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ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH ASSESSING CHILD IMMUNIZATION COVERAGE AND

ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH

ASSESSING CHILD IMMUNIZATION COVERAGE AND ITS DETERMINANTS IN SINANA DISTRICT, BALE ZONE, OROMIA REGIONAL STATE, ETHIOPIA, 2013

BY: - WORKU DECHASSA (BSc)

A THESIS SUBMITTED TO THE GRADUATE STUDIES PROGRAM OF ADDIS ABABA UNIVERSITY IN PARTIAL FULLFILMENT OF THE REQUIREMENTS FOR DEGREE OF MASTERS OF PUBLIC HEALTH (MPH) IN REPRODUCTIVE HEALTH

APRIL 2013 ADDIS ABABA

COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH ASSESSING CHILD IMMUNIZATION COVERAGE AND ITS DETERMINANTS IN

COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH

ASSESSING CHILD IMMUNIZATION COVERAGE AND ITS DETERMINANTS IN SINANA DISTRICT, BALE ZONE, OROMIA REGIONAL STATE, ETHIOPIA, 2013

By: Worku Dechassa (B.Sc.)

------------------------------------------------ Chairman of Dep.Graduate Committee

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Signature

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Date

Mulugeta Betre Gebremariam (MD, MPH) Advisor

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Signature

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Date

__________________________________ External Examiner

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Signature

Date

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Signature

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I

ACKNOWLEDGEMENT

  • I am very grateful to my advisor Dr. Mulugeta Betre Gebremariam of the Department of Reproductive Health and Health Services Management School of Public Health, College Health Science Addis Ababa University (AAU), for his unreserved guidance and constructive suggestions and comments beginning from proposal development. Without his genuine support, this work cannot be a reality.

  • I am also grateful to United Nations Population Fund (UNFPA) for its full financial support of this study and AAU for the all rounded support.

  • I would like to acknowledge the Oromia Health Bureau, Sinana Health Office, and Sinana district

community specially mothers and Focus Group Discussion (FGD) participants of this study. Again I would like to extend my appreciation to Dr. Alemayehu Worku for the invaluable suggestions and comments on software handling and through writing result; and Dr. Wubegzer

Mekonnen for his invaluable suggestion and advice throughout write up of the result.

Due recognition also goes to Dr. Wakgari Daressa for his help during proposal development.

  • I take this opportunity to extend my thanks to all of my teachers, the library, and computer lab

staffs of Addis Ababa University, who have encouraged me during the process of writing the thesis and overall across my stay with them as a student of Masters of Public Health in the Department and all my class mates who helped/encouraged me throughout my stay.

Last but not least, I am in indebted to the encouragement and support of my family, Lemma Demissie for his contribution and my wife Yerom Tafesse for her data entering, advice on technical part of computer and encouraging me throughout my stay as a student in the university. In doing so and else, she has proven that she is my life time partner. Also, I would like to thank all the super visors, local guides and data collectors.

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I

TABLE OF CONTENTS

pages

ACKNOWLEDGEMENT

 

I

TABLE OF CONTENTS

II

List

of

Tables…………

IV

List of Figures ……

..

 

V

Abbreviations and Acronyms

VI

ABSTRACT

 

VII

INTRODUCTION

1

1.1

Background

.....................................................................................................................

1

1.2

Statement of the Problem

 

3

1.3

Significance of the Study

4

LITERATURE REVIEW

 

5

 

10

3.1

General Objective

10

3.2

Specific Objective

10

METHODS

 

11

4.1

Study

area and Period

 

11

4.2

Study Design

11

4.3

Population

11

4.3.1

Source Population……………………………………………………………………… ...11

4.3.2

Study Population…………………………………………………………………………. 11

4.4

Inclusion and Exclusion criteria

....................................................................................

11

4.4.1

Inclusion Criteria:……………………………………………………………………… ..11

4.4.2

Exclusion Criteria:……………………………………………………………………….11

4.5

Sample size determination and Sampling technique

.....................................................

12

4.5.1

Sample size determination: (For quantitative data)………………………………12

4.5.2

Sampling Technique………………………………………………………………………12

4.6

Study variables

13

4.6.1

Variables of the Study…………………………………………………………………….13

4.7

Data collection Instrument

 

13

4.8

Data Collectors Recruitment and Training

14

4.9

Data Collection Process

14

  • 4.10 Data Analysis

..............................................................................................................

15

  • 4.10.1 for Quantitative Data……………………………………………………………………15

  • 4.10.2 for Qualitative Data…………………………………………………………………… ..15

  • 4.11 Data Quality Control

...................................................................................................

15

  • 4.12 The Ethical Consideration

...........................................................................................

16

  • 4.13 Operational and Standard Definitions

16

  • 4.14 Dissemination plan

17

II

RESULTS

.............................................................................................................................................

18

  • 5.1 Socio -demographic Characteristics of Study Population

18

  • 5.2 Maternal Health Care Utilization (antenatal care and postnatal care utilization)

21

  • 5.3 Socio -demographic Characteristics of Children in Sinana district, Bale

21

  • 5.4 Availability and Accessibility of Vaccination Service

.................................................

23

  • 5.5 Knowledge of Mothers/Caretakers on Vaccination and Vaccine Preventable Disease 25

  • 5.6 Attitudes of Respondent toward Immunization

............................................................

29

  • 5.7 Immunization Coverage among 12-23 months aged Children

......................................

29

  • 5.7.1 Immunization Coverage by Card only…………………………………………………30

  • 5.7.2 Immunization Coverage by Card plus Mother Recall……………………………….30

Factor affecting immunization completion for children

31

Socio-demographic Characteristics of Caretakers/Mothers

31

Maternal Health Care Utilization

35

37

39

Child Characteristics

42

46

STRENGTH AND LIMITATION OF THE STUDY

53

CONCLUSIONS AND RECOMMENDATIONS

54

REFERENCES .....................................................................................................................................

56

ANNEXES

59

Annex 1:- current immunization schedule in Ethiopia

59

Annex 2:- conceptual frame work for determinants of immunization coverage in Sinana ..60

Annex3: -Schematic presentation of sampling

61

Annex 4:- Data collection instrument

62

II.QUESTIONNAIRE IN AFAN OROMO VERSION

75

III. Focus group discussion guide

86

Annex 5:- Attitude of the Respondent toward immunization in sinana district

87

Annex6:-Source of information by area of residence in sinana district

88

Annex7:- Reason given by mothers for not completing immunization of children among

partially/ unvaccinated in sinana

89

90

Annex 9:- Letters for declaration

91

III

List of Tables

Pages

Table .1 Socio-demographic and Economic Characteristics of the Respondents in Sinana........19

Table2. Maternal health care utilization, Sinana district, Bale zone………………………............21

Table3. Characteristics of Children Aged 12-23 Months in Sinana district

..............................

22

Table4. Availability and Accessibility of Vaccination site in Sinana district……………… .........23

Table5. Respondents’ information on vaccine and given information on immunization in Sinana25

Table5.1 Respondents Knowledge on Vaccine and Vaccine Preventable Diseases, Sinana…… ...27

Table6. Immunization status of Children aged 12-23 months by Mothers’ history plus

Vaccination card, Sinana district…………….……………………………………………29

Table7. Completion of immunization among children aged 12-23 months by Socio Demographic

Characteristics of Mothers /Caretakers and Fathers in Sinana………………………………… .....33

Table8. Completion of Immunization among Children aged 12-23monts by Maternal Health Care

Utilization, Sinana…………………………………………………………………………36

Table9. Completion of Immunization among 12-23months aged Children by Availability and

Accessibility of health care service, Sinana………………………………………………38

Table10. Completion of Immunization among children aged 12-23 months by Mothers

Knowledge on Vaccine and Vaccine Preventable Diseases in Sinana

.............................

40

Table11. Immunization Completion among children aged between 12-23 months by

Characteristics of Child, Sinana………………………………………………………… ...42

Table12. Multivariate analysis for completion of child immunization (fully immunized) in Sinana district and selected variables, ……………………………………………… ..43

IV

List of Figures

Pages

Figure1. Immunization Coverage by Source of Information in Sinana district……………….…31

Figure2. Reason given by Mother why returned home without getting immunization during

appointment for Child immunization in Sinana…………………………………………………...45

V

Abbreviations and Acronyms

AAU

Addis Ababa University

AFP

Acute Flaccid Paralysis

ANC

Ante natal Care

BCG

Bacille Calmette-Guerin

CMR

Child Mortality Rate

DPT

Diphtheria Pertussis and Tetanus

EDHS

Ethiopia Demographic Health Survey

EOS

Enhanced Out-reach Services

EPI

Expanded Program on Immunization

FGD

Focus Group Discussion

FMOH

Federal Ministry of Health

GAVI

Global Alliance for Vaccines and Immunization

GIVS

Global Immunization Vision and Strategy

HepB

Hepatitis B

HEWs

Health Extension Worker

HIB

Haemophilus Influenza type B

HSDP

Health Sector Development Program

IMCI

Integrated Management of Childhood Illness

MCH

Maternal and Child Health

MDGs

Millennium Development Goals

NGOs

Non-Governmental Organizations

OPV

Oral Polio Virus

RDV

Rural drug vender

RED

Reaching Every District

SOS

Sustainable Out-reach Services

UNICEF

United Nation International Children’s Emergency Fund

UNFPA

United Nation Population Fund

U5MR

Under Five Mortality Rate

VPDs

Vaccine Preventable Diseases

WHO

World Health Organization

VI

ABSTRACT

Background: - Immunization remains one of the most important public health intervention and cost effective strategy to reduce child mortality and morbidity associated with infectious diseases and is estimated to avert between 2 and 3 million deaths each year. The objective of this study was to assess complete immunization coverage and its associated factors among children age 12-23 months in Sinana district. Methods: - A cross-sectional community based survey was conducted in 6 kebeles (PA) of Sinana District from 29, December 2012 16, January 2013. A modified World Health Organization Expanded Program on Immunization cluster sampling methods was used for household selection. Data on 591 children aged 12-23 months and mothers pair were collected by using a pre-tested structured questionnaire through house to house visits from vaccination card and mother’s verbal reports. Bivariate and multivariate logistic regression analyses were used to assess factors associated with fully immunization coverage of children. Results: - of 591 interviewed mothers’ of children, only 10.2% of the mothers have attended secondary and above level of education. Of children included in this study, only 33% of them had vaccination card at time of the survey and about 76.8% of the children aged 12-23 months were fully vaccinated by card plus history. Factors significantly associated with full immunization were antenatal care follow-up (adjusted odds ratio (AOR = 3.7, 95% CI: 2.3- 5.9), mother occupation being farmer (AOD=1.9, 95% CI:1.14-3.1), educational level of father being secondary and above (AOD=3.1, 95%CI:1.3-7.4), household family income greater than one thousand(AOD=3.2, 95% CI:1.4-7.4) , average walking time less than an hour(AOD=3.1, 95% CI:1.5-6.3), ever discuss about immunization with health service extension worker(AOD=2.4, 95%CI:1.32-4.2) and mother’s sufficient knowledge on immunization(AOD=2.5, 95% CI 1.5-4.2) , whereas area of residence , educational level of mother and child sex were not significantly associated. Conclusion: - Even though, immunization coverage of children in sinana district gets improvement over national coverage, yet it is below governmental plan of 90%. Maternal Health care utilization and knowledge of mother about vaccine and Vaccine Preventable Diseases are the main factors associated with complete immunization coverage. It is vital that, local programmatic intervention should be strengthened to upgrade awareness of the community on the importance of immunization, antenatal care and working on advancing economical status of community is the way to optimize children’s immunization coverage.

VII

INTRODUCTION

1.1 Background

Universal immunization of children against six preventable diseases (tuberculosis, diphtheria, Pertussis, tetanus, polio, and measles) is vital to reduce childhood mortality and morbidity across the world and so it is one of the indicators of development in most developing countries with averting 2 to 3 million deaths each year. The Expanded Program on Immunization (EPI) was launched in 1974 as a global program for controlling and reducing death from Vaccine- preventable diseases. Thus, vaccine coverage is estimated, as by convention, with DTP3 coverage achieved among children aged 1223 months (1, 2).

At the end of 2011, immunization was reported to have saved 2-3 million lives; nonetheless, in the same year 1.5 million children are estimated to have died (more than 70% live in ten countries) from VPD a reflection of the incomplete coverage with existing vaccines that persists in many parts of the world. Goal of Global Immunization Vision and Strategy (GIVS), were to reduce global measles deaths with 90% by 2010 or earlier (3, 4).

The WHO Africa region and the Global alliance for vaccines and immunization (GAVI) in 2000 have set a goal of reaching >80% DTP3 coverage in every District in >80% of developing countries by 2005. This goal is referred as the "80/80 goal". To achieve a goal, the GAVI proposed a new approach, Reaching Every District (RED) in 2002 (4). Millennium development goal (MDG) four aims is a two-thirds reduction of U5MR by 2015. Measles immunization coverage is one of the indicators for progress towards MDG 4. In 2008, there were an estimated 164,000 measles deaths globally. WHO estimates that during 20002007, measles-caused deaths

declined by 89% in Africa. However, measles outbreaks continue to occur throughout the region (5).

In 1980, the government of Ethiopia initiated the implementation of EPI with goal of increasing vaccination coverage against the six childhood killer diseases by 10% each year to reach 100% coverage in 1990; this program goal has largely remained unrealized even using different efforts. Despite the high prevalence of VPDs in the country, immunization coverage rates stagnated and remained very low for many years. HSDPIV goal of the ministry of health EPI strategy is to achieve 96% DPT3 coverage in all regions. The major hindering factors in achieving universal immunization includes: low access to services, low number of trained manpower, high turnover of

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staff, lack of fund donors, lack of information, lack of transportation, distance of facility, inadequate awareness of mothers/caregivers, others such as missed opportunities, and high dropout rates; especially through routine approaches (6,7). Strategies and innovations under taken to increase the national EPI coverage were by implementing new approaches such as Sustainable Out-reach Services (SOS) and RED which started in 2004 to benefit from it in reducing child and infant mortality by 25% if fully immunized by one year of age (6, 7). The EDHS 2011; showed coverage level for DPT3 and that of fully immunization to be 36.5% and 24.3%. Oromia region DPT3 and full immunization coverage were 26.8% and 15.6% respectively. According EDHS 2011 DPT3 coverage in many of the regions was below 80%, lowest in Afar region 9%, highest in Tigray 73.4% and in Oromia 26.8% (8). Infant mortality rate stood at 59, 73 and U5MR was 88, 112 per thousand live births for national and Oromia region respectively. Reducing U5MR to 67/1000 by 2015 can only be achieved if cost effective and high impacts interventions developed in support of the child health program are implemented at very high levels of coverage which includes among others: RED strategy, IMCI and enhanced outreach strategy (EOS) (9).

In connection to this pentavalent was introduced in 2006 with objective of increasing pentavalent three (DPT-HepB-Hib3) coverage to 88% by the end of 2011(10, 11). The current immunization schedule in Ethiopia is specified under annex1.

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1.2 Statement of the Problem

Vaccine Preventable Diseases are responsible for about 25% of the 10 million deaths occurring annually among under five years children. Vaccines were widely regarded as an effective but across the world 26.3 million children below the age of one year had not been immunized with DPT3 in 2008(5,12). The WHO African regional office estimated that about 5 million children were un-immunized for DPT3 (2007), 73% of these children live in 10 countries including Ethiopia. Five of the African Region including Ethiopia, were the Region still continuing and even increasing further to the pool of unimmunized children in 2010 and 2011(17)

Although the world is dedicated to reduce death from vaccine preventable diseases, conversely, VPD are estimated to 1.6 million deaths occur every year, of which 50-60% were contributed by Measles (4, 6, 13). Even if estimated number of death from measles dropped from733, 000 deaths in 2000 to 164,000 in 2008(by 78%), still several regions notably South Asia and Sub Saharan African show much lower coverage and measles outbreaks occurred in several African countries during 2008, including the Democratic Republic of the Congo (12,461 reported cases), Ethiopia (3,511), Niger (1,317), and Nigeria (9,960 (14, 18).

In Ethiopia Measles is one of the five major causes of childhood illnesses, which together contribute to 70% of under-five morbidity and mortality (4). According to the WHO measles burden estimator, Ethiopia contributes to 46% of the cases and 51% of the deaths from measles among eight eastern African countries. Low measles immunization rate seems reasonable to attribute a slightly larger proportion of mortality to measles in Ethiopia (15, 16, 18) and there were VPD outbreaks, for which some claimed their lives and disabled many more. For instance, polio outbreak between December 2004 and February 2006, 24 children of these 8 ,9 and 7 children from Tigray, Amhara and Oromia Regional State, were paralyzed respectively, as a result of infection with wild poliovirus type 1 (16).

Majority of district of Ethiopia appeared less optimally performing on DPT3 with anticipated coverage level of 50% in 2011(17).

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1.3 Significance of the Study

In order to increase the child immunization, the underlined causes should be known. To do so, the reason do not immunize their children should be known. In the study area, no immunization related study was conducted before. According to the District report, there were episodes of VPDs in Sinana District for instance in 2008, 2009 and 2010. There were 3, 5 and 2 measles cases respectively which is may be due to low immunization coverage (27).according to district report immunization coverage in Sinana was 85%. But so far community based immunization coverage was not assessed. Therefore, this study will try to fill these gaps by identifying the child immunization coverage and factors associated with full immunization. And will help policy makers, program planning bodies and service providers to remove the obstacles and improve child immunization to attain intended control of vaccine preventable diseases. It also helps as a baseline for future studies.

4

LITERATURE REVIEW

Coverage of immunization and related factors

Immunization stands as good public intervention to reduce and control morbidity and mortality from vaccine preventable diseases so as to achieve increasing immunization coverage and improving its quality is mandatory. There are factors hindering immunization coverage. Of this, some are revealed by study at different areas and reviewed as follows:

According to finding from Xay district of western pacific region in Lao DPT3, coverage was 72%,

higher than the national target of 65%; however, the dropout rate was 21%. Influential factors on fully immunized child was distance, literacy, possession of livestock; mothers knowledge of

immunization target diseases, measles immunization schedule; and mother’s willingness to pay for

immunization, zone of residence and ethnic group were significantly associated with immunization status (28). On other hand, finding from Tehran in Iran among 668 child’s mothers surveyed revealed that more than half (67%) of respondents gave disproportionate importance to mild intercurrent illness as a reason to defer immunization ,Increase in birth order, number of children in household and mother’s age significantly predicted vaccination schedule non- adherence (29).

The cluster survey, which was carried out in Agra district of India in 2006 showed that the reason for non immunization is lack of awareness (52.1%, fear of side effect of vaccination 16.6%, vaccine were not available 6.25%, child was ill 4.6% out of 221 children (31), other study in India, Murshidabad district showed family size, birth order, religion (Musilm55.7% and Hindus 68.4%), motherseducation, and wealth status were significantly associated with fully immunization. Further, the immunization rate was higher where health workers had visited mothers during their pregnancy period and the effectiveness of the persuasion of the health worker was quite evident since the subsequent visits to remind the mothers about immunization improved the coverage further (32).

Study in northern Nigeria revealed, place of birth, ownership of an immunization card, ANC use, maternal knowledge about immunization, and maternal exposure to child health information, social

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influence and paternal approval of immunization were significantly associated with BCG immunization. Both the regularity of vaccine supply to the health facility and the state of residence were associated independently with BCG immunization status (33).

Other study in District of Nigeria (2006) demonstrated that having at least secondary school education, satisfactory immunization knowledge of the mother, retention of immunization card and

mother’s knowledge of immunization was significantly correlated with the rate of full

immunization (24). In relation, the study from Mali (2009) at Kita circle reveal that, ANC use has positive link with full vaccination, distance from the health Centre or socio-economic status. Lack

of information was one reason given for children not being vaccinated against the six EPI diseases

(25).

In Uganda, DPT3 coverage in 2005 was 60%. Some of the factors for low coverage were communities have not internalized the usefulness of immunization and benefits of completing the full doses for children; health workers do not inform or remind mothers/ guardians to come back for more doses and outreach dates, immunization sessions sometimes conflict with farming/family duties especially during planting seasons and this reduces attendance. Static and outreach sessions are sometimes infrequent; vaccine shortage and/or cold chain breakdown and little involvement of local leaders, especially in following up of defaulters (34). On the other hand, evidence from Kenya in 2004 indicated that immunization coverage for three doses of pentavalent vaccine was 100%.The reason for this was found to be season, distance from clinic and family size were each associated with the rate of immunization (20).

As the study in Istanbul shows, the complete vaccination rate for study population was 84.5% and 3.2% were totally non-vaccinated. The reasons for non-vaccination were: their being in the village and failure to reach health care services, lack of knowledge about vaccination, father refusal of vaccination, inter current illness of child during vaccination time, missed opportunities like not to shave off a vial for only one child. Being full vaccinated for children were influenced by mothersand fatherseducational level. Age of the mother (>30), high birth order and children from large family were significantly associated with incomplete immunization in Brazil (23). Another finding from Nouna district Burkina Faso revealed maternal knowledge of the preventive value of immunization was positively related to complete immunization status in rural areas, good

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communication about immunization , availability of immunization booklets, as well as economic

and religious factors appear to positively affect children’s immunization status (26).

In 2000 a Study done in rural Ethiopia by Teklay revealed that the coverage based on card plus history, BCG, DPT1/OPV1, DPT3/OPV3 and measles coverage for 12-23 months old children was 99.1%, 97.3%, 92.7% and 75.5% respectively. BCG scar was 89 %( 81/91) and 76.5% (13/17) among those vaccinated by card and history respectively. Both the residence and mother’s education were significant predictors of immunization status of children, children from rural areas whose mothers were literate had higher immunization coverage than illiterate (22)

National immunization coverage (2006) showed that residence, presence of HEWs in kebeles. Kebelesadministration involvement in EPI planning and review and maternal factors (education and parity) remained in the model as significant predictors for DPT3 vaccination but maternal occupation and child sex were not statistically significant (19).

Moreover, according to national survey EDHS 2011; 24% of children were fully vaccinated and there was gender difference in terms of immunization coverage for example female children are slightly more likely to be fully vaccinated (26%) than male children (23%). Birth order has a close relationship with vaccination coverage; as birth order increases, vaccination coverage generally decreases and 30% of first-born children have been fully immunized, compared with 20% of children of birth order six and above and urban children are more than two times as likely as rural children to have all basic vaccinations (48% compared with 20%). Children whose mothers have secondary education are more likely to be fully immunized than those born to mothers with no education (57 and 20 percent, respectively) (8).

Study in South Ethiopia of Wonago district revealed that 76% believed that immunization was beneficial for their children in preventing the occurrence and spread of diseases. The family income, mothersknowledge, post natal care utilization, and positive attitude toward immunization were significantly related to child immunization completion (35). A survey in Oromia region (2004) shows that in terms of health care access, 60% of households are less than a 2-hour walk (10 km) from a health facility. Two-thirds (66.7%) of children 12-23 months old have access to vaccinations, as represented by the percentage of children who received DPT1. Coverage declines, however, throughout the series of routine vaccinations, as only 45% of children in the region

7

received DPT3. Only 38% received the full series of vaccinations and 26% none received. Women’s lack of time 33%, unaware of the need to vaccinate further or to return for 2 nd or 3 rd dose 20%, not knowing the place or time of immunizations, absence of vaccinators and lack of immunization information 66%, health workers constitute the primary contact for women, followed by community events and radio were among factors identified not to complete the series (36).

In other study of Oromia region, Illubabor zone, it was showed that 65.6% of study children were fully immunized, partially and not immunized at all were 29.2%, 5.2% respectively. The reasons for failure to start or complete the course of immunization were lack of information and lack of motivation constituted 63.2%, 25.0% and 11.8% respectively (37). As survey in Jimma town showed higher acceptance of immunization by mothers who have been educated to above six grades than none educated. The relation between occupation and child immunization were government employee was the first to fully immunize their child than housewives (94% versus 50%). Factors associated with non immunization and defaulters were illiteracy, lack of knowledge about EPI target diseases and attitude of mothers were 45.6% said very useful, 54.1% said useful and the rest 0.3% said not useful (38)

Study in Ambo District, Oromia region (2011) showed, antenatal care follow-up, being born in the

health facility, mothers’ knowledge about the age at which vaccination begins and knowledge

about the age at which vaccination completes were significantly associated with complete immunization whereas area of residence and mother’s socio-demographic characteristics were not significantly associated with full immunization among children (39).

Health facility related factors

Accessibility to a health facility for child immunization can be measured in terms of distance, time spent to reach the facility. In a study from the Philippine, it was found that the immunization coverage decreased when the distance to the immunization site more than 0.5 km (40). In a study conducted in US (at Detroit city), it was reported that the vaccination coverage was lower for children if parents reported problems in accessing the health care system, due to lack of transportation as compared with those who did not report such problems and barriers in the organization and delivery of health care such as fragmentation of primary care services, inaccessibility of health care services, lack of information about the child's immunization status,

8

and complexities of the immunization schedule (41). Study from rural Nigeria (2008), 339 mothers

and 339 children (each mother with eligible child), mothers’ knowledge of immunization (p =

0.006), vaccination at a privately funded health facility (p < 0.001) and distance of the service area were significantly correlated with the rate of full immunization (23).

Validity of the officially reported vaccination coverage

In terms of the validity of reported vaccination coverage (country-generated statistics), some studies show that officially reported immunization coverage was higher than that reported from population based surveys. A study from Mozambique showed uncertainties in population data because the service data which was used by province level and district level was different (43).

Data from the EDHS generally show vaccination coverage to be lower than data in the service statistics from the Ministry of Health. According to EDHS 2011 report, a card plus history 36.5% of children aged 12-23 months had been vaccinated for DPT3 before the age of one year. The EDHS 2011 reported coverage was much lower than the 2010 administrative coverage of 83% for DPT3 from regular reports (8).

In conclusion, different literatures on worldwide at different study sites on immunization coverage

with its influencing or affecting factors such as socio demographic, mothers’ knowledge, attitude,

information related to immunization and health facility related are among factors associated with low immunization coverage as revealed by different literatures.

Determinants of immunization coverage as specified in conceptual frame work for determinants of immunization coverage in Sinana district under annex 2 are socio-demographics, knowledge of the mother, source of information and health facility related factors are considered as factors affecting full immunization status of children among 12-23 months age.

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OBJECTIVE OF THE STUDY

  • 3.1 General Objective

To assess the full immunization coverage of children aged 12-23 months and identify its

determinants in Sinana district, Bale Zone, Oromia region, Ethiopia, 2013

  • 3.2 Specific Objective

    • To assess full Immunization coverage of Children 12 to 23 months in study area

    • To identify factors associated with full immunization coverage in study area.

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METHODS

  • 4.1 Study area & Period

The study was conducted in Sinana District, which is one of the 21 Districts, found in Bale Zone of Oromia Region from 29 December 2012 to 16 January 2013. Oborra and Selka are the capital town of the Sinana District and, located 450 kms to southeast of Addis Ababa. Sinana District has 2 urban and 19 rural Kebeles. According to the 2007 national Census, the total population of Sinana District was 136,194 of which 66,735 (48.99%) and 69,459 (51.01%) were females and males, respectively (44); with 3024(2.22%) 12-23 month old children. There were 6 health centers, 20 health posts and 14 low level private clinics and 7 Rural Drug Vendors in the District. But EPI was all provided by Health Centers and Health Posts. According to 2011/12 District Health Report 85% of children were fully vaccinated (27).

  • 4.2 Study Design

A community based cross-sectional survey involving quantitative and qualitative assessment was employed.

  • 4.3 Population

    • 4.3.1 Source Population

All children aged 12 to 23 months with their mothers/ caretakers living in Sinana district.

  • 4.3.2 Study Population

Sampled children aged 12 to 23 months with their mothers or caretakers

  • 4.4 Inclusion and Exclusion criteria

    • 4.4.1 Inclusion Criteria:

Children (12-23month) with their mothers or caretakers living in the district at least 12 months on

the date of survey, age of the mother/ caretakers 15 years and above and able to be interviewed.

  • 4.4.2 Exclusion Criteria:

Children with their mothers or caretakers that had not been living in district for at least 12 months on the date of survey and age of the caretakers below 15 years at the time of the survey.

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4.5 Sample size determination and Sampling technique

4.5.1 Sample size determination: (For quantitative data)

The sample size required was determined based on single proportion population formula with the assumption of 5% margin of error (d), 95% confidence level(Z), 67.5%estimated mothers knowledge on immunization (39) and considering design effect of two. Sample size was calculated for both specific objectives and maximum sample size was taken.

n o sample size

n o = design eff x (Z 1-α/2 ) 2 x (P)(1-P)

  • d 2

Based on the specifications of the above formula, it gives 674. The total number of eligible children

that lie between 12 and 23 months in the District is 3024 which is <10,000, so by using finite

population correction formula;

n f = n o 1+ n o /N
n f =
n o
1+ n o /N

Where n o =initial sample size,

N= total number of eligible children and

n f =final sample size

By using the above formula n f =551 children and with 10% non-response rate sample size of 606.

For qualitative data (FGD)

Health care providers of Primary Health Care that included head of the selected Health center, provider working on immunization and Health Extension Workers from surrounding sub-sample of health facilities with 8-12 participant/FGD and 8-12 reproductive age mothers per FGD who had child 12-23 months age were selected purposively from selected zones (not participate in quantitative) during census and categorized in to two separate FGD session with consideration of homogeneity.

4.5.2 Sampling Technique

Initially the total kebeles were stratified into rural and urban areas. Then five rural and one urban Kebeles were selected by lottery method from the total Kebeles in the Districts. But each Kebeles have been divided into three zones/sub-kebeles according to the 2004etc kebeles structure Then,

12

from each sampled kebeles, one zones/sub-kebeles was selected by lottery methods. The modified 2005 WHO EPI cluster sampling method was employed to select study households with consideration of each zones/sub-kebeles as one cluster. (45)

Then the selection of the required number of the children was from each of the selected zone/sub- kebeles with proportional allocation of study subjects. The first child in each zone was selected randomly from the center of the zone and the rest of them were selected from the contiguous household till the required number of children had been attained. During survey household with more than one eligible child was observed and only one child was included in interview by lottery method among them. Details of sampling scheme attached in annex3

  • 4.6 Study variables

4.6.1 Variables of the Study

Independent variables: -

Socio-demographic variables: age, sex, marital status mother, religion, number of children, and ethnicity, monthly family income, occupation, and educational status of family , residence, birth order and place of birth for index child.

Health facility related: distance from health service, waiting time for immunization ANC or post natal care usage of mothers, Immunization service and Presence of HEWs in Kebeles.

Knowledge and attitude of mother or caretaker: knowledge of vaccination schedule, vaccine preventable diseases (VPDs), usage of immunization and common symptom of (VPD)

Source of information for immunization: information from mass media, from health worker, from village leader, from friend or family member, given information by health worker on immunization, possible adverse reaction, schedule of immunization and VPD.

Dependent variable: full immunization status of child.

  • 4.7 Data collection Instrument

It is an interviewer-administered structured questionnaire to obtain information from mothers or caretakers of the child by tenth completed trained interviewers. The instrument was constructed from

13

a review of available literature on immunization coverage, WHO questionnaire, and EDHS for immunization coverage and translated in to local language (8, 24, 45).

The knowledge of the mothers/caretakers was assessed by six questions and then, correct response was scored one point and zero point for wrong answer. And attitude of mothers/ caretakers were assessed by five questions and then scored of one point and zero point was given for correct and wrong answers respectively. For data collection the interviewers were used a manual that was prepared by the investigator to help them understand the questionnaire and to used during data collection. For qualitative parts, FGD guides were prepared by investigator.

  • 4.8 Data Collectors Recruitment and Training

Nine data collectors and three supervisors who completed grade twelve and ten were recruited based on a set of criteria such as ability to speak and write Afan Oromo and previous experience on data collection. They were trained for two days by the principal investigator on the purpose of the study, instrument, consent form, how to select child from household, how to interview and how to copy information from immunization card and data collection procedure.

  • 4.9 Data Collection Process

A pre-tested structured questionnaire initially developed in English and later on translated into Afan Oromo was used for data collection. Households with eligible children in the zones were visited by trained data collectors and were recruited until the proportionally allocated sample size in each cluster/zone was achieved. Each survey team (three survey teams) consisted of one supervisor, three data collectors and one local guide and one team collected data for two Kebeles. The supervisors checked for completeness at the end of each day, and ensuring proper selection of the first household in each cluster according to the guidelines developed by investigator. Data collection was undertaken from 29 December, 2012 to 16 January, 2013. Mothers or caretakers were asked to show immunization cards and vaccine received and the dates of immunization were copied from vaccine card. For those whom the vaccination card was not available the mothers/ caretakers were asked on immunization status of child. For DPT and polio, the mother was asked to report the number of DPT/Polio vaccine that the child had received. In order to reduce recall bias for mothers/caretakers history, remainders such as site of administration (injection, orally and scar) were included in instruments.

14

For qualitative data: Three FGDs: one with Health workers group (probed on missed opportunity, Health information delivery system and any obstacle to provided immunization service) and two with mothers group (probed on their knowledge ,attitude towards immunization and barrier for non vaccinating) were conducted. In order to ensure homogeneity of participants, discussants were purposively grouped in to health workers and non-health workers (mothers) groups. Note taking and audio tape were used for recording information.

  • 4.10 Data Analysis

    • 4.10.1 for Quantitative Data

Data was entered to Epi Info version3.5.3 after checking for completeness, then cleaned and transferred to SPSS Version 20.0 for analysis. Frequencies and other descriptive statistics were done. Bivariate analysis was calculated to examine association between dependent and independent variables; Odds ratios (ORs) and their 95% confidence level were calculated. Then, all variables that had p-value less than 0.2 in the bivariate analysis were included in the multivariate logistic regression model to determine the factors associated with full immunization coverage among children aged 1223 months old and adjusted ORs with their 95% CIs were computed to determine the true association. Data were categorized in to four groups to see the association of independent variable with outcome variable; these groups were socio-demographic

characteristics, maternal health care use, child characteristics and mothers’ knowledge of vaccine

and vaccine preventable diseases. Then from each of the group variables that had P-value of less than 0.05 were entered in to final model to control for confounders and to determine true association.

  • 4.10.2 for Qualitative Data

FGD data was transcribed, translated to English by replaying the tape and analyzed thematically and manually.

  • 4.11 Data Quality Control

The questionnaire was prepared initially in English by the investigator and translated into Afan Oromo, and retranslated by another translator to English to compare the consistency. Data collectors and supervisors were trained for two days on the study instrument and data collection procedure and before the actual data collection, the questionnaire was pre-tested on 5% mothers or

15

caretakers of children whose age was between 12 to 23 months in non-selected kebeles and the finding was excluded from main study. The necessary amendments were made up on identification of ambiguities of the questions in the wording, logic and skipping order. The principal investigator and the supervisors checked the collected data for completeness and corrective measures were taken accordingly and 15(2.4%) questionnaire was rejected due to inconsistency and incompleteness. The collected data was cleaned, coded and explored before analysis.

  • 4.12 The Ethical Consideration

Proposal was approved by the Ethical Review Board of the College of Health Sciences School of Public Health, before conducting the study. Permission to undertake the study was obtained from every relevant authority in the Zone, District and respective Kebeles. Pertinent Consent Form and the Information Sheet were duly integrated along with the respective data collection instruments. All the study participants were clearly informed about the objective, benefits, significance and as it has no harm. Finally, verbal informed consent was obtained from each study participant before interview.

  • 4.13 Operational and Standard Definitions

Fully vaccinated: A child between 1223 months old who received one dose of

BCG, at least

three doses of pentavalent, three doses of OPV and one dose of measles vaccine by card plus

mother history

Partially/incompletely immunized: A child 12-23 months old who had missed any one vaccine out of the eight vaccines

Not immunized: A child 12-23 months old who didn’t receive any vaccine.

Coverage by card only: Coverage calculated with numerator based only on documented dose, excluding from the numerator those vaccinated by history.

Coverage by card plus history: Coverage calculated with numerator based on card and mother’s report.

Missed opportunity: Eligible child for vaccination had gone to health facility but didn’t for which he or she is eligible at that day

receive,

16

Sufficient knowledge: Six knowledge questions were asked and correct answer was given score 1 and incorrect answered score 0. Those having scored greater than the mean were classified as having sufficient knowledge.

Positive attitude towards immunization: When the respondent reported accepting attitude to correctly at least 3 correct questions out of four questions prepared about immunization.

Caregiver: is the most responsible person that provides child care for the 12-23months old child whose biological mother could not provide the intimate care.

Index child: refers to 12-23 months old child that is included in the study from a household to have information on the demographic and immunization status and the child chosen from household if there is more than one.

Literate: mothers/caretakers/fathers with formal education or able to read and write.

Dropout rate (DOR): The rate difference between the initial vaccine (BCG or Pentavalent I) and the final vaccines (Pentavalent III or Measles)

BCG to Measles dropout rate: the percent of children vaccinated for BCG who does not receive measles vaccines. BCG /Measles dropout rate (over all dropout rate) = (BCG measles) x 100% BCG Pentavalent I to pentavalent III dropout rate: the percent of children vaccinated for pentavalent I who not receive pentavalent III. Pentavalent I / Pentavalent III dropout rate= (PI-PIII) x100% PI

4.14 Dissemination plan

The results of this study will be disseminated or communicated to the Bale Zonal Health Bureau, Sinana District Health Bureau and other concerned bodies through reports and possible publication in local and international journal and also, presented for Addis Ababa University, primarily, through the formalized Thesis and Defense at the School of Public Health of the College of Health Sciences.

17

RESULTS

5.1 Socio -demographic Characteristics of Study Population

A total of 591 mothers/caretakers of children aged between 1223 months old were interviewed

from 6 kebeles, with a response rate of 98.5%. Of the total 591 respondents, 562(95.1%) were mothers of children and 29(4.9%) were other caretakers. Of the 591,478(80.9%) and 113(19.1%) rural and urban residents respectively; 563(95.3%) of them live in union. The majority 575(97.3%) of respondents belongs to Oromo ethnic group, 313(53%) of them Orthodox Christian followed by

  • 265 (44.8%) Muslim religion followers. The remaining 9(1.5%) and 4(0.7 %) were Protestant and

Catholic respectively. The median age of the respondents were 28(SD=6.1) years, which ranges from17 to 58 years. From the total respondents, 340(57.5%) attended primary school, while 60(10.2%) had secondary

and above level and 191(32.3%) of mothers did not attend any formal education. In line to this,

  • 309 (52.3%), 110(18.6%) and 172(29.1%) of the fathers did attend primary school, secondary or

above and the not gone to school for formal education respectively. Approximately 326(55.1% of mothers and 528(89.3%) of fathers were farmers during the survey.

Majority of the family 432(73.1%) own radio and only 141(23.9% had television, with mean monthly household income of 763.4ETB (SD=725.98) and varying from 100 to 5000 ETB. Table 1 showing socio demographic characteristics of mothers/caretakers given below.

18

Table 1:- Socio-Demographic and Economic Characteristics of the Respondents in Sinana District, Bale Zone, Oromia region, Ethiopia 2012/13(N=591)

Variables

 

Frequency

percent

Relationship Mother

562

95.1

Caretaker

29

4.9

Age of the mothers/caretakers < 20

73

12.4

21-30

362

61.2

31-40

141

23.8

>40

15

2.6

Marital status Single

10

1.7

Married

563

95.3

Divorced

15

2.5

Widowed

3

0.5

Religion Orthodox

313

53.0

Muslim

265

44.8

Protestant

9

1.5

Catholic Ethnic group

4

0.7

Oromo

575

97.3

Amhara Educational level of Mother

16

2.7

Not educated

191

32.3

Primary cycle

340

57.5

Secondary school++

60

10.2

19

Table 1:- Socio-Demographic and Economic Characteristics of the Respondents in Sinana District, Bale Zone, Oromia region, Ethiopia 2012/13 (continued)

Variables

 

Frequency

percent

Occupation of the Mother Housewife

`

225

38.0

Farmer

326

55.1

Other job

40

6.8

Educational level of the Father Not educated

172

29.1

Primary cycle

309

52.3

Secondary school++

110

18.6

Household size Two,

122

20.6

Three

166

28.1

Four

124

21.0

Five and above Occupation of the Father

179

30.3

Farmer

528

89.3

Gov.Employee

22

3.7

Other job Family income in ETB

41

6.9

100-500

310

52.5

501-1000

177

29.9

>1000

104

17.6

Own Radio

Yes

432

73.1

No

159

26.9

Own Television

Yes

141

23.9

No

450

76.1

5.2

Maternal Health Care Utilization (antenatal care and postnatal care

utilization)

About 435(73.6%) of the mothers had ante natal care (ANC) follow up during their pregnancy and 305(51.6%) of them had post natal care follow up. Out of the 591,583 (96.8%) of the mothers ever visited health facility for any purpose with her child and from this 568(99.3%) of the children received immunization during the survey.

Table2:- Maternal health care utilization in Sinana district, Bale zone, Oromia region, Ethiopia

2012/2013

Variables

 

Frequency

percent

ANC visit Yes

Yes

435

73.6

No

156

26.4

PNC visit Yes

305

51.6

No

286

48.4

Ever visit HF for any purpose with child

572

96.8

No Child received vaccines that day

19

3.2

Yes

568

99.3

No

4

0.7

  • 5.3 Socio -demographic Characteristics of Children in Sinana district,

Bale zone

A total of 591 children of age 12-23 months were included; 239(40.4%) females and 352(59.6%) were males. Of the total, 29.6% of children already were aged 23 months; mean age of 17.97 (SD =4.2) months. From the total children who has participated in this study, the 576 (97.5%) were vaccinated at least once and 15(2.5%) never attended immunization. Among the ever vaccinated

21

338(58.7%) started at age below one month and 218(37.8%) of them were below three months and among ever vaccinated 33% had vaccination card during the survey.

Table3:- Socio demographics characteristics of Children Aged 12-23 Months in Sinana District, Bale Zone, Oromia region, Ethiopia 2012/13

Variables

 

Frequency

percent

Child’s Place of Delivery Health Facilities

190

32.1

Home Child’s Birth Order

401

67.9

First

103

17.4

Second

125

21.2

Third

132

22.3

Fourth

82

13.9

Fifth and above Ever Vaccinated

149

25.2

Yes

576

97.5

No

15

2.5

Age at child started vaccination (month) < 1

338

58.7

2-3

218

37.8

4+

20

3.5

Had vaccination Card Yes

190

33.0

No

386

67.0

22

5.4 Availability and Accessibility of Vaccination Service

The availability and accessibility of the vaccination sites were assessed by inquiring about the presence of the service and the average walking time to the health facility. About 584 (98.8%) of respondents reported that they have the access to health facility that provided immunization service and also majority of them 537(92%) reported that they had more access to health post followed by 382(76.9%) to service providing outreach site and 270(46.2%) were access to health center. For the 289(49.5%) of respondents; average walking time to nearest health facility was less than 15minutes and 285(48.8%) of respondents had walked less than an hour and 10(1.7%) walked greater than an hour. From the total, 573(97.9%) of the respondents were visited by health service extension workers and 564(96.4%) were given information on immunization by health service extension workers. 576(97.5%) of the respondents had ever attended immunization service at health facilities and the service on immunization was relatively convenient to them. Of the 576 mothers visited health facility for vaccination, 119(20.7%) turned back home without vaccinating the child at least once. From this, the 69(58.0%) were due to the unavailability of the vaccinator and in 62(52.1%) lack of vaccine.

Table4:- Availability and accessibility of the vaccination site in Sinana district, Bale zone, Oromia region, Ethiopia 2012/13

Variables

frequency

percent (%)

Presence of Health Service Yes

584

98.8

No

7

1.2

Health Center

270

46.2

Health Post Outreach site

537

92

Yes

497

85.1

No

87

14.9

Active outreach site Average walking time to Facility

382

76.9

<15minutes

289

49.5

Less than half an hour

173

29.6

B/n half an hour and an hour

112

19.2

Greater than an hour

10

1.7

Table4:- Availability and accessibility of the vaccination site in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13(continued)

Variables

frequency

percent (%)

Ever receive vaccination at Health Facility Yes

576

97.5

No

15

2.5

Service on vaccination Convenient Yes

570

98.9

No Opening time of HF

6

1.1

Yes

532

93.3

No

38

6.7

Waiting time at HF Yes

537

94.2

No

33

5.8

Distance traveled to HF Yes

557

97.7

No

13

2.3

HEW in the kebeles Yes

585

99.0

No

6

1.0

HEW visited your Home Yes

573

97.9

No Gave information on vaccination

12

2.1

Yes

564

96.4

No

21

3.6

24

5.5 Knowledge of Mothers/Caretakers on Vaccination and Vaccine Preventable Disease

Concerning knowledge of mothers on vaccination and VPD, about 573(97%) of them had ever heard about vaccination. About 548(95.6%) of the mothers had heard from Health service extension worker followed by that 526(91.8%) of them heard on radio. Health professional 502(87.6%), friend 499(87.1%) and village leader 446(77.8%) were also stay sources of vaccination information for the respondents. Majority of the respondents in this study were ever encouraged to get their children immunized. Table5:- Respondents information on vaccination and information given on immunization in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Variables

frequency

percent (%

Ever heard about vaccination Yes

573

97.0

No

18

3.0

On radio Yes

526

91.8

No On Television

47

8.2

Yes

339

59.2

No

234

40.8

From HEW Yes

548

95.6

No From health professional

25

4.4

Yes

502

87.6

No Village leader

71

12.4

Yes

446

77.8

No Friend/family member

127

22.2

Yes

499

87.1

No Ever discuss on vaccination with HW

74

12.9

Yes

446

75.5

No

145

24.5

Ever encouraged to get your child vaccinated Yes

525

88.8

No

66

11.2

Mothers knowledge on Vaccine and Vaccine Preventable Diseases. About 579(98.0%) of the respondents had replied that immunization prevent communicable diseases from their children and 494(83.6%) of the respondent knew vaccine preventable diseases. Respondents were asked for their knowledge on age at which child receives specifically BCG and measles vaccines. From these, 193(43.8%) reported at birth, 226(51.2%) at two weeks and 21(4.8%) said at six weeks for BCG vaccine. Whereas for measles, 362(77.7%) said at six months, 102(21.9%) reported at nine months and 2(0.4%) replied at age of twelve months. Out of the 518 who knew about when the child should complete the immunization, 509 (98.3%) said before one year. Mothers’ were also asked for symptoms of vaccine preventable diseases and majority of caretakers’ 460(98.1%) reported rash of measles followed by cough 452(96.4%) and paralysis in 446(95.1%). Of the 591,421(71.2%) responded correctly on knowledge question, above the mean score 4.95(±1.52 SD) and were classified with sufficient knowledge on immunization and whilst the remaining 170(28.8%) were classified as having poor knowledge.

The respondents were also asked about the number of vaccine preventable diseases they know and majority of the respondents (54.1%) knew more than six vaccine preventable diseases and 48.2% knew at least eight vaccine preventable diseases, 32.7% of respondents knew less than six vaccine preventable diseases, 0.6% of them did not know any of the diseases; and on average, each of mother/caretaker knew six vaccine preventable diseases. From the eight vaccine preventable diseases, majority of respondents 475(96.2%) knew Pertussis followed by measles 466(94.3%) and polio 457(92.5%). And the least vaccine preventable diseases the respondent knew were Meningitis 295(59.7%) and Diphtheria 293(59.3%). Table 5.1 describing knowledge of mothers on vaccination presented below.

26

Table5.1 Respondents Knowledge on vaccine and VPD in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Variables

frequency

percent (%

Does immunization

prevent CD for your child

Yes

579

98.0

No Do you know VPD diseases (N=591)

12

2.0

Yes

494

83.6

No Disease prevented by vaccination (N=494) Tuberculosis

97

16.4

Yes

440

89.1

No

54

10.9

Polio

Yes

457

92.5

No

37

7.5

Diphtheria

Yes

293

59.3

No

201

40.7

Tetanus

Yes

369

74.7

No

125

25.3

Pertussis

Yes

475

96.2

No

19

3.8

Measles

Yes

466

94.3

No

28

5.7

Hepatitis

Yes

348

70.4

No

146

29.6

Meningitis

Yes

295

59.7

No

199

40.3

Table5.1 Respondents Knowledge on vaccine and VPD in Sinana, Bale zone, Oromia, Ethiopia

2012/13(continued)

Variables

frequency

percent (%

Know when Child should receive BCG (N=440) Yes

193

43.9

No Know when Child should receive Measles vaccine (N=466)

247

56.1

Yes

102

23.8

No

364

76.2

Know when Child should complete vaccination (N=591) Yes

518

87.6

No Knew any symptoms of VPD

73

12.4

Yes

469

79.4

No Cough (Tuberculosis/Pertussis)

122

20.6

Yes

452

96.4

No Difficulty in breathing (Diphtheria)

17

3.6

Yes

309

65.9

No

160

34.1

Skin rash (measles) Yes

460

98.1

No

9

1.9

Paralysis (Poliomyelitis) Yes

446

95.1

No

23

4.9

Jaundice (hepatitis B) Yes

374

79.7

No High fever (Pertussis)

95

20.3

Yes

433

92.7

No

34

7.3

Knowledge of Mother on immunization Sufficient

421

71.2

Poor

170

28.8

5.6 Attitudes of Respondent toward Immunization

Of the 591 respondents, 587 (99.3%) answered correctly three and above from five attitude questions, were classified as having positive attitude while the remaining 4(0.7%) who answered below three attitude questions got classified as having negative attitude. 587(99.2%) mothers claimed to having the plan to immunize their children, 582(98.5%) believed that it is helpful to reinitiate if it is discontinued and 584(98.8%) would believe that immunization is beneficial for children. Table depicting about attitude of mothers toward immunization in sinana district is shown under annex5.

5.7 Immunization Coverage among 12-23 months aged Children

From the total of 591 children aged 12-23 months selected and included in this study, 576 (97.5%) of them ever took one or more of the recommended vaccines and 15 (2.5%) were unvaccinated. Only, 190 (33.0%) of mothers showed the child vaccination card during the survey. Of the 576 children ever received vaccination, 454 (76.8%) of them finished all the recommended doses and 122 (20.6%) were not complete the entire doses. Immunization coverage of children indicated in

table6

Table6:- Immunization status of children aged 12-23 months by mothers’ history and vaccination card, Sinana district, Bale zone Oromia region, Ethiopia, 2012/13

Variables

frequency

percent (%

Vaccinated (card plus history) Yes

576

97.5

No

15

2.5

Vaccination card (n=576) Yes

190

33.0

No

386

67.0

Immunization status by card plus history Fully vaccinated

454

76.8

Partially vaccinated

122

20.6

Unvaccinated

15

2.5

5.7.1 Immunization Coverage by Card only

Out of the total surveyed children aged 1223 months, vaccination card was only seen and confirmed for 190 (33.0%) children. Coverage by card only was calculated by taking children who had vaccination card as a numerator. From190 vaccinated by card only, 32.1% received OPV1 and penta1 followed by BCG (31.5%) and OPV2 (31.5%). Penta3 were taken by 30.1% and measles vaccine was taken by 25.9% and based on the made available vaccination card, only 152 (25.7%) children completed all the recommended vaccines.

5.7.2 Immunization Coverage by Card plus Mother Recall

Based on the vaccination card and the mothers’ recall, about 576(97.5%) of the children took at least a single dose of vaccine. From the total reported vaccinated, 454(76.8%) were claimed fully immunized at (95%CL: 73%-80%). Of the recommended vaccine doses, in general polio is the frequent of taken vaccine. Particularly OPV1 was reported of taken by 97.0% of the children followed by the 95.9%penta1, 93.6% took OPV2, 93.2% took pentavelent2 and 85.4% received OPV3. Measles was the least received (77.7%). Nearly 84.6% of the children took penta3 with 11.8% pentavalent dropout rate,19.5% pentavalent1 to measles dropout and 15.8% overall dropout (BCG to measles) rates. The coverage of immunization showed decrement from the initial dose of vaccine to the last doses. Figure 1 showing immunization coverage by source of information (card only, mother history and card plus history) in Sinana district is presented below.

30

120 96.9 95.9 92.2 93.6 100 93.2 85.4 84.6 77.7 80 60.7 64.8 63.8 62.1 62.1
120
96.9
95.9
92.2
93.6
100
93.2
85.4
84.6
77.7
80
60.7
64.8
63.8
62.1
62.1
55.3
card
54.5
60
51.8
History
Card + history
40
31.5
32.1
31.5
32.1
31.1
30.1
30.1
25.9
20
0
BCG
Polio1
Polio2
Polio3
Penta1
Penta2
Penta3
Measles
Percentage

Vaccines

Figure 1:- Immunization Coverage by source of information in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Factor affecting immunization completion for children

In this study, factors associated with full immunization were assessed. These factors include socio demographic characteristics of mothers and children, maternal health care utilization, health facility related, knowledge of caretaker on vaccination and vaccine preventable diseases.

Socio-demographic Characteristics of Caretakers/Mothers

Socio-demographic characteristics of mothers/caretakers were the first set of factors assessed for their association with full immunization coverage using both bivariate and multivariate analyses. Result from bivariate analysis indicate that maternal education, maternal occupation, father’s education, family income and presence of television in the house were the factors that were

31

associated to the increased completion of immunization among 12-23 months of children. Concerning education of the fathers taking not educated as the reference, children of the fathers’ who already had attended primary school were by crude odd ratio of 1.6(95%CI: 1.1, 2.5) times more likely to be fully immunized and those who attended secondary school and above level were crude odd ratio of 3.5(95%CI: 1.8, 6.8) times more likely to be vaccinated than those of uneducated. Among mothers, taking not educated as reference, children of the mothers who already had attended secondary school and above level were by crude odd ratio of 3.1(95%CI:

1.3,7.3) times more likely to complete immunization of their children than those who were not educated.

Mother’s occupation was the other factor that showed a significant association in binary association with completion of child immunization. Children whose mothers’ occupation belong to the farming were by crude odd ratio of 1.9(95%CI: 1.3, 2.9) time more likely to complete vaccination than housewives. Household average family income has also showed association in binary analyses. Household with monthly income of less than five hundred were by crude odd ratio of 0.5(95%CI: 0.2, 0.9) times less likely to complete their children’s immunization.

The presence of television in their home also showed difference in completion of child immunization. Children from the family who had television were by odd ratio of 1.6(95%CI: 1.03, 2.66) times more likely to complete their immunization than family who had no television. But, marital status, religion, ethnic group, occupation of father, family size and presence of radio in the house did not show an association on completion of child immunization.

After adjusting for the other variables, only occupation of mother, educational level of father and family income stayed with association in multivariate association. Concerning occupation, taking housewives as reference, children whose mothers belong to farming were by adjusted odd ratio of 1.9 (95%CI: 1.1, 3.1) times more likely to be fully vaccinated.

Education of the fathers of children also showed association in multivariate, children whose fathers already had attended primary and secondary school were by adjusted odd ratio of 1.8(95%CI: 1.02, 3.11) and 3.1(95%CI: 1.3, 7.4) times more likely to be fully vaccinated than whose father attended no educational level. Concerning average monthly income of the family, children from the household with monthly income greater than one thousand Ethiopian birr were

32

by adjusted odd ratio of 3.2(95%CI:1.4, 7.4) times more likely to complete their vaccination than children from the household with average monthly income of less than five hundred.

Table7: - Completion of immunization among children aged 12-23 months by socio demographic characteristics of mothers /caretakers and fathers in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Variable

Fully Vaccinated No/%

Odd Ratio (95% CI)

 

Yes

No

Crude

Adjusted

Residence Rural

368 (62.3)

110 (18.6)

1

Urban

86 (14.5)

27 (4.6)

0.9 (0.6, 1.5)

NI

Age of the mother/caretaker < 20

52 (8.8)

21 (3.6)

1

21-30

275 (46.5)

87 (14.7)

1.3 (0.7, 2.2)

NI

31-40

113(19.1)

28(4.7)

1.6 (0.9, 3.1)

NI

>40

14 (2.4)

1 (0.2)

5.7 (0.7, 45.7)

NI

Marital status Married

428 (72.4)

135 (22.8)

1

Others

26 (4.4)

2 (0.3)

4.1 (0.9, 17.5)

NI

Religion Orthodox

245 (41.5)

68 (11.5)

1

Muslim

198 (33.5)

67 (11.3)

0.8 (0.6, 1.2)

Others Ethnic group

11 (1.9)

2 (0.3)

1.5 (0.3, 7.1)

NI

Oromo

440 (74.5)

135(22.8)

1

Amhara

14 (2.4)

2 (0.3)

2.1 (0.5, 9.6)

NI

Educational level of mother Not educated

135 (22.8)

56 (9.5)

1

Primary cycle

266 (45.1)

74 (12.5)

1.5 (0.9, 2.2)

0.8 (0.5, 1.4)

Secondary school++ Occupation of the mother

53 (8.9)

7 (1.2)

3.1 (1.4, 7.3)

2 (0.6, 7.3)

Housewife

156 (26.4)

69 (11.6)

1

Farmer

266 (45.0)

60 (10.2)

1.9 (1.3, 2.9)

1.9 (1.1, 3.1)*

other job

32 (5.4)

8 (1.4)

1.8 (0.8, 4.0)

0.6 (0.2, 1.8)

Table7: - completion of immunization among children aged 12-23 months by socio demographic characteristics of mothers /caretakers and fathers in Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13(continued)

Variable

Fully Vaccinated No/%

Odd Ratio (95% CI)

 

Yes

No

Crude

Adjusted

Educational level of the father Not educated

117 (19.8)

55 (9.3)

1

Primary cycle

240 (4.6)

69 (11.7)

1.6 (1.1, 2.5)

1.8 (1.02, 3.1)*

Secondary school++ Family size

97 (16.4)

13 (2.2)

3.5 (1.8, 6.8)

3.1 (1.3, 7.4)*

Two,

99 (16.7)

23 (3.9)

1

NI

Three

124 (20.9)

42 (7.1)

0.7 (0.4, 1.2)

NI

Four

89 (15.1)

35 (5.9)

0.6 (0.3, 1.1)

NI

Five and above Occupation of the father

142 (24.1)

37 (6.3)

0.9 (0.5, 1.6)

NI

Farmer

401 (67.8)

127 (21.5)

1

Gov.Employee

21 (3.6)

1 (0.2)

6.6 (0.9, 49.9)

NI

Other job Family income in ETB

32 (5.4)

9 (1.5)

1.1 (0.5, 2.4)

NI

100-500

237 (40.1)

89 (15.1)

1

501-1000

142 (24)

35 (5.9)

1.5(0.9, 2.4)

1.2 (0.7, 2.1)

>1000

75(12.7)

13(2.2)

2.2 (1.2, 4.1)*

3.2 (1.4, 7.4)*

Own Radio

Yes

338 (57.2)

94 (15.9)

1.3 (0.9, 2.0)

NI

No

116 (19.6)

43 (7.3)

1

Own Television

Yes

117 (19.8)

24 (4.1)

1.6 (1.03, 2.7)*

1.7 (0.9, 3.0)

No

337 (57)

113 (19.1)

1

N.B: numbers in brackets are in percentage, NI- Variable not included in the model *Significant at P-value of <0.05

34

Maternal Health Care Utilization

Antenatal care follow up, post natal care follow up, whether mothers/caretakers ever visited health institution and visited health facility specifically for immunization were assessed in bivariate analysis all assessed factors showed association with completion of child immunization. Mothers who had followed ANC check up during their pregnancy for the index child were by crude odd ratio of 3.0(95%CI: 2.0, 4.5) times more likely to complete vaccination for their children than who had no ANC follow up. In the same way, those who had post natal care follow up were by crude odd ratio of 1.8(95%CI: 1.2, 2.7) times more likely to complete the immunization of their children than who had no postnatal care follow up. The other factor showed association in binary analyses was health facility service utilization which was by crude odd ratio of 32(95%CI: 7.3, 140.5) times more likely to complete immunization for their children than those who did not utilize health service at health facility.

After adjusting for the other variables only ANC utilization retained the independent association in multivariate logistic regression and mother who utilized ANC during pregnancy of the index child were by adjusted odd ratio of 3.7(95%CI: 2.3,5.9) times more likely to fully immunize their

children than mothers’ who had no ANC follow up when they were pregnant.

This finding is supported by the focus group discussion with mothers. All discussants believed that visiting health facility during pregnancy and after delivery are crucial times for mothers and their children. The reason raised were, if mother went to the health facility during pregnancy and post delivery; the professionals would give advice on the progress of pregnancy, well being of baby, place of delivery and what to do after giving birth. Mothers could be advised on child

immunization and how to feed the new born. … 20 years old rural women said that, when a mother took her child to health facility, (to the health professionals) it is a good opportunity for

giving advice on the initiation time of vaccine, when it should get completed and the importance of

completing immunization for child. So, having ANC follow up is necessary for all mothers…”

Table8-showing completion of child immunization by maternal health care utilization is presented below

35

Table8:- completion of immunization among children aged 12-23monts by maternal health care utilization, Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Variable

fully vaccinated

odd ratio (95% CI)

ANC visit

Yes

No

crude

adjusted

Yes

359 (60.7)

76 (12.9)

3.0 (2.0, 4.6)

3.7 (2.3, 5.9)*

No PNC visit

95 (16.1)

61 (10.3)

1

Yes

250(42.3)

55(9.3)

1.8 (1.2, 2.7)

1.0 (0.6, 1.8)

No Visit health facility for any purpose

204 (34.5)

82 (13.9)

1

Yes

452 (76.5)

120 (20.3)

32 (7.3, 140.5)

NI

No Child receive vaccine that day

2 (0.3)

17 (2.9)

1

Yes

450 (78.4)

120 (20.9)

3.8 (0.5, 26.9)

1.8 (0.1, 21.7)

No

2 (0.3)

2 (0.3)

1

N.B: numbers in brackets are in percentage, NI- Variable not included in the model *Significant at P-value of <0.05

36

Availability and Accessibility of Vaccination Service

The association of health care availability and accessibility with the completion of vaccination also was seen by using bivariate and multivariate analysis.

Children of household walked less than an hour were by crude odd ratio of 2.4(95%CI: 1.3,4.2) times more likely to complete their immunization than their age group walked more than an hour. On other hand, mothers of the children who ever received immunization service at health facility were by crude odd ratio of 14.0(95%CI: 4.0, 51.9) times more likely to complete the vaccination of their children than mother who did not ever received immunization service for their children. Mothers of children who found immunization service at the health facility convenient were by crude odd ratio of 6.1(95%CI: 1.4, 25.9) times more likely to complete the vaccination of their children than mothers who did not found service was convenient. Describing about the journey of mothers to the immunization site, those who found the distance travelled convenient were by crude odd ratio of 3.3(95%CI: 1.1, 9.9) times more likely to complete vaccination of their children than the mothers who had not found it convenient. Concerning an average waiting time to get immunization at health facility, mothers who stay for more than three hours were by crude odd ratio of 0.3(95%CI: 0.1, 0.9) times less likely to fully vaccinate their children than those mothers who stay for less than an hour. Mothers/caretakers who ever received information from the health service extension worker were by crude odd ratio of 2.6(95%CI: 1.1, 6.3) times more likely to complete the immunization of their children than mothers who ever not got information. In contrast to this, the presence of health institution and health service extension worker in the kebeles and those household visited by the health service extension worker did not show association for completion of child immunization. Despite bivariate level association, only average walking time to the health facility showed association in multivariate analysis, and household who had walked less than an hour were by adjusted odd ratio of 3.1(95%CI:1.5,6.3) times more likely to fully vaccinate their children when compared to those households required walking less than 15 minutes. On other hand, those who walked for greater than an hour were by adjusted odd ratio of 0.8 (95%CI: 0.2, 2.9) less likely to complete the immunization of their children than mothers who walk for less than 15 minutes. But, this is not statically significant.

37

Table9:- Completion of Child immunization among 12-23months by availability and accessibility of Health Care Service, Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13

Variable

Fully vaccinated

Odd Ratio (95% CI)

Health facility present

Yes

No

Crude

Adjusted

Yes

448 (75.8)

136 (23)

0.6 (0.1, 4.6)

NI

No Average walking time

6 (1)

1 (0.2)

1

<15 minutes

210 (35.5)

79 (13.4)

1

Less than half an hour

136 (23)

37 (6.3)

1.4 (0.9, 2.2)

1.6 (0.9, 2.6)

B/n half an hour and an hour 100 (16.9)

16 (2.7)

2.4 (1.3, 4.2)*

3.1(1.5, 6.3)*

Greater than an hour Service convenient

Waiting time at facility

8(1.4)

5(0.8)

0.6 (0.2, 1.9)

0.8 (0.2, 2.9)

Yes

448 (77.5)

122 (21.1)

6.0 (1.4, 25.9)*

NI

No Distance traveled

3 (0.5)

5 (0.9)

1

Yes

441 (77.4)

116 (20.4)

3.3 (1.1, 9.9)*

2.5 (0.8, 8.7)

No

7(1.2)

6(1.1)

1

Yes

420 (73.7)

117 (20.5)

0.6 (0.2, 1.7)

1.7 (0.6, 4.6)

No Ever attain for immunization

28 (4.9)

5 (0.9)

1

Yes

451 (76.3)

125 (21.2)

14 (4.0, 51.9)

NI

No Turned home without vaccine

3 (0.5)

12 (0.2)

1

Yes

91(15.4)

28(4.7)

0.9(0.6, 1.6)

0.8 (0.5, 1.3)

No Presence of HEW in kebeles

363(61.4)

109(18.5)

1

Yes

449(76)

136(23)

0.7(0.1, 5.7)

NI

No HEW given information

5(.8)

1(.2)

1

Yes

437(74.7)

127(21.7)

2.6(1.1, 6.3)*

0.5(0.2, 1.6)

No

12(2.1)

9(1.5)

1

N.B: numbers in brackets are in percentage, NI- Variable not included in the model *Significant at P-value of <0.05

38

Knowledge and attitudes of mother on vaccination and vaccine preventable diseases

Associations of mothers’ knowledge and attitude about vaccination and VPD with the completion of the Child immunization were third factors assessed. And the result of bivariate showed that Children of the mothers who ever heard about immunization were by crude odd ratio of 3.4(95%CI: 1.4, 8.9) times more likely to complete their vaccine dose than who did not hear about vaccination. In line to this, those mothers who ever heard about immunization on television and from family/friend were by crude odd ratio 1.8(95%CI:1.2, 2.6) and 2.8(95%CI:1.8, 4.7) times more likely to complete the immunization of their children than mothers who did not hear from both sources respectively. In addition to this, Children of the mothers who had ever discussed about immunization with Health service extension worker were by crude odd ratio of 3.9(95%CI:

2.7, 5.8) times more likely to complete the vaccination than their peer who had ever not discussed about immunization with health service extension worker.

How mothers or caretakers could know the schedule of immunization for child was another factor that showed association in binary analysis. Accordingly, mothers who knew the schedule of immunization from family/friend, from immunization card and from health extension worker were by crude odd ratio 1.7(95%CI: 1.1, 2.6), 3.1(95%CI: 1.4, 6.6) and 2.2(95%CI: 1.2, 3.9) times more likely to complete the immunization of their children than who had not informed from those sources respectively. And mothers ever encouraged by health worker/family/village leader were by crude odd ratio of 4.4(95%CI: 2.6, 7.4) times more likely to finish the vaccine of child than who had not ever been encouraged. Mothers who were classified as having sufficient knowledge on vaccine and vaccine preventable diseases were by crude odd ratio of 2.2(95%CI: 1.5, 3.4) times more likely in completion of immunization of their child than those who were classified as having poor knowledge. In contrast to this, attitude of mothers toward immunization did not show association in binary analyses. After adjusting for the other variables, only two variables retained the association in multivariate logistic regression; children whose mothers had sufficient knowledge on vaccine and vaccine preventable diseases were by adjusted odd ratio of 2.5(95%CI:1.5, 4.2) times more likely to be fully vaccinated than children of mothers who had poor knowledge on vaccine and VPD. And mothers who ever had discussed on vaccination with health service extension worker were by adjusted odd

39

ratio of 2.4(95%CI: 1.3, 4.2) times more likely to complete the immunization of their children than mothers who had not discussed on immunization with health service extension worker. Finding of the FGD also indicate, majority of mothers claimed that they remember immunization day during announcement for vaccination. As discussants indicated announcement at outreach site for vaccination of children is held each month on holiday/Sunday. So, this is convenient for mothers to vaccinate their children. Uneducated mother from rural said that, I use outreach service to vaccinate my children. I remember the date from the announcement and since, the outreach site is not far-off, I am vaccinating my children. Some times for other problem I took to health center but for vaccination, I use outreach site.”

Table10:- Completion of immunization among children aged 12-23 months by mother knowledge on vaccine and VPD in Sinana district Bale zone, Oromia region, Ethiopia, 2012/13

Variable

fully vaccinated

odd ratio (95% CI)

Ever heard about vaccination

Yes

No

Crude

Adjusted

Yes

445 (75.3)

128 (21.7)

3.4 (1.4, 8.9)*

NI

No On radio

9 (1.5)

9 (1.5)

1

Yes

407 (71)

119 (20.8)

0.8 (0.4, 1.7)

NI

No On television

38 (6.6)

9 (1.6)

1

Yes

277 (48.3)

62 (10.8)

1.8 (1.2, 2.6)*

0.7 (0.4, 1.2)

No From Health extension worker

168 (29.3)

66 (11.5)

1

Yes

428 (74.7)

120 (20.9)

1.7 (0.7, 3.9)

NI

No Health professional

17 (3)

8 (1.4)

1

Yes

392 (68.4)

110 (19.2)

1.2 (0.7, 2.2)

NI

No From village leader

53 (9.2)

18 (3.2)

1

Yes

353 (61.6)

93 (16.2)

1.4 (0.9, 2.3)

NI

No

92 (16.1)

35 (6.1)

1

Table10:- completion of immunization among children aged 12-23 months by mother knowledge on vaccine and VPD in Sinana district, Bale zone, Oromia region Ethiopia, 2012/13(continued)

Variable

fully vaccinated

odd ratio (95% CI)

From friend/family

Yes

No

Crude

Adjusted

Yes

401 (70)

98 (17.1)

2.8 (1.7, 4.7)*

0.7 (0.3, 1.8)

No Ever discuss on immunization

44 (7.7)

30 (5.2)

1

Yes

372 (62.9)

74 (12.5)

3.9 (2.6, 5.8)*

2.4 (1.3, 4.2)*

No Know schedule of vaccine from Family/friend

82(13.9)

63(10.7)

1

Yes

370 (62.6)

99 (16.8)

1.7 (1.1, 2.6)*

1.3 (0.5, 3.2)

No Immunization card

84 (14.2)

38 (6.4)

1

Yes

439 (74.3)

124 (20.9)

3.1 (1.4, 6.6)* 0.8 (0.2, 2.8)

No Health extension worker

15 (2.5)

13 (2.2)

1

Yes

421 (71.2)

117 (19.8)

2.2 (1.2, 3.9)* 1.1 (0.3, 4.0)

No Encouraged to immunize last year

33 (5.6)

20 (3.4)

1

Yes

422 (71.4)

103 (17.4)

4.4 (2.6, 7.4)* 4.9 (1.0, 21.3)*

No Attitude of mothers/caretakers toward vaccination

32 (5.4)

34 (5.8)

1

Negative attitude

3 (0.5)

1 (0.2)

1

Positive attitude

451 (76.3)

136 (23)

1.11 (0.1, 10.7)

NI

Knowledge of mothers/caretakers on vaccination Poor knowledge

112 (18.9)

58 (9.8)

1

Sufficient knowledge

342 (57.9)

79 (13.4)

2.2 (1.5, 3.4)

2.5(1.5, 4.2)*

Child Characteristics

The associations of the child characteristics like sex, place of delivery and birth order with completion of child immunization were the other variables assessed by this study. From these variables, only child birth order showed significant association with completion of immunization. Child birth order of the third and fourth were by crude odd ratio of 50 %( 95%CI: 0.3, 0.9) and 50 %(95%CI: 0.2, 0.9) less likely to be fully vaccinated than those who were born to the first birth order. Fifth birth order had not showed association in bivariate logistic regression. Sex of child and place of delivery also had not shown association with completion of immunization. Multivariate logistic regression analysis also showed that child birth order being significantly associated with immunization completion and third birth order were 30% (95%CI: 0.2, 0.4) less likely to be fully vaccinated than first birth order.

Table11:- immunization completion among children aged between 12-23 months by characteristics of child in Sinana district, Bale zone, Oromia, Ethiopia, 2012/13

Variable

fully vaccinated

 

Odd Ratio (95% CI)

 

Yes

No

Crude

Adjusted

Sex child Female

275 (46.5)

77 (13.0)

1

Male

179 (30.3)

60 (10.2)

1.2 (0.8, 1.8)

NI

Child place of delivery Home

307 (51.9)

94 (15.9)

1

Health facility

147 (24.9)

43 (7.3)

1.1 (0.7, 1.6)

NI

Child birth order First

86 (14.6)

17 (2.9)

1

Second

98 (16.6)

27 (4.6)

0.7 (0.4, 1.4)

1.6 (0.7, 3.6)

Third

95 (16.1)

37 (6.3)

0.5 (0.3, 0.9)*

0.3 (0.2, 0.4)*

Fourth

57 (9.6)

25 (4.2)

0.5 (0.2, 0.9)*

0.7 (0.4, 1.4)

Fifth

118 (19.9)

31 (5.2)

0.8 (0.4, 1.5)

0.6 (0.3, 1.2)

Table12 multivariate analysis for completion of child immunization (fully immunized) in Sinana district and selected variables, Bale zone, Oromia region, Ethiopia June 2013

Variable

fully vaccinated

 

Odd Ratio (95% CI)

 

Yes

No

Crude

Adjusted

Occupation of mother

Housewife

156

69

1

Farmer

266

60

1.9(1.3, 2.9)

1.7(1.01, 2.8)*

Others

32

8

1.8(0.8, 4.0)

0.6(0.2, 1.9)

Education level of father

Uneducated

117

55

1

Primary cycle

240

69

1.6(1.1, 2.5)

1.6(0.9, 2.6)

Secondary & above

97

13

3.5(1.8, 6.8)

2.8(1.3, 6.2)*

Family income

100-5000

237

89

1

501-1000

142

35

1.5(0.9, 2.4)

1.2(0.7, 2.0)

>1000

75

13

2.2(1.2, 4.1)

3.0(1.3, 6.9)*

Visit ANC

Yes

359

76

3.0(2.0, 4.6)

3.8(2.4, 6.4)*

No

95

61

1

Average waking time

<15 minutes

210

79

1

Less than half an hour

136

37

1.4(0.9, 2.2)

1.5(0.9, 2.5)

B/n half an hour and an hour 100

16

2.4(1.3, 4.2)

3.0(1.5, 6.1)*

Greater than an hour

8

5

0.6(0.2, 1.9)

0.7(0.2, 2.6)

Ever discuss on immunization

Yes

372

74

3.9(2.6, 5.8)

2.1(1.2, 3.9)*

No

82

63

1

Knowledge of mother on immunization

 

Poor knowledge

112

58

1

Sufficient knowledge

342

79

2.2(1.5, 3.4)

2.3(1.3, 3.9)*

Child birth order

First

86 (14.6)

17 (2.9)

1

Second

98 (16.6)

27 (4.6)

0.7 (0.4, 1.4)

0.5 (0.2, 1.2)

Third

95 (16.1)

37 (6.3)

0.5 (0.3, 0.9)*

0.5 (0.2, 1.1)

Fourth

57 (9.6)

25 (4.2)

0.5 (0.2, 0.9)*

0.4 (0.2, 0.9)*

Fifth

118 (19.9)

31 (5.2)

0.8 (0.4, 1.5)

0.7 (0.3, 1.5)

N.B: numbers in brackets are in percentage, *Significant at P-value of <0.05

43

Reasons for not being vaccinated among partially/unvaccinated Children For the mothers or caretakers who had not vaccinated or partially vaccinated their children, the reason they did not vaccinate their children were asked. From the mothers/caretakers not immunized or not completed immunization for their children 85(62.0%) responded due to lack of awareness of need to return for second and third doses of vaccine. Of the 137, 83(60.6%) failed to immunize their children due to lack of awareness of need for immunization. 47.4% of respondents said place or time of immunization is not known and 14.6% of the mothers said that place of immunization is too far. On the other hand, fear of adverse reaction (55.5%), wrong ideas about contraindications (48.2%), lack of faith on immunization (38.7%) and no confirmed information on immunization were reasons for not immunizing the child. Out of the 119(20.1%), of mothers returned to home without vaccinating their children, 69(58.0%) were returned to home due to unavailability of vaccinator at health facility and 62(52.1%) failed to vaccinate their children because of lack of vaccine in facility . In relation to this, focus group discussion indicated; lack of awareness, fear of side effect, less attention mothers give to child immunization and males’ less involvement in child immunization. “One of my friend has many children but none of them were vaccinated, because her husband could not allow her to go for child immunization,” said by educated urban mother. Other ideas raised were fear of adverse reaction which discourages mothers to return again for vaccination. 25 years old rural women said, “Children develop fever for the first three days after vaccination which is very difficult situation till they recovered and I fear not to lose my child due to fever developed as result of vaccination. So, I never go again to vaccinate my child because I have seen the episode…,”

Health workers also indicated that, attitude of the mothers toward immunization; lack of faith on immunization is among reasons that cause immunization of Sinana district low. And other issues they had raised, the mothers did not fully believed in benefit of vaccination rather they consider as the vaccine cause fever. 34 years old female said that, “mothers’ lack of awareness on benefit of vaccine, lead them to believe that vaccine cause diseases and sometimes child develop high fever after vaccination and then mothers never return to the subsequent doses.”

On the other hand, health workers agree that information they are delivering is not need based and does not address whole community. And most of the time health education is given in mass which could not distinguish level of understanding and their educational background. So, this could not

44

motivate mothers for return. “…On providing quality and good health education, we do have problem, information we are providing is less understandable by mothers. So, I cannot say

information we are providing has quality. And it does not address whole community, yet information we had provided, did not bring desired behavioral change…,said by 32 years old male health professional. Reason given by mothers for not completing immunization of children is presented under annex 5

58% 69 Turned home without vaccinating child Vaccine not available 119 Vaccinator were absent 52.10% 62
58%
69
Turned home without
vaccinating child
Vaccine not available
119
Vaccinator were
absent
52.10%
62
20.10%

Figure2: - Reason given by mother why turned home without receiving immunization during appointment for child immunization in Sinana district Bale zone, Oromia region, Ethiopia 2013

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DISCUSSION

Immunization is one of the most successful and cost-effective public health interventions and delivering immunization also offers an opportunity to deliver other preventive service, like vitamin A supplements and deworming. But, parents still do not view immunization as a right, and demand for immunization service is lacking in many communities. ANC follow up, educational level of fathers, occupation of mothers and family income were some of the factors significantly associated with immunization coverage in this study. Despite the improvement, immunization is unfinished agenda. So that, this study tried to assess the full immunization coverage and factors associated with it among 12 to 23 months old children residing in six kebeles of Sinana district.

OPV vaccine coverage was slightly higher than the coverage of the pentavalent vaccine which is given in line with EPI schedule of Ethiopia. This is probably due to the OPV vaccine is given frequently as national campaign in the country. On the other hand, pentavelent3 vaccine coverage was a bit higher than measles vaccine coverage which could be as a result of time gap between two vaccines in which mothers may forget the measles vaccine and dropout from the consequent doses. Across all vaccine doses, from first to consequent doses, there is decrement of coverage which could be due to mothers’ incompliance and time gap between each dose leading mothers to forget the subsequent doses. So, the dropout rate of pentavalent1 to pentavelent3 was 11.8%, pentavelent1 to measles 19.5% and overall BCG to measles dropout was 15.8%. Which is higher than the international goal of <10% set by WHO. But, this finding is less than the study done in Oromia region in which pentavelent1 to pentavalent3 dropout rate was 33 %( 36).

When we compare coverage of Sinana district with that of Kafa, it showed that11.2% increment (37). This could be due to time gap between two studies and awareness of mother on immunization could be changed over time and accessibility to service could be other reason for this difference. Similarly, when we compare immunization coverage of Sinana district with EDHS 2011, the percent of fully vaccinated is higher and proportion of children not vaccinated were decreased by 12.5%. This is likely due to EDHS include data from area of low immunization coverage and time of the survey could also another reason for discrepancy. But Coverage of pentavelent3, measles and fully immunized in Sinana district is lower than the immunization coverage reported in 2011 national and Oromia region health and health related indicators (8,11). The percentage of fully vaccinated was also lower than the district health office report of 2011,

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fully immunized 85 % from woreda versus76.8% of this study. This is probably due to methods used, sample size selection, area covered, over reporting and type of data sources used (27).

Among interviewed mothers, only for 190(33%) of the children immunization card was confirmed. Most of the children took OPV1, followed by Pentavelent1. But, measlesvaccine was the least received vaccine and 76.8%(95%CL:73%,80%) of children finished the recommended doses of immunization. About 97% of mothers had heard about immunization and vaccine preventable diseases. Majority of mothers heard on radio (91.8%), which indicates that mothers had access to population media. Kebeles in which village leaders participated in EPI program by giving information to habitants, motivating mothers and community on health service, also showed improvement in immunizing their children. Which could be the influence of village leaders in community; this in turn indicates the importance of political commitment to improve immunization status of children. About, 83.6% of mothers knew vaccine preventable diseases. And from this, more than half of the respondents knew at least more than six vaccine preventable diseases which are higher than study carried out in Ambo district in which majority of mothers knew more than three vaccine preventable diseases (39).

This study also tried to assess factors affecting immunization status of the children by classifying the status of children into two categories: fully vaccinated and not fully vaccinated. Factor affecting full vaccination status of children were identified by bivariate and multivariate analysis using binary logistic regression.

Based on bivariate analysis, socio demographic characteristic of respondents like educational background of mothers and fathers, mothers’ occupation, family income and presence of television in house were significantly associated to immunization completion of children. Accordingly, mother education is among determinants of immunization completion and those mothers who attended secondary and above education were two times more likely to complete the immunization of their children than mothers with no education. And fathers who attended secondary and above level is four times higher than the once who have no educational background. This is may be as educational status of family gets improved, health seeking behavior of family may perhaps increase. This in turn may have positive impact on child immunization. But, mothers who attended primary education level were not differently associated to immunization completion of children than mothers who did not attend any formal education. Which could be due to primary education

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level may not bring health seeking behavior. Other studies also indicated that mother attended primary education did not bring impact on immunization completion. This result is consistent with that of Istanbul and EDHS 11 as well (8, 21).

Occupation of mothers was other factor that had showed association for completion of child immunization among mothers included in this study. And mothers from farming group were twice more likely to complete the immunization of the child than housewives. The result of other study support this finding , this is probably due to income generation and house hold decision making ability related to occupation ,government promotion for farmer and acknowledgement given to farmer group may influence the income of household(38).

Other factor showed association with child immunization completion were father educational level, children from fathers who attended primary cycle were two times more likely to be fully vaccinated and those from father attended secondary and above were three times more likely to be fully immunized than children from whose father had not attended any formal education. This is similar with finding from EDHS2011, Istanbul, Northern Nigeria, Burkina Faso (8, 21, 24, 26). Father’s educational level is factor that determines vaccine completion. Which could be related to knowledge of the father on vaccine and vaccine preventable diseases. This could give better position for the fathers to immunize their children and health seeking behaviors. In addition to this, it could be designated to the house hold decision making power of fathers. Also, education of the male is higher than the female’s in context of Ethiopia, which may in turn, has positive influence in completion of child immunization.

Average monthly income of Household is the other factor determines immunization completion, household income more than 1000 ETB were three times more likely to complete the immunization of their children than household whose income is less than 500 ETB. This is consistent with study from different area like EDHS2011, Nigeria, Nouna (24, 26, 33), study in south Ethiopia Wonago district revealed that income of family related to health seeking behavior, affording service and transportation service (35).

Other factors showed association with child immunization completion was presence of television, household who have television were nearly two times more likely to complete immunization of their children, this could be, related to information that family got from television. This could be

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more clear and understandable. Advertisement on television is more attractive and contains practice or role model influencing the family to seek immunization for their children. Study in Oromia region in 2004 revealed that presence of radio was factor to complete the immunization of child (36). Age of mother, religion, place of residence, marital status and ethnicity of mother have no association with immunization completion. But evidence from India showed as these factors have association (32)

ANC and postnatal care use of mother also showed a significant association with the child immunization status in bivariate analysis. Mother who had ANC follow up was three times more likely to complete the immunization of child and also mother who had follow postnatal care was two times more likely to complete vaccination of child. This is consistent with study done in Bangladesh, EDHS2011, Mali2009, and North Nigeria. Mothers who had ANC follow up could be informed on importance, schedule and side effect of vaccine and they could be encouraged to complete immunization of child (8, 25, 33).

Mothers who found service on immunization was convenient at health facility were six times more likely to complete vaccination of their children than mother who said it is inconvenient. Also mother who ever heard about immunization and those who received information from health service extension workers were more likely to complete the immunization of their children. This could be related to awareness of mother on immunization and satisfaction on service given. So, mothers could get motivation to complete the vaccination of children. Also mothers who ever discuss about immunization with health service extension worker have high probability to complete the immunization for the children. This finding is consistent with other study in which mothers default from immunization if vaccination time is inconvenient (33, 39).

Child birth order is another factor associated to vaccine completion, child born to the third and above birth order was less likely to be fully vaccinated. This may be large family size compute for resource and mother may lack time to take child to health facility and also could be related to mother’s ANC utilization for first birth order which may increase awareness of mother to immunize child. This is consistent with EDHS11 and study from Brazil (23). But sex of child and place of delivery have not showed association with vaccine completion among 12-23 months old children. Which may indicate no sex discrimination to complete the immunization among male and female .In addition to this, giving birth in health institution does not necessarily mean that

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mothers would come back for subsequent doses. But, study from other places indicated that these factors have a significant association with child immunization status (8, 31, 39). However, this study is consistent with survey in Mozambique in which gender has no difference in completing vaccination (43).

Variables that showed significant association by bivariate analysis were included in multivariate logistic regression analysis for further analysis. From variable included in final model ,occupation of mother, educational level of father, average monthly income, ANC use, average walking time, ever discuss on immunization, knowledge of mother on vaccine and vaccine preventable diseases and birth order of child were those factors found to be associated with child immunization.

Mothers whose occupation is farmer were 1.7 times more likely to complete the immunization of child than housewives; the proportion of not fully vaccinated children are higher among housewives. This could indicate that mothers involved in farming activities are more exposed to information and income of these group is also higher. This is similar with study in Jimma town, south west Ethiopia (38). But education of mother was not significantly associated with child immunization completion after adjusting for other variables. This is similar with case control study done in Wonago district, south Ethiopia in which only average monthly income showed a significant association with defaulting from completing immunization (35) but EDHS11 showed that mother education showed association with child immunization.

Fathers’ education was other factor significantly associated with immunization status of children among 12 to23 month old in multivariate analysis. Children whose father attended secondary and above level were 2.8 times more likely to complete recommended doses of vaccination. This could be duet to household decision making power of father and awareness of father on vaccine and vaccine preventable diseases might make fathers at good position to vaccinate their children. As educational status of father increased, health seeking behavior could be increased and lead to vaccinate their children.

Family income is other factor included in multivariate; children from household whose average monthly income is greater than 1000 ETB were three times more likely to be fully vaccinated than whose income is low. This is probably related to good consumption of family; those families with high income were able to afford service. If income of family is high, they will have access to

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social media, probably exposed to information through different media. This finding is consistent with study done in different areas (8, 26, 35).

Maternal health care utilization was associated with child immunization completion among 12 to 23 months; children whose mothers had ANC follow up were more likely to be fully vaccinated than who did not attend ANC. This finding is consistent with that of India, Ambo District, Mali (at Kita circle, Nigeria (25, 31, 33, 39). This could be due to mothers health seeking behavior and mothers may discuss with health professional on vaccine and vaccine preventable diseases, on importance of immunization, time of vaccine initiation, when it could get completed and possible side effect associated to vaccine. So, it may create good opportunity for mother to vaccinate their children. This could also motivate mothers to use health facility service. Secondary school attended 30 years old urban mother indicated that, since vaccination is very important and has benefit for children, health professionals have to teach both mothers and fathers on benefit of vaccine including side reaction of vaccine, where to go if fever developed and mothers also need to keep the card given by health professionals properly. Attending ANC and giving birth at

institution can help to increases child immunization….”

Average walking time is other factor showed association with completion of child immunization; children whose mothers walked half an hour to an hour were more likely to complete the immunization of their children than mother waking less than 15 minutes. This finding is inconsistent with that of Philippines in which, as distance from health facility get more than 0.5km the immunization coverage decreased. In addition to this, study from Mozambique showed that distance from health facility hinders immunization of children (40, 43). But, the finding of this study could be the presence of health service extension workers in community and outreach service which held on holiday and supported by community mobilization to immunization monthly. So, this could help mothers easily remember immunization day and could be related to outreach service held monthly and supported by announcement to vaccinate children. Moreover, encouragements had done through kebeles leaders and usually outreach service given on Sunday and holiday for those living away from facility. It is also supported by qualitative part, uneducated mother from rural said that, I am using outreach service to vaccinate my child by remembering from announcement and since distance of this outreach is not far-off; I am vaccinating my child

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some times when my child gets sick. I took to health post or health center but for vaccination I am vaccinating at outreach site.”

Concerning knowledge of mothers on vaccine and vaccine preventable diseases; children whose mothers classified as having sufficient knowledge on immunization were twice more likely to be fully vaccinated than whose mother has poor knowledge. this study is consistent with study done in Oromia region Ambo district, and Nouna district, Burkina Faso, Nigeria district, case control study in Wonago district south Ethiopia(23,26, 38,46),as knowledge of mother improved on immunization they could developed positive attitude ;then motivated to complete the immunization. …literate 32 years old women said that, Vaccinated child cannot get diseases

(vaccine preventable diseases) and even pregnant women cannot visage great risk if get vaccinated, they give health baby and never loss their child by death if get their child being

vaccinated ” ...

Child birth order is associated to child immunization completion; and child born to the third and above birth order is 40% less likely to be fully vaccinated than first birth order. That means high proportion of children were found to be fully vaccinated among first birth order which is consistent to EDHS 2011finding in which child birth order related to vaccine completion (8). This could be child born to first birth order may get special focus since it has no resource competition and mothers may follow ANC for first child which may be related to health care utilization indeed.

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STRENGTH AND LIMITATION OF THE STUDY

Strengths

Children age 12 to 23 months were included which may measure recent immunization program performance and immunization completion.

Information was triangulated by both methods

Limitation

Immunization coverage by report of mother may under/over report the immunization coverage because mothers may not remember doses that child took due to recall bias.

Being cross sectional study does not show the cause effect relationship.

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CONCLUSIONS AND RECOMMENDATIONS

Conclusion

About 76.8%(95%CL:73%,80%) of children were fully vaccinated. About 97% of mothers heard about immunization and 95.6% of the mothers heard from health extension workers. 98% of the mothers knew as immunization prevents communicable diseases and 71.2% of the mothers have sufficient knowledge on immunization. Among mothers participated in this study, 99.3% of them have positive attitude. From the total children included in the study, only 33% of them have immunization card. Occupation of mothers/caretakers, household family income, educational level of father, sufficient knowledge, ever discuss about immunization, ANC follow up and average walking time were statistically significant predictors of fully immunization of children.

Being unaware of need for immunization, unaware of need to return for second or third dose, unknown Place and/or time of immunization, fear of side effect, wrong ideas about contraindications, absence of faith in immunization, inconvenient time of immunization absence of vaccinator and vaccine and long waiting time at health facility were reasons for not fully immunizing their children.

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Recommendations

To the health workers

  • Health workers should be always at health facility so that mothers/caretakers are able to fully immunize their child.

  • Need based health education on benefits of vaccine, age of initiation and VPD should be given to mothers and fathers in order to encourage them for immunization.

  • Eligible children that visit health facility for any purpose should be sent to IMNCI and screened for immunization in order to prevent missed opportunities.

  • Health extension workers should encourage mothers to have ANC follow up and should discuss with mothers on one to one about immunization.

To communicable disease prevention and control and zonal health department

  • The zone and district should organize the ways providing sustainable supports such as logistic (vaccine, vaccine care and refrigerators).

  • Establishing outreach site in each village of the kebeles and giving the service on monthly based should be strengthened.

To Governmental bodies/ village leaders

  • Village leaders should work with community to raise the economic status of people and search the way to increase family income level.

  • All village leaders should, thoroughly work with health workers by giving information for communities.

For the future Studies

Future research should include preferably community based with strong study designs that examine whether the variable that appears to be significant in this cross-sectional study.

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