Coverage, Opportunity and Challenges of expanded Program on Immunization among 12-23 Months old Children in Woldia Town, Northeast, Ethiopia, 2018: Mixed cross sectional study

Objective The purpose of this is to assess coverage, opportunity and challenges of EPI among children age 12-23 month in Woldia town, Amhara region, Ethiopia. Result A total of 389 mothers/caretakers were interviewed. Based on vaccination card and mothers/caretakers’ recall, 385 (99%) of the children took at least a single dose of vaccine. About 343 (87.7%) children were fully immunized. Dropout rate was 9% for BCG to measles. Qualitative study revealed that workload, shortage of vaccine and non-compliance of mother/care taker for next schedule date was the major challenge faced by health professionals. In this study, vaccination coverage was low compared to the Millennium Development Goals target. Thus the town health office and concerned stakeholders need to work more to improve performance of the expanded program on immunization in this area.


Introduction
Expanded Program on Immunization (EPI) began by World Health Organization (WHO) in 1974 [1,2]. About 107 million babies (83%) global had gotten at least 3 doses of DTP vaccine; but, nearly 22.4 million miscarried to acquire 3 dosages, exposing huge numbers of children susceptible to vaccine-preventable diseases and death [3,4]. One out of five infants worldwide does not receive 3 life-saving doses of the diphtheria, tetanus and pertussis vaccine [5].
-3 -Below sub-Saharan African, 4.4 million children were die yearly due to transmittable diseases that could be avoidable by immunization [6,7]. It is associated to poor immunization Coverage, challenges and setup were not fully equipped in sub-Saharan Africa countries [8].
EPI was began in 1980 in Ethiopia with the purpose of reducing decease and disease of children and mothers from vaccine avoidable diseases [9].To achieve maximal protection against vaccinepreventable diseases, a child should receive all vaccines [10,11,12,13]. It has been also recognized that vaccine preventable diseases are responsible for 16% of under-five mortality in Ethiopia [14].
Even if Ethiopian government did different efforts, but the coverage rates was stayed highly small for several centuries [16,17].
AS explained by EDHS 2016, two from five children aged 12-23 months (39%) had gotten totally fundamental immunizations at some time, also 22% have gained vaccine by the suitable period time. There was increment of fully vaccinated children aged 12-23 months percentage from 24% to 39% [18]. Based on the EDHS 2016 report, there is a wide difference among regions concerning full immunization coverage ranging from 89% in Addis Ababa to 15 % in Afar region due to different challenges and opportunities as explained in other studies [16, 17, 18, 19& 20].
But in Woldia town there was no previous study that shows the coverage, dropout rate of EPI and asses' different challenge and opportunity of EPI. Therefore the aim of this study is to determine the level of immunization coverage, dropout rate and to explore challenges and opportunity of EPI among all pair of mother to children aged 12-23 months in Woldia town.

Study Area and Period
A community based cross sectional study using mixed method was conducted in Woldia town from April 26-May 11, 2018. Woldia is the capital of the north Wollo zone which is located at about 520 km away from Addis Ababa capital city of Ethiopia. According to 2007 Ethiopia national census the total number of children age 12-23 months is 2250(38). Woldia has 1 general -4 -hospital, 2 health center, and four health post. The Source of population was all children aged 12 to 23 months with their mothers/caretakers living in Woldia town.

Sample size calculation
The sample size was calculated using the single population proportion formula based on the following assumption. Using p = 76% (22), design effect (DE) =1. 5

Sampling technique
Multistage sampling was used to get the sample. Four kebeles were selected from 10 kebeles by simple random technique. The total sample size was allocated proportionally to each kebeles depending on the total number of children. The first house hold had been selected randomly from selected kebeles. The sample for in-depth interview was selected by non-probability purposive sampling method. A total of 11 in-depth interviews were conducted among health professionals and HEW who works under EPI programs in Woldia town (Fig 1).

Operational definition
Fully vaccinated-children are considered as fully vaccinated when they have received all ten vaccines (19,20).
Vaccinated-children are considered as vaccinated when they took at least one dose of the vaccines (19,20).
Dropout rate-It is the rate difference between the first and the last dose (19,20).
Coverage by Card Only. It means coverage made with numerator based on only recorded dose.
Coverage by Card plus History. It means coverage done with numerator based on card and mother's report (19,20).

Data collection tool and Procedure
The questionnaire was developed from previous studies (16, 20, and 17). In-depth interview schedule will be used for collect qualitative data. The interviews were documented appropriately by participant words and the participants speaking was recorded by tape and transcribed to the English word.

Data quality and control measure
The questioner was prepared by English language and translated to Amharic language and again translated to English by professional translators. Pretest was done in 5% of sample size at similar setting near in the study setting (defergie Keble) and necessary modification was done. Training was given for two day about data collection. Completeness of data were checked at the end of each day of data collection by principal investigators and supervisors.

Data processing and Analysis
Data were coded, entered and analyzed using SPSS version 20.Result was presented by table, frequency and graphical techniques were used. Recorded or paper documented file from the qualitative data were transcribed into Microsoft word 2010. Similar topics were grouped together, and those with common features were clustered together until the final themes and sub-themes emerged.

RESULT Sociodemographic Characteristics of the participants.
A total of 389 mothers/caretakers were interviewed with a response rate of 100%. The majority 195 (50.1%) were from age of 25

Dropout Rate for Vaccines
According to the findings from the field survey in the number of children who defaulted on the vaccines from DPT1 and OPV1 to Measles. Forty two children (10.8%) defaulted for Measles getting from both recall and card. The penta1-measle dropout rate for children was 8.3% and penta1-penta3 and pcv1-pcv3 dropout rate was 2.4% and 1.6% respectively .the overall dropout rate (from BCG-Measles) was 9%.

Reasons for Defaulting from Vaccination service
In this study, 2.3 % of respondents reported that the reason for not completing child vaccination was lack of awareness about vaccination and same 2.3% not knowing come back for second and third vaccination, 2.1% fear of side effect, 1.8% vaccination inconvenient time and no vaccination at health facility for each(Additional table 2).

In-depth interview findings
The purpose of this in-depth interview was to explore challenge and opportunity of EPI and also how those challenges relieved. Themes and sub-themes were used that reflect idea of participant.

Theme 1: challenges faced by HW and HEW
HEW and health professionals highlighted that they faced challenges when implementing EPI those are shortages of vaccines, workload, and Non-compliance of mothers with scheduled return dates.

Subtheme 1.1: Shortage of vaccines
Health workers had explained as they have sometimes experienced a scarcities of vaccines.

Subtheme 1.2: Workload
Participants explained that workload decreases the accuracy of records of performance on vaccination and reduces chances of counseling clients on the importance of vaccines.

Subtheme1.3: Non-compliance of mothers with scheduled return dates
According this study, most mothers have not knowledge which diseases are prohibited by vaccines, or needed doses of each vaccine is not known by them.

Theme 2: Possible solutions to relieve faced challenges
The possible solutions were prepared enough work area, sufficient amount of vaccine, having enough staff, more health education about when to return, proper use of card and what vaccine at what age of child give and what type of disease prevented by that specific vaccine.

Subtheme 3.1: Health professional's awareness regarding internal referral system
As confirmed by most study subjects who said: "most health professionals are aware of the internal referral system. Most health professionals also advise mothers who come for maternity services to vaccinate their child".

Subtheme3.2: information accessibility
As confirmed by most participants said; "our community gets information regarding immunization easily from media, HEW and other sources since it is urban community.

Subtheme 3.3: outreach service delivery
HEW said that all kebeles have health extension worker so, the HEW round and searching unvaccinated and partially vaccinated children's if get give a vaccination for child and appoint for next schedule mothers go to near health facility and also give education regarding what health problem is occurred if the child is completed vaccination.

DISCUSSION
This study was conducted to assess coverage, opportunity and challenges of EPI among children in Woldia town, Amhara regional, Ethiopia.  [20, 21, and 22]. This may be due to improving vaccination's access and awareness of a community from time to time. But this study was lower than study done in Debre Markos town (91.7%) [23].This may be due to insufficient vaccine available.
The overall dropout rate for this study was 9%. Dropout rate from pentavalent1 to measles (8.3%) was greater than dropout rate from pentavalent (2.4%).However, this finding was lower than other studies such as EDHS 2011 and a study done in Yirgalem town [15,20]. On the other side, this study has a higher dropout rate from study done in Debre Markos town (5%) [23].This may due to workload, insufficient of vaccine.
In this study, the percentage of fully vaccinated children was 87.7% which showed that there had be significant amount of non-attending children. Participants mentioned different causes for not finishing vaccination to children. Those causes were lack of awareness about immunization, not knowing coming back for second and third vaccination, fear of side effect, inconvenient vaccination time and insufficient vaccine. This finding was supported by other similar studies. [20].
In qualitative study, workload due to staff shortage and inadequate workspace, shortage of vaccine and non-compliance of mother for next scheduled date were the major challenges faced by health professional and health extension worker .This was aligned with a study done in Arebegona district Southern Ethiopia [24].

Conclusions
This study was lower the nationwide MDG target (90.0%). Reasons for incompletion are lack of awareness about immunization, not knowing coming back for other schedules and fear of side effect. Reason for not vaccinating their child, most respondents replied that lack of awareness on importance of vaccination, fear of side effect and sickness of child as a reason.
Work load, non-compliance of mother and shortage of vaccine was the major challenges faced by health professionals and health extension workers.

Limitation of study.
Since the study was cross sectional it did not shown the cause-effect relationship.

Consent for publication
Not applicable.