Vaccine: X 16 (2024) 100454

Contents lists available at ScienceDirect

Vaccine: X
journal homepage: www.elsevier.com/locate/jvacx

In-depth reasons for the high proportion of zero-dose children in

underserved populations of Ethiopia: Results from a qualitative study
Gashaw Andargie Biks a, *, Fisseha Shiferie a, Dawit Abraham Tsegaye a, Wondwossen Asefa b,
Legese Alemayehu a, Tamiru Wondie a, Gobena Seboka a, Adrienne Hayes b, Uche RalphOpara b,
Meseret Zelalem c, Kidist Belete d, Jen Donofrio e, Samson Gebremedhin f
a
Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
b
Project HOPE Headquarter, Washington, DC, United States
c
Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
d
USAID Ethiopia Country Office, Addis Ababa, Ethiopia
e
Bill and Melinda Gates Foundation, United States
f
School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly
Supply and demand barrier designated as zero-dose children. A comprehensive understanding of the supply- and demand-side barriers is
Qualitative essential to inform zero-dose strategies in high-burden countries and achieve global immunization goals. This
Gender norms
qualitative study aimed to identify the barriers for reaching zero-dose and under-immunized children and what
Key informant interview
and explore gender affects access to vaccination services for children in Ethiopia. Data was collected between
Focus group discussion
March-June 2022 using key informant interviews and focus group discussions with participants in underserved
settings. The high proportion of zero-dose children was correlated with inadequate information being provided
by health workers, irregularities in service provision, suboptimal staff motivation, high staff turnover, closure
and inaccessibility of health facilities, lack of functional health posts, service provision limited to selected days or
hours, and gender norms viewing females as responsible for childcare. Demand-side barriers included religious
beliefs, cultural norms, fear of vaccine side effects, and lack of awareness and sustained interventions. Recom­
mendations to increase vaccination coverage include strengthening health systems such as services integration,
human resources capacity building, increasing incentives for health staff, integrating vaccination services,
bolstering the EPI budget especially from the government side, and supporting reliable outreach and static
immunization services. Additionally, immunization policy should be revised to include gender considerations
including male engagement strategies to improve uptake of immunization services.

Introduction infant mortality rates. Unfortunately, sub-Saharan Africa bears the brunt
of this tragic loss, as millions of children succumb to preventable
The 2021 WHO/UNICEF global annual estimate reveals a troubling communicable diseases. The solution to this devastating problem lies in
statistic: the majority of children who have not received any vaccina­ immunization, a transformative process that empowers individuals to
tions, also known as zero-dose children, reside in low- and lower- combat the microbial threats of the world [5].
middle-income countries [1,2]. These nations account for a staggering Immunization is the ultimate shield against infectious diseases,
87 % of the total 18 million zero-dose children worldwide [3]. Among particularly in the realm of childhood health. It not only plays a crucial
them, six populous countries namely India, Nigeria, Indonesia, Ethiopia, role in reducing mortality rates worldwide but also has the potential to
Philippines, and the Democratic Republic of Congo are responsible for significantly improve the overall well-being of communities. In fact, a
half of all zero-dose children [3,4]. However, it is important to note that shocking report by WHO between 2001 and 2008 revealed that nine
there are regional disparities within these countries, resulting in higher million child deaths globally were attributable to vaccine-preventable

* Corresponding author.
E-mail address: Gandargie@projecthope.org (G.A. Biks).

https://doi.org/10.1016/j.jvacx.2024.100454
Received 16 August 2023; Received in revised form 18 January 2024; Accepted 30 January 2024
Available online 1 February 2024
2590-1362/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
G.A. Biks et al. Vaccine: X 16 (2024) 100454

diseases, with sub-Saharan Africa bearing a disproportionately high interventions such as reminders or recall systems, financial incentives,
burden. Within this region alone, 4.4 million innocent lives were trag­ reducing the physical distance to health services and regular monitoring
ically lost [3]. can serve as powerful catalysts for accelerating immunization services
To address this grave issue, it is imperative to fortify routine im­ [18]. By embracing this approach, we gain valuable insights that inform
munization services. By doing so, we can effectively curb the spread of targetted strategies to promote immunization and address challenges
vaccine-preventable diseases and protect the lives of millions across the faced by different communities.
globe [6]. Ethiopia, a nation steadfast in its commitment to safeguarding One significant gap in the evidence base about zero-dose children lies
the sanctity of life, has set an ambitious goal of increasing immunization in understanding the patterns and challenges faced by refugee, migrant,
coverage by 10 % annually. Recognizing the pivotal role of universal and nomadic populations [19]. These populations are constantly on the
immunization in reducing infant and child mortality rates, Ethiopia has move, and their size can be influenced by conflicts, climate shocks, food
made substantial progress in immunizing children against six common shortages, natural calamities, and loss of income [20]. Consequently,
and dangerous diseases such as tuberculosis, diphtheria, pertussis, accessing immunization becomes even more difficult for zero-dose
tetanus, polio, and measles [7]. Ethiopia’s has also a dedication extends children and their families who already face multiple deprivations
to the introduction of supplementary vaccines that provide compre­ related to health and development [21].
hensive protection for our children. These additional vaccines shield To address this gap, our study aims to explore supply and demand-
them from perils such as hepatitis B, Haemophilus influenzae type b side barriers that hinder efforts to reaching zero-dose children in un­
(Hib), pneumococcal diseases (PCV), and the notorious rotavirus [8]. derserved settings of Ethiopia. By exploring the unique context of these
Comprehending the intricate interplay of social, economic and po­ settings, we aim to shed more light on how gender norms, roles and
litical factors surrounding zero dose children is critical in designing relations affects vaccination service provision and utilization within the
effective immunization programs, given their propensity to encounter same study settings.
numerous barriers. Furthermore, it has become evident that factors such
as education, occupation, household income, gender, living conditions, Materials and methods
habitation and awareness continue to exert substantial influence even
when cost-free immunization programs and other health services are Study design
available [9,10]. Existing immunization practices and delivery systems
have failed to adequately meet the needs of populations, especially for The study employed a qualitative design as part of a national zero-
those residing in underserved setting resulting in lower coverage rates. dose evaluation project to explore barriers and enablers contributing
Despite numerous efforts, the inhabitants living in these areas pose a to the high proportion of zero-dose children in underserved and special
significant challenge for achieving the national immunization goals. setting population of Ethiopia from March to June 2022.The overall
Gender-related barriers contribute to the unequal access to vaccinations findings of the study has been documented separately. The study fol­
among children. Research shows that empowering mothers play a sig­ lowed a stepwise qualitative approach, initially seeking input from:
nificant role in reducing the number of unvaccinated or zero dose high-level officials at national level, and subsequently gathering per­
children. Specifically, a survey-based women’s empowerment index spectives from mid and lower-level decision makers and community
indicates that children with empowered mothers are far less likely to be members in selected underserved settings. Qualitative data were
zero-dose [11]. The index measures different aspects of empowerment, collected through key informant interviews (KIIs) and focus group dis­
including social independence. It revealed that children of mothers with cussions (FGDs).
low or medium levels of social independence were more likely to be
zero-dose than those with highly independent mothers [12]. Addressing Study setting
the barriers to immunization associated with women’s empowerment
could lead to a substantial decrease of 4.7 million zero-dose children In total, the study included 22 districts from nine regions (Afar, So­
globally. Consistent with the literature on inequalities in access to mali, Oromia, Southern Nations, and Nationality People (SNNP),
various health services [13], children from poorer households are more Southwest, Gambella, Benishangul Gumuz, Sidama, and Harari) and two
likely to be zero-dose than children from wealthier households [14]. city administrations (Addis Ababa and Dire Dawa) of underserved and
Unfortunately, there appears to have been little progress in reducing this special populations in Ethiopia. The second-round qualitative study
gap over the past decade and the greatest absolute inequalities occur in explored the situation in different study populations (including hard-to-
the poorest countries [15]. While efforts have been made to overcome reach, pastoralist, conflict-affected areas, socially disadvantaged urban,
these inequalities, progress remains limited. The current situation refugees, and internally displaced populations). Multiple perspectives
highlights the need for targeted interventions to ensure equal access to were considered, and data was collected at different levels of the health
immunization for all children regardless of their socioeconomic system and communities in those study settings.
background.
Employing a multi-level qualitative approach offers a unique op­ Study participants
portunity for real time interactions with stakeholders including benefi­
ciaries, healthcare service providers, policy makers, and influencers who The study participants were selected in three levels. In addition, the
form a principal element of any immunization program. This approach study also included study participants from the Ministry of Health
enables a comprehensive understanding of their unbiased perspectives, (MoH) such as EPI team leaders, Directors of Health Extension Program/
which have the potential to influence immunization program coverage Primary Health Care, and health systems special support Directorates
or other desired outcomes. Evidence generated through this approach is and their respective counterparts at regional level were also represented.
critical for identifying the underlying potential drivers, parental con­ Furthermore, key partners including multilateral agencies and nongov­
cerns regarding immunization of their children, specific needs of the ernmental organizations (NGOs) at national and regional level were
underserved settings, and analyzing the levels of influence on health- included. We also interviewed the EPI focal persons at the Ethiopian
related behaviors [14–16]. Unlike most studies are based solely on Pharmaceutical Supply Services placed at central and regional hubs. In
quantitative approaches, which have inherent limitations in capturing addition, community-level respondents including formal and informal
nuanced perspectives, a multi-level qualitative approach allows for a community leaders, Women/Health Development Army (WDA/HDA)
deeper understanding of the various stakeholders and complex contexts members and caregivers, were selected in consultation with local Health
within the community that impact the coverage or other desired out­ Extension Workers (HEWs). The study participants were selected using a
comes related to the immunization program [10,17] for example, purposive sampling criteria, focusing on respondents who were more

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likely to provide valuable and insightful information (Table1). on 12–15 open ended and exploratory questions. The facilitators of the
interviews held PhD qualifications and were trained and experienced
while the note takers had an MPH as qualification. The interviewers
Data collection
were recruited from local universities from the respective regions based
on their merits.
Data were primarily collected through KIIs and FDGs in two phases.
The first phase was completed with the situational analysis phase in
Data analysis
March 2022. This phase captured the perspectives of core partners of the
national immunization program and top-level officials from MoH and
Data from KIIs and FGDs were analyzed using thematic analysis. The
key-informants from all regional states of Ethiopia excluding Tigray. The
audio recordings were transcribed, and translated from five local
second phase involved gathering view points of decision makers
interview languages to English. All KIIs and FGDs were tape recorded.
including zonal and woreda health offices managers, implementing
Coders independently coded each translated transcript, which was then
partners, and health workers deployed at all levels of the primary
reviewed collaboratively to establish standardized themes and codes for
healthcare unit. The second phase also assessed the perspectives of the
the analysis ensuring inter-coder reliability. For better analyses, the
community through conducting in-depth interviews with formal and
transcripts for KIIs were first analyzed for exploratory reasons to learn
informal community leaders and FGDs with caregivers of children in
more about vaccination hindrances and the general usage of health
underserved settings. This phase was completed in June 2022. To ensure
services. This approach helped to distill important preliminary issues
consistency of the interviews and discussions, the KIIs and FGDs were
regarding study themes. After this, transcripts from FGDs were analyzed
facilitated using semi-structured guidelines were used and were based
to complement findings from KIIs. This approach helped to look at
vaccine hindrances from a broader perspective, giving a more holistic
Table 1
explanation of low vaccination coverage by capturing the voices of
Summary of the study participants for Barrier analysis for zero dose children, in
women and community leaders who did not participate in the KIIs and
underserved and special setting population of Ethiopia from March to June
2022.
may have had a different perspective.

List of study participants

Data qualitative assurance
Federal-level respondents (# 14 KII)
MoH, MCH Directorate Deputy Director
To ensure data quality, interviewers underwent a two-day training in
MoH, EPI Team Leader
MoH, Primary Health Care (PHC) Technical Advisor
Addis Ababa. Data collection continued until information saturation is
MoH, Policy and Planning, Monitoring and Evaluation Directorate Director achieved. Verbatim translation and transcription were conducted, and
MoH, Health System and Special System Team Leader the resulting data along with field notes were sent to the researchers for
MoH, Disease Surveillance and Response Directorate Director feedback and analysis. The data collection tools were also validated by
EPHI, Disease Surveillance and Response Directorate
stakeholders including MoH and regional health bureaus (RHBs).
Federal EPSA, Vaccine Supply Manager
Developing themes were identified, and the report was organized in
logical order according to the themes and sub-themes of the analysis.
EPI Focal persons at core partner organizations (UNICEF, WHO, CHAI, PATH)
Regional-level respondents (# 84 KII)
Key quotations were provided to support the interpretation and
RHBs, MCH Director demonstrate how the findings evolved from the actual data.
RHBs, EPI Team Leader or equivalent The validity of the qualitative research was ascertained by ensuring
RHBs, HEP Director that data collection and analysis approaches were compatible with the
Regional EPSA Hubs, EPI Focal Person
five-dimension criteria (credibility, transferability, dependability,
Regional EPHI, PHEM Director
Local partners (2/region): UNICEF, WHO, CDC, JSI, CHAI, Save the Children, confirmability, and reflexivity) set for assuring rigor of qualitative
Transform PHCU research [22,23]. To ensure the credibility, we triangulated the data
coming from different levels (high, middle, and low managers) and types
Zonal or sub-city level respondents (# 36 KII) (government bodies vs partners, health workers vs community repre­
MCHN Directorate Director sentatives) of respondents. Findings were also validated with selected
EPI Team leader key informants, and a two-staged validation workshop was conducted
with the core research team and those who contributed to data gener­
Woreda-level respondents (# 66 KII) ation. This process helped assess the transferability and confirmability of
MCHN Directorate Director the findings by presenting them alongside contextual data such as the
EPI Team Leader
setting and type of population.
HEP Directorate Director
Local implementing partners/ NGOs
Ethical considerations
Primary Health Care Unit (PHCU) (# 88 KII)
MCH/EPI head (Primary hospital) Before data collection, we obtained ethical clearance from the
HEW supervisors (health centres) Institutional Review Board of the Ethiopian Public Health Institute.
MCH/EPI head (health centres) Administrative clearances were obtained from various levels of the
HEWs
health system. Consent was obtained from each participant before they
could join the study. To prevent the risk of COVID-19 transmission,
Community-level respondents (# 39 KII, 22 FGDs) precautionary measures including use of hand sanitizers, face masks,
Kebele administrators
Influential community members
physical distancing, and ventilation of interview settings were practiced.
Women Development Army/Health Development Army (WDA/HDA) Furthermore, the data were used solely for this study and not shared
Local women/caregivers with any third party.

Refugees and IDPs (# 25 KII, 10 FGDs) Results

Humanitarian agencies working in conflict areas/IDPs or refugees.
Health workers at refugee/IDP camps A total of 368 KIIs and 33 FGDs were conducted in the study. To
Community Health Agents (CHAs) at refugee/IDP camps
provide a comprehensive analysis, the study employed the EPI

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component as the main thematic framework and further customized ZHD, SNNP region added that “In the zone, we have 57 health centers;
using WHO health system building blocks to summarize the underlying among these only 36 health centers provide child vaccination services.”
reasons for the significant number of zero-dose children in underserved In major urban areas including Addis Ababa, overcrowding and long
settings of Ethiopia as follows; waiting time cause dissatisfaction and discourage caregivers from
vaccinating their children. The existing open vial policy that requires
certain number of children to be available for providing a BCG or
Service-delivery related barriers measles vaccines is also a major cause of dissatisfaction among clients.
In many settings multidose vaccines are only provided on selected days
Hard-to-reach areas and lack of road infrastructure further impacting client satisfaction.
One of the major supply-side barriers that hinders provision of “In the outreach site, HEWs tell mothers to wait until the required number
vaccination services is physical inaccessibility of health facilities for the of children are available to open a vial. At the end of the day, if adequate
target population in the study areas. The issue is particularly severe in number of children are not available, they will be told to come back on some
the four pastoralist and developing regions and the newly established other day” WDA member, Guangua woreda, Amhara region.
Southwest Ethiopia People’s region. In addition, inaccessibility of health
facilities due to lack of road infrastructure and topographic barriers Outreach vaccination service provision
were also reported in SNNP, Oromia and Amhara regions. “Health In general, the provision of outreach vaccination services are faced
workers cannot reach the pastoralists over all that distance.” Key informant with challenges, leading to its frequent cancellation in most settings
from Ethiopian Orthodox Church Development and Inter-Church Aid (including urban settings like Dire Dawa city Administration and Harari
Commission (EOC-DICAC) region). These challenges include the lack of transportation service to
“Pastoral communities remain inaccessible for 3–4 months during the dry distribute vaccines to health facilities and shortage of human resources
season” Key informant from Hammer WoHO, SNNP region to provide immunization services. In addition, there are no established
Regions like Sidama and Amhara, remote areas are too challenging mechanisms to cover the expenses, including fuel and per diems for
for female HEWs. As reported from Amhara region, female HEWs usu­ health workers.
ally avoid traveling to hard-to-reach areas due to fear of sexual violence Key informant from Gikawo WoHO, Gambella Region stated that “At
and because its physically challenging to them and they fear sexual district level there is no budget to implement outreach program. In some
violence. “HEWs are afraid to go these remote villages because they are districts an NGO was covering the expense. Now the program has phased
women” Key informant from Debark WoHO, Amhara region “The HEP out.” Key informant from a partner organization working in SW region
has to engage both male and female HEWs. It is not possible to cover hard-to- “About 20–30 percent of health facilities [in Southwest region] have mo­
reach areas through female HEWs alone” Key informant from Semen torcycles, but they do not have budget for fuel”.
Mountain Mobile Medical Services Organization Outreach service also lacks regularity because of lack of commitment
and demotivation of HEWs due to financial constraints and lack of
Vaccination service delivery platforms incentive mechanisms. In Sidama and Amhara regions, outreach activ­
ities are not being scheduled regularly because of negligence of HEWs. In
Static vaccination service. Despite MoH‘s direction to provide daily remote districts of Gambella, outreach sessions are organized on quar­
vaccination services through the static approach, the availability of terly basis. Unfortunately, even when appointments are scheduled with
these services still remains limited. For example, a key informant from mothers, HEWs sometimes fail to appear at the outreach sites resulting
Amhara RHB stated that “We have recently identified that there are health in dissatisfaction.
centers and health posts which do not give static immunization service.” “We sit here [at the outreach site] and wait for the HEWs. They may or
In many settings static service is not being provided on regular basis may not come” FGD discussant, Yeki woreda, SW region and WDA
due to closure of health facilities and unavailability of health workers, member, Guangua woreda, Amhara region also stated that “In the
shortage of refrigerators, frequent campaign-based activities, and outreach site, HEWs tell mothers to wait until the required number of children
schedule-based EPI service provision. are available before opening a vial. At the end of the day, if adequate number
A key informant from Agew Awi ZHD, Amhara region stated, “Our of children are not available, they will be told to come back some other time.”
target is to provide static vaccination service at least once per week at health Key informant from Afder ZHD, Somali region mentioned “When we
centers and health posts level that have refrigerators.” Another key infor­ talk about why outreach and mobile programs are not available, the answer is
mant from a health center in Dire Dawa city Administration also simple: there is no budget and the biggest challenge in any district is the
mentioned that “We [health professionals at the health center] provide same.”
static vaccination service on the 15th and 16th day of the month; whereas “Our responsibility is to provide service at the health center. For any
they [HEWs] provide outreach service from 17 to 20 days of the month”. fieldwork we have to be paid (…) Due to lack of budget, we did not provide
The single most important barrier to provide static vaccination ser­ outreach service for more than two years” Key informant from a health
vice is shortage of refrigerators at health posts. Across most regions center in AACA “AACA Health Bureau provides vaccination service pri­
(excluding urban settings), many health posts do not have their own marily through static approach. That is why we have not been able to reach
refrigerators, and vaccines are stored in the nearby health centers. the informal settlements and slum areas.”
“In those health posts having no refrigerator, it is not possible to deliver
the static services on regular basis” said a key informant from Loko Abaya Mobile vaccination service provision
WoHO, Sidama region. The provision of mobile vaccination services in pastoralist settings
Conversely, in Afar and Somali regions the static approach is more such as Somali and Afar regions and some of the districts in Oromia,
actively used due to the weak Health Extension Program, unavailability SNNP, Southwest and Sidama regions, faces significant challenges.
and demotivation of HEWs, absence of refrigerators and interruption of Currently, there is an absence of an effective service delivery modality to
vaccine supplies. In these regions, static service provided at health reach pastoralist and semi pastoralist communities. Integrated mobile
centers level is the only functional approach to deliver vaccination outreach strategy is not being implemented due to shortage of vehicles,
services. fuel, budget, limited number of mobile teams, irregularity in field
“In our district there are two health centers. The vaccination coverage is deployment, and unmanageably large catchment area in Oromia (Bor­
better in areas located near to the health centers. Elsewhere, the coverage is ena and Guji) and Gambella (Neur and Agnuak zones). Similarly, limited
low [because the health posts are not functional]” share one key informant experienec exists in implementingthe mobile strategy in SNNP, South­
from Kori WoHO, Afar region, and another key informant from Gamo west, and Amhara regions.

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Key informant from Loka Abaya District Health Office, Sidama re­ missed out on certain benefits that were previously available.
gion stated that “The communities are semi-pastoralist. But we only provide Key informant from Turmi Health Center, SNNP Region explained
static and outreach service. We do not have any mobile vaccination service.” that “We used to vaccinate children as their parents receive food aid. Later
Key informant from a partner organization working in Oromia Re­ on, mothers who do not get flour start to reject vaccination.”
gion “Mobile teams have been established to serve hard-to-reach areas. While many caregivers understand that vaccination prevents dis­
However, as Oromia is wide, we could not be able to secure adequate re­ eases, there is a lack of in-depth knowledge. Only a few are able to list
sources for the strategy. Consequently, we were forced to prioritize extremely vaccine-preventable diseases beyond measles and polio. Consequently,
inaccessible areas. Even there is no resource to support this too.” Caregivers also lack comprehensive understanding of side effects of
Another key informant from Somali region added “Unless there are vaccines and struggle with knowing how to address them when they
partners that can support the mobile service, it is not possible to provide occur.
service through this approach. We do not have any resource to support it.” “[when infants] face side effects like fever after vaccination, mothers
avoid vaccination in the next appointment day” Key informant from
Catchup vaccination Amhara RHB.
In general, many children in hard-to-reach and pastoralist settings “Sometimes when we mobilize the community for vaccination, few
have not received vaccination as per the schedule due to a multitude of mothers hide their children fearing that they may develop fever if vacci­
supply and demand side barriers. Key informants both from the gov­ nated.” WDA member, Debark Zuria Woreda, Amhara region
ernment and partners sides emphasized that catchup vaccination should “My child was sick for two days after taking vaccination. I decided not to
receive better attention. On a positive note, UNICEF and other partners vaccinate him again.” FGD discussant, Gardamarta woreda, SNNP region.
are supporting the MoH in the development of the guideline and (Post- In the Amhara region, one prevalent practice that has been
Immunization Reaction Investigation) PIRI is also being utilized to commonly reported is that mothers tend to delay vaccination until the
“catch up” on missed vaccinations in hard-to-reach areas. infants gets baptized. This is often due to the fear of potential side ef­
According to a key informant from Harari region, vaccination ser­ fects. These demand side barriers are consistently reported across
vices have been affected due to engagement of health workers in various various settings. In urban areas, educated parents resist booster doses
campaigns, leading to health posts being closed and missed opportu­ provided through campaigns by justifying that the child has already
nities for vaccinations. According to key informant from Harari RHB been vaccinated.
stated that “There were many missed children due to the campaigns (…). Another demand side barrier arises from the challenge of remem­
This is because when there is a campaign, HEWs would be entirely engaged bering immunization schedule, particularly among illiterate caregivers
and health posts get closed, during community Based Health Insurance CBHI who face significant domestic workload, and this poses a significant
campaign the whole staff was out.” constraint on the effectiveness of the vaccination program. In Afar, So­
mali and Borena of Oromia region, the hostile climate restricts move­
Engagement of public hospitals in EPI services ment of caregivers who seek health services for their children, indirectly
In most regions, distinct vaccination catchment areas are assigned to affecting vaccination rates. In Somali, Afar, and parts of SW regions,
primary hospitals to provide immunization services through organizing even though clan leaders are highly influential in their respective
static and outreach services. Currently, many hospitals only provided communities they have not been adequately engaged in promoting
selected antigens (BCG and OPV-0) and their services are limited to vaccination. In southwest, Sidama and Amhara regions, elders and
specific hours and selected days of the week. Even failure to provide BCG grandparents exert negative influence on vaccination.
and OPV-0 to babies born in the hospital has been reported because of “At times grandmothers advise mothers not to vaccinate their children by
poor coordination system between EPI and delivery units. In general, the arguing that the children have already been vaccinated by God” HEW, Chire
major misconception, hospitals frequently assume that vaccination is Woreda, Sidama region.
the duty of health posts and health centers.
Key informant from South Omo ZHD, SNNP region mentioned that Health workforce
“Hospitals and health centers consider that vaccination service provision is
the sole responsibility of the health posts. Only 10 % of the vaccination service While there has been an increasing number of health professionals,
is provided by hospitals and health centers.” Another key informant from shortages of health workers persist in most regions, excluding Addis
SNNP RHB indicated that “Some health centers do not provide immuni­ Ababa city Administration, Harari, and Dire Dawa city Administration.
zation services because they assume vaccination is the duty of health posts.” The regions of Afar, Somali, Southwest, and Gambella, particularly face
critical shortages, weak academic backgrounds, and major skills gaps in
Demand-side barriers providing health services, including EPI.
While widespread resistance to childhood routine vaccination has Key informant from Gamo ZHD, SNNP region “Among the ten kebeles
not been reported in most regions, there are certain exceptions such as in Gardamarta district, only four have HEWs. In the remaining kebeles we
TT and HPV vaccines targeting adolescent girls and Covid-19 vaccines don’t have HEWs.” Another key informant from Surma WoHO, South­
for adults. These vaccines, particularly the first two have been west region added that “Out of the 17 HEWs we have, only four are
frequently associated with unfounded concerns about infertility. diploma holders. The rest are sixth grade complete HEWs who have major
In most FGDs, mothers highlighted that they used to harbor doubts skill gaps.”
the importance of vaccines and held various misconceptions in the past. Experienced health workers leaving the system further exacerbates
However, these knowledge gaps have gradually improved. For instance, the problem, as the transfer of skills become weak resulting in a decline
in Sidama, there was a tradition of using a traditional herb “Hamessa” to in the quality of the immunization services. As reported from SNNP
protect infants from illness. But nowadays, the practice of vaccinating region, experts at zonal and district health offices offered training op­
children has become more accepted and is increasingly becoming a portunities by their respective offices and leave their position immedi­
norm. ately after completing their trainings.
“Previously mothers used to resist vaccination claiming that “Jesus is Key informant from Afar RHB “There is a high staff turnover. A health
their vaccine.” Now, after understanding that vaccinated children are less post which was functioning before two months could not be functioning now.
likely to suffer from diarrhea and pneumonia, the resistance is declining” Key The facility may stay closed until new health workers are hired.”
informant from Chire WoHO, Sidama region. In all the regions HEWs are becoming increasingly demotivated,
The demand of the community to vaccination service provided reluctant, and resistant to implement health programs with the expected
through statistic service is unsatisfactory as they believe they have quality due to workload, lack of incentives, partiality in career

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development opportunities, and working for several years in the same region, more attention is given to food aid and outbreak response. In
setting without change. They also do not get close support by health specific areas like Loka Abaya and SNNP, the focus is primarily on
centers and district health offices. Specially, in relation to the vaccina­ malaria control.
tion program, HEWs engagements in demanding activities like tracing of “If there is a budget coming for Polio campaign, we use it for nutritional
defaulters, provision of vaccination service per schedule and identifi­ screening, deworming, and vitamin A supplementation service.” Key infor­
cation of pregnant women in the community is declining. mant from South Omo ZHD, SNNP region
Key informant from Gambella RHB mentioned “There are areas where “There is a fund coming from [….] to support EPI Equity program. This
the motivation of health professionals is very low. Sometimes vaccines are not fund is meant to cover the per-diem, fuel and other costs required for
given despite the availability of supplies.” vaccination program. However, this money has been used partially for other
Another kebele leader, Ewa woreda, Afar region highlighted “In the programs” Key informant from Gamo ZHD, SNNP region.
past, health workers used to travel by camels to provide vaccination service in
remote areas. But now there is no health workers’ motivation to provide the Partnership and engaging influential community members
service in areas not accessible by cars.” Compared to other programs, there is greater interest and support
Key informant from Debark Zuria WoHO, Amhara region indicated from partners at all levels of the health system towards the EPI. GAVI is
“At kebele-level many activities of the local government are implemented the major donor covering four-fifths of the national budget for vaccine
through HEWs. These are not only engaged in health-related activities, but procurement. In addition, GAVI has also initiatives related to data
also in agriculture, education, and political networking.” quality, human capacity development, and supportive supervision.
Another key informant from Oromia RHB “Many HEWs have worked USAID, Bill & Melinda Gates Foundation, and Rotary International are
at the same health post for about 7–9 years. Initially they were very moti­ also important indirect donors. UNICEF is a major/core partner
vated. But now most of them have established families and are not committed providing technical and financial support to the health system at all
as before.” levels in all regions. Specially at lower levels of the health system,
Health workers’ from Gambella, Somali, and Afar regions demand UNICEF is focuses on activities such as demand promotion, supporting
for unjustified benefit and becoming reluctant to be involved in mobile, microplanning, M&E and data quality assurance.
outreach and demand-creation activities without receiving payments. As “Vaccination coverage is decreasing; it is not like before. It used to be
health workers are receiving per diems in PIRI and vaccination program supported by an NGO, but now the program is discontinued due to security
led by NGOs, they expect the same in other activities. concerns.”, key informant from Kibish Health Centre, Surma woreda,
“Previously, when we go to the community for vaccination, we used to be Southwest region. Another key informant from Gikawo WoHO, Gam­
paid at least 15 birr. Nowadays, we do not even get a penny” Regional MCH bella region “Our district used to be supported by the PIRI program, recently
department representative. the support has been discontinued abruptly and we do not know why. The
Now days, due to weak staff controlling mechanism many HEWs RHB said nothing why it has been discontinued.”
reside in towns and unavailable on duty. Reportedly, HEWs frequently In many KIIs and FGDs study participants mentioned that religious
fail to appear at health posts or outreach sites despite appointing and clan leaders, as well as teachers were highly respected and credible
mothers for vaccination. In many settings, even health centers, do not sources of information. However, there is a need for more concerted
open on time to serve their clients. efforts to engage these community members in the dissemination of
Key informant from Gambella region stated “There are many health vaccination information. Currently, Small-scale practices of community
professionals who receive salary but are not available on duty (….). It is mobilization using clan leaders and elders (Somali region) and religious
difficult to take administrative measures because the issue can get leaders (Amhara and Sidama regions) have been reported. In North
‘politicized.’” Gondar of Amhara region, vaccination schedules are commonly
Another key informant from Teltele Woreda, Oromia “Many HEWs communicated using religious institutions and outreach days are also
leave their workplace on Friday to towns where they live. They return back on aligned with monthly religious holidays.
Monday. So, they provide service only from Tuesday to Thursday.” “For example, there is a health center guard called Abebe [changed
In addition, a key informant from Gambella RHB “One of the major name] who usually walks around the villages to disseminate vaccination
problems with HEWs is that they are not regularly available at health post campaign message using a megaphone. And the people mock him ‘here comes
(…). Caregivers bring their children for vaccination, but no one is available to [Abebe] again.” But the same massage would be taken better if we had used
give the service.” elders and religious leaders” Key informant from Loko Abaya district,
In general, biomedical technicians are available at zonal and district Sidama region. This illustartes the potential for greater involvement of
levels in all regions. However, scarcity of senior technicians was re­ influential community members to enhance the effectiveness of vacci­
ported in Sidama, SW, Harari, Afar and Somali regions. In most settings, nation campaigns.
refrigerators are not being maintained timely due to shortage of skilled
biomedical technicians at districts level, and lack of timely response by Gender-related barriers
officials. Gender related barriers to children’s vaccination in various regions
“Once a refrigerator is broken, it is very unlikely that it would be properly present a significant challenge. Across these regions, men’s limited
maintained. The technicians have a serious skill gap.” Key informant from engagement and lack of involvement in ensuring their children receive
Gulele Sub-city Health Department, Addis Ababa City Administration. vaccines emerge as a gender specific barrier. This stems from the cul­
tural perception that childcare is primarily the responsibility of women.
Leadership and program management Typically, taking children to vaccination centers and communicating
with frontline health workers is usually considered as the duty of
Leadership commitment is a critical factor in the implementation of women. Even health workers themselves may perpetuate these gender
EPI programs. According to key informants from partner organizations stereotypes, further discouraging fathers from participating in their
and lower level health systems, there are instances where the focus of children’s health care. In the FGDs, involvement of men in childcare
the health system shifts from one program to another based on the (including vaccination) was frequently described as the culture of the
contemporary situation and support from donors. For instance, in urban community. In Somali region extreme reports like “men don’t
Amhara region, the ongoing conflict has resulted in reduced the budget know where children get vaccinated” and “vaccination of children is not the
allocated for the health sector and limited availability of vehicles for concern of men” have been raised during the FGDs with local women. In
field programs. Similar challenges have been reported in Afar and some Afar and Somali, women are responsible for managing household chores
districts of SNNP region. In pastoralist settings of Somali and Oromia as well as many outdoor activities, making it difficult for them to take

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their child for vaccination without support from other family members. performance monitoring teams, and supportive supervision are not
“Usually, men are not aware whether their children have received their regularly conducted due to shortage of resources and lack of motivation.
vaccines or not. Men have other important obligations that hinder them from The lack of feedback to frontline health workers is identified as a
taking young children to health facilities.”, a key informant from Somali weakness of the M&E approach.
RHB. “We don’t have adequate budget to conduct M&E activities regularly.
These challenges are compounded by the patriarchal nature of What we get is not even enough to buy consumables.” Key informant from
Ethiopian society, where, women have limited decision-making power Chire WoHO, Sidama region
and control over resources. Unfortunately, women often need permis­ “According to the standard, ZHD is expected to supervise the WoHO
sion and money for transportation from their husbands to take their quarterly, but we didn’t do that. The district should supervise health centers
children to health centers. In most settings (as reported specially from every month, and health center should visit health posts on weekly basis. But
developing regions like Gambella, Afar and Somali) men exert control in practice this has not been done” Key informant Sheka ZHD, Southwest
over their partners (spouses) movements, and this may affect utilization region.
of health services.
Key informant from a partner organization working in Afar region Surveillance of vaccine preventable diseases
stated that “Though a woman has good awareness of vaccination, she may The Ethiopian disease surveillance system monitors over twenty
not bring her child to vaccination because she may have no money for epidemic-prone diseases targeted for eradication/ elimination including
transportation. The money is in his pocket.” In addition, Health profes­ Acute Flaccid Paralysis/polio, measles, and neonatal tetanus, and other
sional from Somali region “When we ask mothers to bring their infants for diseases of public health importance. Among vaccine-preventable dis­
vaccination, they tell us that they have to secure permission from their hus­ eases, measles outbreak frequently occurs in hard-to-reach, conflict-
bands first. Sometimes they decline to come claiming that their husband was affected and pastoralist communities in Ethiopia. Regional Public Health
not willing.” Emergency Management (PHEM) officers have identified poor vacci­
nation coverage and clusters of unvaccinated children as underlying
Information causes for these outbreaks.
“Most of the time what we observe in measles outbreak settings is that 70
Planning, monitoring and evaluation % or 80 % children are not vaccinated”, Key informant from PHEM team
Regarding the vaccination planning process, there was notable of Oromia RHB.
discrepancy between top-level decision makers and frontline health “With regard to monitoring of adverse effects following immunization,
workers. While top-level managers claim that woreda-based and micro PHEM’s mandate is disease notification as it is clearly stipulated in the Na­
plans are being implemented, frontline workers report a lack of bottom- tional Guideline. This is the responsibility of the EFDA not ours.”, Regional
up planning at the ground level. Planning is predominantly centralized PHEM Officer and “Previously adequate attention was not given to AEFI. It
at the district level, with targets distributed to health facilities based on was not an area of focus, there were no reports and appropriate responses.
population conversion factors. The top-down approach has led to con­ Currently reporting AEFI is part of our job.” PHEM Officer from Addis
cerns that microplans are developed merely for completion rather than Ababa city Administration.
being translated into effective practice. Micro plans are developed on
semi-annual basis through bottom-up approach with regional variations Data quality for decision-making
in the implementation and some regions showing stronger commitment, All groups of respondents agreed that, despite recent improvements,
while others face challenges in engaging community due to weak HEP, poor data quality remains a major concern. The groups acknowledged
lack of commitment and difficulty in remote areas. In Oromia, micro­ that data reported by the vaccination program lacks quality. Common
planning is commonly used only for campaigns. indicators of poor data quality include discrepancy between community-
“Micro plans are usually developed for the sake of completion. HEWs based surveys and DHIS-based reports and/or other administrative
develop micro plans simply because they are required to do so. The plans are vaccination coverage reports.
not translated into practice.” Key informant from Agew Awi ZHD, Amhara “The admin report does not correspond with the actual number of zero-
region. dose children on the ground” Key informant from Gamo ZHD, SNNP Re­
In addition, HEW, Chire Woreda, Sidama region stated “We have no gion and key informant from SNNP RHB also added “At health post level,
role in the planning vaccination activities. The plans come directly from the what is found in the tally sheet cannot be the same in the logbook.”
woreda health office and health center.” Several causes contribute to poor data quality such as the lack of
HEWs and few woreda health officers think that developing micro reliable denominators and value for data, carelessness, skill gaps, data
plans according to the RED/REC approach is bulky, time taking, donor/ fabrication and lack of accountability. Sometimes higher bodies are also
partner driven and resource intensive. In Gambella and Sidama regions resistant to accept low/unsatisfactory vaccination coverage data, indi­
micro plans are not prepared with adequate details intentionally due to rectly pressuring health facilities and health workersto revise and
negligence and reluctance. resubmit false report.
Key informant Gamo ZHD, SNNP region “We never used the RED/REC “Significant number of districts reported coverage figures beyond the
strategy for planning. It requires more resources and time.” In addition, key vaccine supplies they received. Unfortunately, I have not seen anyone held
informant from Hamer WoHO, SNNP region mentioned “RED/REC accountable for reporting false data” Key informant from MoH and “If we
strategy has not been implemented. We did not get any training on it.” find false reporting, we will educate the health worker who committed the
In addition, Key informant from WHO Vaccination Program Officer mistake. But we are not taking any other measure.” Key informant from
“The main essence of RED/REC is microplanning. However, micro plans are Loka Abeya WoHO, Sidama region
not translated into practice due to budget shortage.” Key informant from Loka Abaya WoHO, Sidama region stated
According to the key informants, the biggest challenge encountered “Sometimes officials also demand health workers to modify and resubmit
while planning for vaccination is lack of reliable conversion factors for reports. Yes, we have to speak the truth.”
estimating denominators.
Monitoring, evaluation, and learning practices also face challenges Social Behavioral Change Communication (SBCC) and community
due to resource constraint and lack of motivation. According to top level mobilization
managers, in most regions vaccination coverage is being evaluated by Currently in various regions, there seems to be a lack of consistent
Performance Monitoring Teams. However, top-level managers (espe­ and diverse efforts in implementing SBCC to promote EPI. In addition,
cially from developing regions) admitted that review meetings, mobile phones are not commonly used for disseminating health

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messages and reminders across all regions. But there have been some does not provide supplies without request.
encouraging reports of translation of SBCC materials to local languages “We gave training on timely reporting of [vaccine] needs. But, due to staff
or development of new ones in Gambella, Benishangul Gumuz, and turnover, the outcome is not as what we expected. Still continuous training is
SNNP regions. Moreover, multiple regions have reported the use of local needed.”, key informant from Hawassa EPSA Hub. (see Table 2)
radios as a platform to promote immunization.“The community mostly
trusts messages from health workers. They do not give weight to messages Discussion
delivered by us (volunteer community workers)” HDA member, Borena zone,
Oromia region. This study explored reasons for the high proportion of zero-dose
“The problem is, HDAs demand incentives and they do not want to go children in underserved settings of Ethiopia, Through qualitative KIIs
home empty-handed. With the current expensive living situation, no one and FGDs, the study identified key factors contributing to the high
serves for free” Key informant from Gamo ZHD, SNNP region. proportion of zero-dose children including poor counselling skills of
It is observed that health workers sometimes fall short in providing healthcare workers, low staff motivation, high staff turnover, poor staff
comprehensive information about vaccination. This includes crucial control mechanisms, unavailability of HEWs on duty, poor accessibility
details such as purpose of the vaccination, appointment dates for follow of health facilities, inadequate vaccine logistic management system, lack
up doses, and guidance on managing potential side effects. Notably, the of services integration, restricted vaccine open vial policy, inconsistent
failure to provide information specifically about side effects has been immunization service times, lack of information during vaccination
identified as a contributory factor to the discontinuation of vaccinations. days, prolonged waiting time at the immunization sites, lack of micro
“One of the major problems is that the health workers do not transfer the planning and monitoring, small-scale resistance and lack of male
five basic key messages to the mothers. This is what we understand from our engagement and women empowerment.
[field] visits. The key messages are not delivered to mothers for example when These findings are consistent with previous studies conducted in
she should return…” Key informant from Afar RHB. middle- and low -income countries, which have also identified supply-
side barriers such as unavailability of vaccinators, long waiting times,
Immunization financing limited skilled human resources, poor logistics management systems,
and lack of transportation for vaccines and consumables [18,24–26].
The health system allocates limited direct budget for vaccination This study also highlighted issues with the quality of EPI data reporting,
programs, relying heavily on donor funding to cover operational costs as discrepancies between administrative coverage, vaccinator-reported
including expenses for training, supervision and transportation. Many coverage and survey coverage exist. Demand-side barriers were also
key informants expressed concerns about budget shortages impeding identified as major contributors to the low immunization coverage and
their ability to organize trainings, implement micro plans, supply zero dose. These barriers included lack of knowledge, misconceptions,
kerosene for refrigerators, fuel and covering per diems for outreach financial deprivation, lack of women empowerment, lack of partner
activities. support, and distrust of the health system. Other reasons for the low
“It has been more than 40 years since Ethiopia started the vaccination coverage included long waiting times, forgetfulness among caregivers/
program. But the program is still donor dependent and does not stand by it­ parents, inconvenient vaccination times and caregiver workload. In this
self” Regional EPI Focal Person “Otherwise, there is no money allocated for study, EPI staff frequently reported to be unavailable and high staff
vaccination from the government. (…….) Our role is organizing/ facilitating absenteeism were major contributors towards low immunization
the partners working in EPI” Regional MCH Director. coverage. Similarly, other studies stated that performance of the EPI
staff, such as vaccinators are instrumental for improving vaccination
Medical products/technologies coverage and decreasing zero-dose children [27]. This can have a
detrimental impact on immunization coverage and to have high number
Lack of functionality of health posts due to shortage of essential of zero-dose children in the study settings in Ethiopia. This study also
equipment such as functional refrigerators were also identified as a linked the poor performance of frontline workers to the unavailability of
major barrier in all regions except Harari, Dire Dawa City Administra­ proper monitoring and weak control mechanisms for them. This is a
tion (DDCA), and Addis Ababa City Administration (AACA). major weakness of public health facilities in developing countries,
“Most health posts or health centers have non-functional refrigerators. where workers are not held accountable for underperforming [28,29].
Especially when the SDD refrigerators fail, they remain out of service for long The outreach vaccination services that are crucial in targeting unvac­
time due to lack of spare parts and qualified technicians”, key informant cinated children in hard-to-reach and remote areas were found to be
from Gambella RHB. inadequate.
“We only have two refrigerators for the health center and health posts. On the other hand, the quality of EPI data is questionable, with key
At least we need four. We do not have adequate storage capacity to receive all issues in reporting. Discrepancies between administrative coverage,
the vaccines we need”, key informant from Chire WoHO, Sidama region vaccinator-reported coverage and survey coverage is a persistent prob­
and “During our field visits, we frequently observe that the refrigerators [at lem. In Ethiopia, where the birth registry system is not available, the
health facilities] are fully stocked. The available storage capacity at the lower issue of an underreported denominator presents a huge problem in
level is limited”, key informant from Oromia RHB estimating true coverage. These findings are consistent with other study
Limited access to electricity or frequent power outage are among the finding done in other developing countries [30,31].
challenges of the cold chain system. Power outage occurs due to Demand-side barriers to routine immunization services could be
shortage of fuel, lack of budget to purchase kerosene and absence of major contributors to the failure of a program despite its interventions
automatic power back up system. [32]. Demand side barriers include lack of knowledge, misconceptions,
“In our hospital, there are adequate number of refrigerators provided by financial deprivation/lack of women empowerment, lack of partners’
(….), but we face frequent and prolonged power interruption. Our main support, and distrust of the medical systems. Other reasons include long
problem is electricity (….). It is not possible to use the generator for 24 h.”, waiting time, parent’s forgetfulness, inconvenient time, and parents’/
key informant from Klan Hospital, Afar region. caregiver’s workload [31].
Failure of WoHOs to submit Vaccination Requisition Form (VRF) on The other important small-scale resistances were identified in our
time and delay in compiling the VRFs has been reported in all regions. study such as influence of religion and culture on the perception and
Due to inaccessibility, health facilities in Gambella, BG, Southwest, Afar decision-making behavior of mothers or caretakers. This study showed
and Somali regions do not frequently submit their request on time. So, it that similar trends existed in the past; however, with increasing
means, that facility will miss the supply for the next 30 days as PFSA knowledge and awareness of the community regarding benefits of

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Table 2 Table 2 (continued )

Codes, subthemes, and themes, zero dose children’s barriers, in underserved, Codes Subthemes Themes
hard to reach and special setting population in Ethiopia, 2022.
Budget,
Codes Subthemes Themes Limited number of mobile
• Lack of dedicated vehicles Static vaccination service Service delivery teams, irregularity in field
and the lack of platforms deployment,
transportation Unmanageably large
Shortage of motorbikes catchment area
and poor maintenance of Limited experienec
existing ones, • Recent political instability Catchup vaccination
Reliance on camels’ No nationally agreed
transportation, guideline for implementing
Unavailability and catchup vaccination
scarcity of fuel • Geographical barriers Accessibility and
Closure of health facilities hindering access to Availability
and unavailability of health healthcare facilities.
workers, Inadequate infrastructure
Absence and shortage of and transportation systems.
refrigerators, Insufficient vaccine
interruption of vaccine supply and stockouts in
supplies. remote areas.
Frequent campaign-based • Services are limited to Missed opportunities for
activities, and schedule- specific hours and selected vaccination.
based epi service provision. days of the week. Public Hospitals in EPI
Shortage of refrigerators Misconception hospitals Services
at health posts frequently assume that
The weak health exten­ vaccination is the duty of
sion program, health posts and health
Unavailability and demo­ centers
tivation of hews, Failure to provide BCG
Overcrowding and long and OPV-0 to babies born in
waiting time lead to dissat­ the hospital.
isfaction and discourage Poor coordination system
caregivers from vaccinating between EPI and delivery
their children units
Existing open vial policy • Shortages of health workers Weak academic Health Workforce
that requires certain num­ persist in most regions. backgrounds and
ber of children to be avail­ weak academic Experience
able for providing a bcg or backgrounds, Staff storage and
measles vaccines. and major skills gaps in workload
multidose vaccines are providing health services.
only provided on selected Experienced health
days further impacting workers turnover/leaving
client satisfaction. the system
• lack of transportation Outreach vaccination Staff’s workload,
service to distribute services working for several years
vaccines in the same setting without
Shortage of human change
resources declining HEWs
No established engagements in tracing of
mechanisms to cover the defaulters
expenses, including fuel and scarcity of senior
per diems for health technicians
workers weak HEP
Lacks regularity because • HEWs are becoming Motivation and incentives
of lack of commitment and increasingly demotivated,
demotivation of HEWS due reluctant, and resistant
to financial constraints and lack of incentives,
lack of incentive partiality in career
mechanisms development opportunities,
Outreach sites are remote Luck of close support by
described as inaccessible by health centers and district
the community. health offices
HEWS sometimes fail to Demand for unjustified
appear at the outreach sites benefit and becoming
resulting dissatisfaction by reluctant to be involved in
mother/caregivers. mobile, outreach and
• Absence of an effective Mobile vaccination demand-creation activities
service delivery modality to service provision • Inadequate health Health System
reach pastoralist and semi workforce and staff Performance
pastoralist communities capacity.
Integrated mobile Fragmentation and
outreach strategy is not inefficiencies within the
being implemented healthcare system.
Due to shortage of Lack of supportive
vehicles, policies and financing for
Fuel, immunization programs.
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Table 2 (continued ) Table 2 (continued )

Codes Subthemes Themes Codes Subthemes Themes

• Weak staff controlling Poor control mechanisms implementing SBCC to and Community
mechanism. promote EPI Mobilization
Lack of Digital signature Scarce resources
system for human resource Audio-visual aids are not
and linking with financial effectively utilized
system Fall short in providing
Low performance comprehensive
monitoring system/Low information.
performance appraisal Failure to provide
• Ongoing conflict has Focus of the health system Leadership and information about side
resulted in reduced the shifts from one program Program effects.
budget allocated. to another. Management Mobile phones are not
more attention is given to commonly used for
food aid and outbreak disseminating health
response messages and reminders
• men’s limited engagement Gender-related Barriers Use of local radios as a
lack of involvement in platform to promote
ensuring their children immunization
receive vaccines emerge as a Translation of SBCC
gender specific barrier materials to local languages
cultural perception that • Top-level managers claim Planning, Monitoring and
childcare is primarily the that woreda-based and Evaluation
responsibility of women micro plans are being • Vaccination program
Children to vaccination implemented. lacks quality data
centers and communicating Frontline workers report Discrepancy between
with frontline health a lack of bottom-up plan­ community-based sur­
workers is usually ning at the ground level veys and other admin­
considered as the duty of Planning is predomi­ istrative vaccination
women. nantly centralized at the coverage reports
Involvement of men district level lack of reliable de­
vaccination frequently Microplans are developed nominators
described as the culture of merely for completion value for data,
the urban community. rather than being translated carelessness, skill
men don’t know where into effective practice gaps,
children get vaccinated Lack of committment and data fabrication
Vaccination of children is difficulty in remote areas lack of account­
not the concern of men. Commonly used only for ability
limited decision-making campaigns. health managers and
power and control over re­ Regional variations and health workers fail to
sources commitment in the imple­ prioritize record keep­
women often need mentation ing and adequately fill
permission and money for challenges in engaging tally and registry books
transportation from their community Higher bodies resis­
husbands Developing micro plans tant to accept low/un­
men exert control over based on RED/REC satisfactory vaccina­
their partners movements approach is bulky, time tion coverage data,
• Highly respected and Engaging influential taking, donor/partner Indirectly pressuring
credible sources of community members and driven and resource inten­ health facilities and
information Informal Institutions sive. health workers to
Vaccination schedules Micro plan not prepared revise and resubmit
communicated using with Adequate details false report.
religious institutions intentionally due to negli­ Data Quality for Decision-
Outreach days are also gence and reluctance. making
aligned with monthly lack of reliable conver­
religious holidays. sion factors for estimating
• Recently the support has Partnership for denominators
been discontinued abruptly. Vaccination Face challenges due to
Discontinued due to resource constraint and lack
security concerns of motivation
• Inadequate community Community Engagement: supportive supervision
involvement and Unavailability of means are not regularly due to
participation. of Transportation shortage of resources and
Limited trust and lack of motivation
confidence in healthcare The lack of feedback to
providers. frontline health workers
Insufficient • Frequently associated with Social factors and Demand-side
• Health system allocates Operational costs Immunization unfounded concerns about misconceptions Barriers Vaccine
limited direct budget. Financing infertility. Rejection and
budget shortages Certain exceptions such Resistance
impeding their ability as TT and HPV vaccines
Relying heavily on donor targeting adolescent girls
funding such as expenses for and Covid-19 vaccines for
training, supervision, and adults
transportation traditional herb
• Lack of consistent and Social Behavioral Change Information “Hamessa” to protect in­
diverse efforts in Communication (SBCC) fants from illness
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G.A. Biks et al. Vaccine: X 16 (2024) 100454

Table 2 (continued ) Table 2 (continued )

Codes Subthemes Themes Codes Subthemes Themes

Low self-initiated de­ • Failure of WoHOs to Failure to request for

mand for childhood vacci­ submit vaccination vaccines on time
nation requisition form (VRF)
Mothers believed that on time
service provided through Delay in compiling
statistic service is unsatis­ the VRFs are also
factory. blockages to the
mothers tend to delay vaccine logistic system.
vaccination until the infants Health facilities do
gets baptized due to the fear not submit VRF timely
of potential side effects on monthly basis.
Domestic workload Incomplete reporting
Hostile climate restricts
movement of caregivers.
Clan leaders are highly vaccination, there has been substantial change in the perception of
influential in their respec­ people, and uptake of vaccination by the religion and influential com­
tive communities but have
not been adequately
munity leaders. In general, the positive attitude was supported by
engaged in promoting family, community, and religious leader. In practice, the commitment of
vaccination. the parents to vaccinate their children was high, only hampered by lack
Elders and grandparents of time or adequate information. A published article exploring vaccine
exert negative influence on
hesitancy stated that various attitudes seem to result into specific cate­
vaccination.
Prevailing beliefs and gories; for instance, vaccine refusal attitude could be as a result of
misconceptions surround­ having little or no knowledge about vaccine, lack of trust on the vaccine
ing vaccination. or it could as well link to financial limitations [33]. In addition, maternal
Traditional practices and trust on vaccinator was shown to be a factor that influenced the uptake
customs impacting vaccina­
tion uptake.
of vaccination by previous studies [34,35]. Since, women were more
• Limited awareness and Knowledge gap involved in taking the children for vaccination, and communities follow
education regarding the • Shortage of essential Supply interruption certain gender rules; the gender of the vaccinator and hence ability of
importance of equipment and the mother or grandmother to trust the vaccinator was also important.
immunization vaccines
Interestingly, gender based difference was not observed in this study
In urban areas, educated Functional
parents resist booster doses refrigerators in reference to vaccination service utilization which might contribute to
provided through Identified as a major high proportion of zero-dose children. There was no difference in im­
campaigns by justifying that barrier in all regions munization coverage by gender of the child. This finding was similar to
the child has already been except Harari, Dire other studies [11,36] on immunization. At the household level, women’s
vaccinated Dawa City
Administration of Administration
lack of autonomy is a major immunization barrier in our study and
multiple vaccination at inadequate supply of consistent with a study done in Pakistan, where men and religious au­
once, and a fear of vaccine due to national thorities heavily influence decision-making [37,38]. Additionally, the
injections stockout or woman’s restricted mobility prevents her from going to unfamiliar areas
Caregivers also lack procurement delay
or where cultural barriers exist [37]. In addition, our study identified
comprehensive shortage of vehicles
understanding of side to distribute vaccines attitudes towards decision making regarding the benefits of vaccines is
effects of vaccines and timely to all districts critical to efforts to respond to barriers to vaccine uptake. Several
struggle with knowing how unmanageably large women are still unable to make decisions regarding the health of their
to address them when they catchment areas for children, as decisions are made by their male partners/spouses. This
occur. some hubs
Health workers often fail long distance
highlights the need to empower women as well as invest in health in­
to provide adequate between health centers terventions that focus on couples and not individual roles. For instance,
information about potential and health posts various studies have demonstrated that women who discuss health is­
side effects of vaccines. shortage of budget to sues with their spouses and have their partner’s approval on, albeit few,
Mother caregivers believe transport the vaccine
are more likely to seek and utilise health services in a timely manner
they have missed out on
certain benefits that were [39]. In addition, the attitudes of service provider were mentioned as
previously available. deterrents to vaccinations services use. This finding has been reported in
lack of in-depth knowl­ various settings under different health programs [40].
edge Male partners engagement and women empowerment against im­
Only a few are able to list
vaccine-preventable dis­
munization is often noted as major problem in this study. A study con­
eases beyond measles and ducted in Cambodia suggested that women’s decision-making power
polio and autonomy were relevant to maternal and child health outcomes
Medical products/ • Districts and health Difficulty to [41]. It is important to carefully consider the social contexts during
technologies facilities in over- or correctly estimate
program design and implementation for child immunization. We need to
under-forecasting. vaccine need
Hospitals with no effectively address socio-cultural contexts by involving the entire com­
predefined catchment munity, and not only target mothers and female caregivers but also
population active engagement of males in the whole process of immunization ser­
Occasionally health vices. The study also raised the pressing need for women to be
facilities fail to
optimally estimate
empowered to overcome their financial challenges in taking their chil­
their vaccine needs due dren to vaccination centers. The data identified low financial allocation
to erroneous from government side and suggested increase government financial
conversion factors gross domestic product allocation to their health sector, consistent with

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G.A. Biks et al. Vaccine: X 16 (2024) 100454

the recommendation in the Abuja declaration [42]. Increased financial CRediT authorship contribution statement
resources would enable country to equip and upgrade existing health
facilities and to increase their numbers. Targeted resources may moti­ Gashaw Andargie Biks: . Fisseha Shiferie: . Dawit Abraham
vate and enable staff deployed in remote areas for effective outreach Tsegaye: Conceptualization, Methodology, Project administration, Re­
activities to maximize coverage of immunization [31]. In addition, in sources, Writing – review & editing. Wondwossen Asefa: Conceptual­
this study inadequate incentives for vaccinators to facilitate outreach ization, Funding acquisition, Methodology, Project administration,
work was a major issue mentioned in this study. This finding was sup­ Validation, Writing – review & editing. Legese Alemayehu: Concep­
ported by other studies and stated that workers who pay out-of-pocket tualization, Funding acquisition, Project administration, Writing – re­
for outreach work expenses are not reimbursed and has critical impact view & editing. Tamiru Wondie: Conceptualization, Funding
in the immunization services [43,44]. acquisition, Project administration, Validation, Writing – review &
The study acknowledged that immunization is a shared re­ editing. Gobena Seboka: Conceptualization, Project administration,
sponsibility involving community, healthcare service providers, policy Resources, Validation, Writing – review & editing. Adrienne Hayes:
makers, and parents who are active participants in the process. Effective Conceptualization, Project administration, Resources, Validation, Visu­
communication at different levels and consideration of factors especially alization, Writing – review & editing. Uche RalphOpara: . Meseret
at the receiver end is essential to strengthen routine immunization up­ Zelalem: Conceptualization, Funding acquisition, Investigation, Meth­
take. Thus, there is a need to improve the overall clinic environment and odology, Project administration, Resources, Validation, Writing – re­
conduct regular training sessions for healthcare workers not only from a view & editing. Kidist Belete: Conceptualization, Funding acquisition,
technical aspect but also in terms of enhancing their ability to commu­ Investigation, Methodology, Resources, Writing – review & editing. Jen
nicate and create confidence in the beneficiaries. Donofrio: Conceptualization, Formal analysis, Funding acquisition,
This public private partnership (PPP) must be synergised in times of Investigation, Methodology, Project administration, Resources, Super­
emergency and expertise to provide timely and sufficient vaccination vision, Validation, Writing – review & editing. Samson Gebremedhin: .
coverage interventions and PPP in improving vaccination coverage in
the underserved communities. It is anticipated that the interventions
will contribute to the body of knowledge on models of PPPs for Declaration of competing interest
addressing zero-dose immunization service delivery for under-served
populations in Ethiopia. The authors declare that they have no known competing financial
While the study’s strengths included the use of KIIs and FGDs to interests or personal relationships that could have appeared to influence
understand the factors affecting vaccination utilization, it was limited to the work reported in this paper.
residents of underserved settings in Ethiopia and health officials and
providers within the health system. THowever, the external validity of Data availability
the results is enhanced by the fact that many residents of remote under-
served settings in the country share similar challenges in accessing and Data will be made available on request.
utilising vaccination services. Triangulation of responses from different
sources including FGDs and KIIs, aimed to provide a more representative Acknowledgments
picture of the situation.
The authors wish to thank the Kaiser Family Foundation and the
Conclusions Roper Center for Public Opinion Research at Cornell University for
sharing the data used in this analysis. All authors attest they meet the
Our comprehensive analysis reveals that childhood immunization is ICMJE criteria for authorship.
not influenced by a single factor alone, but by a combination of multiple
factors. To effectively address these issues, intervention efforts should
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