| BackgroundViral Hepatitis B, referred to as hepatitis B, is a kind of infectious disease of the most serious harm among viral hepatitis. It is a top10global cause of death in, and each year about1million people die from chronic hepatitis B disease. The number is up to eight times more than HIV/AIDS. At present, China is one of a few countries which have the high prevalence and incidence of Viral Hepatitis B(Hepatitis B Virus, HBV) in the world. About15million people are chronic hepatitis B patients. In China, about54million people suffer new incidence of acute hepatitis B every year. The number of deaths caused by HBV infection of the liver cancer is about12million annually, causing about200billion in terms of direct medical costs. The infection of HBV caused heavy economic burden to patients, their families and the whole society. The impact brought by HBV on socio-economic development cannot be ignored. For many families, HBV is the primary reason for returning to poverty and also triggers a series of social problems. At this stage, it is one of the most prominent public health issues in China.By the end of2008, hepatitis B vaccine have been involved in conventional immune project in more than180WHO members, and national neonatal hepatitis B vaccine EPIs has made great achievements. The incidence of hepatitis B and infection rates of hepatitis B surface antigen (Hepatitis B Surface Antigen, HbsAg) showed a significantly downward trend. Since1987, China began to implement the neonatal hepatitis B vaccine immunization project. In1992, hepatitis B vaccine has been involved in children’s immunization program management by the Ministry of Health. In2002, the State Council approved that the neonatal hepatitis B vaccine was involved in the National Immunization Program. In March2005, the State Council promulgated the "vaccine circulation and vaccination management regulations", requiring national vaccination card system for children. National Immunization Program implemented free vaccination from then on. The effects of these policies are remarkable. The prevalence of hepatitis B virus carriers in China decreased from10.0%in1992to7.2%in2006. But the morbidity and mortality of hepatitis has no obvious decline, even the rising trend. One of important reasons is that in the population above the age of15characterized by high carrier rate of hepatitis B surface antigen, and nearly a half of adults do not have hepatitis B surface antibody protection. Therefore, on the basis of continuing to do neonatal hepatitis B, vaccine immunization planning, it is an urgent task for our country to explore measures and strategies of adult hepatitis B vaccine, in order to improve overall hepatitis B antibody levels and reduce infection and morbidity of hepatitis B in China. On the other hand, HbsAg positive rate has a large difference between urban and rural areas in China,7.9%in urban and11.2%in rural, combined with a huge base of our rural population accounting for about60%of the total population, thus the vast majority of hepatitis B cases are concentrated in rural areas. Regarding the incidence of hepatitis B, rural areas is significantly higher than urban areas. So, in order to reduce the high incidence of hepatitis B, the key emphasis in work should put on the rural areas.In2000, WHO evaluated and sorted the performance of health care services in191countries and regions around the world. On equity, our country is188th, the last fourth among all countries. One of the main reasons is that the gap of medical services between urban and rural areas in China is significant. In2005, the magazine "Truth Seeking", combined with relevant government departments, social organizations and relevant experts, carried out a survey on "China Well-off Index". According to the results of the survey, the public health service satisfaction is located at the bottom of the ranking. How to achieve equity of public health services and how to meet the people’s health care needs are currently becoming hot and difficult problems for our country, government and society.In general, equalization or fairness of essential public health services is embodied by its equity to the specific content, including equity of disease prevention, maternal&children care and health education. Therefore, studying and analyzing equity of disease prevention and health education will help us to better understand the status quo of the equalization of essential public health services, to enhance the equalization of essential public health services. And immunization of hepatitis B vaccine as one of the main content of China’s public health services will have special importance in the field of essential public health services.In view of this, the study will be based on China’s vast rural areas, and conduct a comprehensive analysis of the equity of hepatitis B cognition and hepatitis B vaccination, in order to reflect the equity of China’s rural essential public health services related to hepatitis B, put forward relevant policies and suggestions, finally provide scientific policies and suggestions to realize the equalization of China’s essential public health services.ObjectivesThe general objective of the study is to systematically analyze and reveal the adults’ cognition of hepatitis B and the influencing factors of taking Hepatitis B Vaccine, based on review and summary of the domestic and overseas related studies and the data of field survey. On this base, analyze the fairness of the cognition of rural areas’ adult to hepatitis B and the behavior of hepatitis B vaccine inoculation, so as to seek the contribution rate of every factor and provide policies and suggestions of improving the rate of hepatitis B vaccine immunization and completed immunization rate.The concrete research purpose includes:to know the situation and influences of the cognitive and hepatitis B vaccine inoculation of rural areas’adult; reveal every influencing factors’contribution rate of the equity of hepatitis B vaccine inoculation of rural areas’adult; propose targeted policies to improve the cognitive of hepatitis and fairness of hepatitis B vaccine inoculation of rural areas’adult and raise the degree of cognition about hepatitis B and the rate of hepatitis B vaccine inoculation of adults in rural areas.Data and MethodsThe study mainly adopts cross-sectional design and the method of quantitative research. The data information came from the program-"To what extent do user fees affect Hepatitis B vaccine coverage rates in China?" funded by the National Research Council of Norway. The field survey began in January2011and completed in April2012. The study uses the part of the investigation in2011.The research extracts Hebei province, Shandong province, Jiangsu province, Heilongjiang province, Hainan province, Ningxia province as sample regions, on the basis of geographical position, the level of economic development and gross population; and extracts9counties with the same standard, including2counties extracted from Hebei province, Shading province, Jiangsu province respectively;1county extracted from the other three provinces.3villages were randomly sampled from every county, totally27villages. Then take sample using the method combined PPS with cluster sampling, including all the family members above16years. In questionnaire survey, collect data of the residents’social economic conditions, the cognition of hepatitis B and hepatitis B vaccine; the history of taking hepatitis B vaccine, the behavior of specific inoculation and the wish of inoculation; family situation, including family income, expenditure etc.The research built database using DataEasy software, and conducted data analysis through Stata/SE12.0software. Descriptive statistical analysis, single factor analysis and multivariate analysis method were mainly used to analyze the quantitative data. In multivariate analysis, the research made the use of different analysis model according the difference of dependents. If the dependent variable is a continuous numerical variable, multiple linear regression model analysis was used; if the dependent variable is binary variable, the data was analyzed through the method of unconditional binary Logistic regression model.Results1. Equity analysis of rural adults’hepatitis B cognition(1) Influencing factors of rural adults’hepatitis B cognitionSingle factor and multiple factors analysis showed that age, education level, employment status, income level, and province are the significant factors affecting the cognitive of hepatitis B in rural adults. With the improvement of education level and income level, score of cognition of hepatitis B would gradually increase. In the group of employment status variable, medical staff got the highest scores of cognition of hepatitis B, followed by civil servant, while farmers got the lowest scores. Between provinces, Shandong Province got the highest scores, the next was Heilongjiang Province, while Hainan Province got the lowest scores, and Ningxia got the second lowest scores.Multiple factors analysis shows that education and income level were protective factors of cognition of hepatitis B, with the rise of education level and income level, regression coefficient was increasing. Among different regions, the scores of hepatitis B cognition in Shandong Province, Hebei Province and Heilongjiang Province were significantly higher than Jiangsu Province, and Shandong Province got the highest coefficient3.969. But Hainan Province got the lowest coefficient-1.426.Which shows that if other factors remain unchanged, for every increase of one percentage point of the proportion of adults involved in the survey, the forecast scores of cognition of hepatitis B will decline1.426points.(2)Equity and decomposition analysis of rural adults’hepatitis B cognitionThe distribution of adults’hepatitis B cognition level exist inequity phenomenon, which was indicated by the concentration index (CI)0.0727. This means that the adults who got higher cognitive scores concentrated in wealthier people. The influencing factors included in the analysis model can explain97.30%of the inequity degree of rural adults’hepatitis B cognition; these influencing factors included age, education level, professional status, income level and province. Except for the negative contribution rate of professional status, the others factors’contribution rate were all positive value. Among these factors, the contribution rate of education and income level were significant, and the contribution rate was respectively76.54%and13.90%.The age was an important factor of inequity of adults’cognition of hepatitis B; the contribution rate was5.79%. In contrast, the contribution rate of regional differences was smaller, which can only explain2.17%of the inequity phenomenon.2. Equity analysis of rural adults’hepatitis B vaccination(1) Influencing factors of rural adults’hepatitis B vaccinationSingle factor and multiple factors analysis showed that except gender, age, marital status, education level, employment status, income level, province, the price of hepatitis B vaccine, distance to inoculation site and hepatitis B cognition were all significant factors influencing hepatitis B vaccination. With the increase of age, the rate of hepatitis B vaccine declined. The rate of hepatitis B vaccine was below the current alone population(including unmarried, divorce and widowed population).With the increase of education level, income level and hepatitis B cognition score, the rate of hepatitis B vaccine would go up. In the group of employment status, the farmers’ vaccine rate was lower than other groups. Among different provinces, vaccination rate of Hainan Province was the highest, next was Ningxia, the third was Hebei Province, and Jiangsu Province was the lowest. When the hepatitis B vaccine price was less than40yuan, the vaccination rate is lower with the higher prices. When less than lOyuan, the rate of vaccination would exceed50%. Similarly, when the distance is less than9km to the vaccination sites, the vaccination rates reduce with distance increases, the vaccination rate is much larger than the other three groups when the distance is less than three kilometers.Multivariate analysis showed that the possibility of hepatitis B vaccination for the current alone population was1.385times of the married. The possibility for rural adults’hepatitis B vaccination would increase with the improvement of education level, income level, and hepatitis B cognitive score. The vaccination possibility for population of high school and above was3.75times of population with the primary school level and lower. The vaccination rate of score20points and above was3.56times of score under10points. In the group of employment status, the smallest possibility of hepatitis B vaccination is the group of farmers, vaccination possibility of civil servant and students were respectively3.09and3.13times of farmers’. In geographical differences, the HB vaccination receiving possibility for rural adults in Hebei, Shandong, Heilongjiang and Hainan Province were higher than Jiangsu Province, and the highest vaccination rate was Shandong Province, which was35times more than Jiangsu Province, followed by Hebei Province. But the vaccination possibility of Ningxia was only0.44times of Jiangsu Province. The vaccination possibility of price below10yuan was more than500times of the price of40yuan. But when the vaccine price was between24yuan to40yuan, the vaccination possibility was0.57times of40yuan. The vaccination possibility was lower with the increase of the distance to the vaccination sites, and the distance of less than3km was 221times of9km and the above.(2)Equity and decomposition analysis of rural adults’hepatitis B vaccinationThe distribution of adults’hepatitis B vaccination exist inequity phenomenon, which was indicated by the concentration index (CI)0.1117. That means that hepatitis B vaccination concentrated in wealthier people. The influencing factors included in the analysis model can explain99.15%of the inequity degree of rural adults’ hepatitis B vaccination; these influencing factors included age, marital status, education level, employment status, income level, province, the price of hepatitis B vaccine, distance to inoculation site and hepatitis B cognition. The contribution rate of marital status, provinces, and price of hepatitis B vaccine were all negative value,-1.53%,-10.72%,-96.45%, respectively. The contribution rates of other factors were all positive values. The contribution rate of marital status, educational level and employment status and income level were the highest, and the total contribution rate of these social economic factors reached66.03%. And the contribution rate of educational level and income level were significant. The contribution rate of influencing factors associated with hepatitis B cognition and hepatitis B vaccines (including the price of hepatitis B vaccine, distance to the vaccination sites, hepatitis B cognitive score) was also high, totally31.85%.Thus it can be seen that the influencing factors associated with hepatitis B cognition and hepatitis B vaccines are the important factors of vaccination inequity.Conclusions and Policy ImplicationsThe research found that age, education, employment status, income, and province are the significant factors affecting the cognitive of hepatitis B in rural adults. The distribution of the hepatitis B cognitive level in rural adults is inequitable and the affluent has higher score. This inequity is the result of combination of the above factors as age, education, income and regional differences. Among these factors, income has the largest influence and can be controlled by external intervention. Age, marital status, education, occupational status, income, province, hepatitis B vaccine price, distance to the vaccination sites and hepatitis B cognitive score are significant factors affecting hepatitis B vaccination of rural adults. The distribution of the hepatitis B vaccination in rural adults is inequitable and hepatitis B vaccination is more concentrated in the more affluent group. The above factors as age, education, occupational status, income, distance to the vaccination sites, and hepatitis B cognitive score contributed to this inequality jointly. Among these factors, distance to the vaccination sites has the largest influence, as well as income and cognitive of hepatitis B, can be controlled by external intervention.In order to improve the rate and reduce unfairness of Hepatitis B cognitive level and vaccination, the study has put forward following recommendations:(1) increase farmers’income and narrow the income gap. The most fundamental method is to adjust the agricultural structure, explore the potential of the agricultural income, focus on improving the overall benefit of agriculture; and then be market-oriented, accelerate the innovation of agriculture industrialization and the pace of transferring rural surplus labor, while increasing investment in human capital enhance competition in the labor market by raising the culture level of farmers and vocational skills,; Finally, it is necessary to improve the system of finance, banking, social security and other services and actively promote the development of township enterprises and the process of urbanization to create opportunities for farmers to increase income.(2) Increase education and publicity efforts of hepatitis B-related knowledge. Education for young people can be carried out in the form of some routine school courses or classes. For rural adults, considering the reality of their lower knowledge level, we should design the form that easier to understand, such as opera, comic dialogue and so on, and advocate it by cultural activities in the countryside or through the local TV media.(3) Improve the availability of the hepatitis B vaccination services. We should ensure the quality of hepatitis B vaccination and try to sink the hepatitis B vaccination services to primary health service providers at the same time, in order to improve the availability of the hepatitis B vaccination services. For remote rural areas, we can even provide on-site service, in order to reduce the economic and opportunity costs of the vaccination and increase vaccination rates. |
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