Table 1 Summary of studies’ characteristics and key findings
From: Barriers to childhood immunization in sub-Saharan Africa: A systematic review
Author, year, geographical location and number of countries included in the study | Participants and demographic | Study design | Reported national immunization coverage, Data source, Date | Quality | Key childhood immunization reported barriers | ||
|---|---|---|---|---|---|---|---|
Parental/caretakers barriers | Health systems barriers | Providers barriers | |||||
Tadesse et al. [1], 2009 Ethiopia East Africa, 1 | 126 adults | Cross-sectional | 38·5% National health survey of Ethiopia, 2006 | Moderate | Misunderstanding of side effects, busy with seasonal farm work | Absence of electricity to maintain the cold chain |  |
Obasoha et al. [2], 2018 Nigeria West Africa, 1 | 215 mothers | Cross-sectional | 25%, World Health Organization, Global Immunization Vision and Strategies, 2013 | High | Unaware of the need of immunization, lack of information, fear of side effect | Vaccines not available, vaccinators absence, long distance to cover | Â |
Malande et al. [3], 2014 Uganda East Africa, 1 | 311 caretakers/child pairs | Cross -sectional | Not reported | High | Language barrier, less support from husband | Vaccine stock outs, difficult terrain and poor road network, inadequate transportation means, poor working condition of vaccine fridges, inadequate staff, long distance, transportation difficulties | Lack of knowledge of vaccines adverse effects |
Wiysonge et al. [7], 2012 Sub-Saharan Africa countries, 24 | 27,094 children aged 12–23 month | Second-hand data Analysis | 71%, WHO (2010); vaccine preventable diseases: monitoring syatem-2010 | High | poor households, high illiteracy rates, lack of vaccines information, poor health seeking behaviors (Not going for ANC visit) |  |  |
Tefera et al. [11], 2018 Ethiopia East Africa, 1 | 540 mothers with children aged between 12 and 23 months | Cross -sectional | 86%,WHO/UNICEF Immunization coverage,2015 | High | fear of side reactions, lack of information, being too busy, place/time being unknown, long waiting time, | vaccinators were absent, vaccines were not available, limited health facilities, vaccine site being too far |  |
Porth et al. [12], 2019 Ethiopia East Africa, 1 | 2722 children | Second-hand data Analysis | 39%, Ethiopia Demographic and health survey, 2016 | High | Negative perception of vaccines, religion, waiting too long | limited operating hours, clinic distance | Â |
Kiptoo et al. [13], 2015 Kenya East Africa, 1 | 298 mothers/guardians | Cross - sectional | 86%, Kenya Expanded program on immunization, 2009 | High | lack of knowledge, earning less, many siblings | Inadequate health facilities, long distance for out-reach service | Â |
Cockcroft et al. [14], 2014 Nigeria West Africa, 1 | 2836 children | Cross-sectional | 42%, Nigeria Demographic and Health Survey, 2013 | High | Misconception about vaccines, fear of side effect, negligence, being busy with other household work | Lack of vaccines | Â |
Nolna et al. [15], 2018 ameroonWest Africa, 1 | 1134 caretakers | Cross-sectional | 82%, WHO-UNICEF estimates of DPT3 coverage, 2017 | High | Lack of money, lack of knowledge of vaccines importance, busy with other seasonal work | Shortage of health personnel, inadequate means of transportation | Â |
Zewdie et al. [16], 2016 Ethiopia East Africa, 1 | 28 mothers | Cross-sectional | 88%, Ethiopia National immunization survey, 2013 | Moderate | Lack of information, lack of support from male partners, high workload, fear of mistreatment and lack of cooperation from service providers | Poor arrangement and coordination of immunization services, vaccines stock out, lack of viable defaulter tracking system | Inadequate home visit, lack of commitment, poor counseling skills |
Babirye et al. [17], 2011 Uganda East Africa, 1 | 1000 adults | Cross-sectional | Not reported | High | male partner non-supportive, Lack of clothing, lack of money for vaccine related cost, lack of trust in immunization, fear of associated side effects, less education | Â | Â |
Miyahara et al. [18], 2016 Gambia West Africa, 1 | 50,455 residents including children | Second-hand data Analysis | Not reported | High | living in urban and peri-urban settings, ethnicity, low maternal education, life style | use of multi-dose vails with limited time, long distance | Use of multi-dose vails with limited time |
Pertet et al. [19], 2018 Kenya East Africa, 1 | 515 mothers | Cross-sectional | Not reported | High | Movement of the whole family (migration) | Lack of vaccines, difficult to access the health facility due to bad terrines | Â |
Yenit et al. [20], 2018 Ethiopia East Africa, 1 | 308 mothers | Case-control study | 39%, Ethiopian Demographic and Health Survey, 2016 | High | Delivery at home, lack of antenatal and postnatal care visit, miss conception about vaccines, | Â | Â |
Tugumisirize et al. [21], 2002 Uganda East Africa, 1 | 408 caretakers | Cross-sectional | 29%, Uganda Demographic and Health Survey, 1995 | High | Fear of rude health workers, being busy, low level of formal education, fear of side effects, perceived contradictions, | Long distance | Â |
Babalola S [22]., 2011 Nigeria West Africa, 1 | 882 women | Cross-sectional | Not reported | High | Lack of knowledge about immunization schedule and sources, spouses disapproval of immunization, myth and rumors about side effects, mothers too busy, religious and cultural beliefs, home delivery | Vaccines unavailability, Long distance | Â |
Oladokun et al. [23], 2010 Nigeria West Africa, 1 | 248 mothers | Cross-sectional | 12·7% National immunization survey, 2003 | High | Religion, low mother’s education, mothers not being aware of additional doses | Non-availability of vaccines, |  |
Schwarz et al. [24], 2009 Gabon West Africa, 1 | 262 mothers | Cross-sectional | Not reported | Moderate | feeling ashamed of poverty-associated reasons such as poorly cloth child or dirty, lack of knowledge, | Transportation cost, long distance | Â |
Ismail et al. [25], 2014 Sudan East Africa, 1 | 213 children | Cross-sectional | 60%, Federal Ministry of Health, 2005 | High | lack of knowledge,, mothers too busy, many siblings, fear of side effect | Vaccinators absence, vaccine stock out, long distance | Â |
Rees et al. [26], 1991 South Africa South Africa, 1 | 315 women | Cross-sectional | Not reported | High | low literacy level of mothers | Long distance to reach facility | Â |
Nadella et al. [27], 2019 Tanzania East Africa, 1 | 31,999 children | Secondary data analysis | Not reported | High | Parents not educated, mothers not attending ANC, delivery at home, poor household | Â | Â |
Meleko et al. [28], 2017 Ethiopia East Africa, 1 | 322 mothers/caretakers | cross-sectional | 24.3% Ethiopia Demographic Health Survey (EDHS), 2011 | High | Low parental educational level, delivery at home, parents not utilizing maternal health care services. Lack of knowledge | Â | Â |
Itimi et al. [29], 2012 Nigeria west Africa, 1 | 558 women | cross-sectional | 23% Nigeria Demographic and Health Survey, 2008 | High | Adverse rumor about childhood immunization | Inadequate health personnel (Vaccinators) | Â |
Kagoné et al. [30], 2018 Burkina Faso West Africa, 1 | Not stated | cross-sectional | Not reported | Moderate | Migration, mothers being busy, poor interaction between women and health workers, potential adverse events, and lack of information. | Geographic (hard to reach arears) | Not open multi-dose vails unless a critical number of children are present |
Tobin-West et al. [31], 2012 Nigeria West Africa, 1 | 1560 mothers/caregivers | cross-sectional | Not reported | High | Long waiting time, belief in the efficacy of traditional medicines as an alternative to immunization, poor rapport with health workers, | Frequent shortage of vaccine | Â |
Braka et al. [32], 2011 Uganda East Africa, 1 | 136 caretakers | cross-sectional | 80% W H O Immunization profile—Uganda 1980–2008, 2010 | High | Misconceptions, adverse effects experience, providers’ bad attitudes | Inadequate staff at health center level, poor storage facilities for vaccines, |  |
Ambe et al. [33], 2001 Nigeria West Africa, 1 | 500 mothers | cross-sectional | Not reported | High | Parents don’t have trust in vaccines, parents are abused in hospitals, husband refused/not supportive | Vaccines not available |  |
Tadesse et al. [34], 2009 Ethiopia East Africa, 1 | 226 children | cross-sectional | 49.9% Federal Ministry of Health Ethiopia, 2006 | High | Poor knowledge about immunization, mother’s negative perceptions, low monthly income of parents |  |  |
Jani et al. [35], 2008 Mozambique South Africa, 1 | 668 mothers | cross-sectional | 80% Expanded program on immunization, 1998 | High | Low education level of mothers, long waiting time for vaccination, parent’s forgetfulness, migration, concomitant treatment by traditional healers | Vaccines shortage, Inadequate health workers (Vaccinators) |  |
Eng et al. [36], 1991 Togo West Africa, 1 | 110 mothers/caretakers | cross-sectional | Not reported | Moderate | Lack of knowledge, parent’s forgetfulness, health workers being aggressive, long waiting time, laziness, lack of information about vaccines, low income of parents | Long distance to health facilities |  |
Landoh et al. [37], 2016 Togo West Africa, 1 | 2067 children (12 to 59 months) | Secondary data analysis | Not reported | High | Residence of mother (Muslims dominated), non-schooled mothers, being a single mother, negative cultural beliefs |  |  |
Legesse et al. [38], 2015 Ethiopia East Africa, 1 | 591 children 12 to 23 months and their mothers | cross-sectional | 36.5% Ethiopia Demographic Health Survey (EDHS), 2011 | High | Lack of knowledge, lack of information, low family income, low education level of parents, low maternal health care utilization, fear of adverse reactions, lack of trust on immunization, male partners non supportive | Poor quality of health information regarding immunization, Long distance to health facilities |  |
Wemakor et al. [39], 2018 Ghana West Africa, 1 | 322 children and their mothers | cross-sectional | 77% Ghana Demographic and Health Survey 2014 | Â | Community of residence of mothers, lack of knowledge, | Â | Â |
Adedokun1et al [40], 2017 Nigeria West Africa, 1 | 5754 children aged 12–23 months | Secondary data analysis | 81.5% Federal Ministry of Health Nigeria, 2011 | Moderate | Mothers being illiterate, lack of information about immunization, mothers not attending ANC, delivery at home, economically dis advantage mothers, difficulty getting to health facility due to bad terrines |  |  |
Chidiebere et al. [41], 2014 Nigeria West Africa, 1 | 34,596 women | Secondary data analysis | Not reported | High | Lack of information about immunization, fear of side-effects, delivery at home, place of residence | Immunization centers too far | Â |
Ekouevi et al. [42], 2018 Togo West Africa, 1 | 1128 children aged 12–23 months | cross-sectional | Not reported | High | Mothers not educated, low income, poor road conditions,, | Lack of means of transportation, Long distance to health center |  |
Tadess et al. [43], 2017 Ethiopia East Africa, 1 | 630 mothers/caretakers | Case control | 79% Ethiopian Health Sector Transformation Plan (HSTP), 2009 | High | Inaccessible health facility, poor motivation, unfavorable attitude and bad treatment of health workers, lack of logistics, inconvenient immunization time, inadequate information about immunization | Vaccines shortages | Inadequate communication skills, lack of willingness and restricted vaccine open policy, |
Negussie et al. [44], 2016 Ethiopia East Africa, 1 | 548 children aged 12 to 23 months | Case control | 24% Ethiopia Demographic and Health Survey, 2011 | High | Lack of knowledge about immunization benefits, mother’s negative perception of vaccine side effects, migration of mothers | Unavailability of vaccines |  |
Bosu et al. [45], 1997 Ghana West Africa, 1 | 469 mothers | Cross sectional | 43% Ministry of Health Ghana Maternal and Child Health and Family Planning. Annual Report, 1992 | High | Poor knowledge about immunization, financial difficulties, long waiting times,, attitude of service providers and fear of side-effects | Lack of suitable venues and furniture at outreach clinics, and weak inter-sectoral collaboration, transport difficulties | Poorly motivated service providers |
Desgrées du Loû et al. [46], 1994 Senegal West Africa, 1 | 6078 Mothers/caretakers | Cross sectional | 51% WHO/EPI/CEIS/93.1 (summary for the WHO African Region) 1990 | Moderate | children in large compound with large number of children. | Distance between the child and the health center, difficult geographical terrain |  |
Sato R [47]., 2019 Nigeria West Africa, 1 | 28,085 children | Secondary data analysis | Not reported | Moderate | Have no faith in immunization, lack of awareness of the need for immunization, poor household | Shortage of vaccine, limited health centers immunization point is too far/inconvenient | Â |
Akwataghibe, N. N. et al. [48], 2019 Nigeria West Africa, 1 | 215 children, | Cross sectional | Not reported | High | Ethnicity, culture, household decision making, and gender relations; lack of knowledge and awareness of the value of immunization, negative beliefs and attitudes toward immunization; past experiences with immunization, migration | shortage of health workers, unavailability of vaccines at scheduled times; Inadequate electrical power supply to keep the vaccine cold chain at facilities, long distances for mothers in hard-to-reach areas | Reminders not sent on time about routine immunization or outreach days |
Yismaw, A. E. et al. [49], 2019 Ethiopia East Africa, 1 | 301 mothers/caretakers | cross-sectional | 86% Federal Ministry of Health (2010) | High | Lack of Knowledge of next visit; and lack of knowledge about the benefits of vaccination | long distances to reach nearby health facilities | Â |
Ntenda P [50]., 2019 Malawi East Africa, 1 | 3111 children and mothers | Cross-sectional | 76% WHO (2015) | High | Children born to mothers without education, children poor households, mothers with many sibling, children whose delivery occurred at home, | Inadequate health facility for vaccination, long distances to reach nearby health facilities | Â |
Okenwa, U. J. et al. [51], 2019 Nigeria West Africa, 1 | 344 mothers and their infant | Cross-sectional | Not reported | High | Lack of awareness on timing of valid vaccine, | Vaccine stock-out at the immunization site | Â |
Mthiyane, T. N et al. [52], 2019 South Africa South Africa 1 | 847 eligible children aged 12–59 months | Secondary data analysis | 66% WHO/UNICEF (2015) | High | Low household monthly income, unfriendly health workers, | Vaccine shortage; long distance and transportation costs to reach the clinic for immunization | Low level of education of the primary caregiver, |
Mekonnen, A. G. et al. [53], 2019 Ethiopia East Africa, 1 | 566 children aged 12–23 months and their mothers/caregivers | Cross sectional | 39% Ethiopian demographic health survey report (2016) | High | Forgotten appointment date, the experience of child sickness with previous vaccination, and disrespectful behavior of health professionals | Long distance to the clinic |  |
Ibraheem, R. et al. [54], 2019 Nigeria West Africa, 1 | 480 mother-infant | cross-sectional | 53% Nigeria immunization coverage survey (2016) | High | Lack of antenatal care visit, vaccination on weekend/public holidays lower educational level | Â | Â |