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

Studies on child vaccination in low- and middle-income countries (LMICs) have found a significant association between parental or caregiver literacy and child vaccination. Caregiver illiteracy adversely affects child vaccination status via the capacity to obtain, process, and understand basic information on the benefits and risks associated with child vaccination, which, in turn, lead to poor adherence to the recommended vaccination schedule. Community health centres and health workers, called health extension workers in Ethiopia or Anganwadi workers (AWW) in India, may play an important role in improving vaccination coverage for marginalised children with illiterate caregivers because such workers are often responsible for managing the vaccination process within their community - for example, by informing parents about vaccination benefits and risks. This study examines the association between maternal literacy and immunisation status of children in Ethiopia and southeastern India (Andhra Pradesh and Telangana) and tests whether state-run health centres and community health workers moderate that association.

The study is based on cross-sectional data from samples of children in Ethiopia and India, collected as part of round 2 (2006-2007; age of cohort: 4 to 5 years) within the Young Lives study, the aim of which was to assess the causes and consequences of childhood poverty. In India, sentinel sites were chosen only within the states of Andhra Pradesh and Telangana, while sites were selected nationwide in Ethiopia. The final analytic samples comprised 1,157 children in 22 communities in Ethiopia and 1,455 children in 75 communities in India.

Respondents were asked whether the mother and father of the index child could read and understand a letter or newspaper in their own language, which was Telugu in India, and the most commonly used language in that locality in Ethiopia. Multilevel logistic regression was conducted to estimate the association between maternal literacy and the completion of 4 kinds of child vaccinations (Bacille Calmette-Guérin (BCG), meningococcal (MCV), diphtheria-tetanus-pertussis (DTP3), and polio).

When individual- and household-level covariates were adjusted for, maternal literacy was associated with vaccination status only in Ethiopia. Literate mothers in that country were 2.54 times (95% confidence interval (CI): 1.35-4.75, p = 0.004) more likely to complete all 4 kinds of vaccinations for their child as compared to illiterate mothers. This relationship remained robust even after adjusting for paternal literacy (adjusted odds radio (AOR) = 2.27, 95% CI: 1.18-4.39, p < 0.01).

The presence of a state-run health centre in the respondent's community was positively associated with child vaccination status only in India. That is, children living in a communities where a state-run health centre was located were 6.6 times (95% CI: 1.57-27.70, p < 0.01) more likely to have received the 4 vaccinations than children in communities without a state-run health centre.

The cross-level interaction effect between presence of a state-run health centre and maternal literacy was not significant in either country. However, the cross-level interaction between community health workers and maternal literacy was statistically significant in Ethiopia. This result indicates that the gap in the odds of completing the 4 kinds of vaccinations between illiterate and literate mothers was smaller in communities with community health workers than in communities without community health workers.

According to the researchers, the mostly null findings about the presence of a state-run health centre may be evidence that presence of a such health infrastructure alone does not capture the challenges associated with making health centres effective. For example, distrust in the quality of health centres, or cultural factors, may hinder a mother's visit to a health centre.

Face-to-face and one-on-one interpersonal communication with community health workers is considered to be an effective means for reducing barriers in access to information for marginalised populations such as children of illiterate mothers. As with state-run health centres, however, the presence of community health workers does not ensure that the system is properly functioning. In India, the AWW system has been reported by some to be insufficient in number and/or lacking in capacity in terms of knowledge, skills, attitudes, or motivation. In addition, weak organisational support might explain, in part, a non-significant direct association between community health workers and child vaccination status in India. (To address challenges with their community health worker system, India launched the National Rural Health Mission in 2005 to rejuvenate its rural health system.)

In conclusion, the analysis showed that the availability of community health workers may reduce the impact of maternal illiteracy on child vaccination status, although the result depended on the country. "This finding emphasizes the potential importance of implementing a high-quality community health worker system in expanding vaccination coverage among underserved children in LMICs, especially in countries with a high rate of illiteracy. Although reducing illiteracy itself is a more fundamental and ideal solution, this goal would take a long time to achieve. Thus, improving the number and quality of community health workers may be a good additional step in improving vaccination rates among children of illiterate mothers."