title: Demand- and supply-side determinants of diphtheria-pertussis-tetanus nonvaccination and dropout in rural India.
abstract: Although 93% of 12- to 23-month-old children in India receive at least one vaccine, typically Bacillus Calmette-Guérin, only 75% complete the recommended three doses of diphtheria-pertussis-tetanus (DPT, also referred to as DTP) vaccine. Determinants can be different for nonvaccination and dropout but have not been examined in earlier studies. We use the three-dose DPT series as a proxy for the full sequence of recommended childhood vaccines and examine the determinants of DPT nonvaccination and dropout between doses 1 and 3.
  
  
  
  We analyzed data on 75,728 6- to 23-month-old children in villages across India to study demand- and supply-side factors determining nonvaccination with DPT and dropout between DPT doses 1 and 3, using a multilevel approach. Data come from the District Level Household and Facility Survey 3 (2007-08).
  
  
  
  Individual- and household-level factors were associated with both DPT nonvaccination and dropout between doses 1 and 3. Children whose mothers had no schooling were 2.3 times more likely not to receive any DPT vaccination and 1.5 times more likely to drop out between DPT doses 1 and 3, compared with children whose mothers had 10 or more years of schooling. Although supply-side factors related to availability of public health facilities and immunization-related health workers in villages were not correlated with dropout between DPT doses 1 and 3, children in districts where 46% or more villages had a healthcare subcentre were 1.5 times more likely to receive at least one dose of DPT vaccine compared with children in districts where 30% or fewer villages had subcentres.
  
  
  
  Nonvaccination with DPT in India is influenced by village- and district-level contextual factors over and above individuals' background characteristics. Dropout between DPT doses 1 and 3 is associated more strongly with demand-side factors than with village- and district-level supply-side factors.
authors.affiliation: Public Health Foundation of India, Gurgaon, Haryana, India. Electronic address: arpita.ghosh@phfi.org.
authors.forename: Arpita
authors.initials: A
authors.lastname: Ghosh
authors.affiliation: Center for Disease Dynamics, Economics & Policy, Washington, DC, USA; Princeton University, Princeton, NJ, USA. Electronic address: ramanan@cddep.org.
authors.forename: Ramanan
authors.initials: R
authors.lastname: Laxminarayan
mesh_terms: D000293:Adolescent; D000328:Adult; D004165:Diphtheria / Q000276:immunology / Q000382:microbiology / Q000517:prevention & control*; D015721:Diphtheria-Tetanus-Pertussis Vaccine / Q000008:administration & dosage*; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006306:Health Surveys; D006801:Humans; D017589:Immunization Programs; D007194:India; D007223:Infant; D008297:Male; D008875:Middle Aged; D009035:Mothers / Q000193:education / Q000523:psychology; D010352:Patient Dropouts / Q000523:psychology* / Q000706:statistics & numerical data; D012424:Rural Population; D013742:Tetanus / Q000276:immunology / Q000517:prevention & control* / Q000821:virology; D014611:Vaccination; D014917:Whooping Cough / Q000276:immunology / Q000382:microbiology / Q000517:prevention & control*
chemical_list: D015721:Diphtheria-Tetanus-Pertussis Vaccine
keywords: District Level Household and Facility Survey (DLHS-3) 2007–08; Multilevel modeling; Partial or incomplete immunization; Vaccine uptake