Sanaa Univ J Med Sci 2012;4(1):95-100

Sanaa University Journal of

Medical Sciences
Tetanus Vaccination among Reproductive Age Females in Sanaa City, Yemen
Abdulsalam M. Dallak1*, Ph.D; Nabil Ahmed Al-Rabeei2, Ph.D
Department of Maternal and child Nsg, 2Department of Community health Nsg., Faculty of Medicine and Health Sciences, Sanaa University, Yemen
1

ABSTRACT Background: Tetanus is one of the most common fatal diseases in the world but it is a preventable disease. Yemen health reported that only 11.69% of fertile women were vaccinated in 2008 in Sanaa city. Aim: to examine coverage of, barriers, knowledge, and beliefs related to tetanus vaccination among reproductive age females attending health centers in Sana'a city. Methods: Descriptive crosssectional survey was performed among fertile Yemeni women in Sanaa city-Yemen. 449 fertile Yemeni women were admitted to this study. The data were collected through the structure questionnaire as a face to face interview. Results: the majority of the participants 72.4% heard about tetanus toxoids (TT) vaccine, only 19.4% knew benefits of TT vaccine against maternal and neonatal tetanus. 12.2% identified the target group for vaccination. 48.6% knew correct doses of TT vaccine. A majority 62.6% were do not believe that vaccination is harmful, only 24.9% believed that unclean umbilical cord stump and unclean delivery practices play a role in etiology of tetanus. Only 20.9% had received the complete series of 5 TT vaccines, 56.4% had lack of knowledge about TT vaccine. Conclusion: The study findings have identified a strong need for an education program for the masses about tetanus vaccination, since major deficiencies have been identified. Key words: Tetanus toxoid vaccine, Reproductive age females, Yemen

INTRODUCTION Maternal and neonatal tetanus are important causes of maternal and neonatal mortality. In 1 2008, UNICEF reported that, there is 500,000 infants worldwide die every year because their mothers arent immunized. Tetanus is transmitted to babies by using unsterile instruments that carry the tetanus bacteria when cutting the umbilical cord following delivery. Immunized mothers also can be subject to the disease if post-delivery, post-abortion or postsurgical wounds are exposed to the infectious 2 bacteria. Tetanus can be eliminated through effectively vaccinating infants and women of childbearing age (15-45 years old), as well as

promoting safe and clean delivery practices2. 3 The World Health Organization (WHO) estimates that more than 3,000 cases occur annually in Yemen, with the mortality rate per 1,000 live births at 2.9 Nevertheless, Neonatal tetanus causes 20.3 percent of all neonatal deaths and thus is a major cause of neonatal death in Yemen. Although Neonatal tetanus surveillance in Yemen has improved since 1999 when 133 cases were reported in 12 districts, Neonatal tetanus remains seriously underreported, with many districts and governorates remaining silent despite low Tetanus Toxic (TT) vaccination and clean

*Corresponding author: Dr: Abdulsalam M. Dallak , Departments of MCHN, Faculty of medicine & health scienceSanaa University, Yemen P.O.Box 11331, Sana'a, Yemen E-mail: abonadim2004@yahoo.com

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Abdulsalam Dallak & Nabil Al-Rabeei

delivery coverage. For this reason, Yemens disease reporting system must be reinforced. Yemeni TT immunization coverage remains low, lagging behind coverage achieved for childhood immunization antigens. Moreover, the overall immunization program has declined, with TT coverage appearing to be around 20%. The level of antenatal care during pregnancy remains low, not exceeding 35%. More than 75% of childbirths occur at home and most are not attended by a trained or skilled birth attendant which, along with unhygienic practices during childbirth and umbilical cord care, further adds to Yemens burden of Neonatal tetanus-related mortality. Difficult topography, low accessibility to health services, lack of female health workers, lack of awareness, high illiteracy rate and false rumors are among the most commonly identified reasons for low coverage. Aim of the study The aim of the study was to examine coverage of, barriers, knowledge, and beliefs related to tetanus toxoid vaccine among reproductive age females attending centers in Sanaa City, Yemen. METHODS Study setting The study was conducted among reproductive age females in Sanaa, cityYemen. The Republic of Yemen is considered as one of the states of most growing population in Arabic countries. Despite the observable growth in the number of primary health care centers and health care workers during the last 10 years but the coverage rate for the services increased from 10% in 1970 to 50% in 2000. Study design A descriptive cross-sectional survey was conducted to examine coverage of, barriers, knowledge, and beliefs related to tetanus vaccination among reproductive age females attending health centers in Sanaa City.

Study participants and sampling The study population was Yemeni reproductive age females attending health center in Sana'a city. According to recent administration regulation, Sanaa city is divided into ten districts. Multistage sampling technique was used. The first-stage sampling randomly selected five districts out of ten. The second sampling stage consisted of systematic equal probability sampling (with a random start) of one center from each selected district that participated in the survey. The third stage of sampling was random selected women from each selected center. The population estimates were 1000 fertile women based on the most upto-date figures available from the health center at the time. The sample size was calculated by using Epi Info version 6.0. The sample size has been calculated according to the following criteria: Size of population from which the sample selected (1000); expected frequency (81.8%) depended on previous study4 and worst acceptable value (2.8%). A sample size with 95% confidence level was 422 women, taking into consideration a non-response rate of about 6%, the final sample size was estimated as 449 women. Data collection The data were collected by the research team using structured questionnaire through a face to face interview. The data was collected from November 2009 to January 2010. The questionnaire was started with a discussion of study benefits and purposes and was divided into four parts: (1) demographic characteristics of the study participants; (2) Sources of TT vaccine information; (3) coverage of tetanus toxoid vaccine; (4) barriers; (5) knowledge and (6) beliefs toward tetanus vaccination. The knowledge was assessed through heard about TT vaccine, benefits of vaccination, target group for vaccination and number of TT vaccine. Womans belief toward TT vaccination was assessed through harmful and importance

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of vaccination, modes of transmission, and severity of tetanus disease. Coverage of and barriers for not being TT vaccinated was also obtained. The questionnaire was pilot tested and necessary corrections were made. Ethical consideration The research team informed the study participants about the purpose of the study in simple, clear language and assurance with regards to confidentiality was provided to them. Oral informed consent was obtained. Data analysis For statistical analysis SPSS, version 16.0 was used. Demographic characteristics, knowledge, beliefs, coverage of and barriers for not being vaccination were analyzed using descriptive statistics. RESULTS Demographic characteristics of study participants 449 of reproductive age women were admitted to this study, age range was 15-45 years. 257 (42.8%) were married and 265(57.2%) unmarried. Most of the study participants 332 (73.9%) were Illiterate and 117 (26.1%) literate. Sources of information about tetanus vaccine The findings of the study showed that, 31% received their information about TT vaccine from TV, 11.4% from radio, 10.9% from other sources (relatives or friends), 6.2% from newspaper, 12.9% from health center and 27.6% more than one source. Knowledge toward tetanus vaccine The findings of the study showed that the study showed that the majority of the sample 72.4% heard about TT vaccine while 27.6% did not. Regarding benefits of vaccination, 22.9% of respondents answered to prevent only maternal tetanus, 52% answered to prevent neonatal tetanus, 19.4% answered to prevent maternal and neonatal tetanus and 5.8% don't

know. When asked about target group for vaccination 14.2% of respondents answered for mother only, 50% answered for newborn only, 12.2% identified the target group for vaccination as both mother and neonate, and 23.4% as did not know. As for number of tetanus vaccine 8.7% answered 1-2 doses, 23.1% answered 3-4 doses, 48.6% answered 5 doses and 19.6% didn't know. Table 1. Table 1. Knowledge toward tetanus vaccine
Variables Hearing about TT vaccination Yes No Benefits of vaccination Prevent maternal tetanus Prevent neonatal tetanus Both mother and neonatal Don't know Target group for vaccination Mother New born Both Dont know No. of tetanus vaccination doses 1 to 2 doses 3 to 4 doses 5 doses Don't know n (%) 325 (72.4) 124 (27.6) 103 (22.9) 233 (52) 87 (19.4) 26 (5.8) 64 (14.2) 225 (50) 55 (12.2) 105 (23.4) 39 (8.7) 104 (23.1) 218 (48.6) 88 (19.6)

Beliefs toward tetanus vaccine A majority 62.6% did not believe that vaccination is harmful, only 7.6% believed vaccination is harmful and 39.8% did not know. 57.9% believed that vaccination prevents disease, 6.5% answered that it does not prevent tetanus and 35.9% didn't know. Most of respondents 56.3% believed that unclean umbilical cord stump is a mode of tetanus transmission, 6.2% answered unclean delivery practices, only 24.9% answered both and 12.5% dont know. 46.5% of respondents believed that tetanus can lead to death, 27.6% answered only complications and 25.8% didn't know the seriousness of tetanus. Table 2.

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Coverage of tetanus toxoids vaccine Coverage for tetanus vaccination was investigated. The findings of the study showed that, 48.1% of women did not receive TT vaccination and only 20.9% had received the complete series of 5 TT vaccinations and 31% partially vaccinated. Table 3. Barriers for not being vaccination Table 4 shows that lack of knowledge 56.4% was the main factors for not being vaccination. The availability 23.2% and place and time of vaccination20.5% were other important reasons. Table 2. Beliefs toward tetanus vaccine
Variables Is vaccination harmful Yes No Dont know Vaccination prevents tetanus Yes No Dont know Modes of tetanus transmission Unclean umbilical cord stump Unclean delivery practices Both Dont know Seriousness of tetanus: Death Handicap Dont know n (%) 34 (7.6) 281 (62.6) 134 (29.8) 259 (57.9) 29 (6.5) 188 (35.9) 253 (56.3) 28 (6.2) 112 (24.9) 56 (12.5) 209 (46.5) 124 (27.6) 116 (25.8)

Table 3. Coverage of tetanus vaccine among respondents

Status of tetanus vaccination Complete vaccinated Partially vaccinated Non-vaccinated n (%) 94 (20.9) 139 (31) 216 (48.1)

Table 4. Barriers for non-vaccination and partial vaccination

Barriers Not important Fear of side effect Place of vaccination too far Lack of knowledge Place and/or time of vaccination unknown Vaccine not available n (%) 33 (15) 40 (18.2) 19 (8.6) 124 (56.4) 45 (20.5) 51 (23.2)

DISCUSSION Tetanus occurs almost exclusively in persons who are unvaccinated or inadequately immunized.5 Low accessibility to health services, lack of female health workers, lack of awareness and high illiteracy rate are among the most commonly identified reasons for low coverage. Neonatal tetanus toxoids (NTT) can be prevented if women are immunized before childbirth and clean practices are used during delivery and in caring for the infants umbilical cord.6) Factors such as knowledge, belief and practices of women are also known to contribute to success or failure of immunization program.5, 7 The results of the survey offer insight into the knowledge, beliefs, coverage of and barriers to not being vaccination among reproductive age Yemeni women. The findings of the study showed that TV is the strongest source for providing awareness among the respondents about TT vaccination. However a need exits for expansions in this source as the percentage was only 31% for those received their information about TT vaccine from TV. The results indicated that TV can be a good source for vaccination. Results of the study point out a need to further utilization of this source for this purpose. Health center was noted to be another source for providing information regarding vaccination. It is heartening to note that health centers are responsible for informing a majority of respondents about vaccination but a need exists to work further in this area. This area also requires further strengthening. The important role that media can play in promotion of immunization has been highlighted by earlier reports.8 The present study showed that most of the respondents 72.4% heard about TT vaccination and only 19.4% knew the benefits of TT vaccination to both mother and their neonates. Only 12.2% identified the target group for vaccination. In line with these concerns, it was

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disappointing to note that 23.4% of respondents did not knew the target group for vaccination; Concerns are prevalent regarding knowledge about TT immunization.9 A Need therefore exists to educate the population in this regard. Only 48.6% of women knew number of correct doses of vaccination. Lack of awareness and knowledge toward TT vaccine is in agreement with Waris et al10 and Amna Zeb et al.11 Regarding beliefs of respondents toward TT vaccination, the findings of the study showed that, it is particularly important to note that only 7.6% of respondent believe TT vaccination is harmful while a significant 62.6% feel it can be so. This shows that the respondents have a good understanding about benefits of TT vaccine. Concerns about immunization safety are widely prevalent.12 57.9% beliefs that the vaccination prevents tetanus disease and 24.9% aware the role of unclean umbilical cord stump and unclean delivery practices in the etiology of tetanus disease. 46.5% of respondents were believed that tetanus can lead to death. This means that there were misconceptions among women toward TT vaccination. This finding is in line with those reported earlier in other countries where respondents acknowledged the importance of immunization.7,10 Coverage of tetanus vaccination, however, was as low as 20.9%. A similar result was found by earlier report.13 Approximately half of respondents did not start vaccination. Mothers sometimes do not complete the vaccination schedule despite their positive attitude because of their poor understanding of the concept of vaccination, which health personnel do not take time to explain to them clearly.14 Yawn et al., studying an affluent community in the USA, identified fear of side effects as an important factor for under-immunisation.15 As pointed out by the respondents, lack of awareness and knowledge about tetanus vaccination and barriers have also been reported earlier.16,17 It should not be a surprise that the factors reported

for promotion of vaccination coverage by respondents include improving awareness and knowledge. These factors are already known to have a positive impact on vaccination coverage and therefore it is important to work on these lines in order to improve vaccination coverage to a satisfactory level among our population. Low coverage of TT vaccine was reported by respondents and highlights an alarming situation that requires urgent control measures.
CONCLUSION The study results have identified a strong need for education program for the masses about Tetanus vaccination, since major deficiencies have been identified and the information can be utilized to conduct larger community based survey in order to intervene and improve vaccination coverage status of the population. Further studies among the community are strongly recommended along with debate on this important public health issue. REFERENCES
1. 2. UNICEF.www.unicef.org/media/media_46751.html (accessed on October, 2008 Park. K. Tatanus. Preventive and social medicine. 18 Edition. M/s Banarsidas Bhanot publishers. India. 2005 ;183-185. Word Health report, WHO-Regional Office for the Eastern Mediterranean Region. 2005. www.who.int/immunization. 2005. Waris Qidwai, Syed Sohail Ali et al. Knowledge, attitude and practice regarding immunization among family practice patients. JDUHS 2007, Vol. 1 (1): 1519 Adhikari P, Dhungel S, et al. Knowledge, attitude and practice study regarding facts for life. Nepal Med Coll J 2006; 8: 93-6. www.unicef.org/immunization. 2004 Anjum Q, Omair A, et al. Improving vaccination status of children under five through health education. J Pak Med Assoc 2004; 54: 610-3. Speers T, Lewis J. Journalists and jabs: media coverage of the MMR vaccine. Commun Med 2004; 1:171-81. Coplu N, Esen B et al. Immunity against tetanus and effect of vaccination in Turkey. Scand J Infect Dis 2006; 38:1009-16.

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10. Waris Qidwai and Syed Sohail Ali et al. Knowledge, attitude and practices regarding immunization among family practice patients. JDUHS 2007, 1 (1): 15-19 11. Amna Zeb, Syed AH et al. Knowledge, attitude and practices of reproductive age females about Tetanus Toxoid vaccine: a pilot study J Coll Physicians Surg Pak 2006;16(12):791-3. 12. Smith PJ, Kennedy AM et al. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics 2006; 118: e1287-92. 13. Mapatano MA, Kayembe K, et al. Immunisationrelated knowledge, attitudes and practices of mothers in Kinshasa, Democratic Republic of the Congo. SA Fam Pract 2008;50(2):61

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14. Adhikari P, Dhungel S, Shrestha R et al. Knowledge, attitude and practice (KAP) study regarding facts for life. Nepal Med Coll J 2006; 8: 93-6. 15. Yawn BP, Xia Z, et al. Barriers to immunization in a relatively affluent community. J Am Board Fam Pract 2003;13:32532. 16. Buttery J, La Vincente S et al. Adverse events following immunisation: desperately seeking surveillance. Lancet Infect Dis 2006; 6 : 680-1. 17. Topuzoglu A, Ay P et al. The barriers against childhood immunizations: a qualitative research among socio-economically disadvantaged mothers. Eur J Public Health 2006.

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