KNOWLEDGE AND UPTAKE OF TETANUS TOXOID VACCINE AND ASSOCIATED FACTORS AMONGS PREGNANT WOMEN IN CENTRAL HOSPITAL, WARRI, TABLE OF CONTENT

TOPIC IS SUITABLE FOR:
1-Nursing Science
2-Public Health
3-Midwifery
4-Medical Laboratory Science

TOPIC: KNOWLEDGE AND UPTAKE OF TETANUS TOXOID VACCINE AND ASSOCIATED FACTORS AMONGS PREGNANT WOMEN IN CENTRAL HOSPITAL, WARRI,

TABLE OF CONTENT
Abstract
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study
1.2 Statement of the Problem
1.3 Objectives of the Study
1.4 Research Questions
1.5 Significance of the Study
1.6 Scope of the Study
1.7 Operational Definition of Terms
CHAPTER TWO: LITERATURE REVIEW
2.0: Introduction
2.1 Conceptual Review
2.2 Theoretical Framework
2.3 Empirical Review
2.4 Summary of Reviewed Literature
CHAPTER THREE: RESEARCH METHODOLOGY
3.0 Introduction
3.1 Research Design
3.2 Research Setting
3.3 Population of the Study
3.4 Sample Size Determination
3.5 Sampling Technique
3.6 Research Instrument and Administration
3.7 Method of Data Collection
3.8 Method of Data Analysis
3.9 Validity of the Study
3.10 Reliability of the Study
CHAPTER FOUR: DATA PRESENTATION AND ANALYSIS
4.1 Data Presentation and Analysis 
4.2 Analysis of Research Questions
4.3 Summary of Key Findings
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Discussion of Findings
5.2 Conclusion
5.3 Recommendations
5.4 Limitations of the Study
5.5 Suggestions for Further Studies
References
Appendix

ABSTRACT
The aim of the current research was to examine the Knowledge and Uptake of Tetanus Toxoid Vaccine and its Related Factors Among Pregnant Women in Central Hospital, Warri. It had two aims; to establish the extent of the knowledge on the tetanus toxoid vaccine among the target population and to assess the extent of the vaccine uptake and the factors that are related to the uptake thereof. Methodologically, the research was descriptive survey and the study population was 589 pregnant women who were going through antenatal care in Central Hospital, Warri. The sample population was calculated using Taro Yamane formula of 238 and 226 valid responses were received and analyzed. The participants were recruited using convenience sampling when they are attending antenatal clinics. The research was conducted through a structured questionnaire that was developed on a 5-point Likert scale and frequency, means, and standard deviations were used to analyze the responses. The findings showed that the participants had a high degree of knowledge concerning the tetanus toxoid vaccine especially in the context of its role in the prevention of maternal and neonatal tetanus, its safety and necessity of its multiple doses. The level of uptake has also been established to be quite commendable since the majority of respondents indicated that they had received at least one dose of the vaccine. These were proximity to healthcare services, attitude of the healthcare workers and educational status as key factors influencing uptake. The research thus suggests enhanced antenatal education, better access to healthcare, training of staff, and digital reminder services to improve consistent up-take throughout the pregnancies.

CHAPTER ONE
INTRODUCTION (Preview)
1.1 Background of the Study
The economic growth, political stability, and technological advancement have long been used as measures of human development and well-being of the society. However, the current discussions in the global arena will show that these indicators are still insufficient with an unhealthy population, particularly, the vulnerable groups including women and children. Health systems across the world are responding by paying more attention to the reproductive and overall health of women since it is now known that maternal health is vital to families and to the growth of nations (UNICEF, 2022; World Health Organization, 2024). In the context of this wider agenda, the attempts to improve access to quality prenatal care, minimize deaths that are preventable, and enhance outcomes in pregnancy have been in the center of attention. The discussion has been increasingly moving in the direction of adopting preventive mechanisms, health awareness and in-time medical measures aimed at defending mothers and the unborn babies they carry- all of them being referred to as Maternal Health (Edewor & Ekundayo, 2022; Umeh & Iyanda, 2024).
It is based on this background that immunization is one of the major public health interventions of decreasing infectious-disease burdens within populations. Biomedical intervention in the form of vaccines has a cost-effective effect on reducing morbidity and mortality in children and adults, where pregnant women represent an especially vulnerable group of individuals (World Health Organization, 2023; Adebayo & Onuoha, 2024). Freeland et al. (2023) stipulate that vaccination in pregnancy has two simultaneous advantages: it not only protects the mother but also transfers passive immunity to the unborn child, and this aspect is particularly relevant to low-income countries. National governments and global organizations like GAVI and WHO have therefore supported the immunization programs not only on the basis of their direct protective benefits but also the long-term socio-economic benefits it creates. It is also important to mention studies by Oyedele et al. (2023) and Oluwatosin & Adebayo (2022) that emphasize that increased awareness, accessibility, and cultural acceptance are the key factors that determine the vaccination uptake, with the focus put on rural and semi-urban areas where the rates of maternal death are still high.
The tetanus toxoid vaccine (TTV) is in a unique place among the recommended vaccines to pregnant women because tetanus is a major cause of neonatal and maternal mortality in places where obstetric practices are of poor quality and where delivery conditions are unsanitary (Yakubu et al., 2021; World Health Organization, 2020). To fight this menace, WHO advises a course of TTV in pregnancy to guarantee the safety of a mother and the immunity of a baby. This recommendation is supported by empirical evidence: Okonkwo et al. (2021) showed that at least two doses of TTV during pregnancy will drastically cut down the risk of neonatal tetanus, which is reinforced by Olorunfemi & Bello (2021), who also found an association between the positive pregnancy results and the increase in TTV coverage. Nevertheless, there is a significant difference regarding the distribution of coverage, depending on the maternal knowledge, the capacity of health systems, and the socio-cultural perceptions.
The knowledge on TTV among pregnant women is important in assessing the efficacy of the antenatal health-education and communication methods. Health-seeking behavior and the uptake of recommended interventions during pregnancy are informed by knowledge (Nwankwo & Okorie, 2022; Onyebuchi et al., 2022). Research indicates that women who are well informed about the reason, timing and advantages of TTV have higher chances of taking the doses required. Ayeni & Akinsanya (2023) state that the knowledge gaps are commonly influenced by such aspects as literacy, prior exposure to health education, and trust in the health-care system. Bello & Lawal (2021) express the necessity of health-care providers in filling these gaps through constant communication and culturally sensitive interactions in the course of antenatal visits.
Associated with knowledge is the actual acquisition of TTV which is one of the key indicators of performance in the health system in the case of maternal care. The individual, community, and systemic factors are known to influence the uptake of the vaccine, which can be determined by the accessibility of health facilities, availability of the vaccine, attendance to antenatal services, and autonomy of the women in making health decisions. According to the latest results of the Demographic Health Survey of Nigeria (NPC & ICF, 2021), even though the national policy promotes universal vaccination against infectious diseases during pregnancy, the coverage is below the global goals, and it is explained by uneven attendance of antenatal care and health system logistical issues. Uptake is therefore an important factor that should be examined to explain how maternal immunization policies are implemented.
The determinants of TTV uptake are multi-dimensional, and they include socio-demographic, cultural, health-system and attitudinal factors. Age, parity, level of education, economic level, and distance to health facilities are also related to the uptake level (Gabriel-Job & Ide, 2024; Abdulazeez et al., 2024). Moreover, social-cultural norms, myths, spouse and religious beliefs may act as facilitators and obstacles. Such provider-related factors as respectful maternity care, trust-building, and vaccine availability also contribute. According to Balogun & Osagie (2021), the experience of a patient in the healthcare system tends to dictate his compliance with the further interventions, including TTV.
It is against this background that this paper should take an in depth look into the Central Hospital in Warri. The hospital is in Delta State in Nigeria, a plural urban and peri-urban population with varying socio-economic and education. As noted by Edewor & Ekundayo (2022), Central Hospital is among the primary referral centers of maternal and child health services thus it is a proper environment to study the vaccination practice on maternal immunization. According to the recent audits, a somewhat alternating trend of attendance in the antenatal clinic and TTV coverage can be noted, which justifies a systematic in-depth assessment of the maternal knowledge, vaccination vaccine level and the elements that affect the results. Such local initiatives are necessary to inform the local-specific interventions as emphasized by Okafor & Nwachukwu (2023), and Uba et al. (2024) in order to capture the local health dynamics specific to a particular population. Thus, the study aims to investigate knowledge levels and immunization of tetanus toxoid vaccine by pregnant women who get antenatal care in Central Hospital, Warri, and factors, which influence their decisions to use this essential maternal health intervention. 

1.2 Statement of the Problem 
Even though Maternal and Neonatal Tetanus (MNT) is a fully preventable disorder that still persists as a public health problem in various countries throughout the world; especially in low income ones. On the international scale, the World Health Organization (WHO) and UNICEF introduced the Maternal and Neonatal Tetanus Elimination (MNTE) program which aims at reducing the number of neonatal tetanus cases to below one, every 1,000 live births annually per district level. Although the number of global neonatal tetanus fatalities decreased by a significant 96 percent, or an estimated 787,000 to the current 34,000 in 2015, and later to 7,719 in 2021, which were both much below previous estimates, global elimination goals set in 2015 and targets thereafter were not achieved (World Health Organization, 2020; World Health Organization [WHO], 2024). By the end of December, 2022, 80 percent of the priority countries (47/59) had reached MNTE and there is a high burden in 12 of these countries, largely in Africa. Out of the 28 countries having the highest MNT cases, 16 are in the African Region, and the region is at 90 percent of all neonatal tetanus cases globally with an average of 110,000 deaths a year (UNICEF, 2022). This ongoing burden highlights an outstanding disparity between ideal scenario of rampant MNT eradication and the situation in most of the vulnerable groups.
Nigeria belongs to the 12 countries where the MNTE status was not reached, as of July 2019, and its achievements have been stagnant since then, with the percentage of the newborn children having at least two doses of the tetanus vaccine only 55, with no improvement seen since 2000 (National Population Commission [NPC] & ICF, 2021). A disproportionately high 20 percent of neonatal deaths in Nigeria are caused by neonatal tetanus, as against 1 percent across the globe (Yakubu, Bello, & Musa, 2021). In 2015, the national neonatal mortality rate was 34 deaths per 1,000 live births, and the rate was higher in the rural areas (44 per 1,000 live births) (UNICEF, 2022). Moreover, the actual prevalence of MNT in Nigeria is probably underrepresented, and only a very minor percentage of the cases are reported to health centers, which makes planning and evaluation difficult (Ogundare et al., 2021). Research has shown that in Warri, Delta State, neonatal tetanus cases declined between 2000 and 2004 and once again increased since 2005 and its mortality rate was 40.6 percent (Okike et al., 2024). The proximity of this resurgence, contrasted with the international trend of decline, serves to draw attention to a paradox within the Warri region whereby, as other areas within a country with high HIV-burden push the prevalence down, an individual area of intense concentration suffers a deterioration of the situation which has to be dealt with through highly local solutions. Gaps like shifts in the availability of tetanus toxoid, epileptic electricity supply of cold chain, and shortages of the workforce also contribute to the overall state of the situation in Delta State; its immunization coverage decreased in 2022 to 66 percent following 78 percent in 2019 (Okafor & Ibadin, 2024).
Still at Delta State, Nigeria, where Central Hospital, Warri, is situated, research indicates that the level of knowledge and adoptability of TT vaccine among men and women in pregnancy is not close to ideally wanted (Edewor & Ekundayo, 2022). Although antenatal care (ANC) services are provided, most women do not have awareness of the need to receive TT immunization or suffer structural obstacles like distance to health care facilities and vaccine shortages (Mohammed & Oche, 2021). According to a study conducted in 2024 in Southern Nigeria, only 58 percent of pregnant women were able to define the correct purpose of TT vaccination, which implies the existence of huge health education gaps (Adeyanju, Sprengholz, & Betsch, 2021). In addition, socio-demographic factors associated with immunization include the level of education completed, parity, and social-economic status, but it is less when it comes to data in Warri (Okafor & Nwachukwu, 2023). In such a setting, there is no clear comprehension of the level of knowledge, uptake distribution pattern, and drivers, and therefore, effective interventions to enhance the use of TT vaccination are ineffective.
Although the effectiveness of vaccination using tetanus toxoid against the prevention of MNT is widely acknowledged, no comprehensive understanding exists about forces that drive its utilization, especially at the localized scales in highly burdened nations such as Nigeria. Although past forms of research have isolated general determinants of maternal age, education, wealth, antenatal care (ANC) visits, and the distance to health facilities, certain contradictions concerning the interaction between these determinants in addition to the perfect level of knowledge and uptake among maternal women attending antenatal care in Central Hospital, Warri are not understood (Morhason-Bello et al., 2022; Olorunfemi & Bello, 2021). Prevalence on regional or national levels is sometimes requested by existing studies to conduct local-level studies to provide direction to a targeted intervention (Onyebuchi, Nwafor, & Ugwu, 2022). This research will focus on covering this crucial vacuity by rigorously establishing the existing state of knowledge level of tetanus toxoid vaccine, the level of its vaccination, and determining the particular factor affecting it among expectant women in the hospital situated in Warri.    
1.3 Objectives of the Study
The main objective of this study will be to assess the knowledge and uptake of tetanus toxoid vaccine and associated factors among pregnant women in Central Hospital, Warri. Specifically, the study will seek to:
1.Determine the level of knowledge of tetanus toxoid vaccine among pregnant women attending antenatal care in Central Hospital, Warri.
2.Examine the extent of uptake of tetanus toxoid vaccine among pregnant women in central hospital, Warri.
3.To identify factors associated with the uptake of tetanus toxoid vaccine among pregnant women in central hospital, Warri.
OTHER PARTS OF CHAPTER ONE INCLUDE:
1.4 Research Questions
1.5 Significance of the Study
1.6 Scope of the Study
1.7 Operational Definition of Terms

CHAPTER TWO
LITERATURE REVIEW (Preview)
This chapter critically examines relevant literature that would assist in explaining the research problem and, furthermore, recognizes the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps. This chapter, therefore, focuses on the concept of tetanus toxoid vaccine, knowledge of tetanus toxoid vaccination, uptake of tetanus toxoid vaccine among pregnant women, factors associated with the uptake of tetanus toxoid vaccine, and the importance of tetanus toxoid vaccination during pregnancy at Central Hospital, Warri. The chapter covers the following subheadings:
2.1 Conceptual Framework
2.2 Theoretical Framework
2.3 Empirical Review
2.4 Summary of Literature Review

CHAPTER THREE
RESEARCH METHODOLOGY (Preview)
Research Design: The study adopted a descriptive survey research design.
Population of the Study: The population of the study comprises pregnant women registered for antenatal care at Central Hospital, Warri, during the study period.
Sample Size Determination: The study adopted the Taro Yamane formula to determine a sample size of 238 participants.
Sampling Technique: The study employed a systematic random sampling technique to select the individual respondents.
Research Instrument: The study utilized a self-developed structured questionnaire as the instrument for data collection.
Methods of Data Analysis: The collected data were analyzed using frequencies, percentages, and mean scores to summarize and present the demographic characteristics of the respondents and their responses. The data were analyzed using SPSS version 25 and presented in tables and graphs for easy interpretation.

CHAPTER FOUR; DATA PRESENTATION AND DISCUSSION OF FINDINGS
MAJOR FINDINGS (Preview)
The analysis results were presented in tables. Based on the results obtained from the analysis, the following findings are made:

i. The study found that pregnant women attending antenatal care at Central Hospital, Warri, had a high level of knowledge of the tetanus toxoid vaccine, as evidenced by the majority of respondents agreeing that the vaccine prevents maternal and neonatal tetanus, is safe for both mother and unborn child, and requires multiple doses for adequate protection.

ii. The study found that the uptake of tetanus toxoid vaccine among pregnant women at Central Hospital, Warri, was generally high, as evidenced by the majority of respondents indicating that they had received at least one dose during pregnancy, completed the recommended doses, and received information and reminders about the immunization schedule during antenatal visits. However, consistency in receiving the vaccine across pregnancies was comparatively lower.

iii. The study found that educational level, distance to healthcare facilities, healthcare workers’ attitudes, cultural and religious beliefs, and information received during antenatal visits were factors associated with tetanus toxoid vaccine uptake among pregnant women at Central Hospital, Warri. Antenatal health information and healthcare workers’ attitudes emerged as particularly influential factors in encouraging vaccine uptake.

CHAPTER FIVE:  SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
This chapter covers the following outline:
5.1 Discussion of Findings
5.2 Summary
5.3 Conclusion
5.4 Recommendations
5.5 Limitations of the Study
5.6 Suggestions for Further Studies

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