ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

ASSESSING CHILD IMMUNIZATION COVERAGE AND ITS DETERMINANTS IN

SINANA DISTRICT, BALE ZONE, OROMIA REGIONAL STATE, ETHIOPIA, 2013

BY: - WORKU DECHASSA (BSc)

A THESIS SUBMITTED TO THE GRADUATE STUDIES PROGRAM OF

ADDIS ABABA UNIVERSITY IN PARTIAL FULLFILMENT OF THE
REQUIREMENTS FOR DEGREE OF MASTERS OF PUBLIC HEALTH
(MPH) IN REPRODUCTIVE HEALTH

APRIL 2013
ADDIS ABABA
 COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

ASSESSING CHILD IMMUNIZATION COVERAGE AND ITS DETERMINANTS IN

SINANA DISTRICT, BALE ZONE, OROMIA REGIONAL STATE, ETHIOPIA, 2013

By: Worku Dechassa (B.Sc.)

------------------------------------------------ -------------------------------- ----------------------

Chairman of Dep.Graduate Committee Signature Date

Mulugeta Betre Gebremariam (MD, MPH) ---------------------- ------------------------------

Advisor Signature Date

__________________________________
External Examiner ---------------------------- -------------------------------
Signature Date

_________________________________ --------------------------- ----------------------------------

Internal Examiner Signature Date

I
ACKNOWLEDGEMENT
I am very grateful to my advisor Dr. Mulugeta Betre Gebremariam of the Department of
Reproductive Health and Health Services Management School of Public Health, College Health
Science Addis Ababa University (AAU), for his unreserved guidance and constructive suggestions
and comments beginning from proposal development. Without his genuine support, this work
cannot be a reality.

I am also grateful to United Nations Population Fund (UNFPA) for its full financial support of this
study and AAU for the all rounded support.
I would like to acknowledge the Oromia Health Bureau, Sinana Health Office, and Sinana district
community specially mothers and Focus Group Discussion (FGD) participants of this study.
Again I would like to extend my appreciation to Dr. Alemayehu Worku for the invaluable
suggestions and comments on software handling and through writing result; and Dr. Wubegzer
Mekonnen for his invaluable suggestion and advice throughout write up of the result.

Due recognition also goes to Dr. Wakgari Daressa for his help during proposal development.
I take this opportunity to extend my thanks to all of my teachers, the library, and computer lab
staffs of Addis Ababa University, who have encouraged me during the process of writing the
thesis and overall across my stay with them as a student of Masters of Public Health in the
Department and all my class mates who helped/encouraged me throughout my stay.

Last but not least, I am in indebted to the encouragement and support of my family, Lemma
Demissie for his contribution and my wife Yerom Tafesse for her data entering, advice on
technical part of computer and encouraging me throughout my stay as a student in the university.
In doing so and else, she has proven that she is my life time partner. Also, I would like to thank all
the super visors, local guides and data collectors.

I
TABLE OF CONTENTS pages

ACKNOWLEDGEMENT .......................................................................................................................I
TABLE OF CONTENTS ……………. ................................................................................................ II
List of Tables………… ........................................................................................................................ IV
List of Figures ……............................................................................................................................... V
Abbreviations and Acronyms ............................................................................................................... VI
ABSTRACT ....................................................................................................................................... VII
INTRODUCTION .................................................................................................................................. 1
1.1 Background ..................................................................................................................... 1
1.2 Statement of the Problem ................................................................................................ 3
1.3 Significance of the Study ................................................................................................ 4
LITERATURE REVIEW ....................................................................................................................... 5
OBJECTIVE OF THE STUDY ............................................................................................................ 10
3.1 General Objective .......................................................................................................... 10
3.2 Specific Objective ......................................................................................................... 10
METHODS ........................................................................................................................................... 11
4.1 Study area and Period .................................................................................................... 11
4.2 Study Design ................................................................................................................. 11
4.3 Population...................................................................................................................... 11
4.3.1 Source Population………………………………………………………………………...11
4.3.2 Study Population…………………………………………………………………………. 11
4.4 Inclusion and Exclusion criteria .................................................................................... 11
4.4.1 Inclusion Criteria:………………………………………………………………………..11
4.4.2 Exclusion Criteria:……………………………………………………………………….11
4.5 Sample size determination and Sampling technique ..................................................... 12
4.5.1 Sample size determination: (For quantitative data)………………………………12
4.5.2 Sampling Technique………………………………………………………………………12
4.6 Study variables .............................................................................................................. 13
4.6.1 Variables of the Study…………………………………………………………………….13
4.7 Data collection Instrument ............................................................................................ 13
4.8 Data Collectors Recruitment and Training .................................................................... 14
4.9 Data Collection Process ................................................................................................ 14
4.10 Data Analysis .............................................................................................................. 15
4.10.1 for Quantitative Data……………………………………………………………………15
4.10.2 for Qualitative Data……………………………………………………………………..15
4.11 Data Quality Control ................................................................................................... 15
4.12 The Ethical Consideration ........................................................................................... 16
4.13 Operational and Standard Definitions ......................................................................... 16
4.14 Dissemination plan ...................................................................................................... 17

II
RESULTS ............................................................................................................................................. 18
5.1 Socio -demographic Characteristics of Study Population ............................................. 18
5.2 Maternal Health Care Utilization (antenatal care and postnatal care utilization) ......... 21
5.3 Socio -demographic Characteristics of Children in Sinana district, Bale zone............. 21
5.4 Availability and Accessibility of Vaccination Service ................................................. 23
5.5 Knowledge of Mothers/Caretakers on Vaccination and Vaccine Preventable Disease 25
5.6 Attitudes of Respondent toward Immunization ............................................................ 29
5.7 Immunization Coverage among 12-23 months aged Children ...................................... 29
5.7.1 Immunization Coverage by Card only…………………………………………………30
5.7.2 Immunization Coverage by Card plus Mother Recall……………………………….30
Factor affecting immunization completion for children ....................................................................... 31
Socio-demographic Characteristics of Caretakers/Mothers ................................................ 31
Maternal Health Care Utilization ........................................................................................ 35
Availability and Accessibility of Vaccination Service ....................................................... 37
Knowledge and attitudes of mother on vaccination and vaccine preventable diseases ...... 39
Child Characteristics ........................................................................................................... 42
DISCUSSION....................................................................................................................................... 46
STRENGTH AND LIMITATION OF THE STUDY .......................................................................... 53
CONCLUSIONS AND RECOMMENDATIONS ............................................................................... 54
REFERENCES ..................................................................................................................................... 56
ANNEXES ........................................................................................................................................... 59
Annex 1:- current immunization schedule in Ethiopia ........................................................ 59
Annex 2:- conceptual frame work for determinants of immunization coverage in Sinana..60
Annex3: -Schematic presentation of sampling procedure. .................................................. 61
Annex 4:- Data collection instrument ................................................................................. 62
II.QUESTIONNAIRE IN AFAN OROMO VERSION ....................................................................... 75
III. Focus group discussion guide ......................................................................................................... 86
Annex 5:- Attitude of the Respondent toward immunization in sinana district .................. 87
Annex6:-Source of information by area of residence in sinana district ............................. 88
Annex7:- Reason given by mothers for not completing immunization of children among
partially/ unvaccinated in sinana ........................................................................................ 89
Annex8:- map of study area (Sinana district) ...................................................................... 90
Annex 9:- Letters for declaration ........................................................................................ 91

III
List of Tables Pages

Table .1 Socio-demographic and Economic Characteristics of the Respondents in Sinana…........19

Table2. Maternal health care utilization, Sinana district, Bale zone………………………............21

Table3. Characteristics of Children Aged 12-23 Months in Sinana district …..............................22

Table4. Availability and Accessibility of Vaccination site in Sinana district……………….........23

Table5. Respondents’ information on vaccine and given information on immunization in Sinana25

Table5.1 Respondents Knowledge on Vaccine and Vaccine Preventable Diseases, Sinana……...27

Table6. Immunization status of Children aged 12-23 months by Mothers’ history plus

Vaccination card, Sinana district…………….……………………………………………29

Table7. Completion of immunization among children aged 12-23 months by Socio Demographic

Characteristics of Mothers /Caretakers and Fathers in Sinana………………………………….....33

Table8. Completion of Immunization among Children aged 12-23monts by Maternal Health Care

Utilization, Sinana…………………………………………………………………………36

Table9. Completion of Immunization among 12-23months aged Children by Availability and

Accessibility of health care service, Sinana………………………………………………38

Table10. Completion of Immunization among children aged 12-23 months by Mothers

Knowledge on Vaccine and Vaccine Preventable Diseases in Sinana….............................40

Table11. Immunization Completion among children aged between 12-23 months by

Characteristics of Child, Sinana…………………………………………………………...42

Table12. Multivariate analysis for completion of child immunization (fully immunized)

in Sinana district and selected variables, ………………………………………………..43

IV
List of Figures Pages

Figure1. Immunization Coverage by Source of Information in Sinana district……………….…31

Figure2. Reason given by Mother why returned home without getting immunization during

appointment for Child immunization in Sinana…………………………………………………...45

V
Abbreviations and Acronyms
AAU Addis Ababa University

AFP Acute Flaccid Paralysis

ANC Ante natal Care
BCG Bacille Calmette-Guerin
CMR Child Mortality Rate
DPT Diphtheria Pertussis and Tetanus
EDHS Ethiopia Demographic Health Survey
EOS Enhanced Out-reach Services
EPI Expanded Program on Immunization
FGD Focus Group Discussion
FMOH Federal Ministry of Health
GAVI Global Alliance for Vaccines and Immunization
GIVS Global Immunization Vision and Strategy
HepB Hepatitis B
HEWs Health Extension Worker
HIB Haemophilus Influenza type B
HSDP Health Sector Development Program
IMCI Integrated Management of Childhood Illness
MCH Maternal and Child Health
MDGs Millennium Development Goals
NGOs Non-Governmental Organizations
OPV Oral Polio Virus
RDV Rural drug vender
RED Reaching Every District
SOS Sustainable Out-reach Services
UNICEF United Nation International Children’s Emergency Fund
UNFPA United Nation Population Fund
U5MR Under Five Mortality Rate
VPDs Vaccine Preventable Diseases
WHO World Health Organization

VI
ABSTRACT
Background: - Immunization remains one of the most important public health intervention and
cost effective strategy to reduce child mortality and morbidity associated with infectious diseases
and is estimated to avert between 2 and 3 million deaths each year. The objective of this study was
to assess complete immunization coverage and its associated factors among children age 12-23
months in Sinana district.
Methods: - A cross-sectional community based survey was conducted in 6 kebeles (PA) of Sinana
District from 29, December 2012 –16, January 2013. A modified World Health Organization
Expanded Program on Immunization cluster sampling methods was used for household selection.
Data on 591 children aged 12-23 months and mothers pair were collected by using a pre-tested
structured questionnaire through house to house visits from vaccination card and mother’s verbal
reports. Bivariate and multivariate logistic regression analyses were used to assess factors
associated with fully immunization coverage of children.
Results: - of 591 interviewed mothers’ of children, only 10.2% of the mothers have attended
secondary and above level of education. Of children included in this study, only 33% of them had
vaccination card at time of the survey and about 76.8% of the children aged 12-23 months were
fully vaccinated by card plus history. Factors significantly associated with full immunization were
antenatal care follow-up (adjusted odds ratio (AOR = 3.7, 95% CI: 2.3- 5.9), mother occupation
being farmer (AOD=1.9, 95% CI:1.14-3.1), educational level of father being secondary and above
(AOD=3.1, 95%CI:1.3-7.4), household family income greater than one thousand(AOD=3.2, 95%
CI:1.4-7.4) , average walking time less than an hour(AOD=3.1, 95% CI:1.5-6.3), ever discuss
about immunization with health service extension worker(AOD=2.4, 95%CI:1.32-4.2) and
mother’s sufficient knowledge on immunization(AOD=2.5, 95% CI 1.5-4.2) , whereas area of
residence , educational level of mother and child sex were not significantly associated.
Conclusion: - Even though, immunization coverage of children in sinana district gets
improvement over national coverage, yet it is below governmental plan of 90%. Maternal Health
care utilization and knowledge of mother about vaccine and Vaccine Preventable Diseases are the
main factors associated with complete immunization coverage. It is vital that, local programmatic
intervention should be strengthened to upgrade awareness of the community on the importance of
immunization, antenatal care and working on advancing economical status of community is the
way to optimize children’s immunization coverage.

VII
 INTRODUCTION

1.1 Background
Universal immunization of children against six preventable diseases (tuberculosis, diphtheria,
Pertussis, tetanus, polio, and measles) is vital to reduce childhood mortality and morbidity across
the world and so it is one of the indicators of development in most developing countries with
averting 2 to 3 million deaths each year. The Expanded Program on Immunization (EPI) was
launched in 1974 as a global program for controlling and reducing death from Vaccine-
preventable diseases. Thus, vaccine coverage is estimated, as by convention, with DTP3 coverage
achieved among children aged 12–23 months (1, 2).

At the end of 2011, immunization was reported to have saved 2-3 million lives; nonetheless, in the
same year 1.5 million children are estimated to have died (more than 70% live in ten countries)
from VPD a reflection of the incomplete coverage with existing vaccines that persists in many parts
of the world. Goal of Global Immunization Vision and Strategy (GIVS), were to reduce global
measles deaths with 90% by 2010 or earlier (3, 4).

The WHO Africa region and the Global alliance for vaccines and immunization (GAVI) in 2000
have set a goal of reaching >80% DTP3 coverage in every District in >80% of developing
countries by 2005. This goal is referred as the "80/80 goal". To achieve a goal, the GAVI
proposed a new approach, Reaching Every District (RED) in 2002 (4). Millennium development
goal (MDG) four aims is a two-thirds reduction of U5MR by 2015. Measles immunization
coverage is one of the indicators for progress towards MDG 4. In 2008, there were an estimated
164,000 measles deaths globally. WHO estimates that during 2000–2007, measles-caused deaths
declined by 89% in Africa. However, measles outbreaks continue to occur throughout the region (5).

In 1980, the government of Ethiopia initiated the implementation of EPI with goal of increasing
vaccination coverage against the six childhood killer diseases by 10% each year to reach 100%
coverage in 1990; this program goal has largely remained unrealized even using different efforts.
Despite the high prevalence of VPDs in the country, immunization coverage rates stagnated and
remained very low for many years. HSDPIV goal of the ministry of health EPI strategy is to
achieve 96% DPT3 coverage in all regions. The major hindering factors in achieving universal
immunization includes: low access to services, low number of trained manpower, high turnover of

1
staff, lack of fund donors, lack of information, lack of transportation, distance of facility,
inadequate awareness of mothers/caregivers, others such as missed opportunities, and high
dropout rates; especially through routine approaches (6,7). Strategies and innovations under taken
to increase the national EPI coverage were by implementing new approaches such as Sustainable
Out-reach Services (SOS) and RED which started in 2004 to benefit from it in reducing child and
infant mortality by 25% if fully immunized by one year of age (6, 7). The EDHS 2011; showed
coverage level for DPT3 and that of fully immunization to be 36.5% and 24.3%. Oromia region
DPT3 and full immunization coverage were 26.8% and 15.6% respectively. According EDHS
2011 DPT3 coverage in many of the regions was below 80%, lowest in Afar region 9%, highest in
Tigray 73.4% and in Oromia 26.8% (8). Infant mortality rate stood at 59, 73 and U5MR was 88,
112 per thousand live births for national and Oromia region respectively. Reducing U5MR to
67/1000 by 2015 can only be achieved if cost effective and high impacts interventions developed
in support of the child health program are implemented at very high levels of coverage which
includes among others: RED strategy, IMCI and enhanced outreach strategy (EOS) (9).

In connection to this pentavalent was introduced in 2006 with objective of increasing pentavalent
three (DPT-HepB-Hib3) coverage to 88% by the end of 2011(10, 11). The current immunization
schedule in Ethiopia is specified under annex1.

2
1.2 Statement of the Problem
Vaccine Preventable Diseases are responsible for about 25% of the 10 million deaths occurring
annually among under five years children. Vaccines were widely regarded as an effective but
across the world 26.3 million children below the age of one year had not been immunized with
DPT3 in 2008(5,12). The WHO African regional office estimated that about 5 million children
were un-immunized for DPT3 (2007), 73% of these children live in 10 countries including Ethiopia.
Five of the African Region including Ethiopia, were the Region still continuing and even increasing
further to the pool of unimmunized children in 2010 and 2011(17)

Although the world is dedicated to reduce death from vaccine preventable diseases, conversely,
VPD are estimated to 1.6 million deaths occur every year, of which 50-60% were contributed by
Measles (4, 6, 13). Even if estimated number of death from measles dropped from733, 000 deaths
in 2000 to 164,000 in 2008(by 78%), still several regions notably South Asia and Sub Saharan
African show much lower coverage and measles outbreaks occurred in several African countries
during 2008, including the Democratic Republic of the Congo (12,461 reported cases), Ethiopia
(3,511), Niger (1,317), and Nigeria (9,960 (14, 18).

In Ethiopia Measles is one of the five major causes of childhood illnesses, which together
contribute to 70% of under-five morbidity and mortality (4). According to the WHO measles
burden estimator, Ethiopia contributes to 46% of the cases and 51% of the deaths from measles
among eight eastern African countries. Low measles immunization rate seems reasonable to
attribute a slightly larger proportion of mortality to measles in Ethiopia (15, 16, 18) and there were
VPD outbreaks, for which some claimed their lives and disabled many more. For instance, polio
outbreak between December 2004 and February 2006, 24 children of these 8 ,9 and 7 children from
Tigray, Amhara and Oromia Regional State, were paralyzed respectively, as a result of infection
with wild poliovirus type 1 (16).

Majority of district of Ethiopia appeared less optimally performing on DPT3 with anticipated
coverage level of 50% in 2011(17).

3
 1.3 Significance of the Study
In order to increase the child immunization, the underlined causes should be known. To do so, the
reason do not immunize their children should be known. In the study area, no immunization related
study was conducted before. According to the District report, there were episodes of VPDs in
Sinana District for instance in 2008, 2009 and 2010. There were 3, 5 and 2 measles cases
respectively which is may be due to low immunization coverage (27).according to district report
immunization coverage in Sinana was 85%. But so far community based immunization coverage
was not assessed. Therefore, this study will try to fill these gaps by identifying the child
immunization coverage and factors associated with full immunization. And will help policy makers,
program planning bodies and service providers to remove the obstacles and improve child
immunization to attain intended control of vaccine preventable diseases. It also helps as a baseline
for future studies.

4
 LITERATURE REVIEW
Coverage of immunization and related factors

Immunization stands as good public intervention to reduce and control morbidity and mortality
from vaccine preventable diseases so as to achieve increasing immunization coverage and
improving its quality is mandatory. There are factors hindering immunization coverage. Of this,
some are revealed by study at different areas and reviewed as follows:

According to finding from Xay district of western pacific region in Lao DPT3, coverage was 72%,
higher than the national target of 65%; however, the dropout rate was 21%. Influential factors on
fully immunized child was distance, literacy, possession of livestock; mothers knowledge of
immunization target diseases, measles immunization schedule; and mother’s willingness to pay for
immunization, zone of residence and ethnic group were significantly associated with
immunization status (28). On other hand, finding from Tehran in Iran among 668 child’s mothers
surveyed revealed that more than half (67%) of respondents gave disproportionate importance to
mild intercurrent illness as a reason to defer immunization ,Increase in birth order, number of
children in household and mother’s age significantly predicted vaccination schedule non-
adherence (29).

The cluster survey, which was carried out in Agra district of India in 2006 showed that the reason
for non immunization is lack of awareness (52.1%, fear of side effect of vaccination 16.6%,
vaccine were not available 6.25%, child was ill 4.6% out of 221 children (31), other study in India,
Murshidabad district showed family size, birth order, religion (Musilm55.7% and Hindus 68.4%),
mothers’ education, and wealth status were significantly associated with fully immunization.
Further, the immunization rate was higher where health workers had visited mothers during their
pregnancy period and the effectiveness of the persuasion of the health worker was quite evident
since the subsequent visits to remind the mothers about immunization improved the coverage
further (32).

Study in northern Nigeria revealed, place of birth, ownership of an immunization card, ANC use,
maternal knowledge about immunization, and maternal exposure to child health information, social

5
influence and paternal approval of immunization were significantly associated with BCG
immunization. Both the regularity of vaccine supply to the health facility and the state of residence
were associated independently with BCG immunization status (33).

Other study in District of Nigeria (2006) demonstrated that having at least secondary school
education, satisfactory immunization knowledge of the mother, retention of immunization card and
mother’s knowledge of immunization was significantly correlated with the rate of full
immunization (24). In relation, the study from Mali (2009) at Kita circle reveal that, ANC use has
positive link with full vaccination, distance from the health Centre or socio-economic status. Lack
of information was one reason given for children not being vaccinated against the six EPI diseases
(25).

In Uganda, DPT3 coverage in 2005 was 60%. Some of the factors for low coverage were
communities have not internalized the usefulness of immunization and benefits of completing the
full doses for children; health workers do not inform or remind mothers/ guardians to come back
for more doses and outreach dates, immunization sessions sometimes conflict with farming/family
duties especially during planting seasons and this reduces attendance. Static and outreach sessions
are sometimes infrequent; vaccine shortage and/or cold chain breakdown and little involvement of
local leaders, especially in following up of defaulters (34). On the other hand, evidence from Kenya
in 2004 indicated that immunization coverage for three doses of pentavalent vaccine was 100%.The
reason for this was found to be season, distance from clinic and family size were each associated
with the rate of immunization (20).

As the study in Istanbul shows, the complete vaccination rate for study population was 84.5% and
3.2% were totally non-vaccinated. The reasons for non-vaccination were: their being in the village
and failure to reach health care services, lack of knowledge about vaccination, father refusal of
vaccination, inter current illness of child during vaccination time, missed opportunities like not to
shave off a vial for only one child. Being full vaccinated for children were influenced by mothers’
and fathers’ educational level. Age of the mother (>30), high birth order and children from large
family were significantly associated with incomplete immunization in Brazil (23). Another finding
from Nouna district Burkina Faso revealed maternal knowledge of the preventive value of
immunization was positively related to complete immunization status in rural areas, good

6
communication about immunization , availability of immunization booklets, as well as economic
and religious factors appear to positively affect children’s immunization status (26).

In 2000 a Study done in rural Ethiopia by Teklay revealed that the coverage based on card plus
history, BCG, DPT1/OPV1, DPT3/OPV3 and measles coverage for 12-23 months old children was
99.1%, 97.3%, 92.7% and 75.5% respectively. BCG scar was 89 %( 81/91) and 76.5% (13/17)
among those vaccinated by card and history respectively. Both the residence and mother’s
education were significant predictors of immunization status of children, children from rural areas
whose mothers were literate had higher immunization coverage than illiterate (22)

National immunization coverage (2006) showed that residence, presence of HEWs in kebeles.
Kebeles’ administration involvement in EPI planning and review and maternal factors (education
and parity) remained in the model as significant predictors for DPT3 vaccination but maternal
occupation and child sex were not statistically significant (19).

Moreover, according to national survey EDHS 2011; 24% of children were fully vaccinated and
there was gender difference in terms of immunization coverage for example female children are
slightly more likely to be fully vaccinated (26%) than male children (23%). Birth order has a close
relationship with vaccination coverage; as birth order increases, vaccination coverage generally
decreases and 30% of first-born children have been fully immunized, compared with 20% of
children of birth order six and above and urban children are more than two times as likely as rural
children to have all basic vaccinations (48% compared with 20%). Children whose mothers have
secondary education are more likely to be fully immunized than those born to mothers with no
education (57 and 20 percent, respectively) (8).

Study in South Ethiopia of Wonago district revealed that 76% believed that immunization was
beneficial for their children in preventing the occurrence and spread of diseases. The family income,
mothers’ knowledge, post natal care utilization, and positive attitude toward immunization were
significantly related to child immunization completion (35). A survey in Oromia region (2004)
shows that in terms of health care access, 60% of households are less than a 2-hour walk (10 km)
from a health facility. Two-thirds (66.7%) of children 12-23 months old have access to
vaccinations, as represented by the percentage of children who received DPT1. Coverage declines,
however, throughout the series of routine vaccinations, as only 45% of children in the region

7
received DPT3. Only 38% received the full series of vaccinations and 26% none received.
Women’s lack of time 33%, unaware of the need to vaccinate further or to return for 2nd or 3rd dose
20%, not knowing the place or time of immunizations, absence of vaccinators and lack of
immunization information 66%, health workers constitute the primary contact for women, followed
by community events and radio were among factors identified not to complete the series (36).

In other study of Oromia region, Illubabor zone, it was showed that 65.6% of study children were
fully immunized, partially and not immunized at all were 29.2%, 5.2% respectively. The reasons for
failure to start or complete the course of immunization were lack of information and lack of
motivation constituted 63.2%, 25.0% and 11.8% respectively (37). As survey in Jimma town showed
higher acceptance of immunization by mothers who have been educated to above six grades than
none educated. The relation between occupation and child immunization were government
employee was the first to fully immunize their child than housewives (94% versus 50%). Factors
associated with non immunization and defaulters were illiteracy, lack of knowledge about EPI
target diseases and attitude of mothers were 45.6% said very useful, 54.1% said useful and the rest
0.3% said not useful (38)

Study in Ambo District, Oromia region (2011) showed, antenatal care follow-up, being born in the
health facility, mothers’ knowledge about the age at which vaccination begins and knowledge
about the age at which vaccination completes were significantly associated with complete
immunization whereas area of residence and mother’s socio-demographic characteristics were not
significantly associated with full immunization among children (39).

Health facility related factors

Accessibility to a health facility for child immunization can be measured in terms of distance, time
spent to reach the facility. In a study from the Philippine, it was found that the immunization
coverage decreased when the distance to the immunization site more than 0.5 km (40). In a study
conducted in US (at Detroit city), it was reported that the vaccination coverage was lower for
children if parents reported problems in accessing the health care system, due to lack of
transportation as compared with those who did not report such problems and barriers in the
organization and delivery of health care such as fragmentation of primary care services,
inaccessibility of health care services, lack of information about the child's immunization status,

8
and complexities of the immunization schedule (41). Study from rural Nigeria (2008), 339 mothers
and 339 children (each mother with eligible child), mothers’ knowledge of immunization (p =
0.006), vaccination at a privately funded health facility (p < 0.001) and distance of the service area
were significantly correlated with the rate of full immunization (23).

Validity of the officially reported vaccination coverage

In terms of the validity of reported vaccination coverage (country-generated statistics), some

studies show that officially reported immunization coverage was higher than that reported from
population based surveys. A study from Mozambique showed uncertainties in population data
because the service data which was used by province level and district level was different (43).

Data from the EDHS generally show vaccination coverage to be lower than data in the service
statistics from the Ministry of Health. According to EDHS 2011 report, a card plus history 36.5%
of children aged 12-23 months had been vaccinated for DPT3 before the age of one year. The
EDHS 2011 reported coverage was much lower than the 2010 administrative coverage of 83% for
DPT3 from regular reports (8).

In conclusion, different literatures on worldwide at different study sites on immunization coverage

with its influencing or affecting factors such as socio demographic, mothers’ knowledge, attitude,
information related to immunization and health facility related are among factors associated with
low immunization coverage as revealed by different literatures.

Determinants of immunization coverage as specified in conceptual frame work for determinants of

immunization coverage in Sinana district under annex 2 are socio-demographics, knowledge of
the mother, source of information and health facility related factors are considered as factors
affecting full immunization status of children among 12-23 months age.

9
OBJECTIVE OF THE STUDY

3.1 General Objective

To assess the full immunization coverage of children aged 12-23 months and identify its

determinants in Sinana district, Bale Zone, Oromia region, Ethiopia, 2013

3.2 Specific Objective

 To assess full Immunization coverage of Children 12 to 23 months in study area

 To identify factors associated with full immunization coverage in study area.

10
 METHODS

4.1 Study area & Period

The study was conducted in Sinana District, which is one of the 21 Districts, found in Bale Zone of
Oromia Region from 29 December 2012 to 16 January 2013. Oborra and Selka are the capital town
of the Sinana District and, located 450 kms to southeast of Addis Ababa. Sinana District has 2
urban and 19 rural Kebeles. According to the 2007 national Census, the total population of Sinana
District was 136,194 of which 66,735 (48.99%) and 69,459 (51.01%) were females and males,
respectively (44); with 3024(2.22%) 12-23 month old children. There were 6 health centers, 20
health posts and 14 low level private clinics and 7 Rural Drug Vendors in the District. But EPI was
all provided by Health Centers and Health Posts. According to 2011/12 District Health Report 85%
of children were fully vaccinated (27).

4.2 Study Design

A community based cross-sectional survey involving quantitative and qualitative assessment was
employed.

4.3 Population
4.3.1 Source Population
All children aged 12 to 23 months with their mothers/ caretakers living in Sinana district.

4.3.2 Study Population

Sampled children aged 12 to 23 months with their mothers or caretakers

4.4 Inclusion and Exclusion criteria

4.4.1 Inclusion Criteria:
Children (12-23month) with their mothers or caretakers living in the district at least 12 months on
the date of survey, age of the mother/ caretakers 15 years and above and able to be interviewed.

4.4.2 Exclusion Criteria:

Children with their mothers or caretakers that had not been living in district for at least 12 months
on the date of survey and age of the caretakers below 15 years at the time of the survey.

11
 4.5 Sample size determination and Sampling technique
4.5.1 Sample size determination: (For quantitative data)

The sample size required was determined based on single proportion population formula with the
assumption of 5% margin of error (d), 95% confidence level(Z), 67.5%estimated mothers
knowledge on immunization (39) and considering design effect of two. Sample size was calculated
for both specific objectives and maximum sample size was taken.

no sample size

no = design eff x (Z 1-α/2)2 x (P)(1-P)

d2

Based on the specifications of the above formula, it gives 674. The total number of eligible children
that lie between 12 and 23 months in the District is 3024 which is <10,000, so by using finite
population correction formula; Where no=initial sample size,

nf = no N= total number of eligible children and

1+ no/N
nf =final sample size

By using the above formula nf =551 children and with 10% non-response rate sample size of 606.
1+ no/N

For qualitative data (FGD)

Health care providers of Primary Health Care that included head of the selected Health center,
provider working on immunization and Health Extension Workers from surrounding sub-sample of
health facilities with 8-12 participant/FGD and 8-12 reproductive age mothers per FGD who had
child 12-23 months age were selected purposively from selected zones (not participate in
quantitative) during census and categorized in to two separate FGD session with consideration of
homogeneity.

4.5.2 Sampling Technique

Initially the total kebeles were stratified into rural and urban areas. Then five rural and one urban
Kebeles were selected by lottery method from the total Kebeles in the Districts. But each Kebeles
have been divided into three zones/sub-kebeles according to the 2004etc kebeles structure Then,

12
from each sampled kebeles, one zones/sub-kebeles was selected by lottery methods. The modified
2005 WHO EPI cluster sampling method was employed to select study households with
consideration of each zones/sub-kebeles as one cluster. (45)

Then the selection of the required number of the children was from each of the selected zone/sub-
kebeles with proportional allocation of study subjects. The first child in each zone was selected
randomly from the center of the zone and the rest of them were selected from the contiguous
household till the required number of children had been attained. During survey household with
more than one eligible child was observed and only one child was included in interview by lottery
method among them. Details of sampling scheme attached in annex3

4.6 Study variables

4.6.1 Variables of the Study
Independent variables: -

Socio-demographic variables: age, sex, marital status mother, religion, number of children, and
ethnicity, monthly family income, occupation, and educational status of family , residence, birth
order and place of birth for index child.

Health facility related: distance from health service, waiting time for immunization ANC or post
natal care usage of mothers, Immunization service and Presence of HEWs in Kebeles.

Knowledge and attitude of mother or caretaker: knowledge of vaccination schedule, vaccine

preventable diseases (VPDs), usage of immunization and common symptom of (VPD)

Source of information for immunization: information from mass media, from health worker,
from village leader, from friend or family member, given information by health worker on
immunization, possible adverse reaction, schedule of immunization and VPD.

Dependent variable: full immunization status of child.

4.7 Data collection Instrument

It is an interviewer-administered structured questionnaire to obtain information from mothers or
caretakers of the child by tenth completed trained interviewers. The instrument was constructed from

13
a review of available literature on immunization coverage, WHO questionnaire, and EDHS for
immunization coverage and translated in to local language (8, 24, 45).

The knowledge of the mothers/caretakers was assessed by six questions and then, correct response
was scored one point and zero point for wrong answer. And attitude of mothers/ caretakers were
assessed by five questions and then scored of one point and zero point was given for correct and
wrong answers respectively. For data collection the interviewers were used a manual that was
prepared by the investigator to help them understand the questionnaire and to used during data
collection. For qualitative parts, FGD guides were prepared by investigator.

4.8 Data Collectors Recruitment and Training

Nine data collectors and three supervisors who completed grade twelve and ten were recruited
based on a set of criteria such as ability to speak and write Afan Oromo and previous experience on
data collection. They were trained for two days by the principal investigator on the purpose of the
study, instrument, consent form, how to select child from household, how to interview and how to
copy information from immunization card and data collection procedure.

4.9 Data Collection Process

A pre-tested structured questionnaire initially developed in English and later on translated into Afan
Oromo was used for data collection. Households with eligible children in the zones were visited by
trained data collectors and were recruited until the proportionally allocated sample size in each
cluster/zone was achieved. Each survey team (three survey teams) consisted of one supervisor,
three data collectors and one local guide and one team collected data for two Kebeles. The
supervisors checked for completeness at the end of each day, and ensuring proper selection of the
first household in each cluster according to the guidelines developed by investigator. Data
collection was undertaken from 29 December, 2012 to 16 January, 2013. Mothers or caretakers
were asked to show immunization cards and vaccine received and the dates of immunization were
copied from vaccine card. For those whom the vaccination card was not available the mothers/
caretakers were asked on immunization status of child. For DPT and polio, the mother was asked to
report the number of DPT/Polio vaccine that the child had received. In order to reduce recall bias
for mothers/caretakers history, remainders such as site of administration (injection, orally and scar)
were included in instruments.

14
For qualitative data: Three FGDs: one with Health workers group (probed on missed opportunity,
Health information delivery system and any obstacle to provided immunization service) and two
with mothers group (probed on their knowledge ,attitude towards immunization and barrier for non
vaccinating) were conducted. In order to ensure homogeneity of participants, discussants were
purposively grouped in to health workers and non-health workers (mothers) groups. Note taking
and audio tape were used for recording information.

4.10 Data Analysis

4.10.1 for Quantitative Data
Data was entered to Epi Info version3.5.3 after checking for completeness, then cleaned and
transferred to SPSS Version 20.0 for analysis. Frequencies and other descriptive statistics were
done. Bivariate analysis was calculated to examine association between dependent and
independent variables; Odds ratios (ORs) and their 95% confidence level were calculated. Then,
all variables that had p-value less than 0.2 in the bivariate analysis were included in the
multivariate logistic regression model to determine the factors associated with full immunization
coverage among children aged 12–23 months old and adjusted ORs with their 95% CIs were
computed to determine the true association. Data were categorized in to four groups to see the
association of independent variable with outcome variable; these groups were socio-demographic
characteristics, maternal health care use, child characteristics and mothers’ knowledge of vaccine
and vaccine preventable diseases. Then from each of the group variables that had P-value of less
than 0.05 were entered in to final model to control for confounders and to determine true
association.

4.10.2 for Qualitative Data

FGD data was transcribed, translated to English by replaying the tape and analyzed thematically
and manually.

4.11 Data Quality Control

The questionnaire was prepared initially in English by the investigator and translated into Afan
Oromo, and retranslated by another translator to English to compare the consistency. Data
collectors and supervisors were trained for two days on the study instrument and data collection
procedure and before the actual data collection, the questionnaire was pre-tested on 5% mothers or

15
caretakers of children whose age was between 12 to 23 months in non-selected kebeles and the
finding was excluded from main study. The necessary amendments were made up on identification
of ambiguities of the questions in the wording, logic and skipping order. The principal investigator
and the supervisors checked the collected data for completeness and corrective measures were
taken accordingly and 15(2.4%) questionnaire was rejected due to inconsistency and
incompleteness. The collected data was cleaned, coded and explored before analysis.

4.12 The Ethical Consideration

Proposal was approved by the Ethical Review Board of the College of Health Sciences School of
Public Health, before conducting the study. Permission to undertake the study was obtained from
every relevant authority in the Zone, District and respective Kebeles. Pertinent Consent Form and
the Information Sheet were duly integrated along with the respective data collection instruments.
All the study participants were clearly informed about the objective, benefits, significance and as it
has no harm. Finally, verbal informed consent was obtained from each study participant before
interview.

4.13 Operational and Standard Definitions

Fully vaccinated: A child between 12–23 months old who received one dose of BCG, at least
three doses of pentavalent, three doses of OPV and one dose of measles vaccine by card plus
mother history

Partially/incompletely immunized: A child 12-23 months old who had missed any one vaccine
out of the eight vaccines

Not immunized: A child 12-23 months old who didn’t receive any vaccine.

Coverage by card only: Coverage calculated with numerator based only on documented dose,
excluding from the numerator those vaccinated by history.

Coverage by card plus history: Coverage calculated with numerator based on card and mother’s
report.

Missed opportunity: Eligible child for vaccination had gone to health facility but didn’t receive,
for which he or she is eligible at that day

16
Sufficient knowledge: Six knowledge questions were asked and correct answer was given score 1
and incorrect answered score 0. Those having scored greater than the mean were classified as
having sufficient knowledge.

Positive attitude towards immunization: When the respondent reported accepting attitude to
correctly at least 3 correct questions out of four questions prepared about immunization.

Caregiver: is the most responsible person that provides child care for the 12-23months old child
whose biological mother could not provide the intimate care.

Index child: refers to 12-23 months old child that is included in the study from a household to have
information on the demographic and immunization status and the child chosen from household if
there is more than one.

Literate: mothers/caretakers/fathers with formal education or able to read and write.

Dropout rate (DOR): The rate difference between the initial vaccine (BCG or Pentavalent I) and
the final vaccines (Pentavalent III or Measles)

BCG to Measles dropout rate: the percent of children vaccinated for BCG who does not receive
measles vaccines.
BCG /Measles dropout rate (over all dropout rate) = (BCG –measles) x 100%
BCG
Pentavalent I to pentavalent III dropout rate: the percent of children vaccinated for pentavalent
I who not receive pentavalent III.
Pentavalent I / Pentavalent III dropout rate= (PI-PIII) x100%
PI

4.14 Dissemination plan

The results of this study will be disseminated or communicated to the Bale Zonal Health Bureau,
Sinana District Health Bureau and other concerned bodies through reports and possible publication
in local and international journal and also, presented for Addis Ababa University, primarily,
through the formalized Thesis and Defense at the School of Public Health of the College of Health
Sciences.

17
RESULTS

5.1 Socio -demographic Characteristics of Study Population

A total of 591 mothers/caretakers of children aged between 12–23 months old were interviewed
from 6 kebeles, with a response rate of 98.5%. Of the total 591 respondents, 562(95.1%) were
mothers of children and 29(4.9%) were other caretakers. Of the 591,478(80.9%) and 113(19.1%)
rural and urban residents respectively; 563(95.3%) of them live in union. The majority 575(97.3%)
of respondents belongs to Oromo ethnic group, 313(53%) of them Orthodox Christian followed by
265 (44.8%) Muslim religion followers. The remaining 9(1.5%) and 4(0.7 %) were Protestant and
Catholic respectively.
The median age of the respondents were 28(SD=6.1) years, which ranges from17 to 58 years.
From the total respondents, 340(57.5%) attended primary school, while 60(10.2%) had secondary
and above level and 191(32.3%) of mothers did not attend any formal education. In line to this,
309 (52.3%), 110(18.6%) and 172(29.1%) of the fathers did attend primary school, secondary or
above and the not gone to school for formal education respectively. Approximately 326(55.1% of
mothers and 528(89.3%) of fathers were farmers during the survey.

Majority of the family 432(73.1%) own radio and only 141(23.9% had television, with mean
monthly household income of 763.4ETB (SD=725.98) and varying from 100 to 5000 ETB. Table
1 showing socio demographic characteristics of mothers/caretakers given below.

18
Table 1:- Socio-Demographic and Economic Characteristics of the Respondents in Sinana District,
Bale Zone, Oromia region, Ethiopia 2012/13(N=591)
Variables

Frequency percent
Relationship
Mother 562 95.1
Caretaker 29 4.9
Age of the mothers/caretakers
< 20 73 12.4
21-30 362 61.2
31-40 141 23.8
>40 15 2.6
Marital status
Single 10 1.7
Married 563 95.3
Divorced 15 2.5
Widowed 3 0.5
Religion
Orthodox 313 53.0
Muslim 265 44.8
Protestant 9 1.5
Catholic 4 0.7
Ethnic group
Oromo 575 97.3
Amhara 16 2.7
Educational level of Mother
Not educated 191 32.3
Primary cycle 340 57.5
Secondary school++ 60 10.2

19
Table 1:- Socio-Demographic and Economic Characteristics of the Respondents in Sinana District,
Bale Zone, Oromia region, Ethiopia 2012/13 (continued)
Variables

Frequency percent
Occupation of the Mother
Housewife 225 38.0
Farmer 326 55.1
Other job 40 6.8
Educational level of the Father
Not educated 172 29.1
Primary cycle 309 52.3
Secondary school++ 110 18.6
Household size
Two, 122 20.6
Three 166 28.1
Four 124 21.0
Five and above 179 30.3
Occupation of the Father
Farmer 528 89.3
Gov.Employee ` 22 3.7
Other job 41 6.9
Family income in ETB
100-500 310 52.5
501-1000 177 29.9
>1000 104 17.6
Own Radio
Yes 432 73.1
No 159 26.9
Own Television
Yes 141 23.9
No 450 76.1

20
5.2 Maternal Health Care Utilization (antenatal care and postnatal care
utilization)
About 435(73.6%) of the mothers had ante natal care (ANC) follow up during their pregnancy and
305(51.6%) of them had post natal care follow up. Out of the 591,583 (96.8%) of the mothers ever
visited health facility for any purpose with her child and from this 568(99.3%) of the children
received immunization during the survey.

Table2:- Maternal health care utilization in Sinana district, Bale zone, Oromia region, Ethiopia
2012/2013
Variables

Frequency percent
ANC visit
Yes 435 73.6
No 156 26.4
PNC visit
Yes 305 51.6
No 286 48.4
Ever visit HF for any purpose with
child
Yes 572 96.8
No 19 3.2
Child received vaccines that day
Yes 568 99.3
No 4 0.7

5.3 Socio -demographic Characteristics of Children in Sinana district,

Bale zone
A total of 591 children of age 12-23 months were included; 239(40.4%) females and 352(59.6%)
were males. Of the total, 29.6% of children already were aged 23 months; mean age of 17.97 (SD
=4.2) months. From the total children who has participated in this study, the 576 (97.5%) were
vaccinated at least once and 15(2.5%) never attended immunization. Among the ever vaccinated

21
338(58.7%) started at age below one month and 218(37.8%) of them were below three months and
among ever vaccinated 33% had vaccination card during the survey.

Table3:- Socio demographics characteristics of Children Aged 12-23 Months in Sinana District,
Bale Zone, Oromia region, Ethiopia 2012/13
Variables

Frequency percent
Child’s Place of Delivery
Health Facilities 190 32.1
Home 401 67.9
Child’s Birth Order
First 103 17.4
Second 125 21.2
Third 132 22.3
Fourth 82 13.9
Fifth and above 149 25.2
Ever Vaccinated
Yes 576 97.5
No 15 2.5
Age at child started vaccination (month)
<1 338 58.7
2-3 218 37.8
4+ 20 3.5
Had vaccination Card
Yes 190 33.0
No 386 67.0

22
5.4 Availability and Accessibility of Vaccination Service
The availability and accessibility of the vaccination sites were assessed by inquiring about the
presence of the service and the average walking time to the health facility. About 584 (98.8%) of
respondents reported that they have the access to health facility that provided immunization
service and also majority of them 537(92%) reported that they had more access to health post
followed by 382(76.9%) to service providing outreach site and 270(46.2%) were access to health
center. For the 289(49.5%) of respondents; average walking time to nearest health facility was
less than 15minutes and 285(48.8%) of respondents had walked less than an hour and 10(1.7%)
walked greater than an hour. From the total, 573(97.9%) of the respondents were visited by health
service extension workers and 564(96.4%) were given information on immunization by health
service extension workers. 576(97.5%) of the respondents had ever attended immunization
service at health facilities and the service on immunization was relatively convenient to them. Of
the 576 mothers visited health facility for vaccination, 119(20.7%) turned back home without
vaccinating the child at least once. From this, the 69(58.0%) were due to the unavailability of the
vaccinator and in 62(52.1%) lack of vaccine.

Table4:- Availability and accessibility of the vaccination site in Sinana district, Bale zone, Oromia
region, Ethiopia 2012/13
Variables frequency percent (%)

Presence of Health Service

Yes 584 98.8
No 7 1.2
Health Center 270 46.2
Health Post 537 92
Outreach site
Yes 497 85.1
No 87 14.9
Active outreach site 382 76.9
Average walking time to Facility
<15minutes 289 49.5
Less than half an hour 173 29.6
B/n half an hour and an hour 112 19.2
Greater than an hour 10 1.7

23
Table4:- Availability and accessibility of the vaccination site in Sinana district, Bale zone, Oromia
region, Ethiopia, 2012/13(continued)
Variables frequency percent (%)

Ever receive vaccination at

Health Facility
Yes 576 97.5
No 15 2.5
Service on vaccination Convenient
Yes 570 98.9
No 6 1.1
Opening time of HF
Yes 532 93.3
No 38 6.7
Waiting time at HF
Yes 537 94.2
No 33 5.8
Distance traveled to HF
Yes 557 97.7
No 13 2.3
HEW in the kebeles
Yes 585 99.0
No 6 1.0
HEW visited your Home
Yes 573 97.9
No 12 2.1
Gave information on vaccination
Yes 564 96.4
No 21 3.6

24
5.5 Knowledge of Mothers/Caretakers on Vaccination and Vaccine Preventable
Disease
Concerning knowledge of mothers on vaccination and VPD, about 573(97%) of them had ever
heard about vaccination. About 548(95.6%) of the mothers had heard from Health service
extension worker followed by that 526(91.8%) of them heard on radio. Health professional
502(87.6%), friend 499(87.1%) and village leader 446(77.8%) were also stay sources of
vaccination information for the respondents. Majority of the respondents in this study were ever
encouraged to get their children immunized.
Table5:- Respondents information on vaccination and information given on immunization in
Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13
Variables frequency percent (%

Ever heard about vaccination

Yes 573 97.0
No 18 3.0
On radio
Yes 526 91.8
No 47 8.2
On Television
Yes 339 59.2
No 234 40.8
From HEW
Yes 548 95.6
No 25 4.4
From health professional
Yes 502 87.6
No 71 12.4
Village leader
Yes 446 77.8
No 127 22.2
Friend/family member
Yes 499 87.1
No 74 12.9
Ever discuss on vaccination with HW
Yes 446 75.5
No 145 24.5
Ever encouraged to get your child vaccinated
Yes 525 88.8
No 66 11.2

25
Mother’s knowledge on Vaccine and Vaccine Preventable Diseases.
About 579(98.0%) of the respondents had replied that immunization prevent communicable
diseases from their children and 494(83.6%) of the respondent knew vaccine preventable diseases.
Respondents were asked for their knowledge on age at which child receives specifically BCG and
measles vaccines. From these, 193(43.8%) reported at birth, 226(51.2%) at two weeks and
21(4.8%) said at six weeks for BCG vaccine. Whereas for measles, 362(77.7%) said at six months,
102(21.9%) reported at nine months and 2(0.4%) replied at age of twelve months. Out of the 518
who knew about when the child should complete the immunization, 509 (98.3%) said before one
year. Mothers’ were also asked for symptoms of vaccine preventable diseases and majority of
caretakers’ 460(98.1%) reported rash of measles followed by cough 452(96.4%) and paralysis in
446(95.1%). Of the 591,421(71.2%) responded correctly on knowledge question, above the mean
score 4.95(±1.52 SD) and were classified with sufficient knowledge on immunization and whilst
the remaining 170(28.8%) were classified as having poor knowledge.

The respondents were also asked about the number of vaccine preventable diseases they know and
majority of the respondents (54.1%) knew more than six vaccine preventable diseases and 48.2%
knew at least eight vaccine preventable diseases, 32.7% of respondents knew less than six vaccine
preventable diseases, 0.6% of them did not know any of the diseases; and on average, each of
mother/caretaker knew six vaccine preventable diseases. From the eight vaccine preventable
diseases, majority of respondents 475(96.2%) knew Pertussis followed by measles 466(94.3%)
and polio 457(92.5%). And the least vaccine preventable diseases the respondent knew were
Meningitis 295(59.7%) and Diphtheria 293(59.3%). Table 5.1 describing knowledge of mothers
on vaccination presented below.

26
 Table5.1 Respondents Knowledge on vaccine and VPD in Sinana district, Bale zone, Oromia
region, Ethiopia, 2012/13
Variables frequency percent (%

Does immunization prevent CD for your child

Yes 579 98.0
No 12 2.0
Do you know VPD diseases (N=591)
Yes 494 83.6
No 97 16.4
Disease prevented by vaccination (N=494)
Tuberculosis
Yes 440 89.1
No 54 10.9
Polio
Yes 457 92.5
No 37 7.5
Diphtheria
Yes 293 59.3
No 201 40.7
Tetanus
Yes 369 74.7
No 125 25.3
Pertussis
Yes 475 96.2
No 19 3.8
Measles
Yes 466 94.3
No 28 5.7
Hepatitis
Yes 348 70.4
No 146 29.6
Meningitis
Yes 295 59.7
No 199 40.3

27
 Table5.1 Respondents Knowledge on vaccine and VPD in Sinana, Bale zone, Oromia, Ethiopia
2012/13(continued)
Variables frequency percent (%

Know when Child should receive BCG (N=440)

Yes 193 43.9
No 247 56.1
Know when Child should receive Measles vaccine (N=466)
Yes 102 23.8
No 364 76.2
Know when Child should complete vaccination (N=591)
Yes 518 87.6
No 73 12.4
Knew any symptoms of VPD
Yes 469 79.4
No 122 20.6
Cough (Tuberculosis/Pertussis)
Yes 452 96.4
No 17 3.6
Difficulty in breathing (Diphtheria)
Yes 309 65.9
No 160 34.1
Skin rash (measles)
Yes 460 98.1
No 9 1.9
Paralysis (Poliomyelitis)
Yes 446 95.1
No 23 4.9
Jaundice (hepatitis B)
Yes 374 79.7
No 95 20.3
High fever (Pertussis)
Yes 433 92.7
No 34 7.3
Knowledge of Mother on immunization
Sufficient 421 71.2
Poor 170 28.8

28
5.6 Attitudes of Respondent toward Immunization
Of the 591 respondents, 587 (99.3%) answered correctly three and above from five attitude
questions, were classified as having positive attitude while the remaining 4(0.7%) who answered
below three attitude questions got classified as having negative attitude. 587(99.2%) mothers
claimed to having the plan to immunize their children, 582(98.5%) believed that it is helpful to
reinitiate if it is discontinued and 584(98.8%) would believe that immunization is beneficial for
children. Table depicting about attitude of mothers toward immunization in sinana district is shown
under annex5.

5.7 Immunization Coverage among 12-23 months aged Children

From the total of 591 children aged 12-23 months selected and included in this study, 576 (97.5%)
of them ever took one or more of the recommended vaccines and 15 (2.5%) were unvaccinated.
Only, 190 (33.0%) of mothers showed the child vaccination card during the survey. Of the 576
children ever received vaccination, 454 (76.8%) of them finished all the recommended doses and
122 (20.6%) were not complete the entire doses. Immunization coverage of children indicated in
table6
Table6:- Immunization status of children aged 12-23 months by mothers’ history and vaccination
card, Sinana district, Bale zone Oromia region, Ethiopia, 2012/13
Variables frequency percent (%

Vaccinated (card plus history)

Yes 576 97.5
No 15 2.5
Vaccination card (n=576)
Yes 190 33.0
No 386 67.0
Immunization status by card plus history
Fully vaccinated 454 76.8
Partially vaccinated 122 20.6
Unvaccinated 15 2.5

29
5.7.1 Immunization Coverage by Card only
Out of the total surveyed children aged 12–23 months, vaccination card was only seen and
confirmed for 190 (33.0%) children. Coverage by card only was calculated by taking children who
had vaccination card as a numerator. From190 vaccinated by card only, 32.1% received OPV1 and
penta1 followed by BCG (31.5%) and OPV2 (31.5%). Penta3 were taken by 30.1% and measles
vaccine was taken by 25.9% and based on the made available vaccination card, only 152 (25.7%)
children completed all the recommended vaccines.

5.7.2 Immunization Coverage by Card plus Mother Recall

Based on the vaccination card and the mothers’ recall, about 576(97.5%) of the children took at
least a single dose of vaccine. From the total reported vaccinated, 454(76.8%) were claimed fully
immunized at (95%CL: 73%-80%). Of the recommended vaccine doses, in general polio is the
frequent of taken vaccine. Particularly OPV1 was reported of taken by 97.0% of the children
followed by the 95.9%penta1, 93.6% took OPV2, 93.2% took pentavelent2 and 85.4% received
OPV3. Measles was the least received (77.7%). Nearly 84.6% of the children took penta3 with
11.8% pentavalent dropout rate,19.5% pentavalent1 to measles dropout and 15.8% overall dropout
(BCG to measles) rates. The coverage of immunization showed decrement from the initial dose of
vaccine to the last doses.
Figure 1 showing immunization coverage by source of information (card only, mother history and
card plus history) in Sinana district is presented below.

30
 120

92.2 96.9 93.6 95.9

100 93.2
85.4
84.6
77.7
Percentage

80

60.7 64.8 62.1 63.8 62.1

55.3 card
54.5
60 51.8 History
Card + history
40
31.5 32.1 31.5 30.1 32.1 31.1 30.1
25.9

20

0
BCG Polio1 Polio2 Polio3 Penta1 Penta2 Penta3 Measles

Vaccines

Figure 1:- Immunization Coverage by source of information in Sinana district, Bale zone, Oromia
region, Ethiopia, 2012/13

Factor affecting immunization completion for children

In this study, factors associated with full immunization were assessed. These factors include socio
demographic characteristics of mothers and children, maternal health care utilization, health
facility related, knowledge of caretaker on vaccination and vaccine preventable diseases.

Socio-demographic Characteristics of Caretakers/Mothers

Socio-demographic characteristics of mothers/caretakers were the first set of factors assessed for
their association with full immunization coverage using both bivariate and multivariate analyses.
Result from bivariate analysis indicate that maternal education, maternal occupation, father’s
education, family income and presence of television in the house were the factors that were

31
associated to the increased completion of immunization among 12-23 months of children.
Concerning education of the fathers taking not educated as the reference, children of the fathers’
who already had attended primary school were by crude odd ratio of 1.6(95%CI: 1.1, 2.5) times
more likely to be fully immunized and those who attended secondary school and above level were
crude odd ratio of 3.5(95%CI: 1.8, 6.8) times more likely to be vaccinated than those of
uneducated. Among mothers, taking not educated as reference, children of the mothers who
already had attended secondary school and above level were by crude odd ratio of 3.1(95%CI:
1.3,7.3) times more likely to complete immunization of their children than those who were not
educated.

Mother’s occupation was the other factor that showed a significant association in binary
association with completion of child immunization. Children whose mothers’ occupation belong
to the farming were by crude odd ratio of 1.9(95%CI: 1.3, 2.9) time more likely to complete
vaccination than housewives. Household average family income has also showed association in
binary analyses. Household with monthly income of less than five hundred were by crude odd
ratio of 0.5(95%CI: 0.2, 0.9) times less likely to complete their children’s immunization.

The presence of television in their home also showed difference in completion of child
immunization. Children from the family who had television were by odd ratio of 1.6(95%CI: 1.03,
2.66) times more likely to complete their immunization than family who had no television. But,
marital status, religion, ethnic group, occupation of father, family size and presence of radio in the
house did not show an association on completion of child immunization.

After adjusting for the other variables, only occupation of mother, educational level of father and
family income stayed with association in multivariate association. Concerning occupation, taking
housewives as reference, children whose mothers belong to farming were by adjusted odd ratio of
1.9 (95%CI: 1.1, 3.1) times more likely to be fully vaccinated.

Education of the fathers of children also showed association in multivariate, children whose
fathers already had attended primary and secondary school were by adjusted odd ratio of
1.8(95%CI: 1.02, 3.11) and 3.1(95%CI: 1.3, 7.4) times more likely to be fully vaccinated than
whose father attended no educational level. Concerning average monthly income of the family,
children from the household with monthly income greater than one thousand Ethiopian birr were

32
by adjusted odd ratio of 3.2(95%CI:1.4, 7.4) times more likely to complete their vaccination than
children from the household with average monthly income of less than five hundred.

Table7: - Completion of immunization among children aged 12-23 months by socio demographic
characteristics of mothers /caretakers and fathers in Sinana district, Bale zone, Oromia region,
Ethiopia, 2012/13
Variable Fully Vaccinated No/% Odd Ratio (95% CI)
Yes No Crude Adjusted
Residence
Rural 368 (62.3) 110 (18.6) 1
Urban 86 (14.5) 27 (4.6) 0.9 (0.6, 1.5) NI
Age of the mother/caretaker
< 20 52 (8.8) 21 (3.6) 1
21-30 275 (46.5) 87 (14.7) 1.3 (0.7, 2.2) NI
31-40 113(19.1) 28(4.7) 1.6 (0.9, 3.1) NI
>40 14 (2.4) 1 (0.2) 5.7 (0.7, 45.7) NI
Marital status
Married 428 (72.4) 135 (22.8) 1
Others 26 (4.4) 2 (0.3) 4.1 (0.9, 17.5) NI
Religion
Orthodox 245 (41.5) 68 (11.5) 1
Muslim 198 (33.5) 67 (11.3) 0.8 (0.6, 1.2)
Others 11 (1.9) 2 (0.3) 1.5 (0.3, 7.1) NI
Ethnic group
Oromo 440 (74.5) 135(22.8) 1
Amhara 14 (2.4) 2 (0.3) 2.1 (0.5, 9.6) NI
Educational level of mother
Not educated 135 (22.8) 56 (9.5) 1
Primary cycle 266 (45.1) 74 (12.5) 1.5 (0.9, 2.2) 0.8 (0.5, 1.4)
Secondary school++ 53 (8.9) 7 (1.2) 3.1 (1.4, 7.3) 2 (0.6, 7.3)
Occupation of the mother
Housewife 156 (26.4) 69 (11.6) 1
Farmer 266 (45.0) 60 (10.2) 1.9 (1.3, 2.9) 1.9 (1.1, 3.1)*
other job 32 (5.4) 8 (1.4) 1.8 (0.8, 4.0) 0.6 (0.2, 1.8)

33
Table7: - completion of immunization among children aged 12-23 months by socio demographic
characteristics of mothers /caretakers and fathers in Sinana district, Bale zone, Oromia region,
Ethiopia, 2012/13(continued)
Variable Fully Vaccinated No/% Odd Ratio (95% CI)
Yes No Crude Adjusted
Educational level of the father
Not educated 117 (19.8) 55 (9.3) 1
Primary cycle 240 (4.6) 69 (11.7) 1.6 (1.1, 2.5) 1.8 (1.02, 3.1)*
Secondary school++ 97 (16.4) 13 (2.2) 3.5 (1.8, 6.8) 3.1 (1.3, 7.4)*
Family size
Two, 99 (16.7) 23 (3.9) 1 NI
Three 124 (20.9) 42 (7.1) 0.7 (0.4, 1.2) NI
Four 89 (15.1) 35 (5.9) 0.6 (0.3, 1.1) NI
Five and above 142 (24.1) 37 (6.3) 0.9 (0.5, 1.6) NI
Occupation of the father
Farmer 401 (67.8) 127 (21.5) 1
Gov.Employee 21 (3.6) 1 (0.2) 6.6 (0.9, 49.9) NI
Other job 32 (5.4) 9 (1.5) 1.1 (0.5, 2.4) NI
Family income in ETB
100-500 237 (40.1) 89 (15.1) 1
501-1000 142 (24) 35 (5.9) 1.5(0.9, 2.4) 1.2 (0.7, 2.1)
>1000 75(12.7) 13(2.2) 2.2 (1.2, 4.1)* 3.2 (1.4, 7.4)*
Own Radio
Yes 338 (57.2) 94 (15.9) 1.3 (0.9, 2.0) NI
No 116 (19.6) 43 (7.3) 1
Own Television
Yes 117 (19.8) 24 (4.1) 1.6 (1.03, 2.7)* 1.7 (0.9, 3.0)
No 337 (57) 113 (19.1) 1
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05

34
Maternal Health Care Utilization
Antenatal care follow up, post natal care follow up, whether mothers/caretakers ever visited health
institution and visited health facility specifically for immunization were assessed in bivariate
analysis all assessed factors showed association with completion of child immunization.
Mothers who had followed ANC check up during their pregnancy for the index child were by
crude odd ratio of 3.0(95%CI: 2.0, 4.5) times more likely to complete vaccination for their
children than who had no ANC follow up. In the same way, those who had post natal care follow
up were by crude odd ratio of 1.8(95%CI: 1.2, 2.7) times more likely to complete the
immunization of their children than who had no postnatal care follow up. The other factor showed
association in binary analyses was health facility service utilization which was by crude odd ratio
of 32(95%CI: 7.3, 140.5) times more likely to complete immunization for their children than those
who did not utilize health service at health facility.

After adjusting for the other variables only ANC utilization retained the independent association
in multivariate logistic regression and mother who utilized ANC during pregnancy of the index
child were by adjusted odd ratio of 3.7(95%CI: 2.3,5.9) times more likely to fully immunize their
children than mothers’ who had no ANC follow up when they were pregnant.

This finding is supported by the focus group discussion with mothers. All discussants believed that
visiting health facility during pregnancy and after delivery are crucial times for mothers and their
children. The reason raised were, if mother went to the health facility during pregnancy and post
delivery; the professionals would give advice on the progress of pregnancy, well being of baby,
place of delivery and what to do after giving birth. Mothers could be advised on child
immunization and how to feed the new born. … 20 years old rural women said that, “when a
mother took her child to health facility, (to the health professionals) it is a good opportunity for
giving advice on the initiation time of vaccine, when it should get completed and the importance of
completing immunization for child. So, having ANC follow up is necessary for all mothers…”
Table8-showing completion of child immunization by maternal health care utilization is presented
below

35
Table8:- completion of immunization among children aged 12-23monts by maternal health care
utilization, Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13
Variable fully vaccinated odd ratio (95% CI)
Yes No crude adjusted
ANC visit
Yes 359 (60.7) 76 (12.9) 3.0 (2.0, 4.6) 3.7 (2.3, 5.9)*
No 95 (16.1) 61 (10.3) 1
PNC visit
Yes 250(42.3) 55(9.3) 1.8 (1.2, 2.7) 1.0 (0.6, 1.8)
No 204 (34.5) 82 (13.9) 1
Visit health facility for any purpose
Yes 452 (76.5) 120 (20.3) 32 (7.3, 140.5) NI
No 2 (0.3) 17 (2.9) 1
Child receive vaccine that day
Yes 450 (78.4) 120 (20.9) 3.8 (0.5, 26.9) 1.8 (0.1, 21.7)
No 2 (0.3) 2 (0.3) 1
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05

36
Availability and Accessibility of Vaccination Service
The association of health care availability and accessibility with the completion of vaccination
also was seen by using bivariate and multivariate analysis.

Children of household walked less than an hour were by crude odd ratio of 2.4(95%CI: 1.3,4.2)
times more likely to complete their immunization than their age group walked more than an hour.
On other hand, mothers of the children who ever received immunization service at health facility
were by crude odd ratio of 14.0(95%CI: 4.0, 51.9) times more likely to complete the vaccination
of their children than mother who did not ever received immunization service for their children.
Mothers of children who found immunization service at the health facility convenient were by
crude odd ratio of 6.1(95%CI: 1.4, 25.9) times more likely to complete the vaccination of their
children than mothers who did not found service was convenient. Describing about the journey of
mothers to the immunization site, those who found the distance travelled convenient were by
crude odd ratio of 3.3(95%CI: 1.1, 9.9) times more likely to complete vaccination of their children
than the mothers who had not found it convenient. Concerning an average waiting time to get
immunization at health facility, mothers who stay for more than three hours were by crude odd
ratio of 0.3(95%CI: 0.1, 0.9) times less likely to fully vaccinate their children than those mothers
who stay for less than an hour.
Mothers/caretakers who ever received information from the health service extension worker were
by crude odd ratio of 2.6(95%CI: 1.1, 6.3) times more likely to complete the immunization of their
children than mothers who ever not got information. In contrast to this, the presence of health
institution and health service extension worker in the kebeles and those household visited by the
health service extension worker did not show association for completion of child immunization.
Despite bivariate level association, only average walking time to the health facility showed
association in multivariate analysis, and household who had walked less than an hour were by
adjusted odd ratio of 3.1(95%CI:1.5,6.3) times more likely to fully vaccinate their children when
compared to those households required walking less than 15 minutes. On other hand, those who
walked for greater than an hour were by adjusted odd ratio of 0.8 (95%CI: 0.2, 2.9) less likely to
complete the immunization of their children than mothers who walk for less than 15 minutes. But,
this is not statically significant.

37
Table9:- Completion of Child immunization among 12-23months by availability and
accessibility of Health Care Service, Sinana district, Bale zone, Oromia region, Ethiopia, 2012/13
Variable Fully vaccinated Odd Ratio (95% CI)
Yes No Crude Adjusted
Health facility present
Yes 448 (75.8) 136 (23) 0.6 (0.1, 4.6) NI
No 6 (1) 1 (0.2) 1
Average walking time
<15 minutes 210 (35.5) 79 (13.4) 1
Less than half an hour 136 (23) 37 (6.3) 1.4 (0.9, 2.2) 1.6 (0.9, 2.6)
B/n half an hour and an hour 100 (16.9) 16 (2.7) 2.4 (1.3, 4.2)* 3.1(1.5, 6.3)*
Greater than an hour 8(1.4) 5(0.8) 0.6 (0.2, 1.9) 0.8 (0.2, 2.9)
Service convenient
Yes 448 (77.5) 122 (21.1) 6.0 (1.4, 25.9)* NI
No 3 (0.5) 5 (0.9) 1
Distance traveled
Yes 441 (77.4) 116 (20.4) 3.3 (1.1, 9.9)* 2.5 (0.8, 8.7)
No 7(1.2) 6(1.1) 1
Waiting time at facility
Yes 420 (73.7) 117 (20.5) 0.6 (0.2, 1.7) 1.7 (0.6, 4.6)
No 28 (4.9) 5 (0.9) 1
Ever attain for immunization
Yes 451 (76.3) 125 (21.2) 14 (4.0, 51.9) NI
No 3 (0.5) 12 (0.2) 1
Turned home without vaccine
Yes 91(15.4) 28(4.7) 0.9(0.6, 1.6) 0.8 (0.5, 1.3)
No 363(61.4) 109(18.5) 1
Presence of HEW in kebeles
Yes 449(76) 136(23) 0.7(0.1, 5.7) NI
No 5(.8) 1(.2) 1
HEW given information
Yes 437(74.7) 127(21.7) 2.6(1.1, 6.3)* 0.5(0.2, 1.6)
No 12(2.1) 9(1.5) 1
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05

38
Knowledge and attitudes of mother on vaccination and vaccine
preventable diseases
Associations of mothers’ knowledge and attitude about vaccination and VPD with the completion
of the Child immunization were third factors assessed. And the result of bivariate showed that
Children of the mothers who ever heard about immunization were by crude odd ratio of
3.4(95%CI: 1.4, 8.9) times more likely to complete their vaccine dose than who did not hear about
vaccination. In line to this, those mothers who ever heard about immunization on television and
from family/friend were by crude odd ratio 1.8(95%CI:1.2, 2.6) and 2.8(95%CI:1.8, 4.7) times
more likely to complete the immunization of their children than mothers who did not hear from
both sources respectively. In addition to this, Children of the mothers who had ever discussed
about immunization with Health service extension worker were by crude odd ratio of 3.9(95%CI:
2.7, 5.8) times more likely to complete the vaccination than their peer who had ever not discussed
about immunization with health service extension worker.

How mothers or caretakers could know the schedule of immunization for child was another factor
that showed association in binary analysis. Accordingly, mothers who knew the schedule of
immunization from family/friend, from immunization card and from health extension worker were
by crude odd ratio 1.7(95%CI: 1.1, 2.6), 3.1(95%CI: 1.4, 6.6) and 2.2(95%CI: 1.2, 3.9) times more
likely to complete the immunization of their children than who had not informed from those
sources respectively. And mothers ever encouraged by health worker/family/village leader were
by crude odd ratio of 4.4(95%CI: 2.6, 7.4) times more likely to finish the vaccine of child than
who had not ever been encouraged.
Mothers who were classified as having sufficient knowledge on vaccine and vaccine preventable
diseases were by crude odd ratio of 2.2(95%CI: 1.5, 3.4) times more likely in completion of
immunization of their child than those who were classified as having poor knowledge. In contrast
to this, attitude of mothers toward immunization did not show association in binary analyses. After
adjusting for the other variables, only two variables retained the association in multivariate logistic
regression; children whose mothers had sufficient knowledge on vaccine and vaccine preventable
diseases were by adjusted odd ratio of 2.5(95%CI:1.5, 4.2) times more likely to be fully
vaccinated than children of mothers who had poor knowledge on vaccine and VPD. And mothers
who ever had discussed on vaccination with health service extension worker were by adjusted odd

39
ratio of 2.4(95%CI: 1.3, 4.2) times more likely to complete the immunization of their children than
mothers who had not discussed on immunization with health service extension worker.
Finding of the FGD also indicate, majority of mothers claimed that they remember immunization
day during announcement for vaccination. As discussants indicated announcement at outreach site
for vaccination of children is held each month on holiday/Sunday. So, this is convenient for
mothers to vaccinate their children. Uneducated mother from rural said that, “I use outreach
service to vaccinate my children. I remember the date from the announcement and since, the
outreach site is not far-off, I am vaccinating my children. Some times for other problem I took to
health center but for vaccination, I use outreach site.”

Table10:- Completion of immunization among children aged 12-23 months by mother knowledge
on vaccine and VPD in Sinana district Bale zone, Oromia region, Ethiopia, 2012/13
Variable fully vaccinated odd ratio (95% CI)
Yes No Crude Adjusted
Ever heard about vaccination
Yes 445 (75.3) 128 (21.7) 3.4 (1.4, 8.9)* NI
No 9 (1.5) 9 (1.5) 1
On radio
Yes 407 (71) 119 (20.8) 0.8 (0.4, 1.7) NI
No 38 (6.6) 9 (1.6) 1
On television
Yes 277 (48.3) 62 (10.8) 1.8 (1.2, 2.6)* 0.7 (0.4, 1.2)
No 168 (29.3) 66 (11.5) 1
From Health extension worker
Yes 428 (74.7) 120 (20.9) 1.7 (0.7, 3.9) NI
No 17 (3) 8 (1.4) 1
Health professional
Yes 392 (68.4) 110 (19.2) 1.2 (0.7, 2.2) NI
No 53 (9.2) 18 (3.2) 1
From village leader
Yes 353 (61.6) 93 (16.2) 1.4 (0.9, 2.3) NI
No 92 (16.1) 35 (6.1) 1
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05
40
Table10:- completion of immunization among children aged 12-23 months by mother knowledge
on vaccine and VPD in Sinana district, Bale zone, Oromia region Ethiopia, 2012/13(continued)
Variable fully vaccinated odd ratio (95% CI)
Yes No Crude Adjusted
From friend/family
Yes 401 (70) 98 (17.1) 2.8 (1.7, 4.7)* 0.7 (0.3, 1.8)
No 44 (7.7) 30 (5.2) 1
Ever discuss on immunization
Yes 372 (62.9) 74 (12.5) 3.9 (2.6, 5.8)* 2.4 (1.3, 4.2)*
No 82(13.9) 63(10.7) 1
Know schedule of vaccine from
Family/friend
Yes 370 (62.6) 99 (16.8) 1.7 (1.1, 2.6)* 1.3 (0.5, 3.2)
No 84 (14.2) 38 (6.4) 1
Immunization card
Yes 439 (74.3) 124 (20.9) 3.1 (1.4, 6.6)* 0.8 (0.2, 2.8)
No 15 (2.5) 13 (2.2) 1
Health extension worker
Yes 421 (71.2) 117 (19.8) 2.2 (1.2, 3.9)* 1.1 (0.3, 4.0)
No 33 (5.6) 20 (3.4) 1
Encouraged to immunize last year
Yes 422 (71.4) 103 (17.4) 4.4 (2.6, 7.4)* 4.9 (1.0, 21.3)*
No 32 (5.4) 34 (5.8) 1
Attitude of mothers/caretakers
toward vaccination
Negative attitude 3 (0.5) 1 (0.2) 1
Positive attitude 451 (76.3) 136 (23) 1.11 (0.1, 10.7) NI
Knowledge of mothers/caretakers
on vaccination
Poor knowledge 112 (18.9) 58 (9.8) 1
Sufficient knowledge 342 (57.9) 79 (13.4) 2.2 (1.5, 3.4) 2.5(1.5, 4.2)*
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05

41
Child Characteristics
The associations of the child characteristics like sex, place of delivery and birth order with
completion of child immunization were the other variables assessed by this study. From these
variables, only child birth order showed significant association with completion of immunization.
Child birth order of the third and fourth were by crude odd ratio of 50 %( 95%CI: 0.3, 0.9) and
50 %(95%CI: 0.2, 0.9) less likely to be fully vaccinated than those who were born to the first
birth order. Fifth birth order had not showed association in bivariate logistic regression. Sex of
child and place of delivery also had not shown association with completion of immunization.
Multivariate logistic regression analysis also showed that child birth order being significantly
associated with immunization completion and third birth order were 30% (95%CI: 0.2, 0.4) less
likely to be fully vaccinated than first birth order.

Table11:- immunization completion among children aged between 12-23 months by

characteristics of child in Sinana district, Bale zone, Oromia, Ethiopia, 2012/13
Variable fully vaccinated Odd Ratio (95% CI)
Yes No Crude Adjusted
Sex child
Female 275 (46.5) 77 (13.0) 1
Male 179 (30.3) 60 (10.2) 1.2 (0.8, 1.8) NI
Child place of delivery
Home 307 (51.9) 94 (15.9) 1
Health facility 147 (24.9) 43 (7.3) 1.1 (0.7, 1.6) NI
Child birth order
First 86 (14.6) 17 (2.9) 1
Second 98 (16.6) 27 (4.6) 0.7 (0.4, 1.4) 1.6 (0.7, 3.6)
Third 95 (16.1) 37 (6.3) 0.5 (0.3, 0.9)* 0.3 (0.2, 0.4)*
Fourth 57 (9.6) 25 (4.2) 0.5 (0.2, 0.9)* 0.7 (0.4, 1.4)
Fifth 118 (19.9) 31 (5.2) 0.8 (0.4, 1.5) 0.6 (0.3, 1.2)
N.B: numbers in brackets are in percentage, NI- Variable not included in the model
*Significant at P-value of <0.05

42
Table12 multivariate analysis for completion of child immunization (fully immunized) in Sinana
district and selected variables, Bale zone, Oromia region, Ethiopia June 2013
Variable fully vaccinated Odd Ratio (95% CI)
Yes No Crude Adjusted
Occupation of mother
Housewife 156 69 1
Farmer 266 60 1.9(1.3, 2.9) 1.7(1.01, 2.8)*
Others 32 8 1.8(0.8, 4.0) 0.6(0.2, 1.9)
Education level of father
Uneducated 117 55 1
Primary cycle 240 69 1.6(1.1, 2.5) 1.6(0.9, 2.6)
Secondary & above 97 13 3.5(1.8, 6.8) 2.8(1.3, 6.2)*
Family income
100-5000 237 89 1
501-1000 142 35 1.5(0.9, 2.4) 1.2(0.7, 2.0)
>1000 75 13 2.2(1.2, 4.1) 3.0(1.3, 6.9)*
Visit ANC
Yes 359 76 3.0(2.0, 4.6) 3.8(2.4, 6.4)*
No 95 61 1
Average waking time
<15 minutes 210 79 1
Less than half an hour 136 37 1.4(0.9, 2.2) 1.5(0.9, 2.5)
B/n half an hour and an hour 100 16 2.4(1.3, 4.2) 3.0(1.5, 6.1)*
Greater than an hour 8 5 0.6(0.2, 1.9) 0.7(0.2, 2.6)
Ever discuss on immunization
Yes 372 74 3.9(2.6, 5.8) 2.1(1.2, 3.9)*
No 82 63 1
Knowledge of mother on immunization
Poor knowledge 112 58 1
Sufficient knowledge 342 79 2.2(1.5, 3.4) 2.3(1.3, 3.9)*

Child birth order

First 86 (14.6) 17 (2.9) 1
Second 98 (16.6) 27 (4.6) 0.7 (0.4, 1.4) 0.5 (0.2, 1.2)
Third 95 (16.1) 37 (6.3) 0.5 (0.3, 0.9)* 0.5 (0.2, 1.1)
Fourth 57 (9.6) 25 (4.2) 0.5 (0.2, 0.9)* 0.4 (0.2, 0.9)*
Fifth 118 (19.9) 31 (5.2) 0.8 (0.4, 1.5) 0.7 (0.3, 1.5)
N.B: numbers in brackets are in percentage,
*Significant at P-value of <0.05

43
Reasons for not being vaccinated among partially/unvaccinated Children
For the mothers or caretakers who had not vaccinated or partially vaccinated their children, the
reason they did not vaccinate their children were asked. From the mothers/caretakers not
immunized or not completed immunization for their children 85(62.0%) responded due to lack of
awareness of need to return for second and third doses of vaccine. Of the 137, 83(60.6%) failed to
immunize their children due to lack of awareness of need for immunization. 47.4% of respondents
said place or time of immunization is not known and 14.6% of the mothers said that place of
immunization is too far. On the other hand, fear of adverse reaction (55.5%), wrong ideas about
contraindications (48.2%), lack of faith on immunization (38.7%) and no confirmed information
on immunization were reasons for not immunizing the child. Out of the 119(20.1%), of mothers
returned to home without vaccinating their children, 69(58.0%) were returned to home due to
unavailability of vaccinator at health facility and 62(52.1%) failed to vaccinate their children
because of lack of vaccine in facility . In relation to this, focus group discussion indicated; lack of
awareness, fear of side effect, less attention mothers give to child immunization and males’ less
involvement in child immunization. “One of my friend has many children but none of them were
vaccinated, because her husband could not allow her to go for child immunization,” said by
educated urban mother. Other ideas raised were fear of adverse reaction which discourages
mothers to return again for vaccination. 25 years old rural women said, “Children develop fever
for the first three days after vaccination which is very difficult situation till they recovered and I
fear not to lose my child due to fever developed as result of vaccination. So, I never go again to
vaccinate my child because I have seen the episode…,”

Health workers also indicated that, attitude of the mothers toward immunization; lack of faith on
immunization is among reasons that cause immunization of Sinana district low. And other issues
they had raised, the mothers did not fully believed in benefit of vaccination rather they consider as
the vaccine cause fever. 34 years old female said that, “mothers’ lack of awareness on benefit of
vaccine, lead them to believe that vaccine cause diseases and sometimes child develop high fever
after vaccination and then mothers never return to the subsequent doses.”

On the other hand, health workers agree that information they are delivering is not need based and
does not address whole community. And most of the time health education is given in mass which
could not distinguish level of understanding and their educational background. So, this could not

44
motivate mothers for return. “…On providing quality and good health education, we do have
problem, information we are providing is less understandable by mothers. So, I cannot say
information we are providing has quality. And it does not address whole community, yet
information we had provided, did not bring desired behavioral change…,” said by 32 years old
male health professional. Reason given by mothers for not completing immunization of children is
presented under annex 5

58%

69 Turned home without

vaccinating child
Vaccine not available
119
Vaccinator were
absent
52.10%
62
20.10%

Figure2: - Reason given by mother why turned home without receiving immunization during
appointment for child immunization in Sinana district Bale zone, Oromia region, Ethiopia 2013

45
DISCUSSION
Immunization is one of the most successful and cost-effective public health interventions and
delivering immunization also offers an opportunity to deliver other preventive service, like
vitamin A supplements and deworming. But, parents still do not view immunization as a right, and
demand for immunization service is lacking in many communities. ANC follow up, educational
level of fathers, occupation of mothers and family income were some of the factors significantly
associated with immunization coverage in this study. Despite the improvement, immunization is
unfinished agenda. So that, this study tried to assess the full immunization coverage and factors
associated with it among 12 to 23 months old children residing in six kebeles of Sinana district.

OPV vaccine coverage was slightly higher than the coverage of the pentavalent vaccine which is
given in line with EPI schedule of Ethiopia. This is probably due to the OPV vaccine is given
frequently as national campaign in the country. On the other hand, pentavelent3 vaccine coverage
was a bit higher than measles vaccine coverage which could be as a result of time gap between
two vaccines in which mothers may forget the measles vaccine and dropout from the consequent
doses. Across all vaccine doses, from first to consequent doses, there is decrement of coverage
which could be due to mothers’ incompliance and time gap between each dose leading mothers to
forget the subsequent doses. So, the dropout rate of pentavalent1 to pentavelent3 was 11.8%,
pentavelent1 to measles 19.5% and overall BCG to measles dropout was 15.8%. Which is higher
than the international goal of <10% set by WHO. But, this finding is less than the study done in
Oromia region in which pentavelent1 to pentavalent3 dropout rate was 33 %( 36).

When we compare coverage of Sinana district with that of Kafa, it showed that11.2% increment
(37). This could be due to time gap between two studies and awareness of mother on
immunization could be changed over time and accessibility to service could be other reason for
this difference. Similarly, when we compare immunization coverage of Sinana district with EDHS
2011, the percent of fully vaccinated is higher and proportion of children not vaccinated were
decreased by 12.5%. This is likely due to EDHS include data from area of low immunization
coverage and time of the survey could also another reason for discrepancy. But Coverage of
pentavelent3, measles and fully immunized in Sinana district is lower than the immunization
coverage reported in 2011 national and Oromia region health and health related indicators (8,11).
The percentage of fully vaccinated was also lower than the district health office report of 2011,

46
fully immunized 85 % from woreda versus76.8% of this study. This is probably due to methods
used, sample size selection, area covered, over reporting and type of data sources used (27).

Among interviewed mothers, only for 190(33%) of the children immunization card was confirmed.
Most of the children took OPV1, followed by Pentavelent1. But, measles’ vaccine was the least
received vaccine and 76.8%(95%CL:73%,80%) of children finished the recommended doses of
immunization. About 97% of mothers had heard about immunization and vaccine preventable
diseases. Majority of mothers heard on radio (91.8%), which indicates that mothers had access to
population media. Kebeles in which village leaders participated in EPI program by giving
information to habitants, motivating mothers and community on health service, also showed
improvement in immunizing their children. Which could be the influence of village leaders in
community; this in turn indicates the importance of political commitment to improve
immunization status of children. About, 83.6% of mothers knew vaccine preventable diseases.
And from this, more than half of the respondents knew at least more than six vaccine preventable
diseases which are higher than study carried out in Ambo district in which majority of mothers
knew more than three vaccine preventable diseases (39).

This study also tried to assess factors affecting immunization status of the children by classifying
the status of children into two categories: fully vaccinated and not fully vaccinated. Factor
affecting full vaccination status of children were identified by bivariate and multivariate analysis
using binary logistic regression.

Based on bivariate analysis, socio demographic characteristic of respondents like educational

background of mothers and fathers, mothers’ occupation, family income and presence of television
in house were significantly associated to immunization completion of children. Accordingly,
mother education is among determinants of immunization completion and those mothers who
attended secondary and above education were two times more likely to complete the immunization
of their children than mothers with no education. And fathers who attended secondary and above
level is four times higher than the once who have no educational background. This is may be as
educational status of family gets improved, health seeking behavior of family may perhaps
increase. This in turn may have positive impact on child immunization. But, mothers who attended
primary education level were not differently associated to immunization completion of children
than mothers who did not attend any formal education. Which could be due to primary education

47
level may not bring health seeking behavior. Other studies also indicated that mother attended
primary education did not bring impact on immunization completion. This result is consistent with
that of Istanbul and EDHS 11 as well (8, 21).

Occupation of mothers was other factor that had showed association for completion of child
immunization among mothers included in this study. And mothers from farming group were twice
more likely to complete the immunization of the child than housewives. The result of other study
support this finding , this is probably due to income generation and house hold decision making
ability related to occupation ,government promotion for farmer and acknowledgement given to
farmer group may influence the income of household(38).

Other factor showed association with child immunization completion were father educational level,
children from fathers who attended primary cycle were two times more likely to be fully
vaccinated and those from father attended secondary and above were three times more likely to be
fully immunized than children from whose father had not attended any formal education. This is
similar with finding from EDHS2011, Istanbul, Northern Nigeria, Burkina Faso (8, 21, 24, 26).
Father’s educational level is factor that determines vaccine completion. Which could be related to
knowledge of the father on vaccine and vaccine preventable diseases. This could give better
position for the fathers to immunize their children and health seeking behaviors. In addition to this,
it could be designated to the house hold decision making power of fathers. Also, education of the
male is higher than the female’s in context of Ethiopia, which may in turn, has positive influence
in completion of child immunization.

Average monthly income of Household is the other factor determines immunization completion,
household income more than 1000 ETB were three times more likely to complete the
immunization of their children than household whose income is less than 500 ETB. This is
consistent with study from different area like EDHS2011, Nigeria, Nouna (24, 26, 33), study in
south Ethiopia Wonago district revealed that income of family related to health seeking behavior,
affording service and transportation service (35).

Other factors showed association with child immunization completion was presence of television,
household who have television were nearly two times more likely to complete immunization of
their children, this could be, related to information that family got from television. This could be

48
more clear and understandable. Advertisement on television is more attractive and contains
practice or role model influencing the family to seek immunization for their children. Study in
Oromia region in 2004 revealed that presence of radio was factor to complete the immunization of
child (36). Age of mother, religion, place of residence, marital status and ethnicity of mother have
no association with immunization completion. But evidence from India showed as these factors
have association (32)

ANC and postnatal care use of mother also showed a significant association with the child
immunization status in bivariate analysis. Mother who had ANC follow up was three times more
likely to complete the immunization of child and also mother who had follow postnatal care was
two times more likely to complete vaccination of child. This is consistent with study done in
Bangladesh, EDHS2011, Mali2009, and North Nigeria. Mothers who had ANC follow up could be
informed on importance, schedule and side effect of vaccine and they could be encouraged to
complete immunization of child (8, 25, 33).

Mothers who found service on immunization was convenient at health facility were six times more
likely to complete vaccination of their children than mother who said it is inconvenient. Also
mother who ever heard about immunization and those who received information from health
service extension workers were more likely to complete the immunization of their children. This
could be related to awareness of mother on immunization and satisfaction on service given. So,
mothers could get motivation to complete the vaccination of children. Also mothers who ever
discuss about immunization with health service extension worker have high probability to
complete the immunization for the children. This finding is consistent with other study in which
mothers default from immunization if vaccination time is inconvenient (33, 39).

Child birth order is another factor associated to vaccine completion, child born to the third and
above birth order was less likely to be fully vaccinated. This may be large family size compute for
resource and mother may lack time to take child to health facility and also could be related to
mother’s ANC utilization for first birth order which may increase awareness of mother to
immunize child. This is consistent with EDHS11 and study from Brazil (23). But sex of child and
place of delivery have not showed association with vaccine completion among 12-23 months old
children. Which may indicate no sex discrimination to complete the immunization among male
and female .In addition to this, giving birth in health institution does not necessarily mean that

49
mothers would come back for subsequent doses. But, study from other places indicated that these
factors have a significant association with child immunization status (8, 31, 39). However, this
study is consistent with survey in Mozambique in which gender has no difference in completing
vaccination (43).

Variables that showed significant association by bivariate analysis were included in multivariate
logistic regression analysis for further analysis. From variable included in final model ,occupation
of mother, educational level of father, average monthly income, ANC use, average walking time,
ever discuss on immunization, knowledge of mother on vaccine and vaccine preventable diseases
and birth order of child were those factors found to be associated with child immunization.

Mothers whose occupation is farmer were 1.7 times more likely to complete the immunization of
child than housewives; the proportion of not fully vaccinated children are higher among
housewives. This could indicate that mothers involved in farming activities are more exposed to
information and income of these group is also higher. This is similar with study in Jimma town,
south west Ethiopia (38). But education of mother was not significantly associated with child
immunization completion after adjusting for other variables. This is similar with case control
study done in Wonago district, south Ethiopia in which only average monthly income showed a
significant association with defaulting from completing immunization (35) but EDHS11 showed
that mother education showed association with child immunization.

Fathers’ education was other factor significantly associated with immunization status of children
among 12 to23 month old in multivariate analysis. Children whose father attended secondary and
above level were 2.8 times more likely to complete recommended doses of vaccination. This could
be duet to household decision making power of father and awareness of father on vaccine and
vaccine preventable diseases might make fathers at good position to vaccinate their children. As
educational status of father increased, health seeking behavior could be increased and lead to
vaccinate their children.

Family income is other factor included in multivariate; children from household whose average
monthly income is greater than 1000 ETB were three times more likely to be fully vaccinated
than whose income is low. This is probably related to good consumption of family; those families
with high income were able to afford service. If income of family is high, they will have access to

50
social media, probably exposed to information through different media. This finding is consistent
with study done in different areas (8, 26, 35).

Maternal health care utilization was associated with child immunization completion among 12 to
23 months; children whose mothers had ANC follow up were more likely to be fully vaccinated
than who did not attend ANC. This finding is consistent with that of India, Ambo District, Mali (at
Kita circle, Nigeria (25, 31, 33, 39). This could be due to mothers health seeking behavior and
mothers may discuss with health professional on vaccine and vaccine preventable diseases, on
importance of immunization, time of vaccine initiation, when it could get completed and possible
side effect associated to vaccine. So, it may create good opportunity for mother to vaccinate their
children. This could also motivate mothers to use health facility service. Secondary school
attended 30 years old urban mother indicated that, “since vaccination is very important and has
benefit for children, health professionals have to teach both mothers and fathers on benefit of
vaccine including side reaction of vaccine, where to go if fever developed and mothers also need
to keep the card given by health professionals properly. Attending ANC and giving birth at
institution can help to increases child immunization….”

Average walking time is other factor showed association with completion of child immunization;
children whose mothers walked half an hour to an hour were more likely to complete the
immunization of their children than mother waking less than 15 minutes. This finding is
inconsistent with that of Philippines in which, as distance from health facility get more than 0.5km
the immunization coverage decreased. In addition to this, study from Mozambique showed that
distance from health facility hinders immunization of children (40, 43). But, the finding of this
study could be the presence of health service extension workers in community and outreach
service which held on holiday and supported by community mobilization to immunization
monthly. So, this could help mothers easily remember immunization day and could be related to
outreach service held monthly and supported by announcement to vaccinate children. Moreover,
encouragements had done through kebeles leaders and usually outreach service given on Sunday
and holiday for those living away from facility. It is also supported by qualitative part, uneducated
mother from rural said that, “I am using outreach service to vaccinate my child by remembering
from announcement and since distance of this outreach is not far-off; I am vaccinating my child

51
some times when my child gets sick. I took to health post or health center but for vaccination I am
vaccinating at outreach site.”

Concerning knowledge of mothers on vaccine and vaccine preventable diseases; children whose
mothers classified as having sufficient knowledge on immunization were twice more likely to be
fully vaccinated than whose mother has poor knowledge. this study is consistent with study done
in Oromia region Ambo district, and Nouna district, Burkina Faso, Nigeria district, case control
study in Wonago district south Ethiopia(23,26, 38,46),as knowledge of mother improved on
immunization they could developed positive attitude ;then motivated to complete the
immunization. …literate 32 years old women said that, “Vaccinated child cannot get diseases
(vaccine preventable diseases) and even pregnant women cannot visage great risk if get
vaccinated, they give health baby and never loss their child by death if get their child being
vaccinated...”

Child birth order is associated to child immunization completion; and child born to the third and
above birth order is 40% less likely to be fully vaccinated than first birth order. That means high
proportion of children were found to be fully vaccinated among first birth order which is
consistent to EDHS 2011finding in which child birth order related to vaccine completion (8). This
could be child born to first birth order may get special focus since it has no resource competition
and mothers may follow ANC for first child which may be related to health care utilization indeed.

52
STRENGTH AND LIMITATION OF THE STUDY
Strengths

Children age 12 to 23 months were included which may measure recent immunization program
performance and immunization completion.

Information was triangulated by both methods

Limitation

Immunization coverage by report of mother may under/over report the immunization coverage
because mothers may not remember doses that child took due to recall bias.

Being cross sectional study does not show the cause effect relationship.

53
CONCLUSIONS AND RECOMMENDATIONS
Conclusion

About 76.8%(95%CL:73%,80%) of children were fully vaccinated. About 97% of mothers heard
about immunization and 95.6% of the mothers heard from health extension workers. 98% of the
mothers knew as immunization prevents communicable diseases and 71.2% of the mothers have
sufficient knowledge on immunization. Among mothers participated in this study, 99.3% of them
have positive attitude. From the total children included in the study, only 33% of them have
immunization card. Occupation of mothers/caretakers, household family income, educational level
of father, sufficient knowledge, ever discuss about immunization, ANC follow up and average
walking time were statistically significant predictors of fully immunization of children.

Being unaware of need for immunization, unaware of need to return for second or third dose,
unknown Place and/or time of immunization, fear of side effect, wrong ideas about
contraindications, absence of faith in immunization, inconvenient time of immunization absence
of vaccinator and vaccine and long waiting time at health facility were reasons for not fully
immunizing their children.

54
Recommendations
To the health workers
 Health workers should be always at health facility so that mothers/caretakers are able to
fully immunize their child.
 Need based health education on benefits of vaccine, age of initiation and VPD should be
given to mothers and fathers in order to encourage them for immunization.
 Eligible children that visit health facility for any purpose should be sent to IMNCI and
screened for immunization in order to prevent missed opportunities.
 Health extension workers should encourage mothers to have ANC follow up and should
discuss with mothers on one to one about immunization.
To communicable disease prevention and control and zonal health department
 The zone and district should organize the ways providing sustainable supports such as
logistic (vaccine, vaccine care and refrigerators).
 Establishing outreach site in each village of the kebeles and giving the service on monthly
based should be strengthened.

To Governmental bodies/ village leaders

 Village leaders should work with community to raise the economic status of people and
search the way to increase family income level.
 All village leaders should, thoroughly work with health workers by giving information for
communities.
For the future Studies
 Future research should include preferably community based with strong study designs that
examine whether the variable that appears to be significant in this cross-sectional study.

55
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58
ANNEXES

Annex 1:- current immunization schedule in Ethiopia

Table 13:- current Immunization Schedule in Ethiopia

AGE VACCINE Supplementary

Birth BCG, OPV0

6 weeks DPT-HepB-Hib1(pentavalent 1), OPV1,PCV1

10 weeks DPT-HepB-Hib2(pentavalent 2), OPV2,PCV2

14 weeks DPT- HepB-Hib3(pentavalent 3) , OPV3,PCV3

9 months Measles 1st dose of VitaminA

Source: Guidelines for National Expanded Programs on Immunization, MOH, June 2004

59
 Annex 2:- conceptual frame work for determinants of immunization
coverage in Sinana district Bale zone, Oromia region, Ethiopia2012/13

Socio-demographic factors:

A.
 Age ,resident, Religion
 Sex of index child Health facility related factors:
 Birth order of index child
 Number of family size A.
 MCH utilization
o ANC or post natal care
usage of mothers
. o Immunization service
 Occupation
 Educational level
 Family income  Distance to health facility to
get immunization
 Waiting time, convenience
B.
 Presence of HEWs in Kebeles
B. supplies

Knowledge of mother or care taker on:

 Usage of immunization
 Disease prevented by vaccine
 Schedule of immunization
 Common symptom of vaccine preventable
disease (VPD) Full Immunization status of
Attitude of mother or caretaker on immunization.
children among 12-23 months age

Source of information for immunization

 Mass media
 Health worker, Village leader
 Friend or family member
Given information by health worker on
immunization

 Possible Side effect

 Schedule of immunization
 VPD(vaccine preventable diseases)

Figure3:- Conceptual frame work for determinants of immunization coverage in Sinana district,
Bale zone , Oromia regional state, Ethiopia2012/13 ,as adapted from different literature.

60
 Annex3: -Schematic presentation of sampling procedure.
Sinana district

Stratified sampling

Two Urban kebeles 19 Rural Kebeles 1, 2, 3,4,…. ,18 and 19 PSUs

SRS

SRS for Kebeles

Obora (13,000)
Shallo (6847) Hisu (9403) Sanbitu(9657) H/boka (6692) Hamida (5685)

SSUs
Kebeles
and its total
populatio
3zones 3zone n
3zone 3zone 3zone 3zones Total zones
ss found in the
s s s
Kebeles

Zone1 Zone1 Zone2 Zone1 Zone2

Zone3
Randomly
selected zone in
each Kebeles

124 90 117 119 87 69

Proportional
allocated sample
size or household
(hh) for the study
Zones

606 HH with eligible children

Figure4:-Schematic presentation of sampling procedure for the selection of children between age
12 and 23 months age in Sinana District, Bale Zone, Oromia region, Ethiopia, 2012.
Key: PSUs=primary sampling units=Kebeles

SRS=simple random samplings

SSUs=Secondary Sampling Units

61
Annex 4:- Data collection instrument
I.PART I. SOCIO DEMOGRAPHIC CONDITIONS

NO Questions Responses codes Go to ()

Q101 Resident of respondent 1. Urban
2. Rural
Q102 Relation of the respondent 1. Mother
to the child 2. Caretaker
Q103 Age of the mother/caretaker _________Years

Q104 Marital status of the 1. Single

mother/caretaker 2. Married
3 Divorced
4. Widowed
Q105 Religion of 1. Orthodox
mother/caretaker 2. Muslim
3 .Protestant
4.catholic
88. Other (specify)_______
Q106 Ethnic group of 1. Oromo
mother/caretakers 2. Amhera
3. Somale
4. Guraghe
8. Other(specify)___
Q107 Educational level of 1. Not able to write and read
mother/caretaker 2. Able to write and read
3. Primary school (1-4)
4. Junior school (5-8)
5. Secondary school(9-12)
6. College or University

62
Q108 Occupation of the 1. Housewife
mother/caretaker 2. farmer
3.Government employee
4.Student
5. merchant
6 .daily laborer
88. Other (specify)
Q109 Educational level of the 1. not able to write and read
father 2. able to write and read
3. primary school (1-4)
4. junior school (5-8)
5. secondary school(9-12)
6. college or university
Q110 Number of family size 1. Two,
2. Three
3. Four
4. Five and above
Q111 Occupation of the father 1. Farmer
2. Government employee
3. Student
4.Merchant
5.daily laborer
88. Other (specify----------)
Q112 Monthly family income in _______________
birr
Q113 Does the family own 1. Yes
functional radio? 2. No
Q114 Does the family own 1. Yes
functional Television? 2. No

63
PART II .Information of the index child and mother/care taker

Ask the mother/caretaker about the child whose age is between 12 and 23 months and missed
opportunity, health service utilization by mother/care taker.

Q201 Age of the index child ________ Months

Q202 Sex of the index child 1. Male

2. Female
Q203 Where was your index child 1.public health institution
born? 2. private health institution
3. Home
Q204 Birth order of the index 1. First 3. Third
child? 2. Second 4. Fourth
5.fifth and above
Q205 Did you visit ANC service 1. Yes
when you were pregnant for 2. No
this child? For mother only

Q206 Did you visit PNC for this 1. Yes

child? For mother only 2. No

Q207 Did you visit health facility 1.Yes If NOQ209

for any purpose with your 2.No
current child?
Q208 If Yes for Q207, did the If YesQ301
child receive any vaccines 1. Yes
for which he/she was 2.No
eligible for that day?

Q209 If No for Q208, do you 1.Was not told to vaccinate 1.Yes 2.No
know any reason why your my child
child did not receive the 2. Vaccine was not available 1.Yes 2.No

64
 immunization? 3. Child was severely ill and 1.Yes 2.No
health worker refused to
Interviewer marks all the vaccinate the child
relevant options 4. I refused to get my child 1.Yes 2.No
vaccinated because my child
was ill.
5.Becouse he/she already 1.Yes 2.No
vaccinated
6. Vaccinator didn’t shave off 1.Yes 2.No
vial
PART III: KNOWLEDGE OF MOTHERS/CARE TAKER ON IMMUNIZATION AND
VACCINE PREVENTABLE DISEASES

Q301 Does immunization 1. Yes

prevent communicable 2. No
disease for your child? 99. Do not remember/DKN

Q302 Do you know diseases 1. Yes If No Q304

potentially preventable by 2. No
vaccination? 99. DKN
Q303 If Yes for Q302, Which 1. Tuberculosis 1.Yes 2.No
disease (s) do you know 2. Polio 1.Yes 2.No
that can be prevented by
vaccine? 3. Diphtheria 1.Yes 2.No
Interviewer marks all the 4. Tetanus 1.Yes 2.No
relevant options. 5. Pertusis 1.Yes 2.No
6. Measles 1.Yes 2.No
7. Hepatitis 1.Yes 2.No
8. Meningitis 1.Yes 2.No
9. Liver cancer 1.Yes 2.No
Q304 Do you know when your 1. Yes If NoQ306
child should be given BCG 2. No
vaccine?

Q305 If yes, for Q304 when is it 1. At birth

given? 2. 2weeks 3. 6weeks

65
Q306 Do you know when your 1. Yes If No Q308
child should be given 2. No
measles vaccine?
Q307 If yes, for Q306 when is it 1. 6 month
given? 2. 9 month
3. 12 month
Q308 Do you know when your 1.Yes If No Q310
child completes his/her 2.No
vaccination?
If yes, for Q308 when does 1. Before 12 months
Q309 he/she complete? 2. After 12 months

Q310 Do you know any 1. Yes If NoQ401

symptoms of vaccine 2. No
preventable disease?
Q311 If yes, for Q310 which 1.Cough(Tuberculosis/Pertusis) 1.Yes 2.No
symptom you know? 2.Difficulty in breathing 1.Yes 2.No
Interviewer marks all the (Diphtheria)
relevant options. 3.Skin rash (measles) 1.Yes 2.No
4.Paralysis (Poliomyelitis) 1.Yes 2.No
5.Jaundice (hepatitis B) 1.Yes 2.No
6.High fever (Pertusis) 1.Yes 2.No

PART IV: ATTITUDE OF MOTHERS/CARE TAKER TO WORD IMMUNIZATION

Q401 If you never had immunization 1. Yes

for your child, do you have any 2. No
intention (plan) to get her/him
99. DKN
immunized?
Q402 If you ever had discontinued 1.Yes
immunization for your child, do 2. No
you sense that it is help full to get
99. DKN
him/he reinitiated?

66
Q403 Do you think that immunization 1.Yes
for your child is harmful/has 2.No
adverse complication? 99.DKN
Q404 Do you feel that immunization for 1. Yes
your child is beneficial? 2. No
Q405 Do you advise other mothers to 1. Yes
get their children immunized? 2. No

Part V: Health facility related

Q501 How much an hour (on 1.On foot ____half an

average) does it take to hour
reach the nearest health 2.BY car ______less than
institution from your half an hour
home?
Q502 What is the distance of __________hours of
nearest health institution walk
in hours of walk (on
average) from your
home?
Q503 Have you ever attain 1.Yes If NoQ506
immunization service 2.No
for your index child at
Health facility?
Q504 If yes for Q503Was the 1.Yes
service given on 2.No
immunization is
convenient to you?
Q505 If yes for Q504, what 1. Opening hours 1.Yes 2.No
makes it convenient? 2. waiting time 1.Yes 2.No
Interviewer marks all 3. distance travel 1.Yes 2.No
the relevant options
88. other specify _________
Q506 Have you ever been 1.Yes If NoQ508
turned home without 2.No
getting vaccination
during your
appointment?

67
Q507 If yes for Q506, what 1.Vaccine not available 1.Yes 2.No
was the reason for not 2.Vaccinators were absent 1.Yes 2.No
getting vaccination?
88.Other specify _________
Interviewer marks all
the relevant options
Q508 What was the average 1. Less than an hour
waiting time to get the 2.One to two hour
immunization service 3. Greater than two hours
after you come to health 99.DKN
facility?
Q509 Is there health facility/ 1. Yes If NoQ513
immunization site in 2. No
your kebele? 99.DKN
Q510 If yes for Q509, which 1. health center 1.Yes 2.No
health facility/ 2. health post 1.Yes 2.No
immunization site
3. outreach site 1.Yes 2.No
exists? More than one
99. DKN
answer is possible
Q511 If outreach site is yes for 1. Yes If NoQ513
Q510, does it provide 2. No
immunization service?
Q512 If yes for Q510, how 1. Monthly
often it is? 2. Two monthly
3. Three monthly
4. Four monthly
5. Rarely (once or twice
per year)
99. DKN
Q513 Is there health extension 1. Yes If No Q601
worker in your kebele? 2. No
Q514 If yes for Q513, did 1. Yes
health extension worker 2. No
ever visit your house
Q515 If yes for Q514, was she 1.Yes
given information on 2.No
immunization?

68
 Part VI: Source and given information on immunization

Q601 Did you heard about 1. Yes If NoQ606

immunization before? 2. No
Q602 If yes for Q601, from 1.radio 1.Yes 2.No
whom do you hear about 2.TV 1.Yes 2.No
immunization? 3.Health extension worker(HEW) 1.Yes 2.No
Interviewer marks all the 4. Health professional 1.Yes 2.No
relevant options 5.Village leader 1.Yes 2.No
6.Friend or family member 1.Yes 2.No
Q603 Did the health worker ever 1.Yes If NoQ605
discuss about 2. No
immunization with you?

Q604 If yes forQ603, what did 1. What immunization is/ whom 1.Yes 2.No
he/she discuss about immunization is for
2. Types of disease preventable by 1.Yes 2.No
immunization?
immunization
3.When, how and where vaccines are 1.Yes 2.No
given
4. Advice on side effect and 1.Yes 2.No
contraindication of immunization.
5. Appointment of the next session. 1.Yes 2.No

Q605 From whom/how do you 1. from health volunteers of the 1.Yes 2.No
know of immunization village
schedule of your child? 2. from member of my family 1.Yes 2.No
Interviewer marks all the 3. from head of village 1.Yes 2.No
relevant options 4. I follow from immunization card 1.Yes 2.No
indication
5. from health professional 1.Yes 2.No
6. from HEW 1.Yes 2.No

69
Q606 Did you ever get 1.yes
encouraged by the health 2.no
workers/HEW or local
leaders to immunize your
child during the last year?

Part VII: Immunization status of child

a) Card-based
Q701 Have you ever vaccinated your 1.Yes If NOQ707
Child? 2.No
If yes for Q701, at what age of _________ months
Q702 Your child started?
703 If yes for Q701, where you vaccinate1. health center 1.Yes 2.No
Your child? Interviewer marks 2. health post 1.Yes 2.No
all the relevant options 3. outreach 1.Yes 2.No
Q704 If yes for Q701, do you have a 1. Yes, seen If 1  Q706
Vaccinations card where 2. Yes, not seen If 2Q707
Vaccinations are written down? 3. No card If 3Q705
If yes: may I see it please?
Q705 If there is no immunization card at 1.Has not finished but card was 1.Yes 2.No
hand, do you know why the child lost
has no immunization card? 3. Has finished but card was lost1.Yes 2.No

3.Card is not given to my child 1.Yes 2.No

4.Card is at health institution 1.Yes 2.No
Q706 If yes and seen for Q704,
A. Copy dates for each vaccination from the card.
B. Write ‘44’ in day column if card shows that vaccination was given but no date recorded

70
 Date of Immunization
Antigen day month year
Q706_1 BCG 1.Yes 2.No
Q706_2 OPV0 1.Yes 2.No
Q706_3 OPV1 1.Yes 2.No
Q706_4 OPV2 1.Yes 2.No
Q706_5 OPV3 1.Yes 2.No
Q706_6 Penta1 1.Yes 2.No
Q706_7 Penta2 1.Yes 2.No
Q706_8 Penta3 1.Yes 2.No
Q706_9 Measles 1.Yes 2.No
If yes for Q706_1, is BCG scar present? Observe outer part
of upper right arm. 1.Yes 2.No

CHECK Q706. ARE ALL VACCINES 1. Yes If YesQ709

(BCG TO MEASLES) RECORDED? 2. No If NOQ707

b)For and from maternal or caretaker history

Q707 Did your child receive any 1.Yes If NoQ801

vaccination to prevent her or him 2.No
from getting disease? 99.DKN

Q708 If yes for Q707 ,Please tell me if your child received any of the following vaccinations:
Q708_1 BCG vaccination against tuberculosis 1.Yes If No Q708_3
that is an injection in the arm or 2.No
shoulders that usually causes a scar?
Q708_2 If yes for Q708_1 is BCG scar 1.Yes
present? Observe outer part of the 2.No
upper right arm
Q708_ Was the first polio vaccine received 1.Yes
3 immediately after birth or in the first 2.No

71
 two weeks that given as drop into
mouth?
How many times was the polio number of times
Q708_ vaccine received? ____________
4
DPT/ penta vaccination, that is, an 1.Yes If No Q708_7
Q708_ injection given in the thigh or 2.No
5 buttocks, sometimes at the same time
as polio drops?
Q708_ If yes for Q708_5 how many times number of times
7 was a DPT /penta Vaccination ____________
received?
Q708_ Any vaccine injection to prevent 1.Yes
8 measles on left arm? 2.No

Q708_1 BCG 1.Yes 2.No

Q708_3 OPV0 1.Yes 2.No
Q708_4 OPV1 1.Yes 2.No
Q708_4 OPV2 1.Yes 2.No
Q708_4 OPV3 1.Yes 2.No
Q708_7 Penta1 1.Yes 2.No
Q708_7 Penta2 1.Yes 2.No
Q708_7 Penta3 1.Yes 2.No
Q708_9 Measles 1.Yes 2.No

Record ‘yes’ only if respondent answer ‘yes’ for question BCG, first
polio( 0), e.g. if number of polio and penta received is one times
record ‘yes’ for OPV1, and penta1 and the like and/or measles

72
 vaccines

Q709 Immunization status of child by 1. Not Immunized

interviewer from card and 2.Partially Immunized
mothers/ care taker 3.Fully Immunized

Q710 If the child was fully immunized, __________months

at what age your child
finished immunization?
From card and mothers history
Q711 Fully immunized before 1 year of 1.Yes
age by card and mother history by 2.No
interviewer
Check Q702, Q706,Q710

Part VII: Reasons for immunization failure

Q801 Which reason you think that result you not immunizing /completing immunization of your
child? Interviewer marks all the relevant options
1. Unaware of need for immunization 1.Yes 2.No
2. Unaware of need to return for 2nd or3rd dose 1.Yes 2.No
3. Place and/or time of immunization unknown 1.Yes 2.No

4. Fear of side reactions 1.Yes 2.No

5. Wrong ideas about contraindications 1.Yes 2.No

Q802 What reason you think were not motivated you completing immunization of your child?
Interviewer marks all the relevant options
1. Postponed until another time 1.Yes 2.No
2. No faith in immunization 1.Yes 2.No
3. lack of confirmed information 1.Yes 2.No

73
 4. Others(specify) ______________
Q803 What barrier you think result you not immunizing your child? Interviewer marks all the
relevant options
1. Place of immunization too far 1.Yes 2.No
2. Time of immunization inconvenient 1.Yes 2.No
3. Vaccinator absent 1.Yes 2.No
4. Vaccine not available 1.Yes 2.No
5. Mother/care taker too busy 1.Yes 2.No
6. Family problem, including illness of 1.Yes 2.No
mother/caretaker
7. Child ill – not taken to health facility 1.Yes 2.No
8. Child ill – taken to health facility but not given 1.Yes 2.No
immunization
9. Long waiting time at health facility 1.Yes 2.No
10. fear of side effect 1.Yes 2.No
11.Others (specify) ----------

74
II.QUESTIONNAIRE IN AFAN OROMO VERSION
Gaaffilee kun haagoogii talaali mucaa fi murteessaa talaali Aanaa Sinaanaa sakatta’uuf kan
qophaayedha.
Waraqaa Odeeffannoo
Nagaa gaafachuu! Maqaan koo__________________________jedhama. Garee yuuniversiiti finifinnee irra
dhufan kan wa’ee haagooggi talaali da’immaani fi murteesso talaali iraatti haadholi da;ima umrii ji’a12-23
giddu ta’an qaban giddutti kan gaggeffamudha.kanaafu, gaaffi fi deebiin kun haadholee da’ima umrii
caqasamee qaban keessa kan dura filatamtee gaafatamuun eegala. Wantan isinitti himuun natti tolu keessaa,
deebiin isin gaaffii gaafatamtaniif deebiftan fiixa bahumsa qorannichaa qofaaf osoo hin taane, taalali ijoole
fooyyessuuf, madda odeeffannoo cimaadha ta’ee gargaara. Qorannich qaamolee barbaachisaa ta’aan
hundan kan ilaallamee fi qulqulleffamee yoo ta’uu xalayaan eeyyeemaas argameera.

Qorannoon kun guddina tajaajila fayyaa dargaggootaf bu’aa kan buusu dha. Bu’aan dhuma irratti qorannoo
kana irraa argamu warra ilalatu hundaf kan ibsamu dha. Kanaafuu, qorannoo kana keessatti hirmachun
carraa lammummaa fi hawaasaf faayidaa kan qabu dha.

Odeeffannoo dabalataf +251-9 12-08-11-08/251-9 17-28 27 90 (Worquu Dachaasaa hooggana garee)

Uunka Waliigaltee

Fedhi fi kaayyoo qoranniicha irratti hunda’ee isin/ati nama gaaffi fi deebii kanaaf filatamtan/tee yoo
taatan/tu ,kanaafuu kanatti aanee gaaffilee adda adddaa isin gaaffa dha.Yoo yeroo xinnoo naaf laattan
baay’een isin/si galatefa dha.Gaaffi fi deebiin kun fedha irratti kan hunda’ee yoo ta’u,iccitiin kan
qabamuu ,dhunfatii fi tilmaaman sa’aa walakka kan fudhatuu dha. Koodii lakkofsaan ala maqaan fi wanti
adda isiin godhu tokko illee waraqaa deebii kana irratti hin.gaaffi deebiisu hin barbannee akka deebistanifi
hin dirqamtan,yoo gaaffi addan kutan ba’uu barbada mirga guutuu qabdu.garuu akka gaaffileen
barbachisoo ta’anif bu’aa qabeesa ta’an hubatan yoo deebii guutuu nuf latan baay’ee bu’a qabeeessa ta’a.
Ammaa gara gaaffiti kan dabaruu eega fedha keessaan naaf mirkaanessitan booda. Akka haala ho’aan
hirmaattan fi gahee keessan baatan kabajaan isin gaafa dha.

Gaaffi fi deebii kana ittifufuuf fedha qabdu?

Eeyyee itti fufuuf fedhan qaba__________

Lakki itti hin fufu__________ (Galateeffadhu marii xummur)

Maqaa Nama gaafatuu________________ koodii__________ mallattoo________

Maqaa too’ata______________________ koodii_____________ mallattoo__________

Araadda/ganda__________________ zoonii/ganda xiqqa ____________mana__________

Guuyyaa_______________

75
Kuta 1: Haala wali-galaa ilaalchissee

Lakk Gaaffilee Deebi’i Kodii Kan itti darbamu()

G101 Bakka jireenya ? 1. Magala
2. baadiyyaa
G102 Walitti dhufenya mucaa wajjin 1. hadhaa
qabdu 2. guddiftuu biraa
G103 Umri hadhaa/guddiftuu biraa waggaa _______

G104 Haala fudha fi heerummaa 1. Tan hin heerumiin/ kan hin

haadhaa/ guddiftuu biraa fuudhiin
2. Tan heerumite /kan fuudhe
3. Tan hiikamite /kan hiike
4. Tan irraa duute / kan irraa
du'e
G105 Amanti haadhaa/guddiftuu 1. Kiristiyaana ortoodokisii
biraa 2. Musilimaa
3. Piroteestantii
4. Kaatoolikii
88. kanbiraa(ibsii)______
G106 Saba/sab- lammii/ 1. Oromo
haadhaa/giddiftuu biraa 2.Amaara
3.Somaalee
4. Guraagee
88. kanbiraa(ibsii)______

G107 Sadarka barumsaa haadhaa/ 1. Tan/kan barressuu hin

giddiftuu biraa dandenyee
2. Tan/kan barressuu
dandensuu/danda’u
3. sadarikka 1ffaa(1-4)
4. sadarikka giddu gala (5-8)
5. sadarikka 2ffaa(9-12)
6. kooleejjii/universiti
1. Haadhaa mana
G108 Hojjii haadhaa/ giddiftuu biraa 2. Qoottee bultuuu/bulla
3. Hojjatuu/taa motuumma
4. Baraattuu/barattaa
5. Daldaalttuu/daldallaa
6. Hojjatuu/taa guyyaa
88. kanbiraa(ibsii)_______
G109 Sadarkaa barumsaa abbaa 1.kan barressuu fi dubbisuu hin
mucaa dandenyee
2.kan barressuu fi dubisuu
danda’u
3.sadarikka 1ffaa(1-4)
4.sadarikka giddu gala (5-8)
5.sadarikka 2ffaa(9-12)
6.kooleejjii/universitii
76
 G110 Bayyinaa maatii kessan 1. Lamma
2. Sadi
3. Afur
4. Shani fi isaa ol
G111 Hojjii abbaa mucaa 1.Qootee bulla
2.Hojjataa motuumma
3.Barattaa
4.Daldallaa
5.Hojjataa guyyaa
88.kan biraa(ibsii)_______
G112 Gailin warraa/maatii ji’at ______
mallaqan yeroo tilmamamuu
meqaa?
G113 warri/maatii Televijjiin 1. Eyyee
qaaban? 2. Miti
G114 warri/maatii raadiyyon 1. Eyyee
qaaban? 2. Miti

Kutaa 2:Waa’ee waligala raga mucaa. Gaffillee kanat anaan wa’e itti fayyadama dhabataa fayya haadholli fi
mucaa, mucaa umrin issaa ji’a 12 hang 23 ta’e gaaffadhuu

G201 Umriin mucaa kana Ji’aan_____

meqaa?
G202 Saalli mucaa kana 1. Dhiira
maalii? 2. Dhalaa
G203 Mucaan kee kun essati 1. dhabataa fayyaa umataa
dhalate/tte 2. dhabataa fayyaa dhuffa
3. mana
G204 Mucaan kee/kun kaan 1. 1ffaa 3. 3ffaa4
. ffaa
dhala meqaffaadha? 2 2 4. 4ffaa
5. 5ffaa fi irraa ol
G205 Yeroo mucaa kana ulfa 1.Eyyee
turtee hordofi da’umsa 2.Miti
gootee jirtaa? Haadha
mucaa qofaaf
G206 Egaa mucaa kana 1.Eyyee
deesse booddee hordofi 2.Miti
da’umsa boodde gootee
jirtaa? Haadha mucaa
qofaaf
G207 Fayyadamaa kammifuu 1.Eyyee Yoo 2G209
dhabataa fayya mucaa 2.Miti
kee kana wajjin demtee
beekta?

77
G208 G207f deebiin kee 1.Eyyee Yoo 1G301
Eyyee yoo 2.Miti
ta’ee, mucaan kee
talaali guyyaa san
ga’eef fudhatee/ttee
jira/ti?
G208f deebiin kee Miti 1. akkan taalalchisuu nat hin himnee 1.Eyyee 2.Miti
yoo
G209 ta’ee, sababa mucaan 2. taalalin hin jiruu 1.Eyyee 2.Miti
kee talaali ga’eef
hinfudhatiin beektaa ? 3.mucaan koo wan baayee 1.Eyyee 2.Miti
(Deebii tokko - ol dhukubeef hojattootni fayyaa hin
deebiisu ni danda'ama) kenamuuf jedhan
4. mucaan koo wan baayee 1.Eyyee 2.Miti
dhukubeef ani akka hin kenamneef
godhe
5. mucaan koo duranuu 1.Eyyee 2.Miti
talalfamerraa

6.talalchisaan bilqatti banuu didde 1.Eyyee 2.Miti

Kutaa 3: Beekuumsa haadholiin/guddiftuun biraa taalalirratti ykn dhukubaa talallin ittifaman irratii qaban
ilaalchiisee

G301 Taalalin dhukuba 1.Eyyee

daddarba mucaa 2.Miti
keetirra ni ittissa? 99.hinbeeku

G302 Dhukubaa/oota taalalin 1.Eyyee Yoo 2G304

itfaaman ni beektaa? 2.Miti/lakki
99.nan shakka

G303 G303f deebiin kee 1.dhukuba sombaa 1.Eyyee 2.Miti

Eyyee yoo 2.lamshessaa 1.Eyyee 2.Miti
ta’ee, dhukubaa/ oota 3.difteeri’a 1.Eyyee 2.Miti
kam beektaa? 4.tetanas 1.Eyyee 2.Miti
(Deebii tokko - ol
deebiisu ni danda'ama) 5.qakkee 1.Eyyee 2.Miti
6.shiftii/gifraa 1.Eyyee 2.Miti
8. boquu gogsaa 1.Eyyee 2.Miti
9.dhukuba tiruu 1.Eyyee 2.Miti
1.dhukuba sombaa 1.Eyyee 2.Miti
G304 Yero mucaan kee talaali 1.Eyyee
dhukuba somba 2.Miti
fudhatuu/ttu ni bektaa?
G305 G304f deebiin kee yoo 1.Akkuma dhalateen
eeyyee ta’e yoom 2.Torbaan 4tti
laatama? 3.Torbaan 6tti

78
 G306 Yero mucaan kee 1.Eyyee Yoo 2G308
talaalli dhukuba 2.Miti
shiftoo/gifiraa
fudhatuu/ttu ni bektaa?
G307 G305f deebiin kee 1. ji’a 6tti
Eyyee yoo 2. ji’a 9tti
ta’ee, yoom keenama? 3. ji’a 12tti
G308 Yero mucaan kee 1.Eyyee Yoo 2G310
talaalli fixuu/xxu ni 2.Miti
bektaa?
G308f deebiin kee 1. ji’a 12 dura
G309 Eyyee yoo 2. ji’a 12 booda
ta’ee, yoom fixa/xi?
G310 Malattoo/lee 1.Eyyee Yoo 2G401
dhukubaa/oota taalalin 2.Miti
itifamaan ni beektaa?
G311 G310f deebiin kee 1.quffa(dhukuba somba/qakkee) 1.Eyyee 2.Miti
Eyyee yoo
ta’ee, Malattoo/lee kam 2.rakinaa harganuu() 1.Eyyee 2.Miti
beektaa? 3.shakkaa(shiftoo)/gifira 1.Eyyee 2.Miti
(Deebii tokko - ol
deebiisu ni danda'ama) 4.lamsha’uu(lamsheessaa) 1.Eyyee 2.Miti
5.dhukkuba shimbiroo() 1.Eyyee 2.Miti

6.ho’aa guddaa(qakkee) 1.Eyyee 2.Miti

Kutaa 4: Ilaalcha hadhoolin /guddiftuun bira taalalirrati qaban illalchissee

G401 Yoo hanga ammati mucaa kee 1.Eyyee
talalichisuu baate, talalchisuuf karoora 2.Miti
qabattee jirtaa? 99.hinbarre
G402 yoo kana dura talaalli mucaa keetii addan 1.Eyyee
kutte jirta ta’ee ,debsttee osoo itti 2.miti/lakki
fufsistee fayyidaa qabaf ? 99.nanshakka

Talaallin mucaa kee irratti bala/midhaa 1.Eyyee

G403 gessa jettee yaadda? 2.Miti
99.hinbeeku
G404 Talaallin mucaa keetiif fayidaa qaba 1.Eyyee
jettee yaadaa? 2.Miti
G405 Atii hadhooli biroo akka mucaa isaani 1.Eyyee
talalchisan ni gorsitaa? 2.Miti

79
Kutaa5: Dhabataa fayyaa ilalchissee

G501 Tilmaaman mana keeti kaatee 1. milaan sa’aa meqaa____

dhabata fayyaa siti dhihaatuu 2. konkolaatadhan sa’aa
dhaquuf sa’aa meeqa siit meqaa________
fudhataa?
G502 Tilmaaman mana keeti hanga ______Kms/deemsa lukaatiin
dhabata fayyaa sitii dhihatuu
kiloometira meeqa?
G503 Kanaan dura tajaajila talaallif 1.Eyyee Yoo 2G506
mucaa kee buufata fayyaaa 2.Miti/lakki
fiddee beekta?
G504 Taajajili taalallirratti kenamuu 1.Eyyee
sitii tollerra? 2.Miti
G505 G504f deebiin kee Eyyee yoo 1. yeroo iti banamuu 1.Eyyee 2.Miti
ta’ee, taajajili taalalirra maalsatuu
sit tolee? (Deebii tokko - ol 2.yeroo turtii 1.Eyyee 2.Miti
deebiisu ni danda'ama)
3.fagenyaa demamuu 1.Eyyee 2.Miti
88.kan bira(ibsi) ____

G506 Yeroo bellaama keetii osoo 1.Eyyee Yoo 2G508

taalalli hin arkatiin gafa mana 2.Miti
keetiitti deebitee ni qabda?
G507 G505f deebiin kee Eyyee yoo 1. taalalin hin jiruu 1.Eyyee 2.Miti
ta’ee, sababnii taalali osoo hin 2.taalachisaan hin jiruu 1.Eyyee 2.Miti
argatiin deebiteef maali? (Deebii 3.kan bira(ibsi) _____
tokko - ol deebiisu ni danda'ama)
G508 Jiddu galaan egaa dhabata fayyaa 1. sa’atii tokko gadii
dhuftee tajajilaa taalali 2. sa’a tokko hanga lamma
argachhuuf sa’aat meeqa siit 3. sa’atii lamma calla
fudhataa?
G509 Dhabbani fayyaa/bakki taalallin 1.Eyyee Yoo2G513
iti keenamuu Araddaa keessan 2.Miti
keessa jiraa?

G510 G509f deebiin kee Eyyee yoo 1. bufaata fayyaa 1.Eyyee 2.Miti
ta’ee, dhabbani fayyaa/bakki 2.kella fayyaa 1.Eyyee 2.Miti
taalallin iti keenamuu kamtuu
jiraa? (Deebii tokko - ol deebiisu 9.bakka taalalin iti keenamuu 1.Eyyee 2.Miti
ni danda'ama)
99.hinbeeku
G511 Yoo bakka taalallin itti 1.Eyyee Yoo2G513
keennamuu filannoo G510 keessa 2.Miti
jirate ,tajaajila talaalli fayyaa ni 99.hinbeeku
lata?

G512 G511f deebiin kee Eyyee yoo 1. ji’at yeroo tokkoo

ta’ee, yoom yoomfa argamaa? 2. ji’at yeroo lamma
3. ji’at yeroo sadi

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 4. ji’at yeroo afur
5. darbe darbe (waggati yeroo
tokko ykn lamma)
G513 Hojjatuun exteenshin fayyaa 1.Eyyee Yoo3G601
Araddaa keessan keessa ni jirtii? 2.Miti
G514 G513f deebiin kee Eyyee yoo 1.Eyyee
ta’ee, hojjatuun exteenshin fayyaa 2.Miti
mana kessan dhuftee bektii?
G515 G514f deebiin kee Eyyee yoo 1.Eyyee
ta’ee, waa’ee taalalliirratti 2.Miti
odefaannoo isin keenitee beekti?

Kutaa 6: Burqaa fi oduu taalallirratti kenaman laalchisee

G601 Kanan dura wa’ee taalalli dhageesse 1.Eyyee Yoo 2G606

bektaa? 2.Miti
G602 G601f deebiin kee Eyyee yoo 1. Radiyoon 1.Eyyee 2.Miti
ta’ee,enyuuirra wa’ee talaalli 2.Televiyiin 1.Eyyee 2.Miti
dhagesse? 3.hojjetu exteenshin fayyaa 1.Eyyee 2.Miti
4.ogeessa fayyaa
4.bulchaa gandaa 1.Eyyee 2.Miti
5.michuu ykn maatii manarra 1.Eyyee 2.Miti
G603 Hojjetaan fayyaa wa’ee taalallirratti 1.Eyyee Yoo 2G605
siwaajiin maari’atee bekaa? 2.Miti

G604 G603f deebiin kee Eyyee yoo 1. taalallin maal akka ta’e fi 1.Eyyee 2.Miti
ta’ee,taalallirrati wa’ee maal irraatti eenyuuf akka latamu
walin mari’atan? (Deebii tokko - ol 2. goosotaa dhukuboota 1.Eyyee 2.Miti
deebiisu ni danda'ama) taalallin itiisaman
3. taalallin yoom, akkamit 1.Eyyee 2.Miti
fi essatii akka kenamuu
4. midhaa fi yeroo taalalin 1.Eyyee 2.Miti
hin kenaamnee
5. beellamaa yeroo itti anuu 1.Eyyee 2.Miti

G605 Enyuurra ykn akkamitii beellamaa 1. warra ganda kan feedhin 1.Eyyee 2.Miti
taalali mucaa keetii bektaa? fayyarratii hojetaan irra

2. warraa maatii kootirraa 1.Eyyee 2.Miti

3. itti gafaatamma gandaraa 1.Eyyee 2.Miti
4. kardii taalillirraa 1.Eyyee 2.Miti
hordofuudhan

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 5. ogeessa fayyaarra 1.Eyyee 2.Miti
6. hojjettu exteenshiin 1.eyyee 2.miti
fayyaa
G606 Wagggaa darbee kessaa ogeessi 1.Eyyee
fayyaa/hojjettunexteenshiin fayyaa 2.Miti
ykn itigafaataman ganda akka mucaa
kee taalachistuu sit himee?

Kutaa7: Taalili Mucaa Ilaalchissee

a) odeeffannoo kardiirraa

G701 Mucaa kee taalalchisetee beektaa? 1.Eyyee

2.Miti
G702 G701f deebiin kee Eyyee yoo Ji’a ________
ta’ee, umri meqaati jalqabee?
G703 G701f deebiin kee Eyyee yoo 1.bufaata fayyaa 1.Eyyee 2.Miti
ta’ee, mucaa keessan essatii 2.kella fayyaa 1.Eyyee 2.Miti
taalalchistu? (Deebii tokko-ol deebiisu
ni danda'ama) 3.bakka taalalin iti keenamuu 1.Eyyee 2.Miti

G704 G701f deebiin kee Eyyee yoo 1. Eyyeen laali Yoo1 G706
ta’ee, kardii taalallin irraatti 2. Eyyen, garuu hin laalamnee Yoo2G707
barreefamee qabdaan? 3. kaardin hin jiruu Yoo3G705
Eyyen yoo ta’e,nat agarsiisu
dandessu?

G705 Yoo mucaan keessan kardii talaalli 1.hin xumurree/fixnee garuu ni 1.Eyyee 2.Miti
hin qabanee, sababaa mucaan keessan bade
hin qabaatiniif bektuu? (Deebii tokko-
ol deebiisu ni danda'ama) 2. xumurree/fixee garuu ni bade 1.Eyyee 2.Miti

3.kardiin mucaa kootiif hin 1.Eyyee 2.Miti

kenamnee
4.kardiin dhabbataa fayya jira. 1.Eyyee 2.Miti

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Q706 G704f deebiin kee Eyyee laalee yoo ta’ee
A. guyyaa taalali hundaa assirrat gara galchi
B. toorra(Column) guyyaa jallaat ’44’ barresii yoo taalalin
kenaame guyyaan barrefamu batee
Guyyaa talaali

Guyyaa Ji’a Barra Deebii

G706_1 BCG 1.Eyyee 2.Miti

G706_2 OPV0 1.Eyyee 2.Miti

G706_3 OPV1 1.Eyyee 2.Miti

G706_4 OPV2 1.Eyyee 2.Miti
G706_5 OPV3 1.Eyyee 2.Miti
G706_6 Penta1 1.Eyyee 2.Miti
G706_7 Penta2 1.Eyyee 2.Miti
G706_8 Penta3 1.Eyyee 2.Miti
G706_9 Measles 1.Eyyee 2.Miti

G706_1f deebiin kee Eyyee yoo ta’ee, goodanis BCG jiraa? Irree harka 1.Eyyee 2.Miti
mirgaa gama alaa laali.

b) Odeeffannoo hadhooli /guddiftuu birraa laalichissee

G707 Mucaa kee taalalli dhukubaa isaa/isheerraa itiisuu fuudhaterraa? 1.Eyyee 2.Miti

G708 G706-1f deebiin kee Eyyee yoo ta’ee, yoo mucaa kessan talaalli kanatii anee jiruu fudhaattee nat himi
G708 Taalili BCG dhukubaa somba itiisuu, kan kenaamus irree harka mirgaa 1.Eyyee 2.Miti
_1 yoo ta’u,yeroo heddu godanisni mul’aachu kan danda’u?

G708 G708_1f deebiin kee Eyyee yoo ta’ee, goodanis BCG jiraa? Irree 1.Eyyee 2.Miti
_2 harka mirgaa gama alaa laali.

G708 Taalalin lamshessaa/polio in jalqabaa yeroo mucaan kee dhaaletee ykn 1.Eyyee 2.Miti
_3 torbee lamaan duraa kessatii keenameef jirra, kan kenamus afan mucaa
kessatti busuudhan?
G708 Taalallin lamshessa/polio mucaa keetiif yeroo meqaa kenameef? ___lakk.
_4

83
G708 Taalil DPT ykn pentaavalentii kan sarbaa ykn tessoorra waraanudhaan 1.Eyyee 2.Miti Yoo2Q708_
_5 keenamuu,yeroo baayye polio waalin keenamaaf? 7
G708 G708_5f deebiin kee Eyyee yoo ta’ee, Taalalin DPT ykn _______
_6 pentaavalentii mucaa keetiif yeroo meqaa kenameef?
G708 Taalalli shiftoo/gifira ittisuu kan harkaa bitaaraa waarranamuu 1.Eyyee 2.Miti
_7 fudhaaterraa/jirti?

G708_1 BCG 1.Eyyee 2.Miti

G708_3 OPV0 1.Eyyee 2.Miti
G708_4 OPV1 1.Eyyee 2.Miti
G708_4 OPV2 1.Eyyee 2.Miti
G708_4 OPV3 1.Eyyee 2.Miti
G708_7 Penta1 1.Eyyee 2.Miti
G708_7 Penta2 1.Eyyee 2.Miti
G708_7 Penta3 1.Eyyee 2.Miti
G708_9 Measles 1.Eyyee 2.Miti

Eyyeen barressi yoo deebiin gaaftaamtoo ’eyyee’ ta’ee

gaaffillee BCG, polio jalqabaa(OPV 0) .faakeenyaaf yoo
laakofsii polio fi pentaavalant yeroo tokko ta’e eyyeen
barreesii OPV1fi penta1 dhaaf, measlefis yoo eeyee ta’e qofaa
baresii. Kan kana fakataan.

G709 Kardii fi odeeffannoo hadhaa/guddiftuu biraarrati hunda’uun

haali taalalli mucaa maal fakkataa? 1. hin taalalichisamnee
2. jalqabee garuu hin
xumarree
3. hundaa fudhattee/te

G710 Yoo mucaan taalalli hundaa fudhatee, umrini isaa meqaati

fixee? Kardii fi odeeffannoo hadhaa/guddiftuu biraarrati
hunda’uun Ji’a ________

Mucaan gafaa taalali hunda fudhaate fixuu umriin isaa/ishee 1.Eyyee 2.Miti
G711 waggaa tokko gadii? Odeeffannoo fuunaanan kardi fi
haadha/gudftuu biraarrat hunda’uun.gaaffilee,G702 ,G706fi
G710 ilaali

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Kutaa 8: Sababii kufaati taalali illaalchisee

G801 Odeeffannoo taalalli kam dhabudhan mucaa keessan osoo hin taalalichifamin ykn hin xummurin
hafee jeta/an yaadda/n? (Deebii tokko-ol deebiisu ni danda'ama)
1.Baarbachisuuma taalalli beekku dhabuu 1.Eyyee 2.Miti
2.Barbaachissumma marsaa(dose) 2ffaaf ykn 3ffaaf deebi’u
bekumsaa dhabu. 1.Eyyee 2.Miti
3.baakka fi/ykn yeroo taalali beekku dhabu 1.Eyyee 2.Miti
4.sooda rakkina taalalitiin dhufu 1.Eyyee 2.Miti
5.Ilaalichaa dogoggoraa kan taalalin hin keenamneef irraat 1.Eyyee 2.Miti
G802 Kaakka’umsaa taalilirrat kam dhabudhan mucaa keessan osoo hin taalalichifamin ykn hin xummurin
hafee jatan yaadan? (Deebii tokko-ol deebiisu ni danda'ama)
1.taalali yeroo biraat dabarsuu 1.Eyyee 2.Miti

2.taalalliirratti amantumman hin jiruu 1.Eyyee 2.Miti

3.odeeffannoo mirkina’ee dhabuu 1.Eyyee 2.Miti
4. kan bira(ibsi) _________
G803 Rakkinaa issaa kamtuu mucaa keessan osoo hin taalalichifamin ykn hin xummurin hafee jetaan
yaaddu? (Deebii tokko-ol deebiisu ni danda'ama)
1.baakki taalali fagoodha 1.Eyyee 2.Miti
2.yeroo taalalli namat hin toolu 1.Eyyee 2.Miti
3.taalalichisaan hin jiruu 1.Eyyee 2.Miti
4.taalallin hin argaamu 1.Eyyee 2.Miti
5.haati/ guddiftuun biraa yeroo argachuu dhabuu 1.Eyyee 2.Miti
6.rakkina maatii kan akkaa hatii/gudftuun biraa dhukubsaachuu 1.Eyyee 2.Miti
7.mucaan waan dhukkubeef dhabataa fayya hin gessinee 1.Eyyee 2.Miti
8.mucaan dhukubsaatee dhabataa fayyaa gessee garuu hin 1.Eyyee 2.Miti
taalalchifamnee
9.dhabbataa fayyat yeroon egumsaa dheraa ta’ussaa 1.Eyyee 2.Miti
10. sooda rakkina taalallitiin dhufu 1.Eyyee 2.Miti
11.kan biraa (ibsi) _______

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III. Focus group discussion guide
A. Introduction
1. First of all I would like to thank you all for coming to this discussion session.

2. Your presence is very important.

3. My name is Mr. X.
B. Purpose
We are discussing your reactions about child immunization in your community .So; I am interested
in all your ideas, comments and suggestions. There are no wrong or right answers; therefore please
feel free to agree/ disagree with one another.

All your comments and opinions will be recorded/audiotape so that we could not miss any of your
ideas while trying to take notes. And I assure you that all your comments are confidential, used for
research purpose only. I want our session to be a group discussion, so you need not wait for me to
call on you. Please speak one at a time, so that the tape-recorder can pick up every of your
suggestions and comments. Please stop me incase if you want to add something more.
Each participant is asked to introduce herself and tell us something about you.

Part I. Focus group discussion guide for mothers

1. Do people in your community know about child immunization?

 Usage, disease prevented by immunization with their symptom, schedule, whom

immunization is for?
2. Immunization is very important for every child. Do you agree? / Disagree? Why?

3. Why do people in your community not immunizing their child?

Tips, # of living children, father influence, immunization site is far, no vaccination , no vaccinator,
long waiting time ,fear of possible side effect and important others influence, Ethics of Health
provider ,

4. What do you think should be done to improve child immunization in your community?

Part II. Focus group discussion guide for health workers

1. What do you think that community were not implement information provided by health workers?
Information factors, provider factors,

1. Why do you think is child immunization low in this Woreda and high VPDs? Or in your
catchment’s area?

- Socio-demographic, Knowledge factors, Attitude, Logistic factors and Service provision factors

2. What do you think should be done in order to improve child immunization coverage in your
institution’s catchments?
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Annex 5:- Attitude of the Respondent toward immunization in sinana
district
Table 14:- Attitude of Respondent toward Immunization in Sinana District, Bale Zone, Oromia,
Ethiopia, 2012/13
Variables frequency percent (%

Attitude of Mother toward vaccination of children

Positive 587 99.3
Negative 4 0.7
Intention (plan) to immunize the Child
Yes 586 99.2
No 5 0.8
Helpful to get reinitiated immunization for the Child
Yes 582 98.5
No 9 1.5
Immunization harmful to the Child
Yes 31 5.2
No 560 94.8
Immunization for your child is beneficial
Yes 584 98.8
No 7 1.2
Advise other mothers to get their children immunized
Yes 587 99.3
No 4 0.7

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Annex6:-Source of information by area of residence in sinana district

90.00%

80.00% 78.0%
74.2% 72.8% 71.2%
70.00% 65.1%

60.00%

50.00% 47.8%

40.00%
Urban
30.00%
Rural
20.00% 17.6% 17.6% 15.9%
14.8%
12.7%
11.3%
10.00%

0.00%

Figure5:- Source of information by area of residence in Sinana district Bale zone, Oromia region,
Ethiopia 2012/13

88
Annex7:- Reason given by mothers for not completing immunization of
children among partially/ unvaccinated in sinana district

Table14:-Reason given by mother for not completing immunization of children (n=137) in Sinana
district, Bale zone, Oromia region, Ethiopia, 2012/13

Reason frequency percent (%)

Unaware of need for immunization 83 60.6
Unaware of need to return for 2nd or3rd dose 85 62.0
Place and/or time of immunization unknown 65 47.4
Fear of side effect 76 55.5
Wrong ideas about contraindications 66 48.2
Vaccine date Postponed 46 33.6
No faith in immunization 51 37.2
Lack of confirmed information 53 38.7
Place of immunization too far 20 14.6
Time of immunization inconvenient 41 29.9
Vaccinator absent 31 22.6
Vaccine not available 46 33.6
Mother/caretaker too busy 45 32.8
Family problem, including illness of mothers 40 29.2
Child ill – not taken to health facility 24 17.5
Long waiting time at health facility 43 31.0

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Annex8:- map of study area (Sinana district)

Sinana district

Source: http://www.ocha-eth.org/Maps/downloadables/OROMIYA.pdf

Figure6:- map showing study area

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Annex 9:- Letters for declaration
I, the under signed, declared that this is my original work, has never been presented in this or any other
University, and that all the resources and materials used for the thesis, have been fully acknowledged.

NAME: WORKU DECHASSA HEYI (BSc)

Signature: _______________________________

Date: __________________________________

Place: Addis Ababa University, Ethiopia

Date of submission: June, 2013

This thesis has been submitted for examination with my approval as University advisor.

Name: Mulugeta Betre Gebremariam (MD, MPH)

Signature: _____________________

Date: _________________________

91