Does it really matter where you live? A multilevel analysis of factors associated with missed opportunities for vaccination in sub-Saharan Africa

Abstract

There is an urgent need to examine the magnitude and factors responsible for missed opportunities for vaccination, to rapidly achieve national immunization targets. The objective of the study was to examine the influence of individual, neighbourhood and country level socioeconomic position on missed opportunities for vaccination (MOV) in Sub-Saharan Africa. We used multilevel logistic regression analysis on Demographic and Health Survey data collected between 2007 and 2016 in sub-Saharan Africa. We analysed data on 43,637 children aged 12 to 23 months (Level 1) nested within 15,122 neighbourhoods (Level 2) from 35 countries (Level 3). After adjustment for individual-, neighbourhood- and country-level factors, the following appeared as significant risk factors for increased odds of MOV: high birth order, high number of under-five children in the house, poorest household, lack of maternal education, lack of media access, and living in poorer neighbourhood. According to the intra-country and intra-neighbourhood correlation coefficient, 18.4% and 37.4% of the variance in odds of MOV could be attributed to the country and neighbourhood level factors, respectively; and if a child moved to another country or neighbourhood with a higher probability of MOV, the median increase in their odds of MOV would be 2.47 and 2.56 fold respectively. This study has revealed that the risk of missed opportunities for vaccination in sub-Saharan Africa is influenced by not only individual factors but also by compositional factors such as family’s financial capacity, place of birth and upbringing.

A Multilevel Analysis of the Determinants of HIV Testing in Zimbabwe: Evidence from the Demographic and Health Surveys

“…31 The second explanation could be the fact that females are more likely to be exposed than man to health care services through maternal health care. 16,30,43 As such, the disparity may have been as a result of success of the increased testing uptake during antenatal care.…”

“…While inclusion of wealth, occupation, education and media exposure may indicate the manifestation of economic position of an individual, 30 demographic factors such as gender, parity, religion, marital status and age are considered important because they may capture behavioural factors such as the perception of risk, acceptance of testing and sexual practice. 6 The following are factors which were included at individual level.…”

“…With such background knowledge, it can be argued that variations in HIV testing in Zimbabwe may not have been as a result of individual characteristics alone, but of the effects of community effects in which they live as whole. 10,30 For that reason, this study used 2 level logistic regression models to investigate the community and individual level factors that influence HIV testing behaviour. The basic form of 2 level random intercepts logistic regression model used can be expressed as:…”

“…In line with the effects of risk perception on healthcare utilisation, studies have shown that perceived susceptibility as a result of risky sexual behaviour exacerbates risk perception of HIV infection, in turn leading to underutilisation of health care services. 22 On the other hand, existing literature also suggests that perception of being at risk of a disease is a prerequisite for behaviour change, 30 and that perceived high risk of infection causes people to take precautionary measure including HIV testing and knowing the results in order to reduce the risk of getting the virus. 12,16 According to health behavioural models 31 perceived susceptibility to a particular health problem (e.g., am I at risk of HIV?…”

“…32 At community level, the likelihood of HIV testing may increase for individuals who reside in communities with higher HIV prevalence, high poverty, high risk perception of HIV infection, or within easy access of HIV intervention programmes, compared to individuals living in other communities. 7,18,22,30 While HIV/AIDS stigma may exist within self as a result of imagined fear due to perceived risk of HIV infection based on self-assessment, 33 stigma can also be observed and exerted from the outside world (health care providers, family, community, and friends). Either form of stigma may lead to more people underutilising health care services.…”