What we know and don't know about the immunization program of Ethiopia: a scoping review of the literature

Coverage, spatial distribution and determinants of childhood inactivated poliovirus vaccine immunization in Ethiopia

INTRODUCTION

Polio eradication is a current and common strategy throughout the globe. The study of the newly introduced inactivated poliovirus vaccine provides a grasp on the current status of immunization and identifies any disparities in the implementation of the vaccine throughout Ethiopia. Thus, this study aimed to demonstrate the spatial distribution, coverage, and determinants of inactivated poliovirus vaccine immunization in Ethiopia.

METHOD

Spatial distribution and determinants of inactivated poliovirus vaccine immunization in Ethiopia were conducted using Ethiopian mini-demographic and health survey 2019 data. A total of 2,056 weighted children aged 12 to 35 months were included in the analysis. The association between the outcome and explanatory variables was determined by commuting the adjusted odds ratio at a 95% confidence interval. The p-value of less than 0.05 was used to declare factors as significantly associated with the inactivated poliovirus vaccine immunization.

RESULT

The weighted national coverage of inactivated poliovirus vaccine immunization in Ethiopia was 51.58% at a 95% confidence interval (49.42, 53.74). While the rates of inactivated poliovirus vaccine immunization were observed to be greater in Addis Ababa, Tigiray, Amahara, and Benishangul Gumuz provinces and lower in the Somali, Afar, and SNNPR provinces of Ethiopia, Antenatal care follow-up, place of delivery, place of residence, and region were significantly associated with inactivated poliovirus immunization in Ethiopia.

CONCLUSION

The distribution of inactivated poliovirus immunization was spatially variable across Ethiopia. Only about half of the children aged twelve to thirty-five months received the inactivated poliovirus vaccine in the country. The factors, both at the individual and community level, were significantly associated with inactivated poliovirus immunization. Therefore, policies and strategies could benefit from considering antenatal care follow-up, place of delivery, place of residence, and region while implementing inactivated poliovirus vaccine immunization.

Spatial variation and predictors of incomplete pneumococcal conjugate vaccine (PCV) uptake among children aged 12-35 months in Ethiopia: spatial and multilevel analyses

Background

Despite the Ethiopian government included the Pneumococcal Conjugate Vaccine (PCV) in the national expanded program for immunization in 2011, only 56% of children aged 12-23 months received the full dose of PCV. Despite some studies on PCV uptake in Ethiopia, there was a dearth of information on the geographical distribution and multilevel factors of incomplete PCV uptake. Hence, this study aimed to identify the spatial variations and predictors of incomplete PCV uptake among children aged 12-35 months in Ethiopia.

Methods

The study was based on an in-depth analysis of 2016 Ethiopia Demographic Health Survey data, using a weighted sample of 3,340 women having children aged 12-35 months. Arc-GIS version 10.7 and SaTScan version 9.6 statistical software were used for the spatial analysis. To explore spatial variation and locate spatial clusters of incomplete PCV, the Global Moran's I statistic and Bernoulli-based spatial scan (SaTScan) analysis were carried out, respectively. A multilevel mixed-effect multivariable logistic regression was done by STATA version 16. Adjusted odds ratio (AOR) with its corresponding 95% CI was used as a measure of association, and variables with a p < 0.05 were deemed as significant determinants of incomplete PCV.

Results

The overall prevalence of incomplete PCV in Ethiopia was found to be 54.0% (95% CI: 52.31, 55.69), with significant spatial variation across regions (Moran's I = 0.509, p < 0.001) and nine most likely significant SaTScan clusters. The vast majority of Somali, southeast Afar, and eastern Gambela regions were statistically significant hot spots for incomplete PCV. Lacking ANC visits (AOR = 2.76, 95% CI: 1.91, 4.00), not getting pre-birth Tetanus injections (AOR = 1.84, 95% CI: 1.29, 2.74), home birth (AOR = 1.72, 95% CI: 1.23, 2.34), not having a mobile phone (AOR = 1.64, 95% CI: 1.38, 1.93), and residing in a peripheral region (AOR = 4.63; 95% CI: 2.34, 9.15) were identified as statistically significant predictors of incomplete PCV.

Conclusion

The level of incomplete PCV uptake was found to be high in Ethiopia with a significant spatial variation across regions. Hence, the federal and regional governments should collaborate with NGOs to improve vaccination coverage and design strategies to trace those children with incomplete PCV in peripheral regions. Policymakers and maternal and child health program planners should work together to boost access to maternal health services like antenatal care and skilled delivery services to increase immunization coverage.

Diarrheal disease and associated factors among children aged 6 to 59 months in Oda Bultum District, Eastern Ethiopia: a community-based cross-sectional study

BACKGROUND

Diarrhea is a serious health problem in children under the age of five that is both preventable and treatable. In low-income countries like Ethiopia, children under the age five years frequently experience diarrhea. However, the burden and associated factors of these diarrheal diseases are understudied in Eastern Ethiopia, Thus, this study aimed to determine the factors associated with the prevalence of diarrheal diseases in Eastern Ethiopia from September 1-30, 2022.

METHODS

A cross-sectional study was conducted on the total of 602 children aged 6 to 59 months in Oda Bultum district in eastern Ethiopia. A multistage sampling method was used. Three kebeles were selected from nine kebeles by the lottery method. Data was entered into Epi data 4.0.2 and exported to SPSS version 21 for analysis. Descriptive analysis was used for frequency, mean, and standard deviations. In addition, bivariable, and multivariable Poisson regression model was used to identify predictors of diarrhea along with a 95% confidence interval. Finally, statistical significance was declared at a p-value of 0.05.

RESULT

A total of 602 children were included in this study. The prevalence of diarrhea 7.4% (47/602), 95% CI; 5.5-9.7%) among the children. Factors such as being unvaccinated for any vaccine (AOR = 10.82, 95%CI; 4.58-25.48) and born from a mother who had medium level of empowerment (AOR = 0.34, 95%CI; 0.11-0.88) in the household had statistically significant association with diarrhea among the children compared to their counterparts.

CONCLUSION

The study found that nearly one out of thirteen children aged 6 to 59 months had any form of diarrheal diseases in Oda Bultum District, Eastern Ethiopia. In addition, the study revealed that children who were vaccinated for their age developed diarrhea less likely compared to those who did not receive any form of vaccine for their age. Moreover, children with mothers who had a medium level of empowerment were less likely to get diarrhea than children with mothers who had a low level of empowerment.

High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis

BACKGROUND

Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children.

OBJECTIVE

To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia.

METHODS

A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant.

RESULTS

The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5].

CONCLUSION

In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.

Socioeconomic inequalities in vaccine uptake: A global umbrella review

This global umbrella review aimed to synthesise evidence of socioeconomic inequalities in the uptake of routine vaccinations and identify the mechanisms that may contribute to the association. To our knowledge, no attempt has been made to synthesise the global body of systematic reviews across a variety of vaccines, geographical locations, and measures of SES. The inclusion criteria were as follows: studies assessing vaccination uptake according to education, income, occupation/employment, and/or area-level deprivation; any country or universally recommended routine vaccination (according to the WHO); qualitative or quantitative reviews, published 2011-present. The searches were performed in eight databases. The screening process followed PRISMA-E guidelines, each stage was performed by one reviewer, and a 10% sample checked by a second for consistency. Included reviews underwent data extraction, quality appraisal (AMSTAR-2), and narrative synthesis according to country-context. After deduplication, 9,163 reports underwent title and abstract screening, leaving 119 full texts to be assessed for eligibility. Overall, 26 studies were included in the umbrella review. Evidence for lower uptake amongst disadvantaged SES individuals was found in all 26 reviews. However, 17 reviews showed mixed results, as inverse associations were also identified (lower uptake for advantaged SES, and/or higher uptake for disadvantaged SES). Those that explored high-income countries had a greater prevalence of mixed findings than those focusing on low/middle-income countries. The two most frequently cited mechanisms were vaccination knowledge, and confidence in vaccination or vaccination providers. These mechanisms were often understood by review authors as varying by level of education. We find socioeconomic differences in routine vaccination uptake, but the association did not always follow a gradient. Whilst education may be associated with uptake globally, our study indicates that its role varies by country-context. A limitation is the overlap of some primary studies across the included systematic reviews.

Effect of COVID-19 on Routine Childhood Vaccination in Bahir Dar City, Northwestern, Ethiopia

Despite free vaccinations for all children, Ethiopia is one of the ten countries where most children do not receive all of their basic vaccines. The COVID-19 pandemic has disrupted service delivery and utilization worldwide. In this study, we assessed the effect of the pandemic on routine childhood vaccinations in Bahir Dar, Ethiopia. The data were collected from immunization records, health system monthly reports, and interviews with vaccination professionals. The data were analyzed using interrupted time series and thematic analyses. In 6940 records covering 2018-2022, the number of vaccine doses that were delivered steadily increased except for 2021/22. Vaccine delivery consistently increased prior to the pandemic. Immediately after the first case was reported, there were some disruptions, but they were not statistically significant compared to the pre-pandemic period. In-depth interviews also confirmed this finding, showing early pandemic fear and protective measures had an impact but were not sustained. These results show that COVID-19 has had a transient but non-significant effect on childhood vaccination. Although the interruption was statistically insignificant, it could reverse decades of progress toward safeguarding children from vaccine-preventable diseases. Therefore, we must intensify our initiatives to boost childhood vaccination rates and restore pre-pandemic services to regain momentum and avoid future setbacks.

Missed opportunity for routine vaccination and associated factors among children aged 0-23 months in public health facilities of Jimma Town

The current recommendation obligates children to receive all vaccines within two years of birth. The Expanded Program on Immunization (EPI) was established in Ethiopia to increase the immunization rate by 10% annually and to reach 100% in 10 years but not been achieved in twenty years. Missed opportunity for vaccination (MOV) is one of the major factors in vaccination coverage. Hence, this study aimed to assess the prevalence of MOV and associated factors in Jimma Town public health facilities. A facility-based cross-sectional study design was employed with a quantitative data collection method. The sample size was calculated using a single population proportion formula. The data were collected through face-to-face interviews, and data extraction methods and analyzed using SPSS version 26. The statistical association was decided at p-value <0.05 with 95% CI, and AOR. A total of 422 children were involved in this study making a 100% response rate. The magnitude of MOV was 39.8% (95%CI: 35-45). Parents/caretakers have not attended formal education (AOR = 4.65, CI:1.64-13.24), residing in rural (AOR = 2.60, CI: 1.35-5.03), poor knowledge about immunization (AOR = 2.61, CI: 1.58-4.30), the child not assessed for vaccination status (AOR = 3.01, CI: 1.65-5.49), and parents/caretakers not seen/heard vaccination message in the last month (AOR = 2.42, CI: 1.40-4.18) were statistically positively associated with the MOV. In conclusion, this study indicated that MOV among the children was high in the study facilities. The researchers recommended stakeholders work on strengthening community awareness creation. Additionally, further study incorporating physician-related factors is also suggested.

Childhood vaccination practices and associated factors among mothers/caregivers in Debre Tabor town, Northwest Ethiopia: A cross-sectional study

BACKGROUND

Incomplete immunization and non-immunization increase the risk of disease and death among children. This study aims to assess childhood vaccination practices and associated factors among mothers and caregivers in Debre Tabor town, Amhara region, Ethiopia.

METHODS

A community-based cross-sectional study design was conducted between February 30 and April 30, 2022. The study participants were proportionally allocated to all six kebeles found in the town. A systematic random sampling technique was used to select the study participants. The collected data were checked and coded and then entered into EpiData Version 3.1 and exported into SPSS Version 26. The results were organized using frequency tables, graphs, and charts, and bivariate and multivariable logistic regression were used to test the association of covariates with childhood vaccination practices.

RESULT

Approximately 422 study mothers and caregivers participated in the study, with a response rate of 100%. The mean age was 30.63 years (11.74), which ranged from 18 to 58 years. More than half of the study participants (56.4%) expressed fears about the side effects of vaccination. A majority (78.4%) of the study participants availed of counseling services about vaccination, and 71.1% of them received regular antenatal care. This study found that approximately 280 [66.4%, 95% confidence interval (CI): 61.8-70.6] mothers/caregivers had a history of good childhood vaccination practices. The factors of the fear of side effects [adjusted odds ratio (AOR) = 3.34; 95% CI: 1.72-6.49], no workload (AOR = 6.08; 95% CI: 1.74-21.22), medium workload (AOR = 4.80; 95% CI: 1.57-14.71), being a mother of child/children (AOR = 2.55; 95% CI: 1.27-5.13), positive attitude (AOR = 2.25; 95% CI: 1.32-3.82), and sound knowledge (AOR = 3.88; 95% CI: 2.26-6.68) were significantly associated with childhood vaccination practices.

CONCLUSION

More than half of the study participants had a history of good childhood vaccination practices. However, the rate of such practices was low among mothers and caregivers. The fear of side effects, workload, motherhood, attitude, and knowledge were all factors associated with childhood vaccination practices. Awareness creation and a consideration of the workload of mothers would be helpful in dispelling fears and increasing the rate of good practices among mothers and caregivers.

Spatial distribution of rotavirus immunization coverage in Ethiopia: a geospatial analysis using the Bayesian approach

Introduction

Rotavirus causes substantial morbidity and mortality every year, particularly among under-five children. Despite Rotavirus immunization preventing severe diarrheal disease in children, the vaccination coverage remains inadequate in many African countries including Ethiopia. Measuring rotavirus immunization coverage in a lower geographic area can provide information for designing and implementing a targeted immunization campaign. This study aimed to investigate the spatial distributions of rotavirus immunization coverage in Ethiopia.

Methods

Rotavirus immunization coverage data were obtained from the recent Ethiopian Demographic and Health Survey (EDHS 2019). Covariate data were assembled from different publicly available sources. A Bayesian geostatistics model was used to estimate the national rotavirus immunization coverage at a pixel level and to identify factors associated with the spatial clustering of immunization coverages.

Result

The national rotavirus immunization coverage in Ethiopia was 52.3% (95% CI: 50.3, 54.3). The immunization coverage varied substantially at the sub-national level with spatial clustering of low immunization coverage observed in the Eastern, Southeastern, and Northeastern parts of Ethiopia. The spatial clustering of the rotavirus immunization coverage was positively associated with altitude of the area [mean regression coefficient (β): 0.38; 95% credible interval (95% CrI): 0.18, 0.58] and negatively associated with travel time to the nearest cities in minutes [mean regression coefficient (β): − 0.45; 95% credible interval (95% CrI): (− 0.73, − 0.18)] and distance to the nearest health facilities [mean regression coefficient (β): − 0.71908; 95% credible interval (95% CrI): (− 1.07, − 0.37)].

Conclusions

This study found that the rotavirus immunization coverage varied substantially at sub-national and local levels in Ethiopia. The spatial clustering of rotavirus immunization coverage was associated with geographic and healthcare access factors such as altitude, distance to health facilities, and travel time to the nearest cities. The immunization program should be strengthened in Ethiopia, especially in the Eastern, Southeastern, and Northeastern parts of the Country. Outreach immunization services should be also implemented in areas with low coverage.

Spatiotemporal distributions of immunization coverage in Ethiopia from 2000 to 2019

BACKGROUND

Vaccination is the most important mechanism to improve childhood survival. However, immunization coverage is very low and unevenly distributed throughout the country. Therefore, this study was aimed to investigate the spatiotemporal distribution of immunization coverage in Ethiopia.

METHOD

Immunization coverage data and geospatial covariates data were obtained from EDHS 2000 to 2019 and different publicly available sources. A Bayesian geostatistic model was used to estimate the national immunization coverage at a pixel level and to identify factors associated with the spatial clustering of immunization coverages.

RESULT

The overall immunization coverage in Ethiopia was 38.7%, 36.55%, 51.8%, 67.1% and 66.9% for 2000, 2005, 2011, 2016 and 2019 respectively. Spatial clustering of low immunization coverage was observed in Eastern, Southern, Southwestern, Southeastern and Northeastern parts of Ethiopia in EDHSs. The altitude of the area was positively associated with immunization coverage in 2000, 2005 and 2019 EDHS. The population density was positively associated with immunization coverage in 2000, 2005, 2011 and 2016. Precipitation is also positively associated with immunization coverage in 2016. Moreover, mean annual temperature was positively associated with immunization coverage in 2000, 2005 and 2019 EDHSs. Travel time to the nearest city is negatively associated with immunization coverage in 2000, 2005, 2011 and 2016. Likewise, distance to health facilities was negatively associated with immunization coverage in all the five EDHSs.

CONCLUSION

This study found that immunization coverage in Ethiopia substantially varied across the subnational and local levels. Spatial clustering of low immunization coverage was observed in Southern, Southeastern, Southwestern, Northeastern, and Eastern parts of the country. Altitude, population density, precipitation, temperature, travel time to the nearest city in minutes, and distance to the health facilities were factors that affect the spatial clustering of immunizations coverage. These findings can guide policymakers in Ethiopia to design geographically targeted interventions to increase programs to achieve maximum immunization coverage.

Modeling the relative risk of incidence and mortality of select vaccine-preventable diseases by wealth group and geographic region in Ethiopia

Immunization is one of the most effective public health interventions, saving millions of lives every year. Ethiopia has seen gradual improvements in immunization coverage and access to child health care services; however, inequalities in child mortality across wealth quintiles and regions remain persistent. We model the relative distributional incidence and mortality of four vaccine-preventable diseases (VPDs) (rotavirus diarrhea, human papillomavirus, measles, and pneumonia) by wealth quintile and geographic region in Ethiopia. Our approach significantly extends an earlier methodology, which utilizes the population attributable fraction and differences in the prevalence of risk and prognostic factors by population subgroup to estimate the relative distribution of VPD incidence and mortality. We use a linear system of equations to estimate the joint distribution of risk and prognostic factors in population subgroups, treating each possible combination of risk or prognostic factors as computationally distinct, thereby allowing us to account for individuals with multiple risk factors. Across all modeling scenarios, our analysis found that the poor and those living in rural and primarily pastoralist or agrarian regions have a greater risk than the rich and those living in urban regions of becoming infected with or dying from a VPD. While in absolute terms all population subgroups benefit from health interventions (e.g., vaccination and treatment), current unequal levels and pro-rich gradients of vaccination and treatment-seeking patterns should be redressed so to significantly improve health equity across wealth quintiles and geographic regions in Ethiopia.

Linked vaccination coverage surveys plus serosurveys among Ethiopian toddlers undertaken three years apart to compare coverage and serologic evidence of protection in districts implementing the RED-QI approach

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A seroprotective tetanus titer indicates a toddler has received pentavalent vaccine.

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Serosurveys document increased seroprevalence post-measles vaccination campaigns.

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Vaccination coverage/serosurveys can assess interventions to improve immunizations.

In low and middle-income countries, estimating the proportion of vaccinated toddlers in a population is important for controlling vaccine-preventable diseases by identifying districts where immunization services need strengthening. Estimates measured before and several years after specific interventions can assess program performance. However, employing different methods to derive vaccination coverage estimates often yield differing results.

Methods

Linked vaccination coverage surveys and seroprotection surveys performed among ~300 toddlers 12–23 months of age in districts (woredas), one per region, of Ethiopia (total, ~900 toddlers) in 2013 to estimate the proportion vaccinated with tetanus toxoid (a proxy for pentavalent vaccine) and measles vaccine. The surveys were followed by implementation of the Reaching Every District using Quality Improvement (RED-QI) approach to strengthen the immunization system.

Linked coverage/serosurveys were repeated in 2016 to assess effects of the interventions on vaccination coverage. Indicators included “documented coverage” (vaccination card and/or health facility register records) and “crude coverage” (documented plus parent/caretaker recall for children without cards). Seroprotection thresholds were IgG-ELISA tetanus antitoxin ≥0.05 IU/ml and plaque reduction neutralization (PRN) measles titers ≥120 mIU/ml.

Findings

Improved markers in 2016 over 2013 include coverage of pentavalent vaccination, vaccination timeliness, and fewer missed opportunities to vaccinate. In parallel, tetanus seroprotection increased in the 3 woredas from 59.6% to 79.1%, 72.9% to 83.7%, and 94.3 to 99.3%. In 2015, the Ethiopian government conducted supplemental measles mass vaccination campaigns in several regions including one that involved a project woreda and the campaign overlapped with the RED-QI intervention timeframe; protective measles PRN titers there rose from 31.0% to 50.0%.

Interpretation

The prevalence of seroprotective titers of tetanus antitoxin (stimulated by tetanus toxoid components within pentavalent vaccine) provides a reliable biomarker to identify children who received pentavalent vaccine. In the three study woredas, the RED-QI intervention appeared to improve immunization service delivery, as documented by enhanced pentavalent vaccine coverage, vaccination timeliness, and fewer missed vaccination opportunities. A measles mass vaccination campaign was followed by a markedly increased prevalence of measles PRN antibodies. Collectively, these observations suggest that wider implementation of RED-QI can strengthen immunization, and periodic linked vaccination surveys/serosurveys can monitor changes.

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia

BACKGROUND

Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

OBJECTIVE

This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

METHODS

A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

RESULTS

A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

CONCLUSIONS

Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.

Determinants of Incomplete Vaccination Among Children Aged 12 to 23 Months in Gindhir District, Southeastern Ethiopia: Unmatched Case-Control Study

Background

Incomplete vaccination can put children at greater risk of acquiring vaccine-preventable diseases. In Ethiopia, vaccination coverage against vaccine-preventable diseases is still a significant and persistent public health challenge. Thus, the aim of this study was to identify the determinants of incomplete childhood vaccination among children aged 12-23 months in Gindhir District, Southeast Ethiopia.

Methods

A community-based unmatched case-control design was employed among children aged 12-23 months from 1 to 28 February 2020. A total of 254 cases and 508 controls were included using the stratified random sampling technique. Cases included children aged 12-23 months who missed at least one dose of the routine vaccination, and controls were the children with complete vaccination with all required doses. Binary logistic regression analyses were used to identify the independent factors for children's incomplete vaccination status.

Results

Of all assessed determinants, maternal knowledge about vaccination (AOR=0.50, 95% CI: 0.31, 0.80), educational status (AOR=2.61, 95% CI: 1.19, 5.67), average monthly income (AOR=0.33, 95% CI: 0.15, 0.77), model family (AOR = 2.50, 95% CI: 1.51, 4.14), taking TT vaccine (AOR= 0.45 95% CI: 0.29, 0.78), number of under five children (AOR= 4.90 95% CI: 1.72, 13.93) and birth order (AOR= 6.33, 95% CI: 1.89, 14.87) were found to have statistically significant association with childhood incomplete vaccination.

Conclusion

In this study, the mother's education, model family, birth order, average monthly income, and knowledge were some of the independent determinants of incomplete childhood vaccination. Improving maternal knowledge, income, and educational status should be the expectable measure to reduce incomplete vaccination.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.

Routine health management information system data in Ethiopia: consistency, trends, and challenges

Background: Ethiopia is investing in the routine Health Management Information System. Improved routine data are needed for decision-making in the health sector. Objective: To analyse the quality of the routine Health Management Information System data and triangulate with other sources, such as the Demographic and Health Surveys. Methods: We analysed national Health Management Information System data on 19 indicators of maternal health, neonatal survival, immunization, child nutrition, malaria, and tuberculosis over the 2012-2018 time period. The analyses were conducted by 38 analysts from the Ministry of Health, Ethiopia, and two government agencies who participated in the Operational Research and Coaching for Analysts (ORCA) project between June 2018 and June 2020. Using a World Health Organization Data Quality Review toolkit, we assessed indicator definitions, completeness, internal consistency over time and between related indicators, and external consistency compared with other data sources. Results: Several services reported coverage of above 100%. For many indicators, denominators were based on poor-quality population data estimates. Data on individual vaccinations had relatively good internal consistency. In contrast, there was low external consistency for data on fully vaccinated children, with the routine Health Management Information System showing 89% coverage but the Demographic and Health Survey estimate at 39%. Maternal health indicators displayed increasing coverage over time. Indicators on child nutrition, malaria, and tuberculosis were less consistent. Data on neonatal mortality were incomplete and operationalised as mortality on day 0-6. Our comparisons with survey and population projections indicated that one in eight early neonatal deaths were reported in the routine Health Management Information System. Data quality varied between regions. Conclusions: The quality of routine data gathered in the health system needs further attention. We suggest regular triangulation with data from other sources. We recommend addressing the denominator issues, reducing the complexity of indicators, and aligning indicators to international definitions.