Abstract:
Background: Vaccination is a crucial public health intervention for reducing child mortality and morbidity, but Ethiopia and Africa have not met the Global Vaccine Action Plan's target.
Purpose: The study aimed at developing strategies to overcome barriers towards implementing the Expanded Programme on Immunisation (EPI) in pastoralist communities of Afar.
Research Design: This study used a qualitative approach with exploratory and descriptive design.
Setting: The research study was conducted in the Afar region of Ethiopia.
Population: The population groups of interest were parents or guardians of children aged 12-23 months who had missed one or more vaccines and EPI health workers.
Sampling: The sample size for this study was 77 participants, consisting of 60 parents or guardians and 17 healthcare providers including health extension workers and partners working on EPI. The interviewed participants’ sample size was determined by data saturation. The researcher used non-probability purposive sampling to choose participants.
Data Collection Method and data analysis methods: The interviews were conducted in a language suitable to the participants (in Afar-aff and Amharic language). In-depth semi-structured interviews were conducted for both the participants and focus group discussions (FGD) through the aid of an interview guide. The study utilised thematic analysis to synthesise the recurring themes that emerged across the data. The data collected from the individual in-depth semi-structured interviews, FGD and Key Informant Interviews (KII) were transcribed and organised into themes for presentation using Braun and Clarke’s six phases of data analysis.
Results: Thematic analysis revealed three interrelated themes: (1) individual- and community-level barriers, including caregiver knowledge gaps, fear of vaccine side effects, vaccine hesitancy driven by misinformation, and competing livelihood demands;
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(2) community-level and environmental barriers, encompassing geographic remoteness (50–180 km from health facilities), seasonal flooding, population mobility disrupting multi-dose schedules, and lack of transportation; and (3) health system-level barriers, including insufficient health workforce capacity, inadequate cold-chain infrastructure in extreme temperatures exceeding 45°C, constrained financial resources, and service delivery models designed for settled rather than mobile populations. These barriers interact dynamically across all levels of the Social Ecological Model.
Validated Implementation Strategies: Seven evidence-based strategies were developed and validated through a two-round Delphi process with 15 multidisciplinary experts using the AGREE II instrument: (1) installing mobile solar-powered vaccine carriers for outreach services; (2) utilising colour-coded vaccination follow-up cards; (3) requiring immunisation verification for school enrolment; (4) decorating immunisation wards in fixed health facilities to create child-friendly spaces; (5) incorporating immunisation education into school curricula; (6) implementing mobile phone reminder systems; and (7) engaging knowledgeable family members as immunisation champions. All seven strategies achieved consensus (≥76% agreement) across all six AGREE II domains.
Conclusion: The seven validated strategies—mobile solar-powered vaccine carriers, colour-coded follow-up cards, school enrolment immunisation verification, child-friendly immunisation wards, school-based immunisation education, mobile phone reminder systems, and family immunisation champions—collectively address barriers at individual, community, organisational, and policy levels. Their validation through rigorous Delphi consensus and AGREE II assessment confirms readiness for pilot implementation. The study advances understanding of immunisation systems in mobile pastoralist populations through its novel application of the Social Ecological Model as both analytical and strategy-development framework, offering a replicable evidence-to-action pathway for comparable settings.
