The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage
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. Analyses
- Model (1) estimates the unadjusted association between the outcome and gender inequality (GDI or GII), without controlling for any other factors;
- Model (2) includes controls for annual population growth and age structure (measured as the percentage of the population under 15 years of age), percentage of urban population, and the three individual dimensional indices of the HDI (health index, education index, and GNI index);
- Model (3) includes the same controls as Model (2), but the level of human development is measured through the overall HDI, instead of the three dimension-specific indices;
- Model (4) includes the same controls as Model (2), but the level of human development is measured through three specific economic, education, and health indicators, namely: natural log of GDP per capita PPP, mean years of schooling for the population 25 or older, and the log of current per capita health expenditure PPP.
3. Results
3.1. Descriptive Analyses
3.2. Regression Analyses
3.2.1. Gender Development Index
3.2.2. Gender Inequality Index
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- UN General Assembly. Transforming Our World: The 2030 Agenda for Sustainable Development; United Nations: New York, NY, USA, 2015. [Google Scholar]
- 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] [PubMed]
- Chirowa, F.; Atwood, S.; van der Putten, M. Gender inequality, health expenditure and maternal mortality in sub-Saharan Africa: A secondary data analysis. Afr. J. Prim. Health Care Fam. Med. 2013, 5, a471. [Google Scholar] [CrossRef]
- Marphatia, A.A.; Cole, T.J.; Grijalva-Eternod, C.; Wells, J.C.K. Associations of gender inequality with child malnutrition and mortality across 96 countries. Glob. Health Epidemiol. Genom. 2016, 1, e6. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- McKinlay, J.B. Some contributions from the social system to gender inequalities in heart disease. J. Health Soc. Behav. 1996, 37, 1–26. [Google Scholar] [CrossRef]
- Richardson, E.T.; Collins, S.E.; Kung, T.; Jones, J.H.; Tram, K.H.; Boggiano, V.L.; Bekker, L.G.; Zolopa, A.R. Gender inequality and HIV transmission: A global analysis. J. Int. AIDS Soc. 2014, 17, 19035. [Google Scholar] [CrossRef]
- Thorson, A.; Diwan, V.K. Gender inequalities in tuberculosis: Aspects of infection, notification rates, and compliance. Curr. Opin. Pulm. Med. 2001, 7, 165–169. [Google Scholar] [CrossRef]
- Feletto, M.; Sharkey, A.; Rowley, E.; Gurley, N.; Sinha, A.; Champions, E.; Gupta, A.; Tolhurst, R. A Gender Lens to Advance Equity in Immunisation; Equity Reference Group for Immunisation: New York, NY, USA, 2018. [Google Scholar]
- 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]
- World Health Organization. Why Gender Matters: Immunization Agenda 2030; World Health Organization: Geneva, Switzerland, 2021. [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] [Green Version]
- 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]
- Singh, A. Gender Based Within-Household Inequality in Childhood Immunization in India: Changes over Time and across Regions. PLoS ONE 2012, 7, e35045. [Google Scholar] [CrossRef]
- Singh, P.K. Trends in Child Immunization across Geographical Regions in India: Focus on Urban-Rural and Gender Differentials. PLoS ONE 2013, 8, e73102. [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).
- Gaye, A.; Klugman, J.; Kovacevic, M.; Twigg, S.; Zambrano, E. Measuring key disparities in human development: The gender inequality index. Hum. Dev. Res. Pap. 2010, 46, 1–37. [Google Scholar]
- 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]
- Martin Hilber, A.; Bosch-Capblanch, X.; Schindler, C.; Beck, L.; Sécula, F.; McKenzie, O.; Gari, S.; Stuckli, C.; Merten, S. Gender and Immunisation: Summary Report for SAGE; Swiss Tropical and Public Health Institute: Basel, Switzerland, 2010. [Google Scholar]
- 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]
- Kuchar, E.; Karlikowska-Skwarnik, M.; Han, S.; Nitsch-Osuch, A. Pertussis: History of the Disease and Current Prevention Failure. Adv. Exp. Med. Biol 2016, 934, 77–82. [Google Scholar] [CrossRef]
- Bland, J.; Clements, J. Protecting the world’s children: The story of WHO’s immunization programme. World Health Forum 1998, 19, 162–173. [Google Scholar] [PubMed]
- World Health Organization; Immunization, W.H.O.D. Immunization in Practice: A Practical Guide for Health Staff; World Health Organization: Geneva, Switzerland, 2015. [Google Scholar]
- 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. Brit. Med. Bull. 2015, 113, 5–14. [Google Scholar] [CrossRef] [PubMed]
- 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]
- World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind; World Health Organization: Geneva, Switzerland, 2020. [Google Scholar]
- 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).
- Hosseinpoor, A.R.; Bergen, N.; Schlotheuber, A.; Gacic-Dobo, M.; Hansen, P.M.; Senouci, K.; Boerma, T.; Barros, A.J. State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: A multicountry study of household health surveys. Lancet Glob. Health 2016, 4, e617–e626. [Google Scholar] [CrossRef] [Green Version]
- Levine, O.; Lemango, E.; Befson, J.; Gurley, N.; Rowley, E.; McIlvaine, B. ERG Discussion Paper 08: Tackling Inequities in Immunization Outcomes in Remote Rural Contexts. 2018. Available online: https://www.comminit.com/content/tackling-inequities-immunization-outcomes-remote-rural-contexts (accessed on 15 May 2022).
- Okwo-Bele, J.-M.; Conner, R.; McIlvaine, B.; Rowley, E.; Bernson, J. ERG Discussion Paper 06: Tackling Inequities in Immunization Outcomes in Conflict Contexts. 2018. Available online: https://www.comminit.com/global/content/tackling-inequities-immunization-outcomes-conflict-contexts (accessed on 15 May 2022).
- Mipatrini, D.; Stefanelli, P.; Severoni, S.; Rezza, G. Vaccinations in migrants and refugees: A challenge for European health systems. A systematic review of current scientific evidence. Pathog. Glob. Health 2017, 111, 59–68. [Google Scholar] [CrossRef] [Green Version]
- 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]
- Gauri, V.; Khaleghian, P. Immunization in developing countries: Its political and organizational determinants. World Dev. 2002, 30, 2109–2132. [Google Scholar] [CrossRef] [Green Version]
- United Nations Development Programme. Human Development Report 2020. The Next Frontier: Human Development and the Anthropocene; United Nations Development Programme: New York, NY, USA, 2020. [Google Scholar]
- United Nations Development Programme. Human Development Report 2020—Technical Notes; United Nations Development Programme: New York, NY, USA, 2020. [Google Scholar]
- United Nations Development Programme. Human Development Data Center. Available online: https://hdr.undp.org/en/data (accessed on 10 March 2022).
- World Health Organization. The Global Health Observatory. Available online: https://www.who.int/data/gho (accessed on 10 March 2022).
- United Nations Department of Economics and Social Affairs. World Population Prospects 2019. Available online: https://population.un.org/wpp/ (accessed on 10 March 2022).
- The World Bank. World Development Indicators. Available online: https://datatopics.worldbank.org/world-development-indicators/ (accessed on 10 March 2022).
- Global Data Lab. Available online: https://globaldatalab.org/ (accessed on 10 March 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]
- Merten, S.; Hilber, A.M.; Biaggi, C.; Secula, F.; Bosch-Capblanch, X.; Namgyal, P.; Hombach, J. Gender Determinants of Vaccination Status in Children: Evidence from a Meta-Ethnographic Systematic Review. PLoS ONE 2015, 10, e0135222. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. State of Inequality: Childhood Immunization; World Health Organization: Geneva, Switzerland, 2016. [Google Scholar]
- Streatfield, K.; Singarimbun, M.; Diamond, I. Maternal Education and Child Immunization. Demography 1990, 27, 447–455. [Google Scholar] [CrossRef] [PubMed]
- 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] [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]
- 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] [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]
- Dadari, I.; Higgins-Steele, A.; Sharkey, A.; Charlet, D.; Shahabuddin, A.; Nandy, R.; Jackson, D. Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries. Vaccine 2021, 39, 2434–2444. [Google Scholar] [CrossRef]
- Ozawa, S.; Clark, S.; Portnoy, A.; Grewal, S.; Brenzel, L.; Walker, D.G. Return on Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011–2020. Health Aff. 2016, 35, 199–207. [Google Scholar] [CrossRef] [Green Version]
- Munk, C.; Portnoy, A.; Suharlim, C.; Clarke-Deelder, E.; Brenzel, L.; Resch, S.C.; Menzies, N.A. Systematic review of the costs and effectiveness of interventions to increase infant vaccination coverage in low- and middle-income countries. BMC Health Serv. Res. 2019, 19, 741. [Google Scholar] [CrossRef] [PubMed]
- Permanyer, I. A Critical Assessment of the UNDP’s Gender Inequality Index. Fem. Econ. 2013, 19, 1–32. [Google Scholar] [CrossRef]
- Klasen, S.; Schuler, D. Reforming the Gender-Related Development Index and the Gender Empowerment Measure: Implementing Some Specific Proposals. Fem. Econ. 2011, 17, 1–30. [Google Scholar] [CrossRef]
Category | Indicator | Source |
---|---|---|
Outcomes | Zero-dose DTP prevalence | Human Development Data Center [36] |
DTP3 immunization coverage | WHO Global Health Observatory [37] | |
Gender inequality | Gender development index (GDI) | Human Development Data Center [36] |
Gender inequality index (GII) | Human Development Data Center [36] | |
Demographic characteristics | Average annual rate of population change (%) | World Population Prospects [38] |
Population < 15 years (%) | World Population Prospects [38] | |
Geographical context | Urban population (%) | World Development Indicators [39] |
Human development | Human development index (HDI) (0 to 1) | Human Development Data Center [36] |
Health index (0 to 1) | Global Data Lab [40] | |
Education index (0 to 1) | Global Data Lab [40] | |
Income index (0 to 1) | Global Data Lab [40] | |
GDP per capita, PPP | World Development Indicators [39] | |
Current health expenditure per capita, PPP | WHO Global Health Observatory [37] | |
Mean years schooling population aged 25+ | Global Data Lab [40] |
Zero-Dose DTP (%) | DTP3 Immunization Coverage (%) | ||||||||
---|---|---|---|---|---|---|---|---|---|
Gender development index | Median | Min | Max | N | Median | Min | Max | N | |
High gender inequality | 10.5 | 1 | 49 | 30 | 82.5 | 42 | 99 | 30 | |
Medium/low/negligible gender inequality | 3 | 1 | 35 | 135 | 94 | 57 | 99 | 135 | |
p-value * | <0.001 | <0.001 | |||||||
Gender inequality index | High gender inequality | 10 | 2 | 56 | 25 | 81 | 35 | 95 | 25 |
Medium/low/negligible inequality | 3 | 1 | 34 | 137 | 94 | 54 | 99 | 137 | |
p-value * | <0.001 | <0.001 |
Model 1 (No Controls) | Model 2 | Model 3 | Model 4 | |
---|---|---|---|---|
Zero-dose children | ||||
High gender inequality | 3.651 *** | 1.610 *** | 1.560 ** | 1.688 *** |
95% CI | 2.51–5.31 | 1.13–2.30 | 1.10–2.20 | 1.14–2.51 |
DTP3 immunization coverage | ||||
High gender inequality | 0.278 *** | 0.630 *** | 0.639 *** | 0.582 *** |
95% CI | 0.20–0.39 | 0.46–0.86 | 0.47–0.88 | 0.41–0.83 |
Number of observations | 1628 | 1610 | 1618 | 1401 |
Model 1 (No Controls) | Model 2 | Model 3 | Model 4 | |
---|---|---|---|---|
Zero-dose children | ||||
High gender inequality | 0.208 *** | 0.171 *** | 0.169 *** | 0.180 *** |
95% CI | 0.15–0.27 | 0.06–0.28 | 0.06–0.28 | 0.07–0.29 |
DTP3 immunization coverage | ||||
High gender inequality | −0.324 *** | −0.251 *** | −0.250 *** | −0.295 *** |
95% CI | −0.40–−0.25 | −0.40–−0.10 | −0.40–−0.10 | −0.45–−0.14 |
Number of observations | 1559 | 1541 | 1559 | 1343 |
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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. https://doi.org/10.3390/vaccines10071032
Vidal Fuertes C, Johns NE, Goodman TS, Heidari S, Munro J, Hosseinpoor AR. 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(7):1032. https://doi.org/10.3390/vaccines10071032
Chicago/Turabian StyleVidal Fuertes, Cecilia, Nicole E. Johns, Tracey S. Goodman, Shirin Heidari, Jean Munro, and Ahmad Reza Hosseinpoor. 2022. "The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage" Vaccines 10, no. 7: 1032. https://doi.org/10.3390/vaccines10071032
APA StyleVidal Fuertes, C., Johns, N. E., Goodman, T. S., Heidari, S., Munro, J., & Hosseinpoor, A. R. (2022). The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage. Vaccines, 10(7), 1032. https://doi.org/10.3390/vaccines10071032