| BackgroundHepatitis B virus infection is a major global health problem, especially in China. China is one of the high prevalence countries. In the People’s Republic of China, hepatitis B is one of the top three infectious diseases reported by the Ministry of Health of China, and approximately110000persons die each year from HCC, which accounts for45%of the deaths from HCC worldwide. HCC is the second leading cause of cancer mortality, among them70%-80%are attributable to HBV infection. In1992, the China national hepatitis seroepidemiological survey found that the prevalence of HBsAg for population aged1-59years was9.8%. Based on this survey, it has been estimated that in China,120million people carry HBsAg. The diseases caused by hepatitis B virus infection bring very heavy disease burden to the patients and their family, resulting in lots of social problems, having very negative influence on the metal health of patients and their family members, and causing a large decline of quality of life.HBV vaccine program is currently one of the most effective measures to prevent hepatitis B infection. During the past20years, China has made a great effort to reduce the prevalence of HBV. In1992, the Ministry of Health recommended hepatitis B vaccine for routine immunization of infants but families were charged the vaccine and service fee. In2002, China integrated hepatitis B vaccine into National Expanded Programme on Immunization (EPI), with the cost of vaccine was paid by the government, but the service fee was still allowed as a charge to parents. In May2005, the government required that all infant vaccinations were given at no charge to parents. In2009, the Central Government of China suggested to retroactively immunize teenager (younger than15years old) on HBV for free. The prevalence of HBV carriers in China was markedly reduced after implementing these policies. National hepatitis serosurvey in2006showed that compared to1992, the prevalence of HBsAg among children aged1-14years who were born after hepatitis B vaccine was recommended for routine childhood immunization was much lower than same age groups in1992. At the end of2011, almost all chidren below15years old have finished the hepatitis B vaccination uptake.All these policies mentioned above has reduced the transmission from mother to child, but horizontal transmission, such as sexual transmission or blood transmission, remains a concern among unvaccinated young adults and women in childbearing years. In2009, viral hepatitis (dominated by type B) was the top infectious disease in China, and the incidence rate increased every year from2001-2009, according to Health Statistics from the Ministry of Health. Several researches reported that the incidence rate was high in15-29and30-44age groups], and farmer account for the most part of new case of HBV. The HBV susceptibility rate among age group15to59in rural area of Shandong Province is53.91%. Mathematical modeling based on the data reported by the Ministry of Health of China indicates that hepatitis is approaching its equilibrium with the current immunization program and control measures and retroactive immunization of susceptible adults was suggested. Even among generally healthy adults the risk of chronicity following acute infection is very low:<or=5%, the disease burden is still high. The direct and indirect economic burden was12443.9Yuan and3412.6Yuan one year respectively, and the recessive of economic burden is almost twice of indirect economic burden.If China wants to significantly reduce the incidence and disease burden of HBV, catch-up vaccination of adults aged15-44is important, especially in rural area. Regard to the prevention service, it is always underused even when it was free. For adults in China, hepatitis B vaccine was belonged to the second type of vaccine which was not covered by government and individuals who over than15years must pay for the vaccine and service fee. So the coverage rate is very low, especially in rural area where with relatively low income. Meanwhile, it is unlike vaccination covered by EPI, there is no fixed site for adults to get vaccine. They can choose the facility as they wanted. Some researchers showed that distance, travel cost, and time cost were very important factors of the demand for vaccination.For now, the researches about utilization and demand for hepatitis B vaccination were very few, and focused on the epidemic surveys. A few of studies assessed adult’s decisions whether or not to be immunized, and suggested some demographic variables, such as age, gender, schooling, occupation, household income, and health insurance are playing important roles in hepatitis B vaccination demand, but the effects of accessibility variables and the special health knowledge, such as user fee, travel and waiting time, and travel cost on the hepatitis B vaccine decisions are less clear. Based on the health capital demand theory, Health belevie model and Protection Motivation Theory, a theoretical framework for exploring the demand for hepatitis B vaccination was established, to reveal the utilization in the past, the demand in the future, and the choice of the vaccination site.ObjectiveThe overall objective of the study is analysizing the utilization and demand of hepatitis B vaccine of adults in rural areas and exploring the related influence factors by theoretical and empirical research to provide a theoretical reference and scientific basis for prevention and control decision-making of hepatitis B in rural areas. Specific research objectives include:building a theoretical and empirical model of the individual hepatitis B vaccine demand of adults; revealing the hepatitis B vaccine utilization of adults with different characteristics, and the risk factors of uncompleted vaccination; exploring the individual hepatitis B vaccine demand of unvaccinated group; analysizing preferences of vaccination institutions choice among different characteristics crowd; proposing policy recommendations to increase hepatitis B vaccination services utilization of adults.MethodsThe 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. It was a cross-sectional study. The main focus of the study was analyzing the impact of the direct and indirect costs on utilization and demand of hepatitis B vaccine from the health economics perspective. The target group was the people aged from15-44in rural areas. According to research purposes and the economic level of the survey areas, the paper used six provinces or autonomous regions of the subject, including Jiangsu and Shandong which are high developed, Heilongjiang and Hebei which are middle level, and Hainan and Ningxia which are underdeveloped, respectively. The study collected nine counties totally, and three villages were sampled from every county (or county-level city) in accordance with the distance from vaccination sites (township hospitals mainly), a total of27villages. The study used the method combined PPS with cluster sampling to take sample. The final sample included27villages,4,297households, and9,402individuals. This study was based on the personal health demand to build the utility function of individual vaccine demand and analyze consumer choice behavior at different stages to obtain the information of personal utilization and demand of the hepatitis B vaccine. The analysis methods included descriptive statistical analysis, single factor statistical inference, the Nested Logit regression and non-conditional logistic regression and so on.Results(1) The hepatitis B vaccination rates were from15.87%to22.41%in various regions, an average of19.24%. Vaccine prices, time and transportation costs hindered the utilization of the vaccine. Better health status, considering it is very serious to influence hepatitis B, and the number of correct cognition about transmission routes and vaccine effectiveness had a higher vaccination rate compared with the control group. The cognitive of vaccine efficacy showed the increasing trend with the length of protection time, but the cognition of error transmission route and the influence severity had no influence. The probability of choosing vaccination declined with age ascending, rising with higher level of education, farmers and migrant workers were lowest.(2) Totally speaking, demand analysis of unvaccinated group showed that the personal demand in the areas that village clinics provide vaccination services (area A) was higher than that can not provide vaccination services (area B), and the demand was susceptible to be influenced by subsidies. The price of the vaccine, transportation and time costs had significant impact on the future demand of the individuals; Health related knowledge variables had a significant influence on demand except the cognitive of seriousness of the hepatitis B. Demand increased with the expectation of personal health vaccination; Demand was lower in the high age group than the low age group; Demand of the group that education level is junior middle school was higher than primary school and below; occupation, insurance status and income had no significant influence.When asked the group that haven’t vaccinated and does not intend to in the future under the current policy whether they would like to receive vaccination if the vaccine is free,54.3%crowd without demand will transfer into a demand population. The demand will increase by about10%when compensate10yuan per dose. After that the demand almost didn’t increase with the increasing subsidies, but the individuals in the areas that village clinics provide vaccination services is vulnerable to change their demand with the influence of subsidies.(3) The revealed preference (personal utilization before) analysis indicated that vaccine prices had the weakest impact; while transportation costs had the largest impact.But the stated preference (personal future vaccination willingness) showed that time costs had the smallest impact and the impacts of prices and transportation costs were almost the same.About the knowledge variables related to the individual health expectation, the revealed preference analysis indicated that there existed correlation between higher cognitive level and selection vaccination institutions as township hospital and county-level CDC. There was a certain difference between area A and area B in the stated preference study. High cognitive individuals were more likely to choose township hospitals and county CDC in the region A. But in the area B, high cognitive individual were more likely to choose county level hospitals.The effects of sociodemographic characteristics of the individual in stated preference analysis were not as significant as in the revealed preference analysis. In the revealed preference analysis, individuals of high education level were more tend to choose the Centers for Disease Control and Prevention as the vaccination place, and the increasement of income would improve the probability of choosing the county-level hospitals and village clinics as vaccination institution. In the stated preference analysis, individuals of high education level were more likely to choose the Centers for Disease Control and Prevention as the vaccination place, income in the region A would increase the probability of choosing the village clinics, but reduce the probability of selecting the county-level hospitals. Income would increase the personal choice of the county-level hospitals in the region B, but reduce the choice of the CDC, and other sociodemographic characteristics of the individual had no significant influence on the preference of the institutions selection. (4) Using10yuan as a unit, the estimated coefficients of vaccine prices and transportation costs were not equal in any part of the research results. In the utilization analysis, vaccine price had no significant impact on utilization in region A, but the coefficient of the transportation costs is about twice of the vaccine price coefficient in the region B. The impacts of them on the individual utility were basically the same in demand analysis.In the analysis of the utilization, the time cost (1hour) coefficient was about1/2of the transportation costs, but the coefficient was equal to the coefficient of10yuan in the region B, it was less than1/2of the transportation costs; in needs analysis, the cofficients of the time cost in the two regions were roughly equal to the other two properties.Conclusions and RecommendationsThe level of Hepatitis B vaccine utilization was much lower among the people aged15-44years in China’s rural areas. The risk factors included older age group, low education level, uninsured, low-income, farmer and low cognitive level, at the same time lower health services accessibility, such as higher prices and transportation costs, spending more time would still reduce the level of the hepatitis B vaccine utilization. Completed inoculation rate needs to be improved. The older age groups and uninsured were risk factors of uncompleted vaccination and the compleded inoculation rate is much lower in village-level institutions. Main factors affected the demand of unvaccinated population were vaccine prices, transportation costs and some variables of personal health expectation. Free vaccine and proving subsidies could improve individual demand of vaccination. Preference of vaccination choice was mainly affected by the health expectation of vaccination. The higher expectation people have, the more they tend to choose professional institutions such as township hospitals and disease prevention and control center.According to the conclusions, we propose the following policy proposals:(1) Reduce the price of the vaccine; implement free vaccination on the focus and high-risk groups gradually.Due to the impact of vaccine price on the service utilization and demand, reducing price would increase the demand and utilization of vaccination inevitably, especially when the price is reduced to0, it will greatly improve the demand level of the individuals for vaccination. So it should be considered to implement free vaccination for high-risk and focus groups on the basis of the risk assessment. At the same time, since individuals were more sensitive to the price of village clinic at the same price level, so reducing the price of village clinic has much more effect on vaccination demand than other institutions.(2) Improve the accessibility of vaccination services; arrange the vaccination institutions reasonably; provide vaccination services conveniently and rapidly under the premise of guaranteeing quality.According to the studies above, inoculators did not show a preference for high-level vaccination institutions in selecting vaccination agencies, but would be more inclined to choose the township and village level vaccination institutions. It was very significant to expand the ability of vaccination services in township and village level institutions.The impacts of transportation and time costs on utility of vaccination were much greater than the price of the vaccine, and therefore, in the case of vaccine payment, improving geographical accessibility has a more important role in vaccination.(3) Strengthen publicity relevant knowledge; enhance personal expectations of the health benefits of vaccination.It can be seen from front analysis that there exist relevance between personal health-related knowledge and high service utilization and demand. Through publicity and education on health-related knowledge, personal cognitive level and their perception of health expectations can be improved, this can improve utility level of vaccination; thereby increase the demand and utilization of vaccination.(4) The staff of vaccination institutions should strengthen publicity and education of vaccination to improve compliance.The staff of vaccination institutions should target to the group of lower vaccination rate, such as20to34years old and uninsured group, emphasize on vaccination procedure, and the knowledge of the impact of uncompleted vaccination on vaccine protection rate to improve vaccination compliance. |
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