Table 2.

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

Levels of the ecological framework	Agents of change: How they can make a difference, and why they should be engaged	Entry points for programming: Clusters of intervention strategies
INDIVIDUAL	WOMEN’S GROUPS FOR CAPACITATION Improved maternal health literacy is a contributing factor to the beneficial effects of women’s participation in groups to improve maternal and neonatal health in LMICs.44 Furthermore, benefits are not limited to women with high reported levels of intervention exposure, and spillovers in the community have been documented.59 FOR HEALTH ACCESS A space for women’s dialogue builds women’s confidence and improves access to information related to health needs, which positively impact utilisation.60	EMPOWERING WOMEN WITH KNOWLEDGE, MOTIVATION AND SELF-EFFICACY Strengthen women’s health literacy, particularly in areas with weak health systems and low educational levels. Initiate or leverage women’s groups as a platform for counselling and behaviour promotion focusing on health literacy, and mentoring to access government services and entitlements.
HOUSEHOLD	WOMEN’S GROUPS FOR SOCIAL COHESION OR INTEGRATION Some aspects of women’s time poverty may be mitigated when mothers can share the burden of child care or can rely on assistance from family or the community.31 MEN AS HUSBANDS OR A PARENT Men’s financial contribution to the household remains one of the most significant factors in determining the healthcare that children receive.48 Their involvement in decision-making around child care can increase the likelihood that positive decisions are made to seek immunisation services.31 AS CLIENTS Men may also have support needs requiring referral to external social support mechanisms, especially in challenging settings. Engaging them in questions about their children’s immunisation might encourage them to participate in conversations about health.61 ELDERLY WOMEN AS AUTHORITIES IN HOUSEHOLDS Elderly women with authority in the household can play an important role in helping (or hindering) younger women’s negotiations over decisions and resources that affect their children.31 52	ENCOURAGE FATHERS’ GREATER INPUT INTO CHILD CARE, AND INTEGRATING THE ROLE OF OTHER HOUSEHOLD MEMBERS AND THEIR INVOLVEMENT IN CHILD CARE Create communication platforms and related delivery strategies to engage on positive behaviours related to childhood development focusing on delivering the same messaging (eg, on child immunisation) to both mothers and fathers as well as other decision makers in the household. Complement women’s group interventions with programmes to involve fathers, including facilitating regular sessions with women and men to foster collaborative parenting and decision-making.
COMMUNITY	MEN AS INFLUENCERS Men can have considerable influence in shaping normative values related to vaccine acceptance within the broader societal network (eg, as community facilitators, cultural leaders, religious or political leaders).2 49 AS ALLIES IN WOMEN’S EMPOWERMENT AGENDA Programmes with the potential to shift gender roles by empowering women through improvement in knowledge, decision-making and economic gains, need to consider the roles and interests of men as potential partners in empowerment efforts.45 47 ELDERLY WOMEN AS GATEKEEPERS OF SOCIAL NORMS In communities where older women are seen as respected elders, they can have a strong influence on vaccine acceptance and support for participation in immunisation programmes.49	ESTABLISHING A DIALOGUE WITH LOCAL KNOWLEDGE AND EXPERTISE, AND PROMOTING A SHARED SENSE OF PURPOSE AND ACCOUNTABILITY Engage fathers and other decision makers and influencers in the household and community—including elderly women, on awareness and the importance of vaccination, providing them with information on basic health, and routine immunisation status of their communities.
HEALTH SYSTEM	FEMALE PROVIDERS AS FACILITATORS FOR HEALTHCARE ACCESS In areas where female seclusion and/or gender segregation are prevalent, women are critical for accessing women. Female frontline workers communicate directly with female caregivers and indirectly with other women in the community, thus enabling a larger capacity for trust.61 MOTHERS/WOMEN’S GROUPS AS STEWARDS TO PROMOTE RESPONSIVE SERVICES Mothers’ voices in service planning and programmes, and their direct feedback and guidance can help ensure that services are acceptable and accessible to the most disadvantaged.53	ENGAGING AND ADEQUATELY SUPPORTING FEMALE FRONTLINE WORKERS BY ENSURING LINKAGES WITH THE WIDER HEALTH SYSTEM Recruit women from inside the community—especially where vaccination is religiously or politically controversial—to improve mobilisation, and support efforts to reach marginalised women and children. Ensure mobile health teams have a balanced female/male ration where needed, particularly when home visits are conducted. Consider capacity building/mentoring to improve technical capacity of health personnel, including on providing confidential care to beneficiaries, and interpersonal communication skills to sensibly relate with vulnerable groups. MAKING ADJUSTMENTS TO SERVICE PROVISION BASED ON COMMUNITY PERSPECTIVES OF QUALITY OF CARE Tailor location of outreach services to meet the needs of caregivers and ensure acceptability of services among both mothers and fathers. This may include ensuring the schedule is agreed on with the beneficiaries and enable equal access and opportunity to mothers and fathers, and timely communicating schedule and location to the community. Provide immunisation services at more appropriate and flexible times for women and their families. Approaches may encompass establishing a fast line for mothers and caregivers who come only for vaccination services, designating a space specifically for vaccination to ensure an efficient flow of patients, or changing or extending vaccination session hours.

LMICs, low-income and middle-income countries.