Impact of Gender-biased Parental Perceptions on Under-immunization in Eastern Sudan: A Cross-sectional Study

"This study emphasizes the importance of confronting gender biases in healthcare to guarantee equitable access to vaccinations for boys and girls alike."

Gender-based disparity in childhood immunisations is a public health challenge in some countries, with societal biases often resulting in a preference for vaccinating boys over girls. Such stereotypes, coupled with limited decision-making power for women, hinder access to vaccinations, particularly for female children, thereby increasing their vulnerability to vaccine-preventable diseases (VPDs). In Eastern Sudan, gender disparities are acknowledged, particularly in livelihoods, but their impact on vaccination uptake is unclear. This study aimed to assess the effect of gender-biased parental perceptions on under-immunisation among children in Kassala, Eastern Sudan.

This study was a community-based cross-sectional in rural and urban districts of Kassala locality in Kassala State, Eastern Sudan in November 2022. Data were collected from 400 parents of children aged 6-35 months using a pre-tested, structured questionnaire based on the Behavioral and Social Drivers of Vaccination (BeSD), though translated, adapted, and pre-tested in the local context. This survey, developed by the World Health Organization (WHO), measures four underlying factors: thoughts and feelings, social processes, motivation, and practical issues. The question about perception toward gender-biased vaccination was adapted from a question about decision-making autonomy for vaccination in the BeSD survey.

The data reveal that most children were fully vaccinated with the three doses of the pentavalent vaccine (83%), while 14% were partially vaccinated. The pentavalent vaccine includes diphtheria, tetanus, and pertussis (DTP), as well as hepatitis B and H. Influenzae type b (Hib). During vaccination sessions, oral polio vaccine (OPV) doses are administered along with DTP. 

Findings showed that about one in five parents perceived male vaccination as more important than female vaccination. This parental perception of gender-based importance in vaccination was significantly associated with under-immunisation among children (p-value = 0.049). In addition, males in the study were fully vaccinated 5% more often than females. This preference for male vaccination is likely rooted in societal and cultural gender norms in the Eastern Sudan communities. This bias was significantly related to the children's vaccination status, suggesting a gender-based discrepancy in vaccination coverage that disadvantages female children.

Furthermore, the study underscores a mother's education as a pivotal factor in her child's likelihood of being vaccinated. This finding suggests that maternal literacy impacts health decisions, which can have gender-specific effects depending on societal norms. Evidence shows that higher maternal empowerment is linked to increased vaccination rates, while limited decision-making power for women was identified as one of the gender-related barriers that influences children's vaccination status. Educational initiatives directed at mothers, especially those with limited schooling, could help not only to improve the overall childhood vaccination rate but also to promote equal vaccination opportunities for both boys and girls.

In conclusion, this study sheds light on the effect of gender norms and related determinants on equitable access to vaccinations for boys and girls alike. "These findings can inform social and behavioral strategies to increase vaccine uptake in Eastern Sudan." More research is needed to gain a better understanding of the gender norms related to vaccination and their long-term impact on immunisation demand and resilience in this region.