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Vaccination is a proven equitable intervention if people take advantage of the opportunity to get vaccinated. Niger is a low-income country in West Africa, with a 76% measles 1 vaccination coverage rate in 2016. This study was conducted to identify individual- and neighborhood-level factors that could improve measles 1 vaccination coverage in Niamey, the capital. In October 2016, 460 mothers with children aged 12–23 months were surveyed. The outcome was to determine whether the mother’s child had been vaccinated against measles 1 or not. For individual-level variables of measles 1 vaccination status, the following were included: mother’s age group, mother tongue, maternal education level, husband’s job, where the mother gave birth (at home or at a health center) and whether the mother discussed vaccination with friends. Neighborhood-level factors were access time to the health center, household access to electricity, and a grand-mean-centered wealth score. Multilevel logistic regression analysis was performed. At the individual-level, primary and secondary-educated mothers were more likely to vaccinate their children against measles 1 (aOR 1.97, 95% CI 1.11–3.51). At the neighborhood-level, no factors were identified. Therefore, a strengthened focus on equity-based, individual factors is recommended, including individual motivation, prompts and ability to access vaccination services.
Niger is a landlocked desert country in West Africa, with an estimated population of 16 million people in 2015 [28]. The capital Niamey’s population is estimated to be just over one million. The average annual population growth rate was 4.0% per year from 2010 to 2015, whereas the average annual urban population growth rate was 5.1% per year from 2010 to 2015 [29]. The five health districts in Niamey have population densities ranging from 824 to 4845 people/km2 [28]. The districts are further divided into neighborhoods, which are considered as community-level administrative units in this study. A recent map of land use and the distribution of concrete buildings and steel-sheet roofs demonstrates Niamey’s spatial expansion [30]. According to the 2012 DHS, nearly twenty-five percent of households in Niamey had an indoor water faucet; one-fourth of households had a water faucet within the concession, while approximately half of the households had to use a public water tap. A third of the surveyed households had an indoor improved toilet, half shared toilets with other families, and six percent had no access to sanitation facilities. The average household size in Niamey was 5.8 persons, while 17% of households had more than 9 persons. A quarter of the households had only one room, whereas forty-five percent of households had two rooms [31]. The overall study design, sample size calculation, study participants, data sources, and study management are detailed in the work of Kondo Kunieda et al. [6]. In brief, a cross-sectional household survey was conducted in the capital of Niger, Niamey. Data on the full vaccination coverage and socioeconomic household characteristics of 460 children aged 12–23 months were collected. Of 445 children, 38% were fully vaccinated. Mothers who were satisfied with their health workers’ attitude and had correct vaccination calendar knowledge were more likely to have fully vaccinated children. Mothers who had completed secondary school were also associated with having fully vaccinated their children. For the outcome of this study, measles 1 vaccination status was determined by the dates recorded in the MCH handbook. However, when a mother was unable to show her child’s MCH handbook, she was asked questions on household characteristics, knowledge, attitude, and actions related to child vaccination. When a mother showed her child’s MCH handbook, the surveyors copied all the dates of vaccination onto the survey questionnaire, photographed the page, and asked the mother the same questions as described above. All the data were entered and cleaned with Microsoft Excel and then exported to MLwiN 2.26 (Centre for Multilevel Modelling, University of Bristol, Bristol, UK) for preliminary statistical analyses. The final analyses presented in this paper were performed using Stata 16.1 for Windows (StataCorp LLC, College Station, Texas, USA). Analytical results were then visualized using QGIS Desktop 2.18.13 software. For individual-level variables of measles 1 vaccination status, the following were included: mother’s age group, mother tongue, maternal education level, husband’s job, where the mother gave birth (at home or at a health center) and whether the mother discussed vaccination with friends [13,19]. Neighborhood-level variables included a categorical variable for access time to the health center [5,32], a binary variable for household access to electricity [33], and a grand mean-centered wealth score [33]. Multilevel modeling was employed to assess the relevance of individual- and neighborhood-level factors in predicting measles 1 vaccination status [33,34]. Multilevel modeling also deconstructed the variance attributed to mothers or neighborhoods. The following five models were fitted: model 0 was a null model with no exposure variable, model 1 contained only individual-level variables, and model 2 contained only neighborhood-level variables. Model 3 was a multilevel model that contained all the individual- and neighborhood-level variables. The two-level regression model 3 is as follows: In this two-level regression model, Covij is the vaccination coverage or status of the mother i’s child in the neighborhood j. υ0j,υ30j are variances in measles vaccination status for variable x0, x30 in the neighborhood j. u0j,u30j are random effects at the neighborhood level. ε0j, ε30j are the random effects at the mother level. εij, ε30j represent the differentials in measles vaccination status for variables x0, x30 for mother i in district j. When the individual-level variables are mean-centered, between-mother effects, regardless of neighborhood, are detected for wealth scores.
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