Routine immunization coverage and determinants among children aged 12–23 months in rural southeast Nigeria: evidence from a community-based study

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Despite national immunization programs, coverage remains uneven in many rural areas of Nigeria. This study assessed routine immunization coverage and its determinants among children aged 12–23 months in Izzi Local Government Area, Ebonyi State, Nigeria. Methods A community-based cross-sectional study was conducted among caregivers of children aged 12–23 months. Using a cluster sampling technique, 501 caregivers were interviewed with a structured questionnaire. Data were analyzed using IBM SPSS version 20. Descriptive statistics summarized variables, while Chi-square tests and binary logistic regression identified factors associated with full immunization (p < 0.05). Results Overall, 75.4% of children were fully immunized. Coverage was highest for BCG (94.4%), OPV1 (95.8%), Penta1 (96.6%), and PCV1 (95.6%), but declined slightly for later doses including OPV3 (92.0%), measles (91.0%), and yellow fever (89.8%). Nearly all caregivers (99.4%) had heard of routine immunization, although detailed knowledge was limited. Transportation costs (72.3%) and vaccine unavailability (59.7%) were the most frequently reported barriers. Advice from health workers (76.6%) and availability of free vaccines (73.7%) were key facilitators. In multivariate analysis, caregiver occupation and religion were significant predictors of full immunization. Children of farmers were less likely to be fully immunized compared with those of civil servants (AOR = 0.47; 95% CI: 0.24–0.90; p = 0.023). Conclusion Routine immunization coverage in the study area remains below optimal levels. Strengthening health education and ensuring consistent vaccine availability may improve uptake in rural communities. Pediatrics Routine immunization vaccine coverage determinants of vaccination vaccine-preventable diseases rural Nigeria 1. Introduction Immunization is one of the most cost-effective public health strategies for preventing childhood morbidity and mortality from vaccine-preventable diseases (VPDs) [ 1 ]. Globally, vaccination prevents an estimated 3.5–5 million deaths annually, making it one of the most impactful public health interventions [ 2 ]. Similarly, the Centers for Disease Control and Prevention (CDC) estimates that routine childhood immunization averts approximately 4 million deaths each year worldwide [ 3 ]. To expand global access to lifesaving vaccines, the World Health Organization (WHO) launched the Expanded Programme on Immunization (EPI) in 1974, which recommends timely administration of key childhood vaccines—including Bacille Calmette–Guérin (BCG), oral polio vaccine (OPV), diphtheria–pertussis–tetanus (DPT), and measles vaccines—within the first year of life [ 1 , 4 ]. Despite substantial global progress in vaccine delivery, significant gaps in immunization coverage persist. In 2024, approximately 14.3 million infants worldwide received no routine vaccinations, commonly referred to as “zero-dose” children [ 5 ]. These children are disproportionately concentrated in a small number of low- and middle-income countries with fragile health systems and limited access to healthcare services, including Nigeria [ 5 ]. Persistent inequities in vaccine access continue to undermine global efforts to achieve universal immunization coverage and reduce preventable childhood deaths [ 5 ]. Nigeria bears a substantial share of the global burden of under-immunized children. Recent estimates indicate that over 2.3 million Nigerian children remain zero-dose, highlighting persistent disparities in vaccine access across regions and communities [ 6 ]. Vaccine-preventable diseases therefore remain a significant threat to child survival in the country. According to the 2024 Nigeria Demographic and Health Survey (NDHS), only 39% of children aged 12–23 months are fully vaccinated with all basic antigens, including BCG, three doses of pentavalent vaccine, three doses of OPV, and one dose of measles vaccine [ 7 ]. Coverage gaps are particularly pronounced in rural and underserved communities where barriers such as geographic inaccessibility, limited health infrastructure, and socioeconomic constraints impede vaccine uptake [ 7 ]. Previous studies conducted in Nigeria and other low- and middle-income countries have documented substantial disparities in immunization coverage and identified multiple determinants influencing vaccine uptake. National and subnational analyses consistently show lower immunization coverage among rural populations compared with urban areas [ 8 , 9 ]. For example, studies conducted in Enugu State reported full immunization coverage of 78.9% overall but only 55.5% in rural areas, while research from Oyo and Edo States reported coverage ranging from 80.7% to 81.3%, depending on maternal education and access to immunization services [ 10 – 12 ]. Maternal education, knowledge of vaccination schedules, and access to reliable immunization information have been identified as strong predictors of vaccine uptake [ 1 , 9 , 13 ]. Additionally, healthcare-related factors such as antenatal care attendance, health facility delivery, and postnatal care utilization significantly influence childhood immunization outcomes [ 8 , 10 , 14 ]. Despite these important contributions, empirical evidence on immunization coverage and its determinants remains limited in many rural communities in Southeast Nigeria. Local-level data are critical for understanding context-specific barriers to immunization and for informing targeted interventions aimed at improving vaccine uptake. Therefore, this study assessed routine immunization coverage and determinants among children aged 12–23 months in Izzi Local Government Area (LGA) of Ebonyi State, Nigeria. 2. Methods 2.1 Study area The study was conducted in Izzi LGA, Ebonyi State, South-East Nigeria, one of the largest LGAs in the state. The LGA is located on the Cross-River plain, between the Enyimu and Ebonyi Rivers, tributaries of the Cross River, at approximately 6.58333°N latitude and 8.05°E longitude, covering an area of 86.14 square miles (723.1 km²). The climate is characterized by bimodal rainfall (1,800–2,000 mm annually) from April to November, peaking in July and September, and temperature ranges from 27°C at night to 31°C during the day [ 15 ]. 2.2 Study design The study employed a community-based cross-sectional design using a quantitative approach. This design has been successfully applied in similar studies [ 1 ]. 2.3 Study population The study population comprised mothers or primary caregivers of children aged 12–23 months residing in Izzi LGA. 2.4 Inclusion and exclusion criteria Inclusion criteria : Primary caregivers of children aged 12–23 months residing in Izzi LGA at the time of the study. Children whose immunization status could be verified through vaccination cards or caregiver recall. Caregivers who provided informed consent to participate. Exclusion criteria : Caregivers unable or unwilling to provide information on their child’s immunization status. Children with missing or unverifiable immunization records, where caregivers could not recall vaccinations received. 2.5 Sample size determination The sample size was calculated from the formula derived from the WHO immunization coverage cluster survey methodology [ 16 ]. $$n=\frac{{Z}^{2}.p.(1-p)}{{d}^{2}}*DEFF$$ A where n is the minimum sample size, Z is the standard normal deviate corresponding to the desired confidence level, p is the estimated prevalence of full immunization, d is the margin of error, and DEFF is the design effect to account for cluster sampling. The following parameters were applied: estimated full immunization coverage (p) of 39%, based on findings from the Nigeria Demographic and Health Survey (NDHS) [ 7 ]; a 95% confidence level (Z = 1.96); precision of 5% (d = 0.05); and a design effect of 1.5 to account for clustering. This yielded a minimum sample size of 548 caregivers. After adjusting for a 10% non-response rate, the final sample size was increased to 603 participants. 2.6 Sampling technique A single-stage cluster sampling technique was employed. Five rural communities within Izzi Local Government Area were selected as study clusters based on their accessibility and representation of typical rural settlements within the LGA. Within each selected community, households were systematically approached and screened for eligibility. All households with at least one child aged 12–23 months whose caregiver consented to participate were included in the study until the required sample size was achieved. Probability-proportional-to-size (PPS) sampling was not applied during cluster selection due to the absence of reliable population estimates for individual communities. This limitation may introduce some degree of selection bias; however, efforts were made to include geographically diverse communities within the LGA to enhance representativeness. 2.7 Instrument for data collection Data were collected using a standardized, structured, interviewer-administered questionnaire adapted from Adedire et al. [ 1 ]. The instrument was designed to capture information relevant to the study objectives, including: socio-demographic characteristics of caregivers; knowledge and awareness of routine immunization; the child’s vaccination status based on immunization card review or caregiver recall; and factors influencing immunization uptake, such as access, perceptions, and health-system barriers. 2.8 Procedure for data collection Trained data collectors conducted face-to-face interviews with eligible caregivers using the standardized questionnaire. Prior to fieldwork, enumerators received training on study objectives, ethical conduct, and uniform administration procedures to minimize interviewer bias. For each eligible child, the vaccination history was obtained from the immunization card where available; in the absence of a card, caregiver recall was used to document received vaccines. 2.9 Data management and analysis Completed questionnaires were checked for completeness before data entry. Data were coded, entered, cleaned, and analyzed using IBM SPSS version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize variables, and results were presented as frequencies and percentages. Associations between immunization status and independent variables were examined using the Chi-square test. Variables significant at the bivariate level (p < 0.05) were entered into a binary logistic regression model to identify independent determinants of full immunization. Results were reported as adjusted odds ratios (AORs) with 95% confidence intervals, with statistical significance set at p < 0.05. 3. Results A total of 501 valid questionnaires were analyzed, representing 83.1% of the final calculated sample size (n = 603). 3.1 Socio-demographic characteristics of respondents Table 1 presents the socio-demographic profile of the 501 caregivers surveyed. Most caregivers (57.5%) were aged 25–34 years, while only 4.8% were 45 years or older. Mothers constituted the vast majority of respondents (85.8%). Nearly half (46.9%) had completed secondary education, and 17.2% had tertiary education. Trading (37.9%) and farming (25.7%) were the most common occupations. Over half of the caregivers (53.3%) had more than three children. Christianity was the predominant religion (97.0%). Table 1 Socio-demographic characteristics of respondents (n = 501) Variable Category Frequency (n) Percent (%) Age of caregiver (years) 18–24 99 19.8 25–34 288 57.5 35–44 90 18 45 and above 24 4.8 Relationship to child Father 9 1.8 Grandparent 17 3.4 Mother 430 85.8 Others 45 9 Highest education attained No formal education 77 15.4 Primary 103 20.6 Secondary 235 46.9 Tertiary 86 17.2 Occupation of caregiver Civil servant 60 12 Farming 129 25.7 Trading 190 37.9 Others 122 24.4 Number of children 1–3 234 46.7 Above 3 267 53.3 Religion Christianity 486 97 Traditional religion 15 3 3.2 Caregivers’ knowledge of routine immunization Table 2 summarizes caregivers’ knowledge of routine immunization. Nearly all respondents (99.4%) had heard of routine immunization. The leading sources of information were community health workers (39.9%) and health facilities (36.7%). Only one-third (33.9%) correctly identified the recommended vaccines for children aged 12–23 months. Furthermore, 43.7% accurately stated that routine immunization should be completed by 1–2 years of age. Table 2 Caregivers’ knowledge of routine immunization (n = 501) Variable Category Frequency (n) Percent (%) Heard about routine immunization No 3 0.6 Yes 498 99.4 Main source of information on immunization Community health workers 200 39.9 Family/friends 80 16 Health facility 184 36.7 Mass media 23 4.6 Others 14 2.8 Knows recommended vaccines for children (12–23 months) No 331 66.1 Yes 170 33.9 Perceived age at which child should complete routine immunization 1–2 years 219 43.7 Above 2 years 40 8 Below 1 year 40 8 Don’t know 202 40.3 3.3 Immunization coverage and status of children Table 3 shows that immunization coverage among children aged 12–23 months was high for most antigens. Coverage was highest for BCG (94.4%), OPV1 (95.8%), Penta1 (96.6%), and PCV1 (95.6%). Slight declines were observed with later doses, including OPV3 (92.0%), Penta3 (94.8%), and PCV3 (94.4%). Measles (91.0%) and yellow fever (89.8%) had comparatively lower coverage. Overall, 75.4% of children were fully immunized. Table 3 Immunization coverage and status of children aged 12–23 months (n = 501) Immunization Indicator Frequency Percent (%) BCG vaccination 473 94.4 OPV at birth 459 91.6 OPV 1 480 95.8 OPV 2 476 95 OPV 3 461 92 Penta 1 484 96.6 Penta 2 483 96.4 Penta 3 475 94.8 PCV 1 479 95.6 PCV 2 476 95 PCV 3 473 94.4 Measles vaccination 456 91 Yellow fever vaccination 450 89.8 Fully immunized (all recommended vaccines) 378 75.4 3.4 Barriers and facilitators to immunization As shown in Table 4 , the most frequently reported barriers to immunization were transportation cost (72.3%) and vaccine unavailability (59.7%). Long waiting times (47.1%) and poor staff attitude (17.6%) were less commonly cited. Key facilitators of uptake included advice from health workers (76.6%), availability of free vaccines (73.7%), and awareness campaigns (51.1%), with additional support from community influence (27.9%) and home visits/outreach services (42.1%). Regarding suggested improvements, respondents emphasized the need for enhanced health education campaigns (81.4%) and consistent vaccine availability (77.8%). Other recommendations included increased mobile clinic services (60.5%) and shorter waiting times (34.3%), while fewer respondents suggested involving community or religious leaders (19.4%), extending clinic hours (16.2%), or providing incentives (29.9%). Table 4 Barriers and facilitators to immunization (n = 501) Variable Frequency Percent (%) Barriers to Access Long waiting time at facility 236 47.1 Cost of transportation 362 72.3 Poor attitude of health workers 88 17.6 Vaccine unavailability 299 59.7 Other challenges 117 23.4 Facilitators of Uptake Free vaccines 369 73.7 Advice from health workers 384 76.6 Awareness campaigns 256 51.1 Community influence 140 27.9 Other facilitators 85 17 Home visits/outreach programs 211 42.1 Suggested Improvements Increase awareness through campaigns 408 81.4 Provide more mobile clinics 303 60.5 Improve attitude/training of health workers 123 24.6 Ensure consistent vaccine availability 390 77.8 Reduce waiting time 172 34.3 Involve community/religious leaders 97 19.4 Extend clinic hours 81 16.2 Offer incentives for caregivers 150 29.9 Improve record-keeping and follow-up 140 27.9 3.5 Association between socio-demographic factors and full immunization Chi-square tests examined the association between selected socio-demographic variables and full routine immunization. Caregiver age was significantly associated with full immunization (χ² = 22.57, p < 0.001), with the highest completion observed among caregivers aged 35–44 years (68.2%). Caregiver education also showed a strong association (χ² = 117.48, p < 0.001); children of caregivers with secondary education had the highest coverage (68.1%), while those whose caregivers had no formal education had the lowest (31.2%). Occupation was similarly significant (χ² = 98.23, p < 0.001), with civil servants more likely to have fully immunized children than farmers. Religion was also associated with immunization status (χ² = 59.81, p < 0.001), as Christian caregivers reported substantially higher completion (59.7%) compared with those practicing traditional religions (20.0%). Number of children in the household showed no significant association (p = 0.062). Awareness of routine immunization demonstrated a very strong association with full immunization (χ² = 250.78, df = 4, p < 0.001). Nearly all caregivers (99.4%) had heard of routine immunization, and among them, 58.3% reported complete vaccination for their children, compared with substantially lower completion among those unaware of routine immunization. A binary logistic regression model was fitted to identify independent determinants of full immunization. The model was statistically significant (χ² = 59.51, df = 11, p < 0.001). After adjusting for other variables, occupation of the caregiver and religion remained significant predictors of full immunization. Children whose caregivers were farmers had significantly lower odds of being fully immunized compared with those whose caregivers were civil servants (AOR = 0.47; 95% CI: 0.24–0.90; p = 0.023). Similarly, caregiver religion was significantly associated with full immunization (AOR = 0.28; 95% CI: 0.08–0.94; p = 0.040). Caregiver age, highest level of education, and awareness of routine immunization were not significant predictors of full immunization in the adjusted model (p > 0.05). 4. Discussion The present study (Table 1 ) found that most caregivers were aged 25–34 years, indicating a predominance of young to middle-aged adults. This is consistent with findings from Adedire et al. [ 1 ] and Eze et al. [ 10 ], which reported that caregivers within reproductive and economically active age groups are more likely to engage with immunization services due to greater awareness and exposure to health information. Mothers constituted the overwhelming majority of respondents, with fathers representing only 1.8%, reflecting the dominant role of women as primary decision-makers and caregivers for child health in Nigerian households [ 11 , 12 ]. The low male participation underscores the gendered nature of childcare in African settings and highlights the need for interventions that actively engage fathers in immunization efforts. Regarding education, nearly half of respondents had completed secondary school, while 17.2% attained tertiary education. This higher literacy level may have contributed to greater awareness and positive health-seeking behaviors, aligning with Adedire et al. [ 1 ] and Aheto et al. [ 17 ], who linked caregiver education to improved immunization uptake and child health outcomes. Trading and farming were the dominant occupations, consistent with Eze et al. [ 10 ] and Akwataghibe et al. [ 18 ], who observed the prevalence of informal economic activities among caregivers in South-East Nigeria. While the flexibility of these occupations may facilitate clinic attendance, financial instability could limit consistent access to healthcare. More than half of caregivers reported having more than three children, reflecting the high parity observed in the region, which may affect prioritization of child health services and influence immunization completion [ 11 ]. Christianity was the predominant religion, consistent with regional demographics and prior studies, suggesting that religious homogeneity in the study population likely minimized its confounding effect on immunization uptake [ 1 ]. The present study (Table 2 ) found that nearly all respondents had heard about routine immunization, with community health workers and health facilities serving as the primary sources of information. Despite this high awareness, only about one-third of caregivers correctly identified the recommended vaccines for children aged 12–23 months, and less than half knew the appropriate age for completing the full immunization schedule, highlighting a gap between general awareness and detailed knowledge of vaccination requirements. These findings align with Adedire et al. [ 1 ], who reported that although Nigerian caregivers are generally aware of routine immunization, many lack specific knowledge of vaccine types and schedules. Similarly, Eze et al. [ 10 ] observed that caregivers in Enugu, though aware of immunization, often could not accurately recall the immunization timetable, underscoring the need for ongoing education and reinforcement. The study further supports the evidence that interpersonal communication at service delivery points is critical for translating awareness into actionable knowledge. Akwataghibe et al. [ 18 ] highlighted that while community health workers and mass media can raise awareness, structured education is necessary to ensure caregivers understand the immunization schedule and the importance of completing all doses. This knowledge gap is particularly concerning given that maternal understanding of immunization strongly predicts full coverage, as demonstrated by Ijarotimi et al. [ 11 ] and Adeleye & Mokogwu [ 12 ], who reported that inadequate caregiver knowledge contributes to missed vaccination opportunities. These findings emphasize the need to strengthen health education at both community and facility levels, ensuring that information provided extends beyond general awareness to include specific vaccines, their timing, and the necessity of completing the full immunization schedule. The findings from Table 3 indicate that immunization coverage was generally high across most antigens. BCG, OPV1, Penta1, and PCV1 recorded the highest coverage, consistent with the pattern observed in Nigeria, where initial vaccine doses are often well received due to early contact with health facilities [ 8 , 10 ]. However, coverage declined slightly for subsequent doses such as OPV3, Penta3, and PCV3, reflecting the tendency for vaccine uptake to decrease as the immunization schedule progresses, likely due to challenges with follow-up visits and missed opportunities [ 1 , 11 ]. The relatively lower coverage observed for measles and yellow fever compared to early infant vaccines is consistent with prior studies indicating that vaccines scheduled at later ages often experience reduced compliance due to waning caregiver adherence to clinic visits and logistical constraints [ 10 , 12 ]. The proportion of fully immunized children in this study is comparable to findings from national surveys in Nigeria, which reported full immunization rates around 77% [ 8 ]. Despite this moderate coverage, it remains below the WHO target of 90%, highlighting persistent gaps in universal immunization. These results suggest that while access to vaccines is relatively high, sustaining coverage through the completion of later doses and reaching all eligible children remains a key challenge, reflecting the influence of systemic, behavioral, and contextual barriers on optimal immunization outcomes. The current study (Table 4 ) identified transportation cost and vaccine unavailability as the predominant barriers to routine immunization. These findings are consistent with Adedire et al. [ 1 ], who highlighted financial constraints and poor logistics as major impediments to immunization coverage in Nigeria. Similarly, Njoku [ 9 ] reported that difficulties accessing healthcare and vaccine shortages discouraged caregivers from completing vaccination schedules, underscoring the persisting structural and economic challenges in Nigerian communities. The present study further revealed that long waiting times and poor staff attitude were less frequently reported, which aligns with findings from Akwataghibe et al. [ 18 ], who noted that service-related factors such as waiting time and provider behaviour were barriers but were less significant compared to systemic and financial challenges. On the other hand, the major facilitators of uptake were advice from health workers, availability of free vaccines, and awareness campaigns. These results strongly resonate with Aheto [ 17 ], who emphasized the crucial role of frontline health workers in motivating caregivers to immunize their children. Similarly, Adedire et al. [ 1 ] observed that maternal knowledge and access to immunization information significantly influenced compliance with vaccination schedules. Moreover, the emphasis on free vaccine provision and outreach echoes the observations of Njoku [ 9 ], who found that financial subsidies and community awareness strategies were significant enablers of immunization uptake in low-resource settings. The suggestions from caregivers for improving uptake—including increasing health education campaigns and ensuring consistent vaccine availability—reinforce findings from Adedire et al. [ 1 ] and Njoku [ 9 ], both of whom emphasized the need for continuous community engagement and robust vaccine supply chains. Additional caregiver recommendations such as more mobile clinics and reduced waiting times are in line with Ibraheem et al. [ 14 ], who advocated for decentralised services and timely immunization interventions to reach underserved populations. Interestingly, fewer respondents in this study recommended involvement of community/religious leaders or provision of incentives, which suggests that while structural and health-system factors remain dominant in this context, socio-cultural enablers may have a more limited role in certain Nigerian settings. These findings highlight that removing financial and logistic obstacles, ensuring uninterrupted vaccine supply, and strengthening health worker–caregiver communication are the most effective strategies for sustaining high immunization uptake. The findings of this study reveal clear socio-demographic gradients in routine immunization completion. At the bivariate level, caregiver age, education, occupation, and religion were significantly associated with full immunization, whereas family size was not. These patterns highlight the continuing importance of caregiver characteristics in shaping childhood vaccination outcomes in rural settings. Caregiver age showed a notable association with immunization completion. Older caregivers generally demonstrated higher vaccination completion compared with younger caregivers. This pattern aligns with national analyses of Demographic and Health Survey data, which indicate higher odds of incomplete vaccination among children of younger mothers [ 8 ]. Similarly, Aheto et al. [ 17 ] identified maternal age as an important predictor of uptake of later-schedule vaccines such as PENTA3 and measles. Older caregivers may benefit from greater parenting experience, improved decision-making autonomy, and more stable socioeconomic circumstances, all of which may facilitate adherence to vaccination schedules. However, caregiver age was not a significant predictor in the multivariable logistic regression model, suggesting that its apparent influence may be mediated through other factors such as education or socioeconomic status. Caregiver education also demonstrated a strong association with immunization completion at the bivariate level. This finding is consistent with a large body of literature showing that maternal education is a key determinant of childhood immunization uptake in low- and middle-income countries [ 8 , 11 , 17 ]. Education likely influences vaccination through several pathways, including improved health literacy, greater awareness of immunization schedules, and increased ability to navigate health systems. Adedire et al. [ 1 ] similarly reported that caregivers with better understanding of vaccination schedules were significantly more likely to complete immunization for their children. Nevertheless, education did not remain a significant predictor in the adjusted logistic regression model, indicating that other contextual factors may play a more direct role in determining vaccination completion in this rural setting. Occupation emerged as one of the key determinants of full immunization in the multivariable analysis. In particular, children of caregivers engaged in farming had significantly lower odds of being fully immunized compared with those whose caregivers were civil servants. This finding reflects broader evidence that socioeconomic disadvantage and indirect costs can impede access to vaccination services [ 8 , 10 , 18 ]. Civil servants may benefit from more predictable work schedules, paid leave, and greater proximity to health facilities, which facilitate attendance at immunization sessions. In contrast, farmers often face competing seasonal labour demands, long travel distances, and transportation costs, all of which can delay or prevent completion of vaccination schedules. These structural constraints highlight the importance of strengthening outreach services and improving geographic access to immunization in rural communities. Religion was also independently associated with immunization completion after adjusting for other variables. Children of caregivers belonging to minority religious groups had significantly lower odds of completing vaccination compared with their counterparts in the predominant religious group. Previous studies have similarly shown that religious beliefs, trust in health services, and faith-based messaging can influence vaccination behaviour [ 11 ]. However, in the present study the small number of respondents from minority religious groups suggests that religion may act partly as a proxy for social marginalization or differential access to health information rather than belief systems alone. Addressing such disparities may require culturally sensitive community engagement strategies alongside efforts to improve equitable access to services. Although caregiver awareness of routine immunization was strongly associated with vaccination completion at the bivariate level, it did not remain significant after adjusting for other socio-demographic factors. This finding suggests that awareness alone may not be sufficient to ensure completion of the full vaccination schedule when structural barriers persist. While knowledge and information remain essential components of immunization programs, their effectiveness may depend on concurrent improvements in access, affordability, and service delivery. Similar observations have been reported in other low-resource settings where awareness levels are high but logistical barriers continue to limit vaccination uptake [ 8 , 19 ]. 5. Conclusions This study demonstrated that routine immunization coverage among children aged 12–23 months in rural communities of Izzi Local Government Area, Ebonyi State, remains below optimal levels, with only three-quarters of children fully immunized. Socio-demographic factors—particularly caregiver occupation and religion—emerged as significant determinants of full immunization in adjusted analyses, while caregiver age, education, and awareness showed strong associations at the bivariate level. Children of caregivers engaged in formal employment and those belonging to the predominant religious group were more likely to complete vaccination schedules, highlighting the influence of both socioeconomic and cultural factors. Barriers such as transportation costs and vaccine unavailability underscore the persistent structural challenges in rural settings. Policy interventions should therefore combine structural and informational strategies. Strengthening outreach services, mobile clinics, and reliable vaccine supply is critical to improve access for caregivers in informal occupations and remote areas. Health education campaigns, delivered through culturally appropriate channels and local languages, can enhance awareness and counter misconceptions. Collaborating with faith-based and community leaders may further promote positive attitudes toward immunization. Long-term initiatives to improve female education and access to formal employment are also essential to address underlying socio-economic inequities. Abbreviations BCG – Bacille Calmette–Guérin OPV1–3 – Oral Polio Vaccine, doses 1 to 3 Penta1–3 – Pentavalent vaccine, doses 1 to 3 PCV1–3 – Pneumococcal Conjugate Vaccine, doses 1 to 3 AOR – Adjusted Odds Ratio CI – Confidence Interval VPDs – Vaccine-Preventable Diseases CDC – Centers for Disease Control and Prevention WHO – World Health Organization EPI – Expanded Programme on Immunization DPT – Diphtheria, Pertussis, and Tetanus vaccine NDHS – Nigeria Demographic and Health Survey LGA – Local Government Area PPS – Probability Proportional to Size UNTH – University of Nigeria Teaching Hospital Declarations Ethical consideration The study adhered strictly to international ethical guidelines as outlined in the declaration of Helsinki. Ethical approval for the study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State (reference number NHREC/05/01/2008B-FWA00002458-1RB00002323). All participants were informed about the study’s purpose, procedures, risks, and benefits, and provided written or verbal informed consent before participation. Confidentiality was ensured by using unique identification codes instead of personal identifiers, and all data were securely stored with access restricted to authorized research personnel. Participation was entirely voluntary, and caregivers retained the right to withdraw at any stage without penalty. Consent for publication Not applicable Availability of data and materials The datasets supporting the conclusions of this article are included within the article (and its additional files). Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contribution Luke Oche Peter conceptualized the study, designed the methodology, performed data analysis, and drafted the manuscript. Blessing Adaora Igwilo contributed to study conceptualization, assisted with methodology, participated in data collection, and reviewed the manuscript. Anne Chigedu Ndu provided supervision, validated the study instrument, contributed to conceptualization, and critically reviewed the manuscript. Nnaemeka Emmanuel Akubue provided critical review and feedback on the manuscript. All authors read and approved the final version of the manuscript. Acknowledgments The authors sincerely appreciate the dedication and hard work of the research assistants who facilitated data collection for this study. Their commitment, patience, and attention to detail were invaluable in ensuring the accuracy and completeness of the data. 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Available from: https://www.who.int/news/item/15-07-2025-global- Jean Baptiste AE, Wagai J, Hahné S, Adeniran A, Koko RI, de Vos S et al (2024) High-resolution geospatial mapping of zero-dose and underimmunized children following Nigeria's 2021 Multiple Indicator Cluster Survey/National Immunization Coverage Survey. J Infect Dis 230(1):e131–e138 National Population Commission (NPC), ICF. Nigeria Demographic and Health Survey 2024 – Summary Report. Rockville, MD: NPC & ICF (2024) Available from: https://dhsprogram.com/pubs/pdf/SR294/SR294.pdf Adedokun ST, Uthman OA, Adekanmbi VT, Wiysonge CS (2017) Incomplete childhood immunization in Nigeria: a multilevel analysis of individual and contextual factors. BMC Public Health 17:1–10 Njoku GC, Anukam IN, Ugwuegbu ONF, Ezekwe CE, Ibebuike JE, Vincent CC, Nwagwu AS (2023) Socio-demographic determinants of childhood immunization coverage among mothers in Ogbaku Community, Imo State, Nigeria. J Optom Health Sci (JOHS). ;2(1) Eze P, Agu UJ, Aniebo CL, Agu SA, Lawani LO, Acharya Y (2021) Factors associated with incomplete immunization in children aged 12–23 months at subnational level, Nigeria: a cross-sectional study. BMJ Open 11(6):e047445 Ijarotimi IT, Fatiregun AA, Adebiyi OA, Ilesanmi OS, Ajumobi O (2018) Urban–rural differences in immunization status and associated demographic factors among children 12–59 months in a southwestern state, Nigeria. PLoS ONE 13(11):e0206086 Adeleye OA, Mokogwu N (2015) Determinants of full vaccination status in a rural community with accessible vaccination services in South-South Nigeria. J Community Med Prim Health Care 27(2):12–19 Herliana P, Douiri A (2017) Determinants of immunization coverage of children aged 12–59 months in Indonesia: a cross-sectional study. BMJ Open 7(12):e015790 Ibraheem R, Abdulkadir M, Akintola M, Adeboye M (2019) Determinants of timely presentation for birth dose vaccination at an immunization centre in North-central Nigeria. Ann Glob Health ;85(1) Onyeabor EN, Nwahia OC, Okereke CO, Elom DF (2022) Prevalence of child poverty and deprivations in agrarian communities of Izzi Local Government Area, Ebonyi State, Nigeria: a descriptive approach. Niger Agric J 53(1):177–182 World Health Organization (2018) Vaccination coverage cluster surveys: Reference manual (WHO/IVB/18.09). WHO, Geneva Aheto JMK, Pannell O, Dotse-Gborgbortsi W, Trimner MK, Tatem AJ, Rhoda DA et al (2022) Multilevel analysis of predictors of multiple indicators of childhood vaccination in Nigeria. PLoS ONE 17(5):e0269066 Akwataghibe NN, Ogunsola EA, Broerse JE, Popoola OA, Agbo AI, Dieleman MA (2019) Exploring factors influencing immunization utilization in Nigeria—a mixed methods study. Front Public Health 7:392 Antai D (2009) Inequitable childhood immunization in Nigeria: A multilevel analysis of individual contextual determinants. BMC Infect Dis 9:181. https://doi.org/10.1186/1471-2334-9-181 Additional Declarations The authors declare no competing interests. Supplementary Files IMMUNIZATIONCOVERAGEANDITSDETERMINANTS.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9081262","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603651041,"identity":"578f64c4-9ff0-4225-adff-f52ef32508d6","order_by":0,"name":"Luke Oche Peter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBCDBAZ2BmYGhgogk5m5gYBiZqgWZhDrDEiAkRQtjG0gNgEt5uz9Bx9XVNjl8TPzGBt8nFcbzd8O1PKjYhtOLZY9h5kNz5xJLpZs5jFOnLnteO6Mw4wNjD1nbuPUYnAjmU2yse1A4obDPMaHebcdy20AamFmbMOj5f5j9p8gLftBWv7OOZY7n6CWG8xsjGBbgH5JZmyoyd1ASItlT7KxZMOZ5MQZh9mKDXuOHcjdCNRyEJ9fzNkPPvzYUGGX2N/evFniR01d7rzzhw8++FGBx2Fo/MNg8gBO9Vi01OFTPApGwSgYBSMUAAAIf1uh+SZnoQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Nigeria","correspondingAuthor":true,"prefix":"","firstName":"Luke","middleName":"Oche","lastName":"Peter","suffix":""},{"id":603651042,"identity":"c1288bf7-d236-4804-b935-7c7191802155","order_by":1,"name":"Blessing Adaora Igwilo","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Blessing","middleName":"Adaora","lastName":"Igwilo","suffix":""},{"id":603651043,"identity":"ce2a1517-7ad5-4e31-a3f1-08188ed2d43d","order_by":2,"name":"Anne Chigedu Ndu","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"Chigedu","lastName":"Ndu","suffix":""},{"id":603651044,"identity":"e7bb6695-fe01-4e9d-b2a7-1d0fcbb0ceee","order_by":3,"name":"Nnaemeka Emmanuel Akubue","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Nnaemeka","middleName":"Emmanuel","lastName":"Akubue","suffix":""}],"badges":[],"createdAt":"2026-03-10 08:30:34","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9081262/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9081262/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104392633,"identity":"dcce2994-6ebb-4b69-a9f5-9effcfa2ccd7","added_by":"auto","created_at":"2026-03-11 10:27:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1169590,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9081262/v1/d7ee3b79-8db7-4dc2-b620-b696b408f04c.pdf"},{"id":104392598,"identity":"f8db9c6b-0f8a-4829-ad2a-b318f52cd1bb","added_by":"auto","created_at":"2026-03-11 10:27:26","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":135655,"visible":true,"origin":"","legend":"","description":"","filename":"IMMUNIZATIONCOVERAGEANDITSDETERMINANTS.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-9081262/v1/006bb838e02abe683a48b65f.xlsx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eRoutine immunization coverage and determinants among children aged 12–23 months in rural southeast Nigeria: evidence from a community-based study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eImmunization is one of the most cost-effective public health strategies for preventing childhood morbidity and mortality from vaccine-preventable diseases (VPDs) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, vaccination prevents an estimated 3.5\u0026ndash;5\u0026nbsp;million deaths annually, making it one of the most impactful public health interventions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similarly, the Centers for Disease Control and Prevention (CDC) estimates that routine childhood immunization averts approximately 4\u0026nbsp;million deaths each year worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. To expand global access to lifesaving vaccines, the World Health Organization (WHO) launched the Expanded Programme on Immunization (EPI) in 1974, which recommends timely administration of key childhood vaccines\u0026mdash;including Bacille Calmette\u0026ndash;Gu\u0026eacute;rin (BCG), oral polio vaccine (OPV), diphtheria\u0026ndash;pertussis\u0026ndash;tetanus (DPT), and measles vaccines\u0026mdash;within the first year of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite substantial global progress in vaccine delivery, significant gaps in immunization coverage persist. In 2024, approximately 14.3\u0026nbsp;million infants worldwide received no routine vaccinations, commonly referred to as \u0026ldquo;zero-dose\u0026rdquo; children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These children are disproportionately concentrated in a small number of low- and middle-income countries with fragile health systems and limited access to healthcare services, including Nigeria [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Persistent inequities in vaccine access continue to undermine global efforts to achieve universal immunization coverage and reduce preventable childhood deaths [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNigeria bears a substantial share of the global burden of under-immunized children. Recent estimates indicate that over 2.3\u0026nbsp;million Nigerian children remain zero-dose, highlighting persistent disparities in vaccine access across regions and communities [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Vaccine-preventable diseases therefore remain a significant threat to child survival in the country. According to the 2024 Nigeria Demographic and Health Survey (NDHS), only 39% of children aged 12\u0026ndash;23 months are fully vaccinated with all basic antigens, including BCG, three doses of pentavalent vaccine, three doses of OPV, and one dose of measles vaccine [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Coverage gaps are particularly pronounced in rural and underserved communities where barriers such as geographic inaccessibility, limited health infrastructure, and socioeconomic constraints impede vaccine uptake [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies conducted in Nigeria and other low- and middle-income countries have documented substantial disparities in immunization coverage and identified multiple determinants influencing vaccine uptake. National and subnational analyses consistently show lower immunization coverage among rural populations compared with urban areas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For example, studies conducted in Enugu State reported full immunization coverage of 78.9% overall but only 55.5% in rural areas, while research from Oyo and Edo States reported coverage ranging from 80.7% to 81.3%, depending on maternal education and access to immunization services [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Maternal education, knowledge of vaccination schedules, and access to reliable immunization information have been identified as strong predictors of vaccine uptake [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, healthcare-related factors such as antenatal care attendance, health facility delivery, and postnatal care utilization significantly influence childhood immunization outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these important contributions, empirical evidence on immunization coverage and its determinants remains limited in many rural communities in Southeast Nigeria. Local-level data are critical for understanding context-specific barriers to immunization and for informing targeted interventions aimed at improving vaccine uptake. Therefore, this study assessed routine immunization coverage and determinants among children aged 12\u0026ndash;23 months in Izzi Local Government Area (LGA) of Ebonyi State, Nigeria.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study area\u003c/h2\u003e \u003cp\u003eThe study was conducted in Izzi LGA, Ebonyi State, South-East Nigeria, one of the largest LGAs in the state. The LGA is located on the Cross-River plain, between the Enyimu and Ebonyi Rivers, tributaries of the Cross River, at approximately 6.58333\u0026deg;N latitude and 8.05\u0026deg;E longitude, covering an area of 86.14 square miles (723.1 km\u0026sup2;). The climate is characterized by bimodal rainfall (1,800\u0026ndash;2,000 mm annually) from April to November, peaking in July and September, and temperature ranges from 27\u0026deg;C at night to 31\u0026deg;C during the day [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study design\u003c/h2\u003e \u003cp\u003eThe study employed a community-based cross-sectional design using a quantitative approach. This design has been successfully applied in similar studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study population\u003c/h2\u003e \u003cp\u003eThe study population comprised mothers or primary caregivers of children aged 12\u0026ndash;23 months residing in Izzi LGA.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrimary caregivers of children aged 12\u0026ndash;23 months residing in Izzi LGA at the time of the study.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eChildren whose immunization status could be verified through vaccination cards or caregiver recall.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCaregivers who provided informed consent to participate.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCaregivers unable or unwilling to provide information on their child\u0026rsquo;s immunization status.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eChildren with missing or unverifiable immunization records, where caregivers could not recall vaccinations received.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Sample size determination\u003c/h2\u003e \u003cp\u003eThe sample size was calculated from the formula derived from the WHO immunization coverage cluster survey methodology [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$n=\\frac{{Z}^{2}.p.(1-p)}{{d}^{2}}*DEFF$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA where n is the minimum sample size, Z is the standard normal deviate corresponding to the desired confidence level, p is the estimated prevalence of full immunization, d is the margin of error, and DEFF is the design effect to account for cluster sampling.\u003c/p\u003e \u003cp\u003eThe following parameters were applied: estimated full immunization coverage (p) of 39%, based on findings from the Nigeria Demographic and Health Survey (NDHS) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; a 95% confidence level (Z\u0026thinsp;=\u0026thinsp;1.96); precision of 5% (d\u0026thinsp;=\u0026thinsp;0.05); and a design effect of 1.5 to account for clustering. This yielded a minimum sample size of 548 caregivers. After adjusting for a 10% non-response rate, the final sample size was increased to 603 participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Sampling technique\u003c/h2\u003e \u003cp\u003eA single-stage cluster sampling technique was employed. Five rural communities within Izzi Local Government Area were selected as study clusters based on their accessibility and representation of typical rural settlements within the LGA. Within each selected community, households were systematically approached and screened for eligibility. All households with at least one child aged 12\u0026ndash;23 months whose caregiver consented to participate were included in the study until the required sample size was achieved.\u003c/p\u003e \u003cp\u003eProbability-proportional-to-size (PPS) sampling was not applied during cluster selection due to the absence of reliable population estimates for individual communities. This limitation may introduce some degree of selection bias; however, efforts were made to include geographically diverse communities within the LGA to enhance representativeness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Instrument for data collection\u003c/h2\u003e \u003cp\u003eData were collected using a standardized, structured, interviewer-administered questionnaire adapted from Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The instrument was designed to capture information relevant to the study objectives, including: socio-demographic characteristics of caregivers; knowledge and awareness of routine immunization; the child\u0026rsquo;s vaccination status based on immunization card review or caregiver recall; and factors influencing immunization uptake, such as access, perceptions, and health-system barriers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Procedure for data collection\u003c/h2\u003e \u003cp\u003eTrained data collectors conducted face-to-face interviews with eligible caregivers using the standardized questionnaire. Prior to fieldwork, enumerators received training on study objectives, ethical conduct, and uniform administration procedures to minimize interviewer bias. For each eligible child, the vaccination history was obtained from the immunization card where available; in the absence of a card, caregiver recall was used to document received vaccines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.9 Data management and analysis\u003c/h2\u003e \u003cp\u003eCompleted questionnaires were checked for completeness before data entry. Data were coded, entered, cleaned, and analyzed using IBM SPSS version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize variables, and results were presented as frequencies and percentages. Associations between immunization status and independent variables were examined using the Chi-square test. Variables significant at the bivariate level (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were entered into a binary logistic regression model to identify independent determinants of full immunization. Results were reported as adjusted odds ratios (AORs) with 95% confidence intervals, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 501 valid questionnaires were analyzed, representing 83.1% of the final calculated sample size (n\u0026thinsp;=\u0026thinsp;603).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Socio-demographic characteristics of respondents\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the socio-demographic profile of the 501 caregivers surveyed. Most caregivers (57.5%) were aged 25\u0026ndash;34 years, while only 4.8% were 45 years or older. Mothers constituted the vast majority of respondents (85.8%). Nearly half (46.9%) had completed secondary education, and 17.2% had tertiary education. Trading (37.9%) and farming (25.7%) were the most common occupations. Over half of the caregivers (53.3%) had more than three children. Christianity was the predominant religion (97.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of respondents (n\u0026thinsp;=\u0026thinsp;501)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of caregiver (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship to child\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrandparent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest education attained\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation of caregiver\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil servant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional religion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Caregivers\u0026rsquo; knowledge of routine immunization\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes caregivers\u0026rsquo; knowledge of routine immunization. Nearly all respondents (99.4%) had heard of routine immunization. The leading sources of information were community health workers (39.9%) and health facilities (36.7%). Only one-third (33.9%) correctly identified the recommended vaccines for children aged 12\u0026ndash;23 months. Furthermore, 43.7% accurately stated that routine immunization should be completed by 1\u0026ndash;2 years of age.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCaregivers\u0026rsquo; knowledge of routine immunization (n\u0026thinsp;=\u0026thinsp;501)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeard about routine immunization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain source of information on immunization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily/friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMass media\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnows recommended vaccines for children (12\u0026ndash;23 months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived age at which child should complete routine immunization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003e3.3 Immunization coverage and status of children\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that immunization coverage among children aged 12\u0026ndash;23 months was high for most antigens. Coverage was highest for BCG (94.4%), OPV1 (95.8%), Penta1 (96.6%), and PCV1 (95.6%). Slight declines were observed with later doses, including OPV3 (92.0%), Penta3 (94.8%), and PCV3 (94.4%). Measles (91.0%) and yellow fever (89.8%) had comparatively lower coverage. Overall, 75.4% of children were fully immunized.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImmunization coverage and status of children aged 12\u0026ndash;23 months (n\u0026thinsp;=\u0026thinsp;501)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmunization Indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCG vaccination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPV at birth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPV 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPV 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPV 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePenta 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePenta 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePenta 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCV 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e479\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCV 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCV 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeasles vaccination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYellow fever vaccination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFully immunized (all recommended vaccines)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Barriers and facilitators to immunization\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the most frequently reported barriers to immunization were transportation cost (72.3%) and vaccine unavailability (59.7%). Long waiting times (47.1%) and poor staff attitude (17.6%) were less commonly cited. Key facilitators of uptake included advice from health workers (76.6%), availability of free vaccines (73.7%), and awareness campaigns (51.1%), with additional support from community influence (27.9%) and home visits/outreach services (42.1%).\u003c/p\u003e \u003cp\u003eRegarding suggested improvements, respondents emphasized the need for enhanced health education campaigns (81.4%) and consistent vaccine availability (77.8%). Other recommendations included increased mobile clinic services (60.5%) and shorter waiting times (34.3%), while fewer respondents suggested involving community or religious leaders (19.4%), extending clinic hours (16.2%), or providing incentives (29.9%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers and facilitators to immunization (n\u0026thinsp;=\u0026thinsp;501)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers to Access\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong waiting time at facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost of transportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor attitude of health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccine unavailability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacilitators of Uptake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree vaccines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvice from health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness campaigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome visits/outreach programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuggested Improvements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncrease awareness through campaigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvide more mobile clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprove attitude/training of health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnsure consistent vaccine availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduce waiting time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolve community/religious leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtend clinic hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOffer incentives for caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprove record-keeping and follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Association between socio-demographic factors and full immunization\u003c/h2\u003e \u003cp\u003eChi-square tests examined the association between selected socio-demographic variables and full routine immunization. Caregiver age was significantly associated with full immunization (χ\u0026sup2; = 22.57, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the highest completion observed among caregivers aged 35\u0026ndash;44 years (68.2%). Caregiver education also showed a strong association (χ\u0026sup2; = 117.48, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); children of caregivers with secondary education had the highest coverage (68.1%), while those whose caregivers had no formal education had the lowest (31.2%). Occupation was similarly significant (χ\u0026sup2; = 98.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with civil servants more likely to have fully immunized children than farmers. Religion was also associated with immunization status (χ\u0026sup2; = 59.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as Christian caregivers reported substantially higher completion (59.7%) compared with those practicing traditional religions (20.0%). Number of children in the household showed no significant association (p\u0026thinsp;=\u0026thinsp;0.062).\u003c/p\u003e \u003cp\u003eAwareness of routine immunization demonstrated a very strong association with full immunization (χ\u0026sup2; = 250.78, df\u0026thinsp;=\u0026thinsp;4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Nearly all caregivers (99.4%) had heard of routine immunization, and among them, 58.3% reported complete vaccination for their children, compared with substantially lower completion among those unaware of routine immunization.\u003c/p\u003e \u003cp\u003eA binary logistic regression model was fitted to identify independent determinants of full immunization. The model was statistically significant (χ\u0026sup2; = 59.51, df\u0026thinsp;=\u0026thinsp;11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After adjusting for other variables, occupation of the caregiver and religion remained significant predictors of full immunization. Children whose caregivers were farmers had significantly lower odds of being fully immunized compared with those whose caregivers were civil servants (AOR\u0026thinsp;=\u0026thinsp;0.47; 95% CI: 0.24\u0026ndash;0.90; p\u0026thinsp;=\u0026thinsp;0.023). Similarly, caregiver religion was significantly associated with full immunization (AOR\u0026thinsp;=\u0026thinsp;0.28; 95% CI: 0.08\u0026ndash;0.94; p\u0026thinsp;=\u0026thinsp;0.040). Caregiver age, highest level of education, and awareness of routine immunization were not significant predictors of full immunization in the adjusted model (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) found that most caregivers were aged 25\u0026ndash;34 years, indicating a predominance of young to middle-aged adults. This is consistent with findings from Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Eze et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which reported that caregivers within reproductive and economically active age groups are more likely to engage with immunization services due to greater awareness and exposure to health information. Mothers constituted the overwhelming majority of respondents, with fathers representing only 1.8%, reflecting the dominant role of women as primary decision-makers and caregivers for child health in Nigerian households [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The low male participation underscores the gendered nature of childcare in African settings and highlights the need for interventions that actively engage fathers in immunization efforts. Regarding education, nearly half of respondents had completed secondary school, while 17.2% attained tertiary education. This higher literacy level may have contributed to greater awareness and positive health-seeking behaviors, aligning with Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Aheto et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], who linked caregiver education to improved immunization uptake and child health outcomes. Trading and farming were the dominant occupations, consistent with Eze et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and Akwataghibe et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], who observed the prevalence of informal economic activities among caregivers in South-East Nigeria. While the flexibility of these occupations may facilitate clinic attendance, financial instability could limit consistent access to healthcare. More than half of caregivers reported having more than three children, reflecting the high parity observed in the region, which may affect prioritization of child health services and influence immunization completion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Christianity was the predominant religion, consistent with regional demographics and prior studies, suggesting that religious homogeneity in the study population likely minimized its confounding effect on immunization uptake [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) found that nearly all respondents had heard about routine immunization, with community health workers and health facilities serving as the primary sources of information. Despite this high awareness, only about one-third of caregivers correctly identified the recommended vaccines for children aged 12\u0026ndash;23 months, and less than half knew the appropriate age for completing the full immunization schedule, highlighting a gap between general awareness and detailed knowledge of vaccination requirements. These findings align with Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], who reported that although Nigerian caregivers are generally aware of routine immunization, many lack specific knowledge of vaccine types and schedules. Similarly, Eze et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] observed that caregivers in Enugu, though aware of immunization, often could not accurately recall the immunization timetable, underscoring the need for ongoing education and reinforcement. The study further supports the evidence that interpersonal communication at service delivery points is critical for translating awareness into actionable knowledge. Akwataghibe et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] highlighted that while community health workers and mass media can raise awareness, structured education is necessary to ensure caregivers understand the immunization schedule and the importance of completing all doses. This knowledge gap is particularly concerning given that maternal understanding of immunization strongly predicts full coverage, as demonstrated by Ijarotimi et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and Adeleye \u0026amp; Mokogwu [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who reported that inadequate caregiver knowledge contributes to missed vaccination opportunities. These findings emphasize the need to strengthen health education at both community and facility levels, ensuring that information provided extends beyond general awareness to include specific vaccines, their timing, and the necessity of completing the full immunization schedule.\u003c/p\u003e \u003cp\u003eThe findings from Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e indicate that immunization coverage was generally high across most antigens. BCG, OPV1, Penta1, and PCV1 recorded the highest coverage, consistent with the pattern observed in Nigeria, where initial vaccine doses are often well received due to early contact with health facilities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, coverage declined slightly for subsequent doses such as OPV3, Penta3, and PCV3, reflecting the tendency for vaccine uptake to decrease as the immunization schedule progresses, likely due to challenges with follow-up visits and missed opportunities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The relatively lower coverage observed for measles and yellow fever compared to early infant vaccines is consistent with prior studies indicating that vaccines scheduled at later ages often experience reduced compliance due to waning caregiver adherence to clinic visits and logistical constraints [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The proportion of fully immunized children in this study is comparable to findings from national surveys in Nigeria, which reported full immunization rates around 77% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite this moderate coverage, it remains below the WHO target of 90%, highlighting persistent gaps in universal immunization. These results suggest that while access to vaccines is relatively high, sustaining coverage through the completion of later doses and reaching all eligible children remains a key challenge, reflecting the influence of systemic, behavioral, and contextual barriers on optimal immunization outcomes.\u003c/p\u003e \u003cp\u003eThe current study (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) identified transportation cost and vaccine unavailability as the predominant barriers to routine immunization. These findings are consistent with Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], who highlighted financial constraints and poor logistics as major impediments to immunization coverage in Nigeria. Similarly, Njoku [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that difficulties accessing healthcare and vaccine shortages discouraged caregivers from completing vaccination schedules, underscoring the persisting structural and economic challenges in Nigerian communities. The present study further revealed that long waiting times and poor staff attitude were less frequently reported, which aligns with findings from Akwataghibe et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], who noted that service-related factors such as waiting time and provider behaviour were barriers but were less significant compared to systemic and financial challenges. On the other hand, the major facilitators of uptake were advice from health workers, availability of free vaccines, and awareness campaigns. These results strongly resonate with Aheto [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], who emphasized the crucial role of frontline health workers in motivating caregivers to immunize their children. Similarly, Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] observed that maternal knowledge and access to immunization information significantly influenced compliance with vaccination schedules. Moreover, the emphasis on free vaccine provision and outreach echoes the observations of Njoku [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], who found that financial subsidies and community awareness strategies were significant enablers of immunization uptake in low-resource settings. The suggestions from caregivers for improving uptake\u0026mdash;including increasing health education campaigns and ensuring consistent vaccine availability\u0026mdash;reinforce findings from Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Njoku [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], both of whom emphasized the need for continuous community engagement and robust vaccine supply chains. Additional caregiver recommendations such as more mobile clinics and reduced waiting times are in line with Ibraheem et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], who advocated for decentralised services and timely immunization interventions to reach underserved populations. Interestingly, fewer respondents in this study recommended involvement of community/religious leaders or provision of incentives, which suggests that while structural and health-system factors remain dominant in this context, socio-cultural enablers may have a more limited role in certain Nigerian settings. These findings highlight that removing financial and logistic obstacles, ensuring uninterrupted vaccine supply, and strengthening health worker\u0026ndash;caregiver communication are the most effective strategies for sustaining high immunization uptake.\u003c/p\u003e \u003cp\u003eThe findings of this study reveal clear socio-demographic gradients in routine immunization completion. At the bivariate level, caregiver age, education, occupation, and religion were significantly associated with full immunization, whereas family size was not. These patterns highlight the continuing importance of caregiver characteristics in shaping childhood vaccination outcomes in rural settings. Caregiver age showed a notable association with immunization completion. Older caregivers generally demonstrated higher vaccination completion compared with younger caregivers. This pattern aligns with national analyses of Demographic and Health Survey data, which indicate higher odds of incomplete vaccination among children of younger mothers [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, Aheto et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] identified maternal age as an important predictor of uptake of later-schedule vaccines such as PENTA3 and measles. Older caregivers may benefit from greater parenting experience, improved decision-making autonomy, and more stable socioeconomic circumstances, all of which may facilitate adherence to vaccination schedules. However, caregiver age was not a significant predictor in the multivariable logistic regression model, suggesting that its apparent influence may be mediated through other factors such as education or socioeconomic status.\u003c/p\u003e \u003cp\u003eCaregiver education also demonstrated a strong association with immunization completion at the bivariate level. This finding is consistent with a large body of literature showing that maternal education is a key determinant of childhood immunization uptake in low- and middle-income countries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Education likely influences vaccination through several pathways, including improved health literacy, greater awareness of immunization schedules, and increased ability to navigate health systems. Adedire et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] similarly reported that caregivers with better understanding of vaccination schedules were significantly more likely to complete immunization for their children. Nevertheless, education did not remain a significant predictor in the adjusted logistic regression model, indicating that other contextual factors may play a more direct role in determining vaccination completion in this rural setting.\u003c/p\u003e \u003cp\u003eOccupation emerged as one of the key determinants of full immunization in the multivariable analysis. In particular, children of caregivers engaged in farming had significantly lower odds of being fully immunized compared with those whose caregivers were civil servants. This finding reflects broader evidence that socioeconomic disadvantage and indirect costs can impede access to vaccination services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Civil servants may benefit from more predictable work schedules, paid leave, and greater proximity to health facilities, which facilitate attendance at immunization sessions. In contrast, farmers often face competing seasonal labour demands, long travel distances, and transportation costs, all of which can delay or prevent completion of vaccination schedules. These structural constraints highlight the importance of strengthening outreach services and improving geographic access to immunization in rural communities.\u003c/p\u003e \u003cp\u003eReligion was also independently associated with immunization completion after adjusting for other variables. Children of caregivers belonging to minority religious groups had significantly lower odds of completing vaccination compared with their counterparts in the predominant religious group. Previous studies have similarly shown that religious beliefs, trust in health services, and faith-based messaging can influence vaccination behaviour [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, in the present study the small number of respondents from minority religious groups suggests that religion may act partly as a proxy for social marginalization or differential access to health information rather than belief systems alone. Addressing such disparities may require culturally sensitive community engagement strategies alongside efforts to improve equitable access to services.\u003c/p\u003e \u003cp\u003eAlthough caregiver awareness of routine immunization was strongly associated with vaccination completion at the bivariate level, it did not remain significant after adjusting for other socio-demographic factors. This finding suggests that awareness alone may not be sufficient to ensure completion of the full vaccination schedule when structural barriers persist. While knowledge and information remain essential components of immunization programs, their effectiveness may depend on concurrent improvements in access, affordability, and service delivery. Similar observations have been reported in other low-resource settings where awareness levels are high but logistical barriers continue to limit vaccination uptake [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis study demonstrated that routine immunization coverage among children aged 12\u0026ndash;23 months in rural communities of Izzi Local Government Area, Ebonyi State, remains below optimal levels, with only three-quarters of children fully immunized. Socio-demographic factors\u0026mdash;particularly caregiver occupation and religion\u0026mdash;emerged as significant determinants of full immunization in adjusted analyses, while caregiver age, education, and awareness showed strong associations at the bivariate level. Children of caregivers engaged in formal employment and those belonging to the predominant religious group were more likely to complete vaccination schedules, highlighting the influence of both socioeconomic and cultural factors. Barriers such as transportation costs and vaccine unavailability underscore the persistent structural challenges in rural settings.\u003c/p\u003e \u003cp\u003ePolicy interventions should therefore combine structural and informational strategies. Strengthening outreach services, mobile clinics, and reliable vaccine supply is critical to improve access for caregivers in informal occupations and remote areas. Health education campaigns, delivered through culturally appropriate channels and local languages, can enhance awareness and counter misconceptions. Collaborating with faith-based and community leaders may further promote positive attitudes toward immunization. Long-term initiatives to improve female education and access to formal employment are also essential to address underlying socio-economic inequities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBCG \u0026ndash; Bacille Calmette\u0026ndash;Gu\u0026eacute;rin\u003c/p\u003e\n\u003cp\u003eOPV1\u0026ndash;3 \u0026ndash; Oral Polio Vaccine, doses 1 to 3\u003c/p\u003e\n\u003cp\u003ePenta1\u0026ndash;3 \u0026ndash; Pentavalent vaccine, doses 1 to 3\u003c/p\u003e\n\u003cp\u003ePCV1\u0026ndash;3 \u0026ndash; Pneumococcal Conjugate Vaccine, doses 1 to 3\u003c/p\u003e\n\u003cp\u003eAOR \u0026ndash; Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI \u0026ndash; Confidence Interval\u003c/p\u003e\n\u003cp\u003eVPDs \u0026ndash; Vaccine-Preventable Diseases\u003c/p\u003e\n\u003cp\u003eCDC \u0026ndash; Centers for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003eWHO \u0026ndash; World Health Organization\u003c/p\u003e\n\u003cp\u003eEPI \u0026ndash; Expanded Programme on Immunization\u003c/p\u003e\n\u003cp\u003eDPT \u0026ndash; Diphtheria, Pertussis, and Tetanus vaccine\u003c/p\u003e\n\u003cp\u003eNDHS \u0026ndash; Nigeria Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003eLGA \u0026ndash; Local Government Area\u003c/p\u003e\n\u003cp\u003ePPS \u0026ndash; Probability Proportional to Size\u003c/p\u003e\n\u003cp\u003eUNTH \u0026ndash; University of Nigeria Teaching Hospital\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered strictly to international ethical guidelines as outlined in the declaration of Helsinki. Ethical approval for the study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State (reference number NHREC/05/01/2008B-FWA00002458-1RB00002323). All participants were informed about the study’s purpose, procedures, risks, and benefits, and provided written or verbal informed consent before participation. Confidentiality was ensured by using unique identification codes instead of personal identifiers, and all data were securely stored with access restricted to authorized research personnel. Participation was entirely voluntary, and caregivers retained the right to withdraw at any stage without penalty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article (and its additional files).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLuke Oche Peter conceptualized the study, designed the methodology, performed data analysis, and drafted the manuscript. Blessing Adaora Igwilo contributed to study conceptualization, assisted with methodology, participated in data collection, and reviewed the manuscript. Anne Chigedu Ndu provided supervision, validated the study instrument, contributed to conceptualization, and critically reviewed the manuscript. Nnaemeka Emmanuel Akubue provided critical review and feedback on the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely appreciate the dedication and hard work of the research assistants who facilitated data collection for this study. Their commitment, patience, and attention to detail were invaluable in ensuring the accuracy and completeness of the data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdedire EB, Ajayi I, Fawole OI, Ajumobi O, Kasasa S, Wasswa P, Nguku P (2016) Immunization coverage and its determinants among children aged 12\u0026ndash;23 months in Atakumosa-West District, Osun State, Nigeria: a cross-sectional study. BMC Public Health 16:1\u0026ndash;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Vaccines and immunization: Know the facts. Geneva: WHO (2024) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/vaccines-and-immunization/know-the-facts\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/vaccines-and-immunization/know-the-facts\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Global immunization: Fast facts. 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Global childhood vaccination holds steady, yet over 14 million infants remain unvaccinated. Geneva: WHO (2025) Jul 15. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/15-07-2025-global-\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/15-07-2025-global-\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJean Baptiste AE, Wagai J, Hahn\u0026eacute; S, Adeniran A, Koko RI, de Vos S et al (2024) High-resolution geospatial mapping of zero-dose and underimmunized children following Nigeria's 2021 Multiple Indicator Cluster Survey/National Immunization Coverage Survey. J Infect Dis 230(1):e131\u0026ndash;e138\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Population Commission (NPC), ICF. Nigeria Demographic and Health Survey 2024 \u0026ndash; Summary Report. Rockville, MD: NPC \u0026amp; ICF (2024) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhsprogram.com/pubs/pdf/SR294/SR294.pdf\u003c/span\u003e\u003cspan address=\"https://dhsprogram.com/pubs/pdf/SR294/SR294.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdedokun ST, Uthman OA, Adekanmbi VT, Wiysonge CS (2017) Incomplete childhood immunization in Nigeria: a multilevel analysis of individual and contextual factors. BMC Public Health 17:1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNjoku GC, Anukam IN, Ugwuegbu ONF, Ezekwe CE, Ibebuike JE, Vincent CC, Nwagwu AS (2023) Socio-demographic determinants of childhood immunization coverage among mothers in Ogbaku Community, Imo State, Nigeria. 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J Community Med Prim Health Care 27(2):12\u0026ndash;19\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerliana P, Douiri A (2017) Determinants of immunization coverage of children aged 12\u0026ndash;59 months in Indonesia: a cross-sectional study. BMJ Open 7(12):e015790\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbraheem R, Abdulkadir M, Akintola M, Adeboye M (2019) Determinants of timely presentation for birth dose vaccination at an immunization centre in North-central Nigeria. Ann Glob Health ;85(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnyeabor EN, Nwahia OC, Okereke CO, Elom DF (2022) Prevalence of child poverty and deprivations in agrarian communities of Izzi Local Government Area, Ebonyi State, Nigeria: a descriptive approach. Niger Agric J 53(1):177\u0026ndash;182\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2018) Vaccination coverage cluster surveys: Reference manual (WHO/IVB/18.09). WHO, Geneva\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAheto JMK, Pannell O, Dotse-Gborgbortsi W, Trimner MK, Tatem AJ, Rhoda DA et al (2022) Multilevel analysis of predictors of multiple indicators of childhood vaccination in Nigeria. PLoS ONE 17(5):e0269066\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkwataghibe NN, Ogunsola EA, Broerse JE, Popoola OA, Agbo AI, Dieleman MA (2019) Exploring factors influencing immunization utilization in Nigeria\u0026mdash;a mixed methods study. Front Public Health 7:392\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntai D (2009) Inequitable childhood immunization in Nigeria: A multilevel analysis of individual contextual determinants. BMC Infect Dis 9:181. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2334-9-181\u003c/span\u003e\u003cspan address=\"10.1186/1471-2334-9-181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Routine immunization, vaccine coverage, determinants of vaccination, vaccine-preventable diseases, rural Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-9081262/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9081262/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRoutine immunization is one of the most effective public health strategies for preventing vaccine-preventable diseases in children. Despite national immunization programs, coverage remains uneven in many rural areas of Nigeria. This study assessed routine immunization coverage and its determinants among children aged 12\u0026ndash;23 months in Izzi Local Government Area, Ebonyi State, Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA community-based cross-sectional study was conducted among caregivers of children aged 12\u0026ndash;23 months. Using a cluster sampling technique, 501 caregivers were interviewed with a structured questionnaire. Data were analyzed using IBM SPSS version 20. Descriptive statistics summarized variables, while Chi-square tests and binary logistic regression identified factors associated with full immunization (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 75.4% of children were fully immunized. Coverage was highest for BCG (94.4%), OPV1 (95.8%), Penta1 (96.6%), and PCV1 (95.6%), but declined slightly for later doses including OPV3 (92.0%), measles (91.0%), and yellow fever (89.8%). Nearly all caregivers (99.4%) had heard of routine immunization, although detailed knowledge was limited. Transportation costs (72.3%) and vaccine unavailability (59.7%) were the most frequently reported barriers. Advice from health workers (76.6%) and availability of free vaccines (73.7%) were key facilitators. In multivariate analysis, caregiver occupation and religion were significant predictors of full immunization. Children of farmers were less likely to be fully immunized compared with those of civil servants (AOR\u0026thinsp;=\u0026thinsp;0.47; 95% CI: 0.24\u0026ndash;0.90; p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRoutine immunization coverage in the study area remains below optimal levels. Strengthening health education and ensuring consistent vaccine availability may improve uptake in rural communities.\u003c/p\u003e","manuscriptTitle":"Routine immunization coverage and determinants among children aged 12–23 months in rural southeast Nigeria: evidence from a community-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 10:24:58","doi":"10.21203/rs.3.rs-9081262/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d2c051c-259f-4357-8c8b-807c0976978e","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64230233,"name":"Pediatrics"}],"tags":[],"updatedAt":"2026-03-11T10:24:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 10:24:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9081262","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9081262","identity":"rs-9081262","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}