Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries
Abstract
:1. Introduction
2. Materials and Methods
2.1. Indicators and Data Sources
2.1.1. Immunization Outcomes
2.1.2. Factors Associated with Immunization Coverage
2.1.3. Gender Inequality
2.2. Data Sources
2.3. Analyses
- First, we replicated the adjusted fractional logistic regression as described above with the addition of a covariate which was the country-year average zero-dose DTP prevalence or DTP3 coverage.
- Second, we retained only the most recent year of available data for each subnational region, and conducted the same adjusted fractional logistic regression, but with the clustered standard errors based on country, rather than region.
- Third, we included all available data but used a multi-level mixed effects linear regression approach, using nested random effects of subnational region within country, with covariate fixed effects as defined by the adjusted model above. For these models, we specified random intercepts for both country and region, and random slopes for region, with an identity variance-covariance structure; these specifications were selected based on model performance as assessed by AIC and BIC.
- Fourth, we replicated the mixed-effects linear regression approach using the most recent year of available data for each subnational region, and including only random intercepts for country.
3. Results
3.1. Descriptive Analyses
3.2. Regression Analyses
Models Accounting for Country-Level Clustering
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Feletto, M.; Sharkey, A.; Rowley, E.; Gurley, N.; Sinha, A.; Champions, E.; Gupta, A.; Tolhurst, R. A Gender Lens to Advance Equity in Immunisation; Technical Report for Equity Reference Group for Immunisation: New York, NY, USA, 2018. [Google Scholar]
- Feletto, M.; Sharkey, A. The influence of gender on immunisation: Using an ecological framework to examine intersecting inequities and pathways to change. BMJ Glob. Health 2019, 4, e001711. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Chopra, M.; Bhutta, Z.; Blanc, D.C.; Checchi, F.; Gupta, A.; Lemango, E.T.; Levine, O.S.; Lyimo, D.; Nandy, R.; O’Brien, K.L.; et al. Addressing the persistent inequities in immunization coverage. Bull. World Health Organ. 2020, 98, 146–148. [Google Scholar] [CrossRef] [PubMed]
- Why Gender Matters: Immunization Agenda 2030; World Health Organization: Geneva, Switzerland, 2021.
- The Gender Pay Gap in the Health and Care Sector a Global Analysis in the Time of COVID-19; World Health Organization and the International Labour Organization: Geneva, Switzerland, 2022.
- Wendt, A.; Santos, T.M.; Cata-Preta, B.O.; Costa, J.C.; Mengistu, T.; Hogan, D.R.; Victora, C.G.; Barros, A.J.D. Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys. J. Glob. Health 2022, 12, 04022. [Google Scholar] [CrossRef] [PubMed]
- Johns, N.E.; Santos, T.M.; Arroyave, L.; Cata-Preta, B.O.; Heidari, S.; Kirkby, K.; Munro, J.; Schlotheuber, A.; Wendt, A.; O’Brien, K.; et al. 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. Vaccines 2022, 10, 988. [Google Scholar] [CrossRef]
- Arsenault, C.; Johri, M.; Nandi, A.; Rodriguez, J.M.M.; Hansen, P.M.; Harper, S. Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries. Vaccine 2017, 35, 2479–2488. [Google Scholar] [CrossRef]
- Vidal Fuertes, C.; Johns, N.E.; Goodman, T.S.; Heidari, S.; Munro, J.; Hosseinpoor, A.R. The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage. Vaccines 2022, 10, 1032. [Google Scholar] [CrossRef]
- Ewerling, F.; Raj, A.; Victora, C.G.; Hellwig, F.; Coll, C.V.N.; Barros, A.J.D. A Survey-Based Women’s Empowerment Index for Low- and Middle-Income Countries: The SWPER Goes Global. Int. J. Epidemiol. 2021, 50, 168–193. [Google Scholar] [CrossRef]
- Gavi the Vaccine Alliance. Measuring Our Performance: 2011–2015 Indicators. Available online: https://www.gavi.org/programmes-impact/our-impact/measuring-our-performance/2011-2015-indicators (accessed on 6 June 2022).
- Sodha, S.V.; Dietz, V. Strengthening routine immunization systems to improve global vaccination coverage. Br. Med. Bull. 2015, 113, 5–14. [Google Scholar] [CrossRef]
- Bergen, N.; Cata-Preta, B.O.; Schlotheuber, A.; Santos, T.M.; Danovaro-Holliday, M.C.; Mengistu, T.; Sodha, S.V.; Hogan, D.R.; Barros, A.J.D.; Hosseinpoor, A.R. Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries. Vaccines 2022, 10, 633. [Google Scholar] [CrossRef]
- The DHS Program. Methodology. Available online: https://dhsprogram.com/Methodology/ (accessed on 18 March 2022).
- Streatfield, K.; Singarimbun, M.; Diamond, I. Maternal Education and Child Immunization. Demography 1990, 27, 447–455. [Google Scholar] [CrossRef]
- Vikram, K.; Vanneman, R.; Desai, S. Linkages between maternal education and childhood immunization in India. Soc. Sci. Med. 2012, 75, 331–339. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Abuya, B.A.; Onsomu, E.O.; Kimani, J.K.; Moore, D. Influence of Maternal Education on Child Immunization and Stunting in Kenya. Matern. Child Health J. 2011, 15, 1389–1399. [Google Scholar] [CrossRef] [PubMed]
- Forshaw, J.; Gerver, S.M.; Gill, M.; Cooper, E.; Manikam, L.; Ward, H. The global effect of maternal education on complete childhood vaccination: A systematic review and meta-analysis. BMC Infect. Dis. 2017, 17, 801. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Burroway, R.; Hargrove, A. Education is the antidote: Individual- and community-level effects of maternal education on child immunizations in Nigeria. Soc. Sci. Med. 2018, 213, 63–71. [Google Scholar] [CrossRef]
- Smits, J.; Permanyer, I. The Subnational Human Development Database. Sci. Data 2019, 6, 190038. [Google Scholar] [CrossRef] [Green Version]
- United Nations Development Programme. Gender Development Index (GDI). Available online: https://hdr.undp.org/en/content/gender-development-index-gdi (accessed on 10 March 2022).
- Global Data Lab. Available online: https://globaldatalab.org/ (accessed on 30 August 2022).
- The World Bank. World Development Indicators. Available online: https://databank.worldbank.org/source/world-development-indicators (accessed on 30 August 2022).
- Papke, L.E.; Wooldridge, J.M. Panel data methods for fractional response variables with an application to test pass rates. J. Econom. 2008, 145, 121–133. [Google Scholar] [CrossRef]
- Wooldridge, J.M. Econometric Analysis of Cross Section and Panel Data, 2nd ed.; MIT Press: Cambride, MA, USA, 2010. [Google Scholar]
- StataCorp. Stata Statistical Software: Release 16; StataCorp LLC: College Station, TX, USA, 2019. [Google Scholar]
- WHO/UNICEF. WHO UNICEF Immunization Coverage Estimates 2021 Revision. 2022. Available online: https://data.unicef.org/wp-content/uploads/2016/07/wuenic2021rev_web-update.xlsx (accessed on 30 August 2022).
- Brinda, E.M.; Rajkumar, A.P.; Enemark, U. Association between gender inequality index and child mortality rates: A cross-national study of 138 countries. BMC Public Health 2015, 15, 97. [Google Scholar] [CrossRef]
- Singh, K.; Bloom, S.; Brodish, P. Gender equality as a means to improve maternal and child health in Africa. Health Care Women Int. 2015, 36, 57–69. [Google Scholar] [CrossRef]
- Thorpe, S.; VanderEnde, K.; Peters, C.; Bardin, L.; Yount, K.M. The Influence of Women’s Empowerment on Child Immunization Coverage in Low, Lower-Middle, and Upper-Middle Income Countries: A Systematic Review of the Literature. Matern. Child Health J. 2016, 20, 172–186. [Google Scholar] [CrossRef]
- State of Inequality: Childhood Immunization; World Health Organization: Geneva, Switzerland, 2016.
- Kirkby, K.; Bergen, N.; Schlotheuber, A.; Sodha, S.V.; Danovaro-Holliday, M.C.; Hosseinpoor, A.R. Subnational inequalities in diphtheria-tetanus-pertussis immunization in 24 countries in the African Region. Bull. World Health Organ. 2021, 99, 627–639. [Google Scholar] [CrossRef]
- Cata-Preta, B.O.; Santos, T.M.; Mengistu, T.; Hogan, D.R.; Barros, A.J.D.; Victora, C.G. Zero-dose children and the immunisation cascade: Understanding immunisation pathways in low and middle-income countries. Vaccine 2021, 39, 4564–4570. [Google Scholar] [CrossRef] [PubMed]
- Phillips, S.P. Defining and measuring gender: A social determinant of health whose time has come. Int. J. Equity Health 2005, 4, 11. [Google Scholar] [CrossRef] [PubMed]
- Sen, G.; Östlin, P. Gender as a social determinant of health: Evidence, policies, and innovations. In Gender Equity in Health; Routledge: London, UK, 2009; pp. 23–68. [Google Scholar]
- Immunization Agenda 2030: A Global Strategy to Leave No One Behind; World Health Organization: Geneva, Switzerland, 2020.
- Gavi the Vaccine Alliance. Phase V (2021–2025). Available online: https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025 (accessed on 18 March 2022).
Category | Indicator |
---|---|
Outcomes | Zero-dose DTP prevalence |
DTP3 immunization coverage | |
Gender inequality | Subnational gender development index (SGDI) |
Demographic/geographic characteristics | Average annual rate of population change (%) * |
Population <15 years (%) | |
Urban population (%) | |
Human development | Subnational health index (0 to 1) |
Subnational education index (0 to 1) | |
Subnational income index (0 to 1) |
Zero-Dose DTP (%) | DTP3 Immunization Coverage (%) | ||||||
---|---|---|---|---|---|---|---|
Median | Min | Max | Median | Min | Max | N | |
High gender inequality | 18.2 | 0 | 96.6 | 64.4 | 2.6 | 98.1 | 214 |
Medium/low/negligible gender inequality | 4.8 | 0 | 81.2 | 86.0 | 9.7 | 100 | 852 |
p-value | <0.001 | <0.001 |
Unadjusted | Adjusted | |
---|---|---|
Zero-dose children | ||
High gender inequality | 2.637 *** | 1.742 *** |
95% CI | (2.122–3.275) | (1.384–2.193) |
DTP3 immunization coverage | ||
High gender inequality | 0.437 *** | 0.614 *** |
95% CI | (0.364–0.524) | (0.505–0.746) |
No Country Consideration (Fractional Logistic Model, Full Sample) | Fractional Logistic Model, Plus Country-Year Average Coverage | Fractional Logistic Model, Most Recent Year of Data Only, Country Clustered Standard Errors | Mixed Effects Linear Regression Model, Nested Random Effects | Mixed Effects Linear Regression Model, Most Recent Year of Data Only, Country Random Effect | |
---|---|---|---|---|---|
N | 1066 | 1066 | 702 | 1066 | 702 |
Zero-dose children | |||||
High gender inequality | 5.83 ** | 3.31 ** | 3.48 | 3.64 * | 4.16 * |
95% CI | (3.26–8.39) | (1.82–4.80) | (−1.04–8.00) | (1.36–5.91) | (1.57–6.75) |
DTP3 immunization coverage | |||||
High gender inequality | −8.20 ** | −4.07 ** | −5.16 | −4.22 * | −5.30 * |
95% CI | (−11.64 to −4.77) | (−6.06 to −2.09) | (−11.69–1.38) | (−7.00 to −1.45) | (−8.48 to −2.12) |
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Johns, N.E.; Kirkby, K.; Goodman, T.S.; Heidari, S.; Munro, J.; Shendale, S.; Hosseinpoor, A.R. Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries. Vaccines 2022, 10, 1951. https://doi.org/10.3390/vaccines10111951
Johns NE, Kirkby K, Goodman TS, Heidari S, Munro J, Shendale S, Hosseinpoor AR. Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries. Vaccines. 2022; 10(11):1951. https://doi.org/10.3390/vaccines10111951
Chicago/Turabian StyleJohns, Nicole E., Katherine Kirkby, Tracey S. Goodman, Shirin Heidari, Jean Munro, Stephanie Shendale, and Ahmad Reza Hosseinpoor. 2022. "Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries" Vaccines 10, no. 11: 1951. https://doi.org/10.3390/vaccines10111951
APA StyleJohns, N. E., Kirkby, K., Goodman, T. S., Heidari, S., Munro, J., Shendale, S., & Hosseinpoor, A. R. (2022). Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries. Vaccines, 10(11), 1951. https://doi.org/10.3390/vaccines10111951