Vaccination Coverage and Predictors of Vaccination among Children Aged 12-23 Months in the Pastoralist Communities of Ethiopia: A Mixed Methods Design

"...[I]t is essential to integrate woreda political leaders, community influential leaders and other concerned stakeholder leaders to be involved in vaccine service delivery strategies." - key informant interviewee

Despite substantial progress in Ethiopia's vaccination efforts, disparities in vaccination coverage persist, particularly in underserved and remote regions such as the Afar region of Ethiopia. The Afar region is a percentage pastoralist community characterised by unique sociocultural, economic, and geographical features that can significantly impact healthcare-seeking behaviours, vaccine accessibility, and healthcare delivery strategies. By assessing children's vaccination coverage and its associated factors in pastoralist Ethiopia, this study ultimately aims to contribute insights that can inform targeted interventions to improve immunisation coverage in similar contexts.

The study was conducted in three woredas of the Afar region using a community-based cross-sectional mixed methods design with quantitative and qualitative methods. A total of 419 mothers with children aged 12-23 months participated in the quantitative study via a simple random sampling technique. The qualitative part of the study involved key informant interviews with healthcare workers (HCWs), health extension workers (HEWs), and health development armies. Logistic regression was used to identify factors associated with vaccination, and thematic analysis techniques were used for qualitative data.

The percentage of patients who received full vaccination was 25%, which is lower than the target set by the World Health Organization (WHO). Based on vaccination card observations, the dropout rate from Pentavalent-1 to Pentavalent-3 was found to be 2.9%. Logistic regression analysis revealed:
 

• Mothers and caretakers who had received formal education were almost 4 times more likely to have vaccinated their children than those who had not received formal education [adjusted odds ratio (AOR) = 3.90; 95% confidence interval (CI): (1.53-9.98)]. Educated mothers are better informed about the importance of vaccinations, the diseases they prevent, and the schedules for immunisation; consequently, they are more likely to access healthcare services and more proactive in seeking out and adhering to immunisation schedules.
• The presence of mobile phones at home was found to be significantly associated with the vaccination status of children, as the odds of being vaccinated were 3 times greater among study participants who owned mobile phones than among study participants who had no mobile phones at home [AOR = 2.99; 95% CI: (1.33-6.76)]. In Ethiopia, challenges such as geographic barriers, limited healthcare infrastructure, and low literacy levels often hinder vaccination efforts; therefore, mHealth initiatives can play a crucial role. By providing timely short messaging service (SMS) reminders to parents about upcoming vaccination appointments, mHealth can help reduce missed opportunities and dropouts, especially in remote areas. These interventions can also deliver culturally relevant educational content, increasing awareness and the understanding of vaccines, which is essential in combating misinformation. Furthermore, mHealth can facilitate real-time data collection and tracking, allowing healthcare providers to monitor vaccination coverage and quickly identify regions with low uptake.
• The odds of being vaccinated were 2.39 times greater among mothers who had attended at least one antenatal care (ANC) visit than among mothers who had not attended an ANC follow-up [AOR = 2.39; 95% CI: (1.14-5.01)]. These visits often integrate other maternal and child health services, fostering continued access to healthcare, which increases trust and confidence in the system. And mothers who gave birth at a health facility were 5.79 times more likely to vaccinate their children than mothers who gave birth at home [AOR = 5.79; 95% CI: (2.77-12.12)]. Mothers may be advised and receive education to use postnatal care and vaccination services during institutional birth.

Almost three-quarters (313, 74.7%) of respondents had heard about childhood vaccines. Two hundred and eighty-seven (90.7%) participants mentioned that vaccination is important for protecting children from diseases, and participants also mentioned that vaccination is advantageous for healthy children (224, 71.6%). Respondents revealed that most of the people around their community setting approved of vaccinations (308, 73.5%) and that vaccine approval was made by husbands/partners (301, 97.7%), followed by parents/parent in-laws (134, 43.5%).

On the other hand, respondents also mentioned the disadvantages of vaccines. More than two-thirds (67%) of them reported that vaccines have side effects and that vaccines may make children sick (56.9%). Many different barriers were mentioned by the respondents; of these, the most common were not visiting the village (247, 58.9%), having a domestic workload (180, 43.0%), not accessing a vaccination service (155, 37%), having a closed/vaccinator vacancy at the vaccination site (153, 36.5%), having a long waiting time (138, 32.9%), and not receiving a vaccine at the vaccination site (106, 25.3%). Regarding vaccine refusal, 52 (21.8%) respondents had a history of vaccine refusal for different reasons. The main reasons included being given too many vaccines during the vaccination visit (28, 53.8%), a history of child illness after vaccination (26, 50%), and a fear of injection pain (21, 40.4%).

Study participants described the importance of integrating stakeholders and the need for governmental commitment to vaccination services. They also stressed the importance of community engagement, with one official saying that "community representatives should participate during the planning and implementation of immunization activities. For example, in deciding the outreach sites, target identification, and arrangement of the services. Therefore, their participation will help us to achieve better vaccination coverage." Thus, culturally tailored health education programmes that engage respected local leaders and utilise local languages have the potential to effectively communicate the importance of vaccination in the study context. Such programmes have been shown to improve health outcomes by increasing awareness and changing attitudes toward immunisation within similar contexts.

This study has implications for programme implementers and decision makers either at policy or implementation levels:
 

• Collaborate with local authorities, community leaders, and HEWs to develop and implement community-based initiatives that are tailored to the specific needs of the Afar region.
• Engage with religious leaders and community influencers to promote vaccination as a religious and cultural responsibility.
• Prioritise education for mothers and caretakers to help improve health literacy and decision-making regarding vaccinations.
• Implement mHealth programmes to facilitate the dissemination of health information, appointment reminders, and follow-up care. (These interventions can also deliver culturally relevant educational content, increasing awareness and the understanding of vaccines, which is essential in combating misinformation.)
• Implement targeted interventions that address the unique socioeconomic and geographic challenges faced by pastoralist communities.
• Strengthen ANC services to ensure that pregnant women receive comprehensive care, including information about vaccinations.
• Encourage women to give birth at health facilities, where they can receive immediate postnatal care and vaccinations for their newborns.
• Improve the infrastructure of health facilities and increasing the number of healthcare workers.
• Allocate sufficient resources to support the implementation of these policies, including budgeting for infrastructure development, personnel, and mHealth initiatives.