How do outbreaks affect men and women differently?
Disease outbreaks are known to affect women and men differently. Below we describe some of the ways outbreaks, such as COVID-19 and Ebola, may have different biological, social, economic, and psychological effects on men and women. It is essential to understand that other identity characteristics such as race, ethnicity, economic status and disability status will also interact with gender to exacerbate the impacts and risks for some women more than others. At the end of this article, we provide practical advice on how to consider gender in hygiene programmes. It is acknowledged that gender is not binary, and that diverse gender identities and expressions may be differently impacted by outbreaks, however for the purpose of this paper, women and men are referred to.
Sex and gender differences in infection and mortality – example of COVID-19
Men have a higher risk than women of getting severe symptoms or dying from COVID-19.
COVID-19 does not discriminate in terms of who can be infected, but studies indicate that mortality rates are higher among men than women. Indeed, in 2022, the WHO announced that males account for 57% of global mortalities from COVID-19. Potential explanations include:
Source: WHO - Epi Data (Week 13)
Gender differences in workforce composition and job security
Women are more likely to be in roles that place them at higher risk of infection and are more likely to bear the brunt of the economic consequences of disease outbreaks.
In cultures and societies around the world, women play a lead role in caregiving, both within the home and in health and social services. For example, women represent 67 percent of the health and social sector workforce globally. These professional and caring roles put women at an increased risk of becoming infected and this phenomenon has been documented in many outbreaks, such as the West African Ebola outbreak and in the Zika outbreak in South America. In many countries, women are socially prescribed as being primarily responsible for household labour, like shopping and water collection, tasks which require women to leave the house during outbreaks - again exposing them to risk.
Women represent a smaller proportion of the global workforce who engage in formal employment, but are more likely than men to work on a part-time basis and are much more likely to be engaged in the informal labour market. In low income countries, it is estimated that women account for 85% of the informal sector. The economic consequences of disease outbreaks are therefore more likely to result in reduced employment for women, since informal or part-time workers are more likely to be laid off and have work hours reduced. At the same time, individuals engaged in this type of work are likely to have reduced access to employment protections. The absence of protective mechanisms could result in immediate cessation of income or being forced to continue to work in unsafe conditions (e.g., for informal workers travel may remain essential and physical distancing measures may not be upheld). School closures associated with disease outbreaks may also make it disproportionately harder for women to fulfill their normal work requirements, due to the fact that they perform most of the childcare.
Power dynamics, decision-making and governance during outbreaks
Historically women are typically less involved in decision-making during outbreaks.
Existing inequalities can often become more pronounced during outbreaks. Indeed, this has been recognised during the COVID-19 pandemic and in the Ebola outbreaks in West Africa and DR Congo, where women were less frequently consulted than men and as a consequence, their needs and requirements often went unmet. During the Zika virus outbreak, differences in power between men and women meant that women did not have autonomy over their sexual and reproductive lives. Globally, women are underrepresented within politics and in senior roles within workplaces and therefore, women’s voices are less able to come to the fore during outbreaks. Indeed, as of 2020, just 3.5% of COVID-19 task forces displayed gender parity. This trend is likely contributing to the lack of gender responsive social protection programmes globally. These same patterns are also true within health services. Despite women accounting for the majority of the global health workforce, they are underrepresented in senior health positions. Water departments or water services are key players during outbreaks, since water access enables community-level hygiene practices, yet in this sector too, women have been historically underrepresented. Moreover, women represent 82% of people employed in professional cleaning professions, including the cleaning and maintenance of public WASH facilities or WASH facilities at schools and health centers, exposing them to greater risk of disease.
Source: UN SDG infographic
Domestic and gender based violence
In times of crisis, women and girls may be at higher risk of sexual or intimate partner violence.
Increased rates of violence have been documented during previous outbreaks and disasters and among people who are displaced or living in countries affected by complex emergencies. For example, systematic reviews have estimated that 1 in 5 displaced women have experienced sexual violence. Indeed, the UK’s National Domestic Abuse Helpline witnessed a 65% increase in calls during the first three months of the COVID-19 pandemic. Due to stigma and under-reporting, the true figure may be much higher. The reasons for increased rates of domestic violence include:
Increased tensions within the household. This may be due to economic strain, trauma (e.g., loss of a loved one) or simply spending extended periods within the confines of the household.
Reduced support. Existing community structures and legal systems that would normally support women and girls may be underfunded and lack capacity and therefore weaken and become dysfunctional.
There may be a heightened risk of violence against women and girls in settings where there are weak health systems, weak rule of law and gender inequalities. Women and girls are also made more at risk of violence based on other aspects of their identity. For example, women and girls with disabilities, or women and girls from indigenous or minority ethnic backgrounds face enhanced vulnerability to sexual abuse and exploitation. Sexual and physical violence towards men and boys is also likely to increase during crises, but has historically been poorly documented.
School and workplace closures may increase the risks of adolescent girls being exposed to different forms of sexual exploitation and abuse, and early marriage. In water scarce locations, women and girls may be forced to engage in transactional sex in order obtain sufficient water (see this video for more information about this issue). During outbreaks, families will have a higher demand for water in order to meet increased hygiene needs, so it is possible that this situation may make women and girls more vulnerable to this form of abuse.
In several countries during the COVID-19 pandemic, healthcare workers (the majority of which are women) have been the target of violence, abuse and ostracism and have been accused of spreading COVID-19 in communities. Violence against health workers is not a new phenomenon and has been witnessed in other outbreaks, including the West African Ebola crisis. Organisations and response initiatives may need to look at how to mitigate the risks of violence towards these workers when travelling to and from areas of work and challenge misconceptions through community interactions. Please see this systematic review for further information on the relationship between domestic violence and COVID-19. For reflections on lessons learned on gender based violence within disease outbreaks and humanitarian crises more generally, see this paper.
Decreases in key services
Other key healthcare services may be compromised, putting women at disproportionate risk.
Healthcare funding during crises is often prioritised to meet urgent increases in critical needs and this can result in compromises to other important health care services. Fear among communities and quarantines or physical distancing restrictions can also result in people being less willing to access health care for other purposes. Sexual and reproductive health, maternal and newborn care and vaccination programmes are some of the key health services that are often compromised during outbreaks and this typically has long term impacts on women and child health. For instance, the Ebola and Zika epidemics witnessed an increase in maternal morbidity and mortality, as well as unsafe abortions.
Menstrual hygiene management (MHM) may also be compromised during outbreaks. During the COVID-19 pandemic , we witnessed people panic buying sanitary products resulting in limited access for many. In other settings, the economic impact of outbreaks might mean that women and girls are less able to afford MHM products. In settings where there are existing stigma and taboos surrounding menstruation, these barriers may be at risk of being unreported and undiscussed.
Women are also more likely than men to have a disability and people with disabilities typically have worse access to healthcare and poorer health outcomes than non-disabled people. Moreover, a UK survey found that the risk of experiencing violence, a key determinant of health seeking behavior, is 3.5 times higher in people with disabilities. See this study from Vanuatu for more information on the intersection between disability and gender. Barriers accessing healthcare among women with disabilities are typically more pronounced than for men. These existing inequalities are likely to be exacerbated during disease outbreaks, when health systems are stretched. Indeed, according to CARE International, some 38% of women reported a lack of access to health services among the most significant challenges faced throughout the COVID-19 pandemic. These barriers to health care access are being reflected in gender gaps in COVID-19 vaccine rates reported by some countries. For instance, as of 2021, just 30% of women had received their first dose in Burundi, compared to 70% of men.
Are there gendered differences in mental health conditions associated with outbreaks?
Women may be more at risk of developing post-traumatic stress in response to the outbreak.
For instance, taking COVID-19 as an example, a study in China found that symptoms associated with post-traumatic stress were much higher in the population after the COVID-19 outbreak. They also found that women were more likely than men to show post-traumatic stress symptoms and have difficulty sleeping. A recent study in South Africa supported these findings, reporting significantly higher rates of post-traumatic stress disorder in females compared to males.
What nationwide measures can countries take to reduce the differential gender impact of outbreaks? - COVID-19 example
The WHO’s 2020 Gender and COVID-19 Advocacy Brief suggests that all countries should adopt the following general measures in relation to considering gender within their COVID-19 response strategies:
COVID-19 cases and deaths must be disaggregated by sex and age. Disaggregated data should also be sought on the differential adverse health, social and economic impacts of COVID-19 on women and men. The findings of such analysis should be used to fine-tune response policies.
Countries should include responses to violence against women, and particularly intimate partner violence, as an essential service within the COVID-19 response.
Countries should maintain the availability of, and equitable access to, sexual and reproductive health services and include them in the essential package of health services for the COVID-19 response.
Countries are encouraged to ensure that all front-line health and social workers and caregivers have equitable access to training, PPE and other essential products, psychosocial support and social protection, taking into account the specific needs of women who constitute the majority of such workers.
Countries are encouraged to remove financial and other barriers to COVID-19 testing and treatment services, making them free at the point of use as well as providing equitable access to other essential health services.
Countries are encouraged to provide access to safe water and sanitation facilities. This must be ensured in disadvantaged areas, such as rural communities and informal settlements.
Countries are encouraged to provide safety nets to mitigate the adverse and inequitable social and economic impacts of the pandemic, including sick leave and unemployment benefits. These measures are key to support containment measures.
Countries are encouraged to stress that health is a human right, to ensure that emergency responses to COVID-19 are inclusive and nondiscriminatory, and to avoid excessive use of emergency powers to regulate day-to-day life. Countries should also take measures to identify and counter stigmatizing and discriminatory practices in COVID-19 responses.
Note that many of the principles and activities above can be applied to other disease response programmes. For more information on advocacy, see our resource here.
Practical actions for making hygiene programmes gender inclusive
Below we suggest several simple actions to make sure your disease response programme is addressing the needs of men, women, boys, and girls in your community.
Make sure that hygiene promotion staff include a mix of women and men. It is important that community members feel able to talk openly to hygiene promotion staff and voice their concerns. Having mixed gender hygiene promotion teams can be a key way of achieving this. If you are still doing house to house hygiene promotion, we recommend that hygiene promoters always work in pairs. This will help to maintain quality throughout their work (as pairs can provide feedback to each other) and is important for protection. For example, two individuals may be more able to discuss and respond to any concerns they see within families that they visit.
Consult women, men, girls, and boys. Effective hygiene programmes require ongoing community consultation. This can be challenging to implement at this time, given that organisations are being encouraged to minimise in-person interactions. We suggest setting up a range of mechanisms that will allow you to continue to engage with communities as the crisis progresses.
Be aware of local services to support women and families. Make sure hygiene promotion staff have a list of services available in the local area that they can refer people to. This could include mental health services, general health services, sexual and reproductive health services, women’s refuge centres or protection services and economic assistance programmes. Make sure to consult the organisations providing these services, so that you are aware of how they may have adjusted their services, given the outbreak. Where these services are lacking, advocate for their importance.
Engage local level organisations. In most settings there are established local organisations and networks to support women. This may include Organisations of Persons with Disabilities or local networks supporting older people. These groups are likely to represent a trusted voice within communities and may help your organisations adapt programming to the local context. Working with these groups may also enable certain initiatives to be sustained beyond the outbreak.
Consider how your response programme may contribute to or challenge gender stereotypes. During outbreaks, hygiene promotion is likely to use visual and mass media communication materials. The design of these should be gender sensitive. WaterAid developed some useful guidance on ‘Do’s and Don’ts’ for developing gender-aware materials during the COVID-19 pandemic. For example, they suggest ensuring gender balance in imagery and avoiding stereotypes that show women and girls as the only ones responsible for hygiene practices in the home. It is important that hygiene programmes do not create an unrealistic burden of work for women and girls. Women and girls often have access to different information sources to men and boys so you may also need to utilise a range of delivery channels to ensure no one is left out. For example, many organisations are using mobile phone messaging as a way of reaching people during COVID-19 responses, but women remain much less likely than men to own a mobile phone.
Check that you are effectively reaching and engaging women, girls, men, and boys. When monitoring your programmes, collect gender disaggregated data to make sure that your programmes are inclusive. For example, if you established a phone hotline, you could record information on the number of men who call compared to women. If you are doing household visits, you could record which members of the household were spoken with. Make sure to also set up measures to allow for feedback from communities. When doing this, you may need to actively seek opinions from men, women, girls, and boys. Make sure to also include the opinions of other groups who may be vulnerable to exclusion and discrimination, such as minority groups, older people and people with disabilities and indigenous groups.
Enable women and girls to practice safe menstrual hygiene management (MHM). The following actions can be taken to promote access to products and enable safe MHM. Further ideas are available in this UNICEF resource and in this webinar. Whilst the resources are focused on COVID-19, principles and activities can be applied during other forms of crises.
If sanitary product supplies are limited or sporadic in your setting, consider distributing these products to women and girls. If deciding to do this, be mindful of variations in personal preferences related to MHM products and the effect that distribution could have on markets. Distributions should also consider prioritising groups within the community who may be more likely to lack access at this time. This could include health workers who may struggle to manage their menstruation hygienically, given their increased workload and the additional PPE measures that are in place.
Consider establishing boxes of emergency MHM products in key locations, such as health centres, schools (if open) and in markets. Members of the population can take from these boxes as needed and donate to them if they are able.
Identify women and girls who may be isolating due to the focal disease and ensure that they have all they need to practice safe MHM .
If setting up temporary health facilities, make sure facilities are female-friendly, accessible for all users, and that bathrooms have access to soap, water, and a means of safely disposing of sanitary products. Focusing on this may also be key in many existing health facilities where this is lacking.
Make water points safe and accessible. Women and girls are more likely to be responsible for collecting water. In many regions of the world, this may mean that they have to travel far from the house, wait in line with others and come into contact with surfaces (e.g. pump handles) that may be contaminated (depending on the transmission routes of your focal disease). Making water points safer and more accessible could help protect women and girls. Consider the following simple actions:
If women are travelling more than 30 minutes to get to a water point, this could create a risk for transmission and means families are unlikely to have sufficient water to practice regular handwashing. Consider funding or advocating for increased water provision. Start by identifying ‘quick wins’, such as repairing dysfunctional water points, promoting rain-water harvesting, or encouraging people to store water of different quality within the home (for example, surface water or non-potable water can safely be used for handwashing).
Depending on the transmission route, set up physical distancing measures at frequently utilised water points. In many countries, people set up a ‘jerry can queue’. This involves placing your jerry can in line behind others and waiting your turn. This kind of system can be maximised during outbreaks so that people do not have to stand near each other while queuing for water. Alternatively, simple cues in the physical environment can be used to remind people to stand 1m apart. Cues can be painted onto concrete or stones or a small piece of wood can be laid across a path.
Set up handwashing facilities at water points. When people use water points, they are likely to have to touch surfaces (like taps or pump handles) that others have come into contact with. Requiring everyone to wash their hands with soap before touching these surfaces can reduce contamination.
Try to use the outbreak as an opportunity to redistribute water collection responsibilities more fairly across homes and communities. This requires messaging that targets everyone, not just women, and working with local leaders to create longer-term change.
Other resources on considering gender in disease response programmes
Compendium of Hygiene Promotion in Emergencies - Comprehensive guidelines produced by The German WASH Network, IFRC, Global WASH Cluster and Sustainable Sanitation Alliance in 2022. Includes lots of information on making activities gender inclusive.
Water for Women resources – Learning and knowledge repository on inclusive WASH, which includes categories on gender and social inclusion and sexual and gender minority inclusion.
BEYOND VULNERABILITY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT AND LEADERSHIP IN DISASTER RISK REDUCTION: Critical Actions for the United Nations System – United Nations joint study on the status of gender equality and women’s leadership across the UN system.
CARE’s Gender in Emergencies Toolkit – Offers guidance for implementing a gender-responsive programme, with a section focused on GBV in emergencies.
Gender and COVID-19 - This advocacy brief by the WHO presents ‘key asks’ for national COVID-19 response initiatives.
Gender and COVID-19 Working group resource list - A curated list of documents and guidance covering a broad range of issues related to gender and COVID-19.
Inter Agency Standing Committee Guidance - Practical actions for gender sensitive programmes sector by sector. With a section on WASH provision.
Menstrual Hygiene Management and COVID-19 Response - A resource list compiling documents and guidance on supporting the MHM needs of women and girls during this time.
IFRC guidance on Gender and Inclusion - practical guidance across different phases and components of COVID-19 response.
Protection, gender and inclusion in water, sanitation and hygiene promotion - IFRC guidance published in 2022.
Feminist responses to COVID-19 - reflections and perspectives on the gendered impacts of COVID-19 and the need for feminist approaches to be at the heart of response efforts.
Resources to address gender based violence in Humanitarian situations - this includes ‘pocket book’ guidance for non-experts in a range of languages and a detailed and regularly updated document on mitigating GBV risks.
Advocacy documents on gender and COVID-19 - This document developed by Gender in Humanitarian Action provides simple messages about the gendered impact of outbreaks and practical actions to incorporate into programming. Similarly, this UNFPA document provides a more detailed description of these advocacy points and how they apply to key areas of response.