Socioeconomic Inequalities in Childhood Vaccination in India: Pathways and Interventions

Socioeconomic inequalities in childhood vaccination;Childhood immunization;India;Time-trend in socioeconomic inequalities;Accredited social health activists;Cost effectiveness analysis;Public Health;Health Sciences;Epidemiological Science

Bettampadi, DeeptiSen, Ananda ;

University of Michigan

关键词: Socioeconomic inequalities in childhood vaccination;    Childhood immunization;    India;    Time-trend in socioeconomic inequalities;    Accredited social health activists;    Cost effectiveness analysis;    Public Health;    Health Sciences;    Epidemiological Science;   

Others  :  https://deepblue.lib.umich.edu/bitstream/handle/2027.42/145903/bdeepti_1.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: The Illinois Digital Environment for Access to Learning and Scholarship

【 摘 要 】

India has the largest number of children aged under 5 years of any country in the world but also one of the lowest childhood immunization rates globally. Important health initiatives of the Indian government such as the Universal Immunization Program and the Reproductive and Child Health program have increased childhood vaccination rates and decreased socioeconomic inequalities. However, there is a paucity of national level studies that have utilized data collected after 2006 to examine these issues.In this dissertation, we examined time-trends in socioeconomic inequalities in childhood vaccination over an 11-year period between 2002 and 2013 using cross-sectional data collected during three distinct time-periods: 2002-2004, 2007-2008 and 2012-2013 in 29 Indian states. We assessed the role of availability and acceptability of health services as potential mediators in the association between socioeconomic status and childhood vaccination in 20 Indian states during 2007-2008 and 2012-2013. Finally, we examined the cost-effectiveness of the accredited social health activist (ASHA) program, a community health worker initiative introduced under National Rural Health Mission in 2005, in improving measles vaccination.We examined the associations between socioeconomic status (SES) and full childhood vaccination for three time-periods, stratifying our analyses by time-period and empowered action group (EAG) state status. Non-EAG states experienced decreased full vaccination rates in 2012-2013 compared to 2007-2008. We found that while SES based-inequalities in vaccination rate decreased in both EAG and non-EAG states, they were present to a greater degree in EAG states for all three time-periods; however, the gap in SES based-disparities between EAG and non-EAG states decreased during this 11-year time-period. To examine these inequalities further, we conducted mediation analyses to explore how availability and accessibility of vaccination services could mediate the association between SES and full childhood vaccination during 2007-2008 and 2012-2013. In our analyses, the indirect effect mediated by availability and acceptability of health services was positive and the direct effect of SES on full childhood vaccination was negative for both time-periods. The total direct effect of SES on full childhood was positive in 2007-2008 while negative in 2012-2013.Finally, we conducted a cost-effectiveness analysis of ASHAs with regards to childhood measles vaccination, obtaining parameter estimates for our cohort simulation model from 2012-2013 data and prior literature. ASHAs were highly cost-effective in our univariate sensitivity analyses and most of the bivariate and probabilistic sensitivity analyses. ASHAs remained cost-effective even when their financial incentive to perform measles vaccination related services was increased by 10 times. They remained cost-effective in long-term scenarios where the cohort size of a village decreased over time as more and more children were vaccinated.In view of these findings, the Indian government may want to focus its efforts on both EAG and non-EAG states to receive adequate funding and resources to ensure gains in vaccination are not lost. This study also demonstrates the possibility of vaccine hesitancy and lower full vaccination rates among children from richer households due to availing of vaccine services from private healthcare providers who tend to be less accountable than public healthcare providers in ensuring full vaccination of children. Finally, we quantitatively demonstrate the cost-effectiveness of ASHAs even when considering a single outcome among their myriad responsibilities and show that the financial compensation for ASHAs for services they render can be increased without compromising their cost-effectiveness.