The Effect of War on Expaned Program on Immunization in North East Ethiopia, 2022

doi:10.21203/rs.3.rs-1902815/v1

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Research Article

The Effect of War on Expaned Program on Immunization in North East Ethiopia, 2022

https://doi.org/10.21203/rs.3.rs-1902815/v1

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Background

Population affected by war experience severe public health consequences like displacement, food scarcity, collapse of infrastructure and basic health services. Furthermore, war greatly hinders health programs to be implemented by governmental and non-governmental organizations. One of the programs which face great challenge is the expanded program of immunization which has become crucial due to the emergence of different communicable diseases.

Objective

To assess the dropout rate of immunization after the war, identify associated factors for the dropout and explore the reasons behind for the dropout among under two children in North Wollo zone, Northeast Ethiopia 2022.

Method

A cross-sectional study mixed with phenomenological study design was utilized and the study was conducted in North Wollo zone, Northeast Ethiopia from April to June 2022.

Results

A total of 449 mothers with their children were included in the final analysis which made a response rate of 97%. Only half (50.3%) of the mothers heard about catch-up vaccine. Lost family member due to the war triples the risk of drop out of immunization (AOR: 3.11, 95%CI: 1.63, 5.93) and mothers who never heard about catch-up vaccine are two times more likely to drop out of immunization (AOR: 2.18, 95% CI: 1.39, 3.43).

Conclusions

The dropout rate from immunization is above the WHO cut point. Place of childbirth, hearing about catch-up vaccine, residence, length of the war in the area, and loss of family member due to war were predictors of drop out of immunization.

Immunization

War

North Wollo

Dropout

War is one of the man-made disasters which pose a challenge to human health and health system. It is one of top ten causes of death in the world(1, 2). Population affected by war experience severe public health consequences like displacement, food scarcity, collapse of infrastructure and basic health services which worsen the emerging of different communicable diseases (3).

In the recent war, which lasted for 5 months, many health centers and health posts were destroyed(4, 5). This aggravated the already crawling health services and hindered the work of health programmers. One of the programs which face great challenge is the expanded program on immunization(3, 4).

Expanded Program on Immunization (EPI) is one of the key programs which is under the Maternal, Child Health and Nutrition (MCHN) department of World Health Organization (WHO) and its objective is to prevent and eradicate vaccine preventable diseases(6). “Complete or full immunization” coverage is defined as a child has received a BCG vaccination against tuberculosis; three doses of pentavalent vaccine to prevent diphtheria, pertusis, and tetanus (DPT) and HepB-Hib. at least three doses of polio vaccine; and one dose of measles vaccine within one year of life (7). Dropout rate is the rate difference between the initial vaccine and the last vaccine. Various studies indicated that the main factors affecting immunization were the age of the mother, maternal education, exposure to mass media, antenatal care (ANC) and others(8–11).

Immunization saves lives and helps to protect future generations by eradicating diseases. Nowadays many infectious diseases have become rare or eradicated as a result of immunization programs. African and Southeast Asian countries are the most affected regions by vaccine-preventable disease, which accounted for 50% of all under-five deaths (12, 13).

Ethiopia is also one of the countries in the world with high of immunization dropout rate and child mortality. Full immunization remained 44% in 2019, far from the planned coverage of 90% at the national level and 80% in every district level with all vaccines by 2020(12, 14).

Owing to the war almost all of the health facilities in North Wollo zone were out of service for one to six months depending on the length of the war in the areas. As a result of the war, large number of children in these areas remains at risk of acquiring infectious diseases, most of which are vaccine preventable and can cause serious illness, disability or death. For this reason, the findings of this study could play important roles to create awareness in the community about the problem, to inform health officials to prepare special campaigns and health educations to bring the children back to immunization.

Moreover, identification of modifiable risk factors associated with drop out of immunization is essential not only to alter the trend of vaccine preventable disease, child mortality and its consequences but also to improve the health of future generations. Therefore, the aims of this study were to assess the magnitude of drop out of immunization, identify associated factors and explore the reason behind among under two children in Northeast Ethiopia in order to provide useful information for program managers, policy makers and other stockholders for designing suitable programs.

Data source

A cross-sectional study mixed with Phenomenological study design was utilized and the study was conducted in North Wollo zone, Northeast Ethiopia from April to June 2022 (15, 16). The participants of the study were all randomly selected under two children with their mothers and children whose Mothers were critically ill were excluded. The sample size was determined by using sample size determination for estimation of a single population proportion. Proportion of children who came back to immunization or started after the war took place was (25.8%) or 463 and for the qualitative data sixteen (16) in-depth interviews were conducted from the dropouts.

Multistage sampling technique together with simple random sampling method was used to select the study participants. For the qualitative study, the 16 mothers were selected purposively from the dropouts.

Study Variables

The outcome variable for this study was Drop out of immunization (Yes, No). The Independent variables were socio-demographic related factors (age of mother, mother’s occupational status, and marital status; mother’s educational status, residence, religion, family size, number of under-five children, parity, and sex of the child), House Hold related factors(food security, loss family member from the war, family displaced due to war), the length of war in the area maternal health service utilization related factors(ANC attendance, education during ANC, place of delivery, ever heard of catch-up vaccine, source of information, TT Vaccine, Covid-19 vaccine, place of childbirth).

Data collection tools and procedures

The quantitative data was collected from selected participants by using structured, pretested, interviewer administered questionnaire and the qualitative data was collected through unstructured, in-depth interview using KOBO tool box, an online data collection application. The data were collected through interviewing the mothers and observing the immunization charts for necessary information. Training was given for data collectors supervisors who provide assistant during data collection. To increase the quality of the tool, 5% of the pretest was conducted and the questionnaire was checked and modified on a daily basis based on the suggestions provided by data collectors and supervisors.

Data management and analysis

Data was exported to Excel and then the exported data was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics and bivariate analysis were performed and the adjusted odds ratio (AOR) with a 95% confidence interval was estimated to assess the strength of association and P value of < 0.05 was used to declare the statistical significance in the multivariable analysis. In addition, the fitness of the model was checked using the Hosmer-lemeshow goodness of fit-test with P value 4.294. The qualitative data were analyzed manually using thematic analysis. Excerpts from original transcripts, mainly quotes from the mothers are included in the analysis.

Socio-demographic characteristics of study participants

A total of 449 mothers with their children were included in the final analysis which made a response rate of 97%. Among them the majority of the mothers, 291(64.8%) were aged between 20–34 years, almost all of the respondents were married 426 (94.9%) and more than half, 287(63.9%), were orthodox. Regarding educational status of parents more than half (60.4%) of the mothers had primary education. However, around one fifth of the fathers attended college and above. Half of the mothers (49.5%), were housewives and it was found that around two third (62.6%) of the respondents were residing in rural areas. The male to female ratio in the families of less than two children was almost one to one (Table 1).

Table 1

Socio-demographic characteristics of the study participants in North East Ethiopia, June 2022.
Variable	Characteristics	Frequency	Percentage (%)
Age of mother (in years )	< 20	43	9.6
	20–34	291	64.8
	35 and above	115	25.6
Age of the child (in month )	6-11months	209	46.5
Age of the child (in month )	11-23month	240	53.5
Sex of the child	Male	234	52.1
Sex of the child	Female	215	47.9
Religion	Orthodox	287	63.9
	Muslim	128	28.5
	Protestant	29	6.5
	Others	5	1.1
Marital Status	Married	426	94.9
	Single	6	1.3
	Divorced	15	3.3
	Separated	2	0.4
Educational status of mother	No education	66	14.6
	Elementary	271	60.4
	Secondary	58	13
	Above secondary	54	12
Educational status of father	No education	41	9
	Elementary	193	42.9
	Secondary	137	30.5
	Above secondary	78	17.3
Occupational status of mother	House wife	221	49.2
	Farmer	147	32.7
	Government employee	36	8.0
	Private worker	39	8.7
	Daily laborer	6	1.3
Residence	Urban	168	37.4
Residence	Rural	281	62.6
Family size	Less than five	233	52
Family size	Five and above	215	48
Under 5 children	1(One)	273	60.8
	2(Two)	152	33.9
	3(Three)	24	5.3

Maternal health service utilization

About 366(81.5%) of the mothers had ANC follow up during their last pregnancy and of which 227(62%) got TT vaccine. More than one third, i.e., 36.5% and 35.4% of the mothers gave birth at home and got Covid-19 vaccine respectively. More than half of the mothers (51.1%) did not get immunization education during ANC follow up. Only half (50.3%) of the mothers heard about catch-up vaccine and HEW were the main source of information (27.4%). Above two third (65.5%)of the mothers had to walk for 30 minutes to one hour to reach the nearest health facility and only 35% of the mothers replied that the nearest health facility had alternative power source(Table 2).

Table 2

**Maternal health service utilization in North East Ethiopia, June 2022.**
Variables	Characteristics	Frequency(n)	Frequency (%)
Antenatal Care	Yes	366	81.5
Antenatal Care	No	83	18.5
Education about vaccination	Yes	179	48.9
Education about vaccination	No	187	51.1
Place of birth	Home	164	36.5
Place of birth	Health facility	285	63.5
Heard about Catch-up vaccine	No	223	49.7
Heard about Catch-up vaccine	Yes	226	50.3
Source of Information on catch-up vaccine	Health Facility	32	7.1
	Health extension workers	123	27.4
	Mass media	45	10.0
	Other persons	26	5.8
TT vaccine during your last pregnancy	Yes	227	62.0
TT vaccine during your last pregnancy	No	139	38.0
Covid 19 Vaccination	No	290	64.6
Covid 19 Vaccination	Yes	159	35.4
Who got the vaccine	Mother	63	39.6
	Father	21	13.2
	Mother and Father	53	33.3
	Family	22	13.8
Distance to facility	Less than 30 minutes	146	32.5
	30min to 1 hour	294	65.5
	Above 1 hour	9	2.0
Back to the program	Yes	251	55.9
Back to the program	No	198	44.1
Alternative power Source	No	292	65.0
Alternative power Source	Yes	157	35.0

Household related factors

When we see the household characteristics of the respondents, more than half (57.5%) of the households faced food insecurity. And sixty four (14%) of the respondents said that they lost at least one member of their family during the war. It was also found that 239(53.2%) of the respondents were temporarily displaced to other areas during the war as the war lasted for one to six months in the study areas (Table 3).

Table 3

Household related characteristics in North East Ethiopia, June 2022.
Variables	Characteristics	Frequency(n)	Percentage (%)
Food security status	Secure	191	42.5
Food security status	Insecure	258	57.5
Family Lost in War	Yes	64	14.2
Family Lost in War	No	385	85.5
Family displaced due to war	Yes	239	53.2
Family displaced due to war	No	209	46.8
Time of war (in month).	1month	153	34.0
	5 month	222	49.5
	6 month	74	16.5

Prevalence of immunization dropouts among under two children

In this study 198(44.1%) of the children did not return to the immunization program after the war (Fig. 1).

When we see the immunization prevalence from each specific immunization schedule, only (71)15.8% of the children are fully vaccinated and 64(14.3%) children who were born during the war did not get any sort of vaccination (Fig. 2).

Factors associated with drop out of immunization

In multivariable logistic regression analysis, place of childbirth, heard about catch-up vaccine, residence, length of war in the area and loss family member due to war were significantly associated with drop out of immunization. Lost family member due to the war triples the risk of drop out of immunization (AOR: 3.11, 95%CI: 1.63, 5.93). Furthermore, the odds of drop out of immunization were twice higher in rural area when compared to their counterparts (AOR: 2.22, 95%CI: 1.37, 3.58). In addition, mothers who never heard about catch-up vaccine are two times more likely to drop out of immunization (AOR: 2.18, 95% CI: 1.39, 3.43) than mothers who heard about catch-up vaccine. Home delivery increase the risk of drop out of immunization by 75% (AOR: 1.75, 95% CI: 1.108, 2.765). On the other hand, the dropout rate decreased by 80% (AOR:0.2, 95% CI : 0.12,0.39) and 50%(AOR:0.51, 95% CI : 0.28,0.93) in areas occupied by war for one month and five month in comparison with areas affected by the war for longer periods (Table 4).

Table 4

Both bivariate and multivariate analyses result of factors associated with drop out of immunization among under two children, North East Ethiopia, June 2022.
Variables		Back to the program		COR, (95%CI)	AOR, (95%CI)
Variables		No	Yes	COR, (95%CI)	AOR, (95%CI)
Displacement	Yes	92	148	0.604(0.418,0.886)	0.813(0.523,1.268)
Displacement	No	106	103		1
HHFS	Insecure	129	129	1.768(1.205,2.593)	1.390(0.897,2.153)
HHFS	Secured	69	122		1
Place of birth	Home	95	69	2.433(1.642,3.604)	1.75(1.108,2.765)*
Place of birth	Health facility	103	182		1
Heard about Catch-up vaccine	No	127	96	2.888(1.963,4.249)	2.18(1.386,3.430)**
Heard about Catch-up vaccine	Yes	71	155		1
Covid 19 Vaccination	No	121	168	0.767(0.52,1.132)	0.743(0.474,1.166)
Covid 19 Vaccination	Yes	77	82		1
Residence	Rural	147	134	2.517(1.681,3.765)	2.216(1.374,3.575)**
Residence	Urban	51	117		1
Total time of war in month	1	43	110	0.225(0.124,0.145)	0.200(0.104,0.387)**
	5	108	114	0.544(0.317,0.935)	0.507(0.276,0.930)*
	6	47	27		1
Family Lost in War	Yes	40	24	2.305(1.388,4.131)	3.106(1.628,5.925)**
Family Lost in War	No	158	227		1
Educational status of mother	No education	24	42	1.802(0.809,4.013)	0.756(0.305,1.872)
	Primary Education	140	131	3.371(1.729,6.572)	1.245(0.587,2.642)
	Secondary Education	21	37	1.790(0.787,4.077)	1.063(0.430,2.631)
	Above Secondary	13	41
(Hosmer-lemeshow was fitted with value of 4.294, =p < 0.05, *=p < 0.01).

Qualitative findings

In this study, the main factors identified for drop out of immunization can be categorized in to two main groups which are the client related and health facility related factors (Table 5).

Table 5

**The reasons behind drop out of immunization among under two children in North East Ethiopia, June 2022.**
Client related factors	Health facility related factors
Maternal awareness about catch-up vaccine	The nearby health facility did not start work
Instability due to war (pre occupied in other income generating activities )	Distance from home
Loss chart	Burden on some professionals
Fear of side effects	Waiting time
Husband or other family support

As shown in the above table, the main reason for defaulting from the immunization was lack of awareness about catch-up vaccine, the nearby health facility took long time to be restored to its former service and “When the age of the child increases,” the mothers thought, “it will be painful to the child to take the vaccine.” The majority of the mothers knew the benefits of immunization even though they did not bring their kids back to the program. The high workload on mothers to overcome the burden of the war with the market price inflation compounded by the lack of support from male partners and family members was also found to contribute to the problem.

Maternal awareness about catch-up vaccine

Knowledge of mothers about the presence of catch-up vaccines after the child’s vaccine schedule passed was one determinant factor for the child to drop out of immunization. Most of the mothers thought that once the vaccine was not taken on schedule, it would not help the child to prevent diseases any longer. A 34-year-old mother claimed that, “It is my first time to hear about catch-up vaccine from you, I don’t have the information that it can be continued after once missed.”

Instability due to war (preoccupation with other income generating activities)

At the time of war, women and children are more vulnerable beside nutritional, economic, and psychological burden. They also suffer from family loss due to war; this makes their problem even worse and heartbreaking. Mothers suffer from the economic burden and carry the family burden by themselves. For this reason, their engagement in preventive health services like immunization decreases since they see the preventive service secondary in comparison with the things they faced. A 31-year-old mother who lost her two family members due to the war stated, “I and my kids sacrificed too much in this war; we lost our hope as a family, and with the current market price, I have to work day and night to support my family.”

Loss of chart

Due to the war many families were displaced to other areas temporarily. Two mothers reported that they lost important documents including vaccination card due to this process. Since the health facilities were looted and damaged, it would be difficult to find files and this hindered the facilitation of immunization service. “We have been displaced 3 times due to this war and I lost the chart, as the health facility is also damaged, I was afraid that they will start the vaccination from the beginning.” (a 28-year-old mother).

Fear of side effects

Fear of the side effects of the vaccination was found to be one factor for drop out of immunization. Most of the mothers thought that symptoms like fever, swelling, sleeplessness and Diarrhea would worsen if the child got vaccinated out of the schedule. Thirty-year-old mother claimed, “I quit the program because my child got older after the war; I thought, like circumcision, immunization works best if children are vaccinated at the early age.”

Support from husband or other family members

Some of the interviewed mothers mentioned that being busy with household responsibilities and lack of discussion and support from the husband and other family members was the other reason for drop out of immunization. A thirty-three-year-old mother who supported her family by selling traditional drinks claimed, “You have seen in your own eyes that I am too busy with the house work so I did not get time to go to the health facility. I will be so happy to take my kid to the immunization service if someone helps me at home; I know it is good for his health.”

The damage in the health facilities and their distance from homes

Because of the war in the North Wollo zone, almost all of the health facilities were damaged, looted and destroyed. Most of the facilities could not be restored in a short time after the war. Since the mothers started vaccination in their nearby health centers which took a long time to bring them back to work after the war, it was difficult for them to continue the program. The services were given in some health facilities which were far away from the residence of most of the mothers. Twenty-three-year old mother said, “Our nearby health facility did not go back to work for quite some time after the war that we had to walk for more than two hours to get the vaccination service.”

Burden on some professionals and waiting time

One of health system related factors that contributed to the problem of high dropout rate of immunization was poorly arranged and uncoordinated immunization services with a longer waiting time. It was also found that the governmental sectors were cooperative to give permission for maternal and child care services like immunization and antenatal care but the private ones did not consider this as a right. The crowding in the immunization schedule was high in the urban areas. The service was given in one room and the burden lay in some professionals who had tight schedules of twice a week.

A 25-year- old waiter stated, “Last time I was there; I stayed more than 3 hours which is not possible for me related to my work since I am engaging in income generating activities, I did not have time to wait that long”.

Childhood vaccination is one of the most cost-effective public health interventions to reduce

child morbidity and mortality(17). In this study, the dropout rate of immunization due to the war is 44.1% which is much more higher than studies conducted in war free areas like Ghana and Abobo district, south west Ethiopia (5.5% and 25.8% respectively)(9, 11). This result is also higher than the dropout rates of other countries as stated in global routine vaccine coverage in 2018(13). However, the result is supported by other studies conducted in internal conflict areas of North west Ethiopia and also in the systematic review conducted in 16 countries affected by war(18, 19). The current study indicates that immunization coverage decreases in war-affected areas. As this study only focused on children who started vaccination before the war and those children who were born during the war, the figures in this study might vary from other studies.

In the present study, losing a family member due to the war triples the likelihood of dropping out of immunization. Moreover, this study explored that mothers suffer not only from the economic burden but also carry the family burden by themselves as they lost one or more family members due to the war. For the aforementioned reasons, mothers’ engagement in preventive health services like immunization could decrease considerably. This finding is also supported by studies conducted in Yemen and Syria that noted a negative link between conflict and utilization of health services(20, 21). This might be because of the economic, social, psychological, and other multifaceted effects of war which can hinder the population from preventive services like immunization.

The other predictor variable for dropping out of immunization is residence in rural areas which doubles the risk of dropping out of immunization; this is also consolidated by the qualitative data that explores the damage of the nearby health facilities and the facilities’ distance from home. It was found that both can affect the dropout rate. This finding was also confirmed in other studies such as the study done in northwest Ethiopia, Nepal, EDHS 2016 and Shewarobit (18, 22–24). The possible explanation for this might be health facilities in the rural areas can be far for mothers, and it may take time to rehabilitate and reconstruct the health system in the rural areas. If the nearby health facilities are damaged, mothers have to walk long distances to get services.

Mothers who have never heard about catch-up vaccine are twice more likely to drop out of immunization than mothers who have information about catch-up vaccine. This finding is in lines with studies conducted in Gonder and other parts of Ethiopia including hadya zone (10, 25, 26). The finding can be indicative of the importance of counseling about immunization at different contact points. That is explanatory of the benefits of a strong health extension program to raise awareness and to spread information.

Home delivery increases the risk of drop out of immunization by 75%. This finding is also supported by studies conducted in Nepal and western Ethiopia (11, 23). Mothers who give birth at home are likely to have limited communication with health professionals and information about immunization. On the other hand, another reason for drop out of immunization is losing the immunization chart. This is also the main problem in the other studies conducted in Ghana and Hadiya(9, 26). The problem can be exacerbated because of the knowledge gap among mothers that if they lose the chart, they will begin immunization anew or they fear that the health professional may get disappointed and they may not get the required service.

Like other studies conducted in Northwest Ethiopia and Afar, waiting time in the health facilities is also found to be another cause for immunization dropout in this study. Poor coordination between the health professionals and the burden on some professionals are common impediments to the immunization service, which can extend the waiting time for mothers(18, 27). As mentioned earlier, owing to different reasons associated with the war, mothers shoulder much burden since they engage themselves in household chores and income-generating activities, which make it hard for them to utilize the service.

The other factor that contributed to immunization dropout is fear of side effect of immunization. This result is also supported by studies conducted in Gondar and in other armed conflict areas(10, 21). Most of the mothers misunderstood the mild symptoms that emerged after vaccination will worsen if the child gets vaccinated out of the recommended schedule frame. Finally, this study revealed that dropout rate increases as the time of war is prolonged. Other studies also state the effect of protracted armed conflict in the health care utilization as the multifaceted effects of war on the population increase. studies conducted in Syria and other countries in the world support this finding(20, 28).

Strength and limitation

The strength of this study is that it mainly focuses on previously less assessed war related factors on immunization dropout by using mixed study design. And the limitation of this study is, because of time constraints, it did not try to investigate dropout related issues from the perspectives of service providers which could have generated additional findings.

The dropout rate from immunization is above the WHO cut point. This study is one explanatory of the effect of war on the EPI. Place of childbirth, hearing about catch-up vaccine, residence, length of the war in the area, and loss of family member due to war were predictors of drop out of immunization. In addition to the above issues, massive damage in the health facility, distance of the facility from home, burden on some professionals, waiting time, instability due to war (pre-occupation with other income-generating activities), loss of chart, fear of side effects, and husband or family support were also found to be contributors to the problem.

ANC

Antenatal Care

AMC

Amhara Media Corporation

AOR

Adjusted Odds Ratio

BCG

Bacillus Calmeatte Guerin

Confidence Interval

COR

Crude Odds Ratio

DPT

Diphtheria, Pertusis, and tetanus

EDHS

Ethiopian Demographic and Health Survey

EPI

Expanded Program of Immunization

HEW

Health Extension Workers

SPSS

Statistical Package for Social Science

WHO

World Health Organization.

Ethics approval and consent to participate

Letter of Ethical approval was received from Woldia University Research Ethics Review Committee. Besides, official letter of cooperation was also obtained from woreda administrative office. The mothers were well informed about the aim of the study; it was also explained to them that they had a full right not to be involved in the study and their agreement was ascertained by their verbal consent. The respondents’ confidentiality was assured by excluding names and identifiers from the questionnaire.

Consent for publication

“Not applicable”.

Availability of data and materials

The data that support the findings of the study is available with the correspondent author upon reasonable request.

Competing interests

The author(s) declare that they have no competing interests.

Funding

“Not applicable”

Authors' contributions

MKM came up with the research idea and was involved in all stages of the research. GAL was responsible for conducting of the analysis and interpretation of the findings. While YBB and AMY were prepared the manuscript. All authors read and approved the final manuscript. MKM is acting as the guarantor.

Acknowledgement

First and most, we would like to express our deepest gratitude to Woldia University Research and Publication Office and College of Health Science for giving us such opportunity. Last but not least, we would like to acknowledge the North Wollo Zone Administrative Office, supervisors, data collectors and the study participants for their willingness to take their precious time during the data collection.

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No competing interests reported.

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The Effect of War on Expaned Program on Immunization in North East Ethiopia, 2022

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Abstract

Background

Objective

Method

Results

Conclusions

Figures

Introduction

Methods

Data source

Study Variables

Data collection tools and procedures

Data management and analysis

Results

Socio-demographic characteristics of study participants

Maternal health service utilization

Household related factors

Prevalence of immunization dropouts among under two children

Factors associated with drop out of immunization

Qualitative findings

Maternal awareness about catch-up vaccine

Instability due to war (preoccupation with other income generating activities)

Loss of chart

Fear of side effects

Support from husband or other family members

The damage in the health facilities and their distance from homes

Burden on some professionals and waiting time

Discussion

Strength and limitation

Conclusion

Abbreviations

Declarations

Acknowledgement

References

Additional Declarations

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