Immunization course (12). Thus, drawing inferences of childhood

Immunization has proven to be an effective intervention for the prevention and elimination of life-threatening infectious diseases, and estimated to prevent approximately 2–3 million deaths annually. (1) Despite this immunization coverage in low-income countries is still far from the 90% coverage targeted by the Expanded Program on Immunization (EPI). (2),(3) In Malawi, the percentage of children aged 12–23 months who received complete vaccination dropped from 81% to 76% between 2010 and 2015 (4) which is less than the World Health Organization (WHO) recommended benchmark. Since the inception of the EPI in Malawi, the programme aims to provide the following vaccines: Bacillus Calmette Guerin (BCG) vaccination against tuberculosis; three doses of pentavalent vaccine (DPT-HepB-Hi-b) to prevent diphtheria, pertussis, tetanus, Haemophilus influenzae type b and hepatitis B; at least three doses of polio vaccine; and one dose of measles vaccine. In November 2011 and October 2012, the Government of Malawi introduced the pneumococcal conjugate vaccine (PCV13) and monovalent human rotavirus vaccine (RV1) into the nation’s infant immunization programme respectively. (5)

A large body of research has demonstrated that factors such as child’s characteristics (6), (7), maternal characteristics, (6),(8),(9) maternal healthcare utilization, (6) the distance to health care facilities (7),(10), household wealth (11), immunization schedule, maternal and paternal occupation (10), exposure to media (6),(10), geographical region and place of residence (6) have significant effects on childhood immunization. However, very few studies have investigated the influence of both individual and contextual factors on childhood immunization and whether the effects still exist after controlling for individual-level characteristics (6),(7).

Previous evidence suggests that the community shapes individual opportunities and exposes residents to multiple health risks and resources over their life course (12). Thus, drawing inferences of childhood immunization coverage on either micro or macro level could lead to either atomistic or ecological fallacy. (13) According to our review of the relevant literature, there has been no multilevel study to date that examined the separate and independent contributions of individual and community level factors on the complete immunization in Malawi. We, therefore, conducted this study to examine the influence of individual-level factors along with contextual characteristics on childhood complete immunization in Malawi. Specifically, we aimed to investigate the factors associated with immunization coverage following the inclusion of PCV and RV into the EPI.