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The influence of gender on immunisation: using an ecological framework to examine intersecting inequities and pathways to change
  1. Marta Feletto,
  2. Alyssa Sharkey
  1. Health Section, UNICEF, New York, New York, USA
  1. Correspondence to Dr Alyssa Sharkey; asharkey{at}


There is still a substantial knowledge gap on how gender mediates child health in general, and child immunisation outcomes in particular. Similarly, implementation of interventions to mitigate gender inequities that hinder children from being vaccinated requires additional perspectives and research. We adopt an intersectional approach to gender and delve into the social ecology of implementation, to show how gender inequities and their connection with immunisation are grounded in the interplay between individual, household, community and system factors. We show how an ecological model can be used as an overarching framework to support more precise identification of the mechanisms causing gender inequity and their structural complexity, to identify suitable change agents and interventions that target the underlying causes of marginalisation, and to ensure outcomes are relevant within specific population groups.

  • health systems
  • immunisation
  • public health

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Summary box

  • Effectively addressing gender inequities requires a clear understanding of the reinforcing mechanisms across dimensions of disparity.

  • Gender can lead to different experiences—in relation to immunisation—within households, communities and local health systems and through these different entry points, can affect programme implementation and achievements.

  • Action to address the underlying causes of gender inequity requires mutually reinforcing interventions at different levels.

  • An ecological model provides a valuable framework for analysing, monitoring and addressing gender inequities in immunisation.

  • Developing and funding targeted implementation research is critical to advance an equity agenda, notably by providing countries with guidance on how to address gender inequities as part of health systems strengthening.


Analyses of gender inequity in childhood immunisation have tended to concentrate on sex differentials in coverage between boys and girls, and on how broader aspects of gender inequality—particularly mother’s education—affect child immunisation for both sexes. These studies show that boys and girls have the same likelihood of being vaccinated in most low-income and middle-income countries (LMICs).1 2 A few exceptions exist at subnational levels within socioeconomically and geographically marginalised populations, in that outcomes may favour boys in some contexts, and girls in others.2 3

Consistently across countries, studies also indicate that children of educated mothers are significantly more likely to be immunised. Part of the relationship between mother’s education and childhood immunisation coverage is explained by socioeconomic status and contextual factors, since more educated mothers tend to live in more affluent households and in areas with better access to healthcare and services.4 5 Empirical research also reveals reinforcing mechanisms across dimensions of disparities: children of younger mothers without education, for instance, have compounded disadvantage, which can be exacerbated if they belong to a poor household.1

This Analysis of immunisation research and practice suggests that consideration of the socioecological context in which immunisation programmes are implemented is key to elucidate the complex range of gender inequities that can undermine programmes’ achievements, and to comprehensively address them as part of health system strengthening. The deliberate focus on implementation is meant to benefit decision makers and programme implementers who work towards scaling-up coverage in an equitable way, and help inform the design and implementation of interventions that positively impact immunisation outcomes while advancing gender equity.

Two major considerations emerge from our observations. One is the need to acknowledge the diversity of women’s experiences and realities in the formulation of strategies to achieve better equity.6 7 Women are not a homogeneous population: whether in terms of access to and control of resources, or how they approach their health needs and use services, gender intersects with other dimensions and experiences of exclusion in multiple ways, requiring an intersectional approach to implementing programmes and policies.6 8 The second is the relevance of using an ecological view of the intervention. Implementation of an immunisation programme is an inherently multilevel endeavour, which involves users’ acceptance, providers’ behaviour, healthcare organisations and policy.9 Similarly, the effect of gender can be seen at these multiple and interacting levels, and therefore change must occur across these.

In this analysis, we illustrate how an ecological model can serve as a unifying framework to understand how gender-related barriers contribute to underimmunisation, and how to inform the design of health system responses to gender inequity. In particular, we suggest the ecological framework can be applied to: i) clarify the mechanisms and pathways through which gender can influence implementation efforts and outcomes, ii) identify intervention strategies that address the underlying causes of inequity and iii) frame implementation research questions that help inform those strategies.

Inputs to support this threefold exercise are drawn from the authors’ analysis of the immunisation literature, and targeted consultations with gender and/or vaccine implementation experts. A literature review guided by a purposeful strategy was conducted to identify key issues underpinning the methodological development, research knowledge and practice around gender equity in immunisation. The review also included locating organisations and individuals relevant to the domain; 22 key informants were interviewed across various funding agencies, academia and global or in-country development partners. These consultations were exploratory in nature and attempted to explore the range and nature of intervention strategies that have been put forward across diverse global contexts in an effort to address gender-related barriers in programme implementation. Both activities were undertaken between May and October 2018.

The implementation focus of this paper means that we maintain a deliberate intent to approach gender within the realities of health planning and programme implementation. In this paper, gender inequality is used whenever we are indicating measurable differences in experiences and outcomes across gender,10 11 while gender (in)equity evokes value-based concepts entailing judgements of what is unfair and unjust.10–12 This paper focuses on childhood immunisation; elsewhere, the authors have explored the specific perspectives that adolescent vaccination—notably Human Papillomavirus vaccination—brings to understanding and advancing gender equity.13

Rationale for an ecological framework

Evidence on the impact of gender on health system needs, experiences and outcomes is readily available, yet this knowledge does not always translate easily into the science and practice of implementation. One analysis of implementation science texts, implementation theories, models and frameworks, and Cochrane reviews on implementation strategies revealed that limited research has been carried out or reported to inform how sex and gender impact implementation research and practice.8 Furthermore, although numerous gender analysis frameworks and approaches exist to help policy-makers and implementers assess the extent to which gender is considered and integrated within programmes, these are varied and inconsistent. Morgan et al, for example, found 15 gender frameworks that focused specifically on health, health systems and development, and each differed in its assumptions of what should be analysed and addressed.14 In addition, as these frameworks tend to be an expression of a donor or an agency’s policies and systems for gender mainstreaming, they tend to be structured around planning and review cycles (from country assessments to programme design and development to monitoring and evaluation) but do not give the actual process of implementation much attention.15–19

Innovative approaches are necessary to unravel the complexity of the different layers of influence of gender on immunisation outcomes, and to understand how the mechanisms of action associated with programme implementation may operate differently within and across gender and other stratifiers.

A first step involves considering the ways in which gender dynamically interacts with socioeconomic status, education, age and life-cycle, class/caste, ethno-religious identity and other social markers to shape disparity. These processes are intersecting in that they can alter the impact of any one dimension of inequality taken by itself.20 It follows that unequal outcomes cannot be understood or mitigated by approaches that consider gender as a single subject of inquiry.21 For the purpose of this paper, we focus within this perspective on the extent to which gender—with the intersection of other stratifiers—can affect implementation and the outcomes of immunisation programmes.

Second, and also germane, is the focus on individual-level factors which has led to recommendations or interventions that target behaviour change at the individual level (typically for the caregiver) without regard to the broader environmental context that influences those behaviours.22 Reflecting an ecological view of the intervention means acknowledging the various levels at which gender inequities and their connection with immunisation are experienced. These levels range from the caregiver (individual level) to interpersonal relationships within and between households that may influence or be the very locus of decision-making (household level), to societal networks embodying and sharing norms and values that households draw on when making health-related decisions (community level), to health services providing institutional capacity for individual participation in vaccination programmes and influencing normative values related to vaccine acceptance (institutional/system level) to a broad range of public policy factors including governance and financing that directly affect access to, delivery and sustainability of vaccination programmes (policy level).23 It is important to recognise that these levels are intertwined and interdependent.24 The resulting paradigm is known as the ecological framework and is commonly used in health programme planning.25

As an organising framework, the ecological model facilitates examination of potential barriers or enablers to the access, quality and impact of immunisation programmes, ranging from factors affecting the demand of services (eg, whether a caretaker takes her child for vaccination) to factors affecting health service delivery or supply (eg, how vaccination is made available and delivered), and shows how they are inter-related in shaping vaccination coverage.

The ecological model is also compatible with the perspective of intersectionality which, as noted above, postulates that multiple social identities and positions intersect at the micro level of individual experience to reflect multiple structural-level inequalities at the macro level of societal and health systems.21 26 As an overarching framework, it has the potential to improve equity-driven research and practice in the complex and multidimensional ways that mirror the experiences of women from the individual through to the health system and policy level.

How gender interacts with implementation

This section illustrates how an ecological model is well suited to examine the many ways in which gender, in dynamic interaction with other stratifiers, plays out at multiple levels and through different pathways to influence implementation efforts and outcomes. Barriers to demand for, access to and uptake of immunisation services are well known and the objective is not to provide an exhaustive account of those. Our objective rather is to show how gender can affect programmes’ achievements through patterns of individual and collective decision-making, access to and control over resources for service use, quality of healthcare delivery and biases in service provision (table 1).

Table 1

Gendered dimensions of immunisation services access, quality and impact

Individual level

Women are disproportionately affected by weak health services as they require more services, particularly for reproductive, newborn and child health.27 Furthermore, despite being assigned the role of primary caregivers in the family, women are often not empowered to fulfil this role. They are tied to a gendered division of labour that leaves them with little time or opportunity for health seeking, and their lower status in the household and community limits their capacity to influence and enact decisions about their own and their child’s health (table 1). A large body of evidence demonstrates the strong link between maternal education and child health. Spillovers in the community have also been documented, with positive externalities on childhood immunisation produced by the education of other local women.28 29 There is however much debate concerning the pathways of influence.4 5 Health literacy has been shown to be an important mediator in the relationship between maternal education and child health outcomes. Women who are health literate—irrespective of their education levels—are more likely to vaccinate their children, in both rural and urban settings.30 Where education levels and health systems are particularly weak—such as in rural settings, even moderate levels of health literacy lead to greater use of health services.30 Other studies focusing on the impact of knowledge of immunisation and its benefits confirm a strong effect on vaccination outcomes, at each level of education.2 5 It is also worth noting that, as opposed to formal education, health literacy and health knowledge are modifiable and can be gained informally.5 30

Household level

Women tend to have poorer access to household resources.6 In addition, access to resources does not always imply that women are able to make decisions over their allocation.31 In societies where health-related decision-making is negotiated within the primary household and extended family, mothers may be limited in their bargaining power vis-à-vis the male partner or head of household and vis-à-vis other relatives (eg, elderly women) (table 1).

Community level

As gender shapes identity, household economic and social status, ethnicity and religion also affect ‘identity performance’, for example, how women can occupy a public space, or the community roles for which they are eligible.32 These intersecting hierarchies create and reproduce systemic differences in the positioning of different groups of people within a community,33 and shape people’s relationships to communities.34 They can hinder full community participation in the delivery of primary care services,35 and prevent women and marginalised groups from benefiting from the interventions seeking to help them.32

Health system level

As immunisation services typically target mothers as the primary caregivers of children, they are themselves gendered in the way they are presented, the kind of information they provide and how they are organised and managed.2 Health access and quality of care are typically considered to be separate, but these aspects are interconnected. It is critical to consider the importance of the process of care—ie, the content and nature of user-provider interactions—and the wide array of factors that influence those interactions (from the overall management of the service to staff attitudes and skills) as potential deterrents for women to accessing health services (table 1).

The healthcare system may undermine gender equity from the perspective of women as users, and as providers.6 Women’s role as health providers, both within the formal health system and as informal providers, and the gender imbalance of human resources for health—seeing more women in lower status health occupations—have not been meaningfully addressed in health research or policy.36 37 Yet, the gendered dimensions of their work has come to be acknowledged as a crucial element in the gap between health policy and implementation.38

Policy level

Table 1 presents a few examples of how structural processes and policies may generate, amplify or temper gender inequities. This paper is focused on implementation and only touches on the policy level, but it is worth noting that an enabling policy environment ought to be promoted for interventions to produce social change.39

Health system responses to gender inequities

An ecological approach also lends a framework for programmatic interventions, in relation to the levels of action (eg, individual, household, community or system), change agents and populations of interest, types of intervention and intended impact.

Table 2 presents potential pathways of change and intervention impact, aligning the types of interventions with the levels in which, or agents, channels and settings through which, they can have their effect. Green and Glasgow24 would denote this as ecological alignment. This analysis does not aim to provide a full inventory of content, but rather to showcase the importance of multiple strategies and levels through which the programme may have its intended impacts, and acknowledge the behaviour of diverse, interconnected agents and processes from a system-wide perspective.

Table 2

Change agents and illustrative programmatic entry points to promote gender equity in immunisation

Table 2 includes collated evidence from the literature suggesting that different agents can play a fundamental role in driving change (left-hand column), and inputs from key informants on country implementation experience (right-hand column). Programmatic interventions that have a positive impact on immunisation uptake are widely documented; these range from interventions that stimulate demand for vaccines to those that target health service delivery or supply.40–42 The scope of the interviews we conducted however focused on how interventions are or can be modelled to proactively address the mechanisms through which gender inequity hinders children from being vaccinated.

It emerged that interventions that have been or are being implemented to address gender-related determinants of access to, demand of or uptake of vaccination services are numerous, but there is a lack of research evaluating such efforts. These interventions vary in approach and implementation setting, but cluster around the strategies outlined in table 2.43 They exemplify how implementation can take a gender-informed stance by targeting the gendered dimensions of immunisation services access, quality and impact. For instance, information, education and communication (IEC) interventions are an integral component of immunisation programmes. Yet, in consideration of the gender dynamics that may skew the uptake of information focused on women’s health needs, such as maternal newborn and child health, they ought to reconsider both target and media to take into account the role of decision makers other than the main caregiver, and customise the content to reach low-literacy populations and ethnic or language minorities (table 2). Table 2 also exemplifies how action to address the underlying causes of gender inequity requires multilevel strategies, which promote change at the individual level and simultaneously shape supportive structures at the household, community and health system levels to encourage and support health-sustaining practices such as vaccination.

Opportunities for implementation research

A commitment to address gendered dimensions of immunisation requires tackling the social context of individual health behaviour and community level dynamics, empowering individuals and communities for positive change and fostering transformation of gender inequities within the larger immunisation programme. A strategic approach to implementation research is critical to take the equity agenda forward, and provide clear guidance to countries on how to address gender inequity within the realities of health planning and programme implementation. The approaches outlined in table 2 prompt a number of questions for implementation research, and salient themes worth investigating arise in each of the levels. For instance, interventions to improve health literacy, which have typically been limited in scale, need to be designed with attention to scale-up and sustainability. Other interventions need to be piloted to assess conditions such as feasibility and acceptability. For instance, that communities provide an ideal setting for women’s participation and action is well documented,44 45 but whether community strategies have potential for effectiveness in urban areas or settings with high levels of heterogeneity and transience needs investigating, as does what in these settings may foster a ‘social space’ where women, and men, can gather and be receptive to intervention’s messages and objectives. Finally, interventions need to incorporate monitoring and process evaluation data to understand the conditions and contexts under which they can be successfully implemented. For instance, adjustments to service provision are considered critical in facilitating access but while some can be implemented at low or no cost, others may require a compensation system or deployment of additional staff or revival of competencies. Tested strategies are required for effectively redistributing or capacitating limited human resources for health in underserved areas.

To conclude, implementation research that helps inform the design of health system responses to gender inequity ought to consider not only the impact of these interventions on behavioural outcomes. It should also seek to understand whether these interventions do improve broader outcomes for women. There is mixed evidence for instance on the impact on women’s status and on the relationship between the sexes, of interventions that engage both men and women. Notably, the supportive effect of a man’s involvement in his wife’s use of services or health behaviours has shown to be stronger among fathers with higher levels of education who may be more open to messages concerning shared domestic and child care responsibilities.46 Yet, approaches that hold the potential to shift gender roles by empowering women through improvements in knowledge, decision-making and economic gains have shown in some contexts to exacerbate household dynamics by reinforcing existing power differentials.47 Understanding the structural complexity of gender relations in any given context is critical to reduce gender-related disadvantages in access to health services, quality of services and health outcomes, and to prevent potential unintended consequences and ensure implemented interventions promote rather than hinder gender equity. There is scope to access learning from gender equity initiatives in areas of adult and adolescent health where there are more demonstrated results and to build linkages to these initiatives,48 to elucidate on the challenges of implementing and evaluating interventions that address gendered dimensions of immunisation on one hand, and to create synergistic benefits for children’s health on the other.


As this Analysis has shown, an ecological framework is central to consider immunisation programmes within the broader context that influences implementation and change, including the role that gender inequities may play, and to acknowledge the structural complexity in which interventions are implemented. If immunisation programmes are to effectively scale up coverage and reduce gender inequities, it is critical to understand the different ways in which the intervention is affected when households, communities and health systems interact with it. Furthermore, how gender intersects with various forms of exclusion and the reinforcing mechanisms across dimensions of disparity need to be understood, to more effectively target pockets of marginalisation that may be missed by wide-reach interventions.

An ecological framework has much to offer in supporting more precise identification of inequities, in developing interventions that target the underlying causes of marginalisation and ensuring outcomes are relevant within specific population groups. Addressing gendered structural determinants and associated gendered vulnerabilities is a necessary investment, and impact is dependent on multilevel approaches, that is, mutually reinforcing interventions within an enabling policy environment.


The authors would like to thank Lauren Pandolfelli, Sagri Singh and Shreyasi Jha for their valuable inputs while an earlier version of this framework was under development. The authors would like to thank many stakeholders who gave their time to participate in interviews to discuss country experience of interventions targeting gender-related barriers. The authors would also like to thank Molly Abbruzzese, Feyrouz Kurji and Richard Duncan of the Secretariat for the Equity Reference Group on Immunisation (ERG), who reviewed part of this work that shaped a subsequent discussion paper for the ERG.


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  • Handling editor Stephanie M Topp

  • Contributors MF and AS conceived the analysis. MF developed the paper and AS commented on drafts. Both authors agree with the manuscript’s results and conclusions.

  • Funding This article is based on work funded through a grant from Gavi, The Vaccine Alliance to UNICEF.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available.