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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  
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  
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  
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  
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  
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   
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  
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,   
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  
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  
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  
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  
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  
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   
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   
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)  
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  
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   Community of residence of mothers, lack of knowledge,   
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  
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  
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  
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  
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  
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