Gender Barriers to Immunization: A Synthesis of UNICEF’s Analyses to Advance Equity and Coverage

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper seeks to provide a synthesis of gender barrier analyses across 27 countries with a focus on zero-dose targets, HPV and COVID campaigns and to summarize key recommendations. There is remarkable opportunity in this piece to point to contextual barriers and recommendations but in its current format, this doesn't come through. I've left recommendations throughout which I hope the authorship team will find useful. I think the most work is needed in the Discussion which currently seems to list what we've already read from multiple sections, including the methods. 

In the introduction, rather than list common gender barriers, the authors might consider describing the approaches others have used to map gender barriers i.e. supply/demand  or access/intent. I say this because the current list is missing a lot which makes it feel incomplete and somewhat unhelpful. Also, given that most of the paper is a list of gender barriers, some additional consideration is needed for the framing - and for considering what this piece adds to the literature. 

It would be interesting to know which country methods unearthed new gender barriers not already found in the literature. Did any of the gender analyses use specific gender measures in their quantitative data collection like an agency scale for example? 

2.1 data sources – can you name the countries here?

What were the limitations in a demand driven approach for selecting countries? What do you think you might have missed. 

2.2 more detail is needed on the iterative process used to develop the template. What sources were used to inform the initial approach – what was added/modified in the iterative process – and how were those iterations determined?

Why did the authors choose the SEM for classification? Especially if this was not used in the template or as an organizing principle for all countries in their analysis. This is an important limitation that needs to be explored. 

Rather than a long list of countries in Table 1, could the authors use a map – Excel has a functional feature that will also provide some color coding or shading to indicate strength of representation (i.e. darker if the country was studied more than once). This could also give the reader a sense of the geographic scope.

I imagine some of the barriers contributed to multiple barrier levels – a note should be made in the table that these might be more than 100% of all barriers identified.

I would ask the authors to put the countries in which the data emerged into each row of each table – while it is in the text (at least for systems levels, but not for other levels) , highlighting it in the table will help readers clearly see where each barrier has been identified.

Table 4

Barrier 1– the link to religion and gender is not yet clear.

“As a societal norm, women need to listen to multiple people” – did the data also suggest that these people have more decision making power than women, and that sometimes their opinions are in conflict with each other (i.e. husbands, religious leaders, and mothers in law)

Barrier 2 – The way it’s operationalized suggest this is more of a systems issue – that vaccination ‘time’ is during household duty ‘time’. Suggest rewriting for clarity.

Barrier 5- did any data suggest the opposite? That boys need to be protected FROM vaccines but it’s OK for girls to be vaccinated instead? It would be interesting to see how these definitions are operationalized differently depending on context, not just for this barrier, but across many of the barriers listed in the paper.

Table 5

Barrier 1 – this still isn’t operationalized clearly as a gender barrier and I’m not sure that the operationalization is actually about the importance given to immunization (which might be more about knowledge /value than about household duties).

Barrier 2 – did any of the research explore what happens when women are head of house instead? Data suggests that they are more likely to immunize their children.

Barrier 3 – was any nuance explored? Adolescents negotiate with parents and other decision makers and often receive different/more information about the vaccine through school (if they are in school).

Table 6

Barrier 2- I don’t understand “a public exposure from boys to girls…” Can you reword for clarity?

Barrier 3 – what norms reduce exposure to information? Can you say more here?

Barrier 4 is about misconceptions but the operationalization is about power.

Table 7

Barrier 1 – while this is well explained in the table, it is less clear in the actual text. Suggest revising for clarity and this definitely needs a list of countries for contextualization because this isn’t happening everywhere.

The HPV section was my favorite because it clearly defines the contexts and links the data back to context – although not all the time! I wonder if other sections can take on a similar tone and approach.

Recommendations

The first paragraph offers a series of incomplete thoughts. Can the authors revisit this to make the listing of recommendations more complete. I.e. The first recommendation is to institutionalize gender … [and then provide some information about what this means]. The following paragraphs seem to repeat the recommendation theme without providing much detail. While tables are helpful, this is an important area to flesh out in writing. I also think it’s deeply important to know where each recommendation came from because not all recommendations will work in all places.

Table 8

Recommendation 1 – can you define gender sensitive vs. gender mainstreaming for readers who may be less familiar with these terms.

Discussion

• The second paragraph repeats information about the methodologies – this should be removed.

The discussion misses an important opportunity to embed these findings in the broader literature. These recommendations aren’t new – others have made them – and most of the barriers are not new either. So can the authors situate these findings differently or in a novel way that adds to the body of literature?

Given that the recommendations came from the countries and from participatory processes – could authors reflect on future implementation science initiatives that might test the acceptability, feasibility, etc. of these recommendations among key decision makers?

Some barriers / recommendations could use additional highlighting – like women’s participation in politics and the ways in which they prioritize key issues for women and girls, including immunization.

Author Response

Please see the attachment

Reviewer 1

This paper seeks to provide a synthesis of gender barrier analyses across 27 countries with a focus on zero-dose targets, HPV and COVID campaigns and to summarize key recommendations. There is remarkable opportunity in this piece to point to contextual barriers and recommendations but in its current format, this doesn't come through. I've left recommendations throughout which I hope the authorship team will find useful. I think the most work is needed in the Discussion which currently seems to list what we've already read from multiple sections, including the methods.

We appreciate the valuable comments provided to our paper. We hope that the changes that we have introduced will help to address your comments.

 

In the introduction, rather than list common gender barriers, the authors might consider describing the approaches others have used to map gender barriers i.e. supply/demand  or access/intent. I say this because the current list is missing a lot which makes it feel incomplete and somewhat unhelpful. Also, given that most of the paper is a list of gender barriers, some additional consideration is needed for the framing - and for considering what this piece adds to the literature.

We thank you for this very important comment raised. We have now added an explicit mention of what this paper is adding to the literature, as well as clearly establishing gender barriers as supply and demand barriers.

 

It would be interesting to know which country methods unearthed new gender barriers not already found in the literature. Did any of the gender analyses use specific gender measures in their quantitative data collection like an agency scale for example?

We appreciate that you could raise this very important point. However, the gender analyses conducted by countries did not use specific scales or sophisticated methods to conduct these analysis. Hence, while most of them followed a specific framework (many used the same framework that we used in the synthesis), they did not used an innovative approach to conduct their data collection.

 

2.1 data sources – can you name the countries here?

We have added the name of the countries under this section.

 

What were the limitations in a demand driven approach for selecting countries? What do you think you might have missed.

We thank for raising this veery important point. We have now added the sampling of countries as one potential limitation of the paper in the discussion section.

 

2.2 more detail is needed on the iterative process used to develop the template. What sources were used to inform the initial approach – what was added/modified in the iterative process – and how were those iterations determined?

The process to create the data extraction template was not a formal approach in which we documented each iteration. Rather, we collectively discussed in multiple instances how the template was gathering the data that was relevant to conduct the analyses. We have also added a small mention of the piloting of the data extraction form to make it even clearer.

 

Why did the authors choose the SEM for classification? Especially if this was not used in the template or as an organizing principle for all countries in their analysis. This is an important limitation that needs to be explored.

We thank the reviewer for bringing this veery important consideration. The socio-ecological framework was used as it was the gold-standard instrument to identify gender barriers across UNICEF. While not all the gender analyses used this framework to conduct their gender analysis, we believe it enables a refined analysis and classification of barriers across different levels, enabling a strong set of barriers that are relevant for policies and programs, as we mentioned in the strengths of the discussion section.

 

Rather than a long list of countries in Table 1, could the authors use a map – Excel has a functional feature that will also provide some color coding or shading to indicate strength of representation (i.e. darker if the country was studied more than once). This could also give the reader a sense of the geographic scope.

We have now added a map showing the countries that are included in the synthesis. However, I am not sure we are fully able to post this as it is by following the Creative Commons license of the map and the journal. We will rely on the Editor’s decision to see if we are able to publish it.

 

I imagine some of the barriers contributed to multiple barrier levels – a note should be made in the table that these might be more than 100% of all barriers identified.

We appreciate for this suggestion. We have now added that note as requested, but please note that Table 1 describes the number of documents and not the number of barriers, so the % of barriers has not been shown.

 

I would ask the authors to put the countries in which the data emerged into each row of each table – while it is in the text (at least for systems levels, but not for other levels) , highlighting it in the table will help readers clearly see where each barrier has been identified.

While we agree that this would be an important addition, we also acknowledge that these gender analyses are government document that are owned by the countries and, hence, being single-out specifically in some of the barriers might be a bit sensitive for some of them.

 

Table 4

Barrier 1– the link to religion and gender is not yet clear.

We have not clarified this link in the table.

 

“As a societal norm, women need to listen to multiple people” – did the data also suggest that these people have more decision making power than women, and that sometimes their opinions are in conflict with each other (i.e. husbands, religious leaders, and mothers in law)

While we acknowledge that this would have been a very important caveat to bring forward, we tried to explore the data collected but could not find explicit mentions of conflict among the opinions of people that are present in the society.

 

Barrier 2 – The way it’s operationalized suggest this is more of a systems issue – that vaccination ‘time’ is during household duty ‘time’. Suggest rewriting for clarity.

This is a very important point and, in fact, the barrier about societal norms can also have a system-level part. We tried to rewrite this part of the table for clarity.

It can be interpreted in that way too. Rewritten to clarify.

 

Barrier 5- did any data suggest the opposite? That boys need to be protected FROM vaccines but it’s OK for girls to be vaccinated instead? It would be interesting to see how these definitions are operationalized differently depending on context, not just for this barrier, but across many of the barriers listed in the paper.

This is a very interesting point, but we couldn’t find evidence supporting this hypothesis.

 

Table 5

Barrier 1 – this still isn’t operationalized clearly as a gender barrier and I’m not sure that the operationalization is actually about the importance given to immunization (which might be more about knowledge /value than about household duties).

We appreciate this concern raised. We have now tried to rewrite this barrier to clarify it.

 

Barrier 2 – did any of the research explore what happens when women are head of house instead? Data suggests that they are more likely to immunize their children.

This would have been a very interesting insights, but the data did not provide details when women were head of house, and this could also be because the documents included mainly looked at barriers.

 

Barrier 3 – was any nuance explored? Adolescents negotiate with parents and other decision makers and often receive different/more information about the vaccine through school (if they are in school).

We have added now some more details about this specific barrier, but the analyses were not specific in terms of the different types of information and whether the vaccine was given at school or not.

 

Table 6

Barrier 2- I don’t understand “a public exposure from boys to girls…” Can you reword for clarity?

We have now reworded it for clarity.

 

Barrier 3 – what norms reduce exposure to information? Can you say more here?

We have now reworded it for clarity.

 

Barrier 4 is about misconceptions but the operationalization is about power.

This is absolutely right. For making this clear, we have added the consideration that this barrier takes into account the context provided by community-level barriers (social norms).

 

Table 7

Barrier 1 – while this is well explained in the table, it is less clear in the actual text. Suggest revising for clarity and this definitely needs a list of countries for contextualization because this isn’t happening everywhere.

We thank you for this suggestion. We have revisited the text and provided some rewording for clarification. With respect to the list of countries, as explained in a previous comment, we believe that disclosing the full list of countries per barrier might be sensitive in some of the countries, as the documents synthesized are country-owned produced by governments.

The HPV section was my favorite because it clearly defines the contexts and links the data back to context – although not all the time! I wonder if other sections can take on a similar tone and approach.

We are glad that this section was well appreciated. After implementing these revisions, we tried to clarify the text by providing some levels of detail that would not make the paper to increase much in length, while maintaining the key pieces of information in the tables.

 

Recommendations

The first paragraph offers a series of incomplete thoughts. Can the authors revisit this to make the listing of recommendations more complete. I.e. The first recommendation is to institutionalize gender … [and then provide some information about what this means]. The following paragraphs seem to repeat the recommendation theme without providing much detail. While tables are helpful, this is an important area to flesh out in writing. I also think it’s deeply important to know where each recommendation came from because not all recommendations will work in all places.

We thank the reviewer for bringing this issue to the attention. We have now incorporated more details into this paragraph to facilitate its understanding, while keeping the rest of the paragraphs in the section to provide further details.

 

Table 8

Recommendation 1 – can you define gender sensitive vs. gender mainstreaming for readers who may be less familiar with these terms.

We appreciate this veery important issue raised, and we have now standardized the paper to mainly speak about “gender-responsive”.

 

Discussion

The second paragraph repeats information about the methodologies – this should be removed.

We have now removed this paragraph.

 

The discussion misses an important opportunity to embed these findings in the broader literature. These recommendations aren’t new – others have made them – and most of the barriers are not new either. So can the authors situate these findings differently or in a novel way that adds to the body of literature?

We thank you for raising this veery important comment. We have now added more details in the discussion section comparing the findings of this paper with the existing and broader literature, and we hope we have strengthened this part to significantly add to the body of literature.

Given that the recommendations came from the countries and from participatory processes – could authors reflect on future implementation science initiatives that might test the acceptability, feasibility, etc. of these recommendations among key decision makers?

We have added now the need for implementation research to test the acceptability and feasibility of gender-interventions as part of the implications for research section in the discussion.

 

Some barriers / recommendations could use additional highlighting – like women’s participation in politics and the ways in which they prioritize key issues for women and girls, including immunization.

We have now reflected on this point under the implications for policy and practice section.

 

We completely agree that the findings of this paper can potentially be translated to other areas. We have now reflected into this as part of the implementation for policy and practice, but we did not want to expand further around this, as the focus of the paper (and the journal supplement that we are submitting) is mainly about immunization efforts.

I hope these suggestions are helpful in improving the manuscript.

We are truly thankful for these insightful comments, and we hope we have responded to your comments appropriately.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This research article entitled “Gender barriers to immunization: A synthesis of UNICEF’s analyses to advance equity and coverage” provides valuable information for healthcare providers, public health agencies and policy makers on strategies for reaching immunization targets. The study is of strong importance, the design and methodology are robust and address an important public health issue. Overall, the manuscript is very well written and scientifically rigorous. Thus, I do not have many questions. Below are some comments intended to further strengthen its quality:

Table 2:

• Lack of gender data: Authors mention lack of disaggregated data. I would encourage authors to add “sex and gender disaggregated data” as these variables are extremely relevant to understand if there are sex-biological factors or gender-society that could then be addressed.

Table 3:

• Barrier 1 explains discrimination against women in HC facilities. Women also suffer more violence episodes in HC, such as obstetric violence, underdiagnosis, overdiagnosis of mental health issues even when they have pain/conditions affecting their physical health… Was this addressed within this or other barrier? Could women´s experiences of violence within the HC system make them consult less? 

Table 4

• Barrier 4. Could it also be attributed to lower education, and higher girls drop out for several gender factors such as marrying them, housechores etc?

Table 5

• Barrier 3: Similarly, regarding specifically to adolescent women, is there any data about their autonomy to decide on sexual and reproductive health issues?

Table 7

• Community level: Did authors find that religion plays a role in these societal beliefs about vaccination?
• Please correct “believes” to “beliefs”.

Discussion

• I would encourage authors to discuss further how these findings could be translated and integrated into other HC programs apart from immunization strategies?

I hope these suggestions are helpful in improving the manuscript.

Author Response

Please see the attachment

Reviewer 2

This research article entitled “Gender barriers to immunization: A synthesis of UNICEF’s analyses to advance equity and coverage” provides valuable information for healthcare providers, public health agencies and policy makers on strategies for reaching immunization targets. The study is of strong importance, the design and methodology are robust and address an important public health issue. Overall, the manuscript is very well written and scientifically rigorous. Thus, I do not have many questions. Below are some comments intended to further strengthen its quality:

We really appreciate the time and effort dedicated to our paper. We hope to have responded adequately to the comments raised here.

 

Table 2:

Lack of gender data: Authors mention lack of disaggregated data. I would encourage authors to add “sex and gender disaggregated data” as these variables are extremely relevant to understand if there are sex-biological factors or gender-society that could then be addressed.

We thank you for this important issue raised. We have now used standardly “Sex-disaggregated and gender data” across the paper.

 

Table 3:

Barrier 1 explains discrimination against women in HC facilities. Women also suffer more violence episodes in HC, such as obstetric violence, underdiagnosis, overdiagnosis of mental health issues even when they have pain/conditions affecting their physical health… Was this addressed within this or other barrier? Could women´s experiences of violence within the HC system make them consult less?

This is a very important point and we thank the reviewer for bringing it up. We have found some mentions of gender violence in the documents reviewed, so we have incorporated it into the barrier reported here. However, we have not identified obstetric violence, errors in diagnosing conditions, etc. but mainly because the documents were focused on vaccination efforts. We also have violence against women as a separate barrier under community-level barriers (table 4), which can partially cover this situation as well.

 

Table 4

Barrier 4. Could it also be attributed to lower education, and higher girls drop out for several gender factors such as marrying them, housechores etc?

We completely agree that these were definitely issues that might affect lower education of women and girls. However, it was not fully documented in the gender analyses reviewed, as they might not have had a direct connection with vaccination efforts.

 

Table 5

Barrier 3: Similarly, regarding specifically to adolescent women, is there any data about their autonomy to decide on sexual and reproductive health issues?

We have added some clarification about this barrier in the table as requested by another reviewer. The documents reviewed did not report information about sexual and reproductive rights and health issues, but only because their focus was in vaccination efforts.

 

Table 7

Community level: Did authors find that religion plays a role in these societal beliefs about vaccination?

We did find a role of religious beliefs in community-level barriers (barrier 1 in table 4), but it was mainly through limiting women’s autonomy and decision making power, and not necessarily about vaccine information.

 

Please correct “believes” to “beliefs”.

Thank you for identifying this typo. We have now amended it throughout the text.

 

Discussion

I would encourage authors to discuss further how these findings could be translated and integrated into other HC programs apart from immunization strategies?

We completely agree that the findings of this paper can potentially be translated to other areas. We have now reflected into this as part of the implementation for policy and practice, but we did not want to expand further around this, as the focus of the paper (and the journal supplement that we are submitting) is mainly about immunization efforts.

I hope these suggestions are helpful in improving the manuscript.

We are truly thankful for these insightful comments, and we hope we have responded to your comments appropriately.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for your response to the review request. While I appreciate that the authorship team made many changes to enhance clarity (and they did! they were really helpful) there are still a few outstanding concerns that I believe are important to address. 

1. Please define gender responsiveness the first time you use it.
2. In the introduction, while I appreciate the addition of demand/supply as a framing, to me it doesn't make sense to then follow this with the same short list of barriers. Here I still recommend the authors either present frameworks, or just the demand/supply framework, but remove the list of barriers. Given that the paper focuses so much on barriers I think it's important to spend this time talking about framing more than anything else. However, if this request doesn't feel important to you, I'm fine to drop it as a 'must have'. 
3. In the discussion I'm still not clear how to read the recommendations in 3.4 Again this reads like a list of disjointed thoughts. Please re-read and edit for clarity. 
4. Finally, while I appreciate that new text has been added to the discussion, adding one reference does not represent a deeper exploration of the literature or situation of these findings within that literature. I think this remains an important missed opportunity. In particular I stress this because the findings do largely repeat what is already in the literature - so that needs to be made clear while also emphasizing the unique value proposition of this analysis. 
5. Given that you do not feel comfortable naming the countries by finding, I suggest that you say something about this in your methods and limitations. 

I recognize that responding to reviewer comments can be frustrating when so much work has already gone into a manuscript. Gender work is more important now than ever given the broader geopolitical backlash, reduction in funding, etc. I encourage these changes to strengthen the piece and enhance the power your findings can bring to the journal's audience. 

Author Response

Reviewer 1

Thank you for your response to the review request. While I appreciate that the authorship team made many changes to enhance clarity (and they did! they were really helpful) there are still a few outstanding concerns that I believe are important to address.

We appreciate the time and effort of the reviewers in providing valuable comments to our paper. We hope that the changes that we have introduced will help to address the issues raised this time.

 

Please define gender responsiveness the first time you use it.

Thank you for this comment. We have now introduced a definition of in the background section.

 

In the introduction, while I appreciate the addition of demand/supply as a framing, to me it doesn't make sense to then follow this with the same short list of barriers. Here I still recommend the authors either present frameworks, or just the demand/supply framework, but remove the list of barriers. Given that the paper focuses so much on barriers I think it's important to spend this time talking about framing more than anything else. However, if this request doesn't feel important to you, I'm fine to drop it as a 'must have'.

While we see the value on including some sort of classification for existing barrier, we believe that this might confuse the reader as the whole paper is about classifying immunization barriers. Hence, we opted for dropping this definition in the introduction section.

 

In the discussion I'm still not clear how to read the recommendations in 3.4 Again this reads like a list of disjointed thoughts. Please re-read and edit for clarity.

We have incorporated more details in section 3.4. However, we noted that this is part of the results and not the discussion section, but we hope we have addressed this comment now.

 

Finally, while I appreciate that new text has been added to the discussion, adding one reference does not represent a deeper exploration of the literature or situation of these findings within that literature. I think this remains an important missed opportunity. In particular I stress this because the findings do largely repeat what is already in the literature - so that needs to be made clear while also emphasizing the unique value proposition of this analysis.

Thank you for raising this up. We have now incorporated one additional reference of an evidence synthesis that addresses a similar topic as part of the discussion section. However, we believe that the main message here is that this synthesis is unique as there are limited efforts that have summarized gender-barriers to immunization and, when available, they have mainly been concentrated in synthesizing peer-reviewed literature. We tried to make this more explicit in the discussion section now.

 

Given that you do not feel comfortable naming the countries by finding, I suggest that you say something about this in your methods and limitations.

Thanks for your understanding. We have now included that as a limitation in the discussion section.

 

I recognize that responding to reviewer comments can be frustrating when so much work has already gone into a manuscript. Gender work is more important now than ever given the broader geopolitical backlash, reduction in funding, etc. I encourage these changes to strengthen the piece and enhance the power your findings can bring to the journal's audience.

We really thank your comments to improving the quality of our manuscript. We hope that this version would address your suggestions.

 

 

 

 

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for quickly addressing the concerns.