Immunization coverage and associated factors among children age 12-23 months in Ethiopia: An Umbrella review of Systematic review and Meta-analysis 2024

Immunization coverage and associated factors among children age 12-23 months in Ethiopia: An Umbrella review of Systematic review and Meta-analysis 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Immunization coverage and associated factors among children age 12-23 months in Ethiopia: An Umbrella review of Systematic review and Meta-analysis 2024 Tesfahun Simon Hadaro, Begetayinoral Kussia, Merkin Bekele, Woldetsadik Oshine, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4040022/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Full immunization coverage plays a vital role in public health by enhancing child survival and preventing morbidity and mortality from common childhood illnesses. However, there is a shortage of comprehensive studies providing conclusive evidence on full immunization coverage and associated factors in Ethiopia. Hence, the objective of this umbrella review and meta-analysis was to identify the pooled full immunization coverage and associated factors in Ethiopia. Methods This review used an umbrella review method, by incorporating numerous systematic reviews. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The method involved systematically synthesizing suitable systematic reviews and meta-analyses using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Medical Subject Heading (Mesh) terms and keywords were used to find pertinent review in various online databases, such as PubMed, Cochrane Library, Science Direct, Google Scholar, and HINARI. I-squared statistics were used to assess study heterogeneity. STATA version 17 software was used for statistical analysis, and the 95% CI was used to determine statistical significance. Result In this review, four studies were included. The pooled prevalence of immunization coverage was 60.21% (95% CI: 57.29–63.14). The umbrella review found that factors such as institutional delivery (AOR = 1.93, 95% CI 1.75–2.10), travel time to vaccination site (AOR = 2.39, 95% CI 1.89–2.89), receiving at least one antenatal care visit (AOR = 2.70, 95% CI 2.05–3.33), possessing good maternal knowledge (AOR = 3.77, 95% CI 3.07–4.14), maternal education level (AOR = 2.3, 95% CI 1.7–2.96), and residing in urban areas (AOR = 1.84, 95% CI 1.54–2.14) were significantly associated with achieving full immunization coverage. Conclusion The pooled prevalence of immunization coverage was found to be 60.21%, indicating a substantial gap that needs to be addressed. Factors such as institutional delivery, travel time to vaccination site, antenatal care visits, maternal knowledge, education level, and urban residence were significantly associated with higher immunization rates. These findings underscore the need for targeted interventions to improve access to vaccination services, enhance maternal education and knowledge, and promote institutional delivery. Addressing these factors can help increase immunization coverage and contribute to better overall public health outcomes. Vaccination immunization systematic review meta-analysis Ethiopia Figures Figure 1 Figure 2 Figure 3 1. Introduction Immunization involves administering a vaccine antigen to deliberate immunity or resistance to infectious diseases ( 1 , 2 ). Full immunization coverage plays a vital role in public health by enhancing child survival and preventing morbidity and mortality from common childhood illnesses ( 3 ). Despite an overall increase in global immunization coverage over recent decades, progress has plateaued in recent years ( 4 , 5 ). According to the World Health Organization (WHO) report, approximately 22 million infants worldwide were left unvaccinated ( 6 ). Additionally, global data indicates that millions of children fail to complete their full vaccination courses annually ( 7 ). Furthermore, a considerable number of children in Low and Middle-Income Countries (LMICs) remain either unvaccinated or under-vaccinated, leading to preventable deaths from vaccine-preventable diseases ( 8 , 9 ). Significant progresses have been achieved in bolstering immunization efforts across African nations over the past forty years. Nevertheless, approximately 20–30% of children in these countries still lack vaccination ( 10 ). Moreover, full immunization coverage in Low- and Middle-Income Countries (LMICs) ranges between 56% and 69%. Alarmingly, an estimated 4.3 million infants remain unimmunized, with the majority concentrated in just four African countries: the Democratic Republic of the Congo, Ethiopia, Nigeria, and South Africa ( 11 , 12 ). Additionally, nearly 19% of children aged 12–23 months in Ethiopia did not receive any vaccinations. Systematic review conducted in Ethiopia has shown variability in full immunization coverage, with rates ranging from 57–65% ( 13 – 16 ). Therefore, obtaining a pooled estimate of vaccination coverage from this review will offer more dependable information regarding the overall vaccination coverage in the country. Numerous studies conducted worldwide have identified various factors linked to full immunization coverage, including wealth index, educational status, antenatal care (ANC) attendance, birthplace, and residence ( 13 , 17 , 18 ). Additionally, maternal knowledge of immunization, maternal age, maternal education, type of pregnancy, and household visits by healthcare workers have been recognized as influential factors in Ethiopia ( 14 – 16 ). However, there is an absence of comprehensive studies providing conclusive evidence on full immunization coverage and associated factors in Ethiopia. Hence, the objective of this review and meta-analysis was to determine the pooled full immunization coverage and identify associated factors in Ethiopia. 2. Methods and Materials This comprehensive review used an umbrella review method, incorporating numerous systematic reviews. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The method involved systematically synthesizing suitable systematic reviews and meta-analyses using the AMSTAR tool. 2.1 Eligibility criteria All published articles that were conducted in Ethiopia, written in English, and assessed the coverage of immunization and its associated factors were included in the review. The review needed to meet specific predetermined criteria to be classified as a systematic review or meta-analysis, including: (a) having a clearly outlined literature search strategy, (b) evaluating its included studies using a pertinent tool, and (c) employing a standardized method for combining studies and presenting summary estimates. Whereas Exclusion criteria for reviews were based on the following reasons: inclusion of narrative reviews, editorials, correspondence, abstracts, and methodological studies. Additionally, reviews were excluded if they lacked a clear research question, search strategy, or defined process for selecting articles. 2.2 Search strategy A search strategy was developed and reviewed by two member not involved in its development; no restrictions was applied to the years published, but the papers included was limited to English and Ethiopian publications only. We were search by using the following international online databases to search for papers on coverage of immunization: PubMed, Cochrane Library, Science direct, Google Scholar, and HINARI. In order to find other papers, a search was also done for the reference list of the already retrieved studies from grey literature. The Population, Exposure, Comparison, and Outcomes (PECO) search algorithm was used to find papers. For the online database, search by using mesh terms or keywords. Using the Boolean operators "OR" and "AND," the search terms was combined: (Immunization OR Vaccination OR “Immunization Coverage” OR “Vaccination Coverage”) AND (Children OR “children aged 12–23 months”) AND (Determinant OR Determinants OR “Determinant factor” OR “Determinant factors” OR Factor OR Factors OR “Associated factor” OR “Associated factors”) AND Ethiopia AND Systematic review. 2.3 Study screening and selection The search results were imported into Endnote version viii and underwent a duplication process. Subsequently, the screening and selection of studies occurred in two stages. Initially, title and abstract screening was performed. Following this, a comprehensive review of full texts was conducted. In the first stage, studies mentioning the prevalence and/or determinants of coverage of immunization were identified for full-text review through title and abstract screening, carried out independently by two researchers. During the full-text review, any article deemed potentially eligible by either reviewer was included for further assessment, with both reviewers independently examining them. In instances of disagreement where a consensus couldn't be reached between the researchers, a third researcher reviewed the articles and resolved the discrepancies. 2.4 Data Extraction and management Data extraction from the included SRM (Systematic Review or Meta-analysis) was carried out using a standardized data abstraction form developed in an Excel spreadsheet. For each SRM, the following information was extracted: (a) Identification data (first author's last name and publication year), (b) Review aim, (c) Prevalence or proportion of immunization coverage, (d) Risk factors, (e) Odds ratio or relative risk with 95% confidence intervals for the risk factors, (f) Number of primary studies included within each SRM study and their respective design type, (g) Total number of sample size included, (h) Publication bias assessment methods and scores, (i) Quality assessment methods and scores, (j) Data synthesis methods (random or fixed-effects model), and (k) The authors' main conclusion of the SRM study. 2.5 Risk of bias assessment Every included study underwent a critical appraisal for the validity scoring of its results. To guarantee methodological and evidence quality in the included SRM studies, the Assessment of Multiple Systematic Reviews (AMSTAR) tool was employed ( 19 ). This tool comprises 11 questions designed to assess the quality of approaches used to pool empirical studies within the SRM studies and summarize their estimates. The quality scoring ranged from 0 to 11, with scores of 8–11, 4–7, and < 3 indicating high, medium, and low qualities, respectively. 2.6 Data synthesis and analysis The synthesis of data from the included SRM studies involved employing both qualitative (narrative) and quantitative methods. In cases where multiple estimates were available regarding the prevalence and factors associated with immunization coverage, we presented the range of these estimates and computed an aggregated (pooled) estimate. The statistical program STATA version 17 was used. The inverse variance (I2) and Cochran Q statistics was utilized to investigate the study heterogeneity using cut-offs ( 20 , 21 ). There was considerable heterogeneity among review (I 2 = 98.04%, P ≤ 0.05), a random effects model with a 95% confidence interval (CI) was employed to compute the pooled prevalence of immunization coverage. The assessment of publication bias was hindered due to the inclusion of only four studies. A minimum of 10 studies is typically required to adequately evaluate publication bias. 2.7 Ethical consideration In this investigation, obtaining consent or ethical approval from study participants was unnecessary, as the study relied on data extracted from SRM studies. 3. Result 3.1 Search finding Automated searches generated 204 articles on immunization coverage. Of these, 39 were found in PubMed/MIDLINE, 59 in Google Scholar, 22 in HINARI, 57 in Science Direct, and 22 in the Cochrane Library. After removing duplicates, 98 articles remained. Of these, 91 were excluded during the title and abstract screening because they did not relate to SRM studies on immunization coverage, which was the study’s specific objective. After a detailed review of the remaining 7 articles, three SRM studies were excluded for not addressing the required outcome. As a result, this umbrella review includes a total of four SRM studies. The following sections illustrate the detailed study selection and screening process (Fig. 1 ). 3.2 Characteristics included review This umbrella review incorporated all SRM studies, specifically ( 13 – 16 ), which were derived from observational primary studies. These primary studies consisted of 1 cohort studies, 12 case-control studies, and 80 cross-sectional studies, amounting to a total of 93 studies. The collective sample size across these studies involved 57,113 children. The number of primary studies varied per SRM, ranging from 16 (lowest) to 30 (highest). Additionally, the sample size per meta-analysis exhibited variability, spanning from 8305 (lowest) to 21,672 (highest). Three SRM studies were published in the year 2020 and one were published in 2021. These studies comprehensively examined both the prevalence and determinants of immunization coverage. As per the findings from the four included SRM studies, the reported estimates for the prevalence of immunization coverage varied, with a range from 58.92% (95% CI: 51.26–66.58%), I2 = 99.4–65% (95% CI: 56%-74%), I2 = 98.9%. These statistics highlight the diversity in prevalence rates across the studies. General characteristics of the systematic review and meta-analyses studies are presented in the following sections (Table 1 .docx). Table 1 Systematic review and meta-analysis characteristics included in umbrella review the in Ethiopia 2024. Author Review aim Search strategy Included studies Sample size Risk of bias prevalence AMSTAR Gebeyaw B et al Full immunization coverage and associated factors in Ethiopia Access to various databases, including Public Medline (PubMed), Health Inter-Network Access to Research Initiative (HINARI), Google Scholar, Excerpta Medical Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, African Journal of Online (AJOL), and the Cochrane Library 16 8305 A full evaluation of the studies' quality has been clearly articulated. 65 10 Akine E et al Immunization coverage and its factors among children aged 12–23 months in Ethiopia PubMed, Google Scholar, Cochrane library, and gray literature 30 21,672 A comprehensive assessment of the quality of the studies has been clearly expressed 59 9 Ketem et al Full vaccination coverage among children aged 12–23 months in Ethiopia MEDLINE, CINAHL, EMBASE, Google Scholar, and Science Direct are databases and search platforms commonly utilized 21 12,094 The studies' quality has been thoroughly and clearly evaluated 60 8 Nour et al Predictors of immunization coverage in Ethiopia PubMed, Google Scholar, HINARI, and SCOPUS, Web of Science, African Journals Online, Ethiopian Medical Journals were searched 26 15,042 The quality of the studies has been transparently assessed 57 9 3.3 Methodological quality of the included SRM studies Using the AMSTAR tool the methodological quality of included SRM studies evaluated. The quality of scoring was done out of 11 points and ranged from 8 to 10 ( Table 2 ). Table 2 Methodological quality of the included SRM studies based on AMSTAR tool in Ethiopia, 2024. AMSTAR tool Authors Gebeyaw B et al Akine E et al Ketem et al Nour et al Priori design provided yes no no yes Duplicate study selection and data extraction yes yes yes yes Search comprehensiveness yes yes yes yes Inclusion of grey literature yes yes no no Included and excluded studies provided no no no no Characteristics of the included studies provided yes yes yes yes Scientific quality of the primary studies assessed and documented yes yes yes yes Scientific quality of included studies used appropriately in formulating conclusions yes yes yes yes Appropriateness of methods used to combine studies' findings Yes yes yes yes Conflict of interest yes yes yes yes Likelihood of publication bias was assessed yes yes yes yes Total( 11 ) 10 9 8 9 3.4 Pooled prevalence of Immunization Coverage. From umbrella review of four SRM studies the pooled prevalence of immunization coverage was 60.21% (95% CI, 57.29–63.14). Figure 2 Figure 2 : Pooled prevalence of the coverage of immunization among children age 12–23 months in Ethiopia, 2024. 3.5 Subgroup analysis The subgroup analysis focusing on sample size revealed that the sample less than 15,000 had the highest prevalence of immunization coverage (62.49%, with a confidence interval of 57.59–67.39), whereas sample size greater than or equal to 15,000 had the lowest prevalence (57.87%, with a confidence interval of 56.09–59.85). 3.6 Sensitivity analysis We investigated deeper into the heterogeneity's origins through a leave-one-out sensitivity analysis. This examination showed that excluding each study individually from the analysis did not significantly alter the average estimated prevalence of immunization coverage. The average prevalence remained within the 95% confidence interval of the overall average prevalence obtained when all studies were included. Consequently, the average prevalence of immunization coverage among children was not influenced by any single review. Additionally, the sensitivity analysis revealed that excluding each study individually resulted in the average prevalence of 60.21 (with a 95% confidence interval of 57.29–63.14). 3.7 Meta-regression Substantial heterogeneity was observed among the studies incorporated into the meta-analysis. To explore the sources of this heterogeneity, we conducted a meta-regression analysis, incorporating variables such as publication year and sample size. However, publication year in the meta-regression analysis revealed a significant impact on the observed variation in immunization coverage prevalence with (p-value = 0.00, I2 (%) = 92.45) (Table 3 ). Table 3 Meta-regression analyses were performed to assess the relationship between vaccination coverage among children aged 12–23 months in Ethiopia and two variables: sample size, number of review and publication year of the included review. Variables β (95% CI) P-value Sample size -0.00042 (-0.00103, 0 .00019) 0.18 Publication year 6.36532 (3.06428, 9.66636) 0.00 3.8 Factors associated with immunization coverage in Ethiopia. This Umbrella of systematic review and meta-analysis identified the most often occurring related variables, which were Institutional delivery, time to travel to vaccination site, received at least one antenatal, good maternal knowledge, maternal education and residence (living urban areas) ( Table 4 ). Table 4 Meta-analysis of associated factors of immunization coverage in Ethiopia, 2024 Variable OR(95% CI) Heterogenity Number of review Maternal education 2.3(1.7–2.96) I 2 = 0.0%, p = 0.86 2 Residence(urban) 1.84(1.54–2.14) I 2 = 0.0%, p = 0.71 3 Good maternal knowledge about immunization 3.77(3.07–4.14) I 2 = 0.0%, p = 0.5 3 Received at least on antenatal care follow up 2.70(2.05–3.33) I 2 = 43.7%, p = 0.16 3 Time to travel to vaccination site(< 1 hour) 2.39(1.89–2.89) I 2 = 0.0%, p = 0.53 2 Institutional delivery 1.93(1.75–2.10) I 2 = 0.0%, p = 0.50 3 The analysis included two separate reviews to investigate how where a mother residence relates to the extent of full immunization coverage. The results showed that urban residence were odds of 1.84(1.54–2.14) times more likely immunized their children than rural residence. Three studies were analyzed to investigate the impact of maternal knowledge on full immunization coverage. The results indicated that children born to mothers with a good knowledge about immunization were 3.77 times more likely to be fully immunized. The odds ratio was calculated at 3.77, with a confidence interval of 95% ranging from (3.07–4.14). There was no heterogeneity among the studies I 2 = 0.0%, p = 0.5. Two studies were analyzed to investigate the effect of maternal education on full immunization coverage. The results indicated that children born to mothers with a higher education level were 2.3 times more likely to be fully immunized. The odds ratio was calculated at 2.3, with a confidence interval of 95% ranging from (1.7–2.96). There was no heterogeneity among the studies I 2 = 0.0%, p = 0.86. Three main reviews were employed to evaluate the association between the received antenatal care follow up and immunization coverage. Women who received at least one antenatal care follow up were 2.7 times more motivated to ensure their child received full vaccination compared to mothers who were not received antenatal care [Odds Ratio: 2.7, 95% Confidence Interval: 2.05–3.33, I 2 = 43.7%, p = 0.16. Three main reviews were engaged to evaluate the association between the institutional delivery and immunization coverage. Women who have institutional delivery were 1.93 times more likely to ensure that their child received full vaccination compared to mothers who were not delivered in institutional (Odds Ratio: 1.93, 95% Confidence Interval: 1.93 (1.75–2.10) I 2 = 0.0%, p = 0.50). Two studies were analyzed to investigate the impact time to travel to vaccination site(< 1 hour) on full immunization coverage. The results indicated that children born to mothers with a nearby vaccination site(< 1 hour) were 2.39 times more likely to be fully immunized. The odds ratio was calculated at 2.39, with a confidence interval of 95% ranging from (1.89–2.89). There was no heterogeneity among the studies I 2 = 0.0%, p = 0.53. 4. Discussion Up to now, there have been four SRM reports addressing immunization coverage in Ethiopia. These SRM studies are typically considered as providing strong evidence for making decisions in health programs. However, as the number of individual reviews grows, it can become overwhelming for those seeking information( 22 ). Hence, this umbrella review was undertaken to consolidate the findings of the four SRM studies on immunization coverage into a single document. It revealed that immunization coverage is considerably below the rate recommended by the World Health Organization and a significant public health issue in Ethiopia. Furthermore, various factors like Institutional delivery, time to travel to vaccination site, received at least one antenatal, good maternal knowledge, maternal education and living urban areas were identified as statistically significant. The umbrella review of the four included SRM studies on the coverage of immunization in Ethiopia yielded a summary estimate of 60.21% (95% CI, 57.29–63.14). The results aligned closely with the global immunization rate of 57.8% ( 23 ), the aggregated full vaccination coverage in Ethiopia at 60% ( 16 ), findings from the Demographic and Health Survey (DHS) in ( 24 ), South Africa at 61% ( 25 ), and India at 62% ( 26 ). This similarity may stem from the adoption of comparable child health initiatives, including immunization services, by both the World Health Organization and various non-governmental organizations worldwide. Ethiopia, in particular, has implemented a program similar to those observed globally. However, the result exceeded the studies reported in the Ethiopian Demographic and Health Survey (EDHS) of 2016 (39%) ( 27 ) and the subsequent EDHS report in 2019 (43%) ( 18 ). This variance could be attributed to the methodology of the EDHS survey, which encompasses huge geographical areas, including regions that are difficult to reach, potentially leading to an underestimation of vaccination coverage. Additionally, the observed result surpassed rates reported in studies conducted in low- and middle-income countries (LMICs) (36%) ( 28 ) and a similar study conducted in Nigeria (34.4%) ( 29 ). This discrepancy may arise from differences in the implementation and effectiveness of immunization programs across various regions. The findings from this review revealed lower rates compared to the global report (86%) ( 30 ), a study conducted in Eritrea (83%) ( 31 ), and findings from Malaysia (86.3%) ( 32 ). This difference in immunization rates could potentially be attributed to variations in the quality of healthcare services and demographic differences between developed and developing countries. Developed nations often boast higher standards of healthcare provision and greater access to resources, which may contribute to their ability to achieve higher rates of full immunization coverage. Additionally, it's worth noting that Eritrea received recognition for its outstanding achievement in childhood immunization programs, indicating a context-specific success story that may not be replicated universally. Our review also identified a significant association between the location of residence and the completion of immunization among children. Specifically, children residing in urban areas showed a 1.84 times (I 2 = 0.0%, p = 0.717) higher likelihood of being fully vaccinated compared to those in rural areas. Previous studies investigating the association between residence and immunization coverage have yielded varied results. While some studies have reported a strong link between urban residence and immunization, others have not observed such a connection. This inconsistency may be attributed to inherent socioeconomic disparities across different study settings. In some instances, rural settings may face significantly greater disadvantages compared to urban areas. Disparities in access to healthcare facilities and education are recurring themes identified in numerous studies conducted in urban-rural communities across various countries, including Ethiopia. In this umbrella review, it was observed that women with a good knowledge of immunization were 3.77 times (I 2 0.0%, p = 0.52) more motivated to ensure their children received complete immunization. This finding supported results from studies conducted in various regions, including Ethiopia, Sub-Saharan Africa (SSA) ( 33 ), Nigeria ( 29 ), and England ( 34 ). The common thread across these findings suggests that maternal knowledge regarding the significance of immunization plays an essential role in shaping their attitudes towards national immunization programs, consequently increasing the likelihood of vaccinating their children. The review revealed that mothers who attended antenatal care (ANC) visits for their index child, were 2.7 times (I 2 = 43.7%, p = 0.17) more linked to vaccinate their children compared to those who did not. This finding echoed similar results found in a study conducted in Ethiopia ( 14 ). It is posited that women who attended ANC visits during pregnancy and opted for facility-based deliveries likely received adequate counseling regarding the importance of childhood vaccination. As a result, they may be more motivated to adhere to immunization schedules for their children. The study revealed that children living in close near to immunization sites (within a two-hour radius) were 2.39 (I 2 = 0.0%, p = 0.538) more likely to receive complete vaccination compared to those residing farther away. This trend aligned with findings from studies conducted in Nigeria ( 35 ), and Sub-Saharan Africa (SSA) ( 33 ). The rationale behind this similarity could be attributed to logistical barriers faced by parents residing far from healthcare facilities. Challenges such as limited transportation options or insufficient access to information about immunization programs may hinder their ability to bring their children for vaccination appointments. This umbrella review of systematic review and meta-analysis possess notable strengths, including the utilization of diverse searching strategies, a meticulous assessment of methodological quality, adherence to the PRISMA 2021 extension guideline, and the implementation of funnel test. Despite these strengths, there are several limitations inherent in this review; only English-language articles were included and limited study articles. 5. Conclusion The pooled prevalence of immunization coverage was found to be 60.21%, indicating a substantial gap that needs to be addressed. Factors such as institutional delivery, travel time to vaccination site, antenatal care visits, maternal knowledge, education level, and urban residence were significantly associated with higher immunization rates. These findings underscore the need for targeted interventions to improve access to vaccination services, enhance maternal education and knowledge, and promote institutional delivery. Addressing these factors can help increase immunization coverage and contribute to better overall public health outcomes. 6. Implication of the review In this review, it was observed that vaccination rates increased gradually over time, although the percentage of individuals achieving complete immunization remained relatively low. Despite efforts to enhance childhood vaccine coverage being a top priority in Ethiopia's health agenda, immunization coverage continues to posture a significant health challenge. Methods must be developed to ensure that both private and public healthcare providers implement strategies aimed at diminishing obstacles and grabbing opportunities to administer vaccinations. Given these challenges, it is imperative for the country to strengthen the accomplishment of the health extension program, adopt a comprehensive approach to reach every district, reinforce the health development army within communities, and collaborate with the private sector and non-governmental organizations. Such measures will enhance vaccination coverage across the nation. The government should focus on building community capacity that highlights the advantages of complete immunization for children. It's crucial for individuals and communities to comprehend these benefits and actively engage in the decision-making and delivery processes regarding vaccinations. Community leaders should actively promote and closely collaborate with local health personnel in conducting outreach activities within their communities. However, the increasing complexity of immunization programs underscores the necessity for a proficient and well-trained health workforce. Hence, it is essential for immunization services to be integrated with maternal health services within the existing service delivery setups. This integration ensures convenience for patients, particularly mothers and their children, to access vaccinations at primary healthcare facilities in Ethiopia. Finally, understanding the factors influencing immunization coverage is crucial for enhancing immunization status. The findings also suggest that enhancing health education, expanding services to remote areas, strengthening locally tailored health services, and raising awareness among mothers about completing recommended vaccination doses are essential steps to improve immunization access. Declarations Acknowledgement We extend our gratitude to the Arba Minch University for providing uninterrupted internet access. Additionally, we would like to express our appreciation to all our colleagues for their unwavering assistance during the writing process of this umbrella review of systematic review and meta-analysis Ethics approval and consent: Not applicable Availability of Data and Materials: The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. Consent for publication : Not applicable Funding: No funding was used in this study Competing interests The authors declare that they have no competing interests. Author’s contributions The tasks undertaken by the Tesfahun.S were conceptualization, protocol development, data extraction, revised, statistical analyses, report writing and finalize the draft. Mesfine.A focused on statistical analyses, quality assessment and provided supervision. 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India: Mumbai; 2017. pp. 791–846. Alene M, Yismaw L, Berelie Y, Kassie B. Health care utilization for common childhood illnesses in rural parts of Ethiopia: evidence from the 2016 Ethiopian demographic and health survey. BMC Public Health. 2019;19(1):1–12. Lukusa LA, Ndze VN, Mbeye NM, Wiysonge CS. A systematic review and meta-analysis of the effects of educating parents on the benefits and schedules of childhood vaccinations in low and middle-income countries. Hum Vaccines Immunotherapeutics. 2018;14(8):2058–68. Adeloye D, Jacobs W, Amuta AO, Ogundipe O, Mosaku O, Gadanya MA, et al. Coverage and determinants of childhood immunization in Nigeria: a systematic review and meta-analysis. Vaccine. 2017;35(22):2871–81. Peck M, Gacic-Dobo M, Diallo MS, Nedelec Y, Sodha SS, Wallace AS. Global routine vaccination coverage, 2018. Morbidity and mortality weekly report. 2019; 68(42):937. Kibreab F, Lewycka S, Tewelde A. Impact of mother’s education on full immunization of children aged 12–23 months in Eritrea: population and health survey 2010 data analysis. BMC Public Health. 2020;20:1–10. Lim K, Chan Y, Ani AN, Rohani J, Norfadhilah ZS, Santhi M. Complete immunization coverage and its determinants among children in Malaysia: findings from the National Health and Morbidity Survey (NHMS) 2016.Public health. 2017; 153:52 – 7. Bangura JB, Xiao S, Qiu D, Ouyang F, Chen L. Barriers to childhood immunization in sub-Saharan Africa: A systematic review. BMC Public Health. 2020;20:1–15. Smith LE, Amlôt R, Weinman J, Yiend J, Rubin GJ. A systematic review of factors affecting vaccine uptake in young children. Vaccine. 2017;35(45):6059–69. Sato R. Association between access to a health facility and continuum of vaccination behaviors among Nigerian children. Hum Vaccines Immunotherapeutics. 2020;16(5):1215–20. Additional Declarations No competing interests reported. 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Hadaro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYJCCDwwMNnLy/M0HgGwJGYLKeRgYGGcwMKQZG844lgDSwkOslsOJDAdyDKACBIA9e/vDZh4G5gTGhjOfX92oseBhYD98dANeW3jOGAK1sOWxM/dus845BnQYT1raDbxaJHLYHwOVFTM2nN1mnMMG1CLBY4Zfi/xzkMMkEhsO5DwzzvlHjBYJBpDDDEBamB/nthGj5UyOYeMcgwRQIJsx5/ZJ8LAR8gt7+/GHDW8q/oOi8vHnnG91cvzsh4/h1QIB4BhhYJMAk4SVIwDzB1JUj4JRMApGwcgBAHm5Q/njA9STAAAAAElFTkSuQmCC","orcid":"","institution":"Arbaminch University","correspondingAuthor":true,"prefix":"","firstName":"Tesfahun","middleName":"Simon","lastName":"Hadaro","suffix":""},{"id":281817560,"identity":"3b530946-6f50-4bee-ae48-db8fa20c04ec","order_by":1,"name":"Begetayinoral Kussia","email":"","orcid":"","institution":"Arbaminch University","correspondingAuthor":false,"prefix":"","firstName":"Begetayinoral","middleName":"","lastName":"Kussia","suffix":""},{"id":281817561,"identity":"cefbaf3c-4f32-4b9d-ac4e-1d0a3b911130","order_by":2,"name":"Merkin Bekele","email":"","orcid":"","institution":"Wachemo University","correspondingAuthor":false,"prefix":"","firstName":"Merkin","middleName":"","lastName":"Bekele","suffix":""},{"id":281817562,"identity":"aab7a8da-ae66-4e05-8d28-2e06c836a5d2","order_by":3,"name":"Woldetsadik Oshine","email":"","orcid":"","institution":"Wachemo University","correspondingAuthor":false,"prefix":"","firstName":"Woldetsadik","middleName":"","lastName":"Oshine","suffix":""},{"id":281817563,"identity":"542d8f88-1d8a-439b-a4f4-20e74bb4eb9f","order_by":4,"name":"Mesfin Abebe","email":"","orcid":"","institution":"Dilla University","correspondingAuthor":false,"prefix":"","firstName":"Mesfin","middleName":"","lastName":"Abebe","suffix":""}],"badges":[],"createdAt":"2024-03-08 08:44:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4040022/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4040022/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53969870,"identity":"5e2257fd-cb4e-4686-9238-9708f4d3182f","added_by":"auto","created_at":"2024-04-02 20:37:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":404941,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart showing the search findings for studies on Immunization coverage and associated factors in Ethiopia, 2024.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4040022/v1/bfbffe1c73d0a5935cd9796b.jpg"},{"id":53969869,"identity":"2508a2f0-31b8-4f32-9471-5f9ee0720fe0","added_by":"auto","created_at":"2024-04-02 20:37:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":681980,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis by sample size\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4040022/v1/803120d62b6d9677e1fb73ec.jpg"},{"id":53969872,"identity":"72dd9820-ca24-46e6-b6ac-620efcde0641","added_by":"auto","created_at":"2024-04-02 20:37:38","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":405341,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity analysis\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4040022/v1/89870ad7f7f967e4348984f4.jpg"},{"id":64194384,"identity":"33f86b31-491a-40b7-813b-4b58d4de4746","added_by":"auto","created_at":"2024-09-09 19:54:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2171019,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4040022/v1/ab761274-e040-49c0-b672-5764962eb75d.pdf"},{"id":53970959,"identity":"e039da3c-d626-4c54-85cf-6031448213f6","added_by":"auto","created_at":"2024-04-02 20:45:38","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18215,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMAguideline2020checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-4040022/v1/fb3abc8f7d1ea0fab81b4707.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Immunization coverage and associated factors among children age 12-23 months in Ethiopia: An Umbrella review of Systematic review and Meta-analysis 2024","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eImmunization involves administering a vaccine antigen to deliberate immunity or resistance to infectious diseases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Full immunization coverage plays a vital role in public health by enhancing child survival and preventing morbidity and mortality from common childhood illnesses (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite an overall increase in global immunization coverage over recent decades, progress has plateaued in recent years (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). According to the World Health Organization (WHO) report, approximately 22\u0026nbsp;million infants worldwide were left unvaccinated (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Additionally, global data indicates that millions of children fail to complete their full vaccination courses annually (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Furthermore, a considerable number of children in Low and Middle-Income Countries (LMICs) remain either unvaccinated or under-vaccinated, leading to preventable deaths from vaccine-preventable diseases (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSignificant progresses have been achieved in bolstering immunization efforts across African nations over the past forty years. Nevertheless, approximately 20\u0026ndash;30% of children in these countries still lack vaccination (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Moreover, full immunization coverage in Low- and Middle-Income Countries (LMICs) ranges between 56% and 69%. Alarmingly, an estimated 4.3\u0026nbsp;million infants remain unimmunized, with the majority concentrated in just four African countries: the Democratic Republic of the Congo, Ethiopia, Nigeria, and South Africa (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Additionally, nearly 19% of children aged 12\u0026ndash;23 months in Ethiopia did not receive any vaccinations. Systematic review conducted in Ethiopia has shown variability in full immunization coverage, with rates ranging from 57\u0026ndash;65% (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, obtaining a pooled estimate of vaccination coverage from this review will offer more dependable information regarding the overall vaccination coverage in the country.\u003c/p\u003e \u003cp\u003eNumerous studies conducted worldwide have identified various factors linked to full immunization coverage, including wealth index, educational status, antenatal care (ANC) attendance, birthplace, and residence (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Additionally, maternal knowledge of immunization, maternal age, maternal education, type of pregnancy, and household visits by healthcare workers have been recognized as influential factors in Ethiopia (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, there is an absence of comprehensive studies providing conclusive evidence on full immunization coverage and associated factors in Ethiopia. Hence, the objective of this review and meta-analysis was to determine the pooled full immunization coverage and identify associated factors in Ethiopia.\u003c/p\u003e"},{"header":"2. Methods and Materials","content":"\u003cp\u003eThis comprehensive review used an umbrella review method, incorporating numerous systematic reviews. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The method involved systematically synthesizing suitable systematic reviews and meta-analyses using the AMSTAR tool.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Eligibility criteria\u003c/h2\u003e \u003cp\u003eAll published articles that were conducted in Ethiopia, written in English, and assessed the coverage of immunization and its associated factors were included in the review. The review needed to meet specific predetermined criteria to be classified as a systematic review or meta-analysis, including: (a) having a clearly outlined literature search strategy, (b) evaluating its included studies using a pertinent tool, and (c) employing a standardized method for combining studies and presenting summary estimates. Whereas Exclusion criteria for reviews were based on the following reasons: inclusion of narrative reviews, editorials, correspondence, abstracts, and methodological studies. Additionally, reviews were excluded if they lacked a clear research question, search strategy, or defined process for selecting articles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Search strategy\u003c/h2\u003e \u003cp\u003eA search strategy was developed and reviewed by two member not involved in its development; no restrictions was applied to the years published, but the papers included was limited to English and Ethiopian publications only. We were search by using the following international online databases to search for papers on coverage of immunization: PubMed, Cochrane Library, Science direct, Google Scholar, and HINARI. In order to find other papers, a search was also done for the reference list of the already retrieved studies from grey literature. The Population, Exposure, Comparison, and Outcomes (PECO) search algorithm was used to find papers. For the online database, search by using mesh terms or keywords. Using the Boolean operators \"OR\" and \"AND,\" the search terms was combined: (Immunization OR Vaccination OR \u0026ldquo;Immunization Coverage\u0026rdquo; OR \u0026ldquo;Vaccination Coverage\u0026rdquo;) AND (Children OR \u0026ldquo;children aged 12\u0026ndash;23 months\u0026rdquo;) AND (Determinant OR Determinants OR \u0026ldquo;Determinant factor\u0026rdquo; OR \u0026ldquo;Determinant factors\u0026rdquo; OR Factor OR Factors OR \u0026ldquo;Associated factor\u0026rdquo; OR \u0026ldquo;Associated factors\u0026rdquo;) AND Ethiopia AND Systematic review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study screening and selection\u003c/h2\u003e \u003cp\u003eThe search results were imported into Endnote version viii and underwent a duplication process. Subsequently, the screening and selection of studies occurred in two stages. Initially, title and abstract screening was performed. Following this, a comprehensive review of full texts was conducted. In the first stage, studies mentioning the prevalence and/or determinants of coverage of immunization were identified for full-text review through title and abstract screening, carried out independently by two researchers. During the full-text review, any article deemed potentially eligible by either reviewer was included for further assessment, with both reviewers independently examining them. In instances of disagreement where a consensus couldn't be reached between the researchers, a third researcher reviewed the articles and resolved the discrepancies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Extraction and management\u003c/h2\u003e \u003cp\u003eData extraction from the included SRM (Systematic Review or Meta-analysis) was carried out using a standardized data abstraction form developed in an Excel spreadsheet. For each SRM, the following information was extracted: (a) Identification data (first author's last name and publication year), (b) Review aim, (c) Prevalence or proportion of immunization coverage, (d) Risk factors, (e) Odds ratio or relative risk with 95% confidence intervals for the risk factors, (f) Number of primary studies included within each SRM study and their respective design type, (g) Total number of sample size included, (h) Publication bias assessment methods and scores, (i) Quality assessment methods and scores, (j) Data synthesis methods (random or fixed-effects model), and (k) The authors' main conclusion of the SRM study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Risk of bias assessment\u003c/h2\u003e \u003cp\u003eEvery included study underwent a critical appraisal for the validity scoring of its results. To guarantee methodological and evidence quality in the included SRM studies, the Assessment of Multiple Systematic Reviews (AMSTAR) tool was employed (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This tool comprises 11 questions designed to assess the quality of approaches used to pool empirical studies within the SRM studies and summarize their estimates. The quality scoring ranged from 0 to 11, with scores of 8\u0026ndash;11, 4\u0026ndash;7, and \u0026lt;\u0026thinsp;3 indicating high, medium, and low qualities, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data synthesis and analysis\u003c/h2\u003e \u003cp\u003eThe synthesis of data from the included SRM studies involved employing both qualitative (narrative) and quantitative methods. In cases where multiple estimates were available regarding the prevalence and factors associated with immunization coverage, we presented the range of these estimates and computed an aggregated (pooled) estimate. The statistical program STATA version 17 was used. The inverse variance (I2) and Cochran Q statistics was utilized to investigate the study heterogeneity using cut-offs (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). There was considerable heterogeneity among review (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;98.04%, P\u0026thinsp;\u0026le;\u0026thinsp;0.05), a random effects model with a 95% confidence interval (CI) was employed to compute the pooled prevalence of immunization coverage. The assessment of publication bias was hindered due to the inclusion of only four studies. A minimum of 10 studies is typically required to adequately evaluate publication bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Ethical consideration\u003c/h2\u003e \u003cp\u003eIn this investigation, obtaining consent or ethical approval from study participants was unnecessary, as the study relied on data extracted from SRM studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Result","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Search finding\u003c/h2\u003e \u003cp\u003eAutomated searches generated 204 articles on immunization coverage. Of these, 39 were found in PubMed/MIDLINE, 59 in Google Scholar, 22 in HINARI, 57 in Science Direct, and 22 in the Cochrane Library. After removing duplicates, 98 articles remained. Of these, 91 were excluded during the title and abstract screening because they did not relate to SRM studies on immunization coverage, which was the study\u0026rsquo;s specific objective. After a detailed review of the remaining 7 articles, three SRM studies were excluded for not addressing the required outcome. As a result, this umbrella review includes a total of four SRM studies. The following sections illustrate the detailed study selection and screening process (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Characteristics included review\u003c/h2\u003e \u003cp\u003eThis umbrella review incorporated all SRM studies, specifically (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), which were derived from observational primary studies. These primary studies consisted of 1 cohort studies, 12 case-control studies, and 80 cross-sectional studies, amounting to a total of 93 studies. The collective sample size across these studies involved 57,113 children. The number of primary studies varied per SRM, ranging from 16 (lowest) to 30 (highest). Additionally, the sample size per meta-analysis exhibited variability, spanning from 8305 (lowest) to 21,672 (highest). Three SRM studies were published in the year 2020 and one were published in 2021. These studies comprehensively examined both the prevalence and determinants of immunization coverage. As per the findings from the four included SRM studies, the reported estimates for the prevalence of immunization coverage varied, with a range from 58.92% (95% CI: 51.26\u0026ndash;66.58%), I2\u0026thinsp;=\u0026thinsp;99.4\u0026ndash;65% (95% CI: 56%-74%), I2\u0026thinsp;=\u0026thinsp;98.9%. These statistics highlight the diversity in prevalence rates across the studies. General characteristics of the systematic review and meta-analyses studies are presented in the following sections (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.docx).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSystematic review and meta-analysis characteristics included in umbrella review the in Ethiopia 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview aim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSearch strategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncluded studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRisk of bias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eprevalence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAMSTAR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGebeyaw B et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull immunization coverage and associated factors in\u003c/p\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccess to various databases, including Public Medline (PubMed), Health Inter-Network Access to Research Initiative (HINARI), Google Scholar, Excerpta Medical Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, African Journal of Online (AJOL), and the Cochrane Library\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA full evaluation of the studies' quality has been clearly articulated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAkine E et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmunization coverage and its factors among children aged\u003c/p\u003e \u003cp\u003e12\u0026ndash;23 months in Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePubMed, Google Scholar, Cochrane library, and gray\u003c/p\u003e \u003cp\u003eliterature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21,672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA comprehensive assessment of the quality of the studies has been clearly expressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKetem et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull vaccination coverage among children\u003c/p\u003e \u003cp\u003eaged 12\u0026ndash;23 months in Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMEDLINE, CINAHL, EMBASE, Google Scholar, and Science Direct are databases and search platforms commonly utilized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12,094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe studies' quality has been thoroughly and clearly evaluated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNour et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePredictors of immunization coverage\u003c/p\u003e \u003cp\u003ein\u003c/p\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePubMed, Google Scholar, HINARI, and SCOPUS, Web of Science, African\u003c/p\u003e \u003cp\u003eJournals Online, Ethiopian Medical Journals were searched\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15,042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe quality of the studies has been transparently assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Methodological quality of the included SRM studies\u003c/h2\u003e \u003cp\u003eUsing the AMSTAR tool the methodological quality of included SRM studies evaluated. The quality of scoring was done out of 11 points and ranged from 8 to 10 \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMethodological quality of the included SRM studies based on AMSTAR tool in Ethiopia, 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAMSTAR tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGebeyaw B et al\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAkine E et al\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKetem et al\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNour et al\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePriori design provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuplicate study selection and data extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearch comprehensiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion of grey literature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncluded and excluded studies provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics of the included studies provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScientific quality of the primary studies assessed and documented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScientific quality of included studies used appropriately in formulating conclusions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppropriateness of methods used to combine studies' findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConflict of interest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLikelihood of publication bias was assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Pooled prevalence of Immunization Coverage.\u003c/h2\u003e \u003cp\u003eFrom umbrella review of four SRM studies the pooled prevalence of immunization coverage was 60.21% (95% CI, 57.29\u0026ndash;63.14). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Pooled prevalence of the coverage of immunization among children age 12\u0026ndash;23 months in Ethiopia, 2024.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Subgroup analysis\u003c/h2\u003e \u003cp\u003eThe subgroup analysis focusing on sample size revealed that the sample less than 15,000 had the highest prevalence of immunization coverage (62.49%, with a confidence interval of 57.59\u0026ndash;67.39), whereas sample size greater than or equal to 15,000 had the lowest prevalence (57.87%, with a confidence interval of 56.09\u0026ndash;59.85).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Sensitivity analysis\u003c/h2\u003e \u003cp\u003eWe investigated deeper into the heterogeneity's origins through a leave-one-out sensitivity analysis. This examination showed that excluding each study individually from the analysis did not significantly alter the average estimated prevalence of immunization coverage. The average prevalence remained within the 95% confidence interval of the overall average prevalence obtained when all studies were included. Consequently, the average prevalence of immunization coverage among children was not influenced by any single review. Additionally, the sensitivity analysis revealed that excluding each study individually resulted in the average prevalence of 60.21 (with a 95% confidence interval of 57.29\u0026ndash;63.14).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Meta-regression\u003c/h2\u003e \u003cp\u003eSubstantial heterogeneity was observed among the studies incorporated into the meta-analysis. To explore the sources of this heterogeneity, we conducted a meta-regression analysis, incorporating variables such as publication year and sample size. However, publication year in the meta-regression analysis revealed a significant impact on the observed variation in immunization coverage prevalence with (p-value\u0026thinsp;=\u0026thinsp;0.00, I2 (%)\u0026thinsp;=\u0026thinsp;92.45) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeta-regression analyses were performed to assess the relationship between vaccination coverage among children aged 12\u0026ndash;23 months in Ethiopia and two variables: sample size, number of review and publication year of the included review.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.00042 (-0.00103, 0 .00019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.36532 (3.06428, 9.66636)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Factors associated with immunization coverage in Ethiopia.\u003c/h2\u003e \u003cp\u003eThis Umbrella of systematic review and meta-analysis identified the most often occurring related variables, which were Institutional delivery, time to travel to vaccination site, received at least one antenatal, good maternal knowledge, maternal education and residence (living urban areas) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeta-analysis of associated factors of immunization coverage in Ethiopia, 2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeterogenity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of review\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3(1.7\u0026ndash;2.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence(urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.84(1.54\u0026ndash;2.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood maternal knowledge about immunization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.77(3.07\u0026ndash;4.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived at least on antenatal care follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.70(2.05\u0026ndash;3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;43.7%, p\u0026thinsp;=\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to travel to vaccination site(\u0026lt;\u0026thinsp;1 hour)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.39(1.89\u0026ndash;2.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitutional delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.93(1.75\u0026ndash;2.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis included two separate reviews to investigate how where a mother residence relates to the extent of full immunization coverage. The results showed that urban residence were odds of 1.84(1.54\u0026ndash;2.14) times more likely immunized their children than rural residence.\u003c/p\u003e \u003cp\u003eThree studies were analyzed to investigate the impact of maternal knowledge on full immunization coverage. The results indicated that children born to mothers with a good knowledge about immunization were 3.77 times more likely to be fully immunized. The odds ratio was calculated at 3.77, with a confidence interval of 95% ranging from (3.07\u0026ndash;4.14). There was no heterogeneity among the studies I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.5.\u003c/p\u003e \u003cp\u003eTwo studies were analyzed to investigate the effect of maternal education on full immunization coverage. The results indicated that children born to mothers with a higher education level were 2.3 times more likely to be fully immunized. The odds ratio was calculated at 2.3, with a confidence interval of 95% ranging from (1.7\u0026ndash;2.96). There was no heterogeneity among the studies I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.86.\u003c/p\u003e \u003cp\u003eThree main reviews were employed to evaluate the association between the received antenatal care follow up and immunization coverage. Women who received at least one antenatal care follow up were 2.7 times more motivated to ensure their child received full vaccination compared to mothers who were not received antenatal care [Odds Ratio: 2.7, 95% Confidence Interval: 2.05\u0026ndash;3.33, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;43.7%, p\u0026thinsp;=\u0026thinsp;0.16.\u003c/p\u003e \u003cp\u003eThree main reviews were engaged to evaluate the association between the institutional delivery and immunization coverage. Women who have institutional delivery were 1.93 times more likely to ensure that their child received full vaccination compared to mothers who were not delivered in institutional (Odds Ratio: 1.93, 95% Confidence Interval: 1.93 (1.75\u0026ndash;2.10) I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.50).\u003c/p\u003e \u003cp\u003eTwo studies were analyzed to investigate the impact time to travel to vaccination site(\u0026lt;\u0026thinsp;1 hour) on full immunization coverage. The results indicated that children born to mothers with a nearby vaccination site(\u0026lt;\u0026thinsp;1 hour) were 2.39 times more likely to be fully immunized. The odds ratio was calculated at 2.39, with a confidence interval of 95% ranging from (1.89\u0026ndash;2.89). There was no heterogeneity among the studies I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.53.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eUp to now, there have been four SRM reports addressing immunization coverage in Ethiopia. These SRM studies are typically considered as providing strong evidence for making decisions in health programs. However, as the number of individual reviews grows, it can become overwhelming for those seeking information(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Hence, this umbrella review was undertaken to consolidate the findings of the four SRM studies on immunization coverage into a single document. It revealed that immunization coverage is considerably below the rate recommended by the World Health Organization and a significant public health issue in Ethiopia. Furthermore, various factors like Institutional delivery, time to travel to vaccination site, received at least one antenatal, good maternal knowledge, maternal education and living urban areas were identified as statistically significant.\u003c/p\u003e \u003cp\u003eThe umbrella review of the four included SRM studies on the coverage of immunization in Ethiopia yielded a summary estimate of 60.21% (95% CI, 57.29\u0026ndash;63.14). The results aligned closely with the global immunization rate of 57.8% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), the aggregated full vaccination coverage in Ethiopia at 60% (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), findings from the Demographic and Health Survey (DHS) in (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), South Africa at 61% (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and India at 62% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This similarity may stem from the adoption of comparable child health initiatives, including immunization services, by both the World Health Organization and various non-governmental organizations worldwide. Ethiopia, in particular, has implemented a program similar to those observed globally.\u003c/p\u003e \u003cp\u003eHowever, the result exceeded the studies reported in the Ethiopian Demographic and Health Survey (EDHS) of 2016 (39%) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and the subsequent EDHS report in 2019 (43%) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This variance could be attributed to the methodology of the EDHS survey, which encompasses huge geographical areas, including regions that are difficult to reach, potentially leading to an underestimation of vaccination coverage. Additionally, the observed result surpassed rates reported in studies conducted in low- and middle-income countries (LMICs) (36%) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and a similar study conducted in Nigeria (34.4%) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This discrepancy may arise from differences in the implementation and effectiveness of immunization programs across various regions.\u003c/p\u003e \u003cp\u003eThe findings from this review revealed lower rates compared to the global report (86%) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), a study conducted in Eritrea (83%) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), and findings from Malaysia (86.3%) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This difference in immunization rates could potentially be attributed to variations in the quality of healthcare services and demographic differences between developed and developing countries. Developed nations often boast higher standards of healthcare provision and greater access to resources, which may contribute to their ability to achieve higher rates of full immunization coverage. Additionally, it's worth noting that Eritrea received recognition for its outstanding achievement in childhood immunization programs, indicating a context-specific success story that may not be replicated universally.\u003c/p\u003e \u003cp\u003eOur review also identified a significant association between the location of residence and the completion of immunization among children. Specifically, children residing in urban areas showed a 1.84 times (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.717) higher likelihood of being fully vaccinated compared to those in rural areas. Previous studies investigating the association between residence and immunization coverage have yielded varied results. While some studies have reported a strong link between urban residence and immunization, others have not observed such a connection. This inconsistency may be attributed to inherent socioeconomic disparities across different study settings. In some instances, rural settings may face significantly greater disadvantages compared to urban areas. Disparities in access to healthcare facilities and education are recurring themes identified in numerous studies conducted in urban-rural communities across various countries, including Ethiopia.\u003c/p\u003e \u003cp\u003eIn this umbrella review, it was observed that women with a good knowledge of immunization were 3.77 times (I\u003csup\u003e2\u003c/sup\u003e 0.0%, p\u0026thinsp;=\u0026thinsp;0.52) more motivated to ensure their children received complete immunization. This finding supported results from studies conducted in various regions, including Ethiopia, Sub-Saharan Africa (SSA) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), Nigeria (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and England (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The common thread across these findings suggests that maternal knowledge regarding the significance of immunization plays an essential role in shaping their attitudes towards national immunization programs, consequently increasing the likelihood of vaccinating their children.\u003c/p\u003e \u003cp\u003eThe review revealed that mothers who attended antenatal care (ANC) visits for their index child, were 2.7 times (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;43.7%, p\u0026thinsp;=\u0026thinsp;0.17) more linked to vaccinate their children compared to those who did not. This finding echoed similar results found in a study conducted in Ethiopia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is posited that women who attended ANC visits during pregnancy and opted for facility-based deliveries likely received adequate counseling regarding the importance of childhood vaccination. As a result, they may be more motivated to adhere to immunization schedules for their children.\u003c/p\u003e \u003cp\u003eThe study revealed that children living in close near to immunization sites (within a two-hour radius) were 2.39 (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, p\u0026thinsp;=\u0026thinsp;0.538) more likely to receive complete vaccination compared to those residing farther away. This trend aligned with findings from studies conducted in Nigeria (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and Sub-Saharan Africa (SSA) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The rationale behind this similarity could be attributed to logistical barriers faced by parents residing far from healthcare facilities. Challenges such as limited transportation options or insufficient access to information about immunization programs may hinder their ability to bring their children for vaccination appointments.\u003c/p\u003e \u003cp\u003eThis umbrella review of systematic review and meta-analysis possess notable strengths, including the utilization of diverse searching strategies, a meticulous assessment of methodological quality, adherence to the PRISMA 2021 extension guideline, and the implementation of funnel test. Despite these strengths, there are several limitations inherent in this review; only English-language articles were included and limited study articles.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe pooled prevalence of immunization coverage was found to be 60.21%, indicating a substantial gap that needs to be addressed. Factors such as institutional delivery, travel time to vaccination site, antenatal care visits, maternal knowledge, education level, and urban residence were significantly associated with higher immunization rates. These findings underscore the need for targeted interventions to improve access to vaccination services, enhance maternal education and knowledge, and promote institutional delivery. Addressing these factors can help increase immunization coverage and contribute to better overall public health outcomes.\u003c/p\u003e"},{"header":"6. Implication of the review","content":"\u003cp\u003eIn this review, it was observed that vaccination rates increased gradually over time, although the percentage of individuals achieving complete immunization remained relatively low. Despite efforts to enhance childhood vaccine coverage being a top priority in Ethiopia's health agenda, immunization coverage continues to posture a significant health challenge. Methods must be developed to ensure that both private and public healthcare providers implement strategies aimed at diminishing obstacles and grabbing opportunities to administer vaccinations. Given these challenges, it is imperative for the country to strengthen the accomplishment of the health extension program, adopt a comprehensive approach to reach every district, reinforce the health development army within communities, and collaborate with the private sector and non-governmental organizations. Such measures will enhance vaccination coverage across the nation.\u003c/p\u003e \u003cp\u003eThe government should focus on building community capacity that highlights the advantages of complete immunization for children. It's crucial for individuals and communities to comprehend these benefits and actively engage in the decision-making and delivery processes regarding vaccinations. Community leaders should actively promote and closely collaborate with local health personnel in conducting outreach activities within their communities. However, the increasing complexity of immunization programs underscores the necessity for a proficient and well-trained health workforce. Hence, it is essential for immunization services to be integrated with maternal health services within the existing service delivery setups. This integration ensures convenience for patients, particularly mothers and their children, to access vaccinations at primary healthcare facilities in Ethiopia.\u003c/p\u003e \u003cp\u003eFinally, understanding the factors influencing immunization coverage is crucial for enhancing immunization status. The findings also suggest that enhancing health education, expanding services to remote areas, strengthening locally tailored health services, and raising awareness among mothers about completing recommended vaccination doses are essential steps to improve immunization access.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to the Arba Minch University for providing uninterrupted internet access. Additionally, we would like to express our appreciation to all our colleagues for their unwavering assistance during the writing process of this umbrella review of systematic review and meta-analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was used in this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe tasks undertaken by the Tesfahun.S were conceptualization, protocol development, data extraction, revised, statistical analyses, report writing and finalize the draft. \u0026nbsp;Mesfine.A focused on statistical analyses, quality assessment and provided supervision. The Begetayinoral.K, Woldetsadik.O and Merkin.B groups were primarily responsible for conceptualization, full-text screening and revised the final draft. Finally, final manuscript received approval from all authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGraciaa DS, Collins MH, Wu HM. Zika in 2018: advising travelers amid changing incidence. American College of Physicians; 2018. pp. 337\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVakili R, Ghazizadeh Hashemi A, Khademi G, Ajilian Abbasi M, Saeidi M. Immunization coverage in WHO regions: a review article. Int J Pediatr. 2015;3(21):111\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanderEnde K, Gacic-Dobo M, Diallo MS, Conklin LM, Wallace AS. Global routine vaccination coverage\u0026mdash;2017. 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Hum Vaccines Immunotherapeutics. 2021;17(7):2326\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEshete A, Shewasinad S, Hailemeskel S. Immunization coverage and its determinant factors among children aged 12\u0026ndash;23 months in Ethiopia: a systematic review, and meta-analysis of cross-sectional studies. BMC Pediatr. 2020;20(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNour TY, Farah AM, Ali OM, Osman MO, Aden MA, Abate KH. Predictors of immunization coverage among 12\u0026ndash;23 month old children in Ethiopia: systematic review and meta-analysis. BMC Public Health. 2020;20(1):1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKetema DB, Assemie MA, Alamneh AA, Alene M, Chane KY, Alamneh YM, et al. Full vaccination coverage among children aged 12\u0026ndash;23 months in Ethiopia: a systematic review and meta-analysis. BMC Public Health. 2020;20(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDessie DB, Negeri MA. Determining factors of full immunization of children among 12\u0026ndash;23 months old in rural Ethiopia. Am J Public Health Res. 2018;6(3):160\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIndicators K. Mini demographic and health survey. EPHI and ICF. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuedo-Medina TB, S\u0026aacute;nchez-Meca J, Mar\u0026iacute;n-Mart\u0026iacute;nez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I\u0026sup2; index? Psychol Methods. 2006;11(2):193.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. JBI Evid Implement. 2015;13(3):132\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForshaw J, Gerver SM, Gill M, Cooper E, Manikam L, Ward H. The global effect of maternal education on complete childhood vaccination: a systematic review and meta-analysis. BMC Infect Dis. 2017;17(1):1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRugendo EK. Assessment of Quality of Data of the 2014 Kenya Demographic and Health Survey. Kdhs): University of Nairobi; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoomaney RA, van Wyk B. Cois a, Pillay-van Wyk V. One in five South Africans are multimorbid: An analysis of the 2016 demographic and health survey. PLoS ONE. 2022;17(5):e0269081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIips I. National family health survey (NFHS-4), 2015\u0026ndash;16. International Institute for Population Sciences (IIPS). India: Mumbai; 2017. pp. 791\u0026ndash;846.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlene M, Yismaw L, Berelie Y, Kassie B. Health care utilization for common childhood illnesses in rural parts of Ethiopia: evidence from the 2016 Ethiopian demographic and health survey. BMC Public Health. 2019;19(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukusa LA, Ndze VN, Mbeye NM, Wiysonge CS. A systematic review and meta-analysis of the effects of educating parents on the benefits and schedules of childhood vaccinations in low and middle-income countries. Hum Vaccines Immunotherapeutics. 2018;14(8):2058\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeloye D, Jacobs W, Amuta AO, Ogundipe O, Mosaku O, Gadanya MA, et al. Coverage and determinants of childhood immunization in Nigeria: a systematic review and meta-analysis. Vaccine. 2017;35(22):2871\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeck M, Gacic-Dobo M, Diallo MS, Nedelec Y, Sodha SS, Wallace AS. Global routine vaccination coverage, 2018. Morbidity and mortality weekly report. 2019; 68(42):937.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKibreab F, Lewycka S, Tewelde A. Impact of mother\u0026rsquo;s education on full immunization of children aged 12\u0026ndash;23 months in Eritrea: population and health survey 2010 data analysis. BMC Public Health. 2020;20:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim K, Chan Y, Ani AN, Rohani J, Norfadhilah ZS, Santhi M. Complete immunization coverage and its determinants among children in Malaysia: findings from the National Health and Morbidity Survey (NHMS) 2016.Public health. 2017; 153:52\u0026thinsp;\u0026ndash;\u0026thinsp;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangura JB, Xiao S, Qiu D, Ouyang F, Chen L. Barriers to childhood immunization in sub-Saharan Africa: A systematic review. BMC Public Health. 2020;20:1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith LE, Aml\u0026ocirc;t R, Weinman J, Yiend J, Rubin GJ. A systematic review of factors affecting vaccine uptake in young children. Vaccine. 2017;35(45):6059\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSato R. Association between access to a health facility and continuum of vaccination behaviors among Nigerian children. Hum Vaccines Immunotherapeutics. 2020;16(5):1215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Vaccination, immunization, systematic review, meta-analysis, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4040022/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4040022/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFull immunization coverage plays a vital role in public health by enhancing child survival and preventing morbidity and mortality from common childhood illnesses. However, there is a shortage of comprehensive studies providing conclusive evidence on full immunization coverage and associated factors in Ethiopia. Hence, the objective of this umbrella review and meta-analysis was to identify the pooled full immunization coverage and associated factors in Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis review used an umbrella review method, by incorporating numerous systematic reviews. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The method involved systematically synthesizing suitable systematic reviews and meta-analyses using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Medical Subject Heading (Mesh) terms and keywords were used to find pertinent review in various online databases, such as PubMed, Cochrane Library, Science Direct, Google Scholar, and HINARI. I-squared statistics were used to assess study heterogeneity. STATA version 17 software was used for statistical analysis, and the 95% CI was used to determine statistical significance.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eIn this review, four studies were included. The pooled prevalence of immunization coverage was 60.21% (95% CI: 57.29\u0026ndash;63.14). The umbrella review found that factors such as institutional delivery (AOR\u0026thinsp;=\u0026thinsp;1.93, 95% CI 1.75\u0026ndash;2.10), travel time to vaccination site (AOR\u0026thinsp;=\u0026thinsp;2.39, 95% CI 1.89\u0026ndash;2.89), receiving at least one antenatal care visit (AOR\u0026thinsp;=\u0026thinsp;2.70, 95% CI 2.05\u0026ndash;3.33), possessing good maternal knowledge (AOR\u0026thinsp;=\u0026thinsp;3.77, 95% CI 3.07\u0026ndash;4.14), maternal education level (AOR\u0026thinsp;=\u0026thinsp;2.3, 95% CI 1.7\u0026ndash;2.96), and residing in urban areas (AOR\u0026thinsp;=\u0026thinsp;1.84, 95% CI 1.54\u0026ndash;2.14) were significantly associated with achieving full immunization coverage.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe pooled prevalence of immunization coverage was found to be 60.21%, indicating a substantial gap that needs to be addressed. Factors such as institutional delivery, travel time to vaccination site, antenatal care visits, maternal knowledge, education level, and urban residence were significantly associated with higher immunization rates. These findings underscore the need for targeted interventions to improve access to vaccination services, enhance maternal education and knowledge, and promote institutional delivery. Addressing these factors can help increase immunization coverage and contribute to better overall public health outcomes.\u003c/p\u003e","manuscriptTitle":"Immunization coverage and associated factors among children age 12-23 months in Ethiopia: An Umbrella review of Systematic review and Meta-analysis 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-02 20:37:33","doi":"10.21203/rs.3.rs-4040022/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5589d1bd-236a-4579-8e60-ef2efbc35aa8","owner":[],"postedDate":"April 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T19:46:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-02 20:37:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4040022","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4040022","identity":"rs-4040022","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}