Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys

doi:10.1016/S0140-6736(05)67599-X

The Lancet

Volume 366, Issue 9495, 22–28 October 2005, Pages 1460-1466

https://doi.org/10.1016/S0140-6736(05)67599-X Get rights and content

Summary

Background

In most low-income countries, several child-survival interventions are being implemented. We assessed how these interventions are clustered at the level of the individual child.

Methods

We analysed data from Bangladesh, Benin, Brazil, Cambodia, Eritrea, Haiti, Malawi, Nepal, and Nicaragua. A co-coverage score was obtained by adding the number of interventions received by each child (including BCG, diphtheria-pertussis-tetanus, and measles vaccines), tetanus toxoid for the mother, vitamin A supplementation, antenatal care, skilled delivery, and safe water. Socioeconomic status was assessed through principal components analysis of household assets, and concentration indices were calculated.

Findings

The percentage of children who did not receive a single intervention ranged from 0·3% (14/5495) in Nicaragua to 18·8% (1154/6144) in Cambodia. The proportions receiving all available interventions varied from 0·8% (48/6144) in Cambodia to 13·3% (733/5495) in Nicaragua. There were substantial inequities within all countries. In the poorest wealth quintile, 31% of Cambodian children received no interventions and 17% only one intervention; in Haiti, these figures were 15% and 17%, respectively. Inequities were inversely related to coverage levels. Countries with higher coverage rates tended to show bottom inequity patterns, with the poorest lagging behind all other groups, whereas low-coverage countries showed top inequities with the rich substantially above the rest.

Interpretation

The inequitable clustering of interventions at the level of the child raises the possibility that the introduction of new technologies might primarily benefit children who are already covered by existing interventions. Packaging several interventions through a single delivery strategy, while making economic sense, could contribute to increased inequities unless population coverage is very high. Co-coverage analyses of child-health surveys provide a way to assess these issues.

Introduction

In most low-income countries, coverage rates for child-survival interventions are low, and millions of children die every year from diseases for which there are effective interventions.1, 2 Furthermore, there are important inequities between different social groups in nearly all low-income and middle-income countries3, 4 and even within rural populations that may appear to be uniformly poor.⁵ Children belonging to the poorest families are consistently less likely to receive preventive and curative interventions than those from other families.6, 7

In low-income countries various child-survival interventions are being implemented simultaneously.1, 2 These include preventive interventions such as vaccines, insecticide treated mosquito nets, micronutrient supplementation, nutrition counselling (breastfeeding and complementary feeding), growth monitoring, and appropriate newborn care. Additionally, health systems in most countries provide many case-management interventions, including oral rehydration therapy, antibiotics, and antimalarials.

We assessed the joint distribution of key preventive interventions in children younger than 5 years and investigated how many separate child-survival interventions each child is receiving and whether this number differed by the sex of the child. We also studied the role of social inequities in co-coverage, and discuss here possible implications for planning the delivery of child-survival interventions.

Section snippets

Study samples

We selected low-income countries for which Demographic and Health Surveys (DHS)⁸ datasets obtained since 1999 were available for secondary analysis and included the variables needed for analysis of intervention coverage rates and equity. We attempted to include countries from different regions of the world. Brazil was also included, despite the fact that the survey data were from 1996, as an example of a middle-income country with high coverage of most child-survival interventions. The data

Results

The overall response rates, combining response at household and individual level, were 86% for Brazil, 88% for Nicaragua, and 93% or more for the other seven countries. Table 1 shows the numbers of children available for analysis by sex, age, and socioeconomic group. The smallest dataset was that from Benin and the largest was from Malawi. Boys comprised about half of all samples, and the age distribution was reasonably uniform across the four age-groups studied. Wealth quintiles were

Discussion

The results, drawn from nationally representative samples of children and mothers in nine low-income and middle-income countries, show that even though there are many child-survival intervention programmes running in all countries, some children receive no interventions while others receive many. Furthermore, the probability of receiving interventions is directly associated with socioeconomic level, with poor children receiving fewer interventions than their wealthier peers. This finding

References (26)

G Jones et al.
How many child deaths can we prevent this year?
Lancet
(2003)
GL Darmstadt et al.
Evidence-based, cost-effective interventions: how many newborn babies can we save?
Lancet
(2005)
CG Victora et al.
Explaining trends in inequities: evidence from Brazilian child health studies
Lancet
(2000)
CG Victora et al.
Applying an equity lens to child health and mortality: more of the same is not enough
Lancet
(2003)
DR Gwatkin et al.
Making health systems more equitable
Lancet
(2004)
R Knippenberg et al.
Systematic scaling up of neonatal care in countries
Lancet
(2005)
D Gwatkin et al.
Socioeconomic differences in health, nutrition and population. Health, Nutrition & Population Discussion Paper
(2000)
J Armstrong Schellenberg et al.
Inequities among the very poor: health care for children in rural southern Tanzania
Lancet
(2003)
Demographic and Health Surveys (DHS)
Demographic and Health Surveys (DHS): Bangladesh report 1999/2000

Demographic and Health Surveys (DHS): Benin report 2001

Demographic and Health Surveys (DHS): Brazil report 1996

Demographic and Health Surveys (DHS): Cambodia report 2000

Cited by (145)

Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review
2023, JTO Clinical and Research Reports
Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.
We conducted a scoping review using the Arksey and O’Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities.
Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability.
Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.
Assessing the overlap between immunisation and other essential health interventions in 92 low- and middle-income countries using household surveys: opportunities for expanding immunisation and primary health care
2021, eClinicalMedicine
Citation Excerpt :
For this purpose, it is essential to document the extent to which unvaccinated children and their families are also missing out on other key health interventions. Studies of how access to services and interventions are clustered at individual levels have been described as analyses of cocoverage [11]. Yet, the literature on this issue is scant.
Unvaccinated children may live in households with limited access to other primary health care (PHC) services, and routine vaccination services may provide the opportunity to bring caregivers into contact with the health system. We aimed to investigate the overlap between not being vaccinated and failing to receive other PHC services in low- and middle-income countries (LMICs).
Using Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) data between 2010-2019 from 92 LMICs, we analysed six vaccination indicators based on the bacille Calmette-Guérin (BCG), polio, diphtheria-pertussis-tetanus (DPT) and measles vaccines and their overlap with four other PHC indicators - at least four antenatal care (ANC) visits, institutional delivery, careseeking for common childhood illnesses or symptoms and place for handwashing in the home - in 211,141 children aged 12-23 months. Analyses were stratified according to wealth quintiles and World Bank income levels.
Unvaccinated children and their mothers were systematically less likely to receive the other PHC interventions. These associations were particularly marked for 4+ ANC visits and institutional delivery and modest for careseeking behaviour. Our stratified analyses confirm a systematic disadvantage of unvaccinated children and their families with respect to obtaining other health services in all levels of household wealth and country income.
We suggested that lack of vaccination goes hand in hand with missing out on other health interventions. This represents an opportunity for integrated delivery strategies that may more efficiently reduce inequalities in health service coverage.
Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, The Wellcome Trust, Associação Brasileira de Saúde Coletiva and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.
Zero-dose children and the immunisation cascade: Understanding immunisation pathways in low and middle-income countries
2021, Vaccine
Zero-dose prevalence refers to children who failed to receive any routine vaccination. Little is known about the “immunisation cascade” in low- and middle-income countries (LMICs), defined as how children move from zero dose to full immunisation.
Using data from national surveys carried out in 92 LMICs since 2010 and focusing on the four basic vaccines delivered in infancy (BCG, polio, DPT and MCV), we describe zero-dose prevalence and the immunisation cascade in children aged 12 to 23 months. We also describe the most frequent combinations of vaccines (or co-coverage) among children who are partially immunized. Analyses are stratified by country income groups, household wealth quintiles derived from asset indices, sex of the child and area of residence. Results were pooled across countries using child populations as weights.
In the 92 countries, 7.7% were in the zero-dose group, and 3.3%, 3.4% and 14.6% received one, two or three vaccines, respectively; 70.9% received the four types and 59.9% of the total were fully immunised with all doses of the four vaccines. Three quarters (76.8%) of children who received the first vaccine received all four types. Among children with a single vaccine, polio was the most common in low- and lower-middle income countries, and BCG in upper-middle income countries. There were sharp inequalities according to household wealth, with zero-dose prevalence ranging from 12.5% in the poorest to 3.4% in the wealthiest quintile across all countries. The cascades were similar for boys and girls. In terms of dropout, 4% of children receiving BCG did not receive DPT1, 14% receiving DPT1 did not receive DPT3, and 9% receiving DPT3 did not progress to receive MCV.
Interpretation.
Focusing on zero-dose children is particularly important because those who are reached with the first vaccine are highly likely to also receive remaining vaccines.
Economic-related inequalities in child health interventions: An analysis of 65 low- and middle-income countries
2021, Social Science and Medicine
Citation Excerpt :
The SDG agenda pledged to “leave no one behind”, emphasizing the need for targeted and inclusive strategies for the most marginalized and vulnerable children. Evidence from epidemiological studies and clinical trials indicate that effective interventions in prenatal and delivery care (Victora et al., 2005), hygiene facilities (Bartram and Cairncross, 2010), environmental surroundings (Mutunga, 2011), and access to health resources (Anand and Bärnighausen, 2004; Rutherford et al., 2010) can improve child survival and health. However, prior country-specific (Wagstaff et al., 2003; Victora et al., 2000; Tang et al., 2008; Schellenberg et al., 2003; Limwattananon et al., 2010) and multi-country studies (Equity in maternal and newbo, 2012; Victora et al., 2012; Countdown 2008 Equity Ana, 2008; A.J.D.B and C.G.V, 2013) found that some of these interventions, such as institutional delivery, delivery with skilled birth attendants, and use of modern contraceptives, were disproportionately concentrated among the wealthier population.
To achieve Sustainable Development Goal targets related to child health and well-being, it is important to quantify inequalities in the essential child health interventions. We used the latest available Demographic and Health Surveys from 65 low-income and middle-income countries between 2005 and 2018. We examined economic-related inequalities in 15 essential child health interventions spanning across four domains: nutrition, behavioral health, household environment, and maternal factors. In the pooled analysis, we observed significant inequalities in all child health interventions, except in the use of oral rehydration therapy (ORT) for child diarrhea. The interventions with the largest adjusted difference between the richest (Q5) and the poorest (Q1) groups were in household environment domain: improved sanitation at 55.6 percentage points [PPs] (95% confidence interval [CI]: 54.7, 56.6), low indoor pollution at 43.5 PPs (95% CI: 41.4, 45.9), and safe stool disposal at 39.8 PPs (95% CI: 38.7, 41.0). In 35 countries, the adjusted difference between Q5 and Q1 groups in improved sanitation was found to be larger than 50 PPs. At the same time, country-specific analyses revealed substantial heterogeneity in the extent of inequalities in child health interventions. An inverted-U shape curve was identified between the mean intervention coverage rate and the magnitude of inequalities for household environmental and maternal interventions. This suggests an initial exacerbation of inequality in child health interventions as the coverage increases until it reaches an inflection point at which inequality begins to decline even as the coverage continues to improve. Our findings call for more systematic monitoring of economic-related inequalities in child health interventions to develop equity-oriented policies and programmes in global health.
Antenatal care in Southern Brazil: Coverage, trends and inequalities
2021, Preventive Medicine
We described prenatal care quality for four indicators over a 12-years period among puerperae living in Southern Brazil. Five surveys including all women giving birth between 01/01 to 31/12 in 2007, 2010, 2013, 2016, and 2019 were conducted in Rio Grande, Rio Grande do Sul state, Brazil. A single standardized questionnaire was applied within 48 h after delivery in all the city's maternity hospitals. Outcomes included the followings proportion of pregnant women who started prenatal care in the first trimester and performed at least six medical visits, completed at least two HIV, two syphilis and two qualitative urine tests. These indicators were stratified according to quartiles of household income. Absolute and relative measures of inequalities were calculated. A total of 12,645 (98% of the total) of the 12,914 mothers eligible in the five surveys were successfully interviewed. Coverage for all indicators increased substantially, especially in the poorest quartile for six prenatal care visits starting in the first trimester, and for HIV and qualitative urine tests. The slope index (SII) and the concentration index (CIX) of inequality showed clear disadvantage among the poorest for prenatal visits starting in the first trimester and performing two or more urine tests. There was a substantial increase in coverage for all variables studied in the period. The reduced inequity, mainly for the beginning of the first trimester and for visits and urine tests, was due to the higher coverage achieved in the poorest quartile.
Inequities in On-Time Childhood Vaccination: Evidence From Sub-Saharan Africa
2021, American Journal of Preventive Medicine
Vaccination coverage has improved in the past decade, but inequalities persist: the poorest, least educated, and rural communities are left behind. Programming has focused on increasing coverage and reaching the hardest-to-reach children, but vaccination timeliness is equally important because delays leave children vulnerable to infections. This study examines the levels and inequities of on-time vaccination in the Sub-Saharan African region.
The most recent Demographic and Health Surveys or Multiple Indicator Clusters Surveys since 2000 from Sub-Saharan Africa were used to assess on-time vaccination and inequalities by household wealth, maternal education, and place of residence. Inequalities were quantified using slope index of inequality and concentration index.
The analysis included 153,632 children aged 12–36 months from 40 Sub-Saharan Africa countries. Median on-time vaccination coverage was <50% in all the 4 subregions. Differences in on-time vaccination were observed by place of residence in the Southern (20.8 percentage points, 95% CI=0.8, 40.8), West (17.5 percentage points, 95% CI=5.1, 29.9), and Eastern (20.9 percentage points, 95% CI=6.5, 35.2) regions. Wealth-related inequities were observed in the Southern (22.6 percentage points, 95% CI=4.0, 41.2), Western (30.6 percentage points, 95% CI=19.1, 42.1), and Eastern (26.1 percentage points, 95% CI=8.2, 44.0) regions. Significant education-related differences in on-time vaccination were observed in the Western (20.7 percentage points, 95% CI=10.9, 30.5) and Eastern (21.2 percentage points, 95% CI=7.0, 35.4) regions.
On-time vaccination coverage was low in all subregions and nearly all countries. Inequalities in on-time immunization by household wealth, place of residence, and education existed in most countries. Concrete strategies to improve levels of timeliness are needed.
This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

View all citing articles on Scopus

View full text

ArticlesCo-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Study samples

Results

Discussion

Lancet

Lancet

Lancet

Lancet

Lancet

Lancet

Socioeconomic differences in health, nutrition and population. Health, Nutrition & Population Discussion Paper

Inequities among the very poor: health care for children in rural southern Tanzania

Lancet

Demographic and Health Surveys (DHS)

Demographic and Health Surveys (DHS): Bangladesh report 1999/2000

Demographic and Health Surveys (DHS): Benin report 2001

Demographic and Health Surveys (DHS): Brazil report 1996

Demographic and Health Surveys (DHS): Cambodia report 2000

Articles
Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys