title: Why children are not vaccinated against measles: a cross-sectional study in two Nigerian States.
abstract: BACKGROUND
  Childhood vaccination rates in Nigeria are among the lowest in the world and this affects morbidity and mortality rates. A 2011 mixed methods study in two states in Nigeria examined coverage of measles vaccination and reasons for not vaccinating children.
  
  
  METHODS
  A household survey covered a stratified random cluster sample of 180 enumeration areas in Bauchi and Cross River States. Cluster-adjusted bivariate and then multivariate analysis examined associations between measles vaccination and potential determinants among children aged 12-23 months, including household socio-economic status, parental knowledge and attitudes about vaccination, and access to vaccination services. Focus groups of parents in the same sites subsequently discussed the survey findings and gave reasons for non-vaccination. A knowledge to action strategy shared findings with stakeholders, including state government, local governments and communities, to stimulate evidence-based actions to increase vaccination rates.
  
  
  RESULTS
  Interviewers collected data on 2,836 children aged 12-23 months in Cross River and 2,421 children in Bauchi. Mothers reported 81.8% of children in Cross River and 42.0% in Bauchi had received measles vaccine. In both states, children were more likely to receive measles vaccine if their mothers thought immunisation worthwhile, if immunisation was discussed in the home, if their mothers had more education, and if they had a birth certificate. In Bauchi, maternal awareness about immunization, mothers' involvement in deciding about immunization, and fathers' education increased the chances of vaccination. In Cross River, children from communities with a government immunisation facility were more likely to have received measles vaccine. Focus groups revealed lack of knowledge and negative attitudes about vaccination, and complaints about having to pay for vaccination. Health planners in both states used the findings to support efforts to increase vaccination rates.
  
  
  CONCLUSIONS
  Measles vaccination remains sub-optimal, particularly in Bauchi. Efforts to counter negative perceptions about vaccination and to ensure vaccinations are actually provided free may help to increase vaccination rates. Parents need to be made aware that vaccination should be free, including for children without a birth certificate, and vaccination could be an opportunity for issuing birth certificates. The study provides pointers for state level planning to increase vaccination rates.
authors: CIET Trust Botswana, Gaborone, Botswana.
authors: Anne
authors: A
authors: Cockcroft
authors: Ministry of Health, Bauchi State, Nigeria.
authors: Muhammad U
authors: MU
authors: Usman
authors: CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196 South Africa.
authors: Obrian F
authors: OF
authors: Nyamucherera
authors: State Planning Commission, Cross River State Government, Cross River State, Nigeria.
authors: Henry
authors: H
authors: Emori
authors: State Planning Commission, Cross River State Government, Cross River State, Nigeria.
authors: Bong
authors: B
authors: Duke
authors: Primary Health Care Development Agency, Bauchi State, Nigeria.
authors: Nisser Ali
authors: NA
authors: Umar
authors: CIET-PRAM, Department of Family Medicine, McGill University, Montreal, Canada ; Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors: Neil
authors: N
authors: Andersson
keywords: Children; Immunisation; MDG4; Measles; Nigeria; Vaccination