Factors contributing to compliance with Expanded Programme on Immunization and RTS, S/AS01 schedules among children aged 24–40 months in Central Tongu District of Ghana

(2025) 24:359 Awutey‑Hinidza et al. Malaria Journal https://doi.org/10.1186/s12936-025-05469-5 Malaria Journal Open Access RESEARCH Factors contributing to compliance with Expanded Programme on Immunization and RTS, S/AS01 schedules among children aged 24–40 months in Central Tongu District of Ghana Diana Sena Awutey‑Hinidza1,2*, Margaret Kweku2, Thomas Gyan3, Martin Adjuik2, John Paul Amenu2, Jonathan Mawutor Gmanyami4,5* and Kwaku P. Asante3 Abstract Background The Expanded Programme on Immunization (EPI) is the most successful global childhood programme in reducing mortality and morbidity from vaccine-preventable diseases. Introducing the RTS, S/AS01 malaria vaccine into the routine health system added additional vaccination visits at 24 months. This study determined the factors contribut‑ ing to compliance with EPI, including RTS, S/AS01 malaria vaccine schedules in the Central Tongu District of Ghana. Methods A matched case–control study (1:1) was undertaken between December 2021 and February 2022 among car‑ egivers of children aged 24 to 40 months. Mantel-Haenzel odds ratio and conditional logistic regression analysis were used to determine the strength of association between the level of compliance and independent variables. Results Of the 220 caregivers,110 were cases, and 110 were controls. Good knowledge about vaccines and vaccination schedules among caregivers was 62% (n = 139). Caregivers who earned income 46% (ORMH 0.54, 95% CI 0.29–1.00, p = 0.047); had immunization information 98% (ORMH 0.02, 95% CI 0.00–0.12, p = 0.001); with no obstacles accessing immunization services 98% (ORMH 0.02, 95% CI 0.00–0.12, p < 0.001) and had good knowledge about immunization schedules 70% (ORMH 0.30, 95% CI 0.15–0.61, p < 0.001) were more likely to comply with childhood vaccination. Knowledge of (EPI) services, includ‑ ing RTS, S/AS01 malaria vaccine, was associated with high compliance to overall immunization services and schedules 78% (AOR 0.22, 95% CI 0.06–0.78, p = 0.019). Conclusion Non-compliance with recommended EPI vaccinations, including RTS,S/AS01, was largely due to socioeconomic factors, having information and knowledge about vaccines, immunization schedules, and access to immu‑ nization services. Healthcare providers can improve immunization coverage by emphasizing education on vaccines and vaccine schedules, using technologies and making services accessible in Ghana. Keywords Caregiver, Children, Malaria, RTS,S/AS01, Vaccine, Immunization, Compliance, Schedules, Expanded Program Immunization, Ghana, Volunteer *Correspondence: Diana Sena Awutey‑Hinidza Jonathan Mawutor Gmanyami Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Awutey‑Hinidza et al. Malaria Journal (2025) 24:359 Background Immunization is crucial for safeguarding individuals against specific diseases, especially in developing countries where over 10 million children succumb to preventable illnesses annually [1]. The Expanded Programme on Immunization (EPI) serves as a pivotal link between children and healthcare systems, introducing vital interventions such as vaccines, Long-Lasting Insecticidal Nets (LLINs), de-worming, Vitamin A, and growth assessments [2]. Recognizing the significance of a healthy population in fostering economic growth, global efforts align with the United Nations 2030 Sustainable Development Goals to ensure universal access to vaccines for well-being at all ages. Childhood immunization programmes emerge as cost-effective interventions, diminishing infectious diseases and child mortality [3–5]. Timely vaccination is pivotal for saving lives and ensuring healthy futures for children [6, 7]. Despite high vaccination coverage, studies indicate that timeliness and acquired immunity can be deficient [4, 8]. Ghana’s EPI, initiated in 1978, has significantly reduced infant mortality and morbidity rates and achieved elimination certification for maternal and neonatal tetanus in 2011 [9, 10]. The Volta Region, however, lags in health indicators, particularly immunization coverage of 87 per cent [11] Ghana’s evolving EPI covers 13 Vaccine Preventable Diseases (VPDs), including the new RTS,S/AS01 malaria vaccine [11–14]. The National EPI policy mandates specific vaccinations for children and women, adapting to changes such as the introduction of the pentavalent vaccine in 2002 [7, 11, 15]. Despite successes, challenges persist, with hard-to-reach areas facing barriers like the healthcare system and parental time constraints [16]. Full compliance with the EPI schedule is crucial for achieving vaccination goals and accurately estimating coverage for effective disease prevention in sub-Saharan Africa, including Ghana. Global immunization coverage declined to 83% in 2020, attributed to the COVID-19 pandemic, leaving 23 million children unvaccinated, the highest since 2009 [17, 18]. Ghana Health Service (GHS) remains committed to universal immunization coverage, considering it a key health performance indicator. The EPI Program aims to reduce child morbidity, achieve high antigen coverage, and sustain disease elimination goals. Introducing the RTS,S/AS01 malaria vaccine into the routine system initially faced challenges, including lower reporting of Adverse Events Following Immunization (AEFI) and concerns about severe side effects. Public awareness and trust-building are crucial to combat vaccine hesitancy. Caregiver knowledge of vaccines and Page 2 of 11 caregivers’compliance with childhood immunization schedule, among others, have been noted as key factors in the acceptance of vaccination programmes. Other important factors include access to health services, distribution of health workers, time spent, and loss of earnings by caregivers when accessing vaccination services [6, 7, 10, 12, 14]. It is important to assess whether additional efforts should be made to improve caregiver knowledge and compliance with childhood immunization schedules. Interventions based on socio-cultural-economic and behavioural change of community members have been noted as key to the success of any programme. The effect (...truncated)