Immunization and Vaccination Equity

Over-reliance on Aggregate Coverage Indicators

Several contributors highlighted that national and regional vaccination coverage statistics are typically reported as single averaged figures, which obscure substantial variation within populations. These aggregate indicators often fail to capture:

• Differences between socioeconomic groups
• Geographic micro-inequalities within cities and regions
• Patterns of delayed, incomplete, or interrupted vaccination

As a result, systems may be classified as "high performing" while still allowing clusters of vulnerability to persist, increasing the risk of outbreaks and avoidable disease burden. These patterns are also evident across deprivation groups and over time. [Fig.2]

Insufficient Granularity to Identify System Gaps

Evidence presented during the session highlighted persistent limitations in the level of detail of routinely collected immunization data. [Fig.3] In many settings, data systems do not systematically capture information on:

• Timeliness of vaccination
• Completion rates and drop-out patterns
• Intersectional determinants, including combined, overlapping disadvantages, for example poverty alongside migration status, housing insecurity, or other social risk factors

This lack of detail limits policymakers' and service planners' ability to identify where along the vaccination pathway exclusion occurs. Participants noted that without this level of insight, health systems are constrained in their ability to anticipate gaps. Inequities are often detected only after outbreaks or declines in uptake, rather than prevented through proactive system design.

Data Choices Shape Policy Priorities

Speakers emphasized that what is measured — and what is not — directly influences policy decisions. By focusing primarily on overall uptake, health systems may:

• Underestimate the scale of exclusion among marginalized groups
• Fail to justify targeted or proportionate interventions
• Reinforce a false narrative that inequities are driven by individual choice rather than system design

The discussion highlighted that data gaps are not neutral; they can unintentionally reinforce inequity by rendering some populations statistically invisible. This issue was also linked to broader decision-making frameworks, in which equity considerations are often treated as secondary to efficiency or cost-effectiveness, rather than as core performance criteria.

Implications for Equity-Focused Policy and Practice

The evidence presented demonstrates that improving vaccination equity requires reform of measurement and delivery systems. Participants underscored the need for:

• Disaggregated data that reflects lived realities
• Routine monitoring of timeliness and completion
• Metrics that allow early identification of exclusion
• Data systems capable of informing proportionate universalism

Without such reforms, inequities remain predictable yet insufficiently addressed, limiting the effectiveness of both policy interventions and community-level solutions.

Poverty and Material Constraints as Primary Drivers

A recurring theme across the briefings was the role of poverty as a fundamental determinant of vaccination inequity. Evidence highlighted that families experiencing economic hardship face multiple, compounding barriers, including:

• Costs associated with travel to vaccination sites
• Inability to take time off work or manage childcare for appointments
• Housing instability and frequent changes of address
• Competing priorities linked to financial insecurity

These constraints disproportionately affect families living in deprived areas and contribute to delayed, interrupted, or missed vaccination, even in systems where vaccines themselves are provided free of charge. Speakers stressed that such barriers are often invisible in policy discussions that assume equal capacity to engage with services, reinforcing the misconception that access is universal when, in practice, it is not.

Administrative and Service Design Barriers

Beyond material constraints, the evidence showed that administrative processes and service design choices can themselves function as exclusionary mechanisms. Participants highlighted common barriers such as:

• Complex appointment systems
• Rigid scheduling and limited clinic hours
• Registration requirements that disadvantage mobile or undocumented populations
• Fragmentation between health, social, and community services

These features disproportionately affect families already under strain and can result in missed opportunities for vaccination, particularly when services fail to adapt to the realities of marginalized populations. Speakers noted that such barriers are often unintended but are nonetheless predictable outcomes of systems designed around institutional convenience rather than user need.

Austerity, Service Erosion, and Unequal Capacity to Compensate

Evidence also pointed to the impact of long-term underinvestment in preventive services, particularly in deprived areas. Speakers described how reductions in funding for public health, community outreach, and primary care capacity have:

• Reduced flexibility in service delivery
• Limited the ability to provide tailored or outreach-based vaccination
• Increased pressure on front-line staff

As a result, families with greater resources are often better able to compensate for system shortcomings, while those facing socioeconomic disadvantage are left increasingly exposed to access gaps. This dynamic was described as a key mechanism through which inequality becomes entrenched, even without explicit exclusionary policies. [Fig.4]

Lived Experience and the Accumulation of Barriers

Drawing on community-based and co-designed research, speakers emphasized that barriers rarely occur in isolation. Instead, families often face an accumulation of obstacles, with socioeconomic hardship, administrative complexity, and service inflexibility intersecting. Evidence from community engagement and third-sector interventions illustrated how:

• Small barriers can have disproportionate effects
• Missed appointments can lead to disengagement rather than re-engagement
• Systems often lack mechanisms to recover those who fall behind

Importantly, speakers cautioned against interpreting disengagement as disinterest or refusal, noting that such interpretations risk misattributing system failure to individual behavior.

Implications for Equity-Oriented Access Design

The evidence presented in this section highlights that improving vaccination equity requires intentional redesign of access pathways, informed by an understanding of socioeconomic realities. Participants stressed that effective strategies must:

• Reduce reliance on individual capacity to navigate complex systems
• Increase flexibility in delivery models
• Integrate vaccination with other services used by families
• Recognize poverty and exclusion as core access determinants

Trust as a System Outcome, Not an Individual Attitude

A central insight from the briefings was that trust should be understood as a relational and systemic phenomenon, rather than a fixed attribute of individuals or communities. Speakers noted that trust is built—or eroded—through repeated interactions with public institutions, healthcare services, and government authorities. Where systems are experienced as inconsistent, inaccessible, or unresponsive, mistrust can become a rational response rather than a deviation from expected behavior. Importantly, speakers stressed that communities labeled as "hesitant" are often responding to broader institutional signals rather than rejecting vaccination per se.

Political Context, Institutional Legitimacy, and Spillover Effects

Evidence presented during the meeting demonstrated that confidence in vaccination does not exist in isolation from the political environment. Speakers highlighted how declining trust in governments, public authorities, and expert institutions can spill over into perceptions of vaccination programs, even when vaccines themselves are not the direct source of concern. This dynamic was described as particularly salient in contexts marked by:

• Inconsistent public messaging
• Rapidly changing policies
• Politicization of public health decisions
• Limited transparency in decision-making

Such conditions can undermine institutional credibility and weaken the social contract between communities and health systems, with vaccination becoming a visible proxy for wider discontent.

Moral Economies, Authority, and Community Decision-Making

Several speakers emphasized that vaccination decisions are embedded within moral economies that shape how information is interpreted and acted upon. Evidence from marginalized and religious communities illustrated that trust is often mediated through:

• Local social networks
• Gendered roles and responsibilities
• Religious or community leadership
• Collective rather than individual risk assessment

Crucially, speakers cautioned against assuming that religion or culture constitutes an inherent barrier to vaccination. Instead, mistrust may arise when institutional approaches fail to recognize community diversity, rely on stereotypes, or engage in tokenistic forms of "cultural sensitivity."

Healthcare Professionals as Trusted Intermediaries: Role and Limits

Evidence consistently showed that healthcare professionals remain among the most trusted actors in vaccination decision-making. However, speakers noted that this trust is increasingly strained by:

• Time pressures and workforce shortages
• Limited opportunities for meaningful dialogue
• Inconsistent guidance or lack of institutional support

Participants stressed that trust in healthcare professionals cannot indefinitely compensate for systemic shortcomings. Without adequate support, training, and policy alignment, frontline professionals may be placed in an untenable position, expected to rebuild trust without the tools or authority to address underlying system failures.

Implications for Trust-Building Approaches

The evidence presented suggests that restoring and sustaining trust requires institutional change rather than intensified messaging. Speakers emphasized that effective trust-building strategies must:

• Address structural inequities that shape lived experience
• Ensure consistency and transparency in decision-making
• Recognize and engage with community knowledge and authority
• Support healthcare professionals as relational actors, not just information providers

Participants warned that communication strategies disconnected from these broader considerations risk reinforcing mistrust, particularly among communities that already feel marginalized or overlooked by public institutions.

Moral Economies of Vaccination and Trust

The briefing demonstrated that vaccination is not perceived solely as a biomedical intervention, but as a moral and social act. Routine schedules, for example, implicitly communicate norms about responsible parenting, acceptable risk, and social obligation. Where these institutional norms align with community moral economies, vaccination is reinforced as routine. Where they diverge, trust may be weakened. Speakers highlighted that moral economies are not static. They are shaped by historical experience, political context, and circulating narratives—both formal and informal. In this sense, trust in vaccination reflects not only confidence in vaccines but also confidence in the moral legitimacy of the systems that promote them.

Religion and Vaccination: Moving Beyond Simplistic Explanations

Evidence presented during the meeting cautioned strongly against treating religion as a homogeneous or self-explanatory category in vaccination equity discussions. Speakers noted that public health literature and practice frequently cite "religious beliefs" as a cause of under-vaccination without clearly defining what those beliefs are or how they operate in practice. Importantly, the evidence established that no major religious doctrine explicitly forbids vaccination, and that religious identity alone does not predict vaccination behavior. Instead, mistrust is more often shaped by experiences of exclusion, coercive enforcement, or lack of meaningful engagement with institutions. Framing religion as a barrier was described as analytically limited and potentially counterproductive, as it risks obscuring the structural and relational drivers of inequity.

Authority, Gender Roles, and Networked Decision-Making

Vaccination decisions within marginalized or religious communities are often shaped more by gendered and family-based social networks than by formal religious authorities. Speakers emphasized the influential role of peers, siblings, and trusted community members in shaping vaccination norms, particularly among mothers. These findings challenge the assumption that engagement efforts should focus primarily on religious leaders. Instead, decisions are frequently negotiated within everyday social relationships, where shared experiences and perceived norms exert significant influence. Recognizing these dynamics is essential for designing engagement approaches that reflect how decisions are actually made, rather than how institutions assume they are made.

Implications for Engagement and Equity

The discussion underscored that addressing inequities related to religion and social networks requires sustained, relationship-based engagement, rather than one-off messaging or symbolic consultation. Speakers emphasized the value of partnerships with faith-based and community organizations, the use of trusted communication channels, and shared responsibility for community health. However, it was stressed that such approaches require dedicated public health investment and cannot be delivered solely by primary care teams. Without institutional commitment and resourcing, effective engagement risks remaining fragmented and dependent on individual goodwill.

The Role of Trusted Intermediaries and Community Infrastructure

Evidence from community-based interventions underscored the importance of trusted intermediaries, including community-based organizations, community leaders, and locally embedded services. These actors often have:

• Deep contextual knowledge
• Established relationships of trust
• The ability to engage populations that formal health systems struggle to reach

Speakers stressed that trust is rarely transferable from institutions to communities but is instead mediated through relationships that already exist. Interventions that worked effectively were those that strengthened, rather than bypassed, these existing networks.

Flexible, Multi-Channel, and Locally Adapted Delivery

Evidence showed that successful engagement approaches rely on flexibility and local adaptation, rather than standardized national templates. Effective strategies included:

• Offering vaccination alongside other services used by families
• Using multiple communication formats (e.g., in-person, audio, visual, community media)
• Adjusting delivery in response to feedback and changing circumstances

Speakers cautioned that rigid program requirements and short funding cycles can undermine these approaches, limiting their scalability and sustainability.

Sustainability, Resourcing, and the Risk of Tokenism

A recurring concern across the evidence was the risk of tokenistic engagement, where communities are consulted without meaningful influence over decisions. Speakers noted that:

• Short-term pilots often fail to build lasting trust
• Engagement work is frequently under-resourced
• Community partners may be expected to deliver outcomes without adequate support

Participants stressed that meaningful engagement requires long-term investment, stable funding, and institutional commitment. This is particularly true if it's to be integrated into routine vaccine delivery rather than remain project-based.

Moving Beyond Outreach to Co-Design

Speakers distinguished clearly between traditional outreach models and genuine co-design. While outreach often focuses on disseminating information or encouraging uptake, co-designed approaches involve communities in:

• Identifying barriers and priorities
• Shaping service delivery models
• Determining appropriate communication channels
• Adapting interventions in real time

Evidence presented highlighted that co-design shifts the focus from "how to reach communities" to how systems must change to meet community needs. Importantly, speakers noted that co-design requires a redistribution of power, with institutions accepting uncertainty, shared decision-making, and iterative learning.

Implications for Equity-Focused Program Design

The evidence presented reinforces the need for community engagement to be embedded from the outset of vaccination program design. Speakers emphasized that:

• Engagement should inform how services are structured, not only how messages are framed
• Co-design can surface barriers invisible to formal data systems
• Community-led approaches can enhance both access and trust

Without embedding engagement into core systems and funding models, participants warned that successful local initiatives risk remaining isolated examples rather than drivers of systemic change.

Strengthening Primary Care and the Frontline Workforce

Policy contributors consistently identified primary care and frontline health professionals as central to equitable vaccine delivery, while emphasizing that their effectiveness depends on adequate system support. Key policy messages included:

• Recognizing primary care pediatricians, nurses, pharmacists, and general practitioners as core equity actors, not just delivery points
• Ensuring workforce capacity, training, and protected time for engagement and follow-up
• Reducing administrative burden so professionals can focus on relational care
• Supporting multidisciplinary collaboration across services used by families

Contributors stressed that frontline trust cannot compensate indefinitely for system-level constraints, and that policy frameworks must enable professionals to act on inequity rather than merely absorb its consequences.

Embedding Equity in Health System Governance and Decision-Making

A recurring theme in the policy discussion was the need to embed equity explicitly into health system governance, rather than treating it as an aspirational add-on. Contributors highlighted that decision-making frameworks, including those governing vaccine introduction and evaluation, often prioritize efficiency and coverage without sufficient attention to distributional impact. Key policy directions included:

• Integrating equity considerations into health technology assessment (HTA) and prioritization processes
• Using disaggregated data to inform decisions about service design and resource allocation
• Ensuring that equity is treated as a core performance criterion, not a secondary consideration

This approach was positioned as essential for preventing inequities from being "designed in" during the early stages of vaccine policy development.

Civil Society, Citizens, and Community Voice in Policy Design

Policy contributors emphasized that equitable vaccination systems require sustained engagement with civil society and citizens, particularly those representing underserved or marginalized populations. Rather than episodic consultation, contributors advocated for structured mechanisms that allow community perspectives to inform policy design, implementation, and evaluation. Key policy messages included:

• Formalizing partnerships with civil society organizations as part of the vaccination infrastructure
• Valuing lived experience as a source of policy-relevant evidence
• Supporting advocacy and accountability mechanisms that amplify community voices

These approaches were presented as essential for rebuilding trust and ensuring that policies reflect real-world barriers and priorities.

Communication, Information Ecosystems, and Public Discourse

Policy interventions also addressed the role of communication and information environments in shaping vaccination equity. Contributors cautioned against over-reliance on deficit-based narratives focused on misinformation, noting that such approaches can stigmatize communities and divert attention from structural drivers. Key policy directions included:

• Supporting evidence-based, non-stigmatizing public discourse on vaccination
• Strengthening the role of trusted professional and independent information sources
• Ensuring transparency and consistency in institutional communication strategies to align with system reform, rather than used as substitutes for it

Industry, Innovation, and Shared Responsibility for Equity

The policy discussion also highlighted the role of industry and innovation actors in supporting equitable vaccination outcomes. Contributors stressed that while industry does not control delivery systems, it has a responsibility to contribute to equity-oriented education, transparency, and collaboration. Key policy messages included:

• Supporting healthcare professional education on new vaccines and delivery models
• Engaging constructively with public health and civil society partners
• Aligning innovation with real-world system capacity and equity goals

This perspective reinforced the idea that equity is a shared responsibility across the vaccination ecosystem, rather than the remit of any single actor.