Socio-economic inequality of immunization coverage in India

What Determines the District-Level Disparities in Immunization Coverage in India: Findings from Five Rounds of the National Family Health Survey

India's Universal Immunization Programme has been performing at a sub-optimal level over the past decade, with there being a wide disparity in terms of immunization coverage between states. This study investigates the covariates that affect immunization rates and inequality in India at the individual and district levels. We used data from the five rounds of the National Family Health Survey (NFHS), conducted from 1992-1993 to 2019-2021. We used multilevel binary logistic regression analysis to examine the association between demographic, socio-economic and healthcare factors and a child's full immunization status. Further, we used the Fairlie decomposition technique to understand the relative contribution of explanatory variables to a child's full immunization status between districts with different immunization coverage levels. We found that 76% of children received full immunization in 2019-2021. Children from less wealthy families, urban backgrounds, Muslims, and those with illiterate mothers were found to have lower chances of receiving full immunization. There is no evidence that gender and caste disparities have an impact on immunization coverage in India. We found that having a child's health card is the most significant contributor to reducing the disparities that exist regarding children's full immunization between mid- and low-performing districts. Our study suggests that healthcare-related variables are more crucial than demographic and socio-economic variables when determining ways in which to improve immunization coverage in Indian districts.

Decision-making in childhood vaccination: vaccine hesitancy among caregivers of under-5 children from a tertiary care institution in Eastern India

Background

Acceptance of vaccines has been on a decline in recent times, with vaccine hesitancy being listed as one of the top 10 global health threats. This study analysed vaccine hesitancy and belief towards vaccination among caregivers of children aged below 5 years.

Methods

In this cross-sectional study, 196 caregivers of children aged 6 months to below 5 years who had attended an immunization clinic at a tertiary care institute of Eastern India from March to May 2019 were surveyed. Consecutive sampling was used to recruit eligible study participants. The survey assessed the attitudes of parents towards childhood vaccination by using the Vaccine Hesitancy Scale and their beliefs towards vaccination. Univariate analysis was performed to assess the association of various sociodemographic factors with vaccine hesitancy.

Results

Among the caregivers, most (48%) mothers were aged 26-35 years, literate and homemakers. Vaccine hesitancy was observed in 9.18% of the participants. Only the age of the child was significantly associated with vaccine hesitancy. Nearly half (48.5%) of the participants were concerned about the serious adverse effects of vaccines, and a third (30.6%) agreed that newer vaccines are associated with higher risks than the older ones. Caregivers felt that vaccines are no longer required for uncommon diseases.

Conclusion

Concerns regarding vaccine hesitancy are prevalent even among caregivers attending a tertiary care institute. Thus, additional studies are required to assess hesitancy in urban, rural, remote and inaccessible areas. Policymakers ought to conduct periodic assessments and implement necessary remedial measures for the long-term sustenance of the benefits of the national immunization programme.

District Level Geospatial Analysis of Utilization of ICDS Services Among Children in India

Introduction

Integrated Child Developmental Services (ICDS) is the most extensive government-run health program for children with its foot spread across the complete Indian Territory. ICDS Scheme, has been provided for 40 years and has been successful in some ways. The program in reducing the undernourishment among children over the past decade has been modest and slow in India than what has been reached in other countries with comparable socio-economic measure. Therefore, this study aims to identify the district level clustering of the utilization of ICDS services in India, and the present research also tried to relate it with socio-economic and demographic factors.

Materials and Methods

The data from the fourth round of the National Family Health Survey (NFHS-4) conducted in 2015-16 in India is used to carry out the analysis. We classified the country in 640 districts and employed geospatial techniques like Moran's I, univariate and bivariate local indicators of spatial association (LISA), and spatial error regression.

Results

The non-utilization under ICDS scheme varied between 93% in West Siang district of Arunachal Pradesh and around 7% in the Kandhamal district of Odisha in 2015-16 in India. The univariate LISA results suggest striking geographic clustering of utilization of ICDS services among children in India (Moran's I: 0.612). On another hand, there were regions with substantially low-low clustering of non-utilization of ICDS services in southeast India, including districts in Andhra Pradesh, Chhattisgarh, Southern Madhya Pradesh, Odisha, Telangana, and West Bengal. The findings also suggest that the proportion of the rural population (-0.190), and poor households (-0.132) in the district were significantly and negatively related while the proportion of uneducated women (0.450) was positively related to the non-utilization of ICDS services within the district.

Conclusion

This is the first-ever study that examined the complex interplay of the rural population, female illiteracy, poverty, SC/ST population, and Hindu population with non-utilization of ICDS services among children in the district in India. The study highlights the inter-district geographical disparities in the non-utilization of ICDS services. Further, it confirms that underprivileged districts in terms of the rural population and poor households are also disadvantageous in the utilization of ICDS services.

Public health facility quality and child immunization outcomes in rural India: A decomposition analysis

Universal coverage of routine childhood vaccines remains a challenge in many low- and middle-income countries (LMICs). In India, vaccination campaigns have increased full immunization coverage among 12–23 month old children from an estimated 62% in 2015–2016 to 76% in 2019–2020. Long-term improvements in coverage will likely require systemic changes to both the supply and demand sides of immunization programs. However, the effect of health system inputs on child vaccination outcomes remains poorly quantified in India. We examined the association between the quality of public health facilities and child vaccination outcomes in rural India using data from the nationally representative Integrated Child Health and Immunization Survey (2015–2016) which covered 1,346 public primary health sub-centers and 44,571 households. We constructed two indices of sub-center quality using multiple correspondence analysis: one related to the general health infrastructure quality and the other measuring vaccine service delivery. Using probit regression, we analyzed the relationship between vaccination outcomes in children under 2 years of age and sub-center quality, controlling for household socioeconomic characteristics. Additionally, we conducted Fairlie decomposition analysis by wealth group — bottom wealth quintile relative to the top four wealth quintiles— to examine factors contributing to gaps in immunization between rich and poor households. Infrastructure quality index was positively associated with completion of seven vaccination outcomes: full immunization, DPT-1 (first dose of diphtheria, pertussis, and tetanus), DPT-2, DPT-3, Bacillus Calmette–Guérin (BCG), hepatitis B (birth dose), and on-time vaccination (OTV). Vaccine service delivery index was positively associated with completion of measles vaccination. The distribution of infrastructure quality contributed to increased gaps in full immunization and OTV between rich and poor households, while greater proximity to vaccination site for poorer households reduced these gaps. Improved quality of health facilities, particularly facilities used by low-income households, may improve vaccination outcomes.

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.

Spatial inequalities in skilled birth attendance in India: a spatial-regional model approach

BACKGROUND

Despite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions.

METHODS

The study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran's I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA.

RESULTS

Moran's I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%.

CONCLUSION

The present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women's education.

How to ensure full vaccination? The association of institutional delivery and timely postnatal care with childhood vaccination in a cross-sectional study in rural Bihar, India

Incomplete and absent doses in routine childhood vaccinations are of major concern. Health systems in low- and middle-income countries (LMIC), in particular, often struggle to enable full vaccination of children, which affects their immunity against communicable diseases. Data on child vaccination cards from a cross-sectional primary survey with 1,967 households were used to assess the vaccination status. The association of timely postnatal care (PNC) and the place of delivery with any-dose (at least one dose of each vaccine) and full vaccination of children between 10-20 months in Bihar, India, was investigated. Bivariate and multivariable logistic regression models were used. The vaccines included targeted tuberculosis, hepatitis B, polio, diphtheria/pertussis/tetanus (DPT) and measles. Moreover predictors for perinatal health care uptake were analysed by multivariable logistic regression. Of the 1,011 children with card verification, 47.9% were fully vaccinated. Timely PNC was positively associated with full vaccination (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.06-2.08) and with the administration of at least one dose (any-dose) of polio vaccine (aOR 3.37 95% CI 1.79-6.36), hepatitis B/pentavalent vaccine (aOR 2.11 95% CI 1.24-3.59), and DPT/pentavalent vaccine (aOR 2.29 95% CI 1.35-3.88). Additionally, delivery in a public health care facility was positively associated with at least one dose of hepatitis B/pentavalent vaccine administration (aOR 4.86 95% CI 2.97-7.95). Predictors for timely PNC were institutional delivery (public and private) (aOR 2.7 95% CI 1.96-3.72, aOR 2.38 95% CI 1.56-3.64), at least one ANC visit (aOR 1.59 95% CI 1.18-2.15), wealth quintile (Middle aOR 1.57 95% CI 1.02-2.41, Richer aOR 1.51 95% CI 1.01-2.25, Richest aOR 2.06 95% CI 1.28-3.31) and household size (aOR 0.95 95% CI 0.92-0.99). The findings indicate a correlation between childhood vaccination and timely postnatal care. Further, delivery in a public facility correlates with the administration of at least one dose of hepatitis B vaccine and thus impedes zero-dose vaccination. Increasing uptake of timely PNC, encouraging institutional delivery, and improving vaccination services before discharge of health facilities may lead to improved vaccination rates among children.

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".

Change in full immunization inequalities in Indian children 12-23 months: an analysis of household survey data

BACKGROUND

India has made substantial progress in improving child health in recent years. However, the country continues to account for a large number of vaccine preventable child deaths. We estimated wealth-related full immunization inequalities in India. We also calculated the degree to which predisposing, reinforcing, and enabling factors contribute to these inequalities.

METHODS

We used data from the two rounds of a large nationally representative survey done in all states in India in 2005-06 (n = 9582) and 2015-16 (n = 49,284). Full immunization status was defined as three doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of Bacillus Calmette-Guérin vaccine, and one dose of measles vaccine in children 12-23 months. We compared full immunization coverage by wealth quintiles using descriptive statistics. We calculated concentration indices for full immunization coverage at the national and state levels. Using predisposing, reinforcing, and enabling factors associated with full immunization status identified from the literature, we applied a generalized linear model (GLM) framework with a binomial distribution and an identity link to decompose the concentration index.

RESULTS

National full immunization coverage increased from 43.65% in 2005-06 to 62.46% in 2015-16. Overall, full immunization coverage in both 2005-06 and 2015-16 in all states was lowest in children from poorer households and improved with increasing socioeconomic status. The national concentration index decreased from 0.36 to 0.13 between the two study periods, indicating a reduction in poor-rich inequality. Similar reductions were observed for most states, except in states where inequalities were already minimal (i.e., Tamil Nadu) and in some northeastern states (i.e., Meghalaya and Manipur). In 2005-06, the contributors to wealth-related full immunization inequality were antenatal care, maternal education, and socioeconomic status. The same factors contributed to full immunization inequality in 2015-16 in addition to difficulty reaching a health facility.

CONCLUSIONS

Immunization coverage and wealth-related equality have improved nationally and in most states over the last decade in India. Targeted, context-specific interventions could help address overall wealth-related full immunization inequalities. Intensified government efforts could help in this regard, particularly in high-focus states where child mortality remains high.

Understanding inequalities in child immunization in India: a decomposition approach

The importance of childhood immunization for healthy child growth and development is well recognized and is considered to be the best and most cost-effective lifesaver. Low socioeconomic status has been shown to be associated with low child immunization and health care utilization, but the inequalities in immunization coverage due to social and economic factors are poorly understood. This study aimed to explore the association between child immunization coverage and various socioeconomic factors and to quantify their contributions to generating inequalities in immunization coverage in India. The study data are from the National Family Health Survey-4 conducted in 2015-16. The association between socioeconomic determinants and child full immunization coverage was estimated using the χ2 test and binary logistic regression. Concentration indices were estimated to measure the magnitude of inequality, and these were further decomposed to explain the contribution of different socioeconomic factors to the total disparity in full immunization coverage. The results showed that the uptake of immunization in 2015-16 was highly associated with mother's educational status and household wealth. The concentration index decomposition revealed that inequality (immunization disadvantage) was highest among poorer economic groups and among children whose mothers were illiterate. The overall concentration index value indicates that the weaker socioeconomic groups in India are more disadvantaged in terms of immunization interventions. The results offer insight into the dynamics of the variation in immunization coverage in India and help identify vulnerable populations that should be targeted to decrease socioeconomic inequalities in the country.

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.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Identifying the know-do gap in evidence-based neonatal care practices among informal health care providers-a cross-sectional study from Ujjain, India

Background

More than a quarter of global neonatal deaths are reported from India, and a large proportion of these deaths are preventable. However, in the absence of robust public health care systems in several states in India, informal health care providers (IHCPs) with no formal medical education are the first contact service providers. The aim of this study was to assess the knowledge of IHCPs in basic evidence-based practices in neonatal care in Ujjain district and investigated factors associated with differences in levels of knowledge.

Methods

A cross-sectional survey was conducted using a questionnaire with multiple-choice questions covering the basic elements of neonatal care. The total score of the IHCPs was calculated. Multivariate quantile regression model was used to look for association of IHCPs knowledge score with: the practitioners’ age, years of experience, number of patients treated per day, and whether they attended children in their practice.

Results

Of the 945 IHCPs approached, 830 (88%) participated in the study. The mean ± SD score achieved was 22.3 ± 7.7, with a median score of 21 out of maximum score of 48. Although IHCPs could identify key tenets of enhancing survival chances of neonates, they scored low on the specifics of cord care, breastfeeding, vitamin K use to prevent neonatal hemorrhage, and identification and care of low-birth-weight babies. The practitioners particularly lacked knowledge about neonatal resuscitation, and only a small proportion reported following up on immunizations. Results of quantile regression analysis showed that more than 5 years of practice experience and treating more than 20 patients per day had a statistically significant positive association with the knowledge score at higher quantiles (q75^th and q90th) only. IHCPs treating children had significantly better scores across quantiles accept at the highest quantile (90^th).

Conclusions

The present study highlighted that know-do gap exists in evidence-based practices for all key areas of neonatal care tested among the IHCPs. The study provides the evidence that some IHCPs do possess knowledge in basic evidence-based practices in neonatal care, which could be built upon by future educational interventions. Targeting IHCPs can be an innovative way to reach a large rural population in the study setting and to improve neonatal care services.

Explaining socioeconomic inequalities in immunisation coverage in India: new insights from the fourth National Family Health Survey (2015-16)

BACKGROUND

Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether socioeconomic inequalities in immunisation coverage exist among children aged 12-59 months in India.

METHODS

Data for this observational study came from the fourth round of the National Family Health Survey (2015-16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation.

RESULTS

We found that in India, only 37% of children are fully immunised, 56% are partially immunised, and 7% have never been immunised. There is a disproportionate concentration of immunised children in higher wealth quintiles, demonstrating a socioeconomic gradient in immunisation. The data also confirm this pattern of socioeconomic inequality across regions. Factors such as mother's literacy, institutional delivery, place of residence, geographical location, and socioeconomic status explain the disparities in immunisation coverage.

CONCLUSIONS

In India, there are considerable inequalities in immunisation coverage among children. It is essential to ensure an improvement in immunisation coverage and to understand underlying factors that affect poor uptake and disparities in immunisation coverage in India in order to improve child health and survival and meet the SDGs.

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.

Decomposition of Gender Differences in Body Mass Index in Saudi Arabia using Unconditional Quantile Regression: Analysis of National-Level Survey Data

Understanding gender differences in body mass index (BMI) between males and females has been much debated and received considerable attention. This study aims to decompose gender differentials in the BMI of people of the Kingdom of Saudi Arabia. The study decomposed the BMI gender gap into its associated factors across the entire BMI distribution by using counterfactual regression methods. The main method of analysis was newly developed unconditional quantile regression-based decomposition, which applied Blinder-Oaxaca decomposition using data from the Saudi Health Interview Survey. Gender differentials were found in the BMI, with females showing a higher BMI than males. The aggregate decomposition showed that both the covariate effect and the structural effect were significant at the 25th and 50th quantiles. Detailed decomposition indicated that income level and employment status as well as soda consumption and the consumption of red meat were significantly correlated in explaining gender differentials in BMI across various quantiles, but the magnitude varied by quantile. Our study suggests the government should consider introducing programs that specifically target women to help them reduce BMI. These programs could include organizing sporting events at the workplace and at the national level. Furthermore, the effect of soda consumption could be reduced by levying a tax on beverages, which might reduce the demand for soda due to the increased price.

The trend of full vaccination coverage in infants and inequalities by wealth quintile and maternal education: analysis from four recent demographic and health surveys in Nepal

BACKGROUND

Despite policy intention to reach disadvantaged populations, inequalities in health care resource use and health outcomes persist in Nepal. The current study aimed to investigate the trend of full vaccination coverage among infants and its equity gaps between Nepal Demographic and Health Surveys (NDHS) 2001 and 2016.

METHODS

Using data from NDHS conducted in 2001, 2006, 2011 and 2016, we investigated the trend of coverage of six antigens: Bacille Calmette Guerin (BCG), Diptheria, Pertussis, Tetanus (DPT), Polio, and Measles during their infancy among children aged 12-23 months. We presented trends and correlates of full vaccination coverage by different socio-demographic factors. We measured inequalities in full vaccination coverage by wealth quintile and maternal education using absolute measure (slope index of inequality) and relative measures (Relative index of inequality, concentration index) of inequalities.

RESULTS

Full vaccination coverage among infants steadily increased from 65.6% in 2001 to 87.0% in 2011; however, it decreased to 77.8% in 2016. Province 2 had a significantly lower full vaccination coverage compared to Province1.Although decreasing over time, there were significant inequalities by household wealth quintiles and maternal educational status. The slope index of inequality (SII) for wealth quintiles decreased from - 32.3 [- 45.5,-19.1] in 2001 to an SII of-8.4 [- 18.6,-1.7] in 2016. Similarly, the SII for education decreased from - 61.8 [- 73.5,-50.1] in 2001 to an SII of - 30.5 [- 40.7,-20.2] in 2016. Similarly, the relative index of inequality (RII) also showed an improvement over time, indicating the narrowing equity gap. Additionally, concentration index on full vaccination coverage by wealth quintiles dropped from 0.21 (0.12-0.28) in 2001 to 0.054 (- 0.01-0.12) in 2016. Absolute and relative inequalities were persistently larger by maternal educational status compared to household wealth quintiles throughout the study period.

CONCLUSION

Full vaccination coverage in Nepal increased from 2001 until 2011 but saw a significant decrement away from the national target after 2011. However, the equity gap by household wealth quintile and maternal education status has narrowed over time. National Immunization programs need to give higher emphasis to infants born to mothers with less education, those born in the poorer wealth quintile households, and those living in Province 2.

Socio-economic inequalities in diabetes prevalence in the Kingdom of Saudi Arabia

BACKGROUND

Rising prevalence of non-communicable diseases, including diabetes in the Middle East, is a major public health concern of the 21st century. However, there is a paucity of literature to understand and measure socio-economic inequalities in diabetes prevalence in this region, including the Kingdom of Saudi Arabia (KSA).

METHODS

This study investigated socio-economic inequalities in diabetes prevalence in the KSA using data from the Saudi Arabia Health Interview Survey. Concentration curve, concentration index, and multivariate logistic regression were used to measure and examine income- and education-related inequalities in diabetes prevalence.

RESULTS

The results showed significant socio-economic inequalities in the prevalence of diabetes through analysing a nationally representative sample of the KSA population. Diabetes prevalence was concentrated among the poor and among people with less education. In addition, education-related inequality was higher than income-related inequality.

CONCLUSIONS

The findings of this study are important for policymakers to combat both the increasing prevalence of and socio-economic inequalities in diabetes. The government should promote health education programmes and increase the level of public awareness of diabetes management, especially among the lower educated population in the KSA.

Vaccination uptake and income inequalities within a mass vaccination campaign

BACKGROUND

In July 2013, Israel was swept with fear of a polio outbreak. In response to the importation of wild polio virus, the Ministry decided to take preventive action by administering oral poliovirus vaccine (OPV) to all children born after 1 January 2004 who had received at least one dose of inactivated poliovirus vaccine (IPV) in the past. This study analyzes the vaccination uptake rates resulting from the mass polio vaccination campaign on the basis of health inequality parameters of socioeconomic status (SES), principles of solidarity, and the Gini inequality index. The research explores understanding the value of the Gini inequality index within the context of SES and solidarity.

METHODS

The study is based on data gathered from the Israeli Ministry of Health's administrative records from mother-and-child clinics across Israel. The research population is comprised of resident infants and children whom the Ministry of Health defined as eligible for the OPV between August and December 2013 (the "campaign period"). The analysis was carried out at the municipality level as well as the statistical area level.

RESULTS

The higher the SES level of the municipality where the mother-and-child clinic is located, the lower the OPV vaccination uptake is. The greater the income inequality is in the municipality where the mother-and-child clinic is situated, the lower the vaccination uptake.

CONCLUSIONS

Public health professionals promoting vaccine programs need to make specially-designed efforts both in localities with high average income and in localities with a high level of income diversity/inequality. Such practice will better utilize funds, resources, and manpower dedicated to increasing vaccination uptake across varying populations and communities.

Factors influencing basic vaccination coverage in Myanmar: secondary analysis of 2015 Myanmar demographic and health survey data

BACKGROUND

Immunization is one of the most effective measures for preventing disease when vaccination coverage is sufficient. Although vaccination coverage is known to be influenced by social and cultural barriers, the determinants of childhood immunization in Myanmar remain poorly understood. This study analyzed factors that influenced complete vaccination status (one dose each for Bacillus Calmette-Guérin and measles and three doses each for diphtheria-pertussis and polio) using 2015 data from the Myanmar Demographic Health and Survey.

METHODS

Data from 12 to 23-month-old children and their mothers were extracted from the nationally representative survey results. Bivariate and multivariate analyses with survey-weighted logistic regression were performed to examine the relationships between vaccination status and various sociodemographic and medical factors. The independent variables for the analyses included area of residence, economic status, maternal age, marital status, education, literacy, employment status, antenatal care attendance, tetanus vaccination, place of delivery, postnatal evaluations, child's sex, number of children, previous child death, decision maker(s) regarding child's health, frequency of healthcare visits, paternal education, and paternal occupation.

RESULTS

A representative sample of 904 cases were extracted for the analysis. The overall complete vaccination rate was 55.4%. In the multivariate analysis with backward step-wise selection, complete vaccination was independently associated with middle or high economic status (adjusted odds ratio [AOR]: 2.64, 95% confidence interval [CI]: 1.85-3.78), older maternal age (AOR: 2.87, 95% CI: 1.62-5.10), ≥4 antenatal care visits (AOR: 1.87, 95% CI: 1.28-2.73), and maternal tetanus vaccination before delivery (AOR: 3.26, 95% CI: 1.82-5.85).

CONCLUSION

The first Demographic and Health Survey in Myanmar revealed that only approximately one-half of 12-23-year-old children had received complete vaccination, which was lower than the estimated rate from routine administrative coverage. Our results indicate that incomplete immunization status was associated with low economic status, younger maternal age, fewer antenatal care visits, and no maternal tetanus vaccination. These findings may help improve the targeting and strategic implementation of the Expanded Programme on Immunization.

Decomposing the gap in missed opportunities for vaccination between poor and non-poor in sub-Saharan Africa: A Multicountry Analyses

Understanding the gaps in missed opportunities for vaccination (MOV) in sub-Saharan Africa would inform interventions for improving immunisation coverage to achieving universal childhood immunisation. We aimed to conduct a multicountry analyses to decompose the gap in MOV between poor and non-poor in SSA. We used cross-sectional data from 35 Demographic and Health Surveys in SSA conducted between 2007 and 2016. Descriptive statistics used to understand the gap in MOV between the urban poor and non-poor, and across the selected covariates. Out of the 35 countries included in this analysis, 19 countries showed pro-poor inequality, 5 showed pro-non-poor inequality and remaining 11 countries showed no statistically significant inequality. Among the countries with statistically significant pro-illiterate inequality, the risk difference ranged from 4.2% in DR Congo to 20.1% in Kenya. Important factors responsible for the inequality varied across countries. In Madagascar, the largest contributors to inequality in MOV were media access, number of under-five children, and maternal education. However, in Liberia media access narrowed inequality in MOV between poor and non-poor households. The findings indicate that in most SSA countries, children belonging to poor households are most likely to have MOV and that socio-economic inequality in is determined not only by health system functions, but also by factors beyond the scope of health authorities and care delivery system. The findings suggest the need for addressing social determinants of health.

Inequalities in child immunization coverage in Ghana: evidence from a decomposition analysis

Childhood vaccination has been promoted as a global intervention aimed at improving child survival and health, through the reduction of vaccine preventable deaths. However, there exist significant inequalities in achieving universal coverage of child vaccination among and within countries. In this paper, we examine rural-urban inequalities in child immunizations in Ghana. Using data from the recent two waves of the Ghana Demographic and Health Survey, we examine the probability that a child between 12 and 59 months receives the required vaccinations and proceed to decompose the sources of inequalities in the probability of full immunization between rural and urban areas. We find significant child-specific, maternal and household characteristics on a child's immunization status. The results show that children in rural areas are more likely to complete the required vaccinations. The direction and sources of inequalities in child immunizations have changed between the two survey waves. We find a pro-urban advantage in 2008 arising from differences in observed characteristics whilst a pro-rural advantage emerges in 2014 dominated by the differences in coefficients. Health system development and campaign efforts have focused on rural areas. There is a need to also specifically target vulnerable children in urban areas, to maintain focus on women empowerment and pay attention to children from high socio-economic households in less favourable economic times.

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

Background

Socioeconomic inequalities in child vaccination continue to be a global public health concern. This study aimed to measure and identify factors associated with socioeconomic inequalities in full immunisation coverage against the four core vaccine-preventable diseases (ie, bacille Calmette-Guérin, diphtheria-tetanus-pertussis (three doses), polio (three doses) and measles vaccines) in 46 low/middle-income countries.

Methods

The most recent nationally representative samples of children (aged 10–59 months, n=372 499) collected through the Demographic Health Surveys were used to measure vaccination rates. The concentration index (C) was used to quantify socioeconomic inequalities in vaccination coverage. Furthermore, meta-regression analyses were used to determine factors affecting socioeconomic inequalities in vaccination coverage across countries.

Results

Results suggested that immunisation coverage was pro-rich in most countries (median C=0.161, IQR 0.131). Gambia (C=−0.146, 95% CI −0.223 to −0.069), Namibia (C=−0.093, 95% CI −0.145 to −0.041) and Kyrgyz Republic (C=−0.227, 95% CI −0.304 to −0.15) were the only countries where children who belong to higher socioeconomic status group were less likely to receive all the four core vaccines than their lower socioeconomic status counterparts. Meta-regression analyses suggested that, across countries, the concentration of antenatal care visits among wealthier mothers was positively associated with the concentration of vaccination coverage among wealthier children (coefficient=0.606, 95% CI 0.301 to 0.911).

Conclusions

Pro-rich distribution of child vaccination in most low/middle-income countries remains an important public health policy concern. Policies aimed to improve antenatal care visits among mothers in lower socioeconomic groups may mitigate socioeconomic inequalities in vaccination coverage in low/middle-income countries.

Socioeconomic inequality in Hepatitis B vaccination of rural adults in China

Hepatitis B (HB) vaccination is the most effective way to prevent HB virus infection. While measures taken to control the prevalence of HB have achieved significant results, HB prevalence in rural China among adults remains problematic. This study sheds new light on the determinants of HB vaccine uptake and its inequality according to socioeconomic status in rural areas of China. We interviewed 22,283 adults, aged 18-59 years, from 8444 households, in 48 villages from 8 provinces. Vaccination status was modeled by using two logistic models: whether take at least one HB vaccine and whether to complete the entire vaccination regime. The Erreygers' concentration index ([Formula: see text]) was used to quantify the degree of inequality and the decomposition approach was used to uncover the determinants of inequality in vaccine uptake. We found that the coverage rate of HB vaccination is 20.2%, and the completion rate is 16.0%. The [Formula: see text] of at least one dose (0.081) and three doses (0.076) revealed a substantial pro-rich inequality. Income contributed the largest percentage to HB vaccination inequalities (52.17% for at least one dose and 52.03% for complete vaccinations). HB awareness was another important cause of inequality in HB vaccination (around 30%). These results imply that rich had a greater tendency to vaccinate and inequality favouring the rich was almost equal for the complete three doses. While the factors associated with HB vaccination uptake and inequalities were multifaceted, income status and HB awareness were the main barriers for the poor to take HB vaccine by adults in rural China.

Socioeconomic inequality of diabetes patients' health care utilization in Denmark

Understanding socioeconomic inequalities in health care is critical for achieving health equity. The aim of this paper is threefold: 1) to quantify inequality in diabetes health care service utilization; 2) to understand determinants of these inequalities in relation to socio-demographic and clinical morbidity factors; and 3) to compare the empirical outcome of using income level and educational level as proxies for Socio Economic Status (SES).Data on the entire Danish population of diabetes patients in 2011 (N = 318,729) were applied. Patients' unique personal identification number enabled individual patient data from several national registers to be linked. A concentration index approach with decomposition into contributing factors was applied. Differences in diabetes patients' health care utilization patterns suggest that use of services differ among patients of lower and higher SES, despite the Danish universal health care system. Especially, out-patient services, rehabilitation and specialists in primary care show different utilization patterns according to SES. Comparison of the empirical outcome from using educational level and income level as proxy for patients' SES indicate important differences in inequality estimates. While income, alike other measures of labor market attachment, to a certain extent is explained by morbidity and thus endogenous, education is more decisive for patients' ability to take advantage of the more specialized services provided in a universal health care system.

WEALTH-BASED INEQUALITY IN CHILD IMMUNIZATION IN INDIA: A DECOMPOSITION APPROACH

Despite years of health and medical advancement, children still suffer from infectious diseases that are vaccine preventable. India reacted in 1978 by launching the Expanded Programme on Immunization in an attempt to reduce the incidence of vaccine-preventable diseases (VPDs). Although the nation has made remarkable progress over the years, there is significant variation in immunization coverage across different socioeconomic strata. This study attempted to identify the determinants of wealth-based inequality in child immunization using a new, modified method. The present study was based on 11,001 eligible ever-married women aged 15-49 and their children aged 12-23 months. Data were from the third District Level Household and Facility Survey (DLHS-3) of India, 2007-08. Using an approximation of Erreyger's decomposition technique, the study identified unequal access to antenatal care as the main factor associated with inequality in immunization coverage in India.

Determinants of inequality in the up-to-date fully immunization coverage among children aged 24-35 months: Evidence from Zhejiang province, East China

OBJECTIVE

This study aimed to determine the degree and determinants of inequality in up-to-date fully immunization (UTDFI) coverage among children of Zhejiang province, east China.

METHOD

We used data from the Zhejiang provincial vaccination coverage survey of 2014 and the health outcome was the UTDFI status among children aged 24-35 months. The household income per month was used as an index of socio-economic status for the inequality analysis. The concentration index (CI) was used to quantify the degree of inequality and the decomposition approach was applied to quantify the contributions from demographic factors to inequality in UTDFI coverage.

RESULTS

The UTDFI coverage was 80.63% and the CI for UTDFI coverage was 0.12028 (95% CI: 0.10852-0.13175), indicating that immunization practice significantly favored children with relatively higher socio-economic status. The results of decomposition analysis suggested that 68.2% of the socio-economic inequality in UTDFI coverage should be explained by the mother's education level. Furthermore, factors such as birth order, ethnic group, maternal employment status, residence, immigration status, GDP per-capital and percentage of public health spending of the total health spending also could explain the disparity in UTDFI coverage.

CONCLUSION

There exists inequality in UTDFI coverage among the socio-economic disadvantage children. Health interventions of narrowing the socio-economic inequality in UTDFI coverage will benefit from being supplemented with strategies aimed at poverty and illiteracy reduction.

Fully immunized child: coverage, timing and sequencing of routine immunization in an urban poor settlement in Nairobi, Kenya

BACKGROUND

More efforts have been put in place to increase full immunization coverage rates in the last decade. Little is known about the levels and consequences of delaying or vaccinating children in different schedules. Vaccine effectiveness depends on the timing of its administration, and it is not optimal if given early, delayed or not given as recommended. Evidence of non-specific effects of vaccines is well documented and could be linked to timing and sequencing of immunization. This paper documents the levels of coverage, timing and sequencing of routine childhood vaccines.

METHODS

The study was conducted between 2007 and 2014 in two informal urban settlements in Nairobi. A total of 3856 children, aged 12-23 months and having a vaccination card seen were included in analysis. Vaccination dates recorded from the cards seen were used to define full immunization coverage, timeliness and sequencing. Proportions, medians and Kaplan-Meier curves were used to assess and describe the levels of full immunization coverage, vaccination delays and sequencing.

RESULTS

The findings indicate that 67 % of the children were fully immunized by 12 months of age. Missing measles and third doses of polio and pentavalent vaccine were the main reason for not being fully immunized. Delays were highest for third doses of polio and pentavalent and measles. About 22 % of fully immunized children had vaccines in an out-of-sequence manner with 18 % not receiving pentavalent together with polio vaccine as recommended.

CONCLUSIONS

Results show higher levels of missed opportunities and low coverage of routine childhood vaccinations given at later ages. New strategies are needed to enable health care providers and parents/guardians to work together to increase the levels of completion of all required vaccinations. In particular, more focus is needed on vaccines given in multiple doses (polio, pentavalent and pneumococcal conjugate vaccines).

The performance of the expanded programme on immunization in a rural area of Mozambique

Vaccines are an effective public health measure. Vaccination coverage has improved in Africa in the last decades but has still not reached WHO/UNICEF target of at least 90% first-dose coverage for vaccines in the Expanded Programme on Immunization (EPI) implemented in Mozambique in 1979. There are concerns about reliability of vaccination coverage official data from low-income countries, and inequities in vaccine administration. We randomly sampled 266 under-five years children from Taninga, a poor rural area in Southern Mozambique under a Demographic surveillance system and collected data directly from the individual national health cards when available (BCG, DTP/HepB/Hib, Polio, Measles). We also collected data on socio-economic variables through an interview. Overall, only 5% of the participants did not receive all the doses of the vaccines included in the EPI in a timely manner (overall vaccination coverage 95%, 95% CI: 93.5-95.5%). The socio-economic status was homogenously low and no differences were found between vaccinated and unvaccinated children. Vaccination coverage in Taninga was very high, despite the low socio-economic status of the population. The high performance of the EPI in Taninga is an encouraging experience for achieving high vaccination coverage in low-income rural settings.

Decomposing Wealth-Based Inequalities in Under-Five Mortality in West Africa

BACKGROUND

This study aimed to analysis the inequalities of mortality of children under 5 years in West Africa by examining the determinants and contributing factors to the overall inequality concentration in these countries.

METHOD

Data used came from the DHS surveys conducted in the six countries in West Africa: Burkina Faso (2010), Benin (2006), Cote d'Ivoire 2011), Ghana (2008), Mali (2006), Nigeria (2008) and Niger (2012). The concentration index (CI) and Generalized Linear Model (GLM) with logit link were used to access inequality.

RESULTS

The results show that in all countries, the poorest Q1 have the highest proportions of deaths: Nigeria (31.4%), Cote d'Ivoire (30.4%) and Ghana (36.4%), over 30% of deaths of children under 5 years are among the children of the poorest (Q1) and the absolute differences of proportions Q1-Q5 are more than 20 points (25.8 in Ghana and 23.6 in Nigeria). The contributing factors of inequalities of child mortality were birth order, maternal age, parity and household size. Our findings also showed that the intensity of inequality varies from one country to another.

CONCLUSION

The most important conclusion of this study is to reduce mortality in children under 5 years, it is needed to reduce economic and social inequalities and improve the country's economic and social condition. There is a need for monitoring and assessment inequalities by leading causes of death and morbidity among children in the region in order to advance in understanding the gaps and finding a way to reduce them in West Africa countries.

Inequity in Timeliness of MMR Vaccination in Children Living in the Suburbs of Iranian Cities

INTRODUCTION

High coverage of immunization is one of the indicators of good performance of health system but timely vaccination is another indicator which is associated with protective effect of vaccines. The present study aimed at evaluating the inequity in timely vaccination with a focus on inequities in timeliness by gender, birth order, parents' education and place of residence (rural or urban).

METHODS

A historical cohort study was conducted on children of 24-47 months of age who were living in the suburbs of big cities in Iran and were selected through stratified proportional sampling method. Only children who had vaccine cards -i.e. 3610 children -were included in data analysis. The primary outcome was age-appropriate vaccination of MMR1. Inequity was measured by Concentration Index (C) and Relative Index of Inequity (RII). Inequity indexes were calculated according to the mother and father's education, child birth order, child's sex and the family's place of residence at the time of vaccination.

RESULTS

The overall on-time MMR1 vaccination was 70% and 54.4% for Iranians and Non-Iranians, respectively. The C index of mother and father's education for timely MMR vaccination was 0.023 and was 0.029 in Iranian children as well as 0.044 and 0.019 for non-Iranians, respectively. The C index according to child order in Iranians and Non-Iranians was 0.025 and C=0.078. With regard to children who lived in cities, the on-time vaccination was 0.36% and 0.29% higher than that in rural areas . In male children it was 0.12% and 0.14% higher than that in female children for Iranians and Non-Iranians, respectively.

CONCLUSION

Timeliness MMR vaccination in Iranian children is higher than that in non-Iranian children. Regarding the existence of differences in timely vaccination rate in all Iranian and Non-Iranian children, no evidence was observed for inequity by focusing on parents' education, birth order, gender or place of residence. So, increasing timeliness of vaccination for enhancing the protective effect of vaccines can be considered a health-related goal in Iran after receiving high immunization coverage.

Determinants of immunization inequality among urban poor children: evidence from Nairobi's informal settlements

INTRODUCTION

Despite the relentless efforts to reduce infant and child mortality with the introduction of the National Expanded Programmes on Immunization (EPI) in 1974, major disparities still exist in immunizations coverage across different population sub-groups. In Kenya, for instance, while the proportion of fully immunized children increased from 57% in 2003 to 77% in 2008-9 at national level and 73% in Nairobi, only 58% of children living in informal settlement areas are fully immunized. The study aims to determine the degree and determinants of immunization inequality among the urban poor of Nairobi.

METHOD

We used data from the Nairobi Cross-Sectional Slum Survey of 2012 and the health outcome was full immunization status among children aged 12-23 months. The wealth index was used as a measure of social economic position for inequality analysis. The potential determinants considered included sex of the child and mother's education, their occupation, age at birth of the child, and marital status. The concentration index (CI) was used to quantify the degree of inequality and decomposition approach to assess determinants of inequality in immunization.

RESULTS

The CI for not fully immunized was -0.08 indicating that immunization inequality is mainly concentrated among children from poor families. Decomposition of the results suggests that 78% of this inequality is largely explained by the mother's level of education.

CONCLUSION

There exists immunization inequality among urban poor children in Nairobi and efforts to reduce this inequality should aim at targeting mothers with low level of education during immunization campaigns.

Estimating the spatial distribution of acute undifferentiated fever (AUF) and associated risk factors using emergency call data in India. A symptom-based approach for public health surveillance

The System for Early-warning based on Emergency Data (SEED) is a pilot project to evaluate the use of emergency call data with the main complaint acute undifferentiated fever (AUF) for syndromic surveillance in India. While spatio-temporal methods provide signals to detect potential disease outbreaks, additional information about socio-ecological exposure factors and the main population at risk is necessary for evidence-based public health interventions and future preparedness strategies. The goal of this study is to investigate whether a spatial epidemiological analysis at the ecological level provides information on urban-rural inequalities, socio-ecological exposure factors and the main population at risk for AUF. Our results displayed higher risks in rural areas with strong local variation. Household industries and proximity to forests were the main socio-ecological exposure factors and scheduled tribes were the main population at risk for AUF. These results provide additional information for syndromic surveillance and could be used for evidence-based public health interventions and future preparedness strategies.

The influence of compositional and contextual factors on non-receipt of basic vaccines among children of 12-23-month old in India: a multilevel analysis

BACKGROUND

Children unreached by vaccination are at higher risk of poor health outcomes and India accounts for nearly a quarter of unvaccinated children worldwide. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling.

METHODS AND FINDINGS

We studied characteristics of unvaccinated children using the District Level Health and Facility Survey 3, a nationally representative probability sample containing 65 617 children aged 12-23 months from 34 Indian states and territories. We developed four-level Bayesian binomial regression models to examine the determinants of non-vaccination. The analysis considered two outcomes: completely unvaccinated (CUV) children who had not received any of the eight vaccine doses recommended by India's Universal Immunization Programme, and children who had not received any dose from routine immunisation services (no RI). The no RI category includes CUV children and those who received only polio doses administered via mass campaigns. Overall, 4.83% (95% CI: 4.62-5.06) of children were CUV while 12.01% (11.68-12.35) had received no RI. Individual compositional factors strongly associated with CUV were: non-receipt of tetanus immunisation for mothers during pregnancy (OR = 3.65 [95% CrI: 3.30-4.02]), poorest household wealth index (OR = 2.44 [1.81-3.22] no maternal schooling (OR = 2.43 [1.41-4.05]) and no paternal schooling (OR = 1.83 [1.30-2.48]). In rural settings, the influence of maternal illiteracy disappeared whereas the role of household wealth index was reinforced. Factors associated with no RI were similar to those for CUV, but effect sizes for individual compositional factors were generally larger. Low maternal education was the strongest risk factor associated with no RI in all models. All multilevel models found significant variability at community, district, and state levels net of compositional factors.

CONCLUSION

Non-vaccination in India is strongly related to compositional characteristics and is geographically distinct. Tailored strategies are required to overcome current barriers to immunisation.

Socioeconomic dynamics of gender disparity in childhood immunization in India, 1992-2006

BACKGROUND

Recent evidence indicated that gender disparity in child health is minimal and narrowed over time in India. However, considering the geographical and socio-cultural diversity in India, the gender gap may persist across disaggregated socioeconomic context which may be masked by average level. This study examines the dynamics of gender disparity in childhood immunization across regions, residence, wealth, caste and religion in India during 1992-2006.

METHOD

We used multi-waves of the cross-sectional data of National Family Health Survey conducted in India between 1992-93 and 2005-06. Gender disparity ratio was used to measure the gender gap in childhood immunization across the selected socioeconomic characteristics. Multinomial regression analysis was used to examine the gender gap after accounting for other covariates.

RESULT

Results indicate that, at aggregate level, gender disparity in full immunization is minimal and has stagnated during the study period. However, gender disparity--disfavouring female children--becomes apparent across the regions, poor households, and religion--particularly among Muslims. Adjusted gender disparity ratio indicates that, full immunization is lower among female than male children of the western region, poor household and among Muslims. Between 1992-93 and 2005-06, the disparity in full immunization had narrowed in the northern region whereas it had, astonishingly, increased in some of the western and southern states of the country.

CONCLUSION

Our findings emphasize the need to integrate gender issues in the ongoing immunization programme in India, with particular attention to urban areas, developed states, and to the Muslim community.

Sibling composition and child immunization in India and Pakistan, 1990-2007

BACKGROUND

This study aimed to assess trends in gender differentials in child immunization beyond the conventional male-female dichotomy, by considering gender, surviving siblings, birth order and different compositions of older siblings in tandem, during 1990-2007 in India and Pakistan.

METHODS

Using different rounds of Demographic and Health Survey datasets, we adopted the World Health Organization guidelines for appraising full immunization among children. Sex composition of surviving older siblings was combined. Cochrane-Armitage and the Chi-square tests were used to test linear and nonlinear trends, respectively.

RESULTS

Although child immunization has increased during the period of 1990-2007 in both India and Pakistan, results showed that more than 50% of the eligible children did not receive the recommended immunization. The results also showed that boys and girls with no older surviving siblings and those with only surviving siblings of the opposite sex appeared to have fully immunized proportionally compared with the children with other sibling compositions.

CONCLUSION

The findings confirmed that girls and boys were not always treated equally, and that there was a clear pattern of selective neglect in child immunization in both countries during the period of 1990-2007.

'Looking beyond the male-female dichotomy' - sibling composition and child immunization in India, 1992-2006

This study examines trends in gender differentials in child immunization beyond the conventional male-female dichotomy, by considering older surviving sibling composition between 1992 and 2006 in India. The present study adopts the World Health Organization (WHO) guidelines for appraising full immunization among children utilising three rounds of the National Family Health Survey. Twelve combinations of sex composition of surviving older siblings were constructed. Bivariate differentials and pooled multilevel logistic regression analysis were conducted to assess the trends and patterns of child immunization with respect to various categories of older surviving sibling composition. Although child immunization increased between 1992 and 2006, majority of all eligible children did not receive the recommended immunization. Further, full immunization significantly varies by twelve categories of siblings composition during 1992-2006. The probability of full immunization among male children who did not have any older surviving sibling was 60% in 2005-06, while it was just 26% among female children who had 1+ older surviving sister and brother. This study emphasizes the need to integrate sibling issues in child immunization as a prioritized component in the ongoing Universal Immunization Programme, which could be an effective step towards ensuring full immunization coverage among Indian children.