Gender and Immunization Demand: Final Report and Recommendations

"A deeper understanding of how gender impacts immunization behaviours and outcomes can help inform the design and implementation of more gender responsive immunization programmes."

Immunisation demand efforts are part of social and behaviour change (SBC) strategies to promote healthier, preventive, and protective practices for children and their families. Gender is a critical determinant of health outcomes and impacts demand for - as well as access to and uptake of - immunisation services. This United Nations Children's Fund (UNICEF) document provides guidance to SBC teams, immunisation and health teams, and national partners responsible for planning and implementing immunisation demand efforts on how to integrate a gender perspective into demand interventions. Illustrative examples are embedded throughout in an effort to make this resource user friendly and actionable.

The report builds on a review of literature exploring the intersections of gender, immunisation, and demand. It also draws on the research and analysis conducted for six case studies selected by UNICEF country offices on gender integration in immunisation demand interventions. (See Related Summaries, below.) These sources help explain how immunisation demand and supply are closely connected and overlapping. For example, the lack of female vaccinators in certain countries is a service-related barrier but also one with direct implications on demand for vaccination services. In fact, gender barriers impact each stage of UNICEF's Journey to Health and Immunization framework (see Figure 2 on page 3).

In this context, gender-transformative change goes beyond awareness and behaviour change to foster shifts in the power dynamics that define gender norms and relationships. The level of gender integration in programmes can be gauged on a continuum; Figure 4 on page 5 provides illustrative examples of immunisation demand efforts along this continuum. Typically, an immunisation campaign does not attempt to be transformative (i.e., explicitly seeking to redress gender inequalities, remove structural barriers, and empower disadvantaged populations), but it at least must consider the opportunities, roles, and needs of female and male caregivers to promote equity in vaccine coverage.

Considering that empowered decision-making is an important factor for health-seeking behaviours, the literature indicates that gender-transformative strategies can not only reduce childhood immunisation inequities but contribute to gender equality. UNICEF stresses that recognising the linkages and planning interventions that contribute to immunisation coverage as well as gender norm shifts requires robust gender analysis, strategic planning, and evidence-based design and adaptations. To that end, the report offers a series of practical recommendations to plan, design, implement, and monitor and evaluate demand generation interventions that have integrated gender. These recommendations are organised according to a 5-step programme cycle:

1. Analyse the situation: Understanding and analysing how the socio-cultural context and prevailing gender norms impact vaccine-related decisions for women, men, girls, boys, and gender-diverse people reduces the risk of discovering gender barriers or disparities mid-way into a programme or adding gender as an afterthought. Sample recommendation: Consider diversity within gender. Figure 7 on page 10 provides examples of questions to include in a gender analysis to guide the design and planning of interventions.
2. Design and plan: This stage includes articulating gender-specific results and identifying appropriate communication approaches and platforms. Starting with the development of a theory of change, the practitioner may be guided through this stage by considering what UNICEF deems promising approaches for gender transformative immunisation demand generation, which are described in the report. In short, the approaches include: Engage men, identify and mobilise allies and champions, reach adolescents, and apply behavioural insights and nudges.
3. Engage and communicate: In this step, practitioners develop and pretest communication approaches, materials, and tools. In doing so, they should identify approaches and change strategies and to create messages and materials that meet the distinct needs of girls, boys, women and men. Recommendations include, in brief: Select an appropriate mix of channels, consider integrated entertainment-education programmes, identify the specific communication needs of vulnerable groups, adjust for gendered differences in information access, build trust and address concerns around vaccines, and tailor messages to the specific needs of women and men.
4. Implement: In rolling out the programme and setting up systems to monitor and document the process and outcomes, practitioners should be guided by the identification of the gender barriers that prevent individuals from accessing information or services, participating in activities, and engaging for change. Recommendations for gender-responsive implementation are organised around advice to: Adjust timings to meet needs of women and men, adapt for humanitarian contexts, use social listening and digital engagement, and mobilise community-led action.
5. Evaluate: Applying a gender lens in this step provides an understanding of how the intervention affected different groups of girls, boys, women and men, and gender-diverse people and can inform the design and delivery of gender-responsive or -transformative programmes in the future. For example, there is a need to include gender-sensitive indicators to better understand how gender-related changes are occurring over time; Tables 3-4 on pages 28-29 provide guidance in this area. There is also a need to assess if male engagement in maternal and child health is increasing.

Figure 13 on page 31 summarises the key elements in ensuring gender is included in the programme cycle; Figure 14 on page 32 lays out facilitating factors for gender transformation.

The report concludes with the observation that "Gender inequality exists at structural, community and household levels and needs to be addressed holistically. Ensuring immunization demand strategies are gender responsive requires an explicit integration of gender considerations at the individual, family, community, institutional and societal levels. Ultimately gender transformative immunization demand interventions will contribute towards empowering women and girls, a change that requires and must be facilitated by supportive families and engaged communities and is dependent on the availability of gender responsive health services and policies."

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