Immunisation is one of the vital strategies used to protect children from life-threatening diseases starting at birth. Therefore, vaccination is a weakened, living or deceased microorganism injected into a patient to activate their immune system against the microbe and ward off infectious diseases (Besnier et al. 2019). Vaccination is the most significant and economical public health measure in lowering child mortality and morbidity (Besnier et al. 2019). It is part and parcel of the process of immunisation, which the World Health Organization (WHO 2018) describes as a highly reliable and equally economical infectious disease prevention method. In Ethiopia, 43% of people are fully vaccinated (Melkamu et al. 2020a). Diseases that can be prevented by vaccination are serious public health issues that contribute significantly to child morbidity and mortality (Melkamu, Beyene & Zegeye 2020a).

A pastoralist community is often described as marginal, remote, conflict-prone, food insecure and associated with high levels of vulnerability (Zemariam et al. 2024). Pastoral communities of Ethiopia occupy 61% of the total land mass, and 97% of Ethiopian pastoralists are found in lowland areas of Afar, Somali, Oromia and Southern Nations, Nationalities and Peoples’ Region (SNNPR) (Zemariam et al. 2024).

According to a different global regular vaccination survey, 61% of children who were not vaccinated against the most common diseases during their first year of life reside in 10 countries, including Ethiopia (Nigatu et al. 2024). In addition, Africa has the highest percentage (17%) of children who are not immunised (Nigatu et al. 2024). Statistics showed that Africa and Ethiopia lagged behind the rest of the world and failed to achieve the global vaccine action plan (GVAP) 2011–2020 target. The GVAP 2011–2020 called for all countries to achieve 90% or more of the full national vaccination coverage by 2020 (WHO 2020). By 2015, the GVAP aimed to achieve at least 90% vaccination coverage worldwide and 80% Diphtheria-Pertussis-Tetanus 3 (DPT3) coverage in each district (WHO 2020).

In Ethiopia, diseases preventable by vaccinations are a major cause of morbidity and mortality among children under five (Moh.gov.et 2016). The major causes of child death in the country are meningitis (18%), pneumonia (18%), diarrhoea (18%) and measles (1%) (Moh.gov.et 2016). The Bacillus Calmette–Guérin (BCG), Measles, DPT-Hepatitis B-Hib (HepB + Hib) or Pentavalent, Rotavirus, Pneumococcus Vaccine (RPV) and Oral Polio Vaccine (OPV) are the 10 expanded programme on immunisation (EPI) vaccines that are currently offered in Ethiopia (Moh.gov.et 2016).

As per the Ethiopian Demographic and Health Survey (EDHS) report of 2019, the complete vaccination rate stands at 43% (Hailemeskel, Eshete & Shewasinad 2020). However, national studies between 2003 and August 2019 revealed that Ethiopia had a full vaccination rate of 58.92% (Hailemeskel et al. 2020). The immunisation rates throughout a large portion of the nation are below what is needed to create the necessary degree of herd immunity to stop the spread of eight illnesses targeted by the EPI (Hailemeskel et al. 2020). Similar regional differences exist in full vaccination coverage, which ranges from 12.6% in the Afar region to 75.8% in Addis Ababa (Hailemeskel et al. 2020).

Home delivery, residence, mother’s immunisation knowledge, health workers’ home visits, distance to medical facilities, skewed perceptions about the value of vaccinations and false beliefs about vaccine contraindications were all shown to be predictors of child immunisation (Nigatu et al. 2024). Additionally, studies have shown that vaccine coverage is influenced by the way health workers carry out their duties, the planning and execution of immunisation campaigns, the provision of services and the communication between parents and health professionals (Ketema et al. 2020). Nonetheless, insufficient or nonexistent immunisation of children is associated with systemic impediments (Ketema et al. 2020).

As mentioned by Olawuyi et al. (2023) in their studies, the government of Ethiopia has prioritised immunisation and, in recent years, has worked closely with its partners to increase the coverage in the Afar Region. It is important to understand the underlying causes of vaccine-preventable diseases as well as the reasons given by mothers and caregivers for choosing not to vaccinate their children; furthermore, this is especially true in nations where a significant proportion of children are not vaccinated (Olawuyi et al. 2023). Therefore, the researcher believes that examining the reasons behind immunisation discontinuation or lack thereof may aid in developing health system interventions aimed at enhancing immunisation coverage and, consequently, lowering vaccine-preventable illnesses in the Afar region of Ethiopia. The researcher is also mindful that: (1) people in this region strongly uphold traditional cultural values and beliefs and (2) live in highly traditional environments and recognise that some of these attitudes result in subpar EPI outcomes (Ketema et al. 2020). Thus, this study aimed to detect any barriers that may exist in the local context and to create plans for removing obstacles that stand in the way of the pastoralist communities in Ethiopia’s Afar Regional State, implementing EPI. Future researchers in this and/or related domains, health cadres, healthcare educators, policy makers and decision-makers are expected to use this work as a reference.

The study aimed to explore barriers to EPI service utilisation in pastoralist communities of Afar.

A mixed-methods approach, which integrates both qualitative and quantitative data collection, was most appropriate for this study as it allows for a more comprehensive understanding of the research problem (Dawadi, Shrestha & Giri 2021).

Using a qualitative approach, the researcher explored the barriers to implementing the EPI in pastoralist communities. Using both in-depth semi-structured interviews and focus groups in this qualitative study provided a more comprehensive understanding by leveraging their complementary strengths. In-depth interviews in this study allowed for deep, personal exploration of sensitive topics, while focus groups revealed shared experiences, group dynamics and social perspectives. It is worth noting that the Interviews offer detailed, individual insights, while focus groups are ideal for observing and discussing community-level interactions and perceptions. The study looked at both parents’ and healthcare providers’ perspectives to get a comprehensive understanding of the barriers to immunisation, as they face different challenges and have different views. Combining their perspectives provides a complete picture by identifying issues on both the ‘demand side’ (parental or community-level factors like misconceptions, distance or trust) and the ‘service-delivery or supply side’ (factors on the health system’s end, like staff shortages, vaccine availability or cold chain issues). This dual approach is crucial for designing effective and targeted strategies that address the needs of both the community and the health system.

This part presents the findings of the study, which aimed to identify obstacles to implementing the EPI in Afar pastoralist communities and explore potential solutions. Data were collected in October 2023 through in-depth interviews and FGDs, guided by a constructivist paradigm. Participants included parents, caregivers, health workers and focal persons, whose anonymised responses are presented below. The chapter begins with the biographical profiles of the 10 key informants.

The statements and responses of the interview participants were conceptually developed and evaluated, and are the main findings with their linked subthemes or categories discussed in this section. The study generated three main themes, as shown in Table 1.

The study’s overall findings add to the existing literature on barriers to EPI service utilisation. It examines the general understanding of vaccines and vaccination among participants, highlighting the prevalent lack of information among caregivers and its significant impact on immunisation rates. The findings from this study are not entirely unique – many of the barriers listed (distance, fear of side effects, workforce shortages) are common across low- and middle-income countries (LMICs). In the Afar pastoralist context, barriers differ significantly from those in sedentary or accessible LMIC settings, influenced by the unique nature of mobility, which is integral to their way of life rather than merely a matter of distance.

One typical LMIC barrier is the distance to a static health facility. In many rural agricultural communities, the challenge is that the village is 10 km from the nearest clinic. The solution is often to build a closer health post or provide ambulances. Afar pastoralist difference: The entire community and the health post itself are mobile. The barrier isn’t just that a family lives far from a health post; it’s that the family moves with their herds in search of water and pasture, making any fixed-point service delivery model obsolete. As Participant V stated, ‘The majority of our communities are mobile. This results in the failure to receive or avoid vaccinations’. This is a logistical challenge of a different magnitude.

The interpretation of findings was discussed according to each theme presented above. Lack of information with the mother or caregiver was a frequently reported factor. The findings further corroborated this observation as most of the caregivers participating in the study were unaware of immunisation’s benefits. Similar observations were reported in previous studies that explored reasons for incomplete immunisation and stated that lack of knowledge was the main reason (Saleh & Saleh 2022; Sharma & Singh 2021; Anand et al. 2025).

The researcher believes it is important to understand the perspective of pastoralist communities regarding immunisation. This understanding can provide valuable insights into their knowledge, attitudes and practices related to immunisation. It can also help identify potential barriers and challenges to ensure widespread immunisation coverage within pastoralist communities. By understanding their views on immunisation, targeted and culturally sensitive interventions can be developed to improve immunisation uptake and ultimately contribute to better public health outcomes for these communities. In this study, one key cultural issue is the pastoralist way of life, which involves moving with herds to find water and pasture. This lifestyle clashes with fixed health post locations and scheduled vaccination days, as families may be kilometres away on vaccination day. The structure of the health system inherently prioritises sedentary populations, rendering pastoralist communities ‘hard to reach’ and frequently excluded. To develop effective and culturally sensitive interventions for the EPI in pastoral areas, it is essential to deeply understand their distinct lifestyle and worldview.

A major contributing factor to the low accessibility of immunisation services was distance. According to the study by Eshete et al. (2020), some hard-to-reach locations lack access to health institutions that can administer childhood vaccinations. These findings are consistent with these findings. Families whose home was at least an hour from the vaccination site were less likely to be fully vaccinated (56%) than families whose home was between 30 min and 59 min away (67%) (Eshete et al. 2020). Similar findings were also reported by Fite and Hailu (2019), who found that moms chose to stop the kid’s immunisation regimen due to difficulty commuting or transporting the child to the health facility. It is noteworthy, therefore, that the estimated distance to the health institution affects immunisation propensity.

The utilisation of healthcare services largely depended on access to transportation. In rural areas, when the distance to travel is long and no proper transportation facility is available, it ultimately leads to low utilisation of public healthcare services and an increase in out-of-pocket health expenditure. Floods can make roads impassable and transportation difficult, especially in rural areas with limited infrastructure. A study by Fite and Hailu (2019) confirmed these findings, indicating that parents’ lack of awareness about children’s immunisations, irrational concerns about vaccine safety and lack of access to transportation for community and healthcare providers are some of the barriers to immunisation.

Furthermore, the evidence revealed that parents’ migration from one place to another can create barriers to accessing healthcare services, including vaccinations for their children. When families move, it can disrupt the established vaccination schedule for their children, leading to missed or delayed doses. A similar conclusion was drawn by Akwataghibe et al. (2019), who showed that migration was also a barrier to child vaccine coverage. Additionally, research by Njeru (2019), which was backed by the literature, showed that migrant groups frequently relocate, which makes it challenging to track vaccination status and lowers adherence to vaccination regimens. The studies conducted in Sinana District by De Figueiredo et al. (2020), in Somalia by Mohamud et al. (2020) and in Afghanistan by Pollard and Bijker (2020) supported this finding (Mohamoud et al. 2024). This could be due to similar sociodemographic characteristics of the population that can lead to defaulting of the children from full vaccination.

The study showed that vaccination service usage is influenced by fear of adverse effects that may occur after vaccination administration. The study’s results align with those of a study conducted in India by Vaghela et al. (2021), which found that poor immunisation coverage was caused by concerns about side effects and suggested that methods for improving services be adopted.

A study conducted in Nigeria by Malas and Tolsá (2022) supports the finding that community rumours and fear were factors in vaccine reluctance. Similar findings were also reported by De Figueiredo et al. (2020). Vaccine reluctance and distrust have been seen worldwide across socioeconomic strata, with environmental factors differing within and between nations.

These results are supported by research conducted in Ethiopia by Tagbo, Okafor and Okolie (2020), who found that one of the factors contributing to children’s partial immunisation is mothers’ lack of knowledge about the value of immunisation and the fact that most of them never took their children back to the doctor for follow-up vaccination because they were afraid of the side effects.

Concerning the child vaccination service delivery thematic area, the evidence from the participants indicated that lack of budget, lack of vehicles, lack of sufficient health workforce, absence of HEWs in health posts during visits by parents or caregivers and absence of HEWs from health posts were the reasons for defaulting vaccination.

A Pakistani study by Fahmida et al. (2022) found that limited budget, infrastructural deficits, inconsistent policy, health workforce and insufficient training result in low vaccination uptake. These findings by Fahmida et al. (2022) support this current research’s findings. Additionally, countries like Pakistan continue to struggle with efficiently using and transferring the allotted funding for immunisation (Fahmida et al. 2022). The evidence from the respondents indicated that the lack of vehicles has been a significant challenge for them. This has impacted their ability to commute to work, run errands and access essential services. The lack of vehicles has also limited their mobility and independence, making participating in various activities and opportunities difficult. Some studies also show numerous complaints about the poor funding for outreach initiatives, including the lack of motorbikes (Fahmida et al. 2022).

The evidence from the respondents suggests that a lack of sufficient health workforce is a significant barrier to vaccination programmes. This could mean insufficiently trained healthcare professionals are available to administer vaccines, educate the public about the importance of vaccination and provide follow-up care. This shortage of health workforce may hinder the effectiveness and reach of vaccination programmes, particularly in areas with limited access to healthcare services. One of the challenges facing the immunisation programme is the scarcity of human resources (Malande et al. 2019).

Building capacity is a fundamental component of the immunisation programme. Accurate knowledge transmission is ensured, and the quality of the immunisation programme is directly supported by improving professional knowledge and skills through training and competency assessments. This study is supported by research which indicates that healthcare provider barriers to immunisation include a lack of knowledge about indications for and contraindications to immunisations and poorly trained health staff (Fite & Hailu 2019).

The information provided by the respondents indicated that one of the barriers to the immunisation programme is the lack of HEWs present at the workstation. Other investigations revealed similar observations. According to Ketema et al. (2020), in addition to the irregularity of the outreach and scheduled sessions caused by the absence of vaccinators at the health facilities, poor accessibility and use were also a result of a lack of transportation options.

The researcher’s belief underscores the significance of understanding the various barriers from the community that lead to children missing or defaulting on full vaccination. Identifying and comprehensively analysing these barriers makes it possible to develop targeted interventions and strategies to address the specific challenges that hinder children from receiving complete vaccination. This approach can ultimately improve vaccination rates and overall public health outcomes.

After thoroughly examining the interview data, three main themes and associated sub-themes were found. The report also listed several barriers to the implementation of community immunisation programmes. Among these impediments were community-side barriers that hinder access to immunisation services, such as geographical challenges, transportation issues, and the effects of migration, fear of side effects, reluctance to vaccinate and poor understanding of vaccination. It also explores healthcare system-related barriers, including insufficient resources and workforce limitations. The research contributed creative ways to overcome access obstacles and increase the use of immunisation services.