Of Money and Men: A Scoping Review to Map Gender Barriers to Immunization Coverage in Low- and Middle-Income Countries

"Failing to learn about and address gender barriers to immunization is detrimental to public health programs and policies because without the generation, analysis, and synthesis of gender data, coverage will not change."

Among the multiple factors impeding equitable childhood immunisation coverage in low- and middle-income countries (LMICs), gender barriers - defined as the ways in which gender roles, norms, and relations impede immunisation programme performance - stand out. This scoping review, funded by the Bill and Melinda Gates Foundation, documents the findings of 92 peer-reviewed research papers that describe gender barriers to immunisation and analyses the results.

Studies (focused on 25 or fewer countries) published between 2000 and September 26 2023, the date of the search, documented a range of gender influences of vaccination across 43 countries in Africa and South Asia. The most frequently studied geographies included Nigeria (n = 21), Ethiopia (n = 12), and Pakistan (n = 10). Three large multi-country studies each contained data from approximately 160 countries. Most of the studies assessed barriers to childhood immunisations (n = 63). Specific vaccinations assessed included human papillomavirus, or HPV (n = 21), COVID-19 (n = 7), polio (n = 4), maternal vaccines (n = 2), yellow fever (n = 1), and H1N1 (n = 1).

Results from the gender barriers analysis are presented by 3 principal determinants:

1. Intent to vaccinate - attitudes, perceived norms, and perceived control and represents the demand for vaccines that would result in vaccination in the absence of other barriers. The most common gender influence on intention is women's lack of autonomous decision-making about their health and the health of their children. Some women who opposed their husbands' decision not to immunise their children faced intimate partner violence, including emotional, verbal, and physical violence. On the flip side, in one study, mothers who made healthcare decisions themselves were 4.03 (adjusted odds ratio (AOR) 95% confidence interval (CI) [1.66-9.78]) times more likely to fully vaccinate their children than when decisions were made by husbands alone. Other decision makers play important roles as well, sometimes interacting or compounding. For example, mothers-in-law were found to have an important influencing effect (n = 4) in Guinea, India, Nigeria, and Uganda. Gendered myths and misconceptions were also identified as barriers to immunisation. All studies that measured empowerment found a positive association between women's empowerment and immunisation coverage (n = 10).

2. Community access - the ability or inability to successfully carry out the transaction of vaccine utilisation, representing barriers and facilitators between an individual's intent and the health system's readiness. At the intersection of intent and access is women's occupational status and associated norms, roles, and responsibilities. Access to immunisation is significantly impacted by women's time poverty; direct costs are also a barrier, particularly when female caregivers rely on family members to cover costs. Seven studies identified a lack of male engagement in the household and in caregiving as a barrier, and 4 additional studies recommended male engagement as an important strategy, given their decision-making power.

3. Health facility readiness - the health system's supply of vaccine services to adequately meet demand, which includes immunisation supplies, human resources, and related systems and structures. Challenges with clinic readiness compound female caregivers' time constraints. When it comes to vaccinators themselves, gender-related challenges may arise: For example, in some settings, women cannot be in contact with men who are not related to them. Studies described the effect of women's prior experiences with the healthcare system, both positive and negative, as influencing vaccination coverage. Women's engagement with antenatal care (ANC) emerged as an important predictor of immunisation, indicating that strengthened ANC services could help improve maternal and child immunisation coverage. One one study measured outcomes at the leadership level, assessing the impact of women's political representation on child health outcomes using a dataset covering 162 countries over 30 years. This study found a significant positive effect of women's political representation on measles and diphtheria, pertussis, and tetanus (DPT) vaccination coverage. The authors found that immunisation rates are rising faster in countries with gender quota implementation.

This review has documented a range of gender barriers to immunisation, many of which are interdependent and found across geographies. Key learnings include:

• Some of the most important reasons that women do not bring their children to get vaccinated lie outside of the usual purview of immunisation programming. Household decision-making, for example, which is deeply entwined with social norms governing the appropriate roles for men and women within families, is often perceived as being far outside of the scope of the health system. Similarly, the fact that women often face multiple competing demands on their time is not easily addressed by immunisation-focused interventions.
• However, some of the gender barriers identified in the research are amenable to being addressed with adaptations to existing vaccination programming. For example, training providers on respectful patient treatment could improve women's experiences with the healthcare system, influencing their likelihood to return for immunisation services.
• Men and other family members can be better engaged throughout the immunisation process to relieve the caregiving burden that women tend to manage. Given the overwhelming emotional and physical labour that women face, programmes that seek to engage men, in the community and/or in places of employment, could focus on self-care and family care.
• There is abundant evidence that offering caregivers, especially those living in poverty, compensation for the direct and opportunity costs of immunisation is a highly effective way of putting financial resources into the hands of women, which can enhance their economic independence and be used to vaccinate children.

In conclusion: "This review definitively establishes that gender barriers are highly relevant in many socioeconomic contexts across LMICs....We can only know how important these barriers are with more research that measures the impact of programming on gender barriers to immunization coverage."