Social inequalities in vaccination uptake among children aged 0–59 months living in Madagascar: An analysis of Demographic and Health Survey data from 2008 to 2009
Section snippets
Social inequalities in vaccination
There have been improvements in childhood immunization in recent years: the World Health Organization (WHO) estimates routine vaccinations now avert between two and three million deaths annually [1]. However gains have not been equally distributed: immunization coverage in developed countries far outpaces that in less developed countries (96–81%, respectively) [2]. Research also suggests that even among countries showing marked improvement, national averages may mask differences or increasing
Data
Data come from the most recent (2008–2009) Demographic and Health Survey (DHS) in Madagascar. The DHS is a multi-stage stratified sample of 17,375 households randomly situated within 600 clusters encompassing 109 administrative districts [17]; we limited analysis to children aged 0–4 years, leaving a sample size of 5346 children situated within 593 clusters in 108 districts. Vaccination status in these data are valid and provide results that are often less biased than official statistics [18].
Measures
Descriptive characteristics
Children were 2.5 years old on average and equally divided by gender. Mothers and fathers overwhelmingly had less than a secondary education; more than a fifth lacked a primary school education. The highest coverage was for DPT and TB with decreased coverage for measles and polio and very low coverage for HiB (Table 1).
District variation in childhood vaccination
Overall, district explained 7–13% of the variation in multivariate models, with coverage varying widely for all vaccinations between the [5th, 95th] percentiles: DPT, [30.2%,
Key findings
Vaccination has been used globally to dramatically reduce the burden of disease, but tens of millions of children remain unprotected resulting in 1.5 million vaccine-preventable deaths annually among children [1]. The challenge is not only to increase vaccination coverage, but to do so evenly throughout communities in a country and equitably. These data from Madagascar illustrate that relying on national coverage estimates can mask geographic, administrative, and socioeconomic variation within
Conflict of interest
The authors have no conflicts of interest and received no financial support to complete this study.
Funding
None received.
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