%0 Journal Article
%T Starting then stopping: a nationwide register-based study on the magnitude, predictors, and urban-rural patterns of under-vaccination variation across health centers in The Gambia.
%A Sowe A
%A Namatovu F
%A Cham B
%A Gustafsson PE
%J Glob Health Action
%V 17
%N 1
%D 2024 Dec 31
%M 38826143
%F 2.996
%R 10.1080/16549716.2024.2348788
%X <B>UNASSIGNED: </B>Six million children were under-vaccinated in 2022. Our study aimed to 1) quantify the magnitude of under-vaccination variation between health facilities, 2) assess to which extent individual and health center level factors contributed to the variation, 3) identify individual and health facility factors associated with under-vaccination, and 4), explore rural vs. urban health facility variations.<BR><B>UNASSIGNED: </B>We used data from 61,839 children from The Gambia national routine vaccination register. We cross tabulated under-vaccination status across study variables and fitted two-level random intercept multilevel logistic regression models to measure variance, contribution to the variance, and factors associated with the variance and under-vaccination.<BR><B>UNASSIGNED: </B>We found that 7% of the prevalence of under-vaccination was due to variation between health facilities. Thirty-seven percent of the variation was explained by individual and health center variables. The variables explained 36% of the variance in urban and 19% in rural areas. Children who were not vaccinated at 4 months or with delayed history, due for vaccination in the rainy season, and health facilities with very small or large population to health worker ratios had higher under-vaccination odds.<BR><B>UNASSIGNED: </B>Our study indicates that one of the pathways to improving vaccination coverage is addressing factors driving under-vaccination inequities between health facilities through urban-rural differentiated strategies.<BR>Main findings: Variation in under-vaccination rates between health centers contributes to worsening performance overall and in urban and rural areas.Added knowledge: Our study indicates that one of the paths to improving under-vaccination and consequently total coverage is by addressing the factors driving under-vaccination and its inequity between health facilities.Global health impact for policy and action: Children with delayed or non-vaccination history at four months of age, those due for vaccination in the rainy season especially in urban areas, and health facilities with very small or big birth dose to health worker ratios are potential targets for improving under-vaccination.