Archives of Medicine and Surgery

: 2017  |  Volume : 2  |  Issue : 2  |  Page : 48--54

Assessment of tetanus toxoid coverage among women of reproductive age in Kwarbai, Zaria

Zainab Kwaru Muhammad-Idris1, Adamu Usman Shehu2, Fadila Maryam Isa2,  
1 Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria; Department of Community Medicine, Kaduna State University, Kaduna, Kaduna State, Nigeria
2 Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Correspondence Address:
Dr. Zainab Kwaru Muhammad-Idris
Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State


Context: The World Health Organization 2013 estimates revealed 49,000 newborns died from neonatal tetanus (NT), a 94% reduction from the late 1980s. Over 24 countries, including Nigeria, have still not reached maternal and NT elimination status. Aims: The aims of the study were to assess knowledge and determine the extent of tetanus toxoid (TT) coverage among women of reproductive age in Kwarbai, Zaria, challenged by effects of tetanus and inadequate vaccination. Settings and Design: Kwarbai is essentially an agrarian, trading, and blacksmithing Hausa Muslim-dominated community with rich culture exhibited in its creations, festivals, and local events that bring together people from all over to socialize and share information. Subjects and Methods: The cross-sectional descriptive study was conducted between December 2014 and January 2015. Semi-structured, interviewer and self-administered questionnaires were used to obtain data on reported findings. Statistical Analysis Used: Statistical Package for the Social Sciences software SPSS® version 20 was used. Descriptive statistic measures presented as tables and graphs. Chi-square was applied for the comparison of proportions and associations between categorical variables. Results: Respondents' median age was 27 years, Hausa/Fulani (99%), Muslims (100%), married (82%), have more than four children (25%), and half attained tertiary education (54%). Women, 20–34 years, received more than one dose with education as major determinant of immunization uptake. Although level of TT knowledge is high, very few received the recommended five doses. Misconceptions linked to perceived benefits of the vaccine, route of administration, being a contraceptive and religion were some of the factors that reported to hinder respondents' uptake of the TT vaccine. Unavailability/short supply (81.8%) identified as reason for not receiving vaccine at health facilities. Conclusions: Despite high knowledge, completion of recommended doses of TT vaccine was not guaranteed due to stock-outs coupled with detrimental cultural and religious beliefs.

How to cite this article:
Muhammad-Idris ZK, Shehu AU, Isa FM. Assessment of tetanus toxoid coverage among women of reproductive age in Kwarbai, Zaria.Arch Med Surg 2017;2:48-54

How to cite this URL:
Muhammad-Idris ZK, Shehu AU, Isa FM. Assessment of tetanus toxoid coverage among women of reproductive age in Kwarbai, Zaria. Arch Med Surg [serial online] 2017 [cited 2024 Feb 25 ];2:48-54
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Worldwide, tetanus kills an estimated 180,000 neonates (about 5% of all neonatal deaths [2002 data] and up to 30,000 women (about 5% of all maternal deaths) each year.[1],[2] If the mother is not immunized with the correct number of doses of tetanus toxoid (TT) vaccine, neither she nor her newborn infant is protected against tetanus at delivery.[2] The World Health Organization (WHO) estimates that only 5% of neonatal tetanus (NT) cases are reported, even from countries with well-developed surveillance systems. Since 1989, when the world health assembly called for the elimination of NT, 110 out of 161 developing countries are thought to have achieved elimination (as of the end of 2004). The UNICEF, WHO, and UNFPA agreed in 1999 to set the year 2005 as the target date for worldwide elimination, defined as the reduction of NT cases to <1/1000 live births in every district of every country. This definition is also being used as a proxy for the elimination of maternal tetanus.[2],[3]

The purpose of giving the vaccine to women of childbearing age and to pregnant women is to protect them from tetanus and to protect their newborn infants against NT.[4],[5] Tetanus vaccination produces protective antibody levels in >80% of recipients after two doses.[3],[4] Two doses protect for 1–3 years, although some studies indicate even longer protection.[6] Tetanus vaccine is safe to give during pregnancy.[5],[7] Because tetanus spores are ubiquitous in the environment, eradication is not biologically feasible. High immunization coverage of pregnant women, clean delivery, and identification and implementation of corrective action in high-risk areas are the three primary strategies for eliminating maternal and NT (MNT). Antenatal services provide a convenient opportunity for vaccinating pregnant women.[8],[9] Where antenatal care (ANC) coverage is inadequate, mass immunization of women of childbearing age could be an alternative though expensive option.[4],[7],[10]

Effective surveillance is crucial to monitoring progress and is possible even where resources are scarce.[11] However, obtaining complete and reliable data has proven to be difficult as shown by the low efficacy of reporting. Recent observations have shown that the risk of death from NT may be directly related to poor or inadequate anti-tetanus vaccination of the mothers.[12]

According to the WHO, Nigeria is one of 30 remaining high-risk countries that is yet to achieve the MNT Elimination (MNTE) goal. Available data indicate that 18 states (out of 37) are at risk for MNT. Many hospital-based studies have identified NT as a problem of high magnitude in Nigeria.[13] MNTE is an initiative aimed at reducing MNT cases to such low levels that the disease no longer constitutes a major public health problem. Unlike polio and smallpox, tetanus cannot be eradicated. This is because tetanus spores are constantly present in the environment worldwide. However, this can be reduced to manageable levels and eliminated through immunization of pregnant women and other women of reproductive age (WRA) and promotion of more hygienic deliveries and cord care practices.[14]

The bulk of African countries, Nigeria inclusive, have a very young population with more women in the reproductive age group. This further underscores the need for increased action toward maternal tetanus immunization of women of childbearing age if the scourge is to be controlled.[15] This study, therefore, aimed to contribute toward assessing the knowledge and extent of TT immunization coverage among WRA in Kwarbai, Zaria city.

 Subjects and Methods

The study location

Kwarbai, which served as the study location, is an area that surrounds the Emir of Zazzau's palace. It is bounded to the east by Banzazzau, to the north by Unguwan Alkali, and to the south by Unguwan Katuka and Magajiya. It is essentially dominated by Hausa with few other tribes as settled residents. Majority of the inhabitants are Muslims engaged in farming, blacksmithing, and trading. They are famous for handicraft, tailoring, and embroidery of traditional dressmaking. Major Eid festivals, namely, Eid-El-Fitr, Eid-El-Kabir, and Eid-El-Maulud, celebrated yearly in this area, brings together people from far and near to witness ceremonies at and around the Emir's palace. The people also gather on weekly market days at different settlements to trade in goods and services apart from socializing, sharing information, and exchange of other pleasantries. The study was conducted from December 2014 to January 2015.


This was a cross-sectional descriptive study carried out to determine TT coverage among WRA 15–49 years living in Kwarbai ward, Zaria city. Minimum sample size of 73 was obtained using the statistical formula of n = Z2pq/d2, where, n = minimum sample size, Z = standard normal deviate at 95% confidence interval (1.96), P = prevalence from previous study (0.95) in Turkey,[16]q = complimentary probability = (1 − p) i.e. 1 − 0.95 = 0.05, and d = maximum sample error allowed (level of precision) at 95% confidence limit = 0.05. Due to anticipated nonresponse of 10%, a sample size of 80 was derived and the number was rounded up to 100 to increase the study's precision.

Kwarbai was stratified into districts, and multistage random sampling was conducted. The first stage was a selection of two districts using simple random sampling without replacement. The second stage was a selection of households, whereas the third stage was a selection of eligible women by balloting. Where no eligible woman was found, the household was skipped for another and the woman replaced through the same method.

The semi-structured questionnaire was pretested, and data were collected using interviewer-administered approach. Information about their sociodemographic characteristics, knowledge of TT immunization, and extent of immunization among WRA group (WRAG) and currently pregnant women were sought. Data collected were manually cleaned, entered, and analyzed using IBM Statistical Package for the Social Sciences SPSS ® software, version 20, (Armonk, NY: IBM Corp.). The descriptive aspects of the analysis, frequency distributions, categorical variables, means, and other descriptive measures were determined. Frequency tables and graphs were constructed to represent data. Chi-square test was applied for comparison of proportions and for evaluating associations of categorical variables in contingency tables.


Sociodemographic characteristics of the respondents

As shown in [Table 1], the predominant age of the respondents was 25–29 years (26%). Most were Hausa/Fulani (99%) and 100% were Muslims. About 82% of them were married, with more than half (54%) attaining tertiary education, having >4 living children (25%), and some currently pregnant (26%).{Table 1}

Knowledge of tetanus and tetanus toxoid immunization

Majority of respondents described tetanus as a disease caused by rusted materials (84%). Half of the respondents (50%) indicated poor hygiene, whereas 23% believed that it is a result of poor delivery attendance. Only 20% said that it results from wound injury. Most respondents indicated convulsion (73.2%) as a major symptom of tetanus, whereas fever (47.4%), body ache (33.0%), and headache (32.0%) were also mentioned.

Up to 97% of them were aware of TT immunization. In terms of their source of information, 71.1% heard from health workers, 10.3% from friends/relatives, and only 4.1% from radio and newspaper. No respondent reported television or religious centers as a source. Furthermore, 96.9% of respondents had good knowledge that TT vaccine is given to prevent tetanus with only 3.1% saying it is given to prevent against measles. All respondents interviewed had adequate knowledge on where to obtain TT vaccine with majority (87.6%) indicating hospitals/clinics while 12.4% indicated chemist.

About knowledge on the importance of TT [Figure 1], 70.8% of respondents believed that it protects a newborn child from NT with 33.9% saying it protects mothers from developing tetanus in her life. Majority of respondents said that TT vaccine is given to pregnant women only (51.5%), whereas 38.1% said that it is given to women within the age of 15–49 years. Injection was mentioned as the main route of administration by 93.8% of respondents. From [Table 2], more than three-quarters (82.5%) of respondents said that the vaccine is given during pregnancy, 6.2%, respectively, said before pregnancy or do not know, whereas only 4.1% said after delivery. Majority of respondents (90.7%) correctly know that TT vaccine can protect against tetanus in the mother, whereas 63.9% of the respondents believed that TT vaccine causes problems in women.{Figure 1}{Table 2}

Respondents' perception of tetanus toxoid vaccine problems and relation to ante-natal care

Fifty-two respondents (59.8%) perceived pain and swelling at the injection site as side effects of TT immunization. Some indicated that it can prevent pregnancy in the future (9.2%), cause fever (27.6%), and prevent their children from getting pregnant in the future (3.4%) [Table 2]. A total 84.7% of all respondents interviewed indicated that they go for ANC when pregnant while 15.3% do not. The 26.7% of those that do not attend ANC said they were not allowed to go by their husbands'/family members, 6.7% are too busy with work, and 66.7% gave other reasons such as lack of money and attitude of health-care workers.

Extent of tetanus toxoid immunization

Of the 88 respondents that have ever received TT vaccine, 55.7% received it in a hospital, 33% during antenatal, and 11.4% in a chemist. The reasons given by these respondents for receiving TT vaccine ranged from protection against tetanus (71.6%), being part of ANC service (18.2%) or simply because of family members' encouragement (4.5%), and saw it being given to others (3.4%) with only 2.3% having no known reason at all for receiving it. About 45.5% of these respondents received two doses of TT, 26.1% received only one dose, 12.5% received three and five, respectively, and 3.4% received four doses [Figure 2]. Twelve (25%) respondents that did not receive the vaccine gave culture/religion as the main reason. Up to 38% of respondents indicated that the efficiency of immunization program is good in their area, 26% said that it is fair while 21% do not know.{Figure 2}

Tetanus toxoid immunization among currently pregnant women

The study had 26 respondents that were found to be currently pregnant. Of these, 30.8% were <5 months pregnant, while the majority (69.2%) were well advanced at over 5 months [Table 3]. Of the 13 respondents that received their first dose of TT, 9 (69.2%) received it at <5 months of pregnancy. In relation to the experience of side effects of TT vaccine, 11 out of 26 (45.8%) of the respondents indicated that they experienced some side effects with more than half (54.2%) never experiencing any. Fever (63.6%) was the major side effect reported closely followed by pain at injection site (36.4%). In terms of access to TT vaccination, 81.8% of respondents indicated nonavailability/short supply as major constraints to obtaining the vaccine.{Table 3}

Relationship of sociodemographic characteristics and tetanus toxoid vaccine dose received

Significant statistical relationships were established between the educational status (χ2 = 23.796, df = 12, P = 0.022), marital status (χ2 = 29.427, df = 12, P = 0.013), attendance of ANC (χ2 = 11.349, df = 4, P = 0.023), number of children a woman has (F = 7.625, df = 4, P = 0.007), and the number of doses of TT vaccine received, whereas no statistically significant relationship was observed between age (F = 1.908a, df = 4, P = 0.117) and number of TT doses received and also between reasons why TT immunization is done (χ2 = 18.052, df = 16, P = 0.321) and number of doses received. Respondents' reported reasons why they receive TT immunization include seeing it as protecting them against tetanus, being administered to others or simply because it is part of the routine ANC care that they receive among others.


TT coverage among WRAG in Nigeria is generally low, which is a similar finding obtained from this study. The sociodemographic picture from the study revealed that majority of the respondents were within the age group of 20–34 years, mostly Hausa/Fulani, all Muslims with 82 married. These findings were in keeping with what was found in Nigeria Demographic and Health Survey (NDHS) 2008 and 2013.[17],[18] Thirty-seven of those married received two doses of the TT vaccine, whereas 11 received five doses. This was higher than what was obtained in a study by Qadir et al.[19]

This study revealed a relatively high educational status of the respondents (54% had a tertiary-level education), which may be attributed to their residing in an area well known for high regards for education and due to the existence of several institutions of learning. It also showed that women with higher levels of education were more protected from tetanus and also their children similar to findings from NDHS, 2013.[18] It was also found that those with higher levels of education received more doses of TT vaccine [Table 4] as was found in a similar study in Lahore where TT2 coverage increased with the level of education.[20]{Table 4}

This study shows that there is a significant relationship between a number of children and level of TT immunization; women that have more than four children (32%) received more doses of the vaccine and increased TT2 coverage as similarly observed in a study conducted by Qadir et al.[19] and in Turkey.[16] Half of the respondents (50%) believed that tetanus occurs as a result of poor hygiene, with only 20% saying it occurs as a result of wound injury. This contrasts with a study by Tanjida et al. where 90% of the respondents knew about the cause of tetanus.[21] The study also shows that majority of the respondents knew at least a symptom of tetanus (over 73.2%) similar to but above findings from a study in Saparua, Indonesia, where 57.8% of respondents who were educated also knew at least a symptom.[22]

A high level of knowledge and awareness on TT immunization was demonstrated by most of the respondents in this study (97%). This was in contrast to what was found in a study in Karbala, Mosul where 77.6% of women lacked awareness on TT.[23] Furthermore, this study deviates from a study in Lagos where 65.8% were unaware of TT immunization.[24] Findings from this study showed little or no involvement of the media and religious centers such as Mosques and Churches as sources of information and awareness creation on TT immunization. This is in keeping with the findings by Tanjida et al.[21] It was further observed in this study that women who knew the reason for giving TT vaccination (over 90%) were more immunized, which is in keeping with an Indonesian study.[22] Almost all the respondents interviewed had knowledge of where to obtain TT vaccine (over 87.6%), a finding that was higher than that observed in a study in Lahore, where 18% reported a lack of knowledge of place and time to get vaccinated.[20] The proportion of women with poor knowledge of TT immunization obtained from this study (6.3%) is higher than that reported in Lahore where few of the respondents had poor knowledge.[20]

Even though the level of awareness of TT vaccine was high, there were still some misconceptions, especially regarding the kind of persons given the vaccine (51.5% said that it is given to pregnant women only) and route of administration (6.2% claimed that it was given orally (by mouth) or as a cream). The latter category of women may have confused it with oral polio vaccination given to children at home during mass polio immunization. Furthermore, even though majority of the respondents had adequate knowledge that TT vaccine is given to prevent tetanus, some are not aware that it is given to prevent MNT and also some have a negative perception of it as a form of contraception. This is in accordance with the Lahore [20] and Mosul-Iraq [23] studies where most of the respondents also had misconceptions that it is a form of contraceptive. More than two-thirds of the respondents in this study (84.7%) indicated that they go for ANC when pregnant. This could be the reason attributed to their high level of awareness including reporting that health workers were their major source of information and that hospital/clinic was the appropriate place to obtain the vaccine. This is in accordance with a study in Peshawar.[25] Of the few that do not attend ANC (15.3%), 66.7% gave other personal reasons, 26.7% said that they were not allowed by husbands/family members, and 6.7% indicated they were too busy with work. This is similar to the Mosul-Iraq study.[23] It was also observed that there is a statistical significant relationship between the number of ANC visits and level of TT coverage, similar to observation made in the Ilesa study.[2]

The study indicated that very few of the women (i.e. 12.5%) received the recommended five doses of the vaccine, more than half of them (i.e. 55.7%) received it at a hospital, and majority (84.1%) during ANC visit, which is in accordance with studies, respectively, carried out in Bangladesh and Karachi and Bangladesh where 88% of urban mothers and 84% of rural mothers received TT injection during pregnancy.[6],[19] A study conducted in Khyber Pakhtunkhwa, Peshawar, Pakistan associated lack of immunization with poor socioeconomic conditions of the province.[25] This is very similar to findings from this study where respondents cited religion (25%), husband's refusal (25%), and lack of money (25%) as some of the reasons why they had never received the vaccine. Some (38%) of the respondents indicated that the efficiency of the immunization program is good and it was an important determinant for the number of TT received. Similar observation was made in Bihar, India,[26] where 26% indicated that it is fair and 21% said that they did not know.


The study found that women within the age of 20–34 years received more doses of TT vaccine than those between 15 and 19 years. Most were married and have more than four children. Education was observed to be a major determinant of the level of immunization among respondents though despite the high level of knowledge of TT immunization and where it is obtained, very few received the recommended five doses of the vaccine per schedule. The media were observed to be the least source of TT information. There were some misconceptions in terms of beneficiaries for the vaccine and route of administration in addition to belief held by some that it is a form of contraceptive and others considered it to be against their religion. A major reason for some not receiving the vaccine was its unavailability or short supply (81.8%) at their facilities. A high percentage of the women were also found to attend ANC, a situation that was observed to increase their chances of receiving TT vaccine.


Programs to enlighten WRA group, particularly those within the 15–19-year age bracket, who are less likely to receive the required number of TT doses as revealed from this study, should be developed. They should be reached with information on tetanus and TT immunization, for example, what it is; its symptoms, prevention, and benefits. This can be done through appropriate channels such as existing social media, youth-friendly centers, social gatherings, and even health facilities where they patronize. Enlightenment campaigns should, therefore, form part of the health-care promotion package available to women across the reproductive age spectrumBuilding on the already high level of knowledge among respondents on TT vaccination, the need to take multiple doses should be emphasized regardless of a woman's pregnancy status. This will address the need to receive the recommended five doses by WRA and as prescribed by the WHO standardsUnavailability or short supply of the TT vaccine, which was reported as major constraint to obtaining or gaining access to the vaccine at health facilities should be addressed by the government through the Federal and States Ministries of Health who have responsibility for procuring, distributing, and stocking the vaccines at all levels of care including private health facilities. This will expectedly increase coverage and also ensure availability, adequacy, and regular supply of the TT vaccinesHealth-care workers at all levels of care and not the media are the main source of information on TT vaccine as revealed from this study. They should, therefore, continue to be trained and re-trained on the technicalities of antitetanus vaccination as they are frontline health educators at facility and community levelsReligious leaders, gatekeepers, and influencers should be actively involved to serve as change agents in promoting and mobilizing their communities to adopt the practice of TT immunization. They are better suited to debunk misconceptions and beliefs that the vaccine is a form of contraceptive and thus not against religious teachingsFinally, government, especially at the state and local government area levels, should improve monitoring and supervision of vaccination activities including providing resources for supplemental door-to-door immunization campaigns (as part of and much like is currently practiced for children under 5 years), in addition to clinic-based immunization for WRAG.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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