Socioeconomic inequalities in child vaccination in low/middle-income countries: what accounts for the differences?

Determinants of wealth-related inequalities in full vaccination coverage among children in Nepal: a decomposition analysis of nationally representative household survey data

BACKGROUND

Over the past two decades, child health indicators in Nepal have improved significantly at the national level. Yet, this progress hasn't been uniform across various population subsets. This study identified the determinants associated with childhood full vaccination, assessed wealth-related inequalities, and delved into the key factors driving this inequality.

METHODS

Data for this study were taken from the most recent nationally representative Nepal Demographic and Health Survey 2022. A total of 959 children aged 12-23 months who had received routine childhood basic antigens as per the national immunisation program were considered for analysis. Binary logistic regression models were conducted to identify the associated factors with outcome variable (uptake of full vaccination). The concentration curve and Erreygers normalized concentration index were used to assess inequality in full vaccination. Household wealth quintile index scores were used to measure wealth-related inequality and decomposition analysis was conducted to identify determinants explaining wealth-related inequality in the uptake of childhood vaccination.

RESULTS

The coverage of full vaccination among children was 79.8% at national level. Several factors, including maternal health service utilisation variables (e.g., antenatal care, institutional delivery), financial challenges related to visiting health facilities, and mothers' awareness of health mother group meetings within their ward, were associated with the uptake of full vaccination coverage among children. The concentration curve was below the line of equality, and the relative Erreygers normalized concentration index was 0.090, indicating that full vaccination was disproportionately higher among children from wealthy groups. The decomposition analysis identified institutional delivery (20.21%), the money needed to visit health facilities (14.25%), maternal education (16.79%), maternal age (8.53%), and caste (3.03%) were important contributors to wealth related inequalities in childhood full vaccination uptake.

CONCLUSIONS

There was notable wealth-related inequality in full vaccine uptake among children in Nepal. Multisectoral actions involving responsible stakeholders are pivotal in reducing the inequalities, including promoting access to maternal health services and improving educational attainment among mothers from socioeconomically disadvantaged communities.

An ecological analysis of socio-economic determinants associated with paediatric vaccination coverage in the Campania Region: A population-based study, years 2003-2017

Introduction

Vaccines are the most cost-effective and straightforward intervention against severe infectious diseases. However, in Europe and in Italy, paediatric vaccination coverage for certain vaccines remains suboptimal, with considerable regional differences in Italy. Vaccine coverage varies significantly due to socio-economic and organisational factors. Aim of this study was to assess the influence of the Deprivation Index, the density of General Practitioners and General Paediatricians per inhabitants on the coverage of both mandatory and non-mandatory paediatric vaccinations across local health authorities and health districts in the Campania Region for birth cohorts from 2001 to 2015.

Materials and methods

Population-based, ecological time series analysis focusing on the Campania Region, most populous region in the south of Italy. Vaccination coverage data were extracted from the regional immunization database, whilst information on the Deprivation Index and number of primary care doctors and primary care paediatricians per local health district were extracted from public health records. Univariate descriptive statistics were employed to describe study characteristics, as appropriate, whilst and mixed-effect linear regression models were employed to assess the associations between variables of interest and vaccination coverage.

Results

Overall vaccination coverage has generally increased, except for the MMR vaccine, which showed coverage fluctuations. An increase in the Deprivation Index, indicative of less favourable socio-economic conditions, was associated with decreased vaccination coverage in the 24-month age group for some mandatory vaccines (DTaP: Coef -0.97, 95% CI -1.77 | -0.17; Poliomyelitis: Coef -0.98, 95% CI -1.78 | -0.17; Hepatitis B: Coef -0.90, 95% CI -1.71 | -0.10). Moreover, areas with a greater density of General Paediatricians per inhabitants saw increased coverage for Haemophilus influenzae type b in the 6-year age group (Coef 9.78, 95% CI 1.00 | 18.56).

Conclusions

It is necessary to target public health policies to address vaccination inequalities. These efforts should include expanding vaccination campaigns, enhancing catch-up programs, and increase resource allocation in primary care settings to facilitate the role of General Practitioners and Paediatricians in fostering awareness and adherence.

Socioeconomic inequality and urban-rural disparity of antenatal care visits in Bangladesh: A trend and decomposition analysis

BACKGROUND

Socioeconomic inequality in antenatal care visits is a great concern in developing countries including Bangladesh; however, there is a scarcity of investigation to assess the factors of inequality and these changes over time. In this study, we investigated the trend of socioeconomic inequalities (2004-2017) in 1+ANC and 4+ANC visits, and extracted determinants contributions to the observed inequalities and urban-rural disparities in Bangladesh over the period from 2011 to 2017.

METHODS

The data from the Bangladesh Demographic and Health Surveys (BDHS) conducted in 2004, 2007, 2011 and 2017 were analyzed in this study. The analysis began with exploratory and bivariate analysis, followed by the application of logistic regression models. To measure the inequalities, the Erreygers concentration index was used, and regression-based decomposition analyses were utilized to unravel the determinant's contribution to the observed inequalities. The Blinder-Oaxaca type decomposition is also used to decompose the urban-rural disparity into the factors.

RESULTS

Our analysis results showed that the prevalence of 1+ANC and 4+ANC visits has increased across all the determinants, although the rate of 4+ANC visits remains notably low. The magnitudes of socioeconomic inequality in 4+ANC visits represented an irregular pattern at both the national and urban levels, whereas it increased gradually in rural Bangladesh. However, inequalities in 1+ANC visits declined substantially after 2011 across the national, rural and urban areas of Bangladesh. Decomposition analyses have suggested that wealth status, women's education, place of residence (only for 4+ANC visits), caesarean delivery, husband education, and watching television (TV) are the main determinants to attribute and changes in the level of inequality and urban-rural disparity between the years 2011 and 2017.

CONCLUSIONS

According to the findings of our study, it is imperative for authorities to ensure antenatal care visits are more accessible for rural and underprivileged women. Additionally, should focus on delivering high-quality education, ensuring the completion of education, reducing income disparity as well as launching a program to enhance awareness about health facilities, and the impact of caesarean delivery.

Immunization coverage and its associated factors among children aged 12-23 months in Ethiopia: An umbrella review of systematic review and meta-analysis studies

BACKGROUND

Immunization estimated to prevent 2 to 3 million children deaths every year from vaccine preventable disease. In Ethiopia, limited and inconclusive studies have been conducted on immunization coverage so far. Therefore, this umbrella review was intended to estimate the pooled national immunization coverage and its associated factors among children age 12-23 months in Ethiopia.

METHODS

This umbrella review included five systematic reviews and meta-analyses through literature search from PubMed, Science direct, and web of science, CINHALE, and data bases specific to systematic reviews such as the Cochrane Database of Systematic Reviews and Prospero, the International Prospective Register of Systematic Reviews from May 1 to 30/ 2023. Only systematic reviews and meta-analyses published in English from inception to May 1, 2023, were included. The quality of each study was assessed using Assessment of Multiple Systematic Reviews. Data were extracted using Microsoft excel 2016 and analyzed using STATA 17.0 statistical software. Heterogeneity among studies was assessed using the Cochran Q statistics and I2 test. The pooled effect sizes were determined using pooled proportion for the full vaccination coverage and odds ratios for the associated factors with the corresponding 95% confidence interval were used to declare statically significance.

RESULTS

Five studies with 77,161 children aged 12-23 months were included. The overall pooled full vaccination coverage was 57.72% (95% CI 50.17, 65.28). Institutional delivery (OR: 2.12, 95% CI: 1.78-2.52), travel to vaccination site for <2 hours (OR: 2.43, 95%CI: 1.97-3.00), received at least one antenatal (ANC) visit (OR: 3.2, 95%CI: 2.46-4.1), good maternal knowledge of immunization (OR: 3.63, 95%CI: 2.82-4.67), being informed on immunization schedule (OR: 2.54, 95%CI: 2.02-3.2), living in urban areas (OR: 2, 95% CI: 1.54-2.6), and a household visit by health-care providers (HCP) during the postnatal period (OR: 2.23, 95%CI: 1.22-4.09) were the independent predictors of immunization coverage.

CONCLUSION

This study showed the full immunization coverage in Ethiopia was lower compared to the WHO-recommended level. Besides, the current umbrella review identifies several factors that contribute to higher immunization coverage. These includes; institutional delivery, near to vaccination site, having ANC visit, being urban residence, household visited by HCP, having good knowledge and informed on immunization schedule. Thus, the government should intensify the growth of immunization services by emphasizing outreach initiatives to reach remote areas and professionals must combine child immunization service with other medical services offered by health institutions.

Systematic review of social determinants of childhood immunisation in low- and middle-income countries and equity impact analysis of childhood vaccination coverage in Nigeria

BACKGROUND

Nigeria has a high proportion of the world's underimmunised children. We estimated the inequities in childhood immunisation coverage associated with socioeconomic, geographic, maternal, child, and healthcare characteristics among children aged 12-23 months in Nigeria using a social determinants of health perspective.

METHODS

We conducted a systematic review to identify the social determinants of childhood immunisation associated with inequities in vaccination coverage among low- and middle-income countries. Using the 2018 Nigeria Demographic and Health Survey (DHS), we conducted multiple logistic regression to estimate the association between basic childhood vaccination coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, and 1-dose measles) and socioeconomic, geographic, maternal, child, and healthcare characteristics in Nigeria.

RESULTS

From the systematic review, we identified the key determinants of immunisation to be household wealth, religion, and ethnicity for socioeconomic characteristics; region and place of residence for geographic characteristics; maternal age at birth, maternal education, and household head status for maternal characteristics; sex of child and birth order for child characteristics; and antenatal care and birth setting for healthcare characteristics. Based of the 2018 Nigeria DHS analysis of 6,059 children aged 12-23 months, we estimated that basic vaccination coverage was 31% (95% CI: 29-33) among children aged 12-23 months, whilst 19% (95% CI:18-21) of them were zero-dose children who had received none of the basic vaccines. After controlling for background characteristics, there was a significant increase in the odds of basic vaccination by household wealth (AOR: 3.21 (2.06, 5.00), p < 0.001) for the wealthiest quintile compared to the poorest quintile, antenatal care of four or more antenatal care visits compared to no antenatal care (AOR: 2.87 (2.21, 3.72), p < 0.001), delivery in a health facility compared to home births (AOR 1.32 (1.08, 1.61), p = 0.006), relatively older maternal age of 35-49 years compared to 15-19 years (AOR: 2.25 (1.46, 3.49), p < 0.001), and maternal education of secondary or higher education compared to no formal education (AOR: 1.79 (1.39, 2.31), p < 0.001). Children of Fulani ethnicity in comparison to children of Igbo ethnicity had lower odds of receiving basic vaccinations (AOR: 0.51 (0.26, 0.97), p = 0.039).

CONCLUSIONS

Basic vaccination coverage is below target levels for all groups. Children from the poorest households, of Fulani ethnicity, who were born in home settings, and with young mothers with no formal education nor antenatal care, were associated with lower odds of basic vaccination in Nigeria. We recommend a proportionate universalism approach for addressing the immunisation barriers in the National Programme on Immunization of Nigeria.

Individual and community-level determinants of pentavalent vaccination dropouts among under-five children in the sub-Saharan African countries: A multilevel analysis of the recent demographic and health survey

Background

Globally, each year, about 3 million deaths among children are prevented by pentavalent vaccinations. However, in developing countries, particularly in Sub-Saharan Africa, pentavalent vaccination dropout rates are not well reported. Therefore, this study aimed to assess pentavalent vaccination dropout rates and their determinants among under-five children in Sub-Saharan Africa.

Methods

Data from the recent Demographic and Health Surveys in 33 Sub-Saharan African countries were used for analysis. The study used a total of 358,529 under-five children. The determinants of pentavalent vaccination dropout were determined using a multilevel mixed-effects logistic regression model. Significant factors associated with pentavalent vaccination dropout were declared significant at p-values < 0.05. A model with the lowest deviance and highest logliklihood ratio was selected as the best-fit model.

Results

In Sub-Saharan Africa, one in five under-five children had pentavalent vaccination dropout rates. Factors such as Age (AOR = 1.61, 95 % CI: 1.51, 1.72), educational level (AOR = 1.30, 95 % CI: 1.22, 1.40), place of delivery (AOR = 1.65, 95 % CI: 1.57, 1.73), ANC visits (AOR = 1.34, 95 % CI: 1.23, 1.45), postnatal check-up (AOR = 1.19, 95 % CI: 1.14, 1.25), wealth status (AOR = 1.09, 95 % CI: 1.04, 1.15), distance to health facility (AOR = 1.08, 95 % CI: 1.03, 1.13), media exposure (AOR = 1.12, 95 % 1.15), and geographical region (AOR = 1.60, 95 % CI: 1.49, 1.72) had higher odds of pentavalent vaccination dropouts.

Conclusions

Pentavalent vaccination dropout rates in sub-Saharan Africa among under-five children were high. Both individual and community-level variables were determinants of pentavalent vaccination dropout rates. Government and ministry of health in Sub-Saharan Africa should give attention to those mothers of under-five children who reported distance as a big problem in accessing health facilities and to women who do not utilise antenatal and postnatal check-ups while designing policies and strategies in sub-Saharan Africa.

Comprehensive childhood vaccination and its determinants: Insights from the Indonesia Family Life Survey (IFLS)

BACKGROUND

Immunization is the most effective intervention for reducing morbidity and mortality rates associated with vaccine-preventable diseases. Despite the Indonesian government's inclusion of several childhood vaccinations in the national immunization program (NIP), the number of unvaccinated or partially vaccinated children remains high. This observational study aimed to determine the completeness of childhood immunization and the factors influencing it in Indonesia.

METHODS

Data were extracted from the fifth wave of the Indonesia Family Life Survey (IFLS). The sample (n = 16,236) consists of children residing in 13 provinces, representing over 80% of Indonesia's population. The difference between groups was tested using the chi-square test. Logistic regression was performed to identify the variables associated with the completeness of basic immunization. Immunization is categorized as complete when children have received all the mandatory vaccines recommended by the Ministry of Health. We examined and compared the results using complete case analysis, inverse probability weighting, and multiple imputations.

RESULTS

The highest percentages of complete vaccinations were polio, tuberculosis, and DPT. Children who live in Sumatera and Kalimantan were more likely to be fully immunized, with ORs of 0.6 (95%CI 0.48-0.74) and 0.54 (0.37-0.80), respectively. Children who live in urban areas, have mothers who received the tetanus vaccine during pregnancy, have mothers with a higher level of education and health insurance, have fathers aged 41-50, and live with a large number of family members were more likely to be fully immunized (p < 0.05).

CONCLUSION

Socioeconomic determinants were strongly correlated with the completeness of childhood vaccination in Indonesia.

Wealth-based inequity in full child vaccination coverage: An experience from Mali, Bangladesh, and South Africa. A multilevel poison regression

OBJECTIVES

Every child around the globe should get routine childhood vaccination, which is mostly affected by the country's economic capacity besides the socioeconomic differences. However, how well countries with different economic capacities address equitable child vaccination remains unanswered.

METHODS

Cross-sectional data from the latest Demographic and Health Survey (DHS) database of Mali, Bangladesh, and South Africa was used for this study. The dependent variable was full child vaccination, and wealth-based inequality was assessed using rate-ratio, concentration curve, and concentration index. A multilevel Poisson regression analysis was used to determine the predictors of inequalities. A risk ratio (RR) with a p-value of 0.05 was used to declare statistical significance. All analysis was weighted.

RESULTS

Full child vaccination status was 30.15%, 62.18%, and 46.94% in Mali, Bangladesh, and South Africa respectively. Even if the disparity is higher in Mali, the full vaccination favors the better-off family both in Mali, and Bangladesh respectively [CInd: 0.05, 95% CI: 0.01, 0.09], [CInd: 0.02, 95% CI: 0.001, 0.03], wealth status did not have an effect in South Africa. The multilevel poison regression indicated maternal age, occupation, wealth of household, and frequency of watching television to positively affect full vaccination, whereas the number of children in the house negatively affected full vaccination.

CONCLUSION

Wealth-based inequality in child vaccination was higher in Mali followed by Bangladesh. There was no observable significant equity gap in South Africa. Wealth status, maternal occupation, maternal age, frequency of watching television, and number of children were predictors of full child vaccination.

Timely childhood vaccination in Israel: a national retrospective study of ethnic and socioeconomic disparities

A large proportion of children do not receive vaccines within the recommended timeframe. This study examined ethnic and socioeconomic differences in age-appropriate immunization of children in Israel, where immunization is freely available. Percent of children receiving MMR/V at 12-13 months, and four doses of DTP/IPV/Hib by 18 months were obtained from the National Programme for Quality Measures between 2015 and 2018. Ethnic group (Jewish vs Arab) (defined by proxy by the neighbourhood in which the clinic was located), neighbourhood socioeconomic status and peripherality were obtained. Rates of MMR vaccination were 61% in the Jewish and 82% in the Arab population; for DPT/IPV/Hib 75% in the Jewish, compared to 92% in the Arab population. These patterns were stable over time. Lowest rates occurred in the most peripheral areas for Arab children, and in urban areas for Jewish children. Differences between ethnic groups were significant at higher SES levels. Greater adherence to the vaccination schedule occurred in the Arab minority in contrast to studies showing lower vaccination in ethnic minorities elsewhere. Lower immunization rates among rural Arab children suggest a need for improved access to clinics. Efforts should be directed towards lower SES groups, while emphasizing the importance of timely vaccination in wealthier groups in order to achieve herd immunity.

Discovering new pathways toward integration between health and sustainable development goals with natural language processing and network science

BACKGROUND

Research on health and sustainable development is growing at a pace such that conventional literature review methods appear increasingly unable to synthesize all relevant evidence. This paper employs a novel combination of natural language processing (NLP) and network science techniques to address this problem and to answer two questions: (1) how is health thematically interconnected with the Sustainable Development Goals (SDGs) in global science? (2) What specific themes have emerged in research at the intersection between SDG 3 ("Good health and well-being") and other sustainability goals?

METHODS

After a descriptive analysis of the integration between SDGs in twenty years of global science (2001-2020) as indexed by dimensions.ai, we analyze abstracts of articles that are simultaneously relevant to SDG 3 and at least one other SDG (N = 27,928). We use the top2vec algorithm to discover topics in this corpus and measure semantic closeness between these topics. We then use network science methods to describe the network of substantive relationships between the topics and identify 'zipper themes', actionable domains of research and policy to co-advance health and other sustainability goals simultaneously.

RESULTS

We observe a clear increase in scientific research integrating SDG 3 and other SDGs since 2001, both in absolute and relative terms, especially on topics relevant to interconnections between health and SDGs 2 ("Zero hunger"), 4 ("Quality education"), and 11 ("Sustainable cities and communities"). We distill a network of 197 topics from literature on health and sustainable development, with 19 distinct network communities - areas of growing integration with potential to further bridge health and sustainability science and policy. Literature focused explicitly on the SDGs is highly central in this network, while topical overlaps between SDG 3 and the environmental SDGs (12-15) are under-developed.

CONCLUSION

Our analysis demonstrates the feasibility and promise of NLP and network science for synthesizing large amounts of health-related scientific literature and for suggesting novel research and policy domains to co-advance multiple SDGs. Many of the 'zipper themes' identified by our method resonate with the One Health perspective that human, animal, and plant health are closely interdependent. This and similar perspectives will help meet the challenge of 'rewiring' sustainability research to co-advance goals in health and sustainability.

Incomplete immunization and its determinants among children in Africa: Systematic review and meta-analysis

Immunization is one of the most cost-effective measures to prevent morbidity and mortality in children. Therefore, the purpose of this systematic review and meta-analysis was to determine the pooled prevalence of incomplete immunization among children in Africa as well as its determinants. PubMed, Google Scholar, Scopus, Science Direct, and online institutional repository homes were searched. Studies published within English language, with full text available for searching, and studies conducted in Africa were included in this meta-analysis. A pooled prevalence, Sub-group analysis, sensitivity analysis and meta-regression were conducted. Out of 1305 studies assessed, 26 met our criteria and were included in this study. The pooled prevalence of incomplete immunization was 35.5% (95% CI: 24.4, 42.7), I² = 92.1%). Home birth (AOR=2.7; 95% CI: 1.5-4.9), rural residence (AOR = 4.6; 95% CI: 1.1-20.1), lack of antenatal care visit (AOR = 2.6; 95% CI: 1.4-5.1), lack of knowledge of immunizations (AOR=2.4; 95% CI: 1.3-4.6), and maternal illiteracy (AOR = 1.7: 95%CI: 1.3-2.0) were associated with incomplete immunization. In Africa, the prevalence of incomplete immunization is high. It is important to promote urban residency, knowledge of immunization and antenatal follow up care.

Socioeconomic and residence-based related inequality in childhood vaccination in Sub-Saharan Africa: Evidence from Benin

Background and Aims

Childhood vaccination remains a cost-effective strategy that has expedited the control and elimination of numerous diseases. Although coverage of new vaccines in low- and middle-income countries increased exponentially in the last two decades, progress on expanding routine vaccination services to reach all children remains low, and coverage levels in many countries remains inadequate. This study aimed to examine the pattern of wealth and residence-based related inequality in vaccination coverage through an equity lens.

Methods

We used data from the 2017-2018 Benin Demographic and Health Survey. Statistical and econometrics modeling were used to investigate factors associated with childhood vaccination. The Wagstaff decomposition analysis was used to disentangle the concentration index.

Results

A total of 1993 children were included, with 17% in the wealthiest quintile and 63% were living in rural areas. Findings showed that wealth is positively and significantly associated with vaccination coverage, particularly, for middle-wealth households. A secondary or higher education level of women and partners increased the odds of vaccination compared to no education (p < 0.05). Women with more antenatal care visits, with multiple births, attending postnatal care and delivery in a health facility had increased vaccination coverage (p < 0.01). Inequalities in vaccination coverage are more prominent in rural areas; and are explained by wealth, education, and antenatal care visits.

Conclusion

Inequality in child vaccination varies according to socioeconomic and sociodemographic characteristics and is of interest to health policy. To mitigate inequalities in child vaccination coverage, policymakers should strengthen the availability and accessibility of vaccination and implement educational programs dedicated to vulnerable groups in rural areas.

Essential childhood immunization in 43 low- and middle-income countries: Analysis of spatial trends and socioeconomic inequalities in vaccine coverage

BACKGROUND

Globally, access to life-saving vaccines has improved considerably in the past 5 decades. However, progress has started to slow down and even reverse in recent years. Understanding subnational heterogeneities in essential child immunization will be critical for closing the global vaccination gap.

METHODS AND FINDINGS

We use vaccination information for over 220,000 children across 1,366 administrative regions in 43 low- and middle-income countries (LMICs) from the most recent Demographic and Health Surveys. We estimate essential immunization coverage at the national and subnational levels and quantify socioeconomic inequalities in such coverage using adjusted concentration indices. Within- and between-country variations are summarized via the Theil index. We use local indicator of spatial association (LISA) statistics to identify clusters of administrative regions with high or low values. Finally, we estimate the number of missed vaccinations among children aged 15 to 35 months across all 43 countries and the types of vaccines most often missed. We show that national-level vaccination rates can conceal wide subnational heterogeneities. Large gaps in child immunization are found across West and Central Africa and in South Asia, particularly in regions of Angola, Chad, Nigeria, Guinea, and Afghanistan, where less than 10% of children are fully immunized. Furthermore, children living in these countries consistently lack all 4 basic vaccines included in the WHO's recommended schedule for young children. Across most countries, children from poorer households are less likely to be fully immunized. The main limitations include subnational estimates based on large administrative divisions for some countries and different periods of survey data collection.

CONCLUSIONS

The identified heterogeneities in essential childhood immunization, especially given that some regions consistently are underserved for all basic vaccines, can be used to inform the design and implementation of localized intervention programs aimed at eliminating child suffering and deaths from existing and novel vaccine-preventable diseases.

Causal relationship between health insurance and overall health status of children: Insights from Pakistan

Evaluating the impact of health insurance always remains a methodologically challenging endeavor due to the absence of sample randomization. This paper evaluates the impact of health insurance on the health status of children in Pakistan using the data of the Multiple Indicator Cluster Survey (MICS) for Punjab, Pakistan, from 2017 to 2018. The study adopted the propensity score matching (PSM) method to address the sample selection bias. The sample is matched on potential covariates such as mother characteristics (education level), household head characteristics (gender, age, and education), and other household conditions (such as home dwelling, internet access, wealth index, migration member, number of children residing in the home, as child illness, etc.). The findings revealed that children with insurance have considerably better health than non-insured, at a 1% significance level. The results confirm that health insurance is not a luxury but a need that improves children's overall health. In this regard, governments should enhance and expand programs related to health insurance, especially for children. Health insurance programs will not only help poor people but also improve the overall infrastructure of health services in the country.

Spatial distribution, determinants and trends of full vaccination coverage in children aged 12-59 months in Peru: A subanalysis of the Peruvian Demographic and Health Survey

OBJECTIVE

To assess the spatial distribution, trends and determinants of crude full vaccination coverage (FVC) in children aged 12-59 months between 2010 and 2019 in Peru.

DESIGN, SETTING AND ANALYSIS

A cross-sectional study based on the secondary data analysis of the 2010 and 2019 Peruvian Demographic and Health Surveys (DHSs) was conducted. Logit based multivariate decomposition analysis was employed to identify factors contributing to differences in FVC between 2010 and 2019. The spatial distribution of FVC in 2019 was evaluated through spatial autocorrelation (Global Moran's I), ordinary kriging interpolation (Gaussian process regression) and Bernoulli-based purely spatial scan statistic.

OUTCOME MEASURE

FVC, as crude coverage, was defined as having completely received BCG; three doses of diphtheria, pertussis, and tetanus, and polio vaccines; and measles vaccine by 12 months of age.

PARTICIPANTS

A total of 5 751 and 14 144 children aged 12-59 months from 2010 and 2019 DHSs, respectively, were included.

RESULTS

FVC increased from 53.62% (95% CI 51.75% to 55.49%) in 2010 to 75.86% (95% CI 74.84% to 76.85%) in 2019. Most of the increase (70.39%) was attributable to differences in coefficients effects. Family size, visit of health workers in the last 12 months, age of the mother at first delivery, place of delivery and antenatal care follow-up were all significantly associated with the increase. The trend of FVC was non-linear and increased by 2.22% annually between 2010 and 2019. FVC distribution was heterogeneous at intradepartmental and interdepartmental level. Seven high-risk clusters of incomplete coverage were identified.

CONCLUSIONS

Although FVC has increased in Peru, it still remains below the recommended threshold. The increase of FVC was mainly attributed to the change in the effects of the characteristics of the population. There was high heterogeneity across Peruvian regions with the presence of high-risk clusters. Interventions must be redirected to reduce these geographical disparities.

Vaccine equity in low and middle income countries: a systematic review and meta-analysis

BACKGROUND

Evidence to date has shown that inequality in health, and vaccination coverage in particular, can have ramifications to wider society. However, whilst individual studies have sought to characterise these heterogeneities in immunisation coverage at national level, few have taken a broad and quantitative view of the contributing factors to heterogeneity in immunisation coverage and impact, i.e. the number of cases, deaths, and disability-adjusted life years averted. This systematic review aims to highlight these geographic, demographic, and sociodemographic characteristics through a qualitative and quantitative approach, vital to prioritise and optimise vaccination policies.

METHODS

A systematic review of two databases (PubMed and Web of Science) was undertaken using search terms and keywords to identify studies examining factors on immunisation inequality and heterogeneity in vaccination coverage. Inclusion criteria were applied independently by two researchers. Studies including data on key characteristics of interest were further analysed through a meta-analysis to produce a pooled estimate of the risk ratio using a random effects model for that characteristic.

RESULTS

One hundred and eight studies were included in this review. We found that inequalities in wealth, education, and geographic access can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were not significantly different in terms of full vaccination status compared to urban areas but noted considerable heterogeneity between countries. We found that females were 3% (95%CI[1%, 5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children whose mothers had no formal education were 28% (95%CI[18%,47%]) less likely to be fully vaccinated than those whose mother had primary level, or above, education. Finally, we found that individuals in the poorest wealth quintile were 27% (95%CI [16%,37%]) less likely to be fully vaccinated than those in the richest.

CONCLUSIONS

We found a nuanced picture of inequality in vaccination coverage and access with wealth disparity dominating, and likely driving, other disparities. This review highlights the complex landscape of inequity and further need to design vaccination strategies targeting missed subgroups to improve and recover vaccination coverage following the COVID-19 pandemic.

TRIAL REGISTRATION

Prospero, CRD42021261927.

Pentavalent vaccination in Kenya: coverage and geographical accessibility to health facilities using data from a community demographic and health surveillance system in Kilifi County

Background

There is substantial evidence that immunization is one of the most significant and cost-effective pillars of preventive and promotive health interventions. Effective childhood immunization coverage is thus essential in stemming persistent childhood illnesses. The third dose of pentavalent vaccine for children is an important indicator for assessing performance of the immunisation programme because it mirrors the completeness of a child’s immunisation schedule. Spatial access to an immunizing health facility, especially in sub-Sahara African (SSA) countries, is a significant determinant of Pentavalent 3 vaccination coverage, as the vaccine is mainly administered during routine immunisation schedules at health facilities. Rural areas and densely populated informal settlements are most affected by poor access to healthcare services. We therefore sought to determine vaccination coverage of Pentavalent 3, estimate the travel time to health facilities offering immunisation services, and explore its effect on immunisation coverage in one of the predominantly rural counties on the coast of Kenya.

Methods

We used longitudinal survey data from the health demographic surveillance system implemented in Kaloleni and Rabai Sub-counties in Kenya. To compute the geographical accessibility, we used coordinates of health facilities offering immunisation services, information on land cover, digital elevation models, and road networks of the study area. We then fitted a hierarchical Bayesian multivariable model to explore the effect of travel time on pentavalent vaccine coverage adjusting for confounding factors identified a priori.

Results

Overall coverage of pentavalent vaccine was at 77.3%. The median travel time to a health facility was 41 min (IQR = 18–65) and a total of 1266 (28.5%) children lived more than one-hour of travel-time to a health facility. Geographical access to health facilities significantly affected pentavalent vaccination coverage, with travel times of more than one hour being significantly associated with reduced odds of vaccination (AOR = 0.84 (95% CI 0.74 – 0.94).

Conclusion

Increased travel time significantly affects immunization in this rural community. Improving road networks, establishing new health centres and/or stepping up health outreach activities that include vaccinations in hard-to-reach areas within the county could improve immunisation coverage. These data may be useful in guiding the local department of health on appropriate location of planned immunization centres.

Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries

Despite advances in scaling up new vaccines in low- and middle-income countries, the global number of unvaccinated children has remained high over the past decade. We used 2000–2019 household survey data from 154 surveys representing 89 low- and middle-income countries to assess within-country, economic-related inequality in the prevalence of one-year-old children with zero doses of diphtheria–tetanus–pertussis (DTP) vaccine. Zero-dose DTP prevalence data were disaggregated by household wealth quintile. Difference, ratio, slope index of inequality, concentration index, and excess change measures were calculated to assess the latest situation and change over time, by country income grouping for 17 countries with high zero-dose DTP numbers and prevalence. Across 89 countries, the median prevalence of zero-dose DTP was 7.6%. Within-country inequalities mostly favored the richest quintile, with 19 of 89 countries reporting a rich–poor gap of ≥20.0 percentage points. Low-income countries had higher inequality than lower–middle-income countries and upper–middle-income countries (difference between the median prevalence in the poorest and richest quintiles: 14.4, 8.9, and 2.7 percentage points, respectively). Zero-dose DTP prevalence among the poorest households of low-income countries declined between 2000 and 2009 and between 2010 and 2019, yet economic-related inequality remained high in many countries. Widespread economic-related inequalities in zero-dose DTP prevalence are particularly pronounced in low-income countries and have remained high over the previous decade.

Building evidence for improving vaccine adoption and uptake of childhood vaccinations in low- and middle-income countries: a systematic review

Vaccine coverage for children is an important indicator of the performance of national health and immunization systems. Most of the existing literature has targeted mothers’ low educational level, living in underserved districts and/or remote rural areas and economic poverty that are correlated with low immunization coverage but the supply- and demand-side constraints to immunization in low- and middle- income countries (LMICs) are not well understood. The reliability of claimed administrative immunization coverage in these contexts is questionable. To address these barriers within the present Expanded Programme on Immunization (EPI), the difficulties related to inadequate vaccination uptake must be addressed in more depth. Building on already produced literature, this study aims to determine the extent of immunization coverage among children in LMICs, as well as to fill in the gaps in awareness about system-level obstacles that currently hinder the effective delivery and uptake of immunization services through EPI. By two reviewers, a literature search using PubMed and Google Scholar along with targeted grey literature was conducted on the 2nd of June 2021 by following PRISMA guidelines. The search techniques for electronic databases used both Medical Subject Headings (Mesh) and free-text words were tailored to each database's specific needs using a controlled vocabulary that was limited to the English language from 2000 and 2020. Of the 689 records, eleven articles were included in this review meeting the inclusion criteria. In total, five articles related to vaccination coverage, four studies on components of the routine immunization system, one article on the implementation of new and under-utilized vaccines and one were on vaccines financing. We evaluated the quality of the included studies and extracted into tables created by one investigator and double-checked by another. Review findings suggest that specific strategies to reduce inequality may be required. Vaccine procurement and pricing strategies, as well as vaccine customization to meet the needs of LMICs, are all critical components in strengthening immunization systems. Our findings could be used to establish practical strategies for countries and development partners to address coverage gaps and improve vaccination system effectiveness.

Decomposing socio-economic inequality in vaccination coverage among Pakistani children: A population-based cross-sectional study

There is scarce knowledge about factors contributing to underlying inequalities in vaccination coverage among Pakistani children. Therefore, the main objective of this study is to measure and decompose socioeconomic inequalities in childhood vaccination coverage. Pakistan Demographic and Health Survey, version 2017-18, data were used for analysis. Bivariate association was checked through Chi-square test and concentration curve (CC) and concentration index (CI) were used to assess the existence and nature of inequality. Finally, decomposition analysis was performed to measure the contribution of different factors to the observed inequality. Our findings suggested that vaccination coverage is more concentrated among children of educated mothers (CI = 0.296) and decomposition results suggest that a substantial proportion of the inequality is explained by maternal education, wealth status, paternal education and improved sanitation (34%, 19%, 14% and 21% respectively). Also, differences are observed between regions regarding vaccination coverage. There is need of female-targeted interventions to increase maternal role in the society through better education and decision-making autonomy. Also, the policies to improve the household's wealth status should be considered.

Socioeconomic inequalities in non- coverage of full vaccination among children in Bangladesh: a comparative study of Demographic and Health Surveys, 2007 and 2017-18

BACKGROUND

Vaccination is considered as a powerful and cost-effective weapon against many communicable diseases. An increase in full vaccination among the most vulnerable populations in Bangladesh was observed in the last decade. This study aimed to capture the socioeconomic inequalities in non-coverage of full vaccination among children aged 12-23 months using the nationally representative data from the Bangladesh Demographic and Health Surveys (BDHS).

METHODS

Data for this study have been drawn from the 2007 and 2017-18 BDHS, which covered 10,996 and 20,127 ever-married women aged 15-49 years in 2007 and 2017-18, respectively. Binary logistic regression analysis was performed to find the factors associated with children who did not receive full vaccination. Further, the concentration index was used to observe the socioeconomic inequality for the outcome variable.

RESULTS

The proportion of children who did not get fully vaccinated decreased by more than 6 points (18.2 percent to 11.8 percent) between the years 2007 and 2017-18. In 2017-18, the odds of children who were not fully vaccinated were 58 percent and 53 percent less among mothers who had primary education in 2007 [adjusted odds ratio (AOR): 0.42; confidence interval (CI): 0.24-0.73] and 2017-18 [AOR: 0.47; CI: 0.23-0.94] respectively, compared to mothers with no education. The inequality for children who were not fully vaccinated had declined between two survey periods [concentration index (CCI) value of - 0.13 in 2007 and -0.08 in 2017-18]. The concentration of inequality in children with higher parity who did not receive full vaccination had increased from 5 percent in 2007 to 16.9 percent in 2017-18. There was a drastic increase in the socioeconomic inequality contributed by place of delivery from 2.9 percent (2007) to 60.5 percent (2017-18) among children who did not receive full vaccination.

CONCLUSIONS

The present study provide eminent evidence that non-coverage of full vaccination is more prevalent among children from poor households in Bangladesh, which is mainly associated with factors like mother's education, father's education and working status and household wealth index across the two rounds. These factors suggest multifaceted pro-poor interventions that will protect them from hardship and reduce their socioeconomic inequalities in coverage of full vaccination.

Prevalence, Trends and Conditions for the DTP3 Vaccine: A 25-Year Historical Perspective

Background

The aim was to verify the prevalence of vaccination coverage, tendency and factors of the third dose of the vaccine against diphtheria, tetanus and pertussis-DTP3 in surveys over the period of 25 years in a state of the Northeast of Brazil.

Methods

Cross-sectional and temporal series, utilizing ad hoc database, were extracted from the Health and Nutrition State Research 1991, 1997, 2006 and 2015/2016. Children from 12 to 23 months of age with proof in the vaccination card were included. The vaccination coverage (outcome) of each year was calculated, the tendency throughout the period was analyzed and the associations through Pearson chi-squared were tested. The results of the first and last survey were compared with a significance level of 5%. The reasons of the crude prevalence and confidence intervals of 95% were estimated.

Results

The vaccination coverage in 1991, 1997, 2006 and 2015/2016 was 77.6%, 82.7%, 89.7% and 72.9%, respectively, with an increasing tendency from 1991 to 2006 (p<0.001) and decreasing between 2006 and 2015/2016 (p<0.001). Factors in 1991: low socioeconomic conditions; lack of access to health service and pre-natal care, nutritional deficit and diarrhea in children (p<0.005). In 2015/2016, low socioeconomic conditions and diarrhea persisted and a larger family size, black, negative self-perception of happiness, both from the mother (p<0.05), were identified.

Conclusion

The factors of the recent decrease of vaccination coverage are complex, multifactorial, dependent of context and even on subjective aspects of the maternal perception. Its identification contributed to the understanding of inadequate vaccination at the state level.

Effectiveness of a single-dose mass dengue vaccination in Cebu, Philippines: A case-control study

BACKGROUND

Dengue fever is an important public health problem in the Philippines. In April 2016, the Department of Health launched a three-dose school based dengue vaccination program of nine- to fourteen-year-old children in three regions with the highest number of dengue cases using CYD-TDV (Dengvaxia, Sanofi Pasteur). In July 2017, a community-based dengue vaccination program was implemented in Cebu province. The program was discontinued in December 2017 amidst public controversy, after the first dose had been administered. We assessed the effectiveness of a single dose of CYD-TDV against hospitalized virologically confirmed dengue (VCD).

METHODS

We conducted a case-control study in Cebu province following the dengue mass vaccination. Children who were nine to fourteen years of age during the mass vaccination and subsequently admitted to any of four participating public hospitals with suspected dengue were enrolled in the study as cases. Blood for RT-PCR and clinical and socio-demographic information were obtained. To estimate the level of vaccine protection, vaccination status was compared between children with hospitalized virologically confirmed dengue and controls of the same six-year age-group as the cases, matched on sex, neighborhood and time of occurrence of cases.

FINDINGS

We enrolled 490 cases and 980 controls. Receipt of one dose of CYD-TDV was associated with 26% (95 % CI, -2 to 47%; p = 0 0675) overall protection against hospitalized virologically confirmed dengue and 51% (95 % CI, 23 to 68; p = 0 0016) protection against dengue with warning signs.

INTERPRETATION

A single dose of CYD-TDV given to nine to fourteen-year-old children through a community-based mass vaccination program conferred protection against dengue with warning signs and severe dengue but we were unable to conclude on protection against milder illness.

Leaving No Child Behind: Decomposing Socioeconomic Inequalities in Child Health for India and South Africa

BACKGROUND

The United Nations' 2030 Agenda for Sustainable Development argues for the combating of health inequalities within and among countries, advocating for "leaving no one behind". However, child mortality in developing countries is still high and mainly driven by lack of immunization, food insecurity and nutritional deficiency. The confounding problem is the existence of socioeconomic inequalities among the richest and poorest. Thus, comparing South Africa's and India's Demographic and Health Surveys (DHS) of 2015/16, this study examines socioeconomic inequalities in under-five children's health and its associated factors using three child health indications: full immunization coverage, food insecurity and malnutrition.

METHODS

Erreygers Normalized concentration indices were computed to show how immunization coverage, food insecurity and malnutrition in children varied across socioeconomic groups (household wealth). Concentration curves were plotted to show the cumulative share of immunization coverage, food insecurity and malnutrition against the cumulative share of children ranked from poorest to richest. Subsequent decomposition analysis identified vital factors underpinning the observed socioeconomic inequalities.

RESULTS

The results confirm a strong socioeconomic gradient in food security and malnutrition in India and South Africa. However, while full childhood immunization in South Africa was pro-poor (-0.0236), in India, it was pro-rich (0.1640). Decomposed results reported socioeconomic status, residence, mother's education, and mother's age as primary drivers of health inequalities in full immunization, food security and nutrition among children in both countries.

CONCLUSIONS

The main drivers of the socioeconomic inequalities in both countries across the child health outcomes (full immunization, food insecurity and malnutrition) are socioeconomic status, residence, mother's education, and mother's age. In conclusion, if socioeconomic inequalities in children's health especially food insecurity and malnutrition in South Africa; food insecurity, malnutrition and immunization in India are not addressed then definitely "some under-five children will be left behind".

Finding Children with High Risk of Non-Vaccination in 92 Low- and Middle-Income Countries: A Decision Tree Approach

Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12-23 months at high risk of being zero dose (no doses of the four basic vaccines-BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.

Persistent Socioeconomic Inequalities in Measles Vaccine Uptake in Ethiopia in the Period 2005 to 2016

OBJECTIVE

This study aims to quantify socioeconomic inequalities-and the factors contributing to these inequalities-in measles vaccine uptake among children aged 12 to 23 months in Ethiopia between 2005 and 2016.

METHODS

Inequalities in measles vaccine uptake were investigated based on data from the Ethiopian Demographic and Health Surveys conducted in 2005, 2011, and 2016. Concentration curves and concentration indices were used to measure the degree of inequality, and decomposition analysis was used to identify factors contributing to these inequalities.

RESULTS

The overall level of national measles vaccine uptake in Ethiopia exhibited an increasing trend between 2005 and 2016. As indicated by the concentration index of measles vaccine uptake, however, which was estimated at 0.202 (P < .01) in 2005, 0.226 (P < .01) in 2011, and 0.223 (P < .01) in 2016, measles vaccine uptake became consistently more concentrated among children from more affluent households. The dominance test of the concentration curve further confirmed the persistence of inequalities in measles vaccine uptake over time. Various factors-including maternal educational level, antenatal care use, institutional delivery, and exposure to media-were identified as the most important contributors to the inequalities.

CONCLUSIONS

Although the national measles vaccine uptake showed improvement between 2005 and 2016, socioeconomic inequalities in the uptake persisted over time. Efforts to improve the national immunization coverage should be accompanied by appropriate measures to address the inequalities.

The prospective COVID-19 vaccine: willingness to pay and perception of community members in Ibadan, Nigeria

BACKGROUND

The introduction of the COVID-19 vaccine necessitates the assessment of individual perception regarding the vaccine. This study aimed to assess the perception of community members and willingness to pay for the prospective COVID-19 vaccine in Ibadan, Nigeria.

METHODS

A descriptive cross-sectional study design was used. Data were collected using an interviewer-administered questionnaire in September 2020. We studied community members aged 15 years and above using a multi-stage sampling technique. The perceptions of respondents about the COVID-19 vaccine were assessed on eight questions using the five-point Likert scale with a score point of "1" assigned for "Strongly Agree", "2" for "Agree", "3" for "Not decided", "4" for "Disagree", and "5" for "Strongly disagree". During analysis, we reverse-coded the options by assigning a point of "1" for "Strongly disagree", "2" for "Disagree", "3" for "Not decided", "4" for "Agree", and "5" for "Strongly disagree". However, questions asked in the negative directions were not reverse-coded during analysis. Eight questions were used to assess the perception of community members regarding the prospective COVID-19 vaccine, and overall, the maximum point was 40. Points greater than or equal to 32 points (80%) implied positive perception. Descriptive statistics were done. Chi-square tests were used for the assessment of associations between sociodemographic characteristics and willingness to pay for the prospective COVID-19 vaccine. We conducted logistic regression tests on statistically significant variables at p-values <0.05.

RESULTS

The mean age of the 440 respondents studied was 37.22 ± 15.36 years, 193 (49.00%) were males, and 292 (67.30%) of the respondents had heard of the prospective COVID-19 vaccine. Among them, 232 (79.50%) respondents had positive perception regarding COVID-19 vaccine. Individuals in the fifth wealth quintile were ten times more likely to be willing to pay for the prospective COVID-19 vaccine compared to those in the first wealth quintile (Adjusted Odds Ratio = 9.57, 95% CI [2.88-31.82], p = <0.01).

CONCLUSION

The prospective COVID-19 vaccine should be subsidized or made freely available to everyone.

Characterization of antibodies in human immunoglobulin products from different regions worldwide

AIM

The antibody levels against a broad spectrum of pathogens were assessed in commercial intravenous immunoglobulin (IVIG) manufactured from pooled plasma obtained from different global regions.

METHODS

Twenty-four IVIG commercial lots from eight manufacturers corresponding to 12 brands were analyzed. The plasma was collected in 10 countries/regions. Depending on each pathogen, antibody levels were measured using specific commercial IgG-specific enzyme immunoassay kits or by cell culture neutralization test and guinea pig skin neutralization test. A principal component analysis was performed.

RESULTS

For polio and diphtheria (reference markers of the US authorities), all IVIGs had relevant titers in accordance with reference levels. IVIGs from Canada, Australia, and the USA were positive for titers against globally distributed pathogens or those under vaccination programs in the developed world (parainfluenza, Epstein-Barr, varicella-zoster, influenza B, parvovirus B19, and measles viruses). IVIG from Taiwan and Hong Kong showed low antibody titers for these pathogens but high titers for Pseudomonas aeruginosa. IVIG from India had high titers for pathogens frequently found in developing countries (West Nile, dengue, chikungunya, and hepatitis E viruses and Streptococcus pneumoniae). IVIGs from Argentina, Spain, Israel, and Czechia showed intermediate antibody concentrations.

CONCLUSION

The antibody profile in IVIG was greatly influenced by regional characteristics including climate, vaccination programs, and the prevalence of pathogens in the different countries and regions.

High Inequality and Slow Services Improvement in Newborn and Child Health Interventions in Ethiopia

Background

In the previous years, efforts have been made to reduce the inequality gap in newborn and child health interventions in Ethiopia. However, there is still limited evidence on the extent and trends of inequality on newborn and child health interventions. Thus, we aimed to assess newborn and child health interventions, inequality levels, and trends during four demographic and health survey periods based on inequality dimensions: economic status, education level, residency, and child’s sex in Ethiopia.

Methods

We conducted an inequality analysis on four periods (2000, 2005, 2011, and 2016) of the Ethiopian Demographic and Health Survey (EDHS) data. We estimated inequality related to economic and education status using percentage, relative concentration index, and slope index, while mean percentage difference and ratio were used to assess inequality due to residency and child’s sex.

Results

The coverage of services was concentrated in the richest quintile, highly educated families, and urban dwellers. Child and newborn health intervention service coverage improvement in the past four survey periods was less than 10.0% for all services, and there is high disparity between sub-national regions. Full immunization-related inequality was highest in Ethiopia compared to four east-central African countries.

Conclusion

Increasing service coverage and improving equitable access to routine immunizations could fill the existing inequality gap while focusing on the underserved group. In addition, strengthening regular monitoring processes is also vital to know those left behind.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth

INTRODUCTION

Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth.

METHODS

Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification.

RESULTS

For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment.

CONCLUSIONS

Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Predictors of immunization coverage among 12-23 month old children in Ethiopia: systematic review and meta-analysis

BACKGROUND

Immunization is one of modern medicine's greatest achievements in the last three decades. Annually it can prevent nearly 2 to 3 million deaths. Understanding the determinants of effective immunization coverage is a critical undertaking. Accordingly, we set out to check the best available evidence of outstanding predictors of immunization coverage among children aged 12-23 months in Ethiopia.

METHOD

Electronic databases including PubMed, Google Scholar, HINARI, and SCOPUS, Web of Science, African Journals Online, Ethiopian Medical Journals were searched. The search process, study selection, critical appraisal, and data extraction were done independently by two reviewers using Joanna Briggs Institute Meta-analysis for Review Instrument (JBI-MAStARI). The difference between reviewers was resolved with a third person. The risk of bias was assessed by the Newcastle Ottawa Tool for observational studies. Data were extracted using the Microsoft Excel checklist and exported to STATA 13. Heterogeneity was assessed using I2, Funnel plot and Egger's test was used to check for publication bias.

RESULTS

We identified 26 studies with 15,042 children with mothers/caretakers to assess factors associated with immunization coverage and significant factors were: maternal formal education, (OR = 2.45; 95% CI: 1.62-3.72), paternal formal education, (OR = 1.01; 95% CI: 0.27-3.77), residence, (OR = 2.11; 95% CI: 1.00-4.45), birth at health facility (OR = 1.86; 95% CI: 0.99-3.49), family size less than four, (OR = 1.81; 95% CI: 1.16-2.84), knowledge on age of immunization to be completed (OR = 6.18;95% CI: 3.07-12.43), knowledge on immunization schedule (OR = 2.49; 95% CI: 1.35-4.59), time to travel to health faculties, (OR = 1.74; 95% CI: 0.62-4.89), antennal care, (OR = 3.11; 95% CI: 1.64-5.88), and tetanus toxoid vaccination, (OR = 4.82; 95% CI: 2.99-7.75).

CONCLUSION

Our findings showed that literacy, residence, awareness, family size, maternal health services use, and proximity of the health facilities were factors associated with full immunization. This implies that there is a need for primary health service expansion and health education to "hard to reach areas" to improve immunization coverage for children aged 12-23 months.

Incomplete Vaccination and Its Predictors among Children in Ethiopia: A Systematic Review and Meta-Analysis

Background. Vaccination is an effective public health intervention that has contributed to a substantial reduction in the burden of vaccine-preventable diseases. Abridged evidence on incomplete vaccination is not well established in Ethiopia. Therefore, this meta-analysis aimed to estimate the pooled prevalence of incomplete vaccination and its predictors among children aged 12 to 23 months. Methods. Primary studies conducted in Ethiopia were searched. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) checklist. The analysis was conducted using STATA 14 and RevMan. The presence of statistical heterogeneity was checked using the Cochran Q test, and its level was quantified using I2 statistics. Pooled prevalence and odds ratio (OR) were computed at a 95% confidence interval (CI). Results. The pooled prevalence of incomplete vaccination was 30% (95% CI: 25-35). Maternal illiteracy (OR = 1.96; 95% CI: 1.40, 2.74) and home delivery (OR = 2.78; 95% CI: 2.28, 3.38) were associated factors that increased incomplete vaccination. However, maternal autonomy (OR = 0.54; 95% CI: 0.33, 0.89), maternal knowledge (OR = 0.31; 95% CI: 0.20, 0.47), husband employment (OR = 0.49; 95% CI: 0.35, 0.67), urban residence (OR = 0.61; 95% CI: 0.43, 0.86), ANC visits (OR = 0.30; 95% CI: 0.23, 0.39), postnatal care (OR = 0.39; 95% CI: 0.30, 0.52), and tetanus toxoid vaccine (3+) (OR = 0.42; 95% CI: 0.26, 0.69) were factors that reduced incomplete vaccination. Conclusion. In Ethiopia, 3 out of 10 children have incomplete vaccination. Policies should focus on strengthening and improving women’s education, maternal health knowledge, empowering women, and the utilization of prenatal care can overcome some of the barriers.

Decomposition of socioeconomic inequalities in child vaccination in Ethiopia: results from the 2011 and 2016 demographic and health surveys

OBJECTIVES

Monitoring and addressing unnecessary and avoidable differences in child vaccination is a critical global concern. This study aimed to assess socioeconomic inequalities in basic vaccination coverage among children aged 12-23 months in Ethiopia.

DESIGN, SETTING AND PARTICIPANTS

Secondary analyses of cross-sectional data from the two most recent (2011 and 2016) Ethiopia Demographic and Health Surveys were performed. This analysis included 1930 mother-child pairs in 2011 and 2004 mother-child pairs in 2016.

OUTCOME MEASURES

Completion of basic vaccinations was defined based on whether a child received a single dose of Bacille Calmette-Guerin (BCG), three doses of diphtheria, tetanus toxoids and pertussis (DTP), three doses of oral polio vaccine and one dose of measles vaccine.

METHODS

The concentration Curve and Concentration Indices (CCIs) were used to estimate wealth related to inequalities. The concentration indices were also decomposed to examine the contributing factors to socioeconomic inequalities in childhood vaccination.

RESULTS

From 2011 to 2016, the proportion of children who received basic vaccination increased from 24.6% (95% CI 21.4% to 28.0%) to 38.6% (95% CI 34.6% to 42.9%). While coverage of BCG, DTP and polio immunisation increased during the study period, the uptake of measles vaccine decreased. The positive concentration index shows that basic vaccination coverage was pro-rich (CCI=0.212 in 2011 and CCI=0.172 in 2016). The decomposition analysis shows that use of maternal health services such as family planning and antenatal care, socioeconomic status, exposure to media, urban-rural residence and maternal education explain inequalities in basic vaccination coverage in Ethiopia.

CONCLUSIONS

Childhood vaccination coverage was low in Ethiopia. Vaccination was less likely in poorer than in richer households. Addressing wealth inequalities, enhancing education and improving maternal health service coverage will reduce socioeconomic inequalities in basic vaccination uptake in Ethiopia.

Spatial access inequities and childhood immunisation uptake in Kenya

BACKGROUND

Poor access to immunisation services remains a major barrier to achieving equity and expanding vaccination coverage in many sub-Saharan African countries. In Kenya, the extent to which spatial access affects immunisation coverage is not well understood. The aim of this study was to quantify spatial accessibility to immunising health facilities and determine its influence on immunisation uptake in Kenya while controlling for potential confounders.

METHODS

Spatial databases of immunising facilities, road network, land use and elevation were used within a cost friction algorithim to estimate the travel time to immunising health facilities. Two travel scenarios were evaluated; (1) Walking only and (2) Optimistic scenario combining walking and motorized transport. Mean travel time to health facilities and proportions of the total population living within 1-h to the nearest immunising health facility were computed. Data from a nationally representative cross-sectional survey (KDHS 2014), was used to estimate the effect of mean travel time at survey cluster units for both fully immunised status and third dose of diphtheria-tetanus-pertussis (DPT3) vaccine using multi-level logistic regression models.

RESULTS

Nationally, the mean travel time to immunising health facilities was 63 and 40 min using the walking and the optimistic travel scenarios respectively. Seventy five percent of the total population were within one-hour of walking to an immunising health facility while 93% were within one-hour considering the optimistic scenario. There were substantial variations across the country with 62%(29/47) and 34%(16/47) of the counties with < 90% of the population within one-hour from an immunising health facility using scenarios 1 and 2 respectively. Travel times > 1-h were significantly associated with low immunisation coverage in the univariate analysis for both fully immunised status and DPT3 vaccine. Children living more than 2-h were significantly less likely to be fully immunised [AOR:0.56(0.33-0.94) and receive DPT3 [AOR:0.51(0.21-0.92) after controlling for household wealth, mother's highest education level, parity and urban/rural residence.

CONCLUSION

Travel time to immunising health facilities is a barrier to uptake of childhood vaccines in regions with suboptimal accessibility (> 2-h). Strategies that address access barriers in the hardest to reach communities are needed to enhance equitable access to immunisation services in Kenya.

Vaccine uptake and associated factors in an irregular urban settlement in northeastern Brazil: a cross-sectional study

Background

Globally, childhood immunization saves the lives of 2–3 million children annually by protecting them against vaccine-preventable diseases. In 2017, 116.2 million children were vaccinated worldwide according to the World Health Organization. Nevertheless, figures suggest that 19.5 million children around the world fail to receive the benefits of complete immunization.

Methods

This cross-sectional study analyzed vaccine uptake and the factors associated with incomplete vaccination schedule in children of up to 36 months of age assisted by the family health strategy in an irregular settlement located in a state capital city in northeastern Brazil. This study was nested within a larger study entitled “Health, nutrition and healthcare services in an urban slum population in Recife, Pernambuco”, conducted in 2015. A census included 309 children, with vaccination data obtained, exclusively, from their vaccination cards records. An ad hoc database was constructed with variables of interest. Absolute and relative values were calculated for the socioeconomic, demographic, obstetric and biological data. To identify possible factors associated with incomplete vaccination schedule, crude and multivariable Poisson regression analyses were performed, and conducted in accordance with the forward selection method with robust variance and the adjusted prevalence ratio was calculated with the 95% CI. Variables with p-values < 0.20 in the unadjusted stage were included in the multivariable analysis. The statistical significance of each variable was evaluated using the Wald test, with p-values < 0.05.

Results

Just half of the children (52,1%) was classified as complete vaccination schedule. In the final model, the factors associated with incomplete vaccination schedule were age 12–36 months and the mother who did not complete high school.

Conclusion

The percentage of vaccine uptake found was far below the recommendation of the National Childhood Immunization Schedule and was associated with child’s age and mother’s education level. Based on these findings, the family healthcare teams may elaborate vaccination strategies aimed at reaching the coverage rates established by the national immunization program. Optimizing coverage will ultimately prevent the resurgence, at epidemic level, of infectious diseases that are already under control in this country.

Monitoring inequality changes in full immunization coverage in infants in Latin America and the Caribbean

Objective.

To compare inequalities in full infant vaccination coverage at two different time points between 1992 and 2016 in Latin American and Caribbean countries.

Methods.

Analysis is based on recent available data from Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and Reproductive Health Surveys conducted in 18 countries between 1992 and 2016. Full immunization data from children 12–23 months of age were disaggregated by wealth quintile. Absolute and relative inequalities between the richest and the poorest quintile were measured. Differences were measured for 14 countries with data available for two time points. Significance was determined using 95% confidence intervals.

Results.

The overall median full immunization coverage was 69.9%. Approximately one-third of the countries have a high-income inequality gap, with a median difference of 5.6 percentage points in 8 of 18 countries. Bolivia, Colombia, El Salvador, and Peru have achieved the greatest progress in improving coverage among the poorest quintiles of their population in recent years.

Conclusion.

Full immunization coverage in the countries in the study shows higher-income inequality gaps that are not seen by observing national coverage only, but these differences appear to be reduced over time. Actions monitoring immunization coverage based on income inequalities should be considered for inclusion in the assessment of public health policies to appropriately reduce the gaps in immunization for infants in the lowest-income quintile.

Do household asset wealth measurements depend on who is surveyed? Asset reporting concordance within multi-adult households in rural Uganda

BACKGROUND

In resource-limited settings, the Filmer & Pritchett asset index is frequently used to measure household economic status. Little is known about how its validity is affected by differential reporting or recall within households.

METHODS

As part of a whole-population survey in a rural region of southwestern Uganda, we elicited household asset information from married dyads (404 men and 404 matched women) residing within the same households. We assessed the extent to which the asset index yielded differing measures of relative household wealth, depending on whether the husband's or wife's survey data were used in its calculation. To estimate agreement, we used Cohen's κ for binary and categorical variables, and Cronbach's α for continuous variables. We also assessed the extent to which asset wealth quintiles assigned based on husbands' vs wives' reporting were concordant, and whether discordance was related to demographic characteristics.

RESULTS

For most individual assets, agreement ranged from moderate to very good. Asset index scores based on husbands' vs wives' reporting were positively correlated (Pearson r = 0.85). Corresponding wealth quintiles were moderately concordant (weighted κ = 0.65); 171 households (43%) differed by one or more quintiles when the husbands' vs wives' reporting was used, and 43 (11%) differed by two or more quintiles. Concordance in asset wealth quintile could not be explained by joint educational attainment, age, or age difference.

CONCLUSIONS

There is significant intra-household variability in household asset reporting that can materially affect how households are classified on a widely used measure of relative household asset wealth.

Inequalities in Rotavirus Vaccine Uptake in Ethiopia: A Decomposition Analysis

A previous study in Ethiopia reported significant variation in rotavirus vaccine uptake across socioeconomic strata. This study aims to quantify socioeconomic inequality of rotavirus vaccine uptake in Ethiopia and to identify the contributing factors for the inequality. The concentration curve (CC) and the Erreygers Normalized Concentration Index (ECI) were used to assess the socioeconomic related inequality in rotavirus vaccine uptake using data from the 2016 Ethiopian Demographic and Health Survey. Decomposition analysis was conducted to identify the drivers of inequalities. The CC for rotavirus vaccine uptake lay below the line of equality and the ECI was 0.270 (p < 0.001) indicating that uptake of rotavirus vaccine in Ethiopia was significantly concentrated among children from families with better socioeconomic status. The decomposition analysis showed that underlining inequalities in maternal health care services utilization, including antenatal care use (18.4%) and institutional delivery (8.1%), exposure to media (12.8%), and maternal educational level (9.7%) were responsible for the majority of observed inequalities in the uptake of rotavirus vaccine. The findings suggested that there is significant socioeconomic inequality in rotavirus vaccine uptake in Ethiopia. Multi-sectoral actions are required to reduce the inequalities, inclusive increasing maternal health care services, and educational attainments among economically disadvantaged mothers.

Decomposing socioeconomic inequality in child vaccination in the Gambia, the Kyrgyz Republic and Namibia

Extant work suggested pro-rich distribution of vaccination coverage in low- and middle-income countries (LMICs). However, the current literature also suggested pro-poor distribution of vaccination in some countries, including the Gambia, the Kyrgyz Republic and Namibia. This study aimed to explain socioeconomic inequalities in the completion rate of the four-core vaccines (i.e., Bacille Calmette-Guérin [BCG], diphtheria-tetanus-pertussis [DTP, 3 doses], Polio [3 doses] and Measles vaccines) in the three aforementioned countries. We used the most recent available Demographic Health Surveys (DHS) to measure vaccination completion rates among children (aged 0-59 months, n = 16,752) in the three countries. The normalized concentration index (C_n) was used to quantify and decompose socioeconomic inequalities in vaccination coverage in each country. The negative values of the C_n index suggested that children belong to lower socioeconomic status groups were more likely to be immunized than their higher socioeconomic status counterparts in the Gambia (C_n = -0.101, 95% confidence interval [CI]: -0.128 to -0.074), the Kyrgyz Republic (C_n = -0.097, 95% CI: -0.13 to -0.063) and Namibia (C_n = -0.161, 95% CI: -0.199 to -0.124). The decomposition analysis of the C_n suggested that the difference in child vaccination completion rates between rural and urban areas was the main factor contributing to the concentration of child vaccination among the poor in the Gambia and Namibia. The concentration of child vaccination among the poor in the Kyrgyz Republic was chiefly determined by household wealth. These results suggest that there should be strategies to improve child immunization uptake among urban children in the Gambia and Namibia. Since household wealth was the main factor contributing to the observed pro-poor distribution of child vaccination in the Kyrgyz Republic, further studies are required to understand the reasons for lower vaccination rate among the wealthy children in order to implement the most effective strategies to increase child vaccination uptake.