Socio-demographic Characteristics of Respondents
A total of 824 caregivers of children aged 12 to 36 months participated in the survey, yielding a response rate of 97.5%. The majority of caregivers (52.4%) were aged 31 to 40 years. Regarding marital status, 74.4% were currently married, 13.5% were divorced or separated, 9.7% were widowed, and 2.7% were single. The predominant religion among caregivers was Islam, with 78.4% identifying as Muslim and 21.6% as Christian (Table 1).
Characteristics of the Children
The age distribution of children revealed that 45.4% were between 19 to 24 months old, 21.6% were between 25 to 30 months, and 20.8% were between 12 to 18 months. A total of 53.3% of the children were female, and 46.7% were male. The majority of children (64.2%) were born more than 37 months after their preceding sibling, and 77.2% were born at health facilities (Table 2).
Knowledge on Immunization and Vaccine Preventable Diseases
The primary sources of vaccination information for caregivers were community members (30.8%) and health extension workers (21.6%). Most caregivers (59.1%) believed vaccination prevents disease, whereas 15.3% thought it treated childhood diseases. Caregivers who could identify at least two vaccine-preventable diseases were 36.7%, and those who couldn’t name any were 19.7% (Table 3).
The majority of caregivers (50.6%) believed that vaccination begins at 6 weeks, while 23.4% thought it starts at 4 weeks. Completion of vaccination was most commonly reported as being at 9 months (55%), and 16% did not know the completion age (Table 4).
Maternal Health Care Utilization
Among respondents, 84.8% attended antenatal care (ANC), with 70.5% attending 3 or more times. Most (75.5%) delivered their last child at a health facility. Utilization of modern contraceptives was reported by 66.7%, and 67.5% sought health facility care for their children (Table 5).
Access and Quality of Immunization Services
In the study area, most caregivers (66.9%) reported that vaccinations were administered at health posts, while 26% used health centers, and 7.2% attended hospitals. Accessibility to vaccination sites varies: the majority of caregivers (86.7%) walk to the facilities, whereas 13.3% use transport. Walking times to the nearest health facility are generally moderate, with 51.3% walking for 15-30 minutes, 29.6% taking less than 15 minutes, and 19.1% walking for over 30 minutes ( Table 6).
Regarding health extension workers (HEWs), 520 (63.1%) receive regular visits and advice, while 304 (36.9%) do not. On vaccination days, 677 (82.2%) did not experience long waiting lines, and 595 (72.2%) rated the service as good. Only 123 (14.9%) were refused service, mainly due to vaccine shortages (65, 52.9%), missed vaccination days (19, 15.4%), or illness (21, 17.1%) (Table 7)
Vaccination Status by Card and Maternal Recall
Among the 824 children, 775 (94.1%) received at least one vaccine, while 49 (5.9%) received none. Of those surveyed, 598 (77.2%) had vaccination cards at home. Fully vaccinated children aged 12-36 months were 596 (72.3%) by recall and 504 (61.1%) by card (Table 8)
Reasons for Defaulting Vaccination
For the 179 children who were partially vaccinated, the most common reasons for defaulting were inconvenient vaccination times (41%), lack of awareness about vaccination schedules (28%), perceived lack of importance (12%), fear of side effects (12%), and distance to vaccination sites (6%) ( Figure 1).
Determinants of Vaccination Status
An analysis of factors influencing vaccination status considered socio-demographics, child characteristics, maternal health care utilization, and service quality.
Socio-demographic Characteristics
Caregivers’ marital status and educational level, along with household size, significantly influenced vaccination status. Specifically, widowed caregivers were 7.3 times more likely to hesitate to vaccinate, and divorced caregivers were 4 times more likely compared to married caregivers. Those without formal education were more than twice as likely to hesitate to vaccinate. Larger household sizes (≥5 members) were associated with a 5.4 times higher likelihood of hesitancy compared to smaller households ( Table 9).
Child Characteristics
Children born at home were more likely to be incompletely vaccinated (OR 4.6, 95% CI 1.8-10). Those who experienced child death in the family were also more likely to be incomplete (OR 2.6, 95% CI 1.2-6.8) (Table 10).
Knowledge on vaccination and vaccine preventable diseases
The study indicated that caregivers who received vaccination information from community members were 4.2 times more likely to hesitate in fully vaccinating their children compared to those who got information from health extension workers. Caregivers unaware of the correct number of vaccination sessions were 2.6 times more likely to be hesitant. Those who did not understand the purpose of vaccination were 11.5 times more likely to hesitate, while those who thought vaccinations targeted specific diseases rather than preventing a range of childhood diseases were 10.6 times more hesitant. Additionally, caregivers who could not name any vaccine-preventable diseases were 3.6 times more likely to be hesitant about completing vaccinations. However, knowledge about the number of vaccine sessions and potential health issues related to vaccines did not significantly impact vaccination completion rates ( Table 11).
Maternal Health Care Utilization
The study analyzed the relationship between maternal health care utilization and child vaccination status. It found that mothers who attended antenatal care (ANC) two times or fewer were 2.1 times more likely to hesitate in fully vaccinating their children compared to those who attended ANC three times or more. Additionally, mothers not using modern contraceptives were 10 times more likely to be hesitant about complete vaccination than those who did use modern methods. The study also highlighted that mothers who relied on home treatment for childhood illnesses were 2.5 times more likely to hesitate in completing vaccinations compared to those who sought care at health facilities ( Table 12).
Access and Quality of Vaccination Service
This section examined how access to and quality of vaccination services impacted vaccination completion. It was found that although all children had access to health facilities, the type of facility mattered: caregivers who used health posts were 4.07 times more likely to hesitate in completing vaccinations compared to those using hospitals. The involvement of health extension workers (HEWs) also played a significant role; caregivers who did not receive home visits from HEWs were 14.7 times more likely to hesitate. Furthermore, the time it took to reach a health facility was a significant factor, with those taking over 30 minutes being 9.5 times more likely to hesitate compared to those who took less than 15 minutes ( Table 13).
Demographic Characteristics of Participants in Qualitative Study
A total of 24 participants from the community leaders of each kebele were selected for in-depth interviews. Participants were within the ages of 46 to 65, with a mean age of 56.34 ± 5.51 years. Among the participants, 3 (12.5%) were females, and 21 (87.5%) were males, including 3 religious leaders. All names credited to the quotes below are pseudonyms.
Perception towards Child Vaccination
All the study participants were asked to articulate distinctly their lived experiences regarding how the community members understand and interpret child vaccination. They were also asked to discuss the common rumors circulating among the communities of Tehuledere Woreda.
One of the findings was the importance of childhood vaccination. According to the interviewees’ responses, controversial perceptions were found among the community of Tehuledere Woreda towards child vaccination.
The majority of the participants (n=14) indicated that caregivers of children understand the importance of vaccines for their children. They view vaccination as a way of protecting children from deadly childhood epidemics and ensuring healthy development. Religious and community leaders play a crucial role by providing information, encouraging vaccination, and engaging in dialogue across multiple levels of the Tehuledere community to influence members positively towards child vaccination, thus increasing vaccination rates and reducing vaccine hesitancy.
Sheik Siraj, a 62-year-old religious leader, stated:
“We are comfortable with child vaccination practice and people usually take their children to the vaccination site. We consider vaccination as medicine, and it makes the children grow fast.”
Another 58-year-old male participant said:
“The community is pleased about child vaccination and keeps up with the vaccination program as the imams (religious leaders) and the EDIR (community-based organization) leaders, along with community health workers, advocate the program.”
Zelalem, a 56-year-old participant, shared:
“Child vaccination is a very good activity as many diseases, which were a social problem when we were kids, are now gone. I have three children, two of whom have completed their vaccinations, and one is currently being vaccinated. I saw the villagers remember the vaccination days because they believe vaccinating children is like making a strong fence around their home and their garden.”
Another perception found in the community is that vaccination increases children's mental development. According to the participants, some community members believe that child vaccination not only ensures proper growth and health but also enhances intelligence and social participation. This perception is shaped by the perceived benefits of vaccines.
Zewudu, a 51-year-old participant, said:
“Our community members used to vaccinate their children regularly. I also had my daughter vaccinated because child vaccination made children intelligent, healthy, and well-developed.”
Another 58-year-old male participant stated:
“I have four kids; some of the elders didn’t get vaccinated, but the younger ones are vaccinated. There is a marked difference between vaccinated and non-vaccinated children in terms of their strength and mental ability.”
The study also found that the community perceives vaccination as a tool for enduring different childhood diseases. Participants explained that mothers also benefit from the vaccination program. They claimed that when mothers visit clinics for antenatal follow-ups, they receive information about additional maternal healthcare concepts and use this opportunity to practice institutional delivery and ensure uninterrupted vaccination for their children.
Kedir, a 46-year-old male participant, described:
“Vaccination is a very important practice because I found vaccinated children develop endurance against common diseases like influenza and cough.”
Continuing his explanation, he added: “Not only children but mothers also benefit by maintaining their health status from the early stages of pregnancy. They regularly visit clinics, deliver their children at health facilities, and continue getting vaccinations for their children.”
However, some participants (n=4) indicated that child vaccination might cause health problems. Participants revealed that whenever their children experienced health issues during vaccination, they attributed the problems to the vaccination without seeking clinical confirmation, affecting their decision to vaccinate subsequent children.
Lubaba, a 55-year-old female participant, stated:
“My elder son was vaccinated, but the vaccine caused his body to swell badly. For my next child, I hid my baby to avoid vaccination because I worried the same event might occur.”
Another female participant indicated that it is unnecessary to vaccinate children if they become ill in infancy. She explained: “I didn’t vaccinate my son because, at an early age, he suffered from 'AYNETILA' (a recurring childhood disease). Vaccination and AYNETILA are very unfriendly.”
Religious beliefs and cultural norms also influence perceptions towards child vaccination. A woman strongly believed that every harm and benefit is from Allah and hesitated to vaccinate her child, thinking vaccination could not prevent harm if Allah willed it. Additionally, cultural norms suggest that young children should be kept at home and not exposed to public places, fostering vaccine hesitancy.
Zeyneba, a 52-year-old Muslim female participant, said:
“We believe in Allah. We believe also that all harms and benefits are from Allah. Nothing can prevent us from harm if Allah decides it. There is no difference for my baby whether I vaccinate him or not. But I took my baby to be vaccinated following health extension workers' promotion and call.”
Fentaw, a 64-year-old male participant, stated:
“When very young children are exposed to be seen by others, especially in public places, they will develop discomfort and become unhealthy. People from different 'AHWAL' (states of mood) gather at vaccination sites, making these sites dangerous places for children.”
Rumors towards Child Vaccination
Despite the recognized importance of vaccination, persistent rumors and misconceptions contribute to vaccine hesitancy and lower immunization rates in the community. Some rumors include the belief that vaccines are expired or useless drugs, part of a secret hostile plan, or an act of political revenge. These beliefs suggest that vaccination affects children's natural growth, physical strength, eyesight, and reproductive power.
Ali, a 57-year-old male participant, said:
“I saw individuals who believe and disseminate their beliefs that vaccination is a way of drug disposal. The government sends medicines that are expired, cheap, and useless in the name of child vaccination when other places are not convenient.”
Another 48-year-old male participant stated:
“Formerly, our people believed that child vaccination is a conspiracy of others. This belief was that vaccination makes our children fat and grow fast; once the children grew and became fat, the vaccinators would take and sell them to another place.”
Zegeye, a 48-year-old male participant, shared:
“At the time of political tensions, a rumor circulated among the public that child vaccination is a conspiracy by the enemy to make Amhara kids stunted, less strong, and weak-sighted.”
Another 54-year-old male participant also said:
“It is said, and we suspect, that the so-called child vaccination may harm our children. Despite its validity to protect them from injury, it might be an enemy conspiracy to bring long-term effects on children's proper growth, health, physical strength, and even their reproductive power.”
Continuing, he added: “Some members of the community believe and express that the most important thing for children is food, not vaccination. Vaccination is not food and can never nourish children like food and supplements.”
Participants also indicated that certain individuals spread pseudoscientific information, claiming that vaccines contain chemicals that could negatively alter children's moral qualities.
Tefera, a 54-year-old male participant, said:
“We heard disturbing information from some individuals. It is said that vaccines contain chemicals with different functions. One nourishes the child for good growth and development, but the other is very dangerous. Early vaccinated children will be disloyal to their families and will go against their country's promise when they become adults.”
Another 52-year-old male participant also said:
“When children are injected with unknown substances, we believe it may be medicine. But the vaccinators also inject our children with something that alters their moral qualities, making them persistently bothersome.”