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

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.