Vaccination Dropout, Socioeconomic Inequality and Spatial Distribution of Vaccination Dropout and Zero-Dose Children Aged12-35 Months in Remote and Underseved Settings of Ethiopia.
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Date
2024-04
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Addis Ababa University
Abstract
Vaccination is considered as one of the most successful and cost-effective public health measures, averting
millions of deaths every year. Although vaccination coverage is increasing globally, many children in low-
and middle-income countries drop out of the vaccination continuum. Globally, 25 million children were
either underimmunized or zero-dose in 2021. Inequality in access to childhood vaccinations is also another
major obstacle to the astounding progress in basic vaccination coverage. This study was conducted to
estimate the prevalence of vaccination dropout, examine socioeconomic inequalities in vaccination
dropout, decompose socioeconomic inequalities and map the spatial distribution of zero-dose and
measles vaccination dropout children in underserved settings of Ethiopia. A generalized estimating
equation was used to assess determinants of vaccination dropout and concentration curve and index were
used to estimate wealth related inequality of vaccination dropout. A decomposition analysis approach was
used to decompose socioeconomic inequalities into the contributions of individual factors to inequalities
in vaccination dropout. Spatial autocorrelation was measured using the Global Moran's I statistic. Getis-
Ord Gi* statistics was applied to calculate the spatial variability of zero-dose and measles vaccination
dropout cases. Spatial interpolation technique was also applied to predict unknown values that fall
between known values. A total of 3,646 mothers/caregivers of children participated in the study. The
overall Penta-1 to Penta-3 dropout estimate was 44%. Developing regions and urban slums had the highest
and the lowest vaccination dropout estimates (60.1% and 11.2%), respectively. Caregivers who were
working outside their homes, who did not receive a service from a skilled birth attendant, who were less
gender empowered and who were in the lowest wealth strata had increased odds of Penta-1 to Penta-3
dropout. Inequalities in vaccination dropout were significantly and disproportionately concentrated
among the poor (CI = −0.179; p < 0.01). According to the decomposition analysis, wealth index, place of
residence, skilled birth attendance, and availability of a health facility in the kebele contributed the most
to socioeconomic inequalities in vaccination dropout. Overall, MCV-1 and MCV-2 coverages were 67% and
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35%, respectively. On average, the measles vaccination dropout estimate was 48.3%. Refugees and urban
slums had the highest and the lowest measles vaccination dropout estimates (56.4% and 37.7%),
respectively.
The hot spot analysis detected the highest burden of measles vaccination dropout in the Afar Region’s
zones 1 and 5, the Amhara Region’s North Gondar Zone and the Somali Region’s Siti Zone. Western, eastern
and northern parts of Somali and western and central parts of Afar regions had the highest load of zero-
dose children. Vaccination dropout estimates were high among children residing in remote, hard-to-reach,
and conflict-affected settings of Ethiopia. The overall MCV-1 and MCV-2 coverage estimates were low,
measles vaccination dropout was high. The highest burdens of zero-dose and measles vaccination dropout
cases were detected mainly in the northeastern parts of Ethiopia.
Strengthening horizonal integration of immunization services with maternal & child health services and
empowering women would help reduce vaccination dropout. Due to its recent introduction, the lack of
awareness around MCV-2 needs to be addressed, especially in the northeastern part of Ethiopia.
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Keywords
Vaccination, Children