CHAPTER ONE

INTRODUCTION

Background of the Study

Immunization is a defensive procedure whereby a man is made invulnerable or resistant to an infectious disease, by the administration of a vaccine (Arora, 2018). It is one of the most cost-effective and secure public health interventions in reducing the childhood mortality and morbidity (Mathew G et al., 2017; Shashidhara and Jeyalakshmi 2018). The expanded program on immunization was introduced in 1974 by world health organization (WHO) to give general access to a set of life saving vaccines (Owais et al., 2013; Hu et al., 2018). The national Expanded Program on Immunization (EPI) goals to immunize all children in the range of 0 and 23 months against eight vaccine preventable diseases that include newborn tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus, hepatitis B, Haemophilus influenza type b (Hib), and measles (Masud et al., 2012). Pakistan’s Expanded Program on Immunization (EPI) plan includes administrating single dose of 0.05ml to 0.1ml of BCG/OPV during childbirth, 3 doses of 0.5ml of DPT/OPV/Hepatitis B antibodies at 6, 10 and 14 weeks of age, and 2 doses of 0.5ml of measles immunization at 9 and 15 months of age (Owais et al., 2011; Tariq K and Tariq R 2018; Khan and Aslam 2017; IHMA 2017). The Expanded Program on Immunization (EPI) in Pakistan every year focuses around 5.8 million children aged under 1 year to ensure against 8 antibody preventable illnesses and 5.9 million pregnant ladies to shield them and their new-born from tetanus through routine vaccination administrations (Rasheed et al., 2014). The maternal immunization provides greater protection to pregnant women and their new-born against infectious diseases during the initial couple of long stretches of life (Vojtek et al., 2018; Perrett and Nolan 2017).

Other vaccines used for children and older age people are hepatitis A and B vaccination, Haemophilus influenzae type b, meningococcus, pneumococcus, rotavirus, human papilloma infection and varicella (Okwo-Bele and Cherian 2011). Barriers to complete immunization include poor financial status, lower education level, non-utilization of maternal child health services, missed immunization opportunities and dropped immunization sessions (Sodha and Dietz 2015). Other factors associated with incomplete immunization are little access to services, health staff behavior and practices, trustworthiness of services, false contraindications, parents’ practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs (Favin et al., 2012). Absence of parent awareness and powerless administration also acted as barriers to complete vaccination (Mutua et al., 2017). Cantuária et al. performed a study in 2016 to find the factors associated with incomplete or delayed vaccination across countries. They reasoned that the inoculation status is affected by factors identified with the youngster, parental attitude or knowledge, social context of the family and health care services (Cantuária et al., 2016). Bbaale E in 2013 demonstrated that 50% of youngsters in Uganda were completely vaccinated. Furthermore, 89%, 24%, 52%, and 64% got BCG, DPT, polio and measles immunizations separately. Factors of incomplete vaccination include maternal education, introduction to media, maternal age, occupation, regional and local peculiarities(Bbaale 2013). Rainey et al. conducted a study in 2011 and inferred that the most possible factors of incomplete vaccination were poor access, insufficient antibody supply, wellbeing specialist accessibility and information, missed chance to immunize, vaccinator absent at the booked time for inoculations, place of home (Rainey et al., 2011). Sheikh A in 2013 concluded that the most common primary reason for non-vaccination was lack of information, and the most common secondary reason was religious taboos (Sheikh et al., 2013). Glatman-Freedman A et al. in 2012 revealed that the barriers associated with complete vaccination were parental absence of knowledge regarding benefits of vaccinations, fear of adverse reaction, belief that vaccination is not beneficial or causes harm, absence of motivation, mistrust of health care system and social or cultural pressure against vaccinations (Glatman-Freedman et al., 2012). Negussie A et al. performed a study in 2015 revealed that the barriers to complete vaccination course include child’s birth order, mother’s age, information about immunization benefits and perception of vaccine side effects (Negussie et al., 2015). The current study was conducted to determine the barriers faced by mothers in completion of immunization.

The African continent presents unique challenges to achieving universal immunization coverage. While some countries have made remarkable progress, others continue to struggle with vaccination rates below global targets. Health system weaknesses, including inadequate infrastructure, workforce shortages, and supply chain limitations, create substantial barriers (Wiysonge et al., 2020). Additionally, the region faces particular challenges such as political instability, conflict-induced displacement, and competing health priorities that divert attention from routine immunization. Cultural beliefs and vaccine hesitancy further complicate vaccination efforts in many communities (Dimala et al., 2022). These factors combine to create a complex landscape where even when vaccination services are theoretically available, many children still fail to complete the full immunization schedule. The situation is particularly concerning for diseases like measles and polio, where high population immunity thresholds are required to prevent outbreaks.

Cameroon’s immunization program, established in 1976, follows the WHO-recommended schedule but has struggled to achieve consistent coverage nationwide. Recent data indicate that only about 65% of Cameroonian children receive all recommended vaccines by their first birthday (MINSANTE, 2022). This national average masks significant regional disparities, with some areas reporting much lower coverage rates. The country’s EPI faces multiple systemic challenges, including frequent vaccine stockouts, inadequate cold chain maintenance, and uneven distribution of healthcare resources between urban and rural areas (Ateudjieu et al., 2020). Additionally, Cameroon’s linguistic and cultural diversity creates unique communication challenges for vaccination programs. The ongoing Anglophone crisis in regions like the Southwest has further strained health systems, disrupting routine immunization services and creating populations of internally displaced persons with limited healthcare access. These factors combine to create a challenging environment for maintaining consistent immunization coverage.
Buea, as the capital of Cameroon’s Southwest Region, presents a microcosm of the country’s immunization challenges. The city’s unique geographical setting on the slopes of Mount Cameroon creates physical access barriers for some communities. Buea’s population includes both urban and semi-urban residents, with varying levels of access to healthcare facilities. The ongoing sociopolitical crisis in the Anglophone regions has led to population movements and disrupted health services, creating additional challenges for maintaining immunization continuity (Buea Health District Report, 2022). Preliminary data suggest that EPI completion rates in Buea may be lower than national averages, though comprehensive studies are lacking. The district’s health facilities report significant dropout rates between initial and subsequent vaccinations, indicating systemic barriers to completion. Understanding these local dynamics is crucial for developing targeted interventions that can improve immunization outcomes in this specific context.

Problem Statement

Despite the proven efficacy of immunization in reducing child mortality, a significant proportion of infants in Buea, Cameroon, fail to complete the full schedule of the Expanded Programme on Immunization (EPI). Recent data from the Buea Health District reveal that dropout rates between initial and subsequent vaccinations remain alarmingly high, with many children not receiving critical booster doses (Buea Health District Report, 2022). This incomplete immunization coverage leaves children vulnerable to vaccine-preventable diseases and undermines herd immunity, increasing the risk of outbreaks in the community. While national statistics indicate that only 65% of Cameroonian children complete their vaccination schedules (MINSANTE, 2022), the specific barriers contributing to low completion rates in Buea—particularly in the context of the ongoing Anglophone crisis—remain poorly understood. Identifying these factors is crucial for developing targeted interventions to improve immunization coverage and reduce preventable child morbidity and mortality.

Existing research highlights multiple barriers to immunization completion, including maternal education, health system inefficiencies, and sociocultural beliefs (Oladejo et al., 2021; Dimala et al., 2022). However, these studies have largely focused on national trends or other regions, leaving a gap in context-specific evidence for Buea. The region’s unique challenges, such as displacement due to political instability, geographic barriers, and vaccine hesitancy fueled by misinformation, may exacerbate EPI dropout rates (Nsagha et al., 2021). Without a clear understanding of the local determinants of incomplete immunization, public health efforts risk being misdirected or ineffective. This study seeks to address this gap by examining the factors influencing non-completion of EPI vaccination among mothers of infants aged 0–15 months in Buea. The findings will inform policy and programmatic strategies to strengthen immunization services and ensure equitable protection for all children in the region.

Research Questions

1. What are the maternal-related factors influencing non-completion of the EPI vaccination schedule among mothers of infants aged 0–15 months in Buea?
2. How do health system-related barriers contribute to incomplete immunization among infants in Buea?
3. What sociocultural beliefs and practices affect mothers’ adherence to the full EPI schedule in Buea?
4. To what extent does the ongoing Anglophone crisis impact immunization completion rates in Buea?

General and Specific Objectives

General Objective:
To examine the factors influencing non-completion of the EPI vaccination schedule among mothers of infants aged 0–15 months in Buea, Cameroon.

Specific Objectives:

1. To assess maternal knowledge, attitudes, and practices regarding EPI vaccination in Buea.
2. To identify health system barriers (e.g., vaccine stockouts, long wait times, healthcare worker attitudes) affecting immunization completion.
3. To explore sociocultural and religious beliefs influencing mothers’ decisions on infant vaccination.
4. To evaluate the impact of geographical accessibility and security concerns (due to the Anglophone crisis) on EPI completion rates.