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Knowledge, Attitudes, and Practices Toward Childhood Vaccination
Among Caregivers in Buea Urban Setting: A Cross-Sectional Study
Ngwa Fred Ngunjoh1*, Ngopekba Marie-Noel Matemb1, Ngende Rosine Nyake1, Tabe Stephany Tabot1,
Joe-Wruthia Mesode Lyonga Etutu1, Tanyi Ankeh Mavia Ebini-Ako1, Nkonhoataw Michael Bessem1,
Zyh Akumawah Berinyuy2
1 Faculty of Health Sciences, University of Buea, Buea P.O. Box 63, Cameroon
2 Faculty of Health Sciences, University of Bamenda, Cameroon
DOI: https://dx.doi.org/10.51244/IJRSI.2025.1210000072
Received: 02 October 2025; Accepted: 08 October 2025; Published: 04 November 2025
ABSTRACT
Objectives: Understanding caregivers' knowledge, attitudes, and practices (KAP) toward childhood vaccination
is crucial for improving immunization coverage and addressing vaccine hesitancy. This study utilized the World
Health Organization Behavioral and Social Drivers (WHO BeSD) framework to assess KAP regarding childhood
vaccination among caregivers in Buea urban setting.
Methods: A cross-sectional study was conducted among 439 caregivers with children aged 0-59 months in Buea
urban area. We collected data using a structured questionnaire based on the WHO BeSD tool. We assessed KAP
domains using binary categorization: good knowledge (≥50% positive responses to knowledge indicators),
positive attitude (≥75% positive responses to attitude indicators), and good practice (≥50% positive responses to
practice indicators). Chi-square tests were performed to identify factors associated with each KAP domain.
Results: Among 439 participants, 79.0% demonstrated good knowledge, 82.5% had positive attitudes, and
85.0% showed good vaccination practices. Knowledge was significantly associated with age group (p=0.039),
sex (p=0.027), marital status (p<0.001), occupation (p=0.013), primary caregiver role (p<0.001), and housing
status (p=0.002). Positive attitudes were associated with age group (p=0.002), marital status (p=0.019), health
insurance (p=0.039), primary caregiver role (p=0.042), and number of children (p=0.003). Good practices were
linked to marital status (p<0.001), education level (p=0.007), and health insurance (p=0.011).
Conclusion: While most caregivers demonstrated favorable KAP toward vaccination, targeted interventions
are needed for specific demographic groups, particularly younger caregivers, males, and those with non-primary
caregiver roles to further improve vaccination outcomes.
Keywords: attitudes, Cameroon, childhood vaccination, knowledge, practices
INTRODUCTION
Childhood vaccination remains one of the most cost-effective public health interventions, preventing millions of
deaths annually (WHO, 2025; Ehreth, 2003). Despite global efforts to achieve universal immunization coverage,
vaccine hesitancy and suboptimal vaccination practices continue to pose significant challenges to public health
programs worldwide (MacDonald & SAGE Working Group on Vaccine Hesitancy, 2015; Larson et al., 2014).
Understanding the behavioral and social drivers that influence vaccination decisions is crucial for developing
effective interventions to improve immunization outcomes (WHO, 2014).
The World Health Organization (WHO) developed the Behavioral and Social Drivers (BeSD) framework to
systematically assess factors influencing vaccination behaviors (WHO, 2022). This framework provides a
comprehensive approach to understanding how knowledge, attitudes, and practices (KAP) toward vaccination
interact with social and behavioral determinants to influence immunization decisions (Machingaidze et al.,
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2013). The KAP model has been widely used in public health research to identify gaps in knowledge and
practice, which can be addressed through targeted interventions (Kaliyaperumal, 2004; Launiala, 2009).
In sub-Saharan Africa, including Cameroon, achieving optimal vaccination coverage remains challenging due
to various socioeconomic, cultural, and health system factors (Wiysonge et al., 2012; Restrepo-Méndez et al.,
2016). Previous studies have shown that parental knowledge, attitudes, and practices significantly influence
childhood vaccination uptake (Shrivastwa et al., 2015; Adedokun et al., 2017). However, there is limited research
specifically examining these factors using the WHO BeSD framework in urban settings of Cameroon.
Buea, as an urban center in the Southwest region of Cameroon, represents a diverse population with varying
educational backgrounds, socioeconomic status, and cultural beliefs that may influence vaccination behaviors
(Republic of Cameroon, 2010). Understanding the KAP patterns in this setting is essential for informing local
immunization strategies and improving vaccination coverage.
In this study, we aimed to assess the knowledge, attitudes, and practices toward childhood vaccination among
caregivers in Buea urban setting using the WHO BeSD framework, and identify demographic factors associated
with each KAP domain.
METHODS
Study Design and Setting
A cross-sectional study was conducted in Buea urban area, Southwest region of Cameroon, between February
and June 2024. Buea is a cosmopolitan town with diverse ethnic groups and serves as a regional educational and
administrative center.
Study Population and Sampling
The study population comprised caregivers (parents or guardians) of children aged 0-59 months residing in Buea
urban area. Participants were eligible if they were primary or secondary caregivers of at least one child in the
specified age range, and provided informed consent. Caregivers without children in the target age group were
excluded from the analysis.
Using a convenience sampling approach, participants were recruited from various locations including health
facilities, community centers, and residential areas. The final analysis included 439 caregivers with complete
KAP data.
Data Collection
Data were collected using a structured questionnaire adapted from the WHO BeSD tool (WHO, 2016). The
questionnaire was administered through face-to-face interviews conducted by trained research assistants. The
instrument included sections on:
Sociodemographic characteristics: Age, sex, marital status, education level, occupation, monthly
income, religion, health insurance coverage, primary caregiver role, housing status, and number of
children.
Knowledge assessment: Awareness of vaccination campaigns, information-seeking behavior, confidence
in recognizing vaccine-preventable diseases, and receipt of vaccination information from community
leaders.
Attitude assessment: Beliefs about vaccine safety and effectiveness, perceived importance of childhood
immunization, trust in healthcare workers, and belief in vaccination necessity.
Practice assessment: Child's vaccination status, vaccination schedule adherence, appointment attendance,
and medical advice-seeking behavior.
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Variable Definitions and Scoring
KAP domains were assessed using binary categorization based on composite scores. Knowledge was classified
as "good" if participants scored ≥50% positive responses on knowledge indicators (awareness, information-
seeking, confidence, and community information receipt); Attitude was classified as "positive" if participants
scored ≥75% positive responses on attitude indicators (safety beliefs, importance perception, necessity beliefs,
and healthcare worker trust); and Practice was classified as "good" if participants scored ≥50% positive responses
on practice indicators (vaccination completion, schedule adherence, appointment attendance, and advice-
seeking).
Statistical Analysis
Data were analyzed using appropriate statistical software. Descriptive statistics were used to summarize
participant characteristics and KAP distributions. Chi-square tests of independence were performed to examine
associations between demographic factors and each KAP domain. Effect sizes were assessed using Cramer's V,
with values of 0.1, 0.3, and 0.5 representing small, medium, and large effects, respectively (Cohen, 1988).
Statistical significance was set at p<0.05.
Ethical Considerations
The study was conducted in accordance with the principles of the Declaration of Helsinki. Participants provided
informed consent before data collection. Confidentiality and anonymity were maintained throughout the study
process.
RESULTS
Participant Characteristics
The study included 439 caregivers with children aged 0-59 months. Table 1 presents the demographic
characteristics of participants. Majority of the particpants were females (87.7%), majority were aged 18-30 years
(55.8%), and 49.4% were married. Majority of the participants had university education (53.8%) and 56.0%
were self-employed. Most participants had no health insurance coverage (63.3%) and lived in rented
accommodation (74.3%). The majority were primary caregivers (57.2%) and had one child in the target age
group (56.9%).
Table 1: Demographic characteristics of participants
Variable Category Frequency (n=439) Percentage
Sex Female 385 87.7
Male 54 12.3
Marital Status Married 217 49.4
Single 173 39.4
Separated 21 4.8
Widowed 17 3.9
Divorced 11 2.5
Education University 236 53.8
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Secondary 162 36.9
Primary 29 6.6
No Formal Education 12 2.7
Health Insurance No, currently not covered 278 63.3
Yes, comprehensive coverage 106 24.1
Yes, partial coverage 55 12.5
Knowledge, Attitudes, and Practices Distribution
Figure 1 shows the distribution of KAP toward childhood vaccination. Overall, 79.0% of participants
demonstrated good knowledge, 82.5% had positive attitudes, and 85.0% exhibited good vaccination practices.
The highest scores were observed in the practice domain, followed by attitudes and knowledge.
Figure 1: Distribution of KAP toward childhood vaccination.
Factors Associated with Vaccination Knowledge
Knowledge of vaccination was significantly associated with several demographic factors (Table 2). Age group
showed a significant association (p=0.039), with higher knowledge levels among older caregivers (31-50 years:
84.7%, 51+ years: 87.5%) compared to the younger ones (18-30 years: 74.7%). Female caregivers demonstrated
better knowledge than males (80.8% vs 66.7%, p=0.027).
Marital status was strongly associated with knowledge (p<0.001), with married caregivers showing the highest
knowledge levels (88.0%) compared to separated (61.9%) and widowed caregivers (52.9%). Government
employees had the highest knowledge scores (92.7%), while self-employed caregivers had the lowest (74.4%)
(p=0.013).
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Primary caregiver role was significantly associated with knowledge (p<0.001), with those sharing caregiving
responsibilities demonstrating the highest knowledge (87.3%) compared to non-primary caregivers (57.4%).
Housing status also showed significant association (p=0.002), with participants who lived houses they owned
having better knowledge (81.4%) compared to those with other housing arrangements (51.9%).
Table 2: Factors associated with vaccination knowledge
KAP_Domain Factor Chi-square p value Cramers V
Knowledge of Vaccination Age Group 6.49 0.039 0.12
Sex 4.87 0.027 0.11
Marital Status 26.13 <0.001 0.24
Occupation 10.79 0.013 0.16
Primary Caregiver 20.8 <0.001 0.22
Housing Status 12.86 0.002 0.17
KAP_Domain, Knowledge, Attitudes, and Practices_Domain
Factors Associated with Vaccination Attitudes
Attitudes toward vaccination were significantly associated with age group (p=0.002) (Table 3), with a notable
decrease in positive attitudes among caregivers aged 51+ years (37.5%) compared to younger groups (18-30
years: 82.4%, 31-50 years: 85.2%). Marital status influenced attitudes (p=0.019), with married caregivers
showing more positive attitudes (86.6%) than divorced (72.7%) or widowed caregivers (58.8%).
Health insurance coverage was associated with attitudes (p=0.039), with comprehensive coverage linked to more
positive attitudes (90.6%) compared to partial coverage (78.2%) or no coverage (80.2%). Primary caregiver role
showed significant association (p=0.042), and the number of children was inversely related to positive attitudes
(p=0.003), with caregivers having more than two children showing less positive attitudes (68.9%) compared to
those with one child (85.6%).
Table 3: Factors associated with vaccination attitudes
KAP_Domain Factor Chi square p value Cramers V
Attitudes toward Vaccination Age Group 12.25 0.002 0.17
Marital Status 11.78 0.019 0.16
Health Insurance 6.48 0.039 0.12
Primary Caregiver 6.34 0.042 0.12
Number of Children 11.37 0.003 0.16
KAP_Domain, Knowledge, Attitudes, and Practices_Domain
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Factors Associated with Vaccination Practices
Vaccination practices were significantly associated with marital status (p<0.001), with married caregivers
demonstrating better practices (88.9%) compared to separated (61.9%) or widowed caregivers (58.8%).
Education level showed significant association (p=0.007), with those having no formal education showing poorer
practices (50.0%) compared to other education levels (85.6-89.7%).
Health insurance coverage was associated with practices (p=0.011), with comprehensive coverage linked to
better practices (90.6%) compared to partial coverage (72.7%) or no coverage (85.3%) (Table 4).
Table 4: Factors associated with vaccination practices
KAP_Domain Factor Chi square p value Cramers V
Vaccination Practices Marital Status 20.65 <0.001 0.22
Education Level 12.15 0.007 0.17
Health Insurance 9.07 0.011 0.14
KAP_Domain, Knowledge, Attitudes, and Practices_Domain
Figure 2 presents a heatmap of the significant associations, showing the strength of relationships between
demographic factors and KAP domains. Marital status and primary caregiver role emerged as the strongest
predictors across multiple KAP domains.
Figure 2: KAP domains and demographic association strengths
Demographic Characteristics Visualization
Figure 3 illustrates the distribution of key demographic characteristics among study participants, highlighting
the predominance of female participants, diversity in marital status and education levels, and limited health
insurance coverage in the study population.
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Figure 3: Demographic characteristic Distributions of Participants
DISCUSSION
The findings reveal favorable KAP levels, with practice scores being highest, followed by attitudes and
knowledge. However, significant variations exist across different demographic groups, highlighting
opportunities for targeted interventions.
Knowledge of Vaccination
The 79.0% prevalence of good knowledge found in this study is encouraging and reflects the educational
background of the study population, with over half having university education (Taddese et al., 2018). The
association between sex and knowledge, with females demonstrating better knowledge than males, aligns with
previous studies showing that mothers typically have greater involvement in child health decisions (Thorpe et
al., 2016; Singh & Brodish, 2015). This finding suggests the importance of including fathers and male caregivers
in vaccination education programs.
The strong association between marital status and knowledge may reflect social support systems and shared
decision-making processes in married couples (Story et al., 2012). The superior knowledge among government
employees compared to other occupational groups may be attributed to better access to health information and
formal employment benefits (Wendt et al., 2015).
The finding that primary caregiver role influences knowledge underscores the importance of targeting primary
caregivers in vaccination communication strategies. However, the significant proportion of non-primary
caregivers with poor knowledge (42.6%) highlights the need to extend educational efforts to all family members
involved in child care decisions (Greenaway et al., 2012).
Attitudes Toward Vaccination
The 82.5% prevalence of positive attitudes is consistent with high vaccine acceptance rates reported in other
African urban settings (Tadeese et al., 2009; Wado et al., 2014). The notable decline in positive attitudes among
older caregivers (51+ years: 37.5%) warrants attention. This pattern may reflect generational differences in
health beliefs, exposure to misinformation, or past negative healthcare experiences (Freed et al., 2010).
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The association between health insurance coverage and positive attitudes suggests that healthcare access and
experience with health services influence vaccination perceptions (Gidado et al., 2014). Caregivers with
comprehensive coverage showed the most positive attitudes, possibly due to better healthcare provider
interactions and increased confidence in the health system.
The inverse relationship between number of children and positive attitudes may reflect increased caregiver
burden, competing priorities, or accumulated negative experiences with healthcare services (Antai, 2009). This
finding emphasizes the need for targeted support for families with multiple children.
Vaccination Practices
The 85.0% prevalence of good vaccination practices represents the highest score among the three KAP domains,
suggesting that despite the knowledge gaps and attitude challenges, most caregivers translate their understanding
into appropriate vaccination behaviors. This finding is encouraging for public health efforts and vaccine
confidence in the study area (Favin et al., 2012).
The strong association between marital status and practices mirrors the knowledge findings, reinforcing the
importance of social support in healthcare decision-making (Bbaale, 2013). The education-practice relationship,
with the lowest practices among those with no formal education, highlights education as a key determinant of
health behaviors, and the need for culturally appropriate communication strategies for less educated populations
(Kumar et al., 2010).
Implications for Public Health Practice
The findings suggest some key areas for intervention:
Targeted education programs: Focus on younger caregivers, male caregivers, and those with limited
formal education to improve knowledge levels.
Family-centered approaches: Include all family members, particularly non-primary caregivers, in
vaccination education and decision-making processes.
Health system strengthening: Improve healthcare worker training to better address concerns of older
caregivers and those with multiple children.
Insurance coverage expansion: Advocate for expanded health insurance coverage to improve both access
to vaccination services and attitudes toward vaccination.
The findings of this study have significant policy implications for Cameroon's immunization program and
broader sub-Saharan African contexts. Health policy frameworks should prioritize community engagement
strategies that leverage existing social structures, particularly religious institutions and community leadership
networks, which have proven effective in vaccination promotion across similar settings (Ames et al., 2017).
Given that married caregivers demonstrated superior KAP levels across all domains, policies should emphasize
family-centered vaccination approaches that engage both spouses in decision-making processes. The association
between health insurance coverage and positive vaccination outcomes suggests that expanding universal health
coverage could serve as a dual intervention improving both healthcare access and vaccination attitudes (World
Health Organization, 2022). Community engagement strategies should incorporate door-to-door social
mobilization, announcements during religious services, and collaboration with trusted community leaders, as
these approaches have demonstrated effectiveness in Cameroonian contexts (Ames et al., 2017). Furthermore,
policy frameworks should establish systematic mechanisms for addressing the specific needs of vulnerable
groups identified in this study, including younger caregivers, males, and non-primary caregivers, through
targeted outreach programs that utilize culturally appropriate communication channels and trusted messengers
within these demographic segments (Xie et al., 2024; Orr et al., 2022).
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Theoretical Framework Application
The study findings align with key constructs of the Health Belief Model (HBM), which provides a valuable
theoretical lens for understanding caregiver vaccination behaviors observed in this research (Ellithorpe et al.,
2022; Chen, 2011). The high prevalence of positive attitudes (82.5%) and good practices (85.0%) suggests that
most caregivers perceive significant benefits from childhood vaccination and have low perceived barriers to
vaccination uptake, consistent with HBM predictions for health-promoting behaviors (Handayani et al., 2025;
Bowen et al., 2025). The demographic variations observed, particularly the lower knowledge and attitudes
among specific groups, can be interpreted through HBM constructs of perceived susceptibility and severity—
groups with limited healthcare exposure or lower socioeconomic status may have reduced perception of disease
severity or personal susceptibility (Li et al., 2021). The strong association between health insurance coverage
and positive vaccination outcomes supports the HBM construct of perceived barriers, where financial and access
constraints represent significant obstacles to vaccination behavior (Orr et al., 2022). Future interventions should
systematically address HBM components by enhancing perceived susceptibility through targeted education
about vaccine-preventable disease risks, reinforcing perceived benefits through testimonials and success stories,
reducing perceived barriers through improved healthcare access and convenience, and strengthening self-
efficacy through clear guidance on vaccination schedules and procedures (Orr et al., 2022; Jain et al., 2022).
Study Limitations and Strengths
This study has some limitations. First, the cross-sectional design limits causal inference, and the convenience
sampling may affect generalizability. Second, the binary categorization, while useful for analysis, may mask
nuanced differences in KAP levels. Third, social desirability bias may have influenced responses, particularly
regarding vaccination practices.
An important limitation of this study is its exclusive reliance on quantitative methodology, which limits the depth
of understanding regarding the underlying reasons for demographic variations in KAP levels. While the WHO
BeSD framework provides valuable quantitative insights, qualitative research methods could offer critical
complementary perspectives to explain the "why" behind the observed associations (Ashfield, 2024; Glanz et
al., 2013). Future research should employ mixed-methods approaches that incorporate in-depth interviews, focus
group discussions, and ethnographic observations to explore the cultural, social, and personal factors that
influence vaccination decision-making among different demographic groups (Huang et al., 2024; Eberhardt et
al., 2023). Qualitative exploration could provide crucial insights into the barriers faced by males, younger
caregivers, and non-primary caregivers, potentially revealing specific concerns, misconceptions, or structural
obstacles that quantitative measures cannot capture (Kassabekova et al., 2025). Such research could investigate
how cultural beliefs, past healthcare experiences, social networks, and information sources influence vaccination
attitudes across different demographic segments (Skirrow et al., 2024). Additionally, qualitative methods could
explore the decision-making processes within families, understanding how primary and secondary caregivers
interact in vaccination choices, and identifying optimal intervention points for family-centered approaches
(Ashfield, 2024; Eberhardt et al., 2023). The integration of qualitative insights would enable the development of
more nuanced, culturally sensitive, and theoretically grounded interventions that address the specific contextual
factors influencing vaccination behaviors in urban Cameroonian settings, ultimately contributing to more
effective and sustainable immunization strategies.
However, the study had some strengths which include the use of the standardized WHO BeSD framework,
comprehensive assessment of multiple demographic factors, and focus on an urban setting with diverse
populations. The binary categorization of KAP domains provides clear, actionable results for intervention
planning.
In conclusion, this study reveals generally favorable knowledge, attitudes, and practices toward childhood
vaccination among caregivers in Buea urban setting, with 79.0%, 82.5%, and 85.0% demonstrating good/positive
levels respectively. However, significant demographic variations exist, with younger caregivers, males, those in
certain marital status categories, and non-primary caregivers showing lower KAP levels. These findings provide
valuable insights for designing targeted interventions to further improve vaccination outcomes in urban
Cameroon settings.
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The application of the WHO BeSD framework proves valuable for understanding the multifaceted nature of
vaccination behaviors and identifying specific intervention points. Continued efforts to address identified gaps
through targeted, evidence-based interventions will be crucial for achieving optimal vaccination coverage and
protecting child health in the study population.
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Ethical Approval: This study was approved by the institutional review board, Faculty of Health Sciences,
University of Buea (approval number 2359-01), and conducted in accordance with the principles of the
Declaration of Helsinki.
Conflict of Interest and Data Availability: The authors declare no conflicts of interest. The datasets used in
this study are available from the corresponding author upon reasonable request.