**Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria**

**Jessica C. Shearer 1,\*, Olivia Nava 2, Wendy Prosser 3, Saira Nawaz 1, Salva Mulongo 4, Thérèse Mambu 5, Eric Mafuta 5, Khatia Munguambe 6, Betuel Sigauque 7, Yakubu Joel Cherima 8, Olawale Durosinmi-Etti 8, Obehi Okojie 9, Idris Suleman Hadejia 10, Femi Oyewole 11, Dessie Ayalew Mekonnen 3, Natasha Kanagat 3, Carol Hooks 12, Rebecca Fields 3, Vanessa Richart <sup>3</sup> and Grace Chee <sup>3</sup>**


**Abstract:** Background: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. Methods: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. Results: Caregivers of zerodose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. Conclusions: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

**Keywords:** health inequalities; immunization; equity; inequality; human-centered design; vaccination services; zero-dose children; community
