Behaviors of Yahisuli’s Parents in Early Childhood Immunization in 2018

This descriptive cross-sectional study aims to determine factors associated with Yahisuli's parents' behaviors in early childhood immunization in 2018. To collect data, we used a questionnaire administered to a non-probability convenience sample of 96 parents of children 0-11 months of age. Descriptive analysis allowed us to compare our results with previous work. We recorded an average age of 32.8 years and a male/female sex ratio of 1.3. More than 95% of the parents went to school, of which 58.5% have a high school education. The birth rank of the last child ranged from 3 to 5 with a sex ratio of 1.3 in favor of males. Nearly 15% of children have not been fully vaccinated. In this work, 55 out of 96 parents bring their children to a health facility to be vaccinated to ensure their protection (76.4%) and prevention against infectious diseases (47.3%). On the other hand, 42% do not adhere to vaccination because of ignorance, fear due to children's incessant crying after vaccination, adverse post-immunization events. When it came to vaccines, several misunderstandings were raised. These corroborate rumors observed under other skies. Thus, a descriptive and analytical study on the epidemiological surveillance of adverse effects of vaccines is indispensable in the province of Tshopo.

This descriptive cross-sectional study aims to determine the behavior of Yahisuli's parents in early childhood immunization in 2018. To collect data, we used a questionnaire administered to a non-probability convenience sample of 96 Yahisuli parents caring for a child aged 0 to 11 months. Descriptive analysis allowed us to compare our results with previous work. We recorded an average age of 32.8 years and a male/female sex ratio of 1.3. More than 95% of the parents attended school, of which 58.5% had a high school education. The birth rank of the last child is between 3 and 5 with a sex ratio of 1.3 in favor of males. Nearly 15% of children have not been fully vaccinated. In this work, 55 out of 96 parents bring their children to a health facility to be vaccinated to ensure their protection (76.4%) and prevention against infectious diseases (47.3%). On the other hand, 42% do not adhere to vaccination because of ignorance, fear due to children's incessant crying after vaccination, adverse post-immunization events. When it came to vaccines, several misunderstandings were raised. These corroborate rumors observed under other skies. Thus, a descriptive and analytical study on the epidemiological surveillance of adverse effects of vaccines is indispensable in the province of Tshopo.

Introduction
In the past, vaccines have elicited reactions from the population, linked to the political context of their administration, or to characteristics that are at odds with traditions, sometimes also to intrinsic manufacturing defects.
The changing natural history of infectious diseases and the resurgence of diseases that have almost disappeared make vaccination a central issue in general medicine. Numerous quantitative and qualitative studies have identified determinants of the parents' vaccination decision without providing an in-depth understanding of the motivation for the decision [1].
In the tropics, strengthened by the success of vaccines in reducing infectious diseases worldwide [2], public health organizations would like to complete the elimination of major cosmopolitan diseases (tuberculosis, poliomyelitis, measles), as well as to extend the benefits of vaccination to diseases specific to the geographical area, including parasitosis embedded in particular biotopes [1,3].
However, apart from the challenges to be met by biomedicine, the expectations and vision of the populations concerned must also be taken into consideration. This is not only a legitimate effort, from a human rights perspective, to improve information and foster citizen autonomy, along a path that is developing before our eyes.
Fifty years after the end of colonization, certain reactions of populations in tropical areas reflect a crisis of confidence in vaccination programs driven from above and from outside. The consolidation and even improvement of the results achieved with vaccines and the extension of vaccination coverage to new diseases require a historical, sociological and anthropological reflection on the implementation of programs.
In several countries, the vaccine had entered into competition with an old method using smallpox directly to obtain immunity. In general, the proponents of the vaccine then opposed the modern vaccine par excellence to the archaic, random and dangerous variolization. In Algeria, doctors perceived that resistance to vaccinia was mainly rooted in opposition to the foreign invader. In India, for a long time the English did not hurry to upset the traditional variolization sponsored by the Brahmins. Hindus were resistant to collecting vaccine lymph from the sides of the sacred cow, and shunned operations conducted by vaccinators recruited from the lower castes [1].
The Indian example of variolization, carefully analyzed by historians, highlights that vaccination is never a neutral and anonymous routine operation, immune from suspicion in the community, except perhaps in the case of epidemic-related panic. The rest of the time, the population asks itself questions that are only apparently simple: who vaccinates whom, when, how and why?
Answering these questions is crucial to avoid vaccine resistance, or in modern terms, to predict its acceptability [3]. Even poorly educated populations are quite capable of making relevant clinical observations [4].
Today, one is never completely immune to a break in the cold chain, the spread of altered or defective products, and the sporadic occurrence of measles or polio in vaccinated children.
In DR Congo, despite progress in reducing under-five mortality from 158 deaths per 1,000 live births in 2007 to 104 in 2013, the situation remains worrisome in terms of the global situation and the achievement of sustainable development goals by 2030. This excess mortality is largely due to vaccinepreventable causes. Indeed, the estimated vaccination coverage in 2013 for all antigens was low: only 41% of children aged 12 to 23 months were fully vaccinated [5].
In the province of Tshopo, we observed cases of resistance during mass campaigns, particularly in the health zone of Yalimbongo, Opienge, Bafwasende and Yaleko. In these areas, communities such as the Kitawalists, Idomites, Catholic bongola motema, Nzambé Lumumba are very hostile to vaccination. In fact, during the 2017 supplementary immunization activities, OPV, a live attenuated vaccine, was administered to a child under five years of age in the Yaleko health zone, resulting in acute flaccid paralysis.
Although the health zone of Yahisuli is not spared from cases of resistance and/or refusal of vaccination based on certain suspicions when it comes to vaccines, we have observed that no study on the parents' behavior towards vaccination has been carried out.
It is in this context that we initiated this study to determine the behavior of Yahisuli's parents in the early childhood vaccination in 2018. Specifically, we wanted to describe the characteristics of the parents surveyed, identify the reasons for adherence and dropping out of vaccination as well as their judgments about misunderstandings around the vaccine.

Methodology
This descriptive cross-sectional study took place in the Yahisuli health zone in the province of Tshopo. This zone is mainly occupied by the Topoke, Lokele and Mbole tribes. Our population is composed of parents who are in charge of a child aged 0 to 11 months. Due to the lack of a reliable sampling list, we used a nonprobability convenience sampling of 96 subjects, using a self-administered questionnaire for data collection. Descriptive analysis based on headcount tables, percentage calculations and arithmetic mean allowed us to compare our results with previous work. Parental consent, confidentiality and anonymity were respected.

Presentation of results
Characteristics of surveyed parents Age Sex ratio male/female =1.3. Our respondents are represented at 93.7% of the bride and groom.

Level of education
Activities carried out The majority of our respondents were government employees (41.7%), followed by housewives (30.2%) and farmers (20.8%). More than 90% of our respondents belong to Christianity.

Religion
Household size The household size of the majority of our respondents is between 8 and 10 people (31.3%) or an average of 8 people per household.
Gender of the last child in the family The last child born living in 57.3% of the households surveyed was male. The male/female sex ratio was 1.3.
Child's birth rank The birth rank of the last child of the parents surveyed ranged from 3 to 5 (39.6%). The average birth rank is 5.
Geographic accessibility More than 50% of the parents surveyed are within one kilometer of a health facility.

Parents' behaviour towards vaccination
Vaccination adherence Reason for dropping out of vaccination More than 55% of parents surveyed do not adhere to vaccination because of the effects observed in children after vaccination.
Fully immunized children  Our respondents' fears about bringing their children to immunization reside mainly in the incessant crying after vaccine administration (46.9) and adverse post-immunization events (42.7%).

Method of vaccine administration
Reason of preference for oral administration Reason for preference of administration by injection Immediate effects and effectiveness are the main reasons for injection preference.   More than 60% of the parents suggested that health managers and their partners provide support in terms of medicines and equipment for children.

Discussion
Characteristics of parents years of age, of which 50.8% were in school and less than 20% were unemployed.
Birth rank was second with extremes ranging from 1 to 8 [6].
Ouedraogo L.T. et al. 19] also found that maternal illiteracy (73.3%) influenced adherence to childhood immunization. Low education levels can be a handicap to access to information on immunization. The higher level of education of fathers could be an important asset if they are involved in sensitization activities.
The proportion of married people observed in this work is consistent with the results of the DHS-DRC II survey. The survey found that more than six out of ten (64%) lived in a union: 46% of married women and 18% in a consensual union [5].
Most of our respondents belong to Christianity. This is due to their numbers in the population. However, there is reason to suggest that, according to a study carried out in Benin in 2006, parents practicing the traditional religion (48.1%), large households (29.9%) and those whose child was the third born of the family (28.4%) were not vaccinated [6].
Compared to the sex of the last child born alive, Makoutode et al. observed 50.2% of male children [6]. This corroborates the results of our work.
However, Ependja in a similar survey conducted in Opala found a predominantly female sex ratio. This is due to culture. Indeed, according to Bantu culture, a boy is the heir of the family, especially if he is the first born.
Therefore, parents have a moral obligation to protect him against certain dubious practices that can negatively influence his fertility. References to rumors or misinformation about vaccines and immunization. This gives female children a chance to be seen in large numbers at the Expanded Programme on Immunization [7].
With respect to media exposure, it should be clarified that the household does not need to own a radio, television or buy a newspaper to have access to it. Many people may be able to listen to the radio or watch television at the home of friends or neighbors. These data are particularly important for the development of education, awareness and information dissemination programs in all areas, including health and, in particular, family planning [5]. The results of the 2013-2014 Demographic and Health Survey found that in DR Congo, men are usually more exposed to the media than women [5].
In this study, the proportion of parents who slept elsewhere or were absent from their homes is justified by the instability of households seeking survival for their families. The population is forced to travel long distances to follow the rotating market program. In addition, with the phenomenon of African solidarity in the event of death, some people are sometimes called upon to spend entire nights away from home. This does not exclude prayer vigils in churches.
The health facilities at Yahisuli are located less than a kilometer from the parents surveyed. However, previous studies have shown that parents do not adhere to vaccination when the health facility is more than a 15-minute walk away. This means that geographical accessibility, household size and religion are factors associated with parents' behavior in vaccinating their children.
Accessibility and quality of care are factors that explain the therapeutic management of patients. Various studies have shown that, in general, health center utilization rates decrease as distances to be traveled increase [7].
Other studies carried out in various contexts have also shown that public health facilities are more solicited by populations that are close to them; and that the distances to be covered are relatively short. For example, in Nigeria, the distance is less than two kilometers, and in Ghana 70% of users are less than three thousand kilometers away [7].

Parents' behavior towards immunization
In this work, 55 out of 96 parents bring their children to a health structure to be vaccinated in order to ensure their protection and prevention against infectious diseases. On the other hand, 41 subjects do not adhere to vaccination because of disease and ignorance as well as fear due to children's incessant crying after vaccination, adverse post-immunization events.
Protection and prevention were also cited as the main reasons for adherence.
Those who did not fully vaccinate their children cited fatigue, field work, religion, made to the song dedicated to this pathology. For the parents, the appearance of this abnormal phenomenon defying modern medicine would be due to vaccination [20].
The disease referred to in the responses of our respondents is only the fever observed in children when certain live attenuated vaccines were administered, notably Bacille de Calmette and Guérin, measles vaccine and DTPHepBHib.
These vaccines are given by injection and can induce a mild rise in body temperature. This does not rule out the fear of paralysis of a limb [7].
Regarding vaccination status, Magatte et al. 21] in Senegal, in a comprehensive cross-sectional survey of immunization dropouts among 562 mothers of children aged 10-23 months, found that the proportion of fully immunized children was statistically related to mothers' knowledge of the immunization schedule and the sex of the child. They also found that male children were more likely to be fully immunized. Jennifer [22] found a relationship between birth rank and child immunization status.
Regarding vaccinators and the route of vaccine administration, Moulin said that each vaccine is unique in its presentation, its mode of administration (by injection or by mouth). Injection is preferred in some cultures while the oral route is, depending on the case, appreciated for its ease and analogy with food or depreciated because of its banality. Scarification can be as easily accepted or suspected as a disturbing marking of the body. The personality of the vaccinator by social status, ethnicity, gender, etc. may also be involved [1].

Misunderstandings about vaccines
When it came to vaccines or vaccination, several misunderstandings were raised by our respondents. In 2003, in Nigeria, a highly unstable country in the midst of the WHOsponsored campaign to eradicate childhood paralysis, polio immunization was denounced by the Sharia Supreme Council on a set of arguments against submission to divine providence and malicious interventions by Western powers [9].
Beyond paranoid assertions and rumors of plots, it is true that there are irregularities in the conduct of vaccinations: the interventions planned by the health authorities do not take into account the constraints of the population and the rhythms of work in the fields.
In Mossi country, infantile paralysis is a bird disease related to a jealous deity that should not be thwarted.
The population asks itself the question: why devote so much money and energy to the prevention of a single disease, polio, which has few victims and only sporadically rages, while so many basic needs, such as drinking water or schools, remain unsatisfied?
For Chippaux, the behavior of populations is paradoxical only in appearance, when at the same time they suspect that the vaccines provided free of charge by large international organizations are hiding dark intentions and complain that they do not have access to the latest products of the pharmaceutical industry [10].
10] Inspired by the vision of vaccines as "global public goods" distinct from ordinary medicines, charities have begun to support the spread of expensive new vaccines in tropical countries. 11] However, even this principled and laudable initiative may have appeared to the public as a decision taken over their heads, mobilizing funds and people that could have been better spent in other areas [12].

Conclusion
All in all, the vaccine tools are not exclusively at the service of the State or communities, but are first and foremost at the service of individuals who want to be protected and who wish to benefit from effective immunization corresponding to local risks. This is a historic undertaking that has its letters of glory, but which has also had its tragedies and blunders.
This paradox of vaccinology in the tropics is not inevitable. Thus, we propose to initiate a descriptive and analytical study on the epidemiological surveillance of the adverse effects of vaccines in the expanded program of routine vaccines or in mass campaigns.