ABSTRACT
Background: Although vaccine hesitancy is a global concern, the evaluation on how fear of vaccination affects vaccination-related knowledge, behaviors, and perceptions is extremely scarce in developing countries. This study contributes to the literature by filling the knowledge gap on the fear of vaccination by focusing on Nigerian caregivers.
Methods: The study evaluates the correlation between fear of vaccination and knowledge, actual behaviors, and perception among caregivers in 11 settlements in the Jada local government area of Adamawa State, northeastern Nigeria. The data were collected in September 2019. We use logistic regression analysis to evaluate the correlation.
Results and Discussions: About 15% of caregivers have some form of fear regarding vaccination. However, such fear is not correlated with most of the socio-demographic characteristics among caregivers. Fear is significantly correlated with the lack of accurate vaccination knowledge, with a lower likelihood of vaccination uptake for their children, and with the lack of perceptions of vaccination importance and intention to vaccinate their children. Results from our study are consistent with findings from existing studies conducted in developed countries.
KEYWORDS: Fear, knowledge, vaccination, perceptions, Nigeria
Introduction
Vaccine hesitancy, which is a delay in acceptance or refusal of vaccines despite the availability of vaccination services, is increasing a global concern.1
For example, the recent measles outbreak in New York City in 2019 is considered at least partially due to the vaccine hesitancy. It is believed that there is a large proportion of children who are unvaccinated in a certain community in New York, due to misinformation that vaccines cause harm such as autism.2
Not only the misperceptions of vaccine efficacy but also the actual pain due to needle injection is contributing to the vaccine hesitancy.3 It is estimated that 10% of population in developed countries have needle phobia which prevents them from vaccinating.4 Another study showed that 24% of parents reported fear of needles that lead to immunization noncompliance.5
While there is extensive research done around fear of vaccination in developed countries, the evidence on fear around vaccination is rather scarce in developing countries, especially in African countries.6 Lane et al.,7conducted a global analysis of the prevalence of vaccine hesitancy and reasons of vaccine hesitancy. They found that most of the reasons for vaccine hesitancy identified in developing countries are not based on an assessment but merely an opinion. Thus, there needs a more rigorous assessment to evaluate the prevalence of vaccine hesitancy.
Despite the limited rigorous evidence, there are descriptions and incidences that imply that the vaccine hesitancy is prevalent in developing countries. For example, in the study site of the present study, Nigeria, Islamic leaders famously boycotted the polio vaccination campaign in 2003, due to the distrust of vaccine efficacy.8 Nigeria, despite its economic power as compared to its neighboring countries, struggles with its low vaccination rate. For example, Nigeria has a similar level of GDP per capita as that of Ghana, one of the neighboring countries.9 However, the DPT3 uptake is merely 57% in Nigeria, while it reaches 97% in Ghana in 2018.10 It is believed that one of the reasons of immunization noncompliance in Nigeria is vaccine hesitancy.11
The present study contributes to the literature by providing one of the first evidence on how the vaccine hesitancy, especially the fear of vaccination, is correlated with knowledge, behaviors, and perceptions around vaccination among Nigerian women.
Methods
Study area
This study was conducted in 11 settlements in the Jada local government area of Adamawa State, in the northeastern region of Nigeria, in September 2019. All of 11 settlements were under the catchment area of one health clinic, Jada I PHCC (Primary Health Care Clinic). In each settlement, one woman from each household was selected. Our interviewers visited all the households in each settlement to identify the eligible women. The eligibility criteria were that a mother had a child who was 8 months old or younger at the time of baseline survey. If one household had more than one mother with such children, interviewers randomly selected one of them per household.
The vaccination status among these children aged 8 months old and younger was one of the main focus of our study. Although unlikely, in case women had more than one child aged 8 months or younger, we asked the vaccination status and behaviors among the youngest child.
We chose the age range of 8 months and younger to simplify the procedure to identify the eligible respondents. The study aimed to identify children who had not received all the vaccinations, in order to evaluate how our program influenced their caregivers’ decision for vaccination. Then, focusing on children aged 8 months or younger simplifies the selection process because all of such children still need to receive measles and yellow fever vaccines at the age of 9 months.
Our sample included 412 women from 11 settlements.
Procedures
The questionnaire was administered to all the eligible women who agreed to participate (refusal rate: 0.37%). Administering the questionnaire took about 30 min per respondent.
The questionnaire had four sections: eligibility, background, vaccination behavior, knowledge on vaccination (see Appendix A). The fourth section was to evaluate women’s knowledge and perceptions on child vaccination. In this section, we asked the series of questions to evaluate their knowledge on vaccination such as the number of recommended types of vaccination and timing of critical vaccinations. All the questions to evaluate their knowledge asked each respondent to provide specific numbers. For example, for the number of recommended types of vaccination, we asked “how many types of vaccines does a child need to receive before 12 months old, excluding 12 months?” Then, we had respondents answer the number without interviewers providing any possible choices. We had a similar format for the timing of critical vaccinations. For example, one of the questions we asked was “when is the first time a child needs to receive a vaccine?” We had respondents answer by filling the blank in the following sentence orally: when a child is _______ months old.
We also asked if women were afraid of four components of vaccination separately; 1) needles of injections, 2) side effects of vaccination, 3) that vaccines have no benefit in preventing diseases, 4) that vaccines might be harmful. Through these questions, the extent of perceived fear was assessed in scale. In particular, we provided four scales to measure how fearful the respondents were for each category: not at all afraid, not too much afraid, a little afraid, very much afraid. We only measured the fear around these four categories for general vaccination, and the potential fear in other aspects or for particular vaccines was not assessed.
We also collected sociodemographic information of caregivers and households, as well as vaccination status of the two youngest children under 5 years old. The vaccination status was collected based on the records at immunization card. If caregivers did not have the immunization card, then we relied on caregivers’ self-report. In case caregivers did not recall whether a child received a certain vaccine or not, we recorded the vaccination status as unknown. The vaccination status of the two youngest children was collected to observe the pattern of vaccination behavior by caregivers. We limited to the vaccination status of two youngest children under 5 years old, firstly because we were interested in the recent vaccination pattern. Secondly, most mothers have a maximum of two children under 5 years old; thus, we decided to focus only on two youngest children.
Finally, we also collected caregivers’ perceptions and intentions of child vaccination. For example, we have asked caregivers “How important is it for you that your children complete all the vaccination?”, and they could answer from one of the predetermined scales: not important at all, not too important, a little bit important, and very important. For the intentions, we asked “How likely do you think that your youngest child will be completely vaccinated?”, and the answer was chosen from one of the four scales: not likely at all, not too likely, a little likely, and very likely.
Statistical analysis
The primary objective of this study is to evaluate how mothers’ fear of vaccination is correlated with their vaccination knowledge, actual vaccination status of their children, and perceptions. We use four indicators described above to capture different types of fear: fear of needles, fear of side effects, fear that vaccine has no effect, and fear that vaccine does harm.
We use the logistic regressions to assess the correlations between fear and knowledge, between fear and actual vaccination behaviors, and between fear and perceptions.
Results
Table 1 presents the descriptive statistics of fear indicators. About 18% of the mothers have fear of needles (17.7%) and fear of side effects (18.4%) respectively. A slightly lower percentage of women has the fear that vaccine has no benefit in disease prevention (13.6%) and that vaccine does harm (13.3%). Table 1 columns 3 to 6 presents the correlation matrix among these fear indicators. We observe two patterns. First, the correlation between fear of needles and fear of side effects is high. Second, the correlation between fear that vaccine has no benefit and fear that vaccine does harm is high.
Table 1.
Summary statistics of fear indicators
| Correlation matrix |
||||||
|---|---|---|---|---|---|---|
| Mean (1) | Std Dev (2) | Fear of Needles (3) | Fear of Side Effects (4) | Fear that Vaccine Has no Benefit (5) | Fear that Vaccine Does harm (6) | |
| Fear of needles | 0.177 | 0.382 | 1 | |||
| Fear of side effects | 0.184 | 0.388 | 0.4349 | 1 | ||
| Fear that vaccine has no benefit | 0.136 | 0.343 | 0.1869 | 0.2314 | 1 | |
| Fear that vaccine does harm | 0.133 | 0.341 | 0.2851 | 0.3285 | 0.6565 | 1 |
The number of observations is 412 caregivers who have a child of 8 months old and younger.
Table 2 presents the determinants of fear indicators. Overall, almost no demographic characteristic is correlated with any of fear indicators; education attainment, number of children, working status, and recent experiences of children’s vaccination are not correlated with fear significantly. The exception is mothers’ age. For fear that vaccine has no benefit, women aged 26 to 35 had higher odds of having the fear, as compared to women aged 20 or younger. For fear that vaccine does harm, women aged 21 to 25 had lower odds of having the fear, as compared to women aged 20 or younger.
Table 2.
Determinants of fear
| Fear of needles(1) | Fear of side Effects(2) | Fear that vaccine Has no Benefit(3) | Fear that Vaccine does Harm(4) | |
|---|---|---|---|---|
| Age (control: 20 or below) | ||||
| 21–25 | 0.731 | 0.973 | 0.757 | 0.340** |
| [0.360,1.481] | [0.496,1.908] | [0.297,1.927] | [0.126,0.916] | |
| 26–30 | 0.845 | 0.525 | 2.416** | 1.861 |
| [0.387,1.845] | [0.226,1.221] | [1.018,5.734] | [0.823,4.204] | |
| 31–35 | 0.680 | 1.363 | 2.369* | 1.270 |
| [0.258,1.792] | [0.604,3.077] | [0.921,6.093] | [0.485,3.323] | |
| 36 or above | 0.574 | 1.092 | 1.348 | 1.604 |
| [0.194,1.697] | [0.435,2.739] | [0.476,3.820] | [0.545,4.722] | |
| Education (control: none) | ||||
| Some primary | 0.805 | 0.809 | 0.645 | 1.039 |
| [0.404,1.603] | [0.404,1.619] | [0.274,1.520] | [0.473,2.283] | |
| Secondary and higher | 0.684 | 0.714 | 0.894 | 0.982 |
| [0.362,1.290] | [0.381,1.340] | [0.436,1.833] | [0.479,2.014] | |
| Number of children | 1.051 | 1.017 | 1.043 | 0.918 |
| [0.911,1.213] | [0.888,1.164] | [0.896,1.213] | [0.782,1.079] | |
| Number of children under 5 | 0.909 | 0.706 | 0.753 | 1.016 |
| [0.536,1.541] | [0.389,1.280] | [0.391,1.450] | [0.542,1.904] | |
| Has Paid work | 0.776 | 0.784 | 0.631 | 0.777 |
| [0.446,1.353] | [0.454,1.353] | [0.337,1.181] | [0.416,1.451] | |
| Child vaccination in the past 5 years | 1.266 | 0.777 | 0.649 | 0.731 |
| [0.523,3.061] | [0.277,2.177] | [0.199,2.123] | [0.239,2.230] | |
| N | 397 | 397 | 397 | 397 |
The analysis sample is caregivers who have a child of 8 months old and younger and have no missing information on covariates. The result is based on the logistic regression. * significant at 10% ** significant at 5% *** significant at 1%.
Table 3 presents the correlation between fear indicators and mothers’ knowledge level on vaccination. We tested the correlations between fear and four knowledge indicators on; the number of vaccine-antigen types required for full vaccination, the number of minimum clinic visits for full vaccination, the timing of the first vaccination, and the timing of measles vaccination. The knowledge indicators are dummy variables that take one if the answer is correct and zero otherwise. Fear of needles is negatively correlated with all four knowledge indicators; if a woman has fear of needles, the odds of them having the correct vaccination knowledge is lowered by 60% to 70% (columns 1, 5, 9, 13). Fear of side effects has a similar trend but somewhat weaker; if a woman has fear of side effects, the odds of them having the correct knowledge is lowered by 40% to 50% (columns 2, 6, 10, 14). Fear that vaccine has no benefit and fear that vaccine does harm are strongly and negatively correlated with the correct knowledge on the first vaccination timing (columns 11 and 12) but not with other knowledge indicators.
Table 3.
Correlation between fear and knowledge
| Correct Answers |
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| # Vaccine Types |
# Clinic Visits for vaccination |
||||||||
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | |
| Fear of needles | 0.429* | 0.435*** | 0.446** | ||||||
| [0.174,1.057] | [0.241,0.785] | [0.234,0.849] | |||||||
| Fear of side effects | 0.547 | 0.573* | |||||||
| [0.234,1.281] | [0.327,1.004] | ||||||||
| Fear that vaccine has no benefit | 0.769 | 0.537* | |||||||
| [0.320,1.849] | [0.283,1.022] | ||||||||
| Fear that vaccine does harm | 1.016 | 0.594 | |||||||
| [0.438,2.357] | [0.311,1.133] | ||||||||
| Age (control: 20 or below) | |||||||||
| 21–25 | 1.046 | 1.086 | 1.091 | 1.095 | 1.427 | 1.480 | 1.471 | 1.426 | 0.888 |
| [0.493,2.222] | [0.513,2.298] | [0.516,2.305] | [0.517,2.319] | [0.810,2.516] | [0.843,2.598] | [0.838,2.582] | [0.812,2.504] | [0.438,1.803] | |
| 26–30 | 1.245 | 1.243 | 1.333 | 1.297 | 1.897* | 1.842* | 2.061** | 1.992** | 1.033 |
| [0.538,2.880] | [0.541,2.858] | [0.578,3.071] | [0.564,2.985] | [0.999,3.602] | [0.975,3.480] | [1.086,3.913] | [1.054,3.767] | [0.470,2.271] | |
| 31–35 | 0.460 | 0.486 | 0.496 | 0.482 | 0.843 | 0.914 | 0.950 | 0.905 | 0.618 |
| [0.141,1.501] | [0.148,1.595] | [0.151,1.633] | [0.147,1.583] | [0.404,1.761] | [0.439,1.904] | [0.455,1.983] | [0.436,1.882] | [0.266,1.433] | |
| 36 or above | 0.902 | 1.005 | 1.014 | 1.013 | 1.316 | 1.400 | 1.437 | 1.434 | 0.786 |
| [0.268,3.035] | [0.300,3.364] | [0.301,3.410] | [0.302,3.403] | [0.581,2.979] | [0.620,3.161] | [0.635,3.248] | [0.636,3.232] | [0.307,2.008] | |
| Education (control: none) | |||||||||
| Some primary | 0.460* | 0.465* | 0.466* | 0.471* | 1.866** | 1.854** | 1.814** | 1.856** | 2.929*** |
| [0.200,1.056] | [0.203,1.066] | [0.203,1.067] | [0.206,1.079] | [1.066,3.265] | [1.064,3.232] | [1.041,3.159] | [1.067,3.230] | [1.347,6.369] | |
| Secondary and higher | 0.688 | 0.695 | 0.707 | 0.708 | 1.509 | 1.516* | 1.525* | 1.540* | 1.779* |
| [0.359,1.319] | [0.364,1.327] | [0.371,1.347] | [0.372,1.348] | [0.920,2.475] | [0.927,2.480] | [0.932,2.497] | [0.942,2.519] | [0.950,3.328] | |
| Number of children | 1.000 | 0.993 | 0.988 | 0.986 | 1.087 | 1.084 | 1.082 | 1.076 | 0.878* |
| [0.856,1.168] | [0.852,1.157] | [0.847,1.152] | [0.845,1.150] | [0.971,1.216] | [0.969,1.212] | [0.968,1.210] | [0.962,1.203] | [0.769,1.002] | |
| Number of children under 5 | 1.381 | 1.368 | 1.388 | 1.403 | 0.617** | 0.611** | 0.617** | 0.621** | 3.059*** |
| [0.829,2.300] | [0.821,2.282] | [0.833,2.312] | [0.842,2.336] | [0.397,0.958] | [0.394,0.949] | [0.398,0.956] | [0.401,0.962] | [1.473,6.353] | |
| Has Paid work | 0.711 | 0.712 | 0.716 | 0.726 | 0.843 | 0.852 | 0.846 | 0.862 | 1.734* |
| [0.393,1.286] | [0.394,1.287] | [0.397,1.291] | [0.403,1.307] | [0.544,1.304] | [0.552,1.316] | [0.548,1.307] | [0.559,1.328] | [0.996,3.020] | |
| Child vaccination in the past 5 years | 0.706 | 0.679 | 0.690 | 0.694 | 1.270 | 1.212 | 1.207 | 1.238 | 2.424 |
| [0.278,1.791] | [0.269,1.714] | [0.274,1.735] | [0.276,1.747] | [0.617,2.612] | [0.592,2.478] | [0.589,2.471] | [0.606,2.531] | [0.619,9.496] | |
| N | 382 | 382 | 382 | 382 | 384 | 384 | 384 | 384 | 391 |
| Correct Answers |
|||||||
|---|---|---|---|---|---|---|---|
| The first vaccine timing |
Measles vaccine timing |
||||||
| (10) | (11) | (12) | (13) | (14) | (15) | (16) | |
| Fear of needles | 0.303*** | ||||||
| [0.168,0.547] | |||||||
| Fear of side effects | 0.323*** | 0.513** | |||||
| [0.177,0.589] | [0.296,0.889] | ||||||
| Fear that vaccine has no benefit | 0.374*** | 0.983 | |||||
| [0.191,0.733] | [0.521,1.855] | ||||||
| Fear that vaccine does harm | 0.361*** | 0.720 | |||||
| [0.181,0.722] | [0.380,1.364] | ||||||
| Age (control: 20 or below) | |||||||
| 21–25 | 0.920 | 0.915 | 0.833 | 1.080 | 1.130 | 1.129 | 1.102 |
| [0.450,1.882] | [0.451,1.856] | [0.407,1.704] | [0.608,1.916] | [0.642,1.987] | [0.645,1.979] | [0.627,1.935] | |
| 26–30 | 0.932 | 1.208 | 1.152 | 1.912* | 1.834* | 1.936** | 1.990** |
| [0.417,2.082] | [0.540,2.700] | [0.517,2.568] | [0.984,3.713] | [0.954,3.528] | [1.009,3.713] | [1.037,3.819] | |
| 31–35 | 0.675 | 0.719 | 0.657 | 0.944 | 1.063 | 1.061 | 1.058 |
| [0.287,1.584] | [0.310,1.668] | [0.284,1.520] | [0.448,1.989] | [0.510,2.215] | [0.511,2.203] | [0.510,2.195] | |
| 36 or above | 0.866 | 0.911 | 0.892 | 0.697 | 0.770 | 0.783 | 0.795 |
| [0.332,2.259] | [0.356,2.328] | [0.350,2.278] | [0.303,1.604] | [0.338,1.756] | [0.346,1.775] | [0.350,1.804] | |
| Education (control: none) | |||||||
| Some primary | 2.852*** | 2.800*** | 2.948*** | 1.838** | 1.826** | 1.834** | 1.844** |
| [1.307,6.224] | [1.283,6.111] | [1.348,6.444] | [1.022,3.305] | [1.026,3.252] | [1.037,3.244] | [1.042,3.264] | |
| Secondary and higher | 1.771* | 1.814* | 1.840* | 2.155*** | 2.166*** | 2.190*** | 2.207*** |
| [0.937,3.348] | [0.966,3.407] | [0.978,3.463] | [1.291,3.599] | [1.304,3.595] | [1.323,3.625] | [1.332,3.659] | |
| Number of children | 0.870** | 0.872** | 0.861** | 1.129** | 1.121* | 1.112* | 1.110* |
| [0.760,0.997] | [0.763,0.997] | [0.753,0.984] | [1.003,1.271] | [0.997,1.261] | [0.991,1.249] | [0.988,1.246] | |
| Number of children under 5 | 2.921*** | 2.841*** | 2.905*** | 0.684* | 0.683* | 0.711 | 0.705 |
| [1.408,6.057] | [1.391,5.801] | [1.428,5.911] | [0.439,1.067] | [0.440,1.059] | [0.460,1.098] | [0.457,1.090] | |
| Has Paid work | 1.755** | 1.722* | 1.762** | 1.231 | 1.241 | 1.260 | 1.253 |
| [1.000,3.079] | [0.986,3.006] | [1.010,3.074] | [0.785,1.932] | [0.797,1.932] | [0.811,1.959] | [0.807,1.946] | |
| Child vaccination in the past 5 years | 2.280 | 2.312 | 2.381 | 1.084 | 0.992 | 1.005 | 1.005 |
| [0.578,8.995] | [0.589,9.078] | [0.606,9.354] | [0.517,2.275] | [0.479,2.054] | [0.487,2.075] | [0.487,2.074] | |
| N | 391 | 391 | 391 | 380 | 380 | 380 | 380 |
The analysis sample is caregivers who have a child of 8 months old and younger and have no missing information on covariates. The result is based on the logistic regression. * significant at 10% ** significant at 5% *** significant at 1%.
Other socio-demographic characteristics such as higher educational attainment and the number of children under five are also positively correlated with some of the knowledge indicators.
Table 4 presents the correlation between fear indicators and the actual vaccination status among mothers’ youngest children. Here, we find the strong and consistent results that no matter which fear indicators used, they are all negatively correlated with the likelihood of vaccination. For example, fear of needles is associated with the lower odds that a child completes the vaccination at birth by 77% (column 1). This negative correlation is persistent for vaccination behaviors for any timing; at birth, at 6 weeks, 10 weeks, and 14 weeks.
Table 4.
Correlation between fear and vaccination
| Completed Vacination at birth (BCG, OPV0, HepB) |
Completed Vacination at 6week (OPV1, Penta1, PCV1) |
|||||||
|---|---|---|---|---|---|---|---|---|
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | |
| Fear of needles | 0.230*** | 0.326*** | ||||||
| [0.130,0.407] | [0.184,0.576] | |||||||
| Fear of side effects | 0.344*** | 0.411*** | ||||||
| [0.199,0.597] | [0.238,0.710] | |||||||
| Fear that vaccine has no benefit | 0.365*** | 0.509** | ||||||
| [0.196,0.682] | [0.272,0.950] | |||||||
| Fear that vaccine does harm | 0.290*** | 0.424*** | ||||||
| [0.155,0.546] | [0.225,0.796] | |||||||
| Age (control: 20 or below) | ||||||||
| 21–25 | 1.228 | 1.381 | 1.371 | 1.223 | 0.764 | 0.847 | 0.835 | 0.785 |
| [0.629,2.398] | [0.717,2.660] | [0.717,2.624] | [0.634,2.362] | [0.416,1.402] | [0.465,1.543] | [0.461,1.513] | [0.431,1.429] | |
| 26–30 | 0.868 | 0.898 | 1.118 | 1.099 | 0.724 | 0.738 | 0.859 | 0.843 |
| [0.410,1.835] | [0.429,1.880] | [0.537,2.327] | [0.523,2.309] | [0.362,1.449] | [0.370,1.471] | [0.433,1.704] | [0.424,1.676] | |
| 31–35 | 0.738 | 1.004 | 1.097 | 1.003 | 0.518 | 0.654 | 0.688 | 0.648 |
| [0.304,1.791] | [0.423,2.386] | [0.464,2.591] | [0.424,2.378] | [0.227,1.181] | [0.291,1.469] | [0.307,1.544] | [0.289,1.453] | |
| 36 or above | 0.622 | 0.929 | 0.978 | 0.947 | 1.062 | 1.392 | 1.429 | 1.394 |
| [0.185,2.087] | [0.280,3.089] | [0.298,3.206] | [0.288,3.113] | [0.340,3.315] | [0.448,4.324] | [0.465,4.394] | [0.454,4.281] | |
| Education (control: none) | ||||||||
| Some primary | 1.549 | 1.540 | 1.523 | 1.616 | 1.308 | 1.301 | 1.293 | 1.326 |
| [0.847,2.835] | [0.851,2.789] | [0.845,2.746] | [0.890,2.933] | [0.749,2.286] | [0.748,2.264] | [0.746,2.242] | [0.763,2.303] | |
| Secondary and higher | 2.894*** | 2.838*** | 3.021*** | 3.056*** | 2.196*** | 2.158*** | 2.239*** | 2.278*** |
| [1.626,5.153] | [1.611,5.001] | [1.714,5.325] | [1.728,5.402] | [1.326,3.637] | [1.308,3.561] | [1.361,3.683] | [1.383,3.753] | |
| Number of children | 1.039 | 1.012 | 1.015 | 0.999 | 0.982 | 0.968 | 0.969 | 0.963 |
| [0.909,1.188] | [0.888,1.155] | [0.891,1.157] | [0.876,1.139] | [0.870,1.108] | [0.858,1.091] | [0.860,1.091] | [0.855,1.085] | |
| Number of children under 5 | 0.614** | 0.610** | 0.616** | 0.638** | 0.609** | 0.604** | 0.615** | 0.627** |
| [0.389,0.971] | [0.390,0.956] | [0.395,0.962] | [0.408,1.000] | [0.398,0.930] | [0.395,0.922] | [0.404,0.937] | [0.411,0.956] | |
| Has Paid work | 1.275 | 1.265 | 1.247 | 1.284 | 1.247 | 1.240 | 1.232 | 1.237 |
| [0.776,2.094] | [0.778,2.057] | [0.769,2.024] | [0.789,2.090] | [0.796,1.954] | [0.795,1.935] | [0.791,1.918] | [0.793,1.929] | |
| Child vaccination in the past 5 years | 2.224* | 2.010* | 2.027* | 1.997* | 1.961* | 1.830 | 1.833 | 1.823 |
| [0.977,5.059] | [0.894,4.518] | [0.902,4.555] | [0.888,4.492] | [0.940,4.093] | [0.879,3.812] | [0.882,3.808] | [0.877,3.790] | |
| N | 397 | 397 | 397 | 397 | 391 | 391 | 391 | 391 |
| Completed Vacination at 10week (OPV2, Penta2, PCV2) |
Completed Vacination at 14week (OPV3, Penta3, PCV3) |
|||||||
|---|---|---|---|---|---|---|---|---|
| (9) | (10) | (11) | (12) | (13) | (14) | (15) | (16) | |
| Fear of needles | 0.379*** | 0.304*** | ||||||
| [0.208,0.691] | [0.150,0.613] | |||||||
| Fear of side effects | 0.459*** | 0.544** | ||||||
| [0.260,0.808] | [0.299,0.991] | |||||||
| Fear that vaccine has no benefit | 0.529* | 0.484* | ||||||
| [0.276,1.013] | [0.234,1.001] | |||||||
| Fear that vaccine does harm | 0.412*** | 0.411** | ||||||
| [0.211,0.804] | [0.195,0.866] | |||||||
| Age (control: 20 or below) | ||||||||
| 21–25 | 0.901 | 0.971 | 0.943 | 0.886 | 1.051 | 1.121 | 1.094 | 1.031 |
| [0.500,1.627] | [0.540,1.745] | [0.526,1.689] | [0.493,1.595] | [0.570,1.940] | [0.612,2.051] | [0.597,2.002] | [0.562,1.892] | |
| 26–30 | 0.686 | 0.689 | 0.779 | 0.759 | 0.818 | 0.828 | 0.934 | 0.898 |
| [0.347,1.357] | [0.350,1.357] | [0.396,1.531] | [0.385,1.494] | [0.401,1.671] | [0.409,1.675] | [0.461,1.894] | [0.443,1.820] | |
| 31–35 | 0.699 | 0.836 | 0.863 | 0.816 | 0.777 | 0.923 | 0.981 | 0.916 |
| [0.311,1.572] | [0.374,1.869] | [0.386,1.932] | [0.365,1.824] | [0.330,1.831] | [0.396,2.151] | [0.417,2.306] | [0.392,2.142] | |
| 36 or above | 0.790 | 0.967 | 0.982 | 0.959 | 0.818 | 1.000 | 1.036 | 1.001 |
| [0.261,2.392] | [0.321,2.917] | [0.327,2.945] | [0.320,2.878] | [0.248,2.695] | [0.306,3.265] | [0.316,3.396] | [0.306,3.268] | |
| Education (control: none) | ||||||||
| Some primary | 1.217 | 1.218 | 1.205 | 1.232 | 1.262 | 1.256 | 1.229 | 1.259 |
| [0.694,2.133] | [0.697,2.130] | [0.691,2.104] | [0.704,2.154] | [0.694,2.293] | [0.695,2.268] | [0.680,2.221] | [0.696,2.277] | |
| Secondary and higher | 1.362 | 1.328 | 1.381 | 1.409 | 1.465 | 1.452 | 1.484 | 1.517 |
| [0.834,2.223] | [0.814,2.166] | [0.850,2.244] | [0.865,2.294] | [0.876,2.451] | [0.872,2.419] | [0.893,2.468] | [0.911,2.527] | |
| Number of children | 0.983 | 0.972 | 0.973 | 0.970 | 0.956 | 0.947 | 0.947 | 0.945 |
| [0.871,1.109] | [0.862,1.096] | [0.864,1.097] | [0.861,1.093] | [0.839,1.089] | [0.833,1.077] | [0.833,1.077] | [0.831,1.075] | |
| Number of children under 5 | 0.523*** | 0.518*** | 0.527*** | 0.532*** | 0.538** | 0.544** | 0.549** | 0.555** |
| [0.331,0.827] | [0.328,0.820] | [0.334,0.832] | [0.336,0.843] | [0.324,0.892] | [0.329,0.900] | [0.332,0.907] | [0.335,0.921] | |
| Has Paid work | 1.101 | 1.084 | 1.082 | 1.084 | 0.825 | 0.827 | 0.812 | 0.816 |
| [0.707,1.715] | [0.697,1.686] | [0.697,1.680] | [0.698,1.685] | [0.516,1.318] | [0.520,1.315] | [0.510,1.294] | [0.512,1.298] | |
| Child vaccination in the past 5 years | 2.127** | 1.988* | 1.978* | 1.984* | 1.944 | 1.768 | 1.752 | 1.766 |
| [1.010,4.479] | [0.946,4.176] | [0.945,4.143] | [0.945,4.166] | [0.865,4.369] | [0.797,3.924] | [0.791,3.882] | [0.795,3.922] | |
| N | 386 | 386 | 386 | 386 | 383 | 383 | 383 | 383 |
The analysis sample is caregivers who have a child of 8 months old and younger and have no missing information on covariates. The result is based on the logistic regression. * significant at 10% ** significant at 5% *** significant at 1%.
Interestingly, higher educational attainment was positively correlated with the vaccination only at the earlier stage; at birth and at 6 weeks, but not at the later stage. The higher number of children under five was consistently and negatively correlated with the vaccination uptake of the youngest children, regardless of the timing of vaccination.
Table 5 presents the correlation between fear indicators and perceptions. We have four indicators of perceptions; 1) belief that her child has received all the required vaccinations so far, 2) belief that it is important to complete vaccination in general, 3) belief that it is common that children, in general, receive full vaccination in Jada LGA, and 4) belief that it is likely that her children will receive full vaccination. Fear indicators are negatively correlated with the belief that their children had received all the vaccination (columns 1 to 4). For example, fear of needles decreases the odds of the belief by 76.6%. All the fear indicators are negatively correlated with the odds that mothers think it is important to complete vaccination; fear that vaccine has no benefit decreases the odds of having this perception by up to 64% (columns 5 to 8).
Table 5.
Correlation between fear and perceptions
| Believe that child has received all vaccines so far |
Important to Complete vaccination |
|||||||
|---|---|---|---|---|---|---|---|---|
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | |
| Fear of needles | 0.234*** | 0.342*** | ||||||
| [0.128,0.428] | [0.154,0.760] | |||||||
| Fear of side effects | 0.273*** | 0.333*** | ||||||
| [0.154,0.486] | [0.151,0.735] | |||||||
| Fear that vaccine has no benefit | 0.881 | 0.159*** | ||||||
| [0.478,1.626] | [0.070,0.360] | |||||||
| Fear that vaccine does harm | 0.441** | 0.168*** | ||||||
| [0.234,0.831] | [0.073,0.389] | |||||||
| Age (control: 20 or below) | ||||||||
| 21–25 | 1.557 | 1.687* | 1.627* | 1.526 | 0.648 | 0.688 | 0.676 | 0.528 |
| [0.875,2.770] | [0.950,2.994] | [0.931,2.842] | [0.869,2.680] | [0.216,1.940] | [0.231,2.047] | [0.221,2.066] | [0.168,1.657] | |
| 26–30 | 1.186 | 1.125 | 1.235 | 1.297 | 0.365* | 0.345* | 0.503 | 0.464 |
| [0.622,2.261] | [0.593,2.137] | [0.659,2.316] | [0.688,2.444] | [0.116,1.148] | [0.109,1.092] | [0.154,1.643] | [0.139,1.549] | |
| 31–35 | 1.252 | 1.488 | 1.394 | 1.390 | 0.190** | 0.227** | 0.290* | 0.217** |
| [0.602,2.606] | [0.713,3.105] | [0.682,2.849] | [0.679,2.847] | [0.047,0.772] | [0.058,0.883] | [0.072,1.175] | [0.052,0.901] | |
| 36 or above | 1.190 | 1.374 | 1.319 | 1.376 | 2.698 | 2.898 | 3.277 | 3.406 |
| [0.529,2.679] | [0.606,3.117] | [0.597,2.915] | [0.619,3.058] | [0.547,13.308] | [0.599,14.018] | [0.638,16.823 | [0.662,17.537] | |
| Education (control: none) | ||||||||
| Some primary | 1.426 | 1.430 | 1.435 | 1.450 | 1.817 | 1.828 | 1.590 | 1.766 |
| [0.818,2.486] | [0.823,2.484] | [0.836,2.461] | [0.842,2.497] | [0.635,5.197] | [0.639,5.232] | [0.541,4.680] | [0.601,5.190] | |
| Secondary and higher | 2.349*** | 2.387*** | 2.387*** | 2.421*** | 3.202** | 3.257** | 3.599** | 3.412** |
| [1.405,3.928] | [1.432,3.977] | [1.452,3.923] | [1.467,3.995] | [1.146,8.951] | [1.161,9.138] | [1.247,10.382 | [1.192,9.767] | |
| Number of children | 0.973 | 0.967 | 0.967 | 0.959 | 1.123 | 1.107 | 1.123 | 1.076 |
| [0.869,1.090] | [0.864,1.082] | [0.867,1.080] | [0.858,1.072] | [0.909,1.388] | [0.897,1.366] | [0.901,1.399] | [0.862,1.344] | |
| Number of children under 5 | 0.572** | 0.551*** | 0.598** | 0.596** | 1.006 | 0.944 | 0.914 | 1.074 |
| [0.371,0.882] | [0.356,0.854] | [0.391,0.913] | [0.388,0.915] | [0.451,2.241] | [0.430,2.072] | [0.402,2.082] | [0.476,2.423] | |
| Has Paid work | 1.028 | 1.040 | 1.070 | 1.058 | 1.757 | 1.720 | 1.568 | 1.708 |
| [0.660,1.603] | [0.669,1.616] | [0.696,1.645] | [0.687,1.631] | [0.784,3.939] | [0.769,3.846] | [0.687,3.579] | [0.753,3.873] | |
| Child vaccination in the past 5 years | 2.018* | 1.849 | 1.836 | 1.821 | 2.649 | 2.582 | 2.471 | 2.207 |
| [0.961,4.235] | [0.884,3.868] | [0.890,3.788] | [0.880,3.768] | [0.495,14.184] | [0.484,13.782] | [0.449,13.616 | [0.400,12.185] | |
| N | 394 | 394 | 394 | 394 | 397 | 397 | 397 | 397 |
| Common that children receive full vaccination |
Likely that my child receive all vaccination |
|||||||
|---|---|---|---|---|---|---|---|---|
| (9) | (10) | (11) | (12) | (13) | (14) | (15) | (16) | |
| Fear of needles | 0.600* | 0.112*** | ||||||
| [0.348,1.036] | [0.058,0.214] | |||||||
| Fear of side effects | 0.882 | 0.174*** | ||||||
| [0.515,1.510] | [0.091,0.333] | |||||||
| Fear that vaccine has no benefit | 0.989 | 0.154*** | ||||||
| [0.531,1.842] | [0.075,0.314] | |||||||
| Fear that vaccine does harm | 0.563* | 0.149*** | ||||||
| [0.302,1.049] | [0.074,0.302] | |||||||
| Age (control: 20 or below) | ||||||||
| 21–25 | 1.304 | 1.333 | 1.334 | 1.273 | 1.094 | 1.249 | 1.181 | 0.958 |
| [0.744,2.288] | [0.763,2.330] | [0.763,2.331] | [0.726,2.232] | [0.458,2.615] | [0.539,2.897] | [0.515,2.708] | [0.411,2.233] | |
| 26–30 | 0.940 | 0.940 | 0.952 | 0.991 | 0.754 | 0.726 | 1.132 | 1.085 |
| [0.500,1.770] | [0.500,1.770] | [0.505,1.794] | [0.525,1.870] | [0.293,1.941] | [0.287,1.838] | [0.446,2.870] | [0.421,2.794] | |
| 31–35 | 1.763 | 1.802 | 1.791 | 1.844 | 0.502 | 0.712 | 0.886 | 0.699 |
| [0.838,3.709] | [0.860,3.776] | [0.851,3.767] | [0.875,3.884] | [0.158,1.599] | [0.245,2.071] | [0.303,2.593] | [0.237,2.058] | |
| 36 or above | 0.719 | 0.751 | 0.749 | 0.771 | 1.013 | 1.308 | 1.375 | 1.465 |
| [0.315,1.639] | [0.331,1.704] | [0.330,1.700] | [0.338,1.758] | [0.272,3.773] | [0.378,4.528] | [0.404,4.685] | [0.424,5.062] | |
| Education (control: none) | ||||||||
| Some primary | 0.604* | 0.616* | 0.619* | 0.614* | 0.617 | 0.669 | 0.611 | 0.693 |
| [0.345,1.058] | [0.353,1.075] | [0.355,1.081] | [0.351,1.073] | [0.278,1.367] | [0.311,1.440] | [0.286,1.306] | [0.323,1.487] | |
| Secondary and higher | 1.067 | 1.090 | 1.099 | 1.090 | 1.409 | 1.477 | 1.660 | 1.697 |
| [0.649,1.755] | [0.665,1.789] | [0.671,1.800] | [0.664,1.791] | [0.636,3.126] | [0.680,3.207] | [0.761,3.620] | [0.777,3.705] | |
| Number of children | 1.036 | 1.033 | 1.033 | 1.026 | 1.139 | 1.102 | 1.118 | 1.070 |
| [0.925,1.160] | [0.923,1.155] | [0.923,1.155] | [0.917,1.149] | [0.949,1.367] | [0.923,1.316] | [0.937,1.334] | [0.895,1.278] | |
| Number of children under 5 | 0.681* | 0.682* | 0.685* | 0.684* | 0.716 | 0.702 | 0.712 | 0.804 |
| [0.447,1.037] | [0.448,1.040] | [0.450,1.044] | [0.448,1.043] | [0.381,1.344] | [0.387,1.274] | [0.390,1.299] | [0.441,1.467] | |
| Has Paid work | 1.698** | 1.714** | 1.721** | 1.705** | 1.487 | 1.468 | 1.390 | 1.501 |
| [1.094,2.637] | [1.106,2.657] | [1.109,2.670] | [1.098,2.647] | [0.757,2.921] | [0.764,2.818] | [0.721,2.677] | [0.777,2.899] | |
| Child vaccination in the past 5 years | 0.373*** | 0.368*** | 0.369*** | 0.362*** | 0.881 | 0.765 | 0.773 | 0.724 |
| [0.178,0.782] | [0.176,0.769] | [0.176,0.773] | [0.173,0.758] | [0.313,2.474] | [0.278,2.108] | [0.280,2.134] | [0.260,2.013] | |
| N | 397 | 397 | 397 | 397 | 397 | 397 | 397 | 397 |
The analysis sample is caregivers who have a child of 8 months old and younger and have no missing information on covariates. The result is based on the logistic regression. * significant at 10% ** significant at 5% *** significant at 1%.
On the other hand, fear indicators are only weakly correlated with the belief that it is common that children receive the full vaccination in the neighborhood (column 9 to 12).
Fear is a strong predictor of the belief that it is less likely that her children will receive all the vaccination (column 13 to 16). Fear of needles, for example, decreases the perceived likelihood by 89% (column 13).
Discussion
This paper evaluates how various fear indicators around vaccination are correlated with their knowledge, actual vaccination behaviors, and perceptions among Nigerian women. This paper does not identify the causal effect of fear but rather evaluates the important correlation.
We find that the type of fear that caregivers have is different; fear of needles and fear of side effects are highly correlated with each other, while the fear that vaccine has no benefit and fear that vaccine does harm are correlated with each other. Categorization of fear is important for the policy implication. For example, for those caregivers who have fear of needles and side effects, providing direct solutions to mitigate the pain and side effects might be the most effective to reduce the fear. For example, Buzzy and ShotBlocker are proven ways to mitigate pains and side effects at the time of vaccination.12 On the other hand, we need different solutions to tackle the issue of fear that is based on perceptions; fear that vaccine has no effect and fear that vaccine does harm. Fundamental educational intervention might be necessary to overcome such fear that is psychological.
About 15% of the caregivers have some form of fear regarding vaccination. However, such fear is not correlated with most of the socio-demographic characteristics among caregivers. This insignificant correlation is consistent with other work conducted in developing countries.13 This result implies that fear of vaccination is prevalent for any types of caregivers, regardless of their socio-demographic characteristics. Targeting a particular group of women based on socio-demographic characteristics is not effective in tackling the fear of vaccination.
Fear is significantly correlated with the lack of accurate knowledge about the vaccination schedule, especially the first timing of vaccination. Although there are studies that evaluated the correlation between knowledge and attitude toward vaccination especially in developed countries,14 there has not been a study that directly evaluates the correlation between knowledge and fear, to author’s knowledge. As our study does not detect the causal relationship between knowledge and fear, we cannot pin down if the lack of knowledge causes or augments the fear toward vaccination, or if the fear discourages caregivers from acquiring the knowledge.
Either way, educating caregivers with the knowledge on vaccination schedule can potentially increase the vaccine uptake directly, or potentially indirectly through overcoming the fear. Indeed, education and experiences are important determinants of vaccination knowledge because we found that educational attainment and having young children are positively associated with a higher level of vaccination knowledge, which can then increase the vaccine uptake.
Fear is strongly correlated with actual vaccination behaviors. This is consistent with previous work done in developed countries.5 Fear is negatively correlated with the perceived importance of vaccination completion, as well as the intention to vaccinate. Similar to the actual vaccination, this correlation is found in existent literature in developed countries.15 However, studies that show the correlation between fear and actual vaccination behaviors, as well as between fear and perceptions in developing countries are extremely limited. This paper is one of the first to show the strong correlation between fear, actual behaviors, and perceptions in sub-Saharan countries.
Overall, our findings on the correlation between fear, knowledge, behaviors, and perceptions are consistent with findings from existing studies conducted in developed countries. This present work contributes to the literature on fear of vaccination by providing one of the first evidence in African countries.
Limitations
This study has several limitations. First, because the sample is not representative of the country nor region, we do not generalize findings. Second, we relied on respondents’ responses for measuring the fear of vaccination. As Sato and Takasaki,16pointed out, the subjective measurement of fear might only weakly reflect the behavioral fear of vaccination. For example, even if women state that they have fear of vaccination, Third, fear of vaccination might be multifaceted. However, in this study, we focused on the predetermined definition of fear for general vaccination. Thus, we might have missed caregivers’ fear on other aspects of vaccination, or on a specific vaccination.
Appendix A: Sample Survey on the Section of Vaccination Knowledge
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Citations
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