15. Child Immunization and the Influence of Social Variables on Health Care Utilization

Baffa Aliyu Umar

Immunization is just one part of the concerted campaign of the primary health care program in Nigeria. Over the years, there have been serious concerns and public campaigns on child immunization in Nigeria (Federal of Ministry of Health, 1988). Improved child health is one of the indicators of socioeconomic advancement and quality of life. For many decades, Nigeria, like other sub-Saharan countries, has been recording high morbidity and mortality as a result of the six killer diseases: diphtheria, tetanus, tuberculosis, measles, whooping cough, and poliomyelitis (United Nations Children’s Fund (UNICEF), 1990, 1993, 1994; Umar, 2004, 2006). Other similar critical health conditions and outcomes include cholera, malaria, and cerebral spinal meningitis (CSM).The incidence and prevalence of these diseases are largely due to communicable and infectious conditions. Poor sanitation, poverty, and ignorance can all play a role in facilitating occurrences of these diseases. The fatalities associated with these diseases and associated child-health developments are regrettably preventable (Umar, 2004). Both addressing the diseases as well as working with the population to promote behaviors that will aid in preventing these diseases will be some of the major health challenges for many decades to come.

In 1990, the rate of child mortality was 87/1000 (National Population Commission, 1990). In 2003, the child mortality rate was 100/1000 (National Population Commission, 2004). Still, the rate of mortality for child killer diseases in Nigeria is high, with 109/1000 (UNFPA, 2007). Over the years, there have been mixed records of successes and failures in access, coverage, and service provision on immunization (Babaniyi, 1990; Uplekar, Rangan, & Ogden, 1999; Federal of Ministry of Health, 1988; National Population Commission, 1990; Bondi & Alhaji, 1992). The rates of killer diseases fluctuate and services falter over the years. In Nigeria, an impressive 80% success rate was achieved in 1990 due to political advocacy. Later rates kept decreasing, with progressive decline (UNICEF, 1994). Independent research confirms the decline in coverage and access (Cairo Conference Paper, 1994)., Across all economic levels in Nigeria, there are more full immunizations for the one-year-olds among the richest 20% than the poorest 20%; this socioeconomic-based disparity holds true for both infant and under-five mortality rates as well (Human Development Report, 2006). Measles, though, remains one of the seriously debilitating diseases that still persists and is even obstinately becoming widespread in many places (Umar, 2004). Pockets of polio, likewise, are stubbornly resisting eradication in many countries in Africa. House to house campaigns to immunize children against polio are being intensified, amid heated controversy over the efficacy and safety of the polio vaccine that has trailed the vaccination exercise in some states in northern Nigeria (Umar, 2006). The health education campaign involves the methods and skills of counselling used by the health personnel to make mothers and pregnant women more accepting of vaccination services. The process also involves the use of posters, manuals, lessons, graphic illustrations, media advertisements, and demonstration. The focus of the immunization campaign is on the mother, as the principal actor in managing the health of the child. Huge sums of Naira are being spent to sustain the immunization campaign because the role of the mother is critical in

• Accepting the concept of immunization;
• Becoming motivated to accept immunization to her healthy child, even though there are no visible symptoms of any disease;
• Taking the child to the clinic in spite of demands of household chores, market days and informal domestic production;
• Sourcing money to visit hospital or clinic, especially for those who reside far away from immunization centers; and
• Seeking permission from her husband to immunize her child and get vaccination shots for tetanus toxoid if she is pregnant (Umar, 2004, 2006).

Studies on immunization concentrate on organizational problems (Blum & Philips, 1986). Other researchers such as the National Fertility Survey (NFS) and Demographic and Health Surveys (DHS) have focused only on profiles of target groups and not on beneficiaries of the health service. The central position of the mother in immunization processes is certain. Unfortunately, it has been observed that the mother is not given credible attention in integrating her opinion in order to yield successful vaccination exercises; her views on immunization are not sought. Health campaigns give emphasis on the following instructions and directives on immunization; the mother is not a party to decisions on immunizations. As observed by Umar (2006, p. 118): “By far one of the major weaknesses of immunization program is the way the feelings, wishes, aspiration and interest of the mother as the principal agent in vaccination campaign are not well represented.”

This article examines the relationships between child immunization, health care utilization and culture, family structure, income, sex differentials, and maternal education. Variables, as factors that vary, are some of the aspects of a phenomenon that can be associated with health care utilization. Examples and cases are drawn from Nigeria, Niger, Bangladesh, India, China, Sri Lanka, and North and sub-Saharan Africa in general.

Culture, Mother and Immunization

One of the generally comprehensive definitions of culture is given by Taylor (1958) who sees culture as a complex whole representing the entire entities that constitute the life of a community. Culture is socially learned. It emanates from and, is shared in a particular social context. Other anthropologists such as Boaz (1940) and Kroeber (1958) see culture from different angles. Boaz’s conception of culture focuses on, among other things, the conceptual analysis and relationship of race and culture. Kroeber, on the other hand, views culture as a complex system of symbols of patterned relationships with no clear influence from external factors, like geography.

The renowned anthropologist Radcliffe Brown (1952), links patterned culture with individual behavior, based on the way simple societies mold and condition a person’s attitude and behavior within the context of norms, values and traditional beliefs. A more recent commentary on culture by Hammel (1990) starts by criticizing the way sociologists look at culture. For him, “the ‘sociologist’ pursues arguments that focus on the institutional context of culture broadly conceived, but without attention to the connection between institutions and the behavior of individual actors.” As a result, “sociologist(s)… underplay the agency of actors in the construction of culture” (Hammel, 1990, p. 456). But actors in the process of interaction can perceive, interpret, and help construct culture.

Hammel (1990, p. 475) views culture as providing “The agency (through which) individuals (are) using behavior as symbols selected from a repertoire that has some coherence and endures overtime, but that is created and maintained by patterns of selection by actors as well as by innovation.” At a more abstract level,

The concept of culture as a transitory and negotiated set of understandings is the view that behavior is controlled by its’ own symbolization. It is the evaluative behaviors of actors, playing unceasing mediations as themes provided by their current cultural stock, that creates and recreates as a constantly modified and elaborated system of moral symbols. (Hammel, 1990, p.467 )

Culture then is a “commodity of perception” that develops between interacting actors. As the culture is “continually created in the process of interaction,” the network of the cultural system is facilitated and sustained by the actors themselves, through the “agency” of participatory role.

By this process, the actors operationally “…select behavioral alternatives, balancing and choosing those they think will minimize moral risk and maximize moral gain” (Hammel, 1990, p. 467), like in the case of a mother deciding to patronize immunization services or not. In this vein

Social action can be seen as guided by the statement of actors to one another about behavior in general and in particular; the actors are “members of the same culture” means that they share in some degree of the same evaluative discourse. (Hammel, 1990, p. 469)

It is obvious that culture represents an important part of an individual’s everyday life. The attitudes, beliefs, behaviors, and traditions symbolize the complex whole that represents the cultural system of a given people. The health sub-sector is one of the other units that are greatly influenced by the cultural practices of the society. A society’s conception of health, ill health, and diseases are associated with the cultural standards operative in the society. This underpins the popular conception of the nature and cure of a particular disease—e.g. in traditional, alternative, or complementary medicine. In certain cases, cultural practices can influence an individual’s perception of even modern medicine, e.g. vaccination.

The mother is an important factor in the immunization process. The mother, as a member of the family, interacts with other women in the household and the community in general. The cultural system of the community mediates the nature of the interaction between the actors. Over time the interacting actors develop their ideas about immunization as it pertains to their health and that of their children. This kind of perception endures over time. The cultural understanding of immunization is thus constructed, as it were. The mothers, as actors may evaluate and select possible options on the way they would consider modern immunization. They may have to “negotiate a set of understanding on the ‘moral symbol’ of immunization services” as Hammel puts it. The options on behavioral alternatives on the use of immunization by the mothers are continuously considered. The mother evaluates the moral risk of adopting modern immunization as well as its perceived moral gain. The social interactions between the actors guide their actions in considering what to do. This is based on the assumption that the cultural orientation of mothers has an association with their opinions and actions in regards to immunization.

Culture and Health Care Use

Obermeyer (1993) looked at the socioeconomic, cultural, and demographic factors to explain differences in maternal health care use in Tunisia and Morocco. She found a substantial difference in the use of prenatal care and home versus hospital birth. She raised the question whether low utilization of medical facilities was a function of the low status of (mothers) women. From the samples, Tunisian women are better educated in modern schooling systems and are more predisposed to using modern health systems than Moroccan women.

Using the Demographic Health Surveys (DHS) for Morocco and Tunisia, she found variations in access to distribution of health services, and the status of women. In all, the Tunisian women embrace more modern civil legislations than their Moroccan counterparts do. Obermeyer (1993) thus concludes that the “cultural norms concerning the status of women are at the root of different patterns of health care in the two countries.”

In the area of health care use, however, cultural factors constitute a mediating agency for mothers’ action rather than determining factors. She says:

The reluctance of many women to be delivering (in the hospital) is, in part, a function of their having neither ground for dissatisfaction with the traditional custom of home birth nor compelling motives to seek treatment from a stranger in a hospital. Cultural factors, therefore, appear not as major obstacles to better health, but rather as defining the normal course of action to be taken in the absence of compelling reasons to do otherwise. (Obermeyer, 1993)

This means that health care is a consequence of the strong need for going to the hospital. However, the way things are done culturally may influence the mother when there is no dire need to visit the hospital.

Obermeyer (1993) uses logistic regression analysis to determine the odd ratios (OR) for the probability of receiving prenatal care and delivering in a hospital. In line with Caldwells’ (1979) examination of Nigerian data, she found education to be a strong indicator of type and quality of maternal care. For instance, “in Tunisia, watching television weekly is associated with an increase in the likelihood of both prenatal care (OR = 1.85) and hospital delivery (OR = 1.64); with a similar, if slightly weaker correlation for Morocco [OR = 1.72 and 1.49, respectively]” (Obermeyer, 1993). Umar (2004) has documented similar findings on the relevance of exposure to the media, where the radio, as a major source of information on immunization, is associated with the level of exposure to knowledge on immunization services.

Provision of health care services is seen as largely a proximate determinant of declining mortality. However, with the provision of health services, there is no guarantee for its effective utilization (Basu, 1990); whenever there is disparity in healthcare provision, it is difficult to ascertain. This is possible because there are different bases for the use of the services under different conditions.

The literature on health matters generally looks at use of health services in developing countries as one of the main factors in reducing mortality. Studies by Nations (1985) demonstrate the critical role of health institutions in reducing morbidity, with some case examples from Sri Lanka, Costa Rica, and China. Other authorities in the field, like Caldwell (1986), have confirmed this.

In Nigeria, efforts are still being made to provide accessible healthcare facilities. They are still not enough. The ones available are largely concentrated in state capitals and large towns. Even then, there are disparities by region in awareness, availability, access, and health care utilization across the country (World Bank, 1995). Other logistics, notably transportation networks, impede access to some rural areas, where the majority of the people live. Moreover, the health care facilities available have been commercialized: hospitals have become consulting clinics, with patient paying user fees for cards, consultation and drugs (Alubo, 1990). As such, health care utilization is associated with other complex variables that influence the nature of access to and use of the services by the people.

Perhaps the only exception is immunization, where mothers and children receive “free” inoculation or house-to-house polio vaccination. As discussed elsewhere, even with this there is the problem of organization, logistics, and regular supply of vaccines (see NID’s, 1988; Blum & Phillips, 1986). Indeed, the availability of health care facilities may not be a strong determinant of its utilization. So, availability is a necessary, rather than a sufficient factor in health care use as can be seen the issue of vaccine availability, which even though available at certain times, is not by itself the most sufficient reason for the use of the vaccines (Umar, 2004, 2006). Other factors such as accessibility and transportation cost, seeking permission from the husband, influence from the source of information on immunization, etc. all contribute to determine utilization of immunization services (Umar, 2004, 2006).

Jain (1985) sees the decline infant mortality to be determined by the use of health care facilities in rural India. As reported by Basu (1989, 1990), other studies such as the Narangwal study (Keilman and Associates, 1983) show that infant mortality in children up to 3 years of age was “reduced by about 40% in these experimental villages that received health care services” (Basu, 1990, p. 275).

While some of the petroleum-rich countries of Saudi Arabia, Iraq, and Libya have established state-of-the-art medical technologies to an extent comparable to the advanced countries, yet the problem of infant mortality is not so low as in the West (Caldwell, 1986). Middle Eastern countries have lower infant mortalities than sub-Saharan Africa. For Basu (1990), the “mere existence of health services is not enough.”

In another study in India, Nag (1983; cited in Basu, 1990) shows how in West Bengal, India, there is more economic development than in Kerala, also in India, but with a corresponding increase in infant mortality in comparison to the latter. This is because in Keralan health facilities are evenly spread and the literate women population is predisposed to using health facilities once they are available. In effect, sprawling economic development is not necessarily a factor in reducing infant mortality. The key to understanding the essential elements in health care use is to consider the cultural factors that may enhance or impede the health care utilization. The ability to make a remarkable impact on health matters and to make people accept health intervention is necessary for the program—in addition to taking into consideration “the lifestyle of the people” (Nations, 1985), and the attitude, behavior, and culture of the people. Marriot (1976) shows how the antecedents of local culture, which are mediated by religion, heritage, and social arrangements in the society, influence the social world of health and healing in India. To put it differently, modern medicine must contend with the local way of preventing, treating, and managing health problems.

For Basu (1990, p. 276), there is a “need to design services to suit the culture of a population and to seek to transform patterns of behavior or ideology that are detrimental to actual health maintenance.” Saunders (1954) has long identified the integral role of culture in health care management. Abiodun (1991) and Adeniyi (1991) have also echoed this theme.

Basu conducted an important study on the critical influence on health care use in two Indian regional groups. His research looks at cultural factors as the variables affecting “level and kind of utilization on health care services”. He as hypothesizes that cultural and regional identities are linked with practices, attitude, and knowledge associated with the use of health services. In short, socioeconomic factors do not determine cultural factors, but can modify them.

In Nigeria, it is clear that there are differing regional statistics on infant and maternal mortality in Nigeria (CCP, 1994). The statistics are higher in the North than in the South, comparatively. The underlying cultural factors, vis-à-vis health care utilization, play a role in the differences. In another study, Basu (1989), on the whole, shows that cultural practices may not be uniform by region.

The reductionism, which excludes the social and psychological components in health and illness, is under serious attack. This is because it precludes the basic social factors that can influence the medical condition of the human body. The social and psychological components, embedded in the cultural system of the people, should be incorporated into a more holistic approach to the study of man and illness. As advocated by Abiodun (1991, p. 95), “the holistic approach calls for an integrated use of data, concepts and techniques derived from biological, psychological and social modes of abstraction to explain human behavior and to study and treat all deviation from health in individuals.” Adeniyi (1991, p. 25) arguing from a sociocultural perspective observes that “it has been recognized that most states of health or ill health are intricately interwoven with the cultural system of people and that the ultimate control of any disease require clean understanding of peoples’ style, behaviors and their implications or health and ill health.”

Health services utilization is usually low in the rural setting, as such “there is need for a clear understanding of how (the rural people) perceive and define their health problems and how they seek to solve them” (Adeniyi, 1991, p. 25).

The human behavior as encapsulated in the cultural matrix of the society is expressed in the perception and choices of the values of the people. This is based on the cultural norms, which legitimates behavior on health and ill health.

Specifically, issues in cultural influence of health care use cover:

• Traditional belief about disease, custom, and type of treatment in use;
• The way a preconceived notion of traditional system of disease may preclude or impede proper acceptance of modern methods;
• Social norms and customs that accumulate for long to form a cultural impediment may be the reason for resisting modern method; and
• Utilizing modern health facility is also a habit; it takes time for the habit to be imbibed, internalized, and practiced, just like the traditional methods.

In an attempt to mobilize the local population for vaccination, local circumstances may create conditions for developing the best strategy for making the people participate. Hanks and Hanks (1976) reported this kind of problem in immunizing children in Thai Bang Chan’s community. In this community, the pattern of their response to call for immunization can be summarized as follows:

• Many of the people did not heed to the call for immunization because it coincides with heavy agricultural activities.
• Spreading information on vaccination through headmen was fairly effective. However, this is more effective when this is done through the local school. This carries more weight.
• Immunization campaign is more received when people are aware of threat and danger of an epidemic (Hanks & Hanks, 1976).
• This can be possible in a closely-knit community and where formal education is given serious consideration.

Family Structure and Child Health

This section focuses on the link between family structure and child health. The child is completely dependent on the parents and the general family unit. Some critical family factors facilitate or hinder proper health care for the child. The level of education of the mother, income level of the parents, child sex differentials, and opportunity for health care are all associated with the way parents, specifically a mother, treat child diseases. Empirical researchers show that family structure is strongly associated with child welfare and health. The family, as an important constituent of production and consumption, provides the needed resources for the upkeep of the child, health-wise. The extended family provides the aegis upon which social and health care are facilitated in the household. However, there are varying research findings on child outcome (Desai, 1992).

Scholars from Pennsylvania State University and Demographic and Health Surveys, and Macro International present an important relationship between household structure and childhood immunization in Niger and Nigeria (Gage, Elizabeth, & Piani, 1997). They analyzed the Demographic and Health Surveys (DHS) for Niger (1992) and Nigeria (1990). The work of Gage, Elizabeth, and Piani is relevant to this research. Their analysis posits that household structure is an important determinant of childhood immunization. As such a rather detailed account of their analysis will be given.

Gage et al.’s research was guided by the following hypothetical assumptions:

• The availability of extended family members in a household provides a child with greater access to health care;
• The effects of family structure on child health are attenuated by economic factors;
• The child is the unit of analysis for their research; and
• The explanatory variables for the research are: household structure, region, economic status, and selected characteristics of the child and the mother.

The structure of the household is divided into: (a) Elementary household (a variant of nuclear family) and (b) Extended household (with parents, biological children, other family members and non-relatives).

The elementary household is subdivided into: (a) Single parent family, which consists of a head and biological children only, (b) Nuclear family with head, one spouse and biological children only, and (c) Polygamous family with a head, spouses with biological children only.

The extended household is further divided into: (a) Three generational family including parents and parents-in -law of the household head, and even grand children and (b) Laterally extended households, with primary siblings, cousins, and relations of the head. This classification was done to incorporate the variant cultural patterns in households.

Children by Type of Family Formation

The findings of the research by Gage et al, (1997), show that in both Niger and Nigeria there are smaller percentages of single parent families. They have fewer problems of pre-marital childbearing and separation as compared to the West. Sixty percent of children studied come from elementary homes, with about 40% coming from three generational and laterally extended families. In all, most of the children come from nuclear type of elementary household. Given the fact that “nuclear households are clearly the most common type of living arrangement among rural and urban children in Nigeria…at least two-fifths of Nigerian children are found in these households” (Gage et al., 1997).

Extended families are more prevalent in Niger than in Nigeria; the children have a strong probability of living in three-generational, extended households for the rural areas and laterally extended households for the urban centers, respectively. This structure, they argue, is more evident in Niger than in Nigeria. This data suggest that the constituent social context of family structure may inform the nature or even use of immunization services.

Family Formation and Immunization Coverage in Niger and Nigeria

Niger and Nigeria have some of the lowest immunization coverage (Gage et al., 1997; UNICEF, 2001, 2002), as is the case with many sub-Saharan African countries. This suggests a problem of use, compliance, or immunization coverage. Using the data to comment on immunization coverage Gage et al. (1997, p. 301) observed that “only 17% of children in Niger and 30% of those in Nigeria have received all the recommended vaccines” and an “additional 25% of children in Niger and 32% in Nigeria have received an incomplete set of immunization”

…in rural Nigeria, coverage levels for all types of vaccinations are lower for children from elementary polygamous and nuclear households compared to those from three-generational and laterally extended households; in urban areas of Nigeria, the lowest coverage rate is seen for elementary polygamous households (35.7% have received all vaccinations), followed by three- generational households and nuclear households. Children from laterally extended families have the highest coverage rates: 62.3% are fully immunized. (Gage et al., 1997, p. 301)

Gage et al. strongly observe that: “There are no significant effects of family structure on the likelihood of full immunization in rural urban Niger;” and that “Household structure has stronger effects on children’s chances of full immunization.”

Using complex and various statistical techniques (chi square, multivariate, bivariate, covariance, and finally, logistic regression), the study determined the odds ratio and predicted probabilities of being immunized.

Specifically, Gage et al., find that “In rural areas, children from nuclear and three-generational households show higher odds of full immunization than those from laterally extended households;” and that “In urban areas, nuclear and three generational households are negatively associated with odds of full immunization.”

Based on the above, irrespective of type of residence and economic status, a mother’s education is strongly significant in predicting possibility for full immunizations, and:

…in rural areas, the bivariate analysis shows that the odds of full vaccination coverage or children living in three–generational households (are not as in) laterally extended households. The chance of being fully immunized…is significantly lower for children living in nuclear and elementary polygynous households than for those from laterally extended households. (Gage et al., 1997, pp. 301-302)

The findings show that, economic status cannot wholly explain household differences in full immunization, especially for the elementary polygynous family; the education of the mother is a stronger variable than economic status in determining a child’s odds of complete immunization.

The theoretical premise of Gage et al.’s study is based on the emerging theoretical consideration that children from extended families are better off than those from nuclear-based households. Ordinarily, one would argue otherwise. One would expect few children from nuclear families to be predisposed to better family well-being. The family resources would be enough to cater for the few children. Conversely, a large number of children in extended families may struggle to receive care and attention from the limited pool of family resources. As argued by Gage et al. (1997) the analysis of data from Demographic and Health Survey (DHS) shows that extended households have more amenities and possessions than nuclear households, citing Gage et al. (1996) and Lloyds (1995), to indicate support of data coming from most of sub-Saharan Africa, Cameroon, and Egypt. The research of Murthy, Narayana, Vijayaraghavan, and Pralhad (1985) in India, and Dasgupta, Weatherbie, and Mukhopadhyay (1993) in South East Asia show that higher economic status is associated with extended households than nuclear ones. The bottom line for this thesis is that there are more resources in extended families than in nuclear ones. By extension, as research from United States shows, economic resources in the household are associated with child outcomes (Genonimus, Korenman, & Hillemeier, 1994).

A similar definite conclusion has not been drawn for sub-Saharan Africa. Also, “little is known about linkages between household structure, socioeconomic status, and health seeking behavior” (Gage et al., 1997). Equally, little is known on how the household families operationally mediate to determine child health outcomes.

Gugler and Flanagan (1978) explain how extended families experience a great deal of stress and strain due to the impact of industrialization and urbanization in Africa. But, by and large, the general pool of resources at the disposal of the extended family members predisposes the opportunity for enhancing the wellbeing of the members.

Again as succinctly argued,

One benefit of living in an extended household is that the presence of several adults in the household may contribute to an environment in which health services are used more effectively than in the nuclear household. The smaller size of nuclear households, therefore, may be a critical factor in their lower levels of immunization coverage… (Gage et al., 1997, pp. 302-303)

Gage et al.’s research is ambitious with elaborate statistical analysis. The findings have strengthened the existing knowledge on relevance of family structure on immunizations. The authors have accepted their limitation namely, inadequate variable measurement of living standard as an index of economic status. Also, the measurement was done before the time of vaccination.

Based on this they recommend that “…certainly, the analysis would be strengthened by the inclusion of other dimensions of household’s economic status such as consumption or income level, economic assistance, mother’s earnings, and the internal distribution of resources within households” (Gage et al. 1997, p. 307).

The Family, Income and Health

The economic variable of income is certainly one of the main factors that facilitate understanding of the proximate predisposing elements to living condition. Desai (1992) gives a persuasive presentation on family structure and risk to the child in West Africa and Latin America. There are ambivalent research findings on the relationship between income and child nutrition. The research findings are predicated on the fact that “the income or social class of parents is frequently used to index children’s access to resources” (Desai, 1992).

Thus, it is expected that lower income parents would give less health care than higher income families. However, there are now varying perspectives on the link between income and health care. Alderman (1990) finds a positive correlation between income and health; while Ravallion (1990) establishes a moderate correlation between the two variables. Others, such as Wolfe and Behrman (1983) and Berhman and Deolalikir (1987), found a weak relation between the two variables.

Based on the above, Desai argued that different research designs might account for the inconsistencies in the findings in Ghana, South India, etc. Still, the research findings did not show the vulnerability of children in relation to household income in a cultural context. Thus, we need further understanding of “intra household resource allocation” and differing access to “productive resources”. Drawing data from the Demographic and Health Surveys (DHS) of Ghana, Mali, and Senegal in West Africa as well as from Columbia, Brazil, and the Dominican Republic in Latin America, Desai examined the children who are at risk, given particular income levels and family structures. Desai (1992, p. PAGE) concludes: “if women and children provide much of the food and other subsistence items for themselves, then there is little reason to assume that, at any given level of paternal income, children in polygynous families will have access to fewer resources than children in monogamous families.” Murthy et al. (1985) shows how in Andhra Pradesh children in extended families are nutrition-wise better off than those in nuclear families. This indirectly supports the research of Gage et al. (1997) on household structure and immunization in Nigeria and Niger.

In our rural areas, married women work extra time on the farm to harvest, process, cut firewood, cook the food, and engage in other income generating activities to augment the family’s income. Thus, there is a potential for further supporting the health of the child where the husband fails. This is especially more certain where there is a social network of extended ties in the corporate household. As Gage et al. (1997) comment, social network provides an avenue for transmitting information on immunization. However, little is known about the social processes of exchange of information and networking on immunization in the community. This is an area for future research.

Sex Differentials and Child Health

The demographic factor of health is an essential factor in the gender of the population, and cultural elements associated with it underline the basis for health development. It is not uncommon to hear that a family values male more than female children. And, in the context of sociocultural socialization, the social psychology of the girl child is conditioned to reflect certain standards to a greater degree than the males. Males are seen by many as economic assets and heirs. This is evident in the places where the family depends on working on the farm draw their lineage from the male side and residence and authority is based on a patriarchal set up.

Based on an analysis of Bangladesh Matlab Demographic Surveillance System, Muhuri and Preston (1991) found discrimination against girls as parents maneuver to cope with child survival strategy. Similar findings in India have been shown by Dasgupta (1987). In Matlab, which is regarded as a famous research area on population, fertility, and health, it has been found that male children have more chances of being brought to the hospital than female children. This is even after a free diarrhea treatment has been offered (Chen, Huq, & Souza, 1981). Also following the submission of Basu (1989), previous works by Caldwell (1983) have found that in rural south India male children twice as likely to be taken to the hospital as females. Still in India, Das Gupta (1987) shows how male children are more favored and girls discriminated against; this practice has existed for decades. This selective discrimination tends to worsen the social, economic, and health position of females. Basu (1989) has cautioned that these discriminations are not uniform by region. By extension, this kind of sex differential in regard to access to health care is an area that should be given consideration in research. This is especially necessary because we are witnessing an increase in abuse and neglect of the child, especially the female.

Maternal Education and Child Health

It has become obvious now that mothers’ education is a proximate determinant of child health (Gage et al., 1997). Across cultures, many researchers have confirmed the relationship between enhanced health and acquisition of educational skills by mothers. Muhuri (1995) studied the extent to which differentials in mortality are associated with a mother’s education. Levine et al, (1991) indicates that maternal schooling is a predictor of reduction in fertility and risk in child survival. In addition, husbands’ education is a predictor of fertility reduction, but with no direct linkage with health care variables. As a result of the division of labor, the wife takes more care of the child. Again, educated women take their children to the hospital more often.

For Gage et al. (1997) even socioeconomic variables may not be stronger than education in enhancing the care for child immunization. And, in particular, “mothers education increases the odds of immunization by about 80%” in Niger and Nigeria (Gage et al.,).

Data from the Millennium Development Goals (2006) show that “higher household income and education for mothers double chances for child survival” (United Nations, 2006, p. 13). Already, education is a proximate determinant of reduction in child mortality rates (CCP, 1994). With higher educational status of mothers, there would be lower rates in child mortality.

Many health experts see education as one of the factors influencing health condition. In other words, the lower the level of formal education of mothers the higher is child mortality. Education is a mediating factor that enables and empowers the mother to learn how to take care of her children. (Umar, 2004, p. 9)

Research on child immunization has shown that though mothers are central agents in immunization, they have a low level of formal education; however, they have exposure and knowledge on vaccinations through media advertisements (Umar, 2004). Thus, mothers’ positive perception on immunization may not necessarily be attributed to their education, but to their exposure to available knowledge on immunization. By implication, other sources of information on immunization, other than through formal schooling, can serve to enhance the quality of knowledge in the area. Hence, further research is needed to focus not on education per se, but on sources of information (e.g. media, health campaign, drama, interactions) that can enhance health attitude.

Conclusion

As the business of child vaccination in developing countries is complex, so is the influence of the mechanics and realities of background variables of sex, sociocultural factors, income, and education on usage. The interplay of these factors is closely associated with health care utilization. The nature and structure of the family plays a critical role in the immunization process. However, more research is needed in the areas of communication and networks of social relationships as possible influencers of immunization.

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