Gender can have a substantial effect on vaccine demand, access and uptake. Early data suggests that as of March 2021, women are being vaccinated at slightly higher rates than men globally (comprising 56% of vaccinations across 29 countries with available data). Policies to promote widespread uptake of the COVID-19 vaccine, which is critical for effective control of the pandemic, should recognise and address underlying gendered barriers. Obstacles to men's access include stigmatisation around vaccine uptake and employment environments that restrict access to vaccine delivery points during open hours. In some settings, women's low decision-making power and high care demands in the home, as well as lack of financial resources and access to information, can hinder their access to vaccines.1Gavi The Vaccine Alliance. Gender and immunisation.
https://www.gavi.org/our-alliance/strategy/gender-and-immunisation Studies in Europe2Neumann-Böhme, S., Varghese, N.E., Sabat, I. et al. (2020) Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19. The European Journal of Health Economics. 21, 977–982. https://doi.org/10.1007/s10198-020-01208-6, the UK3Paul, E., Steptoe, A., Fancourt, D. (2021). Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. The Lancet Regional Health Europe. Volume 1 https://doi.org/10.1016/j.lanepe.2020.100012 and the US4Callaghan, T., Moghtaderi, A., Lueck, J. A., Hotez, P. J., Strych, U., Dor, A. Franklin Fowler, E. and Motta, M., (2020) Correlates and Disparities of COVID-19 Vaccine Hesitancy http://dx.doi.org/10.2139/ssrn.3667971 have indicated that women may be less likely than men to accept the COVID-19 vaccine.
Related resource: The 2021 GH5050 Report Gender equality: Flying blind in a time of crisis provides an analysis of the gender-responsiveness of the of global health actors.
Roughly 1 in 10 countries mentioned gender in their vaccination uptake policies. Of the 58 policies reviewed across 37 countries, 91% were gender-blind.
Gender-sensitive vaccination interventions that were identified included monitoring vaccine uptake by demographic characteristics including gender and recognition of the high representation of women in the health and social care workforce when analysing causes of vaccine hesitancy among these groups.
‘Vaccination uptake will be assessed in an ongoing manner to track the implementation of the programme and acceptance of the vaccination in the populations targeted [...]. Analysis will be carried out on uptake by demographic characteristics, such as gender, age, area of residence, [Health Service Executive] region […], workplace settings for [healthcare workers] [...], occupational or clinical risk group.’
‘Special efforts will be made to engage communities in planning, implementation, tracking and reporting on the progress with the vaccination. To ensure maximum success, a focus on healthcare workers [...], gender, vulnerable groups, ethics and transparency will be accorded high priority as part of the plan.’
‘The adult social care workforce has a higher percentage of women and people from ethnically diverse communities than the general population of England, and evidence shows that people in these groups are more likely to be hesitant about taking the COVID-19 vaccine. Reasons for health and social care workers being hesitant include lack of knowledge about the vaccine, misinformation and mistrust of government and perceptions of equality and discrimination in health and public services.’
Risk of exposure to a virus, and adoption of health-protective behaviours in response to that risk, varies according to economic and social factors. Early evidence suggests that women are generally more likely than men to adopt non-pharmaceutical behaviours such as hand washing, face mask use or avoiding public transport to reduce risk of COVID-19 infection.1Capraro, Valerio and Barcelo, Hélène. (2020). The effect of messaging and gender on intentions to wear a face covering to slow down COVID-19 transmission. 10.31234/osf.io/tg7vz Some of these differences in behaviour are driven by gender roles. For example, men in paid employment that cannot be undertaken at home may not have the resources to get to work except by using public transport.
Experience from previous influenza pandemics,2Elaine Vaughan and Timothy Tinker (2009) Effective Health Risk Communication About Pandemic Influenza for Vulnerable Populations. American Journal of Public Health 99, S324_S332, https://doi.org/10.2105/AJPH.2009.162537 and from the HIV epidemic, have highlighted the importance of understanding and addressing the socio-economic context of people’s lives, and their perspectives on risk (and benefit) at the heart of effective public health communications strategies.
Related resource: See our 2021 Report Gender equality: Flying blind in a time of crisis for an analysis of the gender-responsiveness of the activities of global health actors to promote positive health behaviours.
Roughly 2 in 10 countries mentioned gender in their public health communication policies. Of the 127 policies reviewed across 66 countries, almost 9 in 10 were gender-blind. One-third of the policies reviewed were public health communication policies and two-thirds were communication materials.
Gender-responsive public health messaging interventions that were identified included designing communication materials to target men and women, collaborating with civil society groups and community members with influence among populations of men and women, and considering how gender (including norms) affects access to information in the design of campaigns.
‘To promote compliance, messaging may need to be adapted depending on the sex, gender, ability status, parental and caregiving responsibilities, and other socioeconomic or identity factors of individuals. For example, men may be more likely than women to report low levels of concern about the COVID-19 pandemic, including men in the highest risk age groups, and women may be more likely to have caregiving responsibilities (e.g., for children or elderly family members).’
‘[We] will carry out targeted consultations with vulnerable groups to understand concerns/needs in terms of accessing information [… We will] consider provisions for childcare, transport, and safety for any in-person community engagement activities [for women]... [and] develop education materials for pregnant women on basic hygiene practices, infection precautions, and how and where to seek care based on their questions and concerns.’
‘[We will] ensure that crisis and risk communication targets and reaches women, persons living with disabilities and marginalized groups …[We will] design and run communication and engagement campaign[s] that addres[s] harmful gender norms, discriminatory practices and inequalities during crisis [...] recognizing that social, culture and gender norms, roles, and relations influence women’s and men’s vulnerability to infection, exposure, and treatment differently.’
Globally, men are more likely to be hospitalised, develop critical symptoms and die due to COVID-19 compared to women. An important factor is likely to be the higher prevalence among men of chronic diseases associated with increased COVID-19 death rates,1V Jain, J-M Yuan (2020) Systematic review and meta-analysis of predictive symptoms and comorbidities for severe COVID-19 infection. International Journal of Public Health. https://doi.org/10.1101/2020.03.15.20035360 including hypertension, cardiovascular disease and some chronic lung diseases.2Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017 (2018) Global Health Metrics. https://doi.org/10.1016/S0140-6736(18)32279-7 These are often associated with gender norms around exposure to unhealthy behaviours and environments, such as tobacco use, exposure to air pollution, and poor diets. Research also suggests that sex differences in immune response (linked to biology) may contribute to the likelihood of developing severe symptoms.3Scully, E.P., Haverfield, J., Ursin, R.L. et al. (2020) Considering how biological sex impacts immune responses and COVID-19 outcomes. Nature Reviews Immunology 20, 442–447 https://doi.org/10.1038/s41577-020-0348-8
Related resource. See our 2021 Report Gender equality: Flying blind in a time of crisis for an analysis of the gender-responsiveness of the activities of global health actors to promote access to health services.
Roughly 1 in 16 countries were found to mention gender in any of their clinical guidelines. Among the 86 policies reviewed across 51 countries, 6% mentioned gender.
Gender-responsive guidelines for clinical management of COVID-19 included adapted healthcare for different genders, gender-sensitive psychological support for COVID-19 patients and consideration of gender norms that create obstacles to women’s access to health services in the design of health service delivery.
Many COVID-19 clinical guidelines (40%) contained specific guidance on the management of pregnant women but none of these referenced the gendered social or economic barriers to pregnant women’s access to care which can impact their health.
‘The impacts and burden of COVID-19 on health and related health outcomes might differ according to sex/gender and other socio-demographic and economic characteristics, which would require an adapted health care response.’
‘Under the Mental Health and Psychosocial Support for COVID-19 patients section, the document cautions staff providing psychological support to patients to be sensitive to their culture, ethnicity, gender, sexuality.’
Women are estimated to represent 70% of the global health and social care workforce1WHO (2019) Gender equity in the health workforce: Analysis of 104 countries https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf?ua=1 and this is reflected in the 71% of healthcare worker infections that are among women in countries with available data. Women are also more frequently involved in care of family members inside the household which may place them at higher risk of infection.2United Nations (2020) Policy Brief: The Impact of COVID-19 on Women. https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2020/06/report/policy-brief-the-impact-of-covid-19-on-women/policy-brief-the-impact-of-covid-19-on-women-en-1.pdf WHO has warned that without adequate consideration of women in the design of personal protective equipment (PPE), the protection it offers them can be compromised.3WHO (2020) Gender and COVID-19: Advocacy Brief https://www.who.int/publications/i/item/gender-and-covid-19 The impact of working on the frontline may also be taking a heavy toll on health workers’ wellbeing and emerging evidence suggests that women were more at risk of experiencing poor mental health outcomes than men.4Ashley Elizabeth Muller, Elisabet Vivianne Hafstad, Jan Peter William Himmels, Geir Smedslund, Signe Flottorp, Synne Øien Stensland, Stijn Stroobants, Stijn Van de Velde and Gunn Elisabeth Vist (2020) The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review, Psychiatry Research, Volume 293, https://doi.org/10.1016/j.psychres.2020.113441.
See our 2021 Report Gender equality: Flying blind in a time of crisis for an analysis of the gender-responsiveness of the activities of global health actors to protect healthcare workers.
Roughly 1 country in 10 was found to mention gender in any of their guidelines on the protection of healthcare workers reviewed. Among 70 policies reviewed from 42 countries, 16% responded to gender.
Gender-responsive interventions to protect healthcare workers that countries committed to included procurement of sex-specific PPE in recognition of the high proportion of frontline workers that are women and providing gender-sensitive psychological services and other support including childcare.
‘Statistically men are more likely to become seriously ill due to COVID-19. Women are generally under more stress due to increased care and home responsibilities and are more likely to stand in the front line in demanding work related to the epidemic. [...] and are therefore more exposed to infection. Women working in the healthcare sector are generally in closer proximity with patients than men working in the same sector.’ The policy commits to providing PPE and regular diagnostic screening for front line healthcare workers.
‘Given the heightened vulnerability of female frontline workers, clear measures should be in place to prevent and mitigate harassment, abuse or other forms of GBV towards them. [...] Ensure that protective training, provision of Personal Protective Equipment (PPE) (which should be women friendly) and medical care facilities for health-care workers must also be extended to the treatment facility support staff who are primarily women as well as mental health and psychosocial support.’
‘Employers should develop fair and workable human resource plans for emergency situations while taking into consideration gender roles (e.g., women’s tendency to take on more caregiving responsibilities in family and home settings)… [Risk-mitigation measures for healthcare workers include] 'Provid[ing] gender sensitive supports to workers, such as transportation, lodging, and child/elder/pet support as needed.'’
It is essential to collect and analyse sex-disaggregated data in order to identify differences along the COVID-19 testing-to-outcome pathway and investigate how gender may be contributing to those differences. Collecting data on how different identities, including socioeconomic status, ethnicity, sexual orientation, gender identity and refugee status, intersect is also important to understanding who is most vulnerable to adverse health outcomes.
Beyond disaggregated data reporting, COVID-19 surveillance systems, including testing and vital registration, must reach everyone in order to uncover and address inequalities in disease outcomes and in the coverage of public health interventions. While the extent of gender bias in registration of COVID-19 deaths remains unknown, historic bias in vital registration against individuals with fewer resources suggests that there may be an under-counting of female deaths in many countries.1UN ESCAP (2020) Unacounted deaths could obscure COVID-19’s gendered impact https://www.unescap.org/blog/uncounted-deaths-could-obscure-covid-19s-gendered-impacts
Related resource: See our 2021 Report Gender equality: Flying blind in a time of crisis for an analysis of the gender-responsiveness of the activities of global health actors in supporting national COVID-19 surveillance.
Roughly 2 in 10 countries committed to reporting sex-disaggregated data on COVID-19 outcomes. Among 70 policies reviewed across 44 countries, 13% made commitments to sex-disaggregated data reporting. In practice, The COVID-19 Sex-Disaggregated Data Tracker finds that each month roughly 50% of countries report some form of sex-disaggregated data.
Eight countries were found to have both policies that committed to sex-disaggregated data reporting on COVID-19 outcomes, and be reporting data in practice (according to the COVID-19 Sex-disaggregated Data Tracker):
‘Throughout the response, reporting of the characteristics of COVID-19 in Aotearoa New Zealand will continue to be a fundamental part of the surveillance system. This will include reporting of case notification data, including demographics (age, sex, ethnicity, and area level deprivation), geographic location and source of disease.’
‘[We will] conduct a regularly updated, multi-sectoral gender analysis with sex, age and disability disaggregated data collection to identify inequalities, gaps, and capacities to assess the specific impacts of the crisis on the women, girls, men and boys of the affected population.’
Two national policies went beyond sex-disaggregated data reporting, by making gender-responsive commitments to strengthening the surveillance system to more effectively reach marginalised populations:
Bangladesh committed to ‘ensur[ing] the surveillance system is geographically representative across age, gender, vulnerability and levels of risk.’
Bangladesh Preparedness and Response Plan for COVID-19
South Sudan adopted measures to address barriers to testing affecting women:
‘A significant degree of stigma may attach to some diseases, including ... COVID-19. Diagnosis may carry the risk of discrimination, especially when there is weak protection for privacy and confidentiality… Stronger provisions for patient/suspect confidentiality may enhance rates of testing among vulnerable groups, including close contacts of confirmed cases, commercial sex workers, ethnic minorities, and, in some cases, girls/women.’
South Sudan - Standard Operating Procedure for Community Based Surveillance in South Sudan
Experience from previous pandemics shows that secondary health impacts resulting from the reduced capacity of healthcare facilities can be profound. The health of already vulnerable or marginalised groups is often disproportionately impacted by these limitations on healthcare. During the 2014 Ebola virus epidemic in West Africa, access to healthcare services was reduced by 50%, resulting in increased mortality rates among people with malaria, HIV, and TB. Pregnant women were particularly impacted by closure of routine and emergency care, which contributed to a sharp rise in maternal mortality rates.1Jones SA, Gopalakrishnan S, Ameh CA, et al (2016) ‘Women and babies are dying but not of Ebola’: the effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone. BMJ Global Health. https://gh.bmj.com/content/1/3/e000065
Fewer than 1 countries in 8 were found to mention gender in any of their policies on maintaining essential health services during the COVID-19 pandemic. Among the 47 policies reviewed across 29 countries, 9% accounted for gender. Gender-responsive commitments included prioritising the sexual and reproductive health needs of women during the pandemic and conducting a gender analysis of healthcare delivery to assess whether the health needs of different genders are being met. Whilst roughly one-third of the policies prioritised maternal health services and roughly one in five policies focused on sexual and reproductive health services, most did not acknowledge how gender shapes access to these services.
Commitments to meeting the health needs of vulnerable or high risk populations were more prevalent, with over half of the countries, and 49% of all policies reviewed in this area, making reference to reaching these groups with essential services. Examples of vulnerable groups whose health needs some countries targeted included the elderly, indigenous populations, people with disabilities, mental disorders, drug dependencies or chronic illnesses including HIV and non-communicable diseases, pregnant women and children.
‘As health systems prioritize COVID response, the sexual and reproductive services that women usually receive suffer. This could lead to further complications on women’s health, more complications with pregnancies and high infant mortalities' […] We commit to ‘develop[ing] and implement[ing] care pathways for both COVID-19 and essential healthcare services, ensuring special considerations for vulnerable populations (i.e. elderly, patients with chronic diseases, pregnant and lactating women, and children.’
‘Special attention has been paid to women's healthcare and to maintain pregnancy and childbirth services and post-natal care. A decision was made to examine the health of Icelanders from a gender and equality perspective, to assess whether healthcare service provision takes the different needs of women and men into consideration.’