Childhood immunization is one of the most valuable public health interventions available [
In 2014, about 18.7 million children did not receive the 3rd dose of Diphtheria-Pertussis-Tetanus (DPT3) vaccine and 70% of them were live in ten developing countries including Ethiopia [
In Ethiopia, the Expanded Program on Immunization (EPI) program emphasizing six vaccines has been given on a routine and outreach basis since 1980 [
Expanding immunization service is among one of the Ethiopian child survival strategies targeted to protect nearly 3-million annual births against VPDs [
Though, full immunization coverage has been raised from 24% in 2011 to 39% in 2016 EDHS report [
Studies have also reported maternal education, access to health services, family socioeconomic status, child place of delivery, antenatal care (ANC) visits, mothers TT immunization status, knowledge on immunization, sex of the child, place of residence, religious affiliation, and exposure to mass media as predictors of poor immunization coverage [
A community-based cross-sectional study was conducted from September 20 to October 28, 2017, in Sekota Zuria district, Wag-Himra Zone, Amhara Regional State, and Northern Ethiopia. Sekota Zuria is one of the seven districts in Wag-Himra Zone, Amhara Regional State, and found 720kms away from Addis Ababa, the capital of Ethiopia. The district is claimed as one of the hard-to-reach areas in the region and has an estimated area of 1671.56 km2 and 33 rural “kebeles” (the lowest administrative unite). The total population of the district based on projections from 2007 census was 138,846 in 2017, of which under five children account for 13.5% (4,319). The district has seven health centers and 33 health posts, which provide a routine vaccination service for their catchment population.
Children aged 12-23 months who were living in seven randomly selected kebeles of the district were included while those children whose mothers/caregivers found to be mentally/critically ill during the data collection period were excluded from the study. The required sample size was determined by comparing sample sizes obtained from single and double population proportion formulas. For a single population formula, the following assumptions were considered: the proportion of fully immunized children aged 12-23 months from EDHS 2011 which was 24.3%, 95% confidence level, 5% margin of error, % nonresponse rate, and a design effect of 2. The sample size was calculated to be 623. In the double population proportion formula, factors significantly associated from previous studies such as maternal education, institutional delivery, and mothers’ TT immunization were used to calculate the sample sizes using Epi-Info7 StatCalc program using 95% CI, reported odds ratio, and power of 80% [
Study participants were selected by multistage sampling technique. Stage one, seven kebeles were randomly selected and stage two households with children aged 12-23 months were randomly selected and included in the study. Community Health Information System (CHIS) registration log was used as a sampling frame for the selection of households with children 12-23 months. If respondents were not found at home during the data collection, interviewers have revisited the households for the second time and when the interviewers failed to find the eligible participant after two visits, the next household was contacted. (Figure
Sampling framework of immunization coverage and associated factors among children aged 12-23 months in Sekota Zuria district, 2017.
The data collection tool was adapted from EDHS 2011 immunization questionnaire and other relevant literature. It was first prepared in English and translated to Amharic language and back-translated to English to check the consistency of translation. The questionnaire mainly included immunization histories of children, socio-demographic characteristics of mothers, maternal health care utilization, and knowledge of mothers on immunization. Information on vaccination coverage was collected in two ways: from the child vaccination card or from mothers’ verbal report. Information from the child card was extracted in cases where child immunization card was available. When there was no vaccination card for the child or if a vaccine had not been recorded on the card as being given, the mothers were asked to recall the specific vaccines given to her child. The information obtained from the child card was taken in the case where both conditions have been met.
Six diploma nurse data collectors and two supervisors were recruited in the data collection. Data collectors and supervisors were trained on overall data collection procedures and the techniques of interviewing. Before starting the actual data collection, the questionnaire was pretested on 5% of similar respondents in other kebeles of the district which was not included in the final study. All field staffs and the principal investigator have assessed the clarity and completeness of the questionnaire. The collected data was checked for completeness, consistency, accuracy, and clarity by the supervisors and the principal investigator on a daily basis.
Data were cleaned and entered to Epi-Info7 [
Ethical clearance was obtained from Institutional Review Board of University of Gondar. Permission letter was received from Sekota Zuria district health office. Verbal informed consent was obtained from each respondent prior to data collection. Participants were fully informed about the objectives and procedures of the study and their right to refuse participation at any time during the study. Study participants were also informed that all data obtained from them would be kept confidential. At the end of each interview, mothers found to have nonimmunized or partially immunized children were advised to vaccinate their child and to follow the regular immunization sessions.
Six hundred twenty mothers of children aged 12-23 months were included in the study, which makes a response rate of 99.5%. A mean and standard deviation (
Socio-demographic and economic characteristics of mothers and children aged 12-23 months in Sekota Zuria district, Wag-Himra Zone, North East Ethiopia, 2017.
Characteristics | Frequency (N) | Percentage (%) | |
---|---|---|---|
Sex of the child | Male | 303 | 48.9 |
Female | 317 | 51.1 | |
Birth order of the child | 1st | 115 | 18.6 |
2nd -3rd | 269 | 43.4 | |
4th-5th | 149 | 24.0 | |
≥ 6 | 87 | 14.0 | |
Mothers’ age in years | ≤ 24 | 160 | 25.8 |
25-34 | 284 | 45.8 | |
≥ 35 | 176 | 28.4 | |
Maternal education | Illiterate | 309 | 49.8 |
Can read and write | 67 | 10.8 | |
Primary | 171 | 27.6 | |
Secondary and above | 73 | 11.8 | |
Marital status | Married | 544 | 87.7 |
Single | 49 | 7.9 | |
Divorced | 27 | 4.4 | |
Mothers’ occupation | House wife | 169 | 27.3 |
Farmer | 331 | 53.4 | |
Merchant | 54 | 8.7 | |
Government employee | 25 | 4.0 | |
Daily laborer | 41 | 6.6 | |
Religion | Orthodox | 590 | 95.2 |
Muslim | 30 | 4.8 | |
Family size | ≤ 4 | 251 | 40.5 |
≥ 5 | 369 | 59.5 |
Maternal characteristics of mothers and children aged 12-23 months in Sekota Zuria district, Wag-Himra Zone, North East Ethiopia, 2017.
Characteristics | Frequency | Percentage | |
---|---|---|---|
Place of delivery |
Health institution | 345 | 55.6 |
Home | 275 | 44.4 | |
None | 156 | 25.2 | |
PNC check ups | 1-2 times | 269 | 43.4 |
≥ 3 times | 195 | 31.4 | |
None | 378 | 61.0 | |
TT immunization | Once | 162 | 26.1 |
≥ 2 times | 80 | 12.9 | |
None | 137 | 22.1 | |
Average monthly income | 1-2 times | 104 | 16.8 |
≥ 3 times | 379 | 61.1 | |
< 500 | 213 | 34.4 | |
500-1000 | 253 | 40.8 | |
> 1000 | 154 | 24.8 | |
Distance to health facility (in walk time) | ≤ 30 minutes | 328 | 52.9 |
31-60 minutes | 135 | 21.8 | |
> 60 minutes | 157 | 25.3 | |
Knowledge about immunization | Good | 344 | 55.5 |
Poor | 276 | 44.5 |
Of the total included children (N=620), 77.4% (480/620) of them were fully immunized, 15.5% (96/620) were partially immunized, and the rest 7.1% (44/620) had not received any antigen. On the other hand, of the fully immunized children, 87.3% (419/480) had evidence of immunization supported by the card, while vaccination status of 12.7%% (61/480) of the children was determined by mothers to recall. Similarly, 41.7% (40/96) were confirmed as partially immunized by card, while 58.3% (56/96) were based on mothers’ recall.
Overall, 91.5% (567/620) of the children received OPV1, 90.0% (558/620) received both BCG and Pentavalent1, 89.7% (556/620) received PCV1, 80.5% received measles (499/620), and 87.0% (539/620) received the first dose of Rotavirus vaccine. Coverage rates declined for subsequent doses as 78.8% of children received OPV3, 77.3% Pentavalent3, 78.5% PCV3, and 80.0% Rota 2 vaccine. Dropout rate: the proportion of children who started certain vaccine but did not complete the next intended vaccine was 13.8% for OPV1 to OPV3, 13.4% for Pentavalent1 to Pentavalent3, and 10.7% for BCG to Measles (Figure
Vaccination coverage among children aged 12-23 months in Sekota Zuria district, Wag-Himra Zone, Northern Ethiopia, 2017.
On the bivariable analysis, birth order of the child, mothers’ educational status, family size, distance to a health facility, mothers’ knowledge score, place of delivery, ANC follow-up, and tetanus toxoid immunization were found to be significantly associated with children’s full immunization status. However, in the multivariable analysis, mothers’ educational status, place of delivery, mothers’ knowledge score, distance to a health facility, family size, and ANC follow-up were found to be significantly associated.
Mothers who attained secondary or more level of education were 2.39 times more likely to have fully immunized children compared to illiterate mothers (Adjusted Odds Ratio (AOR)=2.39, 95%CI=1.06, 5.36). Mothers who travel ≤ 30 minutes to reach the nearest vaccination site were 2.65 times more likely to fully immunize their children than mothers who travel beyond one hour (AOR=2.65, 95%CI= 1.61, 4.36). Mothers who attended ANC services for three or more times were 2.75 times more likely to have fully immunized children compared to mothers who never had ANC visits (AOR=2.75, 95%CI=1.52, 5.00). Children born in health institutions had 2.58 times more chance of being fully immunized than children born at home (AOR=2.58, 95%CI=1.66, 3.99). Mothers who had good knowledge about immunization were 3.7 times more likely to have a fully immunized child as compared to those who had poor knowledge (AOR=3.7, 95%CI=2.37, 5.79). Children born in households with a family size of five and more were 38% less likely to be fully immunized compared to children in households with four and fewer family members (AOR=0.62, 95%CI=0.38, 0.99). (Table
Bi-variable and multivariable analysis of factors associated with full immunization status of children aged 12-23 months in Sekota Zuria district, Wag-Himra Zone, Ethiopia, 2017.
Characteristics | Category | Fully immunized | Odds Ratio (95% CI) | ||
---|---|---|---|---|---|
Yes | No | COR | AOR | ||
Birth order of the child | 1st | 94 | 21 | 2.12(1.11–4.08) | |
2nd -3rd | 212 | 57 | 1.77(1.03–3.02) | ||
4th -5th | 115 | 34 | 1.61(0.89–2.89) | ||
6th & above | 59 | 28 | 1 | ||
Mothers’ age in years | ≤ 24 | 129 | 31 | 1.61(0.96–2.68) | |
25-34 | 224 | 60 | 1.44(0.93–2.23) | ||
≥ 35 | 127 | 49 | 1 | ||
Maternal education | Illiterate | 224 | 85 | 1 | 1 |
Can read & write | 52 | 15 | 1.32(0.70–2.46) | 1.46(0.71–2.15) | |
Primary | 140 | 31 | 1.71(1.08–2.72) | 1.62(0.96–2.75) | |
|
64 | 9 | 2.69(1.29–5.66) | 2.39(1.06–5.36) |
|
Marital status | Married | 427 | 117 | 1 | |
Single | 35 | 14 | 0.68(0.38–1.32) | ||
Divorced | 18 | 9 | 0.55(0.24–1.25) | ||
Family size | ≤ 4 | 215 | 36 | 1 | |
≥ 5 | 265 | 104 | 0.43(0.28–0.65) | 0.62(0.38–0.99) |
|
Average monthly income | < 500 | 160 | 53 | 1 | |
500-1000 | 193 | 60 | 1.07(0.69–1.63) | ||
≥ 1000 | 127 | 27 | 1.56(0.93–2.62) | ||
Distance to health facility (in walk time) | ≤ 30 minutes | 278 | 50 | 2.83(1.81–4.43) | 2.65(1.61–4.36) |
31-60 minutes | 98 | 37 | 1.35(0.82–2.23) | 1.82(1.03–3.23) |
|
> 60 minutes | 104 | 53 | 1 | 1 | |
Exposure to media | None | 153 | 45 | 1 | 1 |
1-2 times a week | 166 | 61 | 0.80(0.51–1.25) | 0.79(0.48–1.32) | |
≥ 3 times a week | 161 | 34 | 1.39(0.85–2.29) | 1.12(0.64–1.97) | |
Knowledge about immunization | Good | 175 | 101 | 4.51(2.99–6.83) | 3.70(2.37–5.79) |
Poor | 305 | 39 | 1 | 1 | |
Place of delivery | Health institution | 300 | 45 | 3.52(2.36–5.25) | 2.58(1.66–3.99) |
Home | 180 | 95 | 1 | 1 | |
Frequency of ANC attended | None | 103 | 53 | 1 | 1 |
1-2 | 205 | 64 | 1.65(1.07–2.54) | 1.32(0.81–2.15) | |
≥ 3 | 172 | 23 | 3.85(2.23–6.65) | 2.75(1.52–5.00) |
|
PNC check ups | None | 283 | 95 | 1 | |
Once | 129 | 33 | 1.31(0.84–2.05) | ||
≥ 2 | 68 | 12 | 1.90(0.99–3.67) |
This study attempts to assess full immunization coverage and its associated factors among children aged 12-23 months in Sekota Zuria District. Our findings revealed that 77.4% of the children were fully immunized during the survey. Mothers’ educational status, place of delivery, poor mothers’ knowledge, long distance to a health facility, big family size, and ANC follow-up were identified as predictors of full immunization coverage.
The full immunization coverage in the district was higher than the national and regional coverage of the 2016 EDHS report and a study in Areka Town that reported 75.4% [
Decreasing in coverage rates was observed between the subsequent vaccine doses. The dropout rate observed in this study was lower than the National and Regional findings (20%) [
Mothers’ ANC follow-up positively influenced the immunization status of the children especially among those who attended ANC service at least three times compared to mothers who did not attend ANC at all. This finding is consistent with the other research findings from Nigeria [
In this study, maternal education was a predictor of childhood immunization status. The role of maternal education as an important predictor of immunization uptake has also been stated by other studies in Zimbabwe [
The geographical accessibility of health facilities has been found to motivate immunization uptake. Mothers who travel for less than an hour to reach their nearest health facility were more likely to have fully immunized children than those who travel beyond one hour. Long distance is a demotivating factor to immunize children. This finding agrees with other studies carried out in Sudan [
Our study found that having a large family size was adversely affected full immunization status of the children. This is in line with studies conducted in Kenya [
In many studies, household economic status was a significant predictor of immunization status [
Despite generating this important evidence, our study had several limitations such as the following. (1) The effects of health system factors including vaccine availability, health care personnel, and logistics which might have an influence on an uptake of immunizations were not assessed. (2) As data about immunization coverage was collected retrospectively, mothers may not remember all events that took place during an immunization, especially where the card was missing. (3) The study did not address mothers’ attitude, perception, and opinion towards children immunization. Despite all these limitations, we hoped our finding would be valuable in bringing updated information on status and barriers of immunization coverage in the rural areas of Ethiopia.
Our study indicated that the full immunization coverage of the district was higher than the national and regional coverage, but lower than the World Health Organizations target. Mothers’ low educational status, long distance to immunization site, poor mothers’ knowledge about immunization, living in large family size, not attending ANC, and institutional delivery were detrimental to achieving full immunization coverage. Improving mother’s health seeking behavior toward pregnancy follow-up and enhancing mothers’ knowledge on child immunization, strengthening outreach services, community engagement, and actively working with local community-based health agents are recommended to increase number of children to be vaccinated.
Antenatal Care Service
Vaccine Preventable Disease.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The authors declare that they have no competing interest.
Abadi Girmay and Abel Fekadu Dadi were authors involved in the design, implementation of the study, statistical analysis, and drafting of the manuscript. Abel Fekadu Dadi was also involved in final manuscript revision and submission.
We are very grateful to Tigray Region, Wag-Himra Zone Health Bureau, Sekota Zuria District Health Office and kebele leaders for their close support. We sincerely appreciate the study participants, supervisors, and data collectors for their cooperation during the data collection activity.