Immunization Gender Inequity in Pakistan: An Analysis of 6.2 Million Children Born from 2019 to 2022 and Enrolled in the Sindh Electronic Immunization Registry

Abstract

Gender-based inequities in immunization impede the universal coverage of childhood vaccines. Leveraging data from the Government of Sindh’s Electronic Immunization Registry (SEIR), we estimated inequalities in immunization for males and females from the 2019–2022 birth cohorts in Pakistan. We computed male-to-female (M:F) and gender inequality ratios (GIR) Tfor enrollment, vaccine coverage, and timeliness. We also explored the inequities by maternal literacy, geographic location, mode of vaccination delivery, and gender of vaccinators. Between 1 January 2019, and 31 December 2022, 6,235,305 children were enrolled in the SEIR, 52.2% males and 47.8% females. We observed a median M:F ratio of 1.03 at enrollment and at Penta-1, Penta-3, and Measles-1 vaccinations, indicating more males were enrolled in the immunization system than females. Once enrolled, a median GIR of 1.00 indicated similar coverage for females and males over time; however, females experienced a delay in their vaccination timeliness. Low maternal education; residing in remote-rural, rural, and slum regions; and receiving vaccines at fixed sites, as compared to outreach, were associated with fewer females being vaccinated, as compared to males. Our findings suggeste the need to tailor and implement gender-sensitive policies and strategies for improving equity in immunization, especially in vulnerable geographies with persistently high inequalities.

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

“…Measurement of immunization coverage varied as well including comparisons between full vs. partial vs. zero dose and hesitancy, readiness, acceptance, and awareness. Measures of gender inequity varied even more widely; nine quantitative studies used gender scores including SWPER Global [ 8 , 9 ], Gender Inequality Ratio (GIR) [ 10 ], Gender Development Index (GDI) [ 11 ], Gender Inequality Index (GII) [ 11 ], and proxies/indexes for empowerment, decision-making power, and autonomy [ 12 , 13 , 14 , 15 , 16 ].…”

“…Men in the Philippines also preferred to receive the HPV vaccine from male providers, particularly physicians (not nurses) [ 76 ]. Alternatively, other studies noted that a lack of female vaccinators leads to increases in coverage inequities [ 10 , 57 ]. In some settings, women cannot be in contact with men who are not related to them [ 43 , 57 ].…”

Inequality in Immunization: Holding on to Equity as We ‘Catch Up’

“…An encouraging observation while putting together this Special Issue has been the use of a variety of data sources to assess immunization inequalities. Studies have made use of traditional sources of immunization data like administrative data [ 19 , 23 , 32 ] and population surveys [ 18 , 21 , 22 , 27 , 29 , 30 ] (including Demographic and Health Surveys and/or Multiple Indicator Cluster Surveys [ 15 , 20 , 31 ]), while several other studies explored the potential of novel sources such as geospatial data [ 24 , 25 ], electronic immunization registries [ 34 ], dialogues [ 16 ], country appraisals and reports [ 35 ], and funding proposals [ 26 ]. Three review studies relied on synthesis and structured analyses drawing from a multitude of existing studies [ 17 , 33 , 36 ].…”

“…As dimensions of inequality present themselves and intersect in dynamic ways, our modes of understanding must keep up. Several studies in this Special Issue examined multiple dimensions of immunization inequality [ 18 , 19 , 21 , 27 , 29 , 31 , 33 , 36 ], while others focused on specific dimensions, such as gender barriers [ 20 , 34 ] or socioeconomic status [ 15 , 30 , 32 ].…”