A Gender Lens to Advance Equity in Immunization

The United Nations Children's Fund (UNICEF) and the Bill and Melinda Gates Foundation have convened a high-level Equity Reference Group for Immunisation (ERG) to identify new approaches and best practices to accelerate progress on equity in immunisation. In this working paper, members of the ERG and its champions present an overview of gender-related inequities and barriers to immunisation with the aim of stimulating further thinking and discussion. While the primary focus is on child immunisation, the paper includes additional information relevant to the human papillomavirus (HPV) vaccine. It is hoped that the evidence and analysis presented in this discussion paper will inform: (i) country-based coverage and equity assessments; (ii) gender-responsive demand- and supply-related programmatic decisions; and (iii) implementation research to identify additional promising approaches to reduce gender-related barriers.

The paper begins with a set of definitions, presenting an overarching perspective on how gender inequities across contexts can influence both the demand for and supply of immunisation. The analysis of gender inequity in childhood immunisation has tended to concentrate on: (i) sex differentials in coverage between boys and girls, and (ii) how broader aspects of gender inequality - in particular, a mother's education - affect child immunisation for both sexes. The authors make the case that it is critical to consider the ways in which gender interacts with other determinants - e.g., poverty, ethnicity/caste, and migration status - to shape disparity and to mediate immunisation uptake.

The ERG calls for efforts to comprehensively address gender inequity as part of health systems strengthening at every level because there are different pathways through which gender can influence implementation efforts and outcomes. They present a core set of challenge statements that highlight these different pathways:

1. "Mothers and other women are typically the primary caregivers for their children, but their lower status in the household and community limits their capacity to act on their own and their child's behalf.
2. Women are acutely affected by physical and time barriers to accessing immunization services (e.g. distance to services, inconvenient times of services, long queues). These barriers may be amplified or mitigated by other elements of their social position, such as economic status, ethnicity, marital status, age, educational status, caste, and the socio-cultural context, including gender norms.
3. Recognizing that access to health literacy is - in many parts of the world - gendered, women lacking health literacy can have a limited understanding of immunization (such as knowing which diseases vaccines prevent, vaccine dosage and schedule), low motivation to vaccinate their child, and weak capacity to negotiate the health system.
4. Women's experience of quality of service - encompassing responsiveness of services; range of services available; provider attitudes, skills and behaviour; availability of female providers - may deter them from attending health services."

Approaches to understand and address gender in health vary. Examples include: an integrationist approach, which aims to reduce gender-related disadvantages in access to health services, quality of services, and health outcomes, and a transformatory approach, which seeks to refocus the provision of health-related services and interventions in order to ensure they address power relations and promote women's rights and interests equitably with men's. ERG highlights that it is critical to ensure that interventions do not exacerbate gender inequalities by reinforcing existing power differentials.

Evidence suggests that different agents can play a fundamental role in addressing gender inequities in immunisation. One section of the paper highlights how they can make a difference, and why they should be identified and engaged as change agents. An example would be men acting as influencers in the broader societal network (e.g., community facilitators, cultural leaders, religious or political leaders) by shaping normative values related to vaccine acceptance and acting as allies in women's empowerment initiatives.

Drawing on interviews with multiple key informants and a review of reports, articles, and other materials, the ERG then presents some promising approaches that have been evaluated or designed based on formative research or a theory of change, or that have documented implementation experience and lessons learned. These approaches aim to:

• Widen the audience for information, education, and communication (IEC) and strengthen and sustain social mobilisation in under-immunised communities - e.g., Volunteer Community Mobilizers (VCMs) take a "talking book" designed for low-literacy women into communities in Northeast Nigeria and "read" through it with local women. A gold sticker on the front cover attests to the Islamic Society's endorsement.
• Encourage fathers' greater input into child care, and integrate their involvement in child health - e.g., Efforts to increase male engagement in the prevention of mother-to-child transmission of HIV (PMTCT) through the UNICEF-supported Optimizing HIV Treatment Access Initiative in Uganda, the Democratic Republic of the Congo (DRC), Malawi, and Côte d'Ivoire highlight the importance of working with local leaders for community dialogue and social mobilisation, engaging community health workers to reach men, and strengthening male peer cadres.
• Make adjustments to service provision based on community perspectives of time, location, modality, and quality - e.g., A mobile outreach team provides confidential care for beneficiaries, including adolescents, bolstered by capacity building/mentoring to improve technical capacity and (gender-sensitive) interpersonal communication skills.
• Increase local support and promote a shared sense of purpose and accountability - e.g., With consideration to class/caste/ethnicity/religious dynamics, community mobilisers are deployed to areas with low immunisation rates, and women from the local community are recruited to ensure acceptance in the community and ease in mobilisation, as well as minimise safety risks.
• Use descriptive monitoring and improved targeting to identify those who are left behind - e.g., in 2018 in Bangladesh, with a focus on urban populations, e-registers were developed and Expanded Program on Immunization (EPI) registration was linked with the civil registry vital statistics (CRVS) system.

Based on this analysis, the ERG offers a set of actionable recommendations for programming. To cite only one example: Train vaccinators and healthcare workers to be: (a) respectful, responsive, and empathetic to the needs of those who may be stigmatised and vulnerable, as well as those with diverse health beliefs, practices, and cultural and linguistic needs; (b) effective communicators, especially to address vaccine hesitancy and to respond to reports of serious adverse events following immunisation (AEFIs), to maintain trust and allay fears.

The paper concludes with an outline of some of the remaining questions that require additional research, in the ERG's estimation. Given that measurement of gender inequalities and barriers to immunisation can be challenging, the ERG has included as an annex a sampling of metrics currently being used and recommended across global development organisations and research institutions. Links to existing operational guidelines for countries are also provided.

Click here for a 2-page summary of the paper provided by the ERG.