In-depth Reasons for the High Proportion of Zero-dose Children in Underserved Populations of Ethiopia: Results from a Qualitative Study

"Comprehending the intricate interplay of social, economic and political factors surrounding zero dose children is critical in designing effective immunization programs, given their propensity to encounter numerous barriers."



Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly designated as zero-dose children. This qualitative study identifies the supply- and demand-side barriers for reaching zero-dose and under-immunised children and explores how gender affects access to vaccination services for children in Ethiopia.



Data were collected from March-June 2022 using 368 key informant interviews (KIIs) and 33 focus group discussions (FGDs) with participants in underserved settings. The study included 22 districts from nine regions and two city administrations of underserved and special populations in Ethiopia. The second-round qualitative study explored the situation in different study populations (including hard-to-reach, pastoralist, conflict-affected areas, socially disadvantaged urban dwellers, refugees, and internally displaced populations). The study followed a stepwise qualitative approach, initially seeking input from high-level officials at national level, and subsequently gathering perspectives from mid- and lower-level decision makers and community members.



Among the service-delivery related barriers discussed in the article are:

• Hard-to-reach areas and lack of road infrastructure - For example, as reported from Amhara region, female health extension workers (HEWs) usually avoid traveling to hard-to-reach areas due to fear of sexual violence, because it's physically challenging for them, and/or because they fear sexual violence.
• Vaccination service delivery platforms - Despite the Ministry of Health (MoH)'s direction to provide daily vaccination services through the static approach, the availability of these services still remains limited. In major urban areas including Addis Ababa, overcrowding and long waiting time cause dissatisfaction and discourage caregivers from vaccinating their children. In general, the provision of outreach vaccination services are faced with challenges, leading to frequent cancellation in most settings. Even when appointments are scheduled with mothers, HEWs sometimes fail to appear at the outreach sites, resulting in dissatisfaction. Furthermore, there is an absence of an effective service delivery modality to reach pastoralist and semi pastoralist communities. In general, many children in hard-to-reach and pastoralist settings have not received vaccination as per the schedule due to a multitude of supply and demand side barriers.
• Health workforce and programme management - While there has been an increasing number of health professionals, shortages of health workers persist in most regions. Also, according to key informants from partner organizations and lower level health systems, there are instances where the focus of the health system shifts from one programme to another based on the contemporary situation and support from donors.

Among the demand-side barriers discussed in the article are:

• Hesitancy - In most FGDs, mothers highlighted that they used to harbor doubts the importance of vaccines and held various misconceptions in the past. However, these knowledge gaps have gradually improved. For instance, in Sidama, there was a tradition of using the traditional herb Hamessa to protect infants from illness. But nowadays, the practice of vaccinating children has become more accepted and is increasingly becoming a norm.
• Insufficient knowledge - While many caregivers understand that vaccination prevents diseases, only a few are able to list vaccine-preventable diseases beyond measles and polio. Caregivers also lack comprehensive understanding of side effects of vaccines and struggle with knowing how to address them when they occur. In the Amhara region, one prevalent practice that has been commonly reported is that mothers tend to delay vaccination until the infants gets baptised. Related to knowledge barriers is the challenge of remembering the immunisation schedule, particularly among illiterate caregivers who face significant domestic workloads.
• Insecurity - In the Oromia region, the hostile climate restricts movement of caregivers who seek health services for their children, indirectly affecting vaccination rates.
• Lack of engagement/support for vaccination - In Somali, Afar, and parts of southwest regions, even though clan leaders are highly influential in their respective communities, they have not been adequately engaged in promoting vaccination. In southwest, Sidama, and Amhara regions, elders and grandparents exert a negative influence on vaccination. In many KIIs and FGDs, study participants mentioned that religious and clan leaders, as well as teachers, were highly respected and credible sources of information. Small-scale practices of community mobilisation using clan leaders and elders (Somali region) and religious leaders (Amhara and Sidama regions) have been reported. In North Gondar of Amhara region, vaccination schedules are commonly communicated using religious institutions, and outreach days are also aligned with monthly religious holidays. However, there is a need for more concerted efforts to engage these community members in the dissemination of vaccination information.
• Gender-related barriers - Men's limited engagement and lack of involvement in ensuring their children receive vaccines stem from the cultural perception that childcare is primarily the responsibility of women. In most settings (as reported specially from developing regions like Gambella, Afar and Somali), men exert control over their partners' (spouses') movements, and this may affect utilisation of health services.

Regarding the vaccination planning process, there was notable discrepancy between top-level decision makers and frontline health workers. While top-level managers claim that woreda-based and micro plans are being implemented, frontline workers report a lack of bottom-up planning at the ground level. Planning is predominantly centralised at the district level, with targets distributed to health facilities based on population conversion factors. According to the key informants, the biggest challenge encountered while planning for vaccination is lack of reliable conversion factors for estimating denominators. All groups of respondents agreed that, despite recent improvements, poor data quality remains a major concern.



As outlined here, in various regions, there seems to be a lack of consistent and diverse efforts in implementing social and behavioural change communication (SBCC) and community mobilisation to promote immunisation. In addition, mobile phones are not commonly used for disseminating health messages and reminders across all regions. But there have been some encouraging reports of translation of SBCC materials to local languages or development of new ones. Moreover, multiple regions have reported the use of local radios as a platform to promote immunisation.



In sum, 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, and service provision limited to selected days or hours. Demand-side barriers included religious beliefs, cultural and gender norms, fear of vaccine side effects, and lack of awareness and sustained interventions.



Recommendations to increase vaccination coverage include strengthening health systems such as services integration, intensifying human resources capacity building, increasing incentives for health staff, integrating vaccination services, bolstering the immunisation programme budget, and supporting reliable outreach and static immunisation services. In addition, immunisation policy should be revised to include gender considerations, including male engagement strategies to improve uptake of immunisation services.



In conclusion: "The study acknowledged that immunization is a shared responsibility involving community, healthcare service providers, policy makers, and parents who are active participants in the process. Effective communication at different levels and consideration of factors especially at the receiver end is essential to strengthen routine immunization uptake. Thus, there is a need to improve the overall clinic environment and conduct regular training sessions for healthcare workers not only from a technical aspect but also in terms of enhancing their ability to communicate and create confidence in the beneficiaries."