This could suggest

that marital status can have a different influence on immunization knowledge or practice in

according to population group or setting. Differences between countries and ethnic groups

may be due to other factors, including education and culture.

1.7. Transport

Transport is a factor that can prevent caregivers from bringing their children for

vaccination. A study in Nigeria showed that distance to primary health care facilities was

significantly associated with immunization status of the children(Adenike, Adejumoke,

Olufunmi, & Ridwan, 2017).This may be related to socioeconomic factors and cost of

transportation for each immunization, especially where healthcare facilities are not in close

proximity(Adenike et al., 2017). Likewise, a study in Papua New Guinea revealed that distance

and travel expenses are associated with the uptake of immunization (Toikilik et al, 2010). These

findings demonstrate that transportation plays a vital role in the uptake of immunization.

1.8. Women’s role in decision making

21

Several studies have investigated the role of women in health care decisions

(Gakidou.E, Cowling.K, Lozano.R, & Murray.C.J.L, 2010). In many families in Uganda, for

instance, even though mothers are the primary care takers of children, fathers usually make

decisions about participation in government programs and their objections are often one of the

barriers to their children’s vaccination(Nuwuha, Mulindwa, Kabwongyera, & Barenzi, 2000).

Education has been revealed to be one of the main societal factors that impact the role of

women in decisions about childhood vaccination. Many studies have found that maternal

education is the key element in parental adherence to vaccination programs, even though the

education of both parents was found to be essential to health behavior, (Kusuma et al., 2010;

Mitchell et al., 2009; Sullivan, Tegegn, Tessema, Galea, & Hadley, 2009). In this regard, a

study done in sub Saharan Africa revealed that increased health care access in Ethiopia was

related to the high literacy rate among women(Sullivan et al., 2009). In efforts to reduce child

mortality and morbidity, studies have recommended educating mothers about the importance

of family planning, breastfeeding, and immunization programs (Girma.B & Berhane.Y, 2011).

1.9. Place of residence

The 2011 Millennium Development Goal Report describes a higher rate of mortality among

children from rural households. It is thus important to explore whether there are differences in

routine childhood immunization rates between urban and rural communities in low income

countries. A study done in Papua New Guinea demonstrated a significantly higher rate of three-

dose DTP immunization at six months of age in urban compared to rural communities(Toikilik

et al., 2010). Similarly, a study done in Kilifi district in Kenya revealed that children from the

Kilifi Township received pentavalent vaccine doses earlier than children from rural

areas(Moisi, Kabuka, Mitingi, Levine, & Scott, 2010). Likewise, Fernandez, Awofes and

Rammohan(2011) in Indonesia found significantly higher rates of first dose measles

vaccination in urban areas compared to rural areas .That study went on further to state that the

22

differences in immunization coverage between urban and rural children have been linked to

parental education, wealth and the presence of a skilled birth attendant. Furthermore,

misconceptions or lack of knowledge, issues with health services, challenges relating to travel

and transport, and family-related logistic issues have been more frequently reported by

residents of rural areas compared to urban residents(Toikilik et al., 2010). However, a study

that gathered data from multiple African countries revealed that urban communities are not

homogenous with respect to immunization coverage(Cutts, 1991). Specifically, poor urban

residents may represent a large proportion of the population in low income countries. They

may also have a high proportion of migrants or people belonging to different ethnic

groups(Cutts, 1991). Thus, these people may not enjoy the advantages of urban communities

regarding education, proximity to health services, and ease of communication.

2. Knowledge, attitudes and practices of mothers regarding immunization

According to theory of planned behavior, behavior is dependent on a person’s intention

to perform an activity, while intention is determined by an individual’s perspective(The World

Bank, 2010). Therefore, it is important to give information to help shape positive attitudes

towards vaccination and to spread ideas that support the practice of vaccination. A study in

Saudi Arabia demonstrated that parental knowledge and attitudes have a great impact on their

children’s immunization uptake(Alyami et al., 2018). Another study from Saudi Arabia

revealed that the knowledge, attitudes and practices (KAP) of mothers regarding vaccination

is essential for promoting child health as well as the prevention of VPDs(Alshehri et al., 2018).

Supporting a focus on mothers, a study conducted in India revealed that mothers—both urban

and rural—were the main decision makers about children’s vaccination(Mahalingam et al.,

2014). From this, it can be deduced that mothers play a central role in their children’s

immunization status; therefore their KAP regarding immunization should be known.

2.1. Knowledge of childhood immunization

23

It is essential for health workers to develop mothers’ comprehension and positive

perceptions of childhood immunization. Mothers of children under five should be aware of

vaccination services and benefits(Alruwaili et al., 2018).A study done in Uganda revealed that

93.5% of mothers knew that vaccines prevent diseases(Vonasek et al., 2016). A study in Turkey

revealed that parental knowledge is influenced by socio demographic factors(Kara et al., 2018).

Therefore, when communicating with mothers about the importance of vaccination, health

workers should take their socio-demographic factors into consideration.

Lack of knowledge resulted in non-compliance with the immunization schedule. One

study done in Iraq found that insufficient information on vaccination led to children’s poor

immunization status(Qutaiba et al., 2014). This can be solved by health providers describing

the advantages and disadvantages of vaccination and addressing parents’ misconceptions

(Esposito, Principi, Cornaglia, & Group, 2014). Proper communication between health workers

and mothers to offer vaccination information is of vital importance to the uptake of vaccination.

2.2. Attitudes about childhood immunization

Perspectives on and interpretations of health messages have an impact on the outcome

of the child’s vaccination status. A study carried out by analyzing gray literature (e.g., literature

produced by academic, government, or private sources that is not controlled by commercial

publishers)found that having a positive opinion about vaccines is very important(Favin,

Steinglass, Fields, Banerjee, & Sawhney, 2012). Other research done in Papua New Guinea

has revealed that negative outlooks towards vaccination is often due to the side effects of

vaccines(Namuigi & Phuanukoonnon, 2005).It is normal for parents to have both positive and

negative views about vaccination. Information geared towards the parents’ level of

understanding is needed to persuade parents with less intention to vaccinate.

2.3. Practice of childhood immunization

24

It is important for mothers to put into action what they have learned from health workers

based on their opinions and understanding. One study done in Egypt revealed that caregivers’

practice of immunization was good(Ramadan et al., 2016). “Good” referred to adhering to

vaccination schedules and the approaches mothers took to dealing with side effects(Bersen et

al., 2011).In sum, the extent to which mothers translate knowledge from health workers into

practice can assist health care providers to evaluate the effectiveness of their interventions.

3.Relationship between mothers’ knowledge and attitudes about immunization

Researchers have revealed an association between mothers’ knowledge and attitudes

towards childhood immunization. A study carried out in Nigeria by Olujide and colleagues

demonstrated a significant relationship between attitudes and knowledge regarding

vaccination(Olujide, Adekeye, Fred, Olufunke, & Bosede, 2015). Similarly, a study in Uganda

found that mothers’ knowledge and attitudes towards childhood immunization were associated

with practical knowledge about when and how often to go for immunizations, as well as the

site of vaccination(Vonasek et al., 2016). Having a positive perspective and basic knowledge

of immunization is important for mothers to bring their children in for vaccinations.

Studies have also shown that there is a relationship between mothers’ knowledge and

their practices regarding their children’s vaccination. One study in Nigeria has shown that

mothers have good knowledge of immunization. In summary, there is a clear association

between mothers’ knowledge and practices regarding immunization.

Furthermore, many studies have demonstrated an association between mothers’

attitudes and practices regarding immunization. For example, a study in India found that

parents who have a positive attitude about immunization tend to also have good practice with

regards to immunization, compared to parents with a negative attitude(Yadav et al.,

2015).Another study done in Nigeria revealed that mothers with higher level of education have

good knowledge and better attitude regarding immunization(Adefolalu et al,2019).These

25

studies showed that mothers who have high level of knowledge tend to have a positive attitude

towards the practice of immunization.

26

Section VI: Definition of variables

The conceptual and operational definitions of variables in this research are outlined as

follows:

1.Knowledge of immunization

1.1Conceptual definition: For the purposes of this study, knowledge refers to the collection of

information about immunization acquired through education or experience.

1.2. Operational definition: In this study, knowledge will be measured using the KAP

questionnaire regarding immunization created by Sebastian and colleagues(Sebastian,

Parthasarathi, & Ravi, 2017).

2.Attitudesabout immunization

2.1. Conceptual definition: For the purposes of this study, attitude is an individual’s

perspective about immunization, whether positive or negative.

2.2. Operational definition: In this study, attitude will be measured using the KAP

questionnaire regarding immunization(Sebastian et al., 2017).

3.Practice of immunization

3.1. Conceptual definition: For this study, practice refers to the actual application of

immunization information.

3.2. Operational definition: In this study, mothers’ practice will be measured using theKAP

questionnaire regarding immunization (Sebastian et al., 2017).

27

Chapter III: Methodology

The following chapter will discuss the conceptual framework, research design, study

area, population and sample size, and the inclusion and the exclusion criteria. It will also

describe the study setting and sampling selection technique. Lastly, the chapter will also

introduce the instrument, including translation, validity, and reliability. Furthermore, it will

present the procedures for data collection and analysis and plans for obtaining ethical

permission for the study

Section I: Conceptual Framework

Socio-demographic characteristics, knowledge and attitudes are the independent variables

used to predict the mothers’ practicesrelated to immunization (see Figure 2).

Figure 2: Research framework

Attitudesregarding

Immunization

Knowledge regarding

immunization

Practices

regarding

immunization

Socio-demographic

characteristics

28

Section II: Research Design

This study uses a quantitative cross-sectional correlation design. The aim is to

explore the relationships between the variables, including socio-demographic characteristics,

knowledge, attitudes, and practices regarding childhood immunization in Papua New Guinea.

Section III: Study area and setting

The study was conducted in West Sepik province, also known as Sandaun, which

contains four districts, namely Aitape-Lumi, Nuku, Telefomin and Vanimo Green District.

Data will be collected at Sandaun Provincial Hospital in Vanimo Green District, West Sepik,

which is the referral and teaching hospital in that province. The data was collected in the out-

patient unit, and the well-baby clinic of the hospital. The reason for choosing this hospital was

because the outpatient department operates 24hours a day, well baby clinic every Fridays for

vaccination, and half of the patients are from the rural area.

Section IV: Sample size

We estimated the necessary sample size based on multiple linear regression, assuming

R² deviated from zero, using a medium effect size (f²) of 0.15. The significance level(α) was

set at 0.05(two tailed) and the statistical power was set at 0.8.A sample size of 114 women

was recruited for this study.

Section V: Sample Selection

The inclusion and exclusion criteria of this study are as follows:

1.Inclusion Criteria

1.1 Mothers of children under age 5

1.2 Mothers who read and write Tok pisin

1.3 Mothers age 18 and above

29

2.Exclusion Criteria

Mothers of children with chronic diseases, such as heart problems, or premature babies

Section VI: Instruments

The study used KAP questionnaires regarding immunization created by Sebastian et

al, (2017) and it was modified. Permission was given by the author to use the tool (See

Appendix II).

1. Description

This Knowledge, Attitude, and Practice Questionnaires is a reliable and valid tool to

measure parents’ knowledge, attitudes and practices regarding immunization. The instrument

was initially developed in English in 2017 and it has been translated into a local vernacular

language(Kannada) of India(Sebastian et al., 2017). The scale is considered easy and practical

to use.

The survey instrument was an interview directed questionnaire that explored mothers’

knowledge, attitudes and practices and is comprised of four parts. Part A relates to participants’

socio demographic background and includes age, number of children, education level, marital

status, source of information, income, transport, women’s role in decision making, and place

of residence. Part B examined mothers’ general knowledge regarding vaccination using a 10-

item questionnaire. Part C explored mothers’ vaccination attitudes using a seven-item

questionnaire, and part D assessed practices towards childhood immunization using a five-item

questionnaire.

2.Validity and reliability

Sebastian initially tested the psychometric properties of the twenty-two item scale

among parents in India whose babies were between two to five years old (Sebastian et al., 2017).

The results showed that the instrument was reliable and valid. The authors developed the

30

primary version of the questionnaire in English after an extensive literature search to maintain

consistency with English language published literature. The overall scale content validity score

(S-CVI) and the item-content validity index (I-CVI) were 0.96 and 0.96, respectively

(Sebastian et al., 2017). An I-CVI score of 0.78 or higher indicates excellent content validity,

as does an S-CVI score of 0.8 or higher (Gray, Grove & Sutherland, 2017), demonstrating that

this scale is valid to use. The Cronbach’s alpha was 0.89 (Sebastian et al., 2017). According to

Gray and colleagues, a reliability coefficient should be above 0.7, indicating that this

questionnaire is reliable to use (Gray, Grove & Sutherland, 2017).

3.Scoring

The KAP questionnaire scoring was done by allotting zero and one point for each

incorrect and correct answer, respectively. The maximum score is 22(knowledge

domain:10points, attitude domain: 7 points and practice domain: 5 points). A person who

answers questions correctly and obtains higher scores has a higher level of knowledge, and

better attitudes and practices regarding immunization(Sebastian et al., 2017).

4.Translation

This study used the KAP questionnaire tool to measure mothers’ knowledge, attitudes

and practices in the Tok Pisin language of Papua New Guinea. Content Validity of the

translated questionnaire was established by expert validation. Four experts in the field of

pediatrics in Papua New Guinea who have knowledge about immunization and are fluent

speakers of both Tok Pisin and English validated the content of the translated version. The

questionnaires were translated from English into Tok Pisin and reverse translation was done

by two pediatric nurses who speak both languages fluently. They rated the content relevance,

clarity and simplicity of each item using a four-point Likert scale from 1 (irrelevant, not clear,

and not simple) to 4 (very relevant, very clear, and very simple). The content validity index

(CVI) was calculated to obtain the validity score. The CVIs of the study instrument were 0.94

31

for knowledge about immunization, 0.95 for attitudes towards immunization, and 0.96 for

immunization practice. The average content scale validity score was 0.94.

A pilot study was conducted to determine the reliability of the translated questionnaire.

The purpose of the pilot study is to examine the questionnaire administration technique and the

adequacy of the question items. The result of the pilot study was analyzed to determine the

reliability of the translated scale using SPSS version 20, and was found to be 0.7.

Section VII: Research ethics and statements

This study was approved by the Medical Research Advisory Committee (MRAC) of

Papua New Guinea (MRAC No.19.15) and also approved by the research committee of

Sandaun Provincial Hospital. After providing information about the purpose of the study,

guaranteeing anonymity and credibility, clarifying voluntary participation, and indicating the

benefits of the study. Written consent was obtained from the participants who agreed to take

part in the study. (See Appendix I)

Section VIII: Data collection procedure

Data collection took place after the participants have given their consent. Participants

were mothers of children under the age of five. Interviews were carried out with the revised

questionnaires during the morning shifts. When the participants had completed the

questionnaire, the researcher reviewed it thoroughly to ensure it was complete. (See Appendix

I)

Section IX: Data Analysis

The data was analyzed using the Statistical Packaged for Social Sciences (SPSS)

Version 20. The SPSS showed the results in the form of tables and descriptive statistics. The

demographic variables were analyzed in terms of means, standard deviation, frequency, and

percentages. The researcher calculated the means and standard deviation for knowledge,

32

attitude and practice scores. The variables predicting the practice of immunization was

analyzed using hierarchical multiple linear regression. The table below illustrates each variable

alongside statistical procedures used for data analysis

Table3.1 Statistical test for study

Research question Variables Statistics

1. What are the demographic

characteristics of mothers with

children under age five in

Papua New Guinea?

1.Continuous variables:

-Age

-Number of children

2.Categorical:

-Marital status

-Education

-Transport

-Income

-Source of information

- Women’s decision-

making role

-Place of residence

Descriptive statistics:

1. mean, standard deviation,

and range

2. frequency &percentage

33

2. What are the mothers’

knowledge, attitudes, and

practices regarding childhood

immunization?

Knowledge

Attitude

Practice

Descriptive statistics:

Including means, standard

deviation, and range

3.Which factors are most

influential in determining the

actual immunization practices,

when considering demographic

characteristics and mothers’

knowledge and attitudes

regarding childhood

immunization?

Dependent variable:

Knowledge, attitudes,

& practices

Independent variable:

Demographic

characteristics

Inferential Statistics:

Hierarchical Linear

Regression

34

Chapter IV Results and Discussion

This section will discuss the results of this study, taking into account the mothers’

knowledge, attitudes and practices regarding immunization. It will also go into detail to

compare the findings of this study with previous studies.

Section I Results

This study explored the knowledge, attitudes, and practices of mothers regarding

childhood immunization in West Sepik, Papua New Guinea. The researcher included 114

mothers from the general outpatient and well-baby clinic of Sandaun Provincial Hospital. The

study took place from the 1st of July to the 4th of September 2019. All questionnaires were

checked to be sure they were properly filled in. To analyze the results, the study used

descriptive statistics, Pearson’s correlation, independent sample t test, ANOVA, post hoc

comparison and hierarchical linear regression.

Research question 1: What are the demographic characteristics of mothers with children

under five in Papua New Guinea?

The demographic characteristics of the mothers were analyzed with a descriptive analysis.

Participants’ average age was 26.24(SD=5.50) years old. The oldest participant was 45 and the

youngest was 18 years old. The mean of the number of children was 2.55(SD=1.83), ranging

from 1 to 10. In regards to education level, half (50%, n=57) had completed less than high

school, nearly one-third (29.8%, n=34) had at least high school or more, and20.2% (n=23) were

illiterate. As regards to the mothers’ income, 93.9% (n=107) earned more than or equal to K200

and only 6.1% (n=7) earned less than or equal to K200. About 93% (n=106) of the mothers

received immunization knowledge from professional sources and only 7.1% (n=8) from

unprofessional sources.

35

Regarding marital status, 95.6% (n=109) of the mothers were living with their spouse

and only 4.4% (n=5) were not living with their spouse due to being divorced or single. Almost

three-quarters (71.9%,n=82) of the mothers had some types of vehicle transportation to the

clinics and 28.1% (n=32) traveled on foot.

In terms of family decision making related to immunization, the majority chose

immunization, with 76.3% (n=87) of all women reporting that both parents participated in the

decision and only 23.7% (n=27)of mothers made the decision by themselves. Just under two-

thirds (64%, n=73) of the mothers resided in urban areas and 36% (n=41) resided in rural areas.

Most of the demographic variables were re-categorized into two groups as shown in Table 4.1.

Table 4.1 Socio-demographic characteristics of mothers of children under 5 (N=114)

Variables Range Mean(SD) Numbers (%)

Age 18-45 26.24(5.50)

Number of children 1-10 2.55(1.83)

Mothers’ level of education

Illiterate 23(20.2)

<HS 57(50)

At least HS or more 34(29.8)

Income(PNG Kina)

50-100 7(6.1)

101-500 48(42.1)

>500 59(58.8)

<200 7(6.1)

>201 107(93.9)

Source of information

36

Radio 1(0.9)

Neighbor 7(6.1)

Health workers 103(90.4)

Health card 3(2.6)

Unprofessional source 8(7)

Professional source 106(93)

Marital status

Married 109(95.6)

Divorced 1(0.9)

Single 4(3.5)

Living with spouse 109(95.6)

Not living with spouse 5(4.4)

Transportation to clinic

Bus 32(28.1)

Walking 51(44.7)

Company vehicles 29(25.4)

Private vehicles 2(1.8)

On foot 32(28.1)

Not on foot 82(71.9)

Decision making

Mothers alone 27(23.7)

Both parents 87(76.3)

Residence

Urban area 73(64)

37

Rural area 41(36)

SD=standard deviation; HS=high school

Research Question 2: What are the KAP of mothers regarding childhood immunization

in Papua New Guinea?

Mothers’ knowledge, attitudes, and practices regarding childhood immunization were

analyzed by descriptive analysis. Means and standard deviations on knowledge, attitude, and

practice scores were calculated for better assessment. Mothers’ knowledge scores ranged from

5 to 11 with a mean of 9.73(SD=1.42). In general, mothers had good knowledge about

childhood immunization. According to the study findings, 100% (n=114) knew that it was

important to vaccinate their children and that vaccines are safe to use. The high knowledge

scores about immunization among mothers in Papua New Guinea could be due to health

workers giving effective health education on the topic. A total of 99.1% (n=113) knew that it

is important to receive vaccinations during pregnancy. This is so because it protects the mothers

and their children from diseases like tetanus. However, only 80.2% (n=92) of the mothers knew

that the tetanus vaccine is given during pregnancy. Of the participants, 74.6% (n=85) knew that

vaccination enhances immunity and helps the human body fight against diseases. Only 49.1

(n=56) of the mothers knew that fever, swelling and pain at the injection site and rashes are

side effects of vaccination. These findings suggest that health workers education about vaccines

lacks specificity (See table 4.2).

The attitude scores ranged from 5 to7, with a mean of 6.80(SD=0.43), with most

mothers accepting childhood immunization. All (n=114) of the participants knew that

vaccination is important and safe. Also 100% (n=114) of the mothers stated that their culture

has no influence over how they perceive vaccination. A majority of 99.1% (n=113) of the

participants favored vaccination and believed it should be given according to schedule. Nearly

as many, (96.5%,n=110) stated that vaccines should be started in the first week of life. While

38

84.2% (n=96) of the participants said that they would recommend that other mothers bring in

their children for vaccination (See table 4.3).

The vaccination practice scores ranged from 0 to 5, with a mean of 3.17(SD=1.40), with

87.7% (n=100) of the mothers reporting that they would follow the obligatory vaccination

schedule. Seventy-eight (68.4%) of the participants stated that they would get all their children

vaccinated and said they would manage the swelling of the injection site by cold compression.

But 31.6% (n=36) of the mothers stated that they would not get their children vaccinated. This

could be because of the transport issues for those living in the rural areas present obstacles to

getting children vaccinated, although the study did not detect a significant link between

transportation and vaccination. In addition, the cost of transport could present a financial

burden that prevents mothers from bringing their children in for vaccination. About 45.6%

(n=52) of the mothers reported that they would report the minor side effects to the nurse or

health care workers. Just under half (44.7%,n=51) of the mothers stated that they would use

analgesics for swelling and pain after vaccination. This relatively low level of practice to get

children immunized could be due to lack of awareness or lack of understanding among mothers

who are illiterate or who did not complete high school. (See table 4.4)

Table 4.2Immunization knowledge scores of mothers(N=114)

Items Yes n (%) No n (%)

39

Do you think vaccination prevents infectious diseases? 99(86.8) 15(13.2)

Is it important to vaccinate your child? 114(100) -

Can vaccination enhance immunity and help the body fight against diseases? 85(74.6) 29(25.4)

Is completion of vaccination as scheduled important? 109(95.6) 5(4.4)

Is it important to receive vaccination during pregnancy? 113(99.1) 10(0.9)

Is tetanus given during pregnancy? 92(80.7) 22(19.3)

Vaccination should not be given if a child has fever exceeding 38℃ - 114(100)

Are fever, swelling of injection site, rashes and painful injection site are the site

effects of vaccination?

56(49.1) 58(50.9)

Vaccines for child immunization are safe 114(100) -

A child should be vaccinated at: birth, one month, two months, three months,

six months, nine months, eighteen months, seven and eleven years

109(95.6) 5(4.4)

Table 4.3 Immunization attitude scores of mothers (N=114)

Items Yesn (%) Non (%)

Is vaccination important? 114 (100) -

Is vaccination safe? 114 (100) -

Did you recommend others to vaccinate their children? 96 (84.2) 18 (15.8)

Should vaccination be give according to schedule? 113 (99.1) 1 (0.9)

Are you in favor of vaccination? 113 (99.1) 1 (0.9)

Should vaccination be initiated in the first week of life? 110 (96.5) 4 (3.5)

Does your culture have an influence on how you perceive immunization? - 114 (100)

Table 4.4Immunization practice scores of mothers(N=114)

40

Items Yes

n (%)

No

n (%)

Did you get all your children vaccinated? 78(68.4) 36(31.6)

Did you manage swelling by cold compress? 78(68.4) 36(31.6)

Did you use analgesics for swelling and pain after vaccination? 51(44.7) 63(55.3)

Did you report the minor side effects to the nurse or health worker? 52(45.6) 62(54.4)

Did you follow the obligatory vaccination schedule? 100(87.7) 14(12.3)

Table 4.5Mean scores of mothers’ knowledge, attitudes and practices regarding immunization

(N=114)

Variables Minimum Maximum Mean(SD)

Knowledge 5 10 9.73(1.42)

Attitude 5 7 6.80(0.43)

Practice 0 5 3.17(1.40)

SD=Standard Deviation

Relationship between women’s actual immunization practices and demographic factors,

immunization knowledge, and attitudes about immunization

The relationships among socio-demographic characteristics, knowledge, attitudes, and

practices of mothers related to immunization in Papua New Guinea were analyzed with

multiple linear regressions. As seen in Table 4.6, there was no correlation between age and

knowledge, and the number of children and knowledge. The statistical t-test of knowledge and

residence showed that there was a significant difference in knowledge between urban and rural

women (t=-2.73, p=0.008). The ANOVA test for education revealed that there was a

statistically significant relationship between knowledge and education (F=19.28, p<0.001).

Table 4.6Univariate analysis of knowledge and the demographic variables (N=114)

41

Variables N Mean(SD) F/r/t value p value Pos hoc test

Age 26.24(5.50) -.14 .138

Number of children

2.55(1.83) -.14 .132

Residence

Rural 41 9.22(1.61) -2.73 .008**

Urban 73 10.01(1.23)

Education

❶ Illiterate 23 8.43(1.73) 19.28 .001** ❷>❶

❷<HS 57 9.79(1.29) ❸>❷

❸ At least HS or more 34 10.50(0.56) ❸>❶

Note: **p<.001, *p<.005 HS: high school

As seen in Table 4.7, age and the number of children were negatively correlated with

attitude, with age(r=-.26, p=0.006) and number of children(r=-.28, p=0.003). This could imply

that older mothers knew the effect and important of vaccination because as years went by they

had more children and were open to immunization. The t test to identify the relationship

between attitudes and residence revealed that there was a difference between women who lived

in urban or rural areas (t=-2.22, p=0.003). The rationale behind this was because urban mothers

had the opportunity to attend school and were exposed to immunization information that further

changed their attitudes about immunization. As for the education level, there was a significant

difference between the education level and attitudes about vaccination, with an F value of 10.61

and a p value less than 0.001. Mothers who had a higher level of education have more

knowledge on immunization which had an influence on their attitudes towards immunization.

Table 4.7 Univariate analysis of attitude and the demographic variables (N=114)

42

Variables n Mean(SD) F/r/t value p value Pos hoc test

Age 26.24(5.50) -.26 .006*

Number of children 2.55(1.83) -.28 .003*

Residence

Rural 41 6.66(0.53) -2.22 .030*

Urban 73 6.86(0.35)

Education

❶ Illiterate 23 6.48(0.51) 10.61 .001** ❷>❶

❷<HS 57 6.81(0.44)

❸ At least HS or more 34 6.97(0.17) ❸>❶

Note:**p<.001, *p<.005 HS: high school

In Table 4.8, age and number of children were correlated with immunization practice

(age r=-.24, p=0.010 and number of children, r=-.29, p=.010). The t test done to test the

relationship between practice and area of residence revealed that there was a difference

between urban and rural women (t=-2.91, p=0.005). For the education level, the ANOVA test

revealed a statistically significant difference among the three groups (F=16.53, p<0.001).

Table 4.8 Univariate analysis of practice and the demographic variables (N=114)

43

Variables n Mean(SD) F/r/t value p value Pos hoc test

Age 26.24(5.50) -.24 .010*

Number of children 2.55(1.83) -.29 .010*

Residence

Rural 41 2.61(1.74) -2.91 .005**

Urban 73 3.48(1.06)

Education

❶ Illiterate 23 1.87(1.60) 16.53 .001** ❷>❶

❷<HS 57 3.37(1.20)

❸At least HS or more 34 3.71(1.00) ❸>❶

Note: **p<.001, *p<.005 HS: high school

As seen in Table 4.9 below, there was a positive correlation between knowledge and practice

and between attitudes and practice. There was a statistically significant association between

practice and knowledge, with an r value of 0.57 and a p value of less than 0.001. The statistical

association between practice and attitudes had an r value of 0.46 and a p value of less than

0.001.

Table 4.9 Correlation between Knowledge & Attitudes and the Immunization Practice (N=114)

Variables Knowledge Attitude

r p r p

Practice .57** .001 .46** .001

** Correlation is significant at 0.01(2 tailed)

Research Question Three: Which factors are the most influential in determining actual

immunization practices, when considering demographic characteristics and mothers’

knowledge and attitudes regarding childhood immunization?

44

A hierarchical multiple regression was carried out to find predictors of immunization

practice among mothers in Papua New Guinea (the assumptions of linearity, normally

distributed errors, and uncorrelated errors were checked and met). In this study, the dependent

variable (DV) is practice related to immunization and the independent variables (IVs) are socio

demographic factors, knowledge and attitudes related to immunization.

Hierarchical multiple regression tests were used to identify the best predictor of

immunization practice among mothers in Papua New Guinea. When age, number of children,

education, and residence were entered, mothers’ education significantly predicted practice with

a beta value of 0.37 and an F value of 13.96. As indicated by R², 25% of the variance in practice

could be predicted by knowing the mothers’ age, number of children, education, and residence.

When knowledge was added, it improved the predictive power, with the R2 changing to 0.39.

Knowledge was found to predict immunization practice with a beta value of 0.45 and an F

value of 13.96. In Model 3, attitude was added; it improved the predictive value, raising the R²

value to 0.41. About 41% of the variance in practice could be predicted by knowing the

mothers’ age, number of children, education, residence, knowledge and attitude. However, the

hierarchical linear regression revealed that knowledge was the best predictor of practice, with

an F value of 12.54 and a beta value of 0.39 (See table 5).

Table 5 Hierarchical Multiple Regression Analysis Summary Predicting Practice (N=114)

B SEB β T F R² ΔR²

45

Model 1 9.04 .25 .22

Age -.05 .03 -.20 -1.63

Number of children .02 .10 .02 .18

Education .73 .19 .37** 3.93

Residence .49 .26 .17 1.89

Model 2 13.96 .39 0.14

Age -.02 .03 -.08 -.75

Number of children -.07 .09 -.09 -.79

Education .27 .19 .14 1.41

Residence .29 .24 .09 1.20

Knowledge .44 .09 .45** 5.04

Model 3 12.54 .41 0.02

Age -.02 .03 -.06 -.53

Number of children -.07 .09 -.09 -.73

Education .21 .19 .11 1.12

Residence .26 .24 .09 1.11

Knowledge .39 .09 .39** 4.21

Attitude .55 .29 .17 1.93

Note: **p<.001

Section II Discussion

In this section, an attempt is made to highlight the important findings of the present

study with regards to demographic characteristics of mothers and their knowledge, attitudes,

and practices related to immunization. It will further discuss the results by comparing and

contrasting with findings of previous studies.

46

1. Description of the socio demographic characteristics of the study sample

In this study, the average age of mothers with children under age 5 was

26.24(SD=5.504), ranging from 18 to 45. The mean of the number of children under five per

mother was 2.55(SD=1.83), ranging from 1 to 10, indicating that about 76.3% of women had

between 1 and 3 children under age 5. On average, the older a woman gets, the more children

she has. It is common for mothers in rural areas of Papua New Guinea(PNG) to have a

minimum of six children and for urban women to have three children. Health workers offer

contraceptives to mothers, but the women tend to refuse based on cultural beliefs, saying they

will use traditional family planning, consisting of herbs and rituals. However, traditional

planning methods mostly do not turn out as they expected and they come back to the health

clinic with another pregnancy. A survey carried out in 8 provinces(Milne Bay, Gulf, Chimbu,

Southern Highlands, Madang, East Sepik, East New Britain and North Solomons) in PNG

which comprises of the 4 regions, namely Southern, Highlands, Islands and the Momase

regions found that 81% of men from the rural areas and 76% of males from the urban areas

were afraid that the contraceptives might be detrimental to their wives’ health and their future

children (Agyei, 1984).That study went further, stating that another reason was men’s

disapproval for family planning. In addition, they believed benefits of having more children

were financial support in old age and having a happy family. This study was carried in the

Momase region of PNG which shares similar cultural practices to the survey done in 1984 by

Agyei, a Melanesian society, with male having more influence in decision making than women.

.

In this study education level was related to knowledge about immunization. Half of the

participants (50%) of the mothers had primary education. The findings were similar to those of

Adefolalu and colleagues in Nigeria who found that 57.7% of the mothers had primary to

47

secondary education (Adefolalu et al, 2019).A study done in India likewise found that the use

of health care services as well as full immunization of children is associated with the mother’s

level of education (Kusuma, Kumari, Pandav, & Gupta, 2010). Many studies show that

maternal education was one of the factors that contribute to a child’s health. This study was

done in a developing country as well as the other study. Furthermore, both countries that these

studies took place in had a adult literacy rate of about 60%. The high literacy level among

women in this study may partly explain the relatively high knowledge of vaccination. Mothers

who are educated often use the internet and gather as much information they can about

vaccination. In addition, when unsure, they enquire by asking health care professionals during

hospital visits. Many studies have documented that mothers’ education levels influence the

practice of immunization.

In this study, 93.9% of mothers had a family income level of ≥201 Papua New Guinea

Kina and only 6.1% had family incomes ≤200. In PNG, immunization is provided free by the

government. For those mothers living far from health clinics, they only need to pay for their

transport to get to the clinic sites. This study revealed that, 53.3% of the participants travelled

into town by private vehicles or public transportation. However, transportation is a problem in

rural areas due to the difficult terrain, poor conditions and cost. This is supported by a survey

done in PNG by Gibson & Rozelle (2015) which found that health and education services in

rural areas are not easily accessible due to poor road access. This survey was done by collecting

information from the 4 regions in PNG which included Momase region where this study was

conducted. Both of these studies had some participants who lived in rural areas.

Regarding the source of information, 93% of the mothers got their information from

professional sources, specifically health care professionals. This is similar to results of a study

by Hamid and colleagues in a rural area of North Kashmir, India where of the participants

48

(88%) reported that health professionals were their source of information regarding

immunization(Hamid et al,2012).These results could be similar due to the fact that both studies

had participants residing in the rural areas and also both females from these areas have a literacy

of about 60%. This reflects the effective work of the health workers to promote and motivate

mothers about childhood vaccination. Mothers in this study were informed by health

professionals through health education to raise awareness. Only 1% of the mothers got their

information about immunization from radio. This could mean that the radio station in that

province is not being utilized to spread immunization information, as in other provinces. Since

internet data is expensive in PNG and internet coverage in the rural areas is poor, immunization

information should be disseminated via radio as well.

In terms of decision making, 76.3% of the decisions relating to immunization of

children were made by both parents and 23.7% by mothers alone. In this study, more than 95%

of the mothers were living with their spouses. This pattern was similar to a study by Adefolafu

and colleagues in Nigeria where about 95.6% of the mothers were married (Adefolalu et al,

2019).These similarities could be because of the patriarchal society. This could mean that

husband’s involvement has a positive impact on a child’s immunization status. PNG is a

culturally diverse nation, mostly made of patrilineal societies and a handful of matrilineal

societies, but in both, men have dominance over women in terms of decision making (Sai,

2007). In the rural and urban areas of PNG, men commonly hold onto traditional cultural

practices, where tribal discipline and power is given to men who have authority over their clan

and family members. Men make most of the decisions in the family and control most of the

resources, and women are expected to conform to various societal rules and norms, often

having their basic rights denied. This is supported by a United Nations report showing that

PNG has a Gender Inequity Index (GII) value of 0.86(United Nations, 2014). The GII measures

49

three dimensions; reproductive health, empowerment, and economic activity. Women are not

empowered in terms of decision making. In addition, in 2018, PNG had a GII value of 0.74

which ranked it as 161 in terms of gender inequality out of 162 countries, meaning that gender

inequality is exceptionally high(United Nations Development Report, 2019). However, a

minority of men, often those with more education or living in urban areas, are doing away with

these cultural practices.

As for place of residence, in this study, roughly two-thirds most of the women were

living in urban areas (64%), with 36% in rural areas. Residence in urban areas could mean that

they had more opportunity to attend school, which could explain the association between urban

residence and better immunization practices.

2. Mothers’ Knowledge, Attitude and Practices related to immunization

Participants’ knowledge scores ranged from 5 to 11 with a mean of 9.73(1.42), attitude

scores ranged from 5 to 7, with a mean of 6.78(SD=0.43) and, the practice score ranged from

0 to 5, with a mean of 3.17(SD=1.40).About 86.9% of the mothers in this study were aware

that vaccination prevents infectious diseases. This is similar to results of studies conducted in

Egypt, Northern Saudi Arabia and Riyadh, Saudi Arabia, where 93.3%, 85.6% and 82.6%

respectively knew that vaccination prevents infectious diseases(Ramadan et al.,2016; Alruwaili

et al.,2018; Al-zahrani,2013). This could be because immunization is an important public

health intervention effective in preventing infectious diseases to children, public knowledge on

the topic has been boosted and sustained. In addition,74.6% of the mothers knew that

vaccination enhance immunity and so help the body fight against infectious diseases. This

result is similar to findings of study in Riyadh where 89.2% of the parents knew that

vaccination enhance immunity (Al-zahrani, 2013). Another study in India revealed that all

50

(100%) the mothers knew that vaccination boost the immune system(Mereena& Sujatha,

2014). This could be because of the continuous health education by health workers which

enable mothers to grasp the concept of the importance of vaccination.

All (100%) of the mothers knew that it is important to vaccinate their children but what

they knew differed. This result is similar to results of studies conducted in Ikorodu Local

Government Area Nigeria, Democratic Republic of Congo and Kosofe LGA where 100%,

99.8% and 98% of the participants respectively knew about vaccination and the important role

it played in the lives of children under five(Adefolalu et al.,2019; Matapano et

al.,2008;Awodele et al.,2010) These similarities in results could be due to the social structure,

meaning that studies have participants living in tribes who have more knowledge about

immunization educate their fellow tribes’ women, thus increasing their knowledge about

immunization. Furthermore childhood immunization is an important and effective intervention

in the prevention of VDPs.

Knowledge Q4, Attitude Q4 and Practice Q5 are similar and are discussed together here.

In KQ4 95.6% of the mothers knew that completion of child’s vaccination as scheduled is

important. This is contradicting to a study by Angadi and colleagues in India where 97% of the

mothers did not know about the vaccination schedule (Angadi et al., 2013). This difference

observed could be due to the fact that have 20.2% of illiterate mothers while Angadi study

consisted of 38.96% illiterate fathers and 50.32% of illiterate mothers. In Q5 of Attitude

Section, 99.1% of the mothers knew that vaccination should be given according to schedule.

This is similar to results of a study by Ramadan and colleagues in India, where 97.2% of the

mothers knew that children should be vaccinated according to schedule(Ramadan et al.,2016).

While Q5 of Practice section, 87.7% of the mothers followed the obligatory vaccination

schedule and 12.3% did not. This could be due to 20.2% of illiterate mothers in this study.

51

Researchers revealed that maternal education or literacy seemed to be the strongest and the

most important predictor for immunization outcomes(Basu& Stephenson,2005; De &

Bhattacharya, 2002).Education played an important role in this regard.

In Knowledge Q5 and Q6, 99.1% of the mothers knew that it is important to receive

vaccination during pregnancy and 80.7% knew that tetanus vaccine is given during pregnancy.

This is given to protect the mother form tetanus and the baby from neonatal tetanus after the

baby is born. About 90.8% of mothers were aware that tetanus vaccine is important for the

health of the mother and infant (Ramadan et al.,2016).

All(100%) of the mothers knew that vaccines should not be administered if a child has fever

exceeding 38 degree Celsius. A study by Roodpeyma and colleagues in Iran revealed that

45.6% of the mothers knew that fever is a contraindication for vaccines (Roodpeyma et

al.,2007). On this note, there is no contraindication for giving measles/rubella vaccine(Pediatric

Society of Papua New Guinea,2016). This could mean most of the mothers were not aware of

the contraindication of specific vaccines. In supportive, in KQ8, 49.1% of the mothers were

aware that fever, swelling of injection site, rashes are the minor side effects of vaccination and

50.9% did not know that. In PQ2, 68.4% of the participants applied cold compress to swollen

injection site and 31.6% did not. Moreover, in PQ3 44.7% of the mothers used analgesics for

pain and swelling after vaccination and 55.3% did not. Furthermore, in PQ4 45.6% of the

participants reported the minor side effects to the health workers and 54.4% did not. This could

mean that health education given is too general and only emphasized on the benefits and less

emphasis on the minor side effects and contraindications.

In KQ9 AND AQ2, all(100%) of the mothers knew that vaccines for children are safe.

This result is similar to a study by Yousif and colleagues in Saudi Arabia, where 72% of the

mothers knew this (Yousif et al., 2013). This means that participants understood generally

52

knew the benefits of vaccines on their children’s’ health. About 96.5% of the participants knew

that a child should be started at the first week of life(AQ6) and 95.6% of the participants reveled

that a child be vaccinated at birth, one month, two months, three months, six months, nine

months and eighteen months.

The results of this study showed that most of the mothers had a positive attitude towards

immunization. In AQ1, all (100%) of the mothers knew that vaccination is important. This is

congruent to results of studies by Ramadan(98.6%) and Kalyani &Belsiyal(84%) where

mothers knew the importance of vaccination (Ramadan et al.,2016; Kalyani &Balsiyal,2018).

About 84% of the mothers recommend other parents to bring in their children for vaccination.

By extension, almost all the mothers stated that they will follow the recommended vaccination

schedule. This finding was similar to a study in Yemen ( Bamatraf & Jawass, 2010).PNG,

Nigeria and Yemen all offer free immunizations and appear to have had successful campaigns

promoting the idea (Awodele et al.,2010; Bamatraf&Jawass,2010;PNG Pediatric

Society,2016). Furthermore almost all the mothers were in favor of vaccination and all the

mothers revealed that culture did not have an influence on how they perceive immunization.

Though the mothers in this study demonstrated good knowledge and positive attitudes

towards childhood vaccination, their practice towards vaccination appeared to contradict that.

About 36% of the mothers reported that they did not get all their children vaccinated. This

could be because the mothers live in rural areas where accessibility to clinics and going into

town may be a problem due to transportation and financial issues. This is supported by a survey

done in PNG by Gibson &Rozelle(2015) which found that health and education services in

rural areas are not easily accessible due to poor road access.

Relationship between mothers’ Knowledge, Attitude and Practices and demographic

factors

53

The results revealed that age and the number of children did not correlate with

knowledge about immunization. Contrary to this finding, a study done by Mereena and Sujatha

in India reported that age and the number of children correlated with women’s knowledge of

immunization (Mereena& Sujatha, 2014). This could be due to the differences in the number

of sample size and also the study design. The Indian study had more participants (about 300),

compared to the 114 in this study, providing more detailed information that might reveal

differences not apparent in this study, a descriptive research design and used a different KAP

instrument. However, there was a significant difference in knowledge about immunization

according to urban or rural place of residence (t=-2.73, p=.008), with women in urban areas

showing more knowledge about immunization. This finding was similar to results of a study

done by Mugada and colleagues in India, where mothers living in the urban areas also had

greater knowledge of immunization compared to those in rural area s(Mugada et al., 2017).

This may reflect the fact that urban mothers have better access to hospitals and internet and so

are in a better position to get all the information needed. In terms of education, there was a

statistically significant difference in mothers’ knowledge by education level

(F=19.28,p<0.001). This finding was similar to that of a study by Awodele and colleagues in

Nigeria(Awodele et al., 2010).As illustrated in Table 3.1, mothers who were illiterate had less

knowledge than those who had some education but without graduating from high school, and

those with less than high school education did not know as much about immunization as high

school graduates. Mothers who had higher levels of education had more knowledge about

immunization than the mothers with less education.

The results illustrated that there is a negative correlation between age and attitude about

immunization (r=-.26, p=.006) and also between the number of children and attitude about

immunization(r=-.28, p=.003).These findings are similar to results of Mereena and Sujatha’s

54

study in India, which also found a significant difference in attitude related to age and the

number of children. Most of the mothers in that study were between age26 and 30(Mereena&

Sujatha, 2014). This could imply that younger mothers have better attitudesabout

immunization, as the mean age of participants in this study was 26.24.These similarities could

also be due to the fact that the studies were carried out on participants residing in urban and

rural settings and also from low income families. Mereena and Sujatha’s study also found that

attitude about immunization differed according to the number of children, with women who

had more children having a more positive attitude about immunization. This might be explained

by the facts that mothers who have had more than one child have received more information

about immunization over the years, leading to more positive attitudes regarding immunization.

This study also found a statistically significant difference in attitudes towards

immunization by place of residence (r=-2.22, p=.030). Mothers in urban areas have a more

positive attitude towards immunization than mothers in rural areas. As already shown, mothers

in urban areas also have more education and more knowledge about immunization. So their

attitudes about immunization reflect their knowledge, and knowledge can change both

behaviors as well as attitudes. Moreover, there was a significant difference in attitude about

immunization according to level of education (F=10.61, p<0.001). This finding is similar to

results of a study by Adekeye and colleagues in Nigeria (Adekeye et al., 2015),which revealed

that mothers who were illiterate had less positive attitudes towards immunization than mothers

who had primary school education and high school graduates. This shows that having some

form of education is important because it increases one’s level of understanding and changes

attitudes.

The study findings revealed a negative correlation between age and immunization

practice(r=-.24, p=.010) and between the number of children and immunization practice (r=-

55

.294, p=.010). Older mothers had more children than younger women, but were less likely to

immunize all their children than younger mothers. Younger mothers had fewer children but

were more likely to have them all immunized. This is contradictory to a study done by

Adefolalu and colleagues in Nigeria, where older mothers were more mature and brought all

their younger children in for vaccination (Adefolalu et al., 2019). In support of this, a study by

Mohamudand colleagues in Ethiopia found that the rate of complete vaccination of children

increases with the age of their mothers (Mohamud et al., 2014).This could be because the mean

age of those mothers in Ethiopia was 30.96. The results in Ethiopia and Nigeria showing that

mothers with more children were more likely to vaccinate them all could be related to the fact

that mothers received information over the years when having more than one child, leading to

a change in their attitudes and practices regarding immunization.

This study also found that there was a statistically significant difference in practice of

immunization by place of residence (r=-2.91, p=.005). Mothers in the urban areas had better

practice of immunization than mothers in the rural area. Their better immunization practice

reflected their greater knowledge and more positive attitude.

This resultsof this study also showed that there was a significant difference in

immunization practice according to the level of education (F=16.53, p<0.001). This finding is

similar to results of a study by Konwea and colleagues in Nigeria, which likewise found a

significant relationship between education level and immunization, practice (Konwea et al.,

2018). The analysis in this studyrevealed that mothers who were illiterate had less knowledge

than those who had some education without graduating from high school, and those with less

than high school education did not know as much about immunization as high school graduates.

This shows that having some form of education is important because it increases one’s level of

understanding and changes attitudes.

56

Out of the nine demographic factors, only four were found to be significant and have

been discussed above. Factors such as income, source of information about immunization,

marital status, transportation to the clinic, and decision making were not significantly

associated with immunization practice.

The Pearson’s correlation test showed a positive association between knowledge and

practice(r=.57, p<0.001), revealing that mothers who had more knowledge about immunization

were more likely to have their children immunized. This finding was similar to that of a study

by Matapano and colleagues in the Democratic Republic of Congo(Matapano et al.,2018).

Mothers who have higher levels of education tend to have more knowledge, resulting in better

practice of immunization. In addition, there was a positive association between attitude and

practice(r=.46,p<0.001), with better attitude about immunization being associated with greater

likelihood of immunization. Mothers who have some knowledge about immunization have

better attitudes and thus have better practice.

Variables predicting the practice of immunization

This study showed that knowledge (β=0.392) is an important predictor of immunization

practice among mothers in Papua New Guinea. This conclusion, that mothers’ knowledge

about immunization predicts immunization practice, is consistent with findings of the study

done in the Democratic Republic of Congo and the results of a literature review by Favin and

colleagues in Switzerland (Favin et al., 2012; Matapano et al., 2014). Furthermore, knowledge

was identified as an important factor in a study on parents’ decision-making regarding

immunization done in Germany (Zingg & Siergrist, 2012).

57

CHAPTER V Conclusion

This section presents the implications, recommendations, limitations and the conclusions of

the study.

Section I Implications for future research

Knowledge plays a positive and essential role in immunization practice. The

implications of these findings will be discussed as they relate to health policy, public health

education, and nursing practice.

1. Health Policy

Policy makers can use these findings to strengthen and amend health policies of Papua

New Guinea in order to increase childhood immunization coverage. PNG already has good

policies regarding health promotion but they are not being adhered to. Immunization is free

and mandatory in PNG but the vaccination coverage rate remains below eighty percent. The

vaccination rate could be improved if the government puts policies in place such through

58

legislation requiring vaccination for school entry. This has been practiced in many countries

around the world and is found to be effective.

2. Public Health Education

Since knowledge predicted immunization practice, PNG health care workers, especially

the nurses, should take initiative in organizing immunization awareness programs at different

levels of the health care system all the way down to the aid post level. Furthermore, hospitals

and clinics should have visible pamphlets and poster information regarding childhood

immunization available in waiting areas or to be given during health visits. Moreover, health

professionals should go on the radio and talk about the importance of childhood immunization.

And lastly but not least, simple language should be used for ease of comprehension when

targeting the mothers living in both urban settlements and rural areas.

3. Nursing Practice

Nurses should educate mothers at every opportunity about immunization. Nurse

supervisors should draw up schedules regarding health education, including awareness about

immunization as well as other topics, so that nurses do it regularly and routinely. Nurses should

use simple language that mothers can understand when disseminating the information. In

addition, nurse managers should create an incentive structure to reward nurses for providing

health education in the outpatient area or on the wards, and new nurses should be given

encouragement to gain the confidence for doing this. Furthermore illiterate mothers can be

educated with the help of a community leader as a translator because 20.2% of mothers in this

study were illiterate.

Section II Recommendations of the study

Future research could collect data from health cards to match actual immunization

practice with women’s knowledge and attitudes about immunization, which would provide

59

more specific information about the gap between knowledge of immunization and

immunization practice identified in this study. It would also eliminate the possibility of

response bias.

In addition, the findings of this study will serve as a reference for future research

regarding childhood immunization in Papua New Guinea. This study revealed that knowledge

is the best predictor of immunization practice, although the results suggest that a substantial

percentage of children were still not receiving vaccinations. The women scored higher on

knowledge about immunization than on practice. Therefore, a future study should try to

understand the reason for this gap. A qualitative study could provide more insight into the

mothers’ knowledge and attitudes regarding immunization and should be combined with

results of other studies to reduce barriers identified to immunization at clinics to get a fuller

picture of immunization practice in PNG.

The instrument used to measure knowledge, attitudes and practices in this study was

developed by Sebastian and colleagues (2017), however, publication is pending so the results

of the original study are not yet available for comparison. A widely used instrument for another

quantitative study would facilitate comparison. A larger and more representative sample size

would be useful, which would require finding participants in numerous hospitals and clinics in

different parts of the country.

Health education on the benefits of each vaccine should be intensified at health centers

and community gatherings in-order to improve mothers’ knowledge about childhood

immunization. Programs such as female education, adult education and health education should

be strongly encouraged and maintained.

60

Section III Limitations of the study

This study had some limitations in terms of design, sampling and the instrument used.

This was a quantitative cross sectional study with a questionnaire that had all closed questions.

The researcher did not collect information on the actual rate of vaccination to assess the

relationship between intentions and actual practice.Even if the questionnaire asked precise

information about how many children the mother had vaccinated or not vaccinated, it is only

possible to know about her knowledge and attitude about immunization in the present, so it is

not clear what value that information would have. Another limitation of this study was the use

of convenience sampling. Because the mothers were recruited from only one hospital, Sandaun

Provincial Hospital, the study participants consisted of a small portion of Papua New Guinean

mothers. This means the results cannot be generalized to all mothers who have children under

five in PNG. The questionnaire used had all closed questions to avoid the possibility of

misinterpretation of language and to make it easy for both the interviewer and the mothers.

However, closed questions limit the amount of detailed information that could be obtained from

the mothers, as compared to a qualitative study. This questionnaire and was initially in English

then translated in Tok Pisin for the mothers. Although the original intention was to give

participantsa self-administered written quesitonnaire, many women seemed to have difficulty

understanding the questionnaire, so the researcher then conducted an in-person

interview.Therefore, the technique of gathering information was not uniform and may have

introduced some bias, such as social desirability and interview bias. The women knew the

researcher was a health worker, and that health workers expect them to have their children

vaccinated, so in order to please the interviewer they might have been more likely to say they

were getting vaccinations.Furthermore, due to the limited time of data collection; this study

61

was cross sectional in design, so it cannot reflect change in knowledge, attitudes, or practice

over time.

Section IV Conclusion

This study found that mothers’ knowledge about vaccines is one factor that hinders

them from getting their children fully vaccinated. Despite the efforts of health workers to

increase coverage by educating mothers, knowledge remains uneven and not all children are

brought in for vaccination. The findings suggest that, on the one hand, current efforts to educate

mothers about vaccines have not yet been completely successful, and on the other, that health

education alone may not be sufficient. Therefore health education given should be specific on

each vaccine, its benefits and the disadvantages.

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Appendix I: Consent Form

Study Title: Assessing knowledge, attitudes and practices of mothers regarding

immunization in West Sepik Province, Papua New Guinea.

Dear Participant,

You are kindly invited to participate in this study. The aim of this study is to assess

knowledge, attitudes and practices of mothers regarding immunization. Participation is free

and you may withdraw any time during the study. There is no risk to you and you will not be

paid, however, your sincere participation is vital in understanding and educating you as an

important part ofyour child’s health. Your privacy will be protected, so your name will not be

reveal to anyone. Your informatiom will be kept confidential and will not be disclosed to a

third party, but anonymous results may be provided to health care instititutions for the

purpose of improving health education and service care.

Thank you for your time and participation.

I have been informed and understand that by signing this consent form, I give permission to

the reseacher to use my personal information related to the study. I voluntary consent to take

part by answering the questionnaire based on my best knowledge and experience.

Name: ……………………………Signature:………………

(or Finger print)

Date:……………………

Researcher’s Name:………………………………………. Signature: ……………

ID code: …………………………………………………………

74

Appendix II: Instrument

Questionnaire on Knowledge, Attitude and Practice(KAP) of mothers regarding

vaccination

Demographic information

Patient number………

1. Age: ………………………

2. Number of children: ………………….

3. Education level: 1 = Illiterate 2 = Elementary 3 = Primary 4 = High school

5= Secondary

4. Income: 1 = <50PNG KINA 2 = 50-100PNG KINA 3 = 100-500PNG KINA

4 = >500PNG KINA

5. Source of information: 1 = Radio 2 = Neibor 3 = Health workers 4 = Health card

6. Marital status: 1 = Married 2 = Widow 3 = Divorced 4 = Single

7. Transport: 1 = Bus 2 = Walking 3 = Company Vehicles 4 = Private cars

8. Decision Making in family: 1 = Mother 2 = Father

9. Place of residence: 1 = Urban settlement 2 = Rural 3 = Rural remote

Knowledge

Items Yes No

Do you think vaccination prevents infectious diseases?

Is it important to vaccinate your child?

Can vaccination enhance immunity and help the body fight against

diseases?

Is completion of vaccination as scheduled important?

Is it important to receive vaccination during pregnancy?

Is tetanus given during pregnancy?

Vaccination should not be given if a child has fever exceeding 38℃

75

Are fever, swelling of injection site, rashes and painful injection site are

the site effects of vaccination?

Vaccines for child immunization are safe

A child should be vaccinated at: birth, one month, two months, three

months, six months, nine months, eighteen months, seven and eleven

years

Vaccines are give in prevention of military tuberculosis, meningitis,

Hepatits B, polio, diphtheria, tetanus, pertussis, pneumococcal

infections, measles and rubella

Attitudes

Items Yes No

Is vaccination important?

Is vaccination safe?

Will you recommend others to vaccinate their children?

Should vaccination be give according to schedule?

Are you in favor of vaccination?

Should vaccination be initiated in the first week of life?

Does your culture have an influence on how you perceive

immunization?

Practice

Items Yes No

Did you get all your children vaccinated?

Did you manage swelling by cold compress?

Did you use analgesics for swelling and pain after vaccination?

Did you report the minor side effects to the nurse or health worker?

Did you follow the obligatory vaccination schedule?

76

Tok Pisin version

Tok OraitPepa

StadiTaitel: Skelim save, pasinnapraktisbilongol mama long tambusutinsait lo West

SipikProvins, Papua Niugini (PNG).

DiaOl Mama,

Yu welkam long stap insait long dispela wok painimaut. As tingting

em lo painim save, pasinnapraktisbilongol mama lo tambusut. Askim i kam sapos yu ken

halivim long givim tingting bilong yu lo ol askim wei bai mi askim yu. Displa olaskim bai

long sait bilong save, pasinnapraktisbilongtambusut. Tingting wei bai yu i givim ba nonap gat

moni bilong em tasol ba i halivim long givimskultoktokinapim save

napasinbilongbringimbebi longkisimtambusut. Ba yui nonap bungim hevi lo taim bilong ol

dispela askim long wanem halivim bilong yu long givim stretpela tingting bilong yu bai i stap

namel long meri weii givim askimpepa na yu weiyu givim tingting. Yu ken lusimdispelastadi

ani taimsaposyulaik. Olgetatingtingyugivim bai halvim long saitbilonglainim and kisim save

lo hausiknaskul.

Sapos yu wabel long givim tingting bilong yu, bikpela tok tenkiu i kam longyu.

Bai mi putim han mak bilong mi long dispela pepa bilongsoimolsem mi wanbel long toktok

wei mi kisim

Nem: ………………………………………Han mak:……………………………

Dei:……………………………………………

Nem bilong merii askim: ……………………… Han mak: ………………………………

ID Namba: ………………………………………

Askim lo tokpisin

Nambabilongsikman………

1.Krimas: ………………………

1. Nambabilongpikinini: ………………….

77

2. Makbilongskul: 1 = Inoskul 2 = Elementari 3 = Primari 4 = High skul

5= Secondari

3. Makmoni: 1 = <50PNG KINA 2 = 50-100PNG KINA 3 = 100-500PNG KINA

4 = >500PNG KINA

4. As bilong save: 1 = Nius 2 = Neibor 3 = Wokman lo hausik 4 = Klinikbuk

5. Marit: 1 = Marit 2 = Man I dai 3 = 3= Man I lusimmeri 4 = Gat pikininitasolinomarit

6. Transport: 1 = PMV 2 = Wokabaut 3 = kampanikar 4 = Kar bilongfamili

7. Dicisen lo famili: 1 = Mama 2 = Papa

8.Ples u stap: 1 = settlemen long taun 2 = Bus 3 = Bik bus

Askim

Yes No

Tambu sut em I baninsim planti kain sik

Em I gutpela tru lon bebi I kisim tambu sut

Tambu bai apim banis bilon bodi lon paitim sik

Bebi mas kisim tambu sut bihainim ol taim gavman I makim antap

lon pepa olsem insait lon klinik buk bilon bebi

Em I gutpela tru lon givim tambu sut lo bel mama

Bel mama mas kisim tetanus tambu sut

Beb ino nap lo kisim tambu sut taim m igat bikpla skin hot

Skin hot, solap na pen bihainim tambu sut em ol mak tasol

bihainim tambu sut

Bebi sut em I seif

Bebi mas kisim bebi sut lon taim mama I karim em, wanpela mun,

tupelo mun, tripela mun, sixpela mun, nainpela mun na eightinpela

mun

Bebisutembilonbanisimbebilonstronpelasiklon kuru, siklonliva, sik

polio, bikpelakus , sikmiselsna rubella nainfeksonlonbulut

78

Save

Yes No

Bebi sut em gutpela

Bebi sut em seif

Yu toksave lon ol narapla lon kisim bebi go kisim bebi sut?

Bebi mas kisim bebi sut bihainim taim Gavman I makim?

Yu wanbel lo bebisut?

Bebi sapos lo kisim bebi sutin sait lon wanpela wik bihainim taim

mama I karem em?

I gat sampla pasin kastom we I banisim tingting blo yu lon kisim bebi

go kisim bebi sut?

Praktis

Yes No

Olgeta pikinini blon yu aninit lo 5pla krismas kisim bebi sut?

Yu putim kolwara lo laplap na putim antap lo hap we I solap

bihainim bebi sut?

Yu givim pen marasin blo solap na pen bihainim bebisut?

Yu toksave lo nas lon ol mak nogut bihainim bebisut?

Yu bihainim taim Gavman I makim lo kisim bebi sut?

79

Appendix III: Content Validity

Content Validity Index

1. Relevance

1=not relevant

2=relevant but need some revision

3=relevant but need minor revision

4=very relevant

2. Clarity

1=not clear

2=clear but need some revision

3=clear but need minor revision

4=very clear

3. Simplicity

1=not simple

2=simple but need some revision

3=simple but need minor revision

4=very simple

80

Item Relevance Clarity Simplicity Observation

Knowledge 1 2 3 4

□ □ □ □

1 2 3

4

□ □ □

□

1 2 3

4

□ □ □

□

1 Do you think

vaccination prevents

infectious diseases?

2 Is it important to

vaccinate your child?

3 Can vaccination

enhance immunity

and help the body

fight against

diseases?

4 Is completion of

vaccination as

scheduled

important?

5 Is it important to

receive vaccination

during pregnancy?

6 Is tetanus given

during pregnancy?

7 Vaccination should

not be given if a

child has fever

exceeding 38℃

8 Are fever, swelling

of injection site,

rashes and painful

injection site are the

site effects of

vaccination?

9 Vaccines for child

immunization are

safe

10 A child should be

vaccinated at: birth,

one month, two

months, three

months, six months,

nine months,

eighteen months,

81

seven and eleven

years

11 Vaccines are give in

prevention of

military tuberculosis,

meningitis, Hepatits

B, polio, diphtheria,

tetanus, pertussis,

pneumococcal

infections, measles

and rubella

Attitude Relevance

1 2 3 4

□ □ □ □

Clarity

1 2 3

4

□ □ □

□

Simplicity

1 2 3 4

□ □ □ □

Observation

12 Is vaccination

important?

13 Is vaccination

safe?

14 Will you

recommend

others to

vaccinate their

children?

15 Should

vaccination be

give according

to schedule?

16 Are you in favor

of vaccination?

17 Should

vaccination be

initiated in the

first week of

life?

18 Does your

culture have an

influence on

how you

perceive

immunization?

82

Practice Relevance

1 2 3 4

□ □ □ □

Clarity

1 2 3 4

□ □ □ □

Simplicity

1 2 3 4

□ □ □ □

Observation

19 Did you get all

your children

vaccinated?

20 Did you manage

swelling by cold

compress?

21 Did you use

analgesics for

swelling and

pain after

vaccination?

22 Did you report

the minor side

effects to the

nurse or health

worker?

23 Did you follow

the obligatory

vaccination

schedule?

83

Appendix IV: Permission Request for Instrument

Permission to use questionnaire

84

Appendix V: Data Collection Plan

Begin participant sampling

Explain study to participants

Agree Disagree

Give consent form to sign

Survey completed

Check data for completeness

Are all questions answered?

Yes No

Collect form and

thank participant

Ask to complete and check for

completeness

Stop

Administer questionnaire and

explain further if it needs

clarification

85

Appendix VI: Approval letter from Sandaun Provincial Hospital

86

Appendix VII: Approval letter and number from MRAC PNG