In this study, we examined the influenceIn this study, we examined the influence

In this study, we examined the influence of individual-level factors along with contextual characteristics on childhood complete immunization in Malawi. Our findings show evidence of clustering effects of complete immunization at community levels. This suggests that children in the same neighborhood are subject to common contextual influences. The EPI aims at achieving immunization coverage of at least 90% for infant’s national wide (2),(3). Unfortunately, as at 2015, the immunization in Malawi was found to be lower than both national and WHO targets. (4) In this study, the immunization coverage was found to be even lower than which has been previously reported. (11),(15) After adjustments for a wide range of individual- and community-level characteristics, the number of ANC visits, immunization card, the number of under-five children in the household, household wealth, and community distance to the nearest health facility were significant factors associated with complete immunization.    

Having at most one ANC visit was significantly associated with reduced odds of complete immunization. These findings are in line with the studies conducted in Malawi (11) and other sub-Saharan countries (16),(17),(18). A possible explanation might be that, women who have frequent ANC visit might be more satisfied with the health care system and become aware of the need for vaccination which in turn may make them more likely to return for child vaccination. Their interactions with the healthcare providers may foster trust and strengthens the women–provider relationship and in turn, may positively affect women’s health care-seeking behavior. Evidence has shown that utilization of antenatal care encourages the use of subsequent maternal and child health services including vaccination. (19),(20).

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Mothers’ possession of a child health card was previously found to correlate with child’s complete immunization. (21),(22) As in our study, mothers whose children had ”no card/no longer had card” or ”had a card but not seen” were less likely to be completely immunized. Being in possession of a child’s immunization card allows the mother to easily follow the immunization schedule and thus may be able to return on time for the immunization their child. Moreover, having a well-kept immunization card with a clearly-labeled schedule can prevent mothers from missing out on vaccinations appointments. (21) On the hand, mothers who did not have immunization cards might avoid seeking immunization services for fear of ill-treatment from some health care providers as a result of misplaced, lost or spoiled child health card. (23)

Children from families with at most one under-five child in the household were more likely to achieve complete immunization which is consistent with prior research. (20),(24),(25) It was reported that women with fewer children in the household may have more time to commit to the care of an individual child, thus making routine immunization visits easier to prioritize. (20),(25) On the contrary, women with multiple children may synchronize health visits for her children, which could influence whether each child adheres to the recommended schedule. (20),(25) For instance, a child may receive their vaccination in conjunction with a sick visit for a sibling rather than on a scheduled visit for vaccination (25).

In line with prior research, household wealth was also an important factor affecting complete childhood immunization in the present study. (26),(27),(28) Infants born from poor household wealth were less likely to have complete vaccination. Prior researchers suggested that mothers from the poor households may have barriers to access immunization services such as lack of transportation compared to mothers from rich households. (6) On the other hand, higher income may be associated with higher chances to obtain better health knowledge and health-seeking behavior. (6),(29) Thus, mothers from wealthy families may have higher chances to seek modern/medical health services for their families whenever necessary. (10)

In addition to individual-level factors, community-level factors were also associated with complete childhood immunization. As observed elsewhere, (11) residing in communities with the middle and high percentage of households who perceived distance to the nearest health facility were associated with reduced odds of achieving complete immunization. The distance to the nearest health facility could act as a proxy for healthcare service accessibility and availability. Thus, access to health facilities might be an essential factor for vaccination services utilization. In Malawi, over 80% of the population resides in rural areas. (4) Consequently, poor infrastructures (i.e. lack of electricity to store vaccines and poor road network to transport vaccines) may lead to inequitable distribution of health services in the communities. In turn accessibility to vaccination services particularly in hard-to-reach areas and vulnerable populations might be affected. (30) In Egypt, immunization coverage was observed to decline with an increasing distance from the vaccination clinics. (31) In South Africa, the distance to the nearest mobile clinic was significantly positively associated with child vaccination status. (32) Similarly, in Pakistan, children who lived about 2-5 km from the health facility had higher chances of not receiving vaccinations as compared to children who lived <2 km away from the health facility. (33) Limitations This study was prone to recall bias as the respondents who did not have the child health cards, were asked to recall the vaccines that were administered to their children. The cross-sectional nature of the study design limits our ability to draw causal inferences. The use of secondary data limited us to include other variables that could explain complete childhood immunization. Conclusions             Our study has indicated that both individual- and community-level factors have in?uences on complete immunization in Malawi. We found evidence of clustering effects of complete immunization at community-level, which implies that children from the same communities tended to have similar immunization status. Thus, public health programmes designed to improve complete childhood immunization should address individuals and their communities they live in.  Specifically, the focus should be emphasized more on the individual and community level characteristics reported.