The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage

Socioeconomic-related inequities in child immunization: horizontal and vertical dimensions for policy insights

BACKGROUND

The incomplete immunization has potentially exposed vulnerable children, especially from the socioeconomically disadvantage group, to vaccine preventable diseases. The schemes would maximize social benefit only when the immunization is effectively distributed on an equitable principle.

METHOD

The empirical study is based on unit level data from India's National Sample Survey: "Social Consumption: Health Survey- NSS 75th Round (2017-18) database. The nationwide survey is designed on the stratified multi-stage sampling method with an objective to make the sample representative. The egalitarian equity principle requires that distribution of vaccine should be based on health needs of children, irrespective of their socioeconomic and regional factors and the principle is broadly based on two aspects - horizontal and vertical equity. The horizontal inequity (HI) is a direct form of injustice, when children with equal needs of routine immunisation are treated differentially due to their socioeconomic status, while vertical inequity (VI) is indirect form of injustice when children with differential health needs and risks exposure do not receive appropriately unequal but equitable immunisation. Using Indirect Standardisation Method and Erreygers' Corrected Concentration Index, we measure the degree of horizontal and vertical inequities, and then linearly decompose them to identify the major factors contributing towards the respective indices.

CONCLUSION

Our findings show that incomplete immunization is significantly concentrated among children belonging to poorer households. After controlling for the confounding effects of need factors, the inequity is still significantly pro-poor (i.e., horizontal inequity). The decomposition reveals that lower education, lower consumption and rural habitation are the major factors driving the corresponding inequity. Further, the differential effect of the needs between all and the target groups (at least based on education), is observed, however, is not statistically significant enough to realize inequity (i.e., no vertical inequity). Overall, the inequity is being induced via non-need factors. We further find that community health services (like anganwadi) have contributed towards reducing the inequity in child immunization significantly. The paper highlights the policy recommendation that the child immunisation program should target factors driving HI and need to align their distribution in terms of risks exposures.

Impact of gender-biased parental perceptions on under-immunization in Eastern Sudan: a cross-sectional study

Background

Despite global efforts, inequities in vaccine uptake remain, influenced by socioeconomic, geographic, cultural, and gender-related factors. In Eastern Sudan, gender disparities are acknowledged, particularly in livelihoods, but their impact on vaccination uptake is unclear. This study aimed to assess the effect of gender-biased parental perceptions on under-immunization among children in Kassala, Eastern Sudan.

Methods

This study was a community-based cross-sectional in rural and urban districts of Kassala locality in Kassala State, Eastern Sudan in November 2022. Data were collected from parents using a pre-tested, structured questionnaire. The Chi-square or Fisher's exact test was conducted to assess the factors associated with under-immunization among children.

Results

Data were collected from 400 parents. Our data reveal that most children were fully vaccinated with the three doses of the pentavalent vaccine (83%), while 14% were partially vaccinated. Findings showed that about one in five parents perceived male vaccination as more important than female vaccination. This parental perception of gender-based importance in vaccination was significantly associated with under-immunization among children (p-value = 0.049). Additionally, males in our study are fully vaccinated 5% more often than females. Socio-economic factors, including mothers' education and households' income level, were also significantly associated with the vaccination status of the children.

Conclusion

This study shed light on the effect of gender norms and related determinants on equitable access to vaccinations for boys and girls alike. More research is needed to gain a better understanding of the gender norms related to vaccination and their long-term impact on immunization demand and resilience in this region.

Risk factors of diphtheria outbreak in damt district of Al Dhalea Governorate, 2023 -Yemen: a case-control study

BACKGROUND

In Yemen, diphtheria has become an important health problem since 2017 when diphtheria re-emergence as a consequence of war and the collapse of the health system. In 2023, there has been a 57% increase in diphtheria cases compared to 2021 and 2022. Damt district of Al Dhalea Governorate had the highest reported cases for year 2023. The study aims to determine the risk factors associated with diphtheria outbreak in Damt District.

METHODS

A retrospective matched case-control (1:2) was used. All confirmed cases based on the WHO case definition reported from Damt district during 2023 were considered cases. Two age-matched (± 5years) neighborhood controls were recruited per case. A pretested questionnaire was used for collecting data during household interviews including demographic and household characteristics, knowledge of diphtheria, vaccination status, contact with a case of diphtheria, and travel history. Frequency and proportion for quantitative and median with interquartile range (IQR) for quantitative variables. Chi-square and Mann-Whitney tests to compare the distribution of categorical and numerical variables between cases and controls. Univariate and multivariate conditional binary logistic regression, and Adjusted Odds ratio (AOR) with a 95% confidence interval at P < 0.05 were used to identify risk factors.

RESULTS

A total of 118 cases and 236 controls were enrolled, 56% were females (63% of cases vs. 53% of controls). The median (IQR) age was 14 (9,22) years for cases vs 12(7,23) of control, it was significantly higher for females than males in the case group: (16(10,29) Vs 10(6,18), P < 0.001) and control group: (15(8,25) vs 12(7,18), p-value = 0.022). Partial vaccination status AOR = 13.7(6.1-31.1), P-value < 0.001), contacts with a case of diphtheria AOR = 8.5(2.3-31.0), P value < 0.001) and Female gender, AOR = 3.3(CI; 1.1-9.5, P value = 0.029), were the main risk factors.

CONCLUSIONS

Poor vaccination and contact with a case of diphtheria were the main contributors to diphtheria in the Damt district particularly among adult females. Increasing the vaccination coverage with a diphtheria-containing vaccine through routine immunization as well as tetanus-diphtheria vaccine for childbearing age females along with community awareness regarding protection measures during home care of diphtheria cases. Vaccination services as well as gender barriers related to Td vaccination should be investigated.

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.

High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis

BACKGROUND

Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children.

OBJECTIVE

To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia.

METHODS

A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant.

RESULTS

The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5].

CONCLUSION

In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.

In-depth reasons for the high proportion of zero-dose children in underserved populations of Ethiopia: Results from a qualitative study

Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly designated as zero-dose children. A comprehensive understanding of the supply- and demand-side barriers is essential to inform zero-dose strategies in high-burden countries and achieve global immunization goals. This qualitative study aimed to identify the barriers for reaching zero-dose and under-immunized children and what and explore gender affects access to vaccination services for children in Ethiopia. Data was collected between March-June 2022 using key informant interviews and focus group discussions with participants in underserved settings. The high proportion of zero-dose children was correlated with inadequate information being provided by health workers, irregularities in service provision, suboptimal staff motivation, high staff turnover, closure and inaccessibility of health facilities, lack of functional health posts, service provision limited to selected days or hours, and gender norms viewing females as responsible for childcare. Demand-side barriers included religious beliefs, cultural norms, fear of vaccine side effects, and lack of awareness and sustained interventions. Recommendations to increase vaccination coverage include strengthening health systems such as services integration, human resources capacity building, increasing incentives for health staff, integrating vaccination services, bolstering the EPI budget especially from the government side, and supporting reliable outreach and static immunization services. Additionally, immunization policy should be revised to include gender considerations including male engagement strategies to improve uptake of immunization services.

The Importance of Gender-Sensitive Health Care in the Context of Pain, Emergency and Vaccination: A Narrative Review

So far, health care has been insufficiently organized in a gender-sensitive way, which makes the promotion of care that meets the needs of women and men equally emerge as a relevant public health problem. The aim of this narrative review was to outline the need for more gender-sensitive medical care in the context of pain, emergency care and vaccinations. In this narrative review, a selective search was performed in Pubmed, and the databases of the World Health Organization (WHO), the European Institute for Gender Equality and the German Federal Ministry of Health were searched. Study data indicate that there are differences between men and women with regard to the ability to bear pain. On the other hand, socially constructed role expectations in pain and the communication of these are also relevant. Studies indicate that women receive adequate pain medication less often than men with a comparable pain score. Furthermore, study results indicate that the female gender is associated with an increased risk of inadequate emergency care. In terms of vaccine provision, women are less likely than men to utilize or gain access to vaccination services, and there are gender-sensitive differences in vaccine efficacy and safety. Sensitization in teaching, research and care is needed to mitigate gender-specific health inequalities.

Spatio-temporal analysis of childhood vaccine uptake in Nigeria: a hierarchical Bayesian Zero-inflated Poisson approach

BACKGROUND

Globally, child mortality and morbidity remain a serious health challenge and infectious diseases are the leading causes. The use of count models together with spatial analysis of the number of doses of childhood vaccines taken is limited in the literature. We used a Bayesian zero-inflated Poisson regression model with spatio-temporal components to assess the number of doses of childhood vaccines taken among children aged 12-23 months and their associated factors.

METHODS

Data of 19,564 children from 2003, 2008, 2013 and 2018 population-based cross-sectional Nigeria Demographic and Health Survey were used. The childhood vaccines include one dose of Bacillus-Calmette-Guérin; three doses of Diphtheria-Pertussis-Tetanus; three doses of Polio and one dose of Measles. Uptake of all nine vaccines was regarded as full vaccination. We examined the multilevel factors associated with the number of doses of childhood vaccines taken using descriptive, bivariable and multivariable Bayesian models. Analysis was conducted in Stata version 16 and R statistical packages, and visualization in ArcGIS.

RESULTS

The prevalence of full vaccination was 6.5% in 2003, 14.8% in 2008, 21.8% in 2013 and 23.3% in 2018. Full vaccination coverage ranged from 1.7% in Sokoto to 51.9% in Anambra. Factors associated with the number of doses of childhood vaccines taken include maternal age (adjusted Incidence "risk" Ratio (aIRR) = 1.05; 95% Credible Interval (CrI) = 1.03-1.07) for 25-34 years and (aIRR = 1.07; 95% CrI = 1.05-1.10) for 35-49 years and education: (aIRR = 1.11, 95% CrI = 1.09-1.14) for primary and (aIRR = 1.16; 95% CrI = 1.13-1.19) for secondary/tertiary education. Other significant factors are wealth status, antenatal care attendance, working status, use of skilled birth attendants, religion, mother's desire for the child, community poverty rate, community illiteracy, and community unemployment.

CONCLUSION

Although full vaccination has remained low, there have been improvements over the years with wide disparities across the states. Improving the uptake of vaccines by educating women on the benefits of hospital delivery and vaccines through radio jingles and posters should be embraced, and state-specific efforts should be made to address inequality in access to routine vaccination in Nigeria.

Inequalities in Immunization against Maternal and Neonatal Tetanus: A Cross-Sectional Analysis of Protection at Birth Coverage Using Household Health Survey Data from 76 Countries

Substantial progress in maternal and neonatal tetanus elimination has been made in the past 40 years, with dramatic reductions in neonatal tetanus incidence and mortality. However, twelve countries have still not achieved maternal and neonatal tetanus elimination, and many countries that have achieved elimination do not meet key sustainability thresholds to ensure long-lasting elimination. As maternal and neonatal tetanus is a vaccine-preventable disease (with coverage of the infant conferred by maternal immunization during and prior to pregnancy), maternal tetanus immunization coverage is a key metric for monitoring progress towards, equity in, and sustainability of tetanus elimination. In this study, we examine inequalities in tetanus protection at birth, a measure of maternal immunization coverage, across 76 countries and four dimensions of inequality via disaggregated data and summary measures of inequality. We find that substantial inequalities in coverage exist for wealth (with lower coverage among poorer wealth quintiles), maternal age (with lower coverage among younger mothers), maternal education (with lower coverage among less educated mothers), and place of residence (with lower coverage in rural areas). Inequalities existed for all dimensions across low- and lower-middle-income countries, and across maternal education and place of residence across upper-middle-income countries. Though global coverage changed little over the time period 2001-2020, this obscured substantial heterogeneity across countries. Notably, several countries had substantial increases in coverage accompanied by decreases in inequality, highlighting the need for equity considerations in maternal and neonatal tetanus elimination and sustainability efforts.

Cardiac arrest associated with non-toxigenic corynebacterium diphtheria strain: A case report

Here we document a rare, acute, infection caused by non-toxigenic Corynebacterium diphtheriae and the resulting unique and severe clinical sequelae. Our patient was a young man with no known pre-existing conditions that presented in cardiopulmonary arrest. We contrast this case with prior instances of non-toxigenic C. diphtheriae strain infection in the United States and summarize the literature that suggests systemic infection can result in cardiogenic toxicity. We speculate on a possible missed, pre-existing condition that could have increased this patient's susceptibility to poor clinical outcome.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries

The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.