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
Affiliation
IRD Global (Siddiqi, Shah, Chandir); IRD Pakistan (Iftikhar, Siddique, Mehmood, Dharma, Chandir); Gavi, The Vaccine Alliance (Setayesh)
Date
Summary
"Gender equity in immunizations is not an isolated concept but deeply intertwined with females' empowerment, agency, and autonomy."
Pakistan is among the countries where gender inequity in immunisations is a growing concern. Gender-sensitive immunisation strategies are difficult to design in the face of the unavailability of gender-disaggregated data at the micro-level. In addition, there is insufficient understanding of the demand- and supply-side barriers that consistently prevent females from accessing immunisations. Leveraging data from the Government of Sindh's Electronic Immunization Registry (SEIR), this study estimates and reflects on inequalities in immunisation for males and females from the 2019-2022 birth cohorts in Sindh Province, Pakistan.
Between January 1 2019 and December 31 2022, 6,235,305 children were enrolled in the SEIR, 52.2% of whom were males and 47.8% females. There was a median male-to-female (M:F) ratio of 1.03 at enrollment and at Pentavalent-1, Pentavalent-3, and Measles-1 vaccinations, indicating that more males were enrolled in the immunisation system than females. Once enrolled, a median gender inequality ratio (GIR) of 1.00 indicated similar coverage for females and males over time; however, the sub-national analysis at the union council (UC) level shows the difference increased to 300 males being vaccinated for every 100 females in specific UCs. The researchers also observed geographical pockets where females continued to fall behind males, year-on-year, reflecting the persistent nature of the inequalities. "Merely observing the aggregate levels for evidence of gender differentials masked these nuanced yet more pronounced inequities."
Furthermore: "Differences at the micro-geographic level reflected subtle and persistent forms of gender bias and discrimination that continue to affect health outcomes for females over the long term." When comparing the M:F ratios and GIRs, the researchers observed that a larger number of males than females made contact with the immunisation system (even after adjusting for the M:F baseline population). However, once they had been enrolled (in the SEIR), the vaccine coverage rates were similar for both females and males, although females still fell behind males in receiving timely vaccinations."
Per the researchers, these findings have implications for the zero-dose children who have yet to make contact with the health system. The fact that more males than females have been enrolled in the immunisation system reflects "substantial inequities, indicating more females than males are left behind and being added to the higher proportion of zero-dose children. There is a need for rethinking and emphasizing the narrative of 'zero-dose females', and ensuring the use of gender-disaggregated data and gender-sensitive strategies in order to reach the missing children....The analysis of individual UCs suggested there were certain pockets and regions spread throughout the province where females continuously fell behind males on their vaccinations, year-on-year. Targeted, intensified efforts directed to hotspots showing high inequities could be a potential measure to break the pattern of persistent inequities."
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. Within the rural areas, the category of remote-rural and hard-to-reach areas saw M:F ratios as high as 1:14. Several underlying factors have been cited to explain the inequities, the most prominent being the deep-rooted socio-cultural practice of "son preference", which is common in Pakistan. In rural and remote-rural regions, not only are patriarchal practices more deeply entrenched, but, when coupled with multiple other deprivations, including poverty, lack of affordable transportation, and long distances to healthcare services, they lead to discriminatory attitudes by caregivers in favour of males.
In the event of male vaccinators, mothers and female caregivers face even greater societal restrictions when accompanying children for immunisation. Due to sociocultural and gender norms in underserved communities of low- and middle-income countries (LMICs) such as Pakistan, only female frontline health workers have unrestricted access to households, are able to interact with mothers and provide health education, and deliver vaccines to children. The absence of gender-sensitive policies for immunisation was highlighted in this study. None of the 87 remote-rural UCs in Sindh Province had a single female vaccinator. The results showed that the districts of Ghotki, Jacobabad, and Kashmore had high prevalence rates of inequities for females at enrollment and for subsequent antigens. These districts are located within the northern belt of the province, which remains deeply rooted in conservative tribal culture, with a high prevalence of other discriminatory practices against females, including domestic violence and forced child marriages.
Furthermore: "Vaccine hesitancy may contribute to gender inequities in immunization by perpetuating cultural norms and beliefs that prioritize males over females and fuel misinformation and misconceptions about vaccines that disproportionately affect females, limiting access to health services and decision-making power for females."
As outlined here, addressing gender inequities in immunisation requires multilevel, complementary approaches. Feasible policy measures include:
Pakistan is among the countries where gender inequity in immunisations is a growing concern. Gender-sensitive immunisation strategies are difficult to design in the face of the unavailability of gender-disaggregated data at the micro-level. In addition, there is insufficient understanding of the demand- and supply-side barriers that consistently prevent females from accessing immunisations. Leveraging data from the Government of Sindh's Electronic Immunization Registry (SEIR), this study estimates and reflects on inequalities in immunisation for males and females from the 2019-2022 birth cohorts in Sindh Province, Pakistan.
Between January 1 2019 and December 31 2022, 6,235,305 children were enrolled in the SEIR, 52.2% of whom were males and 47.8% females. There was a median male-to-female (M:F) ratio of 1.03 at enrollment and at Pentavalent-1, Pentavalent-3, and Measles-1 vaccinations, indicating that more males were enrolled in the immunisation system than females. Once enrolled, a median gender inequality ratio (GIR) of 1.00 indicated similar coverage for females and males over time; however, the sub-national analysis at the union council (UC) level shows the difference increased to 300 males being vaccinated for every 100 females in specific UCs. The researchers also observed geographical pockets where females continued to fall behind males, year-on-year, reflecting the persistent nature of the inequalities. "Merely observing the aggregate levels for evidence of gender differentials masked these nuanced yet more pronounced inequities."
Furthermore: "Differences at the micro-geographic level reflected subtle and persistent forms of gender bias and discrimination that continue to affect health outcomes for females over the long term." When comparing the M:F ratios and GIRs, the researchers observed that a larger number of males than females made contact with the immunisation system (even after adjusting for the M:F baseline population). However, once they had been enrolled (in the SEIR), the vaccine coverage rates were similar for both females and males, although females still fell behind males in receiving timely vaccinations."
Per the researchers, these findings have implications for the zero-dose children who have yet to make contact with the health system. The fact that more males than females have been enrolled in the immunisation system reflects "substantial inequities, indicating more females than males are left behind and being added to the higher proportion of zero-dose children. There is a need for rethinking and emphasizing the narrative of 'zero-dose females', and ensuring the use of gender-disaggregated data and gender-sensitive strategies in order to reach the missing children....The analysis of individual UCs suggested there were certain pockets and regions spread throughout the province where females continuously fell behind males on their vaccinations, year-on-year. Targeted, intensified efforts directed to hotspots showing high inequities could be a potential measure to break the pattern of persistent inequities."
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. Within the rural areas, the category of remote-rural and hard-to-reach areas saw M:F ratios as high as 1:14. Several underlying factors have been cited to explain the inequities, the most prominent being the deep-rooted socio-cultural practice of "son preference", which is common in Pakistan. In rural and remote-rural regions, not only are patriarchal practices more deeply entrenched, but, when coupled with multiple other deprivations, including poverty, lack of affordable transportation, and long distances to healthcare services, they lead to discriminatory attitudes by caregivers in favour of males.
In the event of male vaccinators, mothers and female caregivers face even greater societal restrictions when accompanying children for immunisation. Due to sociocultural and gender norms in underserved communities of low- and middle-income countries (LMICs) such as Pakistan, only female frontline health workers have unrestricted access to households, are able to interact with mothers and provide health education, and deliver vaccines to children. The absence of gender-sensitive policies for immunisation was highlighted in this study. None of the 87 remote-rural UCs in Sindh Province had a single female vaccinator. The results showed that the districts of Ghotki, Jacobabad, and Kashmore had high prevalence rates of inequities for females at enrollment and for subsequent antigens. These districts are located within the northern belt of the province, which remains deeply rooted in conservative tribal culture, with a high prevalence of other discriminatory practices against females, including domestic violence and forced child marriages.
Furthermore: "Vaccine hesitancy may contribute to gender inequities in immunization by perpetuating cultural norms and beliefs that prioritize males over females and fuel misinformation and misconceptions about vaccines that disproportionately affect females, limiting access to health services and decision-making power for females."
As outlined here, addressing gender inequities in immunisation requires multilevel, complementary approaches. Feasible policy measures include:
- Ensure the inclusion of more female vaccinators in the health workforce to promote building trust concerning vaccines and encourage immunisation uptake among vulnerable communities.
- Focus on overall education for females - specifically, in health literacy - to enhance the female position in the immunisation decision-making process for their children. Female groups in local settings and communities can be initiated or leveraged as a platform for counseling focused on health literacy. These groups could be complemented with programmes to involve fathers, including facilitating regular sessions with females and males to foster collaborative parenting and decision-making.
- Strengthen a gender-centric approach to the overall health system through measures such as separate waiting areas for females in immunisation clinics and the introduction of female-only transport to immunisation centres.
Source
Vaccines 2023, 11, 685. https://doi.org/10.3390/vaccines11030685. Image credit: Wallpaper Flare
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