RESEARCH WORK

ON

Assessing the factors influencing participation in immunization among children aged 12–23

months at Kperisi community in the Wa Municipality.

By

GROUP MEMBERS

Aborah Rose

Agyemang Emmanuel Opoku

Amoako Matilda

Baah Phyllis

Boateng Grace
 CHAPTER ONE

INTRODUCTION

1.1 Background information

Mothers play an important role in immunization of their children. A target of 95% immunization

coverage is necessary for the sustained control of vaccine preventable diseases (Coleman,

Howard & Jenkinson, 2011). Immunization has saved over 20 million lives in the last two

decades (Adeolu, 2001). This is because more than 100 million infants are immunized each year

in the world against vaccine preventable diseases (Do & Hotchkiss, 2013; Adeolu, 2001).

Immunization is defined as the creation of immunity against a particular disease (Zhao &

Luman, 2010). It could be the treatment of an organ and/or making a body immune to subsequent

attack by a particular pathogen through giving of vaccine (Mutua, Kimani-Murage & Ettarh,

2011). These vaccines protect individuals at risks of acquiring infection by inducing a variety of

immune mechanisms (Parve, 2004).

As a result of the benefits to be derived from vaccination, the last week of April every year is set

aside as the World Immunization Week, which aims to promote the use of vaccines to protect

people of all ages against disease (WHO, 2019). The WHO (2019) notes that immunization

saves millions of lives every year and is widely recognized as one of the world’s most successful

and cost-effective health interventions. However, there are still nearly 20 million unvaccinated

and under-vaccinated children in the world today.”

The importance of protecting children against vaccine preventable diseases cannot be under

estimated. Studies have shown that immunization is among the best practices of increasing

human immunity globally (Lakew, Bekele & Biadgilign, 2015). It is a tool for preventing and

eradicating transmittable diseases. Presently, immunization has averted almost two to three
million child deaths yearly worldwide (Burton et al., 2009). Burton et al. (2009) report that about

84% of infants were vaccinated with three doses of diphtheria globally in 2013. In this regard,

over 90% of DPT coverage was maintained among developed countries like America, Europe,

and Western pacific (Burton et al., 2009). However, the achievement of full coverage of

immunization in third world countries has remained a very big problem to grapple with (Ali et

al., 2015).”

The World Health Organization (WHO) defined to mean that “a child has received a BCG

vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and

tetanus (DPT); at least three doses of polio vaccine; and one dose of measles vaccine” (WHO,

2018). Full immunization coverage has therefore, been identified as a key performance indicator

of the entire health sector, especially in sub-Saharan Africa (Abhulimhen-Iyoha & Okolo,

2012).”

Jani et al. (2008) revealed that 28.2 percent of children had not finished the vaccination

programme by two years of age, 25.7 percent had missed vaccination opportunity and 14.9

percent had been wrongly vaccinated. Reasons provided for these incomplete vaccinations were

correlated with accessibility to the vaccination locations, with no education of mothers and kids

born at home or outside Mozambique. On the other hand, the analysis of full immunization

coverage in Ethiopia, showed that sources of information from vaccination card, received

postnatal check-up within two months after birth, women’s awareness of community

conversation programmes and women in the rich wealth index were the predictors of full

immunization coverage (Lakew et al., 2015).

The 2016 immunization data showed that Ghana had reached the Global Vaccine Action Plan

(GVAP) target of 90% coverage for the third dose of the diphtheria-tetanus-pertussis vaccine

(DTP3) (WHO, 2018). Nonetheless, there are some teething problems confronting

the attainment of the full immunization coverage (Adediran et al., 2017). This assertion is in line

with the 2017 report on the National Demographic and Health Survey (DHS) showing low

complete immunization coverage in Ghana among kids aged 12–23 months (GSS, 2017).

It has been ascertained that even as inadequate rates of immunization against childhood diseases

stay a major public health problem in the world's resource-poor regions, it is because

immunization services are poorly understood (Akmatov & Mikolajczyk, 2012; Jani et al., 2008).

Apart from this, the problem could also be attributed to the socio demographic/economic factors

of mothers, health facility/system factors, and socio-cultural factors that impede the successful

implementation of immunization coverage in such poor resource countries (Gram et al., 2014).

Given credence to this assertion, studies have authentically demonstrated that Ghana has

significant health inequities across urban / rural, socio-economic and educational divisions

(MoH, 2011).”

In spite of these concerns, surveys to validate administrative coverage and identify predictors of

immunization status are not given the desired attention in peripheral countries like Ghana

(Mitchell, 2009; Adokiya et al., 2017). To address this deficiency, the Bottleneck analysis

(BNA) process was used to assess gaps in immunization services in Ghana so as to sustain the

gains in immunization coverage (Yawson et al., 2017). Following on from this effort, this study

sought to examine factors influencing participation in immunization among children aged 12–23

months at Kperisi community in the Wa Municipality of the Upper WestRegion of Ghana.

1.2 Statement of Problem

It is suggested that vaccination could reduce child mortality significantly and it is a cost effective

way to improve child health; however, the worldwide statistics show that more than 22 million

children do not receive the basic recommended vaccinations (Wado et al., 2014). For instance,

the World Health Organization (WHO, 2018) indicates that child mortality is still a major

concern to developing countries, including Ghana. The report revealed that about 39 children per

every 1000 live births died in 2017 alone. This is equivalent to 1 in every 26 children dying

before reaching age 5 in 2017. Specifically, about 5.4 million children below age 5 died in 2017,

with half of the number registered in sub Saharan Africa (WHO, 2018; UNICEF, 2018).”

In Ghana, the administrative coverage of the Expanded Programme on Immunization (EPI) is

usually high, whereas childhood immunization status remains low (Adokiya, Baguune & Ndago,

2017). In this regard, majority of children do not receive all the recommended seven (7) vaccines

in 15 doses before one year of age (Adokiya et al., 2017).”

Vaccine refusal by parents who are domiciled in Africa has also contributed to the low

immunization coverage for children in the region (Fredrickson et al., 2004). Fredrickson et al.

(2004) explain that factors, including antenatal care follow ups, health facility birth, and

knowledge of when a child is to start and end immunization, among others, were reported to

have been neglected by parents. Fredrickson et al. (2004) further revealed that this refusal was
usually conditioned on fear of side effect of the vaccine (52%), religious doctrines (28%), belief

that the disease was not harmful (26%), unreliable service provider, and anti-government

sentiments (8%).”

Institutional deficits have also been identified to have accounted for the low turnouts for

immunization in Africa (Gram et al., 2014). Gram et al. (2014) report that shortages of vaccines

during immunization programmes have greatly deterred parents from attending immunization

programmes. Moreover, in addition to the remoteness of healthcare facilities from parents who

are resident in remote villages, the poor attitude of healthcare professionals towards attendees of

immunization programmes and their general unreliability have adversely influenced the

readiness of parents to seek for immunization services (Gram et al., 2014; Fredrickson et al.,

2004).

Yawson et al. (2017) reported that in Ghana, only 50% of regions and districts had health

facilities with at least 80% of health care workers provide in-service training on routine

immunization; only 40% of districts had communities with functional fixed or outreach EPI

service delivery point and over 70% of regions and districts had challenges with effective

coverage of infants aged 0-11 months fully immunized during the past year. This study therefore

seeks to assess the factors influencing participation in immunization among children aged 12–23

months at Kperisi community in the Wa Municipality of the Upper West Region of Ghana.

1.3 Purpose of the Study

The purpose of the study was to assess the factors influencing participation in immunization

among children aged 12–23 months at Kperisi community in the Wa Municipality of the Upper

West Region of Ghana in other to establish possible reasons that could account for low

participation in immunization among children.

1.4 Research Objective

1.4.1 General Objective

The main objective of the study was to assess the factors influencing participation in

immunization among children aged 12–23 months at Kperisi community in the Wa Municipality

of the Upper WestRegion of Ghana.

1.4.2 Specific Objectives

i. To determine the factors influencing participating in immunization in the Kperisi community.

ii. To ascertain the things that prevent people from participating in immunization.

iii. To assess the knowledge level of the people about immunization.

1.5 Research Questions

i. What are the factors influencing participating in immunization in the Kperisi community?

ii. What are the things that prevent people from participating in immunization?

iii. What is the knowledge level of the people about immunization?

1.6 significance of the study

The findings from this study may be shared with the nurses and midwives in health facilities to

receive the findings needed to develop a sound program of health care for mothers with different

social construction for immunization for their babies aged 12-23 months in the Kperisi

community. The findings of this study when published would serve as a resource of reference

material for baseline data in the study area concerning immunization status of babies.

Information generated by the study would be useful for designing interventions and formulating

health educational messages aimed at improving immunization coverage in the district. The
findings from this study also would benefit Governmental organizations such as the Ministry of

Health (MoH), Ghana Health Service (GHS) and the Kperisi Health Directorate concerning the

factors influencing participation in immunization among children aged 12–23 months.

1.7 Scope of the Study

The topic under study selected participants who were within Kperisi community of the Upper

WestRegion of Ghana. The study targeted children aged 12–23 months within Kperisi

community of the Upper WestRegion of Ghana. The study targeted the factors influencing

participation in immunization among children aged 12–23 months.

1.8 Definitions of Terms

Immunization: The process whereby a person is made immune or resistant to an infectious

disease, typically by the administration of a vaccine (WHO, 2016).

Vaccination: This is the administration of a vaccine to stimulate an individual’s immune system

in order to develop specific immunity to a disease causing organism.

Morbidity: Level of ill-health or diseases in a given population.

Child Mortality: Probability of dying between birth and exactly 5 years of age, expressed per

1,000 live births (UNICEF, 2018).

Infant Mortality: Probability of dying between birth and exactly 1 year of age, expressed per

1,000 live births (UNICEF, 2018).

Fully immunized child: A child who has received all the prescribed vaccine doses

considered to protect the child from vaccine preventable diseases.

Immunization Coverage: The percentage of children between the ages 12 – 23 months who

have been vaccinated.

Partially immunized: A child who has missed at least one dose of any of the prescribed

antigens.

Outreach Centre: A place where immunization services are carried out.

1.9 Organization of The Study

This research work is structured into five chapters. Chapter one, consist of an introduction and

background to the study, the problem statement, research aim and objectives of the study,

research questions, the significance of the study and chapter disposition. Chapter two comprises

of a detailed review of literature relevant to the subject of study. Chapter three presents the

methodology of the study including the study design, process of data collection and analysis.

Chapter four however takes on data presentation, analysis and discussions with Chapter five then

summarizes all findings from the study, presents a conclusion of the study as well as

recommendations for both further studies and organizational practice.

 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents a critique of the current relevant literature. It provides a context to the

subject of this research and establishes a gap in the existing literature, providing a rationale for

the study. A variety of sources and databases were used for the literature collection, including

CINAHL, MEDLINE, Pro quest Nursing and Allied Health Source and Google Scholar.

2.2 Concept of immunization

According to the Center for Disease Control (CDC, 2012), the term immunization is often used

interchangeably with the terms vaccination or inoculation. Immunization can be defined as “the

process by which a person or animal becomes protected against a disease” (CDC, 2012, p 2).

Vaccination can be defined as “injection of a killed or weakened infectious organism in order to

prevent the disease” (Burns, Walsh & Popovich, 2010; p 23).

Immunization or vaccination is achieved by means of a vaccine, which is a product that

generates immunity, consequently protecting the body from disease (CDC, 2012). Vaccines are
highly regulated, complex biologic products designed to induce a protective immune response

both effectively and safely (Etana & Deressa, 2012). Vaccines can be administered through

injection, aerosol, or orally (Fischhoff, 2010).

The Expanded Programme on Immunization (EPI)was initiated by the World Health

Organization (WHO) in 1974 to control vaccine preventable diseases worldwide (EPI, 1998).

The World Health Organization launched the Expanded Program of Immunization (EPI) to make

vaccines available to all children and thereby control vaccine preventable diseases worldwide

(Mennito & Darden, 2010; O’Connor, 2011).

The vaccination of children, has led to a significant reduction in morbidity and mortality from

different diseases, thereby lowering the infant mortality rate (Johner & Maslany, 2011; Kumar,

Aggarwal & Gomber, 2010). Research has shown that, with the exception of provision safe

drinking water, “no other human intervention surpasses the impact immunizations have had on

reducing infectious disease and mortality rates, not even antibiotics (Smith, Lipsitch & Almond,

2011; Smith, 2010)

The routine immunization schedule in most countries comprises six vaccine preventable

diseases: namely measles, diphtheria, pertussis, tetanus, polio and tuberculosis (Kim, Johnstone

& Loeb, 2011). Before the age of one year the schedule should be completed by all children

(Bernard, 2000). Women of childbearing age should also be given tetanus toxoid (TT) vaccine to

prevent neonatal tetanus (Adedayo et al, 2009).

Routine vitamin A distribution is often integrated within national EPI programmes, and targets

children aged 6-59 months and post-natal mothers (Betsch, Renkewitz, Betsch & Ulshofer,

2010). Currently, the EPI administers eight vaccines: BCG (tuberculosis vaccine), oral polio
vaccine (OPV), diphtheria pertussis- tetanus (DPT) vaccine, hepatitis B (HepB) vaccine, measles

vaccine, yellow fever vaccine, and Haemophilus influenza type B and tetanus toxoid (TT)

vaccines (Coleman, Howard & Jenkinson, 2011).

According to the World Health Organization (2013), recommended schedule for routine

immunization are BCG should be taken at birth; DPT should be taken at 6, 10 and weeks after

birth; OPV should be taken at birth; 6, 10, 14 weeks and measles and yellow fever vaccine

should be taken at 9 months.

2.2. Factors Influencing Immunization participation

Studies have recognised significant issues that delay or escalate the chance of uptake of

vaccination (Ibnouf et al., 2007; Fernandez, Awotess, & Ramasha, 2011; Masand & Dixit, 2012;

Wiysonge et al., 2012). Some of these comprise mothers socio demographic and media

advertising (Pandey & Lee, 2011; Masand et al., 2012), among others as analyzed below.”

2.2.1. Socio-Demographic Characteristics and Immunization participation

An analysis of the socio-demographic characteristics of the mother and or the children would

help in construing the reasons behind the low or high immunization coverage. Research revealed

that children who are located at the urban settings are more probable to be completely

immunized than in those in the rural settings (Fernandez, Awotess, & Ramasha, 2011; Patra,

2008; Manthal, 2007; Masand & Dixit, 2012; Wiysonge et al., 2012). Other findings of the

research also showed that the results have also shown that the probability of getting

immunization for children under two years was determined by religious convictions, because of
unlikely vaccination of children born to Muslim mothers compared with children born to

Christian mothers (Nath, 2007; Babalola, 2009).”

Kalule-Sabiti et al. (2014) established that Christian mothers tend to have a Western modernized

background compared with Muslims and African traditional religions and therefore, are

supposed to be frequent customers of health facilities. Ha et al. (2009) found that children in

families affiliated with apostolic faith were nearly 6 percentage points less likely to be

immunized with BCG and measles and 5 percentage points less likely to be immunized with

polio compared with children in families affiliated with other Christian organizations in

Zimbabwe.”

Other trainings also showed that maternal variables were highly likely to result in child

vaccination (Pandey & Lee, 2011; Nath, 2007). Some scientists emphasized that mothers with

secondary and higher education were better trained and empowered, so they were more likely to

have their kids immunized than their primary or non-educational counterparts. (Pandey & Lee,

2011; Nath, 2007). Other studies indicated that immunization adherence improved with mothers’

financial status (Etana & Deressa, 2011; Masand et al., 2012). Masand et al. (2012) opined that

women with high financial status were more likely to immunize their children than mothers with

a low financial standing.”

2.2.2. Health facility factors and immunization participation

A study in Ghana observed that inadequate in-service training in routine immunization and

absence of good quality data were major challenges - demand side bottlenecks included fear of

mothers on the safety of multiple vaccines and limited active involvement of communities in

immunization service delivery (Yawson et al., 2017). Therefore, it is expected that an

assessment of health facilities factors will help in throwing more light on the reasons behind the
low or high immunization coverage. For example, a study reported that factors that are linked to

healthcare system, including accessibility, affordability, knowledge and attitudes about

vaccination, and guidance from physicians were also significant determinants of vaccination

(Nagata et al., 2013).

The World Health Organization (2014) commented that attendance to immunization programmes

are usually influenced by poor knowledge of parents about vaccination, lack of convenient

venues and logistics at outreach centres, financial problems, long waiting times, transport

problems, inadequate incentives for service providers and weak Intersectoral collaboration, the

timing of immunization programmes, attitude of service providers, fear of side-effects, and

religious doctrines – these are the main determinants of immunization coverage (WHO, 2014).”

For example, a study reported that availability to healthcare delivery in rural regions was low as

likened to the cities and immunization was considerably higher where nearness to a health

service areas was smaller as the case with city areas (Ibnouf et al., 2007; Rup et al., 2008). For

instance, it has been reported that children in urban areas have a higher prospect of being fully

vaccinated than those resident in rural sectors (Ibnouf et al., 2007; Rup et al., 2008; WHO,

2014). Some analysts reported that this is because accessibility to health services in rural areas is

a major problem in comparison with urban sectors - immunization participation was much higher

in communities that had healthcare centres close to them than those that were remote from

immunization centres (Ibnouf et al., 2007; Rup et al., 2008).

“This problem gets exacerbated when the immunization centre lacks the required doze of

vaccines for all the children present for vaccination (Ibnouf et al., 2007; Rup et al., 2008; WHO,

2014). Available evidence shows that parents whose children fail to receive vaccination on

account of shortages in the quantity of dosage available run the risk of being absent from
subsequent immunization programmes scheduled for the district (Ibnouf et al., 2007; Rup et al.,

2008; WHO, 2014).”

Another aspect is that compliance immunization is similarly greater when women are attended to

by health care providers when pregnant and give birth at health facilities (Babalola, 2009; Etana

& Deressa, 2011; Pandey & Lee, 2011; Masand et al., 2012). However, it is reported that

subsequent attendance at immunization programmes to vaccinate children could be influenced by

perceptions the mother holds concerning services received from the healthcare centres during

pregnancy and delivery (WHO, 2014).”

“Furthermore, use of health services and access to media publications are likewise considered to

be strong determinants of immunization attendance (Ibnouf et al., 2007; Rup et al., 2008; WHO,

2014). Becker et al. (1993) reported that radio and a television ownership was significant in

determining immunization - ownership of these devices improved the probability of

immunization. The idea is that media announcements and advertisements constitute a major

source of information to parents on immunization schedules for respective districts. It educates

parents on the importance of immunization exercises and the likelihood of preventing diseases

that would otherwise have caused the demise or incapacitation of their children (Becker et al.,

1993). Duah-Owusu (2004) established that Ghana has improved access to health information by

commercial outlet.”

2.2.3. Sociocultural factors and immunization participation

It is believed that socio-cultural factors, including myths, beliefs and friends/neighbors, among

others, have an influence on parents’ decision to immunize their children. For instance, a study

explained that vaccine hesitancy is complex and context specific, varying across time, place and

vaccines, which is influenced by factors such as complacency, convenience and confidence

(MacDonald, 2015). Confirming this position, a study found that children of non-educated

fathers in rural areas of Burkina Faso had higher rates of complete immunization coverage than

those in the urban area (Sanou et al., 2009).”

To be able to understand the context within which to assess the influence of social factors on

immunization coverage, the Vaccine Hesitancy Determinants Matrix was developed displaying

factors influencing the behavioural decision to accept, delay or reject some or all vaccines under

three categories: contextual, individual and group, and vaccine/vaccination specific influences

(MacDonald, 2015). Impliedly, Sanou et al. (2009) found that good communication about

immunization and the importance of availability of immunization booklets, as well as economic

and religious factors appeared to positively affect children's immunization status in Burkina

Faso.”

“It has been reported that there is vaccine hesitancy among adults 65 years and above due to

structural social determinants, including social and cultural values, as well as intermediary

determinants including housing-place of residence, behavioural beliefs, social influences,

previous vaccine experiences, perceived susceptibility, sources of information, and perceived

health status (Nagata et al., 2013). Sanou et al. (2009) also informed that the success of

vaccination among children in Burkina Faso was often hampered by the poor economic

conditions of households and insufficient communication and knowledge regarding

immunization issues.”

2.3 Factors affecting full immunization participation of infants

Underlying factors and barriers to immunizations are critical challenges that can be magnified

when a parent has low literacy skills Kumar, Aggarwal and Gomber (2010). Particularly

important, low literacy was linked with limited vocabulary skills that also impacted
understanding of vital concepts, such as being able to communicate the risks, benefits, and safety

of childhood vaccines (Hershberger et al, 2010).

In a descriptive study conducted by Mayinbe, Braa and Bjunne (2005) the findings showed that,

reducing the waiting time for patients to be immunized increased the compliance rate of

immunization. The findings showed that, about 71.9% of mothers agreed with the contact period

as a factor discouraging compliance. Majority of the mothers complained of the long waiting

time before been taking their babies to the health centres for immunization and said that was a

factor negatively affecting them from sending their children to the hospital for healthcare.

Similarly, a study by Takum et al. (2011) stated that one of the barriers to immunization in

Nigeria was the frequent undersupply of vaccines and the need for repeated visits often led to

incomplete immunization of children in those that have no easy access to a Primary Health Care

services. Kumar et al. (2010) in a study also cited some of the factors identified as affecting the

immunization status of children negatively as the place of birth, age of the child in months,

current age of the mother, marital status, occupation, religion, level of education, number of

children, retention of immunization card, place of vaccination, gender, and knowledge score.

In a cross sectional survey conducted by Mosiur and Sarker (2010), using simple random

sampling technique, the study participants were only mothers with infants aged 0-23 months.

The findings revealed that, mothers with lower literacy skills also provided more partially correct

and incorrect answers. The mothers in the sample with lower literacy skills demonstrated a lack

of knowledge and comprehension regarding vaccination safety, with fewer correct responses

given for immunization safety than risks and benefits. The study concluded that mother’s

education was positively associated with immunization status of their children.

In a related development, mothers in a survey identified several reasons why they were not

taking their children to hospital for immunization. Majority of the reasons identified included

worry about the side effects of immunization (98.0%) and their work schedule. The findings

however showed that, the religious belief and cost did not really affect their compliance

negatively. Furthermore, 98.0% claimed that their occupations allow them to take their children

for immunization.

Most of the women representing 60.8% agreed with the statement that health workers behaviour

discouraged compliance. This is in line with findings by Humphreys (2011) who cited provider’s

attitudes and long waiting period as few reasons by mothers for not taking additional

immunization for their children. Indeed a few women were frustrated because they had visited

the facility more than one time with no vaccines on ground, absence of service providers or

disrespectful providers (Kennedy et al, 2011)

A study done at southern district of Nigeria revealed that mothers with lowest education and

unemployed women were less likely to complete a child immunization (Owolabi, 2010).

Educationempowers a woman to accessrelevant health services interacteffectivelyand assimilate

information relating to prenatal care, childhood immunizations and nutritional needs (Stamler,

2012).

In the study conducted in Ghana revealed that there was an obvious significance relationship

between children’s vaccination pattern with mother’s education level (Sadoh & Eregie, 2009).

Stamler (2012) found that mothers who completed at least primary level of education were 1.7

times more likely to have their children fully immunized compared to those who had no

education. Comparatively, a mixed methods pilot study was conducted to assess the relationship
between health literacy and a mother’s ability to understand and communicate information about

childhood immunizations (Mutua et al, 2011).

This study used a convenience sample of 30 mothers in an urban walk-in childhood

immunization clinic in Kenya. The Rapid Estimate of Adult Literacy in Medicine (REALM)

instrument was used to determine the mother’s actual reading skills. For the intervention, the

investigators used the vaccine information sheets, which have a 9th and 10th grade reading level,

for two vaccines to give the mother’s verbal instructions about risks, benefits, and safety of the

vaccines. The findings showed that the younger mothers provided more correct answers,

compared to the older mothers who provided more partially correct or incorrect answers.

The study concluded that mothers age was associated with immunization status of their babies.

In some societies with cultural discrimination against female children, boys have a greater

chance to be vaccinated (Mohamud et al, 2014). Marital status and age of the mothers were not

seen to be associated with the use of immunization services. In other settings, both younger

(Glenda et al., 2004) and older age of mothers (Cui & Gofin, 2007) has been reported to be

associated with incomplete vaccination. Previous studies (Mutua et al, 2011) revealed that

educational status of mothers has a strong association with a high vaccine uptake.

A descriptive cross sectional study aimed at finding out the reasons for partial immunization and

factors responsible for missed opportunities for immunization in children less than one year of

age. Mothers of children within one year of age were the study subjects using a cross-sectional

study design. The results showed that, most of the women said fear of side effects, long distance

to health centres and bad attitude of health care providers were identified as factors preventing

women from taking their babies to hospitals for immunization. The findings also showed that,
majority of the respondents complained of shortage of vaccines at some point in time and even

wondered why such a situation should arise in the first place (Yohannes, Mesganaw & Michelle,

2014).

Similarly, a study by Takum et al. (2011), revealed that vaccination coverage was found to be

low among children in Papum Pare district, Arunachal Pradesh, India. The study revealed that,

majority of the women was not taking their babies to the health centres for immunization that

necessitated the low coverage at the district. One major factor that was identified as a major

barrier to the low coverage status of the children was the attitude of staff at the health centres.

The study concluded that, the attitude of health care providers was not good.

Additionally, a study was conducted to assess mother’s knowledge concerning immunization.

The results showed that, fear of side effects and fear of vaccines getting out of potency was

identified as reasons for non-compliance of immunization. This indicated that vaccines in these

facilities were at high risk of losing their potency (Zhao & Luman, 2010). This observation was

similar to a study in Cameroon and another study in Ethiopia (Humphreys, 2011; Kennedy et al.

2011) where mothers sampled in a survey cited fear of vaccines expiring and side effects as

factors preventing them from taking their babies for immunization.

A study has also linked insufficient refresher training and supervision as a factor preventing

women from effectively taking their babies to health centres for immunization, which might

contribute to the substandard cold chain and vaccine stock management (Rogie, 2013; Owolabi,

2010). However, there was a significant zonal variation in terms of access to vaccination services

for babies with most studies in different places having lower coverage (Mohamud et al. 2014;

Mayinbe, Braa & Bjunne, 2005).

In Ethiopia, the overall Penta 3 coverage, a proxy indicator for utilization of vaccination

services, was found to be low, and significantly lower in Zone 3, Bench Maji Gedio and East

Wolega zones as compared to the North Western zone in Ethiopia (Kennedy et al, 2011). The

study concluded that most of the areas still had low coverage with respect to vaccination

coverage among children.

A study was carried out to examine factors influencing compliance with immunization regimen

among nursing mothers in Moniya Community, Ibadan, Nigeria. The majority, 80.4% of

respondents affirmed that they have taken at least one vaccine while 19.6% claimed they have

not taken any vaccine for their children. More so, 62.8% have fully immunized their last child

while the remaining 37.2% of the respondents did not immunize their children fully (Etana &

Deressa, 2012)

This is consistent with study by that compared with the immunization cards of all the children

aged five years and below admitted into the pediatric wards of the University of Calabar

Teaching Hospital, Calabar, Nigeria with the mothers which reported that only 560 (60.9%) were

fully immunized for age. Finding showed that, 244 (26.6%) were partially immunized and 115

(12.5%) had no form of immunization. The prevalence rate of missed opportunity was 39.1%.

Most of these patients were in the low lower socioeconomic groups. This study has revealed that

the commonest reason for missing immunization was illness of the child at the time of

immunization as stated by 65.4% of the respondents (Fischbacher-Smith, Irwin &

FischbacherSmith, 2010).

Parents objection, disagreement or concern about immunization safety (38.8%), long distance

walking (17.5%) and long waiting time at the health facility (15.2%) are the most common
reasons for partial immunization. Missed opportunities for immunization and partial

immunization need to be avoided in order to enhance the fully immunized percentage for those

children who reach the health facility, especially in rural areas where the immunization coverage

is below the expected national coverage (minimum 80%) (Mennito & Darden, 2010).

According to Mennito and Darden (2010), parental beliefs, such as anti-vaccine beliefs, mistrust

of information, low risk of vaccine-preventable disease, lack of husband support, belief in

alternative health care, and a high risk-benefit ratio were factors which hindered childhood

immunization. Fear of side effects, the number of vaccines, and the long-term effects on health

were also outlined in a survey as factors affecting immunization coverage of children by (Johner

& Maslany, 2011).

The annual report from WHO (2013) showed that more than 30 million children are not

immunized because vaccines are unavailable, health-care facilities are poor or nonexistent, or

families are uninformed or misinformed. In Italy, the study conducted on EPI coverage using

cluster survey of regions comparing mandatory and optional immunizations showed a study

increase in coverage for mandatory vaccines, which were free and cost borne by the national

health office and decreased drastically for optional vaccines which parents were made to pay a

fee for cost of vaccination. In this regard, payment of token fees has been a major hindrance to

EPI service utilization in Italy (Johner & Maslany, 2011).

Fifteen qualitative studies on barriers to childhood immunization were reviewed by

FischbacherSmith, Irwin and Fischbacher-Smith (2010) who discovered a number of themes

relating to personal factors, including issues of harm, risk of adverse effects, concern about pain

caused by immunization, and the belief that immunization should not occur when the child is ill.
This review demonstrates that there are a variety of personal reasons why parents decline

childhood immunization.

In Gansu, China, education was found to be associated with immunization of children. This

means mothers who were educated were 11 times [OR=10.9] more likely to fully vaccinated

their children than children born to mothers without education. In regards to the mother’s

occupation, children born to mothers that were into professional and managerial jobs were 8

times [OR=7.97] more likely to receive full immunization, clerical and service workers were 5

times [OR= 4.82] more likely to have their children fully immunized than mothers that were not

working while children born to mothers that were into other types of job were 2 times [OR=1.67]

more likely to receive full immunization than children born to mother that were not working

(Mohamud et al. 2014).

Distance to the health post which is an alternative measure of accessibility has been found to

affect immunization participation in Kenya (Bond et al, 1998). Close proximity to the clinic was

associated with an increased likelihood of vaccination, with immunization coverage declining

with increasing distance from vaccination clinics in Egypt (Canavan et al. 2014). The overall

vaccination coverage among children aged 12-23 months was found to be as follows: BCG 86%;

Penta1 88%; Penta3 79%; measles 80%; and fully vaccinated 69%; combining all sources of data

(card, register and history). Timely vaccination coverage, as defined by vaccination by 12

months of age was: BCG 81%; Penta1 82%; Penta3 72%; measles 68%; and fully vaccinated

60% (Bergin, 2011; Kuehn, 2010).

Similarly, in a study, it was observed that, most mothers were not told of the possible side effects

of vaccination. Overall, more than a quarter of mothers were not told about side-effects the child

might experience with vaccination. This indicates that there was an opportunity to improve the
client provider interaction. There was also other evidence, particularly a lack of counseling and

discussion with the mother at outreach sessions as vaccinators were usually rushing to complete

the session (Kumar, Aggarwal & Gomber, 2010).

High maternal workload combined with lack of knowledge, and hence less value associated with

vaccination were the main reasons to which the unacceptably high dropout rate was ascribed,

according to a survey. Limited access and poor quality vaccination service were also identified

as the main factors that limit vaccination coverage nationally among children in a survey (Bishop

& Shepherd, 2011)

It has been observed that, low ANC attendance among pregnant women where their knowledge

concerning immunization status was supposed to be good rather turned out to be poor following

limited health education by health staff (Mosiur & Sarker, 2010). It would be optimal to provide

immunization information prior to the mother’s delivery at health centres, since it has been

shown that these mothers respond more to information received earlier rather than at a later date

(Kennedy, et al. 2011; Humphreys, 2011; Hernandez, Montana & Clarke, 2010; Etana &

Deressa, 2012).

2.4 Knowledge of mothers with infants on immunization

Knowledge of mothers is an important factor influencing immunization among infants (Takum et

al, 2011). A number of studies indicate that mothers who have inadequate knowledge about

immunization and immunization schedules were more likely to have children who are not

immunized or partially immunized (Owolabi, 2010; Rogie, 2013).

Stamler (2012) conducted a mixed-methods research study with 15 mothers with one child and

15 mothers with more than one child, who brought their children to a childhood immunization

clinic in Canada. They discovered that mothers had inadequate knowledge and comprehension

regarding vaccine safety in their babies.

The findings revealed that only 23% of the study respondents knew of the importance of

vaccination after taking their babies home whilst the rest had no knowledge on vaccine safety for

their infants. The findings showed that majority of the study participants were very skeptical

about the management of any side effects after vaccination. This prevented a good number of

them from going to the health centres to have their babies immunized. The study concluded that

knowledge of study participants was very low on childhood immunization.

Similarly, Machingaidze, Wiysonge and Hussey (2015) conducted an interviewed with 315

parents of children admitted to a hospital in North India using a semi-structured questionnaire to

determine their reasons for partial immunization or non-immunization. One hundred and forty

(52.4%) of the participants stated that inadequate knowledge about immunization was a reason

that their child was not immunized or partially immunized. The study concluded that knowledge

of study participants concerning immunization was low. The study however found that study

participants had good intention for immunization for their babies.

Another study, Kidane (2006) revealed that women with infants aged 0-23 months in Ethiopia

identified health workers, friends, mass media and family members as their sources of

information on immunization of their children. The study concluded that study participant’s

knowledge on immunization was good. Gautret et al. (2010) have also stated that media stories

frequently share few mother’s views regarding vaccine safety, which can give mothers with
infants less than 24 months the false impression that the majority of mothers shared this opinion.

And this can affect the immunization status of their babies.

A qualitative, focus group design study with 24 mothers in Hawaii was conducted to determine

why their infants, aged 12-23 months, were not fully immunized. One of the findings which

emerged from this research was mother’s knowledge deficits about vaccine schedules and

misunderstanding about the importance of immunizations (Hernandez, Montana & Clarke,

2010). The study concluded that although mothers with infants aged 12-23 months had ever

heard of immunization from friends, health centres and the print media, their knowledge

concerning immunization was inadequate.

Similarly, in a study which included 30 mothers which were interviewed with parents discussing

childhood immunization in three United States cities, namely Kansas City, Philadelphia, and

Eugene, the authors discovered that in general parents had knowledge of understanding of how

vaccines work, which made them less vulnerable to misinformation, including easily-accessible

information on the internet (Fischhoff, 2010).

Kuehn (2010) conducted a mixed-method study, using focus groups and door-to-door surveys in

Bakersfield, California to examine the current immunization status of infants aged zero to 23

months and identify barriers to childhood immunization. A number of knowledge barriers were

identified, such as mother’s confusion regarding what immunizations were, how vaccines work,

why vaccines were important to their babies, and lack of information provided by health care

providers at health centres. The study concluded that mothers with infants aged 0-23 months had

less knowledge on immunization, since they did not know the right time to return for the next

vaccination.
Parental acceptance and rejection of available immunizations is vital to both effective provider

parent communication concerning vaccination decisions and public health campaigns to optimize

vaccination coverage (Kumar, Aggarwal & Gomber, 2010). A large amount of anti-vaccination

media, action groups, and websites may further make matters worse by broadcasting negative

vaccine information and highlighting reasons for concern that often have no scientific evidence

(Mosiur & Sarker, 2010; Painter et al. 2010).

In a descriptive cross sectional study done by Pati et al. (2010), the study employed a mixed

method of data collection. Simple random sampling technique was used to sample the study

respondents. Findings from the study showed that, demographic data of respondents was found

to influence immunization status of their babies. The analysis revealed that, study participant’s

educational status was associated with knowledge of immunization. The study recommended that

more education should be provided to illiterate mothers in the importance of immunization in

their children.

However, a descriptive cross sectional study conducted by Johner and Maslany (2011) revealed

that there was no relationship between residential status of study participants and having the

belief that vaccines works well in babies (p>0.112). Using one-on-one interviews, a qualitative

study (n=30) sought to determine parents’ vaccination comprehension and decision-making

processes (Pati et al. 2010). The respondents of the study were primarily women with infants

aged 0-23 months. This study primarily focused on the effectiveness of childhood vaccine.

Twenty-four of the parents (80%) reported first learning about vaccination from their healthcare

providers, with the others reporting having read about it first from books. When asked about

drawbacks to getting their child vaccinated, 37% of the parents stated lack of knowledge which

they rated as moderately serious. The better parents felt about how well vaccinations had been
explained to them, the more they thought that not vaccinating their child would hurt other

children. In general, parents trusted pro-vaccination communications more than anti-vaccination

ones. When asked what source they would consult for more information on vaccinations, 33% of

parents stated they would ask their healthcare provider or look for a government source while

70% said they would perform an internet search while others stated that they knew the next

schedule for vaccination.

The parents in this study were generally more favorable toward vaccination but had limited

understanding of how vaccines actually work. When asked about the need for additional

information, most parents would consult the internet before asking their health care provider

which may make them vulnerable to false information. The study concluded that knowledge of

mothers on vaccination was adequate.

In Malawi, Ethiopia, India, Bangladesh, and the Philippines, a multiregional study that was done

showed there was a very significant general demand for better quality of vaccination services

among mothers (Sadoh & Eregie, 2009; Kennedy et al. 2011) because damage was being done to

the Expanded Programme on Immunization (EPI) by poor communication between health

workers and clients.

A study conducted by O’Connor(2011) found that there was norelationship between

occupational status of mothers and belief that vaccines work effectively in children (p>0.011).

Niederhauser (2010) carried out a retrospective, cross-sectional study with 30 children under the

age of 0-23 months in all health regions of Catalonia, Spain. The authors discovered that greater
immunization coverage was associated with maternal age over 30 years and increased knowledge

of vaccines for their infants.

The findings revealed that mother’s knowledge based on how good immunization was to their

infants, having last child fully immunized and knowledge on the information on child’s card was

associated with positive immunization compliance of mothers. The findings further revealed that

there was an association between mother’s home to the health centre, parity status and

immunization status of their children (p ˂ 0.003) Mohamud et al. (2014) found that the demand

for vaccination by mothers with infants less than 24 months was caused by knowledge that

vaccines were good for children and/or a strong feeling of exposure to serious illness. The study

however, showed that lactating mothers were not aware of the need for subsequent vaccination.

Painter et al. (2010) has observed that mothers with knowledge on service, child having been at

least vaccinated once and having perceived knowledge that vaccination is good for their baby’s

influence mothers cooperating towards vaccination services. Kennedy et al. (2011) studied the

knowledge, attitudes, and behaviour of mothers on immunization of 841 children in

kindergartens in Italy. The authors found that only 57.8% of mothers were aware of the four

mandatory vaccines for children, namely polio, tetanus, diphtheria, and hepatitis B.

The study found that wrong ideas about contra-indications, no faith in vaccination and unaware

of need to return for subsequent dose among mothers were significantly associated with mother’s

knowledge on immunization. The study concluded that this statistic suggests that Italian mothers

may have an ineffective role in the eradication of vaccine-preventable diseases due to lack of

knowledge about vaccines.

Inadequateknowledge, limited understanding of vaccines,misconceptions,and lack

of appropriate information can contribute to whether or not children are immunized by them
mothers or care takers (Kidane, 2006). Since this could influence the vaccination status of

babies. A study on compliance rates in Kern county, California by Etana and Deressa (2012)

among mothers with infants aged less than 24 months found that parents sited non-compliance as

being due mainly to child’s illness, procrastination and lack of knowledge about immunization

and where to obtain vaccination services.

The study revealed that majority of the mothers cited that enough public education was not done

to encourage mothers to take their children to vaccination centres for immunization. A large

proportion of mothers, appeared to obtain information on side effects from other sources such as

the media or the internet where opponents of vaccinations may invariably publish biased or

unreliable interpretations of proven scientific results. The study concluded that there was an

indication that health workers should intensify their efforts in educating mothers on benefits of

immunization.

In a descriptive cross sectional study conducted by Fischhoff, (2010) findings from the study

showed that, all of the respondents reported having previously obtained immunizations for their

child or children, however almost 20% failed to strongly agree to continue to get their child or

children immunized. The analysis showed that, age of mothers was found to be associated with

immunization status of babies (p ˂ 0.002).

Other socio-demographic variables were not associated with defaulting. Mothers who had

negative attitude about health facility were two times more likely to have defaulter children than

mothers who had positive attitude. The findings of this study imply that it was essential to have a

certain amount of communication between parents, nurses, and pediatric healthcare providers.

However, a study conducted by Bulpitt and Martin (2010) revealed that, mothers age did not

significantly influence the immunization status of their babies. It was found that forgetting, and
not knowing when and where to take the child/children for vaccinations were the factors

identified.

Mennito and Darden (2010) also found that marital status of mothers was associated with the

immunization status of their babies. The results showed that, mothers who were married were

more likely to have faith in vaccination of babies (p˂0.001). The analysis of the data also showed

that higher educated women got the message that immunizations were important and also had

fewer problems with access and concerns with immunizations. A large majority of those

reporting that they did not strongly agree to further immunizations were among the least

educated surveyed. The finding that the level of education did play a role in the primary

caretaker’s decisions to immunize their children was of particular interest in that other factors

surveyed such as marital status and age did.

CHAPTER THREE

METHODOLOGY

3.0 INTRODUCTION

This chapter presents the methods applied to collect data for analysis in the study. It is divided

into sections. These include the study design, the study area, study population (inclusion
criterion, exclusion criterion), sample size, sampling method and selection, study variables, data

collection, pre-testing, quality assurance, data handling and analysis, and ethical considerations.

The chapter ends with a summary where the main ideas have been provided with an insight into

what the reader should expect in the next chapter indicated.”

3.1 STUDY DESIGN

The excellence of any research project is enhanced by a strong knowledge of the research design

and this research was based on a cross-sectional study (Creswell, 2007). Creswell (2007) notes

that the strategy relates to a set of methods with emphasizes on quantitative analyses where study

information is collected using questionnaires, a set of techniques emphasize quantitative

analyses, where data for the research are gathered using questionnaires, and the data analyzed

using statistical techniques. (Creswell, 2007).”

“The cross-sectional research is a research methodology, which enables the researcher to conduct

a one-shot study on the phenomenon under observation in a population at a particular point in

time (Bethlehem, 1999). Bethlehem (1999) observes that here, the investigator gathers

information from a targeted population segment to gather enough information on the issue from a

representative sample in order to make generalizations.

Usually, the variables observed in the sample population are selected using the probability basis

to make inference about the population as a whole. Consequently, since the researcher adopted

the quantitative method, which entails the use of numbers and statistical techniques in analysing

data, it gave the researcher room for generalization and predictions (Blaikie, 2010). Again, the

method ensured that the researcher was able to conduct the study objectively, and make

assumptions based on the findings arrived at (see Easterby-Smith, Thorpe & Jackson, 2012).
3.2 SAMPLE AREA

The study area was Kperisi and is one of the major and busy town in Jaman North District of the

Upper WestRegion. Kperisi circuit is made up of about 1000 population and the people there

engage in farming and trading.

3.3 STUDY POPULATION

This is the total group of individuals from which the sample was drawn (Creswell, 2007). For

the purpose of this research, the population was strategically defined to include only mothers or

caregivers with children between the ages of 12-23 months who lived in the Kperisi community

in the Jaman North District of Ghana.

3.3.1. Inclusion Criteria

The inclusion criteria were mothers or caregivers who:

1. Had a child between 12-23 months.

2. Had a child record booklet or not.

3. Had lived in the community for the past one year.

4. Had a child of 12-23 months who agreed to be part of the study and filled the consent

forms.

3.3.2. Exclusion Criteria

The exclusion criteria were mothers or caregivers who:

1. Had a child less than 12 months or more than twenty-three months (older than 23

months).
 2. Did not reside in the selected area of study

3. Declined to participate in the study.

3.4 SAMPLING FRAME AND SAMPLING TECHNIQUE

Sampling permits the concise and conscious selection of representatives from a group of items,

people in a community, or institution for gathering research data for measurements and analysis

(Creswell, 2007). Creswell (2007) argues that sampling reduces the cost involved in conducting

research, provide accurate information for analysis, and reduce the time required to conduct the

study. The multi-stage sampling method was used to recruit respondents for this research. This

included a combination of the cluster sampling and simple random sampling techniques.

The multi-stage sampling design allowed the researcher to recruit participants on multiple levels.

First, a group was selected and then some or all the units in each group measured. It was the

household level that the final interviewing took place to represent the whole population. In this

design, the size of each primary unit was defined as the number of population units contained in

each primary unit. Hence, the researcher was always certain that all or the primary units were

equal or when they varied, the size of each unit known before any measurement was conducted

(Creswell, 2007).

Using this design, the study first, divided the study area into 50 clusters representing known

neighborhoods using the map of the Kperisi community. The simple random sampling method,

which is a probability sampling technique that allows a researcher to give all potential

respondents equal chance of participating in the research (Creswell, 2007) was then used to

randomly select 25 clusters from which respondents were sampled.

The study recruited 9 respondents from each of the 23 selected clusters and 10 from the

remaining 2 clusters to participate in the study. To accomplish this objective, the study counted

and recruited every other second mother with a child (ren) aged 12 - 23 months, and who was

also a resident of the municipality for at least one year to participate in the research. This

approach was repeated across all selected neighborhoods in the community until the required

number of respondents was sampled for the research (see Shaughnessy, Zechmeister &

Zechmeister, 2006).

3.5 SAMPLE SIZE

The sample size refers to the number of independent, random sample units drawn from the

research population to participate in the study - it represents that number of replicates or subjects

(Creswell, 2007). The study recruited 227 mothers/caregivers to participate in the research. The

sample size for the study was calculated using the Cochran’s (1975), formula;

n= (Z ×Z×PQ)/ (D×D), Where, n = desired sample size,

Z = Reliability coefficient for 95% confidence interval usually set at 1.96.

P = proportion of children who have had their Penta3 0.82 (Kperisi Health Directorate, 2023).

Q= 1-P

= (1-0.82)

D = degree of accuracy desired set at 0.05 probability level.

A coverage of 81.9% (8646/10545) obtained in the year 2017, for Penta3 in the Kperisi

community was used.

Substituting,
n = (Z ×Z×PQ)/ (D×D),

n = (1.96*1.96*) (0.82*0.18) / (0.05*0.05)

n = 226.81

n=227

Adjusting for a non-response rate of 10%, at least a total of 250 mothers (caregivers) of children

aged 12-23 months were determined for the study as sample size.

3.6 DATA COLLECTION PROCEDURE

To obtain adequate information on the study, the primary data gathered views of individual

mothers with children between the ages of 12-23 months residing in the Kperisi community.

That is, a structured questionnaire with sections was designed and administered to the

mothers/caregivers in the community. Section A collected data on the socio-demographic

characteristics of the mothers/caregivers, including their age, educational background,

occupation, religion, ethnicity, among others.

Section B gathered information on factors influencing participating in immunization in the

Kperisi community. Section C collected data on things that prevent people from participating in

immunization. Section D collected data knowledge level of the people about immunization.

The questionnaire as designed as open and close-ended questions was administered through both

interviewer-administered and self-administered approaches based on the educational background

of the participants. Using close-ended questions, the respondents were asked to select “Yes” or

“No” in response to questions; or where multiple choices were provided, to choose the option

that best answered the question. The five-point liker scale measuring a
range of responses was also used. Four research assistants helped in the

distribution/administration of the questionnaires. Each questionnaire was administered within

20-30 minutes at locations convenient to the participants in the selected community.

3.7 PRETESTING OF QUESTIONNAIRES

A pre-test was conducted. It involved selecting, and interviewing 10 mothers/caregivers in the

same manner that was followed in the main study. This helped the study to know whether the

responses to the questionnaire were in line with the type of information needed. In addition, the

results obtained in the pre-test suggested new ideas that were included in the final tool. The pre-

test involved randomly recruited ten mothers/ caregivers as respondents to ensure clarity, ease,

and flexibility of the questions being asked. Errors and anomalies detected were also corrected

before going to the field.

3.8 DATA ANALYSIS PROCEDURES

The returned questionnaires were cleaned, edited and coded before analysis. That is, the

questionnaires answered by the respondents were coded and interpreted using the STATA

Version 15. The data was analyzed using the descriptive statistics (i.e. Mean, Standard

Deviation, etc.). Frequency distribution tables and charts were also presented. Bivariate and

multivariable comparisons were made between immunization status and independent variables

using chi square, Fisher’s exact and logistic regression respectively. Chi square and Fishers exact

was used to determine the association between immunization status and each of the independent

variables. This multiple regression analysis was done to determine which of the variables were

strongly associated with child’s immunization status. The level of significance was accepted at

p<0.05 at 95% confidence interval.

3.9 LIMITATION OF THE STUDY

Some challenges were encountered in the conduct of this research. It required a lot of effort to

convince respondents to agree to participate in the research due to the fear that their privacy

would be exposed. Some of the participant were unable to read and comprehend the questions.

This gave the researchers the added task of reading and interpreting every question. In addition,

the respondents were not located in one area. Hence, the researchers took several days to meet up

with each respondent to collect data. Finally, the researcher incurred huge costs in printing out

the instruments, personal upkeep, and traveling to meet the respondents.

There might be recall bias as mothers who were not having child record booklet or card might

not able to remember all the vaccine the child has taken. The sample size for the study was

relatively low. This may have accounted for the insignificant results obtained in most of the

variables measured. The application of only quantitative methods means that the researcher could

not explore the respondents’ perceptions of the issues raised. All these may restrict the

generalization of the findings of the study beyond the study area.

3.10 DELIMITATION OF THE STUDY

The study focused on infants aged 12-23 months in the Wa Municipality. Per the study

area, the study will only focus on the mothers or caregivers with children between the ages

of 12-23 months in the Wa Municipality. Finally, in relation to study variables, the focus of

the study was on the factors influencing participation in immunization among children

aged 12–23 months at Kperisi community.

3.8 Ethical Considerations/Issues

Ethical clearance for this research was obtained from the Ghana Health Service Ethical Review

Committee. Permission was also obtained from the District Health Directorate, Kperisi. The
participants were recruited into the study based on their decision to participate after the

objectives and the methodology of the study has been explained to them. Participation in the

study was completely voluntary, no gift was given. However, the privacy and confidentiality of

each participant was ensured throughout the study period. Participants were assured that their

names will not be written on the questionnaire and that the consent form with the name and

signature will not be linked to the questionnaire.

 CHAPTER FOUR

RESULTS AND FINDINGS

4.1 Introduction

This chapter presents the results of the data collected from the study participants. The results are

presented using both descriptive and inferential statistics. The study results are presented

according to thematic areas. The major themes under which the findings of the study are

presented include; the demographic data of the respondents, knowledge of mothers with children

aged 12-23 months on immunization, factors influencing immunization, factors affecting

immunization participation of children aged 12-23 months.

4.1. Socio-demographic characteristics of mother of children

Generally, it should be observed that for the purposes of this analysis, the age range used for the

children was between 18 and 23 months. This was because these children were supposed to have

completed their immunization according to the recommendations. A total of 227 mothers

responded to the questionnaires.

The results of the socio-demographic characteristics of mothers of children showed that while

156 (68.7%) were married, 16 (7.1%) were divorced. Whereas 117 (51.5%) were in the age

range 25-34 years, the least number, 16 (7.1%) were in the age range 45 years and above. The

religious background showed that 165 (72.7%) described themselves as Christians and 62

(27.3%) described themselves as Muslim/Traditionalist. On their ethnic affiliation, 88 (38.8%)

were said to be Bono while the least number, 35 (15.4%) described themselves as Ewes.

Relating to the mothers’ level of education, 82 (36.1%) had completed secondary and the least

number, 18 (7.9%) had no formal education. Similarly, the fathers’ level of education indicated
that 106 (46.7%) had attained tertiary whereas the least number, 2 (0.9%) noted that they had no

formal education. With regards to the mothers’ monthly income, whilst the highest number, 52

(22.9%) showed that they earned in the range of GHS200-399, the least number, 23 (10.1%)

earned in the range of GHS800-999. This monthly income of the mothers reflected in their main

occupation as 75 (33.0%) were traders/others and the least number, 40 (17.6%) were said to be

working in the public sector. The results are detailed in table 4.1.

Table 4.1: Socio-demographic characteristics of mother of children

Variable Total N (%)

Marital status
Single 31 (13.7)
Married 156
Cohabiting (68.7)
Divorced 24 (10.6)
16 (7.1)
Mother’s age (years)
15-24 30 (13.2)
25-34 117
35-44 (51.5)
45+ 64 (28.2)
16 (7.1)
Religion (mother)
Christian 165
Muslim/Traditionalist (72.7)
62 (27.3)
Ethnicity (mother)
Akans 35 (15.4)
Bono 88 (38.8)
Ga 57 (25.1)
Others 47 (20.7)
Level of education (mother)
None 18 (7.9)
Primary 58 (25.6)
Secondary 82 (36.1)
Tertiary 69 (30.4)
Level of education (father)
None 2 (0.9)
 Primary 35 (15.4)
Secondary 84 (37.0)
Tertiary 106
(46.7)
Monthly income (mother)
<200 36
200-399 (15.9)
400-599 52
600-799 (22.9)
800-999 29
1,000+ (12.8)
40
(17.6)
23
(10.1)
47
(20.7)
Main occupation (mother)
Public sector 40 (17.6)
Private sector 67 (29.5)
Unemployed 45 (19.8)
Traders/Others 75 (33.0)
Total 227
(100.0)
Field survey, 2023

4.2 Knowledge of mothers with children aged 12-23 months on immunization

In accordance with the specific aims, the primary variable of interest was the study participant’s

self-reported intention, or lack thereof, to have the child vaccinated. This assessment of intention

in the form of knowledge was quantified using a three-point Likert-type scale of “3- agree”,

“2disagree” and “1-neutral” with respect to intention to vaccinate.

The possible scores on these items ranged from one to five. All the values on knowledge were

scored based on the positive answers. Overall knowledge about vaccinations was good, with the

mothers concerning vaccinations of their babies. Overall mean score of knowledge was 15.18 on

the knowledge variables of the study. The lowest value was considered zero with mean score
above 10 considered ‘knowledgeable of the study participants’. Therefore, based on the value

obtained, all the respondents had good knowledge concerning immunization except that the

uptake of vaccination among their babies was found to be low.

Table 4.2: Knowledge of immunization

Variable Frequency Percent

Ever heard of immunization
Yes 227 100
Sources Health centre
110 87.5
Family members 34 28.3
Media 56 46.7
Friends 17 10.0
Market 10 7.5
Source: Field data, 2023
From Table 4.2, all the study participants stated that they had ever heard of immunization from

different sources. Among the few sources this thesis has highlighted as identified by respondents

were health centres (87.5%), media (46.7%) and from friends (10%). These findings from the

study participants were not surprising because considering the educational background of the

study participants, majority of them were educated and their knowledge concerning

immunization might have been informed by their exposure to immunization literature.

Besides, the study participants might have also been educated on the need to have their babies

who are less than 24 months immunized at the various health centres at the study setting since

coverage of immunization at the time of the study was found to be low. See Table 4.2 for details.

Table 4.3: Information gap affecting immunization status of children

Variable Agree Disagree Neutral

 Lack of information 10
Unaware of need for vaccination 57 (20.0%) 160 (72.5) (7.5%)
Unaware of need to return for subsequent dose 55 (24.2%) 167 (74.2) 5 (1.6%)
Time of vaccination unknown 170 (79.2) 57 (20.8%) 0 (0.0%)
Lack of management of any side effects after 170 (79.2) 57 (20.8%) 0 (0.0%)
vaccination

Lack of motivation
Postponed until another time
105 (47.5) 117 (50.0) 5 (2.5%)
No faith in vaccination 90 (40.8%) 127 (54.2) 10
(5.0%)
Rumors 171 (78.3) 29 (11.7%) 27
(10.0%)
Source: Field data, 2023
From Table 4.3, majority (n=160; 72.5%) of the lactating mothers disagreed with the statement

that, lactating mothers had no knowledge of the need for vaccination of their children. This could

suggest that lactating mothers were aware of the need to have their babies vaccinated at the study

setting. From the results (n=167; 74.2%) of respondents disagreed with the statement that

lactating mothers had no knowledge of the need to return for subsequent dose of their children

while (n=170; 79.2%) of lactating mothers agreed with the statement that, mothers lack of

knowledge concerning the place/time of vaccination affect the immunization status of their

children. This result showed that health care workers might have not always informed lactating

mothers what time was ideal for them to have their babies vaccinated at the health centres since

lactating mothers might be thinking that certain times were meant for vaccination only at the

health centres.

From the results, (n=170; 79.2%) of the lactating mothers agreed with the statement that,

mothers lack of knowledge of management of any side effects after vaccination affects the

vaccination status of their babies (Table 4.3). This is probably true for most mothers because, if
the child should experience any side effect after vaccination, and the mother stays far away from

the health centres, it might be a source of worry and restlessness for the whole family. Thus, in

order not to get themselves and their babies into this, lactating mothers might just want to stay

away from vaccination of their babies.

In addition, acceptance of any program is highly dependent on parental attitudes towards

immunization. A fear of adverse effects has a negative impact on paternal attitude towards

immunization especially with communities with low understanding of the benefits of childhood

immunization. From the results, (n=105; 47.5%) of lactating mothers agreed with the statement

that mothers were always motivated to postponed until another time to have their babies

vaccinated.

For most mothers who were engaged in petty trading, if their scheduled date for the next dose

should fall on a market day, it was bound not to have the child vaccinated. It was also showed

that, (n=127; 54.2%) of lactating mothers agreed with the statement that lactating mothers lack

faith in vaccination. The first antecedent of every behavior is the behaviour intention. If mothers

had no knowledge and belief that vaccines do not work for their babies, it was certainly going to

be difficult to have their babies vaccinated. See Table 4.3 for details.

Table 4.4: Compliance rate of mothers

Variable Agree Disagree Neutral

Taken vaccines at least once 132 (59.2%) 81 (39.2%) 4 (1.6%)

Last child fully immunized 146 (66.7%) 71 (33.3%) 0 (0.0%)

 Aware of information on child’s card 170 (74.2%) 52 (22.5%) 5 (3.3%)

Aware of service points 192 (85.0%) 35 (15.0%) 0 (0.0%)

Good intention towards immunization 210 (92.5%) 17 (7.5%) 0 (0.0%)

Source: Field data, 2023

From Table 4.4, majority of the lactating mothers (n=132; 59.2%) agreed with the statement that

their babies had ever taken the vaccines at least once while (n=71; 33.3%) of the respondents

disagreed with the statement that, their last child was fully immunized. It was further showed

that (n=170; 74.2%) of the lactating mothers agreed with the statement that they were aware of

the information on their child’s immunization card while (n=17; 7.5%) of the respondents

disagreed with the statement that they had good intention towards immunization. See Table 4.4

for details.

4.3 Things that prevent mothers from participating in immunization of children aged 12-23

months

Determinants of receipt of vaccination completion are complex and interwoven. Parents’

objection, disagreement or concern about immunization safety, long distance walking and long

waiting time at health facilities are the most common reasons for incomplete vaccination/

immunization of babies.

Identifying the factors that determine full child immunization in a representative sample of the

country will enable the government to provide programmes and service environment through

well-articulated policies, projects and programmes like National Immunization Policy and

Standards of Practice.
This is to ensure increased uptake and ultimately child survival as well as healthy growth of

children in Ghana and enhance their quality of life. The study assessed the factors affecting

immunization status of babies at the study setting. The findings are presented in the table below.

Table 4.5: Things that prevent mothers from participating in immunization of children

aged 12-23 months

Variable Agree Disagree Neutral

Scared of the side effects of the shots 197 27 (15.8%) 3
(81.7%) (2.5%)
Worried about the number of shots my child gets at 90 (45.8%) 137 (54.2%) 0
one time (0.0%)

Always just forgot 175 52 (31.7%) 0

(68.3%) (0.0%)
My health care provider told me not to get my child 0 (0.0%) 227 (100.0%) 0
his/her shots (0.0%)

Do not think the shots work to prevent diseases 52 (31.7%) 175 (68.3%) 0
(0.0%)
Complications from previous injections 50 (35.0%) 177 (65.0%) 0
(0.0%)
The clinic/facility was not open at a time mothers 192 37 (23.3%) 0
could go (76.7%) (0.0%)

Did not have someone to take care of other 52 (31.7%) 175 (68.3%) 0
Children (0.0%)

My child was sick and could not get their shots 20 (10.0%) 207 (90.0%) 0
(0.0%)
The clinic wait was too long 192 35 (23.3%) 0
(76.7%) (0.0%)
Did not know where to take child for shots 40 (20.0%) 180 (76.7%) 7
(3.3%)
Husband disapproves vaccination of babies 0 (0.0%) 227 (100.0%) 0
(0.0%)
Vaccine out of stock 60 (40.8%) 167 (59.2%) 0
(0.0%)
No available appointments at clinic 40 (24.2%) 187 (75.8%) 0
(0.0%)
The shots cost too much 0 (0.0%) 227 (100.0%) 0
 (0.0%)
Time of vaccination inconvenient 185 42 (23.3%) 0
(76.7%) (0.0%)
Place of vaccination too far 170 57 (33.3%) 0
(66.7%) (0.0%)
Vaccinators absent 17 (8.3%) 210 (91.7%) 0
(0.0%)
Health staff are not friendly 187 30 (16.7%) 10 (6.6)
(76.7%)
Source: Field data, 2023
From Table 4.5, as part of factors affecting immunization status of babies by their mothers,

findings showed that, all the study participants representing (n=227, 100%) disagreed with the

statement that, husband disapproves vaccination of babies and the shots cost too much as factors

affecting immunization status of babies. This is because men may not want to take any blame on

the health of the child. Thus, denying women the opportunity to send the child to the hospital is

an indication that the child should be left at home to be cared for.

From the results in Table 4.5, (n=187; 76.7%) of the lactating mothers agreed with the statement

that, health staff were not friendly while (n=192; 76.7%) agreed with the statement that the clinic

wait was too long. For mothers who are business women, spending a long time in the hospital

was seem as a waste of opportunity for them to generate income. Thus, mothers would prefer to

go to the market to make sales at the expense of sending their babies to the health centre for

vaccination unless the child was sick.

From the results, it was also showed that (n=175; 68.3%) of the mothers agreed with the

statement that they always forgot to take their babies to the health centre for vaccination on the

scheduled date while (n=197; 81.7%) of the mothers agreed with the statement that they were

scared of the side effects of the shots. See Table 4.5

Table 4.6: Regression analysis

Variable OR 95% CI P value

Age 3.10 1.63-1.86 0.001
Education status 7.2 0.64-0.87 0.000
Occupation status 3.3 2.46-2.88 0.005
Parity 4.4 1.77-1.93 0.003
Distance 5.4 0.68-0.83 0.002
Source: Field data, 2023
From Table 4.10, the results of the regression analysis showed that, mothers who were staying

far from a health centre were 5.4 times more likely not to have their babies vaccinated (OR=5.4,

CI; 1.63-1.86, P ˂ 0.001). A possible explanation for this could be that visibility of a clinic may

attract a parent’s attention and/or act as a reminder to the parent of the immunization status of the

child. From the results also, the occupation of mothers were more 3.3 times more likely to affect

the vaccination status of babies (OR=3.3, CI; 2.46-2.88, P ˂ 0.005).

4.4 Factors influencing immunization participation of children aged 12-23 months

Table 4.6: Factors influencing immunization participation of children aged 12-23 months

Variable Agree Disagree Neutral

Knowledge and awareness 197 27 (15.8%) 3 (2.5%)
(81.7%)
Experience with past immunization 90 (45.8%) 137 (54.2%) 0 (0.0%)

Religion and culture 175 52 (31.7%) 0 (0.0%)

(68.3%)
Beliefs and attitudes 0 (0.0%) 227 (100.0%) 0 (0.0%)

Socio-economic influence 52 (31.7%) 175 (68.3%) 0 (0.0%)

Source: Field data, 2023

From Table 4.6, as part of factors influencing immunization participation of babies by their

mothers, findings showed that, study participants representing (n=197, 81.7%) agreed with the

statement that, knowledge awareness is one of the factors influencing immunization participation

of babies, (n=175, 68.3%) of the respondents also agreed that a religion and culture is part of the

factors influencing immunization. (n=137, 54.2%) of the respondents disagreed that experience

with past immunization is not part of the factors of the influencing immunization participation,

(n=227, 100%) of the respondents said beliefs an attitudes and (n=175, 68.3%) of the

respondents said, Socio-economic influence is not part of the factors influencing immunization

in the study area.

 CHAPTER FIVE

DISCUSSIONS OF FINDINGS

5.1 Introduction

This chapter of the report closely looks at the main findings of the study and relates them to

available literature where appropriate.

5.2 Knowledge of mothers with children aged 12-23 months on immunization

Expanded programme on Immunization (EPI) in Ghana aims at protecting every child from the

common childhood diseases; namely, tuberculosis, poliomyelitis, diphtheria, neonatal tetanus,

whooping cough, hepatitis B, Haemophilus influenza type b, measles and yellow fever. The

study sought to assess the awareness of mothers with babies less than 24 months of age

knowledge on immunization since that could inform their practice.

Pertaining to the results that were obtained from the respondents, all of them indicated that they

had ever heard of immunization from various sources. However, majority of the respondents

representing 87.5% identified health centres as their sources of information concerning

immunization. This finding from the study supports the study by Hernandez, Montana and

Clarke (2010) where lactating mothers identified various sources of information concerning

immunization.

From the results, majority of the respondents (n=171; 79.2%) identified lack of knowledge of

lactating mothers on how best to manage any side effects after vaccination of their babies as a

hindrance to immunization. This was a worrying phenomenon among the mothers as majority of

them did not want to send their babies to the health centres to have them vaccinated. This finding

from the study points to the ineffective role played by health workers on how best lactating
mothers who have their babies reacting to the vaccines after immunization should do at the study

area.

It is important to state that, information spread quickly especially among mothers who perhaps

might be living in the same vicinity and what happens to one of them is likely to have an

influence on the other one. This finding from the study concurs with the study by Stamler (2012)

where lactating mothers’ inadequate knowledge concerning how to manage any side effects after

vaccination affected them from taking their babies to the health centres to have them immunized.

This was reported to have slowed the rate of vaccination at the health centres and therefore,

affected the vaccination scheduled of their babies.

From the results (n=171; 74.2%) of the study participants disagreed that they were not aware of

the need to return for subsequent dose at the hospital with their babies. This is because lactating

mothers had knowledge on the need to return for subsequent dose of the vaccination with their

babies but might have been occupied on the day of the vaccination. If health workers at the study

place have a way of reaching out to these lactating mothers, perhaps the number of women that

would go for vaccination might be higher. This finding from the study disagrees with the study

done by Mohamud et al. (2014) where lactating mothers were not aware of the need for

subsequent vaccination of their babies at health centres.

Findings from the results showed that, majority of the study participants (n=181; 79.2%)

mentioned that they were not aware of the time of vaccination in the various health centres. This

finding from the study again showed that, mothers with babies less than 24 months old might

have their babies vaccinated at the health centres, but since the time was unknown to them,

lactating mothers felt reluctant to go to the health centres to ask for the right time. This finding

from the study agrees with the study done by Kuehn (2010) where lactating mothers did not have
knowledge of what time they were supposed to have gone for the next vaccination of their

children at health centres.

Concerning the lack of motivation among lactating mothers to send their babies for vaccination

at vaccination centres, most (n=117; 50.0%) of the respondents disagreed with the statement that

they would postponed until another time to have their babies vaccinated. This finding from the

study agrees with the study done by Kidane (2006) where knowledge gap concerning vaccination

scheduled was identified as factor influencing immunization status of babies less than 24 years.

Additionally, findings from the study showed that, (n=187; 78.3%) of the study participants

agreed with the statement that rumors mongering concerning babies that have been vaccinated

and negatives effects might influence mothers not to have their babies vaccinated.

Health workers would have to do more to erase lactating mothers concerning the erroneous

impression that vaccination is not good. This finding from the study agrees with the study done

by Fischhoff (2010) where misinformation concerning vaccination was found to affect the

vaccination scheduled of babies less than 24 months.

Concerning the compliance rate of mothers on vaccination schedule of the babies, the results

showed that (n=207; 92.5%) of the respondents stated that they had good intention towards

immunization. This finding from the study agrees with the study done by Machingaidze,

Wiysonge and Hussey (2015) where mothers had good intention concerning immunization. From

the results, the findings showed that, there was a statistical relationship between age of lactating

mothers and having knowledge of immunization (p ˂ 0.001). Age of lactating mothers was one

of the demographic characteristics hypothesized to influence immunization status of babies. This

could be due to the fact that; younger mothers may not want to go to the health centres to have

themselves been mocked at or laugh at by health staff. This finding from the study agrees with
the study done by Fischhoff (2010) where age of mothers was found to be associated with

immunization status of their babies.

The finding however, disagrees with the study done by Bulpitt and Martin (2010) where age of

lactating mothers was found not to be associated with immunization status of babies. The results

also showed that, there was a relationship between lactating mothers distance from their homes

to the nearest health centre and the immunization status of their children (p ˂ 0.003). This could

be due to the fact that, mothers who were staying far away from the health centres might have

difficulties getting access to the health centres and may have other forms of caring for their

babies.

Distance to the health centres affects lactating mothers negatively because, mothers with less

income may not be able to transport themselves to the nearest health centre even on the date of

schedule and this may affect the immunization status of their babies. This finding from the study

is similar to the study done by Kennedy et al. (2011) where distance was found to be associated

with immunization status of babies.

Inferential analyses of important independent variables, which are expected to have influence on

immunization status were selected and tried to find an association. These variables were selected

on the basis of theoretical explanations and the result of various empirical studies. To determine

the best subset of independent variables that are good predictors of the dependent variable, the p

values with Chi-square were generated.

In this method all the above mentioned variables were entered in a single step. The results found

the residential status and occupation status of respondents to be positively associated with having

faith in immunization of their babies (p ˂ 0.001 & p ˂ 0.001) respectively. This finding from the
study disagrees with the study done by O’Connor (2011) where there was no statistical

relationship between respondents’ occupational status and trusting vaccination of babies.

The results also showed that, there was no relationship between marital status of respondents and

having faith in vaccination (p˂0.012). This finding from the study is at variance with the study

done by Mennito and Darden, (2010) where marital status of women was found to be associated

with having faith in vaccination of babies (p ˂ 0.001). This study showed that parental belief

about immunization safety is the major reason for incomplete immunizations among children.

Additionally, results from the study showed that, there was a relationship between parity of

respondents and immunization schedule of their babies (p ˂ 0.002). This could be due to the fact

that, respondents with children might have knowledge on the importance of vaccination of their

babies and this could have informed their practice. This finding from the study disagrees with the

study done by Niederhauser (2010) where parity of mothers was found not to be associated with

immunization status of women (p >0.011)

Education of lactating mothers was found to be significantly associated with immunization status

of their babies (p ˂ 0.001). Educated mothers are more likely to have good understanding

concerning vaccination of their babies as compared to uneducated mothers. Misinformation and

negative attitude towards vaccination of babies could be erased if mothers had good

understanding of the importance of vaccinating babies. Thus, it is significant to state that, this

study perhaps draw the conclusion based on the data gathered.

This finding from the study concurs with the study done by Pati et al. (2010) where educational

status of mothers was found to influence mothers’ knowledge of immunization. Education is one

of the important variables, which increases women’s ability to adherence to vaccination

enhancing good health of their babies. Low level of education and high illiteracy rate is typical in
developing countries. In fact, education level of mothers is assumed to increase the ability to use

vaccination in a better way. Therefore, in this study, education level is a variable helping to

demand vaccination for their babies enhancing complete status by the respondents.

5.3 Things that prevent mothers from participating in immunization of children aged 12-23

months

The reasons for partial immunization and factors responsible for missed opportunities are poorly

understood and little data is available to explain the phenomenon that could support the decision

making. The study assessed the factors that were found to be affecting immunization status of

babies negatively at the study area.

Provider’s attitudes and long waiting period were cited by few mothers as their reason for not

taking additional immunization for their children. Indeed a few women were frustrated because

they had visited the facility more than one time with no vaccines on ground, absence of service

providers or disrespectful providers. From the results, findings showed that (n=187; 76.7%) of

the study participants identified long waiting times at hospitals as a factor influencing

immunization status of babies. This finding from the study showed that, lactating mothers did not

like to go to the health centres to wait very long enough before they were attended to by health

care workers. This finding from the study agrees with the study done by Humphreys (2011)

where long waiting time was cited as a factor influencing immunization status of babies.

From the results, the findings also showed that (n=137; 68.3%) of the respondents did not see

other children they were having at home at a factor influencing immunization status of their

current babies. This finding from the study is at variance with the study done by Stamler (2012)

where the availability of under-five children was cited as a factor influencing immunization

status of babies.
From the results, the regression analysis found distance to be a factor influencing immunizations

status of babies (OR=5.4, CI; 1.63-1.86, P ˂ 0.001). The results showed that, mothers who were

staying far away from the health centres where 5.4 times more likely not to have their babies

vaccinated. This finding from the study agrees with the study done by Canavan et al. (2014)

where proximity to clinic was found to influence immunization status of babies.

Accessibility as a function of distance and need for using transport were identified as confounder

variables for incomplete vaccination of babies by mothers in the study area. Long distance

trekking involving approximately 1½ h (90 min) to reach the nearest health facility was seen as a

strong non-motivating factor with a negative influence in completing vaccination schedules by

lactating mothers.

The results also showed that, education of lactating mothers were found to influence

immunization status of babies (OR=7.2, CI; 0.64-0.87, P ˂ 0.001). The results showed that

lactating mothers who were educated were 7.2 times more likely to have their babies vaccinated

as compare to those lactating mothers who were not educated. This was found in the model to be

significant.

This finding from the study agrees with the study done by Mohamud et al. (2014) where

education was found to be associated with immunization status of babies. In the study area the

causes of partial immunization among babies need further exploration, but the study attributed

high dropout rate to problems in less demand for vaccinations by mothers especially those in the

rural areas, less client satisfaction with services at health centres, and the ability of the

immunization program to provide those services at accessible points for lactating mothers. The

result is that the coverage rates of immunization for babies was lower than other vaccines due to

a much longer time gap, in which the mothers may forget to return to the health centres.
The results also showed that, occupation of mothers was found to influence the immunization

status of their babies (OR=3.3, CI; 2.46-2.88, P ˂ 0.005). Mothers who were employed were 3.3

more likely to have their babies immunized. This could be due to the reason that, salaried

workers were more likely to have some form of financial security and could afford certain things

by themselves at home.

This finding from the study supports the study done by Bergin (2011) where employment status

of babies was found to influence their immunization status. A client-friendly health facility with

a well-planned and organized fixed and outreach activities that strongly involve the local

community, would help to decrease the mothers’ expenses on transportation and the time spent

for obtaining vaccination service (Walls, Parahoo & Fleming, 2010). To achieve immunization

goals, delivery of potent vaccines through properly maintained cold chain systems and high

quality coverage are indispensable (Smith, 2010).

Additionally, from the results, findings showed that (n=182; 76.7%) of the study participants

cited the behavior of health workers to be bad which was a way influencing the immunization

status of babies. This finding from the study supports the study done by Humphreys, (2011)

where bad attitude of health care providers affected the immunization status of babies.

From the results, finding showed that (n=190; 81.7%) identified side effects a factor influencing

immunization status of babies. This result showed that, health workers have not been very active

in educating mothers about the possible reaction to the vaccines in babies. Given that health

literacy show a significant relationship with barriers to immunizations in this sample, but

education was a factor, education should be focused on addressing the concerns regarding

vaccinations. Immunization education should be aimed towards the parents and caregivers with
lower educational levels. A variety of methods should be implemented to specifically cater to

this population.

This finding from the study agrees with the study done by Takum et al. (2011) where side effects

of vaccines in babies were identified by mothers as a factor influencing immunization status.

More so, majority of the lactating mothers (n=80; 66.7%) of the identified distance to the nearest

health centre as a major factor influencing immunization status of babies. This is because

mothers who were not employed were more likely to find it very difficult to have themselves and

their babies transported to the health centres especially on the scheduled dates. This finding from

the study agrees with the study done by Stamler (2012) where similar results were found among

lactating mothers.

The results also showed that (n=132; 54.2%) of the lactating mothers did not consider the

number of shots their children get at one time as a factor influencing immunization. This finding

from the study is at variance with the study done by Takum et al. (2011) where mothers

considered the number of shots as a factor influencing immunization status of babies. Sometimes

also, the most common reasons for incomplete immunization were inadequate vaccine supply in

health facilities. About one- fifth of the women gave reasons that revealed their lack of

knowledge about immunization benefits, routine immunization schedule and the required

number of doses. Some women believed that their children were too young to receive specific

vaccines, particularly those involving the use of needles and syringes.

More over few women believed that their child had received some vaccines and were apparently

well and thriving there was no need for additional vaccines. Some women also believed that too
many vaccines could be harmful to the child. Large percentage of women gave reasons that

showed total reliance on immunization campaigns for child immunization in most studies.

From the results, findings showed that, all the respondents (n=227; 100%) disagreed with the

statement that their husbands disproved vaccination of their babies with was a factor. This

finding from the study disagrees with the study done by Humphreys (2011). Facility level

determinants including service interruption, training on EPI and defaulter tracing system were

also independent predictors of complete vaccination of babies. Quality of vaccination services as

demonstrated by the validity of doses given, BCG scar formation, card retention and client

provider interactions were generally low.

There is a need to establish an appropriate and uninterrupted vaccine delivery strategy. There is

also an urgent need to improve the cold chain management system through training and

monitoring, as vaccines in some facilities might be at high risk of losing their potency. To

continuously monitor service delivery, quality and the supply chain, a continuous and regular

cycle of planning, monitoring and implementation should be established. Regular and focused

supportive supervision needs to be strengthened at all levels to gain the commitment necessary

for a successful EPI program in the study area.

5.4 Summary of the findings

The study showed that all the respondents were aged above 18 years at the time of the study.

From the results based on the demographic profile of the study respondents, the results showed

that, 28.3% of the respondents were aged above 35 years while 16.7% of the respondents

indicated that they were aged between 18-25 years.

Concerning the marital status of respondents, majority of the respondents representing 66.7%

said they were married while 20.8% indicated that they were unemployed at the time of the
study. Concerning the educational status of respondents, findings revealed that 35.9% of the

respondents had tertiary education with 27.5% of the respondents having more than 4 children.

The results also showed that, 65% of the respondents indicated that they had to walk more than

one hour to reach the nearest health centre.

From the results, all the study participants had knowledge concerning immunization with

majority identifying the health centre (87.5%) as their sources of information. The results

showed that 78.3% of the respondents identified rumors as a form of lack of motivation for them

to take their babies to the health centres for immunization while 40.8% cited lack of faith in

vaccination.

The results showed that, 92.5% of the respondents indicated that they had good intention towards

immunization. The results showed that educational status of mothers, parity status of mothers,

occupational status of the mother and distance to the nearest health centre were positively

associated with immunization status of babies.

Concerning the EPI vaccination coverage of children aged 12-23 months, 30% of babies at the

time of the study had no BCG scare present on the child while respondents cited BCG, Penta 1,

Penta 2, Penta 3, OPVO, PCV, RV1, F/F, M/S1 and M/S2 as the antigen meant for the age of

their babies. The results also showed that, most (34%) of the babies were partially immunized at

the time of the study.

Factors affecting full immunization coverage of children aged 12-23 months were assessed.

From the results, majority of the respondents cited side effects of the shots (81.7%), just

forgetfulness (68.3%) and long waiting time at the clinic (76.7%) as factors affecting

immunization status of babies. On the part of factors influencing participating in immunization,

the findings showed that, knowledge and awareness, experience with past immunizations, socio

economic, beliefs and attitudes and religion and culture were the factors influencing

immunizations at the study area.

A reliable source of information readily at their fingertips can also help to alleviate some of the

concerns regarding immunizations. There is a need to establish an appropriate and uninterrupted

vaccine delivery strategy. The use of mobile technology for vaccine chain management could be

considered for proper forecasting, requisition, and monitoring wastage.

5.5 Conclusions

Immunizations are a vital part of herd immunity and the cornerstone to preventive care in every

community in the world. This study can provide insight towards gearing education to a special

population at the study setting since partial participation of immunization of babies was still

found. According to this study, the educated lactating mothers felt very strongly about having

their children immunized and continuing to keep up their children’s immunizations status. This

group also appeared to have fewer concerns regarding immunizations or with having access to

them. This was not the case for less educated lactating mothers or caregivers. There are several

implications that this fact could have in health education at the study area.

The prevalence of a positive attitude towards immunizations was found to be average in this

group of mothers, and satisfaction with the service was moderate. Knowledge on childhood

immunizations, however, was higher.

In order to improve the vaccination participation in the study area, health care workers should

focus particularly on parents of a compromised education and, further, tailor and target their

information to appropriate levels of each mother’s understanding.

 5.6 Recommendations

• The Kperisi Health Directorate could develop interventions that can be tailored to improve the

childhood immunization rates and provide a foundation for developing effective childhood

vaccination educational materials for mothers especially at the rural areas.

• Kperisi Health Directorate could organize refresher training to enhance the knowledge and skills

of vaccinators.

• Health care workers should develop context-based delivery strategies including mobile based

delivery is crucial to address the low access and utilization of EPI services particularly in

communities/ areas far from health centres. Detailed micro-planning with clear mapping of

communities is required to ensure targeted outreach or mobile services to these populations.

Detailed planning by individual health facilities and districts of how to reach the unreached and

disadvantaged children in the catchment area is essential for improving equity in immunization.

• Ministry of Health should sponsor programs on the need to encourage nursing mothers to comply

fully with the scheme through rigorous immunization awareness/campaigns workshops and

seminars on benefits of immunization in Kperisi circuit.

• Health workers should be tutored on sound work ethics and behaviour to their client. They

should be client-friendly as this variable indicated positive contribution to immunization

compliance by the respondents.

• Respondents claimed that the time spent at the centers was too long a reduction in the time is

expected to further encourage not only participation but also compliance with the regimen.
• Education programmes that can target poor and uneducated people should be put in place so that

they are able to make informed decisions regarding immunization of their children.

• Free health facilities should be made available to every mother so that poor mothers can easily

access them.
 REFERENCES
Abdulraheem, I. S., Onajole, A. T., Jimoh, A. A. G., & Oladipo, A. R. (2011). Reasons
for incomplete vaccination and factors for missed opportunities among rural
Nigerian children. Journal of Public Health and Epidemiology, 3(4), 194-203.
Abiola Adeniyi, A., Eyitope Ogunbodede, O., Sonny Jeboda, O., & Morenike Folayan,
O. (2009). Do maternal factors influence the dental health status of Nigerian
preschool children? International Journal of Paediatrics Dentistry, 19(6), 448-
454. https://doi.org/10.1111/j.1365-263X.2009.01019.x.
Abuya, B. A., Onsomu, E. O., Kimani, J. K., & Moore, D. (2011). Influence of maternal
education on child immunization and stunting in Kenya. Maternal and child
health journal, 15(8), 1389-1399. Doi: https://doi.org/10.1007/s10995-010-0670-
z.
Adediran, A. S., Onyire, B. N., Guvuoke, O. V., Obum, E., & Anyanwu, O. U. (2017).
Immunization Status of Under-5 Children in A Rural Community in Nigeria,
Journal of Dental and Medical Sciences, 16 (1), 126 – 130.
Adedire, E., Ajayi, I., & Ajumobi, O. (2014). Factors associated with complete routine
immunization status of children 12-23 months in rural areas of Osun State
Southwestern Nigeria, American Journal of Tropical Medicine and Hygiene, 11
(2), 99 – 156.
Adedire, E. B., Ajayi, I., Fawole, O. I., Ajumobi, O., Kasasa, S., Wasswa, P., & Nguku,
P. (2016). Immunization coverage and its determinants among children aged 12-
23 months in Atakumosa-west district, Osun State Nigeria: a cross-sectional
study. BMC Public Health, 16(1), 905. DOI https://doi.org/10.1186/s12889-016-
3531-x.
Adokiya, M. N., Baguune, B., & Ndago, J. A. (2017). Evaluation of immunization
coverage and its associated factors among children 12–23 months of age in
Techiman Municipality, Ghana, 2016, Journal of the Belgian Public Health
Association, 75 (1), 28 – 89.
Ahorlu, C. K., Koram, K. A., Ahorlu, C., De Savigny, D., & Weiss, M. G. (2006).

Sociocultural determinants of treatment delay for childhood malaria in southern

Ghana. Tropical Medicine & International Health, 11(7), 1022-1031.

 https://doi.org/10.1111/j.1365-3156.2006.01660.x.

Ajzen, I., & Fishbein, M. (1980). Understanding Attitudes and Predicting Social
Behaviour. Englewood Cliffs, NJ: Prentice Hall.
Ajzen, I. (1996). ‘The directive influence of attitudes on behaviour.’ Gollwitzer PM,
Bargh JA, eds. The Psychology of Action: Linking Cognition and Motivation to
Behaviour.
New York, NY: Guilford, 385 403.
Akmatov, M., & Mikolajczyk, R. (2012). Timeliness of childhood vaccinations in low
and middle-income countries, Journal of Epidemiology Community Health, 66
(7), 14 35.
Ali, Z., Pongpanich, S., Kumar, R., Ghaffar, A., Murred, S., & Safdar, M. R. (2015).
Routine Immunization Status among Children under 5 Years of Age living in
Rural District of Pakistan, International Journal of Health Research and
Innovation, 3 (2), 13-20.
Akmatov, M., & Mikolajczyk, R. (2012). Timeliness of childhood vaccinations in low
and middle-income countries, Journal Epidemiol Community Health, 66 (7), 14 –
36.

Andersen, R. M. (1968). Behavioural Model of Families’ Use of Health Services.

Research Series No 25. Chicago, IL: Center for Health Administration Studies,
University of Chicago.
Andersen, R. M., Kravits, J., & Andersen, O. W. (1975). Equity in Health Services:
Empirical Analyses in social Policy.
Andersen, R. M. (1995). Revisiting the Behavioural Model and Access to Medical Care:
Does It Matter? Journal of Health and Social Behaviour, 36 (1), 1 – 10.
Antai, D. (2009). Faith and child survival: the role of religion in childhood immunization
in Nigeria, Journal of Biosocial Science, 41(1), 57 – 76.
Babalola, S. (2009). Determinants of the Uptake of the Full Dose of Diphtheria-Pertussis
Tetanus Vaccines (DPT3) in Northern Nigeria: A Multilevel Analysis, Maternal
Child Health Journal, 13 (1), 550 – 558.
Balogun, M. R., Sekoni, A. O., Okafor, I. P., Odukoya, O. O., Ezeiru, S. S., Ogunnowo,
B. E., & Campbell, P. C. (2012). Access to information technology and
willingness to receive text message reminders for childhood immunization among
mothers attending a tertiary facility in Lagos, Nigeria. South African Journal of
Child Health, 6(3), 76-80. http://dx.doi.org/10.7196/sajch.439.
Becker, M. H., & Maiman, L. A. (1983). Models of Health Related Behaviour.
Handbook of Health, Health Care and Professions. New York: The Free Press,
539 – 568.
Becker, S. (1993). The determinants of use of maternal and child health services in
Metro Cebu, the Philippines, Health Transition Review, 3(1), 77 – 89.
Blaikie, N. (2010). Designing social research: The logic of anticipation (2nd ed.).
Cambridge, England: Polity Press.
Bosu, W. K., Ahelegbe, D., Edum-Fotwe, E., Kobina, A. B., & Kobina T. P. (1997).
Factors influencing attendance to immunization sessions for children in a rural
district of Ghana, Acta Tropica, 68 (3), 259–267.
Bryman, A., & Bell, E. (2003). Business Research Methods. New York: Oxford
University Press Inc.
Burton, A., Monasch, R., Lautenbach, B., Gacic-Dobo, M., Neill, M., Karimov, R., &
Birmingham, M. (2009). WHO and UNICEF estimates of national infant
immunization coverage: Methods and processes, Bulletin of the World Health
Organisation, 4 (2), 167 – 188.

Carter, W.B. (1990). ‘Health behaviour as a rational process: theory of reasoned action
and multiatribute utility theory’, In: Glanz, K, Lewis FML, Rimer BK, eds.
Health Behaviour and Health Education. San Francisco: Jossey- Bass; 63-90.
Chibwana, A. I., Mathanga, D. P., Chinkhumba, J., & Campbell, C. H. (2009).
Sociocultural predictors of health-seeking behaviour for febrile under-five
children in MwanzaNeno district, Malawi, Malaria Journal, 8 (2), 219 – 233.
Cohen, J. (1988). Statistical Power Analysis for the Behavioural Sciences. (2nd ed.).
Mahwah NJ: Lawrence Erlbaum Associates.
Cohen, L., Manion, L., & Morrison, K. (2000). Research Methods in Education (5th ed.).
London.
Comte, A. (1856). A general view of positivism. London: Smith Elder & Co.
Creswell, J. W. (2007). Qualitative inquiry & research design: Choosing among five
approaches (2nd ed.). Thousand Oaks, CA: Sage Publications.

Dankyi, E.K. (2014). Growing up in a transitional house: a study of Children of

international migrants in Accra, Ghana. Ghana Studies, 14, 133-161.
Datar, A., Mukherji, A., & Sood, N. (2007). Health infrastructure & immunization
coverage in rural India, Indian Journal of Medical Research, 125 (1), 31–42.
Dempsey, A. F., Schaffer, S., Singer, D., Butchart, A., Davis, M., & Freed, G. L. (2011).
Alternative vaccination schedule preferences among parents of young children.
Paediatrics, 128(5), 848-856.
Deressa, W., & Ali, A. (2009). Malaria-related perceptions and practices of women with
children under the age of five years in rural Ethiopia, BMC Public Health, 9(1),
259.
Easterby-Smith, M., Thorpe, R., & Jackson, P. (2012). Management Research. (4th ed.).
London: SAGE Publications Inc.
Etana, B., & Deressa, W. (2012). Factors associated with complete immunization
coverage in children aged 12-23 months in Ambo Woreda, Central Ethiopia,
BMC Public Health, 12 (1), 566 – 78.
Etana, B., & Deressa, W. (2011). Factors Affecting Immunization Status of Children
Aged 12-23 Months in Ambo Woreda, West Shewa Zone of Oromia Regional
State: Addis Ababa University College of Health Science.
Evans, R. G., & Stoddart, G. L. (1990). Producing Health, Consuming Health Care,
Journal of Social Science and Medicine, 2 (4), 1347 – 1363.
Fadhel K. (2002). Positivist and Hermeneutic Paradigm, A Critical Evaluation under
their Structure of Scientific Practice, The Sosland Journal, 21-28.
Fernandez, R. C., Awofeso, N., & Rammohan, A. (2011). Determinants of apparent rural
urban differentials in measles vaccination uptake in Indonesia, Rural and Remote
Health Journal, 11 (1), 1702 – 1715.
Fredrickson, D. D., Davis, T. C., Arnold, C. L., Kennen, E. M., Humiston, S. G., Cross,
J. T., & Bocchini, J. A. (2004). Childhood immunization refusal: Provider and
parent perceptions, Journal of Family Medicine, 36 (6), 431 – 439.
Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International.
2017. Ghana Demographic and Health Survey 2016. Rockville, Maryland, USA:
GSS, GHS, and ICF International.
Ghana Statistical Service (2014). 2010 Population and Housing Census; District
Analytical Report: Sampa Municipal Assembly; Retrieved from
http://www.statsghana.gov.gh [Accessed on 4th December 2018].
Gram, L., Soremekun, S., ten Asbroek, A., Manu, A., O'Leary, M., Hill, Z., ... Kirkwood,
B. R. (2014). Socio-economic determinants and inequities in coverage and
timeliness of early childhood immunization in rural Ghana. Tropical Medicine
and International Health, 19(7), 802-11. https://doi.org/10.1111/tmi.12324
Ha, W., Salama, P., Gwavuya, S., & Kanjala, C. (2009). Equity and Maternal and Child
Health - Is Religion the Forgotten Variable? Evidence from Zimbabwe: UNICEF
2009.
Hagger, M.S., Chatzisarantis, N.L., & Biddle, S.J. (2002). A meta-analytic review of the
theories of reasoned action and planned behaviour in physical activity: predictive
validity and the contribution of additional variables’, J Sport Exer Psychol. 24,
33228.
Haroun, H. M., Mahfouz, M. S., El Mukhtar, M., & Salah, A. (2010). Assessment of the
effect of health education on mothers in Al Maki area, Gezira state, to improve
homecare for children under five with diarrhoea. Journal of family and
community medicine, 17(3), 141-146. doi: 10.4103/1319-1683.74332.
Heale, R., & Twycross, A. (2015). Validity and Reliability in Quantitative Research.
Evidence-Based Nursing, 18(3), 66-67. doi:10.1136/eb-2015-102129.
Ibnouf, A., Van den Borne, H., & Maarse, J. (2007). Factors influencing immunization
coverage among children under five years of age in Khartoum State, Sudan SA
Fam Pract, 49 (8), 14 – 32.
Kalule-Sabiti, I., Amoateng, A. Y., & Ngake, M. (2014). The Effect of Socio-
demographic Factors on the Utilization of Maternal Health Care Services in
Uganda, African Population Studies, 28 (1), 45 – 63.
Kanmiki, E. W., Bawah, A. A., Agorinya, I., Achana, F. S., Awoonor-Williams, J. K.,
Oduro, A. R., & Akazili, J. (2014). Socio-economic and demographic
determinants of under-five mortality in rural northern Ghana, BMC International
Health and Human Rights, 14 (1), 24.
Kassile, T., Lokina, R., Mujinja, P., & Mmbando, B. P. (2014). Determinants of delay in
care seeking among children under five with fever in Dodoma region, central
Tanzania: a cross-sectional study, Review Journal for Malaria, 13 (4), 348.
Kerlinger, F.N. (1983). Foundation of Behavioural Research. (2nd ed.). U.S.A: Holt,
Rinehart and Winston Inc.
Kimberlin, C. L., & Winterstein, A. G. (2008). Research Fundamentals: Validity and
Reliability of Measurement Instruments Used in Research. American Society of
Health-System Pharmacists (AJHP), 65(23), 2276-2284.
doi:10.2146/ajhp070364.
Lakew, Y., Bekele, A., & Biadgilign, S. (2015). Factors influencing full immunization
coverage among 12–23 months of age children in Ethiopia: evidence from the
national demographic and health survey in 2011, Journal of BMC Public Health,
5 (15), 728.
Ledzokuku-Krowor Municipal Assembly (2017). The Composite Budget of the Sampa
Municipal Assembly for the 2017 Fiscal Year; Retrieved from
http://www.ghanadistricts.com [Accessed on 23rd December 2018].
MacDonald, N. E. (2015). Vaccine hesitancy: Definition, scope and determinants.
Vaccine, 33(34), 4161-4164.
Manthal, A. C. (2007). Determinants of vaccination coverage in Malawi: Evidence from
the demographic and health surveys, Malawi Medical Journal, 19 (2), 79 – 82.
Martinez, E. Z., Stuardo, J., & Rocha, Y. (2014). Factors associated with vaccination
coverage in children under 5 years in Angola, Journal of Family Medicine, 48
(6), 906 – 915.
Masand, R., Dixit, A. M., & Gupta, R. K. (2012). Study of immunization status of rural
children (12-23 months age) of district Jaipur, Rajasthan and factors influencing
it: a hospital based study, Journal of Indian Med Assoc., 110 (11), 795 – 799.
Mechanic, D. (1979). Correlates of physician utilization: why do multivariate studies of
physician utilization find trivial psychosocial and organizational effects? Journal
of Health and Social Behaviour, 10 (3), 387-396.
Mitchell, S. (2009). Equity and vaccine uptake: a cross-sectional study of measles
vaccination in Lasbela District, Pakistan, BMC International Health Human
Rights, 9(1), 7 – 23.
Ministry of Health (2014). Immunization programme comprehensive multi - year plan in
line with Global Immunization Vision and Strategies. Accra, Ghana, Ministry of
Health.
Ministry of Health, Ghana. (2016). Ministry of Health National Policy Guidelines.
Accra, Ghana, Ministry of Health.
Mukungwa, T. (2015). Factors associated with full immunization coverage amongst
children aged 12 – 23 months in Zimbabwe, African Population Studies, 29 (2),
1761 – 1765.
Nagata, J. M., Hernández-Ramos, I., Kurup, A. S., Albrecht, D., Vivas-Torrealba, C., &
Franco-Paredes, C. (2013). Social determinants of health and seasonal influenza
vaccination in adults≥ 65 years: a systematic review of qualitative and
quantitative data. BMC Public Health, 13(1), 388. https://doi.org/10.1186/1471-
2458-13-388.
Nath, B. (2007). A study on determinants of immunization coverage among 12-23
months old children in urban slums of Lucknow district, India, India Journal of
Medical Science, 61 (11), 598 – 606.
Ngure, R. (2015). Factors Influencing Low Immunization Coverage among Children
Between 12 - 23 Months in East Pokot, Baringo, BMC Public Health, 1 (2), 1 – 6.
Nonvignon, J., Aikins, M. K. S., Chinbuah, M. A., Abbey, M., Gyapong, M., Garshong,
B. N. A., & Gyapong, J. O. (2010). Treatment choices for fevers in children
underfive years in a rural Ghanaian district. Malaria Journal, 9 (2), 188.
https://doi.org/10.1186/1475-2875-9-188.

Pandey, S., & Lee, H. (2011). Determinants of child immunization in Nepal: The role of
women’s empowerment, Health Education Journal, 3 (11), 67 – 85.
Patra, N. (2008). Exploring the Determinants of Childhood Immunization, Economic
and Political Weekly, 43 (12), 13 – 17.
Patric, D. L. (1988). Poverty, Health Services and Health Status in Rural America, the
Milbank Quarterly Review, 5 (2), 105 – 136.
Perez, F., Ba, H., Dastagire, S. G., & Altmann, M. (2009). The role of community health
workers in improving child health programmes in Mali. BMC international
health and human rights, 9(1), 28. https://doi.org/10.1186/1472-698X-9-28.
Petousis-Harris, H., Grant, C., Goodyear-Smith, F., Turner, N., York, D., Jones, R., &
Stewart, J. (2012). What contributes to delays? The primary care determinants of
immunization timeliness in New Zealand. Journal of primary health care, 4(1),
1220.
Rehman, A., Shaikh, B. T., & Ronis, K. A. (2014). Health care seeking patterns and out
of pocket payments for children under five years of age living in Katchi Abadis
(slums), in Islamabad, Pakistan, International Journal for Equity in Health, 13
(1), 30.
Rivnya, K. M. (1989). Ambulatory Care Use among Non-institutionalized Elderly: A
Causal Model, Journal of Research in Aging, 6 (11), 292 – 311.
Rundall, T. G. (1981). A Suggestion for Improving the Behavioural Model of Physician
Utilization, Journal of Health and Social Behaviour, 3 (7), 103 – 104.
Rup, K. P., Manash, P. B., & Jagadish, M. (2008). Factors Associated with
Immunization Coverage of Children in Assam, India: Over the First Year of Life,
Journal of Tropical Paediatrics, 52 (4), 249 – 52.
Sanou, A., Simboro, S., Kouyaté, B., Dugas, M., Graham, J., & Bibeau, G. (2009).
Assessment of factors associated with complete immunization coverage in
children aged 12-23 months: a cross-sectional study in Nouna district, Burkina
Faso. BMC International Health and Human Rights, 9(1), S10.
https://doi.org/10.1186/1472698X-9-S1-S10.
Schoeps, A., Ouedraogo, N., Kagone, M., Sie, A., Müller, O., & Becher, H. (2013).
Sociodemographic determinants of timely adherence to BCG, Penta3, measles,
and complete vaccination schedule in Burkina Faso. Vaccine, 32(1), 96-102.
https://doi.org/10.1016/j.vaccine.2013.10.063.
Shaughnessy, J. J., Zechmeister, E. B., & Zechmeister, J. S. (2006). Research Methods in
Psychology (7th ed.). New York: Higher Education. pp. 143–192.