Parents’ Decision-making for Childhood Immunization and Prevention of Childhood Diseases – A Cross-Sectional Survey

The childhood vaccination program (EPI) is claimed by the World Health Organization (WHO) to be the most cost-effective intervention to reduce child mortality. Therefore, in low-income countries governments and health authorities invest in vaccination programs to reach herd immunity. However, despite the resources allocated to the EPI, epidemics preventable through vaccines are still reported in these countries. In Cameroon, the Foumbot district in the West region has witnessed measles epidemics since 2010 and in 2013 a polio outbreak was reported.


Methods
The design of this study is a cross-sectional survey. A total of 160 mothers of children between the ages of 12 to 23 months were selected by simple random sampling technique. Pre-tested structured questionnaire was used for data collection. Data was analyzed using SPSS statistical software.

Results
The outcome of this survey shows that 60% of the children studied were completely vaccinated, 37.75% were partially vaccinated, and 1.25% had not received any vaccine. The logistic regression analysis shows that a poor knowledge of infectious diseases (OR=0.3) was a signi cant predictor of partial and no vaccination status in children.

Conclusion
Parents' decision-making for EPI was based on the information and experiences available in the community. Therefore, parents who are poorly educated on VPDs and living in a community with missing information and misinformation about vaccination will probably not complete the EPI. Public health authorities should invest in health education programs with the goal of developing skills for healthseeking behavior in individuals and communities.

Background
Prevention of children of diseases is the primary concern of pediatrics [1] [3] [4]. Since 1974, in order to reach herd immunity, the WHO (World Health Organization) has been motivating health authorities all around the world to invest in the EPI (Expanded Program on Immunization) to ensure vaccination of children around the world against vaccine-preventable childhood diseases (VPDs). Six vaccinepreventable diseases are recommended by the EPI: tuberculosis, polio, diphtheria, tetanus, measles, and pertussis [2]. In 2014, the herd immunity threshold in low-income countries was still below the 92-95% set by the WHO for VPDs except the BCG vaccine [22]. In Cameroon, the proportion of children below 2 years of age who are completely vaccinated for all recommended childhood vaccines [7] [27][28] is still well below the target 80% of eligible children targeted by the Cameroonian government [11]. In September 2013, many cases of paralysis were reported in Foumbot district and Malentuen district in Cameroon. The Genotyping of the viruses showed that a similar virus (Wild Poliomyelitis Virus) affected all the children [12]. Interestingly, the affected children in Cameroon had never been outside the country. The virus genotype linked to the outbreak shows a parenthood to the poliovirus observed in Chad in 2011 [23].
The Foumbot district is a place at risk because of the outbreak. The district hosts one of the largest border fresh-food markets in Cameroon where people from all parts of the country and neighboring countries of Cameroon such as Niger, Chad, Central African Republic, Congo, Gabon, Equatorial Guinea, and Nigeria interact. The risk of expansion of the poliovirus to other parts of the country and to the neighboring countries is high. The parents of the rst con rmed cases were farmers and gardeners who used to visit markets in Malentuen [12]. Although vaccination programs to eradicate measles around the country had already been implemented, a proliferation of measles was reported in nine health districts including the Foumbot district, [24]. Despite the nancial resources allocated to the EPI to achieve herd immunity, VPDs remain a health care concern in Cameroon. The sole provision of vaccination does not guarantee herd immunity throughout the country [7] [27]. Only the BCG coverage, which is given at birth, is above 90%. The coverage of other vaccines in children is still far below 80% expected in all health districts. [7] [11]. Based on actual experiences gained by vaccination practice in each region or community, it is possible to de ne the causes of reticence to the vaccination [14] [17][18] [41] [29][30] [31]. Therefore, programs leading to a higher prevention of infectious diseases in the population can only be de ned, once the underlying reasons for the refusal and/or the interruption of the vaccination program are clearly identi ed. This study identi es, examines the factors affecting complete childhood vaccination in Foumbot district.

Study area
The Foumbot district covers an area of about 1000 km². The district is rural and located in the Noun Division, West region of Cameroon. In 2013, the health district estimated the population to be 62,776 inhabitants (from the 2013 Census), the majority being Bamum. The predominant religion is Islam.
Farming is the main occupation. The district hosts the most important fresh food market in the western region and is divided into eleven health communities, which provide EPI to the local population.

Study design
A cross-sectional survey of parents of children aged 12 to 23 months was performed from 1 st July to 31 st October 2014. This included a questionnaire to record the characteristics of mothers and children, and to evaluate maternal knowledge about vaccination. Only parents of the children were interviewed. Survey participants were selected randomly according to the WHO vaccination coverage cluster survey sampling [5][6][8] [10]. The vaccination coverage has been evaluated by means of the vaccination booklet and EPI register. A child was said to be completely vaccinated if he had received all of the vaccines recommended by the EPI by the time he was selected for the survey.

Sample size determination
Using the sample size calculation methodology presented in the WHO Immunization Coverage Cluster Survey Reference Manual (WHO/IVB/04.23), the sample size required was determined using the coverage of 64% obtained in the western region, a precision of ± 10%, a type 1 error of 10% and a design effect of 1.5, in conformity with the standard WHO methodology [6][8]. Thus, the calculated minimum number of children required was 147.

Participants
During the investigation, data from 160 children and 160 parents were collected in the district randomly. The sampling process was performed according to the simple random sample (SRS) method [5][6]. The rst household was randomly chosen from each selected cluster. Each household was chosen randomly, such that each household had the same probability in the cluster of being chosen during the sampling process [9]. The sampling technique applied allows the researcher to perform the evaluation with a sample that is representative. From this sample, statistical values have been generated to be extrapolated to the whole population of the Foumbot health district.

Data analysis
The data was collected by trained nurses using a French structured questionnaire. The structured questionnaire was adopted from the Demographic Health Survey of Cameroon [7]. The content of the questionnaire included: sociodemographic characteristics, questions related to parents and child health services, parents' perception about vaccination, parents' knowledge about VPDs. The vaccines received by the child were obtained from the vaccination card or through the vaccination history of the child reported by the parent. Prior to data collection, the questionnaire was pre-tested on 5% of the sample on a similar population.
The data from the interview was coded and entered into a computer database using Microsoft O ce Excel 2010. Descriptive statistics were performed by means of EPI info 3.5.4 statistical software program to analyze the sample, to check the association of each independent variable with the complete vaccination. For this purpose, the odds ratios were calculated along with 95% con dence intervals (CI) and the p-value from the Fisher's exact test. The analysis of the factors associated with vaccine incompleteness was carried out by means of the statistical software program SPSS according to a multivariate logistic regression model of the "forward" type: the rst was a bivariate analysis which allowed us to obtain raw odds ratios for each one. of the variables with their 95% con dence intervals and their P values. The variables that obtained a p value <0.5 were statistical signi cant and were all entered into a multivariate logistic regression model to control for confounding factors and to determine which characteristics are independent predictors of the child's vaccination status [ Table 3].

Ethical clearance
This study obtained the authorization of the Faculty of Medicine of the Université des Montagnes and the health authorities of the Foumbot district to be carried out. Verbal informed consent was required for each participant prior to the administration of the questionnaire.  The vaccination status of the child was established by the records in the vaccination booklet, the records in the EPI registration or by the presence of scar in the case of BCG. In the 5 clusters, a total of 160 households were surveyed. It was found that 96 (60%) children had received complete vaccination by the age of two. On the other hand, 62 (38.75%) had received partial vaccination and 2 (1.25%) had not received any vaccine. The dropout rate between the initial vaccine BCG or OPV 0 and the nal vaccine measles is quite high with 36%; that means, over one third of the children were unable to complete the vaccination program [ Table 1].

Parental Perception
Defaulting factors The parents whose children had not completed the EPI mentioned missing information (17%), Lack of interest (6.2%), and lack of exibility and resource (76.5) [ Table 4].
The association of the sociodemographic factors with completion of child vaccination were assessed by this study. The results showed that 52% and 80% of those who are Muslim and

Discussion
This study examined the association and in uence of sociodemographic factors, knowledge of VPDs to complete childhood vaccination.
In this study, 76.5% of the parents whose children did not complete the EPI mentioned barriers linked to exibility and resource [ Table 4]. Referring to Table 2, some health facilities had only 1 or 2 persons in charge of the vaccination. In 2015, Cameroon was still classi ed by the WHO as having an acute shortage of health personnel [38]. Researchers in the USA and in Vietnam observed that the advice of a healthcare professional was the major factor that changed the view of parents who had previously refused to let their children be vaccinated or had delayed vaccination [39] [40]. Therefore, contact with a healthcare professional is an important factor in health decision-making. The results of this study show that starting at birth the vaccination program increased by 2.5 the likelihood to complete the EPI [OR=2.5] [ Table 3]. A study performed in 2000 in a rural community in Edo State in Nigeria showed that early vaccination of children increases the awareness of the parents towards VPDs and vaccination [36]. Administering the rst vaccine at birth is an important step for building con dence in the medical system and in raising parental awareness about VPDs and the role that the vaccination can play in promoting the child's health. However, we found that only 60% of children had completed the EPI at the age of two years, although 98% of the children had received the BCG vaccine at birth. This shows that the awareness towards VPDs has not been reached and the con dence in the medical system was not established. A poor knowledge of VPDs [OR=0.32] was identi ed as the predictor of failure of complete vaccination in children. Additionally, it was found that in the group of parents belonging to Islam, 47.8% of the parents failed to complete the EPI while 20% were reported in other religious groups [ Table 3]. The failure in the vaccination programs in Muslim communities has been reported in Nigeria, Pakistan, and Afghanistan.
[13] [15][20] [21]. In these countries, parents' decision-making was guided by the propaganda against polio vaccine by Muslim fundamentalists. Just like Muslim communities, African communities are regularly affected by negative information on vaccination programs so that medical interventions intersected with cultural perceptions [13]. Most people on the African continent and particularly in rural areas like the Foumbot district cannot identify with the vaccination [14] [35][46]. Consequently, fear "makes sense" [19] [35]. The perception of parents living in these communities regarding vaccination is likely to turn into refusal following stories often linked to a conspiracy theory [13] [15][20] [21]. Because of the slave trade and colonization, many Africans and particularly Muslims are skeptical and suspicious about any intervention from western countries and those who refuse vaccination perceive the EPI as a western propaganda to destroy Africans, Muslims and their local traditions and cultures [34]. This outcome shows that parents' perception regarding vaccination was not generated by the religious principles but by how the information available in the community is perceived and understood. Data from India, Nigeria, and the United Kingdom (UK) shows that for these countries, trust in immunization programs is more often associated with trust in health systems [37] [47]. In 2003, negative information affected the vaccination program in Muslim communities in Nigeria negatively [13] [19][21]. In order to regain con dence, a longterm program was put in place. This program involved different actions and key players to help build support for vaccination: grassroots involvement, change of initiatives, and public and media awareness [20] [33]. In this study, parents with good knowledge of VPDs had a higher likelihood to complete the EPI [OR= 3.08]. Therefore, vaccination coverage increases as parents' knowledge of VPDs increases. This result is similar to studies carried out in Kenya, Nigeria, Senegal, and Turkey where it was found that educating parents particularly on healthcare and on programs to improve quality of life has reduced child mortality and increased life expectancy [16] [15] [41][42] [43]. From these results, health education programs are bene cial as they enable parents to receive knowledge of diseases, healthcare, and prevention. It is not about academic quali cation, which assures only that an individual has learned the theory and, acquired knowledge but does not guarantee that the individual has developed skills to adopt and to implement the knowledge in real life. In Thailand, it was found that women who attended a community empowerment program implemented plans to ght against malaria [44]. They offered malaria education to community members, taught mosquito control actions, promoted the use of insecticide treated bed nets, and also initiated entrepreneurship to increase revenue for the family. In Papua New Guinea, a program empowered members of a community to take charge of the acquisition, distribution and effective utilization of bed nets [44]. This led to a signi cant reduction in the incidence of mortality linked to malaria. Health education should ensure that parents acquire the knowledge of diseases, their causes and consequences, and learn about healthcare with the goal to engage and invest in personal and community health.

Limitations Of The Study
In this study, some limitations were expected because this is a cross-sectional study, and the sampling method is susceptible to selection bias. Only the participants that were present in the district at the time of the interview and that met the survey inclusion criteria were considered in the sample.

Conclusions
"It is often not just what is offered that makes bait out, but how it is perceived by the recipient matters" Simmi Oberoi et al. 2016 This study identi ed predictors of childhood vaccination hesitancy and suggestions were made to support parents' decision-making for childhood immunization and prevention of childhood diseases.
The factors "poor knowledge of VPDs and infectious diseases" and "belonging to Islam" were found to be statistically signi cant and associated with the failure in childhood vaccination [ Table 3]. Although Islam itself is not against the vaccination, it was noticed that negative information about vaccination is frequently spread around in Muslim communities [13][21]. The shortage of health personnel in the Foumbot district [ Table 2] and in Cameroon in general also limits the populations' access to health information and the trust in the medical system. When parents have poor knowledge of VPDs and the con dence in the medical system is not established, they are expected not to trust in the vaccination and in turn to refuse or interrupt the EPI. On the other hand, the factors "good knowledge of VPDs and infectious diseases" and starting vaccination "at birth" were found to be statistically signi cant and positively associated with complete childhood vaccination [ Table 3]. These two factors were advantageous to establish trust in the EPI and therefore generate in parents the perceptions "demand" or "acceptance" of the childhood vaccination. In the literature "Patterns of vaccination acceptance", Stree and et al [32] declared that the perceptions demand, acceptance and refusal may or may not be based on a knowledgeable comprehension of the vaccination but are based on the experience people or communities have with it. Following this declaration, this study has found that decision-making by parents regarding vaccination may or may not be based directly on sociodemographic factors but are based on the experience and the interpretation by the local value system of the existing information available in the community [ Figure 1]. The ndings of this study suggest investing in health education programs targeted at parents who are poorly educated on infectious diseases. These programs should not be limited to how to avoid illness or how to cope with diseases. It should also focus on the understanding of peoples' local health beliefs and practices and consider these beliefs and practices in developing health education programs with the purpose of developing skills in health-seeking behavior in individuals and communities. Based on the outcomes of this study, a community-related framework  Availability of data and materials

List Of Abbreviations
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Figure 1
Community-related conceptual framework of parental decision-making

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. TranlatedfromFrenchtoEnglishQuestionnaireFoumbot.pdf