Subject(s)
Administrative Personnel , Culture , Immunization Programs/organization & administration , Professional Role , Rural Population , Adolescent , Adult , Burkina Faso , Female , Focus Groups , Humans , Immunization Programs/statistics & numerical data , Interviews as Topic , Male , Middle Aged , Young AdultABSTRACT
BACKGROUND: Burkina Faso's immunization program has benefited regularly from national and international support. However, national immunization coverage has been irregular, decreasing from 34.7% in 1993 to 29.3% in 1998, and then increasing to 43.9% in 2003. Undoubtedly, a variety of factors contributed to this pattern. This study aims to identify both individual and systemic factors associated with complete vaccination in 1998 and 2003 and relate them to variations in national and international policies and strategies on vaccination of rural Burkinabé children aged 12-23 months. METHODS: Data from the 1998 and 2003 Demographic and Health Surveys and the Ministry of Health's 1997 and 2002 Statistical Yearbooks, as well as individual interviews with central and regional decision-makers and with field workers in Burkina's healthcare system, were used to carry out a multilevel study that included 805 children in 1998 and 1,360 children in 2003, aged 12-23 months, spread over 44 and 48 rural health districts respectively. RESULTS: In rural areas, complete vaccination coverage went from 25.9% in 1998 to 41.2% in 2003. District resources had no significant effect on coverage and the impact of education declined over time. The factors that continued to have the greatest impact on coverage rates were poverty, with its various dimensions, and the utilization of other healthcare services. However, these factors do not explain the persistent differences in complete vaccination between districts. In 2003, despite a trend toward district homogenization, differences between health districts still accounted for a 7.4% variance in complete vaccination. CONCLUSION: Complete vaccination coverage of children is improving in a context of worsening poverty. Education no longer represents an advantage in relation to vaccination. Continuity from prenatal care to institutional delivery creates a loyalty to healthcare services and is the most significant and stable explanatory factor associated with complete vaccination of children. Healthcare service utilization is the result of a dynamic process of interaction between communities and the healthcare system; understanding this process is the key to understanding better the factors underlying the complete vaccination of children.
Subject(s)
Immunization Programs , Rural Health , Vaccination/statistics & numerical data , Burkina Faso , Health Care Surveys , Humans , Infant , National Health Programs , PovertyABSTRACT
PROBLEM: National and international efforts to immunize children aim to remove barriers that hinder full vaccination programs and to reinforce factors promoting it. Despite Burkina Faso's participation in all international and sub-regional initiatives to protect mothers and children from vaccination-preventable communicable diseases, vaccination coverage there remains low and has grown irregularly, from 34.7% in 1993 to 29.3% in 1998 and 43.9% in 2003. The situation is even more critical in rural than in urban areas. OBJECTIVE: To analyze the contribution of individual and environmental characteristics associated with vaccination of children aged 12-23 months in rural areas in Burkina Faso. Study population and methods. Data from the 1998 DHS (Demographic and Health Survey) and the 1997 Health Ministry Statistical Yearbook were used with a multi-level approach. Analysis distinguished two levels corresponding to the data's hierarchical structure: characteristics of children and their family's environment (level 1) and the health system and social environment (level 2). The study included 805 children aged 12 to 23 months, living in 44 health districts. The dependent variable was the child's vaccination status and is dichotomous (completely vaccinated or not). Completely vaccinated children are those who have received the BCG, the three doses of DTCoq, oral polio, measles and yellow fever vaccines, according to either their vaccination cards or their mothers' statement. RESULTS: The likelihood of vaccination increased with the level of household wealth (OR [well-off/poor]=1.88; [CI: 1.15-3.06] and was strongly associated with use of health services (OR [Prenatal care and assisted delivery/none of these services]=5.64; [CI: 3.16-10.05]). Nevertheless, these 2 variables did not alone explain the differences in vaccination observed between districts. More than 37% of the variation for vaccination completeness can be attributed to differences between health districts. Resources appear to play a minor role but a 1% increase in the proportion of educated women in the district increased the odds of complete vaccination by a factor of 1.14 [CI: 1.01-1.27]. Discussion. Despite universal access to free vaccination, children from poor households are less likely to receive all their vaccines than children from well-off households. This is probably due to indirect costs that stem from vaccination; the financial barrier remains one of the most significant factors preventing complete vaccination. Previous utilization of prenatal care and institutional delivery is more related to dynamics or even interaction between individuals and the health system. In addition to their direct effects, the interrelation between population and health systems may constitute a vaccination culture that may play a major role in explaining vaccination completeness. The resources of the health system bear little relation to vaccination. They are necessary but not sufficient for good health services. The organizational dynamic of health teams, the leadership of health district supervisors and staff motivation are key elements in these processes but were not measured in this study. CONCLUSION: Adding resources to vaccination programs is always a challenge for a number of national healthcare systems. It is not, however, the only key to success. The organization of healthcare systems and the contacts and relationships they establish with their populations appear to be determinant. The local vaccination culture that results from this interaction may be a key to explaining the variations observed between the different health districts.
