5.1.1. Immunization coverage and timeliness
At national level there were six national level surveys conducted to assess immunization coverage ; four EDHS studies (8–11) and two National EPI coverage surveys (5, 12). In addition three FMOH administrative reports (13–15) and two WHO/UNICEF reports were reviewed (16, 17). These studies showed an upward trend in immunization coverage in recent years in Ethiopia. The recent EDHS 2016 report indicated that the national immunization coverage has reached 39% from the coverage reported in 2000 (14%) (11). However, regional disparities exist since 2000 till now where emerging regions have very low immunization coverage consistently. There are also marked urban-rural differences in vaccination coverage over time. The full immunization coverage rates included in the EDHS surveys were found to be far below EPI coverage survey findings, administrative reports and WHO/UNICEF estimates (13, 14, 16, 17) [Table 1]. From the review findings, the overall access to vaccination services was low. Access to vaccination was lowest in the Afar and Somali regions (5, 10, 11). The dropouts from immunization were not in the acceptable range evidenced by the recent EDHS report (20% for Penta). This dropout rate is very high as compared to the target set for 2020 under the comprehensive multiyear plan (4) [Table 1]. The percentage of children who have received no vaccination was also consistently high and stagnant since 2000 (17%) until 2016 (16%) (8, 11).
Table 1
National Evidence on Full immunization coverage and timeliness in Ethiopia
S.N | Author | Design | Sample | Topic | Major findings | Conclusions |
1 | CSA, USAID (2000) | Cross sectional | 2,143 | National EPI coverage survey report in Ethiopia | • DPT I 40% and DPT III 18% • 14% full (0% in Afar and 74% in AA) o Urban 42% and Rural 11% • 17% Not vaccinated | • Substantial differences in the coverage between regions • High dropouts |
2 | CSA, USAID (2005) | Cross sectional | 1, 877 | National EPI coverage survey report in Ethiopia | • DPT I 58% and DPT III 32%, • 20% fully (Afar 0.6% and AA 70%) • 24% No vaccination | • High dropout rates • Many unvaccinated children |
3 | Kidane T(2006) | Cross sectional survey | 6,903 children | National EPI coverage survey report in Ethiopia | • DPT I 84.3% and DPT III 66% • Fully 49.9% (Somali 14% and AA 87% ) • Timely coverage of 20% | • Progress was not uniform in all regions of the country • Dropout rate was high |
4 | CSA, 2011 | Cross sectional survey | 1,927 | National EPI coverage survey report in Ethiopia | • 24% fully vaccinated (Afar 8% and AA 78%) o Urban 48% and rural 20% • 16% No vaccinations | • Disparity between regions • High dropout rate |
5 | EPHI (2012) | Cross sectional survey | 3,762 | National immunization coverage survey | • Receiving all basic vaccination is 50% o Afar and Somali 12.6% while AA 94% • Valid dose of 18.6% | • Access and utilization is low in most regions • High drop-out rates |
6 | FMOH (2014) | HMIS | National | Policy and practice information for action | • Full 77.7% and Penta II 87.6% | • Relatively good coverage |
7 | CSA, USAID (2016) | Cross sectional | 2,004 children | Ethiopian demographic and health survey | • 39% fully (Afar 15% and AA 89%) • 22% were vaccinated timely • No vaccinations 16% | • The EDHS surveys have shown a steady progress in EPI coverage |
8 | FMOH (2015) | HMIS | National | Health and health related Indicators : 2016 | • Penta III 94.4% and Fully 86.6% | • Showed good progress since 2010 coverage of 86% |
9 | WHO/UNICEF (2017) | Estimate | National | WHO and UNICEF estimates of immunization coverage: 2017 revision | • DPT I 85% and DPT III 73% in 2017 | • Showed progress from previous estimates |
10 | FMOH (2018) | HMIS | National | Annual Health Sector Performance report | • Penta III 96% and full coverage 87% • Pent1 to measles drop-out was 13% | • Showed progress |
There were also 15 pocket studies that determined immunization coverage in different regions of the country. Among them two were done in Oromia region with full vaccination coverage of 22.9% (18) and 36% (19), while five were done in Amhara region with full immunization coverage ranging between 58.4 and 91.7% (20–24). Single study done in Afar(25), Somali(26) and Tigray (27) regions showed that the full vaccination coverage was 20.6%, 36.6% and 51% respectively. The remaining four studies were conducted in Southern Nations and Nationalities (SNNP) region which showed immunization coverage ranging from 18.4–73.2% (28–31). Studies were not found from Gambella and Benshangul- Gumuz regions. A survey by USAID in four regions of the country also revealed that full immunization coverage was better than the findings of majority of the studies (69%) (6). The studies generally showed that the vaccination coverage in majority of the study studies was low and the progress was not uniform across different regions of the country. Differences in coverage could be attributed by differences in the sampling frame, design, sample size, representativeness of the sample, and selection methodology, as well as differences in the source of information. Similarly, the Penta3 coverage was much lower than the Penta I coverage in all the studies with unacceptable range of dropout rates resulting in higher number of partially vaccinated children. The percentage of children who have received no vaccination also varied from study area to study area much worsening in SNNP region (28, 29). The results reported from these surveys were generally lower than the administrative reports and national estimates (14, 16) [Table 2].
Table 2
Local evidence on immunization coverage and timeliness of immunization in Ethiopia
S.N | Author | Design | Sample | Topic | Study area | Major findings | Conclusions |
1 | Kidane T (2000) | Cross sectional | 220 | Factors influencing child immunization coverage in a rural District of Ethiopia | Tselemti district, Tigray Ethiopia | • 51% full coverage • BCG to measles defaulter 23.9% | High dropout rate |
2 | Beyene E (2006) | Cross-sectional | 740 | Factors associated with immunization coverage | Zone 3 of Afar Regional State | • Full immunization coverage was 20.6% | Low immunization coverage |
3 | Hussien M (2010) | Cross sectional | 168 | Assessment of Child Immunization Coverage and Associated Factors in Oromia Regional State, Eastern Ethiopia | Kombolcha district, Oromia | • 24.2% not immunized, • 52.9% partial and 22.9% fully • PentaI 73.8% % Penta III 33.1% | Low coverage High dropout rate |
4 | Belachew E (2011) | Cross sectional | 536 | Factors associated with complete immunization coverage | Ambo Woreda, Central Ethiopia | • 36% fully vaccinated • 23.7% unvaccinated | Low coverage |
5 | Waju B(2012) | Cross sectional | 655 children | Childhood immunization coverage in Tehulederie district | Tehulederie district | • 83.1% of children were fully • 14.7% partially vaccinated | Relatively high coverage |
6 | Ayal D (2013) | Cross sectional | 497 | Assessment of fully vaccination coverage and associated factors in Mecha district | Mecha district, North West Ethiopia | • 49.3% were fully immunized • 1.6% c were not vaccinated | Coverage remains very low in the district |
7 | Amanuel D (2013) | Cross sectional | 981 | Determinants of Full Child Immunization; Evidence from Ethiopia | SNNP | • 81.6% children were not fully vaccinated | Low coverage |
8 | Abdi N (2014) | Cross sectional | 582 | Assessment of Child Immunization Coverage and Associated Factors in Oromia Regional State, Eastern Ethiopia | Jigjiga District, Somali Regional State, Ethiopia | • 74.6% were ever vaccinated • 36.6% were fully vaccinated | Coverage was found to be low |
9 | Mastewal W(2014) | Cross sectional | 724 | Factors for Low Routine Immunization Performance Dessie Town, Ethiopia | Dessie Town, Amhara, Ethiopia | • Full coverage 65.2% • 17.9% never get vaccine | Low coverage |
10 | Worku A (2014) | Cross sectional | 630 | Expanded program of immunization coverage and associated factors | Arba Minch town and Zuria District | • 73.2% fully, 20.3% partially and 6.5% received no vaccine | Better than the national immunization coverage |
11 | Melkamu B (2015) | Cross-sectional | 751 | Level of immunization coverage and associated factors among children | Lay Armachiho District | • 76% were fully immunized | High coverage |
12 | Tenaw G (2016) | Cross-sectional | 288 | Vaccination Coverage and Associated Factors | Debre Markos Town, Ethiopia | • 91.7% of children were completely vaccinated | High coverage |
13 | Yemesrach A(2016) | Cross-sectional | 484 | Predictors and Barriers to Full Vaccination among Children in Ethiopia | Worabe, SNNP, Ethiopia | • 61% were fully vaccinated | Relatively high coverage |
14 | Asrat M (2017) | Cross sectional | 322 | Assessment of Child Immunization Coverage and Associated Factors | Mizan Aman Town, | • 49.4% were partially immunized and 42.2% were fully immunized | Coverage was low |
15 | USAID(2015) | Cross-sectional | 1,597 | Extended Program on Immunization (EPI) coverage in selected Ethiopian zones | Seven Zones, Ethiopia | • Penta III of 79% and fully 69% • Timely vaccination of 60% | Child vaccination coverage significantly varied among zones |
Timeliness of the valid doses given, as defined by timely doses provided before 12 months of age, was also assessed in the three studies conducted at national level. Evidenced from the national EPHI study indicated that, valid dose of all basic vaccines under one year was 18.6% by 2012 (5). The EDHS 2016 report also has shown that only 22% of children were vaccinated timely before their first birth day (11). These findings are lower than the full immunization coverage of similar studies indicating that children are not getting the recommended vaccines as per the WHO recommendations. The evidence also indicated that timeliness of immunization is not given due attention in the national EPI program (5, 11, 12). The trend in immunization coverage also revealed that the immunization coverage is far below the target (Fig. 2). Timeliness was also assessed in one local study which indicated that the timely full immunization coverage was 60% that has much better performance as compared with the timeliness coverage reported by national studies (6). Except the one mentioned, none of the local studies reported evidence on timeliness of immunization.
5.1.2. Determinants of immunization service utilization
Barriers and facilitators of immunization program were mainly tied to program acceptability, appropriateness, access and health system constraints. The main determinants associated with inequalities in coverage are multifaceted: From the existing evidence place of residence, region, maternal health services, access to media, distance from health facility and individual socio demographic characteristics of caregivers were found to be predictors of full immunization. There were a total of 6 national and 27 local studies on barriers and facilitators of immunization service uptake for which the findings are summarized below.
Geographic distribution: There were large geographical differences in vaccination coverage in Ethiopia as indicated by the national surveys (5,10,11,32). The immunization coverage in Afar, Somali and Gambella regions were much lower than the coverage’s in Addis Ababa and Diredawa (33,34). The consecutive EDHS surveys also indicated that regional disparities have not been changed over time (11). The local studies also revealed that studies in Amhara and Oromia regions have better immunization coverage though they didn’t achieve the national targets set at national level (4). The survey conducted by USAID in four regions of the country also indicated that there is significant variation in immunization coverage across regions and zones (6).
Household economic status: Household economic status strongly influences the likelihood that a child will be vaccinated. Children in the richest wealth quintile were more likely to be fully vaccinated when compared to children in the poorest quintile in majority of the reviewed studies (5,6,10,11,34). In contrary, family income was found to be insignificant in a study from Arbegona district (35) and another study from SNNP region (28).
Age of caregivers/mothers: Majority of the studies showed that age of caregiver/mother has no significant association with immunization coverage (6,19,29,36). In contrary, from studies conducted in Jijiga town (26) and Arbegona district (35) it was found that it has a significant association with immunization coverage.
Birth order: The birth order of the child was not significant factor in two studies (31,36) while it had significant association with child vaccination in the study from Arbegona district (35).
Family Size: Family size was not addressed in most of the studies. Two studies concluded that family size has no significant association with immunization coverage (35,36) while one study showed that it is a predictor for full immunization coverage (22).
Caregiver/mother’s education: Caregivers/mother’s educational status is an influential factor for using immunization services in all regions. Children of caregivers who have completed secondary or higher education are much better vaccinated than children whose caregiver have no formal education (5,6,12,20,22,25–29,34).
Caregiver/mother’s occupation: Studies indicated that caregivers/mother’s occupation has no significant association with immunization service up take (12,24,29).
Child Sex: In some societies with cultural discrimination against female children, boys have a greater chance to be vaccinated. In almost all studies child sex has no significant association with immunization coverage (6,12,19,22,28,29,31). Only two studies concluded that it has significant association with child immunization (23,24).
Place of residence: Place of residence measured as living in urban or rural area strongly influenced vaccination coverage in majority of the studies. Children in urban areas are significantly more likely to receive all recommended vaccinations than children in rural areas (5,11,12,21,23,26–28). On the other hand , effect of residence was not significant in three of the studies (6,19,29).
Knowledge about vaccination: Mothers knowledge was significantly associated with immunization coverage (19,20,22,29,36). It was identified that children whose mothers had good knowledge on immunization and vaccine-preventable disease were more likely to be fully vaccinated than children whose mother has poor knowledge. This kind of knowledge can change mothers’ health seeking behavior which in turn enhances immunization coverage. Knowledge on child vaccination was not significant predictor as indicated from the two studies (35,36).
Attitude about vaccination: Positive attitude towards immunization was the enabling factors for full immunization(25). Wrong perception on contraindication were significant predictors for partial immunization(18). Similarly, wrong perception about vaccine side effects hinders immunization service uptake (35).
Access to media: Access to media and awareness about community conversation program were also predictors to full immunization coverage in two of the studies (28,32) while it was found to be insignificant in one study (34).
Maternal health services: Attending ANC (19,24,32,36,37),TT vaccination (19,23,26), institutional delivery (19,26,29,34,36,37) and PNC attendance (36) were found to be strong predictors of full immunization coverage. This could have happened due to mother’s health seeking behavior and it may create a good opportunity for the mother to vaccinate their children. On the other hand, in a study from Arbamich town and Zuria ANC follow up was not significant predictor of child immunization (29).
Geographic access: To increase coverage immunization service is supposed to be provided at static sites, outreach sites and through mobile approach for hard to reach areas. Short distance was enabler for full immunization (21,24,29) while distance of a functioning health facility did not show a difference in immunization coverage in another survey (5).
Household visit by health workers: House hold visit by health workers was not significant factor in one study (36) while it has a significant association with child immunization in another study (26).
Community level factors: Community level factors were not well addressed in majority of the studies. A study by Abadura et al. indicated that 21 % of the variation in full immunization is attributed by community level factors. In this study, community ANC utilization rate has also significant association with full immunization coverage (34).
Reasons for vaccine hesitancy and not completing immunization: The reasons for not completing vaccination schedules were reported in some studies as descriptive findings. Among the reasons for defaulting, 41.8% was forgetting the appointment date and 34.2% lack of awareness (36). The most common reasons for not vaccinating the child were fear of side reactions (36%), being too busy (31%) and hearing rumors about vaccines (28%) (38). Qualitative study in Hadiya Zone of Ethiopia also identified the main reasons for defaulting from the immunization program as poor counseling of mothers, unsupportive provider-client relationships and lack of systems for tracking defaulters (39).
5.2. Health service availability
There were five studies which reported child immunization service availability. The evidence from EPHI indicated that 94% of public facilities offered child immunization services compared with 2% of private facilities (5). In general, 80% of health facilities provide immunization service nationally. Regions wise, Benshangul-Gumuz, Tigray, Oromia, SNNP and Amhara regions have better coverage. On the other hand Addis Ababa has the lowest coverage (40) which could be explained by the fact that private health facilities are not engaged in routine immunization services. All the five studies revealed that most of health facilities are providing routine immunization service of which only few provide on daily basis (6, 40, 41).
According to EPHI survey in 2014, 53% of facilities that offer child immunization services have guidelines and 47% of them have at least one staff member trained on child immunization (41). Actions by higher levels in conducting supervision and providing written feedback were the likely significant factors contributing to good immunization performance in Ethiopia (42). Facility level determinants including service interruption, training on EPI and defaulter tracing system were also independent predictors of complete vaccination (6) [Table 3].
Table 3
Evidence on child immunization service availability
S.N | Authors | Design | Sample size | Topic | Study area | Major findings /conclusions |
1 | EPHI (2012) | Cross sectional survey | 585 government run health facilities | Ethiopian national immunization coverage survey | National | • 42.5% of health facilities had a planned session interrupted • Though more than 90% of the health facilities are providing routine EPI service, only 24.4% are providing the services daily • In-service training on EPI service delivery was low for health facility staff within the past year (57%) • The defaulter tracing system exists in 85% of health facilities |
2 | Habtamu B (2015) | Review | More than hundreds of related materials | Review on Measles Situation in Ethiopia; Past and Present | National | Accumulation of unvaccinated children in highly populated areas contributed for the frequent measles outbreaks occurring in different parts of the country |
3 | AschaleT(2014) | A cross-sectional study | 302 health facilities | Factors contributing to routine immunization performance in Ethiopia | National | • Actions by higher levels in conducting supervision and providing written feedback are the likely significant factors contributing to good immunization performance in Ethiopia |
4 | EPHI (2014) | Cross sectional | 835 | Ethiopia Service Provision Assessment Plus Survey | National | • 53% of facilities that offer child immunization services have guidelines and 47% of them have at least one staff member trained • Majority of these facilities have equipment for vaccination services |
5 | USAID (2015) | Cross-sectional household and facility surveys | Selected health facilities | Extended Program on Immunization (EPI) coverage in selected Ethiopian zones | Seven Zones, Ethiopia | • 99% of health posts and 96% of health centers were providing RI • 37% of health centers were providing EPI services on a daily basis • Facility level determinants including service interruption, training on EPI and defaulter tracing system were independent predictors of complete vaccination |
6 | EPHI (2016) | Cross sectional | 705 health facilities | SARA, Ethiopia | National | • 16% of facilities offered immunization services only in daily basis at the facility • Availability of the six antigens ranged between 29 percent for Oral Polio Vaccine to 36 percent for measles |