Rationale for the under-implementation of catch-up vaccination in conflict-affected regions, Northeast Ethiopia

Abstract

Introduction

In conflict-affected settings, catch-up vaccinations are recognized as a crucial strategy to reinforce the Expanded Program on Immunization (EPI) when the standard immunization schedule is interrupted. In the North Wolo zone after the Northern conflict which lasts for six months, 44% of children less than two years old defaulted from the immunization program. This study aims to explore the rationales influencing parents’ decisions not to engage in the catch-up vaccination in the aftermath of the conflict, with the goal of developing evidence-based interventions to improve the health of children in conflict-affected areas.

Method

A phenomenological qualitative study design was conducted in conflict-affected areas of Northeast Ethiopia from July to September 2022. The study included mothers of children aged 6 to 23 months who either defaulted on vaccinations due to conflict and did not return, or who gave birth during the conflict and never initiated vaccinations. Data were collected from 109 mothers through in-depth interviews and focus group discussions. All audio recordings were transcribed, translated, and cleaned for analysis. The thematic analysis was conducted by considering Preliminary or interim analysis started in the field and MAXQDA 2020 software.

Result

The primary client-related factors contributing to the decision not to consider catch-up vaccinations after the conflict included a lack of awareness about these vaccines, loss of vaccination cards, fear of side effects, and the increased workload on mothers, exacerbated by insufficient support from male partners and family members, as well as traditional gender roles. Health facility-related factors included the inability of health facilities to resume previous services, distance from home, the burden on certain healthcare professionals, and long waiting times.

Conclusion

This study reveals that the low uptake of catch-up vaccination in conflict-affected areas is not due to a single cause, but a complex interplay of client and health system barriers. At the individual level, parental decisions are hindered by a lack of information, fear of side effects, and significant gender-based domestic burdens. Simultaneously, health facilities struggle with service limitations, accessibility issues, and overburdened staff.

Introduction

One of the man-made disasters that poses a significant threat to public health and healthcare systems is war. It ranks among the top ten global causes of death [1, 2]. Individuals affected by conflict often experience mass migration, food shortages, infrastructure breakdown, and limited access to essential health services. These challenges not only severely undermine public health but also accelerate the spread of various infectious diseases [3].

Moreover, the psychological impact of war cannot be overlooked. Many individuals suffer from trauma, depression, and anxiety, which can lead to long-term mental health issues that further strain healthcare systems. The disruption of education and loss of livelihood also contribute to a cycle of poverty and poor health outcomes [3].During the six -month conflict in Northern Ethiopia during 2022, many health facilities and health posts were damaged, complicating the implementation of preventive programs such as the Expanding Program of Immunization [4, 5]. This destruction makes it difficult to provide routine vaccinations, increasing the risk of outbreaks of preventable diseases. In addition, the displacement of populations often leads to overcrowded living conditions in refugee camps, creating an environment ripe for the transmission of diseases like cholera and measles [6].

Evidence showed that nearly one-fourth of mortalities among under 5 years old children worldwide are due to vaccine preventable diseases (VPDs) [7]. In order to change this fact, World Health Organization (WHO) launched extended immunization program (EPI) in 1974 [8]. Since its establishment, the program is able to efficiently avert up to three million childhood deaths [9]. Based on the EPI schedule a child is considered as fully immunized if he/she has to receive a BCG vaccination against tuberculosis; three doses of pentavalent vaccine to prevent diphtheria, pertussis, tetanus, and HepB-Hib, at least three doses of polio vaccine, and one dose of measles vaccine within one year of life [10]. Accordingly, 84% of infants around the globe received three doses of DPT [11]. Ethiopia introduced the national vaccination program since 1980 [12] and 44% of children received basic vaccination in 2019 [13]. Despite its life saving benefits, nearly 25 million infants missed their vaccination schedules; 60% live in 10 countries including Ethiopia [14]. This contrasts with leave no one behind in sustainable development goals.

When the immunization schedule is distributed in settings like conflict, catch-up vaccinations will be considered. Catch-up vaccination refers to the action of vaccinating an individual who, for whatever reason, is missing or has not received doses of vaccines for which they are eligible, per the national immunization schedule [15]. In the North Wolo zone after the Northern conflict which lasts from July 2021 and continued to December 2021, 44% of children under two years old defaulted from the immunization program [16]. This study aims to explore the rationales influencing parents’ decisions to overlook the catch-up vaccination schedule for their children under two years old in the aftermath of the conflict to develop evidence-based interventions aimed at improving the health of children.

Methods

Study area and period

A qualitative study design was implemented to investigate the rationales for the lack of engagement in catch-up vaccinations among mothers of children under two years old in conflict-affected areas of the North Wollo Zone from July to September, 2022. Located 521 km from Addis Ababa, the zone borders South Wollo (South), South Gondar (West), Waghimra and Tigray (North), and Afar (East). The zone comprises 14 districts, six governmental hospitals, 30 health centers, and 59 health posts, supported by various non-governmental organizations providing services including maternal and child care. Currently, almost all health facilities have resumed operations with the available resources and provide routine immunization when a child visits a health facility [6, 17].

Study design

A phenomenological methodology was employed. Data were analyzed using thematic analysis to identify, analyze, and report patterns (themes) within the data.

Study participants and sample size

The study participants were mothers of children aged 6 to 23 months who had defaulted from the vaccination program due to the conflict and had not returned for catch-up vaccinations, as well as mothers who gave birth during the conflict and did not initiate vaccinations for their children afterward. A total of twenty-nine in-depth interviews and ten focus group discussions (eight mothers in each group) were conducted with purposefully selected mothers across four districts (Woldia, Harbu, Dawunt, and Meket) in the North Wollo Zone. Information saturation was used to determine the adequacy of the sample size. The mothers were selected in collaboration with local leaders and health extension workers.

Data collection tool and procedures

An interview guide comprising open-ended questions aligned with the study’s objectives was developed in English and subsequently translated into Amharic, the local language, by a professional translator. The tools were validated by experts, who provided insightful reviews and comments. Further revisions were implemented based on feedback gathered from daily recap meetings and field discussions.

Data collection was conducted by four nurses who have prior experience of qualitative data collection under the close supervision of the authors. Upon the selection of mothers as participants, the data collectors explained the study’s objectives and obtained oral consent. The interviews were conducted in a quiet location near the participants’ homes. With the participants’ consent, the interviews were audio recorded, and detailed field notes were taken.

Data quality control

To ensure data quality prior to collection, the tools were validated by experts who provided comprehensive reviews and feedback. Additionally, data collectors underwent three days of training focused on the tools and the data collection process, which included confidentiality and facilitation skills for focus group discussions (FGDs). During the data collection phase, the tools were further refined through field modifications based on daily recap meetings and discussions. Supervisors were present to provide assistance during data collection, and the data was regularly reviewed by supervisors on a daily basis.

Data analysis procedure

At the conclusion of each data collection day, discussions were held regarding fieldwork experiences that involved refining or reformulating questions, shaping the direction for gathering more relevant data. The audio recordings were transcribed verbatim and subsequently translated into English. The data was then cleaned to correct any errors and typos, preparing it for analysis. It was entered into MAXQDA 2020 software to aid in the analysis process and a codebook was prepared. Preliminary or interim analysis started in the field to enhance understanding. This initial analysis also facilitated the thematization of the data, which was finalized and used as a basis for coding in the full-scale thematic analysis.

Result

From the total of 109 mothers with their under two years old children participated in the study 25.7% of the mothers were less than 20 years old and 83.4% were married.Around half of the mothers attend primary education and 38.4% were housewives (Table 1).

Table 1.

Socio-demographic characteristics of study participants in North wollo zone, 2022

Variable	Characteristics	Frequency	Percentage (%)
Age of mother (in years)	< 20	30	27.5
	20–34	51	46.8
	35 and above	28	25.7
Sex of the child	Male	59	54
	Female	50	46
Marital Status	Married	91	83.4
	Single	6	5.6
	Divorced	10	9.1
	Separated	2	1.9
Educational status of mother	No education	31	28.4
	Elementary	53	48.7
	Secondary	13	11.9
	Above secondary	12	11
Occupational status of mother	House wife	38	34.8
	Farmer	27	24.7
	Government employee	2	1.8
	Private worker	26	23.8
	Daily laborer	16	14.6
Residence	Urban	38	34.8
	Rural	71	65.2
Family size	Less than five	25	23
	Five and above	84	77
Under 5 children	1(One)	25	22.9
	2(Two)	63	57.7
	3(Three)	21	19.2

The results of the data analysis are presented thematically, underpinned by illustrative quotations. The results are categorized into two distinct domains: client-related determinants and health facility-level factors.

Client related factors

Maternal awareness about catch-up vaccine

Most of the mothers in the study were not aware of the concept of catch-up vaccination. They believed that a vaccine would only be beneficial if administered according to the original schedule.

For many mothers, the linear perception of vaccination, where each dose must follow a strict timeline, creates a sense of hopelessness if that timeline is disrupted. They often do not realize that vaccines can still provide protection even if administered later than scheduled, additionally, some mothers expressed concerns about potential side effects, such as fever, being exacerbated if vaccinations were delayed.

“This is my first time hearing about the catch-up vaccine from you. I didn’t know that vaccination can continue after missing a dose.”(34 years old, five children, FGD; p-26).

“I had no idea there was a vaccination program available for us; they only seem to vaccinate newborns. I believe it’s because older children cannot tolerate the pain from the needle.”(26 years old, IdI; p-24).

“I quit the program because my child got older after the conflict and had not completed his vaccinations. Therefore, I stopped taking him to the health center. I thought it would not benefit him since he was getting older.”(30 years old, housewife, four children; P-3).

Socio-economic instability due to the conflict

All of the mothers agreed that the conflict which lasted for nearly 6 months in the area created severe socio-economic instability in their life. These instabilities arise from loss of family members, loss of livelihood, and loss of their properties either due to damage or robbery. Therefore, the mothers and their families were forced to work hard to survive. As a result, preventive health services like immunization appeared as a luxury compared to the problems they have to face on daily basis.

A widowed mother who lost her two family members due to the conflict stated that.

“My kids and I sacrificed a lot in this conflict; we lost our hope as a family (her eyes filled with tears) and with the current market price, I have to work day and night to support my family. I do not have time to take my child to a health facility.”(31 years old; p-21).

“I work as daily labor to support my kids, I will take them to the health facility if they are sick, but I have to work every time including weekends.”(27 years old, single mother; p-18).

In the aftermath of the conflict, the mothers reported that they were compelled to prioritize immediate survival needs over preventive health measures. They had to focus on securing basic necessities such as food, shelter, and safety, which left little room for concerns about immunization and other health services.

“I lost hope in my life, I can’t even feed my kids once per day properly, I spent the whole day working in Dailey labor, I haven’t considered taking them to vaccination, and they can’t resist the needle if their stomach is empty” (27 years old, divorced, with twin infants; p-11).

Loss of vaccination card

More than 25 mothers reported losing their vaccination cards were the reasons for not considering catch up vaccine. All of them lost their cards while being displaced from their homes, as they fled to ensure the safety of themselves and their families during the conflict. This loss had significant repercussions on their ability to access healthcare services.

The mothers identified three main reasons for not returning for catch-up vaccinations after losing their vaccination cards.

The first reason was the difficulty in remembering appointment dates for consecutive vaccinations. With the chaos of displacement and the stress of their circumstances, many mothers found it challenging to keep track of these important dates. The disruption of their daily routines made it easy to forget or overlook healthcare appointments.

The second reason involved the perception that immunization services would not be provided without the vaccination cards. Many mothers believed that the absence of documentation would hinder their ability to access services, leading to a sense of hopelessness about their children’s vaccination status. This belief created a barrier, as they felt that without the cards, they would not be allowed to receive the necessary immunizations.

The last reason was the fear that their children might need to restart the entire vaccination schedule. Given that health facilities were also damaged during the conflict, mothers worried that there would be no proper records to track their children’s immunization history. This fear was compounded by the uncertainty surrounding the availability of services and the potential for a lengthy and complicated re-vaccination process.

“We have been displaced three times due to this conflict, and I lost the chart. Since the health facility is also damaged, I was afraid they would make me start the vaccination process from the beginning.”(28 years old, Married; p-94).

“I lost the chart and all my documentation during the conflict. I don’t think they will accept me if I don’t have the chart.” (21 years old; p-101).

Gender role and lack of support from family members

The lack of support from family members was another significant reason mentioned by the mothers for dropping out of the immunization program. In the cultural context of the study area, the responsibility for childcare and household chores falls predominantly on women. This traditional division of labor often leaves mothers with little assistance in managing their multiple roles, which burdensome during times of crisis.

In addition to their domestic responsibilities, many mothers are now compelled to engage in income-generating activities to support their families. The conflict has disrupted normal livelihoods, forcing women to seek work outside the home. This dual burden, juggling childcare and work, leaves them with limited time and energy to visit health facilities for essential immunization services.

The mothers expressed that if they had received more support from their partners or other family members, they would have been more likely to ensure their children completed their vaccinations.

A mother who supported her family by selling traditional drinks claimed that.

“You have seen for yourself that I am overwhelmed with household chores. As a single mother, I haven’t had the time to go to the health facility. I would be very happy to take my child for immunization if someone could help me at home, as I know it is important for his health. If I am away from home for even a moment, a client may come to buy drinks from me, which is my only source of income” (33 years old, single; p-31).

The other reason behind is the presence of gender dynamics, authority, and fear within the family structure, which can significantly impact health-seeking behavior. Some mother expresses a desire to take their child for vaccinations but feels constrained by their husband’s opinion that it is “too late” to vaccinate.

Traditional gender roles that men often hold the primary authority over family matters, including healthcare decision hinder the mothers from seeking the service. They also claimed domestic conflict and violence that can arise when women act independently. This fear can be paralyzing, leading to inaction even when mothers recognize the importance of vaccination.

“I was planning to take the kid to the service, but my husband says it’s too late to vaccinate. So I won’t go. He will kill me if something happens to the kid when I took him without telling him“ (20 years old, housewife; p-45).

“I intended to take my child for vaccination, especially since he has been losing his appetite lately. However, my husband discouraged me from going to the health facility for what he considers minor issues, so I decided not to pursue it.”(30 years old; p-65).

Fear of side effects

Fear of side effects following vaccination is a significant factor contributing to dropout from immunization programs. Many mothers in the study expressed concerns that symptoms such as fever, swelling, sleeplessness, and diarrhea would worsen if their child received vaccinations outside the recommended schedule. This perception create a cycle of fear and hesitation. As a result, they avoid seeking necessary Vaccinations altogether, fearing that the risks of side effects will outweigh the benefits of vaccination.

“Vaccination works best if it is taken in time, unless its only suffering from needle” (25 years old, married; p-54).

“I quiet the program because my child got older after the war, I thought it works best if they are vaccinated in the early age like circumcision. In circumcision, when the child passes the appropriate day, it is very painful and needs time to heal. Immunization is like that: if the appropriate age passes, the child will end up in pain.” (30 years old; p-52).

Health facility related factors

Conflict related damage in the health facilities

Damage to the health facilities from the conflicts in the area was one of the major reasons for interrupting the immunization program. Because of the war in the North Wollo zone, almost all of the health facilities were damaged, looted, and destroyed. Most of the facilities cannot recover in a short time after the war, which has made it difficult for mothers to access vaccination services in the nearby health centers that took a long time to recover. The destruction not only affected physical infrastructure but also led to a significant loss of medical supplies and personnel. According to the mothers, it took a longer period to restore the nearby health facilities after the conflict ended, delaying essential health services.

The lack of accessible health facilities also undermines trust in the healthcare system. Many mothers worry about the safety and quality of care available in the nearby health facilities.

“Our nearby health facility did not go back to work for quite some time after the conflict that we had to walk for more than two hours to get the vaccination service.” (23 years old, married; p-67).

“Our health center didn’t start immunization yet, I don’t think it will recover soon. Even we went to traditional healers when we are sick.”(24 years old, with three children p-81).

The mothers claimed it was challenging for them to continue the immunization program, primarily due to the distance they had to travel to access health services. Many of these facilities were located far from their homes, making the journey not only time-consuming but also physically demanding, especially for those with young children or infants.

The long distances often meant that mothers had to plan their days around these trips, which could disrupt their daily routines and responsibilities. Furthermore, many faced additional barriers such as lack of transportation, financial constraints, and safety concerns along the routes to these distant health facilities. This situation was exacerbated by the ongoing instability in the region, which heightened fears of violence or harassment during their travels.

” The health facility is also empty, no drug no other things its just the building which stands. I prefer to go to traditional healers…….I don’t think I can get service.”(23 years old; p-69).

“We have to travel for hours to get the available service, there is no transportation and the road is not safe “(41 years old, with five children; p-102).

Burden on some professionals and waiting time

One of the health system factors that contributed to the problem was the poorly arranged and coordinated immunization services, which resulted in longer waiting hours. This situation is particularly problematic for mothers working in the private sector, as they often have limited flexibility in their schedules.

Furthermore, while the governmental sector is generally cooperative in granting permission for maternal and child care services, such as immunization and antenatal care, the private sector often fails to recognize these services as a fundamental right. This lack of acknowledgment lead to disparities in access to essential healthcare, with many mothers feeling unsupported and marginalized in their efforts to secure timely immunizations for their children.

In urban areas, the crowding in the immunization schedule is particularly high. Services are often provided in a single room, leading to congestion and an uncomfortable environment for both mothers and children. This situation places a significant burden on a limited number of healthcare professionals who have a tight schedule, offering services only twice a week.

“During the last time I was there, I saw many professionals seating and talking while only three professionals give the service for hundreds.why don’t they corporate for the immunization day?” (22 years old, with two under-five children; p-73).

Additionally, the limited number of health facilities that have been rehabilitated to provide the immunization service creates significant overcrowding in those facilities that are operational. As a result, mothers often find themselves in long lines, waiting for hours to receive vaccinations. The prolonged waiting times further exacerbate the situation With many mothers balancing work and family responsibilities, long delays lead to missed appointments and subsequent gaps in their children’s immunization schedules.

”Last time I was there I stayed more than 3 h which is not possible for me related to my work since I am engaging in income generating activities, I didn’t have time to wait that long.”(25 years old, waiters; p-86).

“Even before the conflict, I waited more than two hours at the nearby health facility. Now we have to go to other health facilities for services, but they might be overcrowded since this is the only health facility providing services these days.”(37 years old; p-91).

Discussion

Catch-up vaccination is a vaccination strategy designed to vaccinate individuals who have not received vaccines in the regular national schedule [15]. A study conducted in Ethiopia showed that lack of awareness on catch-up vaccine increased the odds of vaccination dropout [16].Previously conducted studies also showed poor maternal knowledge about immunization is one of the determinants of vaccination dropout [18–20]. In this study, most of the mothers did not hear about catch-up vaccine which is one of the important health care measures which has to be taken after situations like conflict. This result is one explanation for the need of health education programs and campaigns. This lack of awareness about catch-up vaccinations not only limits their understanding of the options available to them but also contributes significantly to missed vaccination opportunities in the aftermath of the conflict. This knowledge gap will leave the Children unprotected against vaccine-preventable diseases, hospitalizations, or even fatalities and outbreaks within communities.

Though there are limited evidences on how the social and economic impacts of conflicts leads to childhood vaccination dropout, it was reported that the disruption of familial and community structures in conflict areas can cause poor maternal health service utilization [21–23].Previously conducted quantitative studies also showed that poor maternal health service utilization have a direct relationship with vaccination drop out [18–20].

These mothers have limited contact with health providers and are less likely to receive health education on the importance of vaccination. Socio-economic instability, resulting from the loss of family members, livelihoods, and property damage, has forced them to engage in income-generating activities. This shift in priorities is compounded by the emotional toll of the conflict which create a pervasive sense of urgency that makes routine healthcare seem less critical. The mothers express feelings of helplessness and frustration; they understand the importance of vaccinations but feel unable to access these services amid their overwhelming struggles. Consequently, the conflict not only disrupts their immediate lives but also jeopardizes the long-term health and well-being of their families.

In Ethiopian health system vaccination cards are used to make sure that the child received the recommended vaccinations [24]. Loss of vaccination card is one of the determinants of vaccination dropout [25, 26]. The dropout rate might get worse when the health recordings of clients are destroyed with the health facilities and there are no back-up files. Another qualitative study also reported similar finding [27]. It was hypothesized that mothers might default from the program due to the ill-treatment of the health workers while being informed about the loss of the card [26]. These challenges illustrate the broader impact of conflict on healthcare access and the importance of maintaining documentation for immunization. The loss of vaccination cards not only disrupted individual healthcare plans but also contributed to a cycle of neglect in preventive health services.

Most of the of the mothers misunderstood that the mild symptoms emerged after vaccination will be worsen if the child get vaccinated out of the recommended schedule frame [28, 29]. This apprehension can lead to a reluctance to seek timely immunizations, as mothers often weigh the perceived risks of vaccinations against their children’s immediate health. The belief that vaccinations administered outside the recommended timeframe could exacerbate adverse effects reflects a deeper misunderstanding of how vaccines work. Many mothers are not fully informed about the safety and efficacy of vaccines, particularly in relation to catch-up immunizations. This lack of knowledge can create a cycle of fear and avoidance, where parents choose not to vaccinate rather than risk what they perceive as potential harm to their child. Moreover, the anxiety surrounding side effects may be amplified by anecdotal experiences shared within communities. If mothers hear stories of children experiencing severe reactions after vaccinations, it can reinforce their fears and discourage them from pursuing immunization altogether. This is especially true in environments where healthcare communication is limited, and misinformation can spread rapidly.

In patriarchal countries like Ethiopia taking care of the children, including taking them to health facilities for immunization, is mainly considered as the responsibility of mothers. Mothers reported that being the sole caretaker of their children on top of being engaged in household chores and income generating activities prevent them from vaccinating their children. This is in line with the finding of a previously conducted study which reported being busy and lack of partner involvement in child health matters were the contributing factors for vaccination dropout [27]. This highlights the critical role that family dynamics play in health-seeking behavior. When mothers lack support, the logistical challenges of making regular trips to health facilities become overwhelming. The absence of encouragement or assistance can lead to feelings of isolation and frustration, further discouraging them from prioritizing healthcare.

Conflict induced damages to health facilities was one of the most commonly reported factors in this study. Poor and unorganized services, prolonged waiting hours, and walking longer distance to reach to health facilities were some of the challenges that mothers faced while trying to get health services. Evidence showed that armed conflicts leads to poor health service utilization including child immunization by increasing distance to health facilities, damaging health facilities and infrastructures, looting of medical equipment and supplies, and attacking health workers [21–23]. Long wait times can lead to missed appointments which may lead to delays in vaccinations and increase the risk of preventable diseases in children. The overwhelming demand can result in rushed consultations, reducing the quality of care and leaving mothers with unanswered questions about their children’s health.

Conclusion and recommendation

This study reveals that the low uptake of catch-up vaccination in conflict-affected areas is not due to a single cause, but a complex interplay of client and health service delivery barriers. At the individual level, parental decisions are hindered by a lack of information, fear of side effects, and significant gender-based domestic burdens. Simultaneously, health facilities struggle with service limitations, accessibility issues, and overburdened staff.

To improve immunization in post-conflict settings, strategies must adopt approaches that address both rationales. Community engagement is crucial to raise awareness, address fears, and support mothers, who often bear the sole responsibility for childcare. Simultaneously, service delivery strengthening is essential to rebuild accessible infrastructure, improve service management, and implement flexible protocols for lost documentation. Coordinating these efforts will rebuild the community trust essential for successful catch-up campaigns.

Limitation of the study

The main limitation of this study was the constraint to consider the perspective of health facilities by interviewing health professionals and health officials. This omission restricted our ability to explore new ideas and expand our understanding of the research area beyond the health facility service delivery factors explained by the clients. However, health professionals might highlighted broader health system challenges. Incorporating their perspectives would offer a more comprehensive understanding of the multidimensional barriers affecting immunization services.

Author contributions

Muluemebet kassa Mezen Came up with the research idea and was involved in all stages of the research. Yemisrach Belete was responsible for conducting of the analysis and interpretation of the findings. While, both prepared, read and approved the final manuscript. MK is acting as the guarantor.

Funding

Not available.

Data availability

We declare that data and materials will be made available on reasonable request. Muluemebet kassa, the corresponding author, is in charge to respond to the requests and can be contacted through [muluemebet33@gmail.com](mailto: muluemebet33@gmail.com).

Declarations

Ethics approval and consent to participate

Letter of Ethical approval was received from Woldia University Institutional Review Board (IRB).Oral consent was taken from the participants. The mothers were well informed about the aim of the study. The respondents’ confidentiality of information is assured by excluding names and identifiers from the data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.