UNIVERSITY OF CAPE COAST

COLLEGE OF HUMANITIES AND LEGAL STUDIES

FACULTY OF SOCIAL SCIENCES
DEPARTMENT OF POPULATION AND HEALTH

COURSE CODE: POH 903

COURSE TITLE: ADVANCED QUANTITATIVE RESEARCH
TECHNIQUES

COURSE INSTRUCTOR: PROF EUGENE M. K. DARTEH

STUDENT NAME: JOHNSON SAM

INDEX NUMBER: SS/EPD/22/0005
PROGRAM: PHD. EPIDEMIOLOGY AND
BIOSTATISITICS

TOPIC: Childhood Immunization in Ghana: Evidence from the 2003–2022 Demographic

and Health Surveys

Introduction

Childhood Immunisation has been found to be cost-effective and an essential protective

factor worldwide (Getnet et al., 2025; Kaur, 2023; Hogan & Gupta, 2023). Vaccines not only

protect the single individual child being immunised but also protect the community through a

prevention and reduction of the spread of the disease called “herd immunity” (Obanewa, 2019).

Since its introduction in 1974, the Expended Programme on Immunisation (EPI) by the World

Health Organization (WHO) has aimed to ensure that every infant globally will receive vaccines

against the six childhood killer diseases namely; diphtheria, tetanus, pertussis, poliomyelitis,

measles, and tuberculosis (Kaur, 2023; Vakili et al., 2015).

Global coverage of key vaccines such as BCG, diphtheria–tetanus–pertussis (DTP), polio

and measles, a proxy for vaccine programme performance, increased from less than 5% in 1974

to 86% in 2019 before the COVID-19 pandemic, and is now 84% (Shattock, et al., 2024).

Despite these gains, vaccine-preventable diseases (VPDs) remain a leading cause of under-five

mortality worldwide, particularly in low- and middle-income countries (LMICs), where

incomplete vaccination coverage and delays are common (Obanewa, 2019; Williams, Akande &

Abbas, 2024). In Sub-Saharan Africa (SSA), approximately half of children receive basic

vaccines, and in remote areas coverage can be as low as five percent (Wolfson et al., 2008).

Vaccines perform an important role in reducing the incidence, prevalence and impact of common

communicable diseases among children, eventually decreasing the economic and healthcare

weights of a country (Getnet et al., 2025). It remains is a significant plan for further reducing

infant and child mortality (Sissoko et al., 2014).

Although immunization programmes have significantly reduced child morbidity and

mortality, infectious diseases continue to account for a substantial proportion of deaths among
children under five years of age. It is estimated that improvements in global vaccination

coverage could prevent at least 1.5 million deaths annually, with model-based projections

suggesting up to 51 million deaths averted between 2021 and 2030 (Williams, Akande & Abbas,

2024). However, the World Health Organization has reported that global immunization coverage

has remained below the 90% target for over a decade, indicating that a significant proportion of

children are either not vaccinated or do not complete their vaccination schedules (Vakili et al.,

2015).

In high income countries, where immunisation recording is being practiced, most

vaccine-preventable diseases are near record lows (Sally & Kenu, 2017). As a result of these

practices more than one third of the children there have access to basic vaccines, however in the

SSA region only about half of the children get access to basic immunisation. This becomes more

challenges in the poor and remote areas when only five percent of the children have access to

vaccines (Wolfson et al., 2008). There have been substantial improvements in vaccine

introductions and vaccination coverage in low- and middle-income countries since the inception

of Gavi, the Vaccine Alliance in 2000 (Williams, Akande & Abbas, 2024).

In Africa, the immunization agenda remains incomplete, with significant numbers of

children still not receiving life-saving vaccines. It is estimated that approximately three million

children under five years of age die annually in the region, a substantial proportion of which are

preventable through vaccination. One in five children still does not receive essential

immunizations, largely due to inadequate service delivery in remote areas and limited awareness

of vaccine benefits among caregivers (Adjedu, 2021).

In Ghana, despite considerable efforts, under-five mortality is high at 44 per 1000 live

births (UNICEF, 2023). It is higher in poor rural areas compared to urban settings. The current
Sustainable Development Goals (SDGs) aim to reduce global under-five mortality to less than 25

per 1000 live births by 2030 (Kanmiki, Mamun, Phillips & O’Flaherty, 2023). These are quite

ambitious given the prevailing rates of reduction, in Ghana, this requires about a fifty per cent

reduction in under-five mortality. According to the Ghana Demographic Healthy Survey (GDHS)

2014, despite efforts to increase vaccination coverage by 90% nationwide in Ghana, there was a

marginal drop from 79% in 2012 to 77% in 2014. Additionally, this society is also naturally

inclined to traditional herbal treatment due to gross superstition concerning the orthodox medical

practice which in recent times concentrates on both curative and preventive healthcare delivery

systems (Danso, Frimpong, Seneadza, & Ofori, 2023).

In this context, this study focuses specifically on the third dose of the oral polio vaccine

(OPV3). The OPV3 is widely used as a key indicator of routine immunization system

performance because it represents completion of the primary polio vaccination series, reflects

continuity of contact with health services, and is highly sensitive to dropout and inequities in

access to care (World Health Organization, 2017; UNICEF, 2023; Bobo et al., 2022; Clark et al.,

2020). By focusing on OPV3, this study moves beyond simple coverage estimates to examine the

timing of vaccination, thereby providing a more nuanced understanding of immunization

performance in Ghana.

Problem Statement

Timely vaccination is critical to protect children from vaccine-preventable diseases such

as measles, pertussis, and polio, which can cause severe complications including encephalitis,

disability, or death (Anokye et al., 2018; Koppaka, 2011). Among routine childhood vaccines, the

third dose of the oral polio vaccine (OPV3) is a critical milestone, as it reflects completion of the
primary polio immunization series and sustained engagement with health services. However,

most studies in Ghana conceptualize immunization as a binary outcome (fully vs. partially

immunized), failing to capture timeliness and age-appropriate vaccination. Consequently,

children vaccinated months after the recommended schedule remain susceptible to infection, and

the risk of outbreaks persists even in areas with relatively high coverage (Bobo et al., 2022;

Fenta et al., 2021).

Despite improvements in immunization coverage in Ghana, evidence suggests that delays

in vaccination remain common, even among children who eventually receive all recommended

doses. These delays are particularly concerning for vaccines such as OPV3, where incomplete or

late administration reduces the effectiveness of population-level immunity and increases

vulnerability to outbreaks. (Walana, Al‐Azab, Yabasin & Abdul‐Mumin, 2024).

Additionally, prior research has relied on cross-sectional designs with logistic or

multinomial regression models, which do not account for the time-dependent nature of

vaccination nor appropriately handle right-censoring for children not yet vaccinated at the time

of the survey. As a result, dose-to-dose dropout, delayed vaccination, and timing of first contact

with immunization services remain poorly understood nationally (Bobo et al., 2022; Fenta,

Biresaw, Fentaw & Gebremichael, 2021; Anokye et al., 2018;). Timely vaccination is critical

because delays prolong periods of susceptibility to vaccine-preventable diseases, undermine herd

immunity, and increase the risk of outbreaks even in settings with relatively high overall

coverage. A child vaccinated months after the recommended age is epidemiologically distinct

from a child vaccinated on schedule, yet both are often classified identically in coverage-based

analyses (Newcomer et al., 2024).

 To address these gaps, this study applies survival analysis techniques to examine the

timing and determinants of OPV3 vaccination using data from the 2003–2022 Ghana

Demographic and Health Surveys. This approach allows for a more precise understanding of

vaccination dynamics by focusing not only on whether children receive OPV3, but also on when

they receive it, while accounting for clustering at community and regional levels.

General Objective

To examine the timing and determinants of receipt of the third dose of oral polio vaccine

(OPV3) among children in Ghana using Bayesian multilevel survival analysis of Demographic

and Health Survey data. Specifically, the study seeks to;

1. To estimate the age-specific cumulative probability of receiving OPV3.

2. To determine individual-, maternal-, and household-level determinants of OPV3

vaccination timing.

3. To quantify cluster- and regional-level variation in the timing of OPV3 vaccination.

4. To assess temporal changes in the timing of OPV3 vaccination across survey years

(2003–2022).

Research Hypothesis

Studies across SSA show that although childhood immunization coverage has improved,

inequalities persist and delays in vaccination remain common, particularly among

socioeconomically disadvantaged populations and rural communities; evidence from reports

indicates that maternal education, household wealth, geographic location, and access to

maternal health services strongly influence both completion and timeliness of immunization.

Therefore, it is hypothesized that;

 1. There is no significant variation in the age-specific cumulative probability of receiving

OPV3.

2. Individual-, maternal-, and household-level characteristics are not significantly associated

with the timing of OPV3 vaccination.

3. There is no significant cluster-level or regional-level variation in the timing of OPV3

vaccination.

4. There are no significant temporal changes in the timing of OPV3 vaccination across

survey years.

Justification for the Study

This study addresses these gaps by applying multilevel survival analysis to nationally

representative data from the 2003, 2008, 2014, and 2022 Ghana Demographic and Health

Surveys (GDHS). Multilevel modeling allows the identification of individual-, household-, and

community-level determinants of vaccination timing and enables quantification of geographic

and socioeconomic inequalities. By analyzing age-specific vaccination timeliness, this research

provides policy-relevant insights into where, when, and why children fail to receive vaccines on

schedule, informing interventions to improve coverage, reduce under-five mortality, and achieve

Sustainable Development Goal 3.

Data & Methodology

Research Philosophy

This study adopts a positivist research philosophy, which emphasizes objective

measurement, quantifiable data, and empirical observation (Creswell, 2017). Positivism is

commonly associated with quantitative methods, in contrast to interpretivism, which focuses on

subjective understanding through qualitative approaches (Creswell, 2012). Recently, pragmatism

emerges as a flexible paradigm supporting mixed methods research. Positivism shapes key

aspects of inquiry such as ontology, epistemology, axiology, and methodology and supports a

structured approach that enhances the reliability and validity of research findings (Varpio &

MacLeod, 2020; Kneebone, 2002).

Research Design

The Ghana Demographic and Health Survey employed a cross-sectional study design.

Cross sectional studies involve collecting relevant data at a specific point in time, meaning all

data is gathered simultaneously, reflecting the conditions and characteristics of that moment

without a temporal dimension (Kesmodel, 2018). According to Creswell (2014), this research

design enables the exploration of current behaviors, beliefs, customs, and perspectives within a

defined group of participants.

Data Source

The study relied on data from the Ghana Demographic and Health Surveys (GDHS)

conducted in 2003, 2008, 2014, and 2022. These population-based surveys are vital for

monitoring health service utilisation and management, supporting public health decision-makers.

Since 1988, the Ghana Statistical Service has worked with the Ministry of Health and various

stakeholders to conduct the DHS, funded by the United States Agency for International

Development (USAID), the Ghanaian government, and other partners Ghana. The GDHS 2003,

2008, 2014, 2022 (birth recode files) will be used for the study.

Response Variable
 The primary outcome of this study is the timing of receipt of the third dose of the vaccine

OPV3, consistent with the routine immunization schedule recommended by the WHO. OPV3

serves as a critical indicator of completion of the primary polio vaccination series and reflects

continued engagement with routine child health services over time.

In this study, the event of interest is defined as the receipt of OPV3 vaccination. A binary event

indicator is constructed, where children who have received OPV3 are coded as 1, while those

who had not received the vaccine at the time of the survey are coded as 0. Children who have not

yet received OPV3 are treated as right-censored observations, as their eventual vaccination status

beyond the survey period is unknown.

The time-to-event variable is defined as the age of the child in months at the time of OPV3

vaccination. For children who had not received OPV3 by the time of data collection, survival

time is measured as the age in months at the time of the survey. This approach allows for the

appropriate handling of incomplete observations and ensures that all children contribute

information up to the point at which they are observed.

By conceptualizing OPV3 uptake as a time-to-event outcome rather than a simple binary

measure, this study captures not only whether children are vaccinated, but also when vaccination

occurs. This distinction is important, as delays in receiving OPV3 prolong the period during

which children remain vulnerable to infection and may undermine the effectiveness of

immunization programmes. Consequently, the analysis provides a more nuanced understanding

of vaccination dynamics, including the timing, distribution, and determinants of OPV3 uptake

across the population.

Predictor Variables
 This study incorporates a range of explanatory variables structured across multiple levels

to reflect the hierarchical nature of the data and the contextual influences on childhood

vaccination. The selection of predictors is informed by existing literature and the conceptual

understanding that vaccination behaviour is shaped not only by individual characteristics but also

by household and community contexts.

Child-Level Factors

At the individual level, child-specific characteristics are included to account for

biological and early-life influences on vaccination timing. These variables including, sex of the

child, which may capture gender-related differences in healthcare utilization, birth order,

reflecting potential resource dilution or caregiver experience, place of birth (home vs. health

facility), which is closely linked to early contact with immunization services

Maternal characteristics are critical determinants of child health service utilization and

are therefore incorporated as key predictors. These include maternal education level, as a proxy

for health knowledge and decision-making capacity, antenatal care (ANC) attendance,

representing maternal engagement with formal healthcare services during pregnancy, marital

status, which may influence social support and access to resources

Household socioeconomic conditions play an important role in shaping access to

healthcare services. The following variables are including household wealth index, reflecting

economic status and ability to afford healthcare-related costs, place of residence (urban/rural),

capturing disparities in service availability and infrastructure

To account for contextual and geographic influences, higher-level variables are

incorporated into the multilevel framework. These includes, Primary Sampling Unit

(PSU)/cluster, representing community-level grouping of households, region, capturing broader

geographic and administrative variations in health service delivery, aggregated community-level

characteristics, such as average wealth or proxy measures of access to health facilities, derived

from cluster-level data.

Statistical Methods

Descriptive Analysis

Descriptive statistics will be used to summarize the characteristics of the study

population. Categorical variables will be presented as weighted frequencies and percentages,

while continuous variables will be summarized using means and standard deviations or medians

and interquartile ranges, depending on their distribution. To describe patterns of vaccination over

time, survey-weighted proportions will be used to estimate OPV3 uptake across the four survey

waves (2003, 2008, 2014, and 2022), allowing for the assessment of temporal changes in

coverage.

Survival Analysis (Vaccination Timeliness)

The primary analytical approach will be survival analysis to examine the timing of

receipt of the third dose of the Oral Polio Vaccine (OPV3). The event of interest is defined as

receipt of OPV3 vaccination, while children who had not received OPV3 at the time of the

survey will be treated as right-censored observations.

Time-to-event is defined as the age of the child in months at the time of OPV3 vaccination, while

censored observations contribute survival time up to the child’s age at the time of the survey

interview.
The Kaplan–Meier method will be used to estimate the cumulative probability of receiving

OPV3 over time, providing a non-parametric description of vaccination timing. Differences in

survival distributions across key population subgroups will be assessed using the log-rank test.

Given the recommended immunization schedule, OPV3 is expected to be administered at

approximately 14 weeks of age. Vaccination occurring beyond this period will be interpreted as

delayed uptake.

Multilevel Survival Analysis

To account for the hierarchical structure of the data, a multilevel Cox proportional hazards

regression model will be employed. This model allows for the examination of both individual-

level and contextual determinants of OPV3 vaccination timing while adjusting for clustering at

higher levels.

The data structure is defined as follows:

 Level 1: Child

 Level 2: Primary Sampling Unit (PSU) / community

 Level 3: Region

Random effects will be included at the community and regional levels to capture unobserved

heterogeneity and quantify contextual variation in vaccination timing.

The model is specified as:

hijk (t)=h0 (t) exp ⁡( X ijk β +u j +v k )

Where:

 hijk (t)is the hazard of receiving OPV3 at time t for child i in cluster j and region k

 h 0( t)is the baseline hazard function

 X ijk β represents fixed effects of covariates

  u jrepresents the random effect at the cluster level

 v k represents the random effect at the regional level

Model results will be presented as hazard ratios (HRs) with 95% confidence intervals, and

statistical significance will be assessed at the 5% level.

Assessment of Temporal Trends

To examine changes in OPV3 vaccination timing over time, survey year will be included

as a covariate in the multilevel survival model. This will allow for the assessment of whether the

likelihood and timing of OPV3 receipt have improved or declined across the four survey waves.

Survey Design and Software

All analyses will account for the complex survey design of the Demographic and Health

Surveys by incorporating sampling weights, clustering, and stratification to ensure nationally

representative estimates.

Descriptive and survival analyses will be conducted using Stata, while multilevel Cox regression

models will be fitted using appropriate procedures in Stata or R, depending on model

specification and diagnostic requirements.

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