Ethiopia has recently seen a remarkable fall in the proportion of girls who marry in early adolescence, reflecting the country’s lauded efforts to tackle child marriage. However, aggregate national figures mask a more complex reality. This article explores this complexity, drawing on qualitative data with adolescent girls and boys, their caregivers, service providers and community leaders, from the Gender and Adolescence: Global Evidence (GAGE) longitudinal study baseline. Our findings highlight the complex interplay between cultural norms, economic factors, individual voice and agency, and collective support thereof, on the part of leaders and service providers, from grassroots to national levels.
Nicola Jones, Elizabeth Presler-Marshall, Guday Kassahun et al.
Abstract Background Despite child marriage receiving increased attention over the past two decades, research on child marriage in humanitarian settings remains scarce. This study sought to quantify child marriage among Somali adolescent girls residing in Kobe refugee camp in Ethiopia and to identify its correlates and consequences. Methods A cross-sectional survey was conducted using multi-stage cluster-based sampling with probability proportional to size. We randomly sampled households that have at least one female aged 15–49 and at least one adolescent female aged 10–19. In addition to calculating the proportion of girls married under age 18, we used survival methods – namely Kaplan Meier graphs and Cox proportional hazard models – to identify risk factors associated with child marriage in this context. We also used descriptive statistics to describe marital age preferences among female adults and presented measures of important sexual and reproductive health indicators among married adolescent girls. Results A total of 603 adult women were surveyed and a household roster was created with information on 3319 household members, of whom 522 were adolescent girls aged 15–19. Of those, 14% were currently married (95% Confidence Interval [CI] 0.11–0.18), and 11% were ever married under age 18 (95% CI 8–15%). Several variables were found to be significantly associated with hazard of child marriage including schooling, sex and employment status of head of household, as well as number of girls under age 18 in the childhood home.. Adult women tended to incorrectly identify minimum legal age at marriage and preferred low marital age for boys and girls – particularly in households of child brides. Among married adolescent girls, contraceptive use was very low (11%; 95% CI 4.94–22.40), and early childbearing was common (60%; 95% CI 45.56–72.89). Conclusions This research contributes to the evidence base on child marriage in humanitarian settings. Insights generated from this study have the potential to inform programs and interventions aiming to prevent and mitigate the impacts of this harmful practice.
Shatha Elnakib, Kara Hunersen, Janna Metzler et al.
Marriages below the age of 18 are either forced or by own interest, influenced by different factors. The objective of this paper is to describe the role of marriage brokers in adolescent girls’ marriage in West Hararghe, Oromia region, Eastern Ethiopia. Qualitative data were drawn from a formative baseline (March to August 2016) and consecutive studies including the mid-term (May 2018 to August 2018) studies of Abdiboru, a Girls’ SRH and empowerment project. As findings demonstrate, adolescent girls below the legal age of marriage are forced to accept marriage proposals convinced by intermediaries/marriage brokers. Marriage brokers can be peers, relatives, elders or any skillful people in convincing and persuading girls. Marriage brokerage is commercialized and as a result, girls go through the burdens of early marriage and early child bearing. Marriage brokerage is a common act in the study area resulting in brokers to have a significant role on adolescent girls’ marriage. They play an inevitable role in arranging potential matches for adolescent girls. Programmers working on ending child marriage and related areas need to include these influential people in designing interventions.
Background: Immunization is one of the cost-effective public health interventions, and can be used to prevent life-threatening childhood illnesses. This study aimed to assess disparities in child immunization coverage in Ethiopia. Method: Data from the 2012 Ethiopian Expanded Program for Immunization coverage survey was used. In this study, absolute and relative equity analysis was employed based on socioeconomic variables Result: Equity analysis was conducted in 3,748 subjects out of 3,762 child caregivers’ data. The concentration index among the poorest and richest group for BCG immunization coverage was 11%, OPV 3 was 13.3%, Pneumococcal 3 was 38.6%, Pentavalent 3 was 21.5%, Measles was 12.9%, Vitamin A supplementation was 8.9%, and full immunization was 38.6%. Conclusion: Inequalities were observed in child immunization coverage across the socioeconomic groups, with the better-off wealth status, urban residents, and children from an educated mother being more likely to be vaccinated.
Background Though Ethiopia has achieved remarkable progress in immunisation services, there is limited evidence on comprehensive national immunisation coverage. Therefore, this national study evaluated the performance of life-course immunisation services. Methods This study was conducted in all Ethiopian regions and city administrations from March to July 2023. Two-stage stratified cluster sampling was used. About 13666 children aged 12-35 months, 5338 adolescent girls (15–18) and 13843 adults aged 12 years or more were included in the study. Child vaccination status was assessed through reviewing immunisation cards/health facility registration books/caregivers’ recall. A descriptive analysis was done with an adjusted sampling weight. Results Three-fourths of children aged 12-23 months received the first dose of the pentavalent vaccine, and two-thirds received the third dose of the Pentavalent Vaccine. About two-thirds and half of the children received the first and second doses of the Measles vaccine, respectively. The dropout rates for Pentavalent was 14.1% and for Measles, was 19.9%. Full immunisation coverage was 43.9%, and zero-dose children accounted for 24.7%. About 85% of mothers received the first dose of the Tetanus-Diphtheria vaccine. Half of adolescent girls received their first vaccination, and a quarter of them received a second dose of the HPV vaccine. Conclusions Although Ethiopia has made strides in child immunisation, coverage remains below national and global targets. Tetanus-diphtheria vaccine uptake was initially high but dropped significantly by the fourth and fifth doses. HPV vaccine coverage was suboptimal, with most not receiving the second or booster doses. Strengthening national efforts to address both demand and supply barriers is vital for increasing vaccine uptake.
Berhanu Fikadie Endehabtu, Getasew Amare, Yohannes Ayanaw et al.
Abstract In a bid to address the high burden of vaccine-preventable disease and low immunisation coverage in Africa, Ministers of health and finance from several African countries conveyed at the maiden Ministerial Conference on Immunisation at Addis Ababa, Ethiopia on the 25th of February 2016 to pledge political commitments to reduce the prevalence and deaths from vaccine-preventable diseases to the barest minimum. The fulfilment of this pledge across Africa would require the design of contextually tailored sustainable plans to finance the procurement of vaccines and the running of apt immunisation programs. A robust understanding of the trend of immunisation financing in Africa will support the development of suitable national immunization financing plans, guide policy makers to develop immunisation financing strategies focused on domestic resources but factor in donor support; and provide insights for the rejuvenation and expansion of immunisation programs. Our study’s objective is to estimate the minimum fraction of a country’s health budget that should be invested in the national immunisation programme to achieve a national immunisation coverage of 80% or greater depending on the context with and without donors’ support. The study results did not find any evidence to indicate that health expenditure on immunisation (as a proportion of total health expenditure) could be a strong predictor of immunisation coverage. However, we observed an association between total health expenditure (as a % of the GDP) and immunisation coverage, for BCG (p=0.047) and DPT3 (p=0.013) vaccines. Therefore, health expenditure as a percentage of GDP can be considered as an important predictor of immunisation coverage. We demonstrate in selected countries that to achieve the GAVI target of 80% in the countries with low DPT3 coverage, health expenditure as a percentage of GDP would need to be increased by more than 45%. We are optimistic that our study results and recommendations will facilitate the development of strategies that support African countries to increase domestic financing for national immunization programmes towards achieving 2030 targets for immunization coverage. Evidence before this study We conducted a desk review to identify official government records and reports on immunisation financing in African countries in Google scholar, WHO Library, GAVI and World bank databases using keywords such as “immunisation financing”, “health budget”, “health financing policies”, “immunisation financing policies” and “health expenditure”. We identified data for all countries in Africa but were only able to retrieve complete data from 24 countries. We considered the retrieved data for each country to be complete for our study if we found data on immunisation expenditure, health expenditure as a percentage of Gross Domestic Product, Gross Domestic Product, BCG coverage, DPT3 coverage, PCV1 coverage, MCV1 coverage, fertility rates, under-five mortality rates, under-five population and the total population. Added value of this study We sought for any association between immunisation expenditure and health expenditure (as a % of the GDP) and immunisation coverage over a five-year period (2013 to 2017) in twenty-four African countries. To our knowledge, this is the first study that has shown a correlation between immunisation financing, health expenditure and immunisation coverage and how this association varies across countries. Prediction modelling of vaccine coverage time series for countries with less than desired level of coverage (below 80%) enabled us to construct a predictive index that visualised the effect of increasing health expenditure (as a % of the GDP) would have on immunisation coverage with all other variables unchanged. Implications of the available evidence We posit that immunisation expenditure is not a statistically significant predictor for immunisation coverage for DPT3 and BCG vaccines; rather, with strong statistical evidence, health expenditure (as a % of the GDP) can be used to predict immunization coverage. Our prediction model estimated the percentage increase in health expenditure (as a % of the GDP) that would be required for countries with low immunization coverage to attain the target for immunization coverage recommended by the IA2030 Framework for Action.
Israel Oluwaseyidayo Idris, Janet Tapkigen, Luke Ouma et al.
Introduction Child immunisation is a cost-effective strategy to reduce vaccine-preventable diseases. While effective coverage is key to ensuring quality immunisation, little is known about its geographical distribution in Ethiopia. This study aims to assess the spatial distribution of effective coverage of child immunisation and identify areas with low coverage to inform targeted interventions. Methods We used the 2019 Ethiopia Mini Demographic and Health Survey and Ethiopia Service Provision Assessment datasets. After calculating the effective coverage of immunisation, Bayesian model-based geostatistics were employed to assess the spatial distribution of effective immunisation coverage in Ethiopia, using relevant covariates to estimate coverage rates across regions. Results The national effective coverage of immunisation was 34% (95% CI: 31.9% to 36.5%), with significant regional variation. Addis Ababa, western Benishangul-Gumuz, Dire Dawa city administrative, the northern part of South West Ethiopia and the northwest part of Amhara had hotspots for high level of effective coverage of child immunisation. On the other hand, central Amhara, northern Gambela, central Oromia, Sidama, northern Southern Nations, Nationalities and Peoples regions (SNNPR) and Somali had low effective coverage of child immunisation. Travel time to the nearest city (−0.292: 95% CI:−0.533 to −0.052) was found to be negative predictor of spatial distribution. Conclusion There were significant geographical variations in the effective coverage of immunisation services in Ethiopia. Travel time to nearest city was a significant predictor of spatial distribution. Policymakers are advised to prioritise underserved areas and improve spatial predictors to have a safe, effective and life-saving vaccination program in Ethiopia.
Samrawit Birhanu Alemu, Daniel Gashaneh Belay, Aynalem Belay et al.
The COVID-19 pandemic posed significant challenges to healthcare systems globally, including Tanzania, disrupting essential health services, including child basic immunisation programmes. Using an interrupted time series (ITS) analysis, we analysed how the pandemic influenced child fundamental immunisation trends across three key tears: 2020 (partial lockdown), 2021 (introduction of COVID-19 vaccination programmes), and 2022 (post-pandemic recovery phase). The results reveal a slight decline in immunisation coverage in 2020, with no significant impacts when this year is used as an intervention point. However, a sharp decline in 2021 indicates a more substantial disruption in immunisation services, coinciding with the implementation of COVID-19 vaccination campaigns. When 2021 is considered the intervention year, the study finds significant immediate and prolonged impacts, suggesting that the combination of pandemic fatigue, the reallocation of health resources, and public fear may have exacerbated the decline in immunisation rates. By 2022, immunisation coverage showed signs of recovery. These findings highlight the complex and evolving nature of the pandemic’s impact on child immunisation services. This study highlights the need for targeted interventions to restore and maintain essential health services, particularly in global health emergencies. Recommendations include improving healthcare resource allocation during crises, strengthening public health messaging, and expanding community outreach to mitigate long-term service disruptions.
Steven Mwaseba, Emmanuel Mwang’onda, Winnie Donald
Abstract Background The global Immunisation Agenda 2030 highlights coverage and equity as a strategic priority goal to reach high equitable immunisation coverage at national levels and in all districts. We estimated inequities in full immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics among children aged 12–23 months in Kenya. Methods We analysed full immunisation coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines) of 3943 children aged 12–23 months from the 2014 Kenya Demographic and Health Survey. We disaggregated mean coverage by socioeconomic (household wealth, religion, ethnicity), geographic (place of residence, province), maternal (maternal age at birth, maternal education, maternal marital status, maternal household head status), child (sex of child, birth order), and place of birth characteristics, and estimated inequities in full immunisation coverage using bivariate and multivariate logistic regression. Results Immunisation coverage ranged from 82% [81–84] for the third dose of polio to 97.4% [96.7–98.2] for the first dose of DTP-HepB-Hib, while full immunisation coverage was 68% [66–71] in 2014. After controlling for other background characteristics through multivariate logistic regression, children of mothers with primary school education or higher have at least 54% higher odds of being fully immunised compared to children of mothers with no education. Children born in clinical settings had 41% higher odds of being fully immunised compared to children born in home settings. Children in the Coast, Western, Central, and Eastern regions had at least 74% higher odds of being fully immunised compared to children in the North Eastern region, while children in urban areas had 26% lower odds of full immunisation compared to children in rural areas. Children in the middle and richer wealth quintile households were 43–57% more likely to have full immunisation coverage compared to children in the poorest wealth quintile households. Children who were sixth born or higher had 37% lower odds of full immunisation compared to first-born children. Conclusions Children of mothers with no education, born in home settings, in regions with limited health infrastructure, living in poorer households, and of higher birth order are associated with lower rates of full immunisation. Targeted programmes to reach under-immunised children in these subpopulations will lower the inequities in childhood immunisation coverage in Kenya.
Abstract Background: The WHO Immunisation Agenda 2030 highlights coverage and equity as a strategic priority goal to reach high equitable immunisation coverage at national levels and in all districts. We estimated inequities in full immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics among children aged 12-23 months in Kenya. Methods: We analysed full immunisation coverage (1-dose BCG, 3-dose DTP-HepB-Hib, 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines) of 3,943 children aged 12–23 months from the 2014 Kenya Demographic and Health Survey. We disaggregated mean coverage by socioeconomic (household wealth, religion, ethnicity), geographic (place of residence, province), maternal (maternal age at birth, maternal education, maternal marital status, maternal household head status), child (sex of child, birth order), and place of birth characteristics, and estimated inequities in full immunisation coverage using bivariate and multivariate logistic regression. Results: Immunisation coverage ranged from 82% [81–84] for the third dose of polio to 97.4% [96.7–98.2] for the first dose of DTP-HepB-Hib, while full immunisation coverage was 68% [66–71] in 2014. After controlling for other background characteristics, children of mothers with primary school education or higher have at least 54% higher odds of being fully immunised compared to children of mothers with no education. Children born in clinical settings have 41% higher odds of being fully immunised compared to children born in home settings. Children in the Coast, Western, Central, and Eastern regions had at least 74% higher odds of being fully immunised compared to children in the North Eastern region, while children in urban areas had 26% lower odds of full immunisation compared to children in rural areas. Children in the middle and richer wealth quintile households were 43–57% more likely to have full immunisation coverage compared to children in the poorest wealth quintile households. Children who were sixth born or higher had 37% lower odds of full immunisation compared to first-born children. Conclusions: The inequities in full immunisation adversely affect children of mothers with no education, born in home settings, in regions with limited health infrastructure, living in poorer households, and of higher birth order.
