Gender Analysis Report for a Study on Immunization Delay or Dropout between the Infant Series and the 9-Month Touchpoint

"When designing solutions, guide stakeholders to consider gendered power dynamics."

Many children complete their infant series of vaccinations at 14 weeks of age and do not return for vaccines due at 9 months of age, leaving communities at risk of vaccine-preventable diseases. With funding from the Bill and Melinda Gates Foundation (BMGF) and in partnership with Ministries of Health (MoH), VillageReach, Impetus Advisory Group, and the Solina Center for International Development and Research (SCIDaR) are conducting a study in the Democratic Republic of the Congo (DRC), Malawi, Nigeria, and Pakistan to explore the drivers of delay and dropout and then to generate solutions to increase vaccination coverage. In recognition of the important role gender plays in immunisation, the study began with a gender analysis to better understand gender dynamics and disparities to inform the study design and to ensure that gender-specific needs and challenges are considered in the solution development process. This report synthesises findings from a secondary data review, conducted between January and March 2024, and identifies recommendations to adjust data collection methods and tools or to refine the solution development process.

The project approach centres the voices of caregivers and healthcare workers to uncover supply, demand, and access insights through community-based participatory research (CBPR) and then works with communities to generate potential solutions through human-centred design (HCD) to improve immunisation coverage. 

Following an introduction, the report summarises a review of indicators across the four study countries to provide context. Country-specific findings are provided next, and cross-cutting findings and recommendations for the study are provided at the end of the report.

The gender analysis was guided by a framework adapted from the Gender Integration of the Zero Dose Learning Agenda Exemplars in Global Health (EGH) Vaccine Delivery Framework and the JHPIEGO's Gender Analysis Framework. This adapted analysis framework has four key domains: national gender context, intent to vaccinate, community access, and facility readiness. Key findings include the following:

1. National gender context
 

• Although gender policies exist in each study country (including policies on gender-based violence, women's empowerment, and equal access to education), implementation is generally limited. By extension, national immunisation programmes are typically designed without explicit consideration for gender inequities.

2. Intent to vaccinate
 

• In some contexts, female caregivers may have limited autonomy to carry out vaccination decisions: Around 30-40% of women in each of the four countries are involved in key decisions regarding sexual behaviour, healthcare, purchases, and visiting family. This datapoint indicates fairly low agency in decision-making, which is likely to include immunisation decisions.
• Social norms may dictate female caregivers' freedom of movement away from the home. If caregivers face challenges due to limited autonomy (as above) or social norms limiting their ability to seek vaccination at earlier touchpoints, they may be less motivated to seek vaccination services by the 9-month touchpoint.
• Lower education and literacy levels amongst women compared to men may limit women's awareness and knowledge of immunisation recommendations if they are disseminated through writing. This finding is particularly relevant for the 9-month touchpoint, as written vaccination cards are typically used as reminders to return after a longer delay than previous touchpoints.
• Concerns around vaccine safety may differ between men and women and/or based on the child's gender. For example, men and women may have different access to common sources of information about vaccine safety, such as social media. These concerns can become more pronounced by the 9-month touchpoint, particularly if adverse events are experienced at previous touchpoints to further raise concern about vaccine safety.
   

3. Community access
 

• Female caregivers face increased transportation barriers when seeking vaccination. These barriers can decrease motivation to seek vaccination services by the 9-month touchpoint if previous trips to seek vaccination were challenging.
• In addition to seeking vaccination services, female caregivers are often primarily responsible for household tasks, including cooking, cleaning, and caring for other children. These competing responsibilities may prevent a female caregiver from seeking vaccination in general, and as children grow from the early months of infancy into later infancy and become more independent of the mother, these responsibilities may evolve even further.
• Female caregivers may have negative service delivery experiences resulting from interactions with health workers (e.g., resulting from power imbalances with health workers, who are typically men), the physical environment of the health facility, and health facility operations. If caregivers had negative service delivery experiences at earlier touchpoints, it may be more likely that they will be less motivated to seek services by the 9-month touchpoint.

4. Facility readiness
 

• Female caregivers may be required to interact with male providers to receive children's vaccination services. If female caregivers experience discomfort or uncertainty interacting with male immunisers at previous touchpoint, they may be less motivated to return at 9 months.
• Female immunisers and supply chain professionals may experience additional barriers in carrying out their roles in a predominantly male context. Due to these barriers, immunisers could be discouraged from conducting education and mobilisation for caregivers to return at 9 months.
   

VillageReach, Impetus Advisory Group, SCIDaR, and MoH in the four countries used these findings to identify opportunities to consider gender in subsequent phases of the study (primary data collection, analysis, and solution generation).