Socioeconomic and residence-based related inequality in childhood vaccination in Sub-Saharan Africa: Evidence from Benin, Health Science Reports, Avril 2023

Socioeconomic and residence-based related inequality in childhood vaccination in Sub-Saharan Africa: Evidence from Benin, Health Science Reports, Avril 2023

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Auteurs : Eugene Budu, Bright O. Ahinkorah, Wilfried Guets, Edward K. Ameyaw, Mainprice A. Essuman, Sanni Yaya

Site de publication : Health Science Reports

Type de publication : Rapport

Date de publication : Avril 2023

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Childhood vaccination remains a cost-effective strategy that has aided to control and eliminate numerous diseases. Since the beginning of the 20th century, numerous vaccine-preventable diseases (VPDs) have been prevented or even eradicated in many countries through vaccination. Vaccination resulted in the eradication of wild-type poliovirus in the Americas in 1990, the Western Pacific Region in 2000, and Europe in 2002, as well as the eradication of Hemophilus influenza type B in many countries within a few years of conjugate Hib vaccine introduction. Measles, polio, and diphtheria−tetanus−pertussis vaccinations saved the lives of nearly 2.5 million children globally in the first decade of the 21st century. Since 1924, 103 million instances of pediatric illnesses have been averted in the United States, with 26 million cases in the last decade. In the United States, the number of instances of diphtheria, measles, paralytic poliomyelitis, and rubella decreased by more than 99% during the time before and after national vaccination recommendations. Mumps, pertussis, and tetanus cases decreased by more than 92%, while mortality decreased by 99% or more. In Benin, pediatric bacterial meningitis is reported to have declined between 6.5% in 2012 to 1.0% in 2016 due to the introduction of the pneumococcal conjugate (PCV).

Although coverage of new vaccines increased exponentially in low- and middle-income countries (LMICs) between 2000 and 2019, progress on expanding routine vaccination services to reach all children has stalled, and coverage levels in many countries remain below the 90% national coverage recommended by the World Health Organization. In a review published in 2012 based on surveys dating back to 2007, 10% of all children living in LMICs were not vaccinated. Given that vaccination is one of the most cost-effective methods for averting child mortality globally,  this estimate was a startling discovery.

Consequently, some vaccine-preventable illnesses such as measles, mumps, and pertussis have resurfaced and constitute a public health burden. This re-emergence has been connected in part to reduced vaccination coverage among children, especially in Sub-Saharan Africa. In LMICs, VPDs still constitute substantial causes of under-five morbidity and mortality and are also associated with social and economic consequences. There are still significant incidences of child mortality among regions, within nations, and across countries. Sub-Saharan Africa has the highest under-five mortality rate in the world, accounting for 52% of all mortalities in this age range. In 2018, the region’s average under-five mortality rate was 78 deaths per 1000 live births.

Many factors have been marked as impeding vaccination coverage. Among these are reduced public confidence, and other social factors such as education and socioeconomic factors. There also exist reports of inequalities in vaccine coverage. This discrepancy between LMICs can be narrowed if all children, regardless of their geographic, socioeconomic, or demographic makeup, have equitable access to vaccination and its associated benefits. This is not always the case, since many children in various countries are either under-vaccinated or unvaccinated. As a result, vaccine-preventable illnesses continue to be a cause of morbidity and mortality in many LMICs. To avoid VPD epidemics, prompt and high vaccination coverage devoid of inequalities is critical as herd immunity occurs from an under-vaccinated and vulnerable population.

There are still significant incidences of child mortality among regions, within nations, and across countries

Inequality refers to the observed differences in coverage between different populations. Measuring and tracking these disparities might aid in the development of health treatments that give priority to the most vulnerable groups. In countries like Benin, it is reported that the achievement of full vaccination among infants remains a challenge due to inadequate maternal healthcare utilization possibly due to sociodemographic and socioeconomic inequalities and other factors. The study further reports religion, level of education, wealth, and place of residence as significant factors impeding full vaccination among infants. In another study, inequality in zero-dose children was reported to be highest in Benin in a cohort of 25 Sub-Saharan African countries. However, there exists scant information on trends and determinants of inequalities associated with access to childhood vaccination among Beninese. Thus, the factors impeding full vaccination in Benin need to be explored.

A study of 21 national surveys conducted between 2000 and 2013 found that diphtheria−pertussis−tetanus vaccination coverage decreased with time in four countries, including Benin, however these analyses did not explore the influence of family wealth. To this end, this study examined the pattern of wealth and residence-based related inequality in vaccination coverage through an equity lens, focusing on the direction of inequality in vaccination coverage in Benin, using nationally-representative data. The study also assesses the factors influencing the enormous socioeconomic and sociodemographic disparities in child vaccination coverage among Beninese. The findings of the present study would aid policymakers in developing equity-focused vaccination strategies. This might also explain why some vaccination initiatives are more or less effective in reducing inequality in various circumstances.


On the prevalence of childhood vaccination, it was evident that 58.0% of children who were larger than average at birth were vaccinated. Similarly, vaccination was profound among children who were products of single birth (91.1%) and those who were born through vaginal birth (94.2%). The analysis showed that 52.5% of male children, a greater proportion of those whose mothers had 4 or more ANC visits (58.1%) as well as those who had no PNC (77.8%) received the vaccination. Childhood vaccination dominated among children whose mothers reported that distance to the health facility was not a big problem (67.0%), children born in health facilities (93.7%), and children whose mothers were aged 25−29 (33.2%). In the same vein, vaccination was high among children of married women (76.4%), children whose mothers were working (85.0%), those whose mothers had media exposure (64.9%), and children of the richest women (20.0%). We also observed high vaccination among children of Fon and related ethnicity (39.4%), those whose mothers reported 4 births (42.6%) and were not educated (59.5%) as well as children of Christian women (55.2%).

Inequality analyses

Childhood vaccination increased with wealth status, such that each increment in wealth status was associated with an increment in the proportion of children who had a vaccination. Clearly, whilst 66% of children from the richest households were vaccinated, less than half of those in the poorest wealth quintile (43%) were vaccinated.

It was evident that concentration in childhood vaccination disfavored children from the poorest households, ethnicity (Bariba, Dendi, Yoa, loka, Betamaribe, Peulh, and related), children whose mothers had multiple births, mothers that reported one to three ANC visits, and for mothers experiencing big problem with the distance to the health facility.

Childhood vaccination dominated among children whose mothers reported that distance to the health facility was not a big problem (67.0%)

The overall rural-urban inequality attributable to variation in childhood and maternal characteristics represented 25.9% (and 74.1% for the difference due to the coefficient). The factors that contributed significantly toward this variation included Richer (6%), mother’s education level (12%), partner’s education level (11%), and four or more ANC visits (25%).


This study investigated the level and determinants of vaccination coverage in Benin and provides evidence of wealth and residence-based inequalities in vaccination coverage. The findings of the present study highlights important issues worth the needed attention in the implementation of vaccination programs in Benin and other places in the world. Although child vaccination remains an important initiative in preventing many diseases, its implementation and success had been hampered by some sociodemographic and socioeconomic factors. As a result, many LMICs continue to experience health-related consequences due to vaccine-preventable illnesses.

The level of vaccination coverage varies between countries and even within the same country and may be related to varying factors. The present study showed that in 2018, approximately 58% of children were reported to have received full vaccination in Benin. Full vaccine coverage reported in the present study was similar to a pooled prevalence of 59.40% in 9 Sub-Saharan African countries and reflects the generally low vaccine coverage in the region. Recent studies have reported full childhood vaccination coverage of 33.3% in Ethiopia, 45.3% in DR Congo, 70.96% in Senegal, and 79.4% in Kenya. Differences in vaccination coverage as observed between Benin and other countries may be a result of differences in vaccine uptake policies, sociodemographic and economic factors, individual beliefs, vaccine education, and access to vaccination services.

Even among the same population of Beninese, we observed disparities in vaccination, and these were associated with several factors. The findings show the presence of significant poor−rich, educated-uneducated, among other differences in the probability of a child being fully vaccinated in Benin. We observed that vaccination coverage was associated with ANC visits, PNC attendance, deliveries in health facilities, and mother’s wealth similar to that observed in other studies. Particularly, the results showed that when compared to children born to mothers in the poorest wealth index, children born to mothers in the richest wealth index are about 40% more likely to receive full vaccination. Similar to the present observation, child vaccination is reported to be high among children born to rich mothers in Ghana and many African countries. Contrary to the report of decreased vaccination among children to highly educated mothers, children born to mothers who are highly educated are likely to be fully vaccinated in Ghana. In India, compared to children born to mothers with no education, children born to mothers with higher education had 2.3 times the odds of being fully vaccinated. This may be attributed to health knowledge of maternal education and vaccination and enhanced health seeking behavior. Maternal education generally has a significant effect on improved child health. These findings point to the need for complementary initiatives to enhance care usage across the care continuum, from reproductive health services to childhood and adolescence.

In 2018, approximately 58% of children were reported to have received full vaccination in Benin

The reasons for under- and non-vaccination may be complex and dependent on many factors. Results from the decomposition analysis suggest that a substantial proportion of the disparities observed in this study may be explained by single birth, falling within the richest wealth quintile, having a mother without formal education, lack of education of the partner, and ANC visits. The majority of the determinants of inequality in vaccination coverage observed in this study may be described and understood using the Socioeconomic Determinants of Health (SDH) report. These have also been recognized in a study conducted by Wiysonge, Uthman to explain low child vaccination coverage in Sub-Saharan Africa. This means that addressing the SDHs – distribution of power, income, products, and services, as well as people’s living conditions, such as access to healthcare, schools and education, working and leisure conditions, and the status of their home and surroundings would lead to significant improvements in vaccination coverage and reduce inequalities associated with it.


Inequality in childhood vaccination which is greatly driven by socioeconomic and sociodemographic variables as noted in Benin, is a cause for health policy concern. Policies aimed to improve child vaccination coverage among mothers in Benin may recognize these inequalities in vaccination coverage. Strategies such as increased availability and accessibility of vaccination as well as improved maternal education, and attention to the less privileged groups could be targeted to address this issue of concern.