The Role of Maternal Education in Advancing Childhood Immunization: An In-Depth Analysis of MICS Data

The Role of Maternal Education in Advancing Childhood Immunization: An In-Depth Analysis of MICS Data | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Maternal Education in Advancing Childhood Immunization: An In-Depth Analysis of MICS Data M A Raoul Mofleh, Dr Saber Perdes This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7034250/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: This study analyses MICS 2022–2023 data to explore the association between maternal and caregiver education levels and immunization coverage among children aged 12–23 months. It will also estimate immunization coverage at national and provincial levels while further identifying factors associated with incomplete immunization and ultimately offering recommendations to enhance immunization service quality in Afghanistan. Study design : Cross-sectional study. Methods: This paper utilizes data from the Multiple Indicator Cluster Survey (MICS) for the period 2022-2023, collected by the Afghanistan National Statistics and Information Authority (NSIA). Data were collected from 23,338 households during the 2022-2023 period. The number of children eligible for interviews was 33,398, and data collection teams successfully collected data from 32,989 children aged 0-59 months (98.8%). The focus of this paper is on data from the immunization of 6,151 children aged 12-23 months, comprising 3,115 males and 3,036 females. Variables related to the individual were age, sex, antigen-specific attributes related to child immunization status, and breastfeeding status. In addition, we have residence area, region, wealth status, and mother's level of education as household attributes. To obtain the unadjusted odds ratio of the predictor variables on the outcome, univariate logistic regression models were performed. Variables that had a P<0.25 were added to the multivariate logistic regression model to assess and calculate the adjusted odds ratio. The likelihood ratio test has been conducted to compare different univariate and multivariate logistic models. A p<0.05 at a 95% confidence interval has been considered statistically significant. Results: At the national level, 28.27% of children 12-23 months who participated in the study received basic immunization. Coverage varies between provinces, with the highest reported in Bamayan at 78% and the lowest reported in Nooristan at 6.8%. Additionally, the crude coverage rates for specific antigens at 23 months are: 45.25% for BCG, 49.57% for Penta1, 41.49% for Polio3, 41.54% for Penta3, and 34.22% for the measles1 vaccine (Table 2). Only 19.7 percent of the poorest group received basic immunization (268/1350), while 39.2 percent of the richest group was covered by basic immunization; the difference was statistically significant (313/799, p < 0.000). The coverage of basic immunization in urban areas was higher (36.1%, 350/969) compared to rural areas (26.8%, 1396/5208); the difference was statistically significant (p < 0.000). A strong relationship was found between mothers' level of education and basic immunization coverage (p = 0.000). The coverage among children whose mothers were uneducated was only 18.0% (945/5251), whereas it was 57.8% (242 out of 419) for children whose mothers had higher education. Additionally, spoken language had a statistically significant relationship with basic immunization (p = 0.000). Coverage among children whose parents spoke Dari was 39.6% (941 out of 1,435), while only 4.4% (7 out of 157) of children whose parents spoke Nuristani received basic immunization. Conclusions: Mothers with primary or higher education had children with significantly higher percentages of receiving basic immunization, after adjusting for extraneous factors such as wealth and urban-rural disparities. Our findings underscore the urgent need to invest in women's education, particularly in rural and marginalized communities, where female education is scarce, as a crucial pathway to enhancing child health outcomes. Maternal Education Childhood immunization Afghanistan predictors of child immunization Immunization Programs/trends Vaccination Vaccination Coverage Vaccine-Preventable Diseases Vaccines 1. Introduction Researchers widely acknowledge that childhood immunization is one of the most impactful public health interventions, significantly improving child health indicators, including a reduction in under-five mortality (Olusegun et al., 2012 ). Additionally, immunization prevents an estimated 2.5 million deaths globally each year and is among the most cost-effective strategies for disease prevention, having averted at least 37 million deaths between 2000 and 2019 (Lindstrand et al., 2021 ) Besides their direct health benefits, immunization programs have indirectly strengthened primary healthcare systems in low—and middle-income countries globally. This results in women's empowerment through improved family health management, which yields substantial social and economic benefits.(Mugali et al., 2017 ). Despite vaccine availability, immunization coverage remains incomplete in many countries. In 2020, only 17.1 million children missed their first dose of the DPT vaccine, with 60% of these children residing in just ten developing nations, including Afghanistan (Kaur, 2023 ). Though global efforts to eradicate polio have made some significant progress, the disease remains endemic in Afghanistan and Pakistan (Mugali et al., 2017 ). MICS surveys reveal that 60% of global deaths in children under five are due to vaccine-preventable diseases(Lindstrand et al., 2021 ) . The World Health Organization initially launched the Expanded Program on Immunization (EPI) in 1974 to control six key vaccine-preventable diseases: diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis (Farzad et al., 2017 ). Since then, EPI has played a critical role in improving child survival and reducing the global burden of diseases ((Wiysonge et al., 2012 ); ). In Afghanistan, the EPI began in 1978 under the name "Mass Immunization Program." Initially, the goal of the EPI program was to achieve universal coverage. However, decades of conflict, particularly during the Taliban regime in the 1990s, severely disrupted immunization services (Afghanistan, 2011–2015). In 2004, DPT3 coverage in Afghanistan was as low as 8% (Newbrander et al., 2014 )The COVID-19 pandemic further impacted immunization globally, with coverage dropping by 10–50% due to widespread social restrictions(Lindstrand et al., 2021 ) . A systematic review conducted in 2021 (Galadima et al., 2021 )Identified both modifiable (e.g., maternal knowledge, attitudes, and self-efficacy) and non-modifiable (e.g., parental demographics and logistical factors) determinants of immunization in Africa. Other studies have shown that girls are more likely to experience partial immunization than boys and that larger families are at higher risk for under-immunization. Since the Taliban gained control in 2021, the de facto government has imposed significant restrictions on women's and girls' rights, including access to education, employment, and freedom of movement ((Qazi Zada & Qazi Zada, 2024 ). These restrictions have led to an increase in mental health issues among women and girls ((Mohammadi et al., 2024 ). They may have far-reaching consequences for public health interventions, including childhood immunization. This study analyses MICS 2022–2023 data to explore the association between maternal and caregiver education levels and immunization coverage among children aged 12–23 months. It will also estimate immunization coverage at national and provincial levels, while further identifying factors associated with incomplete immunization, and ultimately offer recommendations to enhance immunization service quality in Afghanistan. 2. Methodology 2.1. Study design, setting, and sampling procedure This paper utilizes data from the Multiple Indicator Cluster Survey (MICS) for the period 2022–2023, collected by the Afghanistan National Statistics and Information Authority (NSIA). Developed by the United Nations Children’s Fund (UNICEF), MICS is now a global survey program that provides high-quality, reliable, and internationally comparable statistical data on the status of women and children. It helps monitor progress toward national goals and the Sustainable Development Goals. The Afghanistan MICS 2022-23 survey is a cross-sectional, population-based study of Afghan households. UNICEF has employed a multi-stage, stratified cluster sampling design to generate estimates for various indicators related to the situation of women and children at both national and sub-national levels. Urban and rural areas within each province served as the main sampling strata, with census enumeration areas systematically selected within each stratum based on their size. A total of 23,338 households were sampled, with a response rate of 99.8%. Caretakers of all children under the age of five answered questions. Data were collected from 33,398 children aged 0–59 months in 34 provinces across Afghanistan. Districts and villages were randomly chosen. The MICS6 tools were adapted and translated into local languages, such as Dari and Pashto. All team members received a 31-day training session before fieldwork began, and UNICEF and NSIA staff Table 1 Childhood vaccination schedule in Afghanistan, adapted from Afghanistan’s immunization card issued by the Ministry of Public Health of Afghanistan. Table 1 Childhood vaccination schedule in Afghanistan(Mugali et al., 2017 ) SN Age Vaccine 1 Birth (0–11 Months) BCG 2 Birth (as soon as possible within 14 days of life OPV0 3 6 Weeks Pentavalent 1, OPV1 4 10 Weeks Pentavalent 2, OPV2 5 14 Weeks Pentavalent 3, OPV3 6 9 Months Measles, OPV4 7 18 Months Measles 2.2. Study Population Data collection teams collected data from 23,338 households during the 2022–2023 period. The number of children eligible for interviews was 33,398, and data collection teams successfully collected data from 32,989 children aged 0–59 months (98.8%). The focus of this paper is on data from the immunization of 6,151 children aged 12–23 months, comprising 3,115 males and 3,036 females. 2.3 Study Variables Outcome variable : Basic coverage of immunization was our outcome variable. According to UNICEF, a 12–23-month-old child who is immunized against tuberculosis, polio, diphtheria, tetanus, pertussis, and measles can be deemed as immunized with basic immunization (BCG, OPV3, DTP3, and Measles 1) As per Afghanistan's Expanded Program on Immunization (EPI), every child should receive Bacilli Calmette-Guérin (BCG) and Oral Polio Virus (OPV0) within 14 days of life, OPV3 and Diphtheria, Pertussis and Tetanus (DPT3) at 14 weeks, and measles one at 9 months. We treated children missing any of the vaccines included in the UNICEF definition of basic immunization as not having received basic immunization. We generated a composite variable immunization status where 1) was coded as basic immunized and 0) was coded as not basic immunized (Table 2 ). Exposure variables : The MICS under-five children dataset has 437 variables. To answer the hypothesis of this study using the Stata package 18, we retrieved 76 variables related to household, individual, and socioeconomic features of the study participants. Variables related to the individual were age, sex, antigen-specific attributes related to child immunization status, and breastfeeding status. In addition, we have residence area, region, wealth status, and mother's level of education as household attributes. We analysed the data using Stata 18.0. To account for the complex sampling design of the MICS survey, we applied sample weights throughout the entire analysis. To address the issue of missing data, we employed the comprehensive case analysis approach. To test the association between the categorical variables, we use the Pearson chi-square test. The basic immunization variable was labelled zero if the basic immunization was not complete and one if it was full. To obtain the unadjusted odds ratio of the predictor variables on the outcome, we performed univariate logistic regression models. Variables that had a P < 0.25 were added to the multivariate logistic regression model to assess and calculate the adjusted odds ratio. We conducted the likelihood ratio test to compare different univariate and multivariate logistic models and considered a p < 0.05 at a 95% confidence interval statistically significant. 2.5 Ethical consideration: The MICS datasets do not include participants' identities, and we have not attempted to access any information related to them. We have obtained authorization to analyse the MICS 2022-23 from UNICEF, and the Afghanistan National Statistics and Information Authority (NSIA) has ensured ethical compliance during its implementation. Data is freely available on the UNICEF website. Table 2 Description of variables Individual-level variables Age A numeric variable, 0–59 months Dummy (1 = 0–11 months,2 = 12–23 months, 3 = 24–35 months, 4 = 36–47 months, 5 = 48–59 months) Gender Binary (1 for Males, 0 for Females) Breastfeeding status Binary (1 = Yes, 0 No) Household-level variables Area Binary (Urban 1; Rural 0) Region Dummy (1 = North, 0 otherwise 1 = Central, 0 otherwise 1 = South, 0 otherwise) Mother’s education and Father’s education Categorical (1 = No Education, 1 = Primary, 2 = Secondary, 3 = Higher) Wealth quintile Categorical (0 = Poorest, 1 = Poor, 2 = Middle, 3 = Rich, 4 = Richest,) Basic immunization Binary variable (0 = Not Fully Immunized 1 = Fully Immunized 3. Results 3.1 Background characteristics of participants and children The sampled population comprises 15.69% urban areas and 84.31% rural regions. Participants in the survey reported 33,398 children, with 6177 aged 12 to 23 months serving as the primary focus of this study. Notably, the dataset contained no missing data. The weighted sample of children 12–23 months included 6177 children, with a mean age of 17.6 months (standard deviation = 3.37). The gender distribution shows a somewhat more predominant number of boys, accounting for 50.6% (3,115 out of 6,177) of the sample, compared to 49.4% (3,036 out of 6,177) for girls. The mean age of female caregivers was 38.9 years (standard deviation = 10.9). A significant proportion of female caregivers had no formal education, accounting for 80.7% (4964 out of 6,177). Only 8.3% of female caregivers (513/6,177) had a primary education. The number of female caregivers who had secondary and higher education was 8.2% (505 out of 6151) and 2.7% (169 out of 6177), respectively. Less than 16% of the study participants resided in urban areas (966/6,177). The wealth quantile ranged from the poorest to the richest. A large portion of the participants did not have access to radio; the proportion of radio ownership in rural areas was 0.125 (12.5%), and in urban areas, 0.216 (21.6%). More than half of the caregivers (52%, or 3228 out of 6177) presented immunization cards for their children. Six percent of mothers provided both other documents and immunization cards, and 1.2% of caregivers provided only other documents. 3.2 Coverage by Antigen Initially, crude coverage of basic immunization, as defined by UNICEF, was calculated, which includes BCG, polio, diphtheria, tetanus, pertussis, and measles (BCG, OPV3, DTP3, and Measles 1). At the national level, 28.27% of children 12–23 months who participated in the study received basic immunization. Coverage varies between provinces, with the highest reported in Bamayan at 78% and the lowest reported in Nooristan at 6.8%. The crude coverage rates for the various zones are as follows: 39.14% for the central zone, 31.40% for the eastern zone, 28.71% for the northern, eastern zone, 32.73% for the north zone, 31.84 for the western zone, 9.89% for the southern zone, 18.21 for the Southeastern Zone, and 23.06 for the southwestern zone. Additionally, the crude coverage rates for specific antigens at 23 months are: 45.25% for BCG, 49.57% for Penta1, 41.49% for Polio3, 41.54% for Penta3, and 34.22% for the measles1 vaccine (Table 2 ) 3.3 Factors associated with the immunization status of children aged 12–23 months We have examined associations between wealth index, residential area, mothers’ level of Education, and spoken language. Only 19.7 percent of the poorest group received basic immunization (268/1350), while 39.2 percent of the richest group attained basic immunization; the difference was statistically significant (313/799, p < 0.000). The coverage of basic immunization in urban areas was higher (36.1%, 350/969) compared to rural areas (26.8%, 1396/5208); the difference was statistically significant (p < 0.000). We found a strong relationship between mothers’ level of Education and basic immunization coverage (p = 0.000). The coverage among children whose mothers were uneducated was only 18.0% (945/5251), whereas it was 57.8% (242 out of 419) for children whose mothers had higher Education. Additionally, spoken language had a statistically significant relationship with basic immunization (p = 0.000). Coverage among children whose parents spoke Dari was 39.6% (941 out of 1,435), while only 4.4% (7 out of 157) of children whose parents spoke Nuristani received basic immunization. Table 3 presents the associations between selected socioeconomic and demographic factors and the status of basic immunization in children aged 12 to 23 months. We found significant associations between basic immunization coverage and mothers’ level of Education, residence, children’s gender, and parents' financial status. Children living in urban areas had a significantly higher odds ratio (OR) compared to those in rural areas (1.54, 95% CI 1.33–1.77, p < 0.0001). We found a significant relationship between basic immunization coverage and children’s gender (OR = 1.15, 95% CI 1.028–1.281, p = 0.015). The unadjusted OR for mothers with primary (2.67, 95% CI 1.964–2.851, p = 0.000), secondary (2.34, 95% CI 1.823–3.104, p = 0.000), and higher Education (2.84, 95% CI 2.334–3.468, p = 0.000) were significantly higher compared to mothers with no education. Furthermore, it was found that the adjusted odds ratios for the association between basic immunization coverage and mothers’ primary (2.217, 95% CI 1.964–2.851, p = 0.000), secondary (2.109, 95% CI 1.964–2.851, p = 0.000), and higher education levels (2.298, 95% CI 1.964–2.851, p = 0.000) were significantly lower than the unadjusted odds ratios. Table 3 Factors associated with immunization status, aged 12–23 months (n = 6151) Variables Yes No P value Crude Fully immunized (CARD, n = 6151) Number % Number % Age, months Note: 1439 children out of 4431 children who are classified as not immunized with basic immunization were partially immunized. 12–23 months 1746 28.3 4431 71.73 0 Gender Male 927 29.7 2198 70.34 0.0136 Female 819 26.8 2233 73.17 Mothers' level of Education No Education 945 18.0 4,306 82.0 0.000 Primary 310 63.9 175 36.1 Secondary 116 62.9 175 37.9 Higher 242 57.8 177 42.24 Parents' Spoken Language Dari 941 39.6 1,435 60.4 0.0000 Pashto 581 19.7 2,366 80.3 Uzbeki 124 33.9 241 66.1 Turkmani 54 34.9 54 65.1 Nuristani 7 4.46 150 95.54 Balochi 16 55.2 13 44.8 Pashaie 33 22.2 116 77.8 Residence Urban 350 36.1 619 63.9 0.0000 Rural 1396 26.8 3812 73.2 Wealth Status Poorest 268 19.7 1,092 80.3 0.0000 Poor 435 26.3 1,220 73.7 Middle 363 28.4 913 71.6 Rich 353 34.1 684 65.9 Richest 313 39.2 486 60.8 Table 4 Odds ratio (OR) and 95% confidence interval (CI) of socioeconomic and demographic determinants for basic immunization (n = 6151) Variables Crude Adjusted Crude Fully immunized (CARD, n = 6151) Number % OR/CI P_value OR P_value Age, months 12–23 months 1746 28.3 * * 0 * Gender Male 927 29.7 1.15 (1.028–1.281) 0.015 0.884 (0.786–0.987) 0.033 Female 819 26.8 Reference Mothers' level of Education No Education 945 18.0 Reference Primary 310 63.9 2.67 (1.964–2.851) 0.000 2.217 (1.837–2.675) 0.000 Secondary 116 62.9 2.34 (1.823–3.104) 0.000 2.109 (1.608–2.757) 0.000 Higher 242 57.8 2.84 (2.334–3.468) 0.000 2.298 0.000 Residence Urban 350 36.1 1.54 (1.331–1.779) 0.000 1.016 0.033 Rural 1396 26.8 Reference Wealth Status Poorest 268 19.7 Reference 0.0000 Poor 435 26.3 1.406 (1.17–1.679) 0.000 1.392 0.000 Middle 363 28.4 1.595 (1.341–1.899) 0.000 1.517 0.000 Rich 353 34.1 2.095(1.753–2.503) 0.000 1.810 0.000 Richest 313 39.2 2.635 (2.179–3.188) 0.000 2.031 0.000 However, the adjusted odds ratios were significantly higher than those for mothers with no education. However, they remained significantly higher than those for mothers with no education. Additionally, the association between caregivers’ financial status, categorized as poor, middle income, rich, and most decadent, and basic immunization coverage remained statistically significant after adjusting for variables such as a mother's education level, residence, and gender, indicating higher coverage compared to the poorest group. 4. Discussion This study reveals a statistically significant correlation between maternal education level and childhood immunization coverage in Afghanistan. Children whose mothers had any level of formal Education, primary, secondary, or higher, were materially more likely to receive basic immunization compared to those whose mothers had no education. These findings are consistent with previous research in low- and middle-income countries (LMICs), which shows that maternal Education enhances health-seeking behaviours, increases awareness of disease prevention, and improves access to and utilization of healthcare services (Galadima et al., 2021 ; Farzad et al., 2017 ). The adjusted odds ratio (AOR) for children whose mothers had a higher educational level was more than twice that of children whose mothers had no education (AOR = 2.298), reinforcing the notion that educational attainment is a significant determinant of a child's immunization level. This correlation can be attributed to several factors, including better knowledge of vaccination schedules, improved communication skills with healthcare providers, and stronger agency in household decision-making among educated women. Furthermore, we observed significant disparities in immunization coverage across wealth quintiles and between urban and rural areas. The odds of being fully immunized among children of participants in the wealthiest quintile were twice as high as those in the poorest quintile (adjusted odds ratio, AOR = 2.031). This correlation aligns with earlier studies, which indicate that economic capability enhances access to transportation, information, and quality health services (Akseer et al., 2016; Mugali et al., 2017 ). Though initially, urban residence showed a higher crude odds ratio for immunization, its effect diminished after adjusting for Education and wealth, suggesting that these factors mediate the urban-rural divide in immunization access. Meanwhile, children of participants living in the Southern Zone and children of Nuristani-speaking families had a significantly lower immunization coverage. Disparities of this nature may reflect systemic inequities in healthcare access, geographic barriers, cultural norms, or historical neglect of marginalized communities. The current socio-political context, particularly the ongoing restriction of girls’ Education under the Taliban regime, poses a substantial threat to long-term immunization coverage. Suppose fewer women are allowed to access even basic Education. In that case, future generations may witness a further decline in childhood immunization rates, which could reverse the progress made under previous public health initiatives, such as the Expanded Program on Immunization (EPI). 5. Study limitations While this study offers robust national and sub-national insights using a large, representative dataset, several limitations may be possible. A MICS survey is a cross-sectional study in nature, which limits the ability to draw causal inferences between maternal education and immunization outcomes. In the absence of immunization cards, a significant portion of immunization status data relies on caregiver recall, which introduces the potential for recall bias and misclassification influenced by a significant number of other attributes, for example, a mother's knowledge about vaccines, distance to healthcare facilities, and the frequency of healthcare worker outreach. 5. Conclusion The findings of the present study revealed that mothers who have been educated at a primary school level or higher have children with significantly higher percentages of receiving basic immunization after adjusting for extraneous factors such as wealth and urban-rural disparities. Our findings underscore the urgent need to invest in women's education, particularly in rural and marginalized communities, where female education is scarce, as a crucial pathway to enhancing child health outcomes. In the current context of educational restrictions on girls and women, there is a real risk of reversing decades of progress in public health, strengthening outreach, expanding equitable access to immunization services, and safeguarding education opportunities for girls. It must be a central component of any strategy aimed at improving immunization coverage and child survival in Afghanistan. Declarations Author Contribution I, Dr Mir Ahmad Rasoul Mofleh, conceived and designed this study, analyzed the MICS dataset collected by UNICEF, and wrote the attached manuscript. As the sole author, Dr. M. A. Rasoul Mofleh, I am solely responsible for the content and integrity of this work. Acknowledgement I cordially thank UNICEF for authorizing me to analyze the MICS data. Data Availability The datasets analyzed during the current study are available in the UNICEF repository, [https://mics.unicef.org/surveys?page=3]. References Farzad F, Reyer JA, Yamamoto E, Hamajima N. Socio-economic and demographic determinants of full immunization among children of 12–23 months in Afghanistan. Nagoya J Med Sci. 2017;79(2):179. Galadima AN, Zulkefli NAM, Said SM, Ahmad N. Factors influencing childhood immunisation uptake in Africa: a systematic review. BMC Public Health. 2021;21(1):1475. https://doi.org/10.1186/s12889-021-11466-5 . Kaur G. (2023). Routine vaccination coverage—worldwide, 2022. MMWR. Morbidity and mortality weekly report , 72 . Lindstrand A, Cherian T, Chang-Blanc D, Feikin D, O'Brien KL. The World of Immunization: Achievements, Challenges, and Strategic Vision for the Next Decade. J Infect Dis. 2021;224(12 Suppl 2):S452–67. https://doi.org/10.1093/infdis/jiab284 . Mohammadi AQ, Neyazi A, Habibi D, Mehmood Q, Neyazi M, Griffiths MD. (2024). Female education ban by the Taliban: a descriptive survey study on suicidal ideation, mental health, and health-related quality of life among girls in Afghanistan. J Public Health, fdae111. Mugali RR, Mansoor F, Parwiz S, Ahmad F, Safi N, Higgins-Steele A, Varkey S. Improving immunization in Afghanistan: results from a cross-sectional community-based survey to assess routine immunization coverage. BMC Public Health. 2017;17(1):290. https://doi.org/10.1186/s12889-017-4193-z . Newbrander W, Ickx P, Feroz F, Stanekzai H. Afghanistan's basic package of health services: its development and effects on rebuilding the health system. Glob Public Health 9 Suppl. 2014;1(Suppl 1):S6–28. https://doi.org/10.1080/17441692.2014.916735 . Olusegun OL, Ibe RT, Micheal IM. Curbing maternal and child mortality: The Nigerian experience. Int J Nurs Midwifery. 2012;4(3):33–9. Qazi Zada S, Qazi Zada MZ. (2024). The Taliban and women's human rights in Afghanistan: the way forward. Int J Hum Rights, 1–36. Wiysonge CS, Ngcobo NJ, Jeena PM, Madhi SA, Schoub BD, Hawkridge A, Shey MS, Hussey GD. Advances in childhood immunisation in South Africa: where to now? Programme managers’ views and evidence from systematic reviews. BMC Public Health. 2012;12:1–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7034250","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484264200,"identity":"6c8bbecb-2b1e-499f-aad3-69ad13ea27ad","order_by":0,"name":"M A Raoul Mofleh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYFACxocHGBsgrAMfgCQbO0EtzAYwLQwHZ4C0MJOi5TAPWICABt32ZoYDH3fck5dv7zE4bPNrmzwfMwPjh485uLWYnTnMcHDmmWLDDWfOGBzO7btt2MbMwCw5cxseLTfyDxzmbUtg3CCRA9TSc5sRqIWNmRevlmSGw3/bEuznzwBqsey5bU+cFsa2hMSGG0AtDD9uJxLWAvJLb1tC8oYzxwoO9jbcTm5jZmzG75fjzYwPfrYl2M5vb9744Mef2yDGwQ8f8WhBBYxtYLKBWPUg8IcUxaNgFIyCUTBSAAA/OFtnkDxKNgAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"M","middleName":"A Raoul","lastName":"Mofleh","suffix":""},{"id":484264201,"identity":"9f57ed4b-f06a-49b4-bd67-838e5612c046","order_by":1,"name":"Dr Saber Perdes","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr","firstName":"Saber","middleName":"","lastName":"Perdes","suffix":""}],"badges":[],"createdAt":"2025-07-03 05:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7034250/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7034250/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92263950,"identity":"2e9e25ca-4214-45e4-a720-db3d6560b6b0","added_by":"auto","created_at":"2025-09-26 13:08:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":792369,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7034250/v1/057a229a-041f-43d2-9878-30653e4816ef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Role of Maternal Education in Advancing Childhood Immunization: An In-Depth Analysis of MICS Data","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eResearchers widely acknowledge that childhood immunization is one of the most impactful public health interventions, significantly improving child health indicators, including a reduction in under-five mortality (Olusegun et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Additionally, immunization prevents an estimated 2.5\u0026nbsp;million deaths globally each year and is among the most cost-effective strategies for disease prevention, having averted at least 37\u0026nbsp;million deaths between 2000 and 2019 (Lindstrand et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eBesides their direct health benefits, immunization programs have indirectly strengthened primary healthcare systems in low\u0026mdash;and middle-income countries globally. This results in women's empowerment through improved family health management, which yields substantial social and economic benefits.(Mugali et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Despite vaccine availability, immunization coverage remains incomplete in many countries. In 2020, only 17.1\u0026nbsp;million children missed their first dose of the DPT vaccine, with 60% of these children residing in just ten developing nations, including Afghanistan (Kaur, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThough global efforts to eradicate polio have made some significant progress, the disease remains endemic in Afghanistan and Pakistan (Mugali et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). MICS surveys reveal that 60% of global deaths in children under five are due to vaccine-preventable diseases(Lindstrand et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eThe World Health Organization initially launched the Expanded Program on Immunization (EPI) in 1974 to control six key vaccine-preventable diseases: diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis (Farzad et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Since then, EPI has played a critical role in improving child survival and reducing the global burden of diseases ((Wiysonge et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e); ).\u003c/p\u003e\u003cp\u003eIn Afghanistan, the EPI began in 1978 under the name \"Mass Immunization Program.\" Initially, the goal of the EPI program was to achieve universal coverage. However, decades of conflict, particularly during the Taliban regime in the 1990s, severely disrupted immunization services (Afghanistan, 2011\u0026ndash;2015). In 2004, DPT3 coverage in Afghanistan was as low as 8% (Newbrander et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)The COVID-19 pandemic further impacted immunization globally, with coverage dropping by 10\u0026ndash;50% due to widespread social restrictions(Lindstrand et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eA systematic review conducted in 2021 (Galadima et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)Identified both modifiable (e.g., maternal knowledge, attitudes, and self-efficacy) and non-modifiable (e.g., parental demographics and logistical factors) determinants of immunization in Africa. Other studies have shown that girls are more likely to experience partial immunization than boys and that larger families are at higher risk for under-immunization.\u003c/p\u003e\u003cp\u003eSince the Taliban gained control in 2021, the de facto government has imposed significant restrictions on women's and girls' rights, including access to education, employment, and freedom of movement ((Qazi Zada \u0026amp; Qazi Zada, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These restrictions have led to an increase in mental health issues among women and girls ((Mohammadi et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). They may have far-reaching consequences for public health interventions, including childhood immunization.\u003c/p\u003e\u003cp\u003eThis study analyses MICS 2022\u0026ndash;2023 data to explore the association between maternal and caregiver education levels and immunization coverage among children aged 12\u0026ndash;23 months. It will also estimate immunization coverage at national and provincial levels, while further identifying factors associated with incomplete immunization, and ultimately offer recommendations to enhance immunization service quality in Afghanistan.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design, setting, and sampling procedure\u003c/h2\u003e\u003cp\u003eThis paper utilizes data from the Multiple Indicator Cluster Survey (MICS) for the period 2022\u0026ndash;2023, collected by the Afghanistan National Statistics and Information Authority (NSIA). Developed by the United Nations Children\u0026rsquo;s Fund (UNICEF), MICS is now a global survey program that provides high-quality, reliable, and internationally comparable statistical data on the status of women and children. It helps monitor progress toward national goals and the Sustainable Development Goals.\u003c/p\u003e\u003cp\u003eThe Afghanistan MICS 2022-23 survey is a cross-sectional, population-based study of Afghan households. UNICEF has employed a multi-stage, stratified cluster sampling design to generate estimates for various indicators related to the situation of women and children at both national and sub-national levels. Urban and rural areas within each province served as the main sampling strata, with census enumeration areas systematically selected within each stratum based on their size. A total of 23,338 households were sampled, with a response rate of 99.8%. Caretakers of all children under the age of five answered questions.\u003c/p\u003e\u003cp\u003eData were collected from 33,398 children aged 0\u0026ndash;59 months in 34 provinces across Afghanistan. Districts and villages were randomly chosen. The MICS6 tools were adapted and translated into local languages, such as Dari and Pashto. All team members received a 31-day training session before fieldwork began, and UNICEF and NSIA staff\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003cp\u003eChildhood vaccination schedule in Afghanistan, adapted from Afghanistan\u0026rsquo;s immunization card issued by the Ministry of Public Health of Afghanistan.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChildhood vaccination schedule in Afghanistan(Mugali et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVaccine\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBirth (0\u0026ndash;11\u0026nbsp;Months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBCG\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBirth (as soon as possible within 14\u0026nbsp;days of life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOPV0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026nbsp;Weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePentavalent 1, OPV1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026nbsp;Weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePentavalent 2, OPV2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u0026nbsp;Weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePentavalent 3, OPV3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u0026nbsp;Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMeasles, OPV4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026nbsp;Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMeasles\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study Population\u003c/h2\u003e\u003cp\u003eData collection teams collected data from 23,338 households during the 2022\u0026ndash;2023 period. The number of children eligible for interviews was 33,398, and data collection teams successfully collected data from 32,989 children aged 0\u0026ndash;59 months (98.8%). The focus of this paper is on data from the immunization of 6,151 children aged 12\u0026ndash;23 months, comprising 3,115 males and 3,036 females.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Study Variables\u003c/h2\u003e\u003cp\u003e\u003cb\u003eOutcome variable\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eBasic coverage of immunization was our outcome variable. According to UNICEF, a 12\u0026ndash;23-month-old child who is immunized against tuberculosis, polio, diphtheria, tetanus, pertussis, and measles can be deemed as immunized with basic immunization (BCG, OPV3, DTP3, and Measles 1) As per Afghanistan's Expanded Program on Immunization (EPI), every child should receive Bacilli Calmette-Gu\u0026eacute;rin (BCG) and Oral Polio Virus (OPV0) within 14 days of life, OPV3 and Diphtheria, Pertussis and Tetanus (DPT3) at 14 weeks, and measles one at 9 months. We treated children missing any of the vaccines included in the UNICEF definition of basic immunization as not having received basic immunization. We generated a composite variable immunization status where 1) was coded as basic immunized and 0) was coded as not basic immunized (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eExposure variables\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe MICS under-five children dataset has 437 variables. To answer the hypothesis of this study using the Stata package 18, we retrieved 76 variables related to household, individual, and socioeconomic features of the study participants. Variables related to the individual were age, sex, antigen-specific attributes related to child immunization status, and breastfeeding status. In addition, we have residence area, region, wealth status, and mother's level of education as household attributes.\u003c/p\u003e\u003cp\u003eWe analysed the data using Stata 18.0. To account for the complex sampling design of the MICS survey, we applied sample weights throughout the entire analysis. To address the issue of missing data, we employed the comprehensive case analysis approach. To test the association between the categorical variables, we use the Pearson chi-square test. The basic immunization variable was labelled zero if the basic immunization was not complete and one if it was full. To obtain the unadjusted odds ratio of the predictor variables on the outcome, we performed univariate logistic regression models. Variables that had a P\u0026thinsp;\u0026lt;\u0026thinsp;0.25 were added to the multivariate logistic regression model to assess and calculate the adjusted odds ratio. We conducted the likelihood ratio test to compare different univariate and multivariate logistic models and considered a p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 at a 95% confidence interval statistically significant.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethical consideration:\u003c/h2\u003e\u003cp\u003eThe MICS datasets do not include participants' identities, and we have not attempted to access any information related to them. We have obtained authorization to analyse the MICS 2022-23 from UNICEF, and the Afghanistan National Statistics and Information Authority (NSIA) has ensured ethical compliance during its implementation. Data is freely available on the UNICEF website.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescription of variables\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIndividual-level variables\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA numeric variable, 0\u0026ndash;59 months\u003c/p\u003e\u003cp\u003eDummy (1\u0026nbsp;=\u0026nbsp;0\u0026ndash;11 months,2\u0026nbsp;=\u0026nbsp;12\u0026ndash;23 months,\u003c/p\u003e\u003cp\u003e3\u0026nbsp;=\u0026nbsp;24\u0026ndash;35 months, 4\u0026nbsp;=\u0026nbsp;36\u0026ndash;47 months, 5\u0026nbsp;=\u0026nbsp;48\u0026ndash;59 months)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBinary (1 for Males, 0 for Females)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreastfeeding status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBinary (1\u0026nbsp;=\u0026nbsp;Yes, 0 No)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHousehold-level variables\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBinary (Urban 1; Rural 0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDummy (1\u0026nbsp;=\u0026nbsp;North, 0 otherwise\u003c/p\u003e\u003cp\u003e1\u0026nbsp;=\u0026nbsp;Central, 0 otherwise\u003c/p\u003e\u003cp\u003e1\u0026nbsp;=\u0026nbsp;South, 0 otherwise)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother\u0026rsquo;s education and Father\u0026rsquo;s education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategorical (1\u0026nbsp;=\u0026nbsp;No Education, 1\u0026nbsp;=\u0026nbsp;Primary, \u003c/p\u003e\u003cp\u003e2\u0026nbsp;=\u0026nbsp;Secondary, 3\u0026thinsp;=\u0026thinsp;Higher)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWealth quintile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategorical (0\u0026nbsp;=\u0026nbsp;Poorest, 1\u0026nbsp;=\u0026nbsp;Poor, 2\u0026nbsp;=\u0026nbsp;Middle, \u003c/p\u003e\u003cp\u003e3\u0026nbsp;=\u0026nbsp;Rich, 4\u0026nbsp;=\u0026nbsp;Richest,)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasic immunization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBinary variable (0\u0026thinsp;=\u0026thinsp;Not Fully Immunized 1\u0026thinsp;=\u0026thinsp;Fully Immunized\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Background characteristics of participants and children\u003c/h2\u003e\u003cp\u003eThe sampled population comprises 15.69% urban areas and 84.31% rural regions. Participants in the survey reported 33,398 children, with 6177 aged 12 to 23 months serving as the primary focus of this study. Notably, the dataset contained no missing data. The weighted sample of children 12\u0026ndash;23 months included 6177 children, with a mean age of 17.6 months (standard deviation\u0026thinsp;=\u0026thinsp;3.37).\u003c/p\u003e\u003cp\u003eThe gender distribution shows a somewhat more predominant number of boys, accounting for 50.6% (3,115 out of 6,177) of the sample, compared to 49.4% (3,036 out of 6,177) for girls. The mean age of female caregivers was 38.9 years (standard deviation\u0026thinsp;=\u0026thinsp;10.9). A significant proportion of female caregivers had no formal education, accounting for 80.7% (4964 out of 6,177). Only 8.3% of female caregivers (513/6,177) had a primary education. The number of female caregivers who had secondary and higher education was 8.2% (505 out of 6151) and 2.7% (169 out of 6177), respectively.\u003c/p\u003e\u003cp\u003eLess than 16% of the study participants resided in urban areas (966/6,177). The wealth quantile ranged from the poorest to the richest. A large portion of the participants did not have access to radio; the proportion of radio ownership in rural areas was 0.125 (12.5%), and in urban areas, 0.216 (21.6%).\u003c/p\u003e\u003cp\u003eMore than half of the caregivers (52%, or 3228 out of 6177) presented immunization cards for their children. Six percent of mothers provided both other documents and immunization cards, and 1.2% of caregivers provided only other documents.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Coverage by Antigen\u003c/h2\u003e\u003cp\u003eInitially, crude coverage of basic immunization, as defined by UNICEF, was calculated, which includes BCG, polio, diphtheria, tetanus, pertussis, and measles (BCG, OPV3, DTP3, and Measles 1). At the national level, 28.27% of children 12\u0026ndash;23 months who participated in the study received basic immunization. Coverage varies between provinces, with the highest reported in Bamayan at 78% and the lowest reported in Nooristan at 6.8%.\u003c/p\u003e\u003cp\u003eThe crude coverage rates for the various zones are as follows: 39.14% for the central zone, 31.40% for the eastern zone, 28.71% for the northern, eastern zone, 32.73% for the north zone, 31.84 for the western zone, 9.89% for the southern zone, 18.21 for the Southeastern Zone, and 23.06 for the southwestern zone.\u003c/p\u003e\u003cp\u003eAdditionally, the crude coverage rates for specific antigens at 23 months are: 45.25% for BCG, 49.57% for Penta1, 41.49% for Polio3, 41.54% for Penta3, and 34.22% for the measles1 vaccine (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Factors associated with the immunization status of children aged 12\u0026ndash;23 months\u003c/h2\u003e\u003cp\u003eWe have examined associations between wealth index, residential area, mothers\u0026rsquo; level of Education, and spoken language. Only 19.7 percent of the poorest group received basic immunization (268/1350), while 39.2 percent of the richest group attained basic immunization; the difference was statistically significant (313/799, p\u0026thinsp;\u0026lt;\u0026thinsp;0.000). The coverage of basic immunization in urban areas was higher (36.1%, 350/969) compared to rural areas (26.8%, 1396/5208); the difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.000). We found a strong relationship between mothers\u0026rsquo; level of Education and basic immunization coverage (p\u0026thinsp;=\u0026thinsp;0.000). The coverage among children whose mothers were uneducated was only 18.0% (945/5251), whereas it was 57.8% (242 out of 419) for children whose mothers had higher Education. Additionally, spoken language had a statistically significant relationship with basic immunization (p\u0026thinsp;=\u0026thinsp;0.000). Coverage among children whose parents spoke Dari was 39.6% (941 out of 1,435), while only 4.4% (7 out of 157) of children whose parents spoke Nuristani received basic immunization.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the associations between selected socioeconomic and demographic factors and the status of basic immunization in children aged 12 to 23 months. We found significant associations between basic immunization coverage and mothers\u0026rsquo; level of Education, residence, children\u0026rsquo;s gender, and parents' financial status. Children living in urban areas had a significantly higher odds ratio (OR) compared to those in rural areas (1.54, 95% CI 1.33\u0026ndash;1.77, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). We found a significant relationship between basic immunization coverage and children\u0026rsquo;s gender (OR\u0026thinsp;=\u0026thinsp;1.15, 95% CI 1.028\u0026ndash;1.281, p\u0026thinsp;=\u0026thinsp;0.015). The unadjusted OR for mothers with primary (2.67, 95% CI 1.964\u0026ndash;2.851, p\u0026thinsp;=\u0026thinsp;0.000), secondary (2.34, 95% CI 1.823\u0026ndash;3.104, p\u0026thinsp;=\u0026thinsp;0.000), and higher Education (2.84, 95% CI 2.334\u0026ndash;3.468, p\u0026thinsp;=\u0026thinsp;0.000) were significantly higher compared to mothers with no education. Furthermore, it was found that the adjusted odds ratios for the association between basic immunization coverage and mothers\u0026rsquo; primary (2.217, 95% CI 1.964\u0026ndash;2.851, p\u0026thinsp;=\u0026thinsp;0.000), secondary (2.109, 95% CI 1.964\u0026ndash;2.851, p\u0026thinsp;=\u0026thinsp;0.000), and higher education levels (2.298, 95% CI 1.964\u0026ndash;2.851, p\u0026thinsp;=\u0026thinsp;0.000) were significantly lower than the unadjusted odds ratios.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with immunization status, aged 12\u0026ndash;23 months (n\u0026thinsp;=\u0026thinsp;6151)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude Fully immunized (CARD, n\u0026thinsp;=\u0026thinsp;6151)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge, months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eNote: 1439 children out of 4431 children who are classified as not immunized with basic immunization were partially immunized.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;23 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e70.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e819\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMothers' level of Education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4,306\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e310\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParents' Spoken Language\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDari\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e941\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePashto\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e581\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUzbeki\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTurkmani\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNuristani\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBalochi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePashaie\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e350\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e619\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1396\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWealth Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoorest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,092\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e363\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e913\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRich\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e684\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRichest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e486\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOdds ratio (OR) and 95% confidence interval (CI) of socioeconomic and demographic determinants for basic immunization (n\u0026thinsp;=\u0026thinsp;6151)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCrude\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eAdjusted\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude Fully immunized (CARD, n\u0026thinsp;=\u0026thinsp;6151)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR/CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP_value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP_value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge, months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;23 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.15 (1.028\u0026ndash;1.281)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.884 (0.786\u0026ndash;0.987)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e819\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMothers' level of Education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e310\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.67 (1.964\u0026ndash;2.851)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.217 (1.837\u0026ndash;2.675)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.34 (1.823\u0026ndash;3.104)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.109 (1.608\u0026ndash;2.757)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.84 (2.334\u0026ndash;3.468)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e350\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.54 (1.331\u0026ndash;1.779)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1396\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWealth Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoorest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.406 (1.17\u0026ndash;1.679)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e363\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.595 (1.341\u0026ndash;1.899)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.517\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRich\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.095(1.753\u0026ndash;2.503)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.810\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRichest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.635 (2.179\u0026ndash;3.188)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e2.031\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHowever, the adjusted odds ratios were significantly higher than those for mothers with no education. However, they remained significantly higher than those for mothers with no education. Additionally, the association between caregivers\u0026rsquo; financial status, categorized as poor, middle income, rich, and most decadent, and basic immunization coverage remained statistically significant after adjusting for variables such as a mother's education level, residence, and gender, indicating higher coverage compared to the poorest group.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study reveals a statistically significant correlation between maternal education level and childhood immunization coverage in Afghanistan. Children whose mothers had any level of formal Education, primary, secondary, or higher, were materially more likely to receive basic immunization compared to those whose mothers had no education. These findings are consistent with previous research in low- and middle-income countries (LMICs), which shows that maternal Education enhances health-seeking behaviours, increases awareness of disease prevention, and improves access to and utilization of healthcare services (Galadima et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Farzad et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe adjusted odds ratio (AOR) for children whose mothers had a higher educational level was more than twice that of children whose mothers had no education (AOR\u0026thinsp;=\u0026thinsp;2.298), reinforcing the notion that educational attainment is a significant determinant of a child's immunization level.\u003c/p\u003e\u003cp\u003eThis correlation can be attributed to several factors, including better knowledge of vaccination schedules, improved communication skills with healthcare providers, and stronger agency in household decision-making among educated women. Furthermore, we observed significant disparities in immunization coverage across wealth quintiles and between urban and rural areas. The odds of being fully immunized among children of participants in the wealthiest quintile were twice as high as those in the poorest quintile (adjusted odds ratio, AOR\u0026thinsp;=\u0026thinsp;2.031). This correlation aligns with earlier studies, which indicate that economic capability enhances access to transportation, information, and quality health services (Akseer et al., 2016; Mugali et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Though initially, urban residence showed a higher crude odds ratio for immunization, its effect diminished after adjusting for Education and wealth, suggesting that these factors mediate the urban-rural divide in immunization access. Meanwhile, children of participants living in the Southern Zone and children of Nuristani-speaking families had a significantly lower immunization coverage. Disparities of this nature may reflect systemic inequities in healthcare access, geographic barriers, cultural norms, or historical neglect of marginalized communities.\u003c/p\u003e\u003cp\u003eThe current socio-political context, particularly the ongoing restriction of girls\u0026rsquo; Education under the Taliban regime, poses a substantial threat to long-term immunization coverage. Suppose fewer women are allowed to access even basic Education. In that case, future generations may witness a further decline in childhood immunization rates, which could reverse the progress made under previous public health initiatives, such as the Expanded Program on Immunization (EPI).\u003c/p\u003e\n\u003ch3\u003e5. Study limitations\u003c/h3\u003e\n\u003cp\u003eWhile this study offers robust national and sub-national insights using a large, representative dataset, several limitations may be possible. A MICS survey is a cross-sectional study in nature, which limits the ability to draw causal inferences between maternal education and immunization outcomes. In the absence of immunization cards, a significant portion of immunization status data relies on caregiver recall, which introduces the potential for recall bias and misclassification influenced by a significant number of other attributes, for example, a mother's knowledge about vaccines, distance to healthcare facilities, and the frequency of healthcare worker outreach.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe findings of the present study revealed that mothers who have been educated at a primary school level or higher have children with significantly higher percentages of receiving basic immunization after adjusting for extraneous factors such as wealth and urban-rural disparities. Our findings underscore the urgent need to invest in women's education, particularly in rural and marginalized communities, where female education is scarce, as a crucial pathway to enhancing child health outcomes. In the current context of educational restrictions on girls and women, there is a real risk of reversing decades of progress in public health, strengthening outreach, expanding equitable access to immunization services, and safeguarding education opportunities for girls. It must be a central component of any strategy aimed at improving immunization coverage and child survival in Afghanistan.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eI, Dr Mir Ahmad Rasoul Mofleh, conceived and designed this study, analyzed the MICS dataset collected by UNICEF, and wrote the attached manuscript. As the sole author, Dr. M. A. Rasoul Mofleh, I am solely responsible for the content and integrity of this work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI cordially thank UNICEF for authorizing me to analyze the MICS data.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during the current study are available in the UNICEF repository, [https://mics.unicef.org/surveys?page=3].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFarzad F, Reyer JA, Yamamoto E, Hamajima N. Socio-economic and demographic determinants of full immunization among children of 12\u0026ndash;23 months in Afghanistan. Nagoya J Med Sci. 2017;79(2):179.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaladima AN, Zulkefli NAM, Said SM, Ahmad N. Factors influencing childhood immunisation uptake in Africa: a systematic review. BMC Public Health. 2021;21(1):1475. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-021-11466-5\u003c/span\u003e\u003cspan address=\"10.1186/s12889-021-11466-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur G. (2023). Routine vaccination coverage\u0026mdash;worldwide, 2022. \u003cem\u003eMMWR. Morbidity and mortality weekly report\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLindstrand A, Cherian T, Chang-Blanc D, Feikin D, O'Brien KL. The World of Immunization: Achievements, Challenges, and Strategic Vision for the Next Decade. J Infect Dis. 2021;224(12 Suppl 2):S452\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/infdis/jiab284\u003c/span\u003e\u003cspan address=\"10.1093/infdis/jiab284\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammadi AQ, Neyazi A, Habibi D, Mehmood Q, Neyazi M, Griffiths MD. (2024). Female education ban by the Taliban: a descriptive survey study on suicidal ideation, mental health, and health-related quality of life among girls in Afghanistan. J Public Health, fdae111.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMugali RR, Mansoor F, Parwiz S, Ahmad F, Safi N, Higgins-Steele A, Varkey S. Improving immunization in Afghanistan: results from a cross-sectional community-based survey to assess routine immunization coverage. BMC Public Health. 2017;17(1):290. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-017-4193-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-017-4193-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNewbrander W, Ickx P, Feroz F, Stanekzai H. Afghanistan's basic package of health services: its development and effects on rebuilding the health system. Glob Public Health 9 Suppl. 2014;1(Suppl 1):S6\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17441692.2014.916735\u003c/span\u003e\u003cspan address=\"10.1080/17441692.2014.916735\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlusegun OL, Ibe RT, Micheal IM. Curbing maternal and child mortality: The Nigerian experience. Int J Nurs Midwifery. 2012;4(3):33\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQazi Zada S, Qazi Zada MZ. (2024). The Taliban and women's human rights in Afghanistan: the way forward. Int J Hum Rights, 1\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWiysonge CS, Ngcobo NJ, Jeena PM, Madhi SA, Schoub BD, Hawkridge A, Shey MS, Hussey GD. Advances in childhood immunisation in South Africa: where to now? Programme managers\u0026rsquo; views and evidence from systematic reviews. BMC Public Health. 2012;12:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal Education, Childhood immunization, Afghanistan, predictors of child immunization, Immunization Programs/trends, Vaccination, Vaccination Coverage, Vaccine-Preventable Diseases, Vaccines","lastPublishedDoi":"10.21203/rs.3.rs-7034250/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7034250/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: This study analyses MICS 2022–2023 data to explore the association between maternal and caregiver education levels and immunization coverage among children aged 12–23 months. It will also estimate immunization coverage at national and provincial levels while further identifying factors associated with incomplete immunization and ultimately offering recommendations to enhance immunization service quality in Afghanistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e: Cross-sectional study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This paper utilizes data from the Multiple Indicator Cluster Survey (MICS) for the period 2022-2023, collected by the Afghanistan National Statistics and Information Authority (NSIA). Data were collected from 23,338 households during the 2022-2023 period. The number of children eligible for interviews was 33,398, and data collection teams successfully collected data from 32,989 children aged 0-59 months (98.8%). The focus of this paper is on data from the immunization of 6,151 children aged 12-23 months, comprising 3,115 males and 3,036 females. Variables related to the individual were age, sex, antigen-specific attributes related to child immunization status, and breastfeeding status. In addition, we have residence area, region, wealth status, and mother's level of education as household attributes. To obtain the unadjusted odds ratio of the predictor variables on the outcome, univariate logistic regression models were performed. \u0026nbsp;Variables that had a P\u0026lt;0.25 were added to the multivariate logistic regression model to assess and calculate the adjusted odds ratio. The likelihood ratio test has been conducted to compare different univariate and multivariate logistic models. A p\u0026lt;0.05 at a 95% confidence interval has been considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e At the national level, 28.27% of children 12-23 months who participated in the study received basic immunization. \u0026nbsp;Coverage varies between provinces, with the highest reported in Bamayan at 78% and the lowest reported in Nooristan at 6.8%. Additionally, the crude coverage rates for specific antigens at 23 months are: 45.25% for BCG, 49.57% for Penta1, 41.49% for Polio3, 41.54% for Penta3, and 34.22% for the measles1 vaccine (Table 2). Only 19.7 percent of the poorest group received basic immunization (268/1350), while 39.2 percent of the richest group was covered by basic immunization; the difference was statistically significant (313/799, p \u0026lt; 0.000). \u0026nbsp;The coverage of basic immunization in urban areas was higher (36.1%, 350/969) compared to rural areas (26.8%, 1396/5208); the difference was statistically significant (p \u0026lt; 0.000). \u0026nbsp;\u0026nbsp;A strong relationship was found between mothers' level of education and basic immunization coverage (p = 0.000). The coverage among children whose mothers were uneducated was only 18.0% (945/5251), whereas it was 57.8% (242 out of 419) for children whose mothers had higher education. Additionally, spoken language had a statistically significant relationship with basic immunization (p = 0.000). Coverage among children whose parents spoke Dari was 39.6% (941 out of 1,435), while only 4.4% (7 out of 157) of children whose parents spoke Nuristani received basic immunization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e \u0026nbsp;Mothers with primary or higher education had children with significantly higher percentages of receiving basic immunization, after adjusting for extraneous factors such as wealth and urban-rural disparities. Our findings underscore the urgent need to invest in women's education, particularly in rural and marginalized communities, where female education is scarce, as a crucial pathway to enhancing child health outcomes.\u003c/p\u003e","manuscriptTitle":"The Role of Maternal Education in Advancing Childhood Immunization: An In-Depth Analysis of MICS Data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 13:49:03","doi":"10.21203/rs.3.rs-7034250/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"698591e5-0b87-489a-aa5c-c6bd15be9744","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T13:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 13:49:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7034250","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7034250","identity":"rs-7034250","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}