Routine Immunization Strengthening in Polio High-Risk Geographies: Gender Integrated Approach

"Understanding how gender norms, roles, and cultural restrictions influence access to immunization is critically important for addressing issues related to global vaccine inequity and is a key component of polio eradication..."

Integrating gender into routine immunisation services goes beyond ensuring equal vaccination coverage for girls and boys. This report examines the sociodemographic and immunisation context of specific countries of interest (Afghanistan, Somalia, Central African Republic, South Sudan, Democratic Republic of Congo, Niger, Chad, Guinea, Nigeria, and Pakistan) and describes the association between gender and routine immunisation on the individual, household, community, health system, and policy levels.

A team from the Strategic Analysis, Research & Training (START) Center at the University of Washington conducted a review of academic and grey literature and performed key informant interviews in response to a request by the Bill and Melinda Gates Foundation's Routine Immunization Strengthening in Polio High-Risk Geographies (RISP) and Gender Integration team. This research identified contributing factors and recommendations for ways to improve coverage by targeting gender-specific barriers, which are synthesised in this report and a slide deck presented to the team (see below).

Notably, all 10 countries of interest within the RISP focus have intrinsic factors that disproportionally increase gender-related barriers to immunisation. Religion and religious norms influence gender roles, female mobility outside the home, and women's ability to engage with the health system independently. Within RISP geographies, nurses tend to be women, and doctors tend to be men, and these are among the lowest-ranking countries for gender equality index and political instability. These countries also have high numbers of internally displaced persons (IDPs) due to conflicts and natural disasters.

Considering gender in routine immunisation activities in the 10 countries includes ways in which both gender and gender norms influence accessing routine vaccines at 5 distinct, but interconnected, levels:

1. Individual - sample findings: Individual understanding of vaccination, benefit to children, and knowledge of how vaccines work are all related to immunisation rates. One study found that, compared to mothers who had poor knowledge of vaccination, mothers with moderate to high knowledge of vaccination were about 2 times more likely to vaccinate their child. Other research showed that mothers who had any information about vaccinations were 40-200% more likely to vaccinate their child. Women who receive prenatal care and consult with health workers before giving birth have a greater chance of choosing immunisation for their babies. Employment may enhance maternal autonomy, which in turn promotes maternal health seeking behaviours and child immunisation uptake.
2. Household - sample finding: Generally, as mothers' decision-making power increases, there tends to be an increase in vaccination rates.
3. Community - sample findings from a few RISP countries:
   • In Pakistan, one study reports that intensity of conflict is negatively associated with vaccination, with boys significantly more likely to be vaccinated than girls. Also in this country, there have been incidents of harassment, target killing, security threats, and kidnapping of polio vaccinators. Female community health workers (CHWs) are more likely to work in isolation in remote areas, with a risk of being targeted; attacks against them receive less attention and are reported less frequently. These factors have led to the non-availability of health professionals of all cadres, particularly with female CHWs, further discouraging the community from seeking healthcare. Also, the Taliban instituted 3 fatwas that had serious implications for the role of lady health workers (LHWs) in the community - e.g., one declared that the presence of women in public spaces was a form of public indecency, which affected their ability to travel unaccompanied, which is a key requirement of their job. Furthermore, a daily Taliban radio programme was dedicated to discrediting the primary care programme and the women who worked in it. Individual LHWs were named and shamed as prostitutes and "servants of America".
   • In Afghanistan, it is reported that female healthcare providers working in areas under Taliban control have been "exposed to brutal treatment on an almost daily basis."
   • In India, resistance from mothers-in-law make daughters-in-law hesitant to accept vaccination, some mothers-in-law not seeing the need for vaccination as they did not take their own children. (Similar findings have been reported in Pakistan.) Evidence from India also supports the observation that immunisation levels tend to be weakest for female children in urban slums and rural areas, with one indicating that almost twice as many girls as boys are completely un-immunised in rural Punjab.
   • In Ethiopia, mothers' religion was found to be an important predictor of full polio vaccination status of their children in pastoral and semi-pastoral regions. Children of Muslim mothers were less likely to be vaccinated against polio. This connection has also been reported in Nigeria, especially in the northern parts, where the odds of never-vaccination are increased in children belonging to Muslim households.
4. Health system - among the key factors: a female health worker shortage (e.g., in Afghanistan, there is a relative lack of women with higher education as a result of conflict and gender segregation policies that had prohibited women from receiving education beyond primary school under the Taliban regime); female health worker attrition; few women in senior positions; segregation, recruitment, and job tasks; gender inequality within the health system due to women's lack of representation at higher decision-making levels; and reports of poor services from LHWs. On the other hand, an encouraging example comes out of Pakistan, despite the fact that armed conflict in several districts of the Khyber Pakhtunkhwa province and the Federally Administered Tribal Areas have resulted in over 2.7 million IDPs. Health promotion activities among displaced mothers included the bangle initiative, which emerged as a socially valued incentive (colourful bangles in Pakistan's cultural context signify happiness and hope). The implementation of this health promotion initiative by culturally sensitive female health workers generated wider acceptance among displaced mothers and approval from their male family members.
5. Policy and governance - sample findings: Within Afghanistan, research shows that female CHWs have the highest chance of being able to enter households to identify children and to educate caregivers in decision making around vaccinating all their children. Evidence has shown that childhood immunisation campaigns benefit from strategies aimed at reducing gender inequities like improvement of women's literacy, paid employment, and decision-making autonomy. Though policies and programmes may address gender-specific issues, improvements made to benefit women, like strengthening of education quality and access, benefit both men and women. In addition, paid maternal and paternal leave policies are associated with increased equality in decision making and improved health outcomes, supporting the notion that gender-integrated approaches benefit the quality of services and outcomes for all.

The research identifies the following key opportunities and recommendations for increasing gender equity in immunisation:

• Collect gender-disaggregated data at local and national levels: Policy and funding must require written consideration of gender impacts, strategies to address identified barriers, measurement of relevant indicators, and follow-up at regular intervals to track impact over time.
• Target interventions at the health system level: Opportunities for vaccination must be in convenient locations for women and their children. Programming must also expand availability of female health workers, should there be cultural restrictions on patients and providers of opposite sex. Shifting patient interactions to address women directly and to allow them to make well-informed decisions about their medical care empowers women and provides an opportunity for a gender-transformative intervention.
• Integrate CHWs in the health system: Policies are needed to protect female CHWs' working conditions, to compensate female CHWs adequately for their labour, and to provide room for advancement and leadership. Integrating CHW programmes into budgeting and planning in Ministry of Health strategy increases legitimacy of CHWs in public opinion.
• Identify areas for subtle cultural shifts: Change takes time, particularly when it comes to cultural gender norms. Although many interventions focus on the mother's role or on increasing a mother's decision-making power, considering how to involve fathers in healthcare decision making may improve household cohesiveness and result in an overall increase in vaccination rates. One option is to include both men and women in childbirth and child health education classes.

Click here for the 50-page slide deck in PDF format.