Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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Mothers Related Differentials in Childhood Immunization Uptake in Pakistan * Corresponding Author: Sajid Amin Javed Email: sajidamin78@gmail.com Waqas Imran Email: methegemini@gmail.com Azad Haider Email: azadhaider@gmail.com Farzana Shaheen Email: Sajidamin78@gmail.com Muhammad Iftikhar ul Husnain Email: Iftikharhusnain@yahoo.com 1
Department of economics, Pakistan institute of development economics (PIDE), Quaid-e-Azam university campus, Islamabad, 44000, Pakistan. 2 Riphah International University, I-14 Campus, Islamabad, 44000, Pakistan. 3,5 Department of economics, (COMSATS Institute of Information Technology, Pakistan); Comsats institute of information technology Pakistan, department of economics, Islamabad, 44000. 4 Department of economics, (FUUAST); Federal Urdu University of Arts, Science and Technology (FUUAST), G-7, Islamabad, 44000, Pakistan. ABSTRACT Under immunization contributes 1/5th of the total under-five deaths across the globe. Low adherence to immunization, in developing countries, can be traced in parental socio-economic and demographic characteristics. This study analyzes the impact of mothers’ related differentials, especially women empowerment and education on childhood immunization status in Pakistan using data from Pakistan Demographic and Health Survey (PDHS) 2006-07. Information on last birth preceding 5 years to the survey is used to construct dependent variable (fully immunized=1, not fully immunized=0). Only 43.2% and 34.2% children of age 12-59 months get all 8 doses of recommended vaccines (fully immunized) in urban (n=1155) and rural (n=2595) areas respectively. Logistic regression results suggest that children of mothers having no empowerment, with lower education levels, working in agriculture sector, belonging to lower wealth quintiles and rural background, and children who are female, born in provinces other than Punjab, and born earlier (birth order) are more vulnerable to under immunization. Rural areas must be focused as priority to improve parents’ attitude towards child health, it may result in better child health through improved immunization status. Keywords: Childhood Immunization, Woman Empowerment, Child Health Indicators, Gender Bias , Pakistan INTRODUCTION Child immunization is a notable phenomenon of globalized world to make it safer for children. Pakistan joined Expanded Program on Immunization (EPI) of World Health Organization (WHO) in 1978 however, immunization coverage has been considerably low in Pakistan than the other WHO member countries falling in same socio-economic category and the country is listed amongst the four countries where Polio is getting a resurge bringing immunization issues alive in the debates. Immunization status is an indicator of progress to child health; a compulsory part of Millennium Development Goals (MDGs) (Chowdhury AM., et al. 2003). The role of women in reproductive health has been recognized in recent times and explorations have been made to gauge the impact of women empowerment on mother and child health and health seeking behavior. Women empowerment is to be allowing them “a control over reproductive health, an improved health seeking behavior hence resulting in improved maternal and child health and lower child and maternal mortality rates and slows down population growth rates consequently” (Parashar, S., 2004). Very few studies investigate dynamics and differentials of children immunization in Pakistan. Owais et al. (2010), surveys impact of improved knowledge about vaccination on immunization rates for low-income sites of Karachi. Usman et al. (2010), in a cohort study, find that only 39% children reached to DP3 who took DP1 indicating higher dropouts in Pakistan while Usman et al. (2009) conclude that redesigned cards and center 62
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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based education for mothers can improve immunization uptake in children. None of these studies draws attention on the issue raised in our work and to best of our knowledge immunization status of children in context of women empowerment remains an ignored expedition for Pakistan and this study is very first of its kind. We also improve on existing studies in terms of data used and draw our conclusions based on nationally representative data set. Furthermore, this study provides the reasons and differentials in vaccination coverage by urban and rural dwellings and comparisons with in the factors affecting vaccination coverage in Pakistan by urban and rural status. Childhood immunization uptake in Pakistan is expected to vary between urban and rural strata with rural areas under covered concealed in socio-economic setup, demographic characteristics and cultural barriers. Especially, mothers in urban areas have greater access to sources of information like the mass media and health education campaigns that helps to increase the ratio of fully immunized children (Cassell et al. 2006).This study analyses mother’s related immunization differentials, especially women empowerment, in rural and urban context using data from Pakistan Demographic and Health Survey (PDHS) 2006-07. Immunization Schedule And Coverage For Pakistan Expanded Programme on Immunization (EPI) was initiated in Pakistan in 1978 targeting six vaccine preventable diseases. Later on July 2002, HBV (Hepatitis B) vaccine was added in EPI programme. Inspired by successful attempts in lowering down the rates of small pox prevalence, World Health Organization (WHO) intervened towards Polio eradication globally. As a result of global fight against polio, Polio cases decreased markedly from 2,980 in 1980 to 558 in 1999 in Pakistan (UNICEF update 2012). From year 2000 to 2003, EPI was expanded further in Pakistan and numbers of vaccine centers and vaccination teams were increased to reach the doors missed in 1999 coverage. As a result the number for unvaccinated children affected from Polio decreased from 192 in 2000 to 32 in 2007. However, due to unstable political and security situations in country, some areas remained uncovered resulting in increased polio cases i.e. from 30 (2007) to 144 (2011). Almost similar unstable picture has been observed for vaccination coverage of pertussis, measles, tetanus and diphtheria etc. According to WHO definition of fully immunized children (12-23 months with 8 doses of vaccines), proportion of children who are fully immunized increased from 35.1 percent in 1991 (1990-91 PDHS) to 77.0 percent in 2005 (2004-05 PSLM; but, the proportion declined to 47.3 percent in 2007 (2006-07 PDHS). This volatile trend and low adherence to children immunization calls for the study explaining the factors underlying lower rates of children immunization in Pakistan. Table 1 and 2 provide immunization schedule and coverage for Pakistan on 8 basic vaccines respectively. Huge difference in vaccination coverage based on vaccine card and mother’s report are evident from table 2 wherein later reported always much higher coverage. Punjab has the highest coverage rates for each vaccine as well as over all 8 doses while Baluchistan falls at the bottom in terms of vaccine coverage. Highest proportion of children getting no vaccine is documented for Baluchistan where 29% children remain without any vaccine while this ratio is lowest (3.8%) for Punjab Province. Drop outs are also registered across DPT1-DPT3 and Polio1-Polio3 respectively. Considerably less than half children (43.3%) have all recommended 8 doses of vaccines in Pakistan. Women Empowerment, Child Immunization And Child Health: Theoretical Underpinnings Vaccinations are recognized to be the most popular and cost effective interventions by public sector to ensure children health. An empowered woman is argued to have more concern, conscious and control to get her children vaccinated. Putting it intuitionally, women with higher education level, enjoying financial autonomy and having a role in decision making are more likely to have knowledge and resources and hence practice health seeking attitude. Child health is argued to be an exclusive domain of women (the mothers), especially societies like ours and, hence, improving status of women can result in a better care for children. “A better socio-economic status of women can result in improved child health and lower infant and child mortality rates which in turn, consequently, determine shape and timing of demographics process” (Caldwell and Caldwell, 1993). Education can improve child health by increasing the confidence of an educated mother, and a greater access to information. Caldwell (1994), as quoted in Sangeeta Parashar (2004), argues that “a large number of studies have shown, almost as convincingly as anything can in the social sciences, that a mother’s education has an independent, strong, and positive impact on the survival of her children such as higher levels of immunization, less stunting, and a greater knowledge of ORS”. Furthermore, it is also argued that direct health knowledge, extended ability to access information, increased autonomy amongst educated women increase potential health benefits for child and cause greater investment in child improving, health and immunization status (Caldwell and Caldwell, 1993). With this brief theoretical background and empirical evidence we now move to empirical settings of our study. METHODOLOGY AND DATA This work attempts to gauge the impact of women related differentials, especially women empowerment and education on childhood immunization status in rural-urban context controlled for potential confounding factors including socio-economic, demographic and background dynamics using data from PDHS 2006-07. 63
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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PDHS (2006-07) provides a comprehensive data set on child immunization status based on information obtained from 10,023 ever married women of 15-49 years of age across the country. Work status and occupation of women, level of education, age at marriage, current marital status, pregnancy related discussion with husband during pregnancy, and possibility of setting aside money for pregnancy related issues are available indicators of women empowerment. Indicators for sex refusal of wives, and wife beating justified index are not available in PDHS 2006-07. Consequently woman’s discussions with her husband on pregnancy related issues and ability to set aside money for pregnancy related issues variables are used as proxy measures of empowerment. Some socio-demographic characteristics including mother’s education (Streatfield et al. 1990; Madise & Matthews 1999; Ayaga A.Bawah et al. 2006; Anand & Ba¨rnighausen 2007; Ibnouf et al. 2007; Munthali 2007), occupation of mother, and age difference between husband and wife are used to capture indirect measures of empowerment (Mason 1986). Women empowerment, education and child immunization nexus is controlled for some socio-economic and biological variables including father’s education level, age at first birth (Breiman, RF et al. 2004), regional background (Guerin 1998; Reichler et al. 1998; Buor 2003; Ndiritu et al. 2006), sex of child , birth order, birth interval and wealth index (Defo 1996; Wagstaff and Watanabe 1999; Gwatkin 2000; Vyas and Kumaranayake 2006; Gwatkin et al., 2007; Rahman & Obaida-Nasrin 2010) to avoid confounding in estimated results. In our society, mostly fathers are main decision makers in the families so their education plays an important role in health care decisions. Children having educated fathers are more likely to be fully immunized (Ghulam, Y., et al 2004). Mother’s age at first birth is added to capture the women’s care taking behavior. (Rahman & ObaidaNasrin 2010). Mothers with mature age are considered better care taker of child’s health. Regional background variable, with a classification of four provinces of Pakistan, captures the regional differentials in child immunization across the country. We use “sex of the child” variable to capture “anti-daughters” attitude of parents. This is common in the traditional societies as in Pakistan where families mostly prefer sons and as a result boys are more likely to be fully vaccinated as compared to girls (Pande & Yazbeck-2003; Rahman & Obaida-Nasrin 2010). Lastly, wealth index is included to capture the effect of economic factors in determining the status of health and immunization. Children from well off families are more likely to be vaccinated and enjoy a good health (Pande & Yazbeck2003; Ayaga A.Bawah et al. 2006; Gwatkin et al., 2007). Response Variable The data on immunization is extracted from Women Questionnaire of PDHS 2006/07 and is primarily based on vaccination cards and mothers recall memory in case mothers were unable to produce vaccination cards. This practice is customary in Demographic and Health surveys (DHS) across the globe and is validated by many studies ((Macro Intl., 1993; Langsten & Hill, 1998). Children having all 8 doses (one dose of BCG, 3 doses of each DPT and Polio and 1 dose of Measles) are termed as “fully immunized (code=1)” while all others are reported “not fully immunized (code=0)”. We use information on last birth occurring in 5 years preceding the survey registering sample of 3962 and 1715 children from rural and urban stratum respectively with age of 12-59 month. Risk Factors Table 3 shows the specification of variables used in this study. Continuous variables like, age of parent and age difference between husband and wife are converted into categorical variables. Binary variables including sex of child and head of household, residence, discussion between husband and wife about pregnancy related issues and mother’s liberty to set aside money for the emergency issue are used as categorized in PDHS 2006/07. However, some multi-category variables like education status of parents and occupation of mother along with age of mother at first birth and first marriage were redefined for this study. Mother’s age at first birth and marriage were constructed as binary variable to capture the varying attitude of young mother (<19 years) as compared to mother giving first birth after completing 19 years of their age. Similarly occupation of mother was divided into four major categories i.e. Not Working, Agriculture, Sales and Others wherein agriculture includes agriculture employee and self-employed, Sales comprises of professional technical management, clerical, services, household or domestic jobs and Other category includes skilled, unskilled and some undefined professions. ETHICS STATEMENT A formal approval from Macro International Inc., has been taken through online request to use data for in-depth analysis from www.dhsprogram.com. This study based on secondary data which does not contain any information of respondent personal identification and in survey, consent from respondent was taken before asking any question of the questionnaire. This is original paper and is never been published before in context of Pakistan. RESULTS Descriptive analysis, reported in table 4 below, shows mean age difference of husbands to their wives is almost similar in rural (5.6 years) and urban (5.3 years) area. Mother’s age at first birth is slightly more in urban (mean 64
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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age = 21 years) area than that in rural area (mean age= 20 years). Mothers in rural areas have, on average 4.38 children as compared to 3.73 for mothers residing in urban areas indicating higher fertility in rural mothers. Bivariate Analysis Table 5 reports the percentage of children fully immunized and vice-versa against selected differentials separately for urban and rural sample. Full immunization coverage in urban area (43.2 percent) is 1.3 times more than rural area (34.2 percent). Regional distribution of the coverage varies across rural and urban areas. The lowest coverage has been observed in rural area of Sindh (24.9 percent). It is further found that immunization coverage in urban area of Sindh is 1.5 times more as compared to that in rural area. In bivariate analysis, parent’s education registers a statistically strong association with childhood immunization at 1% level of significance. Higher levels of likelihood to be fully immunized are observed against higher education levels. An interesting finding is that, children of mothers who are rich (by wealth status) and living in rural area are more likely to be immunized as compared to that in urban area (50.2 percent and 46.4 percent, respectively). However, children belonging to economically poor women in rural areas (27.1 percent) are more fully immunized as compared to those belonging to poor women from urban areas (26.0 percent). With reference to empowerment status of women, in urban area the proportion of the probability of children belonging to mothers who set aside money for the emergency situation in their pregnancy, complete all suggested vaccines is higher than those living in rural areas. Children belonging to urban areas are 1.35 times more likely to be immunized as compared to the children in rural areas (48.1 percent and 38.4 percent, respectively). In urban sample, proportion of full immunization status of the children belonging to mothers who often discuss with their husbands about pregnancy related issues is greater as compared to their counterparts in rural areas (36.5 percent and 31.1 percent, respectively). In demographic and biological variables, it is observed that in rural areas mother’s age at first birth, age at marriage and sex of child are significantly associated with immunization status of child. Child sex is significant predictor of child immunization only in rural areas exhibiting an important fact that gender differentials prevailed severely in rural areas and gender bias might result in girls’ under immunization. In rural area, most probably due to low education level, parent do take care more of sons than daughters. It may be because they think sons as earning hand. Strong association (1 % level of significance) between gender of child and immunization status is observed in rural sample as compared to urban sample (10 % level of significance). Male children are preferred over female children 1.15 times in rural areas as compared to the preference of 0.91 times in urban areas. Multivariate Analysis Determinants of immunization status are modeled by using binary logistic regression. Three equations are estimated separately each for urban and rural strata to assess and identify the correlates of child immunization and to capture sensitivity analysis. Only the odds ratios along with confidence intervals are reported in table 6 for the ease of the reader. Model 1(a) and 1(b) carry empowerment indicators for mother’s residing in urban and rural areas respectively. For both the samples, initially age difference between parents, education of parents, occupation of mother, mother’s autonomy to set aside money for pregnancy issues and liberty to talk pregnancy related issues are modeled together for 1059 and 2301 children from urban and rural strata respectively. As is evident from table 6 in both samples, mothers having higher education determine immunization status of children significantly. Our results are in concurrence with Bondy et al. (2009) where higher levels of mother education are associated with higher odds of child immunization. Children belonging to mothers having higher education in rural areas are 2.7 times (p=000; O.R 2.775; 95% CI 1.893-4.008) more likely to be immunized than uneducated mothers whereas this likelihood is comparatively low (p=0.10; O.R 1.561; 95% CI 1.110-2.194) in urban areas. Similar results are reported by Akmatov et al. (2007) for Kazakhstan. Interestingly primary levels of education behave differently in urban and rural set up where it enters significantly for the rural areas only. A plausible explanation can be lower levels of education in rural areas and few mothers are educated up to primary amongst the majority of rural mothers with no education at all. An opposite trend has been observed for the children with fathers having high education. In urban areas highly educated fathers are 1.5 times (p=0.004; O.R 1.702; 95% C.I 1.186-2.444) more likely than uneducated fathers to have children benefited by full immunization. Whereas, this probability is comparatively low for the children having highly educated fathers in rural areas (p=0.125; O.R 1.199; 95% C.I. 0.951-1.513). Moreover in rural areas education of father enters insignificantly but puts positive effect on the immunization status of child. Mothers’ occupation turns to be an insignificant predictor of child immunization in urban areas while agriculture enters only significant determinant in rural areas. Children having mothers working in agriculture sectors in rural areas are 0.7 times (p=0.004; O.R 0.692; 95% C.I 0.539-0.888) less likely to be fully immunized than those not working at all. Working in agriculture is not statistically significant determinant in urban areas and comparatively low odds ratios are documented (p=0.405, O.R 0.549; 95% C.I 0.134-2.249). A probable explanation can be sought in terms of poverty driven working where working does not indicate empowerment rather is taken to meet meals only. On the other side, in urban areas, children belonging to mothers who set 65
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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asides money (p=0.074; O.R 1.279; 95% C.I 0.976-1.677) are more likely to be immunized than those born to similar mothers in rural areas (p=0.183; O.R 1.142; 95% C.I 0.939-1.390). Hence, in rural areas children are relatively 0.9 times less likely to be immunized as compared to children in urban areas with the same background. In second equation we have introduced some biological and demographic variables in base model [see table 6: Equation 2(a) & 2(b) respectively]. In urban stratum, due to addition of new variables, impact of father’s education on the status of childhood immunization decreased. Education levels of parents and occupation of mother behave similar as in model 1(a) and 1(b) with a slight rise in odds ratios. Regarding empowerment indicators, importance of discussions between husband and wife has been observed more for the rural sample whereas opposite statistics has been documented for the mothers who set aside money for the delivery in urban areas. Its significance increases (p=0.074 to p=0.034) for urban stratum. Discussion between couple about pregnancy related issues turns significant at 10 percent level now whereas freedom to set aside money, as an indicator of autonomy, keeps its pattern as in previous models. Among demographic and biological indicators, in both the strata, sex of child, birth order of children and mother’s age at first birth have shown statistically significant effect on immunization status of children where sex of child is significant only for rural sample (p=0.004). This finding has special relevance for Pakistan and draws very important policy implications that in rural areas gender bias results in under immunization of girls. The odds of male children being immunized is higher in rural sample (p=0.004; O.R 1.278; 95% C.I 1.0791.514) than in urban sample (p=0.096; O.R 1.213; 95% C.I 0.997-1.504). In rural areas, on the other hand, boys are 1.3 time (O.R 1.278; 95% C.I 1.079-1.514) more likely to be fully immunized as compared to girls. Experienced mothers are found to have better attitude towards child immunization and children born earlier (birth order 2-4) in rural areas are 0.8 times (p=0.034; O.R 0.818; 95% C.I 0.679-0.985) less likely to have fully immunized than children born later (birth orders of 5 and above). Almost similar pattern are observed for urban areas (p=0.109; O.R 0.786; 95% C.I 0.585-1.055). While in rural areas children belonging to mothers who have at least 19 years of age at birth are 1.3 times (p=0.011, O.R 1.316 ; 95% C.I 1.064-1.629) more likely to be immunized then those belong to mothers having less than 19 years of age at birth indicating possibly lower levels of immunization for children of teen age mothers . But children of mothers of age 19 years or greater from rural background are found relatively 0.9 times less likely as compared to that in urban areas (p=0.056, O.R 1.399; 95% C.I. 0.991-1.976). Households having male heads are negatively affecting immunization status of children in urban sample whereas, opposite trend is documented in rural areas. In rural areas children belonging to households headed by male are 1.2 times (p=0.292, O.R 1.170; 95% C.I 0.874-1.567) more fully immunized than those belongs to female household heads. We introduced some background information (Region of residence and wealth status) of mothers in the third and final equation. In rural stratum, impact of mother’s occupation on childhood immunization registers a consecutively increasing trend from base model to model 3. However, due to its non- significant effect, it has been excluded for the urban stratum. On the other hand, in urban stratum, children of the mothers who set aside money are 1.35 times (p=0.025; O.R 1.355; 95% C.I 1.040-1.767) more likely to be fully immunized than those who do not set asides money and the relation is statistically significant. And the empowered mothers (women discuss with their husband about pregnancy related issues) in rural areas are 1.2 times (p=0.044; O.R 1.208; 95% C.I. 1.006-1.451) more likely to have fully immunized children then those who do not enjoy this liberty and the variable shows increasing levels of significance as we move from model 1 to model 3 (p=0.134-p=0.044). Economic status of mothers enters as significant predictor of immunization status of children irrespective of rural and urban background. It was observed that in rural areas children belonging to rich mothers are 1.8 (O.R 1.832; 95% C.I 1.426-2.353) times more likely to be immunized than poor ones. Whereas, in urban stratum impact of rich status is lower than that in rural. Regional background of children exhibits most important finding of this study and clear rural-urban divide is observed in all four provinces of Pakistan. Children born in urban areas are equally likely to be immunized across the country as the variable enters insignificantly for urban sample indicating similar patterns of immunization. Worth noting, however, is that belonging to rural areas can seriously affect chances of being immunization of a child across the country. The children born in rural Punjab are more likely to be immunized than those born in rural Sindh, KP and Baluchistan. DISCUSSION Instead of running full version of regression model we model different variables in order to test the robustness of relation across the specification as reported in table 6. Age difference is an indicator of communication gap between husband and wife which ultimately affects the weaning of babies but the variable has shown no statistical significance in the model-1(a) and correspondingly model-1(b). Education of mother has positive effect on immunization status of children both in urban and rural samples. The higher the education of mother, the higher is the chance of child being fully immunized. Comparatively, in rural sample mother’s education has strong effect on immunization status of child for primary-middle level of education. In urban sample odds increased from model 1(a) to 2(a) and declined in model 3(a). Similar patterns of odds ratios are 66
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
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observed for rural sample but statistical significance weakens moving from model 1(b) to 3(b). Lower levels of education, up to primary, though plays no role in immunization status of child but is significant predictor for children born in rural areas and the relation is robust across the specifications. Father’s education turned to be significant predictor of child immunization for urban sample whereas it has shown no significance in rural sample. In urban sample statistical significance has lost its strength at primary-middle level of education as we add some demographic and background variables in Model 1(a) and 2(a) respectively while no statistical significance is observed in rural sample. Level of significance rises, for urban sample, along the education level but odds ratios fall as we move from model 1(a) to 3(a) indicating that impact magnitude of father’s education, like other predictors, is context specific. As occupation of mother, in any of its categories, has shown no statistical significance in urban sample (model 1(a) and 2(a)), therefore, it was dropped and not included in model 3(a). On the other hand, statistically significant negative impact is observed for rural children born to mothers working in agriculture sector. The relation is stable with minor change in odds ratios under all three specifications 1(b) to 3(b) indicating the severity of the situation for poverty driven working mothers. Speaking in context of women autonomy/empowerment, the indicators has shown mixed results in terms of statistical significance but positive odds are documented across the specifications for both rural and urban samples. Likelihood of child immunization of women who ever discussed about place of delivery/pregnancy issues with their husband registers positive trend in impact magnitude for both the sample areas but is statically significant only in rural stratum. Similar trend is observed for variable “setting aside money” in context of odds ratios but with opposite pattern in terms of statistical significance and is significant in urban sample. It can be drawn from the findings that concept and impact magnitude of women empowerment varies over urban and rural areas and financial autonomy matters more for urban mothers while rural mothers feel empowered with liberty to discuss pregnancy related issues with their husbands. The women belonging to urban areas and having financial autonomy (set aside money for pregnancy problem) have shown increasing statistical significant effect after controlling the relation for biological and socio economic variables 1(b) to 3(b). After testing an alternative specification, the variable was found insignificant and dropped in Model 3(b). Sex of child along with other demographic characteristics was added to model 2 and 3 respectively. It is not a significant predictor of immunization for children born in urban areas but turns decisive factor for rural children wherein being male children always increase the likelihood of full immunization. Among demographic indicators, birth order has shown strong significant effect on immunization status of child. Similar patterns are observed for first birth in rural and urban sample across the specifications. It is observed that probabilities of birth order to affect immunization status of children are greater in rural sample as compared to urban sample suggesting that birth order matters more for rural areas. Age of mother at first birth has positive and significant effect on immunization of child; however, it has lost its statistical significance in Model 3(a). Oppositely, age at first birth is significant for the rural sample. Socio-economic status and region of residence were significant predictors of child immunization and the details thereof are discussed in respective sections (model 3). CONCLUSION AND RECOMMENDATIONS Significant urban-rural divide is observed both in coverage and attitude towards child immunization in Pakistan. Rural areas show strong gender bias resulting in lower levels of full immunization for girls. Regional immunization coverage is different in rural areas across the provinces whereas, due to door to door campaign and more education in urban areas, it has not shown any difference among the different regions in urban areas of Pakistan. Differentials in determinants of childhood immunization are also documented in urban and rural areas, respectively. Education of parents, birth order of child and wealth status of mothers have been found most important factors influencing complete immunization uptake in rural and urban Pakistan. Linear relation is registered by parental education and wealth status confirming that the higher the education level and wealth status the more likely are the children to be immunized fully. Notably, primary education of mother enters insignificantly in urban sample while it is significant determinant of child immunization in rural areas. Women empowerment indicators, despite all controls, appear to be significant predictors of child immunization irrespective of the rural urban background. In the midst of empowerment indicators, for the urban stratum, only those mothers who set asides money to face emergency of health have shown a significant effect on immunization uptake of children in Pakistan. As in rural areas it was assumed that empowerment is low, it was interesting to find that women who discuss with their husbands about pregnancy related issues are more likely to get their children immunized fully. Quite surprisingly age difference between husband and wife has no significant effect on child immunization in urban as well as rural samples. Lessons for policy making can be drawn from this work in devising population welfare and health policy. As the job is shifted to provinces after 18th constitutional amendment, the provinces must focus on female education, early age marriage issues, and poverty reduction, in major, as these factors turn to be significantly affecting attitude of mothers towards child immunization. Also the findings suggest that Sindh, KP and Baluchistan governments need to take necessary steps for more effective and efficient implementation of EPI 67
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Pakistan as children born in these provinces are likely to be less immunized as compared to those born in Punjab. Female education must be prime priority of the concerned authorities as the successful implementation of health and welfare policy, to a greater extent, depends upon education level of women. Findings of our study, through establishing linear relationship between health outcome and education level, also pin down the importance of higher education for females and challenge the fallacy that education up to middle or matriculation is enough for girls. Also early age marriages need to be discouraged and prohibited strictly as they can result in low health of our future generations due to negligence on the part of mothers towards health of new born. In Pakistan where teen age marriages are common practices and girls are married at very young age this finding has a special relevance. The children born to teen age mothers are more vulnerable to epidemic diseases with higher chances of not fully immunized. Furthermore economic policy should be poverty reduction centered. Poverty should be reduced as it can hinder the provision of health facilities, like vaccinations, due to lack of awareness. As vaccinations are free in Pakistan so poverty can operate through channels other than lack of resources i.e. lack of education etc. Policy makers must also realize that mothers of future are being neglected and remains under immunized. We strongly recommend an effective use of media with extended campaign highlighting these issues and raising awareness among parents about the dangers of early age marriages and gains from female education. Also voices must be raised to create girls friendly environment where there is no gender discrimination against girls. Steps should also be taken to create environment engulfing the rural-urban inequalities in immunization. Rural areas must be focused as priority to improve parents’ attitude towards girls. It is added that achieving Millennium Development Goal (MDG) 3 i.e. empowering women can result in better child health through improved immunization status. ACKNOWLEDGEMENT The part of this paper was written while the first author was Research Fellow at NIPS so thanks are due to colleagues at NIPS for fruitful discussions. REFERENCES Akmatov MK, Kretzschmar M, Krämer A, & Mikolajczyk RT. (2007). Determinants of childhood vaccination coverage in Kazakhstan in a period of societal change: Implications for vaccination policies. Vaccine, 25, 1756–1763. Anand S., & Barnighausen T. (2007). Health workers and vaccination coverage in developing countries: an econometric analysis. Lancet. 369, 1277–1285. Ayaga A. Bawah, James F.P, Martin A, Maya Vaughan-Smith, Bruce MacLeod, & Fred N. Binka (2006). The Impact of Immunization on the Association between Poverty and Child Survival: Evidence from KassenaNankana District of Northern Ghana. Policy Research Division; Population Research Council, WP No. 218. Bondy JN, Thind A, Koval JJ, & Speechley KN. (2009). Identifying the determinants of childhood immunization in the Philippines, Vaccine, 27, 169–175. Breiman, R.F., Streatfield, P.K., & Phelan, M. (2004). Effect of infant immunization on childhood mortality in rural Bangladesh: Analysis of health and demographic surveillance data. Lancet. 364, 2204–2211. Buor, D. (2003). Analysing the primacy of distance in the utilization of health services in the Ahafo-Ano South district. Ghana. International Journal of Health Planning and Management. 18, 293–311. Caldwell J. C. & P. Caldwell. (1993). “Women’s Position and Child Mortality and Morbidity in Less Developed Countries” Pp. 122-139 in Women’s Position and Demographic Change, edited by N. Federici. K. O. Mason, and S. Sogner. Oxford: Clarendon Press. Cassell JA, Leach M, Fairhead JR, Small M, & Mercer CH. (2006). The social shaping of childhood vaccination practice in rural and urban Gambia, Health Policy Plan; 21(5), 373-91. Chowdhury AM, Bhuiya A, Mahmud S, Abdus S, A. K. M., & Karim F. (2003). Immunization divide: who do get vaccinated in Bangladesh? J Health Popul Nutr. 21(3):193–204. Defo, B.K. (1996). Areal and socioeconomic differentials in infant and child mortality in Cameroon. Social Science and Medicine. 42, 399–420. Ghulam, Y., Asim, I.Q., Muhammad, A., & Safina, N. (2004). Socio- Economic Factors Affecting The Trend Towards Vaccination of Mother and Infants In Multan City. Journal of Research (Science). 15(1), pp. 107-112. ISSN 1021-1012. [http://www.bzu.edu.pk/jrscience /vol15no1/16.pdf] Guerin, N. (1998). Assessing immunization coverage: how and why? Vaccine. 16 (Suppl), 81–83. Gwatkin, D. R., Rutstein, S., Johnson, K., Suliman, E., Wagstaff, A. & Amouzou, A. (2007). Socio-Economic Differences In Health, Nutrition, And Population Within Developing Countries: An Overview, Country Reports on HNP and Poverty, World Bank. [http://siteresources.worldbank.org/ INTPAH/Resources/IndicatorsOverview.pdf] 68
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Gwatkin, D.R. (2000). Health inequalities and the health of the poor: What do you know? What can we do? Bulletin of the WHO; 78(1), 3–18. [http://www.who.int/bulletin/archives/78(1)3.pdf] Ibnouf, A.H., Van den Bourne, H.W., & Maarse, J.A. (2007). Factors influencing immunization coverage among children under five years of age in Khartoum state, Sudan, SA Fam Pract, 49(8):14c-f. Langsten, R., & Hill, K. (1998). The Accuracy of Mothers’ Reports of Child Vaccination: Evidence from rural Egypt. Social Science & Medicine, 46(9), 1205–1212. Macro International Inc. (1993). An Assessment of the Quality of Health Data in DHS-1 Surveys. DHA Methodological Reports, No. 2. Calverton, Maryland: Macro International Inc. Madise, N.J., & Matthews, Z. (1999). Heterogeneity of child nutritional status between households: a comparison of six Sub- Saharan African Countries. Population Studies. 53:331–343. Mason, K. (1986). The status of women: Conceptual and methodological issues in demographic studies. Sociological Forum. 1(2), 284-300. Munthali, A.C. (2007). Determinants of vaccination coverage in Malawi: Evidence from the demographic and health surveys. Malawi Medical Journal. 19, 79–82. Ndiritu, M. et al. (2006). Immunization coverage and risk factors for failure to immunize within the Expanded Programme of Immunization in Kenya after the introduction of Haemophilus influenza type b and hepatitis b virus antigens. BMC Public Health. 6, 132. Owais et al. (2011). Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan. BMC Public Health, 11:239. Pande, RP., & Yazbeck, AS. (2003). What's in a country average? Wealth, gender, and regional inequalities in immunization in India. Social Science & Medicine. 57 (11), 2075-2088. Parashar, S. (2004). A Multi-dimensional Approach to Women’s Empowerment and its Links to the Nutritional Status and Immunization of Children in India. Department of Sociology and Maryland Population Research Centre, University of Maryland, College Park, . http://citation.allacademic.com//meta/p_mla_apa_research_citation/1/0/9/1/9/pages109193/p1091931.php. Rahman, M., & Obaida-Nasrin, S. (2010). Factors affecting acceptance of complete immunization coverage of children under five years in rural Bangladesh. Salud Publica de Mexico. 52(2):134-40. Reichler, R.M. et al. (1998). Cluster survey evaluation of coverage and risk factors for failure to be immunized during the 1995 National Immunization Days in Egypt. International Journal of Epidemiology. 27, 1083– 1089. Sangeeta Parashar (2004). A Multifaceted and Multi-dimensional Approach to Women’s Empowerment and its Links to the Nutritional Status and Immunization of Children in India. http://paa2004.princeton.edu/papers/40214 Streatfield, K., Singarimbun, M., & Diamond, I. (1990). Maternal education and child immunization. Demography. 27, 447–455. Usman HR, Akhtar S, Habib F, & Jehan I. (2009). Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan: A randomized controlled trial doi:10.1016/j. Vaccine, 27(3):467-72 Usman HR, Kristensen S, Rahbar MH, Vermund SH, Habib F, & Chamot E. (2010). Determinants of third dose of diphtheria–tetanus–pertussis (DTP) completion among children who received DTP1 at rural immunization centers in Pakistan: a cohort study. Trop Med Int Health, 15(1), 140–7. doi:10.1111/j.13653156.2009.02432.x Vyas, S., & Kumaranayake, L. (2006). Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan; 21:459–68. Wagstaff, A. & Watanabe, N. (1999). Socioeconomic Inequalities in child malnutrition in the developing world. World Bank Policy Research Working Paper No. 2434. [http://ssrn.com/abstract=632505]
Table 1. Immunization schedule in Pakistan Age 0 Age or at the time of Birth 6 Weeks 10 Weeks 14 Weeks 9 Months
Vaccination BCG+POLIO 0 DPT1+HBV1+POLIO1 DPT2+HBV2+POLIO2 DPT3+HBV3+POLIO3 Measles
69
Research on Humanities and Social Sciences ISSN (Paper)2224-5766 ISSN (Online)2225-0484 (Online) Vol.4, No.12, 2014
Table 2. Vaccination Coverage in Pakistan Source of BCG DPT Information/Regions 1 2 23.6 23.3 22.0 Vaccination Card 56.8 51.5 44.5 Mother’s Report Either 85.5 80.9 72.3 − Punjab 76.7 67.3 56.4 − Sindh 71.1 67.5 62.4 − KP^ 63.0 60.8 60.0 − Baluchistan 80.3 74.8 66.5 − Total
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3 20.9 37.5
1 23.4 69.7
64.5 47.6 56.4 46.7 58.5
95.5 92.2 91.3 69.2 93.0
^ KP Khyber Pukhtunkhwa;
93.4 89.9 87.9 66.3 90.6
84.6 84.1 81.0 62.9 83.1
Measles 19.2 40.7
All Basic Vaccines 18.2 29.1
No Vaccine 0.0 6.0
65.1 50.7 56.6 54.0 59.9
52.6 37.0 46.9 35.2 47.3
3.8 6.3 7.5 28.9 6.0
Source: Pakistan Demographic and Health Survey (PDHS) 2006-07
Table 3. Variable description S.No. Variable 1 Age Difference between Father and Mother (Years) 2 Age of Mother at first birth (Years) 3 Age of Mother at first Marriage (Years) 4 Regions 5 Residence 6 Sex of Household Head 7 Education of Mother 8
Education of Father
9 10 11 12
Occupation of Mother Birth Order of Child Sex of Child Mother Ever Discussed with her husband about where to deliver her last child Mother set asides money for the emergency/delivery to her last birth
13
POLIO 2 3 22.0 21.0 68.6 62.1
Construction 0-5®, 6-10, 11 and Above Less than 19®,19 and Above Less than 19®, 19 and Above Punjab®, Sindh, KP and Baluchistan Urban®[1], Rural[2] Male®[1], Female[2] No Education®, Primary to Middle, Secondary and Higher Education No Education®, Primary to Middle, Secondary and Higher Education Not working®, Agriculture, Sales, and Others 0-1, 2-4, 5 and above® Male[1], Female®[2] Discussed[1] and Not Discussed®[0] Yes[1], No®[0]
®= Reference category
Table 4. Descriptive statistics of characteristics of parents by urban and rural residence CHARACTERISTICS OF PARENTS N Min Max Mean S.E Mean Age Difference Between Father Urban and Mother Rural Mother’s Age at 1st birth Urban Rural Mother’s Age at first marriage Urban Rural Birth order number Urban Rural
1131 2527 1155 2594 1155 2594 1155 2594
-19 * -12 12 11 10 10 1 1
* Negative values for spousal age difference indicates wife older than husband and vice versa.
70
44 65 38 42 33 37 15 16
5.35 5.57 20.94 20.51 18.95 18.07 3.73 4.38
0.14 0.12 0.11 0.08 0.11 0.08 0.07 0.05
Std. Deviation 4.86 5.87 3.92 4.11 3.86 3.93 2.32 2.67
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Table 5. Percent distribution of immunization status of children by characteristics of their parents in Pakistan for urban and rural sample I.V(S)1
Categor-ies
Province
Punjab Sindh KP^ Baluchistan
Education of Mother
None Primary to Middle Secondary to High
N.F.I (%) 2 52.0 61.7 65.1 62.5
Urban N F.I (%) 2
χ
2
N.F.I (%)
Rural F.I (%) 2
N
χ2
2
48.0 38.3 34.9 37.5
617 410 86 40
12.71 ***
59.9 75.1 72.8 70.0
40.1 24.9 27.2 30.0
1470 510 475 140
53.66***
64.8 56.1
35.2 43.9
497 289
28.18 ***
69.9 57.6
30.1 42.4
1932 495
69.75***
46.7
53.3
368
42.5
57.5
167
None Primary to Middle Secondary to High
68.8 59.1
31.2 40.9
279 320
70.9 65.8
29.1 34.2
1066 758
49.6
50.4
554
58.4
41.6
762
Occupation of Mother
Not Working Agriculture Sales Others
56.2 78.6 52.9 78.6
43.8 21.4 47.1 21.4
921 14 186 34
3.27
63.6 74.6 65.2 60.0
36.4 25.4 34.8 40.0
1702 485 342 65
21.42***
Wealth Index
Poor Middle Rich
74.0 59.9 53.6
26.0 40.1 46.4
127 172 856
19.53 ***
72.9 62.6 49.8
27.1 37.4 50.2
1500 530 564
100.25***
Discuss with husband about the place of delivery
No Yes
62.7 52.4
37.3 47.6
466 676 (1142)
11.90 ***
68.6 60.0
31.4 40.0
1671 898 (2569 )
19.24***
Set Asides Money for Emergency
No Yes
63.5 51.9
36.5 48.1
466 668 (1134)
14.98 ***
68.9 61.6
31.1 38.4
1426 1130 (2556 )
14.78***
Age Difference
Less Than 6 6-10 11 and Above
56.6 57.4 56.3
43.4 42.6 43.8
632 326 128 (1086)
0.06
64.6 64.6 66.8
35.4 35.4 33.2
0.61
Mother’s Age at First Birth
Less Than 19 19 and Above
61.1 53.9
38.9 46.1
463 692
5.89**
69.6 62.6
30.4 37.4
1332 655 358 (2345 ) 1207 1386
Mother’s Age at First Marriage
Less Than 19 19 and Above
58.7 54.1
41.3 45.9
680 475
2.38
67.6 61.6
32.4 38.4
1818 776
8.71***
Sex of Household
Male Female
56.8 57.4
43.2 42.6
1087 68
0.01
66.3 60.9
33.7 39.1
2370 223
2.66
Sex of Child
Male Female
54.5 59.8
45.5 40.2
660 495
3.18*
63.5 68.4
36.5 31.6
1387 1207
6.93***
Birth Order of Child
Less than 2 2-4 5 and Above
62.6 54.8 56.9 56.8 656
37.4 45.2 43.1 43.2 499
198 595 362 100.0 1155
3.72
70.6 64.9 65.2 65.8 1708
29.4 35.1 34.8 34.2 887
354 1124 1117 100.0 2595
4.21
Education of Father
Total (%) Total (N) * P<=0.1; ** P<=0.05; Not Fully Immunized;
***
P<=0.01; ^ Khyber Pukhtunkhwa;
28.68 ***
() Due to filtered cases, the total will be different from; 1. I.V: Independent Variables;
3. F.I: Fully Immunized;
71
30.93***
14.21***
2. N.F.I:
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Table 6. Logistic regression estimates for childhood immunization in Pakistan for Urban and Rural sample (Odds Ratios) VARIABLES Age Difference (0-5®) 6-10 11-30 Education of Mother (No Education®) Primary to Middle Secondary and Higher Education of Father (No Education®) Primary to Middle
Secondary and Higher Occupation of Mother (None®) Agriculture Sales Others
URBAN Probability of Fully Immunized Children MODEL-1a MODEL-2a MODEL-3a
RURAL Probability of Fully Immunized Children MODEL-1b MODEL-2b MODEL-3b
0.922 (0.696;1.220) 1.141 (0.767;1.700)
1.050 (0.857;1.285) 0.947 (0.734;1.221)
1.124 (0.812;1.557) 1.561 *** (1.110;2.194)
1.298 (0.942;1.787) 1.786 *** (1.258;2.534)
1.195 (0.859;1.661) 1.586 ** (1.105;2.276)
1.494 *** (1.192;1.873) 2.755 *** (1.893;4.008)
1.542 *** (1.236;1.924) 2.374 *** (1.663;3.390)
1.233 * (0.976,1.557) 1.646 *** (1.130;2.398)
1.461 ** (1.017;2.098)
1.421 * (0.995;2.029)
1.398 * (0.978;1.998)
1.080 (0.865;1.347)
1.141 (0.922;1.412)
1.024
1.702 *** (1.186;2.444)
1.650 *** (1.159;2.351)
1.608 *** (1.123;2.301)
1.199 (0.951;1.513)
1.261 (1.007;1.580)
(0.823;1.274) 1.152 (0.910;1.457)
0.549 (0.134;2.249) 1.013 (0.717;1.432) 1.411 (0.680;2.932)
0.467 (0.114;1.920) 0.909 (0.651;1.270) 1.234
0.692*** (0.539;0.888) 0.939 (0.721;1.221) 1.564 (0.890;2.748)
0.702 *** (0.554;0.891) 0.900 (0.698;1.160) 1.454 (0.866;2.440)
0.719 *** (0.560;0.922) 0.925 (0.713;1.200) 1.544 (0.914;2.608)
1.110 (0.842;1.462
1.169 (0.953;1.433)
1.182 * (0.971;1.437)
1.208 ** (1.006;1.451)
1.334 ** (1.025;1.735)
1.355 ** (1.040;1.767)
1.142 (0.939;1.390)
1.165 (0.965;1.407)
1.228 (0.957;1.574)
1.219 (0.949;1.566)
1.278 *** (1.079;1.514)
1.296 *** (1.092;1.537)
0.541 *** (0.365;0.803) 0.786 (0.585;1.055)
0.538 *** (0.363;0.797) 0.785 (0.584;1.056)
0.578 *** (0.438;0.762) 0.818 ** (0.679;0.985)
0.591 *** (0.447;0.781) 0.811 ** (0.672;0.978)
(0.603;2.522) Ever Discussed (No®) Yes
1.079 (0.817;1.424)
1.106 (0.843;1.451)
Set Asides Money (No®) Yes
1.279 * (0.976;1.677)
Sex of Child (Female®) Male Birth Order of Child (5 and Above®) 0-1 2-4 Age of at First Marriage (Less than 19 year®) 19 years and above
0.824 (0.579;1.173)
Age of Mothers At First Birth (Less than 19 years®) 19 years and above
1.011 (0.804;1.273)
1.399 * (0.991;1.976)
1.213 (0.926;1.588)
1.316 ** (1.064;1.629)
0.908 (0.539,1.532)
0.913 (0.539;1.545)
1.170 (0.874;1.567)
1.211 ** (1.016;1.444)
Sex of Head of Household (Male®) Female Wealth Index (Poor®) Middle Rich Province (Punjab®) Sindh
1.257 ** (1.000;1.580) 1.832 *** (1.426;2.353)
0.407 0.801
0.331 0.380
0.630 *** (0.494;0.802) 0.577 *** (0.453;0.735) 0.803 (0.541;1.192) 0.420 0.152
2301
2545
2562
0.367 0.501
0.335 0.424
1.514 (0.727;3.155) 1.132 (0.538;2.379) 1.035 (0.444;2.413) 0.181 0.389
1059
1126
1127
KP^ Baluchistan Constant Hosmer Lemeshow (p-value) Total Cases (Weighted)
1.698 ** (1.011;2.850) 1.551 * (0.969;2.480)
^ Khyber Pukhtunkhwa; *** 1% Level of Significance; ** 5% Level of Significance; * 10% Level of Significance; in parentheses are given confidence interval at 95%; ® stands for reference category
72
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