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

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.