The decision to vaccinate a child: An economic perspective from southern Malawi

Abstract

The dynamics of childhood vaccination uptake in developing countries are unclear. Numerous studies document the relationship between vaccination coverage and access, socio economic and demographic factors. However, there is less knowledge about the relationship between vaccination coverage and carers' motivation and willingness to seek childhood vaccinations. The aim of this paper is to introduce a framework for studying demand for childhood vaccination and to examine the coherence between theoretical predictions and empirical findings in a rural area in Malawi. We interviewed 635 carers with children aged 18–59 months. About 96 percent of the respondents reported to have fully vaccinated their youngest eligible child for all routine vaccinations scheduled in the Expanded Program on Immunization. This paper concludes that easy access to vaccination services cannot explain why demand is high. Many carers had to travel long distances to reach vaccination delivery points and a considerable share of the respondents scored waiting and travelling time as long. Results from the present study, in combination with theoretical predictions, suggest that a high level of trust in distributors of information and vaccines may be an essential explanatory factor for why carers seek immunization for their children, even in the presence of considerable costs. Trust may be an important explanatory factor as it can be seen to generate positive perceived benefits.

Introduction

Childhood vaccination represents one of the most cost effective health interventions in the world (Dean, 2006, chap. 1). UNICEF estimates show that in the last two decades more than 20 million lives have been saved due to acquired protection from childhood vaccinations (UNICEF, 2010). Nevertheless, widespread adequate worldwide vaccination coverage has yet to be attained. There are large variations in vaccination coverage, not only between high and low-income countries but also across and within low-income countries. This differential vaccination coverage can accumulate a pool of susceptible populations that, over time, culminate in the outbreak of vaccine preventable diseases (Jani et al., 2006).

At present, the reasons for differential vaccination coverage are only partially understood. The majority of literature that looks at determinants for vaccination coverage in low-income countries focuses on socio economic and demographic factors such as, education, regional belonging, gender, ethnicity, birth order, religion, household characteristics and family income. The typical tendency found is that vaccination status of children is positively associated with mothers' education (Chowdhury, Bhuiya, Mahmud, Salam, & Karim, 2003; Munthali, 2007; Teklay & Michael, 2003) and socio economic status (Chowdhury et al., 2003; Cui & Gofin, 2007; Nath et al., 2007). Furthermore, numerous studies have found that vaccination coverage is higher in urban areas than in rural areas (Chowdhury et al., 2003; Munthali, 2007). The tendency observed in relation to birth order is that first born children are more likely to be fully vaccinated than their later born siblings (Munthali, 2007; Nath et al., 2007). Concerning gender, boys have, in some areas, been found to have a greater chance of being fully vaccinated than girls (Chowdhury et al., 2003; Nath et al., 2007).

As the above literature indicates, vaccination coverage is related to a number of socio economic factors. Furthermore, a number of studies show how vaccination coverage tends to increase when access to vaccination services is improved. In particular, the use of outreach services and involvement of lay health workers have been recognized as key interventions that can increase vaccination coverage (Ryman, Dietz, & Cairns, 2008). An extensive study based on data from 49 developing countries found that density of health workers (nurses/midwives) had a considerable impact on vaccination coverage. Countries with a high density of health workers tend to achieve higher vaccination coverage than countries with a low density (Anand & Barnighausen, 2007). The study does not conclude whether the difference is mainly attributed to the explanatory mechanism that the density of nurses and midwives increases access to immunisation or if other aspects, such as the educating role of health workers, are part of the explanation.

Numerous studies document the relationship between vaccination coverage and access, socio economic and demographic factors. However, there is less knowledge about the relationship between vaccination coverage and carers' motivation and willingness to seek childhood vaccinations. As Jheeta and Newell (2008) express, the current research into parents' knowledge and attitudes towards childhood vaccination is disproportionately low considering the enormous scale and relevance of this issue. They conclude, based on a review of studies that address carers demand for childhood vaccination in Africa and Asia, that the dynamics of vaccination uptake remain unclear. In particular, very few papers quantify carers' knowledge and attitudes.

The aim of this paper is to introduce a framework for studying demand for childhood vaccination, based on concepts from economics, and to examine the coherence between theoretical predictions and empirical findings in a rural area in southern Malawi. Particular emphasis is placed on understanding demand by focussing on perceived benefits and costs of vaccination, as well as trust as a potential determinant for perceived net benefits. We attempt to measure carers' trust in both distributors of vaccinations and information, in addition to carers' perceptions of potential costs and benefits of vaccinating children. It is our aim to look at demand for childhood vaccinations through an economic lens in order to generate some new hypotheses and provide new insights into the current understanding of why carers seek or refuse to seek childhood vaccinations. We propose that an enhanced understanding of demand can lead to improvements in current approaches to immunization so that the available resources can be used more effectively and equitably. The latter is necessary in order to achieve and sustain high vaccination coverage and consequently reduce mortality rates among children under five.