Association between maternal literacy and child vaccination in Ethiopia and southeastern India and the moderating role of health workers: a multilevel regression analysis of the Young Lives study

ABSTRACT

Background: Child vaccination coverage in low- and middle-income countries is still far from complete, mainly among marginalized people such as children with illiterate mothers.

Objective: This study aims to examine the association between maternal literacy and immunization status of children in Ethiopia and southeastern India (Andhra Pradesh and Telangana) and test whether state-run health centers and community health workers moderate that association.

Methods: This study is based on cross-sectional data from samples of children in Ethiopia and India, collected as part of round 2 within the Young Lives study (2006). Multilevel logistic regression was conducted to estimate the association between maternal literacy and the completion of four kinds of child vaccinations. We further tested for cross-level interactions between state-run health centers or community health workers and maternal literacy. Estimates were adjusted for several individual- and household-level demographic and socioeconomic factors.

Results: Literate mothers were more likely to complete all four kinds of vaccinations for their children compared to illiterate mothers in Ethiopia (Odds Ratio (OR)=4.84, Confidence Interval (CI)=1.75-13.36). Presence of a health center was positively associated with completed vaccinations in India only (OR = 6.60, CI = 1.57–27.70). A cross-level interaction between community health workers and maternal literacy on the vaccination completion status of children was significant in Ethiopia only (OR = 0.29, CI = 0.09–0.96).

Conclusions: Our findings suggest that increased availability of community health workers may reduce the child vaccination gap for illiterate mothers, depending on the country context.

KEYWORDS:

• Vaccination
• maternal literacy
• health center
• health workers
• multilevel regression

Responsible Editor Stig Wall, Umeå University, Sweden

Responsible Editor Stig Wall, Umeå University, Sweden

Acknowledgments

None.

Author contributions

HYL and JO conceived the study. HYL led the statistical analysis and drafted the manuscript. JO provided supervision throughout the data analysis and interpretation. SVS provided overall guidance. TTH, JH, AA, JMP, and JKL helped to interpret the data and provide critical revision. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Approval for this study was granted by the Social Science Division of Oxford University, and research ethics committees in Ethiopia, India and Vietnam.

Paper context

Child immunization coverage in LMICs is still far from complete, mainly among marginalized people such as children with illiterate mothers. This novel study examines whether state-run health centers and community health workers play a moderating role in the association between maternal literacy and child immunization. Community health workers reduced the gap in child immunization between illiterate and literate mothers in Ethiopia.

Data availability

Data are available from the UK Data Service website (at https://discover.ukdataservice.ac.uk/series/?sn=2000060). Users are required to register and apply for a password with the UK Data Service and sign a confidentiality agreement before obtaining access to the data. Also, users are asked to inform the UK Data Service and Young Lives of analysis or publication resulting from their work with the data set.

Supplementary material

Supplemental data for this article can be accessed here.

Additional information

Funding

As this research was based on secondary data from the 'Young Lives' study, the authors received no specific grant from any funding agency in the public, commercial or not-for-profit sectors for this study.