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

Abstract

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.

Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria

“…The Mozambique study identified similar patterns of barriers to vaccination, including the role of gender barriers and power imbalances with health workers. Cross-national quantitative analyses of household survey data show that immunization inequalities are associated with household wealth and maternal education [ 6 ], and that the prevalence of zero-dose children is associated with gender inequality [ 8 ], birth order, birth weight, maternal education, maternal occupation, household wealth, and the number of antenatal care visits [ 9 ].…”

“…Research exists on the drivers of immunization inequality [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ], yet most of the existing research focuses either on individual attributes or health system drivers, without analysis of the social and structural processes that produce inequalities [ 11 ]. Recent attention to the role of gender in immunization (in)equity is overdue [ 8 , 12 ] but too often, gender is explored alone, without consideration of how it intersects and interacts with other social, institutional, and structural dimensions of inequality, including social determinants of health. Novel research approaches are needed to reconceptualize immunization inequality—and potential solutions to overcoming it—from caregivers’ lived perspectives.…”

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

“…The Special Issue features research, reviews, and commentaries that span a range of immunization topics and populations. While there is an emphasis on childhood vaccinations [ 15 , 16 , 17 , 18 ]—exploring inequalities in DTP and measles-containing vaccine (MCV) coverage [ 19 , 20 , 21 , 22 , 23 ] and patterns of inequality in unvaccinated or zero-dose children [ 24 , 25 , 26 , 27 , 28 , 29 ]—contributions also cover inequalities in adult immunization [ 30 ], including protection of pregnant women and their newborns against tetanus [ 31 ] and COVID-19 vaccination [ 32 , 33 ].…”

“…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 ].…”