中国农村地区成人乙肝认知和乙肝疫苗接种的公平性及其分解分析
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摘要
研究背景
乙型病毒性肝炎简称乙肝,是病毒性肝炎中危害最严重的一种传染性疾病,居全球死亡原因的第10位,每年大约有100万人死于慢性乙肝疾病,人数高达艾滋病感染者的8倍以上。我国目前是全世界仅有的少数几个乙肝病毒(Hepatitis B Virus, HBV)高流行和高发病的国家之一,约有慢性乙肝患者1500万人,每年新发急性乙肝病例约54万,每年由HBV感染的肝癌导致死亡的人数约有12万,造成直接医疗费用约200多亿元。乙肝病毒感染给病人、病人家庭、社会造成了沉重的经济负担,给社会经济发展带来不容忽视的影响,是许多家庭因病致贫、因病返贫的重要原因,同时也引发一系列社会问题,是我国现阶段最为突出的公共卫生问题之一
截至2008年,已有180个世界卫生组织(WHO)成员国将乙肝疫苗接种列入常规免疫项目,各国新生儿乙肝疫苗计划免疫都取得了很大成绩,不少国家全人群乙肝发病率、乙肝病毒表面抗原(Hepatitis B Surface Antigen, HbsAg)感染率均呈明显下降的趋势。我国自1987年起开始推行新生儿乙肝疫苗免疫工作,1992年卫生部将乙肝疫苗纳入儿童计划免疫管理,2002年国务院批准将新生儿普种乙肝疫苗纳入国家免疫规划项目,2005年3月国务院颁布《疫苗流通和预防接种管理条例》,规定国家对儿童实行预防接种证制度,国家免疫规划项目的预防接种实行免费。这些政策措施的实施成效非常显著,我国乙肝病毒携带者率从1992年的10.0%下降到2006年的7.2%。但是,我国总人群的肝炎发病率和死亡率并没有明显下降,并且还存在上升的趋势,其中重要原因之一在于,在乙肝表面抗原携带率一直居高不下的15岁以上成人中,有近半数的成人并无乙肝表面抗体的保护。因此,我国在继续做好新生儿乙肝疫苗计划免疫工作的基础上,探索成人接种乙肝疫苗的措施、策略,从而提高我国全体国民整体乙肝抗体水平,降低乙肝感染和发病率,是一项迫在眉睫的任务。另一方面,我国现阶段HbsAg阳性率城乡差异很大,城市为7.9%,农村为11.2%,加之我国农村人口的基数巨大,约占总人口数的60%以上,因此绝大多数乙肝病例都集中在农村地区,从乙肝发病情况来看,也是农村明显高于城市。所以,要想解决我国乙肝高发这一实际情况,乙肝防治的工作重点要放在农村。
WHO在2000年对全世界191个国家和地区的卫生服务状况进行总体评估和排序,公平性方面我国排在188位,在所有国家中排名倒数第4,其中主要原因之一就是我国城乡医疗服务水平差距显著。2005年《求是》杂志社与有关政府部门、社会团体及相关专家联合对“中国小康指数”进行调查,其中对我国“公共服务小康指数”调查结果显示,公共卫生服务满意度位于排名的末位。如何实现公共卫生服务的公平性,满足广大人民群众卫生保健的需要,成为当前我们国家、政府、社会关注的热点和难点问题。
一般来说,基本公共卫生服务的均等化或公平性,是由其具体内容的公平性来体现的,包括疾病预防控制方面的公平性、妇幼保健方面的公平性、健康教育方面的公平性等。因此,研究和分析疾病预防控制和健康教育方面的公平性,将有助于我们更好地了解我国基本公共卫生服务均等化的现状,进而提升我国基本公共卫生服务的均等化水平。其中,乙肝疫苗的免疫接种作为我国公共卫生服务的主要内容之一,在我国现阶段基本公共卫生服务领域具有特别的重要性。
有鉴于此,本研究将立足我国广大农村地区,就成人乙肝认知和乙肝疫苗接种的公平性进行全面、系统的分析,以期反映目前我国农村与乙肝相关的基本公共卫生服务公平性的现状,并有针对性地提出相应的政策建议,从而为实现我国基本公共卫生服务均等化提供科学的政策依据。
研究目的
本研究的总体目标是：通过回顾和总结国内外相关研究成果,结合现场调查资料,对农村成人乙肝认知和乙肝疫苗接种行为进行系统分析,揭示农村地区成人乙肝认知和乙肝疫苗接种的影响因素,在此基础上,对农村成人乙肝认知和乙肝疫苗接种的公平性进行分析,并探讨各个影响因素的贡献率,为提高成人乙肝疫苗接种率和全程接种率提供政策参考。具体研究目的包括：了解我国农村成人乙肝认知和乙肝疫苗接种的情况及影响因素；揭示农村成人乙肝认知公平性各个影响因素的贡献程度；揭示农村成人乙肝疫苗接种公平性各个影响因素的贡献程度；有针对性地提出改善我国农村成人乙肝认知和乙肝疫苗接种公平性状况、提高农村成人乙肝认知程度和乙肝疫苗接种率的政策建议。
资料来源与研究方法
本研究采用横断面研究设计,主要采用定量研究的方法。数据资料来源于挪威国家研究局资助项目《使用者付费对中国乙肝疫苗覆盖率的影响程度研究》基线调查的数据。2011年1月开始现场调查,2012年4月完成,本研究使用该课题数据2011年进行调查的部分。本研究根据地理位置、经济发展水平、人口总数,抽取河北省、山东省、江苏省、黑龙江省、海南省、宁夏回族自治区为样本地区；再根据相同的标准共抽取9个县,其中人口经济大省河北、山东、江苏分别抽取2个县,其他三省各抽取1个县,每县按照随机抽样原则各抽取3个村,共抽取27个村；然后采用按容量比例概率随机抽样(PPS)与整群抽样相结合的方法抽取样本家庭,调查样本家庭里所有16周岁及以上的常驻家庭成员。采用家庭问卷的形式,调查居民的社会经济状况；对乙肝和乙肝疫苗的认知情况；乙肝疫苗接种史、具体接种行为和接种意愿；家庭基本情况,包括家庭年收入、总支等。
本研究数据资料使用DataEasy3.3软件建立数据库,采用Stata/SE12.0软件进行统计分析。主要采用描述性统计分析、单因素分析和多因素分析方法,对定量资料进行分析。在进行多因素分析时,依因变量类型的不同而使用不同的分析模型,若因变量为连续型数值变量,则使用多元线性回归模型进行分析；如为二分类变量,则采用非条件二元Logistic回归模型进行分析。
主要研究结果
1.农村成人乙肝认知公平性分析
(1)农村成人乙肝认知影响因素
单因素、多因素分析显示,年龄、受教育水平、职业状况、收入水平、所在省份5方面因素是影响农村成人乙肝认知的显著性因素。随着受教育水平、收入水平的提高,乙肝认知得分逐渐提高；职业状况分组中,医护人员认知得分最高,公职人员其次,农民的最低；各省份间,山东的得分最高,其次是黑龙江,海南的最低,宁夏的第二低。
多因素分析表明,受教育水平、收入水平是乙肝认知的保护性因素,回归系数随着受教育水平、收入水平的升高而增大；地域上,河北、山东、黑龙江三省农村成人乙肝认知得分均显著高于江苏省,其中山东省回归系数最大,为3.969,海南省的回归系数最小,为-1.426,说明若其他因素保持不变,海南省参加调查的成人比例每增加1个百分点,预测的乙肝认知得分将下降1.426分。
(2)农村成人乙肝认知公平性及其分解分析
我国农村成人乙肝认知水平分布存在着不公平的现象,集中指数(CI)为0.0727,意味着认知得分高者集中于较富裕的人群。纳入分析模型的年龄、受教育水平、职业状况、收入水平、所在省份5方面影响因素,能够解释农村成人乙肝认知不公平程度的97.30%。除职业状况的贡献率为负值外,其余各因素的贡献率均为正值,其中收入、受教育水平的贡献较为显著,贡献率分别为76.54%、13.90%。年龄因素是影响乙肝认知不公平的重要因素,贡献率为5.79%。相比之下,地域差异的贡献率较小,仅能解释约2.17%的不公平现象的产生。
2.农村成人乙肝疫苗接种公平性分析
(1)农村成人乙肝疫苗接种影响因素
单因素、多因素分析显示,除性别外,年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分9方面因素,均是影响乙肝疫苗接种的显著性因素。随着年龄的增大,乙肝疫苗接种率呈下降趋势。已婚人群的接种率低于目前独居(包括未婚、离婚和丧偶者)人群。乙肝疫苗接种率随着受教育水平、收入水平、乙肝认知得分的提高而升高。职业状况分组中,农民的接种率低于其他各组。不同省份中海南省最高,宁夏其次,河北省第三,江苏省接种率最低。乙肝疫苗价格低于40元时,接种率随价格升高而降低,在10元以下时,疫苗接种超过半数。同样,到接种地点的距离小于9公里时,接种率随着距离的减少而增加,距离小于3公里时接种率远大于其他三组。
多因素分析表明,目前独居者接种乙肝疫苗的可能性是已婚者的1.385倍；农村成人乙肝疫苗接种的可能性随着受教育水平、收入水平、乙肝认知得分的增加,乙肝疫苗接种的概率呈现上升趋势。高中及以上人群接种的可能性是小学以下人群的3.75倍,当得分在20分及以上时,乙肝疫苗接种概率是10分以下时的3.56倍。职业分组中,农民乙肝疫苗接种的可能性最小,公职人员和学生接种的可能性分别是农民的3.09倍和3.13倍；地域差异上,河北、山东、黑龙江、海南的农村成人乙肝疫苗接种的概率均高于江苏,其中山东接种的概率最大,是江苏的35倍多,其次是河北,而宁夏农村成人接种乙肝疫苗的概率仅为江苏的0.44倍；乙肝疫苗价格低于10元时疫苗接种的可能性是价格40元及以上时的500多倍,而疫苗价格在24元到40元之间时,疫苗接种的可能性却是40元及以上时的0.57倍；疫苗接种的可能性随着到接种地点距离的增加而降低,距离在3公里以下时的可能性是9公里及以上的221倍。
(2)农村成人乙肝疫苗接种公平性及其分解分析
农村成人乙肝疫苗接种的分布存在着不公平的现象,集中指数(CI)为0.1117,意味着接种乙肝疫苗者多集中于较富裕的人群,纳入分析模型的年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分9方面因素,能够解释农村成人乙肝疫苗接种不公平程度的99.15%。其中婚姻状况、所在省份及乙肝疫苗价格三个因素的贡献率为负值,分别为-1.53%、-10.72%、-96.45%；除此三因素外,其他各因素的贡献率均为正值。婚姻状况、受教育水平、职业状况以及收入等社会经济因素的贡献率最高,为66.03%,其中受教育水平、收入的贡献较为显著,贡献率分别为23.85%和39.84%。与乙肝认知及乙肝疫苗相关的影响因素(包括乙肝疫苗价格、到接种地点的距离、乙肝认知得分)贡献率也较高,为31.85%,可见,与乙肝认知及乙肝疫苗相关的因素是影响乙肝疫苗接种公平性的重要因素。
结论与政策建议
本研究发现,年龄、受教育水平、职业状况、收入、所在省份是影响我国农村成人乙肝认知的显著性因素,我国农村成人乙肝认知水平的分布存在着不公平现象。得分较高者集中于较富裕的人群,这一不公平现象是由上述影响因素中的年龄、受教育水平、收入、地区差异共同作用的结果,其中收入的作用最大,且是可以外部干预控制的。年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分情况,是影响我国农村成人乙肝疫苗接种的显著性因素,我国农村成人乙肝疫苗接种的分布存在着不公平现象。接种乙肝疫苗者多集中于较富裕的人群,上述影响因素中的年龄、受教育水平、职业状况、收入、到接种地点的距离、乙肝认知得分共同作用,促成了这一不平等性,其中到接种地点的距离影响最大,它与收入和乙肝认知都是可以外部干预控制的因素。
为改善我国农村乙肝认知和乙肝疫苗接种不公平、提高乙肝认知水平及乙肝疫苗接种率,我们提出如下建议：(1)增加农民收入、缩小农民间的收入差距。最根本途径就是调整农业结构,挖掘农业内部增收潜力,着力提高农业的综合效益；其次以市场为导向,加快农业产业化经营组织的创新,加快农村剩余劳动力转移步伐,同时加大对农村人力资本投资的力度,通过提高农民的文化水平与职业技能,增强其在劳动力市场的竞争力；最后,要完善财政、金融、社会保障等多种服务体系,积极推进乡镇企业发展与城镇化进程,为农民增收创造机会。在增加农民收入的同时,政府要给予低收入农民、贫困地区农民适当的补贴,减小乙肝疫苗接种的经济负担。(2)加大乙肝相关知识的教育宣传力度。对于青少年的宣传教育可以通过学校的一些常识性课程或者班会的形式开展,而对于农村成年人的宣传教育,应当考虑其文化水平较低的现实,设计成通俗易懂的、老百姓喜闻乐见的形式,如戏曲、相声等文艺形式,通过文化下乡活动或者当地的电视媒体进行宣传。(3)提高乙肝疫苗接种服务的可及性。在保证疫苗接种质量的同时,尽量将接种服务下沉到基层卫生服务提供机构,提高乙肝疫苗接种服务的可及性；对于偏远地区的农村,甚至可以提供上门服务,以减少疫苗接种的经济成本和机会成本,提高接种率。
Background
Viral 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.
Objectives
The 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 Methods
The 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.
Results
1. Equity analysis of rural adults'hepatitis B cognition
(1) Influencing factors of rural adults'hepatitis B cognition
Single 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 cognition
The 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 vaccination
Single 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 vaccination
The 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 Implications
The 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.
乙型病毒性肝炎简称乙肝,是病毒性肝炎中危害最严重的一种传染性疾病,居全球死亡原因的第10位,每年大约有100万人死于慢性乙肝疾病,人数高达艾滋病感染者的8倍以上。我国目前是全世界仅有的少数几个乙肝病毒(Hepatitis B Virus, HBV)高流行和高发病的国家之一,约有慢性乙肝患者1500万人,每年新发急性乙肝病例约54万,每年由HBV感染的肝癌导致死亡的人数约有12万,造成直接医疗费用约200多亿元。乙肝病毒感染给病人、病人家庭、社会造成了沉重的经济负担,给社会经济发展带来不容忽视的影响,是许多家庭因病致贫、因病返贫的重要原因,同时也引发一系列社会问题,是我国现阶段最为突出的公共卫生问题之一
截至2008年,已有180个世界卫生组织(WHO)成员国将乙肝疫苗接种列入常规免疫项目,各国新生儿乙肝疫苗计划免疫都取得了很大成绩,不少国家全人群乙肝发病率、乙肝病毒表面抗原(Hepatitis B Surface Antigen, HbsAg)感染率均呈明显下降的趋势。我国自1987年起开始推行新生儿乙肝疫苗免疫工作,1992年卫生部将乙肝疫苗纳入儿童计划免疫管理,2002年国务院批准将新生儿普种乙肝疫苗纳入国家免疫规划项目,2005年3月国务院颁布《疫苗流通和预防接种管理条例》,规定国家对儿童实行预防接种证制度,国家免疫规划项目的预防接种实行免费。这些政策措施的实施成效非常显著,我国乙肝病毒携带者率从1992年的10.0%下降到2006年的7.2%。但是,我国总人群的肝炎发病率和死亡率并没有明显下降,并且还存在上升的趋势,其中重要原因之一在于,在乙肝表面抗原携带率一直居高不下的15岁以上成人中,有近半数的成人并无乙肝表面抗体的保护。因此,我国在继续做好新生儿乙肝疫苗计划免疫工作的基础上,探索成人接种乙肝疫苗的措施、策略,从而提高我国全体国民整体乙肝抗体水平,降低乙肝感染和发病率,是一项迫在眉睫的任务。另一方面,我国现阶段HbsAg阳性率城乡差异很大,城市为7.9%,农村为11.2%,加之我国农村人口的基数巨大,约占总人口数的60%以上,因此绝大多数乙肝病例都集中在农村地区,从乙肝发病情况来看,也是农村明显高于城市。所以,要想解决我国乙肝高发这一实际情况,乙肝防治的工作重点要放在农村。
WHO在2000年对全世界191个国家和地区的卫生服务状况进行总体评估和排序,公平性方面我国排在188位,在所有国家中排名倒数第4,其中主要原因之一就是我国城乡医疗服务水平差距显著。2005年《求是》杂志社与有关政府部门、社会团体及相关专家联合对“中国小康指数”进行调查,其中对我国“公共服务小康指数”调查结果显示,公共卫生服务满意度位于排名的末位。如何实现公共卫生服务的公平性,满足广大人民群众卫生保健的需要,成为当前我们国家、政府、社会关注的热点和难点问题。
一般来说,基本公共卫生服务的均等化或公平性,是由其具体内容的公平性来体现的,包括疾病预防控制方面的公平性、妇幼保健方面的公平性、健康教育方面的公平性等。因此,研究和分析疾病预防控制和健康教育方面的公平性,将有助于我们更好地了解我国基本公共卫生服务均等化的现状,进而提升我国基本公共卫生服务的均等化水平。其中,乙肝疫苗的免疫接种作为我国公共卫生服务的主要内容之一,在我国现阶段基本公共卫生服务领域具有特别的重要性。
有鉴于此,本研究将立足我国广大农村地区,就成人乙肝认知和乙肝疫苗接种的公平性进行全面、系统的分析,以期反映目前我国农村与乙肝相关的基本公共卫生服务公平性的现状,并有针对性地提出相应的政策建议,从而为实现我国基本公共卫生服务均等化提供科学的政策依据。
研究目的
本研究的总体目标是：通过回顾和总结国内外相关研究成果,结合现场调查资料,对农村成人乙肝认知和乙肝疫苗接种行为进行系统分析,揭示农村地区成人乙肝认知和乙肝疫苗接种的影响因素,在此基础上,对农村成人乙肝认知和乙肝疫苗接种的公平性进行分析,并探讨各个影响因素的贡献率,为提高成人乙肝疫苗接种率和全程接种率提供政策参考。具体研究目的包括：了解我国农村成人乙肝认知和乙肝疫苗接种的情况及影响因素；揭示农村成人乙肝认知公平性各个影响因素的贡献程度；揭示农村成人乙肝疫苗接种公平性各个影响因素的贡献程度；有针对性地提出改善我国农村成人乙肝认知和乙肝疫苗接种公平性状况、提高农村成人乙肝认知程度和乙肝疫苗接种率的政策建议。
资料来源与研究方法
本研究采用横断面研究设计,主要采用定量研究的方法。数据资料来源于挪威国家研究局资助项目《使用者付费对中国乙肝疫苗覆盖率的影响程度研究》基线调查的数据。2011年1月开始现场调查,2012年4月完成,本研究使用该课题数据2011年进行调查的部分。本研究根据地理位置、经济发展水平、人口总数,抽取河北省、山东省、江苏省、黑龙江省、海南省、宁夏回族自治区为样本地区；再根据相同的标准共抽取9个县,其中人口经济大省河北、山东、江苏分别抽取2个县,其他三省各抽取1个县,每县按照随机抽样原则各抽取3个村,共抽取27个村；然后采用按容量比例概率随机抽样(PPS)与整群抽样相结合的方法抽取样本家庭,调查样本家庭里所有16周岁及以上的常驻家庭成员。采用家庭问卷的形式,调查居民的社会经济状况；对乙肝和乙肝疫苗的认知情况；乙肝疫苗接种史、具体接种行为和接种意愿；家庭基本情况,包括家庭年收入、总支等。
本研究数据资料使用DataEasy3.3软件建立数据库,采用Stata/SE12.0软件进行统计分析。主要采用描述性统计分析、单因素分析和多因素分析方法,对定量资料进行分析。在进行多因素分析时,依因变量类型的不同而使用不同的分析模型,若因变量为连续型数值变量,则使用多元线性回归模型进行分析；如为二分类变量,则采用非条件二元Logistic回归模型进行分析。
主要研究结果
1.农村成人乙肝认知公平性分析
(1)农村成人乙肝认知影响因素
单因素、多因素分析显示,年龄、受教育水平、职业状况、收入水平、所在省份5方面因素是影响农村成人乙肝认知的显著性因素。随着受教育水平、收入水平的提高,乙肝认知得分逐渐提高；职业状况分组中,医护人员认知得分最高,公职人员其次,农民的最低；各省份间,山东的得分最高,其次是黑龙江,海南的最低,宁夏的第二低。
多因素分析表明,受教育水平、收入水平是乙肝认知的保护性因素,回归系数随着受教育水平、收入水平的升高而增大；地域上,河北、山东、黑龙江三省农村成人乙肝认知得分均显著高于江苏省,其中山东省回归系数最大,为3.969,海南省的回归系数最小,为-1.426,说明若其他因素保持不变,海南省参加调查的成人比例每增加1个百分点,预测的乙肝认知得分将下降1.426分。
(2)农村成人乙肝认知公平性及其分解分析
我国农村成人乙肝认知水平分布存在着不公平的现象,集中指数(CI)为0.0727,意味着认知得分高者集中于较富裕的人群。纳入分析模型的年龄、受教育水平、职业状况、收入水平、所在省份5方面影响因素,能够解释农村成人乙肝认知不公平程度的97.30%。除职业状况的贡献率为负值外,其余各因素的贡献率均为正值,其中收入、受教育水平的贡献较为显著,贡献率分别为76.54%、13.90%。年龄因素是影响乙肝认知不公平的重要因素,贡献率为5.79%。相比之下,地域差异的贡献率较小,仅能解释约2.17%的不公平现象的产生。
2.农村成人乙肝疫苗接种公平性分析
(1)农村成人乙肝疫苗接种影响因素
单因素、多因素分析显示,除性别外,年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分9方面因素,均是影响乙肝疫苗接种的显著性因素。随着年龄的增大,乙肝疫苗接种率呈下降趋势。已婚人群的接种率低于目前独居(包括未婚、离婚和丧偶者)人群。乙肝疫苗接种率随着受教育水平、收入水平、乙肝认知得分的提高而升高。职业状况分组中,农民的接种率低于其他各组。不同省份中海南省最高,宁夏其次,河北省第三,江苏省接种率最低。乙肝疫苗价格低于40元时,接种率随价格升高而降低,在10元以下时,疫苗接种超过半数。同样,到接种地点的距离小于9公里时,接种率随着距离的减少而增加,距离小于3公里时接种率远大于其他三组。
多因素分析表明,目前独居者接种乙肝疫苗的可能性是已婚者的1.385倍；农村成人乙肝疫苗接种的可能性随着受教育水平、收入水平、乙肝认知得分的增加,乙肝疫苗接种的概率呈现上升趋势。高中及以上人群接种的可能性是小学以下人群的3.75倍,当得分在20分及以上时,乙肝疫苗接种概率是10分以下时的3.56倍。职业分组中,农民乙肝疫苗接种的可能性最小,公职人员和学生接种的可能性分别是农民的3.09倍和3.13倍；地域差异上,河北、山东、黑龙江、海南的农村成人乙肝疫苗接种的概率均高于江苏,其中山东接种的概率最大,是江苏的35倍多,其次是河北,而宁夏农村成人接种乙肝疫苗的概率仅为江苏的0.44倍；乙肝疫苗价格低于10元时疫苗接种的可能性是价格40元及以上时的500多倍,而疫苗价格在24元到40元之间时,疫苗接种的可能性却是40元及以上时的0.57倍；疫苗接种的可能性随着到接种地点距离的增加而降低,距离在3公里以下时的可能性是9公里及以上的221倍。
(2)农村成人乙肝疫苗接种公平性及其分解分析
农村成人乙肝疫苗接种的分布存在着不公平的现象,集中指数(CI)为0.1117,意味着接种乙肝疫苗者多集中于较富裕的人群,纳入分析模型的年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分9方面因素,能够解释农村成人乙肝疫苗接种不公平程度的99.15%。其中婚姻状况、所在省份及乙肝疫苗价格三个因素的贡献率为负值,分别为-1.53%、-10.72%、-96.45%；除此三因素外,其他各因素的贡献率均为正值。婚姻状况、受教育水平、职业状况以及收入等社会经济因素的贡献率最高,为66.03%,其中受教育水平、收入的贡献较为显著,贡献率分别为23.85%和39.84%。与乙肝认知及乙肝疫苗相关的影响因素(包括乙肝疫苗价格、到接种地点的距离、乙肝认知得分)贡献率也较高,为31.85%,可见,与乙肝认知及乙肝疫苗相关的因素是影响乙肝疫苗接种公平性的重要因素。
结论与政策建议
本研究发现,年龄、受教育水平、职业状况、收入、所在省份是影响我国农村成人乙肝认知的显著性因素,我国农村成人乙肝认知水平的分布存在着不公平现象。得分较高者集中于较富裕的人群,这一不公平现象是由上述影响因素中的年龄、受教育水平、收入、地区差异共同作用的结果,其中收入的作用最大,且是可以外部干预控制的。年龄、婚姻状况、受教育水平、职业状况、收入、所在省份、乙肝疫苗价格、到接种地点的距离、乙肝认知得分情况,是影响我国农村成人乙肝疫苗接种的显著性因素,我国农村成人乙肝疫苗接种的分布存在着不公平现象。接种乙肝疫苗者多集中于较富裕的人群,上述影响因素中的年龄、受教育水平、职业状况、收入、到接种地点的距离、乙肝认知得分共同作用,促成了这一不平等性,其中到接种地点的距离影响最大,它与收入和乙肝认知都是可以外部干预控制的因素。
为改善我国农村乙肝认知和乙肝疫苗接种不公平、提高乙肝认知水平及乙肝疫苗接种率,我们提出如下建议：(1)增加农民收入、缩小农民间的收入差距。最根本途径就是调整农业结构,挖掘农业内部增收潜力,着力提高农业的综合效益；其次以市场为导向,加快农业产业化经营组织的创新,加快农村剩余劳动力转移步伐,同时加大对农村人力资本投资的力度,通过提高农民的文化水平与职业技能,增强其在劳动力市场的竞争力；最后,要完善财政、金融、社会保障等多种服务体系,积极推进乡镇企业发展与城镇化进程,为农民增收创造机会。在增加农民收入的同时,政府要给予低收入农民、贫困地区农民适当的补贴,减小乙肝疫苗接种的经济负担。(2)加大乙肝相关知识的教育宣传力度。对于青少年的宣传教育可以通过学校的一些常识性课程或者班会的形式开展,而对于农村成年人的宣传教育,应当考虑其文化水平较低的现实,设计成通俗易懂的、老百姓喜闻乐见的形式,如戏曲、相声等文艺形式,通过文化下乡活动或者当地的电视媒体进行宣传。(3)提高乙肝疫苗接种服务的可及性。在保证疫苗接种质量的同时,尽量将接种服务下沉到基层卫生服务提供机构,提高乙肝疫苗接种服务的可及性；对于偏远地区的农村,甚至可以提供上门服务,以减少疫苗接种的经济成本和机会成本,提高接种率。
Background
Viral 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.
Objectives
The 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 Methods
The 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.
Results
1. Equity analysis of rural adults'hepatitis B cognition
(1) Influencing factors of rural adults'hepatitis B cognition
Single 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 cognition
The 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 vaccination
Single 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 vaccination
The 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 Implications
The 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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