Bridging Gender Gaps in Immunization in Ethiopia: A Life Course and Socio- Ecological Qualitative Study

Bridging Gender Gaps in Immunization in Ethiopia: A Life Course and Socio- Ecological Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging Gender Gaps in Immunization in Ethiopia: A Life Course and Socio- Ecological Qualitative Study Geteneh Moges Assefa, Michael Tarekegn, Kasahun Negash, Azmeraw A. Tesfahun, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8235793/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Ethiopia has made notable progress in expanding routine immunization coverage, yet inequities persist in vaccine uptake and completion. Gender norms and power relations may shape access to and decision-making about vaccination across the life course, but evidence integrating a gender lens with a socio-ecological perspective remains limited. Methods We conducted a multi-site qualitative study in four Ethiopian regions (Amhara, Oromia, Tigray, and Afar) between May and June 2025. Using purposive sampling, we conducted 75 semi-structured interviews with caregivers, health workers, community and religious leaders, and health officials. Interviews were audio-recorded, transcribed, translated into English, and analyzed in NVivo using an inductive coding approach, with themes subsequently organized and interpreted using the socio-ecological model (SEM) and a life-course perspective. Results Gender-related barriers to immunization operated across intrapersonal, interpersonal, institutional, community, and policy levels and varied by life stage (adolescence, pregnancy, and adulthood). At the interpersonal level, participants described “responsibility without authority,” where women were expected to manage vaccination while decision-making power often rested with fathers or elders, contributing to delays and refusals. Intrapersonal and community-level barriers included fertility-related concerns and misinformation, particularly in relation to HPV and COVID-19 vaccines, which also shaped provider communication. Institutionally, service organization, counselling time constraints, and limited age-inclusive job aids reinforced a focus on mothers and young children and reduced routine engagement of men, adolescents, and adults. At the policy level, participants highlighted limited operational guidance, targets, and reporting systems for vaccination beyond under-five services, along with constrained resourcing for adolescent and adult vaccination. Conclusion Gendered norms and system-level priorities jointly constrain life-course immunization in Ethiopia. Strengthening gender-responsive life-course immunization will require addressing household decision-making dynamics, equipping providers with age-inclusive counselling tools, engaging trusted community intermediaries, and aligning operational guidance, targets, and reporting systems to support vaccination beyond childhood. Gender equity Immunization Vaccine hesitancy Socio-ecological model Life-course Ethiopia Qualitative research Figures Figure 1 Figure 2 1. Introduction Vaccination is one of the most effective public health interventions, preventing 2–3 million deaths annually and contributing significantly to reduced childhood mortality and improved population health [ 1 ]. Ethiopia has made significant strides in expanding routine immunization coverage, with over 80% of children receiving the first dose of Diphtheria, Tetanus, and Pertussis (DTP). However, challenges persist in ensuring completion of vaccination schedules, equitable access [ 2 , 3 , 4 , 5 ], and uptake of newer vaccines such as Human Papillomavirus (HPV) and COVID-19 [ 6 ]. Life-course immunization extends beyond infancy and early childhood to include vaccination during adolescence (e.g., HPV), pregnancy (e.g., tetanus-containing vaccines), and adulthood (e.g., COVID-19 and other indicated vaccines). Implementing this approach requires service delivery and communication strategies that reach people across changing social roles, decision-making structures, and access constraints over time [ 5 , 7 ]. Recent studies have highlighted persistent inequities in immunization uptake, especially among children from rural areas, low-income households, and zero-dose communities [5, 6, 7, ]. Gender influences immunization through multiple pathways, including differential access to services (time, mobility, and resources), authority over health decisions within households, and exposure to or ability to challenge—misinformation and social sanctions. Gender, a critical determinant of health, remains an underexplored factor in immunization equity [ 8 , 9 , 10 ]. While women typically serve as primary caregivers, they often face sociocultural and structural barriers to accessing vaccination services for themselves and their children. Studies have shown that misinformation about vaccine safety, such as fears related to fertility, especially regarding the HPV vaccine, contribute to vaccine hesitancy among women and adolescent girls [ 11 , 12 ]. Globally, gender norms influence decision-making power, care-seeking behaviour, and interactions with the health system [ 13 , 14 ]. In Ethiopia, women have limited autonomy in health decisions, particularly in rural settings, which can delay or prevent timely vaccination [ 15 ]. The lack of gender-transformative policies and programs further compounds these barriers [ 16 – 18 ]. Despite the Immunization Agenda 2030’s focus on equity and life course immunization, few studies have operationalized a gender lens or examined barriers beyond childhood [ 19 , 20 , 21 ]. We apply a socio-ecological lens to locate gendered influences at multiple levels—intrapersonal (beliefs and risk perceptions), interpersonal (household authority and caregiving roles), institutional (service organization and provider practices), community (norms and information networks), and policy (guidance, targets, and resourcing). A life-course perspective complements this by recognizing that gender roles and power relations shift across adolescence, pregnancy, and adulthood, shaping both demand for—and delivery of—vaccination at different stages [ 11 , 13 , 22 ]. Despite growing interest in life-course immunization, there is limited qualitative evidence from Ethiopia explaining how gender norms and health-system practices jointly shape vaccine uptake across life stages and across diverse settings [ 23 , 24 ]. This study addresses this gap by exploring gender-related barriers to vaccine uptake across the life course in Ethiopia. Using the SEM enables analysis of multilevel influences—individual, household, institutional, community, and policy—while the life course approach highlights how gendered expectations, autonomy constraints, and exposure to health information shift across age stages. Combining these frameworks strengthens explanatory power and helps identify entry points for tailored interventions across the lifespan. By triangulating perspectives from caregivers, providers, community and religious leaders, and officials across four regions, this study identifies leverage points for more gender-responsive and life-course–oriented immunization strategies. Specifically, we ask: How do gender norms and power relations influence access to and decision-making about vaccination across adolescence, pregnancy, and adulthood, and how do institutional and policy contexts reinforce or mitigate these influences? 2. Materials and Method 2.1. Study Design and Setting This study employed a multi-site case study design with participatory elements. The “case” was defined as gendered barriers affecting uptake and delivery of immunization across the life course within routine immunization services and related community structures in Ethiopia. A multi-site approach enabled comparison across diverse sociocultural and livelihood contexts. The study was conducted in four Ethiopian regions: Amhara, Oromia, Tigray, and Afar. The four regions were purposively selected to capture diversity in geography, culture, pastoralist vs. agrarian livelihoods, and variation in immunization coverage and gender norms. Fieldwork took place between May– June, 2025. The study was guided by two complementary conceptual frameworks: the Socioecological Model (SEM) and the Life Course Approach. The SEM enabled analysis of intrapersonal, interpersonal, institutional, community, and policy-level factors influencing immunization behaviours [ 11 ], while the life course supported interpretation of how gender-related constraints and decision-making dynamics shift across stages such as adolescence, pregnancy/reproductive age, and adulthood [ 13 , 15 ]. Participatory elements included: (i) engagement with regional/district stakeholders to refine the focus of inquiry and ensure relevance; (ii) iterative reflection with field teams during data collection to adapt probes to local contexts; and (iii) synthesis discussions with technical stakeholders to validate the practical interpretation of themes and identify feasible program entry points (without disclosing identifiable participant information). 2.2. Sampling and Participants Participants were selected using purposive sampling to capture information-rich perspectives on gender and immunization. A total of 75 individuals were interviewed, comprising 23 healthcare providers, 22 caregivers or parents, 12 religious or community leaders, and 18 regional and district health officials. This diverse sample enabled exploration of gender-related barriers from multiple stakeholder viewpoints across health system and community levels. Recruitment procedures. Participants were recruited through collaboration with regional and district health offices and health facilities implementing immunization services. Health officials and facility focal persons facilitated initial introductions to eligible participants (caregivers, providers, community/religious leaders, and officials). The research team then provided information about the study, emphasized voluntariness, and obtained consent directly from participants. To reduce power dynamics, interviews were conducted by trained research staff not involved in service delivery or performance supervision. Saturation and sample adequacy. Recruitment continued until thematic saturation was reached, operationalized as the point at which three consecutive interviews did not generate new codes related to gender and immunization drivers. Saturation assessments were conducted during team debriefings, based on ongoing review of emerging codes and memo summaries. 2.3. Data Collection Data were collected using semi-structured interview guides informed by the WHO Behavioural and Social Drivers (BeSD) of Vaccination Framework [ 24 ]. The guides were developed in English, translated into Amharic, Afarigna, Tigrigna, and Afan Oromo, and piloted with three respondents for clarity and cultural relevance in each region. The BeSD framework was particularly relevant for exploring gender because it captures how confidence, social expectations, and practical access barriers intersect with gender norms to shape vaccine decisions. The tools are included as “Supplementary File 1”. Interviews were conducted by trained qualitative researchers fluent in relevant local languages. Prior to fieldwork, the team received training on qualitative interviewing, research ethics, informed consent, confidentiality, and approaches for discussing potentially sensitive gender norms while minimizing social desirability bias (e.g., neutral probes and non-judgmental prompts). To ensure accuracy, a subset of transcripts was reviewed by bilingual team members through spot-checking against audio and back-checking key passages where meaning was sensitive (e.g., fertility fears, household authority, stigma). Discrepancies were resolved through discussion within the team. All interviews were audio-recorded, lasted between 30–60 minutes, and were supplemented by field notes capturing tone, body language, and environmental context. Verbal informed consent was obtained from all participants prior to recording. 2.4. Data Management and Analysis Audio recordings were transcribed verbatim, translated into English, and imported into NVivo for analysis. We used a hybrid approach combining inductive coding with framework organization guided by SEM levels and a life-course lens. Inter-coder reliability was assessed through double-coding of 20% of transcripts. Themes were organized using a framework analysis, aligned with SEM levels and interpreted through the life course lens. During coding, segments were additionally grouped by life stage (early caregiving, adolescence, reproductive age, adulthood) to trace how gendered barriers and autonomy constraints changed over time. Credibility was enhanced via triangulation across participant types and peer validation of coding categories. 2.5. Rigour and Trustworthiness We applied Lincoln and Guba’s criteria to enhance trustworthiness, including credibility, dependability, confirmability, and transferability [ 25 ]. Credibility was strengthened through (i) triangulation across caregivers, providers, leaders, and officials and across four regions; (ii) iterative peer debriefing during coding; and (iii) use of verbatim quotations to anchor interpretations. Dependability was supported by maintaining an audit trail (codebook versions, analytic memos, and coding decisions). Confirmability was supported through reflexive memoing and team discussions to examine assumptions during interpretation. Transferability was supported by providing contextual descriptions of settings, participant categories, and variation across livelihoods and regions. 2.6. Ethical Considerations The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Ethics Committee of the Federal Ministry of Health (protocol code ETCO/Admin/550/25 and date of approval April 01, 2025). All participants were briefed on the study’s purpose, procedures, data handling, and their rights, including voluntary participation and the option to withdraw at any time. Verbal informed consent was obtained before each interview. Confidentiality was maintained by anonymizing transcripts and conducting interviews in private locations chosen by participants. All transcripts were de-identified prior to analysis, and audio files/transcripts were stored on password-protected devices accessible only to the research team. Quotes used in reporting were anonymized to remove names and any potentially identifying details (e.g., facility names). 3. Results 3.1 Participant Characteristics A total of 75 interviews were conducted across four Ethiopian regions, including 57 in-depth interviews (IDIs) and 18 key informant interviews (KIIs). Participants included 23 healthcare providers, 22 caregivers, 12 community/religious leaders, and 18 regional and district health officials. Most caregivers were women (18 out of 22), while most health workers and officials were men. Participants came from both urban and rural settings in Amhara, Oromia, Tigray, and Afar, offering geographically and socially diverse perspectives (Table 1 ). Table 1 Demographic Characteristics of study participants, June 2025 (n = 75). Participant Category Interview Type Sex, n Study Region Total (n) Age Range (years) Male Female Amhara Afar Oromia Tigray Caregivers IDI 4 18 6 5 6 5 22 19–31 Health Providers IDI 14 9 6 5 7 5 23 26–36 Religious Leaders IDI 12 - 3 3 3 3 12 41–50 Government Officials KII 15 3 5 4 5 4 18 31–45 Total 45 30 20 17 21 17 75 19–50 3.2 Gendered Barriers across the Life course through Socio-Ecological Lens We identified gender-related barriers to immunization that operated across socio-ecological levels and varied by life stage. Themes were organized using the socio-ecological model (SEM): intrapersonal, interpersonal, institutional, community, and policy levels. Across these levels, participants described how gender norms shaped responsibility and authority for vaccination decisions, exposure to misinformation (particularly fertility-related concerns), and the extent to which services engaged men, adolescents, and adults. 3.2.1 Intrapersonal level: Gendered risk perceptions and fertility-related concerns across life stages Intrapersonal barriers were often expressed as risk perceptions and fears that differed by life stage. Participants described pregnancy-related concerns about fetal harm, adolescent-stage concerns linked to HPV and fertility rumors, and adult-stage concerns related to COVID-19 vaccines and broader mistrust. These perceptions were reinforced by limited access to clear counselling and by gendered expectations that place women at the center of vaccine responsibility while limiting their decision-making power. “After receiving the vaccine, some said it caused another problem… this misconception makes them refuse the second dose.” (Health worker, Amhara Region) “People say COVID-19 will disappear by itself, so why take the vaccine? They believe the disease is exaggerated.” (Vaccinator, Oromia Region) “Women are afraid to take vaccines when pregnant because no one explains properly. They say they do not want something that hurts their baby.” (Midwife, Amhara Region) One caregiver from the Afar region described, “After the child got fever from the vaccine, I was afraid. Nobody told me that was normal,” and another stating, “Sometimes I worry about side effects and whether it’s safe, but no health worker explained it well,” illustrating gaps in communication from health providers. “There is a rumour that the COVID-19 vaccine causes infertility and blood clotting.” (Vaccinator, female, Tigray Region) These intrapersonal fears—ranging from infertility myths to distrust of health messages—disproportionately shaped decision-making across adolescence, pregnancy, and adulthood. 3.2.2 Interpersonal level: Responsibility and authority in households Participants consistently described a pattern of responsibility without authority, in which mothers were expected to take children for vaccination and manage follow-up, while fathers or elders often held decision-making authority, including the power to approve or refuse vaccination. This dynamic was especially pronounced for newer vaccines and for adolescent girls (e.g., HPV), where permission and fears about fertility intersected with household power relations and disagreements between spouses were common when adverse events occurred. “In our context, mothers take the children for vaccination, but they often need permission from the fathers.” (Government official, Oromia Region) Similarly, one healthcare provider in Oromia explains that in her years of experience she noted that “mothers usually cannot bring their babies alone if their husbands disagree…. Some men forbid it, thinking the child is already healthy,” highlighting how interpersonal dynamics can directly affect child health outcomes. “While I was in the rural area, I witnessed quarrels between couples; husbands blamed their wives for the child’s side effects.” (Vaccinator, Afar Region) “Girls rely on their parents’ decision. Even when we teach them, they say they will only take it if their father agrees.” (School-linked health worker, Oromia Region) Female caregivers, particularly from Afar and Amhara regions frequently expressed a strong internalization of the belief that the responsibility for their children’s health, particularly vaccination, falls solely on mothers. One caregiver from Afar region explained that, “ only mothers are expected to take children for vaccines. Men think it’s not their responsibility or simply don’t know what the vaccines are for,” highlighting the perception that caregiving is exclusively maternal. Similarly, a male caregiver from Tigray region reflected on his past misunderstanding, stating, “I know about vaccines now, but earlier I thought it was just women’s business. No one ever explained to me that I should be involved as a father,” which illustrates how internalized beliefs constrain male engagement. In Oromia region, another caregiver emphasized, “Men usually say their job is to provide money; they don’t think of bringing the child to the health institution. It’s just how things are,” reinforcing how societal expectations define paternal roles narrowly. These narratives reflect broader societal attitudes that place the burden of caregiving squarely on women, reinforcing their exclusion from public health decision-making spaces. Moreover, caregivers reported that heavy domestic workloads and emotional stress reduced their capacity to prioritize immunization. Health workers and religious leaders recognized these gendered challenges, acknowledging that immunization sessions and messaging largely targeted mothers, unintentionally excluding fathers. A provider in Afar admitted, “We don’t receive proper orientation on how to bring fathers into the discussion. Even though we say, ‘both parents should care,’ most sessions are directed at mothers,” and added that, “Health talks are usually given to women. Men are left out because we don’t have guidelines on how to include them. These dynamics reveal how gender norms and power hierarchies within families and interactions with providers significantly influence vaccination behaviours across life stages. 3.2.3 Institutional level: Service organization and workflows that center mothers and young children At the institutional level, participants described how the organization of immunization services implicitly positioned vaccination as a maternal responsibility. Facility workflows, waiting spaces, and health education materials were perceived to be oriented toward mothers of young children, which limited men’s engagement and reduced opportunities for counselling adolescents, pregnant women, and adults. Providers also described staffing and workload constraints that shortened counselling time and limited the ability to address misinformation. "We borrowed vaccines from other facilities. There was nothing in stock when people arrived." (Vaccinator, Amhara Region) These gaps disproportionately impacted women, who were often left without timely services or proper explanations. Another health worker also highlights systemic gaps in workforce preparation, explaining poor counselling and inconsistent service quality. “None of the training is given for our staff who work on the Extended Program for Immunization in my experience.” (Vaccinator, Afar Region) There are only two vaccinators… they become overburdened and result in limited information for caregivers.” (Health worker, Oromia Region) “When people reach the health facility, no supplies are at hand, so they turn back.” (Facility manager, Amhara Region) “It is hard to say staff are trained on gender competencies… there has not been much focus on this.” (Health official, Afar Region) Institutional fragility—particularly workforce shortages and poor communication—contributed to gender-specific missed opportunities, especially for pregnant women and young mothers. The staff were busy. They did not provide me with any information about the vaccine; they only wrote my child’s next appointment.” (Caregiver, Amhara Region) “Pregnant women become worried when nobody explains why they need the vaccines. They say, ‘I don’t want to take something that harms my baby.” (Midwife, Amhara Region) The other perspective this research discovered is that the health facilities often reinforce gender biases by targeting mothers in service delivery. A provider in Afar observed, “Even we providers unconsciously treat immunization as women’s work. Our posters, talks, and appointment cards are directed at mothers. Men don’t feel invited or welcome.” Physical environments within clinics, such as segregated seating and lack of male-focused materials, further discourage fathers, as noted by a Tigray provider: “Mothers sit on one side, and there’s no space or reason for fathers to join in. Men feel out of place and prefer to wait outside.” The lack of formal training and operational guidance for male-inclusive approaches exacerbates these challenges. A public health official in Amhara stated, “There is no official guide or training on how to work with male caregivers or traditional leaders. Everything depends on the individual health worker’s motivation.” Motivated staff, however, can transform service delivery to foster male engagement when institutional support is provided. 3.2.4 Community-Level: Underused Local Influencers Community norms and informal communication networks shaped vaccine attitudes more strongly than formal messaging. Pastoralist communities relied heavily on social networks such as dagu , while religious interpretations influenced whether vaccination was timely or delayed. Despite this high influence, religious and traditional leaders were underutilized in immunization advocacy. While several leaders expressed willingness to promote vaccines, they had rarely been formally engaged. “The community listens more when religious leaders speak.” (Health worker, Afar Region) “I believe religious leaders can debunk myths… but we have never been engaged in vaccination campaigns.” (Religious leader, Afar Region) Religious and community leaders can mobilize male participation but often remain underutilized. As one Afar leader stated, “Our people respect religious words more than anything else. When we tell them vaccination is safe and both parents should participate, they listen carefully. But we rarely get formal invitations or training to support this work,” highlighting the need for formal engagement. Persistent myths about vaccines continue to undermine efforts, with a religious leader in Amhara explaining, “The church supports immunization, but some still believe vaccines cause infertility or diseases. We must keep teaching and confronting these myths openly,” and a caregiver in Oromia adding, “People sometimes say vaccines are foreign and dangerous; that scares many families.” “There is what is called dagu, a way of exchanging information… we use dagu and local influencers to respond to concerns.” (Health extension worker, AfarRegion) “Some delay vaccines until after baptism… that is why the first doses are sometimes missed.” (Community member, Amhara Region) The study also found out that at the community level, deeply rooted social norms significantly influence male involvement. In rural areas, traditional ideals of masculinity discourage fathers from active caregiving. A religious leader from Tigray noted, “In rural areas, if a man carries a child to the health institution, people say he is ‘controlled by his wife.’ That’s why many men stay away. They fear being mocked by neighbours or relatives,” while a community leader from Afar added, “Men are afraid of gossip and prefer not to be seen at maternal health institutions,” demonstrating how social pressures perpetuate exclusion. In contrast, urban and semi-urban areas show gradual norm shifts. In Afar, a public health official explained, “Here in the town ( Semera), more men are supporting vaccination. We have worked hard with local leaders to make that normal. We engage men during community meetings and use media messages to challenge old ideas,” and a caregiver noted, “Younger men in town are more open to participating in child health than older generations,” reflecting evolving attitudes facilitated by leadership and media. These findings show how social structures—religious authority, traditional information systems, and community norms—strongly mediate acceptance across the life course, particularly for adolescents and new mothers. Delays in vaccination were also attributed to religious customs, such as postponing vaccines until after baptism. A religious leader from Tigray noted, “Religious leaders and men want to help, but they are not involved in planning or outreach,” highlighting the untapped potential of influential community actors. Some religious leaders also noted their capacity to challenge internalized beliefs, with one stating, “I believe that the wisdom of vaccination was formulated by God. Health is given from God, but humans must do everything possible to prevent disease… and it is good to use what scientists have discovered,” illustrating how faith can support health promotion. 3.2.5 Policy-Level: Coordination and Gender Integration Gaps At the policy level, participants emphasized limited operational guidance, targets, and resourcing for life-course immunization and for male engagement. Officials and providers described how program priorities and accountability structures remained centered on under-five coverage, contributing to weaker emphasis on adolescents and adults except during campaigns. Officials highlighted a notable absence of explicit guidance for male-inclusive immunization strategies. As an Afar official explained, “The Ministry talks about community engagement but does not detail strategies for involving men or religious leaders. This leaves local teams without clear direction.” Funding and national programmatic priorities similarly focus on women, limiting the sustainability of male-inclusive interventions. “Most outreach campaigns assume women are the only targets. Donors and governments need to allocate specific budgets to engage men and community leaders effectively.” (Public health official, Amhara Region) “The most critical challenge is budget shortfalls… our outreach teams cannot reach all communities.” (Government official, Afar Region) “We could resolve the logistic and budget related issues by negotiating with partners, but due to the weak link and lack of coordination, we are unable to engage productively.” (NGO Technical Assistant, Afar) “Gender has not been given much attention in immunization… it should be included as a component.” (Policy maker, Oromia Region) Policy-level weaknesses, especially inadequate funding and the absence of gender mainstreaming—exacerbated community, interpersonal, and institutional barriers, with cumulative effects across the life course. The below figure shows across settings, gender norms shaped both who is expected to seek vaccination and who has authority to approve it . These interpersonal dynamics interacted with institutional service design that centers mothers and under-five services, community stigma that discourages male participation, and policy environments that provide limited operational guidance for life-course immunization. Together, these multilevel influences contributed to missed opportunities for vaccination during adolescence, pregnancy, and adulthood, particularly when misinformation and fertility concerns were not addressed through trusted counselling and community channels.The below figure depicts across settings, gender norms shaped both who is expected to seek vaccination and who has authority to approve it . These interpersonal dynamics interacted with institutional service design that centers mothers and under-five services, community stigma that discourages male participation, and policy environments that provide limited operational guidance for life-course immunization. Together, these multilevel influences contributed to missed opportunities for vaccination during adolescence, pregnancy, and adulthood, particularly when misinformation and fertility concerns were not addressed through trusted counselling and community channels. 3.3 Health Workers’ Perception of Life-Course Immunization This section describes health workers’ accounts of factors shaping the delivery of life-course immunization, including training and guidance, counselling practices under workload constraints, and prioritization driven by reporting systems and program targets. Using the socio-ecological model (SEM), findings are organized across intrapersonal, interpersonal, community, institutional, and policy levels to illustrate how provider knowledge and practices interact with community expectations, service environments, and policy directives that continue to emphasize under-five immunization. 3.3.1 Intrapersonal-level factors: training, knowledge, and confidence gaps Health workers described substantial intrapersonal challenges that shaped how they perceived and practiced life-course immunization. While most providers reported confidence in administering and promoting childhood vaccines, knowledge of vaccines for other life stages—particularly for adolescents, pregnant women beyond tetanus toxoid (TT), and older adults—was often limited or fragmented. A healthcare provider from Amhara region noted, “Most of our training is centered on vaccines for under-five children. Life-course immunization is a new concept, and many providers have not received detailed instructions about it,” while another provider in Oromia region reflected, “People often think vaccination only means childhood immunization. I have heard colleagues say they are not sure which vaccines should be given after infancy.” Similarly, a provider in Afar region stated, “I’m unsure about the vaccine schedules beyond children; we rarely get updated or specific guidance on these age groups.” Despite these gaps, many providers expressed supportive attitudes toward life-course vaccination. A provider from Tigray region explained, “I understand that vaccination at all stages is beneficial, but without training and resources, it’s hard to promote vaccines for adults with authority,” and a provider in Oromia region added, “We want to educate clients about the importance of all vaccines, but we don't have age-specific guides.” Several participants noted that this mismatch—positive orientation without sufficient guidance or tools—often reduced how proactively providers raised life-course vaccination during routine encounters, particularly when adult vaccination was not framed as a routine expectation. Providers also reported that adult vaccination was frequently viewed as unnecessary in the absence of symptoms, and that rumors—especially infertility-related concerns—shaped their communication comfort. A provider from Afar explained, “Adults are often suspicious when offered vaccines. They ask why they need vaccines if they feel healthy and sometimes fear side effects,” while another in Mille (Afar region) stated, “Rumours about vaccines causing harm or infertility make me cautious to strongly recommend vaccines for adolescents and adults.” One provider added, “We worry people will say we are testing new things on them. Unless it’s a campaign or emergency, many adults resist vaccines.” Overall, intrapersonal-level influences reveal a complex interplay of limited technical knowledge, positive but underutilized attitudes, perceived risks in patient communication, and internalized stigma about adult vaccination. 3.3.2 Interpersonal level: counselling practices and anticipatory avoidance under workload At the interpersonal level, provider–client communication was described as a key determinant of whether life-course immunization was discussed during routine visits. Providers often tailored counselling to what they perceived caregivers expected, which was largely childhood vaccination. A provider in Amhara region explained, “Mothers usually come for their children’s vaccines. When we mention vaccines for pregnant women or older adults, many seem confused and do not ask questions,” while a provider in Oromia region noted, “If caregivers don’t express interest, we don’t want to overwhelm them or seem pushy, so we often avoid discussing vaccines for other family members.” This anticipatory avoidance—based on assumed disinterest or potential resistance—was described as contributing to missed opportunities for broader family-centred vaccination dialogue. A provider in Tigray region observed, “Sometimes when we try to explain vaccines for older people, caregivers smile politely but don’t engage. It’s like they think it’s not their business.” Peer support and team communication were also described as shaping provider confidence. Where routine meetings and mentorship occurred, providers reported stronger capacity to discuss immunization beyond infancy. A public official in Afar region stated, “We have monthly coordination meetings where we discuss immunization programs, including expanding to adult and adolescent vaccines. This helps build our knowledge and confidence,” whereas a public official in Tigray region noted, “Without structured forms or refresher trainings, providers rely on their own understanding, which leads to inconsistent advice and missed opportunities.” Participants also described the influence of trusted local actors on communication and acceptance. A provider from Afar region stated, “When religious leaders speak about vaccines for all ages during community gatherings or prayers, people listen and trust the message more,” and a religious leader added, “We want to help promote life-course immunization but need official information and support to confidently address community concerns.” Some providers indicated that engaging both parents could improve counselling effectiveness. A provider in Amhara region noted, “We encourage both parents to come when possible. When they do, we can explain that vaccines are important for everyone, not just for babies.” Overall, interpersonal dynamics highlight the balance of provider confidence, caregiver receptivity, peer support, and broader social endorsement, emphasizing the need to strengthen communication skills, normalize life-course vaccination in routine visits, and actively involve community influencers. 3.3.3 Community-Level: norms, awareness, and misinformation shaping provider efforts Community norms and collective expectations strongly shaped both demand for life-course immunization and provider willingness to promote it. Providers described a pervasive perception that vaccines are primarily for children. A provider in Amhara explained, “Most people don’t know that vaccines can protect adults or pregnant women from diseases. They think vaccines are just for children,” while a provider in Oromia region added, “Some community members believe vaccines are unnecessary unless they are sick, so preventive vaccination for adults is not common.” Gender norms further influenced provider efforts, with immunization frequently viewed as women’s responsibility and men less likely to attend services. A provider in Tigray remarked, “In our communities, men rarely accompany their families to health institutions or seek vaccines themselves. It’s seen as women’s work,” and a provider in Oromia region noted, “Men don’t ask about vaccines. Even when we explain, they say, ‘It’s the mother’s role.’ This thinking is common.” Misinformation was described as persistent, particularly around infertility, foreign agendas, and exaggerated side effects, especially in relation to HPV and COVID-19 vaccines. A religious leader in Amhara region explained, “Despite church support for vaccines, rumours about harmful effects and foreign plots still circulate, making it hard to convince some people,” and a provider added, “People ask if vaccines are a trick to stop us from having children. This fear still exists, especially with HPV or COVID-19 vaccines.” Providers described difficulty responding calmly and consistently without standardized materials. An Afar region provider highlighted, “Sometimes people argue or refuse in front of others. Without good posters or facts, it’s hard to explain calmly. We need support.” Some participants also described positive examples where respected leaders helped shift norms and increase openness to adult vaccination. A public health official in Afar region stated, “If respected clan or religious leaders promote vaccines for all ages, it helps challenge traditional norms and improves acceptance,” and a provider in Afar described, “In one village, an elder vaccinated his whole family. After that, others started asking more questions. Leadership makes a difference.” 3.3.4 Institutional-Level: service organization, supplies, and information systems Institutional limitations present systemic barriers to life-course immunization. Across regions, providers cited inadequate training, unreliable vaccine supply, weak health information systems, facility design limitations, and staffing shortages as critical impediments. Lack of age-inclusive training was a recurring theme. A provider in Afar stated, “Our formal trainings rarely include detailed information about vaccines for other age groups. We mostly learn about these on the job or through self-study,” while a public official in Amhara added, “Without regular refresher courses focused on life-course immunization, many providers feel uncertain and less motivated to expand services.” Vaccine stock-outs further undermined promotion of adult and adolescent vaccines. A provider in Oromia region explained, “Frequent stock-outs of vaccines for adults and pregnant women make it difficult to provide consistent services, so we focus on childhood vaccines that are always available,” and an Afar region official added, “You feel embarrassed when you tell someone about a vaccine and then they come and it’s not there. It makes you stop promoting it.” Facility design and materials reinforced childhood focus. A Tigray official noted, “The waiting areas and health institution flow are arranged for mothers and children. There is little space or attention given to adult clients, making them feel unwelcome,” while a provider in Oromia region highlighted, “Even posters and counselling materials only show babies and mothers. Adults often ask if the vaccine is really for them.” Data systems also limited accountability for adult vaccination. An Afar region official stated, “Our immunization reports focus on children under five. Adult vaccination data is incomplete or not collected, making it hard to evaluate progress,” and a Tigray official added, “If there is no data or target, no one follows up. It’s not even discussed in performance reviews.” Finally, staff shortages and workload pressures constrained promotion of life-course vaccines. A provider in Afar explained, “We are often overwhelmed with work and few staff. It is challenging to dedicate time to explain vaccines for adults or adolescents,” while a provider in Amhara region noted, “Life-course vaccines are not seen as urgent. So, when time is short, we focus on children and emergencies.” Collectively, these institutional limitations structurally and operationally marginalize life-course immunization. 3.3.5 Policy-Level: operational guidance, targets, and resourcing At the policy level, the absence of clear operational guidance and strategic focus on life-course immunization constrains its uptake. A public health official in Afar explained, “Policy documents heavily focus on under-five vaccination. Life-course immunization is mentioned in passing but lacks operational detail or targets.” This ambiguity leads providers to assume that adult and adolescent vaccination is optional. A Tigray region official remarked, “Without clear targets or job descriptions including adult vaccines, providers focus on what they’re evaluated on—under-five coverage.” Stakeholders across all levels emphasized the need for integrated policies defining roles, indicators, and resource allocation. An Amhara region official highlighted, “We need integrated policies that clearly outline roles, resources, and indicators for life-course vaccination to make it part of routine health services.” Reconstruction periods in conflict-affected regions were viewed as opportunities for inclusive program design. A Tigray region official stated, “Rebuilding after conflict allows us to design inclusive immunization programs from the start, targeting all age groups and marginalized populations.” Resource constraints remain a major limitation. An official from Amhara region noted, “Without dedicated donor funding for adolescent and adult vaccines, life-course immunization will struggle to become sustainable,” and an Afar official added, “We have the motivation but not the money. If it’s not in the budget, we can’t prioritize it.” Furthermore, national guidelines provide limited guidance on engaging community leaders and male household heads. An official from Oromia region explained, “National guidelines focus on child vaccines and do not provide direction on working with community leaders or male heads of households for broader immunization.” In conclusion, policy-level weaknesses, absence of operational detail, unclear directives, insufficient funding, and limited community engagement strategies, contribute to inconsistent service delivery, low provider motivation, and missed public health opportunities. 4. Discussion Our study examined how gender norms and power relations shape immunization behaviors and service delivery across the life course in Ethiopia. Using a socio-ecological lens, we found that barriers operate across intrapersonal, interpersonal, institutional, community, and policy levels, with distinct implications for adolescence, pregnancy, and adulthood. Across regions and participant groups, three cross-cutting mechanisms were prominent: (i) responsibility without authority, where women are expected to manage vaccination but often lack decision-making power; (ii) fertility-related risk perceptions and misinformation, particularly salient for HPV and COVID-19 vaccines; and (iii) system-level prioritization of under-five services, reflected in training, reporting, and accountability structures that limit routine life-course immunization. These findings align with evidence that gendered constraints influence access, acceptance, and interactions with immunization services in LMIC settings [ 12 , 14 , 15 ]. At the interpersonal level, participants described household dynamics that placed the burden of vaccination on mothers while reinforcing gatekeeping roles by fathers or elders. This pattern is consistent with evidence from Ethiopia that women’s autonomy is strongly associated with health service use and care-seeking, and that constrained autonomy can delay or prevent timely preventive services [ 18 ]. Our findings suggest that these household dynamics are amplified for vaccines perceived as “new” or morally sensitive (e.g., HPV), where fertility-related concerns and social sanctions intersect with gendered authority structures [ 14 , 16 ]. Fertility-related misinformation emerged as a recurring barrier shaping both demand and provider communication comfort. Reports of fear that vaccines could compromise fertility or harm reproductive health are consistent with broader literature on HPV vaccine barriers and with work emphasizing behavioral and social drivers of vaccination, including the role of trusted messengers, perceived risks, and misinformation [ 14 , 16 , 17 ] In our study, these concerns were not limited to adolescents; they also shaped perceptions of adult vaccination, especially in the context of COVID-19, where distrust and rumors were described as persistent [ 6 , 17 ]. At the institutional level, our findings indicate that service design and health worker support systems remain oriented toward mothers and young children, limiting routine engagement of men and older age groups. Providers described constrained counselling time under workload pressure and limited access to age-inclusive job aids, which reduced opportunities to address myths and normalize vaccination beyond childhood. These findings echo implementation evidence that immunization coverage depends not only on demand but also on health system capacity, service organization, and effective communication pathways [ 13 ]. They also reinforce the value of applying a socio-ecological perspective when interpreting uptake patterns and designing multi-level responses [ 11 ]. At the community level, participants emphasized masculinity norms and the expectation that immunization is “women’s work,” which discouraged men’s engagement in routine services. However, they also described the influence of religious and community leaders as trusted intermediaries capable of shaping acceptance. This aligns with broader evidence that community perceptions and social norms can either reinforce or mitigate vaccination hesitancy and that strategies leveraging trusted leaders can support uptake when credible information is provided [ 17 , 20 , 21 ]. At the policy level, participants reported that operational guidance, targets, and reporting systems remain centered on under-five coverage, limiting accountability for adolescents and adults. This is especially consequential given that global policy now emphasizes equity and life-course immunization, including reaching missed and underserved populations [ 2 , 5 ] Our findings suggest that the absence of practical guidance on male engagement, combined with limited resourcing for adolescent and adult vaccination, constrains implementation of life-course immunization as a routine health system function [ 5 , 15 , 19 ]. Implications for policy and practice Together, these multilevel findings point to priorities for strengthening gender-responsive life-course immunization in Ethiopia. First, addressing “responsibility without authority” requires engaging men and household decision-makers while reducing the burden placed on mothers, including through communication that frames vaccination as a shared family responsibility [ 12 , 15 ] Second, countering fertility-related myths requires tailored, age-appropriate counselling tools and trusted messenger strategies, including collaboration with community and religious leaders [ 15 , 16 , 17 ] Third, implementing life-course immunization in routine practice will require policy clarity (roles, targets, indicators) and health system investments in workforce training, reporting formats that capture vaccination beyond under-five, and reliable vaccine availability across indicated age groups [ 5 , 13 , 19 ]. Strengths and limitations A key strength of this study is triangulation across caregivers, providers, community and religious leaders, and officials in four regions, enabling a multi-level understanding of gendered barriers across diverse contexts. Limitations include potential social desirability bias in interviews, and the possibility that translation across local languages may have influenced nuance despite quality checks. In addition, the qualitative design supports depth rather than statistical generalizability; however, the findings provide transferable insights for program design in comparable settings [ 25 ]. 5. Conclusion Our findings show that gender norms and power relations shape immunization uptake and service delivery across the life course in Ethiopia through interconnected influences at intrapersonal, interpersonal, institutional, community, and policy levels. Women are often positioned as responsible for vaccination while decision-making authority may rest with fathers or elders, and fertility-related misinformation can undermine confidence in newer vaccines such as HPV and COVID-19. These barriers are reinforced by service organization and accountability systems that prioritize under-five immunization and provide limited routine pathways for engaging men, adolescents, and adults. Strengthening life-course immunization will require gender-responsive approaches that address household decision-making dynamics, equip providers with age-inclusive counselling tools, and align routine services and accountability systems to better engage adolescents, adults, and men. These findings suggest that strengthening life-course immunization in Ethiopia requires gender-responsive action across levels. At the interpersonal and community levels, strategies should address “responsibility without authority” by engaging men and other household decision-makers while reducing burdens placed on mothers, and by leveraging trusted community and religious leaders to counter fertility-related misinformation. At the institutional level, providers need age-inclusive job aids, refresher training, and supportive supervision to normalize counselling beyond childhood and improve responses to rumors. At the policy level, clearer operational guidance, indicators, and resourcing for adolescent and adult vaccination—alongside reporting systems that capture vaccination beyond under-five—are needed to shift routine practice from a child-centered model toward a life-course approach. Declarations Informed Consent Statement Informed consent was obtained from all subjects involved in the study. Participants were fully informed about the study’s purpose, procedures, data handling, and their rights, including voluntary participation and withdrawal at any time. Verbally informed consent was obtained prior to interviews. To ensure confidentiality, interviews were conducted in private settings, and data were anonymized during analysis. Data collectors received training on ethical research conduct, including safeguarding participant privacy and managing sensitive topics related to gender and health behaviors. Conflicts of Interest: “The authors declare no conflicts of interest.” Funding: This research was conducted under the Saving Lives and Livelihoods (SLL) initiative, and did not receive funds. Author Contribution “Conceptualization, methodology, analysis, validation and writing—original writing, G.M.A.; methodology, analysis, writing of the manuscript, (A.A); validation and review of the manuscript; M.T; K.N; V.S; Y.T; G.G; M.D”. All authors have read and agreed to the published version of the manuscript. Acknowledgement We acknowledge Amref Health Africa in Ethiopia for supporting through MasterCard foundation and Africa CDC to conduct this study. We are also grateful to Azmeraw Ayehu Tesfahun (AAT) Research and development consultancy Firm for the support in the process of field work. Data Availability The data presented in this study is available on request from the corresponding author due to privacy reasons. References Shattock AJ, et al. Contribution of vaccination to improved survival and health. Lancet. 2024;403(10441):2307–16. https://doi.org/10.1016/S0140-6736(24)00687-0 . WHO and UNICEF. Estimates of national immunization coverage. 2021. (Accessed September 05, 2025) https://www.who.int/data/gho/data/themes/immunization Kebede SA, et al. Determinants of incomplete immunization among 12–23 months old children in Ethiopia: A multilevel analysis. PLoS ONE. 2025;20(4):e0321947. https://doi.org/10.1371/journal.pone.0321947 . Bantie B, et al. Mapping geographical inequalities of incomplete immunization in Ethiopia. Front Public Health. 2024;12. https://doi.org/10.3389/fpubh.2024.1339539 . World Health Organization. Immunization agenda 2030: A global strategy to leave no one behind. 2020. https://www.immunizationagenda2030.org/ Tadesse AW, et al. COVID-19 vaccine hesitancy and associated factors among parents in Addis Ababa. BMC Public Health. 2023;23(1):554. https://doi.org/10.1186/s12889-023-15345-z . Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology. Oxford University Press; 2002. https://doi.org/10.1093/acprof:oso/9780198578154.001.0001 . Bergen N, et al. Economic-related inequalities in zero-dose children. Vaccines. 2022;10(4):633. https://doi.org/10.3390/vaccines10040633 . Hosseinpoor AR, et al. State of inequality in DTP immunisation coverage. Lancet Glob Health. 2016;4(9):e617–26. https://doi.org/10.1016/S2214-109X(16)30141-3 . Corrêa GC, et al. Measuring zero-dose children: Reflections on age cohort flexibilities. Vaccines. 2024;12(2):195. https://doi.org/10.3390/vaccines12020195 . Olaniyan A, Isiguzo C, Hawk M. The socioecological model as a framework for exploring factors influencing childhood immunization uptake in Lagos State, Nigeria. BMC Public Health. 2021;21(1):867. https://doi.org/10.1186/s12889-021-08677-9 . Closser S, Cox K, Parris TM. Gendered barriers to immunization in low- and middle-income countries. Soc Sci Med. 2022;308:115235. https://doi.org/10.1016/j.socscimed.2022.115235 . Ozawa S, et al. Pathways for improving vaccine coverage in low and middle-income countries. Vaccine. 2019;37(30):4171–7. https://doi.org/10.1016/j.vaccine.2019.06.033 . Bedford H, Attwell K. Vaccine hesitancy and refusal in the context of gender. Vaccine. 2021;39(14):1970–6. https://doi.org/10.1016/j.vaccine.2021.03.044 . UNICEF. A practical guide to integrate a gender lens into immunization programmes. 2019. https://www.unicef.org/rosa/reports/practical-guide-integrate-gender-lens-immunization-programmes Holman DM, et al. Barriers to human papillomavirus vaccination among adolescents: A systematic review. JAMA Pediatr. 2014;168(1):76–82. https://doi.org/10.1001/jamapediatrics.2013.2752 . World Health Organization. Behavioural and social drivers of vaccination: Tools and practical guidance. 2022. https://www.who.int/publications/i/item/9789240054755 Woldemicael G, Tenkorang EY. Women’s autonomy and maternal health-seeking behavior in Ethiopia. Matern Child Health J. 2010;14(6):988–98. https://doi.org/10.1007/s10995-009-0535-2 . Nyasulu BJ, et al. Gender analysis of the WHO online learning program on Immunization Agenda 2030. Front Glob Women’s Health. 2023;4:1172503. https://doi.org/10.3389/fgwh.2023.1172503 . Dhaliwal BK, et al. Community perceptions of vaccination in rural India. BMC Public Health. 2021;21(1):2122. https://doi.org/10.1186/s12889-021-12118-6 . Adamu AA, et al. Understanding demand for childhood vaccinations in Nigeria: A realist review. Lancet Glob Health. 2022;10(7):e1042–55. https://doi.org/10.1016/S2214-109X(22)00159-7 . Eregata GT, et al. Ethiopia’s Essential Health Services Package: An analysis of cost-effectiveness and equity. BMJ Glob Health. 2021;6(3):e006321. https://doi.org/10.1136/bmjgh-2021-006321 . Zida-Compaore WIC, et al. Immunization coverage and factors associated with incomplete vaccination in Lomé. BMC Res Notes. 2019;12(1):84. https://doi.org/10.1186/s13104-019-4118-8 . Mulatu A, et al. Uptake of second dose measles-containing vaccine in central Ethiopia. BMC Public Health. 2025;25(1):1470. https://doi.org/10.1186/s12889-025-01234-5 . Lincoln YS, Guba EG. Naturalistic Inquiry. Sage; 1985. https://doi.org/10.4135/9781412986120 . Additional Declarations No competing interests reported. Supplementary Files Suplementaryfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 23 Dec, 2025 Editor assigned by journal 18 Dec, 2025 Editor invited by journal 10 Dec, 2025 Submission checks completed at journal 10 Dec, 2025 First submitted to journal 10 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8235793","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":565091888,"identity":"1e370a46-f376-44ee-9e73-b5430cfa336f","order_by":0,"name":"Geteneh Moges Assefa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYHACNgbGBhseNmbmA0COhAwxGkBa0uT42dkSQFp4iNVy2Fiyn8cAxCesRT6+99jjwh3MiRsO83x+daPGgoeB/fDRDfi0GB7jSzeeeYYNqIV3m3XOMaDDeNLSbuDV0sZjJs3bxgPWYpzDBtQiwWNGjBYJkMOeGef8I0KLPBtYi4GxZDMP8+PcNiK0GLDlmEnPbEuQ42dmM2PO7ZPgYSPkF/nmM2bShW3/edj4Dz/+nPOtDhhBh4/ht+UAAwMzlM0mASbxKQfb0oDQwvyBkOpRMApGwSgYmQAA/2JAnLMV3RcAAAAASUVORK5CYII=","orcid":"","institution":"Amref Health Africa","correspondingAuthor":true,"prefix":"","firstName":"Geteneh","middleName":"Moges","lastName":"Assefa","suffix":""},{"id":565091894,"identity":"68a0d52c-0f38-4d2b-b41f-8981ce4d0d52","order_by":1,"name":"Michael Tarekegn","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Tarekegn","suffix":""},{"id":565091895,"identity":"60ddb37b-5da5-4447-ac2e-499c61b56a3c","order_by":2,"name":"Kasahun Negash","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Kasahun","middleName":"","lastName":"Negash","suffix":""},{"id":565091896,"identity":"6732f4f0-3f2b-4c54-b8f6-4d5c3d61d5d1","order_by":3,"name":"Azmeraw A. Tesfahun","email":"","orcid":"","institution":"Debre Berhan University","correspondingAuthor":false,"prefix":"","firstName":"Azmeraw","middleName":"A.","lastName":"Tesfahun","suffix":""},{"id":565091900,"identity":"927ef0d5-5597-4669-8791-4ac640c0059b","order_by":4,"name":"Virginia Stulz","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Virginia","middleName":"","lastName":"Stulz","suffix":""},{"id":565091901,"identity":"682ab00a-32e8-4994-847d-b93270eb9833","order_by":5,"name":"Genet G. Kassie","email":"","orcid":"","institution":"Bahir Dar University","correspondingAuthor":false,"prefix":"","firstName":"Genet","middleName":"G.","lastName":"Kassie","suffix":""},{"id":565091908,"identity":"110b9ff5-6237-476b-8684-4db04934f745","order_by":6,"name":"Yawekal Tesga","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"prefix":"","firstName":"Yawekal","middleName":"","lastName":"Tesga","suffix":""},{"id":565091912,"identity":"b813ba1a-cd86-467e-b76b-b894a1d797d8","order_by":7,"name":"Muluken Dessalegn Muluneh","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Muluken","middleName":"Dessalegn","lastName":"Muluneh","suffix":""}],"badges":[],"createdAt":"2025-11-29 09:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8235793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8235793/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99318600,"identity":"2995a36c-90f5-4e20-a6e3-6225764c59e8","added_by":"auto","created_at":"2025-12-31 16:33:43","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120862,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptQualitativepaperGenderandImmunizationCleaned.docx","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/2906945c9fe79057ae68c7ce.docx"},{"id":99223692,"identity":"d57ce211-3ca3-4fa5-8dc6-075b5d062a80","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10179,"visible":true,"origin":"","legend":"","description":"","filename":"c86e8a125755481598ec0178ce953b19.json","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/3f6812e98993a04abfc9996e.json"},{"id":99317720,"identity":"aecdf500-2d6b-446e-a607-b474fdcd3030","added_by":"auto","created_at":"2025-12-31 16:30:38","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73984,"visible":true,"origin":"","legend":"","description":"","filename":"Suplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/2e085dc2923930264c201fd5.docx"},{"id":99223700,"identity":"7b78734a-1db7-4192-83a7-55c4cc81cc54","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115430,"visible":true,"origin":"","legend":"","description":"","filename":"c86e8a125755481598ec0178ce953b191enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/cd559344ad807010a7e26e21.xml"},{"id":99223697,"identity":"fe83f8dc-a2f9-4b2d-90e0-74cfe2261fe7","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":170749,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/658ab8f54f40823fa215c4df.png"},{"id":99317290,"identity":"36fbab49-c012-43cd-addf-51bf6a722216","added_by":"auto","created_at":"2025-12-31 16:29:56","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108857,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/04bf5d0d79bbbbb896cdabcd.png"},{"id":99223701,"identity":"2e3be1aa-76f4-4863-8d7a-6b73a14df496","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107288,"visible":true,"origin":"","legend":"","description":"","filename":"c86e8a125755481598ec0178ce953b191structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/dfcad6ce9b925fbeaeda3a0a.xml"},{"id":99318561,"identity":"49e4d61b-893c-49a8-ad19-0a27594ed8a0","added_by":"auto","created_at":"2025-12-31 16:33:37","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":129925,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/b630ebd84d0c449c273782dd.html"},{"id":99223696,"identity":"d06dae52-b191-447e-b375-b2d0ccb7221a","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":897951,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers to gender equity in immunization across the SEM levels, Ethiopia.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/9fa8969cfb3a64a90c0142fb.jpeg"},{"id":99223695,"identity":"ee4cf8b8-29e4-4d0a-8e22-54ca29709dfa","added_by":"auto","created_at":"2025-12-30 10:01:42","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":838829,"visible":true,"origin":"","legend":"\u003cp\u003eHealth Workers' Perceptions of Life-Course immunization in Ethiopia: A Socio-Ecological Analysis\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/f6cde5fa79d1bb0d9905e0a3.jpeg"},{"id":99323671,"identity":"4778bfca-9ecf-4d4a-9910-81c390ac7e27","added_by":"auto","created_at":"2025-12-31 16:45:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2951994,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/2d31f44c-77a8-4258-9c4b-5c89b317c585.pdf"},{"id":99317697,"identity":"e979909e-1b04-4f1d-9ab4-d46dd3c80183","added_by":"auto","created_at":"2025-12-31 16:30:36","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":73984,"visible":true,"origin":"","legend":"","description":"","filename":"Suplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8235793/v1/e37bf0b62173c6a4b7e6ea36.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging Gender Gaps in Immunization in Ethiopia: A Life Course and Socio- Ecological Qualitative Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eVaccination is one of the most effective public health interventions, preventing 2\u0026ndash;3\u0026nbsp;million deaths annually and contributing significantly to reduced childhood mortality and improved population health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ethiopia has made significant strides in expanding routine immunization coverage, with over 80% of children receiving the first dose of Diphtheria, Tetanus, and Pertussis (DTP). However, challenges persist in ensuring completion of vaccination schedules, equitable access [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and uptake of newer vaccines such as Human Papillomavirus (HPV) and COVID-19 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Life-course immunization extends beyond infancy and early childhood to include vaccination during adolescence (e.g., HPV), pregnancy (e.g., tetanus-containing vaccines), and adulthood (e.g., COVID-19 and other indicated vaccines). Implementing this approach requires service delivery and communication strategies that reach people across changing social roles, decision-making structures, and access constraints over time [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies have highlighted persistent inequities in immunization uptake, especially among children from rural areas, low-income households, and zero-dose communities [5, 6, 7, ]. Gender influences immunization through multiple pathways, including differential access to services (time, mobility, and resources), authority over health decisions within households, and exposure to or ability to challenge\u0026mdash;misinformation and social sanctions. Gender, a critical determinant of health, remains an underexplored factor in immunization equity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While women typically serve as primary caregivers, they often face sociocultural and structural barriers to accessing vaccination services for themselves and their children. Studies have shown that misinformation about vaccine safety, such as fears related to fertility, especially regarding the HPV vaccine, contribute to vaccine hesitancy among women and adolescent girls [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, gender norms influence decision-making power, care-seeking behaviour, and interactions with the health system [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Ethiopia, women have limited autonomy in health decisions, particularly in rural settings, which can delay or prevent timely vaccination [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The lack of gender-transformative policies and programs further compounds these barriers [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Despite the Immunization Agenda 2030\u0026rsquo;s focus on equity and life course immunization, few studies have operationalized a gender lens or examined barriers beyond childhood [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e We apply a socio-ecological lens to locate gendered influences at multiple levels\u0026mdash;intrapersonal (beliefs and risk perceptions), interpersonal (household authority and caregiving roles), institutional (service organization and provider practices), community (norms and information networks), and policy (guidance, targets, and resourcing). A life-course perspective complements this by recognizing that gender roles and power relations shift across adolescence, pregnancy, and adulthood, shaping both demand for\u0026mdash;and delivery of\u0026mdash;vaccination at different stages [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite growing interest in life-course immunization, there is limited qualitative evidence from Ethiopia explaining how gender norms and health-system practices jointly shape vaccine uptake across life stages and across diverse settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This study addresses this gap by exploring gender-related barriers to vaccine uptake across the life course in Ethiopia. Using the SEM enables analysis of multilevel influences\u0026mdash;individual, household, institutional, community, and policy\u0026mdash;while the life course approach highlights how gendered expectations, autonomy constraints, and exposure to health information shift across age stages. Combining these frameworks strengthens explanatory power and helps identify entry points for tailored interventions across the lifespan.\u003c/p\u003e \u003cp\u003eBy triangulating perspectives from caregivers, providers, community and religious leaders, and officials across four regions, this study identifies leverage points for more gender-responsive and life-course\u0026ndash;oriented immunization strategies. Specifically, we ask: How do gender norms and power relations influence access to and decision-making about vaccination across adolescence, pregnancy, and adulthood, and how do institutional and policy contexts reinforce or mitigate these influences?\u003c/p\u003e"},{"header":"2. Materials and Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Setting\u003c/h2\u003e \u003cp\u003e This study employed a multi-site case study design with participatory elements. The \u0026ldquo;case\u0026rdquo; was defined as gendered barriers affecting uptake and delivery of immunization across the life course within routine immunization services and related community structures in Ethiopia. A multi-site approach enabled comparison across diverse sociocultural and livelihood contexts.\u003c/p\u003e \u003cp\u003eThe study was conducted in four Ethiopian regions: Amhara, Oromia, Tigray, and Afar. The four regions were purposively selected to capture diversity in geography, culture, pastoralist vs. agrarian livelihoods, and variation in immunization coverage and gender norms. Fieldwork took place between May\u0026ndash; June, 2025.\u003c/p\u003e \u003cp\u003eThe study was guided by two complementary conceptual frameworks: the Socioecological Model (SEM) and the Life Course Approach. The SEM enabled analysis of intrapersonal, interpersonal, institutional, community, and policy-level factors influencing immunization behaviours [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], while the life course supported interpretation of how gender-related constraints and decision-making dynamics shift across stages such as adolescence, pregnancy/reproductive age, and adulthood [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipatory elements included: (i) engagement with regional/district stakeholders to refine the focus of inquiry and ensure relevance; (ii) iterative reflection with field teams during data collection to adapt probes to local contexts; and (iii) synthesis discussions with technical stakeholders to validate the practical interpretation of themes and identify feasible program entry points (without disclosing identifiable participant information).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sampling and Participants\u003c/h2\u003e \u003cp\u003eParticipants were selected using purposive sampling to capture information-rich perspectives on gender and immunization. A total of 75 individuals were interviewed, comprising 23 healthcare providers, 22 caregivers or parents, 12 religious or community leaders, and 18 regional and district health officials. This diverse sample enabled exploration of gender-related barriers from multiple stakeholder viewpoints across health system and community levels.\u003c/p\u003e \u003cp\u003eRecruitment procedures. Participants were recruited through collaboration with regional and district health offices and health facilities implementing immunization services. Health officials and facility focal persons facilitated initial introductions to eligible participants (caregivers, providers, community/religious leaders, and officials). The research team then provided information about the study, emphasized voluntariness, and obtained consent directly from participants. To reduce power dynamics, interviews were conducted by trained research staff not involved in service delivery or performance supervision.\u003c/p\u003e \u003cp\u003eSaturation and sample adequacy. Recruitment continued until thematic saturation was reached, operationalized as the point at which three consecutive interviews did not generate new codes related to gender and immunization drivers. Saturation assessments were conducted during team debriefings, based on ongoing review of emerging codes and memo summaries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data Collection\u003c/h2\u003e \u003cp\u003eData were collected using semi-structured interview guides informed by the WHO Behavioural and Social Drivers (BeSD) of Vaccination Framework [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The guides were developed in English, translated into Amharic, Afarigna, Tigrigna, and Afan Oromo, and piloted with three respondents for clarity and cultural relevance in each region. The BeSD framework was particularly relevant for exploring gender because it captures how confidence, social expectations, and practical access barriers intersect with gender norms to shape vaccine decisions. The tools are included as \u0026ldquo;Supplementary File 1\u0026rdquo;.\u003c/p\u003e \u003cp\u003eInterviews were conducted by trained qualitative researchers fluent in relevant local languages. Prior to fieldwork, the team received training on qualitative interviewing, research ethics, informed consent, confidentiality, and approaches for discussing potentially sensitive gender norms while minimizing social desirability bias (e.g., neutral probes and non-judgmental prompts). To ensure accuracy, a subset of transcripts was reviewed by bilingual team members through spot-checking against audio and back-checking key passages where meaning was sensitive (e.g., fertility fears, household authority, stigma). Discrepancies were resolved through discussion within the team. All interviews were audio-recorded, lasted between 30\u0026ndash;60 minutes, and were supplemented by field notes capturing tone, body language, and environmental context. Verbal informed consent was obtained from all participants prior to recording.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data Management and Analysis\u003c/h2\u003e \u003cp\u003eAudio recordings were transcribed verbatim, translated into English, and imported into \u003cb\u003eNVivo\u003c/b\u003e for analysis. We used a hybrid approach combining inductive coding with framework organization guided by SEM levels and a life-course lens. Inter-coder reliability was assessed through double-coding of 20% of transcripts.\u003c/p\u003e \u003cp\u003eThemes were organized using a framework analysis, aligned with SEM levels and interpreted through the life course lens. During coding, segments were additionally grouped by life stage (early caregiving, adolescence, reproductive age, adulthood) to trace how gendered barriers and autonomy constraints changed over time. Credibility was enhanced via triangulation across participant types and peer validation of coding categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Rigour and Trustworthiness\u003c/h2\u003e \u003cp\u003eWe applied Lincoln and Guba\u0026rsquo;s criteria to enhance trustworthiness, including credibility, dependability, confirmability, and transferability [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Credibility was strengthened through (i) triangulation across caregivers, providers, leaders, and officials and across four regions; (ii) iterative peer debriefing during coding; and (iii) use of verbatim quotations to anchor interpretations. Dependability was supported by maintaining an audit trail (codebook versions, analytic memos, and coding decisions). Confirmability was supported through reflexive memoing and team discussions to examine assumptions during interpretation. Transferability was supported by providing contextual descriptions of settings, participant categories, and variation across livelihoods and regions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Ethical Considerations\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Ethics Committee of the Federal Ministry of Health (protocol code ETCO/Admin/550/25 and date of approval April 01, 2025). All participants were briefed on the study\u0026rsquo;s purpose, procedures, data handling, and their rights, including voluntary participation and the option to withdraw at any time. Verbal informed consent was obtained before each interview. Confidentiality was maintained by anonymizing transcripts and conducting interviews in private locations chosen by participants. All transcripts were de-identified prior to analysis, and audio files/transcripts were stored on password-protected devices accessible only to the research team. Quotes used in reporting were anonymized to remove names and any potentially identifying details (e.g., facility names).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 75 interviews were conducted across four Ethiopian regions, including 57 in-depth interviews (IDIs) and 18 key informant interviews (KIIs). Participants included 23 healthcare providers, 22 caregivers, 12 community/religious leaders, and 18 regional and district health officials. Most caregivers were women (18 out of 22), while most health workers and officials were men. Participants came from both urban and rural settings in Amhara, Oromia, Tigray, and Afar, offering geographically and socially diverse perspectives (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of study participants, June 2025 (n\u0026thinsp;=\u0026thinsp;75).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParticipant Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInterview Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSex, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003eStudy Region\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge Range (years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfar\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOromia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTigray\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e19\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e26\u0026ndash;36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligious Leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment Officials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e31\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e19\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Gendered Barriers across the Life course through Socio-Ecological Lens\u003c/h2\u003e \u003cp\u003eWe identified gender-related barriers to immunization that operated across socio-ecological levels and varied by life stage. Themes were organized using the socio-ecological model (SEM): intrapersonal, interpersonal, institutional, community, and policy levels. Across these levels, participants described how gender norms shaped responsibility and authority for vaccination decisions, exposure to misinformation (particularly fertility-related concerns), and the extent to which services engaged men, adolescents, and adults.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Intrapersonal level: Gendered risk perceptions and fertility-related concerns across life stages\u003c/h2\u003e \u003cp\u003eIntrapersonal barriers were often expressed as risk perceptions and fears that differed by life stage. Participants described pregnancy-related concerns about fetal harm, adolescent-stage concerns linked to HPV and fertility rumors, and adult-stage concerns related to COVID-19 vaccines and broader mistrust. These perceptions were reinforced by limited access to clear counselling and by gendered expectations that place women at the center of vaccine responsibility while limiting their decision-making power.\u003c/p\u003e \u003cp\u003e\u0026ldquo;After receiving the vaccine, some said it caused another problem\u0026hellip; this misconception makes them refuse the second dose.\u0026rdquo; \u003cem\u003e(Health worker, Amhara Region)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u0026ldquo;People say COVID-19 will disappear by itself, so why take the vaccine? They believe the disease is exaggerated.\u0026rdquo; \u003cem\u003e(Vaccinator, Oromia Region)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u0026ldquo;Women are afraid to take vaccines when pregnant because no one explains properly. They say they do not want something that hurts their baby.\u0026rdquo; \u003cem\u003e(Midwife, Amhara Region)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOne caregiver from the Afar region described, \u003cem\u003e\u0026ldquo;After the child got fever from the vaccine, I was afraid. Nobody told me that was normal,\u0026rdquo;\u003c/em\u003e and another stating, \u003cem\u003e\u0026ldquo;Sometimes I worry about side effects and whether it\u0026rsquo;s safe, but no health worker explained it well,\u0026rdquo;\u003c/em\u003e illustrating gaps in communication from health providers.\u003c/p\u003e \u003cp\u003e\u0026ldquo;There is a rumour that the COVID-19 vaccine causes infertility and blood clotting.\u0026rdquo; \u003cem\u003e(Vaccinator, female, Tigray Region)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThese intrapersonal fears\u0026mdash;ranging from infertility myths to distrust of health messages\u0026mdash;disproportionately shaped decision-making across adolescence, pregnancy, and adulthood.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Interpersonal level: Responsibility and authority in households\u003c/h2\u003e \u003cp\u003eParticipants consistently described a pattern of responsibility without authority, in which mothers were expected to take children for vaccination and manage follow-up, while fathers or elders often held decision-making authority, including the power to approve or refuse vaccination. This dynamic was especially pronounced for newer vaccines and for adolescent girls (e.g., HPV), where permission and fears about fertility intersected with household power relations and disagreements between spouses were common when adverse events occurred.\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;In our context, mothers take the children for vaccination, but they often need permission from the fathers.\u0026rdquo; (Government official, Oromia Region)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSimilarly, one healthcare provider in Oromia explains that in her years of experience she noted that \u003cem\u003e\u0026ldquo;mothers usually cannot bring their babies alone if their husbands disagree\u0026hellip;. Some men forbid it, thinking the child is already healthy,\u0026rdquo;\u003c/em\u003e highlighting how interpersonal dynamics can directly affect child health outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;While I was in the rural area, I witnessed quarrels between couples; husbands blamed their wives for the child\u0026rsquo;s side effects.\u0026rdquo; (Vaccinator, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Girls rely on their parents\u0026rsquo; decision. Even when we teach them, they say they will only take it if their father agrees.\u0026rdquo; (School-linked health worker, Oromia Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFemale caregivers, particularly from Afar and Amhara regions frequently expressed a strong internalization of the belief that the responsibility for their children\u0026rsquo;s health, particularly vaccination, falls solely on mothers. One caregiver from Afar region explained that, \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eonly mothers are expected to take children for vaccines. Men think it\u0026rsquo;s not their responsibility or simply don\u0026rsquo;t know what the vaccines are for,\u0026rdquo;\u003c/em\u003e highlighting the perception that caregiving is exclusively maternal.\u003c/p\u003e \u003cp\u003eSimilarly, a male caregiver from Tigray region reflected on his past misunderstanding, stating, \u003cem\u003e\u0026ldquo;I know about vaccines now, but earlier I thought it was just women\u0026rsquo;s business. No one ever explained to me that I should be involved as a father,\u0026rdquo;\u003c/em\u003e which illustrates how internalized beliefs constrain male engagement. In Oromia region, another caregiver emphasized, \u003cem\u003e\u0026ldquo;Men usually say their job is to provide money; they don\u0026rsquo;t think of bringing the child to the health institution. It\u0026rsquo;s just how things are,\u0026rdquo;\u003c/em\u003e reinforcing how societal expectations define paternal roles narrowly.\u003c/p\u003e \u003cp\u003e These narratives reflect broader societal attitudes that place the burden of caregiving squarely on women, reinforcing their exclusion from public health decision-making spaces. Moreover, caregivers reported that heavy domestic workloads and emotional stress reduced their capacity to prioritize immunization.\u003c/p\u003e \u003cp\u003eHealth workers and religious leaders recognized these gendered challenges, acknowledging that immunization sessions and messaging largely targeted mothers, unintentionally excluding fathers. A provider in Afar admitted, \u003cem\u003e\u0026ldquo;We don\u0026rsquo;t receive proper orientation on how to bring fathers into the discussion. Even though we say, \u0026lsquo;both parents should care,\u0026rsquo; most sessions are directed at mothers,\u0026rdquo;\u003c/em\u003e and added that, \u003cem\u003e\u0026ldquo;Health talks are usually given to women. Men are left out because we don\u0026rsquo;t have guidelines on how to include them.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThese dynamics reveal how gender norms and power hierarchies within families and interactions with providers significantly influence vaccination behaviours across life stages.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Institutional level: Service organization and workflows that center mothers and young children\u003c/h2\u003e \u003cp\u003eAt the institutional level, participants described how the organization of immunization services implicitly positioned vaccination as a maternal responsibility. Facility workflows, waiting spaces, and health education materials were perceived to be oriented toward mothers of young children, which limited men\u0026rsquo;s engagement and reduced opportunities for counselling adolescents, pregnant women, and adults. Providers also described staffing and workload constraints that shortened counselling time and limited the ability to address misinformation.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We borrowed vaccines from other facilities. There was nothing in stock when people arrived.\" (Vaccinator, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese gaps disproportionately impacted women, who were often left without timely services or proper explanations.\u003c/p\u003e \u003cp\u003eAnother health worker also highlights systemic gaps in workforce preparation, explaining poor counselling and inconsistent service quality.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;None of the training is given for our staff who work on the Extended Program for Immunization in my experience.\u0026rdquo; (Vaccinator, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThere are only two vaccinators\u0026hellip; they become overburdened and result in limited information for caregivers.\u0026rdquo; (Health worker, Oromia Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When people reach the health facility, no supplies are at hand, so they turn back.\u0026rdquo; (Facility manager, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is hard to say staff are trained on gender competencies\u0026hellip; there has not been much focus on this.\u0026rdquo; (Health official, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInstitutional fragility\u0026mdash;particularly workforce shortages and poor communication\u0026mdash;contributed to gender-specific missed opportunities, especially for pregnant women and young mothers.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe staff were busy. They did not provide me with any information about the vaccine; they only wrote my child\u0026rsquo;s next appointment.\u0026rdquo; (Caregiver, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Pregnant women become worried when nobody explains why they need the vaccines. They say, \u0026lsquo;I don\u0026rsquo;t want to take something that harms my baby.\u0026rdquo; (Midwife, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe other perspective this research discovered is that the health facilities often reinforce gender biases by targeting mothers in service delivery. A provider in Afar observed, \u003cem\u003e\u0026ldquo;Even we providers unconsciously treat immunization as women\u0026rsquo;s work. Our posters, talks, and appointment cards are directed at mothers. Men don\u0026rsquo;t feel invited or welcome.\u0026rdquo;\u003c/em\u003e Physical environments within clinics, such as segregated seating and lack of male-focused materials, further discourage fathers, as noted by a Tigray provider: \u003cem\u003e\u0026ldquo;Mothers sit on one side, and there\u0026rsquo;s no space or reason for fathers to join in. Men feel out of place and prefer to wait outside.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe lack of formal training and operational guidance for male-inclusive approaches exacerbates these challenges. A public health official in Amhara stated, \u003cem\u003e\u0026ldquo;There is no official guide or training on how to work with male caregivers or traditional leaders. Everything depends on the individual health worker\u0026rsquo;s motivation.\u0026rdquo;\u003c/em\u003e Motivated staff, however, can transform service delivery to foster male engagement when institutional support is provided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4 Community-Level: Underused Local Influencers\u003c/h2\u003e \u003cp\u003eCommunity norms and informal communication networks shaped vaccine attitudes more strongly than formal messaging. Pastoralist communities relied heavily on social networks such as \u003cem\u003edagu\u003c/em\u003e, while religious interpretations influenced whether vaccination was timely or delayed. Despite this high influence, religious and traditional leaders were underutilized in immunization advocacy. While several leaders expressed willingness to promote vaccines, they had rarely been formally engaged.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The community listens more when religious leaders speak.\u0026rdquo; (Health worker, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I believe religious leaders can debunk myths\u0026hellip; but we have never been engaged in vaccination campaigns.\u0026rdquo; (Religious leader, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eReligious and community leaders can mobilize male participation but often remain underutilized. As one Afar leader stated, \u003cem\u003e\u0026ldquo;Our people respect religious words more than anything else. When we tell them vaccination is safe and both parents should participate, they listen carefully. But we rarely get formal invitations or training to support this work,\u0026rdquo;\u003c/em\u003e highlighting the need for formal engagement. Persistent myths about vaccines continue to undermine efforts, with a religious leader in Amhara explaining, \u003cem\u003e\u0026ldquo;The church supports immunization, but some still believe vaccines cause infertility or diseases. We must keep teaching and confronting these myths openly,\u0026rdquo;\u003c/em\u003e and a caregiver in Oromia adding, \u003cem\u003e\u0026ldquo;People sometimes say vaccines are foreign and dangerous; that scares many families.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is what is called dagu, a way of exchanging information\u0026hellip; we use dagu and local influencers to respond to concerns.\u0026rdquo; (Health extension worker, AfarRegion)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some delay vaccines until after baptism\u0026hellip; that is why the first doses are sometimes missed.\u0026rdquo; (Community member, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe study also found out that at the community level, deeply rooted social norms significantly influence male involvement. In rural areas, traditional ideals of masculinity discourage fathers from active caregiving. A religious leader from Tigray noted, \u003cem\u003e\u0026ldquo;In rural areas, if a man carries a child to the health institution, people say he is \u0026lsquo;controlled by his wife.\u0026rsquo; That\u0026rsquo;s why many men stay away. They fear being mocked by neighbours or relatives,\u0026rdquo;\u003c/em\u003e while a community leader from Afar added, \u003cem\u003e\u0026ldquo;Men are afraid of gossip and prefer not to be seen at maternal health institutions,\u0026rdquo;\u003c/em\u003e demonstrating how social pressures perpetuate exclusion.\u003c/p\u003e \u003cp\u003eIn contrast, urban and semi-urban areas show gradual norm shifts. In Afar, a public health official explained, \u003cem\u003e\u0026ldquo;Here in the town (\u003c/em\u003eSemera), \u003cem\u003emore men are supporting vaccination. We have worked hard with local leaders to make that normal. We engage men during community meetings and use media messages to challenge old ideas,\u0026rdquo;\u003c/em\u003e and a caregiver noted, \u003cem\u003e\u0026ldquo;Younger men in town are more open to participating in child health than older generations,\u0026rdquo;\u003c/em\u003e reflecting evolving attitudes facilitated by leadership and media.\u003c/p\u003e \u003cp\u003eThese findings show how social structures\u0026mdash;religious authority, traditional information systems, and community norms\u0026mdash;strongly mediate acceptance across the life course, particularly for adolescents and new mothers.\u003c/p\u003e \u003cp\u003eDelays in vaccination were also attributed to religious customs, such as postponing vaccines until after baptism.\u003c/p\u003e \u003cp\u003eA religious leader from Tigray noted, \u003cem\u003e\u0026ldquo;Religious leaders and men want to help, but they are not involved in planning or outreach,\u0026rdquo;\u003c/em\u003e highlighting the untapped potential of influential community actors.\u003c/p\u003e \u003cp\u003eSome religious leaders also noted their capacity to challenge internalized beliefs, with one stating, \u003cem\u003e\u0026ldquo;I believe that the wisdom of vaccination was formulated by God. Health is given from God, but humans must do everything possible to prevent disease\u0026hellip; and it is good to use what scientists have discovered,\u0026rdquo;\u003c/em\u003e illustrating how faith can support health promotion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.5 Policy-Level: Coordination and Gender Integration Gaps\u003c/h2\u003e \u003cp\u003eAt the policy level, participants emphasized limited operational guidance, targets, and resourcing for life-course immunization and for male engagement. Officials and providers described how program priorities and accountability structures remained centered on under-five coverage, contributing to weaker emphasis on adolescents and adults except during campaigns.\u003c/p\u003e \u003cp\u003eOfficials highlighted a notable absence of explicit guidance for male-inclusive immunization strategies. As an Afar official explained, \u003cem\u003e\u0026ldquo;The Ministry talks about community engagement but does not detail strategies for involving men or religious leaders. This leaves local teams without clear direction.\u0026rdquo;\u003c/em\u003e Funding and national programmatic priorities similarly focus on women, limiting the sustainability of male-inclusive interventions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most outreach campaigns assume women are the only targets. Donors and governments need to allocate specific budgets to engage men and community leaders effectively.\u0026rdquo; (Public health official, Amhara Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The most critical challenge is budget shortfalls\u0026hellip; our outreach teams cannot reach all communities.\u0026rdquo; (Government official, Afar Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We could resolve the logistic and budget related issues by negotiating with partners, but due to the weak link and lack of coordination, we are unable to engage productively.\u0026rdquo; (NGO Technical Assistant, Afar)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Gender has not been given much attention in immunization\u0026hellip; it should be included as a component.\u0026rdquo; (Policy maker, Oromia Region)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePolicy-level weaknesses, especially inadequate funding and the absence of gender mainstreaming\u0026mdash;exacerbated community, interpersonal, and institutional barriers, with cumulative effects across the life course.\u003c/p\u003e \u003cp\u003eThe below figure shows across settings, gender norms shaped both \u003cem\u003ewho is expected to seek vaccination\u003c/em\u003e and \u003cem\u003ewho has authority to approve it\u003c/em\u003e. These interpersonal dynamics interacted with institutional service design that centers mothers and under-five services, community stigma that discourages male participation, and policy environments that provide limited operational guidance for life-course immunization. Together, these multilevel influences contributed to missed opportunities for vaccination during adolescence, pregnancy, and adulthood, particularly when misinformation and fertility concerns were not addressed through trusted counselling and community channels.The below figure depicts across settings, gender norms shaped both \u003cem\u003ewho is expected to seek vaccination\u003c/em\u003e and \u003cem\u003ewho has authority to approve it\u003c/em\u003e. These interpersonal dynamics interacted with institutional service design that centers mothers and under-five services, community stigma that discourages male participation, and policy environments that provide limited operational guidance for life-course immunization. Together, these multilevel influences contributed to missed opportunities for vaccination during adolescence, pregnancy, and adulthood, particularly when misinformation and fertility concerns were not addressed through trusted counselling and community channels.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Health Workers\u0026rsquo; Perception of Life-Course Immunization\u003c/h2\u003e \u003cp\u003eThis section describes health workers\u0026rsquo; accounts of factors shaping the delivery of life-course immunization, including training and guidance, counselling practices under workload constraints, and prioritization driven by reporting systems and program targets. Using the socio-ecological model (SEM), findings are organized across intrapersonal, interpersonal, community, institutional, and policy levels to illustrate how provider knowledge and practices interact with community expectations, service environments, and policy directives that continue to emphasize under-five immunization.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Intrapersonal-level factors: training, knowledge, and confidence gaps\u003c/h2\u003e \u003cp\u003eHealth workers described substantial intrapersonal challenges that shaped how they perceived and practiced life-course immunization. While most providers reported confidence in administering and promoting childhood vaccines, knowledge of vaccines for other life stages\u0026mdash;particularly for adolescents, pregnant women beyond tetanus toxoid (TT), and older adults\u0026mdash;was often limited or fragmented.\u003c/p\u003e \u003cp\u003eA healthcare provider from Amhara region noted, \u0026ldquo;Most of our training is centered on vaccines for under-five children. Life-course immunization is a new concept, and many providers have not received detailed instructions about it,\u0026rdquo; while another provider in Oromia region reflected, \u0026ldquo;People often think vaccination only means childhood immunization. I have heard colleagues say they are not sure which vaccines should be given after infancy.\u0026rdquo; Similarly, a provider in Afar region stated, \u0026ldquo;I\u0026rsquo;m unsure about the vaccine schedules beyond children; we rarely get updated or specific guidance on these age groups.\u0026rdquo;\u003c/p\u003e \u003cp\u003eDespite these gaps, many providers expressed supportive attitudes toward life-course vaccination. A provider from Tigray region explained, \u0026ldquo;I understand that vaccination at all stages is beneficial, but without training and resources, it\u0026rsquo;s hard to promote vaccines for adults with authority,\u0026rdquo; and a provider in Oromia region added, \u0026ldquo;We want to educate clients about the importance of all vaccines, but we don't have age-specific guides.\u0026rdquo; Several participants noted that this mismatch\u0026mdash;positive orientation without sufficient guidance or tools\u0026mdash;often reduced how proactively providers raised life-course vaccination during routine encounters, particularly when adult vaccination was not framed as a routine expectation.\u003c/p\u003e \u003cp\u003eProviders also reported that adult vaccination was frequently viewed as unnecessary in the absence of symptoms, and that rumors\u0026mdash;especially infertility-related concerns\u0026mdash;shaped their communication comfort. A provider from Afar explained, \u0026ldquo;Adults are often suspicious when offered vaccines. They ask why they need vaccines if they feel healthy and sometimes fear side effects,\u0026rdquo; while another in Mille (Afar region) stated, \u0026ldquo;Rumours about vaccines causing harm or infertility make me cautious to strongly recommend vaccines for adolescents and adults.\u0026rdquo; One provider added, \u0026ldquo;We worry people will say we are testing new things on them. Unless it\u0026rsquo;s a campaign or emergency, many adults resist vaccines.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOverall, intrapersonal-level influences reveal a complex interplay of limited technical knowledge, positive but underutilized attitudes, perceived risks in patient communication, and internalized stigma about adult vaccination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Interpersonal level: counselling practices and anticipatory avoidance under workload\u003c/h2\u003e \u003cp\u003eAt the interpersonal level, provider\u0026ndash;client communication was described as a key determinant of whether life-course immunization was discussed during routine visits. Providers often tailored counselling to what they perceived caregivers expected, which was largely childhood vaccination. A provider in Amhara region explained, \u0026ldquo;Mothers usually come for their children\u0026rsquo;s vaccines. When we mention vaccines for pregnant women or older adults, many seem confused and do not ask questions,\u0026rdquo; while a provider in Oromia region noted, \u0026ldquo;If caregivers don\u0026rsquo;t express interest, we don\u0026rsquo;t want to overwhelm them or seem pushy, so we often avoid discussing vaccines for other family members.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThis anticipatory avoidance\u0026mdash;based on assumed disinterest or potential resistance\u0026mdash;was described as contributing to missed opportunities for broader family-centred vaccination dialogue. A provider in Tigray region observed, \u0026ldquo;Sometimes when we try to explain vaccines for older people, caregivers smile politely but don\u0026rsquo;t engage. It\u0026rsquo;s like they think it\u0026rsquo;s not their business.\u0026rdquo;\u003c/p\u003e \u003cp\u003ePeer support and team communication were also described as shaping provider confidence. Where routine meetings and mentorship occurred, providers reported stronger capacity to discuss immunization beyond infancy. A public official in Afar region stated, \u0026ldquo;We have monthly coordination meetings where we discuss immunization programs, including expanding to adult and adolescent vaccines. This helps build our knowledge and confidence,\u0026rdquo; whereas a public official in Tigray region noted, \u0026ldquo;Without structured forms or refresher trainings, providers rely on their own understanding, which leads to inconsistent advice and missed opportunities.\u0026rdquo;\u003c/p\u003e \u003cp\u003e Participants also described the influence of trusted local actors on communication and acceptance. A provider from Afar region stated, \u0026ldquo;When religious leaders speak about vaccines for all ages during community gatherings or prayers, people listen and trust the message more,\u0026rdquo; and a religious leader added, \u0026ldquo;We want to help promote life-course immunization but need official information and support to confidently address community concerns.\u0026rdquo; Some providers indicated that engaging both parents could improve counselling effectiveness. A provider in Amhara region noted, \u0026ldquo;We encourage both parents to come when possible. When they do, we can explain that vaccines are important for everyone, not just for babies.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOverall, interpersonal dynamics highlight the balance of provider confidence, caregiver receptivity, peer support, and broader social endorsement, emphasizing the need to strengthen communication skills, normalize life-course vaccination in routine visits, and actively involve community influencers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Community-Level: norms, awareness, and misinformation shaping provider efforts\u003c/h2\u003e \u003cp\u003eCommunity norms and collective expectations strongly shaped both demand for life-course immunization and provider willingness to promote it. Providers described a pervasive perception that vaccines are primarily for children. A provider in Amhara explained, \u0026ldquo;Most people don\u0026rsquo;t know that vaccines can protect adults or pregnant women from diseases. They think vaccines are just for children,\u0026rdquo; while a provider in Oromia region added, \u0026ldquo;Some community members believe vaccines are unnecessary unless they are sick, so preventive vaccination for adults is not common.\u0026rdquo;\u003c/p\u003e \u003cp\u003eGender norms further influenced provider efforts, with immunization frequently viewed as women\u0026rsquo;s responsibility and men less likely to attend services. A provider in Tigray remarked, \u0026ldquo;In our communities, men rarely accompany their families to health institutions or seek vaccines themselves. It\u0026rsquo;s seen as women\u0026rsquo;s work,\u0026rdquo; and a provider in Oromia region noted, \u0026ldquo;Men don\u0026rsquo;t ask about vaccines. Even when we explain, they say, \u0026lsquo;It\u0026rsquo;s the mother\u0026rsquo;s role.\u0026rsquo; This thinking is common.\u0026rdquo;\u003c/p\u003e \u003cp\u003eMisinformation was described as persistent, particularly around infertility, foreign agendas, and exaggerated side effects, especially in relation to HPV and COVID-19 vaccines. A religious leader in Amhara region explained, \u0026ldquo;Despite church support for vaccines, rumours about harmful effects and foreign plots still circulate, making it hard to convince some people,\u0026rdquo; and a provider added, \u0026ldquo;People ask if vaccines are a trick to stop us from having children. This fear still exists, especially with HPV or COVID-19 vaccines.\u0026rdquo; Providers described difficulty responding calmly and consistently without standardized materials. An Afar region provider highlighted, \u0026ldquo;Sometimes people argue or refuse in front of others. Without good posters or facts, it\u0026rsquo;s hard to explain calmly. We need support.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSome participants also described positive examples where respected leaders helped shift norms and increase openness to adult vaccination. A public health official in Afar region stated, \u0026ldquo;If respected clan or religious leaders promote vaccines for all ages, it helps challenge traditional norms and improves acceptance,\u0026rdquo; and a provider in Afar described, \u0026ldquo;In one village, an elder vaccinated his whole family. After that, others started asking more questions. Leadership makes a difference.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.3.4 Institutional-Level: service organization, supplies, and information systems\u003c/h2\u003e \u003cp\u003eInstitutional limitations present systemic barriers to life-course immunization. Across regions, providers cited inadequate training, unreliable vaccine supply, weak health information systems, facility design limitations, and staffing shortages as critical impediments.\u003c/p\u003e \u003cp\u003eLack of age-inclusive training was a recurring theme. A provider in Afar stated, \u003cem\u003e\u0026ldquo;Our formal trainings rarely include detailed information about vaccines for other age groups. We mostly learn about these on the job or through self-study,\u0026rdquo;\u003c/em\u003e while a public official in Amhara added, \u003cem\u003e\u0026ldquo;Without regular refresher courses focused on life-course immunization, many providers feel uncertain and less motivated to expand services.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eVaccine stock-outs further undermined promotion of adult and adolescent vaccines. A provider in Oromia region explained, \u003cem\u003e\u0026ldquo;Frequent stock-outs of vaccines for adults and pregnant women make it difficult to provide consistent services, so we focus on childhood vaccines that are always available,\u0026rdquo;\u003c/em\u003e and an Afar region official added, \u003cem\u003e\u0026ldquo;You feel embarrassed when you tell someone about a vaccine and then they come and it\u0026rsquo;s not there. It makes you stop promoting it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFacility design and materials reinforced childhood focus. A Tigray official noted, \u003cem\u003e\u0026ldquo;The waiting areas and health institution flow are arranged for mothers and children. There is little space or attention given to adult clients, making them feel unwelcome,\u0026rdquo;\u003c/em\u003e while a provider in Oromia region highlighted, \u003cem\u003e\u0026ldquo;Even posters and counselling materials only show babies and mothers. Adults often ask if the vaccine is really for them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eData systems also limited accountability for adult vaccination. An Afar region official stated, \u003cem\u003e\u0026ldquo;Our immunization reports focus on children under five. Adult vaccination data is incomplete or not collected, making it hard to evaluate progress,\u0026rdquo;\u003c/em\u003e and a Tigray official added, \u003cem\u003e\u0026ldquo;If there is no data or target, no one follows up. It\u0026rsquo;s not even discussed in performance reviews.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFinally, staff shortages and workload pressures constrained promotion of life-course vaccines. A provider in Afar explained, \u003cem\u003e\u0026ldquo;We are often overwhelmed with work and few staff. It is challenging to dedicate time to explain vaccines for adults or adolescents,\u0026rdquo;\u003c/em\u003e while a provider in Amhara region noted, \u003cem\u003e\u0026ldquo;Life-course vaccines are not seen as urgent. So, when time is short, we focus on children and emergencies.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eCollectively, these institutional limitations structurally and operationally marginalize life-course immunization.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e3.3.5 Policy-Level: operational guidance, targets, and resourcing\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eAt the policy level, the absence of clear operational guidance and strategic focus on life-course immunization constrains its uptake. A public health official in Afar explained, \u003cem\u003e\u0026ldquo;Policy documents heavily focus on under-five vaccination. Life-course immunization is mentioned in passing but lacks operational detail or targets.\u0026rdquo;\u003c/em\u003e This ambiguity leads providers to assume that adult and adolescent vaccination is optional. A Tigray region official remarked, \u003cem\u003e\u0026ldquo;Without clear targets or job descriptions including adult vaccines, providers focus on what they\u0026rsquo;re evaluated on\u0026mdash;under-five coverage.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eStakeholders across all levels emphasized the need for integrated policies defining roles, indicators, and resource allocation. An Amhara region official highlighted, \u003cem\u003e\u0026ldquo;We need integrated policies that clearly outline roles, resources, and indicators for life-course vaccination to make it part of routine health services.\u0026rdquo;\u003c/em\u003e Reconstruction periods in conflict-affected regions were viewed as opportunities for inclusive program design. A Tigray region official stated, \u003cem\u003e\u0026ldquo;Rebuilding after conflict allows us to design inclusive immunization programs from the start, targeting all age groups and marginalized populations.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eResource constraints remain a major limitation. An official from Amhara region noted, \u003cem\u003e\u0026ldquo;Without dedicated donor funding for adolescent and adult vaccines, life-course immunization will struggle to become sustainable,\u0026rdquo;\u003c/em\u003e and an Afar official added, \u003cem\u003e\u0026ldquo;We have the motivation but not the money. If it\u0026rsquo;s not in the budget, we can\u0026rsquo;t prioritize it.\u0026rdquo;\u003c/em\u003e Furthermore, national guidelines provide limited guidance on engaging community leaders and male household heads.\u003c/p\u003e \u003cp\u003eAn official from Oromia region explained, \u003cem\u003e\u0026ldquo;National guidelines focus on child vaccines and do not provide direction on working with community leaders or male heads of households for broader immunization.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn conclusion, policy-level weaknesses, absence of operational detail, unclear directives, insufficient funding, and limited community engagement strategies, contribute to inconsistent service delivery, low provider motivation, and missed public health opportunities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur study examined how gender norms and power relations shape immunization behaviors and service delivery across the life course in Ethiopia. Using a socio-ecological lens, we found that barriers operate across intrapersonal, interpersonal, institutional, community, and policy levels, with distinct implications for adolescence, pregnancy, and adulthood. Across regions and participant groups, three cross-cutting mechanisms were prominent: (i) responsibility without authority, where women are expected to manage vaccination but often lack decision-making power; (ii) fertility-related risk perceptions and misinformation, particularly salient for HPV and COVID-19 vaccines; and (iii) system-level prioritization of under-five services, reflected in training, reporting, and accountability structures that limit routine life-course immunization. These findings align with evidence that gendered constraints influence access, acceptance, and interactions with immunization services in LMIC settings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the interpersonal level, participants described household dynamics that placed the burden of vaccination on mothers while reinforcing gatekeeping roles by fathers or elders. This pattern is consistent with evidence from Ethiopia that women\u0026rsquo;s autonomy is strongly associated with health service use and care-seeking, and that constrained autonomy can delay or prevent timely preventive services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our findings suggest that these household dynamics are amplified for vaccines perceived as \u0026ldquo;new\u0026rdquo; or morally sensitive (e.g., HPV), where fertility-related concerns and social sanctions intersect with gendered authority structures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFertility-related misinformation emerged as a recurring barrier shaping both demand and provider communication comfort. Reports of fear that vaccines could compromise fertility or harm reproductive health are consistent with broader literature on HPV vaccine barriers and with work emphasizing behavioral and social drivers of vaccination, including the role of trusted messengers, perceived risks, and misinformation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In our study, these concerns were not limited to adolescents; they also shaped perceptions of adult vaccination, especially in the context of COVID-19, where distrust and rumors were described as persistent [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the institutional level, our findings indicate that service design and health worker support systems remain oriented toward mothers and young children, limiting routine engagement of men and older age groups. Providers described constrained counselling time under workload pressure and limited access to age-inclusive job aids, which reduced opportunities to address myths and normalize vaccination beyond childhood. These findings echo implementation evidence that immunization coverage depends not only on demand but also on health system capacity, service organization, and effective communication pathways [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. They also reinforce the value of applying a socio-ecological perspective when interpreting uptake patterns and designing multi-level responses [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the community level, participants emphasized masculinity norms and the expectation that immunization is \u0026ldquo;women\u0026rsquo;s work,\u0026rdquo; which discouraged men\u0026rsquo;s engagement in routine services. However, they also described the influence of religious and community leaders as trusted intermediaries capable of shaping acceptance. This aligns with broader evidence that community perceptions and social norms can either reinforce or mitigate vaccination hesitancy and that strategies leveraging trusted leaders can support uptake when credible information is provided [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the policy level, participants reported that operational guidance, targets, and reporting systems remain centered on under-five coverage, limiting accountability for adolescents and adults. This is especially consequential given that global policy now emphasizes equity and life-course immunization, including reaching missed and underserved populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Our findings suggest that the absence of practical guidance on male engagement, combined with limited resourcing for adolescent and adult vaccination, constrains implementation of life-course immunization as a routine health system function [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for policy and practice\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTogether, these multilevel findings point to priorities for strengthening gender-responsive life-course immunization in Ethiopia. First, addressing \u0026ldquo;responsibility without authority\u0026rdquo; requires engaging men and household decision-makers while reducing the burden placed on mothers, including through communication that frames vaccination as a shared family responsibility [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Second, countering fertility-related myths requires tailored, age-appropriate counselling tools and trusted messenger strategies, including collaboration with community and religious leaders [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Third, implementing life-course immunization in routine practice will require policy clarity (roles, targets, indicators) and health system investments in workforce training, reporting formats that capture vaccination beyond under-five, and reliable vaccine availability across indicated age groups [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA key strength of this study is triangulation across caregivers, providers, community and religious leaders, and officials in four regions, enabling a multi-level understanding of gendered barriers across diverse contexts. Limitations include potential social desirability bias in interviews, and the possibility that translation across local languages may have influenced nuance despite quality checks. In addition, the qualitative design supports depth rather than statistical generalizability; however, the findings provide transferable insights for program design in comparable settings [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur findings show that gender norms and power relations shape immunization uptake and service delivery across the life course in Ethiopia through interconnected influences at intrapersonal, interpersonal, institutional, community, and policy levels. Women are often positioned as responsible for vaccination while decision-making authority may rest with fathers or elders, and fertility-related misinformation can undermine confidence in newer vaccines such as HPV and COVID-19. These barriers are reinforced by service organization and accountability systems that prioritize under-five immunization and provide limited routine pathways for engaging men, adolescents, and adults. Strengthening life-course immunization will require gender-responsive approaches that address household decision-making dynamics, equip providers with age-inclusive counselling tools, and align routine services and accountability systems to better engage adolescents, adults, and men.\u003c/p\u003e \u003cp\u003eThese findings suggest that strengthening life-course immunization in Ethiopia requires gender-responsive action across levels. At the interpersonal and community levels, strategies should address \u0026ldquo;responsibility without authority\u0026rdquo; by engaging men and other household decision-makers while reducing burdens placed on mothers, and by leveraging trusted community and religious leaders to counter fertility-related misinformation. At the institutional level, providers need age-inclusive job aids, refresher training, and supportive supervision to normalize counselling beyond childhood and improve responses to rumors. At the policy level, clearer operational guidance, indicators, and resourcing for adolescent and adult vaccination\u0026mdash;alongside reporting systems that capture vaccination beyond under-five\u0026mdash;are needed to shift routine practice from a child-centered model toward a life-course approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eInformed Consent Statement\u003c/h2\u003e Informed consent was obtained from all subjects involved in the study. Participants were fully informed about the study\u0026rsquo;s purpose, procedures, data handling, and their rights, including voluntary participation and withdrawal at any time. Verbally informed consent was obtained prior to interviews. To ensure confidentiality, interviews were conducted in private settings, and data were anonymized during analysis. Data collectors received training on ethical research conduct, including safeguarding participant privacy and managing sensitive topics related to gender and health behaviors.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflicts of Interest:\u003c/h2\u003e \u003cp\u003e\u0026ldquo;The authors declare no conflicts of interest.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was conducted under the Saving Lives and Livelihoods (SLL) initiative, and did not receive funds.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e\u0026ldquo;Conceptualization, methodology, analysis, validation and writing\u0026mdash;original writing, G.M.A.; methodology, analysis, writing of the manuscript, (A.A); validation and review of the manuscript; M.T; K.N; V.S; Y.T; G.G; M.D\u0026rdquo;. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge Amref Health Africa in Ethiopia for supporting through MasterCard foundation and Africa CDC to conduct this study. We are also grateful to Azmeraw Ayehu Tesfahun (AAT) Research and development consultancy Firm for the support in the process of field work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data presented in this study is available on request from the corresponding author due to privacy reasons.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShattock AJ, et al. Contribution of vaccination to improved survival and health. Lancet. 2024;403(10441):2307\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(24)00687-0\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(24)00687-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO and UNICEF. Estimates of national immunization coverage. 2021. (Accessed September 05, 2025) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/themes/immunization\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/themes/immunization\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKebede SA, et al. Determinants of incomplete immunization among 12\u0026ndash;23 months old children in Ethiopia: A multilevel analysis. PLoS ONE. 2025;20(4):e0321947. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0321947\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0321947\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBantie B, et al. Mapping geographical inequalities of incomplete immunization in Ethiopia. Front Public Health. 2024;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2024.1339539\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1339539\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Immunization agenda 2030: A global strategy to leave no one behind. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.immunizationagenda2030.org/\u003c/span\u003e\u003cspan address=\"https://www.immunizationagenda2030.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadesse AW, et al. COVID-19 vaccine hesitancy and associated factors among parents in Addis Ababa. BMC Public Health. 2023;23(1):554. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-023-15345-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-15345-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology. Oxford University Press; 2002. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/acprof:oso/9780198578154.001.0001\u003c/span\u003e\u003cspan address=\"10.1093/acprof:oso/9780198578154.001.0001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergen N, et al. Economic-related inequalities in zero-dose children. Vaccines. 2022;10(4):633. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/vaccines10040633\u003c/span\u003e\u003cspan address=\"10.3390/vaccines10040633\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseinpoor AR, et al. State of inequality in DTP immunisation coverage. Lancet Glob Health. 2016;4(9):e617\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2214-109X(16)30141-3\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(16)30141-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorr\u0026ecirc;a GC, et al. Measuring zero-dose children: Reflections on age cohort flexibilities. Vaccines. 2024;12(2):195. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/vaccines12020195\u003c/span\u003e\u003cspan address=\"10.3390/vaccines12020195\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlaniyan A, Isiguzo C, Hawk M. The socioecological model as a framework for exploring factors influencing childhood immunization uptake in Lagos State, Nigeria. BMC Public Health. 2021;21(1):867. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-021-08677-9\u003c/span\u003e\u003cspan address=\"10.1186/s12889-021-08677-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClosser S, Cox K, Parris TM. Gendered barriers to immunization in low- and middle-income countries. Soc Sci Med. 2022;308:115235. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2022.115235\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2022.115235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzawa S, et al. Pathways for improving vaccine coverage in low and middle-income countries. Vaccine. 2019;37(30):4171\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.vaccine.2019.06.033\u003c/span\u003e\u003cspan address=\"10.1016/j.vaccine.2019.06.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBedford H, Attwell K. Vaccine hesitancy and refusal in the context of gender. Vaccine. 2021;39(14):1970\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.vaccine.2021.03.044\u003c/span\u003e\u003cspan address=\"10.1016/j.vaccine.2021.03.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. A practical guide to integrate a gender lens into immunization programmes. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/rosa/reports/practical-guide-integrate-gender-lens-immunization-programmes\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/rosa/reports/practical-guide-integrate-gender-lens-immunization-programmes\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolman DM, et al. Barriers to human papillomavirus vaccination among adolescents: A systematic review. JAMA Pediatr. 2014;168(1):76\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamapediatrics.2013.2752\u003c/span\u003e\u003cspan address=\"10.1001/jamapediatrics.2013.2752\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Behavioural and social drivers of vaccination: Tools and practical guidance. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240054755\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240054755\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoldemicael G, Tenkorang EY. Women\u0026rsquo;s autonomy and maternal health-seeking behavior in Ethiopia. Matern Child Health J. 2010;14(6):988\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10995-009-0535-2\u003c/span\u003e\u003cspan address=\"10.1007/s10995-009-0535-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyasulu BJ, et al. Gender analysis of the WHO online learning program on Immunization Agenda 2030. Front Glob Women\u0026rsquo;s Health. 2023;4:1172503. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fgwh.2023.1172503\u003c/span\u003e\u003cspan address=\"10.3389/fgwh.2023.1172503\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhaliwal BK, et al. Community perceptions of vaccination in rural India. BMC Public Health. 2021;21(1):2122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-021-12118-6\u003c/span\u003e\u003cspan address=\"10.1186/s12889-021-12118-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamu AA, et al. Understanding demand for childhood vaccinations in Nigeria: A realist review. Lancet Glob Health. 2022;10(7):e1042\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2214-109X(22)00159-7\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(22)00159-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEregata GT, et al. Ethiopia\u0026rsquo;s Essential Health Services Package: An analysis of cost-effectiveness and equity. BMJ Glob Health. 2021;6(3):e006321. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjgh-2021-006321\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2021-006321\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZida-Compaore WIC, et al. Immunization coverage and factors associated with incomplete vaccination in Lom\u0026eacute;. BMC Res Notes. 2019;12(1):84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13104-019-4118-8\u003c/span\u003e\u003cspan address=\"10.1186/s13104-019-4118-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulatu A, et al. Uptake of second dose measles-containing vaccine in central Ethiopia. BMC Public Health. 2025;25(1):1470. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-025-01234-5\u003c/span\u003e\u003cspan address=\"10.1186/s12889-025-01234-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLincoln YS, Guba EG. Naturalistic Inquiry. Sage; 1985. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4135/9781412986120\u003c/span\u003e\u003cspan address=\"10.4135/9781412986120\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gender equity, Immunization, Vaccine hesitancy, Socio-ecological model, Life-course, Ethiopia, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8235793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8235793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEthiopia has made notable progress in expanding routine immunization coverage, yet inequities persist in vaccine uptake and completion. Gender norms and power relations may shape access to and decision-making about vaccination across the life course, but evidence integrating a gender lens with a socio-ecological perspective remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a multi-site qualitative study in four Ethiopian regions (Amhara, Oromia, Tigray, and Afar) between May and June 2025. Using purposive sampling, we conducted 75 semi-structured interviews with caregivers, health workers, community and religious leaders, and health officials. Interviews were audio-recorded, transcribed, translated into English, and analyzed in NVivo using an inductive coding approach, with themes subsequently organized and interpreted using the socio-ecological model (SEM) and a life-course perspective.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGender-related barriers to immunization operated across intrapersonal, interpersonal, institutional, community, and policy levels and varied by life stage (adolescence, pregnancy, and adulthood). At the interpersonal level, participants described \u0026ldquo;responsibility without authority,\u0026rdquo; where women were expected to manage vaccination while decision-making power often rested with fathers or elders, contributing to delays and refusals. Intrapersonal and community-level barriers included fertility-related concerns and misinformation, particularly in relation to HPV and COVID-19 vaccines, which also shaped provider communication. Institutionally, service organization, counselling time constraints, and limited age-inclusive job aids reinforced a focus on mothers and young children and reduced routine engagement of men, adolescents, and adults. At the policy level, participants highlighted limited operational guidance, targets, and reporting systems for vaccination beyond under-five services, along with constrained resourcing for adolescent and adult vaccination.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGendered norms and system-level priorities jointly constrain life-course immunization in Ethiopia. Strengthening gender-responsive life-course immunization will require addressing household decision-making dynamics, equipping providers with age-inclusive counselling tools, engaging trusted community intermediaries, and aligning operational guidance, targets, and reporting systems to support vaccination beyond childhood.\u003c/p\u003e","manuscriptTitle":"Bridging Gender Gaps in Immunization in Ethiopia: A Life Course and Socio- Ecological Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 10:01:37","doi":"10.21203/rs.3.rs-8235793/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-02T14:49:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332859887814335527567404689868368980726","date":"2026-03-12T05:52:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65828926040104415070691732940123843756","date":"2026-03-02T02:14:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44173792129605933009738349031436319675","date":"2026-02-02T09:41:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-24T03:17:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-18T23:08:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-10T18:16:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-10T11:07:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-12-10T11:00:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"152f543f-39db-4694-8005-1174244e2f38","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T10:01:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 10:01:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8235793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8235793","identity":"rs-8235793","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}