Barriers and enablers to the integration of family planning, immunization, and nutrition services into RMNCAH-N services in primary health care settings in Ethiopia

Despite national policies promoting integrated Family Planning, Immunization, and Nutrition services, implementation remains challenging in Ethiopia’s diverse primary healthcare settings. This research aimed to identify the barriers and enablers of integrating family planning, immunization, and nutrition services into reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services in selected agrarian and pastoralist regions of Ethiopia. A qualitative case study was conducted in ten primary healthcare units located across three districts: one district in pastoralist Afar region and two districts in the agrarian regions of Oromia and Central Ethiopia. We conducted seven focus group discussions (FGDs), 18 In-depth interviews (IDIs), and 10 key informant interviews (KIIs) with a total of 91 participants selected purposively, including program managers and policy-makers, health workers, and clients. Data were analyzed using a combined deductive and inductive approach guided by the Consolidated Framework for Implementation Research Version 2.0 (CFIR 2.0). 17 of 48 CFIR 2.0 constructs were identified as influencing the integration of Family Planning, Immunization, and Nutrition services into RMNCAH-N touchpoints. Key barriers included: within the inner setting (inadequate facility readiness and limited space, essential supply shortages, poor provider commitment, and negative provider perceptions towards service integration), the outer setting (rural residence and political instability), and individuals and sociocultural factors (male-dominance in healthcare decision-making and restrictive cultural and religious norms particularly in pastoralist communities). Key enablers included: the innovation relative advantage of integration (reduced missed opportunities, lower transportation costs, fewer facility visits, and time savings), supportive inner setting factors such as enhanced teamwork, and improved health-seeking behavior facilitated by integrated health communication. Integration of Family Planning, Immunization, and Nutrition services into RMNCAH-N services is influenced by distinct contextual factors in agrarian and pastoralist settings. To enhance integration, we recommend: improving facility readiness (space and supplies), addressing sociocultural barriers through community engagement, including male involvement, particularly in pastoralist areas, ensuring supply chain reliability, and providing performance-based incentives and continuous professional development to mitigate provider burnout and sustain quality integrated care.