Gender-Responsive Language in the National Policy Guidelines for Immunization in Kenya and Changes in Prevalence of Tetanus Vaccination among Women, 2008-09 to 2014: A Mixed Methods Study

"...a compelling case has been made that analysis of gender-related factors should contribute to development of health policies and programs..."

Global evidence suggests that gender-related disparities and gender-based barriers, such as male spouses/partners playing a vaccine-gatekeeping role at the household level, may explain substantive portions of unmet immunisation-related need. Kenya recently eliminated maternal and neonatal tetanus, but previously had low rates of tetanus vaccination in many districts. This study identifies specific articulation of gender-responsive language in Kenya's National Policy Guidelines for Immunization 2013 to potentially illuminate this progress. Findings from this study might also be adapted to support policy and programme strengthening for all vaccines in Kenya and in other Sub-Saharan African countries.

This study used a mixed-methods approach: content analysis to identify gender-responsive language in Kenya's National Policy Guidelines for Immunization 2013, and logistic regression to analyse data from the Kenya Demographic and Health Surveys (KDHS): 2008-09 (pre-policy) and 2014 (post-policy) to determine whether vaccination utilisation significantly changed pre- and post-policy.

The analysis found that the document mentioned different sub-populations of women and girls throughout, as well as gender-inclusive community sensitisation and mass-media communication strategies. In addition, ground-level outreach and community sensitisation were planned both for the intended populations and for the gatekeepers. In general, the guidelines highlight a comprehensive life-cycle approach, with several mentions of targeted immunisation sensitiation interventions for diverse sub-populations of vaccine-eligible women within the antenatal care system and gatekeepers. The overall language in the policy reflects the principles of African Union's Charter of Rights of Women in Africa, which mandates state provision of comprehensive sexual and reproductive health services.

Participants who responded in 2014 (after implementation of the National Policy Guidelines for Immunization in 2013) had 1.590 times greater adjusted odds of receiving at least one tetanus toxoid injection compared to those who responded in 2008-09. Women's education was associated with greater adjusted odds of reporting at least one tetanus injection. Existing literature also highlights that this covariate is likely associated with autonomy, and that such autonomy has a positive association with women's health seeking behaviour. Frequency of consumption of health communication (more specifically, prevention communication) in mass media via newspaper/magazine, radio, and television was not associated with having ever received a tetanus injection in the study.

Causal attribution to the vaccine policy itself is not appropriate, though the findings do not contradict the broader hypothesis that gender-responsive components in vaccine programming might positively influence both vaccination outreach and a woman's vaccination decision for herself and her children. Furthermore, the gender-responsive components in the policy emerged from a broader national context. For example, media campaigns have been implemented in Kenya, such as the radio programme "Know your Rights Hour", to address tetanus vaccine rumours. It is therefore plausible that multiple factors, measured and unmeasured, may have been associated with both increases in vaccination likelihood and policymakers' use of gender-inclusive language.

Despite the policy's language highlighting a comprehensive sub-population-wise approach, the policy fails to discuss multi-stakeholder dialogues with female representatives from minority groups, public health, decision-making positions, and politicians at the policymaking and programme development stages. The researchers suggest that such dialogues could help identify gender-specific barriers and enablers for tetanus vaccination. Furthermore, the policy references a passive form of vaccine demand, meaning acceptance of vaccines and vaccination services, rather than an active demand - e.g., community demand in the sense of social support for vaccination as a norm. Such disempowered language may reflect confidence challenges (both gender-specific and not) and is not uncommon in vaccination and prevention planning documents.

The researchers conclude that, given Kenya's elimination of maternal and neonatal tetanus, and the outcomes from this study, conducting interviews with vaccine decisionmakers in Kenya could enable learning about community engagement mechanisms in order to understand gender-based disparities in Kenya (e.g., early marriage, female genital mutilation, legalised polygamy). Such insights could motivate incorporation culture-specific gendered language in vaccination policies and gendered metrics in the KDHS going forward.