Influence of Women Empowerment on Childhood (12-23 Months) Immunization Coverage: Recent Evidence from 17 Sub-Saharan African Countries

"Evidence from [this] study supports the hypothesis that women empowerment is significantly associated with childhood immunization coverage."

Literature indicates that childhood immunisation coverage is influenced by a plethora of individual, community, and contextual factors. For example, women's empowerment may impact childhood immunisation coverage by creating an enabling environment for women to be equipped with information, to improve their ability to comprehend health messages, and to help them make informed healthcare decisions that are free from coercion. This study examines the association between women's empowerment and childhood immunisation coverage in sub-Saharan Africa (SSA). Findings from this study may have implications for policy and programmes that seek to improve childhood immunisation coverage in SSA.

This study employed a publicly available dataset from the Demographic and Health Surveys (DHS) conducted between 2017 and 2022. Data from 17 SSA countries were used for the analysis, with a sample of 19,223 children aged 12-23 months. The outcome and exposure variables were full immunisation coverage and women empowerment, respectively. Full immunisation was defined as receipt of: one dose of Bacille Calmette-Guérin; three doses of the diphtheria, pertussis, and tetanus vaccine or the tetravalent/pentavalent vaccine; three doses of the polio vaccine; and one dose of the measles vaccine. Women's empowerment was an index of labour participation, acceptance towards spousal violence, decision-making capacity, and general knowledge level.

The study found that 56.6% of children were fully immunised. Key findings:

• Children of employed mothers were 1.16 times more likely to be fully immunised. Mothers who are employed might have higher household incomes and improved socioeconomic status. This could lead to better access to healthcare facilities, as they may have the financial means to afford the cost of transportation and other ancillary health expenditures. Another perspective is that mothers who are employed might have their own income, which grants them financial autonomy. Such mothers can act promptly without waiting for their partners' approval or the need to gather funds, which can sometimes lead to delays in seeking healthcare.
• Children of mothers with higher acceptance toward violence were less likely to be fully immunised [adjusted odds ratio (aOR) = 0.90, confidence interval (CI) 0.81, 0.99]. Women who have a supportive attitude towards violence may feel threatened to make decisions regarding the healthcare of their children out of fear that they might be abused by their partners.
• The odds of full immunisation were higher among children born to mothers with high [aOR = 1.11, CI 1.01, 1.22] decision-making capacity. Women with high decision-making power tend to have the freedom to decide how to use household resources, hence increasing their autonomy. This autonomy enjoyed by women serves as a motivating factor that informs them to seek healthcare for their children, including having full immunisation.
• Higher odds of full immunisation were found among children born to mothers with a medium [aOR = 1.24, CI 1.13, 1.36] to high [aOR = 1.44, CI 1.27, 1.63] general knowledge level. Having a high knowledge of childhood immunisation implies that mothers would have a better appreciation of the relevance of vaccination, the vaccination schedule, and the possible adverse health effects that are likely to occur in the event of incomplete immunisation. Previous studies have shown that there are normative cultural beliefs and misperceptions that serve as a barrier to childhood immunisation. However, mothers who have high knowledge are informed and would be less likely to comply with the existing cultural norms that hinder childhood immunisation.

Beyond the main hypothesis, the researchers found some significant associations across the covariates. For example:

• Children in rural areas had higher odds of being fully immunised [aOR = 1.13, CI 1.03, 1.23] in contrast to their urban counterparts. Rural communities often have close-knit social structures where information spreads through word-of-mouth and community engagement. In such environments, peer influence and communal support might lead to higher compliance with immunisation schedules. It is also possible that in rural areas, healthcare providers might have more personalised interactions with families due to smaller patient loads. These interactions provide an avenue to educate and raise awareness about the need for full immunisation.
• Children whose mothers had 1-3 [aOR = 0.82, CI 0.76, 0.89] and no antenatal care (ANC) visits [aOR = 0.30, CI 0.26, 0.35] were less likely to be fully immunised compared to their counterparts whose mothers had 4 or more ANC visits. Seeking maternal healthcare services offers an opportunity for healthcare providers to educate the woman about their responsibility to ensure full immunisation of the child.
• The researchers also observed increasing odds of a child being fully immunised with an increasing paternal educational level, with a 39% higher likelihood among those whose father had higher education than their counterparts whose father had no formal education. This finding is expected, as highly educated partners would value the significance of full immunisation and support their partners in taking the child to receive full immunisation.

Recognising the positive association between women's empowerment and childhood immunisation coverage in SSA, the study calls for multi-faceted interventions that address employment opportunities, decision-making capacity, knowledge enhancement, attitudes towards violence, and community engagement. Suggestions include:

• Strengthen the knowledge level of women to make them more assertive in ensuring their children receive full immunisation.
• Implement community sensitisation to promote joint decision-making between partners and to empower women to take more active roles in healthcare choices, including immunisation.
• Empower women through livelihood empowerment interventions such as vocational training programmes, job placement services, or support for entrepreneurship initiatives to encourage and support women's workforce participation, to increase their decision-making capacity, and to foster their resolve to ensure the full immunisation of their children.
• Encourage women to attend ANC and delivery in a healthcare facility, prioritising high-risk sub-populations including adolescent mothers, multiparous women, children born into economically poor households, and those residing in urban areas.