VoICE Immunization Evidence: Geographic inequity
Significant evidence of geographic inequity in vaccine coverage exists within countries, within states, and between populations living in rural, peri-urban, and urban areas.
A study in a population of urban poor in Delhi, India, which examined household and neighborhood-level determinants of childhood immunization, found that less than half of children between 1 and 3.5 years of age received complete immunization as recommended. This was significantly lower than the overall state-level average of 70% immunization coverage.
Inequity in vaccination coverage in India was found between states, within states, 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.
Children living farther from health facilities are less likely to be immunized – or to be immunized on time – than children living closer to facilities
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 for missing the first dose of measles-containing vaccine. Of children who did receive BCG, those living more than 5 km from facilities had a 26% more likely to received BCG vaccine late than children close to the facility.
Despite improvement in equitable vaccination rates across geographies at the national level, local level disparities persist.
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.
Polio eradication investments in some of the countries with the most fragile health systems, provide an opportunity to leverage polio vaccination for other health priorities.
Polio eradication investments in health infrastructure have been concentrated in some of the lowest performing health systems in the world, challenged internally by geography, poverty, armed conflict, etc. These assets can be leveraged to improve the health system and immunization overall nationally.
Children living in slum conditions who are at greater risk of infectious diseases than those in urban areas, are less likely to be vaccinated.
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).
Studies have shown that urban vs. rural dwelling is significantly associated with immunization coverage
Globally, coverage of the third dose of DTP is 8% higher among urban dwellers compared to children raised in a rural environment.