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  Research Article Full Immunization Coverage and Associated Factorsamong Children Aged 12-23 Months in a Hard-to-Reach Areas of Ethiopia   Abadi Girmay  1 and Abel Fekadu Dadi  2 󰀱 Tigray Regional State Health Office, Ethiopia 󰀲 Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences,University of Gondar, Gondar, Ethiopia Correspondence should be addressed to AbelFekadu Dadi;  Received 29 January 2019; Revised 20 April 2019; Accepted 19 May 2019; Published 27 May 2019 Academic Editor: Alessandro MussaCopyright © 󰀲󰀰󰀱󰀹 Abadi Girmay and Abel Fekadu Dadi. Tis is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the srcinal work isproperly cited. Introduction .Childhoodimmunizationaverts󰀲.󰀵millionannualchilddeathsglobally.However,poormonitoring,possiblyduetoalackolocallyavailabledataonimmunization,mightaffectullprotectionovaccinesromVaccinePreventableDiseases.Tisstudy was aimed atbringing data aboutimmunizationservicecoverageand itsassociatedactorsrom Sekota Zuriadistrict,whichisoneo the hard-to-reach areas in Amhara Region, Ethiopia.  Methods . A community-based cross-sectional study was conducted romSeptember 󰀲󰀰toOctober󰀲󰀸,󰀲󰀰󰀱󰀷,among󰀶󰀲󰀰childrenaged󰀱󰀲-󰀲󰀳monthsinsevenrandomly selectedruralkebeleso SekotaZuriadistrict. Socio-demographic child conditions and vaccine-related data were collected using a pretested interviewer-administeredquestionnaire. Multivariable logistic regression analysis was carried out to identiy actorsassociatedwith immunization coverageat a p-value  ≤  󰀰.󰀰󰀵. Crude and Adjusted Odds Ratio (AOR) with their con󿬁dence interval were reported.  Results . 󰀷󰀷.󰀴% (󰀹󰀵%CI:󰀷󰀴.󰀰%-󰀸󰀰.󰀶%)ochildrenaged󰀱󰀲-󰀲󰀳monthswereullyimmunized.Havingantenatalcarevisit(AOR=󰀲.󰀷󰀵,󰀹󰀵%CI:󰀱.󰀵󰀲-󰀵.󰀰),higherlevel o maternal education (AOR=󰀲.󰀳󰀹, 󰀹󰀵%CI: 󰀱.󰀰󰀶-󰀵.󰀳󰀶), mothers’ good knowledge on immunization (AOR=󰀳.󰀷󰀰, 󰀹󰀵%CI: 󰀲.󰀳󰀷-󰀵.󰀷󰀹),shortdistancetohealthacility(AOR=󰀲.󰀶󰀵,󰀹󰀵%CI:󰀱.󰀶󰀱-󰀴.󰀳󰀶),andbeingborninhealthinstitutions(AOR=󰀲.󰀵󰀸,󰀹󰀵%CI:󰀱.󰀶󰀶-󰀳.󰀹󰀹) had increased the odds o ull immunization coverage while having 󿬁ve and more amily size reduced the odds o children’s vaccine uptake (AOR=󰀰.󰀶󰀲, 󰀹󰀵%CI: 󰀰.󰀳󰀸-󰀰.󰀹󰀹).  Conclusion . Full immunization coverage o the district was lower than the targetset by the World Health Organization. Improving mother’s health seeking behavior toward pregnancy ollow-up and enhancingmothers’ knowledge on child immunization, strengthening outreach services, community engagement,and actively working withlocal community-based health agents are recommended to increase number o children to be vaccinated. 1. Introduction Childhood immunization is one o the most valuable pub-lic health interventions available [󰀱] or preventing child-hood morbidity and mortality. Basic immunizations areestimated to avert 󰀲.󰀵 million annual child deaths globally rom diphtheria, tetanus, pertussis, and measles [󰀲]. Despitethis enormous use, immunization coverage in developingcountries has reported to being low [󰀳]. In 󰀲󰀰󰀱󰀱 alone, 󰀱.󰀵million children died rom Vaccine Preventable Diseases(VPDs) [󰀲, 󰀴]. I all currently available vaccines were widely  adopted and every country attained at least a 󰀹󰀰% vaccinecoverage, millions o lives would have been saved globally [󰀴].In 󰀲󰀰󰀱󰀴, about 󰀱󰀸.󰀷 million children did not receive the󰀳rddoseoDiphtheria-Pertussis-etanus(DP󰀳)vaccineand󰀷󰀰% o them were live in ten developing countries includingEthiopia [󰀲, 󰀵]. Global Vaccine Action Plan (GVAP) had put a goal to reach immunization coverage o at least 󰀹󰀰% inevery nation and at least 󰀸󰀰% o DP󰀳 coverage in every district by 󰀲󰀰󰀱󰀵 [󰀶]; however, it was only achieved by 󰀵󰀶 o the 󰀱󰀹󰀴 WHO member states [󰀵]. Te DP󰀳 coverage hasincreasedrom󰀷󰀴%in󰀲󰀰󰀱󰀰to󰀸󰀰%in󰀲󰀰󰀱󰀴inAricawithgreatdisparities among countries. Most countries in Sub-Saharan HindawiInternational Journal of PediatricsVolume 2019, Article ID 1924941, 8 pages  󰀲 International Journal o PediatricsArica (SSA) experienced a DP󰀳 coverage that reached lessthan 󰀵󰀰% [󰀶]. In 󰀲󰀰󰀱󰀴measles vaccine coverage in Arica was󰀷󰀴% and as a result estimated 󰀴󰀸,󰀰󰀰󰀰 measles related-deathswere occurred [󰀶].In Ethiopia, the Expanded Program on Immunization(EPI) program emphasizing six vaccines has been given ona routine and outreach basis since 󰀱󰀹󰀸󰀰 [󰀷–󰀱󰀰]. Ethiopia ollows the WHO immunization schedules and provides theollowing vaccines based on the speci󿬁ed schedules: onedose o Bacillus Calmette-Guerin (BCG) and initial doseo oral polio vaccine ( 󽠵􍠵  ) given at birth; three doses o eachPentavalent (DP-HepB-Hib),OPV,andPneumococcalConjugate Vaccine (PCV) given at 󰀶th, 󰀱󰀰 󽠵ℎ , and 󰀱󰀴th weeks;two doses o Rotavirus vaccine given at 󰀶th and 󰀱󰀰th weeks;and lastly measles vaccine at 󰀹th month [󰀷, 󰀹, 󰀱󰀱]. Expanding immunization service is among one o theEthiopian child survival strategies targeted to protect nearly 󰀳-million annual births against VPDs [󰀱󰀲] but a signi󿬁cantportion o children has not been immunized [󰀱󰀳]. As a resultdeaths in the 󿬁rst ew years o lie in Ethiopia are among thehighest in the world and many o these were believed to beattributed to VPDs [󰀸, 󰀱󰀴]. Tough,ullimmunizationcoveragehasbeenraisedrom󰀲󰀴% in 󰀲󰀰󰀱󰀱 to 󰀳󰀹% in 󰀲󰀰󰀱󰀶 EDHS report [󰀱󰀴, 󰀱󰀵]; this achievement remains ar below the goal set in the 󰀴th HealthSector Development Plan (HSDP-IV) and the GVAP targetplan to achieve 󰀹󰀰% coverage nationally and 󰀸󰀰% in every district or all vaccines by 󰀲󰀰󰀲󰀰 [󰀶, 󰀹]. Studies have also reported maternal education, access tohealth services, amily socioeconomic status, child place o delivery, antenatal care(ANC) visits, mothers immuniza-tion status, knowledge on immunization, sex o the child,place o residence, religious affiliation, and exposure to massmediaaspredictorsopoorimmunization coverage[󰀹,󰀱󰀱,󰀱󰀶– 󰀱󰀸]. However, the relationship o these actors in predictingull immunization has not always been consistent acrossstudy areas. Measles and pertussis are requently reportedand outbreaks o these diseases are recurrently occurring inSekotaZuriaDistrict.Tereore,weaimedatdeterminingullimmunization coverage and identiying its associated actorsin this district. 2. Methods 󰀲.󰀱. Study Setting and Design.  A community-based cross-sectional studywasconductedromSeptember󰀲󰀰toOctober󰀲󰀸, 󰀲󰀰󰀱󰀷, in Sekota Zuria district, Wag-Himra Zone, AmharaRegional State, and Northern Ethiopia. Sekota Zuria is oneo the seven districts in Wag-Himra Zone, Amhara RegionalState, and ound 󰀷󰀲󰀰kms away rom Addis Ababa, the capitaloEthiopia.Tedistrictisclaimedasoneothehard-to-reachareas in the region and has an estimated area o 󰀱󰀶󰀷󰀱.󰀵󰀶km 2 and 󰀳󰀳 rural “kebeles” (the lowest administrative unite). Tetotal population o the district based on projections rom󰀲󰀰󰀰󰀷census was󰀱󰀳󰀸,󰀸󰀴󰀶in󰀲󰀰󰀱󰀷,owhichunder 󿬁ve childrenaccountor󰀱󰀳.󰀵%(󰀴,󰀳󰀱󰀹).Tedistricthassevenhealthcentersand 󰀳󰀳 health posts, which provide a routine vaccinationservice or their catchment population. 󰀲.󰀲. Population and Sampling.  Children aged 󰀱󰀲-󰀲󰀳 monthswho were living in seven randomly selected kebeles o thedistrict were included while those children whose moth-ers/caregivers ound to be mentally/critically ill during thedata collection period were excluded rom the study. Terequired sample size was determined by comparing samplesizes obtained rom singleand double population proportionormulas. For a single population ormula, the ollowingassumptions were considered: the proportion o ully immu-nized children aged 󰀱󰀲-󰀲󰀳 months rom EDHS 󰀲󰀰󰀱󰀱 whichwas 󰀲󰀴.󰀳%, 󰀹󰀵% con󿬁dence level, 󰀵% margin o error, %nonresponse rate, and a design effect o 󰀲. Te sample sizewas calculated to be 󰀶󰀲󰀳. In the double population propor-tion ormula, actors signi󿬁cantly associated rom previousstudies such as maternal education, institutional delivery,and mothers’  immunization were used to calculate thesample sizes using Epi-Ino󰀷 StatCalc program using 󰀹󰀵%CI, reported odds ratio, and power o 󰀸󰀰% [󰀱󰀹]. Finally, 󰀶󰀲󰀳was ound as the biggest sample size o all approaches andconsidered as a 󿬁nal sample size o the study.Study participants were selected by multistage samplingtechnique. Stage one, seven kebeles were randomly selectedand stage two households with children aged 󰀱󰀲-󰀲󰀳 monthswere randomly selected and included in the study. Commu-nity Health Inormation System (CHIS) registration log wasused as a sampling rame or the selection o householdswith children󰀱󰀲-󰀲󰀳months. Irespondents werenotoundathome during the data collection, interviewers have revisitedthehouseholdsorthesecondtimeandwhentheinterviewersailed to 󿬁nd the eligible participant afer two visits, the nexthousehold was contacted. (Figure 󰀱) 󰀲.󰀳. Data Collection.  Te data collection tool was adaptedrom EDHS 󰀲󰀰󰀱󰀱 immunization questionnaire and otherrelevant literature. It was 󿬁rst prepared in English and trans-lated to Amharic language and back-translated to Englishto check the consistency o translation. Te questionnairemainly included immunization histories o children, socio-demographiccharacteristicsomothers,maternal health careutilization, and knowledge o mothers on immunization.Inormation on vaccination coverage was collected in twoways:romthechildvaccination cardorrommothers’verbalreport.Inormationromthechildcardwasextractedincaseswhere child immunization card was available. When therewas no vaccination card or the child or i a vaccine had notbeen recorded on the card as being given, the mothers wereasked to recall the speci󿬁c vaccines given to her child. Teinormation obtained rom the child card was taken in thecase where both conditions have been met.Six diploma nurse data collectors and two supervisorswere recruited in the data collection. Data collectors andsupervisors were trained on overall data collection proce-dures and the techniques o interviewing. Beore starting theactual data collection, the questionnaire was pretested on󰀵% o similar respondents in other kebeles o the districtwhich was not included in the 󿬁nal study. All 󿬁eld staffsand the principal investigator have assessed the clarity andcompleteness o the questionnaire. Te collected data waschecked or completeness, consistency, accuracy, and clarity   International Journal o Pediatrics 󰀳 Sekota Zuria District(33 rural kebeles)semerakebeleWolehkebeleBerberkebeleiyakebeleD/birhankebeleHamusitkebeleSerielkebele Simple random sampling121 10592 5357 83(623)112Probability Proportional to sizeSystematic random sampling F󰁩󰁧󰁵󰁲󰁥 󰀱: Sampling rameworko immunization coverageand associatedactorsamong childrenaged 󰀱󰀲-󰀲󰀳months inSekota Zuria district,󰀲󰀰󰀱󰀷. by the supervisors and the principal investigator on a daily basis. 󰀲.󰀴. Data Processing and Analysis.  Data were cleaned andentered to Epi-Ino󰀷 [󰀲󰀰] and transerred to SPSS version󰀲󰀰 [󰀲󰀱] or urther analysis. A child aged 󰀱󰀲-󰀲󰀳 monthswho received all currently recommended vaccines (one doseo BCG, three doses o Pentavalent, three doses o OPV(excluding OPV󰀰 which provides at birth), three doses o PCV,twodosesoRotavirusvaccine,andonedoseomeasles vaccine) any time beore the data collection was taken asully vaccinated. Conversely, a child aged 󰀱󰀲–󰀲󰀳 months whomissed at least one dose o the recommended vaccines ornot vaccinated at all was considered as not ully vaccinated.Data were presented using descriptive statistics. We havechecked or interaction terms and multicollinearity was alsonot ound. In the bivariable analysis, independent variablessigni󿬁cantly associated with the dependent variable at P- value  ≤  󰀰.󰀲󰀰 were included in the multivariable logisticregressionanalysis andvariables signi󿬁cantly associated atp- value  ≤  󰀰.󰀰󰀵 were identi󿬁ed as predictors o immunizationstatus. Backward stepwise regression method was used toselect the variables. Te degree o association was assessedusing crudeand adjusted oddsratios. Adequacy othe modelwasassessedusingHosmerandLemeshowgoodnesso󿬁t(P- value =󰀰.󰀳󰀰󰀸). 󰀲.󰀵.Ethical Issues.  Ethical clearance wasobtained romInsti-tutional Review Board o University o Gondar. Permissionletter was received rom Sekota Zuria district health office.Verbal inormed consent wasobtained romeachrespondentprior to data collection. Participants were ully inormedabout the objectives and procedures o the study and theirright to reuse participation at any time during the study.Study participants were also inormed that all data obtainedrom them would be kept con󿬁dential. At the end o eachinterview, mothers ound tohave nonimmunized or partially immunizedchildrenwereadvisedtovaccinatetheirchildandto ollow the regular immunization sessions. 3. Results 󰀳.󰀱. Background Characteristics of the Study Population.  Sixhundred twenty mothers o children aged 󰀱󰀲-󰀲󰀳 monthswere included in the study, which makes a response rate o 󰀹󰀹.󰀵%. A mean and standard deviation ( ± SD) o the age o mothers was 󰀲󰀹.󰀳 ( ± 󰀷.󰀲) years. Te mean age o the child was󰀱󰀶.󰀷( ± 󰀳.󰀳󰀹) months and 󰀵󰀱.󰀰% o them were emales. Hal (󰀴󰀹.󰀹%)o the mothers were not able to read and write, while󰀱󰀱.󰀸% o them have attained a secondary or higher level o education. About 󰀹󰀵% o the respondents were OrthodoxChristian while 󰀵.󰀰% o them were Muslims. Nearly 󰀴󰀱.󰀰%o the households had a amily size o our or below and󰀴󰀰.󰀸% o the households had an average monthly incomebetween 󰀵󰀰󰀰 and 󰀱󰀰󰀰󰀰 EB (Ethiopian Birr) (able 󰀱). About󰀵󰀳.󰀰% o the respondents walk 󰀳󰀰 minutes or less to reachthe nearest health acility. More than 󰀷󰀴.󰀰% o the mothershad at least one ANC visit during their last pregnancy.Similarly, 󰀶󰀱.󰀰% o the respondents have received three ormore doses o etanus oxoid () vaccine, 󰀵󰀶.󰀰% o the  󰀴 International Journal o Pediatrics 󰁡󰁢󰁬󰁥 󰀱: Socio-demographic and economic characteristicso mothers and children aged 󰀱󰀲-󰀲󰀳 months in Sekota Zuria district, Wag-HimraZone, North East Ethiopia, 󰀲󰀰󰀱󰀷.Characteristics Frequency(N) Percentage(%)Sex o the child Male 󰀳󰀰󰀳 󰀴󰀸.󰀹Female 󰀳󰀱󰀷 󰀵󰀱.󰀱Birth order o the child󰀱st 󰀱󰀱󰀵 󰀱󰀸.󰀶󰀲nd -󰀳rd 󰀲󰀶󰀹 󰀴󰀳.󰀴󰀴th-󰀵th 󰀱󰀴󰀹 󰀲󰀴.󰀰 ≥ 󰀶 󰀸󰀷 󰀱󰀴.󰀰Mothers’ age in years ≤ 󰀲󰀴 󰀱󰀶󰀰 󰀲󰀵.󰀸󰀲󰀵-󰀳󰀴 󰀲󰀸󰀴 󰀴󰀵.󰀸 ≥ 󰀳󰀵 󰀱󰀷󰀶 󰀲󰀸.󰀴MaternaleducationIlliterate 󰀳󰀰󰀹 󰀴󰀹.󰀸Can read and write 󰀶󰀷 󰀱󰀰.󰀸Primary 󰀱󰀷󰀱 󰀲󰀷.󰀶Secondary and above 󰀷󰀳 󰀱󰀱.󰀸Marital statusMarried 󰀵󰀴󰀴 󰀸󰀷.󰀷Single 󰀴󰀹 󰀷.󰀹Divorced 󰀲󰀷 󰀴.󰀴Mothers’ occupationHouse wie 󰀱󰀶󰀹 󰀲󰀷.󰀳Farmer 󰀳󰀳󰀱 󰀵󰀳.󰀴Merchant 󰀵󰀴 󰀸.󰀷Governmentemployee 󰀲󰀵 󰀴.󰀰Daily laborer 󰀴󰀱 󰀶.󰀶Religion Orthodox 󰀵󰀹󰀰 󰀹󰀵.󰀲Muslim 󰀳󰀰 󰀴.󰀸Family size  ≤ 󰀴 󰀲󰀵󰀱 󰀴󰀰.󰀵 ≥ 󰀵 󰀳󰀶󰀹 󰀵󰀹.󰀵 mothers gave their last birth in health institutions, and 󰀶󰀱.󰀰%hadnopostnatal checkups.Treehundredorty-our(󰀵󰀵.󰀵%)o the respondent had good knowledge about immunization(able 󰀲). 󰀳.󰀲. Immunization Status.  O the total included children(N=󰀶󰀲󰀰), 󰀷󰀷.󰀴% (󰀴󰀸󰀰/󰀶󰀲󰀰) o them were ully immunized,󰀱󰀵.󰀵% (󰀹󰀶/󰀶󰀲󰀰) were partially immunized, and the rest 󰀷.󰀱%(󰀴󰀴/󰀶󰀲󰀰) had not received any antigen. On the other hand, o the ully immunized children, 󰀸󰀷.󰀳% (󰀴󰀱󰀹/󰀴󰀸󰀰) had evidenceo immunization supported by the card, while vaccinationstatus o 󰀱󰀲.󰀷%% (󰀶󰀱/󰀴󰀸󰀰) o the children was determined by mothers to recall. Similarly, 󰀴󰀱.󰀷% (󰀴󰀰/󰀹󰀶) were con󿬁rmed aspartially immunized bycard, while󰀵󰀸.󰀳%(󰀵󰀶/󰀹󰀶)werebasedon mothers’ recall.Overall, 󰀹󰀱.󰀵% (󰀵󰀶󰀷/󰀶󰀲󰀰) o the children received OPV󰀱,󰀹󰀰.󰀰% (󰀵󰀵󰀸/󰀶󰀲󰀰) received both BCG and Pentavalent󰀱, 󰀸󰀹.󰀷%(󰀵󰀵󰀶/󰀶󰀲󰀰) received PCV󰀱, 󰀸󰀰.󰀵% received measles (󰀴󰀹󰀹/󰀶󰀲󰀰),and 󰀸󰀷.󰀰% (󰀵󰀳󰀹/󰀶󰀲󰀰) received the 󿬁rst dose o Rotavirus vac-cine. Coverage rates declined or subsequent doses as 󰀷󰀸.󰀸%o children received OPV󰀳, 󰀷󰀷.󰀳%Pentavalent󰀳, 󰀷󰀸.󰀵% PCV󰀳,and 󰀸󰀰.󰀰% Rota 󰀲 vaccine. Dropout rate: the proportion o childrenwhostarted certainvaccinebutdidnotcompletethenextintendedvaccinewas󰀱󰀳.󰀸%orOPV󰀱toOPV󰀳,󰀱󰀳.󰀴%orPentavalent󰀱 to Pentavalent󰀳, and 󰀱󰀰.󰀷% or BCG to Measles(Figure 󰀲). 󰀳.󰀳. Factors Associated with Full Immunization Status of theChildren.  On the bivariable analysis, birth order o the child,mothers’ educational status, amily size, distance to a healthacility, mothers’ knowledge score, place o delivery, ANCollow-up, and tetanus toxoid immunization were ound tobe signi󿬁cantly associated with children’s ull immunizationstatus. However, in the multivariable analysis, mothers’ edu-cational status, place o delivery, mothers’ knowledge score,distance to a health acility, amily size, and ANC ollow-upwere ound to be signi󿬁cantly associated.Mothers who attained secondary or more level o edu-cation were 󰀲.󰀳󰀹 times more likely to have ully immunizedchildrencomparedtoilliteratemothers(AdjustedOddsRatio(AOR)=󰀲.󰀳󰀹, 󰀹󰀵%CI=󰀱.󰀰󰀶, 󰀵.󰀳󰀶). Mothers who travel  ≤  󰀳󰀰minutes to reach the nearest vaccination site were 󰀲.󰀶󰀵 timesmore likely to ully immunize their children than motherswho travel beyond one hour (AOR=󰀲.󰀶󰀵, 󰀹󰀵%CI= 󰀱.󰀶󰀱, 󰀴.󰀳󰀶).Mothers whoattended ANC services or three or more timeswere󰀲.󰀷󰀵times morelikely tohave ully immunized childrencompared to motherswhonever had ANC visits (AOR=󰀲.󰀷󰀵,󰀹󰀵%CI=󰀱.󰀵󰀲, 󰀵.󰀰󰀰). Children born in health institutions had󰀲.󰀵󰀸 times more chance o being ully immunized than chil-dren born at home (AOR=󰀲.󰀵󰀸, 󰀹󰀵%CI=󰀱.󰀶󰀶, 󰀳.󰀹󰀹). Motherswhohadgoodknowledgeaboutimmunization were󰀳.󰀷timesmore likely to have a ully immunized child as compared tothosewhohadpoorknowledge(AOR=󰀳.󰀷,󰀹󰀵%CI=󰀲.󰀳󰀷,󰀵.󰀷󰀹).


Sep 22, 2019
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