Factors Associated with Low Immunization Coverage in Children Under Five Years in Asuogyaman District in Eastern Region of Ghana

Expanded Programme on Immunization is one of the most successful and cost effective programmes adopted by World Health Organization and other partners to prevent vaccine preventable diseases which are the major cause of infant morbidity and mortality worldwide. Since 2012, Africa has demonstrated unprecedented commitments in the Global Vaccine Action Plan and this has resulted in the protection of millions of children. Despite this, some infants still remained unvaccinated and at risk of vaccine preventable diseases. Even though, Ghana was among countries which achieved 95% DPT3 coverage, this was not evenly distributed across all districts and Asuogyaman District was not an exception. The study assessed the factors associated with low immunization coverage among children under five years in Asuogyaman District. A descriptive cross-sectional study was conducted among mothers/caregivers in the Asuogyaman district. A total of 401 mothers/caregivers were enrolled into the study and structured questionnaire was used to collected data from mothers/caregivers on factors associated with low immunization coverage in children under 5 years. The caregivers were mostly females, 396(98.7%) with mean age of 28.6(±6.7) years and the majority of them, 216(53.9%) were in the age group 20-29 years.  Only 250(62.3%) of the participants had good knowledge on immunization. The level of knowledge of the caregivers was significantly associated with ethnicity (χ 2 =9.83, p=0.043, 16?=0.05"> ), occupation (χ 2 =10.92, p=0.012, 16?=0.05"> ), and place of delivery (χ 2 =4.37, p=0.037,  16?=0.05"> ). Participants who were self-employed were 38% more likely to have good knowledge compared to those who were unemployed (AOR=0.62; 95% CI=0.40-0.95; p=0.030) and those who delivered at home were also twice more likely to have good knowledge on immunization compared to those who delivered at the health facility (AOR=2.12; 95% CI=1.19-3.77; p=0.010). Most of the caregivers, 304(75.8%) had positive attitude and good practices, 346(86.3%) on immunization. Majority of the mothers/caregivers, 353(88.0%) perceive health workers had positive attitude towards them. Conclusion : Immunization services were largely accessible to the caregivers. Knowledge of mothers/caregivers on immunization was low, but they had positive attitude and good practices on immunization. Keywords: Immunization, coverage, Asuogyaman district, Eastern region, Ghana DOI: 10.7176/JHMN/81-09 Publication date: October 31 st 2020

global Diphtheria-Pertussis-Tetanus (DPT) immunization coverage of 86% (Mihigo R, Okeibunor J&, Anya B, Mkanda P, 2017). Since African agreed to the ambitious and unprecedented commitments in the Global Vaccine Action Plan (GVAP) in 2012, vaccination has protected millions of children in African (WHO, 2016). However, in 2014, the number of infants who did not receive the third dose of DPT vaccines in the WHO African Region was estimated to be 7.4 million out of an annual birth cohort of 32.7 million; (Mihigo R, Okeibunor J&, Anya B, Mkanda P, 2017).
In Ghana, the EPI Programme was established in June 1978 with six (6) antigens consisting of BCG, measles, Diphtheria-Pertussis-Tetanus (DPT) and oral polio vaccine for infants. This intervention has reduced morbidity, disability and mortality, in Ghana (Ministry of health, 2016). Tetanus toxoid (TT) vaccination was also introduced to prevent tetanus in pregnant women/mother and neonates. The introduction of the immunization programme was in response to the National Health Policy to reduce illness and deaths due to vaccine preventable diseases (VPDs) contributing massively to the reduction of both infant and child mortality. The EPI programme over the years has been expanded to include other vaccines leading to the introduction of Yellow fever in 1992 and in 2002, Hepatitis B and Haemophilus influenza type B (Hib) was added to DPT to become Pentavalent (Ministry of health, 2016). In 2012, The Ministry of Health introduced two additional vaccines, the pneumococcal, rotavirus and measles second dose at 18 months. In 2013, measles vaccine was replaced with a rubella-containing measles vaccine (Measles-Rubella (MR) vaccine) and in 2016, Meningitis A was also introduced.
Ghana Health Service annual report 2016 indicates a high immunization coverage for all the antigens using PENTA 3 as proxy which was 99%. However, vaccination coverage in Asuogyaman District was lower than the national coverage. Data obtained from Asuogyaman District Health Directorate (DHD) ann ual report 2017 indicates a tremendous decrease in the trend of immunization coverage for all the antigens from 2015 to 2017(as shown in figure 1 and 2) (Asuogyaman DHD report, 2017). This low immu nization coverage has resulted in occurrence of confirmed Vaccine Preventable Diseases (VPDs) such as measles (2) and meningitis (1) in the district (Asuogyaman DHD report, 2017). Although there has been a lot of activities to improve the immunization coverage such as creating of new outreach points, increase in home visit and introduction of school immunization, the coverage is still not improving. The persistence decrease in coverage can be attributed to so many factors associated with low coverage. The study assessed the factors associated with low immunization coverage in children under five years in Asuogyaman district.

Study design
A descriptive cross-sectional study was conducted and structured questionnaires were used to collect the data from the participants. Ethical approval was obtained from the University of Health and Allied Sciences Ethics Review Committee (UHAS-ERC) with reference number UHAS-REC A4 [95] 18-19.

Study setting and population
Asuogyaman District is one of the twenty six districts in the Eastern Region of Ghana. It was created in 1988, covering a total estimated surface area of 1,507 square kilometers with its capital at Atimpoku (Asuogyaman district profile, 2017). The district shares boundary with Afram Plains District in the North, North Tongu District in the South, Manya Krobo District in the West and South Dayi District in the East (Asuogyaman district profile, 2017).

Data collection and sampling
Data collection was carried out by trained research assistants using pre-tested structured questionnaires on demographics characteristics of study participants and also on questions related to factors associated with low immunization coverage of children under five years in the district.
Data was collected at the household level in each of the selected communities which were identified by special codes. An estimated 15-20 minutes was spent with each respondent. Data were collected from selected communities from all the six (6) sub districts in the district from caregivers of children under five (5)  Simple random sampling method was used to select 4 communities from each sub district from a sampling frame consisting of the list of the communities in each sub district by lottery method. The total participants from each sub district were divided by four (4) to get the number of participants for each selected community. Purposive sampling method was used to select the mothers/caregivers interviewed from each house holds from the selected communities.

Data analysis
EpiData manager version 4.0.2.101 was used to create the database template and exported to EpiData entry version 4.0.2.49 for the data entry. After the entry, it was exported to excel for data cleaning and then to Stata version 13 for data analysis.
Microsoft Excel version 2013 was used to draw graphs. Two approaches for data analysis that is descriptive and analytic were used. The descriptive approach included calculation of the frequencies, percentages, tables, charts and graphs whiles the analytic approach included cross tabulations was used to calculate the associations between the variables under study and the significant levels with the use of chi-square. 4.3 Table 1 shows the demographic characteristics of the study participants. A total of 401 mothers/caregivers were enrolled in the study. The mean age of the study participants was 28.6±6.7 years with most of the caregivers in the age groups 20-29 years (53.9%) and 30-39 years (34.7%). Only 2(0.5%) of the mothers/caregivers were teenagers and 44(9.0%) were 40 years and older. Almost all the caregivers were females, 396(98.7%). Most of the participants, 241(60.1%) were married and only 11(2.8%) were separated or divorced. Majority of the participants, 346 (86.3%) had some level of formal education consisting of primary/junior high, 282(70.3%), senior high, 48(12.0%) and tertiary, 16(4.0%). A majority of the participants were Christians, 380(94.8%) with the rest being Muslims and African Traditionalist. Most of the participants were Ewes 254(63.3%) and only 72(18.0%) were Akans. In terms of employment, 61.3% of the participants were employed, whilst as much as 125(38.7%) were unemployed. Those who were employed were selfemployed (54.4%), government employees (3.0%) and private employees (4.0%). Majority of those who were employed had an income level below 200 Ghana Cedis (58.9%) and only 9(4.3%) had an income level above 800 Ghana Cedis per month. 18.5 Table 2 shows the characteristics of children of mothers/caregivers attending immunization sessions. More than half of the children were females, 230(57.4%) and the majority of the children were in the age group of 24-59 months, 191(47.6%). Large proportion of the children 327 (81.5%) were delivered in health facilities. Figure 3 shows the knowledge level of the mothers/caregivers on immunization. Overall, 62.3% (250) of the caregivers had good knowledge while 151(37.7%) had poor knowledge on immunization. ) knew the objective of immunization was to prevent disease. Only 36(9.0%) of the participants knew more than four vaccine-preventable diseases while 81(20.2%) did not know any vaccine-preventable disease. Also, only 163(40.7%) of the participants knew routine EPI services start at birth while a majority 216(53.9%) thought it started 6 weeks after birth, and 18(4.5%) did not know the age at which it starts. Most of the participants 221(55.1%) said they knew the number of sessions required to complete routine EPI services, and 109(48.7%) of them knew 7 or more sessions were required to complete the routine EPI services. Majority of the participants, 328(81.8%) knew a child completes routine EPI services at 18 months and 180(44.9%) reported knowing about some contra-indications of vaccines. Among those who knew some contra-indications of vaccines, 51(26.6%), 63(32.8%), 13(6.8%), 3(1.6%), and 35(18.2%) reported knowing fever, swelling, rash, convulsion, and excessive crying respectively as some contra-indications to vaccine   Table 4 shows the association between the level of knowledge of mothers/caregivers and the demographic characteristics. Level of knowledge was significantly associated with ethnicity (χ 2 =9.83, p=0.043, ), occupation (χ 2 =10.92, p=0.012, ), and place of delivery (χ 2 =4.37, p=0.037, ). However, there was no association between level of knowledge and age, sex, marital status, educational level, religion, income level, age of child, and sex of child (P>0.05). Table 5 shows the predictors of good knowledge among mothers/caregivers on immunization. Level of knowledge was significantly associated with ethnicity, occupation, and place of delivery. After adjusting for possible confounding effect of the variables, participants who were unemployed were 38% less likely to have good knowledge compared to participants who were self-employed and the difference was statistically significant (AOR=0.62; 95% CI=0.40-0.95; p=0.030). Also, participants who delivered at home were 2.1 times more likely to have good knowledge compared to participants who delivered at the health facility (AOR=2.12; 95% CI=1.19-3.77; p=0.010). Figure 4 shows the attitude of mothers/caregivers towards immunization. Overall, 304(75.8) of the participants had a good attitude toward immunization while 97(24.2%) had a poor attitude toward immunization. 12.5 From table 6, a total of 368(91.8%) of the participants reported they normally went for immunization services when the time is due. Also, regarding waiting time at the health facility, 182(45.4%) waited for <15 minutes, 146(36.4%) waited for 15-30 minutes, 47(11.7%) waited for 31-60 minutes, and 26(6.5%) waited for more than 1 hour before getting attended to. A total of 371(92.5%) reported that vaccination sessions did not affect their schedules, while 351(87.5%) had a means of transport to vaccination session. ( ) p Figure 5 shows the practices of immunization by mothers/caregivers. Overall, 346(86.3%) of the participants had good practices of immunization while 55(13.7%) had poor practices of immunization. 11.2 From table 7, almost all the participants, 399(99.5%) said they follow vaccination programs and 399(99.5%) said they will search for other vaccines for their children when the need arises. A majority 396(98.7%) reported managing swelling after vaccination by cold compress and 387(96.5) reported using analgesics for swelling and pain after vaccination. Also, 356(88.8%) participants reported cancelling some of their schedules in order to attend immunization sessions. Figure 6 shows the attitude of staff towards mothers/caregivers during immunization. Out of the 401 participants enrolled in the study, 353(88.0%) reported a good staff attitude towards them while 48(12.0%) reported poor staff attitude. of 25(6.2%) participants reported that health staff maltreated them during vaccination session, with 29(7.2%) of them claiming that the health staff collected money from them. Majority of the caregivers, 396(98.8%) reported meeting health staff at vaccination site for vaccination. Also, 383(95.5%) participants reported having a counseling session during CWC. Various proportion of the participants reported screaming on them when they forget their child's card 28(7.0%), when they miss an immunization session 35(8.7%), when their child become malnourished 58(14.5%) and when they are poorly dressed 18(4.5%). Figure 7 shows the accessibility of immunization services to mothers/caregivers. Majority 372(92.8%) of the mothers/caregivers had accessible immunization services.

Figure 7 Accessibility of Immunization Services
From table 9, majority of the participants, 382(95.3%) reported having vaccination site close to their place of residence. Most of the caregivers, 284(70.8%) travelled less than 15 minutes to get to their vaccination centers and 99(24.7%) had to travel between 15-30 minutes to get to their vaccination centers.  Figure 8 shows the availability of immunization services. A total of 284(70.8%) mothers/caregivers reported having available immunization services in their community.

Figure 8 Availability of Immunization Services
From table 10, most of the caregivers 284(70.8%) knew their local vaccination site schedule and 382(95.3%) claimed they were conveniently located. Most of caregivers 283(70.6%) said the vaccination service schedules were never cancelled and 314(78.3%) claimed they never returned from vaccination session without getting their children vaccinated.

Knowledge, Attitude, and Practices of Mothers/Caregivers towards Immunization
This study revealed that mothers/caregivers attending immunization session in the Asuogyaman district had a fairly good knowledge on immunization (62.3%). The high level of knowledge is important to make mothers/caregivers take their children to immunization sessions since they know its advantage to the children.
The level of knowledge found in this study is however higher than what was found by Birhanu et al (2016) in Ethiopia. In their study, they found that out of 626 mothers who were enrolled in the study, 55.0% had good knowledge on childhood immunization. This difference could be attributed to the health talks delivered at the health facilities as majority of the mothers/caregivers in this study (86.0%) mentioned their source of information to be from health workers compared to only 48.2% receiving information about immunization from health workers in the study in Ethiopia. Hence there is a likelihood of them receiving more accurate information.
The level of knowledge found in this study was however lower than what was found by Alenazi et al. (2017) in Egypt, Joseph, Devarashetty, Reddy, andSushma (2015) in Bengaluru in India and Oryema et. al (2017) in Uganda. In their study, the overall knowledge were 87.2%, 84% and 97% respectively. This discrepancy could be attributed to the higher educational level among the mothers in the study by Alenazi et al. as majority of their participants had either secondary school (33.8%) or college (61%) education with only 5.2% having primary school education. This study found that mothers/caregivers who were unemployed were less likely to have good knowledge compared to those who were self-employed. This could be due to the inability of mothers who were unemployed to transport themselves to enable them access healthcare services due to financial problems, hence depriving them of the privilege to get knowledge on immunization services. Also, mothers who delivered at the home were more likely to have good knowledge compared to mothers who delivered at the health facility. This could be due to the fact that the district under study is made up of many rural communities, and though the mothers may attend antenatal clinic during their pregnancy, most may prefer to deliver at home due to their individual preferences or societal influence. This assumption is however subject to further investigation. This study found the overall attitude of mothers/caregivers toward immunization services to be positive. From this study, about 8 out of every 10 mother/caregiver had a positive attitude towards immunization. This implies that most of the mothers/caregivers enrolled in the study have placed a high value on immunization services and do everything possible to make sure their children get vaccinated. This positive attitude toward immunization would help in increasing the immunization coverage and also ensure that children are vaccinated against infectious diseases thereby giving herd immunity to other children who do not get vaccinated. However, a study conducted by Birhanu, Anteneh, Kibie, & Jejaw (2016) in Ethiopia found only 53.8% of mothers having a positive attitude towards immunization. This discrepancy could be due to the larger sample used in the study by Birhanu et al in Ethiopia (Birhanu et al., 2016). This study also found that about 92% of the mothers/caregivers normally went for immunization sessions. This shows that the mothers place a high value on immunization as they make sure they go for immunization sessions when the time is due. Most of the mothers/caregivers waited less than 30 minutes before they were attended to by health staff. With the waiting time not being long, mothers are likely to go for immunization sessions since their schedules for the day will not be affected that much due to waiting at the health facility for long. Also, immunization sessions did not affect the schedules of about 93% of the mothers/caregivers and this could be attributed to the short waiting time at the health facility. About 88% of the mothers/caregivers also had a means of transport to the immunization centers and this could also account for the high positive attitude exhibited by mothers/caregivers toward immunization. With these factors being in place, the attitude of mothers toward immunization is likely to be high as Chris-Otubor et al. (2015) identified busy schedules of mothers, long waiting time, and transportation challenges to be contributing factors to low immunization coverage (Chris-Otubor et al., 2015).
Mothers/Caregivers practices toward immunization was generally high in this study. About 9 out of every 10 mothers/caregivers had good practices toward immunization activities. Similarly, Birhanu et al. (2016) in their study in Ethiopia found that 84% of the respondents had good practices toward immunization (Birhanu et al., 2016). This implies that most mothers/caregivers enrolled in the study carry out activities that promote or enhance immunization activities and this can contribute positively to increasing immunization levels. In this study, 98.7% reported they manage swelling after vaccination by cold compress and 96.5% said they used analgesics for swelling pain after vaccination. This practice could be due to the counseling given mothers/caregivers during immunization on how to manage any adverse reaction to immunization. This confirms what was found by Alenazi et al. (2017) in their study in Italy who recorded that 85.2% managed swelling by cold compress, and 87.2% used analgesics for swelling and pain after vaccination (Alenazi et al., 2017). However, a survey conducted in Uganda argued that fear of side effects, ignorance, laziness, of mothers/caregivers contribute to low immunization patronage (Vonasek et al., 2016). Also, a study conducted in Techiman Municipality in Ghana reported that low immunization coverage was attributed to mothers being too busy with other tasks and inconvenient time of immunization schedules (Adokiya, Baguune, & Ndago, 2017).
immediately begins with immunization. In-service training should periodically be organized by the district health management team for the health workers to maintain the good practices and to improve upon their knowledge in immunization in the District. Finally, there should be a social support groups created in the community by the community health workers with support from women leaders in the community to empower mothers/caregivers to improve on their knowledge on immunization.

COMPETING INTERESTS
We declare that we have no conflict of interests FUNDING: The study was funded by the Principal Investigator AUTHORS' CONTRIBUTIONS SAB, ESK and AZA conceived the study. CAK and SAB did the data analysis. SAB, JMG, ESK were responsible for the initial draft of the manuscript. All authors reviewed and approved the final version of the manuscript.