A shared agenda for gender and COVID-19 research: priorities based on broadening engagement in science

**Background:** Despite the acute pandemic phase ending, an estimated 2.5 million people died from COVID-19 in 2022, tens of millions suffer from long COVID, and national economies continue to reel. Sex and gender biases deeply mark these evolving experiences, impacting the quality of science and effectiveness of responses. The authors note that global knowledge production on gender and COVID-19 is highly skewed along intersecting lines of privilege. To address this, a collaboration was formed to systematically and inclusively articulate sex, gender, and COVID-19 research needs to support policy-relevant and programming-relevant research. The approach was informed by feminist principles and aimed to broaden engagement beyond typical expert-driven processes.

**Methods:** The collaboration was co-convened by the University of the Western Cape (South Africa) and the United Nations University International Institute for Global Health (Malaysia). Leadership was distributed across all global regions. Five thematic groups guided the process: health behaviour and status, research and development, health service delivery, social determinants, and health governance. Engagement included stakeholder mapping, eight global meetings, six regional consultations, an online discussion board (Buzzboard), and a prioritization survey. Over 1000 unique participants were logged in the master database. The survey was open from 1 July to 31 October 2021 in English, Spanish, French, and Portuguese. A total of 224 responses were received from 173 participants across all thematic surveys. The response rate for completed questionnaires was 24.4% for 709 participants invited through a unique link, increasing to 39.2% when focusing on the 441 thematic group members. Participants rated 214 research questions (36–54 per theme) against three criteria: public health benefit, likelihood of improving gender equality, and urgency.

**Key Results:** The top 21 research questions were identified across all five themes. The single highest-scored question related to the ethical and safe inclusion of pregnant and lactating women in phase 3 and 4 COVID-19 studies. Other top questions included: examining gender differences in vaccine trust and uptake across social categories; assessing post-COVID-19 conditions in pregnant and postpartum women; understanding changes in gender-based violence prevalence during the pandemic; and supporting national statistical systems to produce and use sex-disaggregated data. Only 7 of the 21 top questions focused on evaluating interventions or policies to address inequalities, with the remainder being largely descriptive. The authors note that at the height of the pandemic, only 6 out of 200 countries ever reported sex-disaggregated data across the COVID-19 testing-to-outcome pathway, and only 4% of 4420 registered SARS-CoV-2/COVID-19 studies explicitly planned to include sex/gender for analysis.

**Clinical Implications:** The findings highlight a persistent failure to address basic gender-inclusive practices in clinical research and health information systems, particularly for pregnant and lactating women. The authors argue that strengthening structures to track and guide inclusivity in clinical trials will improve the quality of science, contribute to pandemic preparedness, and improve health outcomes. They reframe the top 21 questions into seven key areas that must be integrated into established COVID-19 research platforms. The paper also demonstrates that feminist, inclusive research prioritization processes are feasible and can broaden participation from LMIC contexts, though they require significant time investment and face challenges around participant fatigue and balancing democracy with efficiency.