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Costa FS, Silva LA, Cata-Preta BO, Santos TM, Ferreira LZ, Mengistu T, Hogan DR, Barros AJ, Victora CG. Child immunization status according to number of siblings and birth order in 85 low- and middle-income countries: a cross-sectional study. EClinicalMedicine 2024; 71:102547. [PMID: 38524919 PMCID: PMC10958219 DOI: 10.1016/j.eclinm.2024.102547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 03/26/2024] Open
Abstract
Background Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010-2020) with information on immunisation status of children aged 12-35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12-35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding Gavi, the Vaccine Alliance.
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Affiliation(s)
- Francine S. Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Larissa A.N. Silva
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Bianca O. Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Public Health Department, Federal University of Parana, Curitiba, Brazil
| | - Thiago M. Santos
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Leonardo Z. Ferreira
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | | | - Aluisio J.D. Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G. Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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Biks GA, Shiferie F, Tsegaye DA, Asefa W, Alemayehu L, Wondie T, Zelalem M, Lakew Y, Belete K, Gebremedhin S. High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis. BMC Public Health 2024; 24:592. [PMID: 38395877 PMCID: PMC10893596 DOI: 10.1186/s12889-024-18077-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children. OBJECTIVE To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia. METHODS A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant. RESULTS The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5]. CONCLUSION In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.
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Affiliation(s)
| | | | | | | | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Meseret Zelalem
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
| | - Yohannes Lakew
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
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Odero CO, Othero D, Were VO, Ouma C. Trends of non-vaccination, under-vaccination and missed opportunities for vaccination (2003-2014) amongst children 0-23 months in Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002906. [PMID: 38319922 PMCID: PMC10846728 DOI: 10.1371/journal.pgph.0002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/20/2024] [Indexed: 02/08/2024]
Abstract
Vaccines are effective and cost-effective. Non-vaccination, under-vaccination, and missed opportunities for vaccination (MOV), have contributed to incomplete vaccination coverage in Kenya. Analyzing their trends is essential for targeting interventions and improvement strategies. This study aimed to assess trends of non-vaccination, under-vaccination, and MOV among children aged 0-23 months in Kenya using data obtained from the Kenya Demographic and Health Surveys (KDHS) conducted in 2003, 2008/09, and 2014. A two-stage, multi-stage, and stratified sampling technique was used. Weighted analysis was conducted to ensure generalizability to the full population. Using the KDHS sample size estimation process, the sample size was estimated for each indicator, with varying standard error estimates, level of coverage and estimated response rates. Final sample size was 2380 (2003), 2237 (2008/09) and 7380 (2014). To determine the level of non-vaccination, under-vaccination and MOV among children aged 0-23 months, a weighted descriptive analysis was used to estimate their prevalence, with 95% confidence intervals (CI) for each year. MOV was defined using an algorithm as a binary variable. Data coding and recoding were done using Stata (version 14; College Station, TX: StataCorp LP). Trends in proportions of non-vaccination, under-vaccination and MOV were compared between 2003, 2008/09, and 2014 using the Cochrane-Armitage trend test. All results with P≤0.05 were considered statistically significant. Trends in proportion of non-vaccination among children aged 0-23 months in Kenya was 13.2%, 6.1% and 3.2% in 2003, 2008/09 and 2014, respectively (P = 0.0001). Trends in proportion of under-vaccination among children aged 0-23 months in Kenya was 54.3%, 50% and 51.3% in 2003, 2008/09 and 2014, respectively (P = 0.0109). The trends in proportion of children who experienced MOV was 22.7% in 2003, 31.9% in 2008/09 and 37.6% in 2014 (P = 0.0001). In the study duration, non-vaccination decreased by 10%, under-vaccination remained relatively stable, and MOV increased by ~15%. There is need for the Government and partners to implement initiatives that improve vaccine access and coverage, particularly in regions with low coverage rates, and to address missed opportunities for vaccination.
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Affiliation(s)
| | - Doreen Othero
- Department of Public Health, Maseno University, Kisumu, Kenya
| | - Vincent Omondi Were
- KEMRI Wellcome-Trust Research Program, Health Economics Research Unit, Kilifi, Kenya
| | - Collins Ouma
- Department of Biomedical Sciences and Technology, Maseno University, Kisumu, Kenya
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Farrenkopf BA, Zhou X, Shet A, Olayinka F, Carr K, Patenaude B, Chido-Amajuoyi OG, Wonodi C. Understanding household-level risk factors for zero dose immunization in 82 low- and middle-income countries. PLoS One 2023; 18:e0287459. [PMID: 38060516 PMCID: PMC10703331 DOI: 10.1371/journal.pone.0287459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/06/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION In 2021, an estimated 18 million children did not receive a single dose of routine vaccinations and constitute the population known as zero dose children. There is growing momentum and investment in reaching zero dose children and addressing the gross inequity in the reach of immunization services. To effectively do so, there is an urgent need to characterize more deeply the population of zero dose children and the barriers they face in accessing routine immunization services. METHODS We utilized the most recent DHS and MICS data spanning 2011 to 2020 from low, lower-middle, and upper-middle income countries. Zero dose status was defined as children aged 12-23 months who had not received any doses of BCG, DTP-containing, polio, and measles-containing vaccines. We estimated the prevalence of zero-dose children in the entire study sample, by country income level, and by region, and characterized the zero dose population by household-level factors. Multivariate logistic regressions were used to determine the household-level sociodemographic and health care access factors associated with zero dose immunization status. To pool multicountry data, we adjusted the original survey weights according to the country's population of children 12-23 months of age. To contextualize our findings, we utilized United Nations Population Division birth cohort data to estimate the study population as a proportion of the global and country income group populations. RESULTS We included a total of 82 countries in our univariate analyses and 68 countries in our multivariate model. Overall, 7.5% of the study population were zero dose children. More than half (51.9%) of this population was concentrated in African countries. Zero dose children were predominantly situated in rural areas (75.8%) and in households in the lowest two wealth quintiles (62.7%) and were born to mothers who completed fewer than four antenatal care (ANC) visits (66.5%) and had home births (58.5%). Yet, surprisingly, a considerable proportion of zero dose children's mothers did receive appropriate care during pregnancy (33.5% of zero dose children have mothers who received at least 4 ANC visits). When controlled for other factors, children had three times the odds (OR = 3.00, 95% CI: 2.72, 3.30) of being zero dose if their mother had not received any tetanus injections, 2.46 times the odds (95% CI: 2.21, 2.74) of being zero dose if their mother had not received any ANC visits, and had nearly twice the odds (OR = 1.87, 95% CI: 1.70, 2.05) of being zero dose if their mother had a home delivery, compared to children of mothers who received at least 2 tetanus injections, received at least 4 ANC visits, and had a facility delivery, respectively. DISCUSSION A lack of access to maternal health care was a strong risk factor of zero dose status and highlights important opportunities to improve the quality and integration of maternal and child health programs. Additionally, because a substantial proportion of zero dose children and their mothers do receive appropriate care, approaches to reach zero dose children should incorporate mitigating missed opportunities for vaccination.
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Affiliation(s)
- Brooke Amara Farrenkopf
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Xiaobin Zhou
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anita Shet
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Folake Olayinka
- United States Department of International Development, Immunization Team, District of Columbia, Washington, DC, United States of America
| | - Kelly Carr
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Bryan Patenaude
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Onyema Greg Chido-Amajuoyi
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Chizoba Wonodi
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Biswas A, Tucker J, Bauhoff S. Performance of predictive algorithms in estimating the risk of being a zero-dose child in India, Mali and Nigeria. BMJ Glob Health 2023; 8:e012836. [PMID: 37821114 PMCID: PMC10583101 DOI: 10.1136/bmjgh-2023-012836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
INTRODUCTION Many children in low-income and middle-income countries fail to receive any routine vaccinations. There is little evidence on how to effectively and efficiently identify and target such 'zero-dose' (ZD) children. METHODS We examined how well predictive algorithms can characterise a child's risk of being ZD based on predictor variables that are available in routine administrative data. We applied supervised learning algorithms with three increasingly rich sets of predictors and multiple years of data from India, Mali and Nigeria. We assessed performance based on specificity, sensitivity and the F1 Score and investigated feature importance. We also examined how performance decays when the model is trained on older data. For data from India in 2015, we further compared the inclusion and exclusion errors of the algorithmic approach with a simple geographical targeting approach based on district full-immunisation coverage. RESULTS Cost-sensitive Ridge classification correctly classifies most ZD children as being at high risk in most country-years (high specificity). Performance did not meaningfully increase when predictors were added beyond an initial sparse set of seven variables. Region and measures of contact with the health system (antenatal care and birth in a facility) had the highest feature importance. Model performance decreased in the time between the data on which the model was trained and the data to which it was applied (test data). The exclusion error of the algorithmic approach was about 9.1% lower than the exclusion error of the geographical approach. Furthermore, the algorithmic approach was able to detect ZD children across 176 more areas as compared with the geographical rule, for the same number of children targeted. INTERPRETATION Predictive algorithms applied to existing data can effectively identify ZD children and could be deployed at low cost to target interventions to reduce ZD prevalence and inequities in vaccination coverage.
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Affiliation(s)
- Arpita Biswas
- Center for Research on Computation and Society, Harvard University John A Paulson School of Engineering and Applied Sciences, Cambridge, Massachusetts, USA
| | - John Tucker
- Computer Science Department, Harvard College, Cambridge, Massachusetts, USA
| | - Sebastian Bauhoff
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Wonodi C, Farrenkopf BA. Defining the Zero Dose Child: A Comparative Analysis of Two Approaches and Their Impact on Assessing the Zero Dose Burden and Vulnerability Profiles across 82 Low- and Middle-Income Countries. Vaccines (Basel) 2023; 11:1543. [PMID: 37896946 PMCID: PMC10611163 DOI: 10.3390/vaccines11101543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 10/29/2023] Open
Abstract
While there is a coordinated effort around reaching zero dose children and closing existing equity gaps in immunization delivery, it is important that there is agreement and clarity around how 'zero dose status' is defined and what is gained and lost by using different indicators for zero dose status. There are two popular approaches used in research, program design, and advocacy to define zero dose status: one uses a single vaccine to serve as a proxy for zero dose status, while another uses a subset of vaccines to identify children who have missed all routine vaccines. We provide a global analysis utilizing the most recent publicly available DHS and MICS data from 2010 to 2020 to compare the number, proportion, and profile of children aged 12 to 23 months who are 'penta-zero dose' (have not received the pentavalent vaccine), 'truly' zero dose (have not received any dose of BCG, polio, pentavalent, or measles vaccines), and 'misclassified' zero dose children (those who are penta-zero dose but have received at least one other vaccine). Our analysis includes 194,829 observations from 82 low- and middle-income countries. Globally, 14.2% of children are penta-zero dose and 7.5% are truly zero dose, suggesting that 46.5% of penta-zero dose children have had at least one contact with the immunization system. While there are similarities in the profile of children that are penta-zero dose and truly zero dose, there are key differences between the proportion of key characteristics among truly zero dose and misclassified zero dose children, including access to maternal and child health services. By understanding the extent of the connection zero dose children may have with the health and immunization system and contrasting it with how much the use of a more feasible definition of zero dose may underestimate the level of vulnerability in the zero dose population, we provide insights that can help immunization programs design strategies that better target the most disadvantaged populations. If the vulnerability profiles of the truly zero dose children are qualitatively different from that of the penta-zero dose children, then failing to distinguish the truly zero dose populations, and how to optimally reach them, may lead to the development of misguided or inefficient strategies for vaccinating the most disadvantaged population of children.
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Bashingwa JJH, Mohan D, Chamberlain S, Scott K, Ummer O, Godfrey A, Mulder N, Moodley D, LeFevre AE. Can we design the next generation of digital health communication programs by leveraging the power of artificial intelligence to segment target audiences, bolster impact and deliver differentiated services? A machine learning analysis of survey data from rural India. BMJ Open 2023; 13:e063354. [PMID: 36931682 PMCID: PMC10030469 DOI: 10.1136/bmjopen-2022-063354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVES Direct to beneficiary (D2B) mobile health communication programmes have been used to provide reproductive, maternal, neonatal and child health information to women and their families in a number of countries globally. Programmes to date have provided the same content, at the same frequency, using the same channel to large beneficiary populations. This manuscript presents a proof of concept approach that uses machine learning to segment populations of women with access to phones and their husbands into distinct clusters to support differential digital programme design and delivery. SETTING Data used in this study were drawn from cross-sectional survey conducted in four districts of Madhya Pradesh, India. PARTICIPANTS Study participant included pregnant women with access to a phone (n=5095) and their husbands (n=3842) RESULTS: We used an iterative process involving K-Means clustering and Lasso regression to segment couples into three distinct clusters. Cluster 1 (n=1408) tended to be poorer, less educated men and women, with low levels of digital access and skills. Cluster 2 (n=666) had a mid-level of digital access and skills among men but not women. Cluster 3 (n=1410) had high digital access and skill among men and moderate access and skills among women. Exposure to the D2B programme 'Kilkari' showed the greatest difference in Cluster 2, including an 8% difference in use of reversible modern contraceptives, 7% in child immunisation at 10 weeks, 3% in child immunisation at 9 months and 4% in the timeliness of immunisation at 10 weeks and 9 months. CONCLUSIONS Findings suggest that segmenting populations into distinct clusters for differentiated programme design and delivery may serve to improve reach and impact. TRIAL REGISTRATION NUMBER NCT03576157.
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Affiliation(s)
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Kerry Scott
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Nicola Mulder
- Computational Biology Division, Department of Integrative Biomedical Sciences, IDM, University of Cape Town Faculty of Heath Sciences, Cape Town, South Africa
| | - Deshendran Moodley
- Department of Computer Science, University of Cape Town, Cape Town, South Africa
- Centre for Artificial Intelligence Research, University of Cape Town, Cape Town, South Africa
| | - Amnesty Elizabeth LeFevre
- Division of Public Health Medicine, University of Cape Town, School of Public Health, Cape Town, South Africa
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Fullman N, Correa GC, Ikilezi G, Phillips DE, Reynolds HW. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. Vaccines (Basel) 2023; 11:vaccines11030647. [PMID: 36992231 DOI: 10.3390/vaccines11030647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.
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Affiliation(s)
- Nancy Fullman
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Gustavo C Correa
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Gloria Ikilezi
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - David E Phillips
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Heidi W Reynolds
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
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Quach A, Spence H, Nguyen C, Graham SM, von Mollendorf C, Mulholland K, Russell FM. Slow progress towards pneumonia control for children in low-and-middle income countries as measured by pneumonia indicators: A systematic review of the literature. J Glob Health 2022; 12:10006. [PMID: 36282893 PMCID: PMC9595578 DOI: 10.7189/jogh.12.10006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD) has the goal of ending preventable childhood deaths from pneumonia and diarrhoea by 2025 with targets and indicators to monitor progress. The aim of this systematic review is to summarise how low-and-middle income countries (LMICs) reported pneumonia-specific GAPPD indicators at national and subnational levels and whether GAPPD targets have been achieved. Methods We searched MEDLINE, Embase, PubMed and Global Health Databases, and the World Health Organization (WHO) website. Publications/reports between 2015 and 2020 reporting on two or more GAPPD-pneumonia indicators from LMICs were included. Data prior to 2015 were included if available in the same report series. Quality of publications was assessed with the Quality Assessment Tool for Quantitative Studies. A narrative synthesis of the literature was performed to describe which countries and WHO regions were reporting on GAPPD indicators and progress in GAPPD coverage targets. Results Our search identified 17 publications/reports meeting inclusion criteria, with six from peer-reviewed publications. Data were available from 139 LMICs between 2010 and 2020, predominantly from Africa. Immunisation coverage rates were the indicators most commonly reported, followed by exclusive breastfeeding rates and pneumonia case management. Most GAPPD indicators were reported at the national level with minimal reporting at the subnational level. Immunisation coverage (Haemophilus influenzae, measles, diphtheria-tetanus-pertussis vaccines) in the WHO Europe, Americas and South-East Asia regions were meeting 90% coverage targets, while pneumococcal conjugate vaccine coverage lagged globally. The remaining GAPPD indicators (breastfeeding, pneumonia case management, antiretroviral prophylaxis, household air pollution) were not meeting GAPPD targets in LMICs. There was a strong negative correlation between pneumonia specific GAPPD coverage rates and under-five mortality (Pearson correlation coefficient range = -0.74, -0.79). Conclusion There is still substantial progress to be made in LMICs to achieve the 2025 GAPPD targets. Current GAPPD indicators along with country reporting mechanisms should be reviewed with consideration of adding undernutrition and access to oxygen therapy as important indicators which impact pneumonia outcomes. Further research on GAPPD indicators over longer time periods and at subnational levels can help identify high-risk populations for targeted pneumonia interventions.
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Affiliation(s)
- Alicia Quach
- Asia-Pacific Health Group, Murdoch Children's Research Institute, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Victoria, Australia
| | - Hollie Spence
- Murdoch Children's Research Institute, Victoria, Australia.,The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Cattram Nguyen
- Asia-Pacific Health Group, Murdoch Children's Research Institute, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Victoria, Australia
| | - Stephen M Graham
- Department of Paediatrics, The University of Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Victoria, Australia.,The Royal Children's Hospital, Parkville, Victoria, Australia.,Burnet Institute, Melbourne, Victoria, Australia
| | - Claire von Mollendorf
- Asia-Pacific Health Group, Murdoch Children's Research Institute, Victoria, Australia
| | - Kim Mulholland
- Department of Paediatrics, The University of Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Victoria, Australia.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiona M Russell
- Asia-Pacific Health Group, Murdoch Children's Research Institute, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Victoria, Australia
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Santos TM, Cata-Preta BO, Wendt A, Arroyave L, Hogan DR, Mengistu T, Barros AJD, Victora CG. Religious affiliation as a driver of immunization coverage: Analyses of zero-dose vaccine prevalence in 66 low- and middle-income countries. Front Public Health 2022; 10:977512. [PMID: 36388274 PMCID: PMC9642099 DOI: 10.3389/fpubh.2022.977512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/05/2022] [Indexed: 01/25/2023] Open
Abstract
Background The literature on the association between religion and immunization coverage is scant, mostly consisting of single-country studies. Analyses in low and middle-income countries (LMICs) to assess whether the proportions of zero-dose children vary according to religion remains necessary to better understand non-socioeconomic immunization barriers and to inform interventions that target zero-dose children. Methods We included 66 LMICs with standardized national surveys carried out since 2010, with information on religion and vaccination. The proportion of children who failed to receive any doses of a diphtheria-pertussis-tetanus (DPT) containing vaccine - a proxy for no access to routine vaccination or "zero-dose" status - was the outcome. Differences among religious groups were assessed using a test for heterogeneity. Additional analyses were performed controlling for the fixed effect of country, household wealth, maternal education, and urban-rural residence to assess associations between religion and immunization. Findings In 27 countries there was significant heterogeneity in no-DPT prevalence according to religion. Pooled analyses adjusted for wealth, maternal education, and area of residence showed that Muslim children had 76% higher no-DPT prevalence than Christian children. Children from the majority religion in each country tended to have lower no-DPT prevalence than the rest of the population except in Muslim-majority countries. Interpretation Analyses of gaps in coverage according to religion are relevant to renewing efforts to reach groups that are being left behind, with an important role in the reduction of zero-dose children.
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Affiliation(s)
- Thiago M. Santos
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil,*Correspondence: Thiago M. Santos
| | - Bianca O. Cata-Preta
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Andrea Wendt
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil,Programa de Pós-Graduação em Tecnologia em Saúde, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Luisa Arroyave
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | | | - Aluisio J. D. Barros
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G. Victora
- Postgraduate Program in Epidemiology, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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11
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Exposure of Zero-Dose Children to Multiple Deprivation: Analyses of Data from 80 Low- and Middle-Income Countries. Vaccines (Basel) 2022; 10:vaccines10091568. [PMID: 36146646 PMCID: PMC9502633 DOI: 10.3390/vaccines10091568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
The concept of multiple deprivation recognizes that the same individuals, households, and communities are often exposed to several forms of scarcity. We assessed whether lack of immunization is also associated with nutritional, environmental, and educational outcomes. We analyzed data from nationally representative surveys from 80 low- and middle-income countries with information on no-DPT (children aged 12-23 months without any doses of a diphtheria, pertussis and tetanus containing vaccine), stunting, wasting, maternal education and use of contraception, improved water and sanitation, and long-lasting insecticidal nets. Analyses of how these characteristics overlap were performed at individual and ecological levels. Principal component analyses (PCA) provided additional information on indicator clustering. In virtually all analyses, no-DPT children were significantly more likely to be exposed to the other markers for deprivation. The strongest, most consistent associations were found with maternal education, water, and sanitation, while the weakest associations were found for wasting and bed nets. No-DPT prevalence reached 46.1% in the most deprived quintile from first PCA component derived from deprivation indicators. All children were immunized in the two least deprived quintiles of the component. Our analyses provide strong support for the hypothesis that unimmunized children are also affected by other forms of deprivation.
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12
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Aheto JMK, Pannell O, Dotse-Gborgbortsi W, Trimner MK, Tatem AJ, Rhoda DA, Cutts FT, Utazi CE. Multilevel analysis of predictors of multiple indicators of childhood vaccination in Nigeria. PLoS One 2022; 17:e0269066. [PMID: 35613138 PMCID: PMC9132327 DOI: 10.1371/journal.pone.0269066] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Substantial inequalities exist in childhood vaccination coverage levels. To increase vaccine uptake, factors that predict vaccination coverage in children should be identified and addressed. Methods Using data from the 2018 Nigeria Demographic and Health Survey and geospatial data sets, we fitted Bayesian multilevel binomial and multinomial logistic regression models to analyse independent predictors of three vaccination outcomes: receipt of the first dose of Pentavalent vaccine (containing diphtheria-tetanus-pertussis, Hemophilus influenzae type B and Hepatitis B vaccines) (PENTA1) (n = 6059) and receipt of the third dose having received the first (PENTA3/1) (n = 3937) in children aged 12–23 months, and receipt of measles vaccine (MV) (n = 11839) among children aged 12–35 months. Results Factors associated with vaccination were broadly similar for documented versus recall evidence of vaccination. Based on any evidence of vaccination, we found that health card/document ownership, receipt of vitamin A and maternal educational level were significantly associated with each outcome. Although the coverage of each vaccine dose was higher in urban than rural areas, urban residence was not significant in multivariable analyses that included travel time. Indicators relating to socio-economic status, as well as ethnic group, skilled birth attendance, lower travel time to the nearest health facility and problems seeking health care were significantly associated with both PENTA1 and MV. Maternal religion was related to PENTA1 and PENTA3/1 and maternal age related to MV and PENTA3/1; other significant variables were associated with one outcome each. Substantial residual community level variances in different strata were observed in the fitted models for each outcome. Conclusion Our analysis has highlighted socio-demographic and health care access factors that affect not only beginning but completing the vaccination series in Nigeria. Other factors not measured by the DHS such as health service quality and community attitudes should also be investigated and addressed to tackle inequities in coverage.
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Affiliation(s)
- Justice Moses K. Aheto
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
- Department of Biostatistics, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
- * E-mail: ,
| | - Oliver Pannell
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Winfred Dotse-Gborgbortsi
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Mary K. Trimner
- Biostat Global Consulting, Worthington, OH, United States of America
| | - Andrew J. Tatem
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Dale A. Rhoda
- Biostat Global Consulting, Worthington, OH, United States of America
| | - Felicity T. Cutts
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - C. Edson Utazi
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
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13
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Cata-Preta BO, Santos TM, Wendt A, Hogan DR, Mengistu T, Barros AJD, Victora CG. Ethnic disparities in immunisation: analyses of zero-dose prevalence in 64 countries. BMJ Glob Health 2022; 7:e008833. [PMID: 35577393 PMCID: PMC9114867 DOI: 10.1136/bmjgh-2022-008833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The Sustainable Development Goals (SDGs) recommend stratification of health indicators by ethnic group, yet there are few studies that have assessed if there are ethnic disparities in childhood immunisation in low-income and middle-income countries (LMICs). METHODS We identified 64 LMICs with standardised national surveys carried out since 2010, which provided information on ethnicity or a proxy variable and on vaccine coverage; 339 ethnic groups were identified after excluding those with fewer than 50 children in the sample and countries with a single ethnic group. Lack of vaccination with diphtheria-pertussis-tetanus vaccine-a proxy for no access to routine vaccination or 'zero-dose' status-was the outcome of interest. Differences among ethnic groups were assessed using a χ2 test for heterogeneity. Additional analyses controlled for household wealth, maternal education and urban-rural residence. FINDINGS The median gap between the highest and lowest zero-dose prevalence ethnic groups in all countries was equal to 10 percentage points (pp) (IQR 4-22), and the median ratio was 3.3 (IQR 1.8-6.7). In 35 of the 64 countries, there was significant heterogeneity in zero-dose prevalence among the ethnic groups. In most countries, adjustment for wealth, education and residence made little difference to the ethnic gaps, but in four countries (Angola, Benin, Nigeria and Philippines), the high-low ethnic gap decreased by over 15 pp after adjustment. Children belonging to a majority group had 29% lower prevalence of zero-dose compared with the rest of the sample. INTERPRETATION Statistically significant ethnic disparities in child immunisation were present in over half of the countries studied. Such inequalities have been seldom described in the published literature. Regular analyses of ethnic disparities are essential for monitoring trends, targeting resources and assessing the impact of health interventions to ensure zero-dose children are not left behind in the SDG era.
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Affiliation(s)
- Bianca O Cata-Preta
- Department of Social Medicine, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Thiago M Santos
- Department of Social Medicine, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Andrea Wendt
- Department of Social Medicine, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | | | - Aluisio J D Barros
- Department of Social Medicine, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G Victora
- Department of Social Medicine, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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14
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Bergen N, Cata-Preta BO, Schlotheuber A, Santos TM, Danovaro-Holliday MC, Mengistu T, Sodha SV, Hogan DR, Barros AJD, Hosseinpoor AR. 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. Vaccines (Basel) 2022; 10:vaccines10040633. [PMID: 35455382 PMCID: PMC9028918 DOI: 10.3390/vaccines10040633] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Nicole Bergen
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland; (N.B.); (A.S.)
| | - Bianca O. Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil; (B.O.C.-P.); (T.M.S.); (A.J.D.B.)
| | - Anne Schlotheuber
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland; (N.B.); (A.S.)
| | - Thiago M. Santos
- International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil; (B.O.C.-P.); (T.M.S.); (A.J.D.B.)
| | - M. Carolina Danovaro-Holliday
- Department of Immunization, Vaccines and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland; (M.C.D.-H.); (S.V.S.)
| | - Tewodaj Mengistu
- Gavi, The Vaccine Alliance, 40 Chemin du Pommier, 1218 Geneva, Switzerland; (T.M.); (D.R.H.)
| | - Samir V. Sodha
- Department of Immunization, Vaccines and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland; (M.C.D.-H.); (S.V.S.)
| | - Daniel R. Hogan
- Gavi, The Vaccine Alliance, 40 Chemin du Pommier, 1218 Geneva, Switzerland; (T.M.); (D.R.H.)
| | - Aluisio J. D. Barros
- International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil; (B.O.C.-P.); (T.M.S.); (A.J.D.B.)
| | - Ahmad Reza Hosseinpoor
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland; (N.B.); (A.S.)
- Correspondence: ; Tel.: +41-22-791-3205
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15
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Wendt A, Santos TM, Cata-Preta BO, Costa JC, Mengistu T, Hogan DR, Victora CG, Barros AJD. Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys. J Glob Health 2022; 12:04022. [PMID: 35356658 PMCID: PMC8943525 DOI: 10.7189/jogh.12.04022] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys. Methods We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries. Results In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level. Conclusions Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.
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Affiliation(s)
- Andrea Wendt
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Thiago M Santos
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Bianca O Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Janaína C Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | | | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Aluísio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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16
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Utazi CE, Pannell O, Aheto JMK, Wigley A, Tejedor-Garavito N, Wunderlich J, Hagedorn B, Hogan D, Tatem AJ. Assessing the characteristics of un- and under-vaccinated children in low- and middle-income countries: A multi-level cross-sectional study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000244. [PMID: 36962232 PMCID: PMC10021434 DOI: 10.1371/journal.pgph.0000244] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/03/2022] [Indexed: 11/18/2022]
Abstract
Achieving equity in vaccination coverage has been a critical priority within the global health community. Despite increased efforts recently, certain populations still have a high proportion of un- and under-vaccinated children in many low- and middle-income countries (LMICs). These populations are often assumed to reside in remote-rural areas, urban slums and conflict-affected areas. Here, we investigate the effects of these key community-level factors, alongside a wide range of other individual, household and community level factors, on vaccination coverage. Using geospatial datasets, including cross-sectional data from the most recent Demographic and Health Surveys conducted between 2008 and 2018 in nine LMICs, we fitted Bayesian multi-level binary logistic regression models to determine key community-level and other factors significantly associated with non- and under-vaccination. We analyzed the odds of receipt of the first doses of diphtheria-tetanus-pertussis (DTP1) vaccine and measles-containing vaccine (MCV1), and receipt of all three recommended DTP doses (DTP3) independently, in children aged 12-23 months. In bivariate analyses, we found that remoteness increased the odds of non- and under-vaccination in nearly all the study countries. We also found evidence that living in conflict and urban slum areas reduced the odds of vaccination, but not in most cases as expected. However, the odds of vaccination were more likely to be lower in urban slums than formal urban areas. Our multivariate analyses revealed that the key community variables-remoteness, conflict and urban slum-were sometimes associated with non- and under-vaccination, but they were not frequently predictors of these outcomes after controlling for other factors. Individual and household factors such as maternal utilization of health services, maternal education and ethnicity, were more common predictors of vaccination. Reaching the Immunisation Agenda 2030 target of reducing the number of zero-dose children by 50% by 2030 will require country tailored analyses and strategies to identify and reach missed communities with reliable immunisation services.
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Affiliation(s)
- C Edson Utazi
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Oliver Pannell
- Flowminder Foundation and WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Justice M K Aheto
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Adelle Wigley
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Natalia Tejedor-Garavito
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | | | - Brittany Hagedorn
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, Washington, WA, United States of America
| | - Dan Hogan
- Gavi, The Vaccine Alliance, Geneva, Switzerland
| | - Andrew J Tatem
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
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17
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Santos TM, Cata-Preta BO, Mengistu T, Victora CG, Hogan DR, Barros AJD. Assessing the overlap between immunisation and other essential health interventions in 92 low- and middle-income countries using household surveys: opportunities for expanding immunisation and primary health care. EClinicalMedicine 2021; 42:101196. [PMID: 34805814 PMCID: PMC8585628 DOI: 10.1016/j.eclinm.2021.101196] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Unvaccinated children may live in households with limited access to other primary health care (PHC) services, and routine vaccination services may provide the opportunity to bring caregivers into contact with the health system. We aimed to investigate the overlap between not being vaccinated and failing to receive other PHC services in low- and middle-income countries (LMICs). METHODS Using Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) data between 2010-2019 from 92 LMICs, we analysed six vaccination indicators based on the bacille Calmette-Guérin (BCG), polio, diphtheria-pertussis-tetanus (DPT) and measles vaccines and their overlap with four other PHC indicators - at least four antenatal care (ANC) visits, institutional delivery, careseeking for common childhood illnesses or symptoms and place for handwashing in the home - in 211,141 children aged 12-23 months. Analyses were stratified according to wealth quintiles and World Bank income levels. FINDINGS Unvaccinated children and their mothers were systematically less likely to receive the other PHC interventions. These associations were particularly marked for 4+ ANC visits and institutional delivery and modest for careseeking behaviour. Our stratified analyses confirm a systematic disadvantage of unvaccinated children and their families with respect to obtaining other health services in all levels of household wealth and country income. INTERPRETATION We suggested that lack of vaccination goes hand in hand with missing out on other health interventions. This represents an opportunity for integrated delivery strategies that may more efficiently reduce inequalities in health service coverage. FUNDING Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, The Wellcome Trust, Associação Brasileira de Saúde Coletiva and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.
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Affiliation(s)
- Thiago M Santos
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- Corresponding author. Thiago M Santos, Institutional address: Rua Marechal Deodoro, 1160 - 96020-220 Pelotas, RS, Brazil
| | - Bianca O Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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18
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Coll CVN, Santos TM, Devries K, Knaul F, Bustreo F, Gatuguta A, Houvessou GM, Barros AJD. Identifying the women most vulnerable to intimate partner violence: A decision tree analysis from 48 low and middle-income countries. EClinicalMedicine 2021; 42:101214. [PMID: 34988411 PMCID: PMC8712229 DOI: 10.1016/j.eclinm.2021.101214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Primary prevention strategies are needed to reduce high rates of intimate partner violence (IPV) in low- and middle-income countries (LMICs). The effectiveness of population-based approaches may be improved by adding initiatives targeted at the most vulnerable groups and tailored to context-specificities. METHODS We applied a decision-tree approach to identify subgroups of women at higher risk of IPV in 48 LMICs and in all countries combined. Data from the most recent Demographic and Health Survey carried out between 2010 and 2019 with available information on IPV and sociodemographic indicators was used. To create the trees, we selected 15 recognized risk factors for IPV in the literature which had a potential for targeting interventions. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months. FINDINGS In the pooled decision tree, witnessing IPV during childhood, a low or medium empowerment level and alcohol use by the partner were the strongest markers of IPV vulnerability. IPV prevalence amongst the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group included women who witnessed IPV during childhood and had lower empowerment levels. These were 12% of the population and 1 in 4 women who experienced IPV in the selected LMICs. Across the individual national trees, subnational regions emerged as the most frequent markers of IPV occurrence. INTERPRETATION Starting with well-known predictors of IPV, the decision-tree approach provides important insights about subpopulations of women where IPV prevalence is high. This information can help designing targeted interventions. For a large proportion of women who experienced IPV, however, no particular risk factors were identified, emphasizing the need for population wide approaches conducted in parallel, including changing social norms, strengthening laws and policies supporting gender equality and women´s rights as well as guaranteeing women´s access to justice systems and comprehensive health services. FUNDING Bill and Melinda Gates Foundation (Grant INV-010051/OPP1199234), Wellcome Trust (Grant Number: 101815/Z/13/Z) and Associação Brasileira de Saúde Coletiva (ABRASCO).
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Affiliation(s)
- Carolina V N Coll
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
- Corresponding author at: International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil.
| | - Thiago M Santos
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
| | - Karen Devries
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Felicia Knaul
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL 33146, United States
| | | | - Anne Gatuguta
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | | | - Aluísio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
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