Gender refers to the roles, behaviours, activities, attributes and opportunities that any society considers appropriate for men, women, girls, boys and people with non-binary identities. It is often relational, as it shapes how men/boys, women/girls and people with non-binary identities interact with each other and the world around them. Gender is hierarchical and produces inequalities that intersect with other social and economic inequities. Due to its social construction, gender frequently varies through spaces, contexts and time, as individuals construct differing roles and identities shaped by broader political, social, historical, and economic circumstances.^1,2,3 Gender, as a social determinant of health and a relational construct of power, manifests in different ways to influence peoples’ experience and access to health care at different levels of the health system.⁹ For example, at an individual level, women’s lack of access to resources can limit the affordability of health services. At a societal level, physical access to health care may be hampered by social norms that require married women to obtain permission from their husbands/partners before they can seek health care. At the system level, how the health services are organized can either facilitate or limit one’s access to health services, for example, if the opening hours do not favour their use by women¹⁰ or the sex of the health provider (e.g. due to religious reasons).

The intersection of gender with an individual’s social variables (e.g. ethnicity, class, socioeconomic status, disability, age, geographical location, sexual orientation and sexual identity etc.) with wider social processes (e.g. ableism, racism etc.) and structural processes (e.g. politics, economy, globalization etc.) culminate in individual life experiences of discrimination, marginalization and social exclusion – all of which have complex effects on an individual’s health and response to interventions. For further guidance on how gender intersects with other social variables refer to the WHO/TDR intersectional gender analysis toolkit.¹ (See: Understanding gender, sex and intersectionality and why it matters for infectious diseases of poverty)

The term “intersectionality” was first coined by Kimberlé Crenshaw in 1989.¹¹ Historically speaking, the concept emerged from various theoretical foundations on feminism.^6,12 Intersectionality is an analytical lens that examines how different social variables (such as gender, class, race, education, ethnicity, age, geographic location, religion, migration status, ability, disability, sexuality etc.) interact to create different experiences of privilege, vulnerability and/or marginalization within structures of power.⁶ An intersectionality approach supports health researchers to understand the drivers of social inequality through due consideration of real-world complexity¹³ in which inequities are rarely the result of single, distinct factors but are the outcome of intersections of different social locations, power relations and experiences.^6,14

The visual representation of intersectionality shown in Figure 1 describes what intersectionality means in practice. It includes three concentric layers that surround each person’s unique circumstances of power, privilege and identity: the inner ring describes an individual’s characteristics (e.g. age, occupation, religion etc.); the middle ring describes social processes (e.g. ableism, racism, discrimination etc.); and the outer ring describes the structural processes (e.g. politics, legal system, capitalism etc.). It highlights how multiple individual social variables (age, gender, education, etc.) interact within wider social processes (ableism, racism, discrimination, etc.) and structural factors (politics, capitalism, etc.) to shape an individual’s position, privilege or disadvantage within society, culminating in an individual being either in a privileged or disadvantaged social category.¹⁵ In practice, the use of an intersectionality approach aids researchers to examine power relations, understand the social variables of research participants and how they interact with systemic structural factors to shape their life experiences.⁷

Table 1 presents key considerations regarding intersectionality, including a focus on social inequality and its implications, power dynamics of social relations, the structural and political context, and researchers’ reflexivity.¹³

To incorporate an intersectional gender lens in IR, we have selected gender as our entry point to analyse and understand access to health care and how people experience and respond to ill-health and health services, as well as other health-seeking experiences. Gender roles, norms and relations intersect with other axes of inequality (e.g. age, experience of racialization, social status and disability) and these intersections, under connected systems and structures of power, influence why and how health is shaped in specific ways. Understanding how gender intersects with other axes of inequality is important in all stages of the IR process, to avoid neglecting the social dynamics that exist in the community context and how these impact on how and for whom a health implementation strategy works.⁵

An intersectional gender analysis in research enables understanding of within-group differences at community level and the complex contexts that drive gender and other social inequalities. Figure 2 below shows the modified intersectional gender analysis wheel where gender is considered as the entry point for doing intersectional gender analysis. This figure helps researchers to think about how gender intersects with other social variables of an individual (for example, age, gender identity, occupation, religion etc.) and interacts within wider processes of social (e.g. ableism, racism, etc.) and structural (e.g. politics, capitalism, etc.) discrimination and privilege to shape an individual’s position within society. This approach helps researchers to examine the inequities created at the intersection of such social factors under specific systems and structures of power, which are also influenced by policy processes that are, in turn, shaped by the contexts in which they operate. In addition, as gender is relational, its intersection with other variables within the intersectionality wheel can culminate in privileges or disadvantaged positions in society. It also enables researchers to understand how gender power dynamics and other contextual factors within the community influence implementation and uptake of a given intervention at the different levels of the health system.¹ (See: The WHO health systems framework)

Various gender analysis frameworks^16,17,18 can be used as a starting point for incorporating gender analysis within research. These frameworks systematize information about gender-related dimensions across various domains of life and examine how these differences affect the lives and health of men, women, boys, and girls, as well as people with non-binary identities. The Jhpiego Gender Analysis framework ¹⁷ (Figure 3) describes four gender relation domains: access to assets; beliefs and perceptions; practices and participation; and institutions, laws and policies. Power pervades each of these domains and is key to understanding how gendered hierarchies exist and how these can be a driver of inequality.

Intersectional gender analysis frameworks help researchers to explore how gender intersects with other social variables to influence access to specific health interventions.¹⁹ (See: Understanding gender, sex and intersectionality and why it matters for infectious diseases of poverty)

For further details on gender analysis frameworks and guidance on how to conduct intersectional gender analysis, refer to the WHO/TDR intersectional gender analysis toolkit.¹ In implementation research, applying an intersectional gender approach enables researchers to understand how gendered power relations and other contextual factors within the community influence implementation and uptake of the intervention at the different levels of the health system. (See: WHO health systems framework)

Evelyn Kabia et al ²⁰ conducted a qualitative study in Kenya to explore how the interaction of personal factors (gender, disability, and poverty) of women living with disabilities and environmental factors influenced their experience while accessing health care (Box 1). Corroborating their findings using the Jhpiego gender framework shows that the intersection of disabled (individual’s social variables) women who were also living in/under poverty conditions with household division of labour (practice and participation), limited mobility (access to opportunities), being dependent (access to assets) and negative attitude of the health workers (institutions, laws and policies) influenced their health-seeking behaviours.

An individual’s social variables interact with local community and structural forces to produce an experience that subsequently affects access to the IR health interventions (Figure 4). If an individual’s gender identity influences their access to resources and decision-making, then this can contribute to the individual being in either a privileged or disadvantaged position, which can subsequently influence access to an IR health intervention. In this way, access to, use of and response to health interventions at a community level are significantly influenced by gender power relations with regards to resource availability, resource allocation, societal values and structural systems.^1,20