**5. Conclusions**

This qualitative study presents drivers of immunization inequality from the perspectives of caregivers, who face multiple, often compounding, barriers related to social, institutional, and structural dynamics. Applying HCD and intersectional approaches highlights the little agency caregivers face in their journeys to vaccinate their children, and how vaccination and PHC services are not designed with their needs in mind. We found that caregivers who face the greatest number of barriers to accessing and receiving quality immunization services tend to face a double burden of living in communities where outreach vaccination strategies are unimplemented due to weak governance and accountability. Based on our experiences, implementing this study and our observation that it was feasible to build empathy and co-design solutions with caregivers, communities, and health system actors, we recommend the integration of HCD and intersectionality approaches and tools in immunization research and programs. Immunization and PHC professionals at all levels can take simple steps to integrate HCD and intersectionality into their planning, management, and implementation processes, such as:


We found that the power of local knowledge must be leveraged as a catalyst for all of these steps.

**Author Contributions:** Authors contributed in the following manners: Conceptualization, J.C.S., O.N., W.P., S.N., S.M., K.M., Y.J.C., D.A.M., N.K., C.H., R.F. and V.R.; Methodology, J.C.S., O.N., S.N., K.M., B.S., Y.J.C., O.D.-E., O.O., I.S.H., F.O., D.A.M., N.K., C.H., R.F., V.R. and G.C.; Validation, J.C.S., O.N., W.P., S.N., S.M., Y.J.C. and N.K.; Formal Analysis, J.C.S., O.N., S.N., S.M., T.M., K.M., O.O. and I.S.H.; Investigation, O.N., S.M., T.M., E.M., K.M., O.O., I.S.H. and F.O.; Resources, J.C.S., O.N., S.N., D.A.M., N.K. and C.H.; Data Curation, T.M., E.M., K.M., O.O. and I.S.H.; Writing—Original Draft Preparation, J.C.S., O.N., W.P., S.N., T.M., E.M., K.M. and D.A.M.; Writing—Review & Editing, J.C.S., O.N., W.P., S.N., B.S., Y.J.C., O.O., I.S.H., D.A.M., N.K., R.F., V.R. and G.C.; Visualization, J.C.S., O.N.; Supervision, J.C.S., O.N., W.P., S.N., S.M., B.S., Y.J.C. and V.R.; Project Administration, S.M., B.S., Y.J.C., V.R. and G.C.; Funding Acquisition, V.R. and G.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** MOMENTUM Routine Immunization Transformation and Equity and this research was funded by the U.S. Agency for International Development (USAID) as part of the MOMENTUM suite of awards, and implemented by the JSI Research & Training Institute, Inc. with partners PATH, Accenture Development Partnerships, Results for Development, CORE Group, and The Manoff Group under USAID cooperative agreement #7200AA20CA00017. For more information about MOMENTUM, visit www.usaidmomentum.org (accessed on 15 January 2023). The contents of this journal article are the sole responsibility of the JSI Research & Training Institute, Inc., and do not necessarily reflect the views of USAID or the United States Government.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Kinshasa School of Public Health (DRC), Eduardo Mondlane University (Mozambique), the Edo and Jigawa State Health and Research Ethics Committee (Nigeria), and the JSI Research and Training Institute.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy concerns of the respondents.

**Acknowledgments:** We would like to thank the following who contributed extensively to research design or implementation: in DRC, Godefroid Mpanya, Constant Kingongo, Eugene Mankiya, Fedy Mukendi, Joel Bompongo, Andre Tonda, Moza Diakiese, Nick'son Sonabo, Rachel Kukia and Anna Acquistapace; in Mozambique, Vasco Muchanga, Valerio Govo, Estevão Manhice, Raquel Carrilho, Melanie Picolo, Agostinho Mauire and Santos Sipaneque; in Nigeria, Otaniyenuwa Eloghosa Obarisiagbon, Amos Paul Bassi, Jagun Moriam Olaide, Chioma Victoria Ugochukwu, Sa'adatu U. Ibrahim Ringim, Ahmed Mohammed Naiya and Olutobi Daniel Adeogo. We are grateful for the support and engagement of national and provincial EPI programs in the three countries, with special thanks to Bassey Okposen and Faisal Shuaib (National Primary Health Care Development Agency, Nigeria). Other technical contributors include Kris Ansin, Benjamin Picillo, Sheetal Sharma, Emma Stewart, and Andi Sutter. We are appreciative of the management support from Katie Wallner, Suyane Viana, Fatou Ceesay and Siessourby-Eileen Soma. Finally, this study would not have been possible without the trust and engagement of mothers, family members, community leaders, community health workers and volunteers, health workers, and health system managers.

**Conflicts of Interest:** The authors declare no conflict of interest.
