Inequitable childhood immunization uptake in Nigeria: a multilevel analysis of individual and contextual determinants

Inequities in Childhood Vaccination Coverage in Zhejiang, Province: Evidence from a Decomposition Analysis on Two-Round Surveys

Objective: The objectives of this study were to determine the degree and risk factors of the inequity in the childhood coverage of full primary immunization (FPI) in Zhejiang province. Method: We used data from two rounds of vaccination coverage surveys among children aged 24–35 months conducted in 2014 and 2017, respectively. The household income per month was used as an index of socioeconomic status for the inequality analysis. The concentration index (CI) was used to quantify the degree of inequality, and the decomposition approach was applied to quantify the contributions from demographic factors to inequality in the coverage of FPI. Results: The coverage rates of FPI were 80.6%, with a CI value of 0.12028 for the 2014 survey, while the coverage rates of FPI were 85.2%, with a CI value of 0.10129 for the 2017 survey. The results of decomposition analysis suggested that 68.2% and 67.1% of the socioeconomic inequality in the coverage of FPI could be explained by the mother’s education level for the 2014 and 2017 survey, respectively. Other risk factors including birth order, ethnic group, mother’s age, maternal employment status, residence, immigration status, GDP per-capita, and the percentage of the total health spending allocated to public health could also explain this inequality. Conclusion: The socioeconomic inequity in the coverage of FPI still remained, although this gap was reduced between 2014 and 2017. Policy recommendations for health interventions on reducing the inequality in the coverage of FPI should be focused on eliminating poverty and women’s illiteracy.

Individual- and community-level determinants of child immunization in the Democratic Republic of Congo: A multilevel analysis

Understanding modifiable determinants of full immunization of children provide a valuable contribution to immunization programs and help reduce disease, disability, and death. This study is aimed to assess the individual and community-level determinants of full immunization coverage among children in the Democratic Republic of Congo. This study used data from the Demographic and Health Survey 2013–14 from the Democratic Republic of Congo. Data regarding total 3,366 children between 12 and 23 months of age were used in this study. Children who were immunized with one dose of BCG, three doses of polio, three doses of DPT, and a dose of measles vaccine was considered fully immunized. Descriptive statistics were calculated for the prevalence and distribution of full immunization coverage. Two-level multilevel logistic regression analysis, with individual-level (level 1) characteristics nested within community-level (level 2) characteristics, was used to assess the individual- and community-level determinants of full immunization coverage. This study found that about 45.3% [95%CI: 42.02, 48.52] of children aged 12–23 months were fully immunized in the DRC. The results confirmed immunization coverage varied and ranged between 5.8% in Mongala province to 70.6% in Nord-Kivu province. Results from multilevel analysis revealed that, four Antenatal Care (ANC) visits [AOR: 1.64; 95%CI: 1.23, 2.18], institutional delivery [AOR: 2.37; 95%CI: 1.52, 3.72], and Postnatal Care (PNC) service utilization [AOR: 1.43; 95%CI: 1.04, 1.95] were statistically significantly associated with the full immunization coverage. Similarly, children of mothers with secondary or higher education [AOR: 1.32; 95%CI: 1.00, 1.81] and from the richest wealth quintile [AOR: 1.96; 95%CI: 1.18, 3.27] had significantly higher odds of being fully immunized compared to their counterparts whose mothers were relatively poorer and less educated. Among the community-level characteristics, residents of the community with a higher rate of institutional delivery [AOR: 2.36; 95%CI: 1.59, 3.51] were found to be positively associated with the full immunization coverage. Also, the random effect result found about 35% of the variation in immunization coverage among the communities was attributed to community-level factors.The Democratic Republic of Congo has a noteworthy gap in full immunization coverage. Modifiable factors–particularly health service utilization including four ANC visits, institutional delivery, and postnatal visits–had a strong positive effect on full immunization coverage. The study underlines the importance of promoting immunization programs tailored to the poor and women with little education.

Coverage, Timelines, and Determinants of Incomplete Immunization in Bangladesh

Immunization has become one of the major contributors to public health globally as it prevents communicable disease, particularly in children. The objective of this study was to estimate the extent of timely immunization coverage and to investigate the determinants of incomplete and untimely vaccination. Methods: The study used data from the latest Bangladesh Demographic Health Survey (BDHS) 2014. A total sample of 1631 children aged 12–23 months who had an Expanded Program on Immunization (EPI) card and immunization history were analyzed. Multivariable logistic regression models were used to determine the significant influencing factors on untimely vaccination (BCG, pentavalent vaccine/OPV, and measles) and incomplete vaccination. The results were presented in terms of adjusted odds ratio (AOR) with a 95% confidence interval and a significance level p < 0.05. Results: The proportions of children who received timely vaccinations were 24% for BCG, 46% for pentavalent 3, and 53% for measles, whereas 76%, 51%, and 36% children failed to receive the BCG, pentavalent 3, and measles vaccines, respectively, in a timely manner. The proportion of early vaccination was 3% for pentavalent 3 and 12% for measles. Several significant influencing factors including age, maternal education and working status, awareness of community clinics, socioeconomic status, and geographic variation significantly contributed to untimely and incomplete vaccination of children in Bangladesh. Conclusions: The study identified some key determinants of untimely and incomplete childhood vaccinations in the context of Bangladesh. The findings will contribute to the improvement of age-specific vaccination and support policy makers in taking the necessary control strategies with respect to delayed and early vaccination in Bangladesh.

Analysis of the effects of individual- and community- level predictors on migrant children's primary immunization in Yiwu city, east China

BACKGROUND

To evaluate the effects of a wide range of individual- and community-level factors on migrant children's primary immunization.

METHODS

Migrant children aged 13-24 months (born from 1 June 2013 to 31 May 2014) were surveyed in Yiwu city, in June 2015. Social-demographic factors and vaccination records were collected. Five factors at community-level including community wealth, distance to the nearest immunization clinic, maternal education, antenatal clinic (ANC) visits, and hospital delivery were constructed. The relationship between individual- and community-level factors and a child's vaccination status for Chinese primary immunization were evaluated by logistic regression model and the adjusted odds ratio (AOR) with the p-values and 95% confidence interval (CI) were calculated.

RESULTS

The community wealth (aOR:1.4; 95% CI:1.1-2.7), the community maternal education (aOR:1.8; 95% CI:1.4-4.5), the community ANC visits (aOR:1.8; 95% CI:1.3-2.8), and the community hospital delivery (aOR:2.2; 95% CI:1.6-4.8) were positively associated with the completeness of primary immunization, while community distance to the nearest immunization clinic was negatively associated with the completeness of primary immunization (aOR:0.7; 95% CI:0.5-0.9). The coverage of completeness of primary immunization was higher among children living in rural areas than those living in urban areas (aOR:1.7; 95% CI: 1.3-3.1).

CONCLUSIONS

In order to achieve better vaccination coverage among migrant children in Yiwu, as well as to close the gaps and disparities of acceptability and accessibility in childhood vaccination in urban areas, policy makers should design interventions based on the factors addressed in this study.

Maternal Employment and Child Survival During the Era of Sustainable Development Goals: Insights from Proportional Hazards Modelling of Nigeria Birth History Data

Background:

One of the targets for the third and fifth Sustainable Development Goals (SDGs) borders on children survival and women economic empowerment, respectively. A robust investigation of the relationship between maternal employment and childhood mortality will provide information useful for programs aimed at ensuring the complementarity of SDG 3 (healthy life for all) and SDG 5 (gender equality, girls and women empowerment).

Objective:

We addressed the following questions: (1) What is the independent relationship between maternal employment and infant (0–11 months) and child (12–59 months) mortality in Nigeria? (2) How does father’s occupation, type of residence, and geopolitical region modify the relationship?

Methods:

We retrospectively analysed cross-sectional data on weighted sample of 31,828 under-five children extracted from the birth history in the 2013 round of Nigeria Demographic and Health Survey, using Cox proportional hazards models. The outcomes of interest were infant (0–11 months) and child (12–59 months) mortality, and the main explanatory variables include maternal employment, involvement in decision making on work earnings, and father’s occupation. Other confounding variables were also controlled.

Findings:

Results showed that about two-third (68.7%) of under-five children had mothers who were working, with the majority engaged in self-employed occupations such as sales or small businesses, agriculture, and other manual labour. Infant mortality rate amongst children of employed mothers (65 per 1000 live births) was slightly less than the unemployed (70 per 1000 live births). A similar pattern was observed for child mortality. Hazards regression models revealed that the risk of both infant and child mortality was higher amongst unemployed women. Sales and agriculture/manual occupation constituted a higher risk for infant and child mortality. Analysis of interaction effects also revealed variations by father’s occupation, type of residence, and geopolitical region.

Conclusion:

The role of maternal employment in child survival is dynamic and depends on the type of occupation, family, and residential and regional context.

Social determinants and BCG efficacy: a call for a socio-biological approach to TB prevention

A high burden of TB mortality persists despite the long-term availability of the bacillus Calmette-Guérin (BCG) vaccine, whose efficacy has been highly variable across populations. Innovative and alternative approaches to TB prevention are urgently needed while optimal biomedical tools continue to be developed. We call for new interdisciplinary collaborations to expand and integrate our understanding of how social determinants influence the biological processes that lead to TB disease, how this translates into differential BCG efficacy and, ultimately, how social protection interventions can play a role in reducing the global burden of TB. After providing an overview of the immune pathways important for the establishment of a response to the BCG vaccine, we outline how social determinants and psychosocial stressors can contribute to the observed variation in BCG efficacy above and beyond these biological factors. We conclude by proposing a new interdisciplinary research model based on the integration of social epidemiology theories with biomedical knowledge.

Role of health determinants in a measles outbreak in Ecuador: a case-control study with aggregated data

BACKGROUND

In 2011-2012, an outbreak of measles occurred in Ecuador. This study sought to ascertain which population characteristics were associated.

METHODS

Case-control study of aggregate data. The unit of analysis was the parish (smallest geographic division). The national communicable disease surveillance database was used to identify 52 case parishes (with at least one confirmed case of measles) and 972 control parishes (no cases of measles). A hierarchical model was used to determine the association of measles with population characteristics and access to health care.

RESULTS

Case parishes were mostly urban and had a higher proportion of children under 1 year of age, heads of household with higher educational attainment, larger indigenous population, lower rates of measles immunization, and lower rates of antenatal care visit attendance. On multivariate analysis, associations were found with educational attainment of head of household ≥8 years (OR: 0.29; 95%CI 0.15-0.57) and ≥1.4% indigenous population (OR: 3.29; 95%CI 1.63-6.68). Antenatal care visit attendance had a protective effect against measles (OR: 0.98; 95%CI 0.97-0.99). Measles vaccination was protective of the outbreak (OR: 0.97; 95%CI 0.95-0.98). The magnitude of these associations was modest, but represents the effect of single protective factors, capable of acting at the population level regardless of socioeconomic, biological, and environmental confounding factors.

CONCLUSION

In Ecuador, the parishes with the highest percentage of indigenous populations and those with the lowest vaccination coverage were the most vulnerable during the measles outbreak.

The influence of the social and cultural environment on maternal mortality in Nigeria: Evidence from the 2013 demographic and health survey

Introduction

Reducing maternal mortality remains a priority for global health. One in five maternal deaths, globally, are from Nigeria.

Objective

This study aimed to assess the sociocultural correlates of maternal mortality in Nigeria.

Methods

We conducted a retrospective analysis of nationally representative data from the 2013 Nigeria Demographic and Health Survey. The analysis was based on responses from the core women’s questionnaire. Maternal mortality was categorized as ‘yes’ for any death while pregnant, during delivery or two months after delivery (as reported by the sibling), and ‘no’ for deaths of other or unknown causes. Multilevel logistic regression analysis was conducted to test for association between maternal mortality and predictor variables of sociocultural status (educational attainment, community women’s education, region, type of residence, religion, and women’s empowerment).

Results

Region, Religion, and the level of community women’s education were independently associated with maternal mortality. Women in the North West were more than twice as likely to report maternal mortality (OR: 2.14; 95% CI: 1.42–3.23) compared to those in the North Central region. Muslim women were 52% more likely to report maternal deaths (OR: 1.52; 95% CI: 1.10–2.11) compared to Christian women. Respondents living in communities where a significant proportion of women have at least secondary schooling were 33% less likely to report that their sisters died of pregnancy-related causes (OR: 0.67; 95% CI: 0.48–0.95).

Conclusion

Efforts to reduce maternal mortality should implement tailored programs that address barriers to health-seeking behavior influenced by cultural beliefs and attitudes, and low educational attainment. Strategies to improve women’s agency should be at the core of these programs; they are essential for reducing maternal mortality and achieving sustainable development goals towards gender equality. Future studies should develop empirically evaluated measures which assess, and further investigate the association between women’s empowerment and maternal health status and outcomes.

The global effect of maternal education on complete childhood vaccination: a systematic review and meta-analysis

Background

There is an established correlation between maternal education and reduction in childhood mortality. One proposed link is that an increase in maternal education will lead to an increase in health care access and vaccine uptake. Vaccinations are a central preventative child health tool, therefore demonstrating the importance of understanding factors that can improve coverage. This review aims to establish if there is a correlation between increasing maternal education and vaccine uptake and if this varies between continents, setting and time.

Methods

An electronic database search was conducted using Medline Ovid, Embase and The Cochrane Library using a combination of keywords and appropriate MeSH terms for maternal education and child vaccination. Bibliographies were also hand searched. Data was extracted and entered onto a Microsoft Excel spreadsheet and analysed using STATA 13.0 software. The primary outcome of effect size of maternal education on completion of childhood vaccinations was analysed at different levels. Secondary outcomes were explored using subgroup analyses of differences between continents, rural or urban settings, and dates.

Results

The online search yielded 3430 papers, 37 were included in this study. The analysis showed increasing child vaccination uptake with increasing maternal education. Overall, analysis showed that the odds of full childhood vaccination were 2.3 times greater in children whose mother received secondary or higher education when compared to children whose mother had no education. There was large variability in the effect size between the studies included.

Conclusions

Improving maternal education is important for increasing childhood vaccination uptake and coverage. Further research is needed in higher income countries.

Trial registration

PROSPERO Registration No: CRD42016042409.

Determinants of immunisation coverage of children aged 12-59 months in Indonesia: a cross-sectional study

OBJECTIVES

Despite the adoption of WHO's Expanded Programme on Immunisation in Indonesia since 1977, a large proportion of children are still completely unimmunised or only partly immunised. This study aimed to assess factors associated with low immunisation coverage of children in Indonesia.

SETTING

Children aged 12-59 months in Indonesia.

PARTICIPANT

The socioeconomic characteristics and immunisation status of the children were obtained from the most recent Demographic and Health Survey, the 2012 Indonesia Demographic and Health Survey. Participants were randomly selected through a two-stage stratified sampling design. Data from 14 401 children aged 12-59 months nested within 1832 census blocks were included in the analysis. Multilevel logistic regression models were constructed to account for hierarchical structure of the data.

RESULTS

The mean age of the children was 30 months and they were equally divided by sex. According to the analysis, 32% of the children were fully immunised in 2012. Coverage was significantly lower among children who lived in Maluku and Papua region (adjusted OR: 1.94; 95% CI 1.42 to 2.64), were 36-47 months old (1.39; 1.20 to 1.60), had higher birth order (1.68; 1.28 to 2.19), had greater family size (1.47; 1.11 to 1.93), whose mother had no education (2.13; 1.22 to 3.72) and from the poorest households (1.58; 1.26 to 1.99). The likelihood of being unimmunised was also higher among children without health insurance (1.16; 1.04 to 1.30) and those who received no antenatal (3.28; 2.09 to 5.15) and postnatal care (1.50; 1.34 to 1.69).

CONCLUSIONS

Socioeconomic factors were strongly associated with the likelihood of being unimmunised in Indonesia. Unimmunised children were geographically clustered and lived among the most deprived population. To achieve WHO target of protective coverage, public health interventions must be designed to meet the needs of these high-risk groups.

THE ROLE OF COMMUNITY STRUCTURE IN SHAPING AFRICAN FERTILITY PATTERN: EVIDENCE FROM DEMOGRAPHIC AND HEALTH SURVEYS

Anthropological explanations of demographic outcomes have emphasized the need to understand how community structures contribute to those outcomes. However, studies on fertility dynamics in Africa have largely focused on micro-level factors, thus ignoring the influence of community contexts. Using the most recent Demographic and Health Survey data from Egypt (Northern Africa), Cameroon (Middle Africa), Kenya (Eastern Africa), Nigeria (Western Africa) and Zimbabwe (Southern Africa), the study employed multilevel Poisson regression models to examine the influence of community factors on African fertility levels and patterns. The number of sampled women (aged 15-44) ranged from 7774 in Kenya (2008-09) to 30,480 in Nigeria (2008). The findings demonstrate some significant community effects on African fertility patterns, even after controlling for a number of individual-level factors. For instance, residence in socioeconomically disadvantaged regions, rural settings, poor neighbourhood and communities with high family size norm were found to be associated with higher fertility levels in the selected countries. The emerging African fertility patterns require the need to go beyond addressing individual-level characteristics in the efforts to reduce fertility levels in Africa.

Evaluation of access and utilization of EPI services amongst children 12-23 months in Kwahu Afram Plains, Eastern region, Ghana

INTRODUCTION

High vaccination coverage is required to successfully control, eliminate and eradicate vaccine preventable diseases (VPDs). In Ghana, access complete vaccination coverage is 77%. However, sustaining high coverages in island communities such as Kwahu Afram Plains North (KAPN) is still a challenge.

METHODS

Study site and settings, an Island district. It targeted children aged 12-23 months. We used a modified WHO EPI 30 by 7 cluster sampling approach. Semi-structured questionnaires were employed for data collection. Wincosas and EpiInfo were used for data entry, management and analysis. The vaccination coverage, antigen-specific coverage calculated. The probability was set at 0.05 and the value was calculated to determine statistical significance of association.

RESULTS

Of the 480 records of children analysed, fully vaccinated accounted 81.3%, partially 16.7% and not vaccinated at all 2.1%. Access was 97.3% and utilization 91.2% with Pentavalent 1-3 dropout rate of 8.8%. Coverage for specific antigens were: BCG (97.1%), OPV 1/Pentavalent 1/PCV 1/Rotarix 1 (97.3%), OPV2/ Pentavalent 2/PCV 2/Rotarix 2 (94.0%), OPV3/ Pentavalent3/PCV 3 (88.8%), MR (87.7%) and YF (87.7%). Vaccination card availability, higher educational level of mothers and lower parity levels were significantly associated (p < 0.05) positively with childhood vaccination status. Invalid doses were 21.6% of childhood total vaccinations. Key reasons accounting for non-vaccination were: distant place of immunization 34.4 % (31/90), mother being busy 14.4% (13/90), vaccine unavailability 10.0% (9/90) and fears of side reactions 8.9% (8/90).

CONCLUSION

EPI childhood vaccination coverage for January, 2016 in KAPN District was high. There is the need to focus on counteracting the reasons identified to account for vaccination failure. This would improve and sustain vaccination coverage.

Acceptability of Reminders for Immunization Appointments via Mobile Devices by Mothers in Ilorin, Nigeria: A Cross-sectional Study

Objectives

Immunization coverage in Nigeria remains low despite the protection it confers. Reminders via mobile phones may be deployed as a means of improving vaccination coverage but requires the participation and cooperation of the caregiver. Therefore, we evaluated the acceptability of reminders for immunization appointment by mothers in Ilorin, Nigeria.

Methods

This descriptive cross-sectional study recruited 526 mothers from two public hospitals in Ilorin. Semi-structured questionnaires were used to collect information on ownership and access to phones, willingness to receive reminders, household, antenatal, and delivery characteristics.

Results

The majority (92.7%) of mothers had a personal phone, and all willingly provided contact details. Over half (69.0%) of mothers were willing to receive reminders. Postsecondary education (odds ratio (OR) = 1.958; 95% confidence interval (CI): 1.232-3.111) and antenatal care attendance by mothers (OR = 8.381; 95% CI: 2.495-28.170) were significant determinants of mothers willingness to receive reminders. Mothers with less than or equal to four children had a three-fold increased odds of wanting reminders. Artisan mothers were less likely to want reminders compared with unemployed mothers (OR = 0.506; 95% CI: 0.291-0.847).

Conclusions

Most mothers are willing to receive reminders on immunization appointments via their mobile phone. Determinants of maternal willingness to receive reminders include mothers with less than four children, postsecondary education, and antenatal care attendance. Program planners should consider utilizing reminders as a strategy to increase the immunization uptake with access to contact details making this feasible.

Using best-worst scaling to rank factors affecting vaccination demand in northern Nigeria

BACKGROUND

Understanding and ranking the reasons for low vaccination uptake among parents in northern Nigeria is critical to implement effective policies to save lives and prevent illnesses. This study applies best-worst scaling (BWS) to rank various factors affecting parents' demand for routine childhood immunization.

METHODS

We conducted a household survey in Nahuche, Zamfara State in northern Nigeria. Nearly two hundred parents with children under age five were asked about their views on 16 factors using a BWS technique. These factors focused on known attributes that influence the demand for childhood immunization, which were identified from a literature review and reviewed by a local advisory board. The survey systematically presented parents with subsets of six factors and asked them to choose which they think are the most and least important in decisions to vaccinate children. We used a sequential best-worst analysis with conditional logistic regression to rank factors.

RESULTS

The perception that vaccinating a child makes one a good parent was the most important motivation for parents in northern Nigeria to vaccinate children. Statements related to trust and social norms were ranked higher in importance compared to those that highlighted perceived benefits and risks, healthcare service, vaccine information, or opportunity costs. Fathers ranked trust in the media and views of their leaders to be of greatest importance, whereas mothers placed greater importance on social perceptions and norms. Parents of children without routine immunization ranked their trust in local leaders about vaccines higher in considerations, and the media's views lower, compared to parents with children who received routine immunization.

CONCLUSIONS

Framing immunization messages in the context of good parenting and hearing these messages from trusted information sources may motivate parental uptake of childhood vaccines. These results are useful to policymakers to prioritize resources in order to increase awareness and demand for childhood immunization.

Understanding vaccine hesitancy in polio eradication in northern Nigeria

BACKGROUND

Vaccine hesitancy constitutes a major threat to the Global Polio Eradication Initiative (GPEI), and to further expansion of routine immunisation. Understanding hesitancy, leading in some cases to refusal, is vital to the success of GPEI. Re-emergence of circulating wild poliovirus in northern Nigeria in mid-2016, after 24months polio-free, gives urgency to this. But it is equally important to protect and sustain the global gains available through routine immunisation in a time of rising scepticism and potential rejection of specific vaccines or immunisation more generally.

METHODS AND FINDINGS

This study is based on a purposive sampling survey of 1653 households in high- and low-performing rural, semiurban and urban areas of three high-risk states of northern Nigeria in 2013-14 (Sokoto, Kano and Bauchi). The survey sought to understand factors at household and community level associated with propensity to refuse polio vaccine. Wealth, female education and knowledge of vaccines were associated with lower propensity to refuse oral polio vaccine (OPV) among rural households. But higher risk of refusal among wealthier, more literate urban household rendered these findings ambiguous. Ethnic and religious identity did not appear to be associated with risk of OPV refusal. Risk of vaccine refusal was highly clustered among households within a small sub-group of sampled settlements. Contrary to expectations, households in these settlements reported higher levels of expectation of government as service provider, but at the same time lesser confidence in the efficacy of their relations with government.

CONCLUSIONS

Results suggest that strategies to address the micro-political dimension of vaccination - expanding community-level engagement, strengthening the role of local government in public health, and enhancing public participation of women - should be effective in reducing non-compliance, asan important set of strategies complementary to conventional didactic/educational approaches and working through religious and traditional 'influencers'.

Factors contributing to regional inequalities in acute respiratory infections symptoms among under-five children in Nigeria: a decomposition analysis

BACKGROUND

Acute respiratory infections (ARI) are major causes of morbidity and mortality in many low-income countries. Although factors associated with ARI symptoms in children under 5 years of age have been identified; however, variation in their prevalence resulting from regional-specific proximate determinants has received little attention. Therefore, we aim to investigate the specific regional determinants of overall and wealth-related inequality in children having ARI in Nigeria over a decade.

METHODS

We analyzed trends in development of ARI symptoms among children under 5 years of age in Nigeria using nationally representative cross sectional surveys carried out in 2003, 2008 and 2013. Overall- and household wealth index based- inequality in the distribution of prevalence of ARI symptoms were estimated by region using Gini index and Concentration Index, respectively. Multivariate logistic regressions for complex survey and decomposition analysis for both indexes were used to calculate percentual contribution.

RESULTS

We found a decreasing trend in development of ARI symptoms over the decade between regions. Children in South Western region had reduced likelihood of developing the symptoms. Concentration index (CI) for the prevalence of ARI symptoms over the years and across regions had negative values (all p < 0.05). Gini index (GI) varies from 0.21 in North East to 0.62 in South Western region. Furthermore, the mapping showed that the extent at which both inequalities contribute to ARI symptoms prevalence in each region is different. The four major sources of wealth-related inequalities were poor households, no maternal education, biomass cooking, and rural area. The major contributors to overall inequalities were having a child aged 6 to 23 months, having no maternal education, having no vaccination card, and having a high birth order/short birth interval.

CONCLUSIONS

Although ARI prevalence decreased over the decade, it has remained unequally distributed between regions and over the time. The sources of those inequalities are context sensitive. Thus, in future health promotion initiatives, it is imperative to account for regional variations in the distribution of ARI.

Evaluation of immunization coverage and its associated factors among children 12-23 months of age in Techiman Municipality, Ghana, 2016

BACKGROUND

In Ghana, Expanded Programme on Immunization administrative coverages are usually high while childhood immunization status remains low. Majority of children do not receive all the recommended 7 vaccines in 15 doses before 1 year of age. Surveys to validate administrative coverages and identify predictors of immunization status are not given the desired attention. Thus, the objective of this study was to evaluate the immunization coverage and its associated factors among children aged 12-23 months in Techiman Municipality, Ghana.

METHODS

A cross-sectional cluster survey was conducted among 600 children. Data was collected using semi-structured questionnaire through face-to-face interviews. The tools were pre-tested in three communities with similar characteristics. The mothers/caregivers were interviewed and additional information extracted from child immunization cards. We observed the presence of Bacillus Calmette-Guerin scar on each child. Data was entered, cleaned and analyzed using Statistical Package for Social Sciences (SPSS) version 17.0. Descriptive statistics such as percentages, frequencies and cross tabulations performed using SPSS while bivariate and multivariate logistic regression analysis conducted using Stata 12.1 version to estimate the Odds Ratio of not being fully immunized.

RESULTS

In total, 89.5% (537/600) of the children were fully immunized, 9.5% partially immunized and 1.0% received no vaccine. In the multivariate analysis, the following determinants were significantly associated with the likelihood of being not fully vaccinated (Odds Ratio (AOR) larger than 1) : age of the mother/caregiver 40-49 years (AOR = 0.15, 95%CI = 0.05-0.87) compared to less than 20 years; marital status (compared to never married/single: being married AOR = 0.29, 95%CI = 0.13-0.68), ethnicity (compared to the main ethnic group Akan: Frafra (AOR = 4.71, 95%CI = 146-15.18) and Kusaasi (AOR = 0.09, 95%CI = 0.02-0.51), religion (compared to Islam: Christianity AOR = 0.17, 95%CI = 0.06-0.50), sex of child (compared to male: female AOR = 0.39, 95%CI = 0.19-0.80) and possession of immunization card (compared to those having the card: those without the card AOR = 84.43, 95%CI = 17.04-418.33). Mothers/caregivers aged 40-49 years, being married, Kusaasi ethnic groups, Christian and female child have a higher likelihood of being fully immunized, while Frafra ethnic group and no immunization card have a higher likelihood of not being fully immunized. We found no association between immunization status and child's relationship to respondent; parity; education; occupation and child's age.

CONCLUSION

Immunization status (89.5%) and coverages ranged 92 to 99% of the vaccine doses is high compared to national and regional. Problems of not fully immunized persists and needs urgent attention. Education on immunization should be intensified by health providers. Moreover, disadvantaged populations should be reached with immunization services using out-reach activities.

Coverage and determinants of childhood immunization in Nigeria: A systematic review and meta-analysis

INTRODUCTION

The proportion of fully immunized children in Nigeria is reportedly low. There are concerns over national immunization data quality, with this possibly limiting country-wide response. We reviewed publicly available evidence on routine immunization across Nigeria to estimate national and zonal coverage of childhood immunization and associated determinants.

METHODS

A systematic search of Medline, EMBASE, Global Health and African Journals Online (AJOL) was conducted. We included population-based studies on childhood immunization in Nigeria. A random effects meta-analysis was conducted on extracted crude rates to arrive at national and zonal pooled estimates for the country.

RESULTS

Our search returned 646 hits. 21 studies covering 25 sites and 26,960 children were selected. The estimated proportion of fully immunized children in Nigeria was 34.4% (95% confidence interval [CI]: 27.0-41.9), with South-south zone having the highest at 51.5% (95% CI: 20.5-82.6), and North-west the lowest at 9.5% (95% CI: 4.6-14.4). Mother's social engagements (OR=4.0, 95% CI: 1.9-8.1) and vaccines unavailability (OR=3.9, 95% CI: 1.2-12.3) were mostly reported for low coverage. Other leading determinants were vaccine safety concerns (OR=3.0, 95% CI: 0.9-9.4), mother's low education (OR=2.5, 95% CI: 1.8-3.6) and poor information (OR=2.0, 95% CI: 0.8-4.7).

CONCLUSION

Our study suggests a low coverage of childhood immunization in Nigeria. Due to the paucity of data in the Northern states, we are still uncertain of the quality of evidence presented. It is hoped that this study will prompt the needed research, public health and policy changes toward increased evenly-spread coverage of childhood immunization in the country.

Maternal characteristics and immunization status of children in North Central of Nigeria

INTRODUCTION

Routine immunization coverage in Nigeria is one of the lowest national coverage rates in the world. The objective of this study was to compare the mother' characteristics and the child's Immunization status in some selected rural and urban communities in the North central part of Nigeria.

METHODS

A descriptive cross sectional study, using a multistage sampling technique to select 600 respondent women with an index child between 0-12 months.

RESULTS

Mean age of rural respondents was 31.40±7.21 years and 32.72+6.77 years among urban respondents, though there was no statistically significant difference in age between the 2 locations (p-0.762). One hundred and ninetyseven (65.7%) and 241(80.3%) of rural and urban respondents respectively were aware of immunization, the difference was statistically significant (p-0.016). knowledge in urban areas was better than among rural respondents. There was statistically significant association between respondents age, employment status, mothers' educational status and the child's immunization status (P<0.05), while variables like parity, age at marriage, marital status, No of children, household income and place of index were not statistically associated with immunization status as P>0.05. More than half 179(59.7%) of rural and 207(69.0%) of urban had good practice of immunization though the difference was not statistically significant (p-0.165).

CONCLUSION

The immunization coverage in urban community was better than that of the rural community. The result of this study has clearly indicated that mothers in Nigeria have improved on taking their children for immunization in both rural and urban area compared to previous reports.

Analysis of the effects of individual and community level factors on childhood immunization in Malawi

BACKGROUND

Empirical evidence regarding the relationship between childhood immunization and individual- and community-level factors in low-income countries has received little attention. We compared the trends and the effects of a wide range of individual- and community-level socioeconomic factors on the likelihood of a child being immunized between 2004 and 2010 in Malawi.

METHODS

We used data from the 2004 and 2010 Malawi Demographic and Health Survey and applied generalized estimating logistic regression equation to analyze data respectively on 2042 and 3496 children aged 12-23months. We compared the relationship between individual- and community-level socioeconomic factors and a child's vaccination status for four basic vaccines recommended by the World Health Organization: bacillus Calmette-Guérin (BCG) vaccine, diphtheria-tetanus-pertussis (DPT3) vaccine, oral polio vaccine (OPV3), and measles-containing vaccine 1 (MCV1).

RESULTS

The trends of vaccination had a similar pattern in 2004 and 2010. The coverage of the four vaccinations was highest for BCG and lowest for OPV3 and complete immunization was higher in 2010. The multivariate analyses show that mother's low education, having one or none antenatal visits, having no immunization card, having immunization card but not seen, residing in poor households, and living in central region were the most significant factors associated with decreased odds of achieving vaccination coverage and complete vaccination in both 2004 and 2010. However, maternal education was more likely to be associated with children's immunization in 2010, while the geographical region was more likely to be associated with children's immunization in 2004.

CONCLUSIONS

There were marked improvements in the national immunization coverage from 2004 to 2010. In order to achieve complete immunization, to further enhance the national immunization coverage as well as to lessen the gaps and disparities in childhood vaccination in Malawi, policy makers should design interventions based on the factors addressed in this study.

Incomplete childhood immunization in Nigeria: a multilevel analysis of individual and contextual factors

Background

Under-five mortality remains high in sub-Saharan Africa despite global decline. One quarter of these deaths are preventable through interventions such as immunization. The aim of this study was to examine the independent effects of individual-, community- and state-level factors on incomplete childhood immunization in Nigeria, which is one of the 10 countries where most of the incompletely immunised children in the world live.

Methods

The study was based on secondary analyses of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel multivariable logistic regression models were applied to the data on 5,754 children aged 12–23 months who were fully immunized or not (level 1), nested within 896 communities (level 2) from 37 states (level 3).

Results

More than three-quarter of the children (76.3%) were not completely immunized. About 83% of children of young mothers (15–24 years) and 94% of those whose mothers are illiterate did not receive full immunization. In the fully adjusted model, the chances of not being fully immunized reduced for children whose mothers attended antenatal clinic (adjusted odds ratio [aOR] = 0.49; 95% credible interval [CrI] = 0.39–0.60), delivered in health facility (aOR = 0.62; 95% CrI = 0.51–0.74) and lived in urban area (aOR = 0.66; 95% CrI = 0.50–0.82). Children whose mothers had difficulty getting to health facility (aOR = 1.28; 95% CrI = 1.02–1.57) and lived in socioeconomically disadvantaged communities (aOR = 2.93; 95% CrI = 1.60–4.71) and states (aOR = 2.69; 955 CrI =1.37–4.73) were more likely to be incompletely immunized.

Conclusions

This study has revealed that the risk of children being incompletely immunized in Nigeria was influenced by not only individual factors but also community- and state-level factors. Interventions to improve child immunization uptake should take into consideration these contextual characteristics.

Assessment of primary health care facilities' service readiness in Nigeria

Background

Effective delivery of healthcare services requires availability of adequate infrastructure, diagnostic medical equipment, drugs and well-trained medical personnel. In Nigeria, poor funding and mismanagement often characterize healthcare service delivery thereby affecting coverage and quality of healthcare services. Therefore, the state of service delivery in Nigeria’s health sector has come under some persistent criticisms. This paper analyzed service readiness of Primary Health Care (PHC) facilities in Nigeria with focus on availability of some essential drugs and medical equipment.

Methods

Service Delivery Indicator (SDI) data for PHC in Nigeria were used. The data were collected from 2480 healthcare facilities from 12 states in the Nigeria’s 6 geopolitical zones between 2013 and 2014. Data were analyzed with descriptive statistics, Principal Component Analysis (PCA) and Ordinary Least Square regression.

Results

Medical disposables such as hand gloves and male condoms were reported to be available in 77.18 and 44.03% of all the healthcare facilities respectively, while immunization services were provided by 86.57%. Functional stethoscopes were reported by 77.22% of the healthcare facilities, while only 68.10% had sphygmomanometers. In the combined healthcare facilities, availability of some basic drugs such as Azithromycin, Nifedipine, Dexamethasone and Misoprostol was low with 10.48, 25.20, 21.94 and 17.06%, respectively, while paracetamol and folic acid both had high availability with 74.31%. Regression results showed that indices of drug and medical equipment availability increased significantly (p < 0.05) among states in southern Nigeria and with presence of some power sources (electricity, generators, batteries and solar), but decreased among dispensaries/health posts. Travel time to headquarters and rural facilities significantly reduced indices of equipment availability (p < 0.05).

Conclusion

It was concluded that for Nigeria to ensure better equity in access to healthcare facilities, which would facilitate achievement of some health-related sustainable development goals (SDGs), quality of services at its healthcare facilities should be improved. Given some differences between availability of basic medical equipment and their functionality, and lack of some basic drugs, proper inventory of medical services should be taken with effort put in place to increase funding and ensure proper management of healthcare resources.

Demand- and supply-side determinants of diphtheria-pertussis-tetanus nonvaccination and dropout in rural India

BACKGROUND

Although 93% of 12- to 23-month-old children in India receive at least one vaccine, typically Bacillus Calmette-Guérin, only 75% complete the recommended three doses of diphtheria-pertussis-tetanus (DPT, also referred to as DTP) vaccine. Determinants can be different for nonvaccination and dropout but have not been examined in earlier studies. We use the three-dose DPT series as a proxy for the full sequence of recommended childhood vaccines and examine the determinants of DPT nonvaccination and dropout between doses 1 and 3.

METHODS

We analyzed data on 75,728 6- to 23-month-old children in villages across India to study demand- and supply-side factors determining nonvaccination with DPT and dropout between DPT doses 1 and 3, using a multilevel approach. Data come from the District Level Household and Facility Survey 3 (2007-08).

RESULTS

Individual- and household-level factors were associated with both DPT nonvaccination and dropout between doses 1 and 3. Children whose mothers had no schooling were 2.3 times more likely not to receive any DPT vaccination and 1.5 times more likely to drop out between DPT doses 1 and 3, compared with children whose mothers had 10 or more years of schooling. Although supply-side factors related to availability of public health facilities and immunization-related health workers in villages were not correlated with dropout between DPT doses 1 and 3, children in districts where 46% or more villages had a healthcare subcentre were 1.5 times more likely to receive at least one dose of DPT vaccine compared with children in districts where 30% or fewer villages had subcentres.

CONCLUSIONS

Nonvaccination with DPT in India is influenced by village- and district-level contextual factors over and above individuals' background characteristics. Dropout between DPT doses 1 and 3 is associated more strongly with demand-side factors than with village- and district-level supply-side factors.

Inequalities in full immunization coverage: trends in low- and middle-income countries

Objective

To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.

Methods

In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.

Findings

In each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.

Conclusion

Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.

Immunisation coverage and its determinants among children aged 12-23 months in Atakumosa-west district, Osun State Nigeria: a cross-sectional study

BACKGROUND

Routine immunisation (RI) contributes immensely to reduction in mortality from vaccine preventable diseases (VPD) among children. The Nigerian Demographic and Health Survey, 2008 revealed that only 58 % of children in Osun State had received all recommended vaccines, which is far below World Health Organization (WHO) target of 80 %. We therefore, assessed RI uptake and its determinants among children in Atakumosa-west district of Osun State.

METHODS

Atakumosa-west district has an estimated population of 90,525 inhabitants. We enrolled 750 mothers of children aged 12-23 months in this cross-sectional study. Semi-structured questionnaires were used to obtain data on socio-demographic characteristics, knowledge of mothers on RI, history of RI in children and factors associated with full RI uptake. A fully-immunised child was defined as a child who had received one dose of Bacillus-Calmette-Guerin, three doses of Oral-Polio-Vaccine, three doses of Diptheria-Pertusis-Tetanus vaccine and one dose of measles vaccine by 12 months of age. We tested for the association between immunisation uptake and its likely determinants using multivariable logistic regression at 0.05 level of significance and 95 % confidence Interval (CI).

RESULTS

Mean ± (SD) age of the mothers and children were 27.9 ± 6.1 years and 17.2 ± 4.0 months, respectively. About 94 % (703/750) of mothers had received antenatal care (ANC) and 63.3 % (475) of the children possessed vaccination cards. Seventy-six percent (571/750) had good knowledge of RI and VPD. About 58 % (275/475) of children who possessed vaccination card were fully-immunised. Mothers antenatal care attendance (aOR = 3.3, 95 % CI = 1.1-8.3), maternal tetanus toxoid immunisation (aOR = 3.2, 95 % CI = 1.1-10.0) access to immunisation information (aOR = 1.8, 95 % CI = 1.1-2.5) and mothers having good knowledge of immunisation (aOR = 2.4, 95 % CI = 1.6-3.8) were significant determinants of full immunisation.

CONCLUSIONS

Routine immunisation uptake was still below WHO target in the study area. Encouraging mothers to attend antenatal care and educational interventions targeted at rural mothers are recommended to improve vaccination status of children in the rural communities.

Explaining socio-economic inequalities in immunization coverage in Nigeria

Globally, in 2013 over 6 million children younger than 5 years died from either an infectious cause or during the neonatal period. A large proportion of these deaths occurred in developing countries, especially in sub-Saharan Africa. Immunization is one way to reduce childhood morbidity and deaths. In Nigeria, however, although immunization is provided without a charge at public facilities, coverage remains low and deaths from vaccine preventable diseases are high. This article seeks to assess inequalities in full and partial immunization coverage in Nigeria. It also assesses inequality in the 'intensity' of immunization coverage and it explains the factors that account for disparities in child immunization coverage in the country. Using nationally representative data, this article shows that disparities exist in the coverage of immunization to the advantage of the rich. Also, factors such as mother's literacy, region and location of the child, and socio-economic status explain the disparities in immunization coverage in Nigeria. Apart from addressing these issues, the article notes the importance of addressing other social determinants of health to reduce the disparities in immunization coverage in the country. These should be in line with the social values of communities so as to ensure acceptability and compliance. We argue that any policy that addresses these issues will likely reduce disparities in immunization coverage and put Nigeria on the road to sustainable development.

Timely immunization completion among children in Vietnam from 2000 to 2011: a multilevel analysis of individual and contextual factors

Background

Since the beginning of 2014, there have been nearly 6,000 confirmed measles cases in northern Vietnam. Of these, more than 86% had neither been immunized nor was their vaccination status confirmed.

Objective

To establish the likelihood that children under five in Vietnam had ‘timely immunization completion’ (2000–2011) and identify factors that account for variations in timely immunization completion.

Design

Secondary data from the Multiple Indicator Cluster Survey (MICS), which sampled women aged 15–49 from the 1999 Vietnamese Population and Housing Census frame, were analyzed. Multilevel analysis using Poisson regression was undertaken.

Results

Proportions of children under five who had timely immunization completion were low, especially for HBV dose 2 and HBV dose 3, which decreased between 2000 and 2011. Among seven vaccines used in the National Expanded Program of Immunization (EPI) in 2000, 2006, and 2011, measles dose 1 had the highest timely immunization completion at 65.3%, 66.7%, and 73.6%, respectively, and hepatitis B dose 1 had the lowest at 17.5%, 19.3%, and 45.5%, respectively. Timely immunization completion was less common among children whose mothers had relatively less household wealth, were from ethnic minorities, lived in rural areas, and had less education. At the community level, the child's region of residence was the main predictor of timely immunization completion, and the availability of hospital delivery and community prenatal care in the local community were also determinants.

Conclusion

The EPI should include ‘timely immunization completion’ as a quality indicator. There should also be greater focus and targeting in rural areas, and among women who have relatively low education, belong to minority groups, and have less household wealth. Further research on this topic using multilevel analysis is needed to better understand how these factors interact.

Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria

Background

The available data on routine immunization in Nigeria show a disparity in coverage between Northern and Southern Nigeria, with the former performing worse. The effect of socio-cultural differences on health-seeking behaviour has been identified in the literature as the main cause of the disparity. Our study analyses the role of supply-side determinants, particularly access to services, in causing these disparities.

Methods

Using routine government data, we compared supply-side determinants of access in two Northern states with two Southern states. The states were identified using criteria-based purposive selection such that the comparisons were made between a low-coverage state in the South and a low-coverage state in the North as well as between a high-coverage state in the South and a high-coverage state in the North.

Results

Human resources and commodities at routine immunization service delivery points were generally insufficient for service delivery in both geographical regions. While disparities were evident between individual states irrespective of regional location, compared to the South, residents in Northern Nigeria were more likely to have vaccination service delivery points located within a 5km radius of their settlements.

Conclusion

Our findings suggest that regional supply-side disparities are not apparent, reinforcing the earlier reported socio-cultural explanations for disparities in routine immunization service uptake between Northern and Southern Nigeria. Nonetheless, improving routine immunisation coverage services require that there are available human resources and that health facilities are equitably distributed.

The 5As: A practical taxonomy for the determinants of vaccine uptake

Suboptimal vaccine uptake in both childhood and adult immunisation programs limits their full potential impact on global health. A recent progress review of the Global Vaccine Action Plan stated that "countries should urgently identify barriers and bottlenecks and implement targeted approaches to increase and sustain coverage". However, vaccination coverage may be determined by a complex mix of demographic, structural, social and behavioral factors. To develop a practical taxonomy to organise the myriad possible root causes of a gap in vaccination coverage rates, we performed a narrative review of the literature and tested whether all non-socio-demographic determinants of coverage could be organised into 4 dimensions: Access, Affordability, Awareness and Acceptance. Forty-three studies were reviewed, from which we identified 23 primary determinants of vaccination uptake. We identified a fifth domain, Activation, which captured interventions such as SMS reminders which effectively nudge people towards getting vaccinated. The 5As taxonomy captured all identified determinants of vaccine uptake. This intuitive taxonomy has already facilitated mutual understanding of the primary determinants of suboptimal coverage within inter-sectorial working groups, a first step towards them developing targeted and effective solutions.

Controversies in faith and health care

Differences in religious faith-based viewpoints (controversies) on the sanctity of human life, acceptable behaviour, health-care technologies and health-care services contribute to the widespread variations in health care worldwide. Faith-linked controversies include family planning, child protection (especially child marriage, female genital mutilation, and immunisation), stigma and harm reduction, violence against women, sexual and reproductive health and HIV, gender, end-of-life issues, and faith activities including prayer. Buddhism, Christianity, Hinduism, Islam, Judaism, and traditional beliefs have similarities and differences in their viewpoints. Improved understanding by health-care providers of the heterogeneity of viewpoints, both within and between faiths, and their effect on health care is important for clinical medicine, public-health programmes, and health-care policy. Increased appreciation in faith leaders of the effect of their teachings on health care is also crucial. This Series paper outlines some faith-related controversies, describes how they influence health-care provision and uptake, and identifies opportunities for research and increased interaction between faith leaders and health-care providers to improve health care.

Individual and community level determinants of childhood full immunization in Ethiopia: a multilevel analysis

Background

Expanded program on immunization is one of the most successful and cost effective public health interventions that protect children against vaccine preventable diseases. The full childhood immunization coverage in many parts of Ethiopia is far from optimal. Hence, the main objective of this study was to assess factors associated with childhood full immunization in Ethiopia.

Methods

The data source for this study was the 2011 Ethiopian Demographic and Health Survey. Multilevel regression analysis techniques were used to conduct the analysis. Accordingly a two level multilevel regression analysis model was built with individuals (level 1) nested with in communities (level 2).

Results

A total of 4983 children aged 12–59 months nested within 520 clusters were included in the analysis. According to the analysis results, in the year 2011, 26 % of children less than 5 years old were fully immunized in Ethiopia. Being born at health institutions, higher level of maternal education, media exposure, region of residence and residing in communities possessing higher maternal antenatal care services utilization were positively associated with childhood full immunization. In contrary to this, the number children aged less than 5 years in the household was negatively associated with childhood full immunization. The random effect results indicated that 21 % of the variation among the communities was due to community level factors.

Conclusions

It was found that various individual and contextual factors were associated with childhood full immunization. In addition, significant community level variation remains after having controlled individual and community level factors which is an indicative of a need for further research on community level factors. Hence, utilizing multilevel modeling in determining the effect of both individual and contextual level factors simultaneously had brought an important output which may help planners, policy and decision makers to emphasize on both individuals and communities in which they live.

REGIONAL VARIATIONS IN INFANT AND CHILD MORTALITY IN NIGERIA: A MULTILEVEL ANALYSIS

There are substantial regional disparities in under-five mortality in Nigeria, and evidence suggests that both individual- and community-level characteristics have an influence on health outcomes. Using 2008 Nigeria Demographic and Health Survey data, this study (1) examines the effects of individual- and community-level characteristics on infant/child mortality in Nigeria and (2) determines the extent to which characteristics at these levels influence regional variations in infant/child mortality in the country. Multilevel Cox proportional hazard analysis was performed on a nationally representative sample of 28,647 children nested within 18,028 mothers of reproductive age, who were also nested within 886 communities. The results indicate that community-level variables (such as region, place of residence, community infrastructure, community hospital delivery and community poverty level) and individual-level factors (including child's sex, birth order, birth interval, maternal education, maternal age and wealth index) are important determinants of infant/child mortality in Nigeria. For instance, the results show a lower risk of death in infancy for children of mothers residing in communities with a high proportion of hospital delivery (HR: 0.70, p < 0.05) and for children whose mothers had secondary or higher education (HR: 0.84, p < 0.05). Although community factors appear to influence the association between individual-level factors and death during infancy and childhood, the findings consistently indicate that community-level characteristics are more important in explaining regional variations in child mortality, while individual-level factors are more important for regional variations in infant mortality. The results of this study underscore the need to look beyond the influence of individual-level factors in addressing regional variations in infant and child mortality in Nigeria.

Why children are not vaccinated against measles: a cross-sectional study in two Nigerian States

BACKGROUND

Childhood vaccination rates in Nigeria are among the lowest in the world and this affects morbidity and mortality rates. A 2011 mixed methods study in two states in Nigeria examined coverage of measles vaccination and reasons for not vaccinating children.

METHODS

A household survey covered a stratified random cluster sample of 180 enumeration areas in Bauchi and Cross River States. Cluster-adjusted bivariate and then multivariate analysis examined associations between measles vaccination and potential determinants among children aged 12-23 months, including household socio-economic status, parental knowledge and attitudes about vaccination, and access to vaccination services. Focus groups of parents in the same sites subsequently discussed the survey findings and gave reasons for non-vaccination. A knowledge to action strategy shared findings with stakeholders, including state government, local governments and communities, to stimulate evidence-based actions to increase vaccination rates.

RESULTS

Interviewers collected data on 2,836 children aged 12-23 months in Cross River and 2,421 children in Bauchi. Mothers reported 81.8% of children in Cross River and 42.0% in Bauchi had received measles vaccine. In both states, children were more likely to receive measles vaccine if their mothers thought immunisation worthwhile, if immunisation was discussed in the home, if their mothers had more education, and if they had a birth certificate. In Bauchi, maternal awareness about immunization, mothers' involvement in deciding about immunization, and fathers' education increased the chances of vaccination. In Cross River, children from communities with a government immunisation facility were more likely to have received measles vaccine. Focus groups revealed lack of knowledge and negative attitudes about vaccination, and complaints about having to pay for vaccination. Health planners in both states used the findings to support efforts to increase vaccination rates.

CONCLUSION

Measles vaccination remains sub-optimal, particularly in Bauchi. Efforts to counter negative perceptions about vaccination and to ensure vaccinations are actually provided free may help to increase vaccination rates. Parents need to be made aware that vaccination should be free, including for children without a birth certificate, and vaccination could be an opportunity for issuing birth certificates. The study provides pointers for state level planning to increase vaccination rates.

Evaluation of invalid vaccine doses in 31 countries of the WHO African Region

We examined (a) the fraction of and extent to which vaccinations were administered earlier than recommended (age-invalid) or with too short intervals between vaccine doses (interval-invalid) in countries of the World Health Organisation (WHO) African Region and (b) individual- and community-level factors associated with invalid vaccinations using multilevel techniques. Data from the Demographic and Health Surveys conducted in the last 10 years in 31 countries were used. Information about childhood vaccinations was based on vaccination records (n=134,442). Invalid vaccinations (diphtheria, tetanus, pertussis [DTP1, DTP3] and measles-containing vaccine (MCV)) were defined using the WHO criteria. The median percentages of invalid DTP1, DTP3 and MCV vaccinations across all countries were 12.1% (interquartile range, 9.4-15.2%), 5.7% (5.0-7.6%), and 15.5% (10.0-18.1%), respectively. Of the invalid DTP1 vaccinations, 7.4% and 5.5% were administered at child's age of less than one and two weeks, respectively. In 12 countries, the proportion of invalid DTP3 vaccinations administered with an interval of less than two weeks before the preceding dose varied between 30% and 50%. In 13 countries, the proportion of MCV doses administered at child's age of less than six months varied between 20% and 45%. Community-level variables explained part of the variation in invalid vaccinations. Invalid vaccinations are common in African countries. Timing of childhood vaccinations should be improved to ensure an optimal protection against vaccine-preventable infections and to avoid unnecessary wastage in these economically deprived countries.

Determinants of uptake of third doses of oral polio and DTP vaccines in the Ibadan North Local Government Area of Nigeria

BACKGROUND

High dropout rates in the uptake of oral polio vaccine (OPV) and DTP vaccine persist despite efforts to improve immunisation coverage. This study identified determinants of uptake of third doses of OPV3 and DTP3 among infants who received first doses of either or both vaccines at immunisation centres in the Ibadan North Local Government Area of Nigeria.

METHODS

Using a cohort study design, 400 mother-child pairs were assessed. A semi-structured, interviewer-administered questionnaire was used to collect data from each participant who were followed up for 90 days. Dates of subsequent doses of the vaccines were recorded. Multivariate analysis was performed using the log-rank test and Cox's regression analysis to identify predictive factors.

RESULTS

Only 43.5% (174/400) and 24.8% (89/359) of children completed the OPV3 and DTP3 vaccines, respectively. Factors predictive of uptake of OPV3 were first birth (HR=1.66, 95% CI 1.11-2.48) and attending a tertiary health facility (HR=2.27, 95% CI 1.41-3.65), while attending a secondary health facility was significant for DTP3 uptake (HR=2.43, 95% CI 1.30-4.61).

CONCLUSIONS

Uptake of third doses of vaccines was influenced by the type of health facility attended and the child birth order. Efforts to reduce vaccination dropouts should include creation of awareness of the importance of completing immunisation schedules for children of higher birth orders as well as improved service delivery at health facilities.

Factors associated with non-utilization of child immunization in Pakistan: evidence from the Demographic and Health Survey 2006-07

Background

The proportion of incompletely immunized children in Pakistan varies from 37-58%, and this has recently resulted in outbreaks of measles and polio. The aim of this paper is to determine the factors associated with incomplete immunization among children aged 12-23 months in Pakistan.

Methods

Secondary analysis was conducted on nationally representative cross-sectional survey data from the Pakistan Demographic and Health Survey, 2006-07. The analysis was limited to ever-married mothers who had delivered their last child during the 23 months immediately preceding the survey (n = 2,435). ‘Complete immunization’ was defined as the child having received twelve doses of five vaccines, and ‘incomplete immunization’ was defined if he/she had missed at least one of these twelve doses. The association between child immunization status and determinants of non-utilization of vaccines was assessed by calculating unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals using a multivariable binary logistic regression.

Results

The findings of this research showed that nearly 66% of children were incompletely immunized against seven preventable childhood diseases. The likelihood of incomplete immunization was significantly associated with the father’s occupation as a manual worker (AOR = 1.47; 95% CI: 1.10-1.97), lack of access to information (AOR = 1.35; 95% CI: 1.09-1.66), non-use of antenatal care (AOR = 1.33; 95% CI: 1.07-1.66), children born in Baluchistan region (AOR = 1.74; 95% CI: 1.12-2.70) and delivery at home (AOR = 1.39; 95% CI: 1.14-1.69).

Conclusions

Despite governmental efforts to increase rates of immunization against childhood diseases, the proportion of incompletely immunized children in Pakistan is still high. Targeted interventions are needed to increase the immunization rates in Pakistan. These interventions need to concentrate on people with low socioeconomic and educational status in order to improve their knowledge of this topic.

Trends and patterns of under-5 vaccination in Nigeria, 1990-2008: what manner of progress?

BACKGROUND

Despite efforts towards reducing childhood morbidity and mortality, Nigeria ranks among countries with the highest rates of vaccine-preventable diseases including tuberculosis, poliomyelitis, measles, diphtheria, pertussis and tetanus. These efforts include regular rounds of immunization days and routine exercises. The government of Nigeria periodically undertakes National Demographic and Health (NDH) surveys, which tap information on various health indices including vaccination coverage. Limited studies have used the NDHS data to examine the trends in vaccination coverage for the assessment of successes or failures of the immunization efforts.

METHODS

This study used four NDH Surveys datasets between 1990 and 2008, which generated child health information including the proportion that had had any or all basic childhood vaccines. A combined total of 44,071 (weighted) children were involved in the study. The trend and pattern of vaccination over 18 years were examined while selected factors were regressed to obtain predictors of child vaccinations in Nigeria.

RESULTS

The most recent survey (2008) reported more complete vaccination apart from 1990, which was said to be inaccurate. In all surveys, children from mothers with higher education, who were delivered in hospitals, lived in urban areas, and whose mothers work outside the home had significantly higher proportions of completed basic vaccination. A lower level of childhood vaccination is observed in the northern parts, while higher rates are observed in the southern parts. More complete vaccination coverage was reported in the 1990 survey, followed by 2008, 1999 and 2003. In addition, children from mothers with higher levels of education, who were delivered in hospitals, who lived in urban areas, and whose mothers work outside the home had significantly higher proportions of completed basic vaccination.

CONCLUSION

Much more work needs to be done if more children are to be covered and thus reduce vaccine-preventable diseases.

Income inequality and schizophrenia: increased schizophrenia incidence in countries with high levels of income inequality

BACKGROUND

Income inequality is associated with numerous negative health outcomes. There is evidence that ecological-level socio-environmental factors may increase risk for schizophrenia.

AIMS

The aim was to investigate whether measures of income inequality are associated with incidence of schizophrenia at the country level.

METHOD

We conducted a systematic review of incidence rates for schizophrenia, reported between 1975 and 2011. For each country, national measures of income inequality (Gini coefficient) along with covariate risk factors for schizophrenia were obtained. Multi-level mixed-effects Poisson regression was performed to investigate the relationship between Gini coefficients and incidence rates of schizophrenia controlling for covariates.

RESULTS

One hundred and seven incidence rates (from 26 countries) were included. Mean incidence of schizophrenia was 18.50 per 100,000 (SD = 11.9; range = 1.7-67). There was a significant positive relationship between incidence rate of schizophrenia and Gini coefficient (β = 1.02; Z = 2.28; p = .02; 95% CI = 1.00, 1.03).

CONCLUSIONS

Countries characterized by a large rich-poor gap may be at increased risk of schizophrenia. We suggest that income inequality impacts negatively on social cohesion, eroding social capital, and that chronic stress associated with living in highly disparate societies places individuals at risk of schizophrenia.

Timeliness of childhood vaccine uptake among children attending a tertiary health service facility-based immunisation clinic in Ghana

Background

Childhood immunisation is a cost-effective activity in health. Immunisation of children has contributed to reducing child morbidity and mortality. In the last two decades, global deaths from vaccine-preventable illnesses have decreased significantly as a result of immunisation. Similar trends have been observed in Ghana following the introduction of the Expanded Programme on Immunisation. The administration of vaccines is based on the period of highest susceptibility among others. Ghana has long used the proportion of children receiving vaccines and the trends in vaccine preventable illness incidence as performance indicators for immunisation. The addition of timeliness of vaccine uptake as an additional performance indicator has been recommended. This study evaluated the timeliness of vaccine uptake among children immunised at the Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Methods

The study was conducted at the Maternal and Child Health clinic of the hospital between February and March 2012. A representative sample of 259 respondents was selected by simple random sampling. Data collection was by a structured questionnaire and included the examination of Child Health records booklet. Data was entered into a Microsoft Office Access database and analysed using Epi Info Version 3.5.1 2008.

Results

The majority of mothers attended antenatal clinics during pregnancy. An overwhelming majority of babies (98.8%) were delivered in a hospital. About 85% of babies were less than 12 months of age. Mean time taken to reach the clinic was 30 minutes. Vaccine uptake was generally timely for initial vaccines. The proportion of children receiving the vaccines later increased with latter vaccines. Overall, 87.3% of babies received vaccines on time with only 5.3% receiving vaccines beyond 28 days of the scheduled date. Children receiving immunisations services in the same facility as they were born were more likely to receive the BCG vaccine on time.

Conclusions

Vaccine uptake is mostly timely among respondents in the study. The BCG vaccine in particular was received on time among children born in the same facility as the immunisation clinic. There is the need to further examine the timeliness of vaccine uptake among children delivered outside health facilities in Ghana.

Demographic, socio-economic and geographic determinants of seasonal influenza vaccine uptake in rural western Kenya, 2011

Influenza-associated acute lower respiratory infections cause a considerable burden of disease in rural and urban sub-Saharan Africa communities with the greatest burden among children. Currently, vaccination is the best way to prevent influenza infection and accompanying morbidities. We examined geographic, socio-economic and demographic factors that contributed to acceptance of childhood seasonal influenza vaccination among children living in a population-based morbidity surveillance system in rural western Kenya, where influenza vaccine was offered free-of-charge to children 6 months-10 years old from April to June, 2011. We evaluated associations between maternal and household demographic variables, socio-economic status, and distance from home to vaccination clinics with family vaccination status. 7249 children from 3735 households were eligible for vaccination. Of these, 2675 (36.9%) were fully vaccinated, 506 (7.0%) were partially vaccinated and 4068 (56.1%) were not vaccinated. Children living in households located >5km radius from the vaccination facilities were significantly less likely to be vaccinated (aOR=0.70; 95% CI 0.54-0.91; p=0.007). Children with mothers aged 25-34 and 35-44 years were more likely to be vaccinated than children with mothers less than 25 years of age (aOR=1.36; 95% CI 1.15-1.62; p<0.001; and aOR=1.35; 95% CI 1.10-1.64; p=0.003, respectively). Finally, children aged 2-5 years and >5 years of age (aOR=1.38; 95% CI 1.20-1.59; p<0.001; and aOR=1.41; 95% CI 1.23-1.63; p<0.001, respectively) and who had a sibling hospitalized within the past year (aOR=1.73; 95% CI 1.40-2.14; p<0.001) were more likely to be vaccinated. Shorter distance from the vaccination center, older maternal and child age, household administrator's occupation that did not require them to be away from the home, and having a sibling hospitalized during the past year were associated with increased likelihood of vaccination against influenza in western Kenya. These findings should inform the design of future childhood seasonal influenza vaccination campaigns in rural Kenya, and perhaps elsewhere in Africa.

Determinants of Maternal Health Care Utilization in Nigeria: a multilevel approach

INTRODUCTION

Fourteen percent of maternal deaths globally occur in Nigeria. Low utilization of maternal health services for delivery may partially explain the high maternal mortality. The aim of this study was to examine the contribution of community factors in explaining variations in the use of health facilities for delivery in Nigeria.

METHODS

Our sample consisted of 17,542 women aged 15-49 years drawn from 2008 Nigeria Demographic and Health Survey, who had had their last birth in the five years before the survey. We employed multilevel analysis to identify community factors related to the use of delivery care.

RESULTS

In addition to several individual factors, region of residence was significantly associated with facility delivery. Women who lived in Northern Nigeria were less likely to deliver in a health facility than those who resided in the Southern part of the country. Residence in communities with a high proportion of women who had secondary and higher education significantly increased the odds of facility delivery whereas ethnic diversity was negatively associated with health facility delivery.

CONCLUSION

Interventions aimed at promoting the use of health facility for childbirth should not only be implemented at the individual level but also tailored to the community level as interventions conceived without consideration for community context are likely to have limited impact. Increasing women's education in disadvantaged communities and region-specific interventions that increase access to health facilities are likely to have far-reaching impacts in reducing maternal mortality.

Contextual determinants of maternal health care service utilization in Nigeria

Despite the high maternal mortality ratio in Nigeria, the use of maternal health care services is very poor. Attempts to explain this situation has focused on individual level factors and the influence of community contextual factors have not received much attention. This study examined the relation of community factors to the use of antenatal care in Nigeria, and explored whether community factors moderated the association between individual characteristics and antenatal care visits. Data were drawn from the 2008 Nigeria Demographic and Health Survey among 16,005 women aged 15-49 years who had had their last delivery in the five years preceding the survey. Results from multi-level models indicated that living in communities with a high proportion of women who delivered in a health facility was associated with four or more antenatal care visits. Residence in high-poverty communities decreased the likelihood of antenatal care attendance. Living in communities with a high proportion of educated women was not significantly related to antenatal care visits. Community factors acted as moderators of the association between educational attainment and antenatal care attendance. Improvement in antenatal care utilization may therefore be enhanced by targeting poverty reduction programs and increasing health facility delivery in disadvantaged communities.

Socio Cultural and Geographical Determinants of Child Immunisation in Borno State, Nigeria

Immunisation has been an important strategy for disease prevention globally. Despite proven successes in other settings, child immunisation has continued to be problematic in developing countries including Nigeria. In addressing the problems, policy in Nigeria is largely directed at overcoming socio cultural issues surrounding parents’ rejection of vaccines. However, determinants of immunisation have geographical implications as well. A cross sectional survey was used to select 484 mothers/caregivers through a multi stage cluster sampling technique from the three senatorial districts of Borno State, Nigeria. Mothers or caregivers of children 12–23 months were interviewed using a structured questionnaire adapted from the Nigeria Demographic and Health Survey (2008). Socio cultural factors measured include mother’s education, religion, husband’s permission and sex of child while spatial variables include location i.e. whether rural or urban, and distance measured in terms of physical distance, cost and perception of physical distance. Descriptive statistics, univariate and multivariate logistic regressions were used to analyse the results. Data indicate that only 10.5% of children were fully immunised. Though immunisation uptake differed between the senatorial districts, this was not significant (P=0.1). In the bivariate analysis, mothers living in urban areas, <1 km to immunisation centre, their perception of travel distance and travel cost were the spatial predictors of immunisation while literacy and husband’s permission were the socio-cultural factors of significance. However, in the multivariate regression only two geographical factors i.e. living in an urban area [odds ratio (OR) 3.42, confidence interval (CI) 1.40–8.33] and mothers’ perception of distance (OR 4.52, CI 2.14–9.55) were protective against under immunisation while mother’s education was the only socio cultural variable of significance (OR 0.10, CI 0.03–0.41). It was concluded that while it is important to address socio cultural issues, policies directed at overcoming the friction of distance especially mobile clinics in rural areas are required to significantly improve immunisation uptake in the state.

Multi-year trend analysis of childhood immunization uptake and coverage in Nigeria

As a leading indicator of child health, under-five mortality was incorporated in the United Nations Millennium Development Goals with the aim of reducing the rate by two-thirds between 1990 and 2015. Under-five mortality in Nigeria is alarmingly high, and many of the diseases that result in mortality are vaccine preventable. This study evaluates the uptake of childhood immunization in Nigeria from 1990 to 2008. A multi-year trend analysis was carried out using Alternating Logistic Regression on 46,130 children nested within 17,380 mothers in 1938 communities from the Nigerian Demographic and Health Surveys from 1990 to 2008. The findings reveal that mother-level and community-level variability are significantly associated with immunization uptake in Nigeria. The model also indicates that children delivered at private hospitals have a higher chance of being immunized than children who are delivered at home. Children from the poorest families (who are more likely to be delivered at home) have a lower chance of being immunized than those from the richest families (OR=0.712; 95% CI, 0.641-0.792). Similarly, the chance of children with a mother with no education being immunized is decreased by 17% compared with children whose mother has at least a primary education. In the same way, children of mothers who are gainfully employed and those of older mothers have statistically significantly higher odds of being immunized. Children of households with a female head are less likely to be immunized than those from male-headed households. The statistical significance of the community-survey year interaction term suggests an increase in the odds of a child being immunized over the years and spread over communities. Evidence-based policy should lay more emphasis on mother- and community-level risk factors in order to increase immunization coverage among Nigerian children.

Decomposing Kenyan socio-economic inequalities in skilled birth attendance and measles immunization

INTRODUCTION

Skilled birth attendance (SBA) and measles immunization reflect two aspects of a health system. In Kenya, their national coverage gaps are substantial but could be largely improved if the total population had the same coverage as the wealthiest quintile. A decomposition analysis allows identifying the factors that influence these wealth-related inequalities in order to develop appropriate policy responses. The main objective of the study was to decompose wealth-related inequalities in SBA and measles immunization into their contributing factors.

METHODS

Data from the Kenyan Demographic and Health Survey 2008/09 were used. The study investigated the effects of socio-economic determinants on [1] coverage and [2] wealth-related inequalities of SBA utilization and measles immunization. Techniques used were multivariate logistic regression and decomposition of the concentration index (C).

RESULTS

SBA utilization and measles immunization coverage differed according to household wealth, parent's education, skilled antenatal care visits, birth order and father's occupation. SBA utilization further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent's education (28%), antenatal care (9%), and province (6%). The overall C for measles immunization was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent's education (28%). Rural residence (-19%) reduced this inequality.

CONCLUSION

Both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups.

The impact of new vaccine introduction on the coverage of existing vaccines: a cross-national, multivariable analysis

BACKGROUND

A surge of new and underutilized vaccine introductions into national immunization programmes has called into question the effect of new vaccine introduction on immunization and health systems. In particular, countries deciding whether to introduce a new or underutilized vaccine into their routine immunization programme may query possible effects on the delivery and coverage of existing vaccines. Using coverage of diphtheria-tetanus-pertussis (DTP) vaccine as a proxy for immunization system performance, this study aims to test whether new vaccine introduction into national immunization programs was associated with changes in coverage of three doses of DTP vaccine among infants.

METHODS AND FINDINGS

DTP3 vaccine coverage was analyzed in 187 countries during 1999-2009 using multivariable cross-national mixed-effect longitudinal models. Controlling for other possible determinants of DTP3 coverage at the national level these models found minimal association between the introduction of Hepatitis-, Haemophilus influenzae type b-, and rotavirus-containing vaccines and DTP3 coverage. Instead, frequent and sometimes large fluctuations in coverage are associated with other development and health systems variables, including the presence of armed conflict, coverage of antenatal care services, infant mortality, the percent of health expenditures that are private and total health expenditures per capita.

CONCLUSIONS

Introductions of new vaccines did not affect national coverage of DTP3 vaccine in the countries studied. Introductions of other new vaccines and multiple vaccine introductions should be monitored for immunization and health systems impacts.

Individual and contextual factors associated with low childhood immunisation coverage in sub-Saharan Africa: a multilevel analysis

Background

In 2010, more than six million children in sub-Saharan Africa did not receive the full series of three doses of the diphtheria-tetanus-pertussis vaccine by one year of age. An evidence-based approach to addressing this burden of un-immunised children requires accurate knowledge of the underlying factors. We therefore developed and tested a model of childhood immunisation that includes individual, community and country-level characteristics.

Method and Findings

We conducted multilevel logistic regression analysis of Demographic and Health Survey data for 27,094 children aged 12–23 months, nested within 8,546 communities from 24 countries in sub-Saharan Africa. According to the intra-country and intra-community correlation coefficient implied by the estimated intercept component variance, 21% and 32% of the variance in unimmunised children were attributable to country- and community-level factors respectively. Children born to mothers (OR 1.35, 95%CI 1.18 to 1.53) and fathers (OR 1.13, 95%CI 1.12 to 1.40) with no formal education were more likely to be unimmunised than those born to parents with secondary or higher education. Children from the poorest households were 36% more likely to be unimmunised than counterparts from the richest households. Maternal access to media significantly reduced the odds of children being unimmunised (OR 0.94, 95%CI 0.94 to 0.99). Mothers with health seeking behaviours were less likely to have unimmunised children (OR 0.56, 95%CI 0.54 to 0.58). However, children from urban areas (OR 1.12, 95% CI 1.01 to 1.23), communities with high illiteracy rates (OR 1.13, 95% CI 1.05 to 1.23), and countries with high fertility rates (OR 4.43, 95% CI 1.04 to 18.92) were more likely to be unimmunised.

Conclusion

We found that individual and contextual factors were associated with childhood immunisation, suggesting that public health programmes designed to improve coverage of childhood immunisation should address people, and the communities and societies in which they live.

Correlates of first dose of measles vaccination delivery and uptake in Indonesia

OBJECTIVE

To determine health systems-related, familial, and cultural factors which influence the delivery and uptake of measles vaccination in Indonesia.

METHODS

Logistic regression analysis of data collected during the 2007 Indonesian Demographic and Health Survey was undertaken by the authors to investigate these factors. The 2007 Indonesian Demographic and Health Survey dataset is a nationally representative, randomly sampled survey containing 15 065 children aged between 9 and 59 months.

RESULTS

72.8% of children had received the measles vaccine. Vaccination coverage was similar for males and females; however, coverage was higher amongst urban children, 80.1%, compared to 68.5% in rural areas. The key findings of the regression analysis were congruent with the results of previous research targeting vaccination coverage. After controlling for all other factors, maternal age, maternal education, wealth, the use of a skilled birth attendant, and postnatal check-ups were positively and significantly (P< 0.01) correlated with measles vaccination. The number of children per household was negatively correlated (P<0.01).

CONCLUSIONS

In order to enhance measles vaccination coverage in Indonesia, delivery to, and uptake by, rural and low socio-economic populations require substantial improvements. Mass health education and health systems improvements are also required.