Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys

9 789290 228776 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys This document presents analysis of two most recent demographic and health surveys from Timor-Leste. The document has made an attempt to identify trend and factors resulting in zero-dose vaccination status of children for measles-containing vaccine to help policy makers and program implementers to design interventions accordingly. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys ISBN: 978 92 9022 877 6 © World Health Organization 2021 Some rights reserved. 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Printed in India Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys iii Contents Foreword ....................................................................................................................v Acronyms ..................................................................................................................vi Summary .................................................................................................................. vii 1. Introduction........................................................................................................... 1 2. Methods ................................................................................................................ 3 2.1 Data source .................................................................................................. 3 2.2 Variables ....................................................................................................... 3 2.3 Statistical analyses ........................................................................................ 4 2.4 Ethical review................................................................................................ 4 3. Results ................................................................................................................... 5 3.1 Sociodemographic characteristics of children used for analysis ...................... 5 3.2 National and subnational trends in status of measles vaccination coverage ... 7 3.3 Factors associated with measles vaccination status in 2016 and 2009–2010 ............................................................................................ 8 3.4 Equity gap in measles vaccination ............................................................... 10 3.5 Trends affecting measles vaccination status by different covariates ............. 14 3.6 Effects of covariates on measles vaccination coverage ................................... 16 4. Discussions .......................................................................................................... 20 5. Conclusion ........................................................................................................... 22 References ............................................................................................................... 23

Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys v Foreword It is my pleasure to present to you the analytical series on the trends and factors affecting zero-vaccination status of children for measles-containing vaccine in the WHO South-East Asia (SEA) Region using Demographic Health Survey data available from seven countries: Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Timor-Leste. Immunization is one of the most cost-effective public health interventions and most countries in the WHO SEA Region introduced the Expanded Programme on Immunization (EPI) in the late 1970s and some in the early 1980s. The efforts of countries to enhance vaccination coverage in the SEA Region has translated into impressive accomplishments against vaccine-preventable diseases: the Region has remained polio-free since 2014; and maternal and neonatal tetanus has been eliminated and sustained in all countries. Furthermore, five SEA Region countries – Bhutan, the Democratic People’s Republic of Korea, Maldives, Sri Lanka and Timor-Leste – have eliminated measles, and Maldives and Sri Lanka have also eliminated rubella. Nevertheless, important challenges remain. The benefits of immunization are unevenly shared: coverage varies widely among and within countries. Each year, a large number of infants do not receive a full course of even basic vaccines, and many more miss out on newer vaccines making them vulnerable to future outbreaks of vaccine-preventable diseases. Gaps and inequalities in immunization coverage exist not only between countries but also within countries for many reasons. Outbreaks of measles are stark reminders that strong immunization systems are necessary to sustain high levels of coverage and to eliminate and eradicate diseases. Since measles is highly infectious, its presence serves as a tracer (like the “canary in the coal mine”) of inadequate coverage and gaps in the health system. High coverage with measles vaccine is an indicator of a strong immunization programme, which may signal a solid foundation for primary health care services and serve as an indicator of the robustness of primary health care systems as envisioned in the Sustainable Development Goals and the WHO Thirteenth General Programme of Work. This document identifies trends and factors affecting zero-vaccination status of children for the measles-containing vaccine in the Region. It may be used as a reference by immunization programme managers, officers and teams across the Region to identify programmatic interventions to deal with the barriers identified by an analysis of the characteristics of vaccinated and not vaccinated children in the seven countries. This will definitely contribute towards achieving the regional goal of measles and rubella elimination by 2023. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveysvi Acronyms BCG bacille Calmette–Guérin (vaccine) Crl credible intervals DHS Demographic and Health Survey DTP diphtheria–tetanus–pertussis HepB hepatitis B JRF joint reporting form MCV measles-containing vaccine MCV1 first dose of measles-containing vaccine OPV oral polio vaccine SEA South-East Asia SIA supplementary immunization activities TLDHS Timor-Leste Demographic and Health Survey UNICEF United Nations Children’s Fund UNTEAT United Nations Integrated Mission in East Timor WHO World Health Organization Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys vii Summary Background The Democratic Republic of Timor-Leste is one of the world’s youngest countries. In Timor-Leste immunization services were re-established, after the independence of the nation, only in March 2000, and since then it has committed itself to improve national vaccination coverage. The share of children receiving full vaccination coverage (one dose of BCG, three doses of DTP and OPV each, and one dose of measles) increased from 18% to 53% between 2003 and 2009–2010, but the figures remained almost unchanged between 2009–2010 and 2016. The Timor-Leste Demographic and Health Survey (TLDHS) 2016 revealed that 49% of the children aged 12–23 months were vaccinated with all basic vaccinations at some point prior to the survey, 62% had received the third dose of DTP (DTP3), and 69% had received the first dose of measles-containing vaccine (MCV1). Although Timor-Leste has achieved measles elimination status through successive supplementary immunization activities (SIAs), the low coverage rate for DTP3 and measles may endanger the sustainability of the elimination achieved. Additionally, there are huge discrepancies in vaccination coverage within the country. Hence it is important to understand the factors that are causing those differences. This study intends to identify those reasons that are playing a part leading to partial vaccination and lack of vaccination of children aged 12–23 months with DTP3 and MCV1 in Timor-Leste. Methods The study sample consisted of the children surveyed in the 2016 DHS and 2009–2010 DHS in Timor-Leste. From these datasets, overall prevalence and the trends of the independent variables of measles vaccine were estimated. Significant change in the distribution of all variables were assessed and multiple logistic regression for both years were used to show the effect of covariates in the outcomes of interest. For the equity analysis, we calculated rate differences (highest–lowest) as absolute measures of inequality and rate ratios (highest/lowest) as relative measures of inequality. Concentration index and concentration curve were used to identify socioeconomic inequality in vaccination with measles-containing vaccines. We used a Bayesian regression model with non-informative prior to estimate the trends in indicators with time. The posterior predictive distributions were used to obtain projections (both national and subnational projections) and credible intervals (CrI) up to the years 2019, 2020 and 2021. Sample weights were included during the estimations of rates and “svy” command was applied in STATA 15.0 version to account for the complex sampling design of DHS. “R” software was used for the national and subnational projections of coverage for measles. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveysviii Results There were no changes in the proportion of children aged 12–23 months who were vaccinated with measles over a five-year period, and some districts showed a slight improvement, including Aileu, Ainaor, Baucau, Liquica and Manatuto. Differences in measles vaccination status are relatively higher for education of mother (23.6 percentage point difference between child born to mother with no education and one with higher education), household wealth quintile (23.8 difference between lowest wealth quintile and highest wealth quintile), ANC visit (23.8 percentage point difference between mother having had at least four ANC visits and less than four ANC visits), education of father (19.5 difference between father with no education and with higher education) as well as mass media exposure of mother (18 percentage point difference between child born to mother with mass media exposure and no exposure). Difference in measles vaccination status is also pronounced by place of delivery (17.2 difference between health facility delivery and delivery elsewhere). The concentration index, which is a composite measure of inequality encompassing all wealth quintiles, increased to 0.198 (0.132–0.266) in 2016 from 0.184 (0.119–0.249) in 2009–2010 for measles vaccination coverage, reflecting an increase in pro–rich inequality. Our study found that a large number of children from rural areas, from Ermera and Covalima districts, from poorest households, with parents having no education, with mother not exposed to mass media, with mother having had less than four ANC visits, born in non-health facilities, and with mothers having had no PNC visit were not vaccinated with the measles vaccine. The study from the multivariate analysis identified that coverage of measles vaccines was significantly higher among children with mothers with secondary education, and all three indicators of maternal and child health care utilization. Furthermore, measles vaccine coverage was also found to higher among children with mothers who were exposed to mass media at least once a week. Those not vaccinated were associated with decreasing level of father education, mother having had less than four ANC visits, mother currently working and mother with no PNC visit within two months of delivery. Conclusions The study showed that the coverage of routine measles vaccination is at lower rate. The coverage was significantly lowest in Ermera district in the latest years. Findings from the latest DHS of 2016 revealed that the coverage of full dose of DTP vaccination was significantly associated with education of father and number of ANC and PNC visits. Likewise, measles vaccination coverage was associated with household wealth quintile, household size, education of father, ANC visit and PNC visit. The findings of the study recommend that special attention should be given to districts with higher rate of not vaccinated children, particularly Covalina, Dili and Ainaro. Since partial DTP vaccination has increased significantly over the years, eventually hindering the coverage of full vaccination, our findings highlight the need of the programme to boost full vaccination coverage in Timor-Leste. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 1 1. Introduction The Democratic Republic of Timor-Leste emerged as a sovereign state after being governed by Portugal for more than 400 years followed by 24 years of occupation by the Republic of Indonesia. Two decades of conflict and resistance over the restoration of independence that happened in 2002 cost the lives of hundreds of thousands of the East Timorese people and the largescale destruction of infrastructure including health facilities (1). However, the turmoil did not end with independence, as Timor-Leste endured internal political conflict in 2006 that caused further loss of infrastructure and the displacement of approximately 15% of the country’s population (2). Despite these challenges, Timor-Leste is one of only five countries in the WHO South-East Asia (SEA) Region to have eliminated measles and one in six countries in the Region to control rubella ahead of the 2023 target (3). Going back in history, immunization services were first introduced in Timor-Leste during the time of Indonesian occupation. In the beginning bacille Calmette–Guérin (vaccine) (BCG), diphtheria-tetanus-pertussis (DTP), oral polio vaccine (OPV) and measles vaccines were offered under the corpus of the immunization services. It was reported that routine immunization coverage was high during the 1990s, but this noticeably declined from late 1998 to the end of Indonesian occupation in 1999. From 1995 to 1998, reported coverage was close to universal for BCG, more than 80% for DTP3 and nearly 90% for measles. From July 1998 to July 1999, the reported coverage dropped to 63.5% for BCG, 55.6% for DTP3 and 55.1% for measles. It must also be mentioned here that immunization services were disrupted during the time when Timor-Leste had been fighting for its independence from Indonesia. It was only in March 2000, during the period of administration of the United Nations Integrated Mission in East Timor (UNTEAT), that immunization services were re-established. However, there were not many health facilities in operation and trained health staff (4). The new nation began the process of rebuilding health infrastructure, and started expanding community-based health services and training health-related manpower. The routine immunization services were re-initiated, and provided the same vaccination package that was being offered during the period of Indonesian occupation – BCG, DTP, OPV and measles. In 2007 hepatitis B (HepB) vaccine was added to the DTP regimen and introduced as tetravalent DTP-HepB vaccine. In 2012, Haemophilus influenzae type b vaccine was added to the tetravalent package and introduced as the pentavalent DTP-HepB-Hib vaccine. From 2016, the single dose of measles vaccine was replaced by two doses of measles-rubella (MR) vaccine, HepB vaccine was introduced as a standalone vaccine to be given at birth, the inactivated polio vaccine and a fourth dose of DTP vaccine was given at 18 months, and a diphtheria-tetanus (DT) booster dose to be administered at the age of six years was added to the schedule (5). Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys2 Since 2000, Timor-Leste redoubled its commitment to improve vaccination coverage. The number of children receiving full vaccination (one dose of BCG, three doses of DTP and OPV each, and one dose of measles) increased from 18% to 53% between 2003 and 2009–2010, but remained almost unchanged between 2009–2010 and 2016 (6,7). The Timor-Leste Demographic and Health Survey (TLDHS) 2016 showed that 49% of the children aged 12–23 months were vaccinated with all basic vaccinations at some point prior to the survey, 62% had received the third dose of DTP (DTP3) and 69% the first dose of measles-containing vaccine (MCV1) (7). Coverage for the same year reported through the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) joint reporting form (JRF) was 79% for DTP3 and 76% for MCV1 (5). Although Timor-Leste has achieved measles elimination status through successive supplementary immunization activities (SIAs), the low coverage rate for measles vaccine may endanger the sustainability of the achievement. Additionally, there are huge discrepancies in vaccination coverage within the country, and so it is important to understand the factors that are leading to these differences. This study intends to identify those reasons that are playing a part in partial vaccination and lack of vaccination of children aged 12–23 months with DTP3 and MCV1 in Timor-Leste. Although a number of studies have reported findings on child full immunization, none of them have generated evidence about the sociodemographic factors associated with administering measles-containing vaccines separately among children aged 12–23 months. This study thus sought to capture the immunization status of children, particularly focusing on measles vaccine, using the two latest country-representative Demographic and Health Survey (DHS) datasets. The main objective of this study is to review the characteristics and factors associated with measles vaccination in Timor-Leste. The specific objectives of the study are to: (1) determine the characteristics of caretakers of children vaccinated with measles- containing vaccines and their trends across years; (2) determine the significance of change and association among variables comparing vaccination status of children for measles-containing vaccines; (3) carry out the immunization equity analysis for measles vaccination; and (4) estimate the national and regional projections for coverage of measles vaccine for the years 2019, 2020 and 2021. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 3 2. Methods 2.1 Data source The data used for the analysis are from Demographic and Health Survey (DHS). The study sample consisted of the children surveyed in the 2016 DHS and 2009–2010 DHS in Timor-Leste. The DHS surveys are cross-sectional, nationally representative household surveys that collect reliable data on health and nutrition, health services utilization, health knowledge and behaviours, maternal and child health, fertility, family planning, etc. The sample for the survey was selected independently in every stratum through a two-stage selection process, to provide estimates for each of the 13 districts and for both urban and rural areas of the country. Households were selected randomly within the selected clusters. The target groups for the 2016 DHS and 2009–2010 DHS were ever-married women aged 15–49 years who reside in randomly selected households across the country. They provided detailed information about their children under the age of 5 years. The 2016 and 2009–2010 DHS survey report with full details of methodology and general findings has already been published. This report presents further analysis of data on the measles vaccination of children aged 12–23 months from these two DHS. The reference made to measles vaccination or vaccination throughout the document refers to vaccination with first dose of measles-containing vaccine and will have to be interpreted accordingly. 2.2 Variables Our outcome variable was measles (vaccinated and not vaccinated). The age group of children we used for analysis was 12–23 months. The source of information on these vaccinations comes from the vaccination card shown by the mothers to interviewers and the recall of the mother. The independent variables of the study were: (1) Geographical characteristics: (I) place of residence (urban or rural), (ii) subnational zones (division); (2) Demographic characteristics: (i) sex of child, (ii) age of mother, (iii) household wealth quintile, (iv) household size, (v) birth order; (3) Parental education and mass media exposure: (i) education of mother, (ii) education of father, (iii) mass media exposure of mother; (4) Parental occupation: (i) mother’s current working status; and (5) Maternal and child health care utilization: (i) at least four ANC visits, (ii) place of delivery, (iii) postnatal visits (within two months). Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys4 2.3 Statistical analyses We calculated estimates of overall prevalence and the trends of the independent variables of measles vaccine. The association between outcome variables and covariates for both years were presented using chi-square test. We also assessed the significant changes in the distribution of all variables from these two DHS. For this analysis, data from the recent (2016) and last (2009–2010) DHS were retabulated and difference between the years was tested for statistical significance using a Z-test disaggregated by different covariates. Similarly, multiple logistic regression for both years was used to show the effect of covariates on the outcomes of interest. P-value <0.05 and 95% confidence interval was used to show the level of significance for the regression model. Before gauging the final model, the collinearity effect among the variables was checked. For the equity analysis, we calculated rate differences (highest–lowest) as absolute measures of inequality and rate ratios (highest/lowest) as relative measures of inequality. The rate ratio is unitless and independent of average levels and scale, whereas the rate difference depends on both average levels and scale. These two commonly used measures of inequality are easy to understand, but comparisons are limited to two extreme groups rather than covering the full population spectrum. Reporting both absolute and relative measures of inequality is recommended to increase transparency, reduce systematic reporting biases, and improve the evidence base for policies aimed at reducing health inequalities. These were presented among all the selected variables in the study. Furthermore, concentration index and concentration curve were used to identify whether socioeconomic inequality exists in receipt of measles-containing vaccines by the children. Sample weights were included during the estimations of rates and “svy” command was applied in STATA 15.0 version to account for the complex sampling design of the DHS. 2.4 Ethical review DHS survey protocols undergo ethical review in the United States of America with ICF’s institutional review board. Informed consent was obtained from every respondent. De-identified data is available upon request from the DHS programme (https://www. dhsprogram.com/data/available-datasets.cfm). Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 5 3. Results 3.1 Sociodemographic characteristics of children used for analysis Table 1 shows the percentage distribution, by sociodemographic characteristics, of children aged 12–23 months in the two consecutive DHS in Timor-Leste. This study is limited to data collected about children who were 12–23 months of age at the time of the survey, resulting in a final sample of 1456 in 2016 and 1752 in 2009–2010. The table shows that there are some changes in sociodemographic structure among children between the two surveys. There is a slight increase in the proportion of children residing in urban areas. In both surveys, the highest number of children were from Dili district, and this number had considerably increased in 2016. There has been no change in the proportion of children by their sex although the number of male children was slightly higher than female children in both surveys. The number of mothers aged 25–34 years has increased over time (from 46% to 53%). The proportion of households with the lowest wealth quintile has reduced, increasing the number of such at the fourth and highest wealth quintiles. While 72% of the children in 2009–2010 lived in a household with six or more members, in 2016 this rate reduced slightly to 66%. The proportion of children who were the first-born child has increased while that of children of the birth order of 4+ has notably reduced. The proportion of mothers having no education has suggestively decreased over 10 years (23% in 2016 vs 33% in 2009–2010). Half of the mothers (50%) in 2016 had completed secondary level of education and 10% had completed higher education by the time of the interview, while this rate was only 38% and 2% respectively in 2009–2010. Similar to mothers, the number of fathers having higher education has also increased over time (from 6% to 16%). The exposure of mothers to the mass media has slightly improved. Proportion of mothers who had worked in the previous 12 months has increased to 67% from 60%. Though the occurrence of at least four ANC visits and health facility delivery has improved over time, that of PNC visits has reduced drastically. In 2016, a total of 77% of the mothers had had all four ANC visits, 52% had delivered in a health facility and 20% had attended PNC visits within two months of giving birth. This in 2009–2010 was at 56%, 22% and 40% respectively. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys6 Table 1. Sociodemographic characteristics of children aged 12–23 months between two consecutive surveys, Timor-Leste DHS 2009-2016 Characteristics 2016 DHS 2009–2010 DHS N % 95% CI N % 95% CI Total 1 456 100 1 752 100 Geographical characteristics Place of residence Urban 405 27.8 [22.6, 33.6] 424 24.2 [20.0, 29.0] Rural 1 051 72.2 [66.4, 77.4] 1 328 75.8 [71.0, 80.0] District Aileu 59 4.1 [2.8, 5.8] 66 3.8 [2.7, 5.4] Ainaro 73 5.0 [3.5, 7.3] 113 6.4 [4.7, 8.8] Baucau 168 11.6 [8.1, 16.2] 180 10.3 [7.2, 14.4] Bobonaro 121 8.3 [5.8, 11.8] 157 9.0 [6.3, 12.6] Covalima 99 6.8 [4.4, 10.5] 69 4.0 [2.7, 5.7] Dili 323 22.2 [17.0, 28.4] 281 16.0 [12.2, 20.8] Ermera 127 8.7 [6.3, 12.0] 200 11.4 [8.2, 15.7] Lautem 78 5.4 [3.7, 7.7] 140 8.0 [5.6, 11.4] Liquica 89 6.1 [4.4, 8.5] 106 6.0 [4.3, 8.4] Manatuto 58 4.0 [2.6, 6.0] 87 5.0 [3.5, 7.0] Munafahi 80 5.5 [3.8, 7.9] 80 4.6 [3.1, 6.6] SAR of Oecussi 87 6.0 [4.2, 8.5] 143 8.2 [5.7, 11.5] Viqueque 93 6.4 [4.3, 9.3] 130 7.4 [5.4, 10.2] Demographic characteristics Sex of the child Male 742 51.0 [47.7, 54.2] 894 51.0 [48.5, 53.5] Female 714 49.0 [45.8, 52.3] 859 49.0 [46.5, 51.5] Age of mother 15–19 years 51 3.5 [2.5, 4.8] 41 2.3 [1.7, 3.1] 20–24 years 335 23.0 [20.5, 25.8] 392 22.4 [20.0, 24.9] 25–34 years 778 53.4 [50.6, 56.3] 797 45.5 [42.8, 48.2] 35–49 years 292 20.0 [17.6, 22.7] 522 29.8 [27.6, 32.2] Household wealth quintile Lowest 268 18.4 [15.5, 21.7] 381 21.7 [19.1, 24.6] Second 301 20.6 [18.0, 23.5] 359 20.5 [18.4, 22.7] Middle 285 19.6 [17.2, 22.2] 349 19.9 [17.8, 22.3] Fourth 324 22.3 [19.7, 25.1] 346 19.7 [17.5, 22.2] Highest 278 19.1 [15.7, 23.0] 317 18.1 [15.0, 21.7] Household size 1–3 69 4.7 [3.5, 6.3] 69 3.9 [3.0, 5.1] 4–5 421 28.9 [25.9, 32.1] 416 23.8 [21.2, 26.5] 6+ 966 66.4 [62.8, 69.7] 1 267 72.3 [69.4, 75.0] Birth order 1 376 25.8 [23.3, 28.5] 325 18.5 [16.6, 20.7] 2–3 537 36.9 [34.1, 39.7] 503 28.7 [26.5, 31.0] 4+ 543 37.3 [34.6, 40.1] 924 52.8 [50.1, 55.4] Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 7 Characteristics 2016 DHS 2009–2010 DHS N % 95% CI N % 95% CI Parental education and mass media exposure Education of mother No education 336 23.1 [20.2, 26.2] 571 32.6 [29.6, 35.7] Primary 252 17.3 [14.9, 20.0] 478 27.3 [24.9, 29.7] Secondary 726 49.9 [46.6, 53.1] 661 37.7 [34.7, 40.9] Higher 143 9.8 [7.8, 12.2] 43 2.4 [1.6, 3.7] Education of father No Education 327 23.0 [20.1, 26.2] 475 27.2 [24.5, 29.9] Primary 258 18.2 [15.8, 20.9] 474 27.1 [24.9, 29.4] Secondary 608 42.8 [39.3, 46.3] 702 40.2 [37.3, 43.1] Higher 227 16.0 [13.2, 19.1] 98 5.6 [4.3, 7.2] Mass media exposure of mother Not at all 538 37.0 [33.3, 40.7] 914 53.0 [49.6, 56.3] At least once a week 347 23.8 [21.1, 26.7] 348 20.2 [17.7, 22.8] Less than once a week 571 39.2 [36.0, 42.6] 463 26.9 [24.1, 29.8] Parental occupation Respondent currently working No 977 67.1 [63.6, 70.4] 1 045 59.6 [56.2, 63.0] Yes 479 32.9 [29.6, 36.4] 707 40.4 [37.0, 43.8] Maternal and child health care utilization At least 4 antenatal care visits No 299 22.6 [19.5, 26.1] 708 43.8 [40.6, 47.0] Yes 1 023 77.4 [73.9, 80.5] 908 56.2 [53.0, 59.4] Place of delivery Elsewhere 704 48.4 [44.3, 52.5] 1 360 77.6 [74.3, 80.6] Health facility 751 51.6 [47.5, 55.7] 393 22.4 [19.4, 25.7] Postnatal care visit (within 2 months) No 1 054 79.8 [76.7, 82.5] 759 60.5 [56.6, 64.2] Yes 267 20.2 [17.5, 23.3] 496 39.5 [35.8, 43.4] 3.2 National and subnational trends in status of measles vaccination coverage Fig. 1 and Table 2 shows the trends in status of measles vaccination coverage at the national and state level between surveys in 2015–2016 and 2005–2006. There are no changes in the proportion of children aged 12–23 months who were vaccinated with measles over a five-year period. Table 2 shows that there is an increment in the proportion of children receiving the measles vaccine in some of the districts including Aileu, Ainaor, Baucau, Liquica and Manatuto. Other districts, on the other hand, showed a reduction in measles vaccination coverage. These districts included Covalima, Bobonaro, Lautem and the Special Administrative Region (SAR) of Oecussi. Districts such as Dili, Ermera, Munafahi and Viqueque showed small variations between 2009–2010 and 2016. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys8 Fig. 1. Trends in status of measles full vaccination coverage among children aged 12–23 months 69.3 67.9 0 10 20 30 40 50 60 70 80 90 100 2016 2009-10 Pe rc en t Table 2. National and subnational trends in status of measles vaccination coverage among children aged 12–23 months between two consecutive surveys, Timor-Leste DHS 2009–2016 Characteristics 2016 DHS 2009–2010 DHS Fully vaccinated Not vaccinated Fully vaccinated Not vaccinated % 95% CI % 95% CI % 95% CI % 95% CI National 69.3 [66.0, 72.5] 30.7 [27.5, 34.0] 67.9 [64.5, 71.0] 32.1 [29.0, 35.5] District Aileu 89.7 [80.7, 94.8] 10.3 [5.2, 19.3] 83.3 [76.0, 88.6] 16.7 [11.4, 24.0] Ainaro 62.1 [51.4, 71.7] 37.9 [28.3, 48.6] 50.4 [38.1, 62.7] 49.6 [37.3, 61.9] Baucau 79.6 [68.9, 87.3] 20.4 [12.7, 31.1] 52.4 [41.8, 62.8] 47.6 [37.2, 58.2] Bobonaro 65.5 [57.4, 72.8] 34.5 [27.2, 42.6] 79.8 [71.3, 86.3] 20.2 [13.7, 28.7] Covalima 59.3 [40.6, 75.6] 40.7 [24.4, 59.4] 79.7 [70.3, 86.7] 20.3 [13.3, 29.7] Dili 74.5 [67.9, 80.2] 25.5 [19.8, 32.1] 73.3 [64.3, 80.8] 26.7 [19.2, 35.7] Ermera 52.5 [38.2, 66.3] 47.5 [33.7, 61.8] 54.2 [41.3, 66.6] 45.8 [33.4, 58.7] Lautem 65.5 [53.5, 75.8] 34.5 [24.2, 46.5] 80.1 [70.3, 87.3] 19.9 [12.7, 29.7] Liquica 70.1 [59.2, 79.1] 29.9 [20.9, 40.8] 66.3 [55.1, 75.9] 33.7 [24.1, 44.9] Manatuto 74.2 [63.7, 82.5] 25.8 [17.5, 36.3] 64.9 [53.2, 75.0] 35.1 [25.0, 46.8] Munafahi 67.5 [54.2, 78.5] 32.5 [21.5, 45.8] 68.4 [58.3, 77.0] 31.6 [23.0, 41.7] SAR of oecussi 68.7 [55.7, 79.3] 31.3 [20.7, 44.3] 74.8 [63.0, 83.8] 25.2 [16.2, 37.0] Viqueque 65.8 [55.8, 74.6] 34.2 [25.4, 44.2] 66.8 [56.3, 75.8] 33.2 [24.2, 43.7] 3.3 Factors associated with measles vaccination status in 2016 and 2009–2010 Table 3 shows the results from the bivariate analysis on measles vaccination coverage in the 2016 and 2009–2010 surveys. Measles vaccination coverage among children aged 12–23 months in the 2015–2016 survey differed significantly by place of residence, district, household wealth quintile, parental education, mass media exposure of mother and all three indicators of maternal and child health care utilization. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 9 The 2009–2010 DHS also showed that measles vaccination coverage differed significantly by place of residence, district, age of mother, household wealth quintile, parental education, mass media exposure and all three indicators of maternal and child health utilization. In the 2016 survey, the measles vaccination coverage was higher in urban areas compared with rural areas (74% vs 68%). By district, Aileu had the highest measles vaccination coverage (90%) and Ermera the lowest (53%). The measles vaccination coverage significantly increases with the increasing level of household wealth quintile. Education of both mothers and fathers was related to the measles vaccination coverage of their children. With higher levels of parental education, we observed higher levels of measles vaccination coverage – 59% among mothers having no education to 82% among mothers with higher education and 57% among fathers having no education to 77% among those with higher education. Measles coverage was also associated with mass media exposure of mother. Furthermore, measles vaccination coverage was found to be higher among children whose mothers had had four or more ANC visits compared to those with less than four ANC visits (76% vs 50%), who had delivery in a health facility over those delivered outside of facilities (78% vs 61%), and among those children who had a postnatal care (PNC) visit within two months of birth (82%) than their counterparts who did not have such a PNC visit (67%). Similar to 2016, in the 2009–2010 survey too the measles vaccination coverage was higher in urban areas compared with rural (74% vs 66%). By district, the proportion of children receiving the measles vaccine was highest in Aileu (83%) and lowest in Ainaro (50%). Mothers in the age group of 20–24 years had the highest coverage and mothers in the age group of 35–49 years had the lowest coverage of measles vaccination for their children. The proportion of children receiving measles vaccination was significantly higher among the fourth quintile group compared with the lowest quintile group (78% vs 54%). Higher proportions of children whose parents had a higher level of education had received the measles vaccine compared with those who had no education. Measles coverage was lowest for children whose mothers had no mass media exposure compared with those whose mothers had at least once-a-week exposure or less than once-a-week exposure. Furthermore, measles vaccine coverage was found to be higher among children whose mothers had had four or more ANC visits compared with children whose mothers had less than four ANC visits (77% vs 57%), among children of those mothers delivering in facilities than those born outside of facilities (80% vs 64%) and among children who had a postnatal care (PNC) visit within two months of birth (81%) than their counterparts who did not (53%). Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys10 3.4 Equity gap in measles vaccination Table 3 also shows the inequality in measles vaccination status indicators presenting: rate difference (absolute inequality), rate ratio (relative inequality), and the relative concentration index. Absolute inequalities in measles vaccination based on rate differences in 2016 In Timor-Leste, differences in measles vaccination coverage are most pronounced for district (37.2 percentage point difference between Aileu and Ermera), ANC visit (25.7 difference between at least four ANC visits and less than four ANC visits), household wealth quintile (23.8 percentage point difference between the highest and lowest quintile), parental education (23.6 percentage point difference between child born to mother with no education and to higher education and 19.5 percentage point difference between child born to father with no education and higher education). Differences in measles vaccination status are also relatively stark for mass media exposure of the mother (18 percentage point difference between mothers who were exposed to mass media at least once a week and those not exposed at all), place of delivery (17.2 percentage point difference between children born in a health facility and those born elsewhere), household size (14.9 percentage point difference between households having 1–3 members and households having 6+ members), and PNC visits (14.7 difference between mother having PNC visit within two months of delivery and mothers not having such a visit). Absolute differences in measles vaccination coverage are not very pronounced for place of residence, sex of child, age of mother, birth order and current working status of mother (Table 3). Relative inequalities in measles vaccination based on rate ratios in 2016 Overall, relative inequalities in measles vaccination status shows the greatest inequalities by district (1.7 percentage points between Aileu and Ermera) and ANC visit of mother (1.5 percentage points for mother having at least four ANC visits compared with mother having less than four ANC visits). The relative inequalities were also higher for household wealth quintile and education of mother (1.4 percentage points for children from the lowest quintile compared to those from the highest quintile and for children born to mother with no education compared with mother with higher education). The relative inequalities were 1.3 by education of father, household size, mass media exposure of mother and place of delivery. Age of mother and PNC visit showed inequalities of 1.2 while place of residence and birth order showed relative inequalities of 1.1. Relative inequalities were not present for male versus female children and currently working mother versus not working mother (Table 3). Inequalities changes over time in measles vaccination Only a small decrease was observed in the absolute inequalities in measles vaccination from 2009–2010 to 2016 in some of the covariates. The absolute inequalities decreased to 14.7% from 28.2% by PNC visit and to 23.6% from 31.7% by education of mother. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 11 Other covariates such as place of residence, sex of child, age of mother, household wealth quintile, mass media exposure of mother and birth order showed a nominal decrease. On the other hand, covariates such as district, household size, ANC visit, place of delivery, mother’s current working status and education of father showed small increments in absolute inequalities over time (Table 3). The concentration index, which is a composite measure of inequality encompassing all wealth quintiles, increased to 0.198 (0.132–0.2665) in 2016 from 0.184 (0.119–0.249) in 2009–2010, reflecting a very nominal increase in pro-rich inequality (Table 3). Table 3. Measles vaccination coverage status among children aged 12–23 months by selected sociodemographic characteristics between two consecutive surveys, Timor-Leste DHS 2009–2016 Characteristics* 2016 DHS 2009–2010 DHS Vaccinated % Not vaccinated % P-value Vaccinated% Not vaccinated % P-value Total 69.3 30.7 67.9 32.1 Geographical characteristics Place of residence Urban 74.2 25.8 0.045 74.3 25.7 0.021 Rural 67.5 32.5 65.8 34.2 Rate difference 6.7 6.7 na 8.5 8.5 na Rate ratio 1.1 1.3 na 1.1 1.3 na District Aileu 89.7 10.3 0.002 83.3 16.7 0.000 Ainaro 62.1 37.9 50.4 49.6 Baucau 79.6 20.4 52.4 47.6 Bobonaro 65.5 34.5 79.8 20.2 Covalima 59.3 40.7 79.7 20.3 Dili 74.5 25.5 73.3 26.7 Ermera 52.5 47.5 54.2 45.8 Lautem 65.5 34.5 80.1 19.9 Liquica 70.1 29.9 66.3 33.7 Manatuto 74.2 25.8 64.9 35.1 Munafahi 67.5 32.5 68.4 31.6 SAR of Oecussi 68.7 31.3 74.8 25.2 Viqueque 65.8 34.2 66.8 33.2 Rate difference 37.2 37.2 na 32.9 32.9 na Rate ratio 1.7 4.6 na 1.7 3.0 na Demographic characteristics Sex of the child Male 68.3 31.7 0.482 69.2 30.8 0.277 Female 70.4 29.6 66.5 33.5 Rate difference 2.1 2.1 na 2.7 2.7 na Rate ratio 1.0 1.1 na 1.0 1.1 na Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys12 Characteristics* 2016 DHS 2009–2010 DHS Vaccinated % Not vaccinated % P-value Vaccinated% Not vaccinated % P-value Age of mother 15–19 years 60.3 39.7 0.422 57.5 42.5 0.011 20–24 years 69.6 30.4 70.8 29.2 25–34 years 70.8 29.2 70.4 29.6 35–49 years 66.5 33.5 62.6 37.4 Rate difference 10.5 10.5 na 13.3 13.3 na Rate ratio 1.2 1.4 na 1.2 1.5 na Household wealth quintile Lowest 54.4 45.6 0.000 53.9 46.1 0.000 Second 61.2 38.8 63.7 36.3 Middle 74.8 25.2 71.0 29.0 Fourth 76.7 23.3 78.0 22.0 Highest 78.2 21.8 74.7 25.3 Rate difference 23.8 23.8 na 24.1 24.1 na Rate ratio 1.4 2.1 na 1.4 2.1 na Household size 1–3 55.5 44.5 0.152 75.6 24.4 0.1384–5 70.4 29.6 71.3 28.7 6+ 69.9 30.1 66.3 33.7 Rate difference 14.9 14.9 na 9.3 9.3 na Rate ratio 1.3 1.5 na 1.1 1.4 na Birth order 1 71.1 28.9 0.396 70.7 29.3 0.1442–3 70.8 29.2 70.2 29.8 4+ 66.7 33.3 65.6 34.4 Rate difference 4.4 4.4 na 5.1 5.1 na Rate ratio 1.1 1.2 na 1.1 1.2 na Parental education and mass media exposure Education of mother No education 58.8 41.2 0.000 58.8 41.2 0.000 Primary 71.8 28.2 67.1 32.9 Secondary 70.8 29.2 74.8 25.2 Higher 82.4 17.6 90.5 9.5 Rate difference 23.6 23.6 na 31.7 31.7 na Rate ratio 1.4 2.3 na 1.5 4.3 na Education of father No education 57.1 42.9 0.000 57.1 42.9 0.000 Primary 67.5 32.5 65.8 34.2 Secondary 73.6 26.4 75.6 24.4 Higher 76.6 23.4 76.9 23.1 Rate difference 19.5 19.5 na 19.8 19.8 na Rate ratio 1.3 1.8 na 1.3 1.9 na Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 13 Characteristics* 2016 DHS 2009–2010 DHS Vaccinated % Not vaccinated % P-value Vaccinated% Not vaccinated % P-value Mass media exposure of mother Not at all 58.8 41.2 0.000 60.3 39.7 0.000 At least once a week 76.8 23.2 69.6 30.4 Less than once a week 74.7 25.3 80.6 19.4 Rate difference 18.0 18.0 na 20.3 20.3 na Rate ratio 1.3 1.8 na 1.3 2.0 na Parental occupation Respondent currently working No 70.3 29.7 0.323 67.2 32.8 0.543 Yes 67.3 32.7 68.8 31.2 Rate difference 3.0 3.0 na 1.6 1.6 na Rate ratio 1.0 1.1 na 1.0 1.1 na Maternal and child health care utilization At least 4 antenatal care visits No 50.4 49.6 0.000 56.7 43.3 0.000 Yes 76.1 23.9 76.5 23.5 Rate difference 25.7 25.7 na 19.8 19.8 na Rate ratio 1.5 2.1 na 1.3 1.8 na Place of delivery Elsewhere 60.5 39.5 0.000 64.3 35.7 0.000 Health facility 77.7 22.3 80.3 19.7 Rate difference 17.2 17.2 na 16.0 16.0 na Rate ratio 1.3 1.8 na 1.2 1.8 na Postnatal care visit (within 2 months) No 67.4 32.6 0.000 53.2 46.8 0.000 Yes 82.1 17.9 81.4 18.6 Rate difference 14.7 14.7 na 28.2 28.2 na Rate ratio 1.2 1.8 na 1.5 2.5 na Concentration index (95% CI) 0.198 [0.132, 0.265] na 0.184 [0.119, 0.249] na *In each survey, the groups with the highest and lowest measles coverage will be used to calculate rate differences and rate ratios for equity analysis; P-value obtained from non-parametric chi-square test. Concentration curves The study used a concentration curve to identify whether socioeconomic inequality exists in measles vaccination and to examine whether it is more pronounced at one point than another. The analyses showed that there has been a nominal increase in measles vaccination in the last five years by pro-rich inequality. The findings from the indices agree with the results of the concentration curves in the two surveys, showing that not vaccinated children are concentrated in poor households. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys14 Fig. 1. Concentration curves: 2016 2009–2010 3.5 Trends affecting measles vaccination status by different covariates Table 4 shows the trend of measles vaccination coverage by different covariates. The measles vaccination coverage showed no changes by all covariates except by district, mass media exposure of mother and PNC visit. The measles vaccine coverage was the same over the five-year period (68% in 2009–2010 and 69% in 2016). By district, a significant reduction in the measles vaccine coverage was noticed in Covalima, Bobonaro and Lautem. On the other hand, Baucau showed a significant increment in measles vaccination coverage over the same period. Measles vaccination coverage was also found to have increased among children whose mothers had no PNC visit while it has reduced significantly among children who mothers had less than once-a-week exposure to mass media. Table 4. Significant differences of different covariates on measles vaccination coverage of children aged 12–23 months between two consecutive surveys, Timor-Leste DHS 2009–2016 Characteristics Vaccinated Not vaccinated 2016 DHS 2011 DHS P– value 2016 DHS 2011 DHS P– value% 95% CI % 95% CI % 95% CI % 95% CI Total 69.3 [66.0, 72.5] 30.7 [27.5, 34.0] 0.395 67.9 [64.5, 71.0] 32.1 [29.0, 35.5] 0.395 Geographical characteristics Place of residence Urban 74.2 [68.8, 79.0] 25.8 [21.0, 31.2] 0.974 74.3 [68.1, 79.6] 25.7 [20.4, 31.9] 0.974 Rural 67.5 [63.4, 71.3] 32.5 [28.7, 36.6] 0.383 65.8 [61.9, 69.5] 34.2 [30.5, 38.1] 0.383 Provinces Aileu 89.7 [80.7, 94.8] 10.3 [5.2, 19.3] 0.299 83.3 [76.0, 88.6] 16.7 [11.4, 24.0] 0.299 Ainaro 62.1 [51.4, 71.7] 37.9 [28.3, 48.6] 0.117 50.4 [38.1, 62.7] 49.6 [37.3, 61.9] 0.117 Baucau 79.6 [68.9, 87.3] 20.4 [12.7, 31.1] 0.000 52.4 [41.8, 62.8] 47.6 [37.2, 58.2] 0.000 Bobonaro 65.5 [57.4, 72.8] 34.5 [27.2, 42.6] 0.007 79.8 [71.3, 86.3] 20.2 [13.7, 28.7] 0.007 Covalima 59.3 [40.6, 75.6] 40.7 [24.4, 59.4] 0.005 79.7 [70.3, 86.7] 20.3 [13.3, 29.7] 0.005 Dili 74.5 [67.9, 80.2] 25.5 [19.8, 32.1] 0.738 73.3 [64.3, 80.8] 26.7 [19.2, 35.7] 0.738 Ermera 52.5 [38.2, 66.3] 47.5 [33.7, 61.8] 0.764 54.2 [41.3, 66.6] 45.8 [33.4, 58.7] 0.764 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 15 Characteristics Vaccinated Not vaccinated 2016 DHS 2011 DHS P– value 2016 DHS 2011 DHS P– value% 95% CI % 95% CI % 95% CI % 95% CI Lautem 65.5 [53.5, 75.8] 34.5 [24.2, 46.5] 0.017 80.1 [70.3, 87.3] 19.9 [12.7, 29.7] 0.017 Liquica 70.1 [59.2, 79.1] 29.9 [20.9, 40.8] 0.571 66.3 [55.1, 75.9] 33.7 [24.1, 44.9] 0.571 Manatuto 74.2 [63.7, 82.5] 25.8 [17.5, 36.3] 0.237 64.9 [53.2, 75.0] 35.1 [25.0, 46.8] 0.237 Munafahi 67.5 [54.2, 78.5] 32.5 [21.5, 45.8] 0.903 68.4 [58.3, 77.0] 31.6 [23.0, 41.7] 0.903 SAR of Oecussi 68.7 [55.7, 79.3] 31.3 [20.7, 44.3] 0.315 74.8 [63.0, 83.8] 25.2 [16.2, 37.0] 0.315 Viqueque 65.8 [55.8, 74.6] 34.2 [25.4, 44.2] 0.876 66.8 [56.3, 75.8] 33.2 [24.2, 43.7] 0.876 Demographic characteristics Sex of the child Male 68.3 [64.1, 72.3] 31.7 [27.7, 35.9] 0.696 69.2 [65.0, 73.0] 30.8 [27.0, 35.0] 0.696 Female 70.4 [65.6, 74.7] 29.6 [25.3, 34.4] 0.098 66.5 [62.4, 70.4] 33.5 [29.6, 37.6] 0.098 Age of mother 15–19 years 60.3 [43.1, 75.2] 39.7 [24.8, 56.9] 0.786 57.5 [42.4, 71.4] 42.5 [28.6, 57.6] 0.786 20–24 years 69.6 [63.7, 75.0] 30.4 [25.0, 36.3] 1.000 70.8 [65.0, 76.1] 29.2 [23.9, 35.0] 1.000 25–34 years 70.8 [66.6, 74.8] 29.2 [25.2, 33.4] 0.700 70.4 [66.3, 74.1] 29.6 [25.9, 33.7] 0.700 35–49 years 66.5 [59.5, 72.9] 33.5 [27.1, 40.5] 0.035 62.6 [57.4, 67.5] 37.4 [32.5, 42.6] 0.035 Household wealth quintile Lowest 54.4 [46.8, 61.8] 45.6 [38.2, 53.2] 0.900 53.9 [47.8, 60.0] 46.1 [40.0, 52.2] 0.900 Second 61.2 [54.1, 67.9] 38.8 [32.1, 45.9] 0.509 63.7 [57.6, 69.3] 36.3 [30.7, 42.4] 0.509 Middle 74.8 [68.7, 80.0] 25.2 [20.0, 31.3] 0.285 71.0 [65.5, 76.0] 29.0 [24.0, 34.5] 0.285 Fourth 76.7 [71.2, 81.5] 23.3 [18.5, 28.8] 0.688 78.0 [72.4, 82.8] 22.0 [17.2, 27.6] 0.688 Highest 78.2 [71.7, 83.6] 21.8 [16.4, 28.3] 0.316 74.7 [67.6, 80.7] 25.3 [19.3, 32.4] 0.316 Household size 1–3 55.5 [40.4, 69.7] 44.5 [30.3, 59.6] 0.013 75.6 [61.9, 85.5] 24.4 [14.5, 38.1] 0.013 4–5 70.4 [64.0, 76.0] 29.6 [24.0, 36.0] 0.775 71.3 [65.4, 76.5] 28.7 [23.5, 34.6] 0.775 6+ 69.9 [66.0, 73.5] 30.1 [26.5, 34.0] 0.071 66.3 [62.6, 69.8] 33.7 [30.2, 37.4] 0.071 Birth order 1 71.1 [64.9, 76.6] 28.9 [23.4, 35.1] 0.907 70.7 [64.4, 76.3] 29.3 [23.7, 35.6] 0.907 2–3 70.8 [65.9, 75.2] 29.2 [24.8, 34.1] 0.832 70.2 [65.3, 74.7] 29.8 [25.3, 34.7] 0.832 4+ 66.7 [61.2, 71.8] 33.3 [28.2, 38.8] 0.668 65.6 [61.4, 69.5] 34.4 [30.5, 38.6] 0.668 Parental education and mass media exposure Education of mother No education 58.8 [51.5, 65.7] 41.2 [34.3, 48.5] 1.000 58.8 [53.3, 64.1] 41.2 [35.9, 46.7] 1.000 Primary 71.8 [64.9, 77.8] 28.2 [22.2, 35.1] 0.193 67.1 [61.6, 72.2] 32.9 [27.8, 38.4] 0.193 Secondary 70.8 [66.3, 74.9] 29.2 [25.1, 33.7] 0.095 74.8 [70.2, 78.8] 25.2 [21.2, 29.8] 0.095 Higher 82.4 [73.7, 88.7] 17.6 [11.3, 26.3] 0.201 90.5 [70.5, 97.4] 9.5 [2.6, 29.5] 0.201 Education of father No education 57.1 [49.8, 64.0] 42.9 [36.0, 50.2] 1.000 57.1 [51.1, 62.8] 42.9 [37.2, 48.9] 1.000 Primary 67.5 [60.5, 73.9] 32.5 [26.1, 39.5] 0.642 65.8 [60.7, 70.5] 34.2 [29.5, 39.3] 0.642 Some secondary 73.6 [69.0, 77.8] 26.4 [22.2, 31.0] 0.406 75.6 [71.5, 79.2] 24.4 [20.8, 28.5] 0.406 Secondary and above 76.6 [68.8, 82.9] 23.4 [17.1, 31.2] 0.953 76.9 [64.8, 85.8] 23.1 [14.2, 35.2] 0.953 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys16 Characteristics Vaccinated Not vaccinated 2016 DHS 2011 DHS P– value 2016 DHS 2011 DHS P– value% 95% CI % 95% CI % 95% CI % 95% CI Mass media exposure of mother Not at all 58.8 [53.2, 64.2] 41.2 [35.8, 46.8] 0.574 60.3 [55.8, 64.6] 39.7 [35.4, 44.2] 0.574 Less than once a week 76.8 [70.5, 82.1] 23.2 [17.9, 29.5] 0.032 69.6 [64.0, 74.6] 30.4 [25.4, 36.0] 0.032 At least once a week 74.7 [69.8, 79.0] 25.3 [21.0, 30.2] 0.024 80.6 [75.8, 84.6] 19.4 [15.4, 24.2] 0.024 Parental occupation Respondent currently working No 70.3 [66.2, 74.2] 29.7 [25.8, 33.8] 0.133 67.2 [63.4, 70.8] 32.8 [29.2, 36.6] 0.133 Yes 67.3 [62.3, 71.9] 32.7 [28.1, 37.7] 0.586 68.8 [64.1, 73.1] 31.2 [26.9, 35.9] 0.586 Maternal and child health care utilization At least 4 antenatal care visits No 50.4 [43.2, 57.6] 49.6 [42.4, 56.8] 0.067 56.7 [51.8, 61.5] 43.3 [38.5, 48.2] 0.067 Yes 76.1 [72.6, 79.4] 23.9 [20.6, 27.4] 0.837 76.5 [72.5, 80.0] 23.5 [20.0, 27.5] 0.837 Place of delivery Elsewhere 60.5 [55.8, 65.0] 39.5 [35.0, 44.2] 0.090 64.3 [60.4, 67.9] 35.7 [32.1, 39.6] 0.090 Health facility 77.7 [73.6, 81.4] 22.3 [18.6, 26.4] 0.309 80.3 [74.6, 85.1] 19.7 [14.9, 25.4] 0.309 Postnatal care visit (within 2 months) No 67.4 [63.6, 71.0] 32.6 [29.0, 36.4] 0.000 53.2 [48.2, 58.1] 46.8 [41.9, 51.8] 0.000 Yes 82.1 [76.2, 86.7] 17.9 [13.3, 23.8] 0.812 81.4 [77.1, 85.1] 18.6 [14.9, 22.9] 0.812 Note: All estimates account for weighting and complex sample design. Figures in parentheses are based on 25–49 sample size and the estimate should be interpreted with caution. Sample size may vary slightly due to missing data. P-value obtained from Z-test for significance of change. 3.6 Effects of covariates on measles vaccination coverage In the adjusted model (Table 5), in the 2016 DHS, the likelihood of children not receiving the measles vaccine was significantly higher in all districts compared with Aileu district. Children from the highest wealth quintile (AOR = 2.1) and fourth and middle quintiles (AOR = 2.0 each) showed higher odds of measles vaccination coverage than those from the lowest quintile. The odds of receiving the measles vaccine were higher for children from household sizes of 4–5 members (AOR = 2.2, P <0.05) and among fathers with secondary-level educated (AOR = 1.6, 95% CI = 1.1–2.4, P <0.05) compared with those children whose fathers had received no education. The findings also showed that children whose mothers had had less than four ANC visits, who did not deliver in a health facility and who did not have a PNC visit within two months of delivery were more likely to remain not vaccinated for measles compared with their counterparts whose mothers had had four or more ANC visits, who delivered in health facility and who had the PNC visit. Children whose mothers were currently working, on the other hand, showed lower odds of receiving measles vaccination. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 17 In 2009–2010 DHS, the likelihood of receiving measles vaccine was significantly lower in rural areas compared with urban areas. Children in all districts compared with Aileu showed the lowest odds of receiving the measles vaccine. Mothers in the age group of 20–24 years had the highest odds of measles vaccine coverage than the other age groups. Children in the fourth wealth quintiles had significantly highest odds of being vaccinated for measles. It was observed that the odds of measles vaccination were higher for children of fathers with secondary-level education compared with those of fathers with no education. The odds of not being vaccinated for measles were lower among children whose mothers were exposed to the mass media, who had had four or more ANC visits and who had a PNC visit within two months of delivery than their counterparts. Table 5. Factors affecting measles vaccination status among children aged 12–23 months between two consecutive surveys, Timor-Leste, DHS 2009–2016 Characteristics 2016 DHS 2009–2010 DHS Vaccinated Not vaccinated Vaccinated Not vaccinated AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Total 1.0 0.2–4.6 1.0 0.2–5.1 1.5 0.4–6.1 0.7 0.2–2.6 Geographical characteristics Place of residence Urban ref. ref. ref. ref. Rural 1.3 0.8–2.0 0.8 0.5–1.2 0.6* 0.4–0.9 1.7* 1.1–2.6 District Aileu ref. ref. ref. ref. Ainaro 0.2** 0.1–0.7 4.4** 1.5–12.8 0.1*** 0.0–0.2 9.2*** 4.1–20.8 Baucau 0.3* 0.1–0.8 3.7* 1.3–10.5 0.2*** 0.1–0.4 5.8*** 2.4–13.9 Bobonaro 0.2*** 0.1–0.4 6.2*** 2.3–17.2 0.5 0.2–1.1 2.1 0.9–4.6 Covalima 0.1*** 0.0–0.4 8.7*** 2.7–27.4 0.2*** 0.1–0.4 6.1*** 2.6–14.4 Dili 0.2*** 0.1–0.5 6.0*** 2.2–16.5 0.3* 0.1–0.8 3.1* 1.2–8.2 Ermera 0.2** 0.1–0.6 4.9** 1.7–13.6 0.1*** 0.0–0.2 9.3*** 4.2–20.7 Lautem 0.1*** 0.0–0.4 7.4*** 2.7–20.1 0.5 0.2–1.4 1.9 0.7–5.0 Liquica 0.3* 0.1–0.7 3.9* 1.3–11.4 0.2*** 0.1–0.4 5.8*** 2.4–13.8 Manatuto 0.2** 0.1–0.6 4.8** 1.7–13.1 0.1*** 0.0–0.3 9.1*** 3.9–21.0 Munafahi 0.3* 0.1–0.7 3.9* 1.4–10.9 0.3** 0.1–0.7 3.3** 1.4–7.4 SAR of Oecussi 0.2** 0.1–0.7 4.7** 1.5–14.8 0.2*** 0.1–0.5 5.0*** 2.1–12.0 Viqueque 0.2*** 0.1–0.5 5.2*** 2.0–13.5 0.5 0.2–1.1 2.0 0.9–4.3 Demographic characteristics Sex of the child Male ref. ref. ref. ref. Female 1.2 0.9–1.6 0.8 0.6–1.2 0.8 0.6–1.1 1.2 0.9–1.6 Age of mother 15–19 years ref. ref. ref. ref. 20–24 years 0.8 0.4–1.8 1.2 0.5–2.7 2.7* 1.1–6.7 0.4* 0.2–0.9 25–34 years 0.9 0.4–1.9 1.2 0.5–2.5 2.4 0.9–6.7 0.4 0.1–1.1 35–49 years 0.7 0.3–1.8 1.4 0.6–3.3 2.2 0.8–6.3 0.5 0.2–1.3 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys18 Characteristics 2016 DHS 2009–2010 DHS Vaccinated Not vaccinated Vaccinated Not vaccinated AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Household wealth quintile Lowest ref. ref. ref. ref. Second 1.2 0.7–1.9 0.8 0.5–1.4 1.3 0.9–1.9 0.8 0.5–1.1 Middle 2.0** 1.2–3.2 0.5** 0.3–0.8 1.5 1.0–2.4 0.7 0.4–1.0 Fourth 2.0* 1.1–3.5 0.5* 0.3–0.9 1.8* 1.1–3.0 0.5* 0.3–0.9 Highest 2.1* 1.0–4.3 0.5* 0.2–1.0 1.0 0.5–1.8 1.1 0.5–2.0 Household size 1–3 ref. ref. ref. ref. 4–5 2.2* 1.0–4.5 0.5* 0.2–1.0 0.7 0.3–1.7 1.4 0.6–3.5 6+ 2.0 0.9–4.2 0.5 0.2–1.1 0.7 0.3–1.6 1.4 0.6–3.3 Birth order 1 ref. ref. ref. ref. 2–3 1.0 0.6–1.7 1.0 0.6–1.6 1.2 0.7–2.1 0.8 0.5–1.4 4+ 1.0 0.6–1.8 1.0 0.5–1.7 1.1 0.6–2.2 0.9 0.5–1.8 Parental education and mass media exposure Education of mother No education ref. ref. ref. ref. Primary 1.4 0.9–2.3 0.7 0.4–1.1 0.8 0.6–1.2 1.2 0.8–1.7 Secondary 0.9 0.6–1.4 1.1 0.7–1.8 0.9 0.6–1.4 1.1 0.7–1.7 Higher 1.7 0.7–3.9 0.6 0.3–1.4 Education of father No education ref. ref. ref. ref. Primary 1.3 0.8–2.1 0.8 0.5–1.2 1.3 0.9–1.9 0.8 0.5–1.1 Secondary 1.6* 1.1–2.4 0.6* 0.4–0.9 1.9** 1.3–2.8 0.5** 0.4–0.8 Higher 1.6 0.8–3.2 0.6 0.3–1.3 1.4 0.5–4.1 0.7 0.2–2.0 Mass media exposure of mother Not at all ref. ref. ref. ref. At least once a week 1.3 0.7–2.2 0.8 0.5–1.4 1.0 0.6–1.5 1.0 0.7–1.6 Less than once a week 1.2 0.8–1.9 0.8 0.5–1.3 2.0** 1.3–3.1 0.5** 0.3–0.8 Parental occupation Respondent currently working No ref. ref. ref. ref. Yes 0.6** 0.4–0.9 1.6** 1.1–2.3 1.2 0.9–1.6 0.8 0.6–1.1 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 19 Characteristics 2016 DHS 2009–2010 DHS Vaccinated Not vaccinated Vaccinated Not vaccinated AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Maternal and child health care utilization At least 4 antenatal care visits No ref. ref. ref. ref. Yes 2.5*** 1.7–3.8 0.4*** 0.3–0.6 1.7*** 1.2–2.4 0.6*** 0.4–0.8 Place of delivery Elsewhere ref. ref. ref. ref. Health facility 1.5* 1.0–2.2 0.7* 0.5–1.0 Postnatal care visit (within 2 months) No ref. ref. ref. ref. Yes 2.3*** 1.5–3.5 0.4*** 0.3–0.7 5.4*** 3.7–7.8 0.2*** 0.1–0.3 *P <0.05, **P <0.001, ***P <0.0001, AOR: adjusted odds ratio, ref.: reference category; P-value obtained from t-statistic Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys20 4. Discussions Timor-Leste is falling behind in achieving the targets set by the Global Vaccine Action Plan (GVAP) of 90% national coverage for all vaccines that are part of national programmes (8). However, estimates of national DTP3 coverage by WHO and UNICEF for the same period goes beyond our results and shows an increasing trend (5,8,9). The data gap between two results could have been because of difference in source of data. Likewise, Timor-Leste had progressed to eliminate measles in 2018 but had stagnant MCV1 coverage over the five-year period between DHS surveys. Timor-Leste had the second lowest MCV1 coverage in the SEA Region as of 2016 (9). But MCV1 coverage was 7% higher than DTP3 coverage. This points towards missed opportunities for vaccination (MOV), as children coming in contact with the health system for their first dose of measles vaccine could have been vaccinated for earlier missed vaccines. Similar circumstances were also reported by Acharya et al. in Nepal (10). Anyie et al. reported that insufficient knowledge of immunization practices among health workers, unavailability of vaccines and malfunctioning of the cold chain equipment were reasons for MOV in Timor-Leste (11). Thus, it is important for a country such as Timor-Leste that is working towards progressive achievements in immunization that no opportunity to increase coverage is missed. Children dropping out from the measles vaccination regimen increased significantly in both rural and urban areas between 2010 and 2016 and children living in rural areas were more at risk of not being vaccinated for DTP. Rural–urban inequalities in the provision of vaccination were pronounced in Indonesia as well (12). However, a study by KC et al. in Nepal did not find any inequalities based on the urban/rural divide (13). Nevertheless, when comparing our results with those of other studies, it must be pointed out that those studies took into account full vaccination coverage and our study only analysed coverage of two individual vaccines, DTP and MCV1. Subnational variation in the proportion of children not vaccinated for measles were stark. The highest burden of partially vaccinated and not vaccinated children for measles could be seen in Ainaro, Covalima and Ermera districts. Furthermore, children not vaccinated for measles increased significantly in Covalima district while it decreased significantly in Baucau district over the five-year period. The significant decrease in the number of not vaccinated children in Baucau could be because of the Immunization Proteje Labarik (IPL) project (2011–2013). This USAID-funded project directly targeted seven districts to increase overall DTP3 and MCV1 coverage in Timor-Leste, and Baucau was one of the seven (14). This result upholds the need to replicate or devise similar projects. Reducing inequalities and ensuring health and well-being is one of the targets of the Sustainable Development Goals (SDGs), but the prevailing wealth inequality in vaccine coverage can preclude the achievement of the SDGs (15). MCV1 coverage in Timor-Leste was pro-rich, signifying that the richest had the highest possibility of completing their Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys 21 vaccine schedules. And that the utmost burden of not vaccinated children belonged to the lowest wealth quintile. Pro-rich inequality in vaccine coverage is common in low- and middle-income countries and this is also demonstrated by results of other studies (10,16–20). Furthermore, DTP non-compliance among children from between the second and fourth quintiles increased significantly in the past five years, which already saw a substantial proportion of not vaccinated children. It has already been realized that re-emergence of vaccine-preventable diseases (VPDs) is very possible in countries that had once eliminated them if coverage cannot be achieved or maintained at the highest proportion, unless the disease has been eliminated from the rest of the world (21,22). Thus, the country should realize that providing vaccines free of cost is not enough to address wealth disparity, and that it should make vaccines more accessible. If child cannot reach the vaccine, then the vaccine should be made to reach the child. The mother who did not receive services from the health facilities during her pregnancy, childbirth and/or post-childbirth was more likely to avoid childhood immunization as evidenced from other studies (20,23–27). Essentially, ANC is considered as the first point of contact of women with the health facility, which gives skilled professionals an opportunity to educate and engage with women. It also plays a central role in the continuum of care. But, if women did not seek care for themselves, the chances that they would seek immunization for their children are less. Thus, if a nation seeks to reduce the burden of not vaccinated children and increase full vaccination, it should direct its efforts towards bringing pregnant women to the health facilities and secure their trust in the services so that they continue to seek services for themselves and their children in the facilities. Educated mothers are pivotal to the better health of the child. As the number of years of education received by the mother increases, child mortality decreases (28). Likewise, mother’s education plays a significant role in the child’s vaccination status. The result of our study also pointed out that as the level of mother’s education improved, the number of children not vaccinated for measles declined significantly. A similar conclusion was reached by other studies (23,29–33). Not only that, the probability of the child with zero-dose measles vaccine increased with a decrease in father’s educational level. A study conducted in six countries with the highest gap in measles coverage also showed positive and significant correlation between father’s education and the likelihood of the child being vaccinated irrespective of mother’s education (34). Similarly, mothers who were not exposed to the mass media (watch TV, listen to the radio or read the newspaper) had lower chances of vaccinating their children; this result is consistent with what has been found in previous studies (18,19,35). It can be concluded that parents with no/lower education are not so keen to complete vaccination for their children. Thus, education and mass media can be used to encourage the people of Timor-Leste to complete the vaccination schedule for their children. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys22 5. Conclusion The study shows that the coverage of measles vaccination is suboptimal and that there is the presence of disparities over the coverage of measles vaccine among children aged 12–23 months across districts in Timor-Leste. The analysis shows that MCV coverage was significantly lowest in Ermera district in the latest years. Findings from the latest DHS (2016) revealed that measles vaccination coverage was associated with household wealth quintile, household size, education of father, ANC visit and PNC visit. Therefore, to achieve maximum coverage with measles vaccination, it is required to address the issues hindering these vaccinations. The findings of the study recommend that special attention should be given to districts with a higher rate of not vaccinated children, particularly Covalina, Dili and Ainaro. 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Coverage and factors associated with full immunisation among children aged 12–59 months in Bangladesh: insights from the nationwide cross-sectional demographic and health survey. BMJ Open. 2019;9:e028020. 9 789290 228776 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Timor-Leste: Analysis from two recent demographic and health surveys This document presents analysis of two most recent demographic and health surveys from Timor-Leste. The document has made an attempt to identify trend and factors resulting in zero-dose vaccination status of children for measles-containing vaccine to help policy makers and program implementers to design interventions accordingly.