{"paper_id":"4d99c226-8dff-4297-8a9a-d10bb4d04c4c","body_text":"Systematic review of pro-equity strategies to improve vaccination among priority populations | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return\"[object Function]\"==o.call(a)}function e(a){return\"string\"==typeof a}function f(){}function g(a){return!a||\"loaded\"==a||\"complete\"==a||\"uninitialized\"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){(\"c\"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){\"img\"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),\"object\"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height=\"0\",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),\"img\"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||\"j\",e(a)?i(\"c\"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName(\"script\")[0],o={}.toString,p=[],q=0,r=\"MozAppearance\"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&\"[object Opera]\"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?\"object\":l?\"script\":\"img\",v=l?\"script\":u,w=Array.isArray||function(a){return\"[object Array]\"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split(\"!\"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split(\"=\"),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(\".\").pop().split(\"?\").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split(\"/\").pop().split(\"?\")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&\"css\"==i.url.split(\".\").pop().split(\"?\").shift()?\"c\":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Systematic review of pro-equity strategies to improve vaccination among priority populations View ORCID Profile Adeline Tinessia , View ORCID Profile Majdi M. Sabahelzain , View ORCID Profile Catherine King , View ORCID Profile Saman Khalatbari-Soltani , View ORCID Profile Praveena Gunaratnam , View ORCID Profile Ibrahim Dadari , View ORCID Profile John Carlo Lorenzo , View ORCID Profile Soumyadeep Bhaumik , View ORCID Profile Meru Sheel doi: https://doi.org/10.1101/2025.06.03.25328765 Adeline Tinessia 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 2 Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Adeline Tinessia Majdi M. Sabahelzain 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 2 Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Majdi M. Sabahelzain Catherine King 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 2 Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Catherine King Saman Khalatbari-Soltani 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Saman Khalatbari-Soltani Praveena Gunaratnam 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 3 Clinton Health Access Initiative (CHAI), Vientiane Capital, Lao People’s Democratic Republic Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Praveena Gunaratnam Ibrahim Dadari 4 Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters , New York, NY, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ibrahim Dadari John Carlo Lorenzo 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 2 Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for John Carlo Lorenzo Soumyadeep Bhaumik 5 Meta-research and Evidence Synthesis Unit, The George Institute for Global Health , Australia 6 Faculty of Medicine and Health, University of New South Wales , Sydney, New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Soumyadeep Bhaumik Meru Sheel 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia 2 Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney , New South Wales, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Meru Sheel For correspondence: meru.sheel{at}sydney.edu.au Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background/Objectives The importance of pro-equity strategies in addressing disadvantages that people and communities face due to their gender, migration status, ethnicity, disability, and place of residence is increasingly being recognised, but analysis of empirical evidence on how they improve vaccination in these priority groups is limited. This systematic review aims to fill this gap. Methods Standard evidence synthesis methods were employed, with searches conducted in four major bibliographic databases in March 2025. Studies were included if they reported on strategies aimed at improving vaccination uptake, coverage, and/or timeliness among priority groups disadvantaged by gender, migration status, disability, ethnicity, or geographical location, with no exclusions based on language, time, or type of vaccination. Excluded studies were those without explicit intervention or outcome data related to vaccination and those not focused on the identified priority groups or settings. A thematic analysis was conducted to map strategies for immunisation programmatic areas. Strategies were also mapped to the Tanahashi coverage framework, which identifies how pro-equity strategies addressed bottlenecks in the delivery of immunisation programs. Results From 20,812 records retrieved, we identified 59 studies showing pro-equity strategies that improved vaccination uptake or coverage (n=54) and timeliness (n=6). Twenty-five pro-equity vaccination strategies under five immunisation system domains were studied. Thirty-nine studies were conducted in high- and middle-income countries. Most (56%) focused on community-oriented strategies and improving acceptability (63%). Few targeted upstream system-level barriers, such as policy and governance (n=7), availability (n=5), or effectiveness (n=10) of immunisation service delivery. No single strategy or approach was universal across the priority groups. However, some approaches were more common in specific populations and settings. Conclusions This review synthesises strategies to address vaccination inequities among underserved populations. Achieving vaccination equity will require context-specific approaches to address individual and systemic barriers across community engagement, service delivery, information systems, and policy and governance. Funding None Introduction The Immunization Agenda 2030 (IA2030) highlights the importance of “coverage and equity” as a strategic priority area to ensure all people are protected by vaccination, regardless of location, age, socioeconomic position or gender ( 1 ). Immunisation inequities, defined as systematic differences in vaccination that leave certain individuals or population groups at risk of being unvaccinated or under-vaccinated, can exist in many forms, including by age, geography and socioeconomic position ( 1 ). The COVID-19 pandemic brought vaccine inequities to the global forefront ( 2 ), and they remain an issue. For example, the numbers and distribution of zero-dose children (defined as children who have not received a single dose of the Diphtheria-Tetanus-Pertussis-DTP vaccine) show deep vaccine inequities across countries and regions ( 3 , 4 ), with 59% of zero-dose children in 2023 living in just 10 countries: India, Nigeria, Ethiopia, Democratic Republic of Congo, Sudan, Indonesia, Yemen, Afghanistan, Angola, and Pakistan ( 4 ). Social, economic, and health system factors shape immunisation inequities. Evidence suggests that vaccination rates are often lower in certain groups, including women and gender minorities; migrants and mobile populations; people living with disabilities; ethnic minorities; and rural or urban poor populations ( 3 – 6 ). Women and men have different experiences in access to vaccination, influenced by the social roles and norms that affect health decisions. For example, a 52-country study found that median DTP3 coverage was 12% greater among children of women with the highest social independence compared with children of women with the lowest ( 6 ). Migrants and mobile populations face healthcare discrimination, language barriers, or lack of trust in local health systems, with a scoping review finding that 70% of studies noted lower rates of immunisation among migrants ( 7 ). People living with disabilities often face physical, social, and systemic barriers to healthcare, which can limit access to vaccination ( 8 , 9 ) and increase their vulnerability to diseases. A study of 97 low- and middle-income countries (LMICs), significant differences in vaccination coverage existed between urban and rural areas, where the pooled prevalence of zero-dose children was 4.7% for rural areas, 12.6% for urban poor and 6.5% among urban non-poor ( 10 ). A systematic review of 64 countries found that the median gap between the highest and lowest zero-dose prevalence ethnic groups in all countries was 10% ( 11 ). These barriers often overlap across individuals, populations, and contexts. Acknowledging these known gaps, there is a need to understand, design, and implement effective strategies to reduce immunisation inequities ( 12 ). Pro-equity vaccination strategies are targeted approaches to improve vaccination among underserved and priority groups, by increasing utilisation and adopting a health system strengthening approach ( 13 – 15 ). Recent publications identified pro-equity vaccine strategies in some Gavi-supported countries ( 13 – 15 ). However, there is limited evidence on the effectiveness of such strategies in reducing coverage gaps. This systematic review aims to identify pro-equity strategies used to improve vaccination amongst priority groups, i.e. women and gender minorities, migrants and mobile population, people living with disabilities, ethnic minorities and urban and rural population, and to inform how to address global gaps in vaccination coverage and equity. Specifically, we examined the impact of these strategies on vaccination uptake, coverage, and/or timeliness. Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist (Appendix A) ( 16 ). The protocol was registered on the International Prospective Registration of Systematic Reviews (PROSPERO 2023 CRD42023449067) ( http://www.crd.york.ac.uk/PROSPERO ) ( 17 ). Eligibility criteria Studies were included if they reported on pro-equity strategies targeting priority groups and vaccine-related outcomes, including change in vaccine uptake, coverage, and/or timeliness. Priority groups included sub-populations disadvantaged due to their gender, migration status, disability, ethnicity, or geographical location (urban/rural). Gender was defined as socially constructed roles, norms and behaviours that societies consider appropriate, which shape relationships within and between gender groups ( 1 ). Migration status included refugees, asylum seekers, and transient populations ( 18 ). Disability was defined as an umbrella term for impairments, activity limitations, and participation restrictions, reflecting the negative interaction between an individual’s health condition and contextual factors ( 19 ). Geographically disadvantaged included urban populations living in slums, informal or high-density areas, and rural populations with limited health care access. We defined pro-equity strategies as those that promoted immunisation access and uptake among priority groups ( 13 ). Randomised controlled trials, quasi-experimental studies, observational studies, cross-sectional studies, pre-post intervention studies, controlled community trials, cluster-randomised trials, mixed methods studies and qualitative studies were included. No language-based or time-based exclusions were made. All types of vaccinations are included. Studies were excluded if they were animal studies, ecological studies, case series, commentaries, reviews, letters or news articles; if they did not explicitly discuss interventions aimed at increasing vaccination uptake, coverage or timeliness; if they did not explicitly have outcome data on vaccination uptake, coverage, or timeliness; or if they did not address one of the priority groups or settings of interest. Search strategy Four databases were searched: Ovid MEDLINE (1946 to March 11, 2025), Ovid Embase Classic (1947 to 1973) + Ovid Embase (1974 to March 19, 2025), OVID Global Health (1910 to Week 11 2025) and Scopus (1823 to March 2025). The detailed strategy is available in Appendix B. An updated search was conducted on 20 March 2025. Grey literature was searched using Google Scholar. References of included studies were also snowballed for additional articles. Study selection Search results were first deduplicated using EndNote and manually checked by the first author (AT). The titles and abstracts of all studies were screened by two reviewers (AT screened all records, JCL and MMS conducted secondary screening of all records, with screening workload shared between them). Full texts were screened independently by AT, JCL and MMS. Disagreements were resolved through consensus with the authorship team. Rayyan was used to manage the review process and record decisions. Data extraction Two reviewers (AT, CL, MMS, SKS, PG, ID) independently extracted data from all included studies. Results were compared by AT, and disagreements were discussed until a consensus was reached. Data were extracted across five domains: study identifiers, study specifics, information on participants, immunisation pro-equity strategy information, and limitations. Microsoft Excel was used for data extraction. Risk of Bias Assessment The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess and evaluate the trustworthiness, relevance, and results D of the included studies ( 20 ). MMAT evaluated studies into high (scores of 4-5/5), moderate (scores of 3/5), and low (scores of 1-2/5) quality. Two researchers assessed each study independently (AT, CL, MMS, SKS, PG, ID), and discrepancies between reviewers were resolved through discussion. Data analysis Priority group characteristics, including country income level, outbreak setting, routine immunisation status, use of multiple interventions in the same study and vaccine outcomes, were tabulated into frequency data. For ease of presentation, data on uptake and coverage were combined. We used thematic analysis to identify and categorise pro-equity immunisation interventions. Intervention descriptions were inductively coded by two reviewers (AT, MMS). Unique codes were classified into discrete strategies, based on similarities in intervention design, delivery, and intent (Supplementary Table 1) and synthesised into five higher-order immunisation system domains: community-oriented, service delivery, health worker capacity oriented, immunisation or health management information system, and policy and governance (Supplementary Table 2). We deductively classified the strategies using the Tanahashi framework ( 21 ), focusing on five domains of health service coverage: availability, accessibility, acceptability, contact, and effectiveness (Supplementary Table 3). Using the Tanahashi approach allowed for the identification of how pro-equity strategies addressed bottlenecks in the delivery of immunisation programs. Results Of the 20,812 identified records, 10,037 records underwent title and abstract screening, 231 underwent full-text review, resulting in 59 studies which met the eligibility criteria ( Figure 1 ). Download figure Open in new tab Figure 1 PRISMA flow diagram for the identification, screening and inclusion procedure of eligible articles found in the literature Characteristics of the included studies Of the 59 included studies, 39 (66%) were conducted in high-income countries (HICs) and upper middle-income countries (UMICs), and the remaining 20 (34%) in LMICs or low-income countries (LICs). Over half (32/59; 54%) targeted children under 18 years of age. Thirty-one (53%) studies focused on improving vaccination outcomes for routine immunisation ( Table 1 ). Three (5%) studies focused on improving outcomes for COVID-19 vaccinations, 3 (5%) for influenza vaccination, and 14 (24%) for HPV vaccination. Twenty-two (37%) were pre-post studies, 16 (27%) observational studies, 11 (19%) randomised controlled trials (RCTs) including group/cluster RCTs, 6 (10%) mixed methods, 3 (5%) case studies, and one a non-randomised controlled trial ( Table 2 ). Twenty-four (41%) were from the United States of America (USA), 4 (7%) were from India and Nigeria each, 3 (5%) from Pakistan, two from Australia, Kenya, United Kingdom (UK), and Hong Kong each, and one study each from Namibia, South Africa, Nepal, France, Switzerland, Denmark, Spain, Rwanda, Thailand, Somalia, Brazil, Uganda, South Sudan, Colombia, and Japan ( Figure 2 ). Download figure Open in new tab Figure 2 Map depicts the distribution of included studies. Numbers depict the number of studies per country. The boundaries and designation shown on this map are software-generated and do not imply any positioning or expression of opinion by the authors or their institutions regarding the legal status of any country, territory, city, or area, or the delimitation of its frontiers and boundaries. View this table: View inline View popup Download powerpoint Table 1. Summary description of studies describing pro-equity strategies to increase vaccine coverage, uptake, or timeliness View this table: View inline View popup Table 2. Characteristics of included studies Across the 59 studies, we identified 67 unique interventions classified into 25 pro-equity strategies (Supplementary Table 1) and five immunisation system domains (Supplementary Table 2) through inductive thematic analyses. Community-oriented strategies were most frequently used to address immunisation inequity (33/59; 56%) while policy and governance were least frequently used (7/59; 12%). When applying the Tanahashi framework (Supplementary Table 3), most studies described strategies addressing acceptability (37/59; 63%). In contrast, only 5 (8%) studies focused on availability and 10 (17%) on effectiveness ( Table 3 ). View this table: View inline View popup Download powerpoint Table 3. Classification of pro-equity strategies by immunisation system, Tanahashi domains, and outcome in the included studies Fifty-four (92%) studies reported increased uptake or coverage, of which 33 (61%) described community-oriented strategies, 18 (33%) service delivery, and 18 (33%) information strategies. Most study interventions targeted acceptability (35/54; 65%), contact (20/54; 37%), or accessibility (17/54; 31%) ( Table 3 ). Six (10%) studies reported improved timeliness, of which 3 (50%) described community-oriented strategies and 3 (50%) information systems. Using the Tanahashi domain, 3 (50%) studies reported strategies classified as acceptability and contact, and 2 (33%) as effectiveness ( Table 4 ). View this table: View inline View popup Download powerpoint Table 4. Distribution of immunisation system and Tanahashi domains by outcomes and priority groups Quality of studies Thirty-one studies were high quality (4-5 score), 18 moderate (score of 3) and 10 lower quality (1-2 score) ( Table 2 ). Lower scores were typically due to limitations such as unclear strategy descriptions or insufficient detail about study design, sampling or outcome measures, which reduced confidence in their findings. Priority group findings Below, we present pro-equity strategies to reduce vaccine inequities by priority groups. Women and other gender or sexual minorities Twelve (20%) of the 59 studies addressed gender-related inequities ( Table 1 ) ( 22 – 33 ). Most studies (8/12; 67%) targeted cisgender women ( 22 – 27 , 30 , 31 ), particularly pregnant and postpartum women (5/12; 42%) ( 23 , 24 , 26 , 27 , 31 ). Four studies (33%) focused on men who have sex with men, using tailored interventions such as mHealth platforms, peer-group discussions, and motivational interviewing ( Table 2 ) ( 28 , 29 , 32 , 33 ). Zero studies targeted transgender or non-binary populations. Most (10/12; 83%) studies had participants aged 18–54 years, and two involved parents of adolescent girls eligible for HPV vaccination. No studies were conducted in LMICs or LICs. Six (50%) studies used multiple interventions, often combining community engagement with provider education ( Table 1 ) ( 23 , 27 – 29 , 32 , 33 ). The majority (9/12, 75%) of gender-related studies used community-oriented strategies to increase vaccination uptake or coverage ( Table 3 ) ( 22 – 25 , 27 – 29 , 32 , 33 ). These interventions included tailored digital campaigns, motivational interviewing, and educational websites to address vaccine hesitancy and knowledge gaps. Another strategy that increased vaccination uptake or coverage is the use of information systems (3/12; 25%), for example, Electronic Medical Record (EMR)-based prompts for healthcare workers or SMS reminders for recipients and caregivers ( 27 , 31 , 32 ). None of the gender-related studies described an increase in timeliness. Most studies used interventions that address demand, with 9 (75%) studies focused on vaccine acceptability ( 22 – 25 , 27 – 29 , 32 , 33 ). Only one study each described interventions classified under Tanahashi’s effectiveness domain ( 26 ), or under availability ( 23 ) ( Table 3 ). Migrants and mobile populations Six (10%) of the 59 studies focused on migrants and mobile populations, including nomadic pastoralists, refugees, and international migrants ( Table 1 ) ( 34 – 39 ). Four (67%) studies targeted children and their caregivers ( 34 , 37 – 39 ), and two studies targeted adults 18 years and over ( 35 , 36 ). The four studies on routine immunisation used interventions such as co-delivery of human and animal vaccination amongst pastoralist communities, integration of nutrition and immunisation services, vaccination campaigns through mobile posts in refugee communities, and collaboration with community leaders ( Table 1 ) ( 34 , 35 , 38 , 39 ). Most (4/6; 67%) applied multiple interventions using community health workers as vaccinators, decentralisation of planning, and vaccination campaigns ( Table 1 ) ( 34 – 36 , 38 ). All studies that targeted migrants and mobile populations increased vaccination uptake or coverage, but no studies described an increase in timeliness. Most (4/6; 67%) studies used service delivery strategies, including mobile clinics in remote areas, targeted vaccination campaigns, and integrated human-animal vaccination services designed for pastoralist communities ( 34 , 37 – 39 ). Community-oriented approaches (3/6; 50%) also increased vaccine uptake or coverage through community engagement and home visits ( 34 , 36 , 38 ). Only one study identified a policy and governance strategy by introducing a temporary protection status that allows migrants access to free vaccination in Colombia ( 36 ) When using the Tanahashi framework, 4 (67%) studies described interventions classified under contact ( 34 , 35 , 38 , 39 ), and 3 (50%) under acceptability ( 34 , 36 , 38 ). These interventions address demand and utilisation of immunisation services. However, only one study describes interventions classified in the effectiveness domain aimed at improving service quality ( 35 ) ( Table 3 ). People living with disability Twelve (20%) of the 59 studies focused on people living with disabilities ( Table 1 ) ( 40 – 51 ). Most studies (11/12; 92%) focused on individuals with physical disability or chronic health conditions, such as rheumatoid arthritis. Only one study specifically included people with intellectual disabilities in the USA ( 40 ) ( Table 2 ). Most studies (9/12; 75%) targeted adults, while 3 (25%) studies focused on caregivers of children. Four (33%) studies used interventions to improve routine immunisation. Only 2 (17%) studies were conducted in LMICs or LICs. Four (33%) studies implemented multiple interventions, such as EMR prompts for clinicians to identify patients due for immunisation, service provider training, and standardised care protocols ( Table 2 ) ( 42 , 43 , 47 , 51 ). Most studies (8/12; 67%) used interventions that improved immunisation management information systems, such as EMR alerts, reminders, and recalls ( 42 – 45 , 47 – 49 , 51 ) ( Table 3 ), including the two studies that reported increased timeliness as an outcome (2/12; 17%) ( 44 , 47 ). Other strategies that improved coverage or uptake are health worker-oriented strategies (4/12; 33%) ( 42 , 43 , 45 , 46 ) and community-oriented strategies (4/12; 33%) ( 40 , 41 , 50 , 51 ). Only one study (8%) reported interventions to improve service delivery, in conjunction with health-worker-oriented and information systems strategies ( 43 ). None used policy or governance approaches. Eight (67%) studies described interventions classified under Tanahashi’s contact domain ( 42 – 45 , 47 – 49 , 51 ), 5 (42%) under acceptability ( 40 , 41 , 43 , 50 , 51 ), and 4 (33%) under effectiveness ( 42 , 43 , 46 , 47 ). No studies described interventions classified under the accessibility domain ( Table 3 ). Ethnic minority Four (7%) of the 59 studies focused on improving vaccination inequities among ethnic minorities ( 52 – 55 ) ( Table 1 ). These included Latinx and African American adults in the USA ( 53 , 54 ), First Nations Australians ( 52 ), and ethnic minorities identifying as Muslim in Japan ( Table 2 ) ( 55 ). Three (75%) studies focused on adults or caregivers, and only one study targeted children and routine immunisation ( Table 1 ) ( 52 ). No studies were conducted in LMICs or LICs. Three (75%) studies implemented multiple interventions, combining culturally tailored outreach with accessible, community-centred service delivery ( 52 – 54 ). All studies focused on ethnic minority populations used community-oriented strategies ( Table 3 ). These included culturally tailored messaging, engagement through trusted community members, and collaboration with ethnic and religious institutions. Only one study identified service delivery type interventions ( 54 ). No studies reported interventions to improve health worker capacity, information systems, or policy and governance. Based on the Tanahashi framework, all studies reported interventions classified under the acceptability domain. Only one study had interventions classified under accessibility ( 54 ), and none under availability, contact, or effectiveness. Interventions in these studies primarily aimed to address demand rather than supply side determinants. Three (75%) studies reported an increase in uptake or coverage. One study reported improved timeliness by providing caregivers with an immunisation calendar designed with cultural artwork ( Table 3 ) ( 52 ). Urban and rural regions Fifteen (25%) of the 59 studies focused on geographic disparities in immunisation ( Table 1 ) ( 56 – 70 ). Most (9/15; 60%) studies targeted rural populations, particularly children under five and their caregivers in countries such as India, Nigeria, Pakistan, Uganda, and Zambia ( 56 – 58 , 60 , 62 – 64 , 68 , 70 ). Six (40%) studies focused on urban populations in areas like urban slums or economically disadvantaged areas ( Table 2 ) ( 59 , 61 , 65 – 67 , 69 ). Most (14/15; 93%) studies focused on routine immunisation. Eleven (73%) studies were conducted in LMICs or LICs ( 56 – 58 , 60 , 61 , 63 , 64 , 66 – 68 , 70 ). Ten (67%) studies reported using multiple interventions within a single study, such as mobile clinic vaccination, reminders and recalls, incentives, and public-private partnership ( Table 2 ) ( 56 , 58 – 60 , 62 , 64 , 65 , 67 , 68 , 70 ). Of the nine studies focused on rural populations, 5 (56%) studies used interventions classified as community-oriented ( 57 , 60 , 63 , 64 , 68 ), and 4 (44%) each as service delivery ( 56 , 58 , 60 , 68 ) and policy and governance strategies ( Table 3 ) ( 56 , 58 , 64 , 68 ). These studies described different interventions such as mobile clinics, school-based vaccination, and decentralised planning to increase vaccination uptake and coverage. In contrast, of the six urban studies, none described policy and governance interventions; rather, two studies described each of the following strategies - community-oriented ( 65 , 69 ), service delivery ( 66 , 67 ), health worker-oriented ( 59 , 67 ), information system ( 59 , 61 ). While interventions aimed at increasing demand were most reported, with 8 (53%) studies across both urban and rural settings reporting interventions to address acceptability, focus on supply and quality of services is also evident through interventions to address accessibility (7/15; 47%), contact (4/15; 27%), and effectiveness 4 (27%). Most (13/15; 87%) studies reported an increase in coverage or uptake, but 2 (13%) reported an increase in timeliness through interventions using collaboration with the community and healthcare worker education ( 62 , 65 ). Multiple priority groups Ten of the 59 studies (17%) examined intersections across the multiple priority groups ( 71 – 80 ) ( Table 1 ). These included ethnic minority women, migrant children in remote areas, and female caregivers in rural and low-income communities ( Table 2 ). The majority (8/10; 80%) targeted children and their caregivers ( 71 , 73 – 75 , 77 – 80 ). However, despite addressing more than one form of disadvantage, few studies analysed how these intersecting factors influenced access or outcomes. Five (50%) studies focused on improving routine immunisation outcomes ( 71 , 73 – 75 , 77 ). Only three studies (30%) were conducted in LMICs or LICs ( 71 , 75 , 78 ). Six (60%) studies implemented multiple interventions, often combining community engagement, service delivery, and digital tracking systems ( Table 1 ) ( 71 , 73 – 75 , 78 , 79 ). Seven (70%) studies focusing on multiple priority groups used community-oriented strategies such as peer-led education, community theatre, and culturally tailored outreach campaigns ( Table 3 ) ( 71 , 74 – 76 , 78 – 80 ). Four (40%) studies described information system strategies ( 72 – 74 , 78 ), and 3 (30%) described service delivery strategies ( 71 , 75 , 77 ), including using postpartum tracking systems and reminders for vaccine series completion. No studies used health worker education or policy-level approaches. When using the Tanahashi framework, 8 (80%) studies reported interventions aimed at addressing acceptability bottlenecks ( 71 , 73 – 76 , 78 – 80 ), 4 (40%) targeted accessibility ( 71 , 75 , 77 , 78 ), and 3 (30%) focused on contact ( 72 – 74 ). No studies described interventions targeting availability and effectiveness bottlenecks. All studies reported an increase in vaccination uptake or coverage. Additionally, one study demonstrated increased vaccination uptake and timeliness by implementing service delivery and community-oriented strategies, with interventions aimed at addressing accessibility and acceptability bottlenecks ( Table 3 ) ( 71 ). Discussion Our systematic review found that despite the increasing recognition of pro-equity strategies in addressing disadvantages that people and communities face due to their gender, migration status, ethnicity, disability, and place of residence, empirical evidence on strategies to improve vaccination outcomes is limited. In this review, we identified 59 studies where use of pro-equity strategies increased vaccine uptake and coverage (54 studies) and timeliness of vaccination (six studies) amongst the five priority groups: gender (12 studies), migrants and mobile population (six studies), people with disability (12 studies), ethnic minorities (four studies), urban-rural regions (15 studies), and multiple priority groups (10 studies). Across the 59 studies, 25 pro-equity strategies were identified, addressing five programmatic areas, including targeting the community (i.e. community-oriented), service delivery, health worker capacity, information systems, and policy and governance. The 25 strategies were also mapped against the Tanahashi domains to systematically examine which aspect of the health system an intervention was targeted towards ( 13 ). Despite the largest number of zero-dose children being in LMICs ( 81 ), most studies were conducted in the USA. Community-oriented strategies that aimed to increase awareness and demand for immunisation services were commonly reported (56%) and included interventions such as community engagement, collaboration with local communities, caregiver education and social media ( 22 – 25 , 27 – 29 , 32 – 34 , 36 , 38 , 40 , 41 , 50 – 55 , 57 , 60 , 63 – 65 , 68 , 69 , 71 , 73 – 76 , 78 – 80 ). Using the Tanahashi framework, 63% of studies addressed acceptability, which aimed to increase the number of people who were willing to be immunised ( 22 – 25 , 27 – 29 , 32 – 34 , 36 , 38 , 40 , 41 , 43 , 50 – 55 , 57 , 58 , 60 , 63 , 65 , 67 – 69 , 71 , 73 – 76 , 78 – 80 ). Both analytical approaches suggested that very few strategies targeted upstream barriers in the health system, i.e. through immunisation policy and governance; or availability of vaccination and immunisation services or effectiveness, which aims to improve service delivery. As expected, we did not find a single strategy or approach universally applied. However, some approaches were more common in certain populations and settings. In addressing gender-related barriers to vaccination, education and information campaigns were frequently reported and used a diverse range of platforms ( 22 – 25 , 27 – 29 , 32 , 33 ). With the introduction of pregnancy vaccination in recent years, and known challenges to uptake ( 82 ), it is not unexpected that many studies (42%) focused on pregnant women. However, we found no studies that targeted vaccination in transgender and non-binary populations. Considering the increased focus on life course vaccination, use of vaccines for epidemic control of diseases like COVID-19 and MPOX, and the increased risk of these populations both from lack of health services perspective and high-risk of transmission in the case of MPOX ( 83 ), there is clearly a need to prioritise the identification of what strategies work in these populations. Migration and population mobility are significant emerging areas in the IA2030 ( 1 ), especially due to the increasing impacts of climate change and conflict-related displacements. Most reported studies have been traditionally conducted in populations such as nomadic groups and refugees, but none looked at internal migration, which are likely to become a significant issue due to climate change. Most (83%) studies addressing vaccination gaps in people with disability were conducted in HIC settings and used a combination of information systems, such as reminders and recalls. For example, EMR to alert when vaccination is due was used in a study of rheumatoid arthritis patients attending an outpatient clinic in the USA ( 44 ). There were limited data on attempts to address service delivery or policy/governance. Only two of the studies were conducted in LMICs, which highlights a significant gap considering the immunisation gap between children with disability compared with those without any disabilities is significant ( 8 , 84 ). A recent scoping review examining challenges and strategies to reduce the number of zero-dose children in children with disabilities reiterated the need for tailored interventions, especially targeting access ( 85 ). However, the study did not examine outcomes or look at a life-course approach. Studies from Fiji have found rates of vaccination to be lowest in adolescents compared with zero-dose children ( 8 ). Data on addressing vaccination gaps in ethnic minorities were limited, and, where available, were generated in HICs and mainly applied interventions that aimed to increase vaccine acceptability focussing on the populations themselves rather than addressing bottlenecks in the health system or systemic issues within the health system which might be associated with lower vaccination rates, such as racial discrimination. As previously noted, the link between ethnic and immunisation disparities in LMICs is well documented ( 11 ), and yet, we found no intervention studies to address this inequity conducted in LMICs. When addressing gaps in vaccination in rural and urban settings, 6 (40%) studies focused on zero-dose children living in dense urban settings ( 86 ). Traditionally, it is viewed that vaccination rates in rural settings were low, especially when compared to urban settings. However, with increasing urbanisation, data suggests that most unvaccinated and under-vaccinated children live in dense urban settings across LMICs ( 87 ). A wide range of interventions were used to address inequities in this priority group, reflective of the complex range of barriers experienced by this group. It is also likely a reflection of Gavi’s recent investment in this area, which has become increasingly important over the past decade ( 86 , 88 ). Interestingly, 10 studies looked at the intersectionality across our five priority groups but mostly focused on increasing community awareness and demand for vaccination through peer-led education, community theatre, and culturally tailored outreach campaigns ( 71 , 73 – 76 , 78 – 80 ). A study from the US examined the intersectional effects of race/ethnicity and disability on flu vaccine use, which found significant race-by-disability interaction in young black adults, who had higher odds of getting vaccinated compared with white adults ( 89 ). Many studies report the negative impacts of intersectionality on health equity broadly ( 90 – 92 ), but not many studies examine strategies that can specifically target immunisation inequities. The purpose of this study was not to identify a single strategy that worked across all priority groups, but to identify gaps and biases in addressing the immunisation inequities. The lack of studies (gender, ethnic minorities) and limited studies (people with disability) in LMICs raises the question of where research is being conducted and why some groups remain untargeted. Considering the burden of inequities across LMICs, there is a clear need to invest in implementation research in these settings. This review builds on existing analyses of pro-equity immunisation strategies, including those by Dadari et al ., who found that over 75% of interventions in select Gavi-supported countries focused on addressing vaccine demand, with limited attention to supply-side issues like vaccine availability and workforce ( 13 ). Our findings align with this pattern, showing a reliance on generating vaccination demand, especially using community-oriented strategies, particularly for gender, migrant, and disability groups, while strategies addressing health systems (availability and effectiveness domains) were rarely used. Other studies, such as those by Ivanova et al . ( 15 ) and Ducharme et al ( 14 ), have reported similar findings with limited studies addressing upstream drivers and bottlenecks in the health system. This finding is not new, as countries, public health practitioners and academics have often critiqued the focus on quick-fixes and project-based approaches to addressing deep-entrenched inequities across immunisation, but also other health programs ( 93 ). Most included studies were small-scale and often lacked disaggregated data limiting generalisability and the ability to determine whether equity gaps were truly reduced. The MMAT results indicate that most studies were of moderate quality with only a few studies assessed as high quality. However, application of the MMAT tool enabled a rigorous appraisal of included studies. This systematic review has multiple strengths. We conducted a broad search across multiple databases, grey literature, and reference lists without language or time restrictions. We included diverse study designs, which allowed for a rich synthesis. Classification of the pro-equity strategies using an inductive thematic analysis approach, followed by a deductive analysis using the Tanahashi framework, enabled a structured and nuanced examination of all the diverse interventions reported across the 59 studies. We were able to link strategies to specific aspects of health systems, service delivery and equity gaps. This dual approach provided a structure for meaningful comparisons across studies and priority groups. This allowed identification of strategies that worked in a nuanced manner. There were some limitations. The heterogeneity of study designs, populations, and outcome measures precluded a meta-analysis and made it challenging to assess comparative effectiveness. Similarly, excluding studies that did not report outcome data does not mean that priority groups were not targeted, but that very few studies examined the real-world effectiveness of these strategies. With the recent global health funding cuts ( 94 , 95 ) and diminishing health budgets, it is important to regularly evaluate and implement interventions that will reduce inequities and will be sustainable. Implementation research using a systems approach that is embedded into regular monitoring and evaluation frameworks might be one such way to address this gap ( 96 , 97 ). In conclusion, we provide a comprehensive synthesis of pro-equity strategies that address vaccination gaps in population groups who are often underserved or excluded from routine immunisation programs. A range of approaches is required to address systemic barriers in the health system, including at the community level, service delivery bottlenecks, information systems, and health system policies and governance, each of which needs to be tailored and adapted for the context. Addressing persistent gaps is essential to achieve IA2030 goals and ensure that no one is left behind. Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper ICMJE All authors attest they meet the ICMJE criteria for authorship. CRediT authorship contribution statement Adeline Tinessia: Investigation, Formal analysis, Writing - original draft, Writing - Review & Editing. Majdi M. Sabahelzain: Investigation, Formal analysis, Writing - Review & Editing. Catherine King: Methodology, Writing - Review & Editing. Saman Khalatbari-Soltani: Investigation, Writing - Review & Editing. Praveena Gunaratnam: Investigation Writing - Review & Editing. Ibrahim Dadari: Investigation, Writing - Review & Editing, John Carlo Lorenzo: Investigation. Soumyadeep Bhaumik: Methodology, Investigation, Writing - Review & Editing. Meru Sheel: Conceptualisation, Methodology, Investigation, Writing - original draft, Writing - Review & Editing, Supervision Data Availability All data produced in the present study are available upon reasonable request to the authors Appendix A: PRISMA Checklist 2020 View this table: View inline View popup Appendix B: Database search strategies Ovid MEDLINE(R) ALL <1946-> exp Immunization/ exp Immunization Programs/ exp Vaccines/ (immunis$ or immuniz$ or vaccin$).tw. 1 or 2 or 3 or 4 exp diversity, equity, inclusion/ exp Health Equity/ 8 equit$.tw. 9 inequit$.tw. (pro adj2 inequit$).tw. (pro-equit$ or proequit$).tw. 12 gender$.tw. (woman or women$ or girl$ or female$).tw. exp Pregnancy/ (pregnan$ or mother$).tw. exp Child/ exp Infant/ (baby or babies or infant$ or toddler$ or child$ or pediatric$ or paediatric$).tw. exp Adult/ 20 adult$.tw. exp Disabled Persons/ (disable$ or disabilit$ or impair$).tw. exp Urban Population/ 24 urban$.tw. exp Rural Population/ 26 rural$.tw. (remote$ or inaccess$).tw. ((hard or difficult$) adj4 reach$).tw. exp “Ethnic and Racial Minorities”/ (ethnic$ adj4 minorit$).tw. exp “Transients and Migrants”/ (migrant$ or immigrant$ or emigrant$).tw. exp Refugees/ 34 refugee$.tw. (asylum$ adj2 seek$).tw. exp “Health Disparate, Minority and Vulnerable Populations”/ (vulnerab$ or disadvantage$ or persecut$ or margin$ or underserv$ or displace$).tw. exp Communication Barriers/ ((communic$ or language$) adj4 barrier$).tw. exp Socioeconomic Factors/ 41 socioeconom$.tw. exp Poverty/ (povert$ or impover$).tw. 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 r 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or or 42 or 43 5 and 44 (un-vaccin$ or unvaccin$ or un-immuni$ or unimmuni$).tw. (under-vaccin$ or undervaccin$ or under-immuni$ or underimmuni$).tw. (partial$ adj2 (vaccin$ or immuni$ or dose$)).tw. (delay$ adj2 (vaccin$ or immuni$ or dose$)).tw. (incomplet$ adj2 (vaccin$ or immuni$ or dose$)).tw. (miss$ adj2 (vaccin$ or immuni$ or dose$)).tw. ((miss$ or lost or loss) adj2 (opportun$ or chance$)).tw. (zero adj1 dos$).tw. (“zero dos$” or zero-dos$).tw. (no adj1 dos$).tw. (lapse$ or forget$ or forgot$).tw. ((leav$ or left) adj2 behind).tw. 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 45 and 58 exp Policy/ exp Policy Making/ exp Program Development/ (policy or policies or program$).tw. (strateg$ or tool$ or interven$ or solution$ or solv$ or approach$ or facilitat$).tw. exp Health Plan Implementation/ 66 implement$.tw. (promot$ or advanc$ or champion$ or advocat$).tw. exp “Delivery of Health Care”/ (health$ adj2 system$).tw. 70 governance$.tw. 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 59 and 71 exp Vaccination Coverage/ (coverage$ or uptake$ or status$ or tim$).tw. 73 or 74 72 and 75 exp animals/ not humans.sh. 76 not 77 Global Health <1910-> exp immunization/ exp immunization programmes/ exp vaccines/ (immunis$ or immuniz$ or vaccin$).tw. 1 or 2 or 3 or 4 6 equit$.tw. exp health inequalities/ 8 inequit$.tw. (pro adj2 inequit$).tw. (pro-equit$ or proequit$).tw. 11 gender$.tw. exp females/ (woman or women$ or girl$ or female$).tw. exp pregnancy/ (pregnan$ or mother$).tw. exp children/ exp infants/ (baby or babies or infant$ or toddler$ or child$ or pediatric$ or paediatric$).tw. exp adults/ 20 adult$.tw. exp people with disabilities/ (disable$ or disabilit$ or impair$).tw. exp urban population/ 24 urban$.tw. exp rural population/ 26 rural$.tw. (remote$ or inaccess$).tw. ((hard or difficult$) adj4 reach$).tw. exp ethnic groups/ (ethnic$ adj4 minorit$).tw. exp migrants/ (migrant$ or immigrant$ or emigrant$).tw. exp refugees/ 34 refugee$.tw. (asylum$ adj2 seek$).tw. (vulnerab$ or disadvantage$ or persecut$ or margin$ or underserv$ or displace$).tw. ((communic$ or language$) adj4 barrier$).tw. exp socioeconomics/ 39 socioeconom$.tw. exp poverty/ (povert$ or impover$).tw. 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 r 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 5 and 42 (un-vaccin$ or unvaccin$ or un-immuni$ or unimmuni$).tw. (under-vaccin$ or undervaccin$ or under-immuni$ or underimmuni$).tw. (partial$ adj2 (vaccin$ or immuni$ or dose$)).tw. (delay$ adj2 (vaccin$ or immuni$ or dose$)).tw. (incomplet$ adj2 (vaccin$ or immuni$ or dose$)).tw. (miss$ adj2 (vaccin$ or immuni$ or dose$)).tw. ((miss$ or lost or loss) adj2 (opportun$ or chance$)).tw. (zero adj1 dos$).tw. (“zero dos$” or zero-dos$).tw. (no adj1 dos$).tw. (lapse$ or forget$ or forgot$).tw. ((leav$ or left) adj2 behind).tw. 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 43 and 56 exp policy/ (policy or policies or program$).tw. (strateg$ or tool$ or interven$ or solution$ or solv$ or approach$ or facilitat$).tw. exp health programmes/ 62 implement$.tw. (promot$ or advanc$ or champion$ or advocat$).tw. (health$ adj2 system$).tw. exp governance/ 66 governance$.tw. 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 57 and 67 (coverage$ or uptake$ or status$ or tim$).tw. 68 and 69 Embase Classic <1947 to 1973> Part 1 of 2, Embase <1974-> exp immunization/ exp vaccine/ (immunis$ or immuniz$ or vaccin$).tw. 1 or 2 or 3 exp “diversity, equity and inclusion”/ exp health equity/ 7 equit$.tw. 8 inequit$.tw. (pro adj2 inequit$).tw. (pro-equit$ or proequit$).tw. exp gender/ 12 gender$.tw. exp female/ (woman or women$ or girl$ or female$).tw. exp pregnancy/ (pregnan$ or mother$).tw. exp child/ (baby or babies or infant$ or toddler$ or child$ or pediatric$ or paediatric$).tw. exp adult/ 20 adult$.tw. exp disabled person/ (disable$ or disabilit$ or impair$).tw. exp urban population/ 24 urban$.tw. exp rural population/ 26 rural$.tw. (remote$ or inaccess$).tw. ((hard or difficult$) adj4 reach$).tw. exp ethnic group/ (ethnic$ adj4 minorit$).tw. exp migration/ (migrant$ or immigrant$ or emigrant$).tw. exp refugee/ 34 refugee$.tw. (asylum$ adj2 seek$).tw. exp vulnerable population/ (vulnerab$ or disadvantage$ or persecut$ or margin$ or underserv$ or displace$).tw. exp communication barrier/ ((communic$ or language$) adj4 barrier$).tw. exp socioeconomics/ 41 socioeconom$.tw. exp poverty/ (povert$ or impover$).tw. 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 r 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or or 41 or 42 or 43 4 and 44 (un-vaccin$ or unvaccin$ or un-immuni$ or unimmuni$).tw. (under-vaccin$ or undervaccin$ or under-immuni$ or underimmuni$).tw. (partial$ adj2 (vaccin$ or immuni$ or dose$)).tw. (delay$ adj2 (vaccin$ or immuni$ or dose$)).tw. (incomplet$ adj2 (vaccin$ or immuni$ or dose$)).tw. (miss$ adj2 (vaccin$ or immuni$ or dose$)).tw. ((miss$ or lost or loss) adj2 (opportun$ or chance$)).tw. (zero adj1 dos$).tw. (“zero dos$” or zero-dos$).tw. (no adj1 dos$).tw. (lapse$ or forget$ or forgot$).tw. ((leav$ or left) adj2 behind).tw. 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 45 and 58 exp policy/ exp program development/ (policy or policies or program$).tw. (strateg$ or tool$ or interven$ or solution$ or solv$ or approach$ or facilitat$).tw. exp health care planning/ 65 implement$.tw. (promot$ or advanc$ or champion$ or advocat$).tw. exp health care delivery/ (health$ adj2 system$).tw. 69 governance$.tw. 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 59 and 70 exp vaccination coverage/ (coverage$ or uptake$ or status$ or tim$).tw. 72 or 73 71 and 74 (animal$ not human$).sh. 75 not 76 SCOPUS ((((TITLE-ABS-KEY (un-vaccin* OR unvaccin* OR un-immuni* OR unimmuni* OR under-vaccin* OR undervaccin* OR under-immuni* OR underimmuni*)) OR (TITLE-ABS-KEY (((partial* W/2 (vaccin* OR immuni* OR dose*))))) OR (TITLE-ABS-KEY (((delay* W/2 (vaccin* OR immuni* OR dose*))))) OR (TITLE-ABS-KEY (((incomplet* OR miss*) W/2 (vaccin* OR immuni* OR dose*)))) OR (TITLE-ABS-KEY ((((miss* OR lost OR loss) W/2 (opportun* OR chance*))))) OR (TITLE-ABS-KEY ((zero W/1 dos*))) OR (TITLE-ABS-KEY ((“zero dos*” OR zero-dos*))) OR (TITLE-ABS-KEY ((no W/1 dos*))) OR (TITLE-ABS-KEY ((no W/1 dos*))) OR (TITLE-ABS-KEY ((((leav* OR left) W/2 behind))))) AND ((TITLE-ABS-KEY (immunis* OR immuniz* OR vaccin*)) AND ((TITLE-ABS-KEY (equit* OR inequit*)) OR (TITLE-ABS-KEY (pro W/2 inequit*)) OR (TITLE-ABS-KEY (pro-equit* OR proequit*)) OR (TITLE-ABS-KEY (gender*)) OR (TITLE-ABS-KEY (woman OR women* OR girl* OR female*)) OR (TITLE-ABS-KEY (pregnan* OR mother*)) OR (TITLE-ABS-KEY (baby OR babies OR infant* OR toddler* OR child* OR pediatric* OR paediatric*)) OR (TIT LE-ABS-KEY (adult*)) OR (TITLE-ABS-KEY (disable* OR disabilit* OR impair*)) OR (TITLE-ABS-KEY (urban* OR rural* OR remote* OR inaccess*)) OR (TITLE-ABS-KEY ((((hard OR difficult*) W/4 reach*)))) OR (TITLE-ABS-KEY (ethnic* W/4 minorit*)) OR (TITLE-ABS-KEY (migrant* OR immigrant* OR emigrant*)) OR (TITLE-ABS-KEY (refugee*)) OR (TITLE-ABS-KEY (asylum* W/2 seek*)) OR (TITLE-ABS-KEY (vulnerab* OR disadvantage* OR persecut* OR margin* OR underserv* OR displace*)) OR (TITLE-ABS-KEY ((((communic* OR language*) W/4 barrier*)))) OR (TITLE-ABS-KEY (socioeconom* OR povert* OR impover*))))) AND ((TITLE-ABS-KEY (policy OR policies OR program*)) OR (TITLE-ABS-KEY (strateg* OR tool* OR interven* OR solution* OR solv* OR approach* OR facilitat*)) OR (T ITLE-ABS-KEY (implement* OR promot* OR advanc* OR champion* OR advocat*)) OR (TITLE-ABS-KEY (health* W/2 system*)) OR (TITLE-ABS-KEY (governance*)))) AND (TITLE-ABS-KEY (coverage* OR uptake* OR status* OR tim*)) AND (EXCLUDE (EXACTKEYWORD, “N onhuman”) OR EXCLUDE (EXACTKEYWORD, “Animals”) OR EXCLUDE (EXACTKEYWO RD, “Animal”)) AND (EXCLUDE (SUBJAREA, “VETE”)) References 1. ↵ 1. 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