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.

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:

Note that gender differences in infection rates, morbidity and mortality have been reported in a host of other infectious diseases, such as cholera and Ebola.

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.

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.

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:

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.

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.

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.

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:

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.

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.

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:

Author: Sian White
Reviewed by: Jane Wilbur, Bethany Caruso, Pryia Nat, Chelsea Huggett
Last updated: 01.03.2023