Research Article

Samuel Kwabena Ofosu*, Martin Banong-le, Priscillia Awo Nortey, Ama Boatemah Sarpong

Samuel Kwabena Ofosu1*, Martin Banong-le2, Priscillia Awo Nortey3, Ama Boatemah Sarpong4

1School of Public Health, University of Ghana, Ghana

2College of Nursing and Midwifery, Ministry of Health, Ghana

3District Health Directorate, Ghana Health Service, Ghana

4Department of Education, Kibi College of Education, Ghana

*Corresponding author: Samuel Kwabena Ofosu, School of Public Health, University of Ghana, Ghana

Received Date: 14 Dec, 2019 ; Accepted Date: 18 Dec, 2019 ; Published Date: 27 Dec, 2019


Background: Childhood immunization is one of the most successful public health interventions worldwide. It has contributed enormously to public health including the eradication of small pox and near eradication of poliomyelitis. High immunization coverage is vital in the control, elimination and eradication of vaccine preventable diseases which accounts for many childhood morbidities and mortalities worldwide. The introduction of the Expanded Programme on Immunization (EPI) has made remarkable progress, which includes improvement of immunization coverage among infants and women resulting in considerable reduction in morbidity and mortality from vaccine-preventable diseases. Though, immunization coverage rates have improved in recent times, there are areas with poor coverage which may possibly lead to build-up of susceptible children and probably cause disease outbreak. Assin North is one of such places with poor immunization coverage.

Methods: A cross sectional survey was conducted to collect data from 672 mothers or caregivers of children between the ages of 12-23 months from 30 randomly selected communities within the Assin north municipality using a structured questionnaire. Immunization card and maternal recall were used to assess vaccination status. Chi square and logistic regression models were used to assess the association between vaccination status and the independent variables.

Results: The proportion of fully immunized children between the ages of 12-23 months in the Assin north district was 85.4 %( 574/672). The rest were partially immunized. Maternal factors that affected immunization coverage included the maternal age, occupation, education level and knowledge on immunization and vaccine preventable diseases. Reasons for immunization failure included mothers too busy, unaware of the need to return for subsequent immunization, and inconvenient immunization schedules to the mothers.

Conclusion: The immunization coverage for children aged 12-23 months in the Assin north municipal is high. It however, fell short of the recommended 90% target. Level of education and source of knowledge were significantly associated with immunization status.


Chi Square; Immunization; Immunization Failure; Regression; Logistics Vaccine Preventable Diseases


Immunization is one of the major public health strategies to avoid childhood illnesses and mortality. In the absence of immunization, more than five million children would die each year because of diseases that could have otherwise been prevented through vaccination(Ngure, 2015). Immunization is one of the most successful and cost-effective public health investments that can be made for future generations. It is a key strategy and indicator of the achievement of the fourth Millennium Development Goals (MDG) and now sustainable development goals(SDGs) which aims at reducing the 1990’s child mortality rate by two thirds by 2015 [1] (Owino, Irimu, Olenja, & Meme, 2009).

Almost one third of deaths among children under 5years are preventable by vaccine. UNICEF and its partners are working to change these numbers and ensure that the lives of all children are successfully protected with vaccines. If immunization is not prioritized, the most marginalized children will not get vaccines, which could mean the difference between life and death (WHO/UNICEF, 2016) Globally, nearly one in five infants thus, an estimated 19.4 million children missed out on the basic vaccines they need to stay healthy in 2015. Low immunization levels compromise gains in all other areas of health for mothers and children. The poorest and most vulnerable children who need immunization the most continue to be the least likely to get it (WHO/UNICEF, 2016).

Available vaccines can protect against about 30 diseases, and the quest to develop other vaccines continues (Ansong et al., 2014). Regardless of interventions made to boost immunization services, 2-3 million children are dying annually from vaccine preventable diseases, and many more fall ill(’World Health Organization’, 2015). Also, 1.5 million deaths could be avoided if global vaccination coverage improves. Global vaccination coverage has remained steadily high for the past few years (’World Health Organization’, 2015).

Vaccination coverage is the percentage of a target population that receives the full schedule of vaccinations. The schedule includes all the vaccinations recommended by the Expanded Program on Immunization (EPI), applied at the correct ages (epidemiological adequacy) and correct intervals (immunological adequacy)(Vision, 2014). Combined institutional activities organized by the public sector at various levels are required to achieve adequate vaccination coverage. Knowledge of vaccination coverage facilitates monitoring the volume of susceptible individuals in the population as well as the identification of factors related to child health and service performance, supporting the planning and restructuring of vaccination program (Martinez, Stuardo, & Rocha, 2014). Investigations into the reasons for low coverage to vaccination programs are proposed by experts in the medical field and aim to guide interventions to reverse this situation and ensure greater protection for the populations at greater risk.

The factors that interfere with vaccination coverage can be grouped into four areas: immunization system (policy), thus structure for vaccine distribution, parent knowledge and attitudes about the vaccination programs, communication and information, and family characteristics. The family characteristics involves low-income status, residence in rural areas, extremes of maternal age, high parity, low maternal education level, larger families, residence in the area for < 1 year, mother working outside the home, lack of knowledge about vaccine-preventable diseases, transportation difficulties, labor disputes around workdays lost to care for children, lack of health insurance, and presence of disease among the children (Town & Ayano, 2015). Vaccination is the administration of a vaccine to stimulate an individual’s immune system in order to develop specific immunity to a disease causing organism; and immunization is the process by which an individual’s immune system becomes fortified against an agent of disease. Immunization can be achieved in an active or passive manner: vaccination is an active form of immunization and the two terms are used interchangeably (Ansong et al., 2014).

In 2012, all 194 WHO Member States endorsed the Global Vaccine Action Plan (GVAP) which committed every member state to achieve a set target of 90 percent DTP3 vaccination coverage by 2015. As a result, the number of children who did not receive routine life-saving vaccinations has dropped to an estimated 19.4 million, down from 33.8 million in 2000. Most progress has been made in India, Ethiopia, and the Democratic Republic of Congo, while coverage in Pakistan and Indonesia is stagnating. While many countries, such as India, Lao, Chad, and Democratic Republic of Congo (DRC) show sustained progress over the longer term, other countries are yet to show improvement in their performance (Indonesia, Pakistan). Other countries have not been able to sustain high coverage levels (Guatemala and Congo), or have seen positive trends reverted recently (Angola and Mauritania) [1].

The Ebola outbreak in West Africa 2014 and 2015 had a different impact in each of the affected countries. Sierra Leone experienced a relatively mild impact on programme performance (-9 percentage points in 2014) and already seems to be recovering well, while Liberia recorded a coverage of 26 percentages in 2014. The number of countries using new vaccines such as rotavirus (81 countries) and pneumococcal conjugate vaccine (128 countries) has increased, but global coverage remains low at 23% and 32%, respectively. Vaccine introduction is especially lagging in middle income countries. These countries are often not able to finance introduction with national resources, while they generally don’t have access to external funding sources [1].

Immunization in Ghana

The introduction of the Expanded Programme on Immunization (EPI) as a key component of Primary Health Care in Ghana dates back to 1978. Since then the EPI has made remarkable progress, which includes improvement of immunization coverage among infants and women resulting in considerable reduction in morbidity and mortality from vaccine-preventable diseases.

In line with global targets set at the World Health Assembly in 1988, the Ghana EPI has expanded its focus from vaccination coverage to include eradication of poliomyelitis and elimination of measles and neonatal tetanus (NT), which requires intensive disease surveillance and control measures. The country also made substantial progress in the reduction of morbidity and mortality due to measles, and has eliminated maternal and neonatal tetanus as a public health problem. Immunization performance has become a key health performance indicator for the entire health sector and is monitored at all levels [2].

The Expanded Program on Immunization (EPI) prescribes that children get vaccinated with Bacillus Calmette-Guerin (BCG) and Oral Polio Vaccine (OPV) at birth; three doses of Pentavalent vaccine, pneumococcal vaccine, and OPV at 6, 10 and 14 weeks of age; rotavirus vaccine at 6 and 10 weeks, Yellow Fever vaccine at 9months and measles vaccine at 9 months and 18 months of age. Penta-3 (Third dose of Diphtheria, Pertussis, Tetanus vaccine) has been used as the proxy indicator to measure the improvement in childhood immunization. The national average of Penta-3 coverage increased from 90% in 2014 to 95.4% in 2015, however 29% (63) of the 216 districts in Ghana, could not achieve the 80% coverage target for Penta 3 coverage in 2015. The Greater Accra region recorded the highest number (44,487) of unimmunized [3].

Problem Statement

In 2015, globally, nearly one in five infants thus, an estimated 19.4 million children missed out on the basic vaccines they need to stay healthy whereas about 86% (116 million) received 3 doses of diphtheria-tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness and disability. By 2015, 126 countries had reached at least 90% coverage of DTP3 vaccine [1] (WHO, 2015a).

The goal of EPI Programme is to obtain and sustain 90% coverage for all the antigens in line with WHO target. The national immunisation records show that there has been an increase in vaccination coverage rates for all the antigens in the country for the past ten years. There are variations in the immunisation coverage rates between regions and among districts.

The Penta-3 coverage in Ghana increased from 90% in 2014 to 95.4% in 2015.However, almost 30 % (63 districts) could not achieve the 80% coverage target for Penta 3 coverage in 2015 (Ghana health service, 2015). Assin North municipality was one of the districts. The municipality had adequate coverage ranging between 83% -94% from 2009 to 2011. However, the coverage from 2012 to 2015 is far below the national average. This coverage ranges between 52%-63 %( DHD, 2016).

Despite all the interventions like mop up campaign, child health promotion, and home visits adopted by the District Health Directorate, the coverage is still below the expected. Therefore, this research which intends to unearth the factors leading to low coverage rate would help identify some challenges associated with low coverage immunization services on the part of mothers/caregivers and the entire district health system and to identify key strategies to improve service coverage.

Explanation of Conceptual Framework

In 1973, Andersen and Newman proposed a framework for evaluating the utilization of health care ((Petrovic & Blank, 2015)). The model assumes that, utilization of health services is a function of predisposing, enabling and need factors. Predisposing characteristics include gender, marital status, and educational status, and occupation, length of time in the community and health beliefs. The health beliefs include attitudes of health workers and knowledge on health. Enabling resources refer to attributes specific to the individual or the community (e.g. income, social network, and access to regular source of care). Need variables reflect illness levels that require the use of health services? It can be perceived by the individual and are influenced by cultural beliefs and values. There is also an enabling resource which could be individual or community attributes.

From the conceptual framework above, routine immunization service coverage is influenced by a number of interrelated factors. Among these interconnected factors is the poor quality of immunization service delivery factor, which in turn is affected by long waiting time experienced caregivers during immunization. Poorly motivated and staff overloaded with a lot of activities at the same time due to low staff numbers and inadequate logistics to be used during immunization sessions like means of transport causing undue delay by the health workers to work.

Another factor that affects the immunization service coverage is socio economic factors including mothers having problem with the means of transport to immunization center due to poor road network linking such communities to the designated centers, lack of funds on the part of mothers to meet some financial obligations like feeding for that long period of stay at the center, transport fare and most importantly mothers inability to pay the token fees collected by staff at the center and this one at times will not be too encouraging for a mother whose child is not sick to come for immunization service.

Immunization strategy chosen by the staff will surely, affects the utilization because strategy determines the distance between the caregiver and the service to be delivered. For instance, home visits gets services closer to the client than static strategy whereby the staff are at one point where the caregiver will have to travel to utilize the service being provided at the facility.

Caregiver’s knowledge and understanding of importance of immunization and the EPI schedule play an indispensable role in EPI service utilization because if caregivers are aware of the dates, time and place for the various categories of the vaccines, they will follow diligently. Coverage also worsens when the DHA’s educational campaign on EPI does not reach a greater section of the mothers in the hinterland or hard-to-reach areas. Therefore, the utilization of the EPI coverage by caregivers is highly dependent on these inevitable enumerated factors.


The commonest childhood diseases namely; Measles, Diarrhea, Pneumonia, Poliomyelitis, Tuberculosis, Tetanus, Yellow Fever, Whooping Cough which were mainly responsible for the mortality in Ghana are now less reported at our facilities dues to the introduction of immunization. Therefore, an effort towards achieving healthier childhood is very critical to all stakeholders or health partners. An assessment of the activities of the program therefore, is vital in realizing the extent to which survival intervention is being utilized by the target population in the respective districts.

This research seeks to assess factors contributing to immunization uptake by children and caregivers, find out possible reasons that might account for low coverage by caregivers. Again the findings of the study would be used as confirmatory evidence to linked previous reports given by the District Health Directorate on EPI or identify difference and suggest corrective measures accordingly.

The study will inform the DHMT, policy makers, funding agencies and other stakeholders on management tools to employ to increase EPI service utilization and reduce defaulter rates, increase coverage levels for of immunization and finally reduce the incidence of vaccine preventable diseases in the Assin north municipality. The research will set the platform for which studies can be conducted for improving EPI service utilization in Ghana.

Literature Review


Vaccination is the administration of a vaccine to stimulate an individual’s immune system in order to develop specific immunity to a disease causing organism; and immunization is the process by which an individual’s immune system becomes stimulated against an agent of disease. Immunization can be achieved in an active or passive manner: vaccination is an active form of immunization, and the two terms are used interchangeably [4](Ansong et al., 2014).

Vaccine preventable infections includes diphtheria, Haemophilus influenzae type B, hepatitis A, hepatitis B, human papilloma virus, influenza, measles, meningococcus, mumps, pertussis, pneumococcus, polio, rotavirus, rubella, smallpox, and tetanus. However, with the exception of smallpox, which was declared globally eradicated in 1980, preventable morbidity from these infections persists. Immunization is essential to the attainment of the Millennium Development Goal (MDG) 4 and reducing childhood mortality by two-thirds during period of 1990 and 2015 [5]. (Ansong et al., 2014).

Vaccines keep children alive and healthy by protecting them against disease. Immunization is especially important for the hardest to reach families as it can also be a bridge to other life-saving care for mothers and children in isolated communities (Shengelia, Tandon, Adams, & Murray, 2005).

Immunization Coverage

Immunization coverage determines the proportion of children who are vaccinated against a particular antigen compared to the number of children expected to be vaccinated. Immunization coverage is a key measure of the health system performance and is measured at national, regional, district and sub-district levels (Tim, Braa, & Bjune, 2006).

(Ngure, 2015)

Administrative coverage data are collected by monitoring the numbers of doses of the antigen administered to the target population divided by the total estimated number of target population to the estimate the percentage coverage [6]. This indicate the status of the vaccinations performed by service providers. Surveys are conducted periodically by reviewing children vaccination histories to identify coverage levels. Surveys are frequently used in conjunction with administrative data. Immunization coverage surveys are also recommended by W.H.O to be used periodically to verify administrative coverage data [7] (UNICEF, 2009). Immunization coverage rates based on administration data are mainly subject to numerator (children vaccinated) and denominator (target population) biases. This can lead to an overestimation and underestimation when children vaccinated outside the target age group are erroneously included in the numerator or when vaccinations are not reported by lower administrative levels such as private sector [8].

Immunization Coverage Levels are Useful in the Following Areas

➢ To monitor the performance of immunization services locally, nationally and internationally.

➢ To guide strategies for the eradication, elimination and control of vaccine preventable diseases.

➢ To identify areas of immunization systems that may require additional resources and focused attention.

➢ To access the need to introduce new vaccines into the immunization system [8].

During 2015, about 86% (116 million) of infants worldwide received 3 doses of diphtheria-tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness and disability or be fatal. By 2015, 126 countries had reached at least 90% coverage of DTP3 vaccine. (WHO/UNICEF, 2016)In 2015, an estimated 19.4 million infants worldwide were not reached with routine immunization services such as DTP3 vaccine. Around 60% of these children live in 10 countries: Angola, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan, the Philippines, and Ukraine [1] Approximately 17% of deaths in children under five are vaccine preventable. An estimated 1.5 million children die annually from diseases that can be prevented by immunization. If all children were immunized with existing vaccines, we could save nearly 25 million lives between 2011and 2020. In 2014, an estimated 86 per cent of infants worldwide were vaccinated with three doses of the vaccine required to fully immunize them against diphtheria, tetanus and pertussis (DTP3 vaccine) up from 20% in 1980.

Globally, it has been estimated that immunization programs prevent approximately 2.5 million deaths each year. The global eradication of smallpox in 1980, near elimination of poliomyelitis and global reduction in other vaccine-preventable diseases, are model examples of disease control through immunization [9]. (Ministry of health, 2016).

The Global vaccine action plan

The Global Vaccine Action Plan (GVAP) is a roadmap to prevent millions of deaths through more equitable access to vaccines. Countries are aiming to achieve vaccination coverage of at least 90% nationally and at least 80% in every district by 2020. While the GVAP should accelerate control of all vaccine-preventable diseases, polio eradication is set as the first milestone. It also aims to spur research and development for the next generation of vaccines [10].

WHO is leading efforts to support regions and countries as they adapt the GVAP for implementation. In April 2016, WHO warned that 5 out of the 6 GVAP targets were off-track, with only 1 target on the introduction of underutilized vaccines showing sufficient progress. This finding was based on the independent assessment report by SAGE.

The GVAP recommends 3 key steps for closing the immunization gap:

• Integrating immunization with other health services, such as postnatal care for mothers and babies;

• Strengthening health systems so that vaccines continue to be given even in times of crisis; and

• Ensuring that everyone can access vaccines and afford to pay for them.

Key challenges

Last year, the Strategic Advisory Group of Experts on immunization (SAGE) identified 5 factors to achieving results in immunization coverage; quality and use of data, community involvement, better access to immunization services for marginalized and displaced populations, and strong health systems (WHO, 2015b) [10].

Immunization in Ghana

The Ghana Immunization Programme was established in June 1978 with six (6) antigens - BCG, measles, Diphtheria-Pertussis-Tetanus (DPT) and oral polio vaccine for infants and Tetanus Toxoid (TT) vaccination for pregnant women to protect against maternal and neonatal tetanus. The establishment of the immunization programme was in response to the National Health Policy to reduce morbidity and mortality due to Vaccine Preventable Diseases (VPDs) which then contributed significantly to both infant and child mortality in the country. Immunization performance has become a strategic health performance indicator for the entire health sector and is monitored at all levels [2].

The goal of the EPI Programme is to reduce child morbidity, mortality and disability associated with vaccine preventable diseases through the provision of high quality immunization services. Specifically, the program aims to Achieve 95% coverage for all antigens by 2019; maintain a polio free status, achieve measles/Rubella elimination, and Sustain MNT elimination.

In the year 2011, Ghana was recognized as one of the countries to have eliminated maternal and neonatal tetanus. In 2015, the country entered the elimination phase for measles and rubella (Ministry of health, 2016) Penta-3 has been used as the proxy to measure the improvement in childhood immunization. The national average of Penta-3 coverage increased from 90% in 2014 to 95.4% in 2015, however 29% (63) of the 216 districts in Ghana, could not achieve the 80% coverage target for Penta 3 coverage in 2015. The Greater Accra region recorded the highest number (44,487) of unimmunized children [11].

Factors Contributing to Immunization Coverage

Improving immunization coverage is vital to promoting child health and reducing childhood diseases and deaths. According to WHO, there is a problem with immunization services when the coverage is below 80% with a dropout rate of above 10%. There are so many factors contributing immunization coverage. Attendance to immunization services are mainly due to; poor knowledge about immunization, lack of suitable venues and furniture at outreach clinics, financial difficulties, long waiting times, transport difficulties, poorly motivated service providers and weak inter sectoral collaboration, the timing of immunization sessions, attitude of service providers and fear of side-effects are the major factors contributing to immunization coverage [12].

(Bosu, Ahelegbe, Edum-Fotwe, Kobina A Bainson, & Kobina Turkson, 1997)

Also, a number of studies have been carried out across the world to find out the significant factors that hinder or increase the likelihood of immunization. Factors that have been found to be significantly associated with vaccination uptake include maternal education and age, socio- economic status, religion, health services utilization and exposure to the media. Research has revealed that children in urban areas are more likely to be fully vaccinated than children in rural areas(Mukungwa, 2015). Accessibility to health facilities in rural areas is poor as compared to urban areas. Studies by Ibnouf et al (2007) and Rup et al (2008) revealed that immunization was significantly higher where distance to a health facility was lower as the case with urban areas.

Studies have also shown that maternal factors accounted for a high likelihood of child vaccination (Ah, 2007). Mothers with secondary education and higher are better informed and more empowered hence are more likely than their counterparts with primary or no education to have their children immunized (Makwana & Yadav, 2014). Other studies have revealed that Immunization compliance increased with mother’s economic status. Mothers with high economic status are more likely to immunize their children than mothers with a poor economic standing (Rahman & Obaida-nasrin, 2010). Immunization compliance is also higher when mothers previously utilized antenatal care services during pregnancy as well as delivered in health facilities (Etana & Deressa, 2012). In a study carried out by Becker et al (1993) possession of a radio and a television was found to be important determinants of immunization. Possession of these gadgets increased the likelihood of immunization. [13] in a study in Ghana to find the social determinants of immunization concurred with these results and concluded that radio and television enhanced access to health information (Dwumoh, Essuman, & Afagbedzi, 2014).

Reasons for Immunization Failure

Kumar s, et al. [14] revealed that the reasons were lack of transport, fear of side effects and misconception (development of autism)(Kumar et al., 2017). Other studies also found that inadequate knowledge about immunization and subsequent dose, belief that vaccine causes side-effects, lack of faith in immunization , The major obstacles were busy schedule of mother, illness of child on the day of immunization and also due to lack of information respectively(Bonu, Rani, & Razum, 2004) With the high under-five mortality in Ghana, full childhood immunization can mitigate morbidity and mortality through prevention of a vaccine-preventable infection. In an effort to improve immunization in Ghana therefore, it is imperative to carry out a study of the factors contributing to full immunization of children in order to provide recommendations for policy formulation and designing implementation programs geared at increasing immunization coverage in the country (Nana & Liverpool, 2000).


Study Site

The study was conducted in the Assin North Municipality in the Central Region of Ghana. The district is mainly rural with a population of about 187,949 with the main occupation been agriculture. For health administrative purposes, the district has been divided into six sub-districts.

Study Design

The study was a cross sectional study. Data were randomly collected from mothers or caregivers with children 12-23 months of age from 30 randomly selected communities in the Assin North Municipality.

Sample Size

Using the sample size calculation methods presented in the WHO immunization coverage cluster survey manual (WHO, 2005), the sample size required was determined using the formula

Nmin = de*z2*p*(1-P)/d2,


Nmi = minimum number of sample size;

De = design effect =1.5;

Z = confidence interval at 95% (standard value of 1.96);

P = estimated prevalence of coverage;

D = with of confidence interval)

Using coverage of 59.2% obtained in the year 2015 for Penta 3 in the Assin North municipality, a design effect of 1.5, a type 1 error of 5%, in the conformity with the standard WHO methodology, the calculated minimum number of children required would be Nmin=1.5*1.962*0.592*(1-0.592)/(0.05)2, Nmin=556. Adjusting for a non-response rate of 10%, at least a total of 612 mothers with children 12-23 months were determined for the study as sample size.

Data Collection

The WHO (2005) cluster survey tool adapted into a structured questionnaire was used to collect data from the participants. Strategies used to administer the questionnaires included one-on-one question and answer technique.

Data Processing and Analysis

Data that was generated was coded and entered into the computer for analysis. Data analysis was done using STATA 14 software. The outcome of interest which is the immunizations status was considered to be fully immunized or partially immunized. The independent variables which included individual factors of the mother, like age, education, occupation antenatal visit, birth order of the child, knowledge of mother on immunization were looked at. Age of mother was modeled as a categorical variables with categories defined as 0(15-24), 1(25-35), 2(35+) years. Antenatal and visit and birth order were modeled as categorical variables with categories defined as 0 (none),1(once), 3 (thrice), 4 (four or more) and 1 (first child), 2 (2nd or 3rd child), 3 (4th child and above) respectively. The data collected was explored using box plot and other descriptive statistics to check the distribution of the data and missing data. Univariate analysis in form of frequencies and percentage was performed on the demographic characteristics of the mother and child. Bivariate and multivariable comparisons were made between immunization status and independent variables using chi square and logistic regression respectively. Chi square was used to determine the association between immunization status and each of the factors or independent variables. Logistics regression was used to find the association between the independent variables that show association in the chi square and the child’s immunization status independently. This was used to determine which of the variables were strongly associated with child’s immunization status. The odd ratio and P values were recorded. A logistics model was considered for the independent variables. An independent variable was included in the model when it had p-value of < 0.05. This tested the association between the dependent and independent variables. Associations were considered significant at 95% confidence intervals with a p-value of less than 0.05.


A total of 672 mothers or caregivers were interviewed and immunization records on 672 children were reviewed from the 30 clusters in the Assin North municipality. The data also had complete records on reasons immunization failure.

Demographic Characteristics of Mothers

The ages of the respondents ranged from 15 to 45 years with a mean of 28.3+ 5.2. Majority of the respondents, 273(40.6%) were within the ages of 25-34 years. The majority ethnic group of the respondents was Akan constituting about 77.5%. A large proportion of mothers or care givers that’s 459(68.3%) had primary education. The major occupation of the mothers involved in the study was trading representing 289(43.0%). About 615(91.5%) of the respondents had four or more antennal visit during pregnancy period. The table 2 below shows the complete distribution of the demographic characteristics of the mother or caregiver.

Demographic characteristics of children

A total of 672 children between the ages of 12-23 months were studied. Out of the 672 children, 52.8% were males. Children between the 2nd and 3rd birth order constituted the majority with a population of 268 (39.9%). A large proportion of mothers or caregivers 411(61.1%) had a midwife or nurse to attend to them during delivery. Most mothers or caregivers 646 (96.1%) had their cards intact. Majority of the children, 574(85.4%) were fully immunized, 90(13.4%) were partially immunized, and 8(1.2%) were not immunized at all. The table below shows.

Maternal Knowledge on Immunization and Vaccine Preventable Diseases

In assessing knowledge on immunization and vaccine preventable diseases, participants were asked to mention the various diseases that are prevented by vaccination. 81 (12.1%) could not mention any disease and 84(12.5%) were able to mention five diseases and above. In the participants response to reasons why children are vaccinated, 390 (58.0%) were able to mention it prevents them from vaccine preventable diseases, 213(31.7%) knew it makes the children strong whiles 27(4.0%) did not know the reasons for vaccination.

Reasons for Childhood Immunization

When participants were asked to mention the various vaccines administered to children during vaccination, 201 (29.9%) mentioned measles, 40(6%), tetanus, 126(18.9%) yellow fever, 11(1.6%) hepatitis B, 92(13.7%) Polio, and 81(12.1%) could not mention. Also, 504(75%) knew BCG was the first vaccine given whiles 50(7.4%) did not know the first vaccine given to the children. When asked about the age at which the first vaccine is given, 255 (38%) mentioned it’s given at first week, 167(24.9%), 71 (10.6%), 133(19.8%) mentioned after one week, first day, after one month respectively. However, 46(6.9%) did not know when it is given. On the knowledge on pentavalent vaccine, a high proportion of the participants,565(84.1%) said penta1 is given after one month whiles,15(2.2%),22(3.3%),70(10.4%) it is given at six weeks or more, first day, after one week respectively. also,435(64.7%) knew the interval between pentavalent vaccine is 1 month whiles others knew they the intervals were 8(1.2%),181(26.9%) one week, more than one month respectively. However,48(7.1%) did not know the interval between pentavalent vaccination. The name of the last vaccine given to children were asked, 143(19.9%) knew it is given at nigh month, 231(34.5%) knew it its 8months, 172(25.6%) knew is one year whiles 114(17.0%) did not know when last vaccine is given.

Finally, when asked of their source of knowledge on immunization and vaccine preventable diseases, a high proportion of the participants 512(76.2%) had their source of knowledge from health centers whiles 51(7.6%), 13(1.9%), 30(4.5%), 32(4.8%), had their knowledge from family members, friends, bookings and reading material and radio and television respectively.

Factors Influencing Immunization Status of a Child

Different variables assumed to be associated with immunization status of the child were included in the study. These variables include socio demographic characteristics of mothers or care givers of the child and characteristics of the child, the mother or care givers knowledge on immunization and vaccine preventable diseases. These factors associated with the child’s immunization completion were analyzed using logistic regression.

Demographic Characteristics of Mothers or Caregivers

The association of mother’s demographic characteristics with immunization status of the children was assessed using bivariate and multivariate analysis by chi square and logistic regression analysis. Mothers source of knowledge, and attendant at birth, were significantly associated with immunization status of the child in a bivariate analysis using chi square with a p- value of < 0.05.

Comparison of Mothers’ Characteristics and Immunization Status

In a bivariate analysis using logistic regression, mothers between the ages of 25- 34 were 1.34(95% CI: 0.83-2.186) times more likely to fully immunized their children as compared to mothers with the age group 15-24. The odds of a child being immunized fully by mothers within the age 35 and above is 1.35(95% CI: 0.76, 2.40) times compared to those within the reference group 15-24. However, when the other maternal characteristics were adjusted for in a multivariate analysis, mother’s age was no more significant determinant of immunization status of the child.

The odd of a child being fully immunized by a mother, who is a Ga, Ewe, Hausa or any other ethnic group is 7.33(95%CI:99,54.01), 0.66(95%CI:0.35,1.26), 2.50(95% C,0.32,19.30), 1.50(95% CI:0.44,5.05) times the of a mother who is a Akan respectively. When all the other maternal factors were adjusted for, ethnicity was not still significantly associated with immunization status. This can be seen in table 8. Educational status of the mother was significantly associated with immunization status of the child. A child with a mother with a primary level education 1.15(95% CI: 0.60, 2.2) times more likely to be fully immunized as compared with an illiterate mother. A mother with a secondary education is also 1.47(95% CI: 0.64, 3.37) times more likely to be completely immunize their children while the odds of being fully immunized by a mother with tertiary education is 0.74(95%CI: 0.24, 2.37) times compared to the illiterate ones. Upon adjusting for all other maternal variables, maternal educational to levels, were not significantly associated with immunization status of the child. showed in table 8.

Mother’s occupation was also significantly associated with a child’s immunization status. The odds of completely immunizing a child by mothers who were traders, farmers, public servant or involved in other occupations is 1.21(95%CI:0.21,4.04), 1.83(95%CI:0.94,3.55), 1.43(95%CI:0.55,3.71) and 2.01(95%CI:0.94,4.31) times compared to mothers who are not employed. After adjust for all other maternal characteristics, mothers who are traders were 1.83(95%CI:0.89,3.75) times more likely to completely vaccinate their children as compared with the unemployed mothers while the mothers who are farmers, public servants and other occupations were no more significantly associated with a child’s immunization status(table).

Mothers with prenatal visits of twice and four or more were 2.44(95% CI: 0.36, 16.55) and 2.63(95% CI: 0.79, 8.70) times more likely to fully immunize their compared to mothers who do not have any antennal care visits during pregnancy. Those with antenatal visits of once or thrice had odds ratio that were not significant When the other maternal characteristics were held constant, mothers with antennal visits of thrice or four or more were 3.9(95% CI:0.60,23.17), 2.70(95% CI 0.73,9.93) times more likely to completely vaccinate their children compared to their counterparts with no antenatal care visit as seen in table 6.

Mothers with at least moderate knowledge on immunization and vaccine preventable diseases were 4.27(95%CI 2.03,7.81) times more likely to fully immunized their children as compared to those with low knowledge. When adjusted for other variables, mothers’ knowledge was still significantly associated with immunization status with odds of 2.74(95%CI :1.45,5.18) times those with low knowledge levels.

Childs Characteristics

Appendix 3 shows the frequencies and percentages of the immunization status of the children between the ages of 12-23 months with respect to the child’s characteristics. The table indicates that, out of 98 children who were partially immunized, 54% were females. About 62.0% of those who were fully immunized were males. About 33.2%, 39.9%, and 26.9% of the children who were fully immunized were within the birth orders, first, 2nd to 3rd, and 4th and above respectively. About 61% of children were partially immunized had a nurse or midwife to deliver the child while 61.1 % of those fully immunized were delivered by nurse or midwife. About 67% of those who were partially immunized children had their vaccination cards while the rest do not have. On the other hand, about 98% of those fully immunized children had their immunization card. Attendance at the birth and retention of cards were only characteristics that were significantly associated with immunization status.

From table 7, attendance at birth is a significant determinant of immunization status. However, the adjusted odd ratio indicates that the odds of a child being fully immunized as a results of being delivered by a TBA is reduced by 21.8% as compared to those who did not have any health personnel to deliver the child. The odds of being fully immunized when the child was delivered by nurse/midwife or doctor is 9.51(95% CI: 1.55-58.18) or 3.5 (95% CI: 1.92, 95.09) times those who were not delivered by and health personnel respectively. Immunization card retention is significant determinant of immunization status. The odds of being fully immunized by a child who had an immunization a card is 1.07(95% CI .36, 3.12) times those who do not have immunization cards. When all other characteristics were held constant, the odds of a child being fully immunized 1.24 times than those without immunization cards.

Reasons for Immunization Failure among Partially and Non-Immunized Children

The respondents who could not complete the routine immunization schedule for their children were asked for there their reasons for immunization failure. A lot of reasons were given as indicated as given. out of 672 respondents, about 33.5% could not complete the immunization for their children because they were not aware of the need for immunization. The second reason given by 32.9% was that they were not aware of the need to return for the subsequent immunizations. Some 16.7% of the respondents did not know where to go for the next vaccination. About 56.3% were not motivated to come for immunization because their vaccinations were postponed until another time hence their inability to complete their immunization. Place of immunization, time of immunization inconvenient, vaccinator absent, family problems including child been sick were the reasons given by 17.6%, 20.1%, 15.3% and 18.5% of the respondents respectively.


Proportion of Children That Have Been Fully Immunized in the Municipality

The aim of the study was to find out factors contributing to low coverage immunization in Assin North Municipality. Based on immunization card and recall, 85.8% children were fully vaccinated, and 14.6% were not fully vaccinated in the year 2016. The pentavalent3 coverage was 91.7% which is above the 2015 WHO/UNICEF coverage of 86% worldwide [1]. The OPV3 vaccine coverage was the same as coverage of the Pentavalent3 vaccine. The Measles coverage was higher than the Yellow Fever vaccine coverage which under normal circumstance should be the same. The higher coverage of OPV3 and Pentavalent 3 is due to frequent mop ups and home visits by the community health nurses.

Beside this, the current finding is higher than the immunization coverage for Penta from 2013, 2014, and 2015 74.7%, 59.3%, and 59.2% coverage respectively. This difference may be due to the under reporting of health and health related indicators data from some areas. From the total interviewed mothers or care givers, 646 (96.1%) mothers showed the vaccination card of their children. From the card most children took BCG and OPV1 vaccines, but only 14.6% did not finished the immunization.

Knowledge of Mothers /Caregivers on Immunization and Vaccine Preventable Diseases

The study also assessed mothers’or care givers knowledge on vaccination and vaccine preventable disease. About 90.1% mothers heard about childhood immunization and vaccine preventable diseases, but only 58.0% of them mentioned that vaccination is use to prevent disease. However, 31% of the respondents had a misconception that vaccination makes their children strong. Even though the percentage with knowledge on the importance of vaccination was average, majority of the children had received some form of vaccination. This may be due to the fact that, immunization is free in Ghana and health workers send vaccines to the doorsteps of the people in the municipality on outreaches and home visits for eligible children. The study also revealed few mothers (12.5%) were able to mention that vaccines prevent 5 or more diseases. The most frequently mentioned diseases were Measles and Poliomyelitis. This may be largely due to National Immunization Days (NIDs) And Measles Supplemental immunization Activities (SIAs) Campaigns. Knowledge on various vaccines, when they are administered; the intervals between the various doses of each vaccine and the age at which vaccination should be completed was very low as in most cases more than 6.6% do not have any idea about the question. This contrast a study conducted by Belachew, 2011 that, mothers who had knowledge on vaccine and vaccine preventable diseases are more likely to fully immunize their children.

Surprisingly, about 76.2% of the respondents received their education from health centers during immunization sessions. This raises the question on the kind of education given to mothers during immunization sessions. Though, radio and television role in educating the public on health, only 4.8% of the respondents had their source of knowledge from these sources. This may be due to the fact that education on immunization and vaccine preventable diseases are less discuss on the radio and television.

Factors Affecting Immunization Status of a Child

The study also assessed factors affecting immunization status of children by grouping them into categories, partially immunized and fully immunized. Maternal and child characteristics affecting immunization status of the children were analyzed separately and factors associated to the immunization status were identified by bivariate and multivariate analysis using chi square and logistics regression.

Based on the bivariate analysis, maternal age. ethnicity, education, occupation and antenatal clinics visits were the maternal characteristics that showed significant association with the immunization status of the child. Older mothers were more likely to fully immunize their children than their younger counterparts. Maternal age and immunization status of children has been a controversial issue for researchers. Some studies say middle age mothers are more likely to immunized their children [5], while some say the younger ones are more likely to complete their immunization [15]. Also mothers with higher educational status were more likely to complete their immunization schedule of their children as compared to their counterparts who are illiterates. Studies conducted in the past [16] show there is a significant association between maternal educational status and immunization status of the child, Mothers or caregivers who have one beyond secondary education and higher are better informed and more empowered hence are more likely than their counterparts with primary or no education to have their children [17]. In this study, mothers with primary education, secondary education and tertiary education level of education were 1.2,1.5,0.75 times respectively more likely to fully immunized their children as compared to their counter parts illiterates. Mothers who were farmers, traders, and public servant and other occupations were 1.83, 2.21, 1.43, 2.01 more likely to fully immunized their children than their un employed counterparts. Also, mothers who had two or more ANC visits were more likely to fully immunized their children. Mothers with two, three, four or more were 2.44, 3.11, 2.6 times respectively are more likely to fully immunized their children than those who attended ANC once or not at all. This is in contrast with the finding by [9] who found ANC follow up have significant associated with the completion of vaccination by adjusted odds ratio of 1.621. However, this support the finding of Rahman and Obaida nasrin in Bangladesh who found that mothers with five or more visits were more likely to completely immunized their children [5].

Furthermore, mothers with moderate knowledge on immunization and vaccine preventable diseases were 5.27 times more likely to complete the immunization schedule of their children. This is in agreement with a study conducted by Belachew in Addis Ababa and Oluwadare in Nigeria [16].

In the Multivariate analysis where all the significant maternal characteristics were put together in a single model, knowledge and attendant at birth was significantly associated with immunization status. Maternal age, ethnicity, occupation, antenatal care visits were no longer significant maternal factors for immunization status. This confirms the findings of [16] who said, these factors were not significantly associated with immunization status. Maternal knowledge and education were still significant his confirms Ibnouf, et al. studies that showed education to be significant after adjusting for other variables [18].

Bivariate analysis of the child’s characteristics revealed that the only significant determinants of immunization status are attendants at birth. Also, in the multivariate analysis, attendant at birth was significantly associated with immunization status. The sex of the child, birth order and retention of immunization cards were not significantly associated with immunization status. This is in contrast with a study that found that males are more likely to be immunized due to gender inequality [9].

Reasons for Immunization Failure

This research also tried to find out the reasons for immunization failure. Ninetyeight (98) out of 672 respondents could not fully immunize their children as scheduled for various reasons. The most frequent reason was mothers been too busy (33.5%). This may be due to the fact that most of the mothers are traders and farmers. About 33.5% of the participants attributed their inability to immunize their children to not aware of the need to return for subsequent immunization. This may confirm the fact that radio and television are not educating people much on health and also health workers are not educating people enough during immunization sessions. About 56.3% also attributed postponement till another time as their major challenge. This may make them forget or the rescheduled time may be inconvenient to them. The other reason which represents about 20.1% of the respondents was place and time not convenient. Sometimes it difficult to get money for transport and also walking through bad weather or forested areas are nightmares for mothers, therefore they will not come for immunization. About 5.6% said their failure was due to family problems including the sickness of the mother. Fear of side reactions like swelling, fever, and headaches accounted for about 3.9% of the respondent’s reason for failure to send their children for immunization. Some of the mother’s about 6.2% said the place and time for the immunization was unknown to them while 3.1% said either the child was sick was brought for immunization. A few, about 2.9% claimed the vaccination center was too far from their homes or have heard of rumors of effects immunization which put them off. Only 0.6% of the respondents attributed to their failure to unavailability of vaccines. This supported the findings of Ayano’s study [9].

Conclusion and Recommendation

Proportion of Children that are Fully Immunized

Fully immunized children between ages 12-23 months in the Assin north municipality was 85.4% which is far above the reported coverage for the years 2013,2014, and 2015. suprisingly, pentavenlent3 coverage which is use as proxy indicator was 91.7% which is also above the who and national target Maternal knowledge on immunization and vaccine preventable diseases were low as majority of the mothers or caregivers interviewed had a knowledge score below 34%.only 9% of them had a score above 67%.about 58.0% knew immunization protect children against childhood immunizable diseases. Knowledge of the names prevented by vaccines was high about 88.0% as participants were able to mention at least one vaccine and the disease that it prevents. However, the names of the various vaccines administered in children, the interval between doses of each vaccine, the age at which the vaccine is given and when I end were low as more than 40% of the respondents did not know the correct answers to the questions.

The maternal and care givers characteristics that were significantly associated with immunization status of the child age, educational level, attendant at birth, occupation and knowledge and educational status. they were significant in the bivariate the multivariate analysis, only attendant at birth was significantly associated with childhood immunization.

Reasons for Immunization Failure

Reasons accounting for routine immunization failure were; Mother too busy, Unaware of the need to come for subsequent doses of vaccine, Time and venue of immunization not to convenient, Postponement of vaccination until another time, Wrong ideas of contraindications.


Immunisation coverage

There is some data discrepancies in the reports generated from the field and what is entered into the dhims2.this in a way have accounted for low coverage. Therefore,

➢ The community health workers should reconcile all their data from the field before they submit to the next level.

➢ The district director should constitute a data validation teams at the various levels so that the under reporting of data will be minimized.

Knowledge on vaccine preventable diseases and immunization

Health education on immunisation should be intensified across all the health facilities in the municipalities. Community health nurses should always update their knowledge on immunisation and vaccine preventable diseases so that they can impart quality education to the mothers and caregivers.

Factors contributing to immunisation failure

➢ Education on immunisation and vaccine preventable diseases should be extended to the local FMs and radio stations as these are powerful media for health education.

➢ Community health nurses and other community health workers should make use of MNCHP funds by intensifying home visits and outreach services.

➢ Further research should be conducted to assess health care providers view on factors contributing to immunisation coverage and reasons for immunisation failure in the municipality.

List of Acronyms

ANC - Antenatal Care

BCG - Bacillus Calmette-Guérin

CI - Confidence Interval

DE - Design Effect

DHA - District Health Administration

DHMT - District Health Management Teams

DPT 3 - Third dose of Diphtheria, Pertussis, Tetanus vaccine

EPI - Expanded Programme on Immunization

GAVI - Global Alliance for Vaccines and Immunization

GHS - Ghana Health Service

HC - Health Centre

Hep B - Hepatitis B (vaccine)

HOS - Hospital (dose received in a hospital)

JHS - Junior High School

MDG’s - Millennium Development Goals

MOH - Ministry of Health

NID’s - National Immunization Days

Nmin - minimum number of children

NT - Neonatal Tetanus

OPV - Oral Polio Virus Vaccine

OUT - Outreach (dose received in an outreach centre)

Penta 3 - Pentavalent Vaccine

PHC - Primary Health Care

RED - Reaching Every District approach

SHS - Senior High School

SIA’s - Supplemented Immunization Activities

TBA - Traditional Birth Attendant

TT - Tetanus Toxoid

UCI - Universal Childhood Immunization

UNICEF - United Nations Children’s Fund

WHA - World Health Assembly

WHO - World Health Organization

WHS - World Health Statistics

YF - Yellow Fever


I declare that except for references to other people’s investigations which have been duly acknowledged, this dissertation is the result of my own research and that this dissertation either in whole or part has not been presented for another degree elsewhere.

Ethical Clearance

Ethical clearance for this research was obtained first from the Ghana Health Service Ethical Review Committee. In the central region, permission was sought from the Regional Director of Health Services. At Assin North municipality; permission was sought from the Municipality Health Directorate to conduct the research. The participants that were recruited in the study were fully informed of the purpose of the research. The participants were assured of their privacy and confidentially of the information given. Data files were protected with a password which was only be known by the researcher. Electronic and hard copy data was stored and locked in a file cabinet which was only accessible to the researcher and the supervisors. Verbal consents were obtained from the chiefs of the communities as well as individuals involved in the research. There was not any compensation for households participating in the study. The researcher had no conflict of interest in the study and the study was self-financed.

Consent for publication

Not applicable

Availability of Data and Material

All data generated during the current study are included in this published article and its supplementary information file (additional files 1).

Competing Interests

The author declares that he has no competing interests.


No external funding was received for this study.


I am very grateful to the Almighty God for his love, mercies, and protection throughout my academic journey. Indeed! He deserves all the praise and adoration. To my supervisor, Dr. Priscillia Nortey, I want to say a big thank you for the advice, direction, ideas and the support given me during the course of this work. I thank you for the motherly love and support to come out with this work. Also, my appreciation goes to Dr. Samuel Tetteh Kwashie (Regional Director of Health Services, Central Region) for the support and mentorship. Also to Dr. Kwaku Ennin Karikari (Deputy Director, Public Health) for his sacrifices made whiles I was away. God richly bless you all. I am also thankful to the Municipal Director of Health, Assin North Municipal, Mrs. Georgina Asumani for all the support given me during the data collection in the district. To Mr. Seth Brako, Ms. Admire Owusu, James, Nicholas and Bertha, I say thank you very much for the support during the data collection. Mr. Daniel Baah and the gallant workers at the Asikuma Odoben Brakwa District Health Directorate, I am for your support in diverse ways. My next appreciation goes to Ama Boatemah Sarpong Mr. Martin Banong-Le, Charles Adjei Mensah, Gideon Duodu and miss Gloria Arhin for their immense support.


Figure 1 : Conceptual Framework on immunisation coverage.

Figure 2: Immunisation Status.

Figure 3: Reasons for Childhood Immunization.

Figure 4: Map of Assin North with Health Facilities and Communities.




Citation: Ofosu KS, Banong-le M, Nortey PA, Sarpong AB (2019) Factors Contributing to Immunization Coverage in Assin North Municipality. Curr Trends Adv Nurs 1: 001. CTAN-001.000001