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

Abstract

This study explores the association between childhood immunization and gender inequality at the national level. Data for the study include annual country-level estimates of immunization among children aged 12–23 months, indicators of gender inequality, and associated factors for up to 165 countries from 2010–2019. The study examined the association between gender inequality, as measured by the gender development index and the gender inequality index, and two key outcomes: prevalence of children who received no doses of the DTP vaccine (zero-dose children) and children who received the third dose of the DTP vaccine (DTP3 coverage). Unadjusted and adjusted fractional logit regression models were used to identify the association between immunization and gender inequality. Gender inequality, as measured by the Gender Development Index, was positively and significantly associated with the proportion of zero-dose children (high inequality AOR = 1.61, 95% CI: 1.13–2.30). Consistently, full DTP3 immunization was negatively and significantly associated with gender inequality (high inequality AOR = 0.63, 95% CI: 0.46–0.86). These associations were robust to the use of an alternative gender inequality measure (the Gender Inequality Index) and were consistent across a range of model specifications controlling for demographic, economic, education, and health-related factors. Gender inequality at the national level is predictive of childhood immunization coverage, highlighting that addressing gender barriers is imperative to achieve universal coverage in immunization and to ensure that no child is left behind in routine vaccination.

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

“…These findings align with prior work examining gender inequality and childhood outcomes, including child mortality and immunization coverage, using different analytic approaches including alternate measures of gender inequality and national or individual units of analysis [6][7][8][9][28][29][30]. These studies consistently find that gender equality, and the related construct of women's empowerment, are associated with improved immunization coverage, decreased child mortality, and other positive child health outcomes.…”

“…We examined variables selected a priori based on prior national-level analyses, to make findings as directly comparable as possible [9]. These factors were chosen to account for demand and supply side factors that influence vaccination and might confound the association between immunization and gender inequality [15][16][17][18][19].…”

“…These include barriers faced by (frequently women) caregivers, such as lower health education and literacy, travel restriction, and limited household decision-making influence; by health workers delivering services (who are disproportionately women), including gender pay gap, workplace harassment and inequitable exposures to health risks; and by policy-makers (where women are frequently under-represented), who enact laws and guidelines which may amplify or reinforce gender inequities [2,5]. Several recent studies have examined the relationship between childhood immunization coverage and measures of gender inequality empirically, at the individual [6,7] and national [8,9] levels. These studies consistently find significant and meaningful associations between greater gender inequality and lower immunization coverage.…”

“…National level analyses that have examined gender barriers and immunization outcomes similarly find that countries with lower gender inequality have higher rates of DTP3 coverage and lower zero-dose DTP prevalence [8,9]. The advantages of national analyses include: readily available data and the ability to examine large numbers of geographies; standard measures of inequality that are comparable across countries and time; and the fact that national averages capture the broader state of women in a society, as laws, economics, health systems, and education are often determined and implemented at the national level.…”

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

“…Since 2018, only a handful of cases have been reported in the U.S. each year, typically among vulnerable populations ( 4 ) including immigrants ( 5 ), the incarcerated ( 6 ), and individuals with vaccine hesitancy ( 7 , 8 ). These socioeconomic variables are disproportionately distributed across individuals within a population, providing a substantial amount of complexity when it comes to population-level health policies and approaches to preventative healthcare and civilian education thereof ( 9 , 10 ). In the U.S., population-level data estimate children aged 13–17 have 90.2% compliance with DTaP vaccines ( 3 ), a level considered sufficient to achieve herd immunity, but one that nevertheless leaves some potential for propagation and outbreak ( 11 , 12 ).…”