Article Text

Original research
Inequalities in full vaccination coverage based on maternal education and wealth quintiles among children aged 12–23 months: further analysis of national cross-sectional surveys of six South Asian countries
  1. Kiran Acharya1,
  2. Dinesh Dharel2,
  3. Raj Kumar Subedi3,
  4. Asmita Bhattarai4,
  5. Yuba Raj Paudel5
  1. 1 New ERA, Rudramati Marga, Kalopul, Kathmandu, Nepal
  2. 2 College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  3. 3 Bhaskar Tejshree Memorial Foundation, Kathmandu, Nepal
  4. 4 Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  5. 5 School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  1. Correspondence to Kiran Acharya; acharya.kiran1{at}


Objective This study was conducted to compare full vaccination coverage and its inequalities (by maternal education and household wealth quintile).

Design This further analysis was based on the data from national-level cross-sectional Demographic and Health Survey (DHS) from six countries in South Asia.

Setting We used most recent DHS data from six South Asian countries: Nepal, India, Pakistan, Bangladesh, Afghanistan and the Maldives. The sample size of children aged 12–23 months ranged from 6697 in the Maldives to 628 900 in India.

Primary and secondary outcome measures To measure absolute and relative inequalities of vaccination coverage, we used regression-based inequality measures, slope index of inequality (SII) and the relative index of inequality (RII), respectively, by maternal education and wealth quintile.

Results Full vaccination coverage was the highest in Bangladesh (84%) and the lowest in Afghanistan (46%), with an average of 61.5% for six countries. Pakistan had the largest inequalities in coverage both by maternal education (SII: −50.0, RII: 0.4) and household wealth quintile (SII: −47.1, RII: 0.5). Absolute inequalities were larger by maternal education compared with wealth quintile in four of the six countries. The relative index of inequality by maternal education was lower in Pakistan (0.5) and Afghanistan (0.5) compared with Nepal (0.7), India (0.7) and Bangladesh (0.7) compared with rest of the countries. By wealth quintiles, RII was lower in Pakistan (0.5) and Afghanistan (0.6) and higher in Nepal (0.9) and Maldives (0.9).

Conclusions The full vaccination coverage in 12–23 months old children was below 85% in all six countries. Inequalities by maternal education were more profound than household wealth-based inequalities in four of six countries studied, supporting the benefits of maternal education to improve child health outcome.

  • health economics
  • epidemiology
  • public health
  • community child health

Data availability statement

Data are available upon reasonable request. Data are available in a public, open access repository. The datasets generated during the current study are available from within the Demographic and Health Survey Program repository (

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

Data are available upon reasonable request. Data are available in a public, open access repository. The datasets generated during the current study are available from within the Demographic and Health Survey Program repository (

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  • Contributors KA, DD and YRP were involved in the design and conception of the study. KA was involved in the analysis. YRP and KA interpreted the findings; DD, RKS, AB, KA and YRP were involved in the write-up of the manuscript. All the authors supervised, reviewed and edited the manuscript. KA have access to the data and are responsible for the overall content as the guarantor. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.