DETERMINANTS OF UPTAKE OF CHILDHOOD IMMUNIZATION   

AMONG MOTHERS OF UNDER-FIVE IN  

ASUOGYAMAN DISTRICT, GHANA 

 

BY 

 

MARY ANNANG 

(157100060) 

 

THIS DISSERTATION IS SUBMITTED TO THE ENSIGN COLLEGE OF 

PUBLIC HEALTH-KPONG, GHANA IN PARTIAL FULFILLMENT OF 

THE REQUIREMENTS FOR THE AWARD OF MASTER OF PUBLIC 

HEALTH DEGREE 

 

JULY, 2017 

 

 

 



ii 

  

DECLARATION 

I Mary Annang, do hereby declare that, apart from references made to works done in relation to 

this subject area which have been duly acknowledged, this work was independently done by me 

under supervision. I further declare that this work has not been submitted for the award of any 

degree in this university or elsewhere. 

 

 

MARY ANNANG         …………………            ……………….. 

(STUDENT)            SIGNATURE                                    DATE 

 

157100060 

STUDENT ID 

 

 

DR. STEPHEN MANORTEY  …………………  ………………… 

(SUPERVISOR)    SIGNATURE                       DATE  

 

 

DR. STEPHEN MANORTEY   ………………… ………………… 

(AG. HEAD OF ACADEMIC PROGRAMME)  SIGNATURE  DATE  

 

 

 



iii 

  

DEDICATION 

This work is dedicated to my parents, Mr. Henry Annang and Mrs. Vida Annang of 

blessed memory, my children, Roselyn Ohenewaah Ansah and Rita Ofosua Ansah. 

I also dedicate this work to my siblings especially Gideon Annang for all their 

support, encouragement and prayers.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iv 

  

ACKNOWLEDGEMENT 

I wish to acknowledge the Almighty for how far he has brought me and for giving me the strength 

and wisdom to go through this program.  

My sincere thanks also go to my supervisor, Dr. Stephen Manortey for his unflinching supervision 

and guidance throughout this work. I equally thank all the staff of Ensign College of Public Health 

for the various roles they have played in making my stay in school a memorable one. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



v 

  

OPERATIONAL DEFINITION OF TERMS 

In this study the following terms were used: 

Knowledge---This refers to what respondents say about having heard of immunization, the six    

                        Childhood killer diseases, and immunization schedules 

Attitude-------This is what respondents feel about immunization and their willingness to     

                        Immunize their children or not. 

Practices------These are acts that promote or inhibits immunization uptake by mothers 

 

 

 

 

 

 

 

 

 

 

 

 



vi 

  

LIST OF ABBREVIATIONS/ ACRONYMS 

AARR   Average Annual Rate of Reduction 

AMC   Advance Market Commitment 

ANC   Antenatal Clinic 

BCG   Bacillus Calmette Guerin 

CHN   Community Health Nurse 

CI                                Confidence Interval 

CWC   Child Welfare Clinics 

DANIDA                    Danish International Development Agency 

DCD   Disease Control Department 

DCO   Disease Control Officer 

DFID                          Department for International Development 

DHS                            Demographic Health Survey 

DPT   Diphtheria Pertussis Tetanus 

DPTHH                       Diphtheria Pertussis Tetanus Hepatitis B Haemophilus Influenzae type b 

EPI   Expanded Program on Immunization 

GIVS   Global Immunization Vision and Strategy 

GVI   Global Alliance for Vaccine and Immunization 

IFFI   International Finance Facility for Immunization 

JHS                             Junior High School 

JICA                           Japan International Cooperation Agency 



vii 

  

LMIC    Lower Middle Income Countries 

MDG    Millennium Development Goals 

MOH    Ministry of Health 

MSL Mean Sea Level 

NDPC    National Development Planning Commission 

NIP    National Immunization Program 

OPV    Oral Polio Vaccine 

PEI Polio Eradication Initiative 

RI    Routine Immunization 

SDG    Sustainable Development Goals 

SSA    Sub-Saharan Africa 

SSS    Senior Secondary School 

TT    Tetanus Toxoid 

U5M Under Five Mortality 

UK    United Kingdom 

UN    United Nations 

UNICEF   United Nations International Children Educational Fund 

VDP    Vaccine Preventable Diseases 

W.H.O    World Health Organization 

 

 

 



viii 

  

ABSTRACT 

 Promoting immunization uptake has the potential to reduce substantially vaccine preventable 

diseases among children. It is a reliable way of combating mortality and morbidity in children. In 

spite of the availability of vaccines, there is low uptake of immunization in developing countries 

such as Ghana. Mothers play a key role in the immunization of their children. This study seeks to 

describe the determinants of uptake of immunization among mothers with children under-five in 

the Asuogyaman district of the Eastern Region of Ghana.  

 A cross-sectional study design using quantitative research tools was employed. The EPI cluster 

sampling strategy was adapted and used to recruit 174 women with children under five years for 

the study. Data from administered questionnaire were analyzed using STATA version 14. 

 The study found out that majority of mothers in the study area had knowledge about 

immunization. Also, most mothers have positive attitude towards immunization and more than 

half had immunized their children. However, “long waiting time” and “too busy “schedule were 

identified by mothers as constrains towards immunization of their children.  

 Measures to improve immunization uptake by mothers should target addressing long waiting time 

as well as making immunization schedules convenient to mothers.  

Keywords: Knowledge, Attitude, Practices, uptake, immunization. 

 

 



ix 

  

TABLE OF CONTENTS 

 
DECLARATION......................................................................................................................................... ii 

DEDICATION............................................................................................................................................ iii 

ACKNOWLEDGEMENT ......................................................................................................................... iv 

OPERATIONAL DEFINITION OF TERMS .......................................................................................... v 

LIST OF ABBREVIATIONS/ ACRONYMS .......................................................................................... vi 

ABSTRACT .............................................................................................................................................. viii 

TABLE OF CONTENTS .......................................................................................................................... ix 

LIST OF TABLES .................................................................................................................................... xii 

LIST OF FIGURES ..................................................................................................................................xiii 

LIST OF MAPS ......................................................................................................................................... xiv 

LIST OF APPENDICES .......................................................................................................................... xv 

CHAPTER ONE ......................................................................................................................................... 1 

1.0 INTRODUCTION ................................................................................................................................. 1 

1.1 Background Information .................................................................................................................. 1 

1.2 Problem statement ............................................................................................................................ 4 

1.3 Rationale of study ............................................................................................................................. 6 

1.4 Conceptual framework ..................................................................................................................... 7 

1.5 Research Questions ........................................................................................................................... 8 

1.6. General objective ......................................................................................................................... 9 

1.7 Specific objectives ......................................................................................................................... 9 

1.8 Profile of Study Area ........................................................................................................................ 9 

1.9 Scope of study .................................................................................................................................. 11 

1.10 Organization of report .................................................................................................................. 11 

CHAPTER TWO ...................................................................................................................................... 12 

2.0 LITERATURE REVIEW .................................................................................................................. 12 

2.1 Immunization .................................................................................................................................. 12 

2.2 The Expanded Program on Immunization (EPI) ......................................................................... 14 

2.2.1 Funding source of EPI program ................................................................................................. 18 



x 

  

2.3 EPI in Ghana ................................................................................................................................... 22 

2.4 Factors influencing uptake of immunization ................................................................................ 27 

CHAPTER THREE .................................................................................................................................. 31 

3.0 METHODOLOGY ............................................................................................................................. 31 

3.1 Study methods and design .............................................................................................................. 31 

3.2 Data Collection Techniques and Tools .......................................................................................... 31 

3.4 Variables .......................................................................................................................................... 32 

3.4.1 Dependent variables ................................................................................................................. 32 

3.4.2 Independent variable ............................................................................................................... 32 

3.5 Sampling .......................................................................................................................................... 32 

3.5.1 Sample Size Determination ......................................................................................................... 33 

3.6 Pre-testing ........................................................................................................................................ 33 

3.7 Data Handling ................................................................................................................................. 34 

3.8 Data analysis .................................................................................................................................... 34 

3.9 Ethical Consideration ..................................................................................................................... 34 

3.10 Limitations of the study ................................................................................................................ 35 

3.11 Assumptions ................................................................................................................................... 35 

CHAPTER FOUR ..................................................................................................................................... 36 

4.0 RESULTS ............................................................................................................................................ 36 

4.1 Introduction ..................................................................................................................................... 36 

4.2 Demographic characteristics of study participants ..................................................................... 36 

4.3 Awareness of Childhood Immunization ........................................................................................ 39 

4.4 Awareness Level and demographic characteristics of respondents ........................................... 39 

4.5 Decision making on immunization ................................................................................................ 41 

4.6 Knowledge of six Childhood killer diseases .................................................................................. 41 

4.7 Knowledge of immunization and prevention of childhood diseases ........................................... 43 

4.8 Knowledge levels of mothers about immunization ...................................................................... 44 

4.9 Immunization status of children .................................................................................................... 45 

4.10: Knowledge of mothers and immunization status of children .................................................. 46 

4.11: Side effects of immunization ....................................................................................................... 47 

4.12: Attitude of mothers towards immunization .............................................................................. 48 

4.13: Practices influencing uptake of immunization .......................................................................... 49 



xi 

  

4.14: Accessibility of immunization centers ........................................................................................ 50 

CHAPTER FIVE ...................................................................................................................................... 54 

5.0 DICUSSION ........................................................................................................................................ 54 

CHAPTER SIX ......................................................................................................................................... 59 

6.0 CONCLUSION AND RECOMMENDATIONS .............................................................................. 59 

6.1 Conclusion ....................................................................................................................................... 59 

6.2 Recommendations ........................................................................................................................... 60 

6.2.1 Asuogyaman District Health Directorate ............................................................................... 60 

6.2.2 Ghana Health Service .............................................................................................................. 61 

6.2.3 Government .............................................................................................................................. 62 

REFERRENCES ....................................................................................................................................... 63 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



xii 

  

LIST OF TABLES 

Table 2.1: Immunization schedule in Ghana……………………………………………….........27 

Table 4.1: Socio-demographic characteristics of study participants………………………….....38 

Table 4.2: Awareness of immunization and socio-demographic characteristics…………...........40 

Table 4.3: Knowledge of mothers about immunization of children……………………………..44 

Table 4.4: Reasons for partial and non-immunization of children……………………………....47 

Table 4.5: Side effects of immunization………………………………………………………....48 

Table 4.6: Practices influencing uptake of immunization………………………………….........49 

Table 4.7: Bivariate analysis between independent variables and immunization status………...52 

 

 

 

 

 

 

 

 

 

 

 

 



xiii 

  

LIST OF FIGURES 

Figure1.1: Conceptual framework….............................................................................................18 

Figure2.1: Organizational structure of EPI in the Ghana Health Service………………..……....26 

Figure 4.1: Sources of information on immunization………………………………………..…..39 

Figure 4.2: Decision making on immunization…………………………………………..……....41 

Figure 4.3: Knowledge of six childhood killer diseases………………………………….……...42 

Figure 4.4: Knowledge of six childhood killer diseases by sub-districts………………………..43 

Figure 4.5: Knowledge of prevention of childhood diseases through immunization…….……...43 

Figure 4.6: Knowledge levels of mothers about immunization……………….………………....45 

Figure 4.7: Immunization status of children……………………………………..……………....46 

Figure 4.8: Attitude of mothers towards immunization………………………….………............49 

Figure 4.9: Accessibility of immunization centers………………………………….…………...50 

Figure 4.10: Sources of immunization……………………………………………….…………..51 

 

 

 

 

 

 

 

 



xiv 

  

LIST OF MAPS 

Map 3.1: Map of Asuogyaman district………………………………………………………....76 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



xv 

  

LIST OF APPENDICES 

Appendix A: Consent Form……………………………………………………………………...67 

Appendix B: IRB Form…………………………………………………...……………………...69 

Appendix C: Questionnaire/Assessment tool…………..………………………………………..70 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



1 

  

CHAPTER ONE 

1.0 INTRODUCTION 

1.1 Background Information 

Immunization remains one of the most crucial public health interventions and a cost effective 

strategy to reduce both the morbidity and mortality associated with infectious diseases. It is 

estimated to avert between 2 to3 million deaths each year worldwide (Legesse & Dechasa, 2015). 

Across the world, universal immunization of children against six preventable diseases 

(Tuberculosis, Diphtheria, Pertussis, Tetanus, Polio, and Measles) is recognized as vital to reduce 

childhood mortality and morbidity. Thus routine immunization (RI) has been noted to contribute 

immensely to  reduction in mortality from these vaccine preventable diseases among children and 

is one of the indicators of development in most developing countries (Adedire et al., 2016). 

Significant gains have been made through immunization resulting in a reduction in the burden of 

vaccine preventable illness globally with an estimated 35 million dollars  spent between 2006 and 

2015 on vaccines (Laryea  et. al., 2014). 

Immunization of children against vaccine preventable diseases continues to receive considerable 

attention by the various health organizations such as World Health Organization (WHO) and 

United Nation for International Children and Education Funds (UNICEF) among others. This has 

been demonstrated in various ways through the development of several policy frameworks for 

member countries to develop effective programmes on vaccines and immunization in order to 

protect children less than five years from dying at an early age. For example the WHO and 

UNICEF developed the Global Immunization Vision and Strategy (GIVS) in 2006 aimed to help 



2 

  

countries to vaccinate more people, especially those who reside in hard to reach communities 

(Chambogo et. al, 2016). Also in their study, Duclos et. al., (2009) revealed that the GIVS was 

developed by WHO and UNICEF as a framework for strengthening national immunization 

programmes and protect as many people as possible against more diseases by expanding the reach 

of immunization, including new vaccines, to every eligible person. It is for this reason child health 

immunization has been made the center of the Millennium Development Goals (MDG) (NDPC, 

2006) which is an intervention strategy to maintain the health of children and prevent them from 

dying at an early age (UNICEF, 2007). This policy framework has proved effective in terms of 

coverage where about three quarters of the world’s child population is reached with the required 

vaccines. For example, global mortality has reduced by 74% and out of this Africa accounts for 

89% reduction in measles (Adebiyi, 2013). Additionally, the average annual rate of reduction 

(AARR) in Under Five Mortality (U5M) rate observed from 1990 to 2006 was 1% in Sub-Saharan 

Africa (SSA); but an AARR of 10.5% between 2007 and 2015 is required for the region to succeed 

at then SDG3 target (UNICEF, 2007).  

Despite improved world coverage of child vaccines, only half of the children in Sub-Saharan 

Africa get access to basic immunization and in poorer remote areas of developing countries, only 

one in twenty children have access to vaccination (UNICEF, 2007). So far the concept child 

immunization has become critical a phenomenon for the survival of children less than five years. 

This has been confirmed by a UNICEF report that child immunization can save the lives of 2.5 

million children every year in developing countries. It is for this reason that the WHO established 

the expanded programme on immunization (EPI) in 1974, with the goal of ensuring full 

accessibility of routine immunization vaccines to all children. According to the EPI, a child should 



3 

  

receive Bacillus Calmette Guerin (BCG), three doses of oral polio vaccine (OPV) and Diphtheria 

Pertussis Tetanus (DPT), and measles vaccines by 12 months of age to ensure maximum protection 

against VPDs. Receipt of these vaccines at the recommended ages and intervals will provide the 

children adequate protection from VPDs (Adedire et al., 2016). 

In Ghana, immunization has been a core public health activity through the EPI since1985. Ghana’s 

high under-5 mortality rate coupled with the non-availability of skilled healthcare professionals 

and health facilities make immunization an essential health intervention. Vaccine administration 

at recommended age is important as such recommendations are based on the estimation of the age 

at which a child’s risk for target diseases is highest. The Measles vaccine for example is 

administered earlier, usually by 9 months of age, in most developing countries such as Ghana and 

Nigeria because of the higher risks of transmission of the disease compared with developed 

countries as England where the vaccine is given later. Timely receipt of vaccines is important 

because it ensures that the recipient is protected from target diseases as early as possible. Delayed 

administration of vaccines can result in longer periods of susceptibility among children which can 

result in an epidemic when a case of a specific vaccine preventable illness occurs (Laryea et al., 

2014). 

A study showed that from a global perspective, child mortality has drastically decreased from 12.6 

million in 1990 to 6.3 million in 2013 through vaccines and immunization with the help of 

governments and organizations (Bustreo et al. 2014).  Also globally the annual number of deaths 

in children under-five fell to 57 per 1000 births in 2010 from 88 per 1000 births in 1990. In terms 

of coverage rate, DTP3 (three doses of vaccine for diphtheria–tetanus–pertussis) in low-income 

countries under Global Alliance for Vaccines and Immunization (GAVI) rose from 68% in 2000 

to 83% in 2013 (Boachie-Yiadom, 2014). The benefits of child immunization to economies are 



4 

  

that it increases human capital and worker productivity. It also enhances school attendance, 

cognitive abilities of the child as a teenager and a determinant of adult labour market success and 

earnings. It is for these reasons Ghana pays critical attention to child immunization programs as a 

means to contribute to the overall reduction in poverty by reducing Vaccine Preventable Diseases 

(VPD) (Gram et al., 2014). These notwithstanding, VPDs are still responsible for about 25% of 

the 10 million deaths occurring annually among children under five years of age.  This is partly 

related to the fact that mothers in Ghana for example have been found wanting in their roles in 

terms of Knowledge, Attitude and Practice towards immunization of their children against the six 

killer diseases (Duclos et al., 2009).  

 

1.2 Problem statement 

Globally, it is estimated that about two to three million deaths occurs yearly as a result of vaccine 

preventable diseases (VPD) with approximately 1.5 million deaths among under-five children 

(Adedire et al., 2016). Despite the efforts to improve immunization services, approximately 27 

million infants were not vaccinated against measles or tetanus in 2007 globally. As a result, 2–3 

million children are dying annually from easily preventable diseases, and many more fall ill (Etana 

& Deressa, 2012). Also Gram et al., (2014) in their study found that  worldwide, 6.9 million babies 

under the age of five die every year; 99% of these deaths take place in developing countries. Infant 

mortality rate and the mortality rate of children under 5 years of age constitute two of the most 

useful indicators to gauge the level of development of a country and to compare among countries. 

Of the 35 countries in the world with the highest rates of mortality of children under 5 years of 

age, 33 are in sub-Saharan Africa (Levine & Robins-browne, 2009). Each year millions of children 



5 

  

worldwide, mostly from low- and middle-income countries (LMICs), do not receive the full series 

of vaccines on their national routine immunization schedule (Oyo-Ita et. al., 2016). 

A significant proportion of these deaths are attributable to vaccine-preventable infectious diseases 

such as Haemophilus influenzae B (Hib), measles, pertussis and tetanus. At the end of 2011, 

immunization was reported to have saved 2 to 3 million lives; nonetheless, in the same year 1.5 

million children are estimated to have died (more than 70% live in ten African and Asian countries) 

from VPDs. This is a reflection of the incomplete uptake or coverage with existing vaccines that 

persists in many parts of the world (Legesse & Dechasa, 2015). Thus Odusanya et al., (2008) 

revealed despite the availability of vaccines for immunization, vaccine preventable diseases 

remain the most common cause of childhood mortality with an estimated three million deaths each 

year and this could be due to problems with uptake of immunization. 

Children who missed vaccines or are partially vaccinated are said to be at high risk of vaccine 

preventable diseases that claim millions of lives each year. It is also estimated that 10 million 

children under-five years die, one third of which is attributable to infectious diseases that would 

have been vaccine prevented (Mvula et al., 2016). Also, delayed vaccine uptake may have 

implications for public health programmes including the occurrence of fatal disease in individuals, 

outbreaks, and negatively impact national and international targets of disease elimination (Laryea 

et al., 2014). 

In 2013 approximately 6.2 million children under the age of five died worldwide, and 3 million of 

these deaths occurred in Sub-Saharan Africa (SSA) and it is estimated that if global vaccine 

coverage increased to 90% by 2015, then approximately two million deaths of children under the 

age of five would be prevented (Sodha & Dietz, 2015). 



6 

  

 In the Sub- Saharan African countries, vaccine coverage rates remain well below the WHO goal 

of 90% and various factors have been suggested including factors influencing immunization 

uptake (Vonasek et al., 2016). The Asuogyaman district of the Eastern Region is one of the districts 

in Ghana with low immunization coverage. Of the many factors suggested to influence low 

childhood immunization coverage in under resourced settings, factors determining the uptake of 

immunization at the level of the parents has largely been overlooked. The aim of this study is to 

assess the determinants of immunization uptake among mothers with under-five children in the 

Asuogyaman district of the Eastern Region of Ghana. 

 

1.3 Rationale of study 

In 2008, the WHO Strategic Advisory Group of Experts on Immunization called for increased 

information about the factors leading to non-vaccination and under-vaccination of children in order 

to develop strategies to improve the uptake of childhood immunizations. Surveying the 

determinants of immunization uptake among mothers is an important step towards understanding 

the factors that influence vaccine non-acceptance in a particular setting in order to develop 

strategies that will improve immunization (Vonasek et al., 2016). 

Assessing immunization uptake helps to evaluate progress in achieving programme objectives and 

in improving service delivery. In addition, evaluation of immunization uptake provides evidence 

whether substantial progress towards achieving vaccination targets is being made. Such positive 

evidence is required for continuing support from donor-supported initiatives like the Global 

Alliance for Vaccines and Immunizations (GAVI) (Odusanyaet al., 2008). 



7 

  

WHO estimated that 17% of global annual under-five mortality could be prevented through 

increasing routine immunization uptake of which 2.2% could be prevented through pertussis 

vaccination, 2.3% through Hib vaccination, 1.3% through measles vaccination, 0.7% through 

tetanus vaccination, 5.2% through rotavirus vaccination and 5.4% through pneumococcal 

vaccination. Clearly, immunization uptake plays a key role in the global strategy for improving 

child survival hence the need to identify factors determining uptake among mothers with children 

under-five (Gram et al., 2014). Furthermore, identifying the determinants of uptake of 

immunization among mothers will guide evidenced-based interventions to improve immunization 

coverage in the community. This study looks at the determinants of uptake of immunization among 

mothers with children under five in the Asuogyaman district in the Eastern Region of Ghana. 

 

1.4 Conceptual framework 

The study hypothesizes immunization uptake by mothers with children under five years is 

determined by a number of factors including Knowledge about immunization, attitude towards 

immunization, practices emanating from the side of mothers and immunization services and socio-

demographics characteristics of the study population. Figure 1.1 illustrates the conceptual 

framework of the study. 

 

 

 



8 

  

 

 

 

 

 

 

 

 

 

 

Figure 1.1: Conceptual framework 

Source: Author’s construct, 2017 

 

1.5 Research Questions 

1. What is the knowledge of mothers regarding immunization of their children? 

2. What is the attitude of mothers towards immunization of their children? 

3. What is the relationship between mothers’ knowledge and immunization of their children? 

4. What percentage of mothers with children under five are compliant with immunization of their 

children? 

Knowledge of 

immunization 
Attitude towards 

immunization 

Socio demographics characteristics 

of the study population 
 

Immunization  

uptake 

Practices 



9 

  

1.6. General objective 

The general objective of the study was to identify the determinants of uptake of immunization 

among mothers with children under-five in the Asuogyaman District in the Eastern Region in 

Ghana. 

 

1.7 Specific objectives 

The following were the specific objectives of the study: 

1. To determine the knowledge of mothers regarding immunization 

2. To examine the attitude of mothers towards immunization 

3. To evaluate the relationship between mothers’ knowledge of the six childhood killer diseases 

and immunization status of their children. 

4. To determine the percentage of mothers who are compliant with immunization of their children. 

 

1.8 Profile of Study Area 

The Asuogyaman District is located approximately between latitudes 6º 34º N and 6º 10º N and 

longitudes 0º 1º W and 0º14E. It is about 120m above Mean Sea Level (MSL). It covers a total 

estimated surface area of 1,507 sq. km, constituting 5.7 percent of the total area of the Eastern 

Region. Also the Afram Plains South District borders the district to the north and the Upper and 

Lower Manya districts to the south and west respectively. Asuogyaman is a traditional district 



10 

  

situated between the Volta and Eastern Regions and share borders to the east with Kpando, North 

Dayi, Ho and the North Tongu Districts of the Volta Region.  The major towns in the district are 

namely, Akosombo, Atimpoku, Gyakiti, Senchi, New Akrade, Akwamufie, Anum, Boso etc. are 

located on either banks of the Volta Lake. 

The population of the district is heterogeneous in terms of ethnicity and religion. The predominant 

ethnic group is the Ewe (45.8%), followed by the Ga-Adangme (28.1%) and Akan (11.6%). Other 

ethnic groups make up the remaining portion of the population. The dominant practiced religion 

in the district are Christianity (89%), followed by Islam (3.7%) and African Traditional religion 

(2.4%) respectively. There also exist smaller groups of people who adhere to other religious 

practices or have no religious affiliations. The district has a total population of 98,046, as at the 

2010 National Population and Housing Census, representing 3.7% of population of Eastern Region 

and a total of (52.0%) more female than males (48.0%).( GSS,2014). 

The Asuogyaman District is essentially a rural district with majority of the people in the district 

living in the rural areas representing (70.6%) compared to the urban areas representing (29.4%).  

Child mortality rate is 8.7% per 1000 live births and it is very high in Yilo Krobo (13.6) and Kwahu 

East (12.9). Marital status of 39,706 of females 12 years and older showed that females married 

with basic education is 57.8% and those married with no education are 27.7%. The non-

formal/consensual and union or living together show females with no education came to 22.8% 

whiles those with basic education arrived at 69.2%.(GSS,2014). 

 



11 

  

1.9 Scope of study 

The study assessed the determinants of uptake of immunization among mothers with children 

under five years in the Asuogyaman district of the Eastern Region of Ghana.  The study specifically 

assessed mother’s knowledge, attitude and practices determining immunization uptake. Thus, the 

study results are limited to the Asuogyaman district. However, the findings may be extrapolated 

to apply to other districts in terms of decision making since statistical methods where employed in 

the study. 

 

1.10 Organization of report 

The entire study is organized into six chapters. Chapter One is the Introduction and covers areas 

such as background of the study, statement of the problem, research questions, objectives of the 

research, rational of the study and the scope of the study. Chapter Two, covers the literature review. 

Chapter Three is the research methodology; whiles Chapter Four presents the research findings. 

Chapter Five (5) deals with analyses and discussion of the findings. The final Chapter is Six, and 

comprises of conclusion and recommendations. 

 



12 

  

CHAPTER TWO 

2.0 LITERATURE REVIEW 

2.1 Immunization 

Immunization is the process of stimulating an active immunologic defense in preparation of 

meeting the challenge of future exposure to diseases. Therefore, it is the introduction of weakened, 

live or dead micro-organism called vaccines to the body system to stimulate the production of the 

antibodies to confer immunity (Bullough & Bullough, 1990). Immunization and vaccination are 

used interchangeably in this study. However, strictly speaking, vaccination is the process of 

administrating a vaccine while immunization is the response of the system following vaccination. 

In other words, immunization consists of the process of developing immunity after being 

administered with vaccines. Vaccines are modified or attenuated product of a micro-organism to 

mimic natural infection and evoking an immunologic response that presents little or no risk to the 

recipient. Thus, the recommended doses, routes, techniques of administration and schedules must 

be followed for predictable effective immunization and this may differ from one country to another 

(Bullough & Bullough 1990) 

 Immunization has been described as one of the greatest public health achievements of the 20th 

century and is seen widely as a worthwhile and cost-effective public health measure. Vaccination 

programmes have led to large reductions in disability and death from polio, measles, tetanus, 

rubella, diphtheria and Haemophilus influenzae type b.(Etana & Deressa,2012) However, over 24 

million children are still without access to this important health intervention contributing to 

millions of preventable child deaths in Lower Middle Income Countries (LMICs). Efforts to 



13 

  

improve vaccination coverage in LMICs are central to meeting the Millennium Development 

Goals (MDGs) now Sustainable Development Goals (SDG) of reducing child mortality (Saeterdal, 

Lewin, & Glenton, 2014). Also, immunization is a powerful public health strategy for improving 

child survival, not only by directly combating key diseases that kill children but also by providing 

a platform for other health services (Oyo-Ita et. al., 2016). Through immunization a number of 

serious childhood diseases have been successfully prevented or eradicated. For instance the 

immunization campaign carried out from 1967 to 1977 by the WHO eradicated the natural 

occurrence of small pox (Etana & Deressa, 2012). 

In order to understand the importance of vaccines to human beings, one must have insight into its 

history. The first vaccine introduced to control cowpox was discovered by Edward Jenner in 1978 

then vaccine for anthrax in animals and rabies in human beings was discovered in 1877 followed 

by the discovery of tuberculosis vaccine by Robert Koch in 1890, the BCG vaccine by Léon 

Charles Albert Calmette and Cameille Guérin, vaccine against diphtheria in 1890 by Emil Adolf 

Behring and Shibasaburo Kitasato, vaccine for whooping cough by Bordetella Pertussis between 

1923-1929 (Parish, 1965). Also immunization against tetanus in humans was demonstrated by 

Gaston Léon Ramon and Christian Zoeller; inactivated vaccine for poliomyelitis was prepared by 

Jonas Edward Salk around 1954 and active vaccines for poliomyelitis was prepared by Albert 

Bruce Sabin from 1953 to 1955 and Samuel Katz later produced measles vaccines (Parish, 1965).  

These were serious attempts made by concerned medical scientist to prevent human beings from 

contracting such dangerous diseases. 

Till date, immunization continues to be a major public health issue demanding a lot of focus and 

attention. Thus Sodha et al. observed that a successful immunization system requires the 



14 

  

synchronization of multiple programme components to provide a child the opportunity to be 

successfully vaccinated (Sodha & Dietz, 2015). Vaccines must be procured, and successfully 

delivered to the service delivery level, while constantly maintained through a functioning cold 

chain. Health workers must be trained in vaccine management, handling and administration; data 

recording and reporting and appropriate interaction with caregivers of young children. Creating 

community demand for immunization is critical to ensuring that caregivers value vaccination, and 

know when and where to bring their children to be vaccinated. The overall coordination, 

management and implementation of these activities require political support, sustained financing, 

supervision and the appropriate monitoring and use of high-quality data. Thus immunization has 

become a critical component of policies that aim to address health inequity (Bawah et al., 2010). 

 

2.2 The Expanded Program on Immunization (EPI) 

One of the triumphs of public health was the establishment of the Expanded Programme on 

Immunization (EPI) by veterans of the Smallpox Eradication Program. In 1974, a concerted global 

effort to use immunization as a public health strategy began when the WHO launched the EPI 

following the successful global smallpox eradication programme (Oyo-Ital et al., 2016). At the 

launch, WHO recommended a standard immunization schedule covering six basic antigens (i.e. 

tuberculosis (Bacille Calmette-Guérin (BCG)), polio, diphtheria, tetanus, pertussis, and measles), 

which are generally referred to as traditional EPI vaccines. With the emergence of new vaccines, 

more killer diseases can be prevented in infancy and adolescence. These vaccines include (but are 

not limited to) hepatitis B, Haemophilus influenza type b (Hib), human papilloma virus, 



15 

  

pneumococcal conjugate, rotavirus, yellow fever, meningococcal meningitis A, Japanese 

encephalitis, and rubella vaccines (Oyo-Ita let al., 2016). 

According to the EPI, a child should receive BCG, three doses of oral polio vaccine (OPV) and 

Diphtheria Pertussis Tetanus (DPT), and measles vaccines by 12 months of age to ensure 

maximum protection against VPDs. Receipt of these vaccines at the recommended ages and 

intervals will provide the children adequate protection from VPDs (Adedire et al., 2016). The 

traditional EPI vaccines are estimated to prevent 2.5 million child deaths annually (mainly from 

measles, pertussis, tetanus, and diphtheria), as well as to prevent severe morbidity for millions 

more children around the world from devastating diseases such as poliomyelitis and tuberculous 

meningitis (Oyo-Ita et al., 2016). 

 At the initiation of the EPI, it was estimated that only 5% of infants in the developing world 

received immunizations. By the late 1980s, with impetus and coordination from the Task Force 

for Child Survival, a coalition of the United Nations (UN) and other agencies dedicated to 

increasing access to EPI vaccines, coverage extended to 80% of the world’s children. However, 

by the mid-1990s immunization rates began to drop again, as the EPI infrastructure decayed 

without adequate replacement(Levine & Robins-browne, 2009). 

Since the inception of the EPI, the WHO has targeted the six vaccine-preventable diseases through 

training, surveillance, and coordination with national immunization programs and other 

organizations. Vaccine coverage currently being reported by WHO include: 

• BCG: to prevent certain types of tuberculosis, mainly during the first year of life, 

administered soon after a child's birth; 



16 

  

• OPV: three doses to protect against poliomyelitis, given during the first year of life. 

Volunteers, rather than trained health workers can administer oral polio vaccine, as it does 

not require injection equipment. Some countries also use a killed, inactivated polio vaccine 

that needs to be injected. 

• DPT: usually three doses of a combined vaccine that protects against diphtheria, pertussis, 

and tetanus, given during the first year of life. 

• Measles: a single dose of measles vaccine given during the first year of life, usually at 9 

months (but at 12-15 months in industrialized countries). 

•  Yellow Fever (in endemic countries): during the first year of life for children over 6 

months of age in the endemic countries of tropical and subtropical Africa and South 

America, often administered at the same time as measles immunization 

• Hepatitis B: usually three doses of a vaccine to prevent hepatitis B, recommended as part 

of routine infant immunization schedule, given at same time as DPT. A combined DPT-

Hepatitis B vaccine also exists. 

•   Hib: usually three doses of haemophilus influenzae type b vaccine to protect against 

meningitis and Hib pneumonia administered as part of DPT immunization. This can also 

be delivered as a combined DPT-Hepatitis B-Hib vaccine. 

•   TT (Tetanus Toxoid): a vaccine administered to pregnant women or women of 

childbearing age, consisting of at least two doses (with five providing lifelong protection), 

to prevent neonatal tetanus. 

Of these eight vaccines, information on coverage is readily available for most countries for most 

years since 1980 from country immunization programs for BCG, OPV3, DPT-3, and measles. TT 



17 

  

coverage data are available for about one-half of low-and middle income countries, whereas 

yellow fever coverage (where recommended) and hepatitis B coverage estimates are available in 

less than 20 percent of countries. Incidence of the diseases prevented by these vaccines varies 

across countries, and the use of coverage measures should take these differences into account. 

Polio eradication is in its final stages, with many countries now being free of polio. Different 

strategies are used in administering polio, including mass campaigns to reach children 0-4 years 

old, irrespective of immunization history. Therefore, as an indicator of routine service delivery 

effectiveness, OPV3 coverage rates are less suitable. Measles has virtually disappeared from the 

Americas and periodic mass campaigns targeting young children irrespective of immunization 

history have become an important strategy. But in Africa and Asia, where measles remains an 

important cause of child mortality, monitoring coverage levels is still essential. BCG monitoring 

is less frequently used because the vaccine is delivered once, often by midwives and other birth 

attendants, rather than by immunization in many countries in equatorial Africa and in some 

countries in South America. Hib and Hepatitis B are too new and not in use in many countries. 

For these reasons, DPT3 coverage rates are the most frequently used to monitor immunization 

coverage levels and trends. The WHO recommended schedule is to administer the vaccine at three 

different times during the first year of life (often at around 6, 10 and 14 weeks, but this varies from 

country to country) (Adedire et al., 2016) The developing countries in Africa, South Asia, and East 

Asia and the Pacific observe this schedule. A four-dose schedule, with a booster dose administered 

in the second or third year of life is typical in European countries, while a five-dose schedule (two 

booster doses) is typical in the Latin American region. The existence of schedules allows the 

construction of more refined monitoring indicators: in addition to coverage with one, two, or three 



18 

  

doses of DPT, coverage by age can be monitored to assess age appropriate coverage. The multiple 

dose standard also enables calculation of dropout rates, which indicate what proportion of children 

receive 1 but not 2, or 2 but not 3 doses of the vaccine. Dropout rates can be used as indicators of 

a health system's ability to deliver services. 

 

2.2.1 Funding source of EPI program 

Financing for vaccines for immunization has being a major issue since the inception of the EPI. 

Beginning in the late 1990s, a revolution in global health cooperation and in vaccine financing 

occurred, allowing immunization issues to be confronted (Levine & Robins-browne, 2009). 

In 1990, the World Summit for Children was convened at the UN headquarters in New York City 

to commemorate the Year of the Child. Immunizations were highlighted as the most cost-effective 

intervention to save the lives of young children in developing countries and steps were undertaken 

to start a new global initiative to ultimately create a temperature-stable ‘Children’s Vaccine’ that 

with a single non parenteral inoculation would confer durable immunity against many infectious 

diseases. Many governments, UN agencies and other partners involved in immunization pledged 

funds and other resources to the newly established ‘Children’s Vaccine Initiative’, which came to 

be housed within the WHO headquarters in Geneva, Switzerland. Regrettably, over the next few 

years few governments or agencies fully honored their commitments made at the World Summit 

for Children and, as a consequence, the Children’s Vaccine Initiative was not able to realize its 

potential or achieve all its goals. In fact, slippage was occurring and fewer children in developing 



19 

  

countries were receiving immunizations than during the peak years of the 1980s(Levine & Robins-

browne, 2009) 

In March 1998, James D Wolfensohn, president of the World Bank, invited the heads of the other 

UN agencies involved in financing, procuring and delivering immunizations to children in the 

developing world and an assortment of other critical stakeholders (for example, representatives of 

vaccine industry, major institutes working on vaccine research, non-governmental agencies, and 

philanthropic entities such as the Rockefeller Foundation) to a meeting in Washington, DC to 

discuss the emerging crisis in global immunization. Discussions brought consensus on the fact that 

there was a crisis that had to be addressed. A commitment was made to form a Working Group to 

survey the immunization landscape and interview stakeholders globally from ministers of health 

to immunization field workers to permit identification of the most pressing problems and develop 

action plans to remedy the situation. The Working Group, with official representatives from the 

WHO, UNICEF, the World Bank, vaccine industry and the Rockefeller Foundation and with 

several additional nonvoting observers, completed its work between June 1998 and October 1999. 

From this work a new coalition of stakeholders committed to providing immunizations for the 

world’s children was formed: the Global Alliance for Vaccines and Immunization (GAVI). GAVI 

had its launch within the UN agencies at UNICEF headquarters in New York City in November 

1999, followed by the worldwide launch at the World Economic Forum in Davos, Switzerland in 

February 2000. GAVI (currently known as the GAVI Alliance) identified three fundamental gaps: 

1. Access, an unacceptably large number of the world’s infants in developing countries did 

not have ready access to immunization services;  



20 

  

2. Equity, new vaccines (specifically hepatitis B and Hib conjugate) that were routinely 

being administered to infants in industrialized countries were not available to infants in 

developing countries;  

3.  lack of investment, insufficient investment was being made on research to develop 

vaccines against several diseases that are major afflictions in developing countries but are 

relatively uncommon in industrialized countries (for example, malaria, tuberculosis, 

meningococcal A disease, Shigella).  

By the time of the launch of GAVI, the Bill and Melinda Gates Foundation was emerging as an 

electrifying new philanthropic force, bringing to the table previously unseen levels of financial 

resources, energy and commitment. A Fund was established to provide GAVI with financial 

resources to address the gaps and meet its strategic objectives. The Fund began with a donation of 

$750 million from Bill and Melinda Gates and a challenge to other donors to match that amount. 

Various governments and other donors followed suit, thereby putting significant financial 

resources at GAVI’s disposal. The Fund (which over the years has had various names including 

the ‘Children’s Vaccine Fund’, the ‘Vaccine Fund’ and currently, the ‘GAVI Fund’) began with 

three ‘windows’.  

• Window 1 provided funds to applicants from the world’s 74 poorest countries to strengthen 

immunization services, including refurbishing the EPI cold chain. This Immunization 

Services Support maintains a performance-based grant system.  

• Window 2 allowed selected countries with good immunization coverage among the 74 

eligible countries to apply to receive free HBV and Hib conjugate for the entire infant birth 



21 

  

cohort for 5 years. The GAVI Alliance has more recently progressed to 10-year 

commitments for new vaccine introduction.  

• Window 3, which opened 2 years after the other two, provided funds to accelerate the 

development and introduction of two critically needed new vaccines, pneumococcal 

conjugates and rotavirus vaccines(Levine & Robins-browne, 2009). In 2006, the GAVI 

Fund was recapitalized.  

In addition, two substantial other funding sources became available. These were the International 

Finance Facility for Immunization (IFFI) and Advanced Market Commitment (AMC).  

The IFFI was originally conceived by Gordon Brown when he was Chancellor of the Exchequer. 

Eight donors (the UK, France, Italy, Spain, Sweden, Norway, Brazil and South Africa) have 

pledged $3.9 billion to the IFFI. Sovereign obligations guarantee ‘immunization bonds’ that are 

sold in the capital markets. Money raised by the bond sales is then channeled by GAVI to support 

vaccines and immunization programs in developing countries, thereby providing long-term 

funding that allows long-term planning. Ultimately, IFFI repays bondholders with long-term funds 

committed by the donors (Levine & Robins-browne, 2009). 

Although the GAVI Fund and IFFI provide important financial resources to strengthen 

immunization services and supply new vaccines, some of the newest vaccines are particularly 

expensive. The Advanced Market Commitment (AMC), yet another novel financial tool, was 

developed to provide funding for particularly needed new vaccines. AMC represents a financial 

commitment by donors to subsidize future purchase (at an agreed price) of a vaccine under 

development that meets certain technical specifications. Because pneumonia is the largest killer of 

children in the developing world and S. pneumoniae is the single most common cause of bacterial 



22 

  

pneumonia, there is great anticipation that infant mortality and morbidity can be substantially 

reduced following the programmatic introduction of pneumococcal vaccines. Consequently, 

pneumococcal conjugate vaccines were selected as the first to benefit from an AMC.  

To be eligible for procurement through the AMC, a specific multivalent pneumococcal vaccine 

must meet a series of specific target product profile criteria, such as encompassing glycoconjugates 

to prevent serotypes 14, 1 and 5 diseases. The recently licensed 10-valent GSK pneumococcal 

conjugate vaccine and the as yet unlicensed 13-valent Wyeth Vaccines conjugate vaccine would 

meet this requirement. Developing countries must demonstrate demand for the vaccine and they 

must pay a small portion of the cost. The governments of Italy, the UK, Canada, Russia and 

Norway and the Gates Foundation pledged $1.5 billion to the pneumococcal conjugate AMC 

(Levine & Robins-browne, 2009). 

 

2.3 EPI in Ghana 

In response to the worldwide call to improve child survival, Ghana launched the EPI in June 1978 

with six antigens BCG, measles, diphtheria-pertussis-tetanus (DPT) and oral polio for children 

under one year of age together with tetanus toxoid (TT) vaccination for pregnant women. The 

launch was in line with the national health policy to reduce morbidity and mortality of vaccine 

preventable diseases which then contributed significantly to both infant and child mortality in the 

country. It was also in consonance with the immunization policy of the government which sought 

to ensure that all children receive these vaccines before their first birthday of life (MOH, 2014) 



23 

  

The EPI which is responsible for immunization in Ghana is located within the Diseases Control 

Department (DCD) of the Public Health Division of the Ghana Health Service. It is headed by a 

Public Health Specialist and assisted by trained personnel who are specialists in areas that include 

logistics management, data management, cold chain management, injection safety, social 

mobilization and communication (MOH, 2014).  Figure2.1 below illustrates the organizational 

structure of the health sector with particular emphasis on the management and coordination of EPI 

program in Ghana. 

The mission of the program is to contribute to the overall poverty reduction goal of the government 

through the decrease in the magnitude of vaccine preventable diseases. This is carried out through 

the use of cost effective, efficacious and safe vaccines, new and under used vaccines and 

technologies to protect more people whilst contributing to the overall health systems strengthening 

in an integrated manner. Ghana has been at the forefront of showcasing immunization as the 

platform for health systems strengthening in Sub Saharan Africa (MOH, 2014). 

In 1992, fourteen years after the launch, the government added yellow fever vaccination to the 

National immunization programme (NIP). The Polio Eradication Initiative (PEI) introduced in 

1996 offered a major boost to the NIP through the resources offered for capacity building at all 

levels, funds for operational activities, adequate cold chain logistics, systems strengthening, 

partnerships, transportation facilities (MOH, 2014).  

In January 2002, the Government of Ghana in partnership with the GAVI initiative and supported 

by other health development partners such as WHO, UNICEF, World Bank, USAID, JICA, 

Rotary, DFID, DANIDA, Civil Society Organizations etc. increased the number of antigens with 



24 

  

two new vaccines - the Hepatitis B and the Haemophilus influenza type b (also known as Hib). 

The two new vaccines were combined with the DPT into DPT-HepB+Hib (commonly referred to 

as the Pentavalent vaccine in the country) (MOH, 2014). 

The Government of Ghana has been responsible for the total cost of traditional vaccines and 

injection supplies since the inception of EPI in 1978. It shares the cost of the Pentavalent and 

Yellow Fever proportionately with GAVI as agreed upon in the financial sustainability plan at the 

beginning of the introduction of the Pentavalent vaccine in 2002 until 2007 when the country 

rolled-on to the co-payment scheme under the bridge financing mechanism. Development Partners 

(DPs) provide support in various forms including campaigns. Some of the partners support needy 

districts with additional resources to improve on their immunization programmes. Immunization 

coverage has been on steady increase and as at the end of December 2007, 106 districts out of the 

138 in the country, representing 84% achieved penta3 coverage of more than 80%. Incidence of 

most of the childhood killer diseases in the country have declined significantly (MOH, 2014). 

Three strategies are implored for the delivery of the immunization services in the country- static 

at health centers, outreach in the communities and campaigns to reach out to most of the unreached 

populations. Static and outreach immunization services are delivered mostly at Child Welfare 

Clinics (CWC) by Community Health Nurses (CHNs) and Disease Control Officers (DCOs). At 

the CWC, other services like growth monitoring, vitamin A supplementation, de-worming are all 

delivered. Table 2.1 shows the new immunization schedule in Ghana. 

According to Gram et al., (2014), the national schedule in Ghana follows that of the EPI. Newborn 

children are scheduled to receive BCG and live oral polio vaccine at birth; pentavalent diphtheria-

pertussis-tetanus-Hib-Hep B (DPTHH) as well as polio vaccines at 6, 10 and 14 weeks; and 



25 

  

measles and yellow fever vaccine at 9 months. Static immunization clinics are held in public 

hospitals, health centers and community-based health planning services compounds on set days at 

specified time intervals, usually once a month. Mothers living in communities near static facilities 

are mobilized to attend the immunization clinics. Mobile teams hold clinics where no static health 

clinics exist or where vaccine uptake is low. Private facilities refer clientele to public facilities for 

immunization services. Staff at the immunization clinics record all vaccines administered in clinic-

based registers as well as in the infants’ child vaccination cards. Staff refer to these cards to 

determine what vaccines need to be administered; when the mother attends without the card, 

maternal recall of vaccination is used instead. Mass polio immunizations are organized twice a 

year countrywide in Ghana on specific days called National Immunization Days. Special 

campaigns are also organized in response to outbreaks of diseases such as measles. One week a 

year is also set aside as child health week, and based on the selected theme, activities may include 

immunization of children.  



26 

  

 

Figure 2.1: Organizational structure of EPI in the Ghana Health Service 

Source: Ghana Health Service EPI 5YPOW (2002-2006), October 2002. 

 

 

 

 

 

 

 

 

 

 



27 

  

Table 2.1; Immunization schedule in Ghana 

Vaccine/ 
Antigen 

Dosage 
Dosage 

Required 

Minimum 
Interval 
Between 

Doses 

Minimum 
 Age To Start 

Mode of 
Administratio

n 

Site of 
Administratio

n 

BCG 

0.05ml up 
to 11 

months 
0.10ml 
after 11 
months 

1 dose None 
At birth (or 

first contact) 
Intra-dermal 

Right Upper 
Arm 

Pentavalent 

0.5 ml 
3 doses 

6, 10 and 14 
weeks 

4 week 

At 6 week (or 
first contact 

after that 
age) 

Intra-
muscular 

Outer Upper 
Aspect of Left 

Thigh 

*Pneumo 
Outer Upper 

Aspect of Left 
Thigh 

Polio 2 drops 

4 doses 
At birth, 6, 10 

and 14 
weeks 

4 week 
At birth 

within the 
first 2 weeks 

Oral Mouth 

* Rotarix 1.2 ml 
2 doses 

6 and 10 
weeks 

4 week 

At 6 week (or 
first contact 

after that 
age) 

Oral Mouth 

Measles 
1st dose 

0.5 ml 

2 doses 
9 months 

9 months 
At 9 months 

Sub- 
cutaneous 

Right Upper 
Arm *Measles 

2nd dose 
18 months At 18 months 

Yellow 
Fever 

0.5 ml 1 dose None At 9 months 
Sub- 

cutaneous 
Right Upper 

Arm 
Tetanus 
Toxoid 

0.5 ml 2 doses One month 
Pregnant 
Women 

Intra- 
muscularly 

Upper Arm 

Vitamin A 
100,000 IU 
200,000 IU 

10 6 months 6 months Oral Mouth 

Source: MOH Immunization Programme, Comprehensive Multi-Year Plan (2010-2014) 

 

2.4 Factors influencing uptake of immunization 

In order to increase child immunization uptake, the underlying causes and parents’ reasons not to 

immunize their children should be known (Legesse & Dechasa, 2015).  

Vaccine preventable diseases outbreaks are linked to inadequate levels of immunization uptake 

and several factors are associated with poor uptake of immunization in resources-limited countries. 

A study involving 24 African countries showed immunization uptake is linked, at the contextual 



28 

  

level, to high community illiteracy rates, high country fertility rates, and living in urban areas, 

while, at the individual level, they are linked to poorest households, uneducated parents, parents 

with no access to media and/or with low health seeking behaviors and the relative effect of the 

above factors may significantly vary according to the geographical area. The study further noted 

that in Africa, a more detailed and comprehensive information at district level is necessary in order 

to develop and implement appropriate strategies for improving immunization uptake (Russo et al., 

2015). 

Legesse & Dechasa (2015) in a study to assess child immunization uptake and its determinants in 

Sinana District, Southeast Ethiopia, they identified that the major hindering factors from achieving 

universal immunization include: low access to services, low number of trained manpower, high 

staff turnover, lack of fund donors, lack of information, lack of transportation, distance from health 

facilities, inadequate awareness of mothers/caregivers, others such as missed opportunities, and 

high dropout rates especially through routine approaches. 

Studies done in south and north Ethiopia showed that, mothers’ educational status, urban residence 

and perceived health care support are significantly associated with complete immunization uptake. 

Studies in Mozambique, India and Bangladesh also showed utilization of maternal health care 

service like ANC, tetanus toxoid vaccination and institutional delivery is associated with complete 

immunization status of children. In addition, low access to services, inadequate awareness of 

caregivers, missed opportunities, and high dropout rate are major factors contributing to low 

immunization uptake (Etana & Deressa, 2012). 

Research throughout Africa has shown that parental poverty and low educational attainment are 

adversely associated with the survival of children. Extensive scientific evidence also demonstrates 



29 

  

that low-cost vaccines are effective in reducing childhood mortality. Therefore, the adverse child-

survival effects of poverty and low parental educational are widely assumed to be offset by the 

promotion of comprehensive childhood immunization. Thus immunization has become a critical 

component of policies that aim to address health inequity. Nonetheless, an examination of the 

impact of immunization on the association between poverty and child survival should be appraised 

directly. Health conditions, particularly for children, are worsening throughout Sub-Saharan 

Africa despite the widespread promotion of immunization in the region, challenging the 

assumption that immunization offsets the effects of poverty and this could be attributed to the 

variations in uptake of immunization (Bawah et al., 2010). 

In Ghana the 1998 DHS revealed that the risk of infant mortality within the first year of birth 

amongst various ethnic groups was due to the differences in socio-economic status (Duah-Owusu, 

2003). Most of the challenges mothers face in ensuring that their children get immunized from the 

six killer diseases are classified as socio-economic and cultural influences comprising of low 

income/poverty, illiteracy, superstition, religious taboos, emphasis on cure and traditional healers 

among others. 

Some other studies that have found associations between immunization of children and the 

individual education of a mother are Cutts et al., (1991) in Guinea; Bhuiya et al., (1995) in 

Bangladesh and Matthews et al., (1997) in Ghana.  

 Boachie-Yiadom (2014) support the fact that there is a direct positive relationship between 

education and knowledge of mothers towards early child immunization against the six killer 

diseases and the survival rate of children less than 5 years. Otherwise such high levels of illiteracy 



30 

  

usually affect the knowledge of mothers on immunization leading to their negative attitude towards 

child immunization (Adebiyi, 2013).  

A qualitative survey by Bosu et al on factors influencing attendance to immunization session at 

Eguafo-Abrem District of Ghana was carried out on 469 mothers with children less than 2 years 

revealed that 73% of the mothers attended child welfare clinics regularly however, the study 

indicated that one of the major factors hindering attendance were poor knowledge about 

immunization. (Bosu et al., 1997). Another study suggested that parental attitudes towards overall 

health care greatly influence behavior toward vaccinations (Downs, et al., 2008). Similarly, in an 

earlier study Lindberg (2002) commented that mothers’ attitude in terms of how they think or feel 

affects their willingness that is their behavior to immunize their children that are less than 5 years 

from the six killer diseases (Lindberg, 2002). 

There are several factors that influence mothers’ attitude towards immunizing their children and 

one of them is poverty or low income. For example, Panned and Yazbeck (2003) revealed that 

children of the poorest wealth quintiles were likely to be unimmunized in rural residences.  

Many researchers (Topuzoglu et al., 2005; Cui and Golfing, 2007; Pande, 2003) argue that the 

socio-economic status of mothers affect their attitude towards immunizing their children less than 

5 years.  

Furthermore, mothers engage in certain practices for example complementary / alternative 

medicine (Gust et al., 2003; Stokley et al., 2008) hence prevent them from immunizing their 

children. This practice is further supported by Poland and Jacobson (2001) that mothers depend 

on ‘rules of thumb’ or heuristics to make vaccination decisions for their children. 

 

 



31 

  

CHAPTER THREE 

3.0 METHODOLOGY 

 

3.1 Study methods and design 

A cross-sectional study design involving quantitative study tools was used in the study to describe 

the determinants of uptake of immunization among mothers of children under five years in the 

Asuogyaman District. 

The quantitative approach was used to enable gathering of quantitative data and descriptive 

analysis of the data. The quantitative data was derived using a structured questionnaire which was 

interviewer-administered to collect primary data from respondents. 

 

3.2 Data Collection Techniques and Tools 

Field data collection was done between January 2017 and February, 2017 using structured 

questionnaire comprising closed ended questions.  

 

3.3 Study population 

The study population included 174 mothers in the Asuogyaman district who had children under 

five years of age. All mothers who had children under five years were thus recruited and the 

questionnaires administered to them. 



32 

  

3.4 Variables 

The variables of this study comprised the dependent and independent variables 

 

3.4.1 Dependent variables 

The dependent variable of the study was immunization uptake. 

 

3.4.2 Independent variable 

The independent variables of the study included: socio-demographic characteristics, knowledge of 

immunization, attitude of mothers towards immunization and practices influencing immunization 

uptake. 

 

3.5 Sampling 

The EPI cluster sampling method was adapted and used to categorize the Asuogyaman district into 

clusters according to the various sub-districts. The convenient sampling method was then 

employed to collect data from the study participants. This method is appropriate giving the nature 

of the study population. Households within each cluster or sub district were visited conveniently 

to identify mothers with children between under five years. Any mother encountered on the field 

who met the inclusion criteria was interviewed. 

 



33 

  

3.5.1 Sample Size Determination 

A sample size of 174 was derived based on the sample size formula for a single population shown 

below (Cochran, 1977): 

𝑛 =  
𝑍2𝑃(1 − 𝑃)

𝑑2
 

 

Where, 

n = sample size required. 

Z = Z score at confidence level (95% level of confidence) = 1.96. 

P = 2010 National prevalence of childhood immunization uptake (87% =0.87). Derived from 

literature. 

d = Margin of error (5% =0.05). 

Substituting, 

n= [(1.96)2 (0.87 × 0.13)] / (0.05)2 =174.  

 

3.6 Pre-testing 

The questionnaire for the study was pre-tested in Akosombo Township. This helped in identifying 

errors and re-structuring of the questionnaire.  

 



34 

  

3.7 Data Handling 

The data collected on each respondent was cross checked after each day’s field work to ensure that 

the questionnaire were completely and appropriately filled and all information accurately 

collected. The administered questionnaires were cleaned, coded and entered into Microsoft Excel. 

The data was validated and exported to STATA Statistical software package (StataCorp.2007. 

Stata Statistical Software. Release 14. Stata Corp LP, College Station, TX, USA) for analysis. 

 

3.8 Data analysis 

 Descriptive analysis was carried on the socio- demographic characteristics of study participants 

and to determine knowledge and attitude towards immunization whilst Pearson’s chi-square test 

was conducted at 95% confidence interval (CI) to establish associations between mothers’ 

awareness and immunization of their children. Statistical significance was considered at 95% 

confidence interval and p-values less than 0.05 (p<0.05). The results were presented in tables, 

graphs and charts. 

 

3.9 Ethical Consideration 

To ensure that the research meets ethical standards, ethical approval was sought and obtained from 

the Ensign College of Public Health Ethics Review Board. Also, an administrative approval was 

sought from the District Health Directorate. A consent form stating the purpose of the study was 

attached to each questionnaire and explained to the respondent before they were allowed to sign 



35 

  

and participate in the exercise. The consent form clearly stated issues of confidentiality and 

anonymity to the respondent as well as risk and benefits of the study. 

 

3.10 Limitations of the study 

The study participants were recruited from five out of the six sub-districts of the Asuogyaman 

district due to challenges encountered during the data collection stage. Thus, the findings could 

not be generalized as true reflection of the entire Asuogyaman district given the small size of the 

sample used. Also, responses on immunization statuses of children were mostly by verbal 

confirmation rather than immunization cards. As a result, findings on immunization statuses of the 

children could be misleading due to false confirmation by mothers. 

 

3.11 Assumptions 

The following assumption was made in the study: Vaccines for all the vaccine preventable 

childhood diseases were available in the Asuogyaman district in all the immunization centers. 

 

 

 

 

 



36 

  

 

CHAPTER FOUR 

4.0 RESULTS 

4.1 Introduction 

This chapter presents the results of the empirical study. There are seven sections in this chapter. 

 

4.2 Demographic characteristics of study participants 

There was a 100% response rate in terms of the questionnaires administered since they were 

interviewer administered. Of the 174 mothers who participated in the study, majority, 98 (56%) 

were within the age range of twenty-one years to thirty years, whilst 51 (29%) fell between ages 

thirty-one and forty years. Only 8 (5%) of the mothers were above forty years. 

Also, most, 154 (89%) of the respondents professed faith in Christianity, 17 (9%) reported being 

Muslims with only 3 (2%) of the mothers acknowledged being practitioners of the African 

Traditional Religion. In terms of marital status of the mothers, 135 (78%) of the mothers were 

married, 27 (15%) were single, 9 (5%) were co-habiting whilst 3 (2%) were either divorced or 

separated at the time of the study. 

While 71 (41%) of the mothers reported being Ewes, 64 (37%) are Akans and 33 (19%) are Ga/ 

Adangme. Only 2 (1%) of the mothers are Hausa. On the highest attained level of formal education 

at the time of the study, most of the mothers 89 (51%), had Middle/Junior High School education, 

40 (23%) had Senior High School/ Vocational education, 13 (7%) had primary school education 



37 

  

while 21 (12%) and 11 (6%) had tertiary level education and no formal education respectively. 

Majority 138 (79%) of the mothers had between one and three children, 34 (20%) had between 4 

and six children whilst only 2 (1%) of the mothers had seven children and above. Table 4.1 shows 

details of the demographic characteristics of the study respondents. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



38 

  

Table 4.1: Socio-demographic characteristics of study participants 

Variable Frequency Percent (%) 

Age 

15-20 

21-30 

31-40 

41-49 

Marital Status 

Single 

Married 

Divorce/Separated 

Co-habiting 

Ethnic Group 

Akan 

Ga-Adangme 

Ewe 

Hausa 

Others 

Educational level 

None 

Primary 

Middle/JHS 

SSS/Vocational 

Tertiary 

Religion 

Christianity 

Islam 

Traditional 

Number of Children 

1-3 

4-6 

7 Above 

 

17 

98 

51 

8 

 

27 

135 

9 

3 

 

64 

33 

71 

2 

4 

 

11 

13 

89 

40 

21 

 

154 

17 

3 

 

138 

34 

2 

 

 

10 

56 

29 

5 

 

15 

78 

5 

2 

 

37 

19 

41 

1 

2 

 

6 

8 

51 

23 

12 

 

89 

10 

1 

 

79 

20 

1 



39 

  

4.3 Awareness of Childhood Immunization 

In order to determine mother’s level of awareness of childhood immunization, they were asked to 

indicate “Yes” or “No” to the question if they have ever head of childhood immunization. Most 

168 (97%) of the mothers who took part in the study indicated Yes while only 6 (3%) indicated 

No. With regards to sources of information on immunization, the health facility was the major 

source through which mothers were aware of immunization 93 (53%). This was followed by the 

Radio/Television 48 (28%), with only 13 (7%) mothers indicated Newspaper as their source of 

information on immunization as shown in Figure 4.1. 

 

Figure 4.1: Sources of information on immunization 

 

4.4 Awareness Level and demographic characteristics of respondents 

A Pearson’s Chi-square test was performed at 95% confidence interval to determine the level of 

association between mothers’ awareness of immunization and their demographic characteristics. 

The results showed that ethnic group of mothers was statistically associated with awareness of 

Health Facility Radio/TV Newspaper Friends/Family Social media
Community

van
Others

Series1 93 48 13 6 1 2 11

0

10

20

30

40

50

60

70

80

90

100

P
e
rc
e
n
ta
ge



40 

  

immunization. However, age, marital status, educational level, religion and number of children of 

mothers were not statistically associated with awareness of immunization as shown in table 4.2 

below. 

Table 4.2: Bivariate analysis between Awareness level and demographic characteristics 

Variable Frequency Awareness of immunization 

Yes                            No 

P-Value 

Age 

15-20 

21-30 

31-40 

41-49 

Marital status 

Single 

Married 

Divorced/Separated 

Co-habiting 

Ethnic group 

Akan 

Ga/Adangme 

Ewe 

Hausa 

Others 

Educational level 

None 

Primary 

JHS 

SHS 

Tertiary 

Religion 

Christianity 

Islam 

ATR 

Number of Children  

1-3 

4-6 

7 Above 

 

17 

98 

51 

8 

 

27 

135 

9 

3 

 

64 

33 

71 

2 

4 

 

11 

13 

89 

40 

21 

 

154 

17 

3 

 

138 

34 

2 

 

15 (89)                   2 (11) 

86 (88)                 12 (12) 

51 (100)                   0 (0) 

8 (100)                     0 (0) 

 

27 (100)                   0 (0) 

123 (91)                 12 (9) 

9 (100)                      0 (0) 

2 (71)                      1 (29) 

 

63 (98)                     1 (2)  

33 (100)                    0 (0) 

57 (80)                  14 (20) 

2 (100)                      0 (0) 

4 (100)                      0 (0) 

 

9 (82)                       1(18) 

12 (92)                      1 (8) 

83 (93)                      6 (7) 

40 (100)                     0 (0) 

21 (100)                    0 (0)  

 

140 (91)                  14 (9)  

17 (100)                     0 (0) 

3 (100)                       0 (0) 

 

131 (95)                    7 (5)  

32 (94)                       2 (6) 

2 (100)                       0 (0)                     

 

0.176 

 

 

 

 

0.103 

 

 

 

 

0.010 

 

 

 

 

 

0.652 

 

 

 

 

 

0.801 

 

 

 

0.500 

 

 



41 

  

4.5 Decision making on immunization 

All mothers in the study responded to a question on decision making in terms of immunization. Of 

the 174 respondents, 139 (80%) reported that decision on immunization of the children are made 

by them. However, 2 (1%) of mothers indicated that other people take immunization decisions for 

them as shown in Figure 4.2. 

 

Figure 4.2 Decision making on immunization 

 

4.6 Knowledge of six Childhood killer diseases 

The knowledge of study respondents with respect to the six childhood killer diseases was assessed. 

Majority 145 (83%) of the mothers mentioned Polio as one of the six childhood killer diseases. 

This was followed by measles 136 (78%) and the least reported of the diseases was Diphtheria 34 

(20%). Figure 4.3 shows details of mothers’ knowledge of the six childhood killer diseases.  

Self
80%

Spouse
4%

Parents
15%

Others
1%



42 

  

 

Figure 4.3: Knowledge of six childhood killer diseases 

Also, among the five different clusters of sub district from which the study participants were 

drawn, the Akosombo sub-district has the highest 28(80%) percentage of women with knowledge 

on the six childhood killer diseases. This was followed by the Akwamufie/Apegusu sub-district 

23(66%) whilst the Atimpoku sub-district has the lowest number of women with knowledge on 

the six childhood killer diseases as shown in Figure 4.4.  

 

Diptheria Tuberculosis Tetanus Measles Poliomyelitis Yellow fever

Series1 34 47 42 136 145 38

0

20

40

60

80

100

120

140

160

Fr
e
q
u
e
n
cy



43 

  

 

Figure 4.4: Knowledge of six childhood killer diseases by sub districts 

 

4.7 Knowledge of immunization and prevention of childhood diseases 

In assessing mothers’ knowledge of immunization, the study found widespread knowledge among 

mothers with respect to prevention of childhood diseases through immunization. Most 155 (89%) 

of the mothers reported that immunization prevents childhood diseases whilst only 4 (2%) mothers 

were undecided as to whether immunization prevents childhood diseases or not as shown in Figure 

4.5 

 

Figure 4.5: Knowledge of prevention of childhood diseases through immunization 

0% 20% 40% 60% 80% 100%

Akosombo

Akwamufie/Apegusu

Adjena/Gyakiti

Atimpoku

Senchi/Akrade

Akosombo Akwamufie/Apegusu Adjena/Gyakiti Atimpoku Senchi/Akrade

Series1 80% 66% 60% 31% 49%

Y E S

N O

U N D E C I D E D

Yes No Undecided

Series1 89% 9% 2%



44 

  

Also, the knowledge of mothers about immunization of their children was assessed on a number 

of issues pertaining to immunization. The findings are presented in table 4.3below. 

Table 4.3: Knowledge of mothers about immunization of children 

Variable Frequency Percentage (%) 

Knowledge of need for immunization 

Knowledge about contraindications 

Knowledge of place or time of immunization 

Knowledge of need for follow up doses 

Knowledge of doses given at each interval 

146 

12 

91 

87 

9 

84 

7 

52 

50 

5 

 

4.8 Knowledge levels of mothers about immunization 

The knowledge of mothers regarding immunization was classified into levels of no knowledge, 

low knowledge, average knowledge and high knowledge depending on their ability to mention the 

vaccine preventable six childhood killer diseases. Mothers who were able to mentioned 5-6 of the 

six childhood killer diseases were classified as having high knowledge, those who were able to 

mentioned 3-4 diseases were classified as having average knowledge, those who mentioned 1-2 

diseases were classified as having low knowledge whilst those who could not mention any of the 

six childhood killer diseases were classified as having no knowledge. The results as shown in 

Figure 4.6 indicates that only 4 (2%) of the mothers have high knowledge whilst 35 (20%) could 

not mention any of the vaccine preventable six childhood killer diseases and thus classified as 

having no knowledge. 



45 

  

 

Figure 4.6: Knowledge levels of mothers about immunization 

 

 

4.9 Immunization status of children 

More than half 93 (53%) of the mothers who participated in this study indicated that they have 

fully immunized their children. 67 (39%) of the mothers have partially immunized their children 

whilst 14 (8%) said they have not immunized their children as shown in Figure 4.7. 

 

20%

59%

19%

2%

No knowledge

Low knowledge

Average knowledge

High knowledge



46 

  

 

Figure 4.7: Immunization status of children 

 

4.10: Knowledge of mothers and immunization status of children 

A chi-square test was done at 95% confident interval to determine any relationship between 

mother’s knowledge and immunization status of their children. There was no significant 

association between mother’s level of knowledge and immunization status of their children. 

Also among the reasons given by mothers for partially immunizing or not immunizing their 

children, being too busy was the prominent reason given by mothers as shown in table 4.4. 

 

 

 

 

0% 10% 20% 30% 40% 50% 60%

Fully immunized

Partially immunized

Not immunized

Fully immunized Partially immunized Not immunized

Series1 53% 39% 8%



47 

  

Table 4.4: Reasons for partial and non-immunization of children 

Reason Frequency Percent (%) 

Too busy 

Family problem 

Vaccine not available 

Time for immunization not convenient 

Don’t believe in the effectiveness of the vaccine 

Heard bad things about vaccines and immunization 

Not aware of immunization 

Long queues and waiting time at immunization centers 

Not aware of need for follow up doses 

Did not know schedule and place of immunization 

Side effects 

  

78 

13 

3 

5 

1 

4 

6 

32 

28 

2 

3 

 

 

44 

7 

2 

3 

0.1 

2 

3 

18 

16 

1 

2 

 

 

 

4.11: Side effects of immunization 

Mothers reported on side effects noticed after immunization of their children. Findings revealed 

that 45 (26%) of the mothers reported “felt ill or tired, fever on day of injection” as the commonest 

side effect observed in their children after immunization. Table 4.5 presents details of the different 

side effects reported by study participants. 



48 

  

Table 4.5: Side effects of immunization 

Side effect Frequency Percent (%) 

Felt ill or tired, fever on day of immunization 

Hives, Swelling 

Mumps/rash/itching 

Redness at site of injection 

Seizures 

Vomiting/diarrhea 

Shortness of breath 

Eye irritation 

Others 

45 

23 

2 

7 

0 

0 

0 

0 

0 

26 

13 

0.1 

4 

0 

0 

0 

0 

0 

 

4.12: Attitude of mothers towards immunization 

The general attitude of mothers towards immunization of their children was determined using a 

range of questions. The results showed that majority of mothers in the study have positive attitude 

towards immunization as 123 (71%) of mothers see immunization as a good thing for their children 

and will encourage their colleagues to immunize their children However, some mothers were 

uncertain with respect to their attitude towards immunization of their children as shown in Figure 

4.8. 



49 

  

 

Figure 4.8: Attitude of mothers towards Immunization 

 

4.13: Practices influencing uptake of immunization 

Mothers were asked to indicate practices that affect their behavior towards immunization of their 

children. The results are shown in Table 4.6. 

Table 4.6: Practices influencing uptake of immunization 

Practice Frequency Percent (%) 

Frequent unavailability of vaccines 

Frequent absence of vaccinator 

Inconvenient time for immunization 

Cultural or religious background 

Long waiting time 

17 

8 

83 

26 

104 

10 

5 

48 

15 

60 

Poitive attitude Negative attitude Don't know

71%

12%
17%



50 

  

4.14: Accessibility of immunization centers 

Most mothers consider immunization centers as accessible and not far from them. Of the 174 

mothers who responded to questions on accessibility of immunization centers, 114 (66%) of them 

regarded the immunization centers as accessible and not far from them as shown in Figure 4.9. 

 

 

Figure 4.9: Accessibility of immunization centers 

 

Also, the hospital was identified as the major source of immunization with 98 (56%) of mothers 

indicating that the hospital is their source of immunization for their children. This was followed 

by outreach programs with 36 (21%) as shown in Figure 4.10.  

 

66%

34%

Yes No



51 

  

 

Figure 4.10: Source of immunization 

 

Determinants of immunization uptake 

A bivariate analysis was done to identify the independent variables associated with immunization 

status. The results showed that access to immunization center and Ethnicity were significantly 

associated with immunization status as shown in Table 4.7. 

 

 

 

 

Table 4.7: Bivariate analysis between selected independent variables and immunization 

status 

0% 10% 20% 30% 40% 50% 60%

Hospital

Clinic

Healthpost

Outreach

Private

Hospital Clinic Healthpost Outreach Private

Series1 56% 14% 7% 21% 2%



52 

  

Variable 

 

Age of Mother 

15-20 

21-30 

31-40 

41-49 

                          Immunization Status 

Full                      Partial                  Don’t Know 

 

7(41)                           7(41)                          3(18) 

49(50)                       42(43)                        7(7) 

30(59)                       18(35)                        3(6) 

6(74)                           1(13)                              

1(13) 

P-value 

 

 

0.542 

Source of information 

Health Facility 

Radio/TV 

Newspaper 

Friends/Family 

Social Media 

Community Van 

Others 

 

53(57)                       38(41)                         2(2) 

25(52)                       20(42)                         3(6) 

6(46)                         4(31)                           3(23) 

3(50)                         1(17)                           2(33) 

1(100)                       0(0)                             0(0) 

0(0)                           1(50)                           1(50) 

4(36)                         4(36)                           3(28) 

 

0.993 

 

 

 

 

 

 

 

 

 

Attitude towards 

Immunization 

Positive 

Negative 

Don’t Know 

 

 

78(63)                       40(32)                       6(5) 

9(43)                         8(38)                         4(19) 

5(17)                         20(69)                       4(14) 

 

0.608 

Access to Immunization 

center 

Yes 

No 

 

 

62(54)                       49(43)                       3(3) 

30(50)                       19(32)                       11(18) 

 

0.043 

Educational level 

None 

Primary 

Middle/JHS 

SHS/Vocational 

Tertiary 

 

7(64)                         3(27)                          1(9) 

6(46)                          5(38)                         2(15) 

54(61)                        31(35)                    4(4) 

18(45)                        21(53)                   1(2) 

7(33)                          8(38)                     6(29) 

 

0.799 

Religion   



53 

  

Christianity 

Islam 

Traditional 

88(57)                    61(40)                      5(3) 

3(18)                      6(35)                        8(47) 

1(33)                      1(33)                        1(34) 

0.956 

Ethnicity 

Akan 

Ga-Adangme 

Ewe 

Hausa 

Others 

 

41(64)                    19(30)                      4(6) 

22(67)                    9(27)                        2(6) 

25(35)                    38(53)                      8(12) 

1(50)                      1(50)                        0(0) 

3(75)                     1(25)                        0(0)         

 

0.048 

 

 

 

 

 

 

 

 

 

 

 

 

 



54 

  

CHAPTER FIVE 

5.0 DICUSSION 

The study assessed the determinants of immunization uptake among mothers of the Asuogyaman 

district of the Eastern Region of Ghana. In terms of socio-demographic characteristics, the general 

age of the study participants could be described as youthful as most (56%) of them were within 

the age range of 21-30 years. The dominant religion of the respondents was Christianity (88%) 

and this is consistent with reports by the Ghana Demographic Health Survey that, Christianity is 

the dominant religion of Ghana. Even though the study location was in the eastern region, a region 

dominated by the Akan ethnic group, the study found majority (41%) of the participants to be 

Ewes with 37% being Akan. This could be due to the close proximity of the study location to the 

Volta Region. 

In terms of knowledge and awareness of immunization, all most all 168 (97%) of the mothers have 

heard about immunization. This is similar to studies done in Ethiopia on assessment of child 

immunization coverage and determinant which found that majority 573 (97%) of mothers have 

ever heard about immunization(Legesse & Dechasa, 2015). Another study found that, of the total 

respondents, about 96% heard about vaccination and vaccine preventable diseases (Etana & 

Deressa, 2012). The health care facility emerged in this study as the main source of information 

on immunization with 93 (53%) of the mothers reporting it as their source of information. This 

however, contradicts results of studies from Siana District of Ethiopia which reports Health 

Extension Workers as the major source of information on immunization for mothers (Legesse & 

Dechaasa, 2015). Which could in such settings, the mothers were being reached by the Extension 



55 

  

Workers who like their counterparts in the agricultural sector rather reach out to their clientele than 

waiting for them to visit the facility.  

The study found that only ethnic group of mothers as a background characteristics of study 

respondents was significantly associated with awareness of immunization whilst educational level, 

religion, number of children born, marital status and age were not statistically associated with 

awareness of immunization. A study in Cameroon, however, found educational level and income 

level of mothers as being associated with awareness of immunization(Russo et al., 2015). These 

differences in findings could be due to differences in ways of carrying out immunization. For 

instance, most health educations including immunization are mostly done in the Akan language 

which is the popular and common language of communication in Ghana. Thus, a mother who is 

Akan is likely to be aware of immunization compared to a mother who is not Akan and does not 

understand the Akan language. 

Also, in a bivariate analysis, access to immunization center and ethnicity of mothers were found 

to be significantly associated with immunization status of their children. This is however, not 

surprising since access to immunization service provision avenues has been consistently been 

reported as a predictor to immunization uptake (Etana & Deressa, 2012; Adedire et al., 2016). 

In addition, the knowledge of mothers on immunization was assessed and the findings revealed 

that, most 155 (89%) of the mothers know that immunization prevents vaccine preventable 

diseases among their children. Vonasek et al., (2016), in their study in Uganda found that majority 

of mothers were able to state that childhood immunizations protect children from diseases (93.5%). 

Also, in Ethiopia, studies showed that the majority of respondents (79.5%) knew that the objective 

of immunizing children was to prevent disease(Etana & Deressa, 2012). However, their knowledge 



56 

  

in naming the six childhood killer diseases was generally low. Only 4 (2%) of the mothers could 

mention between 5-6 of the  six childhood killer diseases and were classified as having high 

knowledge whilst majority 103 (59%) of the mothers mentioned between 1-2 of the six childhood 

diseases and hence were classified as having low knowledge. This difference in knowledge of 

mothers in terms of immunization preventing vaccine preventable diseases and knowledge of the 

six childhood killer diseases could be attributable to the fact that majority of the mothers had 

primary level of education. As a result, their ability to recall all the six childhood killer diseases 

will be less compared with their ability to recall education given to them on the fact that 

immunization prevents vaccine preventable diseases. Meanwhile, a study in Ethiopia reveals that 

overall more than two-third, 421(71.2%) of mothers in their study were knowledgeable (have good 

on vaccine preventable diseases) (Legesse & Dechasa, 2015). The large sample size of 591 used 

in their study could be accountable for the difference compared to the small sample size of 174 

used in this study. Poliomyelitis 145 (83%) was the highly known six childhood disease among 

the mothers and this was followed by measles 136 (78%). This agrees with a study in Uganda 

which showed that the most common vaccine preventable diseases identified were polio (81.3%) 

and measles (77.5%) (Vonasek et al., 2016).  The easily recognizable physical manifestations of 

the signs of these diseases could be responsible for the ease with which mothers remember them. 

Also, contrary to expectation that knowledge level of mothers in terms of immunization will 

influence the immunization of their children, the study found that level of knowledge of mothers 

was not associated with immunization status of their children. A study by Vonasek et al., (2016), 

reported similar findings in Uganda that mothers level of knowledge regarding vaccination and 

immunization was not significantly associated with immunization of their children. This 

contradicts findings from other studies which showed that knowledge of mothers and caregivers 



57 

  

on immunization against vaccine preventable diseases was associated with immunization of their 

children(Legesse & Dechasa, 2015). Also, in Nigeria a study found that maternal knowledge of 

routine immunization was a significant predictor of full immunization of  children by their mothers 

(Adedire et al., 2016). 

Moreover, majority 93 (53%) of the mothers reported that they have fully immunized their children 

whilst 67 (39%) have reported that they have partially immunized their children. Only 14 (8%) of 

the mothers reported that they have not immunized their children. These findings in terms of 

percentages of fully immunized children are far lower than results of studies in Cameroon which 

found that 84.5% of the children were fully immunized by their children with only 15.5% of the 

children being partially immunized by their mothers(Russo et al., 2015). Another study in Nigeria 

also found 82.3% of the children in the study were fully immunized (Odusanya et al., 2008). Study 

participants were also asked to indicate reasons responsible for their partial and non- immunization 

of their children. “Too busy” was the most prominent reason cited by study participants as being 

responsible for their partial and non-immunization of their children. This is similar to other studies 

which found that among partially immunized children, the main reported mothers’ reason for not 

being able to vaccinate their children was “to be very busy”(Russo et al., 2015). However, 

Vonasek et al., (2016), found that in Uganda, the two most common reasons given by mothers for 

partial or non-immunization of their children were “fearful of side effects” and 

“ignorance/disinterest/laziness,”. 

Furthermore, mothers reported side effects of immunization in this study. The most reported side 

effect by mothers was that their felt ill or tired and had fever on day of immunization 45 (26%). 



58 

  

This findings disagree with studies in Nigeria which reported coughing as the most reported side 

effect observed by mothers after va