Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth

Gender preferences for multiple attributes of soil and water conservation in Northern Rwanda

Despite the dominance of female labor in agricultural production, female-controlled farm plots have lower efficiency compared to plot managed by male-headed households, which indicates a huge gender disparity in agricultural productivity. Overlooking gender preferences when designing interventions that promote the conservation of soil and water resources might face challenges in adoption and could result in ineffective policies to close the gender gap. This study seeks to analyze gender-specific preferences regarding attributes of soil and water conservation (SWC) in northern Rwanda. A best-worst survey was conducted among 653 respondents, comprising 253 males and 400 females, representing 422 households surveyed between September and December 2019. The analysis of BWS data involved assessing attribute-level relative importance, Pearson correlation, and maximum difference scaling using multinomial logit (MNL). Findings from attribute-level importance analysis revealed significant gender-based disparities in preferences across three important SWC attribute scenarios: the high scenario (between 65 % and 100 %), the moderate scenario (between 50 % and 65 %), and the basic scenario (with <50 % relative importance). The study identified heterogeneity in preferences regarding the relative importance of SWC attribute levels. Pearson correlation analysis revealed substantial synergies among attribute levels linked to land consolidation, improved land tenure, and joint SWC decision-making between genders. Additionally, the study identified trade-offs among multiple levels of SWC attributes, including households' SWC decision-making and physical and structural measures. The results from MNL regression show that both males and females exhibit positive preferences for multiple levels of SWC attributes, but show negative preferences when it comes to household decisions involving multiple SWC strategies. The study highlights the importance of equal opportunities for males and females' participation in agricultural transformation through the adoption of SWC technologies as a fundamental step towards sustainable agricultural intensification. It advocates for gender transformational approaches to incentivize the scaling up of SWC practices and promote packages with lower uptake rates. Additionally, the study suggests enhancing knowledge and extension education in SWC to better understand diverse needs and preferences of female farmers.

Of Money and Men: A Scoping Review to Map Gender Barriers to Immunization Coverage in Low- and Middle-Income Countries

Among the multiple factors impeding equitable childhood immunization coverage in low- and middle-income countries (LMICs), gender barriers stand out as perhaps the most universal. Despite increasing recognition of the importance of gender considerations in immunization programming, there has not yet been a systematic assessment of the evidence on gender barriers to immunization. We conducted a scoping review to fill that gap, identifying 92 articles that described gender barriers to immunization. Studies documented a range of gender influencers across 43 countries in Africa and South Asia. The barrier to immunization coverage most frequently cited in the literature is women's lack of autonomous decision-making. Access to immunization is significantly impacted by women's time poverty; direct costs are also a barrier, particularly when female caregivers rely on family members to cover costs. Challenges with clinic readiness compound female caregiver's time constraints. Some of the most important gender barriers lie outside of the usual purview of immunization programming but other barriers can be addressed with adaptations to vaccination programming. We can only know how important these barriers are with more research that measures the impact of programming on gender barriers to immunization coverage.

Estimated effect of age of marriage on utilisation of India's Integrated Child Development Service programme

BACKGROUND

Age of marriage among women is considered an important indicator of their readiness for familial integration and parenting. This study estimated the effect of age of marriage of young mothers (aged 15-24 years) on utilisation of various services for their children, provided under the Integrated Child Development Service (ICDS) programme in India.

METHODS

Data from the nationally representative 2019-2021 National Family Health Survey of India were analysed. Mothers' age of menarche was used as an instrumental variable to isolate the effect of age of marriage on whether their children received (1) food, (2) health check-up, (3) immunisation, (4) early childhood care or preschooling or (5) weight measurement services from ICDS.

RESULTS

Nationally, 67.9% (95% CI 67.6%, 68.3%) of children received food (sample: 60 578), 61.8% (95% CI 61.4%, 62.1%) received a health check-up (sample: 60 316), 60.0% (95% CI 59.6%, 60.4%) received immunisation services (sample: 60 537), 52.0% (95% CI 51.6%, 52.4%) received early childhood care or preschooling (sample: 60 458) and 62.9% (95% CI 62.5%, 63.3%) received weight measurement services (sample: 60 278). Findings from instrumental variable analysis suggest that a 1-year increase in age of marriage could yield a 9 percentage point increase (95% CI 4%-13%; p<0.001) in utilisation of immunisation services. Although postponement of marriage positively affected utilisation of each of the other four ICDS components, these effects were not statistically significant.

CONCLUSION

Postponing age of marriage among young women is an effective intervention for promoting uptake of child immunisation services. Our findings support the Government of India's 2021 Bill to raise legal age of marriage of women.

Influence of women empowerment on childhood (12-23 months) immunization coverage: Recent evidence from 17 sub-Saharan African countries

BACKGROUND

There is a global consensus that child immunization plays an important role in promoting the health and well-being of children. Despite the quintessential role of immunization, not all children receive full immunization coverage. We examined the association between women empowerment and childhood immunization coverage in sub-Saharan Africa (SSA).

METHODS

The most recent Demographic and Health Survey data of 17 SSA countries were used for the analysis, with a sample of 19,223. The outcome and exposure variables were full immunization coverage and women empowerment, respectively. Full immunization was computed from percentage of children between the ages of 12 and 23 months who had received the following vaccines at any point in time: one dose of Bacille Calmette-Guérin, three doses of the vaccine protecting against diphtheria, pertussis, and tetanus or the tetravalent/pentavalent vaccine, three doses of the polio vaccine, and one dose of the measles vaccine (either as a standalone measles vaccine or as part of a combination with other immunogens). Women's empowerment was an index of labour participation, acceptance towards spousal violence, decision-making capacity and general knowledge level. Descriptive analysis and multilevel logistic regression were performed. Results were reported in adjusted odds ratio with a corresponding 95% confidence interval.

RESULTS

The study found that 56.6% of children were fully immunized. Children of employed mothers were 1.16 times more likely to be fully immunized. Children of mothers with higher acceptance toward violence were less likely to be fully immunized [aOR = 0.90, CI 0.81, 0.99]. The odds of full immunization were higher among children born to mothers with high [aOR = 1.11, CI 1.01, 1.22] decision-making capacity. Higher odds of full immunization were found among children born to mothers with medium [aOR = 1.24, CI 1.13, 1.36] to high [aOR = 1.44, CI 1.27, 1.63] general knowledge level.

CONCLUSIONS

We conclude that empowering women through livelihood empowerment interventions can increase their decision-making capacity and foster their resolve to ensure the full immunization of their children. This can be achieved by consciously investing in initiatives such as vocational training programs, job placement services, or support for entrepreneurship initiatives to encourage and support women's workforce participation.

Women's empowerment and uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic areas of the sub-Saharan African (SSA) region. However, there is limited understanding of the association between women's empowerment and the uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp-SP) in Kenya. This study examines the association between women's empowerment indicators (decision-making power, control of assets, education, and employment status) and the uptake of three or more doses of IPTp-SP in the Lake endemic region of Kenya.

METHODS

The analysis utilized a dataset from a cross-sectional baseline survey of 3129 women aged 15-49 years in Kisumu and Migori Counties who had a live birth within the last 2 years preceding the study. Data were collected between June to August 2021. A descriptive analysis was conducted to show the distribution of respondents by key background characteristics, and bivariate and multivariate logistic regression to examine statistically significant associations between women's empowerment measures and the uptake of 3+ doses of IPTp-SP.

RESULTS

Among the 3129 women surveyed, 1978 (65.7%) received 3+ doses of IPTp-SP during their most recent pregnancy. Controlling for individual characteristics and the number of ANC visits, the odds of taking 3+ doses of IPTp-SP increased among women who had high decision-making autonomy (AOR = 2.33; CI = 1.81-3.01; P < 0.001); and tertiary level of educational attainment (AOR = 1.51; CI = 1.10-2.06). However, the association between control of assets and uptake of IPTp-SP was positive but not statistically significant.

CONCLUSION

Women's decision-making autonomy and educational attainment were positively associated with the uptake of IPTp-SP. As a result, maternal health interventions should focus on less empowered women, specifically those with less decision-making autonomy and no/low formal education, as they are less likely to achieve optimal uptake of IPTp-SP during pregnancy.

Associations between dimensions of empowerment and nutritional status among married adolescent girls in East Africa: a structural equation modelling study

BACKGROUND

Empowering adolescent girls is an important component of combating malnutrition in this age group. Because empowerment is multidimensional and context specific, it can be difficult for policymakers and practitioners to target the dimensions of empowerment associated with adolescent girls' nutrition in a particular setting. This study sought to identify the empowerment dimensions significantly associated with married adolescent girls' nutritional status in East Africa; a region where malnutrition and gender inequality stubbornly persist.

METHODS

We used cross-sectional Demographic and Health Survey (DHS) data from Ethiopia (2016), Kenya (2014), Tanzania (2015-16) and Uganda (2016) to construct and test theoretically informed structural equation models of the relationship between six dimensions of empowerment and BMI-for-age and haemoglobin levels for married adolescent girls aged 15-19 years.

RESULTS

Our models were found to be a good fit for the data. Married adolescent girls' access to information, measured by their education level and mass media use, was directly and positively associated with their BMI-for-age (p < 0.05). Asset ownership, measured by owning a house or land alone or jointly, was directly and positively associated with haemoglobin (p < 0.05) and reduced odds of being moderately to severely anemic. Rejecting justifications for intimate partner violence, a measure of respondents' intrinsic agency, was directly and positively associated with the odds of being overweight or obese. Adolescent girls' level of empowerment across all dimensions had a direct relationship with their country of residence and household wealth.

CONCLUSIONS

Our findings suggest that investment in girls' access to information through education and mass/social media and their economic empowerment may be important contributors to their overall empowerment and nutritional status. However, caution is needed as greater autonomy may contribute to increased consumption of unhealthy foods that can contribute to overweight and obesity. Strategies to empower married adolescent girls should be tailored to their specific circumstances. There is an urgent need for better data on adolescent empowerment and health, including increased research into age-, sex- and gender-appropriate empowerment measures and longitudinal data to assess causality. The use of statistical models should be complemented by robust qualitative research to further results interpretation.

Vaccine cold chain management and cold storage technology to address the challenges of vaccination programs

The outbreaks of infectious diseases that spread across countries have generally existed for centuries. An example is the occurrence of the COVID-19 pandemic in 2020, which led to the loss of lives and economic depreciation. One of the essential ways of handling the spread of viruses is the discovery and administration of vaccines. However, the major challenges of vaccination programs are associated with the vaccine cold chain management and cold storage facilities. This paper discusses how vaccine cold chain management and cold storage technology can address the challenges of vaccination programs. Specifically, it examines different systems for preserving vaccines in either liquid or frozen form to help ensure that they are not damaged during distribution from manufacturing facilities. Furthermore, A vaccine is likely to provide very low efficacy when it is not properly stored. According to preliminary studies, the inability to store vaccine properly is partly due to the incompetency of many stakeholders, especially in technical matters. The novelty of this study is to thoroughly explore cold storage technology for a faster and more comprehensive vaccine distribution hence it is expected to be one of the reference and inspiration for stakeholders.

Gender-Related Inequality in Childhood Immunization Coverage: A Cross-Sectional Analysis of DTP3 Coverage and Zero-Dose DTP Prevalence in 52 Countries Using the SWPER Global Index

Gender-related barriers to immunization are key targets to improve immunization coverage and equity. We used individual-level demographic and health survey data from 52 low- and middle-income countries to examine the relationship between women’s social independence (measured by the Survey-based Women’s emPowERment (SWPER) Global Index) and childhood immunization. The primary outcome was receipt of three doses of the diphtheria-tetanus-pertussis vaccine (DTP3) among children aged 12–35 months; we secondarily examined failure to receive any doses of DTP-containing vaccines. We summarized immunization coverage indicators by social independence tertile and estimated crude and adjusted summary measures of absolute and relative inequality. We conducted all analyses at the country level using individual data; median results across the 52 examined countries are also presented. In crude comparisons, median DTP3 coverage was 12.3 (95% CI 7.9; 16.3) percentage points higher among children of women with the highest social independence compared with children of women with the lowest. Thirty countries (58%) had a difference in coverage between those with the highest and lowest social independence of at least 10 percentage points. In adjusted models, the median coverage was 7.4 (95% CI 5.0; 9.1) percentage points higher among children of women with the highest social independence. Most countries (41, 79%) had statistically significant relative inequality in DTP3 coverage by social independence. The findings suggest that greater social independence for women was associated with better childhood immunization outcomes, adding evidence in support of gender-transformative strategies to reduce childhood immunization inequities.

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

Women Empowerment Facilitates Complete Immunization in Indonesian Children: Cross-sectional Study

Objectives

The primary objective of this study was to examine the effect of women’s empowerment on the immunization of Indonesian children. The secondary objective was to examine the effect of wealth as a factor modifying this association.

Methods

We utilized data from the 2017 Indonesian Demographic and Health Survey (IDHS). The subjects were married women with children aged 12–23 months (n=3532). Complete immunization was defined using the 2017 IDHS definition. Multiple components of women’s empowerment were measured: enabling resources, decision-making involvement, and attitude toward intimate partner violence. The primary analysis was conducted using binomial logistic regression. Model 1 represented only the indicators of women’s empowerment and model 2 controlled for socio-demographic variables. Subgroup analyses were conducted for each wealth group.

Results

The primary analysis using model 1 identified several empowerment indicators that facilitated complete immunization. The analysis using model 2 found that maternal education and involvement in decision-making processes facilitated complete immunization in children. Subgroup analyses identified that wealth had a modifying effect. The indicators of women’s empowerment were strong determinants of complete immunization in lower wealth quintiles but insignificant in middle-income and higher-income quintiles.

Conclusions

To our knowledge, this study is the first to explore women’s empowerment as a determinant of child immunization in Indonesia. The results indicate that women’s empowerment must be considered in Indonesia’s child immunization program. Women’s empowerment was not found to be a determinant in higher wealth quintiles, which led us to rethink the conceptual framework of the effect of women’s empowerment on health outcomes.

Vaccination status and factors associated among children age 12–23 months in Ethiopia, based on 2016 EDHS: Logit based multinomial logistic regression analysis

Background

Childhood immunization is one of the most cost-effective prevention measures for children’s mortality and morbidity, saving 2–3 million lives per year. In Ethiopia, under-five mortality rates, about 190,000 children die each year. Different research conducted in Ethiopia on childhood vaccination have focused on either vaccination coverage of individual vaccine or complete and incomplete vaccination. As far as my literature searching, studies separated the vaccination status into non-vaccinated, partially vaccinated and full vaccinated and assorted factors among children age 12–23 month in Ethiopia were limited. Therefore, the aim of this study was to identify factors associated with vaccination status among children 12–23 months of age in Ethiopia.

Method

A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 1911 children age 12–23 months of age were included in the study. Logit based Multinomial logistic regression analysis was computed to distinguish factors associated with routine vaccination of children aged 12–23 months. P-value less than 0.05 was used to declare statistical significance of each independent variables, and adjusted odd ratio (AOR) with 95% confidence interval were used to present the result and STATA 14 was utilized for data management and analysis.

Result

Overall the prevalence of full vaccinated children was 35%, while 49% of children were partially vaccinated and 16% were non-vaccinated. In multinomial analysis, having focused ANC (at least four visits) contrasted to no ANC visits at all had 9.7 higher odd of being fully vaccinated than not vaccinated [AOR = 9.74, 95% CI = 3.52–26.94], and 5 times higher odd of being partially vaccinated than not vaccinated [AOR = 4.97, 95% CI = 2.00–12.33].

Conclusion

The present study found that childhood full vaccination status was low compared with the World Health Organization targets. Frequency of ANC visit and visited by field worker were significantly associated both partially and full vaccination whereas, visited health facility last 12 months and wealth status were significantly associated with childhood full vaccination.

Women's Empowerment and Children's Complete Vaccination in the Democratic Republic of the Congo: A Cross-Sectional Analysis

(1) Background: The empowerment of women contributes to better child health and wellness. This study aimed to examine the association between women’s empowerment and complete vaccination of children, as recommended in the National Expanded Program on Immunization (EPI) in the Democratic Republic of the Congo (DRC). (2) Methods: In this cross-sectional study, a principal component analysis (PCA) was conducted on data from the Multiple-Indicator Cluster Survey 6 (MICS-6) to determine the dimensions of women’s empowerment. Logistic regression analysis was used to assess the association between women’s empowerment and complete vaccination of children stratified by household wealth. In total, 3524 women with children aged 12–23 months were included in the study. (3) Results: Women’s empowerment was defined by three dimensions, namely intrinsic agency, enabling resources, and social independence. Children of women with high levels of empowerment had higher odds of complete vaccination, with values of 1.63 (p = 0.002) and 1.59 (p = 0.012) for intrinsic agency and enabling resources of the empowerment, respectively, compared to the children of women with low levels of empowerment; however, social independence failed to be associated with the vaccination status of children. After stratification by household wealth, the OR of complete vaccination was higher in women from middle-income households with high levels of intrinsic agency (OR: 2.35, p = 0.021) compared to women from poor households with high levels of intrinsic agency (OR: 1.92, p = 0.004). (4) Conclusions: Higher levels of women’s empowerment, especially intrinsic agency and enabling resources, were associated with complete vaccination in children in the DRC. Household wealth status influenced the associations. The empowerment of women is crucial in promoting the complete vaccination of children and providing equal access to vaccines.

Associations between women's empowerment and child development, growth, and nurturing care practices in sub-Saharan Africa: A cross-sectional analysis of demographic and health survey data

BACKGROUND

Approximately 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Women's empowerment may help provide inputs of nurturing care for early development and growth by building caregiver capacity and family support. We examined the associations between women's empowerment and child development, growth, early learning, and nutrition in sub-Saharan Africa (SSA).

METHODS AND FINDINGS

We pooled data on married women (15 to 49 years) and their children (36 to 59 months) from Demographic and Health Surveys that collected data on child development (2011 to 2018) in 9 SSA countries (N = 21,434): Benin, Burundi, Cameroon, Chad, Congo, Rwanda, Senegal, Togo, and Uganda. We constructed a women's empowerment score using factor analysis and assigned women to country-specific quintile categories. The child outcomes included cognitive, socioemotional, literacy-numeracy, and physical development (Early Childhood Development Index), linear growth (height-for-age Z-score (HAZ) and stunting (HAZ <-2). Early learning outcomes were number of parental stimulation activities (range 0 to 6) and learning resources (range 0 to 4). The nutrition outcome was child dietary diversity score (DDS, range 0 to 7). We assessed the relationship between women's empowerment and child development, growth, early learning, and nutrition using multivariate generalized linear models. On average, households in our sample were large (8.5 ± 5.7 members) and primarily living in rural areas (71%). Women were 31 ± 6.6 years on average, 54% had no education, and 31% had completed primary education. Children were 47 ± 7 months old and 49% were female. About 23% of children had suboptimal cognitive development, 31% had suboptimal socioemotional development, and 90% had suboptimal literacy-numeracy development. Only 9% of children had suboptimal physical development, but 35% were stunted. Approximately 14% of mothers and 3% of fathers provided ≥4 stimulation activities. Relative to the lowest quintile category, children of women in the highest empowerment quintile category were less likely to have suboptimal cognitive development (relative risk (RR) 0.89; 95% confidence interval (CI) 0.80, 0.99), had higher HAZ (mean difference (MD) 0.09; 95% CI 0.02, 0.16), lower risk of stunting (RR 0.93; 95% CI 0.87, 1.00), higher DDS (MD 0.17; 95% CI 0.06, 0.29), had 0.07 (95% CI 0.01, 0.13) additional learning resources, and received 0.16 (95% CI 0.06, 0.25) additional stimulation activities from their mothers and 0.23 (95% CI 0.17 to 0.29) additional activities from their fathers. We found no evidence that women's empowerment was associated with socioemotional, literacy-numeracy, or physical development. Study limitations include the possibility of reverse causality and suboptimal assessments of the outcomes and exposure.

CONCLUSIONS

Women's empowerment was positively associated with early child cognitive development, child growth, early learning, and nutrition outcomes in SSA. Efforts to improve child development and growth should consider women's empowerment as a potential strategy.