Preference in the use of full childhood immunizations in Ethiopia: The role of maternal health services

Background: Immunizations represent a successful and cost-effective public health strategy in preventing common childhood diseases. Ethiopia has made remarkable progress in increasing its full immunization coverage, but significant gaps remain. This study aims to measure the preference in the use of full immunizations for children aged 12–23 months in Ethiopia and examine the role of key maternal health services. Methods: This is a cross-sectional study and uses data from a nationally generalizable survey, the Ethiopian Demographic and Health Survey, 2016. It includes a representative sample of 2,168 children aged 12–23 months. The main outcome was full immunization, measured based on the WHO guidelines (Bacillus Calmette–Guérin [BCG], diphtheria, tetanus, and pertussis [DPT], polio, and measles vaccines). The main exposure variables were provision of three key maternal health services (antenatal care, delivery services, and tetanus vaccine) as well as other sociodemographic factors. Descriptive statistics and multivariate logistic regression analyses were conducted. Results: This study found the overall full immunization coverage in Ethiopia to be much lower (39%) than the WHO-recommended rate (≥90%). There were distinctive differences in the preference in the use of full immunization coverage for various vaccines (BCG 70.0%, polio 56.5%, measles 55.3%, and DPT 53.9%). The maternal health service variables (antenatal care, delivery services, and tetanus vaccine) were significantly associated with the full immunization of children aged 12–23 months (P<0.001). In the full model, the maternal health service variables remained significant, along with other socioeconomic predictors of full immunization, including sex of the household head (P<0.001), maternal education (P<0.05), wealth index (P<0.01), and religion (P<0.001). Conclusion: Full immunization coverage has been identified as a critical factor in the prevention of morbidity and mortality from childhood diseases. Future progress in the provision of key maternal health services can have a positive impact in narrowing the gap in immunization coverage. Ethiopia has an estimated population of 105 million people, making it the second most populous country of Africa.29 The population is characterized by disproportionately high mortality and fertility rates, and it is currently growing at a rate of 2.6% per annum.30 Administratively, Ethiopia has nine regional states, each one further divided into zones, districts, and sub-districts. The country has an agrarian economy, where agriculture accounts for >60% of its gross domestic product (GDP) and employs nearly 85% of its population.14 In Ethiopia, infectious and communicable diseases account for 60%–80% of the health problems.6 The country also suffers from poor healthcare infrastructure and high levels of health disparities.31 Despite efforts in ensuring universal access to healthcare through the National Health Sector Development Program,32 the country is still experiencing high childhood mortality mainly due to poor immunization coverage of vaccine-preventable diseases.17,33 The Ethiopia Demographic and Health Surveys (EDHS) are used to collect sociodemographic characteristics and key maternal and child health information from a nation-wide representative sample of households. EDHS are carried out nationally by the Central Statistical Agency under the guidance of the Ministry of Health and with the technical support of ORC Macro International.28,30 The data were collected by a two-stage sampling method and used standardized household questionnaires. Maternal and child health information were obtained from eligible women aged 15–49 years in each household surveyed. A total weighted sample of 2,168 children participated in this study. For the purposes of this study, selected household information on sociodemographics, child and mother’s health, and birth histories were used. The main outcome variable was full vaccination. Since our unit of analysis was children aged 12–23 months, only women of reproductive age, who had reported having a child within the reference time period were considered (N=2,168). Immunization status was divided into two categories: complete/full, if the child had received all eight recommended doses of vaccinations, and incomplete, if the child missed one or more of the recommended doses. The main exposure variables of interest were composed of antenatal care, delivery services, and tetanus vaccine. Antenatal care services included provision of health education sessions and clinical physical examinations for the pregnant woman and were divided into two categories as follows: women who attended at least four antenatal care visits and those with <4 visits. Delivery services were also grouped into two categories as follows: mothers who delivered their last child in a healthcare setting (hospitals and private and government clinics) and those who delivered at other settings (home). Tetanus vaccination was also grouped into two categories as follows: mothers who received at least two vaccinations during their pregnancy (as recommended by WHO)34 and those who did not. The impact of these exposure variables, along with other key socioeconomic characteristics, on the preference of the use of full childhood immunizations was investigated in this study. Household economic status was measured by the use of a wealth index, which EDHS constructed from selected key household assets.28 Information on parental education was measured as the reported number of years of maternal/paternal education and then allocated within conventional educational categories (eg, no education, primary level, secondary level, and post-secondary level education). Data cleaning, management, and analysis were carried out by using SPSS Statistics Version 20 (IBM Corporation, Armonk, NY, USA). Sample weights were applied in our analysis as recommended by EDHS28 to compensate for the unequal probability of participant selection between the different geographical regions as well as to account for non-responses. Descriptive statistics were used to examine the distributions of the main outcome, the exposure variables, and other demographic and socioeconomic characteristics. The associations between these factors were assessed using logistic regression. The analysis was performed in two stages. First, only the main exposure variables (antenatal care, delivery services, and tetanus vaccine) were taken into consideration and examined to determine their individual and combined effects on the main outcome (full immunization). Second, multivariable logistic regression modeling was conducted, and a P-value of ≤0.05 was considered to be statistically significant. Manual backward selection was used for our model building. A change in regression coefficient of 20% or more (Δβ≥20%) was used to determine whether variables were confounders.35 The goodness of fit in our final model was tested using the Hosmer–Lemeshow test.36