Assessment of sociodemographic factors and socio-economic status affecting the coverage of compulsory and private immunization services in Istanbul, Turkey
Introduction
The national primary healthcare organization in Turkey emerged from the Socialization of Health Services Law dated 1961. There are currently 5773 government health centres and 282 government maternal and child health and family planning (MCH-FP) centres providing outpatient healthcare services, immunization and family planning services at the primary level in the country.1
The national vaccination schedule in Turkey includes Bacille Calmette-Guérin (BCG), oral polio vaccine (OPV), diphtheria, tetanus, pertussis (DTP), measles and hepatitis B vaccine (HBV). These vaccinations are provided free of charge. Although measles, mumps, rubella (MMR), haemophilus influenza type b (Hib) and Varicella vaccines are not included in the national schedule, they can be purchased from pharmacies and administrated at government health centres or at private clinics.
The Expanded Programme of Immunization (EPI) aims for 95% coverage for each antigen and complete vaccination schedules for 90% of children under 1 year of age.1
Istanbul is the biggest metropolitan city of Turkey, Eastern Europe and the Middle East. According to the Turkish Demographic and Health Survey reported in 2003, vaccination coverage rates in the Istanbul region for children under 2 years were as follows: 92.3% for BCG, 92.3% for DPT first dose, 77.5% for DPT second dose, 72.5% for DPT third dose, 89.7% for OPV first dose, 83.6% for OPV second dose, 78.2% for OPV third dose, 85.8% for measles, and 62.3% for full vaccination (BCG, measles and three doses of DPT and OPV).2 There is still a gap between the EPI targets and the vaccination coverage rates in our country and in our region. Our research area was an urban area in Istanbul that included suburban areas. We have country level vaccination coverage information for compulsory vaccines, but there is no information about the coverage of private vaccines and the vaccination coverage of subgroups (such as socio-economically deprived groups) in the health district population. Midlevel health managers in health districts need more community-based information about the vaccination status of their population in order to define the priorities, determine the disadvantaged groups, and plan and implement interventions that aim to improve vaccination coverage in their localities. Sociodemographic and socio-economic factors, health centre region and immigration to Istanbul from different parts of Turkey can be important determining factors in the utilization of vaccination services.
The primary objective of the study was to determine the compulsory and private vaccination coverage for children under 5 years and under 1 year in the Umraniye Health District and to establish strategies for improving the vaccination services. Other objectives were to define the areas that present higher risks for non-vaccination and to determine the factors that influence vaccination coverage. When higher risk groups and higher risk areas are defined, limited resources can be used more effectively in order to increase vaccination coverage.
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Methods
Survey data were collected in the first 2 weeks of June 2002. The vaccination status of 3405 subjects from 2940 houses was assessed. Sociodemographic characteristics of the survey population were similar to those of the district population (Table 1).
Study area
Umraniye Health District is one of the 32 health districts of Istanbul and has a population of 613,717. Primary level healthcare services are provided through 15 health centres and two MCH-FP centres. A district health directorate working under the Provincial Health Directorate of Istanbul manages all these health centres. There are also four private hospitals, 22 private outpatient clinics (group practice) and 55 private surgeries in the area. The Public Health Department of Marmara University
Survey design
A ‘30×7’ cluster sampling design was adopted as the sampling method. The World Health Organization recommends this method as it is a rapid and economic sampling technique.3 Clusters were defined as streets and 30 streets were selected at random from each healthcare region.
In each street, face-to-face interviews were conducted with seven families who had children under the age of 5 years. The vaccination status of each child under 5 years was determined by interviewing the mother or another
Statistical analysis
Crude odds ratios (ORs) and confidence intervals (CIs) were calculated from cross tabs. Adjusted ORs for the sociodemographic and socio-economic characteristics, health centre region and inner country immigration were evaluated as possible related factors with the vaccination coverage rate for children under 5 years and under 1 year using the backward elimination method in logistic regression. SPSS 11.0 software was used for statistical analysis.
Results
The general sociodemographic and socio-economic characteristics and the coverage for compulsory and private (optional) vaccines of the sampled population are presented in Table 2.
Primary healthcare centres were the primary units used for vaccination services. The rate of vaccination coverage was as follows: HBV first dose, 89.9%; HBV second dose, 88.2%; HBV third dose, 84.6%; BCG, 94.8%; DPT first dose, 94.4%; DPT second dose, 92.5%; DPT third dose, 90.1%; OPV first dose, 94.1%; OPV second
Discussion
In our study, more than half of the coverage data were based on vaccination cards and the rest were based on maternal recall. In the Turkish Demographic and Health Survey, the same method was used and similar coverage results were observed; only 54% of the information was collected from vaccination cards.2 There are studies showing that maternal recall is reliable.5, 6 Therefore, we believe that the use of maternal recall of vaccination status had no negative effect on our study. As expected, a
Acknowledgements
The authors wish to thank research assistants Seyhan Hidiroglu, Yucel Gurbuz, Aktan Karahan, Mine Solakoglu Ucar and Ozgu Kesmezacar who helped to collect the data, and Pınar Ay and Asya Topuzoglu for translating the manuscript. The authors would also like to thank the Umraniye Health District staff who facilitated the fieldwork.
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