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Background: Immunization remains one of the most important public health interventions to reduce child morbidity and mortality. The 2011 national demographic and health survey (DHS) indicated low full immunization coverage among children aged 12-23 months in Ethiopia. Factors contributing to the low coverage of immunization have been poorly understood. The aim of this study was to identify factors associated with full immunization coverage among children aged 12-23 months in Ethiopia. Methods: This study used the 2011 Ethiopian demographic and health survey data. The survey was cross sectional by design and used a multistage cluster sampling procedure. A total of 1,927 mothers with children of 12-23 months of age were extracted from the children’s dataset. Mothers’ self-reported data and observations of vaccination cards were used to determine vaccine coverage. An adjusted odds ratio (AOR) with 95 % confidence intervals (CI) was used to outline the independent predictors. Results: The prevalence of fully immunized children was 24.3 %. Specific vaccination coverage for three doses of DPT, three doses of polio, measles and BCG were 36.5 %, 44.3 %, 55.7 % and 66.3 %, respectively. The multivariable analysis showed that sources of information from vaccination card [AOR 95 % CI; 7.7 (5.95-10.06)], received postnatal check-up within two months after birth [AOR 95 % CI; 1.8 (1.28-2.56)], women’s awareness of community conversation program [AOR 95 % CI; 1.9 (1.44-2.49)] and women in the rich wealth index [AOR 95 % CI; 1.4 (1.06-1.94)] were the predictors of full immunization coverage. Women from Afar [AOR 95 % CI; 0.07 (0.01-0.68)], Amhara [AOR 95 % CI; 0.33 (0.13-0.81)], Oromiya [AOR 95 % CI; 0.15 (0.06-0.37)], Somali [AOR 95 % CI; 0.15 (0.04-0.55)] and Southern Nation and Nationalities People administrative regions [AOR 95 % CI; 0.35 (0.14-0.87)] were less likely to fully vaccinate their children. Conclusion: The overall full immunization coverage in Ethiopia was considerably low as compared to the national target set (66 %). Health service use and access to information on maternal and child health were found to predict full immunization coverage. Appropriate strategies should be devised to enhance health information and accessibility for full immunization coverage by addressing the variations among regions.
The 2011 Ethiopian Demographic and Health Survey (EDHS) was conducted in nine regional states of Ethiopia namely; Tigray, Afar, Amhara, Oromiya, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples (SNNP), Gambella and Harari and two city Administrations (Addis Ababa and Dire Dawa). Ethiopia is one of the sub-Saharan countries found in the horn of Africa with a population of 73.5 million based on the 2007 national population and housing census [26]. This study used the 2011 EDHS data. The survey employed a two-stage cluster sampling design. All women age 15–49 who were usual residents or who slept in the selected households the night before the survey were eligible. A total of 17,385 eligible women were identified and finally 16,515 women in the age group 15–49 were interviewed. The detailed methodology is found elsewhere [8]. Of all interviewed women, 11,654 gave birth in the past five years and 10,808 were interviewed for vaccination status. Children between 12–23 months of age are the youngest cohort who have reached the age by which they should be fully vaccinated. This age group was our target population for our analysis. So a total of 1,927 women with 12–23 months of children were extracted from the variable current age of child’s in the dataset. Information on a wide-range of potential independent variables (i.e. socio-demographic, economic, fertility history and health service use) were extracted accordingly. After reviewing the detailed data coding, further recoding of variables was done to better suit with other studies for comparison and intervention recommendations. The EDHS data include a women’s questionnaire that measures socio-demographic characteristics of the mothers, information on reproductive health and service use behaviors, as well as child-specific information for all births in the past five years from women of reproductive age group between 15–49 years. The 2011 EDHS collected information on vaccination coverage in two ways: (1) from vaccination cards shown to the interviewers and (2) from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card available for the child or if a vaccine had not been recorded on the card as being given, the respondent was asked to recall the vaccines given to her child. In this analysis, the dependent variable was full immunization coverage. According to the WHO guideline [27], “complete or full immunization” coverage is defined as a child has received a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertusis, and tetanus (DPT); at least three doses of polio vaccine; and one dose of measles vaccine. This dependent variable had five response categories: no, vaccination date on card, reported by mothers, vaccination marked on card and DK (don’t know). We recoded each variable into 0 and 1. No responses were recoded as “0” and labeled “not received the vaccine”, while the other responses “vaccination date on card, reported by mothers, vaccination marked on card” were recoded together as “1” and labeled “received the vaccine”. Then, we added all yes – zero scores and labeled them “Immunization status”. The immunization status was recoded as “0” if the child had received all the doses of vaccinations and categorized as “complete or full immunization” or “1” if the child had missed one or more doses of vaccinations and categorized as “incomplete immunization”. The individual level exposure variables considered in this study were age of mothers, mother’s occupation, child death, parity, religion, women’s education, husband’s education, wealth index, birth order, awareness of community conversation (CC) program, sources of vaccination information, received postnatal check-up within 2 months after birth, antenatal care follow up of at least 4 times, place of delivery, number of living children in the household, sex of child and marital status. Whereas place of residence, agro-climatic zone and administrative regions were considered as the community level exposure variables. In this manuscript, ANC attendance refers to when women get services during pregnancy according to the WHO recommendations of at least four ANC visits for low-risk pregnant women and parity is defined as the number of children ever born. The wealth index constructed from household assets and characteristics available in the survey was used [8]. Occupational status was defined as non-paid and paid who were engaged in the areas of professional/technical/managerial, clerical, sales and services, skilled manual, unskilled manual and agricultural occupation classifications of the country. Descriptive statistics including prevalence and frequency distributions were used to determine the level of full immunization coverage by socio-demographic characteristics. Bivariate analysis was used to show the association between socio-demographic characteristics and full immunization coverage. Variables that were determined statistically significant at p-value <0.25 during bivariate analysis were considered for adjustment in the multivariable logistic regression model [28, 29]. This cut off point prevented removing variables that would potentially have an effect during multivariable analysis. A stepwise approach was used to assess the iteration of variables and to control potential confounders [30]. In the multivariable model, odds ratio with 95 % CI was used. A multi-collinearity test was done and as a result marital status and birth order were omitted from the multivariable analysis because of collinearity with variance inflation factors (VIF) of greater than 10 [31]. Sample weights were applied in order to compensate for the unequal probability of selection between the strata that has been geographically defined as well as for non-responses. A detailed explanation of the weighting procedure can be found in the DHS 2011 [8]. The “svy” command in STATA version 11 (Stata Corporation, College Station, TX, USA) was used to weight the survey data. The 2011 EDHS data is available to the general public by request in different formats from the Measure DHS website [http://www.measuredhs.com]. We submitted a request to the Measure DHS by briefly stating the objectives of this analysis and thereafter received permission to download the children’s’ dataset in SPSS format.
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