The Influence of Gender on Immunisation: Using an Ecological Framework to Examine Intersecting Inequities and Pathways to Change

"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."

Gender can lead to different experiences in relation to childhood immunisation at multiple and interacting levels - within households, communities, and local health systems - and, through these different entry points, can affect programme implementation and achievements. This paper illustrates 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 this paper, gender inequality is used to indicate measurable differences in experiences and outcomes across gender, while gender (in)equity evokes value-based concepts entailing judgements of what is unfair and unjust.

The paper begins by presenting a rationale for the ecological framework, which essentially means acknowledging the various (intertwined and interdependent) levels at which gender inequities and their connection with immunisation are experienced. The ecological model is compatible with the perspective of intersectionality, which 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.

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 (e.g., whether a caretaker takes her child for vaccination) to factors affecting health service delivery or supply (e.g., how vaccination is made available and delivered), and shows how they are interrelated in shaping vaccination coverage.

Inputs to support this exercise are drawn from the authors' analysis of the immunisation literature, and 22 key informant interviews (KIIs) with gender and/or vaccine implementation experts. Both activities were undertaken between May and October 2018.

Table 1 in the paper shows how gender can affect programme implementation - 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. Through the lens of the ecological model, we can see how gender interacts with implementation at the:

• Individual level - example: Research has found that women who are health literate - irrespective of their education levels - are more likely to vaccinate their children, in both rural and urban settings. As opposed to formal education, health literacy and health knowledge are modifiable and can be gained informally.
• Household level - example: 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.
• Community level - Gender can intersect with ethnicity and religion to hinder full community participation in the delivery of primary care services and to prevent women and marginalised groups from benefiting from the interventions seeking to help them.
• Health system level - As immunisation services typically recognise 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.
• Policy level - Structural processes and policies may generate, amplify, or temper gender inequities. (See Table 1 for examples.)

An ecological approach also lends a framework for programmatic interventions in relation to the levels of action (e.g., individual, household, community, system, or policy), 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. It includes collated evidence from the literature suggesting that different agents (e.g., women's groups, men, female providers) can play a fundamental role in driving change (left-hand column), and inputs from key informants on country implementation experience (right-hand column).

These interventions vary in approach and implementation setting, but they all target 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, the ecological framework suggests that such interventions ought to take into account the role of decision makers other than the main caregiver and to customise the content to reach low-literacy populations and ethnic or language minorities. 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 vaccination.

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. Incorporating monitoring and process evaluation data into interventions can clarify the conditions and contexts under which they can be successfully implemented. Questions for implementation research also remain and invite investigation. For instance, it has been documented that communities can provide a fruitful setting for women's participation and action, "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."

In conclusion: "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....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."