VoICE Immunization Evidence: Gender Inequity
Gender differences in immunization coverage and careseeking contribute to the excess mortality for girls seen in some settings. These coverage inequities are more pronounced in families with multiple siblings.
In an analysis of statewide survey data collected in Bihar, India, researchers reported that female newborns had significantly lower odds of receiving care if ill compared to male newborns (80.6% vs. 89.1%) and lower odds of having a postnatal check up visit within a month of birth (5.4% vs. 7.3%). This gender inequity is more pronounced among families at lower wealth levels and those with higher numbers of siblings.
A study that examined the gender-gap in immunization coverage in a rural area of Bangladesh showed that poverty, low maternal education, and second or higher birth order had a stronger negative effect on the likelihood of full immunization coverage for girls compared to boys. In other words, girls from households in this area that were below the poverty line were 11% less likely to be fully immunized than boys from households below the poverty line. Girls were also 6% less likely than boys to be fully vaccinated if their mothers did not attend high school, and 5% less likely than boys to be vaccinated if they were not the first born child in the family.
High female under-5 mortality rates, the result of gender bias, highlights the need for more proactive attention to the issue of postnatal sex discrimination.
An analysis of under-5 mortality rates (U5MR) in India’s 35 states and union territories and 640 districts was conducted in order to estimate excess female mortality. When comparing India’s census data to data from 46 countries without gender bias, researchers found that more than 90% of districts had excess female mortality. The four largest states in northern India accounted for two-thirds of India’s total number. In more than 10% of northern Indian districts, excess U5MR exceeded 30 per 1000 live births, showing that geography is also a key factor in infant and child death among girls. Low economic development, gender inequity, and high fertility were the main predictors of excess female mortality.
Children of mothers with greater decision-making autonomy and power are more likely to be fully vaccinated
A study looking at the relationship between gender roles and full immunization coverage of children in Nigeria found that children of mothers who did not have decision-making autonomy were half as likely to be fully immunized than mothers with autonomy. To further assess the roles of gender and relationship power, children were nearly twice as likely to be fully vaccinated in households where only the mother contributed to household earnings compared to children whose parents contributed equally.
A review of measles vaccination data found that female children experience substantially higher mortality risks from measles relative to male children, and greater reductions in mortality with vaccination. In essence, vaccinating female children against measles provides them with the same survival chances as unvaccinated male children.
Across multiple studies reviewed, the effect of measles vaccine appears to be more beneficial to girls than to boys.
Delivery of HPV vaccine to girls in the school setting can provide opportunities to deliver expanded health services to all children, including boys.
Introduction of HPV vaccine in Rwanda occurred through a new school-based delivery program which provided the opportunity to offer additional health services to all school-children (girls and boys) including health promotion sessions, de-worming and opportunities for voluntary, free circumcision.
A multiple-strategy community intervention program of the National Rural Health Mission (NRHM) in India, designed to reduce maternal and child health (MCH) inequalities was implemented between 2005 and 2012. The gender gap in immunization coverage swung from significantly favoring boys before the intervention to a slight advantage for girls by the end of the intervention. Specifically the coverage differentials changed as follows: for full immunization (5.7% to -0.6%), for BCG immunization (1.9 to -0.9 points), for oral polio vaccine (4% to 0%) and for measles vaccine (4.2% to 0.1%).
An impact evaluation for a women’s empowerment program in India found that the children of mothers who participated the empowerment program were significantly more likely to be vaccinated against DTP, measles, and tuberculosis than children of mothers not involved in the program. This study also found that the women’s empowerment program had positive spillover effects: In villages where the program occurred, children of mothers not in the program (non-participants) were 9 to 32% more likely to be immunized against measles than in villages where the program did not occur (controls). Overall, measles vaccine coverage was nearly 25% higher in the program villages compared to the control villages.
In a systematic review of qualitative research from low- and middle-income countries, women’s low social status was shown to be a barrier to their children accessing vaccinations. Specific barriers included access to education, income, resource allocation and autonomous decision-making related to time. The author’s suggest that expanding the responsibility for children’s health to both parents (mothers and fathers) may be one important element in removing persistent barriers to immunization often faced by mothers.
A study conducted in Pakistan exploring the association of maternal education and empowerment with childhood polio vaccination found a positive association between maternal empowerment, defined as mother’s involvement in decision-making regarding family, healthcare and other issues, and complete polio vaccination of their children.
An analysis of data from the 2011 Ethiopian Demographic and Health Survey investigated the relationship between individual- and community-levels of women’s autonomy and children’s immunization status. The results show that community-level autonomy is associated with an increased number of children’s immunizations above and beyond that of individual-level women’s autonomy. These results indicate that empowering women within households not only improves the individual mother’s children’s health, but also serves to improve the lives of other children within the community.
A systematic review of studies from countries in Africa and Southeast Asia investigated the relationship between a woman’s “Agency” (defined as the woman’s ability to state her goals and to act upon them with motivation and purpose) and childhood immunizations in lower-income settings. The review found a general pattern among studies in which higher agency among mothers was associated with higher odds of childhood immunizations. Empowering women in these settings show promise as a means to improve child health.
Disparities in immunization coverage between girls and boys persist in some communities, despite apparent equity in coverage at the global level. Focused efforts to erase these areas of persistent gender inequity in vaccine coverage are needed.
A study conducted in the urban poor in Delhi, India found that the odds of complete vaccination were lower in female children than in male children. The female:male complete immunization coverage ratio showed only 78 females received complete immunizations per every 100 males immunized. The authors note that this gender inequity effect in immunization has not changed in many Indian states despite increasing overall vaccine coverage rates.
A study looking at DHS data from 67 countries found that, globally, girls and boys had the same likelihood of being vaccinated. In some countries where there is known gender inequity and son preference, girls were more likely to not be vaccinated.
Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.
An analysis of data from India’s National Family Health Survey designed to examine the trends and patterns of inequalities over time showed, that despite a decline in urban-rural and gender differences over time, children residing in rural areas and girls remained disadvantaged. Moreover regions that had the lowest gender inequality in 1992 showed an increase in gender difference over time. Similarly, urban-rural inequality increased in one region during the 1992–2006 data collection period.
Most often the caretakers of sick children, women stand to lose significant time and money while attending a sick child. These losses are significant for potentially vaccine-preventable infections severe enough to warrant hospitalization
In a study in the Gambia – a setting where healthcare is free of charge to patients – pneumococcal disease nonetheless placed a heavy financial burden on families seeking treatment before arrival at the hospital, paying for transportation costs, drugs, diagnostic tests and even burial in the case of death. 50-80% of the cost of treating an episode of pneumococcal disease was born by the health system, which still left families to cover a cost up to 10 times their average daily household budget. In addition the estimated treatment cost for inpatient pneumonia of $109 is nearly 4 times the annual per capita expenditure for health in The Gambia.
In general, low- and middle-income countries with high levels of gender inequality have lower levels of immunization coverage
An ecological study designed to investigate the association between child mortality rates and Gender Inequality using the United Nations Development Programme’s Gender Inequality Index (GII), showed that low- and middle-income countries have significantly higher gender inequality and under-5 mortality rates than high-income countries. Greater gender inequality was significantly correlated with lower immunization coverage, and with higher neonatal, infant and under-5 mortality.
To better understand the drivers of vaccination coverage and equity, a 2017 study examined the country-level factors influencing vaccination coverage in 45 low- and lower-middle income Gavi-supported nations. Countries with the least gender equality – as measured by reproductive health, women-held parliamentary seats, educational attainment and other factors – also had lower rates of vaccine coverage.
In an analysis of immunization coverage in 45 low- and lower-middle income Gavi-eligible countries, researchers found that overall, maternal and paternal education were two of the most significant drivers of coverage inequities in these countries. Pooling the data from all countries, the authors found that “children of the most educated mothers are 1.45 times more likle to have received DTP3 than children of the least educated mothers.” The same held true for measles vaccines with a 1.45-fold likelihood of vaccination in children of the most educated mothers.