Gender Analysis of the World Health Organization Online Learning Program on Immunization Agenda 2030

"...findings confirm that gender inequality and harmful gender norms in many settings create barriers and are the main reasons for suboptimal immunization coverage."

Gender inequalities deeply influence access to healthcare, affecting immunisation rates. To that end, the Immunization Agenda 2030 (IA2030) recognises gender as an important cross-cutting dimension for all its seven strategic priorities and commits to addressing gender-related barriers to immunisation and advancing gender equality to realise its vision. To accelerate awareness about the IA2030 and its accompanying Gender Guide (at Related Summaries, below) and to strengthen capacity, the World Health Organization (WHO) offers a 6-week online certification course (WHO IA2030 Scholar Level 1 course) that involves participants preparing an action plan. This study examines the action plans submitted by participants in the 2021 course to assess the extent of successful gender mainstreaming in the action plans. The analysis further identifies the common gender-related barriers reported by the course participants and the approaches proposed to address and overcome these barriers.

In total, 256 action plans were submitted by 137 (54%) men and 119 (46%) women who participated in the course. These participants have expertise in immunisation programmes across 31 countries. In addition to a quantitative analysis of these 256 action plans, a qualitative analysis was carried out on a sample of action plans with a peer review score above 75% (111 out of 256), employing narrative thematic analysis to categorise and explore gender incorporation and identified barriers based on the IA2030 Gender Guide. For the sample of 111 action plans, the country representation of each barrier was quite diverse, although the highest counts were from Nigeria, India, and Ghana.

Among the 111 analysed action plans, gender considerations were present in almost all plans, underscoring the effectiveness of integrating gender perspectives in the course curriculum. "By drawing attention to the importance of gender in immunizations and offering tools on how to identify and address gender-related barriers, the course participants were able to identify gender-related barriers and propose solutions to overcome them."

Overall, the most frequently cited barriers were:

• Low education and health literacy - The action plans shared that the lack of knowledge or incorrect knowledge about immunisation services leads to hesitancy or refusal of vaccines. In 15 of 58 action plans citing the barrier to health literacy and education, the participants indicated that male engagement can positively contribute to immunisation uptake. Providing health literacy and education at the community level could significantly impact vaccination efforts by tackling misconceptions, beliefs, and distrust of healthcare providers and vaccines.
• Issues related to accessing quality immunisation services - The participants highlighted how the quality, acceptability, and accessibility of immunisation services can be influenced by the number of healthcare staff and clinics or hospitals available in a location, the gender of the healthcare staff that caters to the preferences and needs of the community, and hygiene of the environment and respectful attitude of the staff. The action plans to highlight gender-related barriers to quality service called attention to an institutional level neglect to ensure gender balance in a workforce that delivers service and care, better engagement of men and fathers at the facility level, and increased entry points for men.
• Gendered dynamics in decision-making within households - Cultural, social, legal, or other restraints can limit the participation of an individual in decision-making, with the majority of action plans [57% (22/38)] under this category addressing the limited autonomy of women. Most immunisation information is designed to reach women, further reflecting the stereotype of women as caregivers, yet it is also important to reach men with accurate information about the benefits of immunisations.
• Limited access to resources and mobility, predominantly impacting women - For example, 51% of action plans in this category stated that women are not allowed to travel to health facilities alone due to gender norms or sociocultural and security reasons. More active engagement of men in immunization services, once again, was noted as an important approach to circumvent this barrier. While it would not be gender transformative and does not address the underlying harmful gender norms, it could serve as an interim step to improve immunisation.

With regard to gender-responsive approaches in the 111 sample of action plans:

• A majority of the action plans [66% (74/111)] directly addressed the barrier to extending and improving immunisation services as critical to expanding coverage and equity. Leveraging existing funding options can provide support for pro-gender strategies and interventions.
• 59 action plans [53%] proposed approaches for social mobilisation and community engagement to improve gender-aware health literacy, with some recommending the dissemination of educational messages and tailored communication strategies.
• 38 action plans [34%] proposed community engagement by involving reputable community members that ranged from family members to traditional birth attendants, community focal persons, health workers, village health teams, traditional institutions, local councils, support groups, or women leaders in the community.
• It was proposed in 38 action plans [34%] to mainstream gender into immunisation by investing in gender data and analysis. Some action plans suggested the inclusion of qualitative methods to understand embedded gender-related barriers for service providers and recipients.
• The recommendation to improve immunisation coverage by focusing information and messaging on the engagement of men in caregiving and immunisation decisions was included in 30 action plans [27%]. For this recommendation, action plans included conducting health promotion activities about the importance of involving male partners in vaccination using radio stations, television stations, community information centres, or information mobile vans to educate communities. Several also suggested designing immunisation materials, messages, and interventions to challenge harmful gender norms, roles, or stereotypes.
• Innovation in healthcare institutions was highlighted in 9 action plans [8%], where it was suggested to incorporate gender and sex dimensions in the research process to better contextualise healthcare and make digital healthcare technologies more accessible.

Topics and themes that were more frequently mentioned by women course participants were as follows: the need for male engagement in immunisation activities, the health literacy gap caused by information designed to reach women alone, and the importance of disseminating educational messages to raise community awareness. Notably, the barrier cited by more men than women course participants was the compounded burden of work and caregiving faced by women.

The action plans highlight areas where certain gender norms persist. As the researchers' reflections on the findings indicate, "Showcasing the intersection of gender with other social determinants of health can significantly improve health policy and health institutions by making them more gender-sensitive and ideally gender-transformative." Thus, they suggest, an intersectional approach, recognising diverse social markers impacting immunisation, is vital to address disparities effectively. To support that approach, gender-sensitive data and deeper understanding of intersectional dynamics could be helpful. The study highlights the importance of gender-transformative interventions, including community engagement and efforts reaching out to both men and women, to enhance immunisation coverage. It also points to "the necessity of a comprehensive and contextually sensitive implementation strategy that carefully considers potential challenges to ensure the success and sustainability of the proposed interventions and holds the potential for transforming harmful gender norms."

In conclusion: "this analysis supports the importance of mainstreaming gender in immunization capacity-building efforts to raise greater awareness and equip immunization professionals to deliver more gender-responsive immunization programs. This, in turn, has the potential to improve the effectiveness of immunization programs and reach more children and people with vaccines, while at the same time promoting gender equality. Continuous efforts and support to mainstream gender in such capacity-building initiatives are valuable and could contribute to more gender-responsive and even gender-transformative programs and better policy and immunization services at local, sub-national, and national levels."