Immunization Without Records: Examining the Impact of Missing Vaccine Cards on Caregiver Recall and Associated Factors Among Public School Children in Rural Nigeria

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In such settings, caregivers’ recall of their ward’s vaccination history may be the only available source of information, potentially leading to discrepancies in immunization status. This study aims to evaluate the availability of vaccine cards, assess caregiver recall, and identify factors associated with the absence of vaccination records among public school students in a rural Nigerian community. Methods A cross-sectional study was conducted among 2780 public school students and their caregivers in a rural community in Anambra State, Nigeria. Data on vaccination card availability, caregiver recall of vaccines, and demographic characteristics were collected through structured interviews. Logistic regression was employed to identify factors associated with the presence of vaccination cards, with odds ratios (ORs) and 95% confidence intervals (CIs) used to quantify associations, with the following adjustments. Results Majority (88.7%) of the subjects did not have a vaccination card. Following adjustments, male students were 36% less likely to have a vaccine card compared to females (aOR: 0.638, 95% CI: 0.443–0.918, p = 0.0155). Older students were also less likely to have a vaccine card (aOR: 0.881 per year increase in age, 95% CI: 0.827–0.938, p < 0.001). Higher caregiver recall percentages were associated with a slightly decreased likelihood of having a vaccine card (aOR: 0.960, 95% CI: 0.947–0.974, p < 0.001). Conclusion This study revealed significant gaps in immunization record-keeping in rural Nigeria, where a majority of children lack vaccination cards, and caregiver recall remains unreliable. These findings underscore the urgent need for enhanced record-keeping practices and innovative digital solutions to accurately track vaccination status. Strengthening these systems is crucial for improving vaccine coverage, supporting public health initiatives, and protecting children from preventable diseases in resource-limited settings. Immunization records Caregiver recall Rural Nigeria Vaccination coverage Health disparities Low-resource settings Figures Figure 1 BACKGROUND Immunization remains one of the most effective public health interventions, preventing millions of deaths each year and reducing the spread of contagious diseases such as measles, tetanus, and polio.[ 1 ] Despite global efforts to achieve universal vaccine coverage, challenges persist, particularly in rural and underserved communities where access to healthcare facilities and reliable record-keeping systems is often limited.[ 2 , 3 ] In many low- and middle-income countries, vaccination cards serve as the primary means of tracking a child’s immunization status.[ 4 , 5 ] However, the absence or loss of these cards can result in incomplete vaccination records, posing a significant threat to the efficacy of immunization programs.[ 6 , 7 ] In Nigeria, vaccination coverage has improved over the years, yet considerable barriers remain, especially in rural regions where healthcare access and proper record-keeping infrastructure are often lacking. Studies have indicated that many caregivers in such areas struggle to accurately recall their children’s immunization history when vaccination cards are unavailable.[ 4 , 5 ] This issue is further exacerbated by the reliance on paper-based documentation, which is prone to being lost, damaged, or rendered inaccurate over time.[ 8 , 9 ] As a result, healthcare providers face difficulties in verifying a child’s immunization status, leading to missed or delayed vaccinations and, in some cases, unnecessary repeated doses.[ 2 , 3 ] The reliance on caregiver recall, in the absence of official vaccination records, further complicates the situation. Evidence suggests that when caregivers are tasked with recalling their child’s immunization history, the accuracy of their recollections is often inadequate.[ 1 ] This can lead to gaps in vaccination coverage, leaving children vulnerable to preventable diseases, particularly in regions with limited access to healthcare services.[ 6 , 7 ] These gaps not only endanger individual children but also undermine broader public health efforts aimed at achieving herd immunity and controlling outbreaks.[ 8 , 9 ] Addressing these gaps in immunization record-keeping is crucial for improving vaccination compliance and ensuring that children receive the full course of vaccines required for protection against preventable diseases. Strategies such as strengthening record-keeping practices, educating caregivers on the importance of retaining vaccination cards, and introducing digital solutions to replace paper-based systems have been suggested as potential solutions.[ 1 ] By improving the reliability of immunization records, healthcare providers can better track and monitor vaccination schedules, reducing the risk of missed immunizations and enhancing overall health outcomes for children, particularly in resource-limited settings.[ 8 , 9 ] Our study aims to evaluate the availability of vaccination cards and assess caregiver recall of their children’s immunization status in a rural Nigerian community. Understanding the scale of this issue will provide insights into the gaps in current immunization practices and inform future interventions aimed at improving vaccination compliance and health outcomes in rural and underserved populations. METHOD Study Design This research employed a cross-sectional design to identify factors associated with missing immunization records among public school students and to explore the relationship between the availability of vaccination cards and caregiver recall in the rural community of Anam, located in Anambra State, Nigeria. Study Setting The study was conducted in 25 public nursery, primary and secondary schools in the rural community of Anam, located in Anambra State, Nigeria. These schools were randomly selected to ensure a representative sample of students from the community. Study Population The study population consisted of 2780 public school students and their respective caregivers from Anam, a rural community in Anambra State. Data Collection Data were collected through structured interviews with caregivers of 2780 public school children across 25 randomly selected schools in Anam, Anambra State, Nigeria. The interviews captured demographic information, including the children's age, gender, class, and state of origin, as well as the caregivers' age, gender, and occupation. These demographic details were systematically gathered to provide a comprehensive profile of the study participants. Following the collection of demographic data, caregivers were asked to recall their children’s immunization history. This recall-based approach enabled the collection of vaccination data directly from the caregivers, ensuring consistency across all participants. Interviewers were trained to ensure accuracy during data collection, and responses were meticulously recorded to minimize errors. Data Analysis Data was cleaned and analyzed using Python version 3.9. Descriptive statistics were used to summarize the demographic variables and the availability of vaccination cards. Continuous variables, such as the ages of the children and caregivers, were expressed as medians with interquartile ranges (IQR), while categorical variables like gender, state of origin, and occupation were presented as frequencies and percentages. For the main analysis, we employed logistic regression to identify factors associated with vaccine card availability. The dependent variable was the availability of vaccination cards (coded as 1 for "Yes" and 0 for "No"). Independent variables included the child’s age, gender, class, state of origin, caregiver’s age, gender, occupation, and vaccine recall percentage. The logistic regression analysis produced odds ratios (ORs) with 95% confidence intervals (CIs) to assess the strength and direction of associations. A p-value of less than 0.05 was considered statistically significant. RESULTS Demographics of Study Population A total of 2780 children from 25 randomly selected public schools participated in the study, alongside their respective caregivers. The median age of the children was 9 years (IQR: 5–11), with an age range of 2 to 28 years (Table 1 ). Males comprised the majority of the children, accounting for 76.1% (n = 2116), while females made up 23.9% (n = 664). Most of the children were in primary school (65.2%), with a smaller proportion in nursery (27.5%) and secondary school (7.3%). Caregivers had a median age of 48 years (IQR: 43–53), with ages ranging from 20 to 111 years. Like the children, 76.1% of caregivers were male. Regarding occupations, 82.4% of caregivers were involved in farming or fishing, followed by 9.6% in business, and 6.5% identified as civil servants (Table 1 ). Table 1 Demographics of the Study Subjects and Caregivers Variable Frequency Range/Percentage(%) Mean age of Subject (years) 9.0 (5.0–11.0) 2.0–28.0 Gender Male 2116 76.1 Female 664 23.9 Class Nursery 765 27.5 Primary 1812 65.2 Secondary 203 7.3 State of Origin Anambra 2750 98.9 Kogi 16 0.6 Ebonyi 11 0.4 Benue 2 0.1 Enugu 1 0.02 Mean Age of Guardian (years) 48.0 (43.0–53.0) 20.0–111.0 Guardian Gender Male 2116 76.1 Female 664 23.9 Occupation Farmer/Fishing 2290 82.4 Business 268 9.6 Civil Servant 182 6.5 Others 40 1.4 Vaccine Card Availability and Recall of Vaccination History Out of the 2780 children, only 11.3% (n = 315) had vaccination cards, while the majority (88.7%, n = 2465) did not possess any vaccination cards at the time of the study. Among the caregivers interviewed, only 531 (19.1%) were able to recall their children’s vaccination history without the aid of vaccination cards (Fig. 1). Among the 531 caregivers who recalled their children's vaccination history, several vaccines were commonly mentioned, albeit with varying levels of recall (Figure I). Vitamin A supplementation had the highest recall rates, with 54.8% of caregivers recalling the 200-unit dose and 53.1% recalling the 100-unit dose. Other vaccines with notable recall rates included BCG (34.8%), the first dose of measles vaccine (MCV1, 33.7%), and the second dose of measles vaccine (MCV2, 32.6%). However, recall rates for other essential vaccines, such as the Oral Polio Vaccine (OPV), were much lower, with OPV 1, OPV 2, and OPV 3 recalled by 27.5%, 23.0%, and 19.4% of caregivers, respectively. Similarly, the Pentavalent vaccine series (Penta 1, 2, and 3) had relatively low recall rates, ranging from 10.9% for Penta 1 to just 6.6% for Penta 3. The Yellow Fever vaccine was recalled by only 13.7% of caregivers, and the Meningitis (CSM) vaccine was recalled by 11.5% of caregivers. Out of the 24 vaccines assessed (Fig. 1), the percentage recalled by the caregivers, which were given to their respective wards, varied significantly. The mean percentage of vaccines recalled was 20.8% (± 13.35) with a range of 4.2–66.7%. Figure I: Vaccine Recall Rates Among Caregivers Factors Associated with Vaccine Card Availability Table 2 presents the univariate and multivariate logistic regression analyses identifying factors associated with vaccine card availability. In the univariate analysis, several demographic factors were significantly associated with vaccine card availability. Older children were 5.2% less likely per year increase in age to have a vaccination card (OR: 0.948, 95% CI: 0.918–0.979, p = 0.001), while male children were 30% less likely to possess a vaccination card compared to female children (OR: 0.700, 95% CI: 0.553–0.886, p = 0.003). Multivariate analysis revealed that after adjusting for potential confounders, male children remained 36% less likely to have a vaccination card compared to females (adjusted OR: 0.638, 95% CI: 0.443–0.918, p = 0.0155). Additionally, older children were 11.9% less likely to have a vaccination card per year increase in age (adjusted OR: 0.881, 95% CI: 0.827–0.938, p < 0.001). Caregiver Recall and Vaccine Card Availability Higher vaccine recall percentages among caregivers were significantly associated with a slightly decreased likelihood of having a vaccine card, with each percentage increase in recall decreasing the likelihood by 4% (adjusted OR: 0.960, 95% CI: 0.947–0.974, p < 0.001). Table 2 Regression Analysis of Determinants of Vaccine Card Availability Univariate Logistic Regression Multivariate Logistic Regression OR 95% CI p-value OR 95% CI p-value Age (years) 0.948 0.918–0.979 0.001 * 0.881 0.827–0.938 < 0.001 * Gender Female (ref) Male 0.700 0.553–0.886 0.003 * 0.638 0.443–0.918 0.0155 * Class Nursery (ref) Primary 1.229 0.941–1.606 0.130 — — — Secondary † † † — — — State of Origin Anambra (ref) Benue 7.814 0.488–125.241 0.146 — — — Ebonyi 0.781 0.100–6.125 0.814 — — — Enugu † † † — — — Kogi 0.521 0.069–3.957 0.528 — — — Guardian's Age 0.989 0.977–1.000 0.058 1.014 0.996–1.033 0.1235 Guardian's Gender Female (ref) Male 1.005 0.763–1.323 0.973 — — — Guardian's Occupation Civil servant (ref) Farmer 1.162 0.702–1.922 0.559 — — — Business 1.324 0.723–2.425 0.364 — — — Others 1.012 0.323–3.171 0.983 — — — Vaccine Recall Percentage 0.963 0.950–0.976 < 0.001 * 0.960 0.947–0.974 < 0.001 * † Note: Odds ratios could not be estimated due to sparse data. * Statistically Significant Discussion This study aimed to explore the availability of vaccination cards, caregiver recall of immunization history, and the demographic factors associated with vaccine card availability among public school children in rural Nigeria. Our findings highlight critical gaps in immunization record-keeping, with only 11.3% of the children having a vaccination card, and further demonstrate the challenges of relying on caregiver recall in such resource-limited settings. The low availability of vaccination cards (11.3%) is consistent with previous studies conducted in similar rural settings across low- and middle-income countries.[ 5 , 10 – 13 ] The absence of formal immunization records presents a significant barrier to accurate vaccination tracking. In our study, caregivers often relied on memory to recall their children's vaccination history, and only 19.1% of them were able to recall this information without a vaccination card. This reliance on memory poses risks to public health, as caregivers may inadvertently overreport or underreport their children's immunization status.[ 7 ] Interventions are necessary to enhance record-keeping, whether through improved distribution of physical vaccination cards or the introduction of digital systems to track and store immunization data.[ 9 ] Our logistic regression analysis identified several factors associated with vaccine card availability. Notably, male children were significantly less likely to have a vaccination card compared to females (adjusted OR: 0.638, 95% CI: 0.443–0.918, p = 0.0155). This finding may reflect broader socio-cultural biases that prioritize female children's health documentation over males, or it may indicate differences in parental attitudes toward healthcare for boys versus girls in the community.[ 14 ] Age was another significant predictor of vaccine card availability, with older children less likely to possess a vaccination card (adjusted OR: 0.881 per year increase in age, 95% CI: 0.827–0.938, p < 0.001). This may be attributed to the progressive loss or damage of cards over time, particularly in rural communities where record-keeping infrastructure is weak.[ 15 ] Additionally, older children might have received their vaccinations during earlier periods when immunization campaigns were less robust, leading to lower rates of documented immunizations.[ 16 ] Interestingly, higher caregiver recall percentages were associated with a decreased likelihood of having a vaccine card (adjusted OR: 0.960, 95% CI: 0.947–0.974, p < 0.001). This counterintuitive finding suggests that caregivers without vaccination cards might compensate by relying more heavily on their memory. However, this recall is prone to error, as seen in the wide variability in recall accuracy (ranging from 4.2–66.7%). This underscores the limitations of relying solely on caregiver memory for immunization data and emphasizes the need for reliable, accessible records.[ 17 ] The reliance on caregiver recall in the absence of vaccination cards poses several challenges for public health. Inaccurate recall can lead to missed or unnecessary vaccinations, undermining the effectiveness of immunization programs and increasing the risk of vaccine-preventable diseases.[ 18 ] To address these issues, public health initiatives should focus on improving vaccination card retention by educating caregivers about the importance of these records and ensuring that vaccination cards are routinely provided and replaced when lost or damaged.[ 19 ] Additionally, the introduction of digital health solutions, such as electronic immunization registries, could help overcome the limitations of paper-based records and enhance vaccination tracking in rural areas.[ 9 ] This study is one of the first to systematically assess the availability of vaccination cards and caregiver recall in rural Nigeria. The large sample size and the inclusion of multiple demographic variables in the logistic regression model strengthen the validity of our findings. However, the study is not without limitations. As with all recall-based studies, the accuracy of the caregivers' recollections cannot be verified, and the absence of vaccination cards may have introduced recall bias.[ 12 ] Additionally, our cross-sectional design limits the ability to establish causality between demographic factors and vaccine card availability.[ 20 ] Conclusion The findings of this study highlight significant gaps in vaccination record-keeping in rural Nigeria, with the vast majority of children lacking vaccination cards. Male children and older children were particularly less likely to have vaccine cards, while higher caregiver recall percentages were associated with lower card availability. These findings underscore the need for interventions that improve both record-keeping and caregiver education. Digital health solutions and targeted public health campaigns could play a critical role in ensuring that all children receive and retain accurate immunization records, thereby improving vaccination coverage and health outcomes in rural, underserved populations. Declarations Ethics Approval and Consent to Participate Ethical approval for this study was obtained from the Anambra State Ministry of Health Research Ethics Committee (ASMOHREC) with the approval number ASMOHREC/2024/29102024. Written informed consent was provided by all caregivers participating in this study, ensuring adherence to ethical standards for research involving human subjects. Consent for Publication All authors have reviewed the manuscript and consented to its publication. Competing Interests The authors declare that they have no competing interests. Authors' Information The authors are affiliated with the Developing Access to Analytics Initiative, Nigeria, with specialisations in public health and paediatric healthcare. Chisom Nri-Ezedi is an Assistant Professor in Paediatrics at Nnamdi Azikiwe University, Awka, Nigeria. Funding No specific funding was obtained for this study. Author Contribution I.O conceptualised the study and led data collection. A.I.I and A.O managed data entry. C.A.N provided statistical support, final analysis, and manuscript preparation. All authors contributed to and approved the final manuscript. Acknowledgements The authors would like to thank the caregivers and school staff who participated in and facilitated the study in Anambra State. Data Availability Data is provided within the manuscript or supplementary information References World Health Organization (WHO). Immunization coverage [Internet]. [cited 2024 Oct 11]; https://www.who.int/news-room/fact-sheets/detail/immunization-coverage CDC Global Immunization Strategic Framework | Global Immunization | CDC [Internet]. [cited 2024 Oct 11]; https://www.cdc.gov/global-immunization/about/strategic-framework.html Health system and. immunisation strengthening [Internet]. [cited 2024 Oct 12]; https://www.gavi.org/programmes-impact/types-support/health-system-and-immunisation-strengthening Akwataghibe NN, Ogunsola EA, Broerse JEW, Popoola OA, Agbo AI, Dieleman MA. Exploring Factors Influencing Immunization Utilization in Nigeria-A Mixed Methods Study. Front Public Health [Internet]. 2019 [cited 2024 Oct 11];7. https://pubmed.ncbi.nlm.nih.gov/31921755/ Brown DW, Gacic-Dobo M. Home-based record prevalence among children aged 12–23 months from 180 demographic and health surveys. Vaccine [Internet] 2015 [cited 2024 Oct 12];33:2584–93. https://pubmed.ncbi.nlm.nih.gov/25887089/ Fatiregun AA, Lochlainn LN, Kaboré L, Dosumu M, Isere E, Olaoye I et al. Missed opportunities for vaccination among children aged 0–23 months visiting health facilities in a southwest State of Nigeria, December 2019. PLoS One [Internet] 2021 [cited 2024 Oct 11];16. https://pubmed.ncbi.nlm.nih.gov/34449777/ Dansereau E, Brown D, Stashko L, Danovaro-Holliday MC. A systematic review of the agreement of recall, home-based records, facility records, BCG scar, and serology for ascertaining vaccination status in low and middle-income countries. Gates Open Res [Internet]. 2019 [cited 2024 Oct 12];3. /pmc/articles/PMC7110941/ Akwataghibe NN, Ogunsola EA, Popoola OA, Agbo AI, Dieleman MA. Using participatory action research to improve immunization utilization in areas with pockets of unimmunized children in Nigeria. Health Res Policy Syst [Internet] 2021 [cited 2024 Oct 11];19:1–14. https://health-policy-systems.biomedcentral.com/articles/ 10.1186/s12961-021-00719-9 Danovaro-Holliday MC, Dansereau E, Rhoda DA, Brown DW, Cutts FT, Gacic-Dobo M. Collecting and using reliable vaccination coverage survey estimates: Summary and recommendations from the Meeting to share lessons learnt from the roll-out of the updated WHO Vaccination Coverage Cluster Survey Reference Manual and to set an operational research agenda around vaccination coverage surveys, Geneva, 18–21 April 2017. Vaccine [Internet] 2018 [cited 2024 Oct 12];36:5150. Available from: /pmc/articles/PMC6099121/. Seror V, Cortaredona S, Ly EY, Ndiaye S, Gaye I, Fall M et al. Vaccination card availability and childhood immunization in Senegal. BMC Public Health [Internet] 2020 [cited 2024 Oct 12];20:1–13. https://bmcpublichealth.biomedcentral.com/articles/ 10.1186/s12889-020-08792-5 Eze P, Aniebo CL, Agu UJ, Agu SA, Acharya Y. Validity of maternal recall for estimating childhood vaccination coverage – Evidence from Nigeria. Vaccine. 2022;40:28–36. Miles M, Ryman TK, Dietz V, Zell E, Luman ET. Validity of vaccination cards and parental recall to estimate vaccination coverage: a systematic review of the literature. Vaccine [Internet] 2013 [cited 2024 Oct 12];31:1560–8. https://pubmed.ncbi.nlm.nih.gov/23196207/ Akmatov MK, Mikolajczyk RT. Timeliness of childhood vaccinations in 31 low and middle-income countries. J Epidemiol Community Health (1978) [Internet] 2012 [cited 2024 Oct 12];66. https://pubmed.ncbi.nlm.nih.gov/21551179/ Smith PJ, Chu SY, Barker LE. Children who have received no vaccines: who are they and where do they live? Pediatrics [Internet] 2004 [cited 2024 Oct 12];114:187–95. https://pubmed.ncbi.nlm.nih.gov/15231927/ Odutola A, Afolabi MO, Ogundare EO, Lowe-Jallow YN, Worwui A, Okebe J et al. Risk factors for delay in age-appropriate vaccinations among Gambian children. BMC Health Serv Res [Internet] 2015 [cited 2024 Oct 12];15:1–9. https://bmchealthservres.biomedcentral.com/articles/ 10.1186/s12913-015-1015-9 Restrepo-Méndez MC, Barros AJD, Wong KLM, Johnson HL, Pariyo G, França GVA et al. Inequalities in full immunization coverage: trends in low- and middle-income countries. Bull World Health Organ [Internet]. 2016 [cited 2024 Oct 12];94:794. /pmc/articles/PMC5096343/ Binyaruka P, Borghi J. Validity of parental recalls to estimate vaccination coverage: Evidence from Tanzania. BMC Health Serv Res [Internet] 2018 [cited 2024 Oct 12];18:1–9. https://bmchealthservres.biomedcentral.com/articles/ 10.1186/s12913-018-3270-z Cutts FT, Claquin P, Danovaro-Holliday MC, Rhoda DA. Monitoring vaccination coverage: Defining the role of surveys. Vaccine [Internet] 2016 [cited 2024 Oct 12];34:4103–9. https://pubmed.ncbi.nlm.nih.gov/27349841/ Tsehay AK, Worku GT, Alemu YM. Determinants of BCG vaccination coverage in Ethiopia: a cross-sectional survey. BMJ Open [Internet] 2019 [cited 2024 Oct 12];9. /pmc/articles/PMC6398717/ Setia MS. Methodology Series Module 3: Cross-sectional Studies. Indian J Dermatol [Internet] 2016 [cited 2024 Oct 12];61:261–4. https://pubmed.ncbi.nlm.nih.gov/27293245/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Nov, 2024 Editor assigned by journal 04 Nov, 2024 Submission checks completed at journal 04 Nov, 2024 First submitted to journal 01 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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underserved communities where access to healthcare facilities and reliable record-keeping systems is often limited.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] In many low- and middle-income countries, vaccination cards serve as the primary means of tracking a child\u0026rsquo;s immunization status.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] However, the absence or loss of these cards can result in incomplete vaccination records, posing a significant threat to the efficacy of immunization programs.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Nigeria, vaccination coverage has improved over the years, yet considerable barriers remain, especially in rural regions where healthcare access and proper record-keeping infrastructure are often lacking. Studies have indicated that many caregivers in such areas struggle to accurately recall their children\u0026rsquo;s immunization history when vaccination cards are unavailable.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] This issue is further exacerbated by the reliance on paper-based documentation, which is prone to being lost, damaged, or rendered inaccurate over time.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] As a result, healthcare providers face difficulties in verifying a child\u0026rsquo;s immunization status, leading to missed or delayed vaccinations and, in some cases, unnecessary repeated doses.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe reliance on caregiver recall, in the absence of official vaccination records, further complicates the situation. Evidence suggests that when caregivers are tasked with recalling their child\u0026rsquo;s immunization history, the accuracy of their recollections is often inadequate.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis can lead to gaps in vaccination coverage, leaving children vulnerable to preventable diseases, particularly in regions with limited access to healthcare services.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] These gaps not only endanger individual children but also undermine broader public health efforts aimed at achieving herd immunity and controlling outbreaks.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAddressing these gaps in immunization record-keeping is crucial for improving vaccination compliance and ensuring that children receive the full course of vaccines required for protection against preventable diseases. Strategies such as strengthening record-keeping practices, educating caregivers on the importance of retaining vaccination cards, and introducing digital solutions to replace paper-based systems have been suggested as potential solutions.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] By improving the reliability of immunization records, healthcare providers can better track and monitor vaccination schedules, reducing the risk of missed immunizations and enhancing overall health outcomes for children, particularly in resource-limited settings.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur study aims to evaluate the availability of vaccination cards and assess caregiver recall of their children\u0026rsquo;s immunization status in a rural Nigerian community. Understanding the scale of this issue will provide insights into the gaps in current immunization practices and inform future interventions aimed at improving vaccination compliance and health outcomes in rural and underserved populations.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cp\u003e \u003cstrong\u003eStudy Design\u003c/strong\u003e \u003cp\u003eThis research employed a cross-sectional design to identify factors associated with missing immunization records among public school students and to explore the relationship between the availability of vaccination cards and caregiver recall in the rural community of Anam, located in Anambra State, Nigeria.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Setting\u003c/strong\u003e \u003cp\u003eThe study was conducted in 25 public nursery, primary and secondary schools in the rural community of Anam, located in Anambra State, Nigeria. These schools were randomly selected to ensure a representative sample of students from the community.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Population\u003c/strong\u003e \u003cp\u003eThe study population consisted of 2780 public school students and their respective caregivers from Anam, a rural community in Anambra State.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Collection\u003c/strong\u003e \u003cp\u003eData were collected through structured interviews with caregivers of 2780 public school children across 25 randomly selected schools in Anam, Anambra State, Nigeria. The interviews captured demographic information, including the children's age, gender, class, and state of origin, as well as the caregivers' age, gender, and occupation. These demographic details were systematically gathered to provide a comprehensive profile of the study participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFollowing the collection of demographic data, caregivers were asked to recall their children\u0026rsquo;s immunization history. This recall-based approach enabled the collection of vaccination data directly from the caregivers, ensuring consistency across all participants. Interviewers were trained to ensure accuracy during data collection, and responses were meticulously recorded to minimize errors.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Analysis\u003c/strong\u003e \u003cp\u003eData was cleaned and analyzed using Python version 3.9. Descriptive statistics were used to summarize the demographic variables and the availability of vaccination cards. Continuous variables, such as the ages of the children and caregivers, were expressed as medians with interquartile ranges (IQR), while categorical variables like gender, state of origin, and occupation were presented as frequencies and percentages.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFor the main analysis, we employed logistic regression to identify factors associated with vaccine card availability. The dependent variable was the availability of vaccination cards (coded as 1 for \"Yes\" and 0 for \"No\"). Independent variables included the child\u0026rsquo;s age, gender, class, state of origin, caregiver\u0026rsquo;s age, gender, occupation, and vaccine recall percentage.\u003c/p\u003e \u003cp\u003eThe logistic regression analysis produced odds ratios (ORs) with 95% confidence intervals (CIs) to assess the strength and direction of associations. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDemographics of Study Population\u003c/h2\u003e \u003cp\u003eA total of 2780 children from 25 randomly selected public schools participated in the study, alongside their respective caregivers. The median age of the children was 9 years (IQR: 5\u0026ndash;11), with an age range of 2 to 28 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Males comprised the majority of the children, accounting for 76.1% (n\u0026thinsp;=\u0026thinsp;2116), while females made up 23.9% (n\u0026thinsp;=\u0026thinsp;664). Most of the children were in primary school (65.2%), with a smaller proportion in nursery (27.5%) and secondary school (7.3%).\u003c/p\u003e \u003cp\u003eCaregivers had a median age of 48 years (IQR: 43\u0026ndash;53), with ages ranging from 20 to 111 years. Like the children, 76.1% of caregivers were male. Regarding occupations, 82.4% of caregivers were involved in farming or fishing, followed by 9.6% in business, and 6.5% identified as civil servants (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the Study Subjects and Caregivers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange/Percentage(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age of Subject (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (5.0\u0026ndash;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026ndash;28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e765\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState of Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnambra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKogi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEbonyi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnugu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age of Guardian (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.0 (43.0\u0026ndash;53.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.0\u0026ndash;111.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer/Fishing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCivil Servant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVaccine Card Availability and Recall of Vaccination History\u003c/h3\u003e\n\u003cp\u003eOut of the 2780 children, only 11.3% (n\u0026thinsp;=\u0026thinsp;315) had vaccination cards, while the majority (88.7%, n\u0026thinsp;=\u0026thinsp;2465) did not possess any vaccination cards at the time of the study. Among the caregivers interviewed, only 531 (19.1%) were able to recall their children\u0026rsquo;s vaccination history without the aid of vaccination cards (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eAmong the 531 caregivers who recalled their children's vaccination history, several vaccines were commonly mentioned, albeit with varying levels of recall (Figure I). Vitamin A supplementation had the highest recall rates, with 54.8% of caregivers recalling the 200-unit dose and 53.1% recalling the 100-unit dose. Other vaccines with notable recall rates included BCG (34.8%), the first dose of measles vaccine (MCV1, 33.7%), and the second dose of measles vaccine (MCV2, 32.6%).\u003c/p\u003e \u003cp\u003eHowever, recall rates for other essential vaccines, such as the Oral Polio Vaccine (OPV), were much lower, with OPV 1, OPV 2, and OPV 3 recalled by 27.5%, 23.0%, and 19.4% of caregivers, respectively. Similarly, the Pentavalent vaccine series (Penta 1, 2, and 3) had relatively low recall rates, ranging from 10.9% for Penta 1 to just 6.6% for Penta 3. The Yellow Fever vaccine was recalled by only 13.7% of caregivers, and the Meningitis (CSM) vaccine was recalled by 11.5% of caregivers.\u003c/p\u003e \u003cp\u003eOut of the 24 vaccines assessed (Fig.\u0026nbsp;1), the percentage recalled by the caregivers, which were given to their respective wards, varied significantly. The mean percentage of vaccines recalled was 20.8% (\u0026plusmn;\u0026thinsp;13.35) with a range of 4.2\u0026ndash;66.7%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure I: Vaccine Recall Rates Among Caregivers\u003c/p\u003e\n\u003ch3\u003eFactors Associated with Vaccine Card Availability\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the univariate and multivariate logistic regression analyses identifying factors associated with vaccine card availability. In the univariate analysis, several demographic factors were significantly associated with vaccine card availability. Older children were 5.2% less likely per year increase in age to have a vaccination card (OR: 0.948, 95% CI: 0.918\u0026ndash;0.979, p\u0026thinsp;=\u0026thinsp;0.001), while male children were 30% less likely to possess a vaccination card compared to female children (OR: 0.700, 95% CI: 0.553\u0026ndash;0.886, p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003eMultivariate analysis revealed that after adjusting for potential confounders, male children remained 36% less likely to have a vaccination card compared to females (adjusted OR: 0.638, 95% CI: 0.443\u0026ndash;0.918, p\u0026thinsp;=\u0026thinsp;0.0155). Additionally, older children were 11.9% less likely to have a vaccination card per year increase in age (adjusted OR: 0.881, 95% CI: 0.827\u0026ndash;0.938, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003ch3\u003eCaregiver Recall and Vaccine Card Availability\u003c/h3\u003e\n\u003cp\u003eHigher vaccine recall percentages among caregivers were significantly associated with a slightly decreased likelihood of having a vaccine card, with each percentage increase in recall decreasing the likelihood by 4% (adjusted OR: 0.960, 95% CI: 0.947\u0026ndash;0.974, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression Analysis of Determinants of Vaccine Card Availability\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate Logistic Regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eMultivariate Logistic Regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.918\u0026ndash;0.979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.827\u0026ndash;0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.553\u0026ndash;0.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.443\u0026ndash;0.918\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0155\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursery (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.941\u0026ndash;1.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState of Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnambra (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.488\u0026ndash;125.241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEbonyi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.100\u0026ndash;6.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnugu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKogi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.069\u0026ndash;3.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian's Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.977\u0026ndash;1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.996\u0026ndash;1.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.1235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian's Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.763\u0026ndash;1.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian's Occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCivil servant (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.702\u0026ndash;1.922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.723\u0026ndash;2.425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.323\u0026ndash;3.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccine Recall Percentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.950\u0026ndash;0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.947\u0026ndash;0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eNote: Odds ratios could not be estimated due to sparse data.\u003c/p\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eStatistically Significant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the availability of vaccination cards, caregiver recall of immunization history, and the demographic factors associated with vaccine card availability among public school children in rural Nigeria. Our findings highlight critical gaps in immunization record-keeping, with only 11.3% of the children having a vaccination card, and further demonstrate the challenges of relying on caregiver recall in such resource-limited settings.\u003c/p\u003e \u003cp\u003eThe low availability of vaccination cards (11.3%) is consistent with previous studies conducted in similar rural settings across low- and middle-income countries.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The absence of formal immunization records presents a significant barrier to accurate vaccination tracking. In our study, caregivers often relied on memory to recall their children's vaccination history, and only 19.1% of them were able to recall this information without a vaccination card. This reliance on memory poses risks to public health, as caregivers may inadvertently overreport or underreport their children's immunization status.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Interventions are necessary to enhance record-keeping, whether through improved distribution of physical vaccination cards or the introduction of digital systems to track and store immunization data.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur logistic regression analysis identified several factors associated with vaccine card availability. Notably, male children were significantly less likely to have a vaccination card compared to females (adjusted OR: 0.638, 95% CI: 0.443\u0026ndash;0.918, p\u0026thinsp;=\u0026thinsp;0.0155). This finding may reflect broader socio-cultural biases that prioritize female children's health documentation over males, or it may indicate differences in parental attitudes toward healthcare for boys versus girls in the community.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAge was another significant predictor of vaccine card availability, with older children less likely to possess a vaccination card (adjusted OR: 0.881 per year increase in age, 95% CI: 0.827\u0026ndash;0.938, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This may be attributed to the progressive loss or damage of cards over time, particularly in rural communities where record-keeping infrastructure is weak.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Additionally, older children might have received their vaccinations during earlier periods when immunization campaigns were less robust, leading to lower rates of documented immunizations.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eInterestingly, higher caregiver recall percentages were associated with a decreased likelihood of having a vaccine card (adjusted OR: 0.960, 95% CI: 0.947\u0026ndash;0.974, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This counterintuitive finding suggests that caregivers without vaccination cards might compensate by relying more heavily on their memory. However, this recall is prone to error, as seen in the wide variability in recall accuracy (ranging from 4.2\u0026ndash;66.7%). This underscores the limitations of relying solely on caregiver memory for immunization data and emphasizes the need for reliable, accessible records.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe reliance on caregiver recall in the absence of vaccination cards poses several challenges for public health. Inaccurate recall can lead to missed or unnecessary vaccinations, undermining the effectiveness of immunization programs and increasing the risk of vaccine-preventable diseases.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] To address these issues, public health initiatives should focus on improving vaccination card retention by educating caregivers about the importance of these records and ensuring that vaccination cards are routinely provided and replaced when lost or damaged.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Additionally, the introduction of digital health solutions, such as electronic immunization registries, could help overcome the limitations of paper-based records and enhance vaccination tracking in rural areas.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study is one of the first to systematically assess the availability of vaccination cards and caregiver recall in rural Nigeria. The large sample size and the inclusion of multiple demographic variables in the logistic regression model strengthen the validity of our findings. However, the study is not without limitations. As with all recall-based studies, the accuracy of the caregivers' recollections cannot be verified, and the absence of vaccination cards may have introduced recall bias.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Additionally, our cross-sectional design limits the ability to establish causality between demographic factors and vaccine card availability.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study highlight significant gaps in vaccination record-keeping in rural Nigeria, with the vast majority of children lacking vaccination cards. Male children and older children were particularly less likely to have vaccine cards, while higher caregiver recall percentages were associated with lower card availability. These findings underscore the need for interventions that improve both record-keeping and caregiver education. Digital health solutions and targeted public health campaigns could play a critical role in ensuring that all children receive and retain accurate immunization records, thereby improving vaccination coverage and health outcomes in rural, underserved populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e \u003cp\u003e Ethical approval for this study was obtained from the Anambra State Ministry of Health Research Ethics Committee (ASMOHREC) with the approval number ASMOHREC/2024/29102024. Written informed consent was provided by all caregivers participating in this study, ensuring adherence to ethical standards for research involving human subjects.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication\u003c/strong\u003e \u003cp\u003e All authors have reviewed the manuscript and consented to its publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthors' Information\u003c/h2\u003e \u003cp\u003eThe authors are affiliated with the Developing Access to Analytics Initiative, Nigeria, with specialisations in public health and paediatric healthcare. Chisom Nri-Ezedi is an Assistant Professor in Paediatrics at Nnamdi Azikiwe University, Awka, Nigeria.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo specific funding was obtained for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eI.O conceptualised the study and led data collection. A.I.I and A.O managed data entry. C.A.N provided statistical support, final analysis, and manuscript preparation. All authors contributed to and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e The authors would like to thank the caregivers and school staff who participated in and facilitated the study in Anambra State.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Immunization coverage [Internet]. 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Front Public Health [Internet]. 2019 [cited 2024 Oct 11];7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/31921755/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/31921755/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown DW, Gacic-Dobo M. Home-based record prevalence among children aged 12\u0026ndash;23 months from 180 demographic and health surveys. 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Indian J Dermatol [Internet] 2016 [cited 2024 Oct 12];61:261\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/27293245/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/27293245/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Immunization records, Caregiver recall, Rural Nigeria, Vaccination coverage, Health disparities, Low-resource settings","lastPublishedDoi":"10.21203/rs.3.rs-5370663/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5370663/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eImmunization remains a cornerstone of public health, yet maintaining accurate vaccination records is a challenge in rural communities where vaccine cards are often missing. In such settings, caregivers\u0026rsquo; recall of their ward\u0026rsquo;s vaccination history may be the only available source of information, potentially leading to discrepancies in immunization status. This study aims to evaluate the availability of vaccine cards, assess caregiver recall, and identify factors associated with the absence of vaccination records among public school students in a rural Nigerian community.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted among 2780 public school students and their caregivers in a rural community in Anambra State, Nigeria. Data on vaccination card availability, caregiver recall of vaccines, and demographic characteristics were collected through structured interviews. Logistic regression was employed to identify factors associated with the presence of vaccination cards, with odds ratios (ORs) and 95% confidence intervals (CIs) used to quantify associations, with the following adjustments.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMajority (88.7%) of the subjects did not have a vaccination card. Following adjustments, male students were 36% less likely to have a vaccine card compared to females (aOR: 0.638, 95% CI: 0.443\u0026ndash;0.918, p\u0026thinsp;=\u0026thinsp;0.0155). Older students were also less likely to have a vaccine card (aOR: 0.881 per year increase in age, 95% CI: 0.827\u0026ndash;0.938, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Higher caregiver recall percentages were associated with a slightly decreased likelihood of having a vaccine card (aOR: 0.960, 95% CI: 0.947\u0026ndash;0.974, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study revealed significant gaps in immunization record-keeping in rural Nigeria, where a majority of children lack vaccination cards, and caregiver recall remains unreliable. These findings underscore the urgent need for enhanced record-keeping practices and innovative digital solutions to accurately track vaccination status. Strengthening these systems is crucial for improving vaccine coverage, supporting public health initiatives, and protecting children from preventable diseases in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Immunization Without Records: Examining the Impact of Missing Vaccine Cards on Caregiver Recall and Associated Factors Among Public School Children in Rural Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-02 22:22:51","doi":"10.21203/rs.3.rs-5370663/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-06T09:24:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-04T13:15:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-04T13:11:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-11-01T05:05:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d16ea72-958a-41a5-8c24-ff6137bbb96d","owner":[],"postedDate":"December 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T07:08:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-02 22:22:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5370663","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5370663","identity":"rs-5370663","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}