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*Corresponding author: E-mail: ezenelson24@gmail.com; 
 
 
 

Asian Journal of Immunology 
 
1(1): 30-35, 2018; Article no.AJI.44949 
 

 
 

 

 

Reasons for Childhood Immunisation Drop-out in 
Rural Health Facilities in Abakaliki, Nigeria 

 
N. C. Eze1* 

 
1
Department of Community Medicine, Federal Teaching Hospital Abakaliki, Nigeria. 

 
Author’s contribution 

 
The sole author designed, analysed, interpreted and prepared the manuscript. 

 
Article Information 

 
DOI: 10.9734/AJI/2018/44949 

Editor(s): 
(1) Dr. Tania Mara Pinto Dabes Guimaraes, Associate Professor, Faculty of Pharmacy, Federal University of Minas Gerais, 

Belo Horizonte, Minas Gerais, Brazil. 
(2) Dr. Juandy Jo, Science Analytical Team Leader, Danone Nutricia Research, Singapore. 

(3) Dr. Darko Nozic, Professor, Higher Medical School in Belgrade, University of Belgrade, Serbia. 
Reviewers: 

(1) Giuseppe Gregori, Italy. 
(2) Pooja Sarmah, Sapthagiri Institute of Medical Sciences, Rajiv Gandhi University of Health Sciences, India. 

(3) Amanda Mcrae, University of the West Indies, Trinidad and Tobago. 
(4) Franco Mantovan, University of Verona, Italy. 

Complete Peer review History: http://www.sciencedomain.org/review-history/27672 

 
 
 

Received 18
th

 September 2018 
Accepted 26

th
 November 2018 

Published 8
th

 December 2018 

 
 

ABSTRACT 
 

Background: High rate of childhood vaccination drop-outs is a significant public health problem in 
rural areas of developing countries especially in Nigeria. The reasons for immunisation drop-out are 
poorly understood and little or no data is available to explain the phenomenon that could support 
the decision making. This study, therefore, determined the reasons for immunisation drop-out in the 
rural areas of Abakaliki, Nigeria. 
Materials and Methods: Descriptive analytical cross- sectional study design was used for the 
survey. Data were collected using pretested, semi-structured interviewer administered 
questionnaire from 290 mothers/caregivers accessing childhood immunisation services in Mile Four 
and St. Vincent hospitals selected using systematic random sampling technique. Reasons for 
immunisation drop-out were gotten from caregivers when they brought their children for 
immunisation in subsequent immunisation dates after the drop-out interval. Analysis was done 
using SPSS version 22 and level of statistical significance set at p< 0.05 and confidence level at 
95%. Ethical approval was obtained from the Research and Ethics Committee (REC) of the Federal 
Teaching Hospital Abakaliki (FETHA), Ebonyi State, Nigeria.  
Results: The mean age of respondents in Mile Four hospital was 26.6 ±4.9 years while 27.1±4.2 
years in the St.Vincent hospital. The reasons for immunisation drop-out in Mile Four were no 

Original Research Article 



 
 
 
 

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31 

 

money for transport (2.1%), caregiver travelled (1.4%), baby was sick (1.4%), far distance to health 
facility (0.7%). In St.Vincent reasons cited were- Far distance to health facility (6.2%), no money for 
transport (4.8%), Mother was sick (2.8%), caregiver travelled (2.1%) and baby was sick (2.1%).Far 
distance to health facility was a predictor of immunisation drop-out in St. Vincent group. It is 2.8 
times more likely to cause immunisation drop-out than near distance to health facility. 
Conclusion: High rate of immunisation drop-outs need to be addressed collectively both by 
individuals and government in order to achieve the targeted 95% immunisation coverage necessary 
for the sustained control of vaccine preventable diseases. 
 

 
Keywords: Immunisation drop-out; reasons; rural infants; Abakaliki; Nigeria. 

 

1. INTRODUCTION 
 
Immunisation drop-out and coverage rates at 
primary health care (PHC) level indicate the level 
at which communities utilise the preventive 
services and thus serve as a measure of the 
strength of public health system. They also 
measure the effectiveness of the immunisation 
programme [1]. Immunisation drop-outs refer to 
infants who have used or missed immunisation 
services and do not return for subsequent 
vaccinations. When drop-outs exceed 10 
percent, it indicates a problem of utilisation of 
services. In most settings where full 
immunisation coverage is low, most infants 
receive at least one dose of pentavalent 
vaccines, but the proportion that receive the 
needed second and third doses drops 
significantly [1]. However differences in the 
indicators of access and utilisation of 
immunisation services exist [2,3]. Indicators of 
access to health services among other factors 
include level of education, sex, patriarchal social 
arrangement, rural residence, poverty, religious 
and cultural beliefs about certain diseases and 
location of health facilities etc. Indicators of 
utilisation of immunisation services include 
quality of staff skills, protocols of treatment, 
availability of supplies and environment of health 
facilities, physical and financial accessibility of 
services, knowledge of what services exist, 
education about how to best utilise self and 
practitioner-provided services and cultural norms 
of treatment [2,3]. In previous studies most 
important reason given for immunisation dropout 
was distance to health facility [4]. However, 
reasons for childhood immunisation drop out are 
unknown in the study area, hence this study 
determined the reasons for dropout in rural areas 
of Abakaliki, Ebonyi State Nigeria. 
 

2. MATERIALS AND METHODS  
 
Descriptive analytical cross- sectional study 
design was used for the survey. Vaccines such 

as BCG, OPV0 and HBV0 are given at birth, 
OPV1, PCV1, Penta1 are given at 6

th
 week of 

life, OPV2, PCV2, Penta2 are given at 10
th
 week 

of life, OPV3, PCV3, Penta3 are given at 14
th
 

week of life while Measles, Yellow fever, 
Meningitis vaccines are given at 9

th
 month of life. 

These vaccines are given free. This minimum 
sample size for the study was determined using 
the formula for comparing two proportions [5,6]. 
They were selected using systematic random 
sampling technique. Data were collected using 
semi-structured interviewer administered 
questionnaire on the mothers/caregivers and 
immunisation registers of 290 infants who were 
brought for immunisation in Mile Four and 
St.Vincent hospitals in Ebonyi and Izzi local 
Government Areas of Ebonyi State after the 
drop-out interval. Reasons for immunisation 
drop-out were gotten from caregivers when they 
brought their children for immunisation in 
subsequent immunisation dates after the drop-
out interval. The interval considered as drop-out 
period was 4 weeks after due date for the uptake 
of that vaccine. Analysis was done using SPSS 
version 22.0. Chi-squared test was used to 
determine association or differences between 
proportion of the variables and the level of 
statistical significance set at p< 0.05 and 
confidence level at 95%. Logistic regression 
model was used to determine predictors of 
immunisation drop-out. Ethical approval was 
obtained from the Research and Ethics 
Committee (REC) of the Federal Teaching 
Hospital Abakaliki (FETHA), Ebonyi State, 
Nigeria.  
 

3. RESULTS 

 
The mean age of respondents in Mile Four 
hospital was 26.6 ±4.9 years while 27.1±4.2 
years in the St. Vincent hospital. 
 
Fig. 1 showed the proportion of infants who 
dropped-out of immunisation in both groups. It 
also shows between group comparisons of 



 
 
 
 

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32 

 

immunisation drop-outs which was found to be 
statistically significant (p<0.01). Table 2 showed 
the reasons for immunisation drop-out among 
respondents in both groups. More caregivers 
(6.2%) in St. Vincent cited distance to the health 
facility as the major reason for immunisation 
drop-out compared to those in Mile Four (0.7%), 
a difference that was significant (p=0.01). Other 
reasons were not significant (p>0.05). In Table 3, 
far distance to health facility was a predictor of 

immunisation drop-out in St.Vincent hospital. It 
was 2.8 times more likely to cause immunisation 
drop-out than near distance to health facility. 
 
Immunisation drop-outs refer to infants who have 
used or missed immunisation services and do 
not return for subsequent vaccinations. Missed 
immunisation is when infants scheduled for 
immunisation did not come at that given date but 
returned later for uptake of the given vaccination. 

 
Table 1. Socio-demographic characteristics of respondents in both health facilities 

 

Variables Mile four 

(n=145) 

Freq. (%) 

St. Vincent 

 (n=145) 

Freq. (%) 

 χ
2 

 

 

p-value 

Sex      

 Male 5 (3.4) 4 (2.8) FT 0.73 

 Female 140 (96.6) 141 (97.2)   

Age group (years)     

 15-19 11 (7.6) 9 (6.2) 6.38 0.16 

 20-24 50 (34.5) 37 (25.5)   

 25-29 48 (33.1) 68 (46.9)   

 30-39 36 (24.8) 31 (21.4)   

Marital status      

 Married 137 (94.5) 134 (92.4) 2.44 0.69 

 Single  8 (5.5) 11 (7.5 )   

Education      

 Primary 10 (6.8) 17 (11.7) 3.67 0.15 

 Secondary 88 (60.7) 93 (64.1)   

 Tertiary 47 (32.4) 35 (24.1)   

Employment      

 Paid employment 25 (17.2) 21 (14.5) 2.75 0.25 

 Self employment 56 (38.6) 70 (48.3)   

 Unemployed 64 (44.1) 54 (37.2)   

Religion      

 Christianity 142 (97.9) 143 (98.6) FT 1.00 

 Others 3 (2.1) 2 (1.4)   
FT= Fisher’s exact test 

 
Table 2. Respondents’ reasons for immunisation drop-out in each study group 

 

Variables Mile four group 

(n=145) 

Freq. (%) 

St. Vincent group 

(n=145) 

Freq. (%) 

χ
2 

p-value 

Reasons for dropping-out Yes Yes   

Distance to facility 1 (0.7) 9 (6.2) 6.6 0.01٭ 

No money for transport 3 (2.1) 7 (4.8) 1.6 0.33 

Caregiver travelled 2 (1.4) 3 (2.1) 0.2 1.00 

Baby was sick  2 (1.4) 3 (2.1) 0.2 1.00 

Mother was sick 0 (0.0) 4 (2.8) FT 0.12 

FT= Fisher’s exact test; ٭statistically significant 



 
 
 
 

Eze; AJI, 1(1): 30-35, 2018; Article no.AJI.44949 
 

 

 
33 

 

Table 3. Predictors of immunisation drop-out at St. Vincent hospital 
 

Variables Immunisation drop-out 

 AOR 95% CI of AOR P-value 

Marital status    
Not married 1   
Married 4.31 -0.89-10.51 0.09 
Educational status    
<Secondary 1   
≥Secondary 0.79 -0.39-1.61 0.59 
Far distance to health facility    
No 1   
Yes 2.78 1.47-6.76 0.05** 

**Predictor 
 

 
Fig. 1. Showing proportion of missed immunisation and immunisation drop-outs in both 

facilities 
 

4. DISCUSSION 
 

Reasons for immunisation drop-out in most 
health facilities especially in rural areas of 
developing countries are not well understood. 
However, in similar settings, reasons may also 
be similar. Reasons given for immunisation drop-
out in Mile Four were no money for transport 
(2.1%), caregiver travelled (1.4%), baby was sick 
(1.4%), far distance to health facility (0.7%) while 
in St.Vincent hospital, reasons cited were far 
distance to health facility (6.2%), no money for 
transport (4.8%), mother was sick (2.8%), 

caregiver travelled (2.1%) and baby was sick 
(2.1%). There is a significant difference in the 
proportion of caregivers who cited far distance to 
health as reason for drop-out in the intervention 
and control groups. There is no difference in the 
proportion of respondents who gave other 
reasons in both groups. 
 

In this study, caregivers did not demonstrate lack 
of commitment to immunisation, rather they gave 
far distance to health facility and no money for 
transport as major reasons why they could not 
come back to study centres for further vaccines, 

25.60% 

5.50% 

33.10% 

22.10% 

0.00% 

5.00% 

10.00% 

15.00% 

20.00% 

25.00% 

30.00% 

35.00% 

Missed Immunisation Immunisation drop-out 

P
ro

p
o

rt
io

n
 

Immunisation  outcome 

Mile Four hospital 

St. Vincent hospital  



 
 
 
 

Eze; AJI, 1(1): 30-35, 2018; Article no.AJI.44949 
 

 

 
34 

 

and they actually continued the immunisation in 
centers close to their residential areas. In a study 
by Itimi et al. [7] mothers were not returning for 
immunisation due to lack of motivation, poor 
attitude of the health workers and relocation to a 
new environment. However the reason in this 
study could be that, the first doses which were 
received in the study center coincided with the 
mother’s post natal care checkup visits. When 
there was no longer a need for the mothers to 
return to the center for their own check-up, they 
now went to nearer centers for their children’s 
immunisation. The fact that immunisation was 
continued in nearby health centers was an 
indication that these group of parents actually are 
aware of the importance of this intervention. It is 
also interesting to note that this study 
demonstrated average drop-out in both males 
and females infants with that of the males being 
marginally lower though not statistically 
significant. The magnitude of its public health 
importance cannot be over-emphasised. For 
every child recalled for immunisation, so much 
has been done to prevent disease, morbidity and 
mortality in that child, prevent disabilities as well 
as disease transmission to many others who 
might have gotten infected through the child and 
also boosting herd immunity [4]. 
 
Similar reasons found in Umuahia and Enugu, 
Nigeria were- because of far distance (49%) and 
38% for no contact [4], health facility was far, 
health workers not always available, child was 
sick, mother was too busy, vaccination time 
inconvenient, caregiver not aware of another 
dose of vaccination among others [8]. Other 
factors include mothers’ poor knowledge of 
immunisation against targeted diseases, parents’ 
concern about immunisation safety, long waiting 
time at the health facility and long distance from 
the hospital, false contraindications like catarrh 
and fever in the infant [9,10], immunisation 
awareness [11]. In Benin, it was reported that 
cost of transportation and man hours lost in time 
spent attending the clinic were reasons for high 
drop-out rate [12]. These factors need to be 
addressed to reduce the drop-out rates.  Other 
factors are lack of political will, poor work attitude 
and mal-orientation of health workers, poor 
health infrastructure, religious 
insurgency/terrorism, ignorance, cultural/religious 
average aversion to vaccine acceptance or use, 
misconceptions about safety of the vaccines and 
lack of awareness about availability of 
vaccination services, inadequate cold chain 
facilities and vaccine stock-outs [13-15]. In that 
study, marital status was found as a predictor for 

immunisation completion compared to higher 
maternal educational status (secondary 
education and above) and occupation 
(government employees) found to be important 
independent predictors for immunisation 
completion among mothers/caregivers of infants 
in Enugu [8].  
 

5. CONCLUSION 
 

The reasons given for immunisation drop-outs in 
this study especially far distance to health facility 
and no money for transport call for more 
decentralised primary health care centres mostly 
in rural areas in order to achieve the targeted 
95% immunisation coverage necessary for the 
sustained control of vaccine preventable 
diseases. 
 

CONSENT 
 

As per international standard or university 
standard, patient’s written consent has been 
collected and preserved by the author(s). 
 

ETHICAL APPROVAL 
 

As per international standard or university 
standard, written approval of Ethics committee 
has been collected and preserved by the 
author(s). 
 

COMPETING INTERESTS 
 
Author has declared that no competing interests 
exist. 
 

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_________________________________________________________________________________ 
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provided the original work is properly cited. 
 
 
 

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The peer review history for this paper can be accessed here: 

http://www.sciencedomain.org/review-history/27672 

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