Age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community of Afar region, Ethiopia

ABSTRACT

Achieving and maintaining high-level immunization coverage is the priority of the health-care delivery system. However, any delay in receiving the vaccine leaves youngsters inadequately protected. Timely vaccination has scarcely been reported and given little attention in developing nations like Ethiopia, which hinders effective interventions. Therefore, this study aimed to assess age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community. A community-based cross-sectional study has conducted among 340 mothers/caregivers of children aged less than one year in Samara-logia city administration. A systematic random sampling technique was employed to identify and enroll mothers-child paired. The logistic regression analysis had done to identify the factors associated with age-appropriate vaccination practice. The statistical association had measured, and a p-value < 0.05 was considered statistically significant. In this study, a total of 331 mothers/caregivers–child pairs participated with a response rate of 97.3%. The age-appropriate vaccination practice was 43.7% (95% CI, 38%, 49.5%). Mothers who had higher educational level (Adjusted odds ratio (AOR)) = AOR = 2.89, 95% CI (1.14, 7.3), antenatal care follow-up (AOR = 2.1, 95% CI (1.04, 4.1)), and had good knowledge on vaccination (AOR = 3.1, 95% CI (1.4, 6.78)) were associated with increased odds of age-appropriate vaccination practice.

KEYWORDS:

• Age-appropriate
• vaccination
• under one year children
• Samara–logia city administration
• Afar region

Introduction

Vaccination is one of the foremost cost-efficient health interventions, through that many serious childhood diseases were successfully prevented.¹ The beginning of an expanded program on immunization in 1974, and the widespread use of vaccines has considerably reduced vaccine-preventable morbidity and mortality.^2,3

Despite improvements, immunization is an unfinished agenda in many developing countries, including Ethiopia. About 1.5 million children were estimated to have died, and more than 70% of them live in ten African and Asian countries.^4,5 In sub-Saharan Africa, 4.4 million children died yearly due to transmittable diseases that could be avoidable by immunization.⁶ In Ethiopia, frequent measles outbreaks, high child morbidity, and mortality rates were among the consequences of low immunization coverage, and immunization currently averts an estimated 2 to 3 million deaths every year.^7,8

Countries including Ethiopia were planned to succeed vaccination coverage of ≥90% across the nation and ≥80% in each district by 2020.⁸ However, findings indicate that low access to services, inadequate awareness of vaccination, missing opportunities, inconvenient vaccination schedules, distance from health facilities, and worry of vaccine side effects were the main factors conducive to low vaccination coverage.^2,9

In Ethiopia, the routine schedule recommends that infants should receive the following vaccine schedule: one dose of Bacillus Calmette-Guerin (BCG) at birth or as soon as possible, three doses of diphtheria, pertussis, and tetanus (DPT) with hepatitis B (HepB) and Hemophilus influenza type b (Hib) (DPT-HepB-Hib), three doses of pneumococcal vaccine (PCV), and three doses of oral polio vaccine (OPV) at 6, 10, and 14 weeks. Moreover, two-dose of the Rota vaccine (R) at 6, 10 weeks, and one dose of measles vaccine at nine months.⁸

Ethiopia has shown encouraging enhancements in the accessibility and provision of primary health-care services, particularly since the beginning of the health extension program.¹⁰ Besides, the country implemented the Women’s Development Army (WDA) initiative.¹¹ Despite this intervention, the age-appropriate vaccination coverage remained low and challenging.¹² In Ethiopia, the percentage of children age 12–23 months who received all vaccinations increased from 14% in 2000 to 43% in 2019.¹² However, according to the 2016 Ethiopian demographic health survey in the Afar region, it was 19.8%. Vaccine-preventable diseases are responsible for 16% of under-five mortality in Ethiopia.¹³

Achieving and maintaining high-level vaccination coverage is the priority of health-care delivery systems. However, any delay in receiving regular vaccines leaves children inadequately protected and in danger of infectious diseases. The timeliness of vaccinations at the earliest applicable age is a public health goal. However, this information is commonly lacking as coverage is the mainly used method. Besides, it compromises herd immunity with a consequent potential risk of outbreaks.^14,15 Therefore, this study aimed to assess age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community of the Afar region, Ethiopia.

Methods

Study design and participants

A community-based cross-sectional study has conducted among 331 mothers/caregivers with children aged <12 months in Samara-logia city administration during January 2020. The location of city administration is at 580-kilometer northeast of Addis Ababa (the capital of Ethiopia). The average altitude of the town is 420 meters above sea level. The annual rainfall is below 200 millimeters, and the average temperature is 35 degrees centigrade. According to the Afar National Regional State Health Bureau Report, the city administration have populations of 59,255. The women in the reproductive age group were about 14,579, with 7314 were children aged less than five years, and 850 were children aged <12 months. The city administration has 13 ketenas (the lowest administrative units). There are also one primary hospital, two government health centers, and 15 private clinics.

Sample size determination and sampling techniques

The sample size was determined using single population proportion formula with the assumption: 5% type one error, 95% confidence interval (CI), P = 15.2% fully vaccinated children in the Afar region.¹⁶ Then, we added 10% to compensate for the nonresponse, and the final sample size became 340.

n = (Zα/2)² p (1-p)

d²

Where: n = required sample size, Zα/2 = critical value for normal distribution at 95% confidence level (1.96), p = proportion of fully vaccinated children in Afar region, d = 0.04 (4% margin of error).

Out of thirteen ketenas: Eight ketanas in logia city and five ketenas in semera city, six ketenas were selected (four ketenas from Logia city and two from Semera city) using the lottery method. The calculated sample size had proportionally allocated to randomly selected ketenas. There was a total of 850 children aged <12 months in the randomly selected ketenas (i.e., Ketena-1 = 78, Ketena-2 = 257, Ketena-3 = 95 and Ketena-4 = 145, ktena-5 = 155, and ketene-7 = 120). A systematic random sampling technique was employed to enroll the study participants. Accordingly, every three participants were selected using a systematic random sampling technique till the required sample size.

Study variables

Dependent variable

In this study, the dependent variable was ‘age-appropriate vaccination practice’ among mothers/caregivers of children aged <12 months. Age-appropriate vaccination is mothers/caregivers who vaccinated their children timely within the WHO recommended period and national EPI schedule. Vaccination of children on the recommended was coded as ‘1’ and coded as ‘0’ if the child received the vaccine earlier than the recommended age, or delay for regression analysis.

Independent variables: The independent variables were socio-demographic characteristics (sex, parent education, parent occupation, family size, number of children, and birth order), knowledge on vaccination, and maternal health services characteristics (antenatal care service, post-natal care, tetanus toxoid vaccination status, place of delivery, knowledge status (good or Poor)).

Operational definitions

Fully vaccinated: If he/she had received all of the doses of the following vaccines: BCG, OPV0, DTP-HepB1-Hib1, OPV1, Rota1, PCV1, DTP-HepB1-Hib2, OPV2, Rota2, PCV2, DTP -HepB1-Hib3, OPV3, PCV 3, and measles.¹⁷

Age-appropriate vaccination practice: If infants had received all doses of vaccine timely according to the expanded program immunization (EPI) schedule.¹⁷

Drop out: When an infant missed any one of the vaccines does.¹⁷

Knowledge: Is defined as when study participant’s knowledge on vaccines about previous information on the vaccine, source of information, number of vaccine-preventable diseases, the right time to start vaccination, number of sessions to complete vaccination, and age to complete vaccination.

Good knowledge: Is defined as scoring 75%-100% from the knowledge measuring question and coded as 1 for regression analysis.

Poor knowledge: Is defined as scoring <75% from the measuring questions and coded as 0 for regression analysis.

Data collection tools and techniques

Data were collected using a pretested, structured, and interviewer-administered questionnaire adapted from literature reviews and the 2016 Ethiopian Demographic and Health Survey (see Appendix). The questionnaire consists of socio-demographic, knowledge on vaccination and maternal health services characteristics, and vaccination status. The adapted questionnaire was modified and contextualized to fit the local circumstances and the research objective.

The questionnaire was prepared first in English and translated into Amharic and back to English to check for consistency. The Amharic version of the questionnaire has used to collect the data. The tool pretested on 5% of mothers having children aged <12 months other than selected kebeles in Dubti district. Information about children’s vaccination status had been collected from children’s vaccination cards. For children without a vaccination card, the mothers/caregivers were asked to recall. A scare on vaccination sites was observed. The data was collected by five-diploma nurses. The data collectors and the supervisors (two diploma nurses) were trained for two days by the researcher on the study instrument, how to approach study participants, and data collection procedure.

Data quality control methods

Diploma nurses who can speak the local language had been recruited as data collectors. Data collectors and supervisors trained on the study objective, the questionnaires, how to approach study participants and consent form to ensure quality data. The questionnaire was pretested on 5% of mothers/caregivers with children aged <one year other than selected kebeles in Dubti district. The pretest was done to ensure clarity, wordings, logical sequence, skip patterns of the questions and the amendment made accordingly. The supervisors checked the day-to-day activities of data collectors regarding the completion of questionnaires and clarity of responses.

Data management and analysis

The data were checked for completeness, coded, recorded, and entered into Epi data version 3.1 software and exported to statistical package for social science (SPSS) version 20 for analysis. The descriptive analysis was done, and the results were presented using texts, frequency tables, figures, and mean with standard deviation (±SD).

A binary logistic regression analysis was done to assess the association between the independent variables with the dependent variable. Socio-demographic characteristics (sex, parent education, parent occupation, family size, number of children, and birth order), knowledge on vaccination and maternal health services characteristics (antenatal care service, post-natal care, tetanus toxoid vaccination status, place of delivery, knowledge status) were the independent variables included in the binary analysis. Thus, independent variables with a p-value less than 0.25 considered in the final model. Correlation between independent variables was assessed, but we did not find any correlation. The model fitness also checked using the Hosmer-Lemeshow model fitness test. Finally, multivariable logistic regression analysis was done to control potential confounders and identify the factors associated with age-appropriate vaccination practice. A statistical significance level was declared at a p-value of less than 0.05.

Ethical considerations

The study was approved by the Ethical Review Committee (ERC) of Samara University. An official letter written from Samara University to the samara-logia city administration Office. Then permission and support letter was written to each selected ketena. The participants enrolled in the study were informed about the study objectives, expected outcomes, benefits, and the risks associated with it. The verbal consent was taken from the participants before the interview. Confidentiality of responses was maintained during the study period.

Results

Socio-demographic characteristics

In this study, a total of 331 mothers/caregivers-child pairs were included in the study with a response rate of 97.3%. The mean age of mothers was 33.5 (with a standard deviation of ±8.02) years, and about 126 (38.1%) of the mothers were in the age group of 20–34 years. In this study, 278 (84%) mothers/caregivers were Muslim, and 220 (66.5%) mothers were Afar in the Ethnic group. In this study, 177 (53.5%) children were male. The mean age of children was 6.71 (±2.92) months, and about 235 (71%) children were in the age group of 6–11 months (Table 1).

Table 1. Socio-demographic characteristics of mothers/caregivers and children aged less than one year in Samara-logia city administration, Afar region, Northeast Ethiopia, January 2020

Variables	Category	Frequency (n)	Percentage %
Child age in month	<6	96	29
	6–11	235	71
Mean (± SD)	6.71 (± 2.92)
Sex	Male	177	53.5
	Female	154	46.5
Number of children	1–2	77	23.3
	3–4	66	19.9
	>4	188	56.8
Birth order number	1	21	6.3
	2–3	93	28.1
	4–5	121	36.6
	>5	96	29
Religion	Muslim	278	84
	Orthodox	53	16
Ethnicity	Afar	220	66.5
	Amhara	94	28.4
	Tigre	17	5.1
Maternal age in years	<20	15	4.5
	20–34	126	38.1
	>34	190	57.4
Mean (± SD)	33.5 (± 8.02)
Family size	1–3	22	6.6
	4–5	93	28.1
	>5	216	65.3
Marital status	Married	311	94
	Divorced	20	6
Maternal education	No education	117	35.3
	Primary	106	32
	Secondary	69	20.98
	Higher	39	11.8
Maternal occupation	Housewife	110	33.2
	Government	84	25.4
	Daily labor	76	23.0
	Merchant	61	18.4
Household income (Ethio birr)	≤1000	45	13.6
	1001–200	91	27.5
	>2000	195	58.9

Knowledge on vaccination and maternal health services characteristic

In this study, 331 (100%) mothers/caregivers had heard about vaccination. About 272 (82.2%) mothers/caregivers know the existence of 10 available vaccines, 185 (5.9) five sessions for full vaccination, 294 (8.8%) complete immunization at nine months of age, and 267 (0.5%) had good knowledge on vaccinations. In this study, 233 (0.4%) mothers/caregivers had antenatal care follow-up (ANC), 36 (15.4%) had four and above ANC visits, and 135 (40.8%) delivered at health facilities. In this study, 164 (49.5%) mothers/caregivers have heard the source of information on vaccination programs from health facilities, and 159 (48%) from television (Table 2).

Table 2. Knowledge on vaccination and maternal health services utilization characteristics of mothers/caregivers with children aged less than one year in Samara-logia city administration, Afar region, Northeast Ethiopia, January 2020

Variables	Category	Frequency (n)	Percentage (%)
Ever heard about vaccination	Yes	331	100
	No	0	0
If yes, source of information	Health facilities	164	49.5
	Television	159	48
	Radio	8	2.4
Number of vaccine-preventable diseases	10	272	82.2
	<10	59	17.8
Number of sessions for fully vaccinated	Three	28	8.5
	Four	22	6.6
	Five	185	55.9
	I don’t know	96	29
The right time for vaccination begins	Soon after birth	284	85.8
	Six weeks after birth	14	4.2
	Any time	33	10
Age child complete immunization	9 months	294	88.8
	11 months	37	11.2
Overall knowledge on vaccination	Good	267	80.7
	Poor	64	19.3
ANC follow-up	Yes	233	70.4
	No	98	29.6
Number of ANC visits	1	75	32.2
	2–3	122	52.4
	>4	36	15.4
Received tetanus toxoid vaccine	Yes	194	82.6
	No	41	17.4
Place of delivery	Health facility	135	40.8
	Home	196	59.2
Post-natal care services	136	136	41.1
	19	195	58.9

Vaccination coverage

In this study, 295 (89.1%) children ever vaccinated, 158 (53.6%) had vaccination card, 129 (43.7%) age-appropriate vaccination, 101 (34.2%), vaccinated for measles, and 78 (23.6%) were fully vaccinated (Figure 1).

Figure 1. Percentage of vaccination coverage among children aged less than one year in Samara-logia city administration, Afar region, Northeast Ethiopia, January 2020

Factors associated with age-appropriate vaccination practice

Binary logistic regression analysis showed that maternal educational level, antenatal care (ANC), post-natal care, and good knowledge on vaccination were statistically associated with age-appropriate vaccination practice at p-value < 0.05 (Table 3). In multivariable logistic regression analysis, maternal education, antenatal care (ANC), and good knowledge on vaccinations were statistically associated with age-appropriate vaccination practice at p < .05 (Table 3).

Table 3. Binary and multivariable logistic regression analysis showing factors associated age-appropriate vaccination practice among mothers/caregivers with children aged less than one year in Samara-logia city administration, Afar region, northeast Ethiopia, January 2020

Variables	Category	Age-appropriate vaccination practice		COR 95% CI	AOR 95% CI
		Yes, n (%)	No (%)
Sex	Male	78 (60.5)	86 (51.8)	1.42 (0.89, 2.26)	1.1 (0.56, 2)
	Female	51 (39.5)	80 (48.2)	1	1
Marital status	Married	124 (96.1)	152 (91.6)	2.28 (0.8, 6.52)	1.93 (0.6, 6.15)
	Divorced	5 (3.9)	14 (8.4)	1	1
Maternal education	No education	42 (32.6)	71 (42.8)	1	1
	Primary	41 (31.8)	48 (28.9)	1.44 (0.82, 2.54)	0.91 (0.45, 1.78)
	Secondary	27 (20.9)	37 (22.3)	1.23 (0.66, 2.31)	1.21 (0.56, 2.59)
	Higher	19 (14.7)	10 (6)	3.2 (1.36, 7.5)	2.89 (1.14, 7.3) *
Knowledge on vaccination	Good	118 (91.5)	133 (80.1)	2.7 (1.28, 5.5)	3.1 (1.4, 6.78) *
	Poor	11 (8.5)	33 (19.9)	1	1
ANC follow-up	Yes	108 (83.7)	113 (68.1)	2.4 (1.36, 4.26)	2.1 (1.04, 4.1) *
	No	21 (16.3)	53 (31.9)	1	1
Post-natal care	Yes	66 (51.2)	60 (36.1)	1.85 (1.16, 2.96)	1.54 (0.82, 2.92)
	No	63 (48.8)	106 (63.9)	1	1

*Significant at p < .05.

In this study, the odds of age-appropriate vaccination practice among mothers/caregivers who had higher educational levels were 2.89 times more than mothers/caregivers who had no education (AOR = 2.89, 95% CI (1.14, 7.3)). The mother who had antenatal care follow-up was 2.1 times more likely to age-appropriate vaccination practice than their counterpart (AOR = 2.1, 95% CI (1.04, 4.1)). The odds of age-appropriate vaccination practice among mothers/caregivers who had good knowledge of vaccination were three-fold higher compared to their counterparts (AOR = 3.1, 95% CI (1.4, 6.78)) (Table 3).

Discussion

This study aimed to assess age-appropriate vaccination practice and associated factors among mothers/caregivers of children aged less than one year. Based on this, the prevalence of age-appropriate vaccination practice was 43.7% (95% CI, 38%, 49.5%). Moreover, mother/caregivers who had higher education, good knowledge on vaccination, and antenatal care (ANC) follow-up were predictors of age-appropriate vaccination practice.

Though the World Health Organization (WHO) and the Ethiopian expanded program on immunization (EPI) recommend infants should receive the vaccine on age-appropriate basis,^8,18 this study showed that 43.7% [95% CI: 38.3%, 49.5%] children less than 1 year were age-appropriate vaccination. This study was similar to studies conducted in Uganda, 45.6%,¹⁹ and nearly the study done in China range from 43.72% to 59.25% for different types of vaccine.²⁰ In this study, the age-appropriate vaccination practice was lower than studies done in Tanzania 82.7% to 88.5%,²¹ Saudi Arabia 73%,²² Ghana 87.3%,²³ Cameron 73.3%,²⁴ in Senegal 78.4%,²⁴ Kenya 71–91%,²⁵ Senegal 78.4%,²⁶ and South Africa 58% to 88%.²⁷ The reason might be due to less attention for age-appropriate vaccination and the lack of timeliness indicators in the Ethiopian vaccination programs. Moreover, most of the studies were facility-based, and it could be a good opportunity for infants to vaccinate BCG and OPV0 vaccine on age-appropriate.

However, age-appropriate vaccination practice was higher than studies done in India 29.5%,²⁸ Gambia 36.7%,²⁹ and Kenya 30.3%.²⁶ The reason might be the women’s development army and deployed health extension workers at the community level in Ethiopia might increase awareness creation on vaccination programs through the house to house visits.^10,11

In this study, the odds of age-appropriate vaccination practice among mothers/caregivers who had higher educational levels were 2.89 times more than mothers/caregivers who had no education. This study was consistent with studies done in Tanzania,²¹ Cameron,²⁴ Malawi,³⁰ Saudi Arabia,²² and China.²⁰ The reason might be education could increase communication and have a positive influence on childhood immunization. Several studies show that maternal educational level can improve vaccination of children.^31,32

The mothers/caregivers who had antenatal care follow-up were 2.1 times more likely to age-appropriate vaccination practice than their counterparts. This study was in line with studies done in Tanzania,²¹ Sinana District, Southeast Ethiopia,³³ and Ambo woreda, Central Ethiopia.³⁴ The reason might be mothers/caregivers who had attended antenatal care follow-up services can receive counseling services on the vaccination programs.

Furthermore, the odds of age-appropriate vaccination practice among mothers/caregivers who had good knowledge of vaccination were three-fold higher than their counterparts. Similar findings had reported in northeast Ethiopia,³⁵ Tigray Region, Northern Ethiopia,³⁶ Sinana District, Southeast Ethiopia,³³ India,²⁸ and Pakistan.³⁷ The reason might be the mothers/caregivers having prior knowledge on the importance of vaccines helps mothers/caregiver to vaccinate their children on age-appropriate vaccination based on the National recommended schedule. It had noted that there was an increased age-appropriate vaccination practice among mothers exposed to media.^38,39 Therefore, to improve the age-appropriate vaccination practice increasing knowledge of mothers/caregivers on vaccination programs, access to education for mothers/caregivers, and improving maternal health services utilization like antenatal care follow-up services is mandatory.

Limitation: Variables such as illness and unavailability of both parents could not address in the study though these variables are significant. The fact that the urban vaccination centers are static does not rule out the difficulty in accessing them. However, the inability to reach vaccination was purposefully left as the study had done in urban city administration where there are one primary hospital and two government health centers providing static routine vaccination programs. There might be recall bias on age-appropriate vaccination. Moreover, cause and effect relation had not been addressed because of the cross-sectional study design.

Conclusion

This study showed that four of nine children aged less than one year were age-appropriate vaccination, and it is low compared to WHO and national EPI recommendations. Maternal education, antenatal care (ANC), and good knowledge of vaccination were predictors of age-appropriate vaccinations. Therefore, increasing knowledge of mothers/caregivers on vaccination programs, access to education for mothers/caregivers, and improving maternal health services utilization is significant. Besides, age-appropriate vaccination indicator needs addressing in the health-care delivery and information management system.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Contributor statement

SA has conceived the study, carried out the overall design, execution the study, performed data collection and statistical analysis. EW and BM revised the study design, data collection techniques and helped the statistical analysis. EW has drafted the manuscript, and all authors read and finally approved this manuscript for submission.

Appendix

English version questionnaire

Part I. Socio demographic characteristics

Code	Questions	Possible responses	Skip to
101	Age of child in months?	… . … . … . … . … … (months)
102	Sex of the child?	Male Female
103	How many children do you have?	… … … … … … … … … . (number)
104	Birth order of the current child	… . … … (number)
105	Religion	Muslim Orthodox Protestant Others
106	Ethnicity	Afar Amhara Tigre Oromo Other
107	How much is household family size	… … … … … … number)
108	What is your age? Or caregiver?	… … … … … … … . (years)
109	What is your marital status?	Married Divorced Widowed
110	What is your educational status?	No education Primary Secondary Higher
111	What is your occupational status?	Housewife Semi pastoral Government Daily labor Merchant Other
112	How much is household family monthly income?	… … … … … (Ethio birr

Part II. Knowledge and maternal health service characteristics

Code	Questions	Possible responses	Skip to
201	Have you ever heard about vaccination?	Yes No	If no, skip 207
202	If yes, where do you heard?	Radio school Television Health facility/HEWs Others
203	If yes, how many vaccines preventable diseases do you know?	… . … . … . … . … .(number)
204	How many sessions are needed for a child to be fully vaccinated?	Once Two Three four Five I don’t know
205	What is the right time to begin immunization?	soon after birth Six weeks after birth after a year any time I don’t know other specify__________
206	At what age do you think the child should complete immunization?	_______________(months)
207	Did you have antenatal care follow up (ANC) while pregnant of this child?	Yes No	If no, skip to 209
208	If yes, number of ANC visits	… … … … … .(number)
209	Did you receive tetanus toxoid immunization while you were pregnant of the current child?	Yes No
210	Did you have post-natal care for the current child?	Yes No
211	Where did you deliver the current?	Health facilities Home

Part III. Vaccination status

301	Did you vaccinate your current child?	Yes No		If no, skip to 307
302	Did your child vaccinated on age-appropriate?	Yes No		Observe vaccination card or ask the mother most precise age and date of vaccination
303	Do you have vaccination card?	Yes No
304	If vaccinated, which vaccine did he/she took?	BCG	Yes No Not eligible for age	Observe card, any scar on shoulder or arm, sets of injection, and roots of administration
		Polio zero	≫
		Polio 1	≫
		Polio 2	≫
		Polio 3	≫
		Penta 1	≫
		Penta 2	≫
		Penta 3	≫
		PCV 1	≫
		PCV 2	≫
		PCV 3	≫
		Rota 1	≫
		Rota 2	≫
		Measles	≫
305	What is the Vaccination status of your child?	Not vaccinated at all On schedule/not eligible for the next upcoming vaccine Fully vaccinated
306	If drop out what is the reason?	Vaccination time is inconvenient vaccination unavailability Lack of awareness on the importance of vaccination Not knowing vaccination time and sets Not knowing whether to come back for second and third vaccination Others
307	What was reason for not ever vaccinated?	Absence of health facility in the district Vaccination damage children Religion and culture perception vaccination Lack of awareness about vaccination Fear of side effect Others