The Vaccine Blog
youmevaccines@gmail.com
The Vaccine Blog
youmevaccines@gmail.com
What does vaccine hesitancy have to do with gender-based discrimination? How are they related, and why is this worth discussing? I`ve discussed before the discrepancies between men and women in vaccine uptake, and also some of the historical and contemporary reasons behind it. These include how women were historically mistreated in healthcare, and in some regions and cultures still are (read more about this here). One can`t address hesitancy about vaccines or other healthcare procedures without placing gender-based discrimination at the forefront.
This has been acknowledged not just by the general public, but also by major healthcare authorities. At the 65th Commission on the Status of Women, Dr. Princess Nothemba Simelela, Assistant Director-General (ADG) and Senior Advisor to the DG on Strategic Programmatic Priorities WHO, said that “If we don’t put gender equality at the forefront of the COVID-19 response, we will all lose.” The World Health Organisation website also discussed various barriers faced by women when attempting to access COVID-19 vaccination sites and other healthcare services. For instance, in many areas, women faced restrictions on mobility to vaccination sites and other healthcare facilities. Further, a 2021 study published by Roberta Guerrina and colleagues investigated health and gender inequalities exacerbated by the COVID 19 pandemic. I feel that the word “exacerbated” is appropriate here because the pandemic did not necessarily cause such inequalities. It highlighted them and made them a more acute issue. In any case, the study found that women are disproportionately affected by increased burdens of care, both professionally and personally. Further, such increased exposure to infected individuals placed women at elevated risk of contracting COVID-19 themselves. The paper also highlighted that impact assessments need to be carried out in policymaking and research to reduce the effect of unintended consequences on differing demographics. Not only this, women faced limited decision-making power and limited access to and control over resources linked to health. This includes information about vaccines and vaccine safety.
This last point is troubling as there can often be gender-based differences in COVID-19 disease severity and vaccine efficacy. For instance, a 2021 study published by Nicholas A. Bos found “evidence of a potential role of sex in COVID - 19 vaccine efficacy was described. It strengthens the need to include sex as a core variable in the clinical trial design of COVID-19 vaccines.” Not only this, a 2022 study published by Vered Daitch assessed inclusion rates of women in more recent randomised controlled trials, or RCTs ( a type of study where the experimental and control groups are both chosen at random from the general population). The authors examined 300 of these types of papers for inclusion rates of women. The study found that the “ enrollment rate of women in all the examined fields was lower than 50%, except for immune system diseases, which had an enrollment rate of 68%”. Also, 11 of the studies examined did not even report on the number of women included in the study.
Finally, a 2021 study by Amy Vassallo and colleagues reviewed clinical trial data highlighting missed opportunities to apply a sex/gender specific dimension to clinical trials of COVID 19 vaccines. They also highlighted that future such studies on vaccination should have sex-sensitive designs and implementations. I`d personally argue that this should apply to clinical trials more broadly.
It also gets more complex than this. Across the literature, it`s shown that other demographic factors interact with gender to result in these discrepancies in healthcare outcomes. As such, it is difficult to discuss gender in isolation from such other factors. A woman may be from an ethnic minority group for instance, and also from a disadvantaged background. She may also have had several negative experiences with the healthcare system due to prejudices and inequities within the system. There may also be other factors she is not aware of shaping this perception. She will understandably develop a vastly different perception of the healthcare system than a woman who less of these factors apply to, or who none of these factors apply to. My central point here is that there are many interrelated factors that shape any given woman's perception of the healthcare system and therefore of vaccines. Of course, this also applies to men however that`s outside the scope of this specific post.
With this understanding, one can understand how these interrelated demographic features can place certain groups at a disadvantage. For example, a 2022 study by Suman Pal and colleagues on gender and race-based health disparities in COVID-19 outcomes on hospitalised patients in the U.S found that “the intersection of gender and racial identities are associated with significant disparities in the outcomes of patients hospitalised for COVID-19 in the United States. “ More recently, a 2023 study published by Leyla Larsson and colleagues showed vaccine inequities across age, sex, educational achievement, and socioeconomic status. More specifically, vaccine coverage rates were lower among women, those with lower educational attainment, and those from disadvantaged socioeconomic backgrounds. This does not only apply to vaccination, but sets of health protective behaviours in a broader sense. For example, a 2022 study by gender differences in risk perception, health protective behaviours, vaccine hesitancy, and compliance with contact-tracing using a hypothetical viral pandemic.
The next logical question is what the impact of this is on the health of women. Why do women have worse health outcomes than men across many health metrics? Of course, there are a number of biological variables. According to a 2007 paper by Carol Vlassoff, such biological factors include genetics, hormones and reproductive factors, as well as different physiological characteristics throughout their lives. However, according to the same paper, until recently, male models were used for clinical trials and their findings applied to women who were seen as “little men.” For example, according to the same paper, “protocols for the diagnosis and treatment of heart disease, the number one cause of all deaths in the United States, were based upon findings from middle-aged white male patients. As a result, women were diagnosed later with more advanced disease and were consequently harder to treat successfully.” There are also more recent examples. We`ve all heard the advice to sleep 8 hours at night, probably from when we were young children. Our parents most likely also swore by this advice.However, new research is now emerging supporting the statement that women need slightly more sleep, and better-quality sleep, than men. For example, a study published in 2021 by Maria Hrozanova and her colleagues investigated the differences in sleep between male and female endurance athletes, and also the influence of the menstrual cycle on such sleep patterns. According to the authors,women had “longer time in bed and deep sleep, and shorter light sleep during menstrual bleeding vs. non-bleeding days.” In sum, the observed differences in sleep may relate to female athletes' menstrual cycles. It's important to note that this is not intended to be a complete list of physiological differences between men and women. Rather, it is to illustrate the importance of integrating sex sensitivity into research design and implementation.
It is therefore clear that the influence of the feminist movement could spark a change in the culture of science and healthcare to one where gender and sex equity are the norm. For me, gender and sex equity are defined as reducing bias against women in clinics and research to the greatest extent possible. That phrase “to the greatest extent possible” is important. It acknowledges that systemic inequalities unfortunately still exist, and likely will continue to exist for the foreseeable future. However, we can iterate towards the most equal research, and the most equal culture, possible. We can make progress within those limitations. This will (in time) have the effect of women being seamlessly integrated into clinical trials. Additionally, another aim would be to develop a culture in medicine and science where women`s unique health needs, opinions, and values are held in the same regard as men`s have been historically. There won't even need to be conversation about it, or much thought about it really. It will simply be done. That would be the ideal endpoint.
However, it will not be a quick or easy process, and won't simply be just about writing new regulations, processes, and clinical trial designs. It will involve a larger-scale cultural change within the global scientific and medical community. This shift will involve many smaller components; the influence of which we generally don't think about. These include changes to the way we communicate to the people we engage with to the media we consume. Even how often we engage with certain groups of people, and how often we consume differing types of media has an effect on our perceptions. In other words, it's not just what we do that matters - it's how often we do it. For that reason, when we consider larger-scale cultural changes, it's helpful to break it down into its component parts in this way. Another point I'd add is that culture changes over time. It is crucial to remain attuned to how culture in healthcare is changing by tracking how culture-shaping behaviours are changing over time (namely, the behaviours I mentioned above - communication styles, media consumption,among many others). This applies both at local, national and global levels.
The feminist movement has been one of the key drivers of such cultural change with respect to how women are perceived both within and outside scientific and medical circles. According to a 2021 paper published by Ayelet Shai and various colleagues, “the feminist women’s health movement empowered women’s knowledge regarding their health and battled against paternalistic and oppressive practices within healthcare systems.” Not only this, but according to a paper published by Jodi Pawluski in 2016,there exists “an extensive literature confirming that women’s health is tied to long-term productivity: the development and economic performance of nations depends, in part, upon how each country protects and promotes the health of women.”
Therefore, it follows that this influence can be applied to improve sex sensitivity in the clinic and in research.
However, before discussing that we need a definition of feminism, and a brief discussion of how this definition can be applied to clinical trials. At its very core, feminism does not deny that there are biological and psychological differences between men and women. Although there is difficulty establishing a universal definition of feminism; it generally says that our opportunities and representation should not be limited based upon biological differences. That is it. Applying that to clinical trials, that means that representation of women in studies should not be limited based on our differences to men.
However, according to an article on theconversation.com “ in the last 20 years, mainstream medical research has genuinely started to explore gender differences and bias in both academic and clinical medicine. “ Further, in 2008, the World Health Organisation issued guidelines on “teaching gender competence.” Not only this, women and other minorities are beginning to speak up and be vocal about their experiences of healthcare. One will find endless testimonials in research papers, YouTube videos, blog posts, social media posts and so on. This direct patient feedback is invaluable, as it will contribute to a larger and more accurate body of knowledge of patient experiences and medical effects they experience after treatment. Such developments allow more tailored care techniques to be developed and allow a higher standard of care to be developed for all patients who have been historically underrepresented - be they ethnic minorities, those with chronic health conditions, and many others besides.
Of course, there is never a one size fits all approach, as I've stated before. That said, we can develop standardised approaches to cater to underrepresented groups of patients in healthcare - be it in the clinic, the research lab, or in any other healthcare setting. Not only this, it will help establish a strong base of trust between minority groups (in this instance, women) and health authorities. This in turn will reinforce communication between these key stakeholders, and further enhance care quality for everyone involved. With this base of trust established, women will be much more likely to accept vaccination and other public health measures. Another key point I'll add is that a long-term approach needs to be taken to improving women's health outcomes. This can occur both at the level of research and in clinical assessments. Trust is a feature of long term relationships; meaning that it is a priority all the time. That is the approach we need to take to building trust between women and health authorities. With this comes better communication strategies. When future pandemics or health emergencies occur (and they will), such communication strategies will allow the best solutions to be achieved.
Conclusion
It is well established across the literature that mistrust is a key factor in vaccine hesitancy. There is significant evidence that women face health inequities exacerbated by the SARS-CoV2 pandemic. Women have historically been underrepresented in research, and in many cases continue to be. In fact, it is only in the past two decades that this has been seriously investigated. This can have significant impacts on many aspects of women's healthcare. This can lead to women being distrustful of healthcare institutions in a holistic sense, as opposed to simply mistrusting vaccines in isolation. As such, there are many contributing factors to this mistrust that interact in complex ways. As is well known with vaccine hesitancy, these factors can vary with time, place and vaccine. Such variability means that there are diverse reasons for vaccine hesitancy in women. This in turn means that hesitancy is a dynamic phenomenon and as such we should be flexible in our approaches over time, place and vaccine. To complement this, we should also view trust as something to maintain long-term. It shouldn't be something that is only discussed in cases where there are disease outbreaks or other public health emergencies. Building trust is a longer-term commitment in any context. Thanks for reading
For access to other insightful articles and other benefits; do consider becoming a paying subscriber on substack
References
