Geographic Inequity

Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

Key Evidence: Full immunization coverage, within the Democratic Republic of Congo, varies drastically by region. In the province with the lowest coverage, approximately 5% of children were fully immunized, while in the province with highest coverage, over 70% of children were fully immunized.

Key Evidence: Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys, and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

Key Evidence: An study using GIS to quantify the percent of pregnant women in Mozambique without access to tetanus toxoid (TT) vaccine at varying distances from health facilities estimated that if women cannot travel more than 5 km to a TT immunization site there will be almost 18,000 neonatal tetanus cases each year that could be prevented, costing the country more than US$362 million in treatment costs and lost productivity. Covering 99% of women with TT will currently require people to travel up to 35 km to obtain an immunization.

From the VoICE Editors: GIS, a geospatial information system, is a computer system capable of capturing, storing, analyzing, and displaying geographically referenced information.

Key Evidence: Children in Tanzania living 5 km or greater distance from the nearest healthcare facility were less likely to be immunized than children living less than 5 km from facilities. Compared to children living close a health facility, children far from a health facility had almost three times the risk of missing out on BCG, 84% higher risk of missing the third dose of DTP, and 48% higher risk of missing the first dose of measles-containing vaccine. Of children who did receive BCG, those living more than 5 km from facilities were 26% more likely to received BCG vaccine late than children close to the facility.

Key Evidence: An equity impact analysis of the 2016 Ethiopia Demographic and Health Survey dataset identified significant disparities in full immunization coverage across different regions of Ethiopia among children aged up to 36 months. Children in the Addis Ababa and Dire Dawa regions of Ethiopia were 7 times more likely to have full vaccination coverage compared to children living in the Afar region, a rural region with large numbers of pastoralist nomadic communities.

Key Evidence: In an analysis of of data from India’s National Family Health Survey showed that, despite a decline in urban-rural and gender differences over time, girls and children residing in rural areas remained disadvantaged. Moreover, regions that had the lowest gender inequality in 1992 observed an increase in gender difference over time. Similarly, urban-rural inequality increased in one region during the data collection period.

Key Evidence: A study in Kenya estimated that the failure to vaccinate the 21% of children considered hard-to-reach (living beyond a 5 km radius of a vaccination post) against measles would result — over 4 years — in more than 1,400 measles cases, 257 deaths, and cost nearly US$10 million, mainly in productivity losses from caretakers missing work.

Key Evidence: Children in slum settings have higher burdens of vaccine-preventable disease (one study found children in slums in Manila, Philippines were 9 times more likely to have tuberculosis than other urban children) and lower rates of immunization (a study in Niger found 35% coverage in slums vs. 86% in non-slum urban areas).

Key Evidence: Wealth and mother’s education are significant predictors of vaccination rates in both urban and rural settings.  However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings. This suggests the need for tailored vaccine programs.

From the VoICE editors: This study compared the significance of risk factors for low vaccination rates in rural versus urban settings in Tanzania. 

Key Evidence: Children living in urban areas are significantly more likely to be only partially immunized compared to children in rural areas. In this study, the authors suggest this may be the result of the tendency for those living in urban slums to move frequently, resulting in only partial immunization.

From the VoICE Editors: In this study, conducted in India, no significant difference was found in rates of non-vaccination (children receiving no vaccines) in rural versus urban communities.

Key Evidence: The use of antenatal care (ANC) services among pregnant adolescents in low- and middle-income countries, including tetanus toxoid vaccination, was lowest among women who lived in rural areas, had completed less education, and who were of poorer wealth quintiles.

Key Evidence: Globally, coverage of the third dose of DTP is 8% higher among urban dwellers compared to children raised in a rural environment.