Seeing Old Problems Through a New Lens: Recognizing and Addressing Gender Barriers to Equitable Immunization - Webinar Recording

"Gender and immunization over the life course has become a key priority in the immunization space....Addressing gender inequity is critically important for us to drive down the number of zero-dose children." - Dr. Folake Olayinka

Hosted by the United States Agency for International Development (USAID)-supported MOMENTUM Routine Immunization Transformation and Equity, this webinar shared key learnings about how gender barriers obstruct equitable access to immunisation services throughout a person's life. The discussion also highlighted the global movement to strengthen country-level implementers' capacity, commitment, and confidence to develop and implement strategies addressing gender-related barriers to immunisation.

As the session's moderator, Rebecca Fields, Technical Lead for the MOMENTUM Routine Immunization Transformation and Equity project explained in her opening remarks, over the past few years, there has been growing recognition that gender-related barriers play a sometimes-hidden role in keeping the most vulnerable people from being vaccinated. She asked webinar participants to consider a common challenge in immunisation: a vaccine stockout. Usually, a vaccine stockout is regarded as a supply chain problem. But most caregivers are female, and from a female caregiver's point of view, a vaccine stockout means she cannot get her child fully vaccinated when she goes to the health centre or to the outreach session. Returning in the hopes a vaccine will be available the next time means she has to take more time off from her family and household duties and may need to renegotiate with her husband or partner for resources to go for vaccination. She may find that it's just too difficult to deal with those obstacles in order to take her child back for that preventive service. Her decision, if she decides not to go back, is sometimes misinterpreted as negligence or vaccine hesitance, whereas in fact, there may be important gender dimensions that underpin her decisions.

Webinar speakers included:

• Dr. Folake Olayinka, USAID Immunization Team Leader and Lead Technical Advisor, COVID-19 Vaccination Access and Delivery Initiative - Dr. Olayinka looked particularly at gender barriers in the Global Polio Eradication Initiative (GPEI), along with some examples of what has worked in that context. For example, deciding to allow vaccination during mass campaigns is not always the sole decision of the mother. What has worked in the GPEI is:
  • Increasing the proportion of female vaccinators, supervisors, mobilisers, and monitors, as well as the proportion of women in leadership positions;
  • Disaggregating data at all levels of eradication: campaign data, surveillance data, and communication and behaviour change data;
  • Flexibly accommodating women's schedules and locations;
  • Building the capacity of patient women mobilisers who are able to talk convincingly to families and convert refusers to acceptors; and
  • Creating gender-sensitive polio messaging, and mentoring women to have confidence in delivering these messages as coaches or community resource persons who work to build community trust in immunisation and reduce vaccine hesitancy.

  Dr. Olayinka also examined USAID's commitment to equity for immunisation over the life course for all vaccines, including the COVID-19 vaccine. She concluded with a look at ongoing actions and priorities for integrating gender into USAID programming (e.g., promoting a shared sense of purpose and accountability through engagement of fathers and other decision makers/ influencers in the household and community).

• Jean Munro, Senior Manager, Gender Equality, Gavi, The Vaccine Alliance - Ms. Munro outlined: Gavi's commitment to gender equity and programming, what that commitment looks like in terms of steps within the Secretariat, Gavi's process for designing grant applications, and the types of interventions they're now seeing in countries. In brief, gender is central to the new Gavi 5.0 strategy, whose vision is to leave no one behind with immunisation. The policy has a goal to identify and overcome gender-related barriers to reach under-immunised children, individuals, and communities, and it encompasses three main areas of work. The first is to identify and address the underlying gender-related barriers faced specifically by caregivers, health workers, and adolescents. It encourages and advocates for women's and girls' full and equal participation in decision-making related to health programming and wellbeing to overcome differences in immunisation coverage between girls and boys. Within the Secretariat, steps to mainstream gender across Gavi practices include: (i) Galvanising support and enhancing capacity, understanding, and skills by providing informal learning sessions and webinars, as well as formal training courses, and by sharing stories on gender and immunisation; (ii) increasing coordination across Gavi to ensure more complementary programmes and to build on programming guidance and lessons learned; and (iii) refining guidance to support an inclusive and diverse portfolio planning process for developing grant applications, including, for example, promoting the use of participatory approaches such as human-centred design (HCD), which can be an effective way to bring out communities' identification of gender-related barriers. Ms. Munro discussed Gavi's use of a gender lens in the implementation of the Zero Dose Strategy, as well as learnings from promising gender-responsive interventions in various countries around the world (e.g., leveraging female mobilisers in Afghanistan's polio Immunization Communication Network).
• Dr. Sofia de Almeida, United Nations Children's Fund (UNICEF) Social and Behaviour Change Specialist for East and Southern Africa Regional Office - Dr. Sofia de Almeida described UNICEF work across several countries in the sub-region of East and Southern Africa (ESA) to both identify and analyse gender barriers to immunisation, particularly in this presentation with reference to COVID-19 vaccination. Overall, analysis of behavioural data among the general population and health workers shows that in some ESA countries, women have lower levels of trust and confidence in the COVID-19 vaccine when compared to men. They have also less willingness to recommend the vaccine, less perception that their communities and coworkers will get the vaccine, and slightly less intention in some countries, and they also reported more challenges to access to COVID-19 vaccines. She also described the measures taken to reduce barriers and shared some emerging findings. Programmatic recommendations include:
  • Invest in trust-building interventions, such as safe discussion spaces with experts and trusted sources, and amplify new evidence as it becomes available to better address myths and misinformation (e.g., related to breastfeeding and infertility).
  • Engage with key stakeholders playing a fundamental role in addressing gender inequities in immunisation (e.g., men (parent, husband, or influencer), elderly women, female providers).
  • Amplify community voices, attitudes, perceptions, concerns, and needs, such as by showcasing women as vaccine champions and agents of change.
  • Partner with women's organisations, faith-based organisations, and other community-based groups to ensure that accurate information is available to communities and that gender perspectives are considered in planning, designing, and monitoring.
  • Adapt services to women's needs by considering extended and flexible vaccination hours to accommodate working hours and caregivers' responsibilities and/or by delivering vaccination services in places where women congregate (e.g., markets, churches).
  • Commit to obtaining gender-disaggregated data for priority health indicators at both national and local levels.
  • Integrate COVID-19 vaccinations into existing service delivery that responds to gender-specific needs, such as community-based sexual and reproductive health services, nutrition services, and antenatal care.
  • Train healthcare workers to confidently counsel women, allowing them to make informed decisions regarding vaccination, and administer the vaccines without any reluctance.

  One slide provides a country example showing how evidence-based intervention can contribute to equitable vaccinations by scaling up COVID-19 vaccination among women. (For more on this project, see Related Summaries, below.) In South Sudan, UNICEF supported quantitative and qualitative research using an HCD approach and a behavioural and social driver survey to understand what is hampering women's COVID-19 vaccine uptake in regions with low performance, in order to gather informed planning and decision making. A strong evidence-based advocacy approach for outreach sites was implemented, alongside with other activities such as robust community mobilisation and radio talk shows featuring two-way communications and tailored messages based on qualitative findings about gender-related issues. Implementation of those interventions was critical to increase uptake among women from 26% in September 2021 to 48% in April 2022. Dr. Almeida's final slide highlights the importance of behavioural insights and evidence generation to inform planning and decision-making to contribute to equitable vaccination. Some lessons learned that she argues should be applied to address gender barriers for routine immunisation (RI) are:

  1. Collect social and behavioural data: Previous and ongoing data collection exercises provide understanding of barriers and challenges faced by women in accessing immunisation services more broadly - not only for COVID-19 vaccination. So, it's important to use data for COVID-19 vaccination to understand barriers and inform planning.
     • Disaggregated and time-series data collection is critical to understand specific needs and barriers and understand changes over time. Additional qualitative research on subgroups among women is relevant to better understand reasons hampering the uptake and to customise interventions and messages.
     • Moving to integration - consider combine research tools to understand drivers for COVID-19 vaccination and RI to inform planning and decision making for this phase and to leverage RI. Use opportunities of COVID-19 vaccination research to collect social and behavioural data on RI.
  2. Ensure self-efficiency so that women can complete their vaccination: Adjust service provision to specific women's needs (such as offering extended times, partnering with women's groups to support competing priorities, or integrating delivery of essential health services).
  3. Invest in trust-building interventions - Trust in vaccines is connected with trust in science, trust in health workers, and trust in health, so investing in trust-building interventions can improve demand for immunisation. Specific activities such as providing safe discussion spaces so women can address specific queries to trusted sources, increasing the number of female social mobilisers, partnering with women organisations, engaging with men to transform gender norms, and reinforcing and showcasing pro-vaccine social norms (e.g., leveraging key influencers, peers, and female influencers) have been contributing to increase of uptake of the COVID-19 vaccine and can be applied to leverage RI.
  4. Improve access: Include women in planning processes (e.g., microplanning), partner with private sector to improve transport, and consider outreach. Another important lesson learnt is the coordination with key areas, such as service delivery, to improve access and increase uptake - for example, by tailoring demand promotion interventions followed by providing access to vaccination.
• Anumegha Bhatnagar, Risk Communication Lead on MOMENTUM's Routine Immunization Transformation and Equity programme in India - Since November 2021, through USAID-support, MOMENTUM Routine Immunization Transformation and Equity has helped more than 3 million people in 18 Indian states receive their last recommended dose of a COVID-19 vaccine. The project focuses on improving access to COVID-19 vaccination among women and gender-diverse communities who are pregnant and lactating, members of the transgender community, and migrant workers. Engagement strategies include:
  • Development of gender-specific communications materials in multiple formats;
  • Women's rallies to increase awareness;
  • Involvement of women community and religious leaders;
  • Engagement of champions from the transgender community; and
  • Vaccination camps for older women and transgender women.

  For example, the Wonder Women Campaign tells the stories of women who led from the front, overcoming many barriers to help vaccinate people against the COVID-19 virus. It features: (i) social media - From teaser posts to individual stories of wonder women, social media platforms such as Facebook, Twitter, Instagram, and state social media handles were deployed extensively to celebrate the role of women; (ii) posters - They were displayed in on-the-ground events and activities and projected on-screen during congregations; and (iii) a booklet - The Wonder Women Crusaders of COVID-19 Vaccination Program was disseminated to the government officials and key stakeholders.

• Dr. Anuradha Sunil, Medical Director of the Indian Society of Agribusiness Professionals (ISAP) - ISAP, a MOMENTUM Routine Immunization Transformation and Equity project subawardee, is implementing the MOMENTUM Routine Immunization programme in 8 districts spanning across two states (Tamil Nadu and Jharkhand). ISAP has developed specific strategies to work with each of the vulnerable groups - e.g., women migrant workers - and established partnerships at the district level. For example, as a part of mobilisation and awareness creation, ISAP started door-to-door vaccination outside of work hours to reach out to farm workers and the unorganised work sector. They also arranged special vaccination camps at workplaces in convergence with employers and women community institutions. They developed and deployed technology solutions for creating awareness. They sent out reminders and messages about side effects counseling. There was also convergence and partnership with other women-centric government schemes. Namely, several districts have specific women programmes where a large amount of women beneficiaries are enrolled, so ISAP reached out to these government institutions for partnership. As a result, ISAP saw an increase in the numbers of vaccinated female migrant laborers and improved awareness regarding the safety profile of the vaccination and its minor side effects.

A Q&A session followed the presentations and featured inquiries such as: "Can you please share more information about how USAID is encouraging countries to collect and use gender data?"

Click here for the webinar speakers' presentations (49 pages, PDF).