International Journal of
Nursing and Midwifery

  • Abbreviation: Int. J. Nurs. Midwifery
  • Language: English
  • ISSN: 2141-2456
  • DOI: 10.5897/IJNM
  • Start Year: 2009
  • Published Articles: 211

Full Length Research Paper

Effect of tetanus toxoid immunization training program on knowledge and attitude on female nursing students in Government Universities in Khartoum State

Amani Abdelgader Mohamed
  • Amani Abdelgader Mohamed
  • Department of Nursing, Sabia University College, Jazan University, Saudi Arabia.
  • Google Scholar
Faiza Ali Nasor
  • Faiza Ali Nasor
  • Faculty of Nursing Sciences. Khartoum University, Sudan
  • Google Scholar

  •  Received: 09 January 2020
  •  Accepted: 17 April 2020
  •  Published: 30 April 2020


Tetanus is an acute infectious disease, most cases occur due to lack of vaccination or incomplete immunization on exposure leading to increase morbidity and mortality. Studies reveal that adequate knowledge regarding tetanus is more important for the prevention of maternal and neonatal tetanus in the future. The study aims to study effect of tetanus toxoid immunization training program on knowledge and attitude of female nursing students in government universities in Khartoum state. The Experimental design was used. The study was done in Government Universities in Khartoum state which has faculty of nursing, randomly; Tow University selected study group and the rest control group. A total of 181 students were recruited study group and 246 control group. Data were collected from both groups using structure close end questionnaire and attitude scale; pre intervention and training program offered to the study group and after six months data recollected from both groups. Mean knowledge changed from 1.5709 pre to 1.8154 post interventions for the study group and showed statistically significant with p-value = 0.000, while control group showed statistical significant knowledge. Total mean percent for positive attitude 65 (48%) pre were changed to 72.8 post intervention; while negative attitude were changed from 34.55% pre to 27.28% post in the study group. In the control group, Wilcoxon ranged test showed a statistical significant in the control group from pre to post intervention. From the study group, health education is effective and is the best strategy to improve knowledge, attitudes and increased vaccination status of participants.

Key words: Effect, tetanus, training, program, students.



Tetanus is a vaccine-preventable disease that causes an annual deaths of 309,000 and in the year2000, it killed about 200,000 new  born  (Ogbeyi  et  al., 2017). Tetanus spores are widespread in the environment and transmission occurs when spores are introduced into the body, usually through a puncture-type  wound  (Ogbeyi et al., 2017; Abir et al., 2017; Sirri, 2007).  When it enters the body, it produces a toxin that causes muscular rigidness, spasms, and makes breathing difficult resulting in death among all age groups. Tetanus is an acute infectious disease, most cases occur due to lack of vaccination or incomplete immunization on exposure leading to increase morbidity and mortality (Ogbeyi  et al., 2017; Abir et al., 2017).  Deaths due to tetanus in developing countries are 135 times higher than those in developed countries (Sirri, 2007). Tetanus that strikes women during pregnancy or within 6 weeks of the termination of pregnancy is called maternal tetanus. Maternal tetanus (MT) is responsible for at least 5% of maternal deaths (Nora, 2012; Naeem et al., 2010).

It is a deadly infectious disease for which immunization is available in expanded program of immunization (EPI) at both Infant level and for females of reproductive age.  More than 95% of patients who develop tetanus have not been previously immunized (Naeem et al., 2010; Njidda et al., 2017; Qadir et al., 2007; Ahmed et al., 2001).

Worldwide, more than 50,000 maternal deaths occur per year, but still, more than 270,000 newborns and 30,000 women die of tetanus yearly (Qadir et al., 2007). As a result of improved maternal immunization with tetanus toxoid (TT), approximately 725,000 cases of neonatal tetanus are prevented worldwide (Njidda et al., 2017). Maternal and Neonatal tetanus (MNNT) can be prevented by immunizing women of childbearing age during pregnancy or outside of pregnancy, through hygienic birth practices and immunization of women of childbearing age with the (TT) vaccine (WHO, 2006; Obaid, 2007; Millennium Development Goals, 2005-2015).Despite the effort done to eliminate MNT, most of the countries had achieved elimination leaving 40 countries that still have not eliminated the disease (Federal Ministry of Health, 2005),Sudan is one of them. The EPI policy in Sudan is to give tetanus vaccination to all pregnant women. In addition to routine provision of vaccination conducted in the health facilities, MNT campaigns are conducted in high risk districts targeting all women of childbearing age (15-45 years) (Federal Ministry of Health, 2005; El-Sayed, 2006). The main aim of the EPI program is to eliminate MNT or lower the incidence to less than 1 per 1000 live births (WHO, 2006; Obaid, 2007; Shultz, 2015; Shafiq, 2017).

A study on the knowledge of tetanus immunization among internees in a government medical college of Kolkata found that 57.4% internees were not aware of the number of doses of tetanus vaccine recommended for children under the age of 16 years and 76.8% internees were not aware of the number of doses of tetanus vaccine recommended for women of child bearing age (Chowdhury et al., 2011).Another  study done on knowledge regarding tetanus and status of (TT) vaccination among nurses in a tertiary hospital, Dhaka India, presented  that knowledge was found to be unsatisfactory and  significantly  higher   among   married andmultipara women (p<0.005, p<0.05) respectively. Moreover, those who were vaccinated also had significantly higher knowledge on vaccination schedule (p<0.001)(Sobhan et al., 2007). A study from Turkey reported that because tetanus immunity of women in child bearing age was not sufficient, the government introduced supplemental immunization activities for all women in child bearing age and for all children (Essen, 2006).

The (TT) vaccination of pregnant women was included in the WHO’s (EPI) as early as the mid-1970s and is now a standard practice (Shultz, 2015; Shafiq, 2017; Chowdhury et al., 2011).Increasing knowledge about tetanus is an important precondition to improve the increase of TT coverage. Other factors influencing TT immunization coverage showed that the awareness of mothers, place of residence and maternal education are predictors for TT immunization status (Qadir et al., 2007; Sobhan et al., 2007; Essen, 2006; Blencowe et al., 2010; Singh  et al., 2012; Tanjida  et al., 2009).

Importance of TT given to women who are or who becomes pregnantis that antibodies forms in her body and readily crosses to the placenta, thereby protecting the newborn against tetanus during birth.  A few months after wards a three dose of tetanus toxoid vaccine provides protection against maternal and neonatal tetanus for at least five years. A maximum of five doses will protect women through their childbearing years. MNT is both forms of generalized tetanus and has similar clinical courses (Blencowe et al., 2010; Singh et al., 2012; = 2016; Mijal, 2009; Verma and Khann, 2012; Hadeel and Iqbal, 2014).

In Sudan, there is no available information on the TT vaccination coverage of women in childbearing age. But in the pilot study, the researcher opines that the young girls had lack of knowledge attitude and practice of Vaccination.Thus, it is important to assess knowledge attitude and practice of TT immunization for women in child bearing age.However, the study aims to increase level of knowledge and attitude of the university students from structural training program of TT vaccine for women in child bearing age.


The Expanded Program on Immunization (EPI) rescheduled five doses of TT for all women of childbearing age, but the strategy could not attain the coverage as expected, because large number women of child bearing age were not aware of the benefit of immunization and complete protection against tetanus (Chowdhury et al., 2011). Even the educated females of child-bearing age do not seem to have the knowledge of complete immunization against tetanus. It has also been reported that even where knowledge was adequate, the practice  did  not  corresponds with knowledge, which suggested additional factors might have been preventing translation of knowledge into ones practice.(17) In the view of the fact that in developing countries, majority of deliveries are assisted by non-health workers, increasing coverage of tetanus toxoid is desirable.


H1: Undergraduate students who receive TT vaccination training program will have highest percentage of level of knowledge and attitude than group not received TT program.

H0: There is no change on the level of knowledge and attitude among the students who took the TT vaccination training program to the control group

Aims of the study

To study the effect of tetanus toxoid immunization training program on knowledge and attitude of female nursing students in Government Universities in Khartoum state



Study design

A quasi experimental research design was used.

Study setting

The study targeted all Government Universities that have faculty of nursing sciences in Khartoum State and these universities are International University of Africa, Alzaiem Alazhari University, Khartoum North University, Al-Neelain University, Khartoum University, and Omdurman Islamic university. However the study was conducted in five universities, Al-Neelain University was not accepted to participate in the study.


Female students in first year were included in the study. Only females were included because the TT is only given to females in the reproductive age, since they will be married soon and may face a lot of problems during deliveries or miscarriages due to unsafe environments. First year students were chosen because they have not been exposed to any vaccination topics as not to have any confounding factor that can contaminate the data and to facilitate the follow up during the four years of being in the universities.

Inclusion criteria

The study included female students in first year.

Exclusion criteria

The study excluded male students.

Sampling procedure

Simple random sample was used, two universities were study group and the rest were control group.

Sample size

For total coverage, study group was 181students and control group was 246 students.

Variables under study

Dependent variable

Knowledge and attitude of tetanus toxoid vaccine in child bearing age.

Independent variable

Training program on tetanus toxoid immunization for women in child bearing age.

Methods of data collection

Data were collected using structured closed ended questionnaire to assess the students’ knowledge on tetanus toxoid immunization in childbearing age, as well as attitude scale pre and post intervention.

Development of data collection tools

Structured knowledge questionnaire

(i) The researcher developed the questionnaire in reference to related original research articles, and literature (Appendix I).

(ii)The questionnaire consists of three parts:

Section I: Consist of demographic variables such as age, marital status, residence and university name.

Section II: consist of questions for knowledge information on tetanus and tetanus toxoid immunization in childbearing age.

(iii) The questionnaire was pretested in the study population before usage for knowledge questions; a correct answer will give 1 point while a wrong answer will give 0. Wilcoxon study rank test was used to determine and compare the changes or improvement on the level of the knowledge for the study population.

Section III: Immunization status of the participant

Attitudes scale

There were 10 questions for the attitude which were answerable by “Strongly Agree”, “Agree”, “Disagree”, and “Strongly Disagree”. Pre-intervention and post intervention mean percentage were analyzed using descriptive and inferential statistics (Appendix II)

Work plan

Phase I: Assessment phase

Data were collected from the intervention and control group using structured questionnaire and attitude  scale  which  was  considered as baseline data before the program about tetanus toxoid immunization in child bearing age.

Phase II: Implement TT training program

In which tetanus toxoid immunization in childbearing age program material was developed by the researcher based on available resources and review of relevant literature including WHO and booklets regarding tetanus toxoid immunization in childbearing age to help the participant in receiving the message. The program activities were implemented through two sessions; the time period for each session was two hours for study group, one week for each university. The program were presented in a clear, concise manner and focused on the point to be learned, using different methods such as lectures, pictures, broacher discussion, and videotapes.

Phase III: Evaluation phase

Evaluation of the program for TT immunization of women in childbearing age were done six months after implementation of the program, data were collected using the same method of data collection used in phase one.

Data analysis method

(i) The collected data were interred in to SPSS variation 20.

(ii) The data were organized, tabulated and analyzed using descriptive statistics. 

(iii) The inferential statistics (nonparametric test Wilcoxon sign rank test) were used to find out the differences in knowledge and attitude between pre and post-test for study and control group. The results were presented in Tables 1 to 7 and Figures 1 to 4.













Ethical consideration

Official consent was obtained from the Graduate College Medical and Health Studies Board -University of Khartoum.

An official consent was obtained from the dean of faculties of nursing students.

The researcher made it clear to the participants in the study that they could withdrawal at any time and their rights will be protected.

High confidentiality were observed during filling questionnaire.




Interventional study was conducted in all Government Universities in Khartoum state that has faculty of nursing sciences, to study the effect of tetanus toxoid immunization training Program on   knowledge   and   attitude  of  female  nursing students. All the data was obtained from a sample of 181 of students in the study group, and 246 of the students for control group, both groups were enrolled in the study. The data collected were analyzed statistically and the result were categorized in parts which are demographic variable, previous immunization, sources of information, numbers of doses and reasons for not being immunized for the study and control groups. These also include knowledge of study and control group and the statistical test for it, practicing immunization and finally mean percentage of the attitude. The study has shown the fallowing findings as explained in the Figures 1 to 4 and Tables 1 to 7.




An interventional study was conducted to study the effect of tetanus toxoid immunization training program on knowledge and attitude of female nursing students. In this study, mean knowledge was changed obviously from 1.5709 pre to 1.8154 post interventions. The result supported by MIJAL study,  showed changed  in mean score from 4.77 pre to 13.52 post intervention, Mijal (2009)  compared study done in china which showed inadequate knowledge and misunderstanding regarding TT immunization in study participants pre intervention program (Hadeel and Iqbal, 2014).  In  this  study  Wilcoxon  signed  rank  test showed statistical insignificant for knowledge between study and control group, and this support educational program can help in changing knowledge. In this study knowledge was adequate in some items, such as purpose of vaccine was 98%   pre   changed   to   100  post;   however,  in adequate in other items. This is similar to the study done in Iraqi which showed their knowledge of study participants were adequate in some items and inadequate in other items (Essen, 2006).

Knowledge regarding signs and symptoms of study group was inadequate pre intervention, which represent 31.9 changed to 92, 8 post, and knowledge regarding period of communicability were changed from 18.2 pre to 56.2 post, compared to control group which  was changed negatively from 42.2 to 36.6, which meanseducational program has positive effect on changing knowledge in study participant . Total mean percent of knowledge items were changed in the study group (pre 47.8 to 85.8 post and for control group 56.1pre changed to 57.2 post).

In this study, attitude was changed for study group pre and post, total mean percent for positive attitude 65 (48%) pre were changed to 72.8 post intervention; while negative attitudes were changed from 34.55%pre to 27.28% post. Wilcoxon Signed Ranks test showed statistically significant in study group pre and post intervention with (p value = 0.000) this is similar to MIJAL study, attitude was statistically significant (Mijal, 2009).Concerning attitude of control group, it was insignificant among pre and post intervention.

This study showed that most participant source of information about tetanus toxoid immunization was family (41.4%), media 30.3%, and health center 18.8 for study group and family39%, media 26% and health center 17.5 for control group. This is compared to a study done in Dhaka, which showed respondent’s source of knowledge about TT immunization was watching television 35%, health workers 24%, newspaper 16%, radio 13% and other sources 12% (Chowdhury et al., 2011).

In this study 16.6% of study group were immunized pre and 29.8% post. For participants who were not immunized, misconception had a higher percentage, 62%and tetanus toxoid not available at the near center, 23% for study group. Compared to study done by TanjidaShilpi, among the group not vaccinated, 50% respondents told their unawareness about need for vaccination   against  tetanus  before  the   start   of   their reproductive life, 15.4% said they lack information regarding place and time of vaccination and 19.6% complained about inconvenience in schedule and place of vaccination (Tanjida  et al., 2009).

In this study, participant who were immunized only one number of doses are 13.8 pre and 14.4 post, 0.06%pre to 8.3% post for two. This is similar to the study done by Mijalstating there was dramatic change in dose two from 0% pre to 100 post (Mijal, 2009).



1. Use a mass media campaign to create awareness among women, in childbearing age and families about the importance of TT vaccination & consequences of not being vaccinated.

2. Health promotion by making the TT vaccine available & accessible for all women at their reproductive age in the university.

3. Improve the monitoring and supervision of vaccination activities by ministry of health.

4. Regular training program about immunization for students in child bearing age

5. Regular refresh seminars are needed.




The educational program resulted in significant changed of knowledge from pre to post intervention for study group, also changed of attitude and increased vaccination status of the participant from pre intervention to post intervention .we need also further study and increasing sample size for generalizability of the study.



The author has not declared any conflict of interests.



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