Abstract

Childhood vaccination remains a cornerstone of public health, yet adherence in rural settings is often undermined by entrenched cultural and religious barriers intertwined with limited health education. This study investigates these dynamics through a case study of rural clinics in Enugu North Local Government Area, Enugu State, Nigeria. Employing a mixed-methods approach, including surveys, interviews, and focus group discussions with caregivers, healthcare providers, and community leaders, the research aims to identify specific barriers, assess their impact on vaccination uptake, and evaluate the role of targeted health education interventions. Findings are expected to reveal how traditional beliefs and faith-based misconceptions perpetuate vaccine hesitancy, contributing to suboptimal immunization coverage. The study proposes culturally sensitive strategies to enhance adherence, offering insights for localized public health programming to reduce zero-dose children and bolster herd immunity in underserved communities.

1.1 Background of the Study

Globally, childhood vaccination has averted an estimated 154 million deaths over the past 50 years, yet progress has stalled, with 14.3 million infants classified as zero-dose children in 2024, missing all routine vaccines. According to the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), coverage for the third dose of the diphtheria-tetanus-pertussis (DTP3) vaccine reached only 85% in 2024, a marginal improvement from 84% in 2023, but still leaving nearly 20 million children vulnerable to preventable diseases like measles and polio. This plateau is particularly pronounced in low- and middle-income countries, where regional disparities exacerbate inequities; for instance, sub-Saharan Africa accounts for over half of unvaccinated children, driven by systemic challenges including supply chain disruptions and conflict. The resurgence of vaccine-preventable outbreaks, such as the 2023-2024 measles epidemics in 60 countries, underscores the urgency of addressing these gaps to meet the Immunization Agenda 2030 targets.

In Nigeria, childhood immunization coverage lags behind global averages, with national DTP3 rates hovering at 62% in 2023, reflecting a patchwork of urban-rural divides and regional variations. The country bears a disproportionate burden, contributing to 2.5 million zero-dose children annually, fueled by factors such as insecurity, logistical hurdles, and entrenched misconceptions. Recent scoping reviews highlight that while governance and health system weaknesses play roles, caregiver-related barriers—including poverty and negative perceptions of healthcare workers—compound the issue, leading to dropout rates as high as 40% after initial doses. In the South-East geopolitical zone, where Enugu State is located, coverage fares slightly better at around 70% for full immunization, yet rural areas remain hotspots for under-vaccination due to geographic isolation and cultural insularity.

Enugu State exemplifies these challenges, with routine immunization data from 2020 revealing inconsistencies and underreporting across facilities, resulting in completeness rates below 80% and timeliness under 65%. In rural communities of Enugu North Local Government Area (LGA), a predominantly agrarian zone with limited infrastructure, full vaccination coverage stands at approximately 61.3%, marred by zero-dose prevalence of 1.6% and under-vaccination at 2.8%. Studies in similar under-resourced settings within Enugu indicate that perceived poor service quality, drug unavailability, and long waiting times deter utilization, with only 28.7% of residents citing quality concerns as a primary barrier. These local dynamics are amplified by the area’s demographic profile, where over 60% of the population relies on subsistence farming, exacerbating access inequities for women and children.

Cultural and religious barriers further entrench vaccine hesitancy in Nigeria, where traditional beliefs often clash with biomedical interventions; for example, misconceptions portraying vaccines as harbingers of infertility or spiritual impurity are rampant, particularly in faith-dominated communities. In the South-East, Igbo cultural norms emphasizing communal rituals and ancestral protections can delay or supplant clinic visits, while Christian sects advocating faith healing outright reject vaccinations. Religious leaders’ endorsements—or lack thereof—profoundly influence adherence, as seen in cases where mosque or church sermons propagate doubts, reducing uptake by up to 36% in affected households. These factors intersect with gender dynamics, where patriarchal structures require spousal approval for health decisions, disproportionately affecting adolescent mothers in rural Enugu.

Health education emerges as a critical lever to dismantle these barriers, yet its efficacy in rural Nigeria is hampered by low literacy (below 50% in Enugu’s rural zones) and language mismatches between providers and caregivers. Tailored interventions, such as community dialogues led by trusted elders, have shown promise in boosting awareness, but scalability remains limited without addressing underlying cultural resistance. This study thus positions health education not merely as dissemination but as a culturally attuned dialogue to foster trust and adherence in Enugu North’s clinics.

1.2 Statement of the Problem

Despite national and global efforts to achieve universal childhood immunization, rural clinics in Enugu North LGA report persistently low adherence rates, with full vaccination coverage at just 61.3% and notable zero-dose cases linked to cultural taboos and religious doctrines that frame vaccines as antithetical to traditional healing or divine will. These barriers manifest in parental refusals, high dropout rates post-initial doses, and reliance on herbal remedies, exacerbating outbreaks of diseases like measles, which claimed over 1,000 lives in Nigeria in 2023 alone. Compounding this, health education programs in these clinics are often top-down, ignoring local Igbo cosmologies and Christian fundamentalist views, leading to mistrust and underutilization—evidenced by timeliness of reporting below 65% and perceived service quality deterring 28.7% of potential users. Without targeted interventions, this cycle perpetuates health inequities, leaving vulnerable children in Enugu North at risk and straining limited resources in understaffed rural facilities.

1.3 Objective of the Study

General Objective: To examine the cultural and religious barriers to health education and their influence on childhood vaccination adherence in rural clinics of Enugu North Local Government Area, Enugu State.

Specific Objectives:

1. To identify the prevalent cultural and religious barriers affecting health education delivery in the study area.
2. To assess the extent to which these barriers influence caregivers’ adherence to childhood vaccination schedules.
3. To evaluate the role of culturally adapted health education strategies in mitigating these barriers and improving vaccination uptake.

1.4 Significance of the Study

This study holds substantial implications for public health policy in Nigeria, particularly in bridging the immunization gap in rural South-East contexts like Enugu North. By delineating specific cultural and religious impediments—such as faith-based refusals and traditional gender roles—it provides empirical evidence to inform the National Primary Health Care Development Agency’s (NPHCDA) strategies, enabling the design of localized interventions that integrate religious leaders into outreach efforts. Policymakers can leverage these insights to allocate resources more equitably, potentially elevating DTP3 coverage from 62% nationally to align with WHO’s 90% target, thereby averting future outbreaks and reducing the economic burden of vaccine-preventable diseases estimated at $1.5 billion annually in Nigeria. Furthermore, the findings advocate for mandatory cultural competency training in medical curricula, fostering a cadre of providers attuned to community nuances.

Academically and at the community level, the research enriches the discourse on health behavior theories by applying them to Igbo-specific contexts, offering a model for future ethnographic studies in sub-Saharan Africa. For Enugu North’s residents, it empowers grassroots advocacy through validated data on barriers, potentially galvanizing community-led health education forums that respect local worldviews while promoting evidence-based practices. Ultimately, enhanced adherence could safeguard over 5,000 at-risk children in the LGA, fostering intergenerational health equity and sustainable development in line with Sustainable Development Goal.

1.5 Research Questions

1. What are the prevalent cultural and religious barriers affecting health education delivery in rural clinics of Enugu North LGA?
2. To what extent do these barriers influence caregivers’ adherence to childhood vaccination schedules?
3. How effective are culturally adapted health education strategies in mitigating these barriers and improving vaccination uptake?

1.6 Hypothesis

H1: There is no significant association between cultural and religious beliefs and the barriers to health education delivery in rural Enugu North clinics.

H2: Cultural and religious barriers do not significantly influence the level of childhood vaccination adherence among caregivers in the study area.

H3: Culturally adapted health education strategies have no significant positive effect on mitigating barriers and enhancing vaccination uptake in Enugu North LGA.

1.7 Scope of the Study

This study is delimited to rural clinics within Enugu North Local Government Area, Enugu State, focusing on caregivers of children aged 0-23 months attending immunization services. It encompasses cultural and religious barriers to health education and their direct impact on vaccination adherence, excluding urban facilities or other LGAs. Data collection spans three months in 2025, utilizing mixed methods but not extending to intervention implementation.

1.8 Definition of Terms

• Cultural Barriers: Social norms, traditions, and practices within a community that hinder acceptance of health interventions, such as Igbo rituals prioritizing ancestral healing over biomedical vaccines (Kuss et al., 2024).
• Religious Barriers: Faith-based doctrines or interpretations that conflict with vaccination, including Christian faith-healing rejections or Islamic misconceptions about vaccine purity (Hamina et al., 2025).
• Health Education: Structured dissemination of information on disease prevention tailored to cultural contexts, aimed at empowering caregivers to make informed health decisions (Nwokoro et al., 2022).
• Childhood Vaccination Adherence: The consistent completion of recommended immunization schedules for children under five, measured by full coverage of antigens like DTP3 and measles (Ugwu et al., 2025).

References

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