Leveraging Women's Groups: Evidence on Pro-equity Interventions to Improve Immunization Coverage for Zero-dose Children and Missed Communities

"Evidence presented in this brief suggests interventions involving women's groups are a promising strategy and should be considered as a potential way to improve reach to zero-dose children and missed communities."

This brief reviews literature on interventions that involve women's groups in low- and middle-income countries (LMICs) and how they may contribute to changes to child health outcomes, including but not limited to immunisation, within vulnerable, marginalised, or otherwise underserved communities, particularly missed communities and those with a high prevalence of zero-dose children (those who have not received a single vaccine to prevent disease). 

The brief forms part of a series of rapid literature reviews (involving peer-reviewed and grey literature published between January 2010 through November 2022) conducted by FHI 360 and supported by the Vaccine Alliance (Gavi). The purpose of the reviews is to synthesise existing evidence on the effectiveness and implementation considerations for selected interventions that could help achieve more equitable immunisation coverage, specifically helping to reach zero-dose children and missed communities (population groups that face multiple deprivations, such as socio-economic inequities and gender-related barriers). Results of syntheses are presented through evidence briefs (see Related Summaries below for others in this series with implications for social change communication) and an online Evidence Map. The objectives of the evidence briefs are to understand which strategies are effective, identify implementation considerations, and assess gaps in knowledge and understanding. Overall, they are meant to help programme planners assess whether an intervention, such as women's groups, should be considered for reaching zero-dose children and missed communities. For this reason, the mapping and the briefs use a categorisation scheme to rate interventions as: potentially ineffective, inconclusive, promising, or proven.

As explained in the brief, women's groups "are community-based groups of women who meet to discuss shared experiences, acquire new knowledge, and build social networks while working toward common goals related to health, economic empowerment, autonomy, or other factors." Women's groups interventions, according to the review criteria, can involve establishing, facilitating, or engaging women's groups in improving child health outcomes.
 
The rapid review had the following specific objectives:
 

• Evaluate the extent to which interventions involving women's groups/women's organisations are effective in improving child health outcomes through demand creation among marginalised or vulnerable communities, including those with high prevalence of zero-dose children, especially within immunisation programmes.
• Assess the impact of women's groups/women's associations within vulnerable, marginalised, or underserved communities on women's empowerment as a potential pathway to improving child health outcomes, especially for zero-dose children and missed communities.
• Identify the implementation considerations for interventions involving women's groups/women's associations among vulnerable, marginalised, or underserved communities pertaining to child health outcomes, especially immunisation.

The following is a summary of the findings as highlighted in the brief:  

Effectiveness of women's groups in reaching zero-dose children and missed/marginalised communities: Results from studies included in the review suggest that interventions that engage women's groups can be effective in improving reach to vulnerable communities. Findings from one effectiveness study showed significant increases in vaccination rates, and many other effectiveness studies showed improvements in other child health outcomes. For these reasons, along with limited implementation concerns, this intervention was classified as "promising".

In addition, studies on the impact of women's groups most frequently occurred in remote rural settings and among populations in vulnerable contexts, such as economically poor and young women, Indigenous communities, and those with limited access to health care. Furthermore, the effects of interventions engaging women's groups were found to be either more impactful among groups with the most vulnerability or had equitable impact across socioeconomic statuses. Some studies suggested that group participation contributes to women's empowerment, while others suggested that existing structural and societal norms constrain women's ability to participate in group-based interventions.

Main facilitators and barriers to implementation:
 

• Facilitators include being community-led and supported, having high cost-effectiveness, leveraging locally recruited facilitators, and providing new information to members.
• Barriers include lack of time for women to attend, lack of structure and organisation of meetings, and social taboos that restrict women from participating.

Key gaps: Key gaps include a lack of variety of intervention types that engage women's groups (most were participatory learning and action cycles), lack of implementation in fragile or conflict settings and economically poor urban areas, limited evidence specific to the effects of women's groups on immunisation and particularly zero-dose children, and lack of evidence specific to whether interventions affect women's empowerment or address gender-related barriers and the possible impact of empowerment on health-related outcomes.

Going forward, the brief notes that because this is not yet considered a "proven" intervention, and no data exists on the impact of women's groups on zero-dose children, it will be important to include a learning agenda and implementation research alongside efforts to implement interventions involving women's groups to reach zero-dose children and missed communities so that what is learned can be understood and applied. In doing so, the brief stresses the need for the following steps:
 

1. Identify missed communities and those with a high prevalence of zero-dose children, and prioritise these populations with interventions involving women's groups.
2. Ensure equitable participation from marginalised women or women in vulnerable settings who may be less likely to participate, such as: those with lower socioeconomic statuses, lower education rates, and certain caste associations; younger women pregnant for the first time; those from women-headed households; and women with infants.
3. Tailor the intervention to the local context, accounting for literacy rates and education levels, social norms related to how women are able to travel and participate, religious considerations, local languages, and respect of local practices. This approach can be supported by using facilitators from the communities. Relatedly, as women in missed communities often have low utilisation of sexual and reproductive health and maternal health services, it would be useful for interventions involving women's groups to involve both topics to improve health outcomes for both women and children.
4. If existing women's groups are the focus of an intervention to improve child health, ensure that members are meaningfully engaged in designing and implementing the activities and that activities are responsive to the priorities and goals of the group. Otherwise, interventions run the risk of instrumentalising the groups to achieve certain external goals, which is a strategy unlikely to succeed and one that runs counter to expanding women's power and agency. Relatedly, simply establishing a women's group is likely insufficient to affect change; ensuring intervention activities work to amplify women's voices and concerns is critical.