Gender-related Barriers to Immunization: Zero-dose Children in Egypt, Iraq, Sudan, Syria and Yemen

"Expanded focus on the 'zero-dose agenda' can play a critical role in tackling existing inequities, increasing the visibility of marginalized and excluded groups and communities and may provide an entry point for strengthening key services across sectors and agencies..."

Gender norms, roles, and relations affect people's access to health services and health-related information, as well as their health-seeking behaviours, including for immunisation. Commissioned by the United Nations Children's Fund (UNICEF) Middle East and North Africa Regional Office (MENARO), this report explores gender-related barriers to immunisation in Egypt, Iraq, Sudan, Syria and Yemen, with a focus on zero-dose and under-immunised children. Promising and innovative practices from these five countries to overcome gender-related barriers to immunisation are highlighted, along with recommended approaches and entry points for addressing these demand and supply-side barriers at the individual, household, community, social, and institutional levels in order to increase immunisation reach and coverage.

The report draws on a desk review of existing literature related to gender and immunisation in the UNICEF MENARO region as well a gender and zero-dose questionnaire completed by UNICEF Country Offices, complemented by interviews with key informants. Representing Phase I of UNICEF MENARO's efforts to identify and address gender-related barriers to immunisation, this report provides a snapshot overview of some of the challenges and barriers in zero-dose communities, with a recommendation to conduct in-depth research at the community level through interviews and focus group discussions with caregivers and service providers during the second phase.

Findings are divided into five main sections for the MENA countries included in this review, with each country section further divided into the following sub-sections: overview of zero-dose children; gender roles and responsibilities; access to and control over resources; beliefs, norms, and perceptions; needs, preferences, and challenges; enabling factors and partnerships; and recommended approaches and entry points for addressing gender-related barriers.

Overall, the research found that zero-dose children are geographically dispersed within each of the five countries, with each area facing specific vulnerabilities and challenges related to conflict, insecurity, poverty, lack of basic health infrastructure, and displacement, characterised by entrenched gender inequality. Marginalised communities such as nomadic populations, internally displaced persons, ethnic minorities, and persons living with disabilities face compounded discrimination and disadvantage.

Gender-related barriers to immunisation are therefore manifested in several ways on different levels, including: women's restricted mobility; lack of access to transportation, money, time, information, and other critical resources; the prevalence of gender-based violence; women's limited agency in household decision-making dynamics; and men's low engagement and participation in children's health and caretaking. The lack of gender-responsive health systems create additional barriers on the institutional level for the health workforce and caregivers.

The report concludes with summary recommendations for addressing gender-related barriers to immunisation, which should be further tailored to each country context through the development of practical action plans. In sum, seven selective recommended approaches from each of three categories include:

Addressing individual/household level barriers:
 

• Conduct in-depth country-specific intersectional gender analyses at the community level with the participation of caregivers and health workers in areas with zero-dose children.
• Address caregivers' practical needs that prevent access to immunisation services, such as providing transport vouchers and support, enhancing house-to-house outreach and mobile teams, linking immunisation with cash transfer programmes, and bundling immunization with other high-demand services (e.g., nutrition, reproductive, maternal, and child health).
• Utilise human-centred design (HCD), drawing on existing motivations, daily realities, habits, and limitations to find effective solutions jointly with communities for tackling gender barriers in zero-dose communities.
• Leverage diverse communication channels and trusted influencers to reach different sub-groups of people with different levels of literacy, ensuring intersectional gender analysis informs social and behaviour change (SBC) programming in zero-dose areas.
• Ensure channels and communication modalities for immunisation and health-related messaging are accessible to those with lower literacy levels and cater to gender-specific preferences (for example, prioritising edutainment approaches and face-to-face outreach in areas with high illiteracy, systematically conducting intersectional gender analysis as part of outreach and communications interventions, and acknowledging and addressing the digital gender divide).
• Actively tackle gender-related misconceptions and myths about vaccines leading to under-immunisation.
• Develop gender-transformative parenting interventions to generate immunisation demand and address barriers in zero-dose communities that include components for engaging fathers, supporting parenting alliances, and building capacity of frontline service providers.

Addressing social and community-level barriers:
 

• Enhance collaboration with local non-governmental organisations and civil society groups, including women's groups, informal networks, and youth organisations and groups (such as the Zainabiat in Yemen) to identify gender-related barriers to immunisation and generate demand.
• Continue engagement with religious leaders, building on gender-responsive interventions carried out in Syria's Deir-ez-Zor, where outreach with religious leaders used gender equality messaging from religious scriptures to influence gender-discriminatory attitudes to immunise zero-dose girls.
• Explore building engagement with women religious leaders (for example, in Sudan) as message multipliers for immunisation outreach in zero-dose communities.
• Expand outreach with targeted interventions to specifically marginalised groups experiencing multiple layers of oppression and disadvantage, such as the Muhamasheen in Yemen, utilising HCD and participatory approaches.
• Strengthen women's meaningful participation in community-level decision-making structures.
• Build linkages with ongoing community engagement/adolescent programming - for example, in areas with high rates of child marriage and early pregnancy, adolescent programming may offer a platform for identifying ways to reach families with immunisation-related messaging.
• Utilise community engagement programmes where mothers are already meeting as entry points to disseminate information about the benefits of immunisation and schedules of upcoming campaigns (for example, mother-to-mother clubs in Yemen).

Addressing institutional/structural barriers:
 

• Bring immunisation services and vaccine-related outreach closer to communities where possible and into areas where women can easily access, and consider the timing of services to ensure equitable access - for example, by offering evening or after-hours vaccination services to meet the needs of working caregivers.
• Develop and strengthen safeguarding measures to protect vaccinators and other frontline workers from sexual and gender-based violence, ensuring access to confidential complaint and reporting mechanisms and offering regular training for staff.
• Create mechanisms to meaningfully engage with vaccinators and community health workers to jointly identify challenges and barriers and appropriate solutions through HCD and participatory approaches (for example, through co-design initiatives with health workers).
• Support gender-responsive health system strengthening, addressing infrastructural issues at health facilities (for example, curtains to ensure privacy, separate waiting areas, lockable toilets) and health workforce capacity building on gender-responsive communication.
• Strengthen cross-sectoral integration and bundling of immunisation services with other services and sectors in high demand (e.g., reproductive health).
• Integrate gender issues and highlight the importance of analysing and addressing gender-related barriers in immunisation-related strategies, policies, and national action plans, including in SBC communication plans.
• Intensify efforts to systematically collect, analyse, and use data disaggregated by sex and additional factors, ensuring that these data are shared to higher reporting levels from service delivery points and that they are used to guide programming.