Determinants of defaulter to full vaccination among children aged 12-23 months in Siraro District, West Arsi zone, Oromia, Ethiopia: A Case-Control study

doi:10.21203/rs.3.rs-2213834/v1

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Research Article

Determinants of defaulter to full vaccination among children aged 12-23 months in Siraro District, West Arsi zone, Oromia, Ethiopia: A Case-Control study

https://doi.org/10.21203/rs.3.rs-2213834/v1

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Background

Vaccination is one of the most cost– effective global public health interventions to reduce childhood morbidity and mortality. Defaulter to full vaccination can put the children at greater risk of acquiring vaccine preventable disease outbreaks and the reason for not full vaccination is not well-explored and there are limited evidence about defaulters of full vaccination in Ethiopia.

Objectives

To identify determinants of defaulter to full vaccination among children aged 12–23 months in Siraro District, West Arsi Zone, Oromia Region, Ethiopia.

Methods

A Community-based unmatched case–control study was conducted among children aged 12–23 months from March 20 to April 30, 2022 with a total sample size of 444 (148 cases and 296 controls). Cases were children aged 12–23 months who had missed at least one dose of the routine vaccination and controls were children who had received all the recommended routine vaccination. Consecutive sampling and simple random sampling techniques were used to select representative cases and controls respectively. Data were collected using a structured questionnaire, entered into Epi-data version 4.6 and exported to Statistical Package for Social Sciences version 26 for analysis. Logistic regression was used to identify determinants of defaulter to full vaccination and adjusted odds ratio with 95% confidence interval at p value ≤ 0.05 was used to declare statistical significance of association.

Result

Of the assessed determinants of defaulter to full vaccination; inadequate knowledge of mothers/caretakers (AOR = 4.32, 95% CI:2.78–6.70), educational status of father unable to read and write (AOR = 3.66, 95% CI:1.29–10.39), time to reach health facility ≥ 30 minutes (AOR = 2.45, 95% CI:1.51–3.97), not told about the type of vaccine received (AOR = 2.37, 95% CI;1.27–4.45), no parents discussion on vaccination (AOR = 2.16, 95% CI:1.24–3.79), home delivery (AOR = 2.43, 95% CI:1.39–4.25) and not participated in pregnant mother conference (AOR = 2.47, 95% CI = 1.35–4.49) were the identified determinants of defaulter to full vaccination.

Conclusion

Mothers knowledge, father’s education, place of delivery, time to reach health facility, health workers told type of vaccine received, participation in pregnant mother conference and parents discussion on vaccination were the determinants of defaulter to full vaccination status. Thus, the district health office should work on defaulters of vaccination by strengthening immunization service delivery and improving maternal knowledge on vaccination through pregnant mother conference participation.

Determinants

Defaulter

Full Vaccination

Siraro District

West Arsi Zone

Vaccination is the process of inducing a protective response in an individual's body against a specific illness by administering vaccines and one of the most cost– effective global public health interventions to reduce childhood morbidity and mortality (1, 2). Defaulter to full vaccination is a condition in which a child missed routine vaccination schedule and not become fully vaccinated for any reasons that can put children at greater risk of acquiring vaccine preventable diseases (3, 4). Partial child vaccination against vaccine preventable diseases is a significant public health challenge in developing countries and still in presence of vaccination, the children die by vaccine preventable disease every year in developing countries(5, 6). Expanding universal age-specific immunization program is one of the areas where preventive public health policy has become successful (3). Currently, the EPI has emerged as highly effective and efficient method to improve child survival and the program’s interventions led to the notable reduction in vaccine-preventable diseases worldwide(3, 7).

Globally, vaccine preventable diseases are still the most common causes of childhood mortality with an estimated 3 million deaths every year, mainly in Africa and Asia (8). In 2019 about 21.8 million eligible children did not receive 3 doses of diphtheria ,pertussis and tetanus vaccine (DTP3); among them, 9.6 million (44%) started, but did not complete, DPT 3-dose series (5). Immunizations have brought comprehensive health to many children globally and have been concrete in protecting children against vaccine-preventable diseases (VPDs) in low-and middle-income countries. But, vaccination coverage is still a major public health challenge in many third world countries, particularly in resource-limited areas (9, 10).

In spite of the fact that Africa has achieved remarkable progress in immunization services, large numbers of children remain unvaccinated and under-vaccinated (7, 8). Sub-Saharan Africa countries still there is the highest child mortality rate in the world and the region had an average child mortality rate of 76 deaths per 1000 live births in 2019 (9). In most of these countries, poor functioning health service delivery system, difficult topography and armed conflict prevents the efforts to meet immunization targets, especially for children living in hard to reach areas (4). Most die because they do not access effective interventions that would combat common and preventable childhood illnesses (11, 12).

According to the Ethiopian Federal Ministry of Health vaccination schedule, fully vaccination is considered as if the child has received one dose of Bacillus Calumete Guerin (BCG) vaccination against tuberculosis at birth or at the first clinical contact, three doses of pentavalent vaccine (DPT-HepB -Hib), three doses of polio vaccine, three dose of pneumococcal conjugate vaccine (PCV) at age of 6, 10, and 14 weeks. In addition, two dose of rotavirus vaccine at age of 6 and 10 weeks and one dose of measles vaccine at 9 months or soon before their first birth year and that the vaccinations be recorded on a vaccination card that is given to the parents or caretakers (10, 13, 14).

In Ethiopia, full vaccination against vaccine-preventable diseases are still a significant and persistent public health challenge (4, 15). Expanding immunization service is among one of the Ethiopian child survival strategies targeted to protect an estimated over 2-million annual childbirths from VPDs but a significant portion of children were not been vaccinated. As a result, the children in the first year of life in Ethiopia are among the highest rate of acquiring VPDs and many of these reasons were believed to be due to defaulter to full vaccination (6, 15).

The full vaccination coverage has been raised from 39% in 2016 to 43% in 2019 EDHS report and about 19% children in 12-23months age group have not received any vaccinations at all (16). The highest coverage of full vaccination in Addis Ababa (83%) and lowest in Afar region due to different challenges and opportunities as explained in other studies (20%) (5, 13). Studies have also reported that maternal education, place of delivery, antenatal care (ANC) visits, postnatal care follow up, place of residence and exposure to mass media as predictors of poor child immunization status (13, 14, 17, 19).

However, most of the studies were cross-sectional and failed to include certain variables or factors that could be pertinent in the Ethiopian context, such as socioeconomic status, attitude and service satisfaction towards immunization services provision at grassroots of individual family members and few community-based studies are available. In the study area, defaulter to childhood vaccination is a critical problem and determinants of defaulter to full vaccinations were not well known and still in presence of vaccination service some of children were not become fully vaccinated throughout a year. According to Siraro District DHIS2 report in 2021/2022, the full vaccination status of the children were 87.8% and the reason for the rest was unknown. In addition, there is frequent vaccine preventable disease outbreaks such as Polio and Measles. Due to these unknown factors and limited evidence about defaulters of childhood vaccination, identifying determinants of defaulter to full vaccination at community level is important to address and overcome the reasons for not full vaccination. Therefore, the aim of this study was to identify determinants of defaulter to full vaccination among children aged 12 to 23 months in Siraro District, West Arsi Zone, Ethiopia.

Study Design, Period and Area

A Community-based unmatched case–control study design was conducted from March 20 to April 30, 2022 in Siraro District. The district is found in the West Arsi Zone and composed of 4 urban and 28 rural kebeles. Kebele is the smallest administrative unit below district according to Ethiopian context. The District is located in South west of Ethiopia at 64 Km far from the capital city of zone Shashemene and 314 Km from capital city of the country Addis Ababa. In line with the national immunization strategies, the district is providing Expanded Program on Immunization services through static and outreach strategies. There are 38 outreach sites which providing immunization services for communities living more than 5 km from the nearest health facility. The District Health Office is directly involved in providing support to primary health care units through conducting supportive supervision and quarterly review meetings.

According to the Siraro District Health Office estimate in 2021/22, the total population in the District is 217,572 with 35,749 under-five children and the estimated children aged 12–23 months are 16,326. The District has 1 Primary Hospital, 7 Health Centers and 27 functional Health Posts regarding Public health facilities’ coverage and there are 139 health professionals and 54 health extension workers (HEWs) in the district (Source: Siraro District Health Office).

Source Population And Study Population

The source and study population were all children aged 12 to 23 months with their mothers/ caretakers who had received at least one dose of the routine vaccination and living in eligible households from randomly selected kebeles in Siraro District. Cases were children between the ages of 12–23 months with their mothers/ caretakers who had missed at least one dose of the recommended routine vaccination for any reason and not full vaccinated for age as per national immunization schedule. Controls were children aged 12–23 months with their mothers /caretakers who had received all the recommended routine vaccination as per national immunization schedule for full vaccination by the age of their first birth year.

Inclusion Criteria And Exclusion Criteria

Inclusion Criteria: Children aged 12–23 months with their mothers/caretakers living in Siraro District for at least 6 months before the date of data collection. Children who had a full address from Family folder and living with their mothers/ caretakers at the time of the study and who are permanent residents in Siraro District were included in this study.

Exclusion Criteria: Child mothers/caretakers who had missed child vaccination card and have no date of childbirth (whose vaccination cards not available or lost were excluded in order to reduce recall and selection bias) and those unable to interview due to illness and hearing problems.

Sample Size Determination

The sample size was calculated based on double population proportion formula by using Epi Info statistical software version 7.2 for unmatched case–control study design by considering the determinant variables from previous case-control studies conducted in Ethiopia and compared to get a large sample(7, 13). The predictor variable not attended postnatal care follow up considered as a significant determinant of defaulter to full vaccination from previous studies since it gave the maximum sample size. Among controls 45.9% of mothers not attended postnatal care follow up, while among cases it was 75.3% and OR = 3.58 (7). Using the assumptions of 80% power (Zβ = 0.84), 95% confidence level (Zα/2 = 1.96), a case to control ratio of 1:2 and after adding 10% non-response rate and design effect of 1.5, the total sample size was 444 (148 cases and 296 controls).

Sampling Procedures

The appropriate representative kebeles and households were selected by using multistage sampling from 32 kebeles in the district. Initially, the kebeles found in the district were stratified into urban and rural. There are 28 rural and 4 urban kebeles in the district. Eight rural and two urban kebeles were selected randomly using lottery method by considering rule of thumb (30%) of kebeles from each stratum (Fig. 1). All eligible cases and controls were listed with their full address from the Family folder of nearby health post separately for each selected kebeles before actual data collection. Family folder is a registry book containing all family members’ profiles in the kebele.

Finally,148 cases were selected using consecutive sampling based on the principles of subsequent nearest eligible households and 296 controls were selected by using simple random sampling technique after proportional allocation to the number of children aged 12 to 23 months to the number of children in each kebele using computer-generated technique. When there are two or more children in eligible household one of them were selected using lottery method. In case of absenteeism of respondents during visit, after checking three times visits the next eligible households were included.

Study Variables

Dependent Variable

Defaulter to full vaccination status

Independent Variables

Sociodemographic characteristics of mother/caretakers (age, marital status, educational status occupation, residence, family size, income)

Child biographic related characteristics (child age, sex, birth order, birth interval)

Vaccination service delivery related characteristics (time to reach health facility, waiting time, postponing schedule, parents discussion on vaccination)

Knowledge, Attitude and Service Satisfaction of mothers/ caretakers on child vaccination

Maternal Health service utilization related characteristics (Antenatal care visit, postnatal care visit, place of delivery, pregnant mother conference participation, model family training)

Measurements And Operational Definitions

Defaulter (cases)

A child aged 12 to 23 months old who had started the routine immunization and missed at least one dose of the recommended routine vaccination schedule for any reasons were considered as defaulter (6).

Full vaccination (controls)

A child aged 12–23 months who had received all the recommended routine vaccination as per national immunization schedule for full vaccination by the age of their first birth year were considered as full vaccination (6).

Knowledge about child vaccination

Mothers/caretakers were asked ten questions which are related to the child vaccination using “Yes, No and I don’t know” options. The correct answers were given a value of 1 and 0 for incorrect answers. After computing the sum score for each respondent, the minimum points to be scored were 0 and the maximum 10. The mean value of knowledge score (6.22) was used as a cut-off point to categorize knowledge into two groups. The variable was dichotomized into having “adequate knowledge” about vaccination for those respondents scored greater than or equal to mean score of knowledge points (≥ 6.22) and “inadequate knowledge” about vaccination for those respondents scored less than mean score of knowledge points (< 6.22) (4, 13).

Attitude toward child vaccination

Six questions were used to assess mothers/caretakers’ attitude towards child vaccination using five point Likert scale questions that have 1 to 5 options, were 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. The sum score of mothers/caretakers’ attitude were computed and converted to give the minimum and maximum points of caretakers’ attitude score from 6 to 30 respectively. The variable was dichotomized into having “favorable attitude” toward child vaccination if the mothers/caretakers attitude score value greater than mean score (> 16.57), and “unfavorable attitude” toward child vaccination if the mothers/caretakers attitude score value less than or equal to mean score (≤ 16.57) (14).

Satisfaction towards child vaccination

Mothers/caretakers were asked seven service satisfaction related questions using a five point Likert scale questions that starts from 1 to 5 options (were 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Each variable was measured on 5 points and which together yields a minimum of 7 and a maximum of 35. A response to 7 measuring items were added and converted to give an individual level of mothers/caretakers satisfaction score from 1–100% for each item. The variable was dichotomized into “satisfied” and “not satisfied”. Mothers/caretakers who scored 75% and above on 7 satisfaction measuring items were considered as “satisfied”, and those who scored less than 75% as “not satisfied” (7).

Caretaker

Caretaker is the most responsible person who provides care to the child other than mother due to different reasons such as parents death, adoption of child, separated from family and others(6, 17).

Data Collection Tool and procedures

Data were collected using interviewer-administered structured questionnaire to obtain information from mothers/caregivers of the child by trained interviewers. The instrument was constructed from a review of available literatures on child immunization (4, 7, 13, 14). The questionnaire has seven parts, which includes sociodemographic characteristics of respondents, child biographic characteristics, child vaccination service delivery characteristics, mothers/caretakers’ knowledge on child vaccination, mothers/caretakers’ attitude towards child vaccination, immunization service satisfaction and maternal health service utilization characteristics.

The mothers/caregivers knowledge and attitude were assessed by ten and six questions respectively. Service satisfaction were assessed by seven questions related to immunization service satisfaction. For assessment of mothers/caretakers attitude and service satisfaction a five-point Likert scale questions were used and each questionnaire measures Likert scale response options scored from 1 to 5, (were 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree).

Six Diploma Nurses as data collectors and three BSc health professional supervisors were recruited based on a set of criteria, which includes understanding of the local language, Afan Oromo, and previous data collection experience. Data Collectors were trained for two days by the investigator on the purpose of the study, data collection tools or instruments, how to take consent, how to select children from households, how to interview and extract information from vaccination card and the overall data collection procedures.

Data Quality Assurance

The questionnaire was prepared in English, translated into Afan Oromo (local language of the area), and retranslated to English by other translator who is a health professional to ensure consistency of the tool. Pretest of the questionnaire was done on mothers/care givers by taking 5% of the total sample size (23 participants with 8 cases and 15 controls) in two kebeles that were not included in the study before actual data collection to identify any problems and check the clarity by ensuring the tool accurately addressed the research questions.

After the pretest the investigator, data collectors and supervisors were discussed on the questionnaire for any inconsistencies and ambiguity before actual data collection and the necessary adjustments were made on the questionnaire before using for actual data collection. Content validity of the tool was cross-checked by another health professional. Data collectors and supervisors were trained on the study instrument and data collection procedure. The investigator and supervisors were checked the collected data for consistency and completeness every day at the end of each data collection day and necessary corrective measures was taken accordingly

Data processing and analysis

The collected data were checked for completeness, consistencies and accuracy. Data were coded and entered in to Epi Data manager version 4.6, cleaned and analyzed using SPSS version 26.0. After cleaning data for inconsistencies and missing values the descriptive statistics were used to present the data with the different variables by tables and graphs. The binary logistic regression was used to identify the determinant variables. To control potential confounders, independent variables with P-value < 0.25 in the bivariable analysis was considered for multivariable logistic regression analysis and multi-collinearity of independent variables were checked by using Standard error (SE). The Standard error of 2 was used as cut off point to indicate the presence of multi-collinearity between independent variables however; in this study, it is found to be less than 2 standard error.

The model fitness test was checked by Hosmer and Lemeshow goodness of test and the model was fit to data. The statistical significance of the variables were interpreted using adjusted odd ratio (AOR) with 95% confidence interval and p-value ≤ 0.05 to identify independent determinants of defaulter to full vaccination. Finally, the result was presented in the form of text, using tables, figures and charts.

Sociodemographic Characteristics of study participants

A total of 437 study participants (145 cases and 292 controls) were included in this study and making a response rate of 98.4%. The mean age of study participants were 28.42 (SD = ± 5.83) years for cases and 27.10 (SD = ± 5.69) years for controls, which ranges from 17–40 years for cases and 17–42 years for controls. The majority of child mothers/caretakers marital status and Religion were married and Muslim, 138 (95.2%) and 122 (84.1%) among cases and 275 (94.2%) and 222 (76%) among controls respectively.

Concerning educational status of study participants, 101 (69.7%) of cases and 163 (55.8%) of controls were unable to read and write. Regarding occupational status of child mothers/caretakers 117 (80.7%) of cases and 231 (79.1%) of controls were housewife. Forty one (28.3%) of cases and 77 (26.4%) of the controls had a family size greater than or equal to five. Sixty-eight (51.9%) households of cases and 134 (51.1%) of controls had an average household monthly income of less than or equal to 1000 Ethiopian Birr (Table 1).

Table 1

Socio-demographic characteristics of child mothers/caretakers on determinants of defaulter to full vaccination among children aged from 12 to 23 months in Siraro District, West Arsi Zone, Oromia, Ethiopia 2022 (n = 437)
Variables	Cases, n (%)	Control, n (%)
Age of respondents (in year)
≤ 24	42 (29.0)	109 (37.3)
25–29	38 (26.2)	93 (31.9)
30–34	38 (26.2)	48 (16.4)
≥ 35	27 (18.6)	42 (14.4)
Marital status
Married	138 (95.2)	275 (94.2)
Others marital status^a	7 (4.8)	17(5.8)
Religion
Muslim	122 (84.1)	222 (76.0)
Protestant	13 (9.0(	41 (14.0)
Orthodox	10 (6.9)	29 (10.0)
Residence
Rural	126 (86.9)	254 (87.0)
Urban	19 (13.1)	38 (13.0)
Education of Mother
Unable to read and write	101 (69.7)	163 (55.8)
Primary (1–8)	27 (18.6)	86 (29.5)
Secondary (9–12) and above	17 (11.7)	43 (14.7)
Education of Father
Unable to read and write	93 (64.1)	148 (50.7)
Primary (1–8)	40 (27.6)	92 (31.5)
Secondary (9–12) and above	12 (8.3)	52 (17.8)
Occupation of Mother
House wife	117 (80.7)	231 (79.1)
Merchant	15 (10.3)	41 (14.0)
Private employee	7 (4.8)	5 (1.8)
Government employee	6 (4.1)	15 (5.1)
Occupation of Father
Farmer	109 (75.2)	208 (71.2)
Merchant	23 (15.9)	60 (20.5)
Private employee	7 (4.8)	6 (2.1)
Government employee	6 (4.1)	18 (6.2)
Family size
Less than five	104 (71.7)	215 (73.6)
Greater than or equal to five	41 (28.3)	77 (26.4)
Monthly income (ETB)
≤ 1000	68 (51.9)	134 (51.2)
1001–2000	29 (22.1)	49 (18.7)
2001–3000	14 (10.7)	16 (6.1)
≥ 3001	20 (15.3)	63 (24.0)
^a= marital status of respondents including widowed, divorced, single

Child Biographic Related Characteristics

The mean age of children were 16.77 (SD = ± 3.09) months among cases and 17.21 (SD = ± 3.11) months among controls. About the half of the children under the study were male by sex, 71 (49.0%) among cases and 148 (50.7%) among controls. Concerning birth order of the child 66 (45.5%) among cases and 105 (36%) among controls were born fourth and above birth order. The median birth interval of children under the study were 24.0 (IQR = 6.33) months among cases and 24.0 (IQR = 6.35) months among controls respectively. The majority of respondents relation to the child were mothers, 125 (86.2%) among cases and 255 (87.3%) among controls (Table 2).

Table 2

Child biographic related characteristics on determinants of defaulter to full vaccination among children aged from 12 to 23 months in Siraro District, West Arsi Zone, Oromia, Ethiopia 2022 (n = 437)
Variables	Cases, n (%)	Control, n (%)
Sex of the child
Male	71 (49.0)	148 (50.7)
Female	74 (51.0)	144 (49.3)
Birth order of the child
First birth order	20 (13.8)	40 (13.7)
Second birth order	30 (20.7)	88 (30.1)
Third birth order	29 (20.0)	59 (20.2)
Fourth and above birth order	66 (45.5)	105 (36.0)
Birth Interval (in months)
< 24	67 (53.6)	145 (57.5)
24–36	53 (42.4)	93 (36.9)
> 36	5 (3.4)	14 (5.6)
Respondents relation to child
Mother	125 (86.2)	255 (87.3)
Caretaker	20 (13.8)	37 (12.7)

Knowledge, Attitude and service satisfaction related characteristics.

Of the interviewed child mothers/caretakers 84 (57.9%) among cases and 72 (24.7%) among controls were had inadequate knowledge about child vaccination. Concerning mothers/caretakers attitude towards child vaccination 53 (36.6%) among cases and 23 (42.1%) among controls had unfavorable attitude towards child vaccination. Regarding vaccination service satisfaction by child mothers/caretakers 117 (80.7%) among cases and 217 (74.3%) among controls were not satisfied on child vaccination service (Fig. 2).

Child Vaccination Service Delivery Related Characteristics

Concerning time to reach health facility for child vaccination by mothers/caretakers, 74 (51.0%) among cases and 86 (29.5%) among controls had spent greater than 30 minutes to reach the vaccination site by on foot walk time. About 43 (29.7%) mothers/caretakers of cases and 51 (17.5%) of controls had spent greater than or equal to fifteen minutes for waiting time at health facility during child vaccination. About 78 (53.8%) mothers/caretakers of cases and 124 (42.5%) of controls had no access to media.

Concerning mothers/caretakers information about vaccination 54 (37.2%) mothers of cases and 46 (15.8%) mothers of controls didn’t got information about possible vaccine side effects and 94 (64.8%) mothers/caretakers of cases and 267 (91.4%) of controls had got information about next vaccination schedules. About 88 (60.7%) mothers/caretakers of cases and 211 (72.3%) of controls were faced postponing vaccine schedule during they visited health facility for child vaccination (Table 3). Concerning child mothers/caretakers source of information for child vaccination 62 (42.8%) of cases and 155 (53.1%) of controls were got information from Health workers (Figs. 3).

Table 3

Child Vaccination Service Delivery related characteristics on determinants of defaulter to full vaccination among children aged from 12 to 23 months in Siraro District, West Arsi Zone, Oromia, Ethiopia 2022 (n = 437)
Variables	Cases, n (%)	Control,n (%
Time to reach health facility (in walk time)
Less than or equal to 30 minutes	71 (49.0)	206 (70.5)
Greater than 30 minutes	74 (51.0)	86 (29.5)
Waiting time at health facility (minutes)
Less than 15 minutes	102 (70.3)	241 (82.5)
Greater than or equal to 15 minutes	43 (29.7)	51 (17.5)
Means of transportation to health Facility
On foot walk	98 (67.6)	196 (67.1)
By transportation	47 (32.4)	96 (32.9)
Does transportation means incur payments
Yes	41 (87.2)	81 (84.4)
No	6 (12.8)	15 (15.6)
Access to media
Yes	67 (46.2)	168 (57.5)
No	78 (53.8)	124 (42.5)
Counselled on benefit of immunization by HEWs
Yes	105 (72.4)	269 (92.1)
No	40 (27.6)	23 (7.9)
Health workers told type of vaccine received
Yes	74 (51.0)	236 (80.8)
No	71 (49.0)	56 (19.2)
Information about possible vaccine side effects
Yes	91 (62.8)	246 (84.2)
No	54 (37.2)	46 (15.8)
Information on next vaccine schedule
Yes	94 (64.8)	267 (91.4)
No	51 (35.2)	25 (8.6)
Postponing vaccine schedule
Yes	88 (60.7)	211 (72.3)
No	57 (39.3)	81 (27.7)
Parents discussion on immunization
Yes	67 (46.2)	215 (73.6)
No	78 (53.8)	77 (26.4)

Maternal Health Service Utilization Related Characteristics

Of the child mothers 103 (71.0%) among cases and 263 (90.1%) among controls were attended ANC follow up. Among those mothers who had attended ANC follow up, only 26 (25.2%) of cases and 84 (31.9%) of controls were attended fourth and above visit. Concerning child mothers participation in pregnant mother conference 94 (64.8%) among cases and 258 (88.4%) among controls were participated in pregnant mothers conferences. Of these mothers, only 67 (46.2%) among cases and 191 (65.4%) among controls were counselled on child vaccination after delivery. Forty-four (30.3%) mothers of cases and 176 (60.3%) of controls were attended PNC follow up. Of the interviewed child mothers, 34 (23.4%) among cases and 134 (45.9%) among controls were attended model family training (Table 4). About 71 (49.0%) mothers of cases and 234 (80.1%) of controls were gave birth at health facility (Fig. 4).

Table 4

Maternal Health Service Utilization related characteristics on determinants of defaulter to full vaccination among children aged from 12 to 23 months in Siraro District, West Arsi Zone, Oromia, Ethiopia 2022 (n = 437)
Variables	Cases, n (%)	Control, n (%)
Attended antenatal care follow up
Yes	103 (71.0)	263 (90.1)
No	42 (29.0)	29 (9.9)
Number of ANC Visit attended
First Visit	13 (12.6)	33 (12.5)
Second Visit	33 (32.0)	71 (27.1)
Third Visit	31 (30.1)	75 (28.5)
Fourth and above Visit	26 (25.3)	84 (31.9)
Tetanus Toxoid Vaccination during ANC Visit
Yes	89 (86.6)	241 (91.6)
No	14 (13.4)	22 (8.4)
Participation in Pregnant Mother Conference
Yes	94 (64.8)	258 (88.4)
No	51 (35.2)	34 (11.6)
Place of delivery
Health facility	71 (49.0)	234 (80.1)
Home	74 (51.0)	58 (19.9)
Counselled on child immunization after delivery
Yes	67 (46.2)	191 (65.4)
No	78 (53.8)	101 (34.6)
Attended PNC follow up
Yes	44 (30.3)	176 (60.3)
No	101 (69.7)	116 (39.7)
Number of PNC Visit
Only one visit	32 (72.7)	98 (55.7)
Two and above visit	12 (27.3)	78 (44.3)
Using modern contraceptive method
Yes	59 (40.7)	187 (64.0)
No	86 (59.3)	105 (36.0)
Attended model family training
Yes	34 (23.4)	134 (45.9)
No	111 (76.6)	158 (54.1)
Graduated as model family
Yes	19 (13.1)	102 (34.9)
No	126 (86.9)	190 (65.1)

The Most Defaulted Vaccine Types by children

Measles (20.4%), PCV3 (11.4%) and Penta3 (10.9%) were the most defaulted vaccines types that was identified from selected child mothers/ caretakers history with cross checking from children’s vaccination card (Fig. 5)

Determinants Of Defaulter To Full Vaccination

Of all assessed determinants of defaulter to full vaccination fourteen variables shows association in bivariable analysis; educational status of mother, educational status of father, average monthly income, time to reach health facility, health workers told types of vaccine received, next vaccine schedule, knowledge of mothers/caretakers, service satisfaction, ANC follow up, place of delivery, PNC follow up, attended model family training, participation in pregnant mother conference and parents discussion on immunization.

All variables with a p value < 0.25 in the bivariable analysis were entered into multivariable logistic regression analysis after adjusting for confounders. The odds of defaulter to full vaccination of the children were 4.32 times more likely higher among child mothers/caretakers who had inadequate knowledge about child vaccination as compared to those who had adequate knowledge of child vaccination (AOR = 4.32, 95% CI:2.79–6.70).

The odds of defaulter to full vaccinations of the children were 3.6 times more likely among unable to read and write educational status of child fathers as compared to those attended secondary (9–12) and above education (AOR = 3.66, 95% CI:1.29–10.39). The child born from mothers /caretakers who had spent time taken to reach health facility greater than 30 minutes were 2.45 times higher odds of defaulter to full vaccination than those mothers/caretakers who spent less than or equal to 30 minutes (AOR = 2.45, 95% CI:1.51–3.97). The result of this study signifies that the odds of defaulter to full vaccination of children were 2.37 times more likely higher among child mothers/caretakers who didn’t told about the type of vaccine received by health workers than those who had told type of vaccine received (AOR = 2.37, 95% CI:1.27–4.45).

The odds of defaulter to full vaccination of the children were 2.16 times more likely higher among child mothers/caretakers who had no parents discussion on child immunization as compared to their counterparts (AOR = 2.16, 95% CI:1.24–3.79). This study also showed that, child mothers/caretakers who had gave birth at home were 2.43 times more likely higher odds of defaulter to full vaccination of their children as compared to those who had gave birth at health facility (AOR = 2.43, 95% CI:1.39–4.25). The odds of defaulter to full vaccinations of the children were 2.47 times higher among child mothers/caretakers who did not participated in pregnant mother conference than those who had participation in pregnant mother conference (AOR = 2.47, 95% CI:1.35–4.49) (Table 5).

Table 5

Bivariable and Multivariable analysis on determinants of defaulter to full vaccination among Children Aged 12–23 Months in Siraro District, West Arsi Zone, Ethiopia 2022 (n = 437)
Variables	Cases, n(%)	Control, n(%)	COR(95%CI)	AOR(95%CI)	P Value
Educational status of Mothers/caretakers
Unable to read and write	101 (69.7)	163 (55.8)	1.57 (0.85, 2.89)*	1.01 (0.44, 2.33)	0.97
Primary (1–8)	27 (18.6)	86 (29.5)	0.79 (0.39, 1.61)	0.60 (0.25, 1.43)	0.25
Secondary (9–12) and above	17 (11.7)	43 (14.7)	1	1
Educational status of Fathers
Unable to read and write	93 (64.1)	148 (50.7)	2.72 (1.38, 5.37)*	3.66 (1.29, 10.39)	0.02**
Primary (1–8)	40 (27.6)	92 (31.5)	1.88 (0.91, 3.91)	2.42 (0.88, 6.61)	0.85
Secondary (9–12) and above	12 (8.3)	52 (17.8)	1	1
Average monthly income (ETB)
≤ 1000	68 (51.9)	134 (51.1)	1.59 (0.89, 2.86) *	1.20 (0.48, 3.03)	0.69
1001–2000	29 (22.1)	49 (18.7)	1.86 (0.94, 3.68)	1.42 (0.56, 3.61)	0.45
2001–3000	14 (10.7)	16 (6.1)	2.75 (1.15, 6.62)	1.43 (0.73, 2.74)	0.13
≥ 3001	20 (15.3)	63 (24.0)	1	1
Time to reach health facility (in walk time)
Less than or equal to 30 minutes	71 (49.0)	206 (70.5)	1	1
Greater than 30 minutes	74 (51.0)	86 (29.5)	2.49 (1.65, 3.76)*	2.45 (1.51, 3.97)	< 0.001**
Health workers told type of vaccine received
Yes	74 (51.0)	236 (80.8)	1	1
No	71 (49.0)	56 (19.2)	4.04 (2.61, 6.25)*	2.37 (1.27, 4.45)	0.01**
Information about next vaccine schedule
Yes	94 (64.8)	267 (91.4)	1	1
No	51 (35.2)	25 (8.6)	5.79 (3.40, 9.87)*	2.28 (0.94, 5.55)	0.71
Parents discussion on child immunization
Yes	67 (46.2)	215 (73.6)	1	1
No	78 (53.8)	77 (26.4)	3.25 (2.14, 4.93)*	2.16 (1.24, 3.79)	0.01**
Knowledge about child vaccination
Inadequate knowledge	84 (57.9)	72 (24.7)	4.20 (.2.75, 6.43)*	4.32 (2.79, 6.70)	< 0.001**
Adequate knowledge	61 (42.1)	220 (75.3)	1	1
Immunization Service Satisfaction
Not satisfied	117 (80.7)	217 (74.3)	1.44 (0.89, 2.36)*	1.46 (0.87, 2.44)	0.152
Satisfied	28 (19.3)	75 (25.7)	1	1
Attended ANC follow up
Yes	103 (71.0)	263 (90.1)	1	1
No	42 (29.0)	29 (9.9)	3.69 (2.19, 6.25)*	2.70 (0.95, 2.13)	0.62
Place of delivery
Health facility	71 (49.0)	234 (80.1)	1	1
Home	74 (51.0)	58 (19.9)	4.21 (2.72, 6.49)*	2.43 (1.39, 4.25)	0.002**
Attended PNC follow up
Yes	44 (30.3)	176 (60.3)	1	1
No	101 (69.7)	116 (39.7)	3.48 (2.28, 5.32)*	1.64 (0.95, 2.81)	0.074
Participation in pregnant mother conference
Yes	94 (64.8)	258 (88.4)	1	1
No	51 (35.2)	34 (11.6)	4.12 (1.44, 3.26)*	2.47 (1.35, 4.49)	0.003**
Attended model family training
Yes	34 (23.4)	134 (45.9)	1	1
No	111 (76.6)	158 (54.1)	2.76 (1.76, 4.33)*	1.16 (0.58, 2.33)	0.63
AOR = Adjusted Odds Ratio, COR = Crude Odds Ratio, CI = Confidence Interval, () Variable category with p value < 0.25 in bivariable analysis, () statistically significant at p-value < 0.05, 1 =* Reference group

This study was aimed to assess determinants of defaulter to full vaccination among children aged 12–23 months in Siraro District, Ethiopia. The identified determinants of defaulter to full vaccination in this study were inadequate knowledge of mothers/caretakers, unable to read and write educational status of child fathers, time to reach health facility greater than 30 minutes, home delivery, health workers not told type of vaccine received, caretakers did not participated in pregnant mother conference and no parents discussion on child immunization.

Knowledge of mothers/caretakers’ about child vaccination was associated with defaulter to full vaccination. Children born from mothers /caretakers who had inadequate knowledge on child vaccination were more likelihood of defaulter to full vaccination than those who had adequate knowledge of child vaccination. This finding is consistent with study done in Gindhir district, Wadla district, Nigeria and Rwanda (11, 13, 20, 21). Which indicates poor knowledge of mothers on child immunization can leads to defaulter to full vaccination. This might be due to child mothers who don’t know more about childhood vaccination and those not getting awareness about immunization may be reluctant in completing their child vaccination based on appropriate vaccine schedules. Having adequate knowledge may help them to have an interest to vaccinate their child.

According to this study, educational status of fathers were another determinant that showed a significant association with defaulter to full vaccination status of children. Those children born from fathers unable to read and write educational status were positively associated with defaulter to full vaccination than those fathers attended secondary and above education. This result is consistent with the study conducted at Pawi district (22), Sinana district (23), and Nigeria (21). Those child fathers who had no formal education could have inadequate information about vaccine-preventable diseases and the use of vaccination. This might be due to uneducated fathers could have no adequate understanding and decision-making skills on different child health service issues, including the importance of vaccination of children.

Time taken to reach health facility was one of the independent determinant of defaulter to full vaccination. Child mothers/caretakers who had spent greater than 30 minutes to reach health facility were more likely to default their child from full vaccination than those who had spent less than or equal to 30 minutes. This finding is in line with a study done in the Laelay Adiabo District of Tigray and Debra Markos Town (4, 24). Studies in Kenya and Somalia Putland also found that long time to vaccination site were a determinant of defaulter to full vaccination (25, 26). This may be due to the long time spent to reach health facility for child vaccination costs to the mothers/caretakers and this could may causes child mothers/caretakers to default their children from completion of immunization.

The result of this study revealed that child mothers/caretakers who did not told about the type of vaccine received by health workers were two times more likely to have defaulter to full vaccination of their children than those who had told type of vaccine received by health workers. The study conducted at Woldia Town in Ethiopia supports this finding. Which indicates that lack of awareness about type of vaccine received were the factor for defaulter to full vaccination of children (27). This might be due to mothers/caretakers may forgot wether the child was received all types of recommended vaccine. In addition, health care providers may not properly counsel on the next appointments and types of vaccine given to the child that may leads to defaulter to full vaccination of the children.

The study also found that mothers/caretakers who had no parents ever discussion on child immunization were 2 times more likely to have defaulter to full vaccination of their children than those who had parents discussion on child vaccination. This finding is supported by study done in Sinana District (23) and Afghanistan (28). Which shows the likelihood of defaulting from full vaccination of child immunization was more likely higher among mothers who have poor parents’ discussion on child vaccination. This could be due to household decision-making power of father and awareness of father on Vaccine Preventable Diseases may influences child mothers/caretakers to vaccinate their children.

Child born from mothers/caretakers who had gave birth at home were positively associated with defaulter to full vaccinations than those who had gave birth at health facility. The finding is consistent with the study conducted in different parts of Ethiopia (6, 22, 29) and Somalia (30). Which indicates giving birth at home had a direct and significant association with defaulter to full vaccination status of the children. This could be due to child mothers/caretakers who had gave birth at home miss chance of getting information on vaccination and health education about child immunization. This may causes the mothers/caretakers to default their children from completing full vaccination.

The child mothers/caretakers who did not participated in pregnant mother conference were had more likelihood of defaulter to full vaccinations of their children than those who had participation in pregnant mother conference. The finding is supported by study done in Afar region (31) and Oromia region in Central Ethiopia (29). This might be due to the mothers/caretakers who had not attended pregnant women conferences lacks more information and understanding on child vaccination, not have sufficient awareness about vaccine-preventable diseases and not knows more about the importance of vaccines. This could may enhances the risk of defaulter to full vaccination of the children.

Strength And Limitation Of The Study

Being community-based study and excluding those child mothers/caretakers who had missed child vaccination card and vaccination card had no date of childbirth in order to reduce recall and selection bias gives the strength for this study. As limitations, the risk factors of defaulters of vaccination may differ among the child mothers/caretakers that needs investigation through detail follow up of the defaulters’ processes from basic roots that requires prospective study was not applied in this study.

In this study, inadequate knowledge of mothers/caretakers’ about child vaccination, unable to read and write educational status of child fathers, time to reach health facility greater than 30 minutes, child mothers/caretakers who didn’t told about the type of vaccine received, home delivery, mothers who did not participated in pregnant women conference and no parents ever discussion on child vaccination were the identified determinants of defaulter to full vaccination. Thus, the district health office should work on defaulters of vaccination by strengthening immunization service delivery and health communication activities by improving maternal knowledge and awareness on child vaccination through encouraging women participation in pregnant mother conferences. Promoting institutional delivery to improve child vaccination through health extension packages for further understanding of vaccine preventable diseases and the importance of vaccines. Specific planning for children found in hard to reach area, focus on distribution of vaccination sites and add new vaccination sites as needed to address the issue of long travel time to reach health facility.

Health professionals should work on transferring appropriate health information to the child mothers/caretakers about the type of vaccine received, next vaccination schedule and importance of child vaccination to prevent child defaulting from vaccination. Moreover, the future researchers should conduct further study on the topic using prospective study design to investigate the detail processes of defaulter to full vaccination from basic roots through ongoing process of child vaccination follow up.

ANC: Antenatal Care, AOR: Adjusted Odds Ratio, COR: Crude Odds Ratio, DPT: Diphtheria Pertussis Tetanus, EDHS: Ethiopian Demographic Health Survey, EPI: Expanded Program on Immunization, Hib: Haemophilus influenzae type b, HepB: Hepatitis B, MCV: Measles Vaccine, PCV: Pneumococcal Conjugate Vaccine, SPSS: Statistical Package for Social Sciences, VPDs: Vaccine Preventable Disease, WHO: World Health Organization.

Ethical approval and Consent to participate

The ethical letter was obtained from Research Ethical Review Committee of Salale University, College of Health Science, before conducting the study based on the Declaration of the Helsinki. Letter of Permission was obtained from Siraro District Health Office and respective kebeles to undertake the study. All the study participants were clearly informed about the objectives or purposes of procedures, privacy and confidentiality issues of the study. Their right to refuse or not to participate in the study at any time they want was assured. Finally, the informed written consent was obtained from each study participant before starting data collection.

Availability of Data and Materials

All the data sets generated during and/or analyzed during the study are included into the study and available from the corresponding author on reasonable request.

Conflicts of Interests

The authors declared that they have no conflicts of interests.

Funding

The study was funded by Salale University on behalf of Oromia Health Bureau (OHB) sponsorship Author Contributions

AHG and TN participated on Conceptualization, data curation, formal analysis, investigation, funding acquisition, methodology, project administration, resources, software, supervision, validation, visualization, writing original draft, writing review and editing the manuscript. DBS, MT, BSD, NSD and SMD were involved on methodology, resources, data curation, analysis, investigation, supervision, validation, writing review and editing the manuscript.

Acknowledgement

First, we would like to express our deepest gratitude to Salale University, College of Health Sciences for providing this opportunity to participate on this research project activity. In addition, we would like to extend our appreciation and thanks to all data collectors, supervisors, study participants and the Siraro District Health Office for their kind supports during conducting this study.

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No competing interests reported.

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Determinants of defaulter to full vaccination among children aged 12-23 months in Siraro District, West Arsi zone, Oromia, Ethiopia: A Case-Control study

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Abstract

Background

Objectives

Methods

Result

Conclusion

Figures

Introduction

Methods and Materials

Study Design, Period and Area

Source Population And Study Population

Inclusion Criteria And Exclusion Criteria

Sample Size Determination

Sampling Procedures

Study Variables

Dependent Variable

Independent Variables

Measurements And Operational Definitions

Data Collection Tool and procedures

Data Quality Assurance

Data processing and analysis

Result

Sociodemographic Characteristics of study participants

Child Biographic Related Characteristics

Knowledge, Attitude and service satisfaction related characteristics.

Child Vaccination Service Delivery Related Characteristics

Maternal Health Service Utilization Related Characteristics

The Most Defaulted Vaccine Types by children

Determinants Of Defaulter To Full Vaccination

Discussion

Strength And Limitation Of The Study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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