The influence of maternal migration on child vaccination in Kenya: An inverse probability of treatment-weighted analysis.

OBJECTIVES: Kenya has substantially improved child mortality between 1990 and 2019, with under-5 mortality decreasing from 104 to 43 deaths per 1000 live births. However, only two-thirds of Kenyan children receive all recommended vaccines by 1 year, making it essential to identify undervaccinated subpopulations. Internal migrants are a potentially vulnerable group at risk of decreased access to healthcare. This analysis explored how maternal migration within Kenya influences childhood vaccination. METHODS: Data were from the 2014 Kenya Demographic and Health Survey, a nationally representative cross-sectional survey. Logistic regressions assessed relationships between maternal migration and full and up-to-date child vaccination using inverse probability of treatment weighting. Two exposure variables were examined: migration status and stream (e.g. rural-urban). Multiple imputation was used to impute up-to-date status for children without vaccination cards to reduce selection bias. RESULTS: After accounting for selection and confounding biases, all relationships between migration status and migration stream and full and up-to-date vaccination became statistically insignificant. CONCLUSIONS: Null findings indicate that, in Kenya, characteristics enabling migration, rather than the process of migration itself, drive differential vaccination behavior between migrants and non-migrants. This finding is an important deviation from previous literature, which did not rigorously address important biases.

Inequities in On-Time Childhood Vaccination: Evidence From Sub-Saharan Africa.

INTRODUCTION: Vaccination coverage has improved in the past decade, but inequalities persist: the poorest, least educated, and rural communities are left behind. Programming has focused on increasing coverage and reaching the hardest-to-reach children, but vaccination timeliness is equally important because delays leave children vulnerable to infections. This study examines the levels and inequities of on-time vaccination in the Sub-Saharan African region. METHODS: The most recent Demographic and Health Surveys or Multiple Indicator Clusters Surveys since 2000 from Sub-Saharan Africa were used to assess on-time vaccination and inequalities by household wealth, maternal education, and place of residence. Inequalities were quantified using slope index of inequality and concentration index. RESULTS: The analysis included 153,632 children aged 12-36 months from 40 Sub-Saharan Africa countries. Median on-time vaccination coverage was <50% in all the 4 subregions. Differences in on-time vaccination were observed by place of residence in the Southern (20.8 percentage points, 95% CI=0.8, 40.8), West (17.5 percentage points, 95% CI=5.1, 29.9), and Eastern (20.9 percentage points, 95% CI=6.5, 35.2) regions. Wealth-related inequities were observed in the Southern (22.6 percentage points, 95% CI=4.0, 41.2), Western (30.6 percentage points, 95% CI=19.1, 42.1), and Eastern (26.1 percentage points, 95% CI=8.2, 44.0) regions. Significant education-related differences in on-time vaccination were observed in the Western (20.7 percentage points, 95% CI=10.9, 30.5) and Eastern (21.2 percentage points, 95% CI=7.0, 35.4) regions. CONCLUSIONS: On-time vaccination coverage was low in all subregions and nearly all countries. Inequalities in on-time immunization by household wealth, place of residence, and education existed in most countries. Concrete strategies to improve levels of timeliness are needed. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth.

INTRODUCTION: Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth. METHODS: Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification. RESULTS: For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment. CONCLUSIONS: Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Vaccination timeliness among newborns and infants in Ethiopia.

BACKGROUND: We characterize the risk factors for delayed polio dose 1, diphtheria-tetanus-pertussis (DTP) dose 1, pentavalent dose 1, and measles dose 1 in Ethiopian infants. We also examine the interaction between institutional delivery and demographic factors on the birth doses of the BCG and polio vaccines to better understand factors influencing vaccination. METHODS: Using the 2011 Ethiopia Demographic and Health Survey, we calculated the distribution of the study population across different demographic and vaccination characteristics. We computed acceleration factors using a multivariable accelerated failure time model with a Weibull distribution to account for left and right censoring. For the birth doses, we further specified an interaction term between institutional delivery and every other a priori specified independent variable to test whether institutional delivery modifies sociodemographic disparities in vaccination timeliness. RESULTS: Low wealth status, home delivery, and ethnicity are risk factors for delayed vaccination of polio 1, DPT 1, pentavalent 1, and measles 1. Religion is a risk factor for measles 1 vaccination delay and rural residence are risk factors for delayed DPT1 and polio 1 doses. For birth doses of polio and BCG, institutional delivery attenuated many sociodemographic disparities in vaccination delay, except for urbanicity, which showed rural dwellers with more delay than urban dwellers with an institutional vs home birth. CONCLUSIONS: Less delayed vaccination among children with institutional deliveries highlights the importance of perinatal care and the potential for promoting healthy behaviors to parents. Persistent disparities between urban and rural residents, even among those with institutional births, can be targeted for future interventions. Timely vaccination is key to prevention of unnecessary childhood mortality.

Have community health workers increased the delivery of maternal and child healthcare in India?

Background: Accredited Social Health Activists (ASHAs) are community health workers in rural India. This study estimates the proportion of villages with an ASHA and examines the impact of increased ASHA placement on changes in healthcare. Methods: Information about ASHA placement and maternal and child healthcare was obtained from the District-Level Household Surveys from 2007 to 2008 and 2012 to 2013. In this ecological analysis, the difference in district-level proportions of maternal and child healthcare outcomes between 2012-13 and 2007-08 was regressed onto the difference in ASHA placement between those years. Results: Within 218 districts from 21 states, the average proportion of villages with an ASHA increased from 39.1 to 76.2%, unmet need for family planning increased from 14.7 to 22.4%, institutional delivery increased from 61.6 to 82.5%, and full immunization coverage decreased from 71.2 to 65.1%. A 1% increase in ASHA placement resulted in 0.05% less unmet need for family planning and 0.22% more full immunization, but no changes in institutional delivery. Conclusions: ASHAs provide essential services to their community by acting as a conduit to healthcare services, but they may require more training about certain services like promoting institutional delivery to be effective in increasing access to these health services.