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The global effect of maternal education on complete childhood vaccination: a systematic review and meta-analysis

BMC Infectious DiseasesBMC series – open, inclusive and trusted201717:801

https://doi.org/10.1186/s12879-017-2890-y

Received: 21 February 2017

Accepted: 6 December 2017

Published: 28 December 2017

Abstract

Background

There is an established correlation between maternal education and reduction in childhood mortality. One proposed link is that an increase in maternal education will lead to an increase in health care access and vaccine uptake. Vaccinations are a central preventative child health tool, therefore demonstrating the importance of understanding factors that can improve coverage. This review aims to establish if there is a correlation between increasing maternal education and vaccine uptake and if this varies between continents, setting and time.

Methods

An electronic database search was conducted using Medline Ovid, Embase and The Cochrane Library using a combination of keywords and appropriate MeSH terms for maternal education and child vaccination. Bibliographies were also hand searched. Data was extracted and entered onto a Microsoft Excel spreadsheet and analysed using STATA 13.0 software. The primary outcome of effect size of maternal education on completion of childhood vaccinations was analysed at different levels. Secondary outcomes were explored using subgroup analyses of differences between continents, rural or urban settings, and dates.

Results

The online search yielded 3430 papers, 37 were included in this study. The analysis showed increasing child vaccination uptake with increasing maternal education. Overall, analysis showed that the odds of full childhood vaccination were 2.3 times greater in children whose mother received secondary or higher education when compared to children whose mother had no education. There was large variability in the effect size between the studies included.

Conclusions

Improving maternal education is important for increasing childhood vaccination uptake and coverage. Further research is needed in higher income countries.

Trial registration

PROSPERO Registration No: CRD42016042409.

Keywords

Maternal educationChild healthVaccinationImmunisation

Background

Despite the fact more children than ever are being vaccinated, millions of children each year fail to receive the complete routine immunization schedule [1]. Although the reason for this is likely multifactorial, it has been demonstrated that there is an association between maternal education and vaccination uptake [2, 3].

Childhood vaccinations are imperative for decreasing childhood mortality [1]. For this reason, global initiatives such as the Expanded Program on Immunization (EPI) and the Global Alliance for Vaccine and Immunization (GAVI) have been put in place, outlining essential vaccinations and reinforcing their uptake [46]. Despite this, it is estimated that 1.5 million children under 5 years die from vaccine-preventable diseases annually [7]. Although literature has shown low caregiver education to be a common variable for under or non-immunization of children, there is no research to confirm whether it is a consistent finding and the overall effect size has not been established [2, 3, 8].

The main aim of this study was to establish the global effect of maternal education on childhood vaccination in those under 12 years by quantifying the association between increasing maternal education and vaccine coverage in children, and assessing the variation in effect of maternal education by continent, setting, and over time.

Methods

Protocol, eligibility criteria, information sources and search

Medline, Embase, and the Cochrane Library were electronically searched on the 29th June 2016 using a combination of keywords and MeSH terms describing maternal education and child vaccination uptake. The search was restricted to English language and limited to those published between 1990 and 2016.

Study selection, data collection and data items

Observational studies of mothers with children under 12 years were included. Studies had an exposure variable of maternal education which is cross comparable such as “level of schooling achieved” or “literate versus illiterate” with a comparison group within the article.

The primary outcome assessed was completion of the full national or EPI schedule. Secondary outcomes were difference between continents, settings and dates.

Studies were subject to the following exclusion criteria: vaccine uptake not presented as raw, unadjusted data; unable to access the full text; review or narrative design; random control trials; case control trials not proportionate to the total population; studies where the exposure was another variable but maternal education was adjusted for in the analysis; studies with the outcome of specific vaccines, receipt of any vaccine, or vaccines not in the EPI.

Two authors (JF and MG, or EC and MG) independently screened all the titles. Abstracts were reviewed of potentially relevant articles, and full texts were retrieved to ascertain whether the inclusion criteria were fully met. Discrepancies were discussed until a consensus was reached. Data was extracted from included papers regarding study characteristics, including publication information (author and year), study country, setting, design, period, population total, children’s age, maternal education parameter and vaccine types. The number of children per maternal education level, the number of children fully vaccinated per maternal education level, and the percentage of children fully vaccinated per maternal education level were extracted for data analysis.

When the paper presented more than one set of results, for example different years, locations or age-groups, the paper was split into alphabetically ordered groups. For the 2 cohort studies included, the oldest age followed in the study was used (7 months old).

Risk of bias

Papers were assessed for quality and risk of bias using an adapted version of the certified “Quality Assessment Tool for Quantitative Studies” by the Effective Public Health Practice Project (EPHPP) [911]. Each study was assessed according to the representativeness of the sample, study design, controlling of confounders, blinding of exposure for cohort studies, data collection measurements, and reporting of withdrawals and drop outs for cohort studies. The articles were given a global rating of strong, moderate or weak. All studies were kept in regardless of quality due to the small number of studies available and recognition of the limitations of the scoring systems [10, 12].

Summary measures and synthesis of results

For the meta-analysis the maternal education variables were collapsed into a binary categorical variable (“none/primary” and “secondary/higher”). In papers where there were only two categories for maternal education level and the level of education and the type of schooling received was not clear, i.e. “illiterate versus literate”, “not educated versus educated”, the educated variable was classified as “none/primary” as the level of education was not stated. For the six studies that divided papers into the categories “literate” and “illiterate” a separate meta-analysis was conducted for comparison. This is because the quality of education within countries can be highly varied, meaning we cannot conclude that a primary level education will result in maternal literacy [13]. Papers were excluded from the meta-analysis if the lowest level of education category included were “primary / secondary,” “<high school,” or “<12 years.”

A pooled odds ratio, using the collapsed categories from each included paper, was calculated using a DerSimonian-Laird [14] random effects model, as large heterogeneity was anticipated considering the differences in study characteristics, such as varied populations, healthcare, settings and education systems. The analysis was performed in Stata version 13.0 [15].

Sub-group analysis was also conducted for continent, setting, and for date the study was conducted. For the setting sub-group analysis, studies which were performed at a national or regional level were removed. In the date sub-group analysis, the data set was divided into two groups based upon the year that the studies were conducted, before and after 2000 to coincide with the release of the Millennium Development Goals.

All of the extracted papers were included into the pooled estimate analysis. The maternal education levels quoted in the papers were categorised into none, primary, secondary or tertiary to get an overall percentage of children fully vaccinated for each level.

Where dichotomous variables were stated, the lowest level was taken as this was the minimum amount the woman had received. Variables of “can read and write”, “literate” and “mother educated” were categorised as primary as these skills can be achieved from primary school level. Where the paper included a variable with “less than”, the country setting was taken into consideration due to variations in levels of mandatory education between countries.

Forest plots were created for the overall analyses and for each of the stratified analyses. These showed the individual study odds ratios and 95% Confidence Intervals, the DerSimmonian-Laired pooled estimate and the I2-value for heterogeneity.

Publication bias

A scatter plot of number of children included in the studies against the prevalence of fully vaccinated children was created using STATA to assess for publication bias of the included papers.

Results

Study selection

The online search yielded 3430 results. Titles and abstracts were screened and duplicates or irrelevant articles were removed. In total, 218 full texts were retrieved and screened, with 37 articles being included in this review. Reasons for exclusion are outlined in Fig. 1, with the main reason being a lack of raw data.
Fig. 1

A flow diagram of study selection

Four papers were excluded from the meta-analysis as the lowest level of education was higher than primary.

Study range and characteristics

Of the 37 included papers, 35 were cross-sectional studies, the remaining 2 were cohort studies. All of the data from the studies was conducted between 1989 and 2013. India had eight studies, which is the greatest total number of studies per country. When assessing by continent, 18 were undertaken in Africa, 12 in Asia, three in Europe, three in North America and one in South America. This showed a dominance of research in lower income countries. The majority of the studies were regional or national, but six studies were set in urban areas, five in rural and one study compared both. Many were population based studies, and two were conducted in a hospital setting.

Full details of the included articles are presented in Table 1 showing the characteristics of the papers included and the quality of the studies that were compared. The majority (26 studies) were of moderate quality, with only one found to be of strong quality. Ten studies scored a global score of weak but were still included in the analysis due to the small number of studies available. Most of the studies were well conducted, but their cross-sectional study design meant the global score was brought down. The sample size ranged from 220 households (with 110 children) to 21,212 children in a cross-sectional American study. The total number of children was 112,841, with a mean of 836 children and median of 190 children per study (calculated from Table 2). Of the 33 included in the meta-analysis, the total number of children was 92,192, with a mean of 2794 and a median of 693. The age range was from birth to seven years, with the majority of studies using 12–23 months as the objective population due to the EPI schedule targeting this age group [16]. The papers using demographic health survey (DHS) data were conducted on women aged 15–49 years old. On most other papers, this was not specified.
Table 1

Study characteristics

Reference

Country

Study setting

Study design

Study period

Population

Children’s age

Vaccine type

Maternal education parameter

Quality

Al-Sheikh et al. 1999a [17]

Iraq

Urban

Cross-sectional

1989–1994

341 families (186 urban), 662 children (326 urban)

0–2 years

BCG, DPT-OPV(3), measles, MMR, DPT-OPV(1st booster)

Illiterate; Reads and writes; Primary; Intermediate; Secondary;

Institute; College; Postgraduate

Weak

Al-Sheikh et al. 1999b [17]

Iraq

Rural

Cross-sectional

1989–1994

341 families (155 rural), 662 children (336 rural)

0–2 years

Completion of BCG, DPT-OPV(3), measles, MMR, DPT-OPV(1st booster)

Illiterate; Reads and writes; Primary; Intermediate; Secondary;

Institute; College; Postgraduate

Animaw et al., 2014 [24]

Ethiopia

Region

Cross-sectional

March 2013

630 children

12–23 months

1 dose BCG, 3 doses Polio, 3 doses Pentavalant, 3 doses PCV, 1 dose Measles

None; Primary school; High school

Moderate

Antai 2009 [4]

Nigeria

National

Cross-sectional

2003

Interviews from 3725 women aged 15 to 49 years with 6029 live born children

12 months and older

BCG, Polio (3), DPT (3)

and Measles vaccinations

No education; Primary; Secondary or higher

Moderate

Antai 2012 [20]

Nigeria

National

Cross-sectional

2008

24,910 women aged

15–49 years with live-born children within 5 years before the survey

12 months to 5 years

8 childhood vaccinations in the EPI – BCG, DPT 3 doses, OPV 3 doses, and measles vaccine

No education; Primary school; Secondary school or higher

Moderate

Bbaale et al. 2013 [25]

Uganda

National

Cross-sectional

2006

7591 children

12–36 months

Full vaccination, BCG, DPT, Polio, Measles vaccinations

None, primary, secondary, post-secondary

Moderate

Branco et al. 2014 [26]

Brazil

Urban

Cross-sectional

January 2010

282 children

12–59 months

1 dose BCG, 3 doses Hep B, 3 doses DTP-Hib, 3 doses OPV, 2 doses Rotavirus, 1 dose Yellow fever, 1 dose MMR

0–8 years of schooling; >8 years of schooling

Moderate

Brenner et al. 2001 [27]

USA

Urban

Cohort

August 1995 to September 1996

369 singleton births from 3 hospitals from low-income, inner-city patients

Cohort followed until 7 months

UTD at 7 months if had received 3 DTP, 3 HIB, and 2 polio vaccinations

<12 years; ≥12 years

Strong

Calhoun et al. 2014 [28]

Kenya

Region

Cross-sectional

June–July 2003

244 children

12–23 months

3 doses Polio, 1 dose BCG, 1 dose Measles, 3 doses DPT or pentavalent

Years of schooling: 0–8, 8 or more

Moderate

Chhabra et al. 2007 [29]

India

Urban

Cross-sectional

October 2003 to January 2004

693 children

24–47 months

BCG, DPT and OPV (3 primary and booster), measles and MMR

Nil; 1–8 years; >8 years

Moderate

Danis et al. 2010 [18]

Greece

National

Cross-sectional

Academic year

2004–2005

3609 parent/ guardian-child pairs

3434 pairs in the final analysis.

Children in first year of Greek grammar school

6–7 years (Mean age 6.76 years)

5 doses of DTP vaccine, 5 doses of poliomyelitis vaccine, 2 doses of MMR vaccine, 3 doses of HBV vaccine and full vaccination for Hib

<9 years; 9–11 years; 12 years (high school); College/ university graduate

Moderate

Elliott et al. 2006a [30]

India

Rural

Cross-sectional

September 2003

470 families

9 months

BCG, OPV (4), DPT (3) and measles

Illiterate; Literate

Weak

Elliott et al. 2006b [30]

India

Rural

Cross-sectional

September 2003

470 families

18 months

BCG, OPV (5), DPT (4) and measles

Illiterate; Literate

Elliott et al. 2006c [30]

India

Rural

Cross-sectional

September 2003

470 families

6 years

BCG, OPV (5), DPT (4), measles and DT

Illiterate; Literate

Fatiregun et al. 2012 [31]

Nigeria

Region

Cross-sectional

2007

540 interviews, 525

respondents

mothers of children

12–23 months

BCG, dose of measles, three doses (1,2,3) of DPT, four doses (0–3) of OPV

Primary/ secondary; Post secondary

Moderate

Fatiregun et al. 2013 [32]

Nigeria

Region

Cross-sectional

2006

1178 mothers

12–23 months

BCG, 4 doses OPV, 3 doses DPT, 3 doses Hetaptitis B

Tertiary education; Secondary education; Primary education; None

Moderate

Huq et al. 2008 [33]

Bangladesh

National

Cross-sectional

1999–2000

755 children

12–23 months

BCG and measles vaccinations and all 3 doses of the DPT and polio vaccines

Below primary; Secondary; Higher secondary

Moderate

Jahn et al. 2008 [34]

Malawi

Rural

Cross-sectional

21st August 2002 to 22nd July 2004

5418 children

Under 5 years old

BCG, OPV3, DPT3 and measles vaccine before their 1st birthday

<5 years primary; Primary 5 + years; Sec./tert.

Moderate

Kidane et al. 2003 [35]

Ethiopia

Region

Cross-sectional

2000

220 households

12–23 months

BCG, measles, 3 doses of DPT/OPV

Illiterate; Literate

Weak

Koumaré et al. 2009 [36]

Mali

Region

Cross-sectional

July 2006

750 children

12–23 months

BCG, DTCP1, DTCP2, and DTCP3 and measles

Mother not educated; Mother educated

Weak

Kumar et al. 2010 [37]

India

Hospital/

Urban

Cross-sectional

April to July 2007

325 children (148 males, 177 females) admitted to paediatrics ward at a tertiary care hospital

12–60 months

BCG, 3 doses of DPT/OPV and measles

≤primary; >primary

Weak

Luman et al. 2003 [38]

USA

National

Cross-sectional

July 2000– June 2001

21,212 children

19 to 35 months

4 doses of DPT vaccine, 3 doses of poliovirus vaccine, 1 dose of MMR vaccine, 3 or 4 doses of Hib vaccine, and 3 doses of HBV vaccine (the 4:3:1:3:3 series).

<High school; High school; >High school; College graduate

Moderate

Mohamud et al. 2014 [39]

Ethiopia

Region

Cross-sectional

10 April 2011–5 May 2011

582 households

12–23 months

1 dose BCG, 1 dose Measles, 3 doses pent/OPV before 1 year of age

Illiterate; Literate

Moderate

Odusanya et al. 2008 [40]

Nigeria

Rural

Cross-sectional

September 2006

339 mothers and children

12–23 months

BCG, 3 doses of OPV & DTP, 3 doses of HBV and measles vaccine

None/ primary; Secondary/ university

Moderate

Okoro et al. 2014 [41]

Nigeria

Region

Cross-sectional

May to December

168 children

6 months – 5 years

Full schedule (not specified)

No formal education; Primary; Secondary; Post-secondary; University

Moderate

Pati et al. 2011 [42]

USA

Urban

Cohort

June 15th 2005

to August 6th 2006

506 Medicaid-eligible mother-infant dyads

Cohort followed until 7 months

UTD at 7 months if received 3 HepB, 2 polio, at least 2 Hib, 3 PCV7

and 3 DTaP containing vaccines

Less than high school; High school; More than high school

Moderate

Phukan et al. 2008 [43]

India

Region

Cross-sectional

June and July 2003

616 children

12–23 months

6 EPI vaccines in time

Illiterate; Primary; Middle; Higher

Weak

Robert et al. 2014a [44]

Belgium

Region

Cross-sectional

2012

519 children

18–24 months

Hexavalent, pneumococcal, MMR, meningococcal C

Maximum secondary level; Higher than secondary level

Moderate

Robert et al. 2014b [44]

Belgium

Region

Cross-sectional

2012

538 children

18–24 months

Hexavalent, pneumococcal, MMR, meningococcal C

Maximum secondary level; Higher than secondary level

Rossi et al. 2015 [45]

Zimbabwe

National

Cross-sectional

2010–2011

1031 children

12–23 months

1 dose BCG, 1 dose Measles, 3 doses of Polio, 3 doses DPT/Pentavalent

No education or primary; Secondary or higher

Moderate

Schoeps et al. 2013 [46]

Burkina Faso

Region

Cross-sectional

September 2008 – December 2009

1665 children

12–23 months

BCG, Oral Polio, Pentavalent, yellow fever, measles

Any; None

Moderate

Setse et al. 2006 [47]

Zambia

Hospital/

Urban

Cross-sectional

January 1998 and October 2000

473 children hospitalised with measles- 372 in subgroup analysis

4 and 60 months

BCG and completed the series of DTP and OPV vaccines.

Less than 7 years; 7 years; Greater than 7 years

Moderate

Sia et al. 2009 [5]

Burkina Faso

Rural

Cross-sectional

1998

805 children

12–23 months

BCG, measles, yellow fever vaccines and 3 doses of DTP and OPV

No schooling; Primary or secondary school

Moderate

Singh et al. 2000 [48]

India

National

Cross-sectional

June–October 1999

18,783 children

12–23 months

BCG, DPT, OPV, Measles

Illiterate; Primary; Middle; Higher secondary; Graduate

Weak

Singh et al. 2001 [49]

India

Region

Cross-sectional

June–October 1999

6171 children

12–32 months

BCG, DPT, OPV, Measles

Illiterate; Primary

Middle; Higher secondary; Graduate

Weak

Som et al. 2010 [50]

India

Region

Cross-sectional

2002 to 2004

1279 children

12–35 months

BCG, 3 injections of DPT, 3 doses of polio (excluding polio 0) and 1 of measles

Can’t read and write; Can read and write

Moderate

Streatfield et al. 1990 [51]

Indonesia

Rural

Cross-sectional

1989

519 mother-child dyads

Under the age of 5 years

DPT, BCG, and anti-polio

Not literate; Some primary; Complete primary; Secondary school

Weak

Thang et al. 2007 [52]

Vietnam

National

Cross-sectional

2002

468 children

11–23 months

BCG vaccination 3 doses of DPT vaccine; at least 3 doses of polio vaccine; and 1 dose of measles vaccine

Illiterate; Lower primary; Completed primary; Completed secondary; Completed high school +

Moderate

Torun et al. 2006 [53]

Turkey

Region

Cross-sectional

2005

Parents of 221 children

9 month-6 years of age

<18 months completely vaccinated if had 1 dose of BCG, 3 doses of HBV, OPV and DPT and 1 dose of Measles vaccine. >18 months completely vaccinated if had booster doses for OPV and DPT vaccines

Illiterate; Graduated primary school; Graduated secondary school or higher education

Moderate

Waters et al. 2004a [54]

Cameroon

National

Cross-sectional

1998

2123 children

Younger than 3 years

By 6 weeks- 1st dose of DPT and the 2nd dose of polio vaccine;

By 10 weeks- 2nd dose of DPT and the 3rd dose of polio vaccine;

By 14 weeks- 3rd DPT dose;

By 9 months- measles vaccine

Less than primary school; Primary school; Secondary education; Higher education

Moderate

Waters et al. 2004b [54]

Cameroon

National

Cross-sectional

2000

3582 children

Younger than 5 years

Less than primary school; Primary school

Secondary education or higher education

Yadav et al. 2004 [55]

India

Regional

Cross-sectional

June–October 1999

1481 children

12–23 months

BCG, DPT3, OPV3, Measles

Illiterate; Primary; Middle; Hr. Secondary;

Graduate

Weak

Abbreviations: UTD up to date, EPI Expanded Program on Immunization, OPV oral polio vaccine, BCG bacille Calmette-Guérin (tuberculosis) vaccine, DPT diphtheria, pertussis, tetanus vaccine, Hib haemophilus influenzae type b, HBV hepatitis B virus, MMR measles, mumps & rubella vaccine, DT diphtheria and tetanus, PCV7 pneumococcal conjugate vaccine (7-valent), DTaP diphtheria, tetanus and acellular pertussis vaccine, DTCP diphtheria, tetanus, pertussis, poliomyelitis vaccine

Table 2

Study results

Reference

Maternal education parameter

# children whose mothers had education level

# children who have received full vaccination schedule

% children who received full vaccination schedule

(1 d.p.)

cOR for vaccination (2 d.p.)

Al-Sheikh et al. 1999a [17]

Illiterate

27

22

81.5

1

Reads and writes

69

41

59.4

0.33

Primary

78

42

53.8

0.27

Intermediate

32

22

68.8

0.5

Secondary

53

29

54.7

0.27

Institute

43

27

62.8

0.38

College

23

12

52.2

0.25

Postgraduate

1

1

100

/

Al-Sheikh et al. 1999b [17]

Illiterate

143

34

23.8

1

Reads and writes

121

34

28.1

1.25

Primary

50

10

20

0.8

Intermediate

5

2

40

2.14

Secondary

7

5

71.4

8.01

Institute

6

4

66.7

6.41

College

4

4

100

/

Postgraduate

0

/

/

/

Animaw et al. 2014 [24]

None

262

150

57.3

1.00

Primary

252

211

83.8

3.84

High school

116

100

86.2

4.66

Antai 2009 [4]

No education

2155

169

7.8

1

Primary

805

142

17.6

2.52

Secondary or higher

771

194

25.2

3.95

Antai 2012 [20]

No education

12,265

722

5.9

1

Primary school

5724

1159

20.2

4.06

Secondary school or higher

6921

2402

34.7

8.50

Bbaale et al. 2013 [25]

No education

1824

967

53.0

1.00

Primary

4686

2484

53.0

1.00

Secondary

896

520

58.0

1.23

Post-secondary

185

117

63.2

1.52

Branco et al. 2014 [26]

0–8 years of schooling

151

116

76.8

1.00

>8 years of schooling

130

117

90

2.72

Brenner et al. 2001 [27]

<12 years

145

55a

38

1

≥12 years

179

77a

43

1.23

Calhoun et al. 2014 [28]

0–7 years of schooling

132

35

26.5

1.00

≥8 years of schooling

23

11

47.8

2.54

Chhabra et al. 2007 [29]

Nil

378b

130

34.4

1

1–8 years

106b

51

48.1

1.77

>8 years

209b

106

50.7

1.96

Danis et al. 2010 [18]

<9 years

536

278

51.9

1

9–11 years

429

240

55.9

1.18

12 years (high school)

1336

859

64.3

1.67

College/ university graduate

985

670

68

1.97

Elliott et al. 2006a [30]

Illiterate

332b

240

72.3

1

Literate

139b

123

88.5

2.95

Elliott et al. 2006b [30]

Illiterate

318b

210

66

1

Literate

127b

113

89

4.15

Elliott et al. 2006c [30]

Illiterate

139b

73

52.5

1

Literate

49b

35

71.4

2.26

Fatiregun et al. 2012 [31]

Primary/ secondary

297

76

25.6

1

Post secondary

228

94

41.2

2.04

Fatiregun et al. 2013 [32]

None

129

24

18.6

1.00

Primary

468

128

27.4

1.65

Secondary

523

225

43.0

3.30

Tertiary

58

51

87.9

31.88

Huq et al. 2008 [33]

Below primary

485

307a

63.3

1

Secondary

221

164a

74.2

1.67

Higher secondary

49

46a

93.9

8.92

Jahn et al. 2008 [34]

<5 years primary

237

140

59.1

1

Primary 5 + years

1364

903

66.2

1.36

Sec./tert.

304

233

76.6

2.27

Kidane et al. 2003 [35]

Illiterate

92

66

71.7

1

Literate

18

17

94.4

6.70

Koumaré et al. 2009 [36]

Mother not educated

639

376a

58.8

1

Mother educated

111

73a

65.8

1.35

Kumar et al. 2010 [37]

≤primary

223

12

5.4

1

>primary

92

46

50.0

17.58

Luman et al. 2003 [38]

<High school

3157

2147a

68.0

1

High school

7160

5191a

72.5

1.24

>High school

4375

3233a

73.9

1.33

College graduate

8698

6915a

79.5

1.82

Mohamud et al. 2014 [39]

Illiterate

510

167

32.7

1.00

Litterate

72

46

63.9

3.63

Odusanya et al. 2008 [40]

None/ primary

107

57

53.3

1

Secondary/ university

232

153

65.9

1.70

Okoro et al. 2014 [41]

No formal education

12

7

58.3

1.00

Primary

33

16

48.5

0.67

Secondary

55

36

65.5

1.35

Post-secondary

28

24

85.7

4.29

University

40

32

80.0

2.86

Pati et al. 2011 [42]

Less than high school

159

63

39.6

1

High school

119

55

46.2

1.31

More than high school

228

101

44.3

1.21

Phukan et al. 2008 [43]

Illiterate

132

50

37.9

1

Primary

81

41

50.6

1.68

Middle

344

242

70.3

3.89

Higher

59

50

84.7

9.11

Robert et al. 2014a [44]

Maximum secondary level

293

237

80.8

1.00

Higher than secondary level

214

177

82.9

1.13

Robert et al. 2014b [44]

Maximum secondary level

296

242

81.6

1.06

Higher than secondary level

233

197

84.4

1.29

Rossi et al. 2015 [45]

No education or primary

320

177

55.2

1.00

Secondary or higher

711

500

70.3

1.91

Schoeps et al. 2013 [46]

None

1435

250

17.4

1.00

Any

230

57

24.8

1.56

Setse et al. 2006 [47]

Less than 7 years

137

92a

67c

1

7 years

114

87a

76c

1.56

Greater than 7 years

121

105a

87c

3.30

Sia et al. 2009 [5]

No schooling

850

172a

20.2

1

Primary or secondary school

48

18a

37.5

2.37

Singh et al. 2000 [48]

Illiterate

7337

3404a

46.4

1

Primary

2946

1912a

64.9

2.14

Middle

3044

2143a

70.4

2.75

Higher secondary

3433

2705a

78.8

4.29

Graduate

2023

1705a

84.3

6.20

Singh et al. 2001 [49]

Illiterate

3421

1143a

33.4

1

Primary

900

496a

55.1

2.45

Middle

718

442a

61.5

3.19

Higher secondary

580

416a

71.8

5.08

Graduate

552

442a

80

7.98

Som et al. 2010 [50]

Can’t read and write

400

151a

37.8

1

Can read and write

879

538a

61.2

2.60

Streatfield et al. 1990 [51]

Not literate

78

35a

45.1

1

Some primary

129

40a

31.1

0.55

Complete primary

177

59a

33.6

0.62

Secondary school

81

44a

54.9

1.48

Thang et al. 2007 [52]

Illiterate

33

13a

39.5

1

Lower primary

74

37a

50

1.53

Completed primary

157

100a

63.5

2.66

Completed secondary

122

94a

77.4

5.25

Completed high school +

83

69 a

82.9

7.43

Torun et al. 2006 [53]

Illiterate

31b

15

48.4

1

Graduated primary school

157b

141

89.8

9.4

Graduated secondary school or higher education

33b

31

93.9

16.53

Waters et al. 2004a [54]

Less than primary school

438

105a

24

1

Primary school

603

235a

39

2.02

Secondary education

473

246a

52

3.43

Higher education

12

8a

67

6.43

Waters et al. 2004b [54]

Less than primary school

961

202a

21

1

Primary school

1137

387a

34

1.94

Secondary education or higher education

840

403a

48

3.47

Yadav et al. 2004 [55]

Illiterate

835d

407a

48.7

1

Primary

241

180a

74.8

3.13

Middle

190

142a

74.9

3.14

Hr. Secondary

119

93a

78.2

3.78

Graduate

96

77a

80.2

4.27

d.p. = decimal places

a Number of children fully vaccinated calculated using available data in the paper (i.e. % uptake x total number of children)

b Total number of children per maternal education level calculated from adding row total

c Reverse percentage calculated from data in paper (percentage incompletely vaccinated presented)

d Number of children with an illiterate mother calculated from deducting number in other levels from total population size

Maternal education levels varied between the study settings, with those set in higher income countries having higher baselines, potentially due to difference in schooling between countries. Dichotomous variables were used in 14 studies where the woman was classed as either literate or not, or above or below a set threshold.

Data extraction

The raw results show a general increase in vaccination completion with increasing maternal education within the separate papers (Table 2). The odd ratios between the highest and lowest education levels within the studies ranged from 0.25, showing a decrease in completion, to 31.88 showing hugely increased odds of the children being fully vaccinated if the mother was more educated than the baseline group. Only two studies showed decreased odds between lowest and highest education levels, with the rest all showing a positive trend. Percentage fully vaccinated also varied widely from 1.0% to 100% with an average of 55.9% having completed the immunisation schedule. These variations are further explored by the meta-analysis.

Meta-analysis

Overall, the meta-analysis showed that the odds of full childhood vaccination were 2.31 times (95% CI 1.90–2.79) greater in children whose mothers had received secondary or higher education when compared to those whose mothers had no education or primary level education (Fig. 2). Although all but four studies showed a positive effect of being highly educated, the effect size varied greatly between papers, with an overall I-squared value of 95.0% (p < 0.001), indicating a high level of heterogeneity.
Fig. 2

Odds ratio of children being fully vaccinated if mother educated to a secondary level compared with no or primary education

Illiteracy vs. literacy

Figure 3 shows a separate meta-analysis of six studies which split mothers based upon whether they were literate or illiterate. It demonstrates full vaccination of children was more likely in mothers that were literate compared to illiterate, with an odds ratio of 2.87 (95% CI 2.39–3.46).
Fig. 3

Odds ratio of children being fully vaccinated if mother is literate compared with illiterate

Continent

Subgroup analysis of continents (Fig. 4) showed the overall effect size is highest in Asia, where the odds of full childhood vaccination were 2.65 times (95% CI 2.08–3.37) greater if the mother was more educated. Only one result out of 11 was not statistically significant (Al-Sheikh et al. 1999a) [17].
Fig. 4

Odds ratio of children being fully vaccinated if mother educated to a secondary level compared with no or primary education, according to continent

The overall effect for Africa was increased odds of 2.34 (95% CI 1.69–3.24) for completion of childhood vaccination with higher maternal education. There were no statistically insignificant papers in this subgroup.

The overall effect was lower in the higher income continent of Europe, with increased odds of 1.47 (95% CI 1.14–1.89) for completion of childhood vaccination with higher maternal education. Furthermore, three-quarters of European papers had statistically insignificant results, and low heterogeneity.

Setting

Within the setting subgroup analysis (Fig. 5), vaccination of children was most likely in highly educated women in rural areas, with an odds ratio 2.17 (95% CI 1.48–3.17). There was no statistically significant difference in the odds ratios between the rural and urban settings.
Fig. 5

odds ratio of children being fully vaccinated if mother educated to a secondary level compared with no or primary education, according to setting

Timing

As seen in Fig. 6, studies conducted before 2000 show an odds ratio of 2.58 (95% CI 2.04–3.26). The overall odds ratio for studies conducted from 2001 is 2.18 (95% CI 1.62–2.94). Although the odds of complete child vaccination are slightly lower in the later time period, there was no statistically significant difference in the odds ratios.
Fig. 6

Odds ratio of children being fully vaccinated if mother educated to a secondary level compared with no or primary education, according to time period

Summary estimate of vaccine completion by maternal education level

Collapsing of the different maternal education variables into the 4 categories, none, primary, secondary or tertiary education, to obtain the pooled estimate of the percentage of children fully vaccinated per strata is shown in Table 3. This demonstrates an increase in completion of vaccination as the maternal education level increases. Only 42.8% (95% CI 35.2–50.4) of children whose mothers had no education were fully vaccinated. This increases to 80.2% (95% CI 75.5–85.0) amongst children whose mothers had completed tertiary education. The pooled summary also shows that there is the overall prevalence of vaccination uptake was 57.8% (95% CI: 52.4–63.1).
Table 3

Pooled summary vaccination completion per education level

Maternal education level

Pooled child vaccination completion (%)

95% confidence interval

I-squared (%)

None

42.8

35.2–50.4

99.7

Primary

56.6

49.5–63.7

99.4

Secondary

64.3

56.1–72.5

99.2

Tertiary

80.2

75.5–85.0

89.3

However, there is significant heterogeneity between studies, as reflected in the I-squared values. This demonstrates that maternal education is not the only determinant of vaccination uptake.

Discussion

Summary

The primary finding of this review is that an increase in maternal education is correlated with increased childhood vaccination. However, the overall effect size of maternal education on vaccination completion cannot be concluded due to heterogeneity between the studies. Summary estimates of percentage of children fully vaccinated according to the level of maternal education showed a step-wise increase in overall percentages as maternal education increased from none to tertiary. Additionally, a significant difference was shown on the meta-analysis between literate and illiterate women, displaying that increased literacy has a beneficial impact on vaccination uptake.

This review also demonstrated a difference in the size of the effect seen between Asia and Africa compared to Europe. The higher odds ratio of maternal education on vaccination uptake in Asia and Africa may demonstrate that education plays a more important role in lower income countries. This could be due to societal development as areas with better education may also have improved healthcare access. Whilst the effect is lower in Europe, it is still positive. This demonstrates the importance of maternal education even in the presence of good health care programmes.

No difference in the effect of maternal education on vaccine uptake was found between urban and rural settings. It is of note that many of the studies were population based so are likely to be representative; however, two studies were conducted in a hospital setting so are less generalizable.

The results also show no difference in the effect of maternal education on vaccine uptake between time periods.

The heterogeneity seen between the results may be due to a number of other factors which may also affect vaccination uptake, such as availability of the immunizations, distance to healthcare facility, household income and maternal age which would confound the effect size [18]. Despite the presence of confounders, there remains a strong correlation between maternal education and child vaccination completion.

Limitations

As with all studies, this review has some limitations. The main one was the exclusion of non-English papers which could potentially lead to language bias. Moreover, authors were not contacted for the raw data if the study had been excluded due to lack of published data in the required format.

In addition, condensing the maternal education variables may have hidden subtle patterns between the smaller jumps in education level. Furthermore, this meant that in studies with dichotomous variables of educated against not, and illiterate vs literate, the educated variable was also categorised as “none/primary” in the meta-analysis. Due to the differences in the settings of the studies, there was no universal standard for measuring level of education. In order to compare them in this review, they were categorised into set variables which contributed to the high heterogeneity.

Implications of this review

This current review adds further evidence of the association between maternal education and child mortality reduction [19]. It is possible that child vaccination uptake is in fact one of the pathways for which this relationship is seen. It also shows that child vaccination uptake is not solely down to supply of vaccinations, and programs which aim to increase the dispersion of immunizations need to concentrate on these additional factors [20]. Furthermore, it adds to the current argument of the importance of educating women and gender equality [21]. Despite these associations this study does not answer the question of exactly how maternal education increases vaccine uptake. One link may be that increasing maternal education leads to more access to healthcare and therefore vaccine uptake. However, previous studies have theorised that maternal education, specifically literacy, enhance cognition and communication skills which encourage healthier lifestyle choices leading to lower childhood mortality [22].

The meta-analysis looking at literacy levels demonstrated that one of the potential mediators between maternal education and complete vaccination was maternal literacy. This is further supported by Balogun et al. who found that mothers who were literate, regardless of their education level, were more likely to vaccinate their children [23]. This therefore implies that improving the educational standards to ensure literacy will have a greater impact on increased childhood vaccination than simply increasing the throughput of girls in education.

Overall it is clear that female education is crucial in improving child health and should be considered when policies surrounding child health are implemented. Whilst this study cannot provide an overall total effect size of maternal education on child vaccination uptake, it does demonstrate that there is a consistently positive effect. This should be taken into consideration when global health policies aiming to increase the uptake of child vaccination are applied. It also highlights the importance of female education on wider factors other than self-improvement and the economy [19].

Conclusions

This review highlights the positive effect of maternal education on childhood vaccination uptake across different continents, settings, and time periods.

It has been long established that childhood mortality is decreased by childhood vaccination [21]. This analysis identified that increased maternal education leads to increased childhood vaccination uptake and, in turn, will decrease childhood mortality.

Declarations

Acknowledgements

Not applicable

Funding

No specific funding was obtained for this study. Logan Manikam is funded by an NIHR Doctoral Research Fellowship. Sarah Gerver was funded by an MRC Population Health Science Post-Doctoral Fellowship.

Availability of data and materials

Available on request.

Authors’ contributions

JF screened articles, performed data extraction, and was a major contributor in writing the manuscript. SG performed statistical analysis of the data sets. MG and EC screened articles, performed data extraction, and were major contributors in writing the manuscript. LM and HW were involved in study design and contributors in writing the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
School of Public Health, Imperial College London, London, UK
(2)
St George’s, University of London, London, UK
(3)
UCL Great Ormond Street Institute of Child Health, London, UK

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Copyright

© The Author(s). 2017

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