Factors Influencing Childhood Immunisation Uptake in Africa: A Systematic Review

"...recommend an immunisation health education intervention among pregnant women...which may hopefully improve childhood immunisation uptake among countries with poor coverage in Africa."

Despite the benefits of childhood immunisation, routine vaccination coverage for all recommended Expanded Programme on Immunization vaccines has remained poor in some African countries, such as Nigeria (31%), Ethiopia (43%), Uganda (55%), and Ghana (57%). The aim of this study is to collate evidence on the factors that influence childhood immunisation uptake in Africa and to provide evidence for future researchers in developing, implementing, and evaluating interventions among African populations to improve childhood immunisation uptake.

The researchers conducted a systematic review of articles on the factors influencing under-five childhood immunisation uptake in Africa from database(s) inception to 2020. They included 51 studies. Statistically significant factors found to influence childhood immunisation uptake were classified into modifiable and non-modifiable factors and were further categorised into different groups based on relevance.

Modifiable factors include:

• Obstetric factors - e.g., mothers who frequented health facilities during pregnancy may have received counselling on childhood immunisation; in antenatal care settings, the importance of timely childhood immunisation uptake tends to be communicated regularly. Similarly, children who were delivered in hospitals were more likely to have complete vaccination status compared with children delivered at home. Mothers who had hospital deliveries may receive advice after delivery, where the importance of timely immunisation of the baby may be emphasised. The maternal tetanus toxoid (MTT) vaccine was also noted to be a factor influencing childhood immunisation uptake. This finding could be attributed to the knowledge that mothers may have obtained regarding the benefit of childhood immunisation uptake during MTT vaccination at the health centre.
• Maternal knowledge - e.g., mothers with knowledge of immunisation schedules may know the exact time for each childhood immunisation uptake and they might also know the benefit of timely immunisation uptake for their children. The more knowledge they acquire, the higher the tendency of increased confidence toward childhood immunisation uptake.
• Maternal attitude and self-efficacy - e.g., among 248 defaulting mothers in Ibadan, Nigeria, more than half of this group reported that the reason for defaulting was that they considered childhood immunisation to be a waste of time. Studies have shown that mothers who have their child immunisation records were more likely to have their children fully immunised compared with mothers without child immunisation records.
• Maternal outcome expectation - e.g., having an expectation of the protection that follows childhood immunisation significantly influences childhood immunisation. The more knowledge mothers acquired with regard to the benefit of child immunisation and consequences of not immunising a child, the higher their confidence in childhood immunisation.

In this review, non-modifiable factors are considered to include: parental socio-demographic factors (maternal age, maternal education, paternal education, maternal marital status, area of residence, wealth index, number of siblings, religion, ethnicity and family income); child socio-demographic factors (gender, age); and environmental factors (distance to health facility, mode of transportation, accessibility of vaccination site, satisfaction with vaccine services, quality of vaccine provider clients relationship, and availability of vaccine).

As an example of the latter category, in Nigeria, cultural beliefs against immunisation are found to be detrimental towards childhood immunisation uptake. These beliefs could be linked to the circulation of false information about vaccines via either family or religious networks. Per the researchers: "Traditional and religious leaders are highly respected and are generally regarded and accepted as the custodians of traditions entrusted to them to provide traditional guidance to their respective communities. Therefore, their involvement in immunisation activities will help increase immunisation acceptance and uptake since the community trust their views on various matters..."

In conclusion: "The findings of the study will benefit policy makers in making decisions and formulating appropriate guidelines and policies with regards to childhood immunisation uptake in Africa. These findings can also enable other researchers to plan an appropriate health education intervention encompassing an appropriate health behavioural theory to address the factors affecting childhood immunisation uptake among African countries. The strengthening of childhood immunisation policies, strategies and further research examining the causal relationship on childhood immunisation in Africa are required."