Abstract
Background and Objective
Immunization is a cornerstone of public health, significantly reducing child mortality and morbidity worldwide. Despite global progress, millions of children, particularly in low- and middle-income countries (LMICs), still lack access to lifesaving vaccines. In Ghana, disparities in vaccination coverage persist, with sub-national inequities affecting the achievement of universal immunization. This study aimed to evaluate routine immunization coverage among children under two years of age in Ghana's Eastern and Oti regions, focusing on identifying gaps and informing targeted interventions to improve immunization outcomes.
Method
A cross-sectional study was conducted using a multistage stratified sampling approach. Data were collected from 1,114 eligible children aged 24–35 months across 73 enumeration areas in 11 districts. Vaccination information was obtained from vaccination cards or caregiver recall. Descriptive statistics and binary logistic regression were used to analyze vaccination coverage and identify factors associated with full immunization. Data were weighted to account for the multistage sampling design.
Results
Full vaccination coverage for all antigens (excluding hepatitis B) was 18.7% (95% CI: 16.5%—21.1%), with higher rates in rural 19.7% (95% CI: 16.8%—23.1%) than urban areas 17.4% (95% CI: 14.3%—21.0%). Coverage for basic antigens was 78.8% (95% CI: 76.3%—81.1%), with rural areas 82.4% (95% CI: 79.2%—85.3%) outperforming urban areas 74.4% (95% CI: 70.4%—78.0%). The Oti region had higher coverage for basic antigens 85.3% (95% CI: 81.3%—88.5%) and the national schedule 62.1% (95% CI: 52.2%—62.4%) compared to the Eastern region. In the Eastern region, older children were more likely to be fully vaccinated (aOR: 1.06, 95% CI: 1.01—1.12, p = 0.021), while in the Oti region, age (aOR: 0.96, 95% CI: 0.89—1.04) was not a significant factor.
Conclusion
The study highlights significant disparities in vaccination coverage between urban and rural areas and across regions. Targeted interventions are needed to address gaps in coverage, particularly in urban areas where full vaccination rates remain lower. Strengthening health systems, leveraging technology, and improving community engagement are critical steps toward achieving equitable and high vaccination coverage for all children in Ghana.
Keywords: Routine immunization, Vaccination coverage, Children under two, Determinants of immunization, Ghana
Background
Immunization is widely recognized as one of the most successful and cost-effective public health interventions, playing a critical role in preventing infectious diseases, reducing child mortality, and improving overall population health [19, 31]. Vaccines have been instrumental in eradicating smallpox, near-eliminating polio, and significantly reducing diseases such as measles, tetanus, and diphtheria [25] 20252025). Despite these achievements, global vaccination coverage remains uneven, with millions of children, particularly in low- and middle-income countries (LMICs), still lacking access to lifesaving vaccines [9]. In 2022, an estimated 20.5 million children worldwide did not receive essential vaccines, marking an increase of 2.1 million since 2019 [25]. This alarming trend underscores the urgent need to address barriers to immunization, particularly in regions where vaccine coverage remains suboptimal.
Ghana, like many other LMICs, has made significant strides in expanding its immunization program through the National Expanded Programme on Immunization (EPI). Established in 1978, the EPI initially focused on six vaccine-preventable diseases: tuberculosis, diphtheria, pertussis, tetanus, polio, and measles [5, 26]. Over the years, the program has expanded to include additional vaccines, such as yellow fever (YF), hepatitis B, Haemophilus influenzae type b (Hib), pneumococcal conjugate vaccine (PCV), rotavirus vaccine, Men A, and the recently introduced malaria vaccine, RTS,S/AS01E [7]. These vaccines are crucial for protecting children against diseases that are leading causes of morbidity and mortality among children under five years of age in Ghana [12].
The RTS,S/AS01E malaria vaccine consists of four doses per child and has shown promise in reducing malaria cases and deaths. However, its uptake has been suboptimal, with coverage dropping from 76% at the first dose to 66% at the third dose, and 55% at the fourth dose [1]. This drop-off highlights demand-side challenges such as caregiver hesitancy and limited awareness, as well as supply-side barriers like health worker strikes and logistical constraints [30].
Despite these efforts, disparities in vaccination coverage persist across regions and within populations. The 2022 Ghana Demographic and Health Survey (GDHS) revealed that 75% of children aged 12–23 months were fully vaccinated against basic antigens (children who have received all the following: One dose of BCG vaccine, three doses of polio vaccine given as oral polio vaccine (OPV)– excluding OPV at birth (OPV0), inactivated polio vaccine (IPV), three doses of Pentavalent vaccine (Penta) and one dose of measles-rubella vaccine (MR)). For vaccination according to national schedule (children who have received the following: BCG, three doses of Pentavalent (Penta), four doses of OPV (including OPV given at birth), one dose of IPV, one dose of yellow fever vaccine, three doses of pneumococcal vaccine (PCV), two doses of rotavirus vaccine, two doses of measles-rubella vaccine (MR) and one dose of the meningitis A vaccine (MenA)), only 56% were fully vaccinated [12]. Regional disparities are also evident, with the Northern region recording the lowest vaccination coverage (56%) and the Western North region achieving the highest (88%) [12]. These disparities highlight the need for targeted interventions to address inequities in vaccine access and uptake, particularly in underserved and hard-to-reach areas.
The disparities in vaccination coverage between urban and rural areas are particularly striking. While rural areas often face challenges such as limited healthcare infrastructure and long distances to health facilities, they tend to have higher vaccination coverage compared to urban areas. This paradox can be attributed to the effectiveness of community-based interventions, such as the Community Health Planning Services (CHPS) program, which is more active in rural areas [6]. The CHPS program involves community health nurses providing outreach services, conducting home visits, and tracing defaulters, which has been instrumental in improving vaccine coverage in rural areas [6]. In contrast, urban areas face unique challenges, such as higher population density, more complex healthcare systems, and vaccine hesitancy, which may contribute to lower coverage rates [5].
The role of technology in improving vaccination coverage cannot be overstated. In recent years, there has been growing interest in the use of digital tools, such as electronic immunization registries and biometric systems, to improve vaccine tracking, reduce duplication, and ensure accurate data collection [19]. For example, Simprints, a biometric technology company, is collaborating with Ghana Health Service to pilot a dual-modality biometric system that uses fingerprints and facial recognition to identify and verify children during vaccination [19, 21, 22]. This technology has the potential to address challenges related to vaccine tracking and defaulter tracing, particularly in hard-to-reach areas[17, 17]. However, the successful implementation of such technologies requires significant investment in infrastructure, training, and community engagement.
Despite the progress made in expanding immunization coverage, several challenges remain. These include vaccine stockouts, cold chain deficits, limited funding for outreach activities, and structural, administrative, and accountability issues [23]. These challenges contribute to inconsistent coverage and highlight the need for sustained investment in health systems strengthening. Additionally, the COVID-19 pandemic has further exacerbated these challenges, disrupting routine immunization services and leading to a decline in vaccination coverage in many countries, including Ghana [8]. The pandemic has also highlighted the importance of building resilient health systems that can withstand shocks and continue to deliver essential health services, including immunization.
While Ghana has made significant progress in expanding its immunization program, disparities in vaccination coverage persist. Addressing these disparities will require targeted interventions that strengthen health systems and leverage technology to improve vaccine tracking and delivery. This study aims to evaluate routine immunization coverage among children under two years of age in the Eastern and Oti regions of Ghana, with a focus on identifying gaps and informing targeted interventions to improve immunization outcomes. The findings will contribute to the growing body of evidence on vaccine coverage in LMICs and support efforts to achieve equitable access to immunization.
Methodology
Study design
The study utilized a cross-sectional design and a multistage stratified approach. The study was conducted in two regions (Eastern and Oti). The Eastern and Oti regions were selected to reflect varying demographic and healthcare contexts. Eastern is more urbanized, while Oti is predominantly rural, allowing for a comparison of urban–rural immunization coverage. The study team obtained a sampling frame of all enumeration areas (EAs) in the two regions (Oti and Eastern) from the 2021 Ghana Population and Housing Census (PHC) from the Ghana Statistical Service (GSS). The 2021 PHC provided a complete list of all enumeration areas in the country. The team implemented a two-stage stratified sample selection approach using enumeration areas (sampling frame– first stage) as primary sampling units. Additionally, all households were stratified by region (Eastern and Oti) and residence (urban and rural), resulting in four strata: Eastern-Urban, Eastern-Rural, Oti-Urban, and Oti-Rural. For the secondary sampling units, households were selected in every urban and rural EA (cluster) using a probability systematic sampling approach.
Instrument development
The survey instrument was adapted from the Ghana Demographic and Health Survey (GDHS) and WHO's EPI coverage tool to ensure comparability and contextual relevance. A pilot test was conducted in the Greater Accra Region to assess clarity, flow, and response validity. Revisions based on pilot findings improved question structure and skip patterns. Key variables included the child’s age, sex, vaccine doses received and caregiver demographics.
Survey participants and approach
The participants were children aged 24–35 months, born between March 2020 and April 2021. This period overlaps with the COVID-19 pandemic, which may have disrupted routine immunization services and caregiver access to health facilities. To measure immunization coverage across the two regions, household surveys were conducted using a stratified approach with data collection tools. In every household, immunization information was collected/extracted from vaccination records (cards) as the primary source. Where the record book was unavailable, vaccination history was obtained based on the caregiver’s recall.
Sample size calculations
The routine vaccination coverage was estimated in each of the two (Eastern and Oti) regions, taking into consideration the estimated coverage in each region. Therefore, the estimated effective sample size was calculated using the following equation [29]:
 |
where n was the required effective sample size (number of study participants in the study) and 
was the standard normal variate at type I error (α) = 5%. We assumed a full immunization coverage to be on average 72% [12] in each region, according to the Ghana Demographic and Health Survey report, with confidence intervals not wider than (precision) ± 5%. Therefore, the effective sample size for each stratum was approximated to be 355. We assumed a design effect of 1.3, and with 2 strata, the total respondents was estimated to be 923.
Sampling strategy
The crude birth rate of 27.55 live births per 1,000 population in Ghana was used as a planning metric for estimating the number of children under two years of age per enumeration area [13]. This was approximated to 30 per 1,000 with an average household size of approximately 4. According to the 2021 Ghana Population and Housing Census, an enumeration area (EA) in the Eastern and Oti regions contained an average of 179 and 116 households, respectively [13]. This gave an average of 148 households per EA. Based on the 2020 birth rates, we estimated approximately 20 children under two years per EA.. We anticipated that not all households with the target population were going to be available at home during the interviews, so for each cluster, we collected information from 15 households with children under two years of age. We estimated that the average number of households required to enroll 15 children was 125. For effective sampling, utilization of resources, and representativeness, we used probability proportional to estimated size and sampled approximately 75 EAs from both Eastern and Oti regions to meet our sample requirements. Among the two regions,there were a total of 2,549 EAs in urban areas and 3,878 EAs in rural areas. The total number of districts selected for the two regions was 11.
Procedure
The sample was stratified into two stages using the sampling frame, with each district split into urban and rural areas. Samples were selected independently in each sampling stratum. In the first stage, 73 EAs were randomly selected, with 33 EAs allocated to urban areas and 40 to rural areas based on probability proportional to size. In the second stage of selection, a cluster sampling approach was adopted whereby all households within the selected EAs were visited and all eligible children sampled, and caregivers interviewed. The sampled EAs and their allocations were provided to field staff. Data collection took place over a two-week period from 5th July 2024 to 17th July 2025.
Data quality assessment
Field data collectors were monitored by supervisors and the research team. These supervisors reviewed all data collected via the tablet for inconsistencies and errors and reconciled these to the extent possible with data collectors. To ensure birth and immunization dates entered by the research assistants (RAs) were correct, a verification team verified these dates using pictures of the immunization pages taken by the field staff. The principal investigators ensured adequate monitoring of research supervisors. The electronic data collection tool was also developed with appropriate control, logic, and skip patterns aimed at improving data quality. The pilot test also helped to incorporate suggestions to obtain the final tool.
Training of field supervisors and enumerators
Training of field supervisors and enumerators was carried out, taking into consideration the survey objectives and tools. All data collectors were trained on the procedures for collecting quantitative data, ethics, methods for maintaining data confidentiality, and appropriate handling and storage of study data and information. They were also trained to recognize, respond to, and report any adverse events.
Pretesting of the survey tools
Before the main survey commenced, a pretest was conducted to test all aspects of the survey (including data entry) in the Greater Accra region, and this was carried out during the training. This was to build the capacity of supervisors and enumerators in administering the survey tools. Feedback and lessons learned from the experience of pretesting the tools informed revisions to the survey questionnaire.
Data analysis
Data analysis started immediately after data collection had been completed. Data cleaning was carried out in Microsoft Excel. Descriptive analysis was done for both continuous variables (median, interquartile range), and categorical variables (frequencies, proportions, and on charts). The dataset was analyzed using Excel, Stata MP version 18 (Stata Corp., College Station, TX, USA).
All the analyses were weighted, considering the multistage approach described in the survey subsection of the report. In calculating the weights, we considered the survey design and participants'nonresponse. Post-stratification adjustments were also applied.. The design weight was calculated using the reciprocal of the probability that the respondent was selected to participate in the survey, which is the product of the probabilities of selection at each stage. These were dependent on the following scenarios: First, the probability that the primary sampling unit (PSU) was selected from the sampling frame of all the PSUs. Secondly, the probability is based on the segmentation of the PSUs, with that segment selected from the list of all the segments derived from the PSUs. This probability was 1 for the immunization survey. Thirdly, the probability of selecting the household from the list of all households in the segments as described above. For the immunization survey, this probability was 1. Finally, the probability of selecting a respondent given that there were other eligible respondents in the household. Again, this probability was 1 for the immunization survey. Therefore, the total probability that a respondent is selected was obtained using the following mathematical expression.
 |
With the design weight being the reciprocal of the Pselection and given as:
 |
Full vaccination coverage– all antigens
Full vaccination coverage was defined as children receiving all the recommended antigens, excluding the hepatitis B birth dose, at the time of survey for a child aged 24–35 months. Though the Hepatitis B vaccine at birth is part of the routine childhood immunization schedule in Ghana, the country has not included it in the category of"basic antigens"calculations. Mainly because it hasn’t been considered as one of the mandatory vaccines at birth.
Full vaccination coverage– Basic antigens
Full vaccination coverage based on the basic antigen is defined as children aged 24–35 months who have received all the following:
One dose of BCG vaccine
Three doses of polio vaccine given as oral polio vaccine (OPV)– excluding OPV at birth (OPV0),
Inactivated polio vaccine (IPV)
Three doses of Pentavalent vaccine (Penta)
One dose of measles-rubella vaccine (MR)
Full vaccination coverage– national schedule
Full vaccination coverage based on the national schedule is defined for children aged 24–35 months as those who have received all the following:
BCG
Three doses of Pentavalent (Penta)
Four doses of OPV (including OPV given at birth),
One dose of IPV
One dose of yellow fever vaccine,
Three doses of pneumococcal vaccine (PCV),
Two doses of rotavirus vaccine,
Two doses of measles-rubella vaccine (MR).
One dose of the meningitis A vaccine (MenA)
Malaria vaccine schedule
In Ghana, the malaria vaccine (RTS,S/AS01, also known as Mosquirix) is administered in a four-dose schedule, with the first dose given at 6 months of age, followed by 7 months, 9 months, and at 18 months for the second, third, and fourth doses respectively.
Results
Descriptive characteristics of study sample
In the immunization survey, caregivers of 1,147 children aged 24 −35 months were interviewed. Out of which 10 had no information on their district and region of residence, 22 were outside the age range, and 1 did not have information on vaccination status. The final eligible sample for analysis was 1,114 children Fig. 1.
Fig. 1.
Eligibility of samples in the study
Summary of the baseline survey conducted
The survey was conducted in 73 enumeration areas (EAs) from 11 districts. There were a total of 40 rural clusters in 10 districts and 33 urban clusters in 11 districts. Eight of the districts were from the Eastern region, with 52 EAs, while the other 3 from the Oti region had 22 EAs. A total of 564 respondents were from rural areas and 550 from urban areas, with 740 respondents from the Eastern region and 374 from the Oti region.
A majority (91.7%, n = 1,021) had their vaccine card seen and confirmed by interviewers. Most of the children were females (53.6%, n = 597/1,114). The median age of the children was 29 (IQR: 26–32) months, Table 1.
Table 1.
Summary of baseline survey information
| Area | Region | ||||
|---|---|---|---|---|---|
| Overall | Rural | Urban | Eastern | Oti | |
| Number of districts, N | 11 | 10 a | 11b | 8 | 3 |
| Number of EAs (clusters), N | 73 | 40 | 33 | 52 | 22 |
| Total eligible interviews, N | 1,114 | 564 | 550 | 740 | 374 |
| Vaccination information status | |||||
| Yes, card seen, n/N (%) | 1,021/1,114 (91.7) | 540/564 (95.7) | 481/550 (87.5) | 655/740 (88.5) | 366/374 (97.9) |
| Yes, card not seen, n/N (%) | 4/1,114 (0.4) | 1/564 (0.2) | 3/550 (0.5) | 4/740 (0.5) | 0/374 (0.0) |
| Yes, no card, n/N (%) | 86/1,114 (7.7) | 23/564 (4.1) | 63/550 (11.5) | 78/740 (10.5) | 8/374 (2.1) |
| Not, vaccinated, n/N (%) | 3/1,114 (0.3) | 0/564 (0.0) | 3/550 (0.5) | 3/740 (0.4) | 0/374 (0.0) |
| Sex of participants | |||||
| Males | 517/1,114 (46.4) | 245/564 (43.4) | 272/550 (49.5) | 346/740 (46.8) | 171/374 (45.7) |
| Females | 597/1,114 (53.6) | 319/564 (56.6) | 278/550 (50.5) | 394/740 (53.2) | 203/374 (54.3) |
| Age of child, Median (IQR) | 29 (26–32) | 29 (26–32) | 29 (26–32) | 29 (26–32) | 29 (26–32) |
aDistricts with rural areas
bDistricts with urban areas
nnumber of cases in a subgroup
Ntotal sample
IQRinterquartile range
Immunization coverage
Full vaccination coverage– All antigens
Full vaccination coverage (excluding hepatitis B) among the children was estimated to be 18.7% (95% CI: 16.5% to 21.1%). In the rural areas, full vaccination coverage was 19.7% (95% CI: 16.8% to 23.1%) and 17.4% (95% CI: 14.3%—21.0%) for urban areas. Full vaccination coverage in the Oti region was 22.7% (95% CI: 18.8% to 27.3%), which was higher than the 16.7% (95% CI: 14.2% to 19.5%) in the Eastern region (excluding malaria vaccine), Fig. 2.
Fig. 2.
Full vaccination coverage of all antigens
Full vaccination coverage– Basic antigens
Full vaccination coverage for basic antigens among the children was 78.8% (95% CI: 76.3% to 81.1%). In the rural areas, it was 82.4% (95% CI: 79.2% to 85.3%) and 74.4% (95% CI: 70.4% to 78.0%) for urban areas. In the Oti region, it was 85.3% (95% CI: 81.3% to 88.5%) and 75.6% (95% CI: 72.3% to 78.5%) for the Eastern region, Fig. 3.
Fig. 3.
Full Vaccination coverage of basic antigens
Full vaccination coverage– National schedule
By the time of the survey, 55.6% (95% CI: 52.7% to 58.5%) of children aged 24 to 35 months received full vaccination according to the national schedule. It was 58.1% (95% CI: 54.1% to 62.0%) in the rural areas and 52.5% (95% CI: 48.2% to 56.9%) in urban areas. For the Oti region, it was and 52.4% (95% CI: 48.8% to 55.9%) for the Eastern region, Fig. 4.
Fig. 4.
DHS full Vaccination coverage of antigens according to the national schedule
Antigen-specific coverage
Coverage of the vaccine given at birth (BCG) was 95.5% and 78.8% for OPV-0. Coverage for OPV antigens was 93.6% for OPV-1 and 88.1% for OPV-3. Coverage of Pentavalent antigens was 95.1% for Penta-1 and 92.7% for Penta-3. Pneumococcal virus antigen coverage was 94.8% for PCV-1 and 91.5% for PCV-3. Coverage for malaria antigens was 62.7% for malaria-1, 60.4% for malaria-2, 60.2% for malaria-3, and 55.1% for malaria-4. The meningococcal conjugate vaccine was 74.1%, Fig. 5. In Table 2, the coverages of the antigens are provided by the source of estimates, either from the vaccine card or recall of the caregivers, or a combination of the two. The unweighted estimates of the coverages are provided alongside the weighted estimates.
Fig. 5.
Antigen specific coverages among children in the study
Table 2.
Immunization coverage estimates among all children in the study based on card or recall (if card is not available)
| Vaccine dose | Estimates from Cards (N = 1,027) | Estimates from Recall (N = 80) | Either Card or Recall (N = 1,114) | |||
|---|---|---|---|---|---|---|
| Weighted | Unweighted | Weighted | Unweighted | Weighted | Unweighted | |
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| BCG * | 95.9 (94.5, 97.0) | 95.8 (94.4, 96.9) | 100.0 (-) | 100.0 (-) | 95.5 (94.1, 96.6) | 95.8 (94.4, 96.9) |
| OPV0 | 81.2 (78.7, 83.5) | 78.5 (75.8, 80.9) | 58.1 (47.3, 68.2) | 61.6 (50.8, 71.4) | 78.8 (76.3, 81.1) | 78.5 (75.8, 80.9) |
| OPV1 * | 97.5 (96.4, 98.3) | 97.3 (96.1, 98.1) | 56.0 (45.2, 66.3) | 58.1 (47.4, 68.2) | 93.6 (92.0, 94.9) | 97.3 (96.1, 98.1) |
| OPV2 * | 97.3 (96.1, 98.1) | 96.8 (95.5, 97.7) | 39.6 (29.7, 50.5) | 40.7 (30.7, 51.5) | 92.1 (90.4, 93.6) | 96.8 (95.5, 97.7) |
| OPV3 * | 95.8 (94.4, 96.9) | 95.3 (93.8, 96.4) | 5.3 (2.1, 12.7) | 4.7 (1.7, 11.9) | 88.1 (86.1, 89.9) | 95.3 (93.8, 96.4) |
| Hepatitis B | 1.7 (1.1, 2.7) | 1.5 (0.9, 2.4) | 1.5 (1.0, 2.5) | 1.5 (0.9, 2.4) | ||
| IPV * | 97.0 (95.7, 97.9) | 96.5 (95.1, 97.4) | 88.8 (86.8, 90.5) | 96.5 (95.1, 97.4) | ||
| Penta/DPT-/Hep B/Hib 1 * | 98.8 (97.9, 99.3) | 98.6 (97.7, 99.2) | 60.1 (49.2, 70.0) | 64.0 (53.2, 73.5) | 95.1 (93.6, 96.2) | 98.6 (97.7, 99.2) |
| Penta/DPT/Hep 2/Hib 2 * | 98.8 (97.9, 99.3) | 98.6 (97.7, 99.2) | 55.6 (44.9, 65.9) | 58.1 (47.4, 68.2) | 94.7 (93.2, 95.9) | 98.6 (97.7, 99.2) |
| Penta/DPT/Hep B/3 * | 97.8 (96.7, 98.6) | 97.6 (96.4, 98.3) | 41.4 (31.3, 52.2) | 41.9 (31.8, 52.6) | 92.7 (91.0, 94.1) | 97.6 (96.4, 98.3) |
| PCV-1 | 98.8 (97.9, 99.3) | 98.5 (97.6, 99.1) | 57.2 (46.4, 67.4) | 61.6 (50.8, 71.4) | 94.8 (93.3, 96.0) | 98.5 (97.6, 99.1) |
| PCV-2 | 98.4 (97.4, 99.0) | 98.1 (97.1, 98.8) | 50.0 (39.4, 60.6) | 52.3 (41.7, 62.8) | 93.9 (92.3, 95.2) | 98.1 (97.1, 98.8) |
| PCV-3 | 97.5 (96.4, 98.3) | 97.3 (96.1, 98.1) | 29.5 (20.7, 40.2) | 30.2 (21.4, 40.9) | 91.5 (89.7, 93.0) | 97.3 (96.1, 98.1) |
| Rotavirus 1 | 97.9 (96.8, 98.6) | 97.7 (96.6, 98.5) | 43.2 (33.0, 54.0) | 45.3 (35.0, 56.1) | 92.9 (91.2, 94.3) | 97.7 (96.6, 98.5) |
| Rotavirus 2 | 97.4 (96.2, 98.2) | 97.3 (96.1, 98.1) | 38.7 (28.8, 49.5) | 39.5 (29.7, 50.3) | 92.1 (90.4, 93.6) | 97.3 (96.1, 98.1) |
| Rotavirus 3 | 55.1 (52.0, 58.1) | 51.7 (48.6, 54.8) | 19.4 (12.3, 29.3) | 19.8 (12.6, 29.7) | 51.9 (49.0, 54.8) | 51.7 (48.6, 54.8) |
| Measles-Rubella 1 * | 93.9 (92.3, 95.2) | 93.1 (91.4, 94.5) | 54.9 (44.1, 65.2) | 58.1 (47.4, 68.2) | 90.2 (88.3, 91.8) | 93.1 (91.4, 94.5) |
| Measles-Rubella 2 | 82.4 (79.9, 84.6) | 80.7 (78.2, 83.0) | 41.5 (31.4, 52.3) | 43.0 (32.9, 53.8) | 78.6 (76.1, 80.9) | 80.7 (78.2, 83.0) |
| Malaria Vaccine 1 | 63.8 (58.7, 68.6) | 57.7 (52.5, 62.6) | 19.6 (3.3, 63.9) | 25.0 (4.6, 69.7) | 62.7 (57.7, 67.5) | 57.7 (52.5, 62.6) |
| Malaria Vaccine 2 | 61.4 (56.3, 66.3) | 54.9 (49.8, 60.0) | 19.6 (3.3, 63.9) | 25.0 (4.6, 69.7) | 60.4 (55.3, 65.3) | 54.9 (49.8, 60.0) |
| Malaria Vaccine 3 | 61.3 (56.2, 66.2) | 54.1 (49.0, 59.2) | 13.3 (1.5, 60.9) | 12.5 (1.1, 64.2) | 60.2 (55.1, 65.1) | 54.1 (49.0, 59.2) |
| Malaria Vaccine 4 | 56.1 (50.9, 61.1) | 49.5 (44.3, 54.6) | 13.3 (1.5, 60.9) | 12.5 (1.1, 64.2) | 55.1 (50.0, 60.1) | 49.5 (44.3, 54.6) |
| Vitamin A1 | 87.8 (85.7, 89.7) | 86.1 (83.8, 88.1) | 80.4 (77.9, 82.6) | 86.1 (83.8, 88.1) | ||
| Vitamin A2 | 78.6 (76.0, 81.1) | 76.5 (73.8, 79.0) | 72.0 (69.3, 74.6) | 76.5 (73.8, 79.0) | ||
| Vitamin A3 | 62.9 (59.9, 65.8) | 61.2 (58.2, 64.2) | 57.6 (54.7, 60.5) | 61.2 (58.2, 64.2) | ||
| Yellow Fever | 92.9 (91.2, 94.4) | 92.0 (90.1, 93.5) | 51.3 (40.6, 61.8) | 52.3 (41.7, 62.8) | 89.0 (87.0, 90.7) | 92.0 (90.1, 93.5) |
| Men A | 80.9 (78.4, 83.2) | 78.8 (76.2, 81.2) | 74.1 (71.4, 76.5) | 78.8 (76.2, 81.2) | ||
| Full vaccination coverage 1 | 20.1 (17.8, 22.7) | 17.9 (15.7, 20.4) | 0.0 (-) | 0.0 (-) | 18.7 (16.5, 21.1) | 17.9 (15.7, 20.4) |
| Full vaccination coverage (Basic antigen) 2 | 85.8 (83.5, 87.8) | 84.2 (81.9, 86.3) | 3.1 (0.9, 9.9) | 2.3 (0.6, 9.0) | 78.8 (76.3, 81.1) | 84.2 (81.9, 86.3) |
| Full vaccination coverage (National schedule) 3 | 60.6 (57.6, 63.6) | 56.2 (53.2, 59.2) | 1.5 (0.3, 8.2) | 1.2 (0.2, 8.0) | 55.6 (52.7, 58.5) | 56.2 (53.2, 59.2) |
1Full vaccination coverage was defined as children who have received all the antigens in the tables excluding Hepatitis B. For children in the Eastern region, Malaria was further excluded in addition to excluding the hepatitis b antigen at birth
2Full vaccination coverage for basic antigen is define as children who have received 1 dose of BCG vaccine, 3 doses of OPV vaccine, 1 dose of IPV vaccine, 3 doses of Penta and 1 dose of MR vaccine
3Full vaccination coverage according to the national schedule is defined as children who have received BCG, 3 doses of Penta vaccine, 4 doses of OPV (including OPV-0), 1 dose of IPV vaccine, 1 dose of yellow fever vaccine, 3 doses of PCV, 2 doses of rotavirus vaccine, 2 doses of MR vaccines, and 1 dose of meningitis A vaccine
Antigen-specific coverages by rural–urban residency
In Table 3, the antigen-specific coverages are presented by rural and urban areas of residence among the study participants. The full coverage (weighted), excluding hepatitis B, was 19.7% for rural and 17.4% for urban. Full vaccination coverage (basic antigen and national schedule) for rural areas was 82.4% and 58.1%, while that of urban areas was 74.4% and 52.5%, respectively.
Table 3.
Immunization coverage among all children in the study by area of residence
| Vaccine dose | Rural areas | Urban areas | ||
|---|---|---|---|---|
| Weighted | Unweighted | Weighted | Unweighted | |
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| BCG * | 96.0 (94.1, 97.3) | 95.7 (93.7, 97.2) | 94.9 (92.6, 96.5) | 95.8 (93.6, 97.3) |
| OPV0 | 77.6 (74.1, 80.7) | 74.1 (70.2, 77.6) | 80.3 (76.6, 83.6) | 83.4 (79.8, 86.4) |
| OPV1 * | 95.6 (93.7, 97.0) | 97.4 (95.7, 98.5) | 91.1 (88.3, 93.3) | 97.1 (95.1, 98.3) |
| OPV2 * | 94.9 (92.8, 96.4) | 97.6 (95.9, 98.6) | 88.8 (85.7, 91.3) | 95.8 (93.6, 97.3) |
| OPV3 * | 92.3 (89.8, 94.1) | 95.9 (93.9, 97.3) | 83.1 (79.6, 86.1) | 94.6 (92.2, 96.3) |
| Hepatitis B | 1.0 (0.4, 2.2) | 0.9 (0.4, 2.2) | 2.2 (1.2, 3.9) | 2.1 (1.1, 3.8) |
| IPV * | 93.1 (90.8, 94.8) | 96.9 (95.0, 98.0) | 83.6 (80.1, 86.6) | 96.0 (93.9, 97.5) |
| Penta-1 * | 96.8 (95.1, 97.9) | 98.5 (97.1, 99.3) | 93.0 (90.4, 94.9) | 98.8 (97.2, 99.4) |
| Penta-2 * | 96.6 (94.8, 97.8) | 98.5 (97.1, 99.3) | 92.5 (89.8, 94.5) | 98.8 (97.2, 99.4) |
| Penta-3 * | 95.7 (93.7, 97.0) | 98.0 (96.4, 98.9) | 89.2 (86.1, 91.6) | 97.1 (95.1, 98.3) |
| PCV-1 | 96.5 (94.7, 97.7) | 98.1 (96.6, 99.0) | 92.7 (90.1, 94.7) | 99.0 (97.5, 99.6) |
| PCV-2 | 96.4 (94.6, 97.6) | 98.3 (96.8, 99.1) | 90.9 (88.0, 93.1) | 97.9 (96.2, 98.9) |
| PCV-3 | 94.9 (92.8, 96.4) | 97.6 (95.9, 98.6) | 87.5 (84.3, 90.1) | 96.9 (94.9, 98.1) |
| Rotavirus 1 | 95.1 (93.0, 96.5) | 97.4 (95.7, 98.5) | 90.3 (87.3, 92.6) | 98.1 (96.4, 99.0) |
| Rotavirus 2 | 94.9 (92.8, 96.4) | 97.4 (95.7, 98.5) | 88.8 (85.7, 91.2) | 97.1 (95.1, 98.3) |
| Rotavirus 3 | 51.4 (47.4, 55.3) | 49.8 (45.6, 54.0) | 52.6 (48.2, 56.9) | 53.8 (49.4, 58.3) |
| Measles-Rubella 1 * | 92.1 (89.7, 94.0) | 93.5 (91.1, 95.3) | 87.8 (84.7, 90.4) | 92.7 (90.0, 94.7) |
| Measles-Rubella 2 | 81.3 (78.0, 84.2) | 82.2 (78.8, 85.2) | 75.3 (71.4, 78.9) | 79.0 (75.1, 82.4) |
| Malaria Vaccine 1 | 65.8 (59.9, 71.3) | 66.3 (60.2, 71.8) | 54.7 (45.0, 64.1) | 37.8 (29.2, 47.3) |
| Malaria Vaccine 2 | 62.9 (57.0, 68.5) | 63.1 (57.0, 68.9) | 54.0 (44.2, 63.4) | 36.0 (27.6, 45.5) |
| Malaria Vaccine 3 | 61.9 (55.9, 67.5) | 62.0 (55.8, 67.7) | 55.8 (46.1, 65.2) | 36.0 (27.6, 45.5) |
| Malaria Vaccine 4 | 55.9 (49.9, 61.8) | 56.1 (49.9, 62.1) | 52.9 (43.1, 62.4) | 34.2 (25.9, 43.6) |
| Vitamin A1 | 83.8 (80.6, 86.5) | 85.4 (82.1, 88.1) | 76.3 (72.4, 79.8) | 86.9 (83.6, 89.6) |
| Vitamin A2 | 77.7 (74.2, 80.8) | 79.8 (76.2, 83.0) | 65.1 (60.9, 69.2) | 72.8 (68.6, 76.6) |
| Vitamin A3 | 63.4 (59.5, 67.2) | 65.0 (60.9, 68.9) | 50.5 (46.2, 54.9) | 57.0 (52.5, 61.3) |
| Yellow Fever | 90.9 (88.3, 92.9) | 92.0 (89.4, 94.0) | 86.7 (83.5, 89.4) | 91.9 (89.1, 94.0) |
| Men A | 79.8 (76.4, 82.8) | 81.5 (78.0, 84.5) | 67.2 (62.9, 71.1) | 75.9 (71.8, 79.5) |
| Full vaccination coverage 1 | 19.7 (16.8, 23.1) | 18.7 (15.6, 22.2) | 17.4 (14.3, 21.0) | 17.0 (13.9, 20.7) |
| Full vaccination coverage (Basic antigen) 2 | 82.4 (79.2, 85.3) | 85.2 (81.9, 87.9) | 74.4 (70.4, 78.0) | 83.2 (79.5, 86.3) |
| Full vaccination coverage (National schedule) 3 | 58.1 (54.1, 62.0) | 55.0 (50.8, 59.2) | 52.5 (48.2, 56.9) | 57.6 (53.1, 61.9) |
1Full vaccination coverage was defined as children who have received all the antigens in the tables excluding Hepatitis B. For children in the Eastern region, Malaria was further excluded in addition to excluding the hepatitis b antigen at birth
2Full vaccination coverage for basic antigen is define as children who have received 1 dose of BCG vaccine, 3 doses of OPV vaccine, 1 dose of IPV vaccine, 3 doses of Penta and 1 dose of MR vaccine
3Full vaccination coverage according to the national schedule is defined as children who have received BCG, 3 doses of Penta vaccine, 4 doses of OPV (including OPV-0), 1 dose of IPV vaccine, 1 dose of yellow fever vaccine, 3 doses of PCV, 2 doses of rotavirus vaccine, 2 doses of MR vaccines, and 1 dose of meningitis A vaccine
Antigen-specific coverages by region of residence
Table 4, shows that the Oti region had higher full vaccination coverage (excluding hepatitis B), 22.7%, basic antigens, 85.3%, and national schedule, 62.1%, than the Eastern region, with 16.7% full, 75.6% basic antigen, and 52.4% national schedule.
Table 4.
Immunization coverage among all children in the study by region of residence
| Vaccine dose | Region of residence | |||
|---|---|---|---|---|
| Eastern region | Oti region | |||
| Weighted | Unweighted | Weighted | Unweighted | |
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| BCG * | 96.1 (94.5, 97.3) | 96.8 (95.1, 97.9) | 94.2 (91.3, 96.2) | 94.0 (91.0, 96.0) |
| OPV0 | 79.2 (76.1, 82.0) | 80.3 (77.1, 83.2) | 78.0 (73.5, 81.9) | 75.1 (70.4, 79.3) |
| OPV1 * | 91.1 (88.9, 93.0) | 96.3 (94.6, 97.5) | 98.5 (96.6, 99.4) | 98.9 (97.1, 99.6) |
| OPV2 * | 89.6 (87.2, 91.6) | 96.8 (95.1, 97.9) | 97.2 (94.9, 98.5) | 96.7 (94.3, 98.1) |
| OPV3 * | 84.8 (82.0, 87.2) | 94.8 (92.8, 96.3) | 94.7 (91.9, 96.6) | 96.2 (93.6, 97.7) |
| Hepatitis B | 2.0 (1.2, 3.2) | 1.8 (1.0, 3.2) | 0.7 (0.2, 2.4) | 0.8 (0.3, 2.5) |
| IPV * | 85.3 (82.6, 87.7) | 96.2 (94.4, 97.4) | 95.7 (93.1, 97.4) | 97.0 (94.6, 98.3) |
| Penta-1 * | 93.3 (91.2, 94.9) | 98.5 (97.2, 99.2) | 98.7 (96.8, 99.4) | 98.9 (97.1, 99.6) |
| Penta-2 * | 93.3 (91.3, 94.9) | 98.8 (97.6, 99.4) | 97.6 (95.4, 98.7) | 98.4 (96.4, 99.3) |
| Penta-3 * | 90.6 (88.2, 92.5) | 97.6 (96.0, 98.5) | 97.1 (94.8, 98.4) | 97.5 (95.3, 98.7) |
| PCV-1 | 92.9 (90.8, 94.6) | 98.5 (97.2, 99.2) | 98.5 (96.6, 99.4) | 98.6 (96.8, 99.4) |
| PCV-2 | 91.8 (89.6, 93.6) | 98.0 (96.6, 98.8) | 98.1 (96.1, 99.1) | 98.4 (96.4, 99.3) |
| PCV-3 | 89.0 (86.5, 91.1) | 97.3 (95.7, 98.3) | 96.6 (94.2, 98.1) | 97.3 (95.0, 98.5) |
| Rotavirus 1 | 90.2 (87.8, 92.1) | 97.3 (95.7, 98.3) | 98.4 (96.4, 99.3) | 98.6 (96.8, 99.4) |
| Rotavirus 2 | 89.7 (87.2, 91.6) | 97.1 (95.5, 98.1) | 97.0 (94.7, 98.3) | 97.5 (95.3, 98.7) |
| Rotavirus 3 | 46.1 (42.6, 49.7) | 48.1 (44.3, 51.9) | 63.5 (58.5, 68.3) | 58.2 (53.1, 63.2) |
| Measles-Rubella 1 * | 88.4 (85.9, 90.5) | 93.6 (91.4, 95.2) | 93.7 (90.8, 95.8) | 92.3 (89.1, 94.7) |
| Measles-Rubella 2 | 75.3 (72.1, 78.3) | 79.5 (76.3, 82.5) | 85.1 (81.1, 88.4) | 82.8 (78.6, 86.3) |
| Malaria Vaccine 1 | - | - | 62.7 (57.7, 67.5) | 57.7 (52.5, 62.6) |
| Malaria Vaccine 2 | - | - | 60.4 (55.3, 65.3) | 54.9 (49.8, 60.0) |
| Malaria Vaccine 3 | - | - | 60.2 (55.1, 65.1) | 54.1 (49.0, 59.2) |
| Malaria Vaccine 4 | - | - | 55.1 (50.0, 60.1) | 49.5 (44.3, 54.6) |
| Vitamin A1 | 77.2 (74.1, 80.1) | 87.0 (84.2, 89.4) | 86.7 (82.8, 89.8) | 84.4 (80.3, 87.8) |
| Vitamin A2 | 66.2 (62.7, 69.5) | 73.6 (70.1, 76.8) | 83.7 (79.5, 87.1) | 81.7 (77.4, 85.3) |
| Vitamin A3 | 51.4 (47.8, 55.0) | 56.9 (53.1, 60.7) | 70.1 (65.2, 74.5) | 68.9 (63.9, 73.4) |
| Yellow Fever | 86.5 (83.8, 88.8) | 91.6 (89.2, 93.5) | 94.1 (91.1, 96.1) | 92.6 (89.4, 94.9) |
| Men A | 69.1 (65.7, 72.4) | 76.9 (73.6, 80.0) | 83.9 (79.8, 87.3) | 82.2 (78.0, 85.8) |
| Full vaccination coverage 1 | 16.7 (14.1, 19.5) | 17.3 (14.5, 20.3) | 22.7 (18.8, 27.3) | 19.1 (15.4, 23.5) |
| Full vaccination coverage (Basic antigen) 2 | 75.6 (72.3, 78.5) | 83.8 (80.8, 86.4) | 85.3 (81.3, 88.5) | 85.0 (80.9, 88.3) |
| Full vaccination coverage (National schedule) 3 | 52.4 (48.8, 55.9) | 55.6 (51.7, 59.3) | 62.1 (57.0, 66.9) | 57.4 (52.2, 62.4) |
1Full vaccination coverage was defined as children who have received all the antigens in the tables excluding Hepatitis B. For children in the Eastern region, Malaria was further excluded in addition to excluding the hepatitis b antigen at birth
2Full vaccination coverage for basic antigen is define as children who have received 1 dose of BCG vaccine, 3 doses of OPV vaccine, 1 dose of IPV vaccine, 3 doses of Penta and 1 dose of MR vaccine
3Full vaccination coverage according to the national schedule is defined as children who have received BCG, 3 doses of Penta vaccine, 4 doses of OPV (including OPV-0), 1 dose of IPV vaccine, 1 dose of yellow fever vaccine, 3 doses of PCV, 2 doses of rotavirus vaccine, 2 doses of MR vaccines, and 1 dose of meningitis A vaccine
Binary regression model of factors associated with vaccination status
Full vaccination coverage of antigens according to the national schedule
The odds of full vaccination coverage according to the national schedule were 44% higher in the Oti region compared to the Eastern region (aOR: 1.44, 95% CI: 1.05–1.99, p = 0.025). Also, the odds of full vaccination varied significantly across the other districts when compared to Asuogyaman in the Eastern region, except for the Kadjebi district in the Oti region Table 5. Sub-analysis of only children from the Eastern region showed that a monthly increase in the child's age was associated with 7% increased odds of full vaccination coverage (aOR: 1.07, 95% CI: 1.01–1.14, p = 0.017). Relative to children in the Asuogyaman districts in the Eastern region, the odds of full vaccination were lower in all the other districts in the Eastern region. Also, a sub-analysis of only children from the Oti region showed that a monthly increase in the child's age was associated with 11% decreased odds of full vaccination (aOR: 0.89, 95% CI: 0.83–0.95, p = 0.001). Relative to children in the Jasikan districts in the Oti region, the odds of full vaccination were fourfold higher among children from the Kadjebi (aOR: 4.43, aOR: 2.17–9.05, p < 0.001), Table 5.
Table 5.
Binary logistic regresasion analysis of factors associated with full basic vaccination coverage according to the national schedule
| Variables | Full basic vaccination coverage according to the national schedule among children | |||||
|---|---|---|---|---|---|---|
| Both regions | Eastern region only | Oti region only | ||||
| aOR [95% CI] | P-value | aOR [95% CI] | P-value | aOR [95% CI] | P-value | |
| Age of child (months) a | 1.00 (0.96, 1.04) | 0.972 | 1.07 (1.01, 1.14) | 0.017 | 0.89 (0.83, 0.95) | 0.001 |
| Sex of child a | ||||||
| Male | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Female | 0.86 (0.64, 1.17) | 0.337 | 1.01 (0.68, 1.51) | 0.964 | 0.69 (0.41, 1.18) | 0.176 |
| Place of residence a | ||||||
| Rural | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Urban | 0.85 (0.62, 1.15) | 0.294 | 0.89 (0.55, 1.43) | 0.623 | 0.98 (0.54, 1.76) | 0.935 |
| Region of residence b | - | - | - | - | ||
| Eastern | 1.00 (reference) | - | - | - | - | |
| Oti | 1.44 (1.05, 1.99) | 0.025 | - | - | - | - |
| District of residence b | ||||||
| Abuakwa North | 0.31 (0.15, 0.66) | 0.002 | 0.31 (0.14, 0.67) | 0.003 | - | - |
| Akyemansa | 0.17 (0.07, 0.40) | < 0.001 | 0.18 (0.08, 0.42) | < 0.001 | - | - |
| Asuogyaman | 1.00 (reference) | 1.00 (reference) | - | - | ||
| Fanteakwa North | 0.41 (0.19, 0.87) | 0.021 | 0.42 (0.20, 0.90) | 0.025 | - | - |
| Kwahu West | 0.54 (0.28, 1.05) | 0.068 | 0.54 (0.28, 1.05) | 0.068 | - | - |
| New Juaben South | 0.48 (0.24, 0.98) | 0.044 | 0.49 (0.23, 1.03) | 0.060 | - | - |
| Upper Manya Krobo | 0.36 (0.15, 0.84) | 0.018 | 0.35 (0.15, 0.83) | 0.017 | - | - |
| West Akim | 0.42 (0.19, 0.93) | 0.033 | 0.43 (0.19, 0.97) | 0.041 | - | - |
| Jasikan | 0.27 (0.13, 0.59) | 0.001 | - | - | 1.00 (reference) | |
| Krachi East | 0.18 (0.07, 0.46) | < 0.001 | - | - | 0.70 (0.24, 1.99) | 0.500 |
| Kadjebi | 1.15 (0.68, 1.96) | 0.599 | - | - | 4.43 (2.17, 9.05) | < 0.001 |
aOR adjusted odds ratio, CI confidence interval
a: Estimated together with adjusting for age in months, sex of child and place of residence together as covariates
b: Estimated independently after adjusting for age in months, sex of child and place of residence together as covariates
Full vaccination coverage according to basic antigens
In both regions, the odds of full coverage according to the basic antigens were 38% less in urban areas compared to rural areas (aOR: 0.62, 95% CI: 0.46–0.82, p = 0.001). The odds were 70% higher in the Oti region compared to the Eastern region (aOR: 1.70, 95% CI: 1.21–2.40, p = 0.002). The odds varied significantly across the other districts when compared to Asuogyaman in the Eastern region Table 6. Sub-analysis of only children from the Eastern region showed that a monthly increase in the child's age was associated with 6% increased odds of full vaccination coverage (aOR: 1.06, 95% CI: 1.01–1.12, p = 0.021). The odds of full vaccination coverage were 36% less among children from the urban areas in the Eastern region compared to the rural areas (aOR: 0.64, 95% CI: 0.42–0.98, p = 0.039). Relative to children in the Asuogyaman district in the Eastern region, the odds were lower in all the other districts in the Eastern region. However, the sub-analysis of only children from the Oti region did not identify any significant factors based on basic antigens vaccination coverage Table 6.
Table 6.
Binary logistic regresasion analysis of factors associated with DHS full basic vaccination coverage
| Variables | DHS Full basic vaccination coverage | |||||
|---|---|---|---|---|---|---|
| Both regions | Eastern region only | Oti region only | ||||
| aOR [95% CI] | P-value | aOR [95% CI] | P-value | aOR [95% CI] | P-value | |
| Age of child (months) a | 1.03 (0.99, 1.08) | 0.138 | 1.06 (1.01, 1.12) | 0.021 | 0.96 (0.89, 1.04) | 0.349 |
| Sex of child a | ||||||
| Male | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Female | 1.04 (0.78, 1.39) | 0.787 | 1.18 (0.83, 1.66) | 0.358 | 0.76 (0.42, 1.38) | 0.372 |
| Place of residence a | ||||||
| Rural | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Urban | 0.62 (0.46, 0.82) | 0.001 | 0.64 (0.42, 0.98) | 0.039 | 1.18 (0.60, 2.31) | 0.626 |
| Region of residence b | - | - | - | - | ||
| Eastern | 1.00 (reference) | - | - | - | - | |
| Oti | 1.70 (1.21, 2.40) | 0.002 | - | - | - | - |
| District of residence b | ||||||
| Abuakwa North | 0.25 (0.09, 0.70) | 0.008 | 0.27 (0.10, 0.75) | 0.012 | - | - |
| Akyemansa | 0.21 (0.08, 0.56) | 0.002 | 0.21 (0.08, 0.56) | 0.002 | - | - |
| Asuogyaman | 1.00 (reference) | 1.00 (reference) | - | - | ||
| Fanteakwa North | 0.20 (0.07, 0.55) | 0.002 | 0.20 (0.07, 0.55) | 0.002 | - | - |
| Kwahu West | 0.14 (0.05, 0.37) | < 0.001 | 0.15 (0.06, 0.39) | < 0.001 | - | - |
| New Juaben South | 0.18 (0.07, 0.47) | 0.001 | 0.20 (0.07, 0.54) | 0.002 | - | - |
| Upper Manya Krobo | 0.14 (0.05, 0.41) | < 0.001 | 0.14 (0.05, 0.39) | < 0.001 | - | - |
| West Akim | 0.13 (0.05, 0.35) | < 0.001 | 0.14 (0.05, 0.38) | < 0.001 | - | - |
| Jasikan | 0.45 (0.15, 1.34) | 0.152 | - | - | 1.00 (reference) | |
| Krachi East | 0.27 (0.09, 0.76) | 0.013 | - | - | 0.56 (0.24, 1.31) | 0.179 |
| Kadjebi | 0.35 (0.13, 0.93) | 0.035 | - | - | 0.73 (0.35, 1.55) | 0.418 |
aOR: adjusted odds ratio. CI: confidence interval
a: Estimated together with adjusting for age in months, sex of child and place of residence together as covariates
b: Estimated independently after adjusting for age in months, sex of child and place of residence together as covariates
Discussion
The study findings reveal several important insights into the state of routine immunization coverage among children under two years of age in the Eastern and Oti regions of Ghana. Overall, the results indicate that while coverage for individual antigens is relatively high, full immunization coverage remains suboptimal, particularly for the national schedule and basic antigens. The study also highlights significant disparities in vaccine coverage between urban and rural areas, as well as between regions.
Vaccination coverage and disparities
The study found that full vaccination coverage for all antigens (excluding hepatitis B-birthdose) was 18.7%, with higher rates in rural areas (19.7%) compared to urban areas (17.4%). This finding is consistent with previous studies that have documented higher vaccination coverage in rural areas, attributed to better community engagement and outreach services [2, 5, 6]. The Community Health Planning Services (CHPs) program, which is more active in rural areas, has been instrumental in improving vaccine coverage through home visits and defaulter tracing [6, 15].
The Oti region outperformed the Eastern region in basic antigen coverage, with 85.3% of children fully vaccinated compared to 75.6% in the Eastern region. Similarly, the Oti region had higher coverage for the national schedule (62.1%) compared to the Eastern region (52.4%). These regional disparities may be attributed to differences in healthcare infrastructure, the effectiveness of vaccination campaigns, and the predominance of rural populations in the Oti region [5],Owusu-Ansah et al., 2020). The Eastern region, which is more urbanized, may encounter challenges such as caregiver absenteeism due to economic activities, resulting in missed vaccination appointments [5, 10]. It is important to mention that many of the children in the study were born during the COVID-19 pandemic (2020–2021), which likely disrupted access to vaccination services, especially in urban centers affected by lockdowns, movement restrictions, and healthcare resource diversion.
Factors influencing vaccination uptake
The study identified several factors associated with vaccination uptake, including age, place of residence, and region. In the Eastern region, older children were more likely to be fully vaccinated, while in the Oti region, older children were less likely to be vaccinated. This finding is consistent with studies by [3, 4, 27]. This finding suggests that age-specific strategies may be needed to improve vaccination coverage in different regions [11]. Additionally, urban areas had lower odds of full vaccination coverage compared to rural areas, highlighting the need for targeted interventions in urban settings [28].
District-level differences also played a significant role in vaccination outcomes. For example, children in the Asuogyaman district in the Eastern region had higher odds of full vaccination compared to other districts, while children in the Kadjebi district in the Oti region had significantly higher odds of full vaccination compared to other districts in the region [24]. This is consistent with observations made by Wassenaar et al.,[27]. These findings underscore the importance of local context in shaping vaccination outcomes and the need for district-level interventions to address disparities.
Challenges and opportunities
The study highlights several challenges to achieving high vaccination coverage, particularly in urban areas and for specific vaccines such as the malaria vaccine. The low uptake of the malaria vaccine in the Oti region (62.7% for the first dose and 55.1% for the fourth dose) is concerning, given Ghana's high malaria burden[14, 16]. Worthy of mention is the fact that the malaria vaccine is relatively new, with a schedule that is somehow different from the other established vaccines, and so this could account for the low coverage. Factors such as caregiver hesitancy, logistical challenges, and a lack of awareness regarding the vaccination schedule may contribute to low uptake [18, 30]. Logistical issues, including the distance to vaccination sites, financial constraints, and inconvenient timing, have been linked to missed vaccinations. Additionally, knowledge gaps and forgetfulness can further influence low vaccine uptake. These factors may help explain the low uptake observed in our study.plain the low uptake observed in our study [14, 16]. Addressing these challenges will require targeted interventions, including community education campaigns, improved vaccine delivery systems, and the use of technology to track and remind caregivers of vaccination appointments [20]. Improving data quality and enabling real-time monitoring of vaccination coverage could play a critical role in achieving equitable vaccine access.
Implications for policy and practice
The findings of this study have important implications for policy and practice. First, there is a need for targeted interventions to address gaps in vaccine coverage, particularly in urban areas, and for specific vaccines such as the malaria vaccine. Strategies such as community outreach programs, mobile vaccination clinics, and the use of local influencers to promote vaccination could help improve coverage in underserved areas [11, 28]. Regional and district-level variations in coverage further highlight the importance of tailoring immunization programs to local contexts.
Additionally, the finding that child age influences vaccination uptake differently across regions suggests a need for timely, age-targeted reminder systems and education campaigns to prevent missed opportunities. Interventions must go beyond national averages to focus on equity and precision targeting, ensuring that no child is left behind in the drive toward universal immunization.
Finally, the study highlights the need for further research to understand the drivers of vaccine hesitancy and low uptake, particularly for newer vaccines such as the malaria vaccine. Qualitative studies exploring caregiver perspectives and experiences could provide valuable insights into the barriers to vaccination and inform the design of targeted interventions [24, 28].
Recommendations for stakeholders and policymakers
Based on the findings of the study, the following are the main actionable recommendations for stakeholders, policymakers, and decision-makers to improve routine immunization coverage among children under two years of age in Ghana:
Improve coverage of basic antigens and national schedule vaccines
Challenge: Full immunization coverage for basic antigens (78.8%) and the national schedule (55.6%) remains suboptimal, with specific antigens like OPV0, OPV3, IPV, YF, MR, and Men A showing lower coverage rates.
- Action:
- ◦ Prioritize improving coverage for basic antigens and national schedule vaccines through targeted interventions, such as defaulters tracing and reminder systems for caregivers.
- ◦ Strengthen the Community Health Planning Services (CHPS) program, particularly in rural areas, to ensure consistent outreach and follow-up for children who miss scheduled vaccinations.
- ◦ Provide additional training for healthcare workers to emphasize the importance of completing the full vaccination schedule and to address any gaps in service delivery.
Enhance malaria vaccine uptake in endemic regions
Challenge: The uptake of the malaria vaccine (RTS,S/AS01E) is low, with coverage dropping significantly between the first and fourth doses (62.7% to 55.1%).
- Action:
- ◦ Conduct community engagement programs to educate caregivers about the benefits of the malaria vaccine and address concerns related to side effects or misconceptions.
- ◦ Implement strategies to reduce dropout rates, such as SMS reminders, home visits, and incentives for caregivers who complete the full vaccine schedule.
- ◦ Strengthen collaboration between the Ghana Health Service and local leaders to promote the malaria vaccine as a critical tool in reducing malaria-related morbidity and mortality.
Conclusion and limitations
This study provides valuable insights into immunization coverage among children under two years old in the Eastern and Oti regions of Ghana. While overall vaccination rates for individual antigens were relatively high, full immunization coverage remained low, particularly in urban areas. Disparities in vaccination rates between rural and urban areas, as well as between the Eastern and Oti regions, underscore the need for targeted interventions to improve vaccine accessibility and adherence.
However, the study has several limitations. The cross-sectional design only captures immunization coverage at one point in time and does not account for changes in vaccination trends. Additionally, reliance on caregiver recall for vaccination history in cases where vaccine cards were unavailable may introduce recall bias. Most of the participants (children) in the study were born during the COVID-19 pandemic (2020–2021), which might have disrupted access to vaccination services, especially in urban centers affected by lockdowns, movement restrictions, and healthcare resource diversion. Lastly, logistical constraints and variations in healthcare infrastructure across districts may have influenced the findings, limiting the generalizability of the results. Future research should explore longitudinal approaches and integrate qualitative assessments to better understand the barriers to full immunization coverage.
Acknowledgements
We sincerely appreciate the field supervisors, research assistants, district health information officers, community leaders, heads of health facilities, healthcare workers, community members, and regional and district health directorates for their respective contributions to the success of this study.
Clinical trial number
Not applicable.
Authors’ contributions
CG conceptualization. CG and YA cleaned and analyzed the data. CG, YA, and JA drafted the manuscript. Methodology: CG, YA, JA, ETS, ETM, FBdV, SKA, SD, CT, CL, and NU. CG, JA, ETS, ETM, FBdV, SKA, SD, CT, CL, and NU reviewed and revised the manuscript. Supervision: CG, YA, JA, ETS, ETM, FBdV, SKA, SD, CT, CL, and NU.
Funding
The authors did not receive any funding for the publication of the work.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
All methods were conducted following the regulations and principles of the Helsinki Declaration (World Medical Association, 2013). This study was approved by the Ghana Health Service Ethics Review Committee (GHS-ERC:026/05/24). Consent to participate and to extract children’s (aged 24–35 months) information from the immunization folder was obtained from the children’s parents and, in some cases, their caregivers. The parents or caregivers who provided informed consent were 18 years and above. The parents or caregivers either signed or thumbprinted the informed consent forms on behalf of the children. The study was voluntary, and the consenting process was explained to participants so they could willingly decide to participate. Participants had the flexibility to withdraw at any time during the survey process. Permission to conduct the study in the selected facilities was obtained from the Ghana Health Service through Simprints Technology. The various regional and district directorates for health services were engaged for permission in their respective regions and districts to conduct the research.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Chris Guure, Email: cbguure@ug.edu.gh.
Ernest Tei Maya, Email: emaya@ug.edu.gh.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.