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

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.