Factors influencing missed opportunities for vaccination among children aged 0-23 months within the Hohoe Municipality: A facility-based study.

doi:10.21203/rs.3.rs-3313871/v1

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Factors influencing missed opportunities for vaccination among children aged 0-23 months within the Hohoe Municipality: A facility-based study.

https://doi.org/10.21203/rs.3.rs-3313871/v1

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Background

Immunization is a crucial public health strategy for increasing child survival by directly addressing major diseases that kill children as well as serving as a foundation for other health services. Every year, more than 31 million children under the age of five in sub-Saharan Africa are affected by diseases that are preventable by vaccination and more than half a million pass away because they lack access to the needed vaccines. Missed Opportunities for Vaccination (MOV) hinder Sustainable Development Goal (SDG) 3 which seeks to guarantee healthy lives and promote well-being for all ages from being reached. The study sought to determine the factors impeding MOV among caregivers with children aged 0-23 months in the Hohoe municipality.

Methods

A cross-sectional design was deployed in the study. Structured questionnaires were administered to caregivers with children aged 0-23 months within the sampled health facilities in the Hohoe municipality using registers from the child welfare clinic (CWC). A total of 378 caregivers between the ages of 18 years and above were recruited to participate in the study. Kobo Collect version 1.30.1 was used for data collection and was exported into an Excel format for analysis using STATA version 16.

Results

A total of 378 caregivers with children aged 0-23 months participated in this study. The study found the prevalence of MOV to be (22.2%). The mean ±standard deviation (SD) of the knowledge scores was 1.8 ± 0.4 and the attitude score was 1.6 ± 0.5. Most caregivers (80%) had poor knowledge on immunisation and more than half (63.8%) showed a positive attitude towards immunisation despite their poor knowledge. Multivariate analysis revealed that caregivers’ knowledge [cOR= 2.14(1.05,4.38) p<0.001] and attitude [aOR=3.12(1.81,5.37) p<0.001] were predictors of MOV.

Conclusion

MOV is prevalent in many settings and it impedes immunisation coverage. Knowledge and attitude of caregivers were associated with missed opportunities. Findings from the study showed a high proportion of caregivers with poor knowledge regardless of their good attitude towards infant vaccination. Hence, there is a need to intensify strategies to raise their knowledge to help combat missed opportunities in the Hohoe municipality.

Epidemiology

Factors

missed opportunity

Vaccination

Approximately 2 and 3 million deaths are prevented yearly by immunization, and this has been a useful technique for controlling and eradicating infectious diseases that are life-threatening [1]. Immunization prevents an estimated 600,000 adult deaths and 2.5 million child deaths annually throughout the world [2]. Every year, more than 31 million children under the age of five in sub-Saharan Africa are affected by diseases that can be prevented by vaccination, and more than 500,000 of them lose their lives because they cannot get the necessary vaccine[3].

A MOV includes any contact with health services by a child or adult who is eligible for vaccination (unvaccinated, partially vaccinated, and free of contraindications to vaccination), which does not result in the individual receiving one or more vaccine doses for which he or she is eligible [4]. Immunization plays a critical part in attaining SDG 3 by ensuring healthy lives and fostering well-being for all ages [5]. The vaccine coverage rates in some regions of Ghana have stagnated and stayed quite low for years despite the country's immunization program's progress [6]. In the Hohoe municipality, the routine immunization coverage rate has declined over the past three years for all antigens ranging from 69% in 2017, 41.0% in 2018 and 40.8 in 2019 [7] and this falls below the global vaccine action plan for district coverage (80%). This study was conducted to determine the underlying causes of MOV among children under 5 years old in the municipality and to propose measures to improve vaccination coverage.

Study site and context

The study was carried out in the Hohoe Municipal in the Volta Region of Ghana which is one of the eighteen (18) municipalities in the region. The municipality has a total population of about 210,620 of which 106,978(50.2%) constitute females and 103,642(49.8%) constitute males with a growth rate of 2.4% [8]. The municipality has been divided into four (4) Sub-municipalities namely: Alavanyo, Agumatsa, Gbi-South and Hohoe-sub. The tribes in the municipality include the Ewes, the Likpes, the Akpafus, the Lolobi and the Santrokofi. This study was conducted among four (4) hospitals and four (4) CHPS compounds within Hohoe-sub and Agumatsa. A simple random method was used to select these health facilities from those two sub-districts. All these facilities offered CWC.

Study design, population and sample size

This quantitative study employed a cross-sectional design and the study was conducted between March to April 2021. Caregivers aged 18 years and above participated in the study. All CWC registries at the chosen healthcare facilities were used to choose the study's sample. A minimum sample size of 378 was obtained from the formula n= \(\frac{{\varvec{z}}^{2}\frac{\varvec{\alpha }}{2} \times \varvec{p}\left(1-\varvec{p}\right)}{{\varvec{e}}^{2}}\) [9].

Where \({\varvec{z}}^{2}\frac{\varvec{\alpha }}{2}\)= 1.96,

p = 44.2% from an annual report from the Hohoe Municipal Health Directorate, 2020,

e = 0.05 (5%) non-response rate.

n=\(\frac{{\left(1.96\right)}^{2} X0.442(1-0.0442) }{{\left(0.05\right)}^{2}}\)

n = 379

A final sample size of 397 caregivers was chosen for this study, taking into account a non-response rate of 5%.

Data collection and sampling

Based on the researched literature, a structured, closed-ended questionnaire was created. The questionnaire was altered to include demographic characteristics such as sex, age, marital status, and level of education as well as attitudes and knowledge of caregivers about immunization, infant characteristics and immunisation status. Research assistants who had previously worked on a facility-based investigation were trained, supervised and used. Proper data collection methods were ensured in adherence to the study’s protocol. The data collection tool was pretested and all identified errors were rectified before the actual study. Systematic random sampling was utilized to choose all caregivers who met inclusion criteria till the sample size was reached. Those who declined consent or were too ill to consent were excluded from the study.

Definition of variables

Outcome variable

Experiencing a MOV was the outcome variable for this study. A missed opportunity was considered as any contact with a health facility by a child who is eligible for vaccination during an immunization session and he/she does not receive the vaccine doses for which he or she is eligible. The outcome variable was categorized as “Yes” for experiencing a MOV and “No” for not experiencing MOV.

Exposure variables

The primary exposure variables considered for this study were the caregiver’s socio-demographic characteristics, knowledge and attitudes towards infant immunization. A composite variable was generated to assess the knowledge and attitude level of mothers. A value above the mean score was categorized as good knowledge and a value below the mean score was considered poor knowledge and vice versa for maternal attitude.

Data management and statistical analysis

Data was collected using KoboCollect. Data cleaning, validation and analysis were done using MS Excel Stata version 16.0. Categorical data were presented using summarized frequencies and percentages, normally distributed continuous variables were summarized using mean and standard deviations and skewed continuous data were summarized using median and interquartile ranges. Chi-square tests (expectations < 5) were conducted to determine factors predicting MOV. Logistic regression models were used to determine the strength of the association between the independent variables and the outcome variable (missed opportunity). Statistical significance was considered at a 5% alpha level.

The study recruited 378 caregivers with a 100% response rate.

Socio-demographic Characteristics of Caregivers.

Almost all caregivers (96.0%) were females with a majority (68.0%) of them being 30 years and below. The average age of the caregivers was 13.7 years with a standard deviation of ± 6.3. The majority of caregivers (53.2%) were married and more than two-thirds (85.2%) were Christians. The Ewe ethnic group (66.7%) was most predominant and the majority of them were working (69.1%). About 35.2% of the caregivers had completed the JHS educational level and more than half of them 57.1% have ever given birth one or two times. Most of the caregivers (73.3%) had their residences close to the immunisation centres and the majority (79.6%) got to immunization sites by foot (Table 1).

Table 1

Socio-demographic Characteristics of caregivers in the Hohoe Municipality (n = 378)
Variable	Frequency(n)	Percentage(%)
Sex
Male	15	4.0
Female	363	96.0
Mean age of caregivers (SD)[Years]	13.74(± 6.30)
Age (years)
18–30 years	257	68.0
31 years and above	121	32.0
Marital status
Married	201	53.2
Not married	177	46.8
Religion
Christianity	323	85.5
Islamic	55	14.5
Ethnicity
Ewe	252	66.7
Akan	26	6.9
Kotokoli	38	10.1
Guan	17	4.5
Kokomba	23	6.1
Others	22	5.8
Occupational status
Not working	117	31.0
Working	261	69.1
Educational status
None	72	19.1
Primary	57	15.1
JHS	133	35.2
SHS/TECH/VOC	82	21.2
Tertiary	34	9.0
Number of children (Mean)[S.D]	2.01(± 1.15)
1–2	216	57.1
3–5	140	37.0
5+	22	5.8
Long-distance to immunisation site
Yes	101	26.7
No	277	73.3
Means of transportation
Vehicle	77	20.37
Foot	301	79.6

Socio-demographic characteristics of infants.

More than half (56.1%) of the infants were males and the majority (55.3%) were less than 12 months. Nearly all infants (98.4%) were delivered at a health facility and all of them had their vaccination cards present at the time of the study (Table 2).

Table 2

Demographic characteristics of infants in the Hohoe Municipality (n = 378)
Variables	Frequency(n)	Percentage (%)
Child demographics
Mean age of child (SD)[Months]	22.51(± 13.54)
Age group of children (Months)
0–11	209	55.3
12–23	169	44.7
Sex
Male	212	56.1
Female	166	43.9
Place of birth
Health Facility	372	98.4
Home	6	1.6
Immunisation card
Yes	378	100
No	0	0

Infant immunization status

The majority (65.1%) out of 378 children with valid vaccination records were partially immunised and had missed at least one dose of the nine vaccines or had not received all the recommended vaccines by WHO. However, only 34.9% were fully immunised and had received all the vaccine doses considered to protect them from vaccine-preventable diseases as recommended by WHO. Out of the fully immunized children, (37.3%) were less than one year while (32.0%) were above one year of age. More than half (62.7%) and (68.1%) of the partially immunised children were less than a year and above one year respectively (Fig. 1).

Prevalence of MOV

The study found 22.2% MOV among children aged 0–23 months. The prevalence was higher among males (25.5%) compared to females (18.1%). The prevalence (22.5%) was slightly high among infants aged 11 months and below compared to those above the age of 11 months (22.0%). Prevalence among partially immunized children was higher (82.1%) compared to those who were fully immunised (17.7%) (Table 3).

Table 3

Prevalence of MOV
Variable Missed opportunity(n = 84) Yes n (%) No n(%)
Mean Age of Child (SD)[Months]	22.51(± 13.54)
Age group of children (Months)
0–11	46(22.5)	163(78.0)
12–23	38(22.0)	131(77.5)
Sex
Male	54(25.5)	158(74.5)
Female	30(18.1)	136(81.9)
Place of birth
Health Facility	82(22.0)	290(78.0)
Home	2(33.3)	4(67.0)
Fully immunised
No	69(82.1)	177(60.2)
Yes	15(17.7)	117(39.8)

Caregivers’ knowledge on immunisation

About two-thirds (65.6%) of caregivers had no idea when infant vaccination starts and less than half (37.3%) of caregivers knew the purpose of vaccines for their children. The mean ± standard deviation (SD) of knowledge scores was 1.8 and ± 0.4 respectively. Overall knowledge score showed that approximately, (80%) have poor knowledge while a few (20%) have good knowledge on when infant immunisation starts and the purpose of vaccines in their wards. Health professionals were the major source of information for about 79.8% of caregivers (Table 4).

Table 4

Percentage distribution of caregivers knowledge on immunisation
Variables	Frequency(n = 378)	Percent (%)
Sources of information
Health professionals	301	79.8
Television & Radio	10	2.5
Friends	67	17.7
Infant vaccination programme starts
Just after birth 130 34.4
After one month	82	21.7
Don’t know	166	65.6
Vaccine’s purpose
Not sure what they are for	169	44.7
So children would grow up healthy	55	14.6
To cure/heal diseases	13	3.4
To prevent diseases Overall knowledge score	141	37.3
Poor	76	20.1
Good	302	79.9

Attitude of caregivers towards immunisation.

In assessing caregivers’ attitudes towards immunisation, findings revealed a mean attitude score ± 1.6 and [SD 0.5. A higher proportion (79.4%) attended immunisation sessions regularly regardless of distance and cost of transportation to vaccination sites. However, (60.5%) had a fear of side effects after vaccination. Overall attitude score showed that the majority (63.8%) had a good attitude towards immunisation and the rest (36.2%) had a poor attitude towards immunisation (Table 5).

Table 5

Percentage distribution of caregivers attitudes towards immunisation
Variable	Frequency(n = 378)	Percent (%)
Regular immunisation attendance
Yes	300	79.4
No	78	20.6
Distance as a barrier to immunization centre
Yes	35	9.3
No	343	90.7
Cost of transportation as a barrier to immunization centre
Yes	43	13.2
No	282	86.8
Fear of side effects of vaccines after vaccination
Yes	227	60.1
No	151	40.0
Overall attitude score
Poor	137	36.2%
Good	241	63.8%

Association between knowledge and attitude of caregivers and missed MOV

Having good knowledge and attitude towards immunisation was a predictor to MOV in this study. Establishing an association between knowledge and attitude of caregivers on missed opportunities, the study found that (11.9%) of infants of caregivers who had good knowledge experienced missed opportunities and a high proportion (88.1%) of infants of caregivers with poor knowledge had missed opportunities. The odds of MOV was 2.14 times high among infants of caregivers with poor knowledge compared to those of caregivers with good knowledge [COR = 2.14(1.05,4.38) p = < 0.001]. Also, infants of caregivers with a poor attitude towards immunisation [AOR 3.12(1.81,5.37) p = < 0.001] had thrice the odds of experiencing missed opportunities in immunisation compared to their counterparts (Table 6).

Table 6

Association between attitude and knowledge of caregivers and MOV
Variable	Yes n= [84]	No n= [294]		p-value	AOR (95%Cl)	p-value
	n (%)	n (%)
Caregivers’ knowledge
Good	10(11.9)	66(22.5)	Ref		Ref
Poor	74(88.1)	228(77.6)	2.14(1.05,4.38)	0.037*	1.98(0.95,4.09)	0.067
Caregivers attitude
Good	52(61.9)	247(84.0)	Ref		Ref
Poor	32(8.1)	47(16.0)	3.23(1.89,5.55)	< 0.001*	3.12(1.81,5.37)	< 0.001*

*Statistically significant p-value < 0.05 at 95% Cl

Prevalence of MOV

In this cross-sectional study, the prevalence of MOV in the Hohoe Municipality was explored. The study found the prevalence of MOV to be 22.2%. This prevalence was lower than findings from previous studies in Ethiopia and Ondo State in Nigeria and a systematic review study among children in Africa were 74.9%, 33% and 27.3% respectively[10, 11, 12]. A high degree of client satisfaction among caregivers who received immunization services inside the study's jurisdiction may account for the difference in these inequalities. On the other hand, MOV (22.2%) in this study was higher than MOV (4.6%) in South Africa [13]. This reflection may be due to the socio-cultural differences in health-seeking behaviours among caregivers of these children.

Immunisation and caregivers’ knowledge

The study found that the caregiver’s knowledge was a predictor of infant MOV [COR = 2.14(1.05,4.38) p = < 0.001]. The main source of immunisation information to (80%) of the caregivers was the healthcare workers. This finding was in line with a previous study conducted in Nigeria [14]. Also, our findings found that approximately (80%) of caregivers demonstrated poor knowledge of immunisation while a few (20%) of them had good knowledge. Hence, children of caregivers who lacked knowledge of immunisation were more likely to have incomplete immunisation and missed opportunities. This finding resonates with other studies finding conducted in Kenya and Nigeria [15, 16]. This could be due to the inadequate diverse sources of immunisation information. Although their main source of information was health workers, the poor knowledge of immunisation may be a result of health workers focusing more on the regular attendance of caregivers and the importance of increasing attendance than emphasizing the importance of the vaccines to their infants. This points to the fact that there is a gap in the knowledge and health education programmes and comprehensive education regarding immunisation should be tailored to increase their knowledge of immunisation.

Attitude of caregivers towards immunisation.

More than half (60%) of caregivers reported they feared the side effects after vaccination and the findings were higher than that of a study in Croatia. Also, more than three-fifths (63.8%) of the caregivers showed a good attitude towards immunisation regardless of misconceptions and side effects of immunisation and other reasons likely to influence their attitude. This finding gives credence to a study in Croatia [17]. The attitude of caregivers towards immunisation was a predictor of missed opportunities [AOR 3.12(1.81,5.37) p = < 0.001] and infants of caregivers with poor attitudes were more likely to have missed opportunities. Similarly to other studies conducted in India, Khartoum and Ethiopia, infants whose caregivers had poor attitudes experienced missed opportunities [18, 19, 20]. Although knowledge of immunisation was very poor, there was a positive attitude immunisation programme. This implies that their knowledge does not influence their attitude towards immunisation. This reflection could be because immunisation services are free in Ghana and health workers send vaccines to the doorstep of the people living in the municipality on outreaches and home visits.

Limitations and opportunities

The study acknowledges the opportunities and limitations of the assessment approach used. A cause-and-effect relationship could not be established because the study employed a cross-sectional survey and might not have been able to capture all MOV. Again, because the study was located in a healthcare institution, only caregivers who were present on the day of data collection were included. Additionally, since just two of the municipality's subdistricts were represented in the findings, conclusions from this study cannot be applied to the entire study population. Therefore, considering MOV from a larger perspective is crucial for future research.

Immunisation has been one of the health interventions that has attained a significant level of effectiveness over the years, however, there are still grounds to cover to achieve the set of goals of ensuring all eligible children access and utilize immunisation. A missed opportunity has been one of the major challenges to attaining this goal for immunisation. The study found (22.2%) prevalence of MOV. Caregiver’s attitude and knowledge were significantly associated with missed opportunities in this study. The study's findings revealed that a large percentage of caregivers had little information about vaccinations yet had a favourable attitude regarding vaccination. Despite the low proportion of missed opportunities for vaccination among children of caregivers in the municipality, infant immunization is paramount to their survival and as such, there is a need to intensify strategies to curb these barriers. This is crucial for achieving SDG 3 goal 2, which aims to eliminate the preventable deaths of infants and children under 5 by 2030.

MOV

Missed Opportunities for Vaccination

SDGs

Sustainable Development Goals

VPDs

Vaccine-Preventable Diseases

CWC

Child Welfare Clinic

AOR

Adjusted Odds Ratio

COR

Crude Odds Ratio

Ethical consideration

The University of Health and Allied Sciences Research Ethics Committee (UHAS-REC) granted ethical approval with Protocol Number: (UHAS-REC A.9[86] 20-21). The Hohoe Municipal Health Directorate gave authorization before the study could be carried out. The Hohoe Municipal Hospital's in-charges were also asked for permission before administering the questionnaire to the subjects. Individual consent was done in the languages of Ewe, Twi, and English. The study's goal was well explained to the participants. Participants were made aware of the voluntary nature of the process, their right to withdraw at any moment, and the guarantee of data confidentiality. Last but not least, before the interview, written permission was requested from each participant who was at least 18 years old and agreed to participate. Endorsement by participants was done by either a signature or a thumbprint.

Consent for publication

Not applicable.

Availability of data and materials

The dataset generated and analyzed during this study is available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Authors’ contributions

DMO originated the research idea, performed the literature review, participated in data collection, processing, and analysis and drafted the manuscript. DMO and SYA provided critical comments which improved the scientific quality of the manuscript. All authors approved the final draft of the manuscript for submission.

Acknowledgments

We wish to extend our gratitude to the Research Assistants, study participants, the Hohoe Municipal Health Directorate, and the management of the health facilities for their support during the period of the study.

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Supplementaryfile.pdf
Data collection tool

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Factors influencing missed opportunities for vaccination among children aged 0-23 months within the Hohoe Municipality: A facility-based study.

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Abstract

Figures

Introduction

Methods

Study site and context

Study design, population and sample size

Data collection and sampling

Definition of variables

Outcome variable

Exposure variables

Data management and statistical analysis

Results

Infant immunization status

Prevalence of MOV

Caregivers’ knowledge on immunisation

Association between knowledge and attitude of caregivers and missed MOV

Discussion

Prevalence of MOV

Immunisation and caregivers’ knowledge

Limitations and opportunities

Conclusion

Abbreviations

Declarations

References

Supplementary Files

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