Equity and vaccine uptake: a cross-sectional study of measles vaccination in Lasbela District, Pakistan

Abstract

BackgroundAchieving equity means increased uptake of health services for those who need it most. But the poorest families continue to have the poorest service. In Pakistan, large numbers of children do not access vaccination against measles despite the national government's effort to achieve universal coverage.MethodsA cross-sectional study of a random sample of 23 rural and 9 urban communities in the Lasbela district of south Pakistan, explored knowledge, attitudes and discussion around measles vaccination. Several socioeconomic variables allowed examination of the role of inequities in vaccination uptake; 2479 mothers provided information about 4007 children aged 10 to 59 months. A Mantel-Haenszel stratification analysis, with and without adjustment for clustering, clarified determinants of measles vaccination in urban and rural areas.ResultsA high proportion of mothers had appropriate knowledge of and positive attitudes to vaccination; many discussed vaccination, but only one half of children aged 10-59 months accessed vaccination. In urban areas, having an educated mother, discussing vaccinations, having correct knowledge about vaccinations, living in a community with a government vaccination facility within 5 km, and living in houses with better roofs were associated with vaccination uptake after adjusting for the effect of each of these variables and for clustering; maternal education was an equity factor even among those with good access. In rural areas, the combination of roof quality and access (vaccination post within 5 km) along with discussion about vaccines and knowledge about vaccines had an effect on uptake.ConclusionStagnating rates of vaccination coverage may be related to increasing inequities. A hopeful finding is that discussion about vaccines and knowledge about vaccines had a positive effect that was independent of the negative effect of inequity - in both urban and rural areas. At least as a short term strategy, there seems to be reason to expect an intervention increasing knowledge and discussion about vaccination in this district might increase uptake.

The effect of social determinants on immunization programs

“…48 Education of families about vaccines was shown to be associated with higher immunization coverage of children. 10 Community-based, culturally sensitive educational programs where educators originated from among the target population were positively received by Bedouin Arab mothers in Southern Israel. 48 In this regard, increased cultural sensitivity including language appropriate interventions were helpful among immigrant populations in high-income countries.…”

“…8 A higher quality of roofing was found to be positively associated with overall vaccination rates in Delhi, India 9 and with higher measles immunization rates in the Lasbella district in Pakistan. 10 These observations suggest that families that possess better housing are more likely to have their children immunized.…”

“…9 In another cross-sectional survey conducted in Pakistan, maternal education as well as parents being fully informed about vaccinations were associated with full immunization of their children. 10 Furthermore, general health knowledge was improved among both men and women who have had access to higher education, 12 suggesting the key role education plays in healthy behaviors including childhood immunizations. Lack of education can potentially lead to misconceptions about vaccines.…”

“…Although the education of both parents was found to be important for healthy behaviors, 12 maternal education in particular has been cited as a key element in parental adherence to vaccination programs. 9,10,28 In this regard, a study conducted in sub-Saharan Africa demonstrated that women's literacy was positively associated with increased healthcare access and usage. 29 In Ethiopia, studies led to the recommendation to educate mothers on the importance of family planning, breast feeding and immunization programs in efforts to reduce child morbidity and mortality.…”

“…46 In this regard, a study conducted in Burkina Faso demonstrated that mortality of children under five years of age increased by 50% when the walking distance to healthcare facilities was longer than four hours, 47 and a study conducted in Pakistan showed that proximity to government healthcare centers led to increase in children's immunization coverage. 10 Another study conducted among the Bedouin Arabs in southern Israel, many of whom have lived a nomadic lifestyle away from Maternal and Child Centers, and are thus similar to populations in low-income countries, demonstrated low infant immunization coverage prior to the establishment of a population-specific intervention program. 48 Financial factors.…”