Table 1.

Gendered dimensions of immunisation services access, quality and impact

Levels of the ecological framework	Drivers of inequality	Implications for immunisation services
INDIVIDUAL (main caregiver)	FINANCIAL BARRIERS AND PRIORITISATION Direct and indirect costs (eg, service fees or informal charges, and transportation); Missed opportunities for income generation	In low-resourced settings, a mother needs to raise the necessary resources, or mobilise the necessary means of transport to take her child to vaccination.49 Yet, women tend to have poorer access to, and control over resources within households and communities.6 50 Economic barriers are particularly relevant for single mothers and those in low-income households. In the presence of conflicting needs or livelihood insecurity, subsistence and immediate problem-solving strategies take priority over long-term health needs in general, and preventive interventions like vaccination in particular.49
	HEALTH LITERACY	Recognising that access to health literacy is—in many parts of the world—gendered, women lacking health literacy have a limited understanding of immunisation (such as knowing which diseases vaccines prevent, vaccine dosage and schedule), low motivation to vaccinate their child and less capacity to negotiate the health system.2 30 31
	PHYSICAL AND TIME BARRIERS Distance to services, poor infrastructure; Inconvenient times of services and long queues; Unpredictability of posts in areas with difficult access	Women’s responsibility for ‘reproductive’ work (ie, work required for the maintenance of the household—including cooking and cleaning, and fetching water and firewood—and the care of children and the sick) and diversified livelihood activities, pose heavy demands on their time and may constrain service use.2 49 Physical and time barriers may be amplified in the context or setting in which women live. For instance, time costs owing to poor infrastructure are greatest in rural areas, while increasing participation in the workforce is a major time barrier in urban areas. Women may experience lack of mobility due either to gender norms that restrict female mobility in public, or lack of transportation.49 Mobility may also be restricted by safety and security concerns.51
	ACCEPTABILITY OF HEALTH SERVICES Poor facilities and equipment; Unreliable vaccine supplies; Experience of healthcare quality	Mother-provider interactions at the health facility are underpinned by socioeconomic and gendered differentials (eg, poor women have to interact with higher-status vaccinators—who may be men, and also higher-status mothers).3 Lack of privacy and confidentiality in health facilities can result in mother-provider interactions being shared publicly, and expose disadvantaged women to public scrutiny or criticisms.3 49 Women in more traditional areas may not seek care for themselves or even for their children unless they have access to a female provider. Availability of female health professionals is particularly important where sociocultural and/or religious norms and practices restrict social and physical contact between men and women.38
HOUSEHOLD (including extended family and lineage grouping)	-INTRA-HOUSEHOLD ACCESS TO RESOURCES	Women tend to have less access to household income and assets, and income generating opportunities.6
	HEALTH-RELATED DECISION MAKING	In many settings, women’s success in negotiating decisions and resources that affect their children partly depends on their bargaining position in the gendered and generational hierarchies of the household.5 49 52
COMMUNITY	PARTICIPATION AND REPRESENTATION	Gender and other structural relationships—eg, family wealth, caste/ethnicity, etc—define membership and participation in formal and informal structures and processes through which people make decisions, establish leadership or organise social and economic activities in their community.35 50 53 As a result, women’s participatory voice and power in community programming—including many health initiatives—is often limited.33
	SOCIAL COHESION AND INTEGRATION	In migrant families and in communities with more fluid, heterogenous and transient populations, women are more likely to lack the social support networks that could encourage health seeking, eg, with financial assistance or help with their chores.49
	ACCEPTABILITY OF IMMUNISATION SERVICES	Local knowledge and expertise is important in determining acceptance of vaccination. Young mothers may trust and rely on elderly women as source of knowledge and information, more than health workers.49 Similarly, key authority figures, religious institutions, teachers and local media outlets may formulate conflicting positions towards vaccination, which may gain currency in the respective settings.2 49 Politically motivated resistance to vaccination is typically asked by men or leaders in the community. Whether or not they agree with the view of these authority figures, women in these settings may feel considerable pressure not to vaccinate their child.2 49
/HEALTH SYSTEM	HUMAN RESOURCES AND OVERALL MANAGEMENT OF THE SERVICE Service organisation; Availability of essential commodities and staff (male and female); Range of services available	Gender (male vs female) and/or geographic (urban vs rural and/or remote facilities) imbalance in the distribution of human resources for health affect service provision and delivery.54 Health providers face increased demands with declining resources for health services.55 Female health workers—particularly those at the front line—themselves face gender biases and discrimination where they occupy lower status health occupations.38 56 Similarly, female community health workers are under-recognised, underpaid and overworked, and often lack support from the wider health system.57
	PERFORMANCE AND QUALITY OF CARE Responsiveness of services; Provider attitudes and skills; Accountability for performance	Interpersonal relationships between user and provider, which characterise service delivery, are an important marker of quality of care.6 The social distance between user and provider—which Favin et al 55 refer to as the gaps with respect to gender, education, class, caste, ethnicity and other social stratifications—is important in shaping the interaction.38 Discriminatory values, norms and practices and biases in the health system can deter women from attending services.6
POLICY	GOVERNANCE AND STAKEHOLDER ENGAGEMENT	Women are less likely to be in senior, decision-making or policy-making roles than their male counterparts.54 Their low levels of representation draw less attention to women’s needs, both as users and providers.27
	HEALTH REFORM PROGRAMMES AND MECHANISMS	Health sector reforms that have been implemented in many countries have rarely considered their implications for gender equity in general, and gender equity in healthcare in particular.58
	POLICIES, LAWS AND REGULATIONS THAT MAY AFFECT IMMUNISATION	Policy and legislative frameworks and leadership are critical to build accountability for gender equity into health systems.39 There is a number of challenges to integrating gender into medical curricula, including institutional resistance and limited expertise among faculty to teach gender and women’s health issues.18 Attempts at integrating gender in health provider training have largely remained at small scale.18