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2. METHODS AND MATERIALS
Study Area and Period
A community based cross sectional study using both quantitative and qualitative method was conducted in Woldia town. Woldia is the capital of the north Wollo zone which is located at about 360 km from Bahir Dar capital city of Amhara region and 520 km away from Addis Ababa capital city of Ethiopia, this town has an elevation of 2112 m above sea level which administratively structured by ten Keble, and According to 2007 Ethiopia national census the projected population size of town is 79,667 in 2010. of whom 40,303 are men, 39,365 are women and 2250 are children’s of age 12-23 months with a total house hold of 16347(38). The majority of the inhabitant practiced Ethiopian orthodox with 80.49% while 18.46% of the population they were Muslim. Two largest ethnic group reported in this were the Amhara (93.92%) and Tigray (4.32%) (28).Woldia has 1 general hospital, 2 health center, four health post and more than nine private clinics. Vaccination service is being provided in 2 health center and hospital free of charge. The study was conducted from April 26-May 11, 2018. The Source of population was all children aged 12 to 23 months with their mothers/caretakers living in Woldia town were the source population. Mothers or caretakers whose aged 18 years and above with children aged between 12 and 23 months were included in this study.

Sample size calculation
The sample size for this study was calculated using the single population proportion formula based on the following assumption. Using a p value previous study done in Lay Armachiho district north Gondar zone in 2014 fully vaccinate children age 12-23 month is 76%(22) design effect (DE) was considered as1.5.
Where, n is sample size
Za/2- with 95 % confidence interval equal to 1.96
P- Estimation of EPI coverage which is 76%
W –margin of error which is 1-confidence level=1-0.95=0.05
n= (1.96)2*(0.76) (1-0.76)/ (0.05)2=280*1.5 = 420
Our total population is; 10,000 so; we use the following correction formula
nf=no/(N+no/N)

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nf = 420 = 354
1 + 420
2250
By adding 10% non-response rate we get a final sample size is 389
Where, nf= Final sample size,
no= total sample size from the above formula and
N = total population (children age 12-23 month in Woldia town in 2010)
Sampling technique
Multistage sampling was used to take the appropriate sample. Initially, Woldia town has 10 kebeles out of those 4 kebeles were selected (40% of the kebeles will considered to be included in the study) by simple random technique (lottery method). The total sample size was allocated proportionally to each kebeles depending on the total number of children aged 12 to 23 months. The sampling frame was obtained from health extension workers registration books. In each kebeles, the first house- hold was selected randomly from the central location of the kebeles. The subsequent household was selected according to the inclusion criteria based on the principle of next nearest household. Households in the kebeles were visited until the proportionally allocated sample size for each kebeles was fulfilled. One child was selected randomly from those households having two and more children. 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
The following operational definitions were used:
Fully vaccinated- children are considered as fully vaccinated when they have received a vaccination against tuberculosis (BCG), three doses each of the Penta, PCV and four doses of polio vaccines and measles vaccination by the age of 12 months(19,20).
Partially vaccinated- children are considered as partially vaccinated when they miss at least one dose of the above mentioned vaccines on fully vaccinated definition (19, 20).
Unvaccinated- children are considered as unvaccinated when they did not receive any dose of the above mentioned vaccines on fully vaccinated definition (19, 20).
Vaccinated- children are considered as vaccinated when they who took at least one dose of the above mentioned vaccines on fully vaccinated definition (19, 20).
Dropout rate-This is the rate difference between the first and the last dose or the rate difference between the initial vaccine and the last vaccine (19, 20).
Health service utilization of mothers-utilization of ANC, contraceptive and delivery service by the mothers from government or private health institution (19, 20).
Coverage by Card Only. Coverage by card only meant coverage calculated with numerator based only on documented dose, excluding the numerator of those vaccinated by history.
Coverage by Card plus History. Coverage by card plus history meant coverage calculated with numerator based on card and mother’s report (19, 20).
Caretaker’s .Caretaker is the most responsible person that provides care for the child that has no mother due to different reasons (death, separated from husband, and others) (19,20).
Data collection tool and Procedure
The questionnaire was adapted and modified from Ethiopian EPI Survey of 2012, DHS and other previous studies questionnaires. The research aimed to collect both quantitative and qualitative data. For cross sectional survey interviewer administered questioners were administered to mothers or care takers. The questioner contained five sections. Socio- demographic characteristics, maternal health care utilization, accessibility and quality of vaccination service, family size, Vaccination histories of children, and knowledge of mothers or immediate caretakers on vaccination and Reasons for defaulting were captured into the questionnaire. It was translated into Amharic and translated back to English by professional translators for consistency. The child's vaccination dates number of doses and dates of other visits to the health facility was extracted and collected from vaccination card and history. Information about mother’s knowledge on vaccination and the program, and accessibility to the nearest health facility was obtained through verbal information. If vaccination card was unavailable for the child, the mothers/caretakers were asked for vaccination history. The number of doses the child took and how (the route of vaccine administered) was used to identify given antigen for the child. Respondents that were not available during the first visit were revisited within the day or during the interviewer’s stay in the area. For Data collectors a two days intensive training was given before data collection. Training was given by Amharic language on how to ask and fill the question, selection criteria of households and children, and how to approach the mothers/caretakers.
In-depth interview schedule will be used for collect qualitative data. The schedule contained open ended question about challenge and opportunity of EPI. The interviews were documented appropriately by participant words and the participants speaking was recorded by tape. Finally, their speaking was transcribed to the English word. Data collection was done from April 26-may11 for two weeks. This was after Approval to proceed with the study from our advisers.
Before the actual data collection days, the questionnaire were pre-tested for completeness and appropriateness to the local context on 5% (20 mother/caretaker) of mother with children’s aged 12-23 month in Defergie Keble and was modified accordingly.
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 to increase its quality and ensure that the translated version did not alter the meaning of the questioner. Pretest was done in 5% of sample size at similar setting near in the study setting (defergie Keble) one week before scheduled data collection day to improve the tool. Based on the pretest, necessary modification was done. The data collectors were trained for two day on principle, ethical considerations, and meaning of the questions included in the questionnaire to standardize their interviewing technique and to ask question in consistent manner and strict supervision of the data collector was done. Questionnaires were checked for completeness at the end of each day of data collection by principal investigator.

Data processing and Analysis
Quantitative Data were coded, entered and analyzed using SPSS version 20 for Windows. Summary statistics such as, percentages, frequency and graphical techniques were used.
Recorded or paper documented file from the qualitative data were transcribed into Microsoft word 2010. Transcripts were read and understood by all participants. Similar topics were grouped together, and those with common features were clustered together until the final themes and sub-themes emerged. Themes and their sub-themes were arranged based on their commonality.
Ethical consideration
Ethical clearance was obtained from Faculty of Health Science, Department of Nursing, and Woldia University. An official letter was written from the Department of Nursing to Woldia city of Administration to get permission and support to each respected kebeles. After brief explanation of the objectives and purpose of the study, verbal informed consent was obtained from each study participant. Participants were also informed that participation was on voluntary basis and they have the right to stop their participation at any time. Study participants were also informed that all data obtained from them would be kept confidential by using codes instead of any personal identifiers.
3. RESULT
Sociodemographic Characteristics of the Study Population.
A total of 389 mothers/caretakers of children aged 12–23 months were interviewed with a response rate of 100%. The majority 195 (50.1%) were between the age of 25 and 31, 88 (22.5%) were between 32-38 years, 71(18.3%) were between 18-24 years and the remaining 35 (9%) were 39 and above with mean age of 29.59, median of 28 and ranges from 19-44 years.The immediate caregivers of the children were mothers (97.9%), fathers (1.8%) and other family members (0.3%). Concerning marital status, 84.8% of the caregivers were currently married followed by 11.6% divorced and the rest 3.6% were widowed. With regard to religion, 324 (83.3%) were orthodox while 56 (14.4%) were Muslim and rest 9(2.3%) were protestant. The majority 371 (95.4%) belong to the Amhara ethnic group. Among the interviewed caregivers, 30.3% have elementary, 54.7% have secondary and above, 4.1% have able to read and write and the rest 10.8% were with unable to read and write. By occupation 226 (58.1%) were housewives and 52 (13.4%) were government employees. With regard to the income of respondents, 66(17%) were with monthly income less than 500 birr and 258 (66.3%) were with monthly income greater than 500 birr (Table.1).
Family size and characteristics of the child
Among the respondents 171 (44%) have one child, 161(41.4%) have 2 or 3 children, 50 (12.9%) have 4 or 5 children, 7 (1.8%) have greater than 6 children. The average family size of the study population was 4 ranging from 2 to 9, in which most families had less than 5 members (70.4%). The mean age of the children was 17.38 months (range 12–23) and 218 (56%) were of the male gender (Table 2).
Immunization Coverage of Children Aged 12–23 Months.
Only, 98 (25.2%) of mothers/caretakers showed the child vaccination card during the survey. From the total of 389 children aged 12–23 months selected and included in this study, 385 (99%) of them have taken one or more of the recommended vaccines and 4 (1%) were unvaccinated according to finding from card plus history. Of total vaccinated child, 341 (87.7%) of them finished all the recommended doses and 44(11.3%) did not complete the entire doses.
Immunization Coverage by Card Only.
Out of the total surveyed children aged 12–23 months, vaccination card was only seen and confirmed for 98 (25.2%) children. Coverage by card only was calculated by taking children who had vaccination card as a numerator. From 98 vaccinated by card only, 98.9% received OPV1 followed by BCG (92.8%) and OPV2 (96.9%). Penta 3 was taken by 86.7% and measles vaccine was taken by 72.4%.
Immunization Coverage by Card plus Mother Recall.
Based on the vaccination card and the mother’s/caretakers recall, 385 (99%) of the children took at least a single dose of vaccine. From the total study participants, 341 (87.7%) were claimed fully immunized, 44 (11.3%) were partially vaccinated, and 4(1%) were unvaccinated (Table 3).
Dropout Rate for Vaccines
The problem of dropout was with the subsequent antigens specifically measles which are given as last vaccines to end the entire immunization programme. There was an increase, 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 DPT-HepB-Hib1-measle dropout rate for children was 8.3% and DPT-HepB-Hib1- DPT-HepB-Hib3 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
To determine reasons why care givers failed to complete their child vaccination, the survey asked the specific reason. The findings of the survey showed that 2.3 % of caregivers reported that the reason for not completing child vaccination was lack of awareness about completing vaccination schedule and same 2.3% not knowing whether to come back for second and third vaccination, 2.1% fear of side effect, 1.8% was vaccination time is inconvenient and same as 1.8% because of no vaccination at health facility at the time of vaccination day. There were 4 children who never vaccinated and different reasons were given by mothers and the reason given by more than half of for not vaccinating their children was lack of awareness on importance of vaccination and the remaining respondents answered fear of side effect and child was sick as a reason(Table 4).
In-depth interview findings
The main purpose for conducting the in-depth interview with personnel of health worker and health extension worker 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. Direct excerpts from participants’ narratives are included to confirm the interview sessions conducted by the researchers.
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
Subtheme 1.1: Shortage of vaccines
Health workers had explained as they have sometimes experienced a scarcities of vaccines. Sometimes we find that the mothers come at 10 and above weeks to health facilities. Therefore those late comer children have not gotten some vaccines like rotavirus that cannot be given after 6 months.’ This was confirmed by a participant who said:
‘You know, there are a lot of problems that we are facing related to the implementation of EPI which include the fact that those vaccines are not enough or are not available to us to immunize the children that come here expecting us to immunize them.

Participants explained that workload decreases the accuracy of records of performance on vaccination and reduces chances of counseling clients on the importance of vaccines. It may cause clients to wait on the queue for long time. Many clients are reluctant to return for subsequent visits if they experienced long waiting times in prior visits. Participant said that the cause of work load is inadequate workspace and High patient/ staff ratio. This quote from a participant explains the effect of inadequate workspace. “You realize that you might want to divide tasks built becomes difficult because of the space. Small working space results in crowding of patients this affects privacy of clients and quality of services given.
Subtheme1.3: Non-compliance of mothers with scheduled return dates
In this study, all mothers had no problem with directions given by health care workers during EPI implementation. This finding was confirmed by a participant who said: ‘It makes happy as a health worker to perform immunizations if mothers respect the appointment date, and it makes unhappy when mothers do not bring children on the appointment dates because this seems like we are not doing our work, emphasizing that mothers must respect their return dates.’
Non-compliance might result from poor understanding of immunization advantages and other related issues by children’s mothers. According this study, most mothers have not knowledge which diseases are prevented by which vaccines, or how many doses of each are needed.
Theme 2: Possible solutions to relieve faced challenges
A participant was put different solutions in order to alleviate the above challenges. Among those;
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.
Theme 3: opportunity that increases EPI Coverage
Subtheme 3.1: Health professional’s awareness regarding internal referral system
This was confirmed by a participant who said: “most health professionals are aware of the internal referral system. They check the immunization status of children who come for other child health services and refer to the immunization room when necessary. Most health professionals also advise mothers who come for maternity services to vaccinate their child”.
Subtheme3.2: information accessibility
This was confirmed by a participant said; “our community gets information regarding immunization easily from media, HEW and other sources since it is urban community”, so if the community has an awareness regarding the benefit, session needed to complete, age to start and Finish vaccination this increases utilization of EPI.
Subtheme 3.3: near health facility
As you know factor that affect vaccination of children is distance to health institution and accessibility of transport. Participant said “in Woldia town almost all mothers get immunization service at a near health facility, easily accessible of transport so this favors the increment of taking vaccination and completing the schedules”.
Subtheme 3.4: 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 and by identifying the cause of default, unvaccinated and appoint for next schedule mothers go to near health facility and they should vaccinate the child and also give education regarding what health problem is occurred if the child is un vaccinate or default and important of completing vaccination.
4. DISCUSSION
This study was conducted in urban community to assess coverage, opportunity and challenges of EPI among children age 12-23 month residing in selected kebeles of Woldia town found in north Wollo zone Amhara regional state of Ethiopia.
Immunization coverage was assessed using the availability of vaccination card and maternal recall (history). Based on immunization card and history, 343(87.7%) children were fully vaccinated, and 44(11.3%), 4(1%) were partially vaccinated and unvaccinated respectively. Coverage for each vaccine was 96.9% for BCG, 98.2% for OPV1, 97.4% for OPV2,94.6% for OPV3, 96.2% for pentavalent1, 96.9% for pentavalent2, 93.9% for pentavalent3, 95.9% for pneumococcal conjugated vaccine (PCV1), 97.4% for PCV2, 94.3% for PCV3, 96.4 for Rota1, 94.8 for Rota2and 88.2% for measles vaccine. According to the EPI schedule of Ethiopia, OPV and pentavalent vaccines are being given with similar schedule, however, OPV coverage was slightly higher than pentavalent which could be due to the fact that there are national immunization supplement campaigns for OPV and measles. The result showed increased vaccination coverage when compared to previous study done in different areas 20, 21, and 22.this may be due to increasing access of vaccination and community awareness from time to time. But this study is lower than study done in Debre Markos town in 2016 which showed a total number of fully vaccinated children aged 12-23 month was 91.7% 23.this may be due to no vaccine available at the time of vaccination in the study area.
The overall dropout rate for this study was 9%. Dropout rate from pentavalent1 to measles (8.3%) was higher than dropout rate from pentavalent1 to pentavalent3 (2.4%) and from PCV1 to PCV3 (1.6%). This longer interval time between the third dose of pentavalent and measles showed that a number of children may not return for measles vaccine. However, this finding was lower than other studies such as EDHS 2011(DPT (43%) and polio (46%)) and a study done in Yirgalem town in Sidama zone (penta1 to measles (18%)) 15, 20.
The difference may be due EDHS 2011 finding was done based all Ethiopia regions data. But still know our study has a higher dropout rate from study done in Debre Markos town Amhara region which showed overall dropout rate was 5%.23 This due to there are different challenges in our study area like workload, no vaccination at the day of vaccination.
This study revealed that there was decreasing in coverage of immunization from BCG (96.9%) to measles (88.2%) and the proportion of fully immunized children (87.7%) which indicated that there was significant proportion of defaulting children. Participants mentioned different reasons for not completing immunization to children. These reasons were 2.3 % of caregivers reported that the reason for not completing child vaccination was lack of awareness about completing vaccination schedule and same 2.3% not knowing whether to come back for second and third vaccination, 2.1% fear of side effect, 1.8% was vaccination time is inconvenient and same as 1.8% because of no vaccination at health facility at the time of vaccination day. Most of reasons given by the care givers have similarity with the reasons provided by other caregivers on other similar studies. 20.
From the 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 is almost similar with a study done in Arebegona district Southern Ethiopia 24.

Conclusion and Recommendation
Level of immunization coverage was found to be low among children aged 12–23 months in Woldia town compared to the national MDG target (at least 90.0%) to be achieved by 2015. Reasons for incompletion are mostly because of lack of awareness about completing vaccination schedule not knowing whether to come back for second and fear of side effect. Also as a reason for not vaccinating their child, most respondents replied that lack of awareness on importance of vaccination and the remaining respondents answered fear of side effect and child was sick as a reason.
Work load, non-compliance of mother for next schedule vaccination date and shortage of vaccine was the major challenges faced by health professionals and health extension workers. Near health facility, information accessibility regarding immunization and health worker awareness regarding internal referral system were a good opportunity that increases immunization coverage.
Limitation of study
This study may have recall bias.
Since the study was cross sectional it did not shown the cause- effect relationship.

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