2.2.3. Co-Creation Workshops

Immediately following data collection, the research teams facilitated workshops with study participants and other relevant stakeholders at the district level. These co-creation workshops aimed to validate emerging findings from the data collection phase, strengthen feelings of empathy for caregivers, and identify locally relevant interventions to overcome identified barriers. The research team first summarized findings and facilitated discussion, and then implemented HCD tools adapted by the project to achieve the empathy and solution-identification objectives: the mothers' vaccination ecosystem; solution briefs; and a solutioning activity (Table 1). All study participants were invited and workshops were attended by 20–30 individuals, including caregivers. Experienced facilitators were attentive to the possibly negative consequences of mixing multiple levels of social power, and took care to ensure the respect for and confidentiality of the caregiver attendees. Caregivers' confidentiality was protected by the use of persona tools to share fictionalized findings based on the synthesis of experiences across all interviewees (Table 2). Community-level co-creation workshops were followed by district-level and then state/provincial and/or national workshops, to share insights and solutions from the level below, validate findings at each level, and assess motivation and priority for community-developed solutions across the other levels. Research teams generated additional insights on stakeholder motivations, preferences, and needs by observing the group discussions and taking notes.


**Table 1.** HCD tools used during co-creation workshops.

**Table 2.** Select caregiver personas used during co-creation workshops, based on study findings.


2.2.4. Cross-Country Synthesis

The research team reviewed country finding reports and manually re-coded data and findings according to the UNICEF framework and through the lens of intersectionality and power dynamics at the individual, institutional, and structural levels [13]. The team discussed key findings to better understand barriers and facilitators faced by caregivers and how they differed by context. This led to the identification of three mid-level themes

which the team considered to be of broad importance and actionable, and emphasized the empathy mindset for caregivers and communities.

Ethical approval was granted from the Kinshasa School of Public Health (DRC), the University Eduardo Mondlane (Mozambique), and the Edo and Jigawa State Health and Research Ethics Committee (Nigeria). Consent to participate was obtained by investigators trained in ethical procedures and prior to any observation or engagement. Team members read the consent form to participants in the local language and provided time to ask questions and clarify concerns. The team obtained written or verbal consent (in some situations) after answering the participants' questions and before beginning the activity or observation. As described in the consent form provided to the participants, all participants could request to withdraw from participation at any time.

#### **3. Results**

Table 3 summarizes the number of study participants by country and level of the health system. The section below presents synthesized findings from across the three countries, according to three emergent mid-level themes.


**Table 3.** Study participants.

FGD: focus group discussion; EPI: Expanded Program on Immunization; MEL: Monitoring, Evaluation, and Learning.

#### *3.1. Social and Structural Factors Intersect to Produce Inequitable Power Relationships and Limit Health System Actors' Empathy for Caregivers*

Across all the countries, most of the caregivers interviewed expressed the desire for their child to be vaccinated, and most were aware of the general benefits of vaccines. However, gender, social factors, and structural inequalities intersected and interacted to produce a variety of barriers for caregivers (Table 4). The type and magnitude of these barriers differed by a caregivers' social status, wealth, place of residence, and economic role—which in turn varied by country and region—and often played out as power dynamics that produced inequitable access to and quality of immunization services. Most caregivers reported some difficulty juggling their gender-prescribed tasks related to childcare and domestic work with getting a child vaccinated. These difficulties were more common among caregivers who faced other financial or time-related resource barriers, whether because of poverty or because the child's father worked or lived away from the home. Gender inequality was sometimes apparent in the caregivers' lack of agency to make a decision about whether to vaccinate her child. While most caregivers said they were able to

make a decision themselves about vaccination, we also heard cases where caregivers noted they were not the key decision-makers, and this pertained more often to caregivers of zerodose children. Decision-making divergence worked in both directions: sometimes women followed their male partners' preference to not get vaccinated, and sometimes they followed his preference to get vaccinated. When decision-making agency intersected with wealth and women relied on their male partners for financial support to access vaccination, it often resulted in the child not getting vaccinated. When husbands assisted with practical aspects, such as childcare or transport, which was reported by some respondents, caregivers were more likely to seek vaccination. Gender dynamics were also presented in conversations related to adverse events following immunization (AEFI). Many caregivers reported that they feared AEFI, such as fever or fussiness, as an uncomfortable infant disrupted the household dynamic, and this fear increased if their husband had complained.

**Table 4.** Examples of findings through the intersectionality lens.


Equity-limiting power dynamics also existed within the health system, where health workers wielded power from relative privilege over clients, and experienced disempowerment from managers and institutions that did not value them. This created a vicious cycle of negative power relations between health workers and clients. We observed that caregivers of low socioeconomic status experienced more disrespectful care from health workers (all countries) and were most likely to be blamed for not vaccinating their children (DRC). These particular caregivers expressed feelings of shame for being inappropriately dressed (DRC, Mozambique). In the DRC and Mozambique, caregivers of zero-dose children felt a sense of shame or exclusion that prevented them from accessing services, and caregivers who experienced blame or disrespect at the vaccination facility were the least likely to return. Caregivers in the DRC and Nigeria reported having to pay illicit fees for vaccine services or cards, and transport costs, which resulted in some caregivers being unable to afford services. In the DRC these illicit fees were the consequence of health workers being unpaid; in Nigeria they were explained as necessary to run an underfunded system. Many caregivers reported being unable to overcome at least one cost-related barrier, whether the service fees, costs of transportation to reach the facility, or opportunity costs of leaving paid or unpaid work. In Nigeria, financial and non-financial incentives were given by partners to caregivers, to cover the opportunity cost and transport costs. In the DRC many respondents reported that they had appreciated receiving nutritional and other non-cash incentives in the past, and had lost trust in the health system when those incentives were ended. Cost barriers were most challenging for caregivers of zero-dose children and intersected with gender and other access barriers to limit vaccination (see Table 2 for caregiver personas used during the co-creation workshops to illustrate these intersections).

Negative beliefs or misinformation about vaccination or vaccines were rarely the sole barrier to vaccination, although they did exist and interact with other barriers in a caregivers' overall influencing environment, particularly for the caregivers of zero-dose children. Interviews highlighted the critical role of religious leaders in influencing decisions—either towards or away from vaccines—in all countries. Our data suggest a lesser influence of CHWs or community health volunteers, often because they themselves did not have sufficient information on immunization services to counteract misinformation or provide practical information. In all communities, they faced retention and motivation challenges due to limited financing for community health, weakening their potential as a trusted link to the health system.
