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

Inequality in Childhood Immunization Coverage: A Scoping Review of Data Sources, Analyses, and Reporting Methods

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

Women's Empowerment and Associated Factors in Kinshasa, Democratic Republic of Congo: A Secondary Data Analysis of the Performance Monitoring Assessment Survey

Empowering women and promoting gender equality is crucial for accelerating sustainable development in fragile countries, including the Democratic Republic of Congo (DRC). However, there is scarce existing knowledge or understanding of the factors determining women's empowerment in these contexts. We aimed to assess women's empowerment and determine its associated factors in Kinshasa, DRC. We analyzed data from the 2021 Performance Monitoring Assessment (PMA) survey. A sample of 1365 women of childbearing age was retained for this study. Twenty empowerment items related to household decision-making, contraception use, and husband/partner influence were considered. We calculated the average women's empowerment index (aWEI), identified the women's empowerment variables using principal component analysis (PCA), and determined the associated factors for the first three principal components through the performance of multivariate binary logistic regression. In Kinshasa, the overall aWEI was estimated at 0.65. It was low for household decision-making (0.34) and high for husband/partner influence domains (0.93). Three principal components were identified and named, including the absence of threats, control of sexuality, and participation in decision-making. The factors associated with these components were having internet access, being in free union with a partner, being aged 40-49 years, and residing in a non-slum area. Increasing access to information would enable women in Kinshasa to make strategic decisions about their lives, benefiting themselves and others.

Oral and Inactivated Polio Vaccine Coverage and Determinants of Coverage Inequality Among the Most At-Risk Populations in Ethiopia

Combining oral (OPV) and inactivated (IPV) poliovirus vaccines prevents importation of poliovirus and emergence of circulating vaccine-derived poliovirus. We measured the coverage with IPV and third dose of OPV (OPV-3) and identified determinants of coverage inequality in the most at-risk populations in Ethiopia. A national survey representing 10 partly overlapping underserved populations-pastoralists, conflict-affected areas, urban slums, hard-to-reach settings, developing regions, newly formed regions, internally displaced people (IDPs), refugees, and districts neighboring international and interregional boundaries-was conducted among children 12 to 35 months old (N = 3,646). Socioeconomic inequality was measured using the concentration index (CIX) and decomposed using a regression-based approach. One-third (95% CI: 31.5-34.0%) of the children received OPV-3 and IPV. The dual coverage was below 50% in developing regions (19.2%), pastoralists (22.0%), IDPs (22.3%), districts neighboring international (24.1%) and interregional (33.3%) boundaries, refugees (27.0%), conflict-affected areas (29.3%), newly formed regions (33.5%), and hard-to-reach areas (38.9%). Conversely, coverage was better in urban slums (78%). Children from poorest households, living in villages that do not have health posts, and having limited health facility access had increased odds of not receiving the vaccines. Low paternal education, dissatisfaction with vaccination service, fear of vaccine side effects, living in female-headed households, having employed and less empowered mothers were also risk factors. IPV-OPV3 coverage favored the rich (CIX = -0.161, P < 0.001), and causes of inequality were: inaccessibility of health facilities (13.3%), dissatisfaction with vaccination service (12.8%), and maternal (4.9%) and paternal (4.9%) illiteracy. Polio vaccination coverage in the most at-risk populations in Ethiopia is suboptimal, threatening the polio eradication initiative.

Vaccination dropout and wealth related inequality among children aged 12-35 months in remote and underserved settings of Ethiopia: a cross-sectional evaluation survey

Background

Vaccination is one of the most cost-effective public health interventions that prevents millions of deaths. Although immunization coverage is increasing globally, many children in low- and middle-income countries drop out of the vaccination continuum. This study aimed at determining vaccination dropout rates and predictors in children aged 12-35 months in remote and underserved areas of Ethiopia.

Methods

This study was part of a cross-sectional evaluation survey that was conducted in 2022 in Ethiopia. The study settings include pastoralist, developing & newly established regions, conflict affected areas, urban slums, internally displaced populations and refugees. A sample of 3,646 children aged 12-35 months were selected using a cluster sampling approach. Vaccination dropout was estimated as the proportion of children who did not get the subsequent vaccine among those who received the first vaccine. A generalized estimating equation was used to assess determinants of the dropout rate and findings were presented using an adjusted odds ratio with 95% confidence interval. Concentration curve and index were used to estimate wealth related inequality of vaccination dropout.

Results

A total of 3,646 caregivers of children participated in the study with a response rate of 97.7%. The BCG to Penta-3 (52.5%), BCG to MCV-2 (57.4%), and Penta-1 to Penta-3 (43.9%) dropouts were all high. The highest Penta-1 to Penta-3 dropout rate was found in developing regions (60.1%) and the lowest was in urban slums (11.2%). Caregivers who were working outside their homes [AOR (95% CI) = 3.67 (1.24-10.86)], who had no postnatal care follow-up visits [AOR (95%CI) = 1.66 (1.15-2.39)], who did not receive a service from a skilled birth attendant [AOR (95%CI) = 1.64 (1.21-2.27)], who were older than 45 years [AOR (95% CI) = 12.49 (3.87-40.33)], and who were less gender empowered [AOR (95%CI) = 1.63 (1.24-2.15)] had increased odds of Penta-1 to Penta-3 dropout. The odds of dropout for children from poor caregivers was nearly two times higher compared to their wealthy counterparts [AOR (95%CI) = 1.87 (1.38-2.52)].

Conclusion

Vaccination dropout estimates were high among children residing in remote and underserved settings. Poor wealth quintile, advanced maternal age, low women empowerment, and limited utilization of maternity care services contributed to vaccination dropout.

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.