**3. Results**

The findings from this study are organized according to the study objectives, which are (i) the backsliding of immunization in urban, (ii) immunization challenges and predictors in urban and peri-urban settings, and (iii) identified pro-equity strategies.

#### *3.1. Backsliding of Immunization in Urban*

Some papers provided an estimation of the magnitude of coverage backsliding in country contexts that are mostly urbanized or in context of urban and peri-urban settings. A nationwide ecological study in Brazil looked at the coverage figures of yellow fever vaccination before and during the COVID-19 pandemic. This study was conducted between April 2019 and March 2021 and found a 48.55% decline in the median yellow fever vaccination doses administered nationwide 1 year after pandemic control measures were instituted (April 2020–March 2021) compared to the pre-pandemic period (April 2019–March 2020) [14]. Some of the states with substantial decline rates included Paraná (49.97%), Sao Paulo (43.25%), and regions such as the North (34.71%), Midwest (21.72%), South (63.50%), and Southeast (34.42%). Brazil is a largely urbanized country with urbanization between 65% and 90% across the states.

A 2022 multi-city phenomenological qualitative study in India by Sahoo et al. documented the experiences of urban slum-dwelling women with maternal and child health services during the COVID-19 pandemic [15]. This study was conducted in four cities (one city with a dense slum population per state) across four states: Bhubaneswar Municipal Corporation (Bubaneswal, Odisha, India), Rishikesh Municipal Corporation (Rishikesh, Uttarakhand), Bhilai Municipal Corporation (Chetis Gerbilee, Chhattisgarh, India), and North Lakhimpur Municipal Board (North Lakhimpur, Assam, India). All participants reported getting their children vaccinated during the pandemic with little or no backsliding reported.

Manzoor and colleagues conducted a cross-sectional study to document the impact of the COVID-19 pandemic on routine childhood immunization in Mirpur, Azad Kashmir, Pakistan [16]. The study found that the COVID-19 pandemic had a major impact on the timing of routine immunization for children in Pakistan, where about 80% of caregivers had scheduled vaccinations for their children, 18% had delayed vaccination schedules, while 2% missed vaccination during the COVID-19 pandemic. The fear of contracting the COVID-19 virus was a key factor that resulted in delaying vaccination mentioned by about 65% of participants, and 40% reported that home is the preferred location to get their children vaccinated.

A comparative cross-sectional study in Wolaita of southwest Ethiopia documented the disparities in full immunization coverage among urban and rural children aged 12–23 months [17]. The study found that knowledge of and attitude towards immunization and fear of COVID-19 at the health facility and place of delivery were predictor variables for full vaccination coverage and that urban children had a higher full vaccination than rural children by a 15% point estimate.

A natural experiment, which assessed the impact of the COVID-19 pandemic on coverage of Reproductive, Maternal, and Newborn Health interventions in Ethiopia at the early stages of the pandemic, showed a significant reduction in coverage of BCG vaccination and chlorohexidine use in urban areas amongst the cohort impacted by COVID-19 outbreaks with little or no significant reductions in women seeking either preventative or curative health services [18].

A descriptive and retrospective cross-sectional study conducted in Yaoundé, Cameroon, showed a decline in the number of pediatric consultations by 52% in April and by 34% in May 2020, compared with rates during the same periods in 2019 (*p* < 0.01), following the partial confinement recommended by the government [19]. The demand for BCG vaccines, third dose of DPT, polio, and MMR in children, as well as tetanus vaccines in childbearing women showed a decline [19].

A 51% decline in the daily average total number of vaccinations administered during lockdown compared to the baseline was found throughout the Sindh province in Pakistan from a pre- and post-study analyzing provincial electronic immunization data; the paper examined the impact of the COVID-19 pandemic response on the uptake of routine immunizations with the highest decline seen in BCG vaccines at fixed sites [6]. It was also noted that slum union councils had a slightly larger decrease in immunization coverage than nonslum urban areas (53.8% vs. 51.3%). Some of the predictors of getting vaccinated included children born at health facilities and children of mothers with higher education levels.

Based on a study that analyzed routine statistics and a national household survey in Brazil, a decline of about 20% in vaccines administered to children aged 2 months or older was seen during March and April 2020, when social distancing was at the highest level compared to January and February of the same year [20]. This study also showed that children from poor households and the least developed regions of the country were most affected compared to other children.
