TYPE Original Research
PUBLISHED 15 September 2023
DOI 10.3389/fpubh.2023.1230492
Knowledge, attitudes, and 
OPEN ACCESS practices of caregivers on 
EDITED BY
Zijun Wang,  childhood immunization in 
The Rockefeller University, United States
REVIEWED BY Okaikoi sub-metro of Accra, 
Nkengafac Villyen Motaze,  
North-West University, South Africa  
Olatunde Ogundare,  Ghana
Ekiti State University, Nigeria  
Sheikh Minhaj Ahmed,  
Lilavati Hospital and Research Centre, India Samuel E. Danso 1,2, Augustina Frimpong 3, Nana A. H. Seneadza 1 
*CORRESPONDENCE and Michael F. Ofori 3*
Michael F. Ofori  
 mofori@noguchi.ug.edu.gh 1 Department of Community Health, University of Ghana Medical and Dental School, College of Health 
Science, Accra, Ghana, 2 GA East Hospital, Accra, Ghana, 329 May 2023  Department of Immunology, Noguchi RECEIVED 
21 August 2023 Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, GhanaACCEPTED 
PUBLISHED 15 September 2023
CITATION Background: Immunization remains one of the most cost-effective health 
Danso SE, Frimpong A, Seneadza NAH and 
Ofori MF (2023) Knowledge, attitudes, and interventions. However, there are still issues of vaccine hesitancy especially in 
practices of caregivers on childhood caregivers who are required to protect their children from vaccine-preventable 
immunization in Okaikoi sub-metro of Accra, diseases. This thwarts the overall vaccine coverage in disease-endemic areas such 
Ghana.
Front. Public Health 11:1230492. as sub-Saharan Africa. Therefore, to determine the factors that promote vaccine 
doi: 10.3389/fpubh.2023.1230492 hesitancy in caregivers, this study sought to assess the knowledge, attitude, and 
COPYRIGHT practices of caregivers on childhood immunization in Okaikoi, a sub-metro of 
© 2023 Danso, Frimpong, Seneadza and Ofori. Accra in Ghana.
This is an open-access article distributed under 
the terms of the Creative Commons Attribution Methods: A cross-sectional study on childhood immunization was conducted to 
License (CC BY). The use, distribution or determine the knowledge, attitudes, and practices of caregivers. A total of 120 
reproduction in other forums is permitted, caregivers with infants aged 12 months to 23 months were interviewed with a 
provided the original author(s) and the 
copyright owner(s) are credited and that the structured questionnaire containing open-ended and closed-ended queries.
original publication in this journal is cited, in Results: From the community, infants whose caregivers had adhered completely 
accordance with accepted academic practice. 
No use, distribution or reproduction is to immunization constituted 53.3% while the rest were partially immunized. The 
permitted which does not comply with these two main deterrents to complete immunization were time constraints (25.8%) 
terms. and forgetfulness (17.5%). It was observed that vaccination uptake and maternal 
level of education, as well as vaccination adverse reaction, did not impact the 
completion of the EPI program by these caregivers. Unfortunately, it was noted 
that caregivers with higher education levels were unable to complete their 
vaccination schedules due to their busy work schedules. Nonetheless, the main 
deterrent to adhering to complete childhood immunization was poor maternal 
knowledge (58%).
Conclusion: The study revealed that, the caregivers in the community had poor 
knowledge on vaccination and its benefits, and therefore, with no strict adherence 
to vaccination schedules. This promoted the incomplete immunization of 
children in the community by their caregivers. Also, since the main source of 
information with regard to immunization in the sub-metro was through the 
antenatal and postnatal child welfare clinics and the media, we recommend that 
the health workers collaborate with media personnel to ensure that standardized 
information is disseminated.
KEYWORDS
immunization, child immunization, attitudes, Ghana, immunization coverage
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Background Methods
Immunization is a low-cost approach to averting debility and Ethical consideration
disease from vaccine-preventable diseases (VPD). Active 
immunization averts over 2 million deaths each year in developing The study protocol was reviewed and approved by the Ethical and 
countries (1). Importantly, childhood immunization has been Protocol Review Committee of the University of Ghana Medical 
reported to provide herd immunity by preventing infectious School, Accra, Ghana (UGMS-CHDRC/077/2016). Permission was 
diseases in the adult population (2). However, vaccine uptake has first sought from opinion leaders of the Okaikoi Sub-Metro of Accra 
been decreasing gradually in these areas due to parent’s failure to with the aid of the Public Health Nurses who work in the community. 
vaccinate their children (3, 4). Nevertheless, VPD remains a major Then, written informed consent was obtained from the study 
cost of morbidity and mortality in children under 5 years of age in participants (caregivers) by providing the purpose of the study and the 
developing areas including Africa (5, 6). For instance, in 2014, it assurance of confidentiality. Involvement in the study was voluntary 
was estimated that the WHO African region accounted for a higher and participants were given the choice to withdraw from the study at 
proportion of 33% of the worldwide cases of pertussis (7). any time. Questionnaires were administered to recruited participants 
Therefore, increasing the coverage of childhood vaccinations in and the completed questionnaires were kept under strict confidentiality.
Africa is a requirement to achieve the Global Vaccine Action Plan 
targets (8, 9). Most sub-Saharan African countries including 
Ghana have very low childhood immunization coverage despite Study design
improvement over the past years (10). For Ghana to achieve the 
Sustainable Development Goal (SDG) 3, of ending preventable This was a cross-sectional community-based study that used 
deaths of children under 5 years of age by 2030, routine vaccination quantitative techniques to obtain information from respondents. The 
structures should be  considered and constructed since infants interview was conducted in English language and was translated into 
denied routine vaccination have been found to be 6 times more the local language (Twi or Ga) for caregivers who could not use the 
prone to acquiring pertussis than infants who were immunized. English language.
Additionally, they were even more likely to contract measles, a 
disease with debilitating infections (11).
It has been reported that inadequate knowledge of immunization Study area
and the perception of caregivers are among the hindrances to 
vaccination uptake (12, 13). A major contributor to achieving The study was carried out in the Okaikoi South sub-metro, one of 
vaccination coverage and uptake in Ghana is equipping mothers with the 13 constituencies of the Greater Accra Region in Ghana. The 
the prerequisite knowledge about the benefits of immunization. This sub-metro is situated in the western part of the city of Accra, covers 
might impact their attitude and encourage their participation in an area of 24 km2, and has a population of 340,380, with a population 
vaccination services. Essentially, this also depends primarily on the density of 14,183 persons/km2. The Kaneshie Polyclinic located in the 
public’s knowledge of vaccine-preventable diseases and the Okaikoi South sub-metro was established in 1964 and was the first to 
availability and accessibility of these immunization services. be built in Greater Accra. There are 18 private hospitals and clinics, 
Additionally, knowing the sources of these caregiver’s information on two (2) quasi-government clinics (Cocoa Clinic and Police Depot 
vaccination will help the health system in the country to prioritize Clinic), two (2) Christian Health Association clinics, and three (3) 
the areas that need further improvement. Unfortunately, this has been private maternity homes. The Okaikoi sub-metro is an old community 
a stumbling block in sub-Saharan Africa, where policymakers ignore and other Ghanaian tribes are marginal. The inhabitants are civil and 
awareness, knowledge, and conditions of non-immunized and public servants, entrepreneurs, traders, and a few farmers. The 
partially immunized populaces (14). inhabitants accept both conventional and herbal medicine.
According to the Ghana Demographic Healthy Survey (GDHS) 
2014, despite efforts to increase vaccination coverage by 90% 
nationwide in Ghana, there was a marginal drop from 79% in 2012 Sampling strategy
to 77% in 2014. Additionally, this society is also naturally inclined 
to traditional herbal treatment due to gross superstition concerning The Okaikoi sub-metro has five zones. The names of the zones 
the orthodox medical practice which in recent times concentrates were written on small pieces of paper and the Abeka zone was 
on both curative and preventive healthcare delivery systems randomly selected through balloting. Two communities under the 
(15, 16). Abeka zone, Nii Boi town and Abeka, were also selected by balloting. 
This study was aimed at determining the basic knowledge and Each selected community was divided into two blocks and a block was 
attitude of mothers about immunization and how these affect the also selected using balloting. Then, within the selected block, the 
full immunization status of their children. This study, therefore, number of houses to be included in the study was selected using the 
recruited parents or guardians of infants aged 12 months to formula below:
23 months to determine the knowledge, attitude, and practices of 
mothers or guardians of childhood immunization in Ghana. It is K = N/n w here N is the number of houses within the selected 
believed that such information will boost the efforts of health block [360].
workers in Ghana to improve childhood immunization in Ghana.  n is the sample size [120].
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Danso et al. 10.3389/fpubh.2023.1230492
A house number 1 and K-value thus house numbered 2 was Christians with the second most common religion being Islam. All 
selected for the interview. caregivers had postnatal books that were used for records during 
Then, every Kth (thus every second house) house was interviewed childhood immunizations at health facilities or immunization centers.
for the study. If the subsequent second house had no caregiver with a We also assessed the educational status of the participants as well 
child aged 12 months to 23 months, then another block was selected as their current occupation. We found that more than 80% of the 
by balloting. Together, a sample size of 120 mothers or guardians women had some form of formal education with approximately 38% 
(caregivers) with infants aged 12 months to 23 months were selected. completing tertiary education (Figure 1). In addition, 25.9% did not 
The sample size was chosen because of the convenience of time go beyond the basic (Primary and Junior High school) level and 58.4% 
and money. of respondents did not go beyond the Senior Secondary school level. 
The remaining 3.3% had no form of formal education. Interestingly, 
only 30% of these women were public servants with approximately 
Study population 32.5% being traders and the remaining being in other vocational 
trades or jobs (Table 2).
Caregivers of children aged 12–23 months, who were residents in 
the Okaikoi South sub-metro (Abeka zone) in the Greater Accra 
Region of Ghana, were recruited for the study. This age group Assessment of the knowledge of 
represents the youngest cohort of infants qualified for the Expanded vaccination in caregivers
Program on Immunization (EPI) in Ghana.
The levels of the caregivers’ knowledge of vaccination are shown in 
Table  3. During the interviews, all the respondents stated that 
Data collection instruments and methods immunization was useful and showed a moderate level of knowledge of 
vaccination. Of the 120 respondents, 113 representing 94.2% of the 
The study questionnaires were in three parts. The first part was on respondents believed that childhood immunizations protected their 
the participant’s demographics, the second part was on the knowledge children from diseases. The rest gave the following reasons for childhood 
of childhood immunization, and the third was on the caregiver’s 
attitude and practice toward vaccination. The knowledge and attitude TABLE 1 Demographic characteristics of caregivers and their children 
of study participants were examined using both closed and open- enrolled in the study.
ended queries contained in structured or dichotomous and multiple Age of child (months) n (%)
choices. Knowledge was assessed using a 3-point scale. Higher scores 12–14 25
indicated good knowledge, median scores indicated moderate 
knowledge, and lower/no scores indicated less or no knowledge (17, 15–17 23.3
18). The study questionnaires were prepared in English and later 18–20 35
translated verbally into the local languages where necessary. 21–23 16.7
Questionnaires were administered and interviews were conducted Sex of child
face-to-face with study participants.
Male 41.7
Female 58.3
Statistical analysis Age of mother (years)
<20 2.5
The data were analyzed using the Statistical Package for the Social 
20–24 15.8
Sciences [SPSS] and Microsoft Excel. The results of the study were 
represented using cross tabs, tables, bar graphs, and pie charts. 25–29 49.2
30–34 22.5
35–39 6.7
Results >39 3.3
Characteristics of study participants Marital status %
Married 75
A total of 120 caregivers were enrolled in this study with each Co-habiting 19.2
parent having one child at the age for immunization. Fifty of the Never married 5
infants representing 41.7% were males and 58.3% were females. 
Divorce 0.8
These caregivers were interviewed to assess factors associated with 
the completion of childhood immunization. The group of children Religious affiliation %
enrolled in this mother–child pair was less than 24 months old. Most Christianity 77.5
of these caregivers were between 25 and 29 years of age, representing Islamic 19.2
49.2%, whereas the proportion of respondents aged below 20 years Traditionalist 1.7
constituted 2.5%. Moreover, most of these women were married with 
less than 6% living as single parents (Table 1). Most caregivers were Pagan 1.7
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FIGURE 1
Distribution of the highest education of caregivers. A bar chart of the educational level of respondents. The graph shows that 3.3% of the respondents 
had no formal education, whereas the percentage of respondents with tertiary education was 38.3%.
TABLE 2 Distribution of caregivers’ occupation. TABLE 3 Mother’s perceived knowledge of childhood immunization.
Occupation % Reasons for vaccination n (%)
Trader 32.5 Disease prevention 94.2
Public servant 30 Curing diseases 1.7
Vocational jobs 21.7 Makes children brilliant 3.3
Housewife 10 Makes children stronger 0.8
Student 5.8 Source of information about n(%)
vaccination
immunization: making children brilliant (3.3%), curing diseases (1.7%), Health center (antenatal and child 80.8
and less than 1% stated that immunization makes children stronger. welfare clinic)
A majority of the caregivers knew that vaccination could thwart School 10.8
Poliomyelitis, Measles, Tetanus, and Yellow fever. However, Family 1.7
approximately half of these respondents did not know that diphtheria Friends 3.3
(57.5%), whooping cough (52.5%), and hepatitis B (40%) were 
vaccine-preventable diseases. Interestingly, some respondents thought Diseases prevented by vaccination
malaria (31.7%) and HIV/AIDS (18.3%) were vaccine-preventable. Diseases Yes (%) No (%) Do not know (%)
The majority of caregivers (80%) stated that their knowledge of Measles 80.8 – 19.2
vaccination came from the health center where they visited for Whooping cough 38.3 9.2 52.5
vaccinations (94%; Table 3).
Tuberculosis 52.5 11.7 35.8
With regard to the ages required for vaccination, only 
approximately 33% of caregivers knew when the children were to Diphtheria 36.7 5.8 57.5
be sent for immunizations (Figure 2). Over 67% of the caregivers knew Poliomyelitis 84.2 – 15.8
about vaccine adverse reactions with most of their information source Tetanus 80.8 5.8 13.4
being from healthcare workers (49.2%; Table 4). Importantly, we found 
Yellow fever 60.8 1.7 37.5
that poor maternal knowledge, time constraints, and illiteracy were the 
most contributing factors affecting vaccine hesitancy (Figure 3). Hepatitis B 55 5 40
Malaria 31.7 43.3 25
Cholera 25.8 47.5 26.7
Assessment of caregivers’ attitude toward HIV 18.3 59.2 22.5
vaccination
When asked what would affect their attitude toward reactions (Figure  4A). Additionally, the majority of the 
vaccination, most of these caregivers cited vaccine adverse respondents (36.7%) stated that the 6th-week, 10th-week, and 
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14th-week vaccines, oral polio 1, pentavalent (diphtheria, Furthermore, assessing the caregiver’s educational status in 
pertussis, tetanus, hepatitis B, and Haemophilus influenzae B), and completing immunization schedules for their infants, the majority of 
Pneumovax, respectively, were associated with adverse reactions the caregivers with secondary and basic education completed 
(Figure 4B). However, despite listing vaccine adverse reactions, it vaccination schedules compared to women with tertiary education 
was observed that approximately 53.3% of the caregivers had (Figure 5).
completed the vaccinations required in the EPI program compared 
to 46.7% who failed to complete the vaccination requirement 
(partial vaccination). The main reasons for partial vaccination Discussion and conclusion
given were time constraints (55.4%), forgetfulness (37.5%), and 
that it was expensive (7.1%). In this study, a total of 120 caregivers with children less than 
23 months in a suburb in Accra, Ghana, were enrolled to assess their 
knowledge, attitude, and practices on immunization to determine the 
efficacy of the National Expanded Program of Immunization in 
Ghana. Generally, the results show that caregivers have a poor 
knowledge of vaccination which may likely contribute to vaccine 
hesitancy. Interestingly, we found out that highly educated caregivers 
were more likely to miss the vaccination schedules compared to those 
with less formal education. This is in contrast to other studies that 
have associated high vaccination rates among well-educated caregivers 
(19–21).
Of note, despite the generally positive attitude toward 
vaccination, the major reason that could depart from this was the 
TABLE 4 Sources of information on vaccination adverse reactions.
Information source n (%)
FIGURE 2 Health workers 49.2
Percentage of respondents with correct knowledge regarding child’s 
age for immunizations. Approximately 76.7% of caregivers stated that Personal experience 12.5
they knew the ages at which their wards are to be immunized and Family/friends 2.5
the rest did not but upon assessing, only 33.3% had good knowledge 
of the ages for immunization, while 45.8% had moderate knowledge Media 3.3
and 20.8% had no knowledge.
N/A 32.5
FIGURE 3
Major factors serving as a hindrance to vaccine uptake. Poor maternal knowledge and time constraints were the major hindrances to child 
immunization in the Okaikoi sub-metro.
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issue of vaccine adverse events mostly observed in infants within 
3 months of birth (22). These adverse events according to the 
caregivers were mostly observed in Oral Polio vaccine/
Pentavalent/Rotavirus (given at 6, 10, and 14 weeks of life) 
followed by OPV/BCG (given at birth). The major source of 
information regarding vaccination adverse reactions was from 
health workers during antenatal and child welfare clinics. This is 
also the major source that contributes to the caregiver’s knowledge 
regarding vaccination and has the potential to positively improve 
vaccination uptake (23). One important way for Ghana to improve 
the strides in vaccination uptake is to make good use of these cost-
effective early morning health talks through standardized 
vaccination information. This vaccination information is not 
standardized between regions (24, 25). Standardized vaccination 
information dissemination during early morning health talks in 
clinics can improve vaccination uptake.
Despite this, more than half of the study population had 
completed the EPI program for children. However, the main reason 
for incomplete vaccination in the remaining was time constraints (26, 
27). In contrast to other studies, this was commonly observed in 
highly educated women compared to those with secondary and less 
formal education (28). It could be explained that the demands of 
corporate jobs could have been attributed to this. However, it can 
be  curtailed if most official jobs can allocate some free time for 
caregivers eligible for the EPI program to adhere to their 
FIGURE 4
Types of common adverse reactions developed after immunization vaccination schedules.
in infants of respondents. (A) The pie chart shows the percentage of Another major issue observed was that most of the caregivers 
infants and the common adverse reactions developed after 
vaccination. In total, 57 out of the 120 caregivers representing 47.5% were unaware of the immunization calendar. Some could not 
reported that their wards developed vaccination adverse reactions, determine when such information was readily available in their 
40% did not report any vaccination reaction, and 12.5% were child immunization record books (recorded in weeks after 
indifferent. (B) The majority of the respondents (36.7%) stated that 
the 6th-week, 10th-week, and 14th-week vaccines, oral polio 1, delivery). It will be  worthwhile if health workers provide a 
pentavalent, and Pneumovax, respectively, are associated with calendar in addition to what is already available or write the next 
adverse reactions. vaccination due date eligibly for caregivers, and provide further 
education to them on the use of other vaccination information in 
FIGURE 5
Comparison between mother’s educational level and children’s immunization status.
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Danso et al. 10.3389/fpubh.2023.1230492
the record books. This will help curtail the fears of adverse events, Ethics statement
and proper time record on the vaccinations they need to complete, 
when, how, and what to expect. The studies involving humans were approved by Ethical and 
It was observed that most of the education received by Protocol Review Committee, University of Ghana Medical School, 
caregivers on vaccination was from health workers, media, family, Ghana. The studies were conducted in accordance with the local 
and friends. The media being a source of information on legislation and institutional requirements. The participants provided 
immunization for caregivers should be cautioned. Importantly, it their written informed consent to participate in this study.
must be  ensured that the right information or standardized 
vaccination information is being disseminated. This was also 
positive since it implies that healthcare professionals can Author contributions
collaborate with media agencies to raise awareness on vaccination 
as well as vaccine adverse events to educate the public on the SD, NS, and MO conceived the idea and designed the experiments. 
benefits of vaccination for a community, vaccination schedules, NS supervised the study. AF assisted in the experimental design. SD, 
and vaccine follow-ups. Importantly, it will ensure that the right AF, and MO wrote the manuscript. All authors contributed to the 
information is disseminated and preventive measures associated article and approved the submitted version.
with diseases such as HIV are adhered to since some of these 
mothers even considered HIV to be a vaccine-preventable disease.
A major limitation of the study is the small sample size Acknowledgments
which was mainly due to time limitations since the study was 
conducted in partial fulfillment of a medical degree at the The authors are grateful to the study participants including 
University of Ghana. However, in conclusion, the study shows caregivers and their children, and the staff of the Kaneshie Polyclinic.
that more than 50% of the caregivers had poor knowledge of 
vaccination. In addition, other factors that promoted vaccine 
hesitancy included misinformation on vaccine adverse events, Conflict of interest
time constraints, and poor use of information provided in child 
immunization record books. Importantly, we  observed that The authors declare that the research was conducted in the 
neither social status nor education level impacted the completion absence of any commercial or financial relationships that could 
of immunization in this group of caregivers. This implies that be construed as a potential conflict of interest.
more awareness needs to be created and involving the media in 
this will be very useful.
Publisher’s note
Data availability statement All claims expressed in this article are solely those of the authors 
and do not necessarily represent those of their affiliated organizations, 
The original contributions presented in the study are included in or those of the publisher, the editors and the reviewers. Any product 
the article/supplementary material, further inquiries can be directed that may be evaluated in this article, or claim that may be made by its 
to the corresponding author. manufacturer, is not guaranteed or endorsed by the publisher.
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