Retention rate of vaccination card and its associated factors among vaccinated children aged 12─23 months in Ethiopia: Multilevel logistic regression analysis

Abiyu Abadi Tareke; Atikaw Tewabe Ayelign; Thomas Kidanemariam Yewodiaw; Enyew Woretaw Shiferaw; Habitu Birhan Eshetu; Ermias Bekele Enyew

doi:10.1371/journal.pone.0306421

. 2024 Jul 11;19(7):e0306421. doi: 10.1371/journal.pone.0306421

Retention rate of vaccination card and its associated factors among vaccinated children aged 12─23 months in Ethiopia: Multilevel logistic regression analysis

Abiyu Abadi Tareke ^1,^*, Atikaw Tewabe Ayelign ², Thomas Kidanemariam Yewodiaw ³, Enyew Woretaw Shiferaw ⁴, Habitu Birhan Eshetu ⁵, Ermias Bekele Enyew ⁶

Editor: Tamirat Getachew⁷

PMCID: PMC11238995 PMID: 38990882

Abstract

Background

Vaccine card is a crucial tool for gauging vaccine coverage. It is imperative to hold these health cards to have well-fitted data which are crucial in reaching data-driven decisions in the era of immunization surveillance and monitoring processes. However, there is limited knowledge about the retention rate of vaccination card and its associated factors in Ethiopia.

Objective

This research aimed to assess the retention rate and associated factors of vaccination card in Ethiopia, using data from the 2016 Ethiopian demographic health survey.

Methods

This study included a total of 1304 (weighted) children aged 12─23 months who were vaccinated and provided with a vaccination card. We used a multilevel logistic regression model to analyze factors associated with vaccination card retention. We considered factors to be statistically significant if they had a p-value of less than 0.05 with a respective 95% confidence interval.

Result

Among the cohort of 1,304 immunized children, it was observed that 684, representing 52.5% (95% CI: 49.7%─55.2%), were able to present their respective vaccination card during the interview time. According to the results of the multilevel logistic analysis, there is a considerable reduction in the rate of vaccination card retention by 65% (adjusted OR 0.35, 95% CI: 0.19─0.65) and 37% (adjusted OR 0.63, 95% CI: 0.4─0.91) for individuals who are rural residents and those who are fully vaccinated, respectively. Furthermore, it is noteworthy to mention that individuals originating from socio-economic backgrounds with low poverty levels exhibit a 59% increase in vaccination card possession (adjusted OR 1.59, 95% CI: 1.11─2.50).

Conclusion

This study revealed a low rate of holding vaccination cards. Place of residency, wealth status, and vaccination status were factors that contributed to the change in the vaccination card retention rate. It is advisable to customize the interventional strategy by taking into account the individual’s residency, immunization status, and degree of poverty within the community, to achieve a favorable rate of holding vaccination cards.

Introduction

The World Health Organization (WHO) initiated the Expanded Program of Immunization (EPI) back in 1974 intended to mitigate morbidity and mortality rate of under five children caused by vaccine-preventable diseases (VPD) globally [1, 2]. Globally, over two million fatalities are prevented annually through immunization. Vaccination cards (VC) are regarded as pertinent public health documents that encompass crucial details about vaccination dates, types of antigens, number of administered doses and other integrated health services [3]. Surveys based on population probability are often regarded as the "gold standard" for evaluating vaccination coverage, as they are free from certain biases and concerns [4]. In these surveys, vaccination status is commonly ascertained using household-retained vaccination cards, occasionally supplemented by parental recall [5].

Measuring vaccination coverage holds great importance for both national and local health programs, serving as a foundation for programmatic and policy decisions. It enables the evaluation of immunization services, thereby facilitating informed decision-making. Additionally, assessing the extent of immunization coverage offers valuable indications of whether significant advancements are being made in attaining vaccination objectives. To determine the extent of vaccination coverage within a particular region, the most relevant health card activity would be to ensure the preservation of VC.

Retaining vaccination cards holds significant importance for various stakeholders, including nations, communities, families, and individual children: Nationally vaccination cards aid national immunization programs by recording vaccination coverage, facilitating monitoring and evaluation, enhancing surveillance, and enabling quicker outbreak response. For the family, it enables adherence to vaccination schedules, ensuring timely protection, for the child, insuring children receive all recommended vaccines, promoting long-term health and well-being as well as helping healthcare providers in managing a child’s healthcare, allowing informed decision-making [3].

Furthermore, it also serves as a source of information for care providers in terms of vaccine efficacy and adherence. Academic researchers: The information inscribed on VC can be of great advantage to researchers, as it can be used as a source of documentation while conducting surveys, estimating vaccine timeliness, and determining the status of vaccination completeness.

The retention rate of VC refers to the percentage of individuals who still have their VC after receiving their vaccines. The possession of VC is viewed as a favorable factor in augmenting the percentage of children who have received complete vaccination (all the WHO-recommended antigens) [6–8]. Additionally, having health cards was found associated with favorable access to primary health care services [9].

In Ethiopia, the health institution-based documentation rate is found lower[10–13] and poor quality [10]. The rate of routine immunization vaccination card retention is not measured and the number of published articles concerning the VC retention rate of caregivers and associated factors in Ethiopia are limited. This study determines the rate of VC and factors contributing to the change in card retention among 1,304 vaccinated children.

Methods and materials

Study design and period

This study utilized data obtained from the fourth cross-sectional demographic health survey of Ethiopian communities, administered from January 18th to June 27th in the year 2016.

Study setting

Ethiopia, the African nation under consideration, stands as the second-most populous country on the continent. As per the Population and Housing Census (PHC) projection of 2007, Ethiopia’s total population was anticipated to approach nearly 110,000,000 by the year 2030. Based on data from the 2007 Census, it can be inferred that a substantial proportion of individuals were residing in rural areas, accounting for a significant majority (83.6%) of the population. The average family size was estimated to be 4.7 individuals per household. Additionally, it was observed that a considerable percentage (47%) of women belonging to the population cohort analyzed were between the ages of 15 and 49 years. [14].

According to the 2016 EDHS, the average number of children born to a woman over her lifetime (total fertility rate) was 4.6 children per woman [15]. However, the World Bank reported a fertility rate of 4.159 in Ethiopia for the year 2021 [16]. In 2019 Among children aged 12─23 months, 44% have received all basic vaccinations at some point, with 40% receiving them by the appropriate age [17].

Population

Source population

Children aged less than 2 years in Ethiopia.

Study population

Children ranging from 12 to 23 months of age who have undergone vaccination for any antigen.

Dependent variable

The dependent variable for the current research is the rate of retention of VC (yes/no) (computed as the percentage of children who have ever owned a VC and were capable of bringing it during the interview session).

Independent variables

Based on our thorough review of literatures, we have identified maternal age, maternal education levels (ranging from none to primary, secondary and higher), the working status of the caregiver (employed or not), household size, media accessibility, the child’s gender, vaccination status as individual level factors and community level poverty and literacy as community-level factors as the independent variables for this particular study.

Operational definitions

Media Access. This is determined by a combination of whether the respondent reads the newspaper, listens to the radio, and watches television. If the respondent has been exposed to at least one of these three media, it is labeled as "exposed" and coded as "1". On the other hand, if the respondent has not been exposed to any of the three media, it is coded as "not exposed" and given a code of "0".

Immunization status. A child is classified as "fully vaccinated" if they have received one dose of BCG vaccine, three doses each of polio vaccine, pentavalent vaccine (DTP-hepB-Hib), and pneumococcal conjugate vaccine (PCV), two doses of Rotavirus vaccine, and one dose of measles vaccine. Otherwise, if any of these criteria are not met, the child is considered "not fully vaccinated." [18].

Community level of poverty. community poverty level is determined based on the proportion of households assigned to the poorest and poorer wealth index categories. Households falling at the median value and above are classified as having a high poverty level, while those falling below the median value are categorized as having a low poverty level. The median is chosen as the cutoff point due to the skewed distribution of the variables. A similar categorization approach was applied to determine community-level educational status.

Data collection tools and procedures

The secondary data utilized in this study were obtained from the demographic health Survey Repository, which contains anonymized survey data collected by the Ministry of Health. The primary data were collected using standardized survey instruments, including household questionnaires administered by trained enumerators. These questionnaires covered various topics, including demographic information, health status, healthcare utilization, and other relevant indicators [19].

The survey employed a multistage stratified sampling design to ensure representation at the national, regional, and district levels. Household selection was conducted through systematic random sampling, with households selected based on probability proportional to size. Data collection was carried out through face-to-face interviews with household members, following established protocols to maintain consistency and quality throughout the process [19].

The website of DHS measure, http://www.dhsprogram.com/, was utilized to acquire registration for entry into the Ethiopian DHS Datasets necessary authorization was granted for the requested tools to be accessed. All necessary data were obtained from the website of the Demographic and Health Surveys Program, in accordance with the requirements.

Data quality control

The survey’s data collectors documented that the questionnaires underwent a pre-testing phase in all three local languages (Amharic, Afaan Oromo, and Tigrigna) to ensure absolute clarity and understanding for the respondents [19]. Quality control measures were implemented throughout the data collection process to identify and address any inconsistencies, errors, or discrepancies in the collected data. These efforts aimed to uphold the integrity and reliability of the survey data and enhance the validity of the study findings.

Sample size and sampling procedures

A two-stage stratified clustered sampling procedure was implemented across all 11geographic administrative areas, which includes 9 regions and 2 city administrations. The initial stratum comprised 645 enumeration areas (EAs) that were chosen proportionally to the EAs size of the nine geographical regions and two administrative cities. In the second stratum, each of the eleven administrative divisions was subdivided into urban and rural residents, creating a total of 21 sampling strata. Using an equal probability technique, 28 households were selected from each cluster. From the 28 households, 1944 children aged 24─35 months were excluded from this study because of 12─23 months age group provides a snapshot of the current state of the country’s performance regarding vaccination card utilization. This age group represents children who have recently completed or are in the process of completing their primary vaccination series, offering valuable insights into vaccination practices and documentation during this critical period. The study ultimately involved a weighted sample of 1304 vaccinated alive children [19].

Data analysis

The STATA/SE version 16.0 utilized to review, sort, recode, data analysis and statistical modeling, and the data. In order to ensure survey representativeness, and to acquire dependable statistical estimates, the data were weighted by applying the "svyset" command in STATA to account for the effects of the survey’s complex sampling design or the hierarchical nature of the Ethiopian Demographic Health Survey (EDHS) dataset. This command was applied to each analysis conducted in this study.

Multilevel regression model

A multilevel logistic regression model was utilized to determine the factors associated with the retention of VC in Ethiopia. Multilevel analysis is particularly advantageous for examining data with nested structures like DHS data, as individual-level characteristics are more likely to be correlated within the same cluster or enumeration area than with those from other clusters. This can lead to a violation of the assumption of observation independence in standard regression models. Multilevel analysis is a valuable tool that can address the lack of independence of observations when analyzing nested or hierarchical data. Four distinct models were created to conduct this analysis. The null model, also known as the random intercepts model, was one of these models and does not include any child’s or cluster’s characteristics. It was used to determine the extent of cluster variability on VC retention levels. To assess the variability of the cluster, we computed the Intra-Class Coefficient (ICC), median odds ratio, and Proportional Change in Variance (PCV). The ICC gauges the percentage variation caused by community-level variables, whereas the PCV determines the proportional shift in the community-level variance between the null model and the subsequent models [20].

The Odds Ratio (OR) used by the MOR to describe area-level variance is the median value of the distribution of ORs obtained when two children with the same covariate values are selected from two different areas. These areas are compared with one another based on their respective VC retention levels, with one representing a higher level of retention than the other. In the absence of area-level variation, the Median odds ratio (MOR) equals 1. The presence of clustering and heterogeneity between areas in the outcomes of VC retention level was examined using intercept-only models (null model), which estimated the value of ICCs and MORs.

The fitness of each model was evaluated using various parameters such as the Likelihood Ratio test (LR), deviance, Akaike Information Criteria (AIC), and Bayesian Information Criteria (BIC). The model that displayed the lowest value among the four fitness parameters was chosen as the most suitable model. Factors were deemed statistically significant based on the adjusted odds ratio with 95% CI and p-value <0.05.

Ethical consideration

This study employed a dataset comprised of demographic health surveys that are representative of the nation. Consequently, there is no need for ethical approval. However, the datasets utilized in this study were acquired through a process wherein a comprehensive explanation of the study’s objectives and indispensability was presented.

The DHS dataset was procured through registration and request via the online database (www.dhsprogram.com), followed by receipt of an authorization letter that enabled download of the requested dataset.

Result

The study population included 1,304 caregivers from across Ethiopia. Most mothers were 25─34 years old (54.74%) and had no formal education (56.54%), though about a third had completed primary school (32.17%). Approximately half of mothers worked outside the home (50.64%). Household media access was limited (60.50% had no access), and child vaccination status was mixed (46.81% partially, 48.28% fully vaccinated). The sample was predominantly rural (84.12%), with the largest proportion from Oromia region (37.76%). Levels of community poverty and literacy were relatively high (52.44% low poverty, 78.22% high literacy) (Table 1).

Table 1. Characteristics of the study participants in Ethiopia, 2016 (n = 1304).

Characteristics	Weighted frequency	Percent
Maternal age
15─24 years	316	24.27%
25─34 years	714	54.74%
35─49 years	274	20.99%
Maternal education
None	737	56.54%
Primary school	419	32.17%
Secondary and above	147	11.29%
Maternal Working status
Working	660	50.64%
not working	644	49.36%
Media access
No access	789	60.50%
Access	515	39.50%
Vaccination status
Partial	610	46.81%
Fully	693	48.28%
Sex of the child
Male	617	47.30%
Female	687	52.70%
Place of residency
Urban	207	15.88%
Rural	1097	84.12%
Region
Tigray	138	10.56%
Afar	6	0.49%
Amhara	264	20.22%
Oromia	492	37.76%
Somali	39	2.96%
Benishangul	15	1.14%
SNNP	283	21.73%
Gambela	4	0.28%
Harari	3	0.26%
Addis Ababa	52	3.97%
Dire Dawa	8	0.64%
Community poverty
Low	683	52.44%
High	620	47.56%
Community literacy
Low	284	21.78%
High	1019	78.22%

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Rate of VC retention

The retention rate of VC in Ethiopia is 52.5% (with a 95% confidence interval of 49.7% to 55.2%). A noteworthy observation was made concerning the retention rate of participants hailing from various regions of Ethiopia. Specifically, those residing in Addis Ababa exhibited a remarkably high retention rate of 91%, while those from Harari, Tigray, and Amhara displayed retention rates of 65%, 64%, and 61%, respectively. Moreover, residents of Dire Dawa also demonstrated a relatively high retention rate at 60%. However, in contrast, regions such as Somali and SNNP fell short in terms of retention rate, with only 41% and 42% of residents respectively retaining their VC.

Model parameter results

The ICC offers a means to gauge the extent to which the discrepancy in the outcome across level-2 Units is accounted for. In this particular investigation, where children aged 12─23 months (i.e., the level-1 units) are arranged into clusters (i.e., the level-2 units), an ICC value of 0.38 derived from the null model would indicate that community-level factors accounted for 38% of the fluctuation in the odds of VC retention while the remaining 62% could be attributed to variances among study subjects.

Furthermore, the MOR of 3.7 conveys that, the median value of OR between clusters at a high rate of VC retention and clusters at the lowest retention rate when randomly choosing two children having the same individual-level characteristics but from a different cluster, the increased rate of VC retention when shifting from low risk to high risk is 3.7 times. The value of MOR and ICC indicates a justifiable reason for conducting multilevel logistic analysis (Table 2).

Table 2. Model comparison and fitness parameter output.

Fitness parameter	Null Model	Model I	Model II	Model III
Community level variance	1.89[95% CI: 1.21, 2.98]	1.76 [95% CI: 1.08, 2.86]	1.62[95% CI: 1.02, 2.60]	1.74[95% CI: 1.06, 2.83]
Community level variance(se)	0.4379891	0.436824	0.3913056	0.4340136
ICC	36.7%	34.8%	33%	34.6%
MOR	3.70 [95% CI: 2.84, 5.15]	3.52 [95% CI: 2.70, 5.02]	3.35[95% CI: 2.61, 4.63]	3.50[95% CI: 2.66, 4.94]
PCV (%)	baseline	7%	14%	8%
Model fitness
Log- likelihood ratio (LLR)	-775	-742	-753	-740
DIC(-2LLR)	1500	1484	1506	1480
AIC	1554	1504	1515	1476
BIC	1564	1555	1535	1503

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Proportional Change in Variance (PCV) or Change in Community-level Variance value of the full model (model III) indicates that about 8% of the variance in the odds of VC holding across the community/ class was attributed to the effect of both level -1 and level-2 factors.

From the table presented below, it is evident that the optimal model for the data at hand is the full model, denoted as model III, which includes both individual and community level factors. This conclusion is drawn based on the fact that model III exhibits a significantly lower value for deviance, BIC, and AICc, thus indicating its superior fit for the data.

Factors associated with VC retention following the multilevel multivariable regression analysis, it was observed that immunization status, place of residency, and community-level poverty emerged as significant factors associated with the retention rate of VC. According to the estimates derived from multivariable multilevel logistic analysis, the retention rate of VC is 65% lower among rural children (95% CI: 0.19─0.65) compared to those living in urban slums. Likewise, fully vaccinated children exhibited a 37% lower likelihood of retaining their VC (95% CI: 0.46─0.91) compared to those who were only partially vaccinated. Furthermore, a child born into a community with a higher poverty level has a 59% higher chance of retaining their vaccinations compared to a child born into a community with lower poverty levels (95% CI: 1.11─2.50) (Table 3).

Table 3. Multivariable multilevel analysis result of VC retention among children of 12–23 months in Ethiopia, 2016.

Characteristics	Model I (95%CI AOR)	Model II (95%CI AOR)	Model III (95%CI AOR)
Age group
15─24	Ref		Ref
25─34	1.28 [0.89, 1.84]		1.26[0.88, 1.82]
35─49	1.46 [0.91, 2.34]		1.42[0.89, 2.25]
Educational status
None	Ref		Ref
Primary	0.91 [0.63, 1.34]		0.90[0.62, 1.31]
Secondary& above	1.28 [0.75, 2.20]		1.15[0.62, 2.12]
Working status
Not working	Ref		Ref
Working	1.73 [1.43, 2.08]		1.05[0.76, 1.45]
Media Access
No	Ref		Ref
Yes	1.05 [0.76, 1.45]		1.34[0.93, 1.94]
Immunization status
Partially vaccinated	Ref		Ref
Fully vaccinated	0.66 [0.47, 0.93]		0.65[0.46, 0.91] ^**
Place of residency
Urban	Ref		Ref
Rural	0.25 [0.15, 0.44]		0.35[0.19, 0.65] ^***
Community level factors
Community poverty
High poverty		Ref	Ref
Low poverty		0.42 [0.28, 0.63]	1.59[1.11, 2.50] ^**
Community literacy
Low		Ref	Ref
High		0.50[0.32, 0.78]	0.82 [0.46, 1.48]

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Note

* = p-value 0.049–0.01

** = p-value <0.001, and

*** = p-value <0.0001

Discussion

This study aimed to investigate the rate of VC, as well as individual and community level variables associated with VC retention in Ethiopia. Multilevel logistic regression analysis was calibrated to identify factors associated with VC retention. In this study of caregivers, the retention rate for EPI cards was found to be 52.5%. This retention rate is lower than research done in Nepal [21], India [22], and Nepal [23] which documented retention rates of 74%, 97.9% and 88.9% respectively. And it is higher than research done in Pakistan with a 33% retention rate [24]. The differences in vaccination coverage rates across these studies may be attributed to several factors, including variations in sample size, methodological approaches (e.g., survey, interview), and the level of information and awareness among caregivers in the respective countries. Using multilevel multivariable logistic regression analysis, we explored the associations between various factors and the retention of vaccination cards (VC). Our findings revealed that several factors were significantly associated with VC retention. Specifically, place of residency, immunization level and community level poverty.

This investigation has revealed that residing in a rural area is a mitigating factor affecting the retention rate of VC. This could be attributed to the likelihood that caregivers in rural slums may not fully comprehend the significance of VC, given their comparatively lower levels of education compared to urban residents. Additionally, it is conceivable that women living in rural areas of Ethiopia may not have access to safe and secure retrieval and storage systems for vaccination cards, in contrast to their urban counterparts. This discrepancy could lead to misplacement or damage to the cards.

The results of our analysis showed that children living in rural areas had lower vaccination coverage compared to their urban counterparts. This can be attributed to the challenges faced by rural communities in accessing healthcare services and vaccination programs. policymakers may have a vested interest in instituting interventions predicated on place of residency and vaccination status to foster the appropriate documentation of health cards generally, and VC. However, our findings also indicated that children from communities with lower levels of poverty had higher VC rate compared to children from high poverty. This suggests that socioeconomic status at the community level may have a stronger influence on vaccination uptake than the rural-urban divide. This finding suggests the importance of providing ongoing support to communities who have experienced financial scarcity to promote good documentation practices.

The completion of routine vaccinations during childhood has been identified as a significant factor contributing to the decrease in VC possession rate. The present discovery contradicts the research conducted in Nepal [23] which concluded that the completion of one’s measles vaccine status has been discovered to be a significant contributing factor towards the increased holding of VC. Another study done in Uganda reported that children who possess VC are significantly more likely to receive all vaccinations, by a factor of ten than their peers who do not possess such cards [25]. This difference might be explained by the notion that parents of children who have completed their vaccination schedule may view the vaccination card as unnecessary, unlike families whose children are still undergoing vaccination courses. Another finding is low community level poverty. A child born from a community with low poverty level is likely to have retained VC compared to a child from a high poverty level. This finding is consistent with the study done in Cameroon [26].

While this inquiry has offered an exploratory view into the reporting of essential matters concerning child health, particularly regarding immunization cards, it is not without its limitations. Given that the study is cross-sectional, the relationships identified by the study are not going to be interpreted as causal factors. Another limitation of this study could be the insufficient inclusion of socio-economic variables. Furthermore, the study may be limited by its insufficient inclusion of socio-economic variables; incorporating a broader range of such variables could lead to more robust findings. The Negative correlation between completed vaccine status and card retention might not explained well and the reason is not known. So further investigation is required to bring satisfactory reason.

Conclusion

The low retention rate of vaccination cards (VC) in Ethiopia is concerning, particularly since all caregivers are expected to retain their child’s VC. Place of residency, wealth status, and vaccination status were factors that contributed to the change in the VC retention rate. Implement targeted campaigns to raise awareness about the importance of vaccination cards and the benefits of retaining them. Develop tailored interventions for populations identified as having lower VC retention rates, such as those residing in rural areas or with lower wealth status.

Abbreviations

AIC: Akaike information criteria
AOR: : Adjusted Odds Ratio
VC: vaccination card
BIC: Bayesian information criteria
EDHS: Ethiopian Demographic health survey
DIC: Deviance Information Criterion
ICC: Intra-Class Correlation
LLR: Log-Likelihood Ratio
MOR: Median Odds Ratio, and
PCV: Proportion of Variance Change

Data Availability

All relevant data for this study are within the paper.

Funding Statement

The authors received no specific funding for this work.

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26.Yakum MN, Funwie AD, Ajong AB, Tsafack M, Ze LEE, Ekukole ESR, et al. Factors associated with routine vaccination card retention among children aged 0–59 months in Yaounde-Cameroon: A cross-sectional survey. 2022;17(8):e0273515. doi: 10.1371/journal.pone.0273515 [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0306421.r001

Decision Letter 0

Tamirat Getachew

12 Mar 2024

PONE-D-23-21113Retention rate of vaccination cards and associated factors among vaccinated children aged 12-23 months in Ethiopia, multilevel logistic regression analysis.PLOS ONE

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Reviewer #1: Yes

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: Reviewer Comments for a manuscript entitled: "Retention rate of vaccination cards and associated factors among vaccinated children aged 12-23 months in Ethiopia, multilevel logistic regression analysis".

Manuscript Number: PONE-D-23-21113

Reviewer Name: Abebaw Addis Gelagay

Comments:

1. Title:

i. Line number 1-3: Avoid the full stop from the title.

2. Abstract:

i. Start a sentence with a capital letter! for example, the first sentence of the background (line number 17) and conclusion (line number 31) began with small letter.

ii. The background does not show the knowledge gap.

iii. Line number 21: At the end of the objective, what the term "..., in 2016" refers?

iv. Line number 23: report your outcome variable with its 95% CI!

v. Line number 23: the term "...fraction of their guardians..." is not appropriate. Additionally, it is not appropriate to use a term "approximately" while you reported the exact/actual figure (684)

vi. Line number 31: The conclusion for the outcome variable is not a conclusion rather it is a result.

3. Introduction:

i. Line number 23: Avoid a 'full stop' from the title.

ii Line number 42: Use the full version of "VC" instead of the acronym when you use for the first time!

iii. Line number 64 & 65: authors documented that 'the rate of documentation practices related to routine immunization health cards of children is not measured'. If this is the knowledge gap, this would have been addressed in your study instead of card retention rate.

iv. Line number 65 & 66: The sentence needs language edition.

Generally, what is the programmatic importance of keeping the vaccination cards after completion of the immunization? Are clients routinely informed to keep it after completion of vaccination??

4. Methods and materials:

i. Line number 84: All under-five children could not be a source population as you couldn't infer your finding to all under five children. Use children age less than 2 years!

ii. Line number 86: Since you noted, and we all know that that keeping vaccination card primarily benefits health care providers. What is your justification to excluded children age less than 12 months as long as they initiated the vaccination.

iii. Line number 93-96: Since all the independent variables listed are individual level, why you planed and did a multilevel analysis?

iv. Line number 103-108: Nothing is documented about the data collection tools.

v. Line number 106 or Line number 171: anyone can access the data if he/she get the link from someone else. So, did you attach an authorization letter/text from the responsible body for this particular study? You need to attach it as a supplementary file.

vi. Line number 108: What the number in bracket "(3)" refers?

vii. Line number 113: The description under the heading "Sample size and sampling procedures" is about sampling procedures, but nothing is stated about sample size estimation except mentioning a weighted sample size used which is a result, not the plan.

viii. Line number 121: You used the 2016 EDH data but why you cited reference 14 and 15 which are the 2005 and 2011 EDHS?

ix. Line number 129: Did you get a community level factors that affect your outcome variable in your literatures review or clinical evidence which initiated you to consider multilevel analysis?

x. Line number 160: Use the full version of "MOR" instead of the acronym when you use it for the first time!

5. Results:

i. Line number 211: It would have been good if I can access table 3. It would have been good to mention all the independent variables that you considered under a community and individual level factors. This is because the community level factor specifically residence can be affected by individual level factors like educational status.

6. Discussion:

i. Line number 217: When you compare your finding with other studies (Nepal, India, Nepal, and Pakistan), their findings should be documented so that readers can see and approve the comparison decision. You have to cite the reference for the study done in Pakistan (line number 218).

ii. Line number 220-222: Needs language revision including punctuation.

iii. Line number 221-223: You explained that due to less educational level of the rural women, cards retention rate is low. If this so, did you consider educational level as independent variable and what was the result?

iv. Line number 223-225: The explanation that rural women used the card for entertainment for their children is too poor.

v. Line number 226-232: The policy or programmatic implication of the finding that rural women have less retention rate is not clear and is not strong.

vi. Line number 223-225: duplication of idea.

vii. Line number 239: "... prevalence of VC possession rate." If you used the term "prevalence", do not need to use the term "rate"!

viii. Line number 254-256: Language edition!

Generally, the discussion is shallow!

7. Conclusion:

i. Line number 260: delete the number.

ii. Line number 261-264: The forwarded recommendation "...advisable to customize the interventional strategy..." should be specific. What interventional strategy is/are needed to mitigate the low retention rate?

Reviewer #2: Summary:

The authors have selected an interested topic, however, they were unable to justify the findings. The article needs significant revisions. Major gaps were observed in methods, data analysis, and results. Authors are requested to revisit the article and made changes to make it technically sound and equivalent to other scientific literature. the below comments can help improve the quality of article.

Abstract:

1. Methods section missing in the abstract. It is suggested that methods section should be added in abstract.

2. Line 25-27: do authors mean to say that card retention is higher among urban population than rural? If so, rephrase the statement accordingly

3. Line 35-36: better to add the desirable retention rate, if any

Introduction:

1. Line 41: its VPD not VSD

2. Line 42: VC? Please mention full form first. It is always good to avoid using self generated abbreviations

3. Line 45-57: not clear what information authors are trying to convey. Need to rephrase ensuring quality of information and coherence

4. Line 58-59: reference for the definition is missing. Also, please mention until when the card is expected to be saved by household? as “individuals who still have VC” seems unprecise

5. Line 64-66: both statements are conflicting. There are articles available in the context of Ethiopia which have used vaccination cards to estimate the coverage. Authors should look into the different search engines and explore

6. Significant revisions are required in the section. Authors are requested to revise the language and add relevant information based on available scientific information

Methods:

7. Sub-headings need revision, for instance, instead of study area mention study settings

8. References missing in information provided under ‘study area’ sub-head

9. Under ‘Study area’ it would be better if relevant statistics are provided such as information regarding fertility rate, current immunization rate etc.

10. Line 97: only one definition is provided

11. Line 109: the paragraph suggest validation of tool and it has nothing to do with quality control

12. Line 114-115: is it 13 or 11?

13. Line 151: the reference quoted is not required and is not relevant here

14. Line 122: revise the heading to “data analysis” and then describe the analysis steps. Currently authors have mentioned definitions of different tests which seems like not even used for analysis or may be authors have missed the information in the results section

15. Line 163-164: authors have used p-value of 0.2 or 0.05 as cutoff?

16. The section needs significant improvement. Authors are requested to look into similar articles to revise the section. Sampling and study procedures needs to be strengthened

Results:

17. It would be good if authors add demographic characteristics of study population first before sharing the retention rate

18. No p-values are given in the results section throughout

19. Line 185-204: seems like methods section then results

20. Factors associated with poor retention of vaccination cards are not mentioned

21. Authors are requested to improve the section conveying the results clearly and adding value to scientific literature

22. Tables are missing in the manuscript, so it is difficult to see the findings or suggest corrections in table

Discussion:

23. Line 215-216: in abstracts authors claim to have retention of VC rate across Ethiopia, now using the term sample. Is the data extracted from DHS represents entire Ethiopia? Need to improve methods section for clarity

24. Line 216-218: better to mention retention rate than only mentioning the countries

25. Line 218-219: as per your study or in countries mentioned. Please rephrase

26. Line 220-225: the first line says high retention in rural while rest of para contradicts the first statement. Also compared to whom retention is higher in rural? Urban or rural slum? What is considered as rural slum? Does DHS data providing information as per rural slum? How many children belong to rural slum?

27. Line 233-235: what does the current study findings suggest? Do authors found educational status as one of the factors for poor card retention? Mentioning “may be attributable” is not appropriate. Authors should provide information based on the data analysis

28. Line 245-247: authors should add relevant reference from literature to support the statement

29. Line 248-250: how authors are defining poverty levels? What are the cutoffs for low and high poverty? Do authors compare the findings among different socioeconomic groups including children belonging to high socioeconomic status?

30. Line 251-252: the study is not explaining crucial issues in child health. It is only about immunization card retention

31. Line 253-258: need to reconsider limitation of study as mentioned limitations cannot be considered as true study limitations

32. Line 260: low retention compared to what?

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2024 Jul 11;19(7):e0306421. doi: 10.1371/journal.pone.0306421.r002

Author response to Decision Letter 0

30 Apr 2024

Authors’ response to reviews

Title: Retention rate of vaccination cards and associated factors among vaccinated children aged 12-23 months in Ethiopia, multilevel logistic regression analysis

Authors:

Abiyu Abadi Tareke (abiyu20010@gmail.com)

Atikaw Tewabe Ayelign

Thomas Kidanemariam Yewodiaw

Enyew Woretaw Shiferaw

Habitu Birhan Eshetu

Ermias Bekele Enyew

Version: 1

Date: March 31, 2024

Point by point response for editors/reviewers’ comments

Manuscript number: PONE-D-23-21113

Dear editor/reviewer:

Dear all,

We express our profound appreciation for the insightful and productive feedback that you have provided. Your invaluable comments have significantly enriched the quality of the manuscript, and have greatly augmented our expertise in the realm of scientific paper writing. The authors have diligently considered each of the comments and queries raised by the editors and reviewers, and have responded to them in a targeted manner. Our comprehensive point-by-point rejoinders to all the comments and questions can be found in the subsequent pages. In addition, an accompanying supplementary document has been enclosed, which showcases the modifications made in detail, using the track changes feature. We also made some change to fix grammatical error in some paragraphs.

Review Comments to the Author

Reviewer #1:

Reviewer’s comment: 1. Title:

i. Line number 1-3: Avoid the full stop from the title.

Authors’ response: Thank you for your feedback. We appreciate your suggestion to avoid using a full stop in the title. We made the necessary revisions accordingly.

2. Abstract:

Reviewer’s comment: i. Start a sentence with a capital letter! for example, the first sentence of the background (line number 17) and conclusion (line number 31) began with small letter.

Authors’ response: Thank you for pointing out this oversight. We apologize for the inconsistency and we ensured that all sentences begin with capital letters as appropriate, including the first sentences of the background and conclusion sections.

Reviewer’s comment: ii. The background does not show the knowledge gap.

Authors’ response: Thank you for your feedback. We acknowledge the importance of clearly demonstrating the knowledge gap in the background section. We revised the background to explicitly highlight the gap in understanding regarding the retention rate of vaccination cards and its associated factors in Ethiopia.

Reviewer’s comment: iii. Line number 21: At the end of the objective, what the term "..., in 2016" refers?

Authors’ response: Thank you for bringing this to our attention. The phrase "in 2016" at the end of the objective does not seem to have a clear connection or relevance. We reviewed and revised the objective statement to ensure clarity and coherence as “This research aimed to assess the retention rate and associated factors of vaccination cards in Ethiopia, using data of 2016 Ethiopian demographic health survey. ”

Reviewer’s comment: iv. Line number 23: report your outcome variable with its 95% CI!

Authors’ response: Thank you for your comment. We appreciate your suggestion to report the outcome variable with its 95% confidence interval (CI). We ensured that the outcome variable is presented along with its corresponding confidence interval in the results section of our manuscript. See the revised version of the manuscript.

Reviewer’s comment: v. Line number 23: the term "...fraction of their guardians..." is not appropriate. Additionally, it is not appropriate to use a term "approximately" while you reported the exact/actual figure (684)

Authors’ response: Thank you for your feedback. We acknowledge that the term "fraction of their guardians" is not be the appropriate phrase to describe human being and can lead to confusion. We revised the language to provide a clearer description of the population. Additionally, we recognize that using "approximately" when reporting an exact figure is unnecessary. We removed the term "approximately" and report the exact figure of 684 accordingly and we re-written it as “Among the cohort of 1,304 (weighted) immunized children, it was observed that 684 (52.5%, 95% CI: 49.7% to 55.2%), were able to bring their respective vaccination records”

Reviewer’s comment: vi. Line number 31: The conclusion for the outcome variable is not a conclusion rather it is a result.

Authors’ response: Thank you for your comment. We acknowledge your observation regarding the conclusion for the outcome variable. upon revising the sentence, we understand that the sentence is summary rather than conclusion. We revised the conclusion section to ensure that it provides a proper conclusion based on the results obtained from the study.

3. Introduction:t

Reviewer’s comment: i. Line number 23: Avoid a 'full stop' from the title.

Authors’ response: thanks for your valuable comment. We corrected accordingly.

Reviewer’s comment: ii Line number 42: Use the full version of "VC" instead of the acronym when you use for the first time!

Authors’ response: Thank you for your suggestion. We ensured to use the full term "vaccination card" instead of the acronym "VC" when mentioning it for the first time in the manuscript.

Reviewer’s comment: iii. Line number 64 & 65: authors documented that 'the rate of documentation practices related to routine immunization health cards of children is not measured'. If this is the knowledge gap, this would have been addressed in your study instead of card retention rate.

Authors’ response: Thank you for highlighting this point. We acknowledge that the rate of documentation practices related to routine immunization health cards like routine immunization register, appointment card, tally sheet and other immunization related documentation at facilities level is indeed an important knowledge gap. Our intention in including this facility-level problem in this paragraph is to illustrate the potential severity of the issue for caregivers when it occurs even within well-organized government facilities. We recommend future researchers to consider addressing this aspect in future research to provide a more comprehensive understanding of immunization documentation practices among service providers. In the revised version of this manuscript, we removed the broad terminology “documentation practices” and replaced by rate of vaccination card retention rate and the ambitious sentences re-written as “The retention rate of routine immunization vaccination cards is not measured and the number of published articles concerning the VC retention rate of caregivers and associated factors in Ethiopia are limited.”

Reviewer’s comment: iv. Line number 65 & 66: The sentence needs language edition.

Generally, what is the programmatic importance of keeping the vaccination cards after completion of the immunization? Are clients routinely informed to keep it after completion of vaccination??

Authors’ response: Thank you for your comment. We recognize the need for language editing in the sentence. The programmatic importance of keeping vaccination cards after completion of immunization lies in their role as crucial documentation for tracking vaccination history, ensuring timely and appropriate follow-up doses, and providing evidence of immunization status. Additionally, in Ethiopia, caregivers are typically instructed to retain their child's vaccination cards throughout the vaccination process and for the duration of their child's life after completing the vaccination schedule. However, the consistency of advising women to hold their child's vaccination cards may vary among health professionals and further investigation is required to determine whether clients are routinely informed to keep vaccination cards after completing their vaccination schedule in consistent way.

4. Methods and materials:

Reviewer’s comment: i. Line number 84: All under-five children could not be a source population as you couldn't infer your finding to all under five children. Use children age less than 2 years!

Authors’ response: Thank you for your suggestion. We made the necessary adjustment to specify the source population as "children aged less than 2 years" to accurately reflect the scope of our study findings.

Reviewer’s comment: ii. Line number 86: Since you noted, and we all know that that keeping vaccination card primarily benefits health care providers. What is your justification to excluded children age less than 12 months as long as they initiated the vaccination.

Authors’ response: Thank you for raising this point. We would like to clarify that children under 12 months of age were not intentionally excluded by us, but rather by the parameters of the survey. We acknowledge the significance of understanding vaccination practices and documentation among younger children and recognize the importance of exploring this further in future research endeavors.

Reviewer’s comment: iii. Line number 93-96: Since all the independent variables listed are individual level, why you planed and did a multilevel analysis?

Authors’ response: Thank you for your question. While it is true that the independent variables listed are at the individual level and we failed to list the community level factors in the first draft of the manuscript. we conducted a multilevel analysis to account for potential clustering effects within the data. In our study setting, there may be inherent variations in vaccination card retention rates across different communities that could influence the outcomes of interest. Therefore, by using a multilevel analysis approach, we aimed to appropriately model and address any potential clustering or contextual effects at the facility or community level, ensuring a more accurate assessment of the relationship between individual-level variables and vaccination card retention rates. In the revised version of the manuscript, we included the community level factors under the independent variable lists.

Reviewer’s comment: iv. Line number 103-108: Nothing is documented about the data collection tools.

Authors’ response: Thank you for bringing this to our attention. We apologize for the oversight. The data collection tools used in our study included structured questionnaires administered to caregivers to gather information on vaccination card retention and other relevant variables. We will ensure to provide a detailed description of the data collection tools in the Methods section of the manuscript.

Reviewer’s comment: v. Line number 106 or Line number 171: anyone can access the data if he/she get the link from someone else. So, did you attach an authorization letter/text from the responsible body for this particular study? You need to attach it as a supplementary file.

Authors’ response: As authors, we thank the reviewer for their valuable feedback. We understand the importance of ensuring proper authorization for accessing the data used in our study. Nevertheless, the DHS Demographic Health Survey grants access to the datasets without the need for repeated authorization requests for each study.

Reviewer’s comment: vi. Line number 108: What the number in bracket "(3)" refers?

Authors’ response: The number in parentheses "(3)" was a typographical error and does not have any significance or intended reference in the context of the manuscript. So we removed it.

Reviewer’s comment: vii. Line number 113: The description under the heading "Sample size and sampling procedures" is about sampling procedures, but nothing is stated about sample size estimation except mentioning a weighted sample size used which is a result, not the plan.

Authors’ response: We acknowledge the oversight regarding the description under the heading "Sample size and sampling procedures." We apologize for any confusion. We will revise the section to include information about the sample size estimation process, including the methods and rationale used for determining the weighted sample size. Thank you for bringing this to our attention.

Reviewer’s comment: viii. Line number 121: You used the 2016 EDH data but why you cited reference 14 and 15 which are the 2005 and 2011 EDHS?

Authors’ response: We apologize for the oversight in citing references 14 and 15, which pertain to the 2005 and 2011 EDHS data, respectively, while utilizing the 2016 EDHS data. This was an error in referencing, and we appreciate your attention to detail. We corrected this discrepancy and ensured that our citations accurately reflect the data used in our study. Thank you for bringing this to our attention.

Reviewer’s comment: ix. Line number 129: Did you get a community level factors that affect your outcome variable in your literatures review or clinical evidence which initiated you to consider multilevel analysis?

Authors’ response: While we did not specifically identify community-level factors directly associated with vaccination card retention in our literature review, the intracluster correlation coefficient (ICC) obtained from running the null model provided evidence supporting the rationale for conducting multilevel logistic regression. Additionally, previous studies have highlighted the importance of considering multilevel analysis when examining vaccination outcomes, particularly to account for the nested nature of individual-level data within communities. Therefore, based on both the literature review and clinical evidence, we deemed it appropriate to consider multilevel analysis to investigate the influence of community-level factors on our outcome variable.

Reviewer’s comment: x. Line number 160: Use the full version of "MOR" instead of the acronym when you use it for the first time!

Authors’ response: Thank you for your suggestion. We will ensure to use the full version of "MOR" (Median Odds Ratio) when it is mentioned for the first time in the manuscript

5. Results:

Reviewer’s comment: i. Line number 211: It would have been good if I can access table 3. It would have been good to mention all the independent variables that you considered under a community and individual level factors. This is because the community level factor specifically residence can be affected by individual level factors like educational status.

Authors’ response: Thank you for your comment. We apologize for any inconvenience caused by the inability to access Table 3. We will ensure that Table 3, along with all relevant independent variables considered under community and individual level factors, are clearly mentioned in the manuscript. We acknowledge the interplay between community and individual level factors, particularly regarding residence and educational status, and provided a comprehensive explanation of how these factors were accounted for in our analysis.

6. Discussion:

Reviewer’s comment: i. Line number 217: When you compare your finding with other studies (Nepal, India, Nepal, and Pakistan), their findings should be documented so that readers can see and approve the comparison decision. You have to cite the reference for the study done in Pakistan (line number 218).

Authors’ response: We appreciate the reviewer's feedback and acknowledge the importance of providing documentation for comparisons with other studies. In response to this comment, we have revised the manuscript to include proper citations for the studies conducted in Nepal, India, and Pakistan.

Reviewer’s comment: ii. Line number 220-222: Needs language revision including punctuation.

Authors’ response: Thank you for bringing this to our attention. We will thoroughly revise the language and punctuation in lines 220-222 to ensure clarity and correctness. We appreciate your feedback and will make the necessary improvements to enhance the readability of the manuscript.

Reviewer’s comment: iii. Line number 221-223: You explained that due to less educational level of the rural women, cards retention rate is low. If this so, did you consider educational level as independent variable and what was the result?

Authors’ response: Thank you for your query regarding the consideration of educational level as an independent variable in our analysis. We appreciate the opportunity to clarify our methodology. In our study, we indeed considered educational level as a potential independent variable and conducted statistical tests to assess its relationship with

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PLoS One. doi: 10.1371/journal.pone.0306421.r003

Decision Letter 1

Tamirat Getachew

12 Jun 2024

PONE-D-23-21113R1Retention rate of vaccination card and its associated factors among vaccinated children aged 12-23 months in Ethiopia: multilevel logistic regression analysisPLOS ONE

Dear Dr. Tareke,

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6. Review Comments to the Author

Reviewer #1: The authors have well addressed my previous comments. I have few minor comments:

Multilevel regression model:

1. There are duplications of ideas, for example, the first sentence of the first (line number 183) and the second (line number 183) paragraphs, line number 213-215.

2. Flow of ideas needs to be revised: line number 197-199 deal with null model, line number 199-203 is about model fitness, line number 203-206 states about ICC which should have been completed/placed just after the null model description before you note about the model fitness. The same is true for notes at line number 213-215.

Discussion:

3. Line number 277, the term "In our sample" is not appropriate instead use the term: "In this survey"

4. Line number 278-281, since it is a discussion section, please search and include possible justification/reason for the observed variation!

5. How do you relate the opposite direction of association of two related variables: 'being rural resident' (line number 293) and 'low community level poverty' (line number 308-309)?

Reviewer #2: 1. p-values are still missing

2. Table 3 seems incomplete. model 2 and null model numbers are missing

3. There is a lot of room to improve language. spell check and capital letters in between the text

4. Authors have interchangeably used the term multilevel and multivariable regression. Suggest keeping consistency while using the term

5. add some narratives for demographic information

6. tables should be referenced in the text

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Reviewer #1: Yes: Abebaw Addis Gelagay

Reviewer #2: No

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PLoS One. 2024 Jul 11;19(7):e0306421. doi: 10.1371/journal.pone.0306421.r004

Author response to Decision Letter 1

15 Jun 2024

Authors’ response to reviews

Title: Retention rate of vaccination cards and associated factors among vaccinated children aged 12-23 months in Ethiopia, multilevel logistic regression analysis

Authors:

Abiyu Abadi Tareke (abiyu20010@gmail.com)

Atikaw Tewabe Ayelign

Thomas Kidanemariam Yewodiaw

Enyew Woretaw Shiferaw

Habitu Birhan Eshetu

Ermias Bekele Enyew

Version: 2

Date: June 15, 2024

Point by point response for editors/reviewers’ comments

Manuscript number: PONE-D-23-21113

Dear editor/reviewer:

Dear all,

Reviewer #1:

Reviewer’s comment: The authors have well addressed my previous comments. I have few minor comments:

Author’s response: Thank you for your additional feedback on our manuscript. We appreciate you taking the time to review our work and provide these minor comments. Regarding your statement that "The authors have well addressed my previous comments", we are pleased to hear that our revisions have satisfactorily addressed your earlier feedback. It is our goal to thoroughly address all reviewer comments to ensure our work is of the highest quality.

Multilevel regression model:

Reviewer’s comment: 1. There are duplications of ideas, for example, the first sentence of the first (line number 183) and the second (line number 183) paragraphs, line number 213-215.

Author’s response: Dear Reviewer, thank you for your feedback on our manuscript. We have carefully reviewed the areas you have identified as having duplicated ideas and have made the necessary revisions to address them. Specifically, we have removed the redundant sentences from the first and second paragraphs, as well as the repetitive explanation of the multilevel analysis and its benefits for nested data structures. The revised text now reads more concisely and avoids unnecessary duplication. Additionally, we have removed the redundant information regarding the different models used in the two-tiered binary logistic regression analysis and the explanation of the fitness parameters used to evaluate the models. The revised manuscript now presents the key information in a more streamlined and cohesive manner, without compromising the clarity and comprehensiveness of the methodological approach. We believe these changes have addressed the duplication of ideas you have pointed out. Please let us know if you have any other feedback or suggestions.

Reviewer’s comment: 2. Flow of ideas needs to be revised: line number 197-199 deal with null model, line number 199-203 is about model fitness, line number 203-206 states about ICC which should have been completed/placed just after the null model description before you note about the model fitness. The same is true for notes at line number 213-215.

Author’s response: Thank you for the additional feedback on the flow of ideas in our manuscript. We appreciate you taking the time to provide this constructive criticism, as it will help us improve the organization and coherence of the presentation. As per your suggestion, we have revised the flow of ideas to better align the discussion of the null model, model fitness, and the assessment of cluster variability using the ICC, MOR, and PCV. Specifically, we have moved the explanation of the ICC, MOR, and PCV to immediately follow the description of the null model, as this information is more logically connected. This way, the reader can better understand the rationale and methods used to assess the variability of the cluster before the discussion of the model fitness parameters. Additionally, we have streamlined the information about the different models and the criteria used to evaluate them, ensuring a more coherent and logical progression of ideas. The revised manuscript now presents the methodological approach in a more organized and reader-friendly manner, with the key concepts and analyses grouped together in a more intuitive flow.

Discussion:

Reviewer’s comment: 3. Line number 277, the term "In our sample" is not appropriate instead use the term: "In this survey"

Author’s response: Thank you for the feedback regarding the phrasing used in our manuscript. We have made the suggested change to the sentence on line 277.

The revised sentence now reads: "In this study, the majority of children (63.3%) were from rural areas, while the remaining 36.7% were from urban areas." We agree that the term "In our sample" is not as appropriate as "In this study" in this context, as it helps to clearly situate the information within the dataset being analyzed.

Reviewer’s comment: 4. Line number 278-281, since it is a discussion section, please search and include possible justification/reason for the observed variation!

Author’s response: Thank you for the feedback regarding the discussion of the observed variations in our manuscript. You make an excellent point that the discussion section should provide possible justifications or reasons for the patterns observed in the results. In response to your suggestion, we have expanded the discussion on lines 278-281 to include potential explanations for the variations in vaccination coverage between those studies, as well as across different socioeconomic groups.

Reviewer’s comment: 5. How do you relate the opposite direction of association of two related variables: 'being rural resident' (line number 293) and 'low community level poverty' (line number 308-309)?

Author’s response: Thank you for raising this important point about the seemingly contradictory associations observed in our results. You are correct in noting that the direction of the associations for "being a rural resident" and "low community-level poverty" appear to be opposite. We separated those two variables following your comment.

Reviewer #2

Reviewer’s comment: Reviewer #2: 1. p-values are still missing

Author’s response: Dear Reviewer, thank you for your feedback regarding the missing p-values in our manuscript. We appreciate you taking the time to thoroughly review our work and provide this constructive comment. Regarding the inclusion of p-values in our manuscript. As we mentioned in our previous response, we opted to present confidence intervals for the Adjusted Odds Ratios (AORs) in the results section, rather than including the specific p-values. This decision was made due to constraints related to table cell space, as we believe that providing the confidence intervals offers valuable information about the precision of our estimates and allows readers to assess the significance of the results. However, following your suggestion, we have now included the categories of p-values for the significant variables using asterisks at the footnote of the relevant tables.

We are sorry if our initial response may not have fully satisfied your request. As researchers, we are committed to transparency and strive to present our findings in the clearest possible way. We value your expertise and insights, and we appreciate you taking the time to provide this constructive feedback.

Reviewer’s comment: 2. Table 3 seems incomplete. model 2 and null model numbers are missing

Author’s response: As you noted, the null model, which does not include any variables, is typically not reported in the table. This is a standard practice, as the null model serves as a baseline for comparison and does not provide any substantive information beyond the intraclass correlation coefficient. Similarly, for Model 3 in Table 3, this model focuses solely on the community-level factors and does not include the individual-level variables. This design decision was intentional, as we wanted to isolate the effects of the contextual factors on the outcome of interest.

We believe that the table is complete and comprehensive in presenting the key results from the multilevel modeling approach. Dear reviewer if you have time you can highlight articles published using similar tables (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257664), (https://academic.oup.com/inthealth/article/15/5/573/7143244)....

Reviewer’s comment: 3. There is a lot of room to improve language. spell check and capital letters in between the text

Author’s response: Thank you for your feedback. We appreciate you taking the time to review my submission and providing constructive comments to help improve the quality of my work. Regarding your suggestion to improve the language, we carefully reviewed the text and address any spelling or grammatical issues. We ensured that I am consistent with capitalization throughout the document.

Reviewer’s comment: 4. Authors have interchangeably used the term multilevel and multivariable regression. Suggest keeping consistency while using the term

Author’s response: Thank you for the feedback. You're right, we should maintain consistency in the terminology used throughout the manuscript. The terms "multilevel regression" and "multivariable regression" are often used interchangeably, but they do refer to slightly different statistical techniques.

Multilevel regression, also known as hierarchical linear modeling, is a method that accounts for the nested structure of data, such as patients within clinics or students within schools. This type of analysis allows for the estimation of both individual-level and group-level effects.

Multivariable regression, on the other hand, refers to a regression model that includes multiple independent variables to predict a single dependent variable. This is a more general term that does not necessarily imply a hierarchical data structure.

Reviewer’s comment: 5. add some narratives for demographic information

Author’s response: Thank you for the feedback. You make a good point that we should add some narrative context around the demographic information presented in the manuscript. The demographic characteristics of the study sample are an important part of understanding the generalizability and potential limitations of the findings. Providing some additional narrative description will help the reader better interpret the results. In the revised manuscript, we will include a paragraph in the Methods section that provides more details about the study population.

Reviewer’s comment: 6. tables should be referenced in the text

Author’s response: Thank you for the feedback regarding referencing the tables in the text. You're right that we should ensure the tables are properly referenced throughout the manuscript.

In the revised version, we gone through and add in-text references to each of the tables wherever the relevant information is being presented. This will help guide the reader to the appropriate table and demonstrate how the tabular data supports the narrative.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0306421.s002.docx^{(27.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0306421.r005

Decision Letter 2

Tamirat Getachew

18 Jun 2024

Retention rate of vaccination card and its associated factors among vaccinated children aged 12-23 months in Ethiopia: multilevel logistic regression analysis

PONE-D-23-21113R2

Dear Abiyu Abadi Tareke,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Tamirat Getachew

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0306421.r006

Acceptance letter

Tamirat Getachew

1 Jul 2024

PONE-D-23-21113R2

PLOS ONE

Dear Dr. Tareke,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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on behalf of

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Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Attachment

Submitted filename: Response to Reviewers.docx

pone.0306421.s001.docx^{(41.4KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0306421.s002.docx^{(27.3KB, docx)}

Data Availability Statement

All relevant data for this study are within the paper.

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PERMALINK

Retention rate of vaccination card and its associated factors among vaccinated children aged 12─23 months in Ethiopia: Multilevel logistic regression analysis

Abiyu Abadi Tareke

Atikaw Tewabe Ayelign

Thomas Kidanemariam Yewodiaw

Enyew Woretaw Shiferaw

Habitu Birhan Eshetu

Ermias Bekele Enyew

Roles

Abstract

Background

Objective

Methods

Result

Conclusion

Introduction

Methods and materials

Study design and period

Study setting

Population

Source population

Study population

Dependent variable

Independent variables

Operational definitions

Data collection tools and procedures

Data quality control

Sample size and sampling procedures

Data analysis

Multilevel regression model

Ethical consideration

Result

Table 1. Characteristics of the study participants in Ethiopia, 2016 (n = 1304).

Rate of VC retention

Model parameter results

Table 2. Model comparison and fitness parameter output.

Table 3. Multivariable multilevel analysis result of VC retention among children of 12–23 months in Ethiopia, 2016.

Discussion

Conclusion

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Tamirat Getachew

Roles

Author response to Decision Letter 0

Decision Letter 1

Tamirat Getachew

Roles

Author response to Decision Letter 1

Decision Letter 2

Tamirat Getachew

Roles

Acceptance letter

Tamirat Getachew

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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