A light touch intervention with a heavy lift – gender, space and risk in a global vaccination programme

ABSTRACT Frontline workers (FLWs) in the Global Polio Eradication Initiative go door-to-door delivering polio vaccine to children. They have played a pivotal role in eliminating wild polio from most countries on earth; at the same time, they face significant bodily risk. STRIPE, an international consortium, conducted a mixed-methods study exploring the knowledge and experiences of polio staff in seven countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We surveyed 826 polio FLWs and conducted semi-structured interviews with 22 of them. We used a body work framework to guide analysis. Polio workers perform a different kind of body work than many other FLWs. Delivering a few drops of oral vaccine takes a light touch, but gendered spaces can make the work physically dangerous. Polio’s FLWs must bend or break gendered space norms as they move from house-to-house. Navigating male spaces carries risk for women, including lethal risk, particularly in conflict settings. Workers manoeuvre between skeptical community members and the demands of supervisors which generates emotional labour. Providing FLWs with more power to make operational decisions and providing them with robust teams and remuneration would improve the likelihood that they could act to improve their working conditions.

income countries (Twigg, 1999;Twigg et al., 2011) but there is a vast global health workforce that seeks to improve the health of populations and provide care in myriad contexts. Polio FLWs in particular carry out a very different kind of labour in a range of international contexts, one instructive for body work theory.

Methods
This research was conducted through the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) consortium, a collaboration between Johns Hopkins University (JHU) and seven academic and research institutions representing countries with different epidemiologic profiles of polio: Afghanistan, Bangladesh, Democratic Republic of the Congo (DRC), Ethiopia, Nigeria, India and Indonesia .
We employed an explanatory mixed methods design comprised of a quantitative survey and keyinformant interviews to explore lessons that the polio experience can offer to other global health programmes. In each country, we developed a theoretical list of all actors directly involved in implementing polio eradication-related activities for 12 or more continuous months between 1988 to date; we then reached out to people in these groups to build our sample.
The survey was conducted in each of the seven countries, as well as at the global level, with people that worked or were affiliated with key institutions collaborating on the GPEI (e.g. WHO, UNICEF, Rotary, CDC, BMGF). Respondents were asked about their job roles, and FLWs were identified as those who directly interacted with the population in achieving one or more of the GPEI objectives, especially vaccination and other services delivery, working mainly at the subnational and district levels. These included frontline government health workers and 'volunteers'.
A polio universe was defined as individuals who have been working in the GPEI continuously for 12 months or longer (M. Peters et al., 2020), and a standard questionnaire was administered to individuals, including FLWs, within the polio universe in each country included in the STRIPE consortium and at the global level. The questionnaire was administered to better understand challenges faced in conducting polio eradication work and to identify lessons learned across contexts. The questionnaire was designed collaboratively by members of the consortium using constructs from implementation science frameworks to describe facilitators and barriers to polio eradication activities, unintended consequences, and the range of strategies developed and employed in different settings (Damschroder et al., 2009).
The questionnaire was pre-tested in English at JHU, edited based on feedback and translated into the local language(s).
Survey respondents who agreed to follow-up and indicated that they had played a major role in working to resolve these key challenges faced during polio eradication, were invited to participate in a key-informant interview (KII). The KII tool was designed using the Socioecological Model (SEM) as a guiding framework (Stokols, 1996). The SEM considers the complex relationships between factors that influence the individual, interpersonal, organisation, community and larger environment. This tool prompted participants to describe their experiences in polio eradication at each of these levels.
Surveys and KIIs were conducted by trained local researchers (both men and women) in each country. Interviews were audio-recorded and transcribed into English. Data were collected between August 2018 and December 2019. The survey and interview tools have both been published elsewhere .

Analysis
For this research, we reviewed data from surveys and KIIs conducted with FLWs. All quantitative data analyses were conducted in STATA I/C (version 14); KIIs were manually coded in Dedoose ©, a qualitative software, by members of the JHU-research team using deductive and inductive coding approaches. The codebook was collaboratively developed with the research teams in each country and analysis results were validated with each country team.
This study was reviewed and approved by the Institutional Review Boards of each academic institution and country included in the STRIPE consortium. Consent was sought prior to the survey and KII.

Participant characteristics
The survey included 826 frontline workers across 14 countries, the majority of whom were based in the seven STRIPE countries (97.9%); KIIs were conducted with 22 FLWs who completed the survey in those settings (see Table 1). Half of the key informants (n = 11) identified as women; we did not collect gender data on survey respondents.
Among survey respondents, the average number of years of experience in their role as FLW was 11.45 years; most worked as agents of sub-district government (n = 348), district government (n = 201) and WHO (n = 145) (respondents could select more than one, reflecting on their entire career with the initiative). Survey respondents were asked to indicate which objective(s) they worked on in their role(s). Forty-seven percent (n = 650) vaccinated populations, 19.11% (n = 266) conducted community engagement, and 12% (n = 169) conducted acute flaccid paralysis (AFP) environmental surveillance. Other activities included strengthening delivery systems, monitoring & evaluation, strategy development, partnership alliance and resource mobilisation.
Key informants more deeply explored barriers to their work related to these and other barriers.

Spatial risks
Within the GPEI women have become an increasingly large portion of the workforce, preferred for many frontline tasks. They are uniquely able to access households when men cannot (i.e. when women are at home alone) and women can provide care to women and children in conservative communities.
We have female staff now while we had only male staff giving awareness in mosques where women were intended to go for vaccination. Now, as a result of having female staff we can vaccinate children, women and go home by home not missing any children. -Afghanistan, F This poses a series of spatial barriers and risks, largely discussed by participants in Afghanistan, DRC and Ethiopia, as women move house-to-house to raise awareness and provide polio vaccines. Some participants discussed challenges women workers face with spatial mobility and accessing 'hard-to-reach' communities. These difficulties include navigating transportation options that may be seen as less appropriate or immodest such as needing to take motorbikes to move through difficult terrain or needing to stay overnight in unfamiliar and sometimes unsafe environments. FLWs who travelled long distances were sometimes required by their organisations to stay overnight so they were not travelling at night.
When they ask us to go with them for any support, we cannot go with them as vaccinators use motorbikes which is only suitable for male outreach staff. Therefore, we cannot do anything to help them and give vaccines to females at home. -Afghanistan, F FLWs experienced physical and emotional risks while they moved through different, sometimes hostile spaces. One male participant in Indonesia described FLWs being threatened with machetes and another male FLW in Nigeria described being beaten and his phone stolen. Women FLWs from Ethiopia and Afghanistan reported experiencing harassment while trying to conduct their work.
When female staff are going to the field, on the way, they face hundreds of people specially boys saying, 'you are beautiful, you walk beautifully.' We are teased. -Afghanistan, F While providing 2 drops of oral polio vaccine to each child only requires a light touch, physically manoeuvring large catchment areas, widely dispersed settlements and conducting repeated campaigns can be exhausting.
… because the work was hard to look for polio cases here and there, to get to know anyone who has paralysis, you have to follow to know what it is, the work was difficult for us to reach this level. -DRC, F The work makes you tired, working home-to-home makes you tired. When you go, you don't get them. When you go the next day, you don't get them at home because they are out for work. Such things have an effect. -Ethiopia, F FLWs were required to cover large geographic spaces with changing team sizes and varying sets of expectations for their workload and deliverables. This was particularly noticeable when team members left or when team sizes were reduced due to funding.
It's teamwork, and when someone leaves, you have to work in that person's place and take time to train another person. Don't you see? It's a lot of work to do. It's just overloading us, we're really overloaded. -DRC, F Physically manoeuvring these spaces can also bare physical risk and possible injury. Areas with limited cold chain capabilities not only require FLWs to cover large areas, but also to carry and maintain ice boxes for vaccine storage. One participant in Ethiopia described an injury they obtained during their work and the limited support they subsequently received, I faced an accidental bone fracture during polio campaigning while I was carrying vaccine with ice box to vaccinate children in the community. Still, I haven't been fully recovered from that injury which has lasted 10 years. In the case of other organizations their employees have insurance but the Ministry of Health wouldn't do this. For sure the employees of the Ministry try to protect themselves from ill health but we have no safety measures for our life and family. In this respect the program is not interrupted but I am interrupted from my personal objective by the program because I faced permanent disability. -Ethiopia, M Conflict and insecurity also pose significant physical and mental risks to frontline workers. In Afghanistan, the foregoing violence between the former Afghanistan government and the Taliban, a fundamentalist Islamic militia that took over power in August 2021, has been described as crippling (Norris et al., 2016), and polio workers have been targeted and killed as a result, as recently as last year (2021) (UN, 2021). Boko Haram, a militant Islamist group in Nigeria, forbids Muslims to take part in any Western activity (i.e. vaccination), and has threatened polio worker safety . In such settings, FLWs were asked to face additional and ever-present risks that could result in injury, death, or loss of friends and colleagues.
We worked a lot. We went into some places, we were beaten up because these areas are inaccessible but you just go there for the children to be vaccinated but there criminals beat you up and they even take the tools. -DRC, F I am not feeling secure here in Kabul then think of insecure provinces what is happening there. We had one case of polio here in 2018. This is because of insecurity and workers cannot work properly and reach to people and vaccinate people. -Afghanistan, F

Emotional labour
In addition to physical labour, polio FLWs face emotional labour resulting from ongoing skepticism and refusals from the communities they serve. Emotional labour requires skilled identification and management of emotions due to job expectations, usually to facilitate the effective and smooth operation of an organisation (Hochschild, 1984;Morris & Feldman, 1996). FLWs in all seven STRIPE countries engaged in considerable emotional labour around convincing people to accept polio vaccine. In some contexts of this study, polio vaccine refusals were rare. But in othersparticularly places where polio campaigns were frequent and other government services poorrefusals were a major issue. When parents were visited repeatedly, door-to-door, by polio FLWs offering polio vaccine, but did not receive other, urgently needed government services, this was a particular reason for frustration and refusals (Neel et al., 2021;Renne, 2006). Communities who desperately needed more government services, but who only experienced polio vaccines, were often frustrated. FLWs bore the brunt of this frustration, experiencing criticisms and insults. Some accepted us, and some didn't. There are some peoples that say, 'we [had to wait for] services after all these people [received their services]'. We try our best to convince them [how hard we work], we inform them we won't go out for lunch, we inform them we don't go till all children get vaccinated … There are some people who thank us after the service. There are others who want to get the services immediately when they come and insult us after they got the service. -Ethiopia, F When you go house-to-house during the campaign, sometimes the community perceive that you do it for your benefit. There are such perceptions. -Ethiopia, F Compounding distrust in some areas was the fact that many polio-endemic communities are marginalised populations who have been targeted by their own governments and international agents in the past, and thus have excellent reason to distrust those actors.
These larger dynamics were beyond the power of FLWs to address. They had no power over geopolitics, or decision-making regarding allocation of government services. Their job was to convince parents to accept polio vaccine for their childrenthese other factors notwithstanding. Navigating these conversations required intense emotional labour.
Vaccine refusals were described by FLWs as frustrating and deeply at odds with FLW knowledge regarding the dangers of the disease and the efficacy of the vaccines. FLWs described repeatedly cajoling people into getting vaccinations, even when they didn't want them and expressed desires for other services.
Sometimes the community mixes up everything. Because one vaccine is considered not halal, [not permissible for Muslims], they think that another vaccine is the same. So, there is still a challenge to educate the community, increase their awareness about the dangers of the diseases since these diseases can only be prevented by immunization and also from the system point of view. Sometimes because we compete with other programs, so many officials in the regions, who are not routinely approached or given information continuously, they may also hear more prioritized programs at that time, for example TB or something. So, we must conduct continuous approach. -Indonesia, F Some FLWs were motivated and able, usually through national-level support and infrastructure (Solomon, 2021), to provide additional services which increased community trust in them.
When our training was only polio initially, our communication package was only for polio. They told our community mobilizers that every time I am talking to the mother about the polio her child is having fever, child is having diarrhea, child is having other problem. So, we added other diseases in the package like diarrhea control, ORS distribution so then community got some trust that these people are not only interested in polio but also in my child's health. So, those small things helped us. -India, M But other FLWs experienced frustration with an overall lack of materials to properly conduct their work, for example, a functioning cold chain to keep the vaccine cold. FLWs often serve as a conduit between communities and the larger health system. They therefore must manage relationships with both while wielding little power to influence either.

Hierarchies and power
FLWs manage and negotiate tasks within gendered hierarchies. Women are often less mobile than men and must rely on male co-workers for supervision and safety in some contexts. Women workers were (and continue to be) slow to be promoted to management and supervisory positions (Kalbarczyk et al., 2021). In the home, women faced additional gendered hierarchies, expected to complete domestic duties in addition to their polio work.
During implementation more women were employed and this occupied them for several hours and caused problems in their homes. Some returned before the closure of the activities which delayed smooth implementation. -DRC, F FLWs were also required to follow strict regimens and rules. This included, for example, acceptable modes of transportation and number of overnight stays allowed and financially supported. Some women FLWs felt unsafe in the required lodges but were unable to return home in one day due to the long distances.

Remuneration
FLWs across different country contexts reflected on the role of finances both at an organisational level, influencing their ability to work, and at an individual level, influencing their motivation. FLWs reported difficulties receiving reimbursements and pay in a timely manner and largely felt underpaid in comparison to administrators.
It is expected that [FLWs] exhaustively spend their time at the campaign. They get a small amount of payment for their work. We provide some support for fuel and mobile card expenses. Very little support (trying to show in his hands). -Ethiopia, M I don't know where the [polio] budget comes from. It is very small. On the polio activity the one working hard and the one getting paid are no fair. Many are benefitting from it without effort, but the one suffering for it is different. Every administrator will be included [in the payment], I don't know the reason. I am staying here, but the HEWs who vaccinate on a house to house visit are paid very little amount despite their effort -Ethiopia, F There are tools they must give us to function better, the central office is also limited … Let us have training to have knowledge not acquired on the school bench. Let them also equip structures starting from the central office, it will work better … Let them fix the pay especially for the community [volunteer] because it is a difficult job, it is they who work in the field, it is they too who give us the data that we take to the hierarchy. They are threatened. The hierarchy benefits from it but those who do the work on the ground do not benefit from it. They are also parents and at the end of 3 days they are given only $15. And while they are working for the country, their children are suffering. -DRC, F A combination of reduced polio funds over time, corruption, and a need for ongoing funding created barriers for maintaining teams at the right size to keep the polio programme going. Some FLWs also reported using personal funds to complete their work.
The economy has affected work. The means do not always follow. There are events such as looting, some election-related disorder that disrupts immunization activities sometimes. The reform has also disturbed things. The state does not contribute much in areas like surveillance. Epidemics occur but there is no money for the response if partners do not intervene. -DRC, M What do I say about legal environment? I don't know. The health system, health finance, there is no health financing here. You know we are doing this thing now, NHIS community-based, but I don't think people are buying into it because the government is not even advertising. -Nigeria, M While FLWs can yield substantial power within the communities they serve, particularly as representatives of the GPEI, they struggle to find this power within the health system hierarchies, more broadly in the context of global aid. Participants were keenly aware of the role of politics and how political systems could improve or hinder their work Regarding the politics vaccines were imported as a donation this will affect a country image and also fail to utilize these donated vaccines is as whole it is a problem of the country management system. -Ethiopia, F For those shortcomings, we are honest; we are not involved, because we also can't do anything, that's policy. We will only try to help if it has been decided between WHO, UNICEF and Ministry of Health, and (then) we spread -Indonesia, F

FLW developed strategies and solutions
FLWs in DRC, Ethiopia and Indonesia reported developing solutions and trying new strategies to combat many of the challenges they faced. Broadly this included engaging other staff in polio eradication, working closely with community members, and working within physical and social contours of the community landscape. It is important to note however that FLWs in most contexts have little ability to change systems, but they are able to leverage opportunities, particularly when supported by infrastructure and structures at the national level (Neel et al., 2021).
To tackle the problem of inadequate staff some FLWs sought to integrate their teams and collaborate with other groups (i.e. animal specialists for pastoral communities in Ethiopia) wherever possible, though this was constrained by national-level decision-making.
Here what we have done is that we create open discussion with team members and the working team members were coordinated and take responsibility with a sense of ownership to implement the program activities to eradicate polio from the Ethiopia with commitment and make them to work with interest we armed them with the belt of moral wellbeing. -Ethiopia, F FLWs also became adept at engaging community members to elicit support. In many settings, this was done through awareness-raising activities that targeted community and religious leaders.
We are engaged with lots of activities in the community so we know the behavior of that community based on the polio program activities, practice and knowledge we can implement other programs. For example, when we design campaigning for other programs we know challenges that could face us in that community from the experiences we got during polio program so we could design the solutions ahead of time. -Ethiopia, F Given the range of health needs expressed by communities, FLWs also served as advocates and in some settings effectively promoted the integration of other services (where able and supported by the national system).
During the campaign, we give some notions to relais [volunteers]. For example, when you enter a compound, you can ask questions if there are people who are sick. Instead of them staying at home, let them bring them to the hospital. For example, the problem of malaria, we have the RDT that are free and the drugs too. We can easily give to those people. There is a communication given to relais [volunteers] even if you find pregnant women, you have to guide them. Instead of staying at home, let them go to the health centre so that they can be taken care of. So, beyond polio, the polio eradication program is also looking at other diseases. -DRC, F By spending so much time with specific communities, FLWs gained substantial knowledge about the physical and social contours of each community landscape. This provided opportunity for innovation in service delivery approaches, including identifying common public areas appropriate for vaccination activities.
For example, in my area has bus station, market, we came to those places. Children could get vaccination at the nearest NIDs station, for example children with their parents in train station, or terminal, we did screening for child's polio immunization status. -Indonesia, F

Discussion
Body work involves direct, hands-on activities, handling, assessing and manipulating bodies. It is gendered work, performed differently by men and women, that can also intersect with race, class, age and a mix of other identities (Twigg et al., 2011). Our research highlights the depth and breadth of work conducted by polio FLWs globally from the range of activities (surveillance to delivering vaccines) to the physical to emotional labour required to successfully conduct these activities. Given that body work in health and healthcare has largely been studied in high-income settings and has not been applied in the global FLW literature, we offer new insights and propose responsive strategies to support FLWs in global programmes.
This study uniquely explores the extent and risk of polio FLW movement through different spaces, including hard-to-reach areas, conflict areas and large catchment areas. Delivering a few drops of oral vaccine takes only a light touch, but gendered outdoor spaces, power and political dynamics can make the work physically and emotionally challenging for workers. Polio's FLWs must bend or break gendered space norms as they move from house-to-house, vaccinating children. Workers navigate skeptical parents and community leaders, and the demands of supervisors, which requires significant emotional labour.
Emotional labour, 'the effort involved in displaying organizationally sanctioned emotions by those whose jobs require interaction with clients or customers and for whom these interactions are an important component of their work' (Wharton, 1999), has been studied from a gender lens, in different industries (mostly service-related), and largely in high-income country settings (Erickson & Ritter, 2001;Jackson, 2019). But looking at emotional labour in the global health setting involves a recognition of the contextual nature of the gender-based power imbalances that FLWs face, dynamics that affect their ability to manage their own and their clients' emotions. Our findings on the additional emotional burdens that FLWs face offer insights into how emotional labour can be conceptualised in global health, and why emotional labour may be an important component of FLWs' work satisfaction and burnout (Ara, 2018).
Navigating male spaces carries serious safety and security risks for women, including lethal risk. Women FLWs have reported fear of and experiences with violence (both physical and sexual) in their communities and within the health system (Razee et al., 2012;Steege et al., 2018). This is particularly true in conflict-affected settings including those represented in this study (i.e. Afghanistan, DRC, Ethiopia and Nigeria) (Steege et al., 2018;Teela et al., 2009). In addition to navigating physical spaces, many of the challenges FLWs faced were institutionally gendered, including receipt of low pay and organisational hierarchies at work, within the GPEI globally, and at home. While some body work theorists have explored the gendered intersection of work and home on the body (Ungerson, 1997), the experiences of polio workers uniquely highlight this complexity. We have previously reported that GPEI represented the first opportunity for many women to leave the home and enter the workforce (Kalbarczyk et al., 2021). In several settings women FLWs managed emerging dynamics in their own homes (i.e. husband disapproval and ongoing home labour) in addition to those in their communities (Kalbarczyk et al., 2021;Steege et al., 2018). This is known as the 'double burden' of work that women tend to face when managing paid work and domestic labour expectations. In all countries, women and girls do the bulk of unpaid care work, roughly two to four times more than men (IWDA, 2016). Women FLWs must navigate the demands generated by this 'double burden' and sometimes face unique risks in the process. Married women FLWs have been shown to face increased threats of domestic violence (Ahmad, 2002;Steege et al., 2018). Unmarried women FLWs face some different risks including loss of social status and marginalisation (Ahmad, 2002;Maes et al., 2019;Steege et al., 2018). And the voluntary nature of this work for many women FLWs can add psychosocial and economic stressors (Maes et al., 2019;Najafizada et al., 2014).
The success of global initiatives like the GPEI relies heavily on the body work of FLWs so it is critical to reflect on how these individuals, who are largely women, can be supported by their organisations. The importance of such body work is neither accounted for nor adequately compensated when planning or implementing global health initiatives given the limitation of existing labour arrangements to acknowledge the significance of such efforts. Moreover, because the body work involves workers from perceived lower cadres in the hierarchies of global public health (Mumtaz et al., 2013), these workers lack agency and access to venues to voice concerns and to change the status quowhich worsens extant inequities in the health system and communities supported by these initiatives.
Other studies have highlighted how FLWs in different settings perceive organisational injusticefrom inequitable pay to being asked to uphold health of communities while their own health is put at risk (Aberese-Ako et al., 2014;Kruse et al., 2009;Mishra, 2014;Scott & Shanker, 2010). We believe it is beyond time programmes provide increased and timely compensation to FLWs given their heavy workload and range of challenges, especially in hard-to-reach areas. At a bare minimum, programmes must ensure FLWs do not bear any personal financial responsibilities to conduct their work safely, a problem not unique to polio workers (Akinyemi et al., 2019). This includes providing insurance and compensation for work-related injuries and increased access to hardship loan schemes. While injury and disability insurance are available for most regular workers to minimise physical loss and loss of bodily functions while discharging one's duty, such benefits should be considered and extended to 'volunteers' and FLWs in each setting where such risks are elevated, e.g. in insecure and conflict-affected settings. During the 2014 Ebola epidemic, risk insurance and additional income were found to motivate FLWs to conduct their work (Raven et al., 2018). The COVID-19 response, which largely relies on the same pool of workers, has also highlighted why this additional protection is crucial for workers. In Bangladesh, CARE, a humanitarian organisation, developed a 'corona insurance' scheme for health care providers, frontline workers and community members (Pallares, 2020). As we have seen in many STRIPE countries, and most recently in Ethiopia, conflict can emerge, subside and re-emerge. Therefore, such schemes should be explored more broadly, and not only during emergencies.
FLWs are also increasingly relied upon to deliver a wide range of services, in part due to task shifting and health system re-orientation toward horizontal programming (Morton et al., 2016). An unintended consequence of this has been FLW demotivation. Both financial and non-financial incentive schemes have been widely discussed as motivators for improved performance (Ensor et al., 2009;Henderson & Tulloch, 2008). A study on volunteer community health workers in Ethiopia explored possible motivators including providing opportunities for training, recognition by the community and district leaders, certificates and access to medical insurance (Haile et al., 2014). In some cases, recognition for supervisors and supportive work environments can also increase worker motivation and job satisfaction (Chuang et al., 2012). Incentive schemes must be carefully tailored to FLWs in different settings, accounting for their values and bodily experiences.
Viewing this suite of dynamics through the lens of body work theory adds some additional insights to ongoing conversations. That FLWs experience safety and security concerns, that their mobility can be limited, and that their remuneration could be better are all documented in the literature (Steege et al., 2018). These discussions are often practical ones, relatively divorced from social theory aside from 'frameworks' (a common theorisation method in public health which often consist simply of a list of relevant domains, connected in some cases by arrows). This straightforward approach can have value. But more sophisticated social theory can lead to deeper insights.
Consideration of the emotional labour that FLWs must engage in is often absent from these discussions. But emotional labour matters: jobs that require people to do a lot of it can have impacts on both psychological well-being and job burnout (Erickson & Ritter, 2001;Wharton, 2009). Attention to emotional labour can shed light on additional dimensions of how these dynamics matter. Also, looking globally is helpful for body work theory. Considering body work in global context reveals dimensions of it that are not obvious in research focusing mostly on the United States and Europe. The body work literature as a whole tends to focus on physical interactions between people, and not on the experiences of women crossing the invisible boundaries that demarcate gendered space. This, too, is body work that carries with it intense emotional and physical risks.
The hierarchies and power dynamics that place FLWs at increased risk of doing greater body work is more intractable to resolve in most societies, especially those hierarchies and power dynamics that intersect gender, race, ethnicity and class. These issues need to be confronted first by bringing them to light as this paper and others in the series are seeking to do. In terms of decision-making, FLWs are often considered 'doers' and are rarely positioned to make operational decisions. This is despite their intimate knowledge and awareness of the communities they serve. Stakeholder engagement is widely lauded as crucial to implementation (Handley et al., 2016;Peters et al., 2017). Given the depth and breadth of their knowledge and skills, FLWs must be seen as valuable stakeholders to be engaged throughout the implementation process, from design to dissemination. This includes representation in planning and management meetings where they can contribute to the design of feasible, acceptable and appropriate implementation plans. One approach that could link non-financial incentives and the inclusion of FLWs in decision-making is to offer trainings and certificates in programme management and community leadership. Women comprise 80% of the health workforce (and 90% if you consider only FLWs) but only hold 25% of leadership roles (Dhatt & Keeling, 2021); this approach has the potential to bolster women's leadership at the frontline.

Limitations
This study is subject to certain limitations. This large study was conducted in seven countries with diverse social and political contexts. In seeking to balance reporting results from these seven contexts, there is a loss of contextual depth and knowledge specific to each setting. We also recognise that Pakistan, one of the two countries in the world that remains polio endemic, was not included in our study. We sought to highlight existing knowledge about FLWs in Pakistan in our background and discussion but recognise that the experiences of FLWs in Pakistan are unique, and not captured by our data. Given the focus on gender in the analysis, it was clearly a missed opportunity when we did not collect gender for survey participants. We did, however, encourage gender diversity in recruitment of KII participants in all country settings. Finally, data collectors across settings included both men and women so some women FLWs may have been less comfortable discussing their experiences with male interviewers. Each team made an effort to ensure representation of men and women within the data collection team to increase the likelihood that FLWs would be interviewed by women.

Conclusion
The cost of success of global health programmes like the GPEI weighs significant on the bodies of FLWs, who are largely women. This is sometimes less tangible, and difficult to describe, but critical for achieving overall programme goals, especially when trying to reach the last mile. Global programmes should consider the range of body work FLWs face and design responsive systems that support them physically, emotionally and hierarchically within their organisations.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported by Bill and Melinda Gates Foundation [grant number OPP1178578].