Factors influencing child vaccine communication practices in Gondar town

Abstract

BACKGROUND

Communication is a critical tool for promoting child immunization by enhancing vaccine acceptance and uptake. However, its effectiveness in enhancing child immunization coverage is often hampered by multiple factors. The town of Gondar has been suffering from a conflict/civil war and has low child immunization coverage. Hence, exploring the diverse barriers that negatively influence communication practices in Gondar town is important.

AIM

To explore the barriers to child vaccine communication aimed at promoting child immunization in Gondar town.

METHODS

A qualitative descriptive design was employed from May 2024 to June 2024. Data were collected through in-depth interviews and focus group discussions (FGDs) with ten purposively selected health professionals providing routine vaccination services, as well as 18 mothers or caregivers of children participated in three FGDs. The data were thematically analyzed.

RESULTS

There are multiple interconnected factors hindering child vaccine communication in the study area. Health system-related barriers included shortages of communication materials, insufficient immunization-communication training for health professionals, and limited staffing, which, together with heavy workloads, constrained providers’ ability to engage effectively with caregivers. Individual, interpersonal and community-related factors also played a significant role; limited time availability among mothers, language-related challenges and low community involvement reduced opportunities for effective vaccine communication. Additionally, policy and structural challenges, such as child birth registration-related tasks, inadequate transportation, insecurity, and interruptions caused by the coronavirus disease 2019 pandemic, impeded the delivery and uptake of vaccination messages. Jointly, these findings highlight that barriers to effective child vaccine communication are multifaceted.

CONCLUSION

Child vaccine communication faces barriers across multiple levels. Integrated strategies, training, communication materials, health-system support, caregiver engagement, and policy coordination are essential for consistent communication and improved vaccination uptake in Gondar.

Key Words: Child vaccine; Communication practices; Communication barriers; Promoting child immunization; Amhara region; Qualitative inquiry

Core Tip: Child vaccine communication is an essential tool for ensuring immunization. However, it is hindered by interconnected factors across multiple levels in Gondar town. This qualitative enquiry revealed that barriers at the individual, interpersonal, organizational, and policy levels negatively affect both the effectiveness and adequacy of child vaccine communication in the study area. Hence, health facilities, immunization program implementors and policy makers should pay attention to these multi-level factors while planning and implementing child vaccine communication interventions.

INTRODUCTION

Childhood vaccination is one of the most effective public health interventions for preventing infectious, vaccine-preventable diseases and has substantially contributed to the global reduction of under-five mortality[1,2]. Despite these achievements, many low- and middle-income countries continue to experience suboptimal immunization coverage, underscoring the need to move beyond biomedical solutions and integrate social science–informed approaches into immunization programs, particularly those related to health communication.

In Ethiopia, childhood immunization coverage and the quality of immunization data remain persistent public health challenges. These issues have been further compounded by disruptions associated with the coronavirus disease 2019 (COVID-19) pandemic and recurrent conflict, which have weakened health information systems and strained routine immunization services[3]. While national efforts have largely focused on improving service availability and system performance, less attention has been given to the adequacy and quality of interactions between health professionals and caregivers during vaccination encounters.

Effective communication is a critical determinant of vaccine acceptance and uptake, as parents often rely on health professionals as their primary source of immunization information[4]. However, evidence indicates that vaccine communication during routine immunization services is frequently constrained by multiple factors, including inadequate provider communication skills and weak health system support, which limit the effectiveness of information exchange and contribute to vaccine hesitancy and missed or delayed vaccinations[5]. Although these barriers have been documented in broader contexts, there is limited qualitative evidence that explores how such challenges manifest in specific local settings within the Amhara region of Ethiopia, specifically the town of Gondar.

Several studies have examined the timely vaccination of children in the town of Gondar in northwest Ethiopia[6]. However, previous studies have not examined the role of communication in vaccination. Instead, the studies emphasized immunization coverage in the town, thereby neglecting the communication. Hence, there is a clear gap in context-specific, in-depth understanding of the factors influencing child vaccine communication practices in Gondar. Gondar has the second-lowest child immunization coverage in the Amhara region. Addressing this gap is essential to inform the design of appropriate communication strategies that enhance caregiver engagement and support improved immunization coverage. This study aims to explore the factors influencing child vaccine communication practices in the area, thereby contributing new qualitative insights to strengthen immunization communication interventions.

The study poses the following specific research questions: (1) What are the individual and interpersonal level factors that affect effective child vaccine communication practice in Gondar? (2) What are the health system and community level factors hindering child vaccine communication practice in the area? and (3) What are the policy-level factors negatively influencing effective child vaccine communication in the area?

MATERIALS AND METHODS

Qualitative research has become increasingly essential in public health studies, particularly those that aim to explore the various factors influencing public health promotion interventions[7]. Specifically, qualitative description seeks to present participants’ experiences in a straightforward way, remaining close to their own words rather than relying on analytical frameworks[8]. A qualitative descriptive design is the most appropriate approach for the stated objectives because the study seeks to identify, describe, and understand factors impeding child vaccine communication from the perspectives of those directly involved—caregivers, and health providers—without imposing pre-existing theoretical interpretations. Therefore, the study utilized a qualitative descriptive design to examine the factors affecting child vaccine communication practices in Gondar from May 2024 to June 2024. The issue of data timeliness is unlikely to confound the findings of this study, as no major changes in national immunization policy, communication strategies, or service delivery models occurred during the period (May 4, 2024 to June 21, 2024).

Area, participants and sampling techniques

The selected study sites were purposively chosen based on vaccination coverage data from the Expanded Program on Immunization (EPI) reports over the past 5 consecutive years. The study included health professionals who have been providing child vaccination services and mothers/caregivers with children aged 0-15 months old using purposive sampling of 10 immunization service providers from three health centers. Additionally, 18 focus group discussion (FGD) participant mothers were purposively selected based on their ability to effectively describe their ideas and active involvement in health issues. The researcher’s justification behind using a purposive sampling technique was the need to obtain detailed insight from people who are experienced and have good communication skills and experiences, enabling them to provide detailed insights and information[9]. The goal of using communication ability as an inclusion criterion was not to select more knowledgeable participants about the issue under investigation, but rather to ensure data quality and credibility, which is essential for capturing nuanced communication barriers. In so doing, the EPI focal persons, the health facility director/administrators, and the leaders of women development army were contacted to select the most skillful and experienced immunization service providers and mothers/caregivers.

Data collection tools and procedures

The study employed in-depth interviews and FGDs to collect data from health professionals providing vaccination services and mothers of children aged 0-15 months old, both whom were purposively selected. The interview and FGD guiding questions were semi-structured with the motive of obtaining detailed information about the research problem and for flexibility. The researchers conducted a pre-test to improve the tools through checking the clarity, order and flow of questions and the time required to accomplish the interview and FGDs[10]. Based on the finding of the pilot test, unclear questions were rephrased, redundant items were deleted, and probing questions were added to enhance depth of responses. The in-depth interview lasted approximately 55 minutes, and the FGD question lasted 60 minutes. While collecting the data. The interviews and FGDs were audio-recorded and the researchers took notes.

Data collection, analysis technique and procedures

All interviews were conducted by the principal researcher, who has experience in getting health services in health facilities, but no prior relationship with participants. The data were analyzed using thematic analysis. All interviews were transcribed, cross-checked with audio recordings, and read multiple times to ensure familiarity with the data[11]. Words and phrases reflecting related meanings were identified and coded inductively. After preparing the data for analysis, transcripts were translated into English and reviewed for accuracy and consistency by two independent professionals. This process was performed step by step, with preliminary codes refined across transcripts to develop a coherent codebook that guided the final stages of analysis[12].

Specifically, initial coding resulted in 23 distinct codes, which were compared and clustered based on conceptual similarity to generate 11 preliminary themes. These themes were reviewed against the full dataset to ensure internal coherence and clear distinctions, and overlapping themes were merged to produce a final set of five themes representing participants' shared experiences[13].

Coding was conducted by a single researcher to maintain consistency in interpretation. Rigor was enhanced through coding, with regular peer debriefing to enhance analytic rigor. Preliminary codes and emerging themes were discussed with experienced qualitative researchers during peer debriefing to reduce potential bias[14]. Codes were iteratively refined and compared across participants. Reflexive notes documented assumptions and analytic decisions. The researcher engaged in peer debriefing and cross-checked findings with previous studies with similar findings[15]. Data saturation was achieved by the 10^th participant and by the third FGD discussion through monitored coding throughout data collection.

The socio-ecological model (SEM) was used to guide the study by structuring the identification of multi-level constructs, informing interview guide development, and organizing analysis around hypothesized pathways across individual, interpersonal, health system, community, and policy levels.

Ethical consideration

Ethical clearance for the study was obtained from the Institutional Review Board of Bahir Dar University (Approval No. 14/IRB/24), in accordance with the Declaration of Helsinki standards for research involving human subjects. Following this clearance, the Amhara Region Public Health Institute issued a support letter (Ref. No. APHIHRTT 03/2098) to the health bureaus of the study sites. Participants were fully informed about the study's purpose and their right to withdraw at any time. They also were assured that their data would remain anonymous and be used in publications. Written consent forms were signed by all respondents, ensuring that all ethical considerations related to human subjects were addressed in the study.

Maintaining trustworthiness

The trustworthiness of qualitative data can be maintained through employing different strategies, including triangulation, providing detailed transcription of the participant sampling technique, thick description, and peer debriefing[15]. Thus, the researchers maintained the trustworthiness of the qualitative data by using different data collection methods to triangulate the findings, through inviting research colleagues to evaluate the study and describing all the necessary procedures and techniques of data acquisition and analysis.

RESULTS

Demographic characteristics

Participant interviewees’ (health professionals) and FGD discussants (mothers/caregivers') demographic characteristics are presented below.

The data presented in Table 1 indicate that all participants were female (100%). Of the interviewees, 30% were aged 18-25 years, 50% were aged 26-35 years, 10% were aged 36-45 years and 10% were aged 46-55 years. This suggests that the majority of the participants were 26-35 years old. Additionally, 40% of the participants had education levels below a degree and 60% of participants had degree or above education level. The table also shows that 30% of the participants had 6-10 years of work experience, 50% had 11-15 years of work experience and 20% had 16 years or more work experience, which implies that the majority had 11-15 years of experience.

Table 1 Demographic characteristics of interview participants.

Variables		n	%
Sex	Male	0	0
	Female	10	100
Age (year)	18-25	3	30
	26-35	5	50
	36-45	1	10
	46-55	1	10
	Above 56	0	0
Education level	Below bachelor degree	4	40
	Degree and above	6	60
Work experience (year)	1-5	0	0
	6-10	3	30
	11-15	5	50
	Above 16	2	20

Additionally, Table 2 reveals that 33.3% of mothers/caregivers were aged 18-25 years, 50% were aged 26-35 years and 16.7% were in aged 36-45 years. Regarding education level, 11.1% completed primary education, 22.2% attended secondary school, 27.8% had below degree education, and 38.9% had a degree or above. The table also demonstrates that 33.3% of mothers were housewives, 44.4% were self-employed and 22.3% were government employees, highlighting that the majority are self-employed.

Table 2 Demographic characteristics of focus group discussion participants.

Variables		n	%
Age (year)	18-25	6	33.3
	26-35	9	50
	36-45	3	16.7
	46-55	0	0
	Above 56	0	0
Education level	No formal education	0	0
	Primary education	2	11.1
	Secondary education	4	22.2
	Below degree	5	27.8
Occupation	Degree and above	7	38.9
	House wife	6	33.3
	Self-employed	8	44.4
	Government employees	4	22.3

DISCUSSION

The result that is presented is discussed and interpreted using SEM as an analytical framework.

Individual-level factors

The findings illustrate that individual-level factors such as time limitations, knowledge gaps, communication skills, and personal constraints affect communication about child vaccines. These factors operate on both the caregiver and provider sides, shaping not only the experience of vaccination but also the effectiveness of communication about child health.

In relation to caregivers’ time constraint and priorities, most caregivers reported that they are overwhelmed by responsibilities at home and work, which restricts the time they can spend at the clinic. As one participant explained, “Almost all of us are busy with either or both home and office tasks. We do not have time to discuss with the health workers about our babies’ health. Instead, we need the vaccines to be given quickly” (focus group discussion 2, participant 1).

This finding aligns with evidence from Ethiopia and beyond showing that long waiting times, workload, and competing priorities discourage caregivers from engaging in extended dialogue with providers and may reduce opportunities for in-depth discussion about vaccines. Qualitative research in Ethiopia identified workload and long waiting time as barriers to caregiver engagement during immunization services, along with language barriers and poor interpersonal communication that further limit meaningful interactions[16]. In other settings, caregivers similarly reported that clinic environments and time pressures negatively influenced their ability to receive adequate information during vaccination encounters[17].

The study found that language and knowledge barriers in child vaccine communication influenced child vaccine communication. Health workers in this study highlighted challenges with translating vaccine names from English into Amharic, often resorting to describing the disease rather than naming the vaccine. This contributes to communication gaps, where caregivers may leave the clinic unsure about what vaccines were given or what they are called in their own language. As a health worker noted: “Since I learned each vaccine in English, I did not know what they exactly meant in Amharic. Consequently, the language of communication is creating a communication gap” (health worker number 9).

Language barriers in health settings have been documented as a significant challenge for effective communication globally, where language discordance undermines patient understanding and clinician–patient dialogue[18]. Specifically for immunizations in Ethiopia, the inability of the caregiver to identify vaccines by name and limited explanations by providers reduce caregivers’ comprehension of immunization messages[19].

Communication training and skill training is also described as the individual level factor, hampering child vaccine communication. Specifically, health workers also described inadequate communication training, with sessions focused on technical aspects of new vaccines rather than ongoing development of interpersonal communication skills: “I took immunization communication training once. However, I had already forgotten what I was trained in. Instead, relatively, training specifically about the nature of a recently introduced vaccine. Hence, I cannot confidently say that I talk with the mothers in an efficient manner” (health worker number 3).

This reflects broader evidence that health worker communication training often lacks reinforcement and emphasis on interpersonal skills, even though such skills are critical for effective vaccine communication. A recent qualitative study of healthcare professionals revealed that many practitioners feel they lack sufficient time, information, and communication skills specific to vaccine discussions, and that tailored vaccine communication training is needed[20]. Similarly, in the Ethiopian context, studies have recommended training health workers on the essentials of immunization and interpersonal communication to improve caregiver understanding and continued use of services[21].

Together, these findings imply that caregivers’ practical constraints and health workers’ communication challenges interact to limit the quality of child vaccine communication. Caregivers’ urgency to complete clinic visits quickly and return to responsibilities can limit their ability to absorb information; at the same time, health workers may not feel equipped, either linguistically or through sustained training, to provide clear, caregiver-centered communication.

Interpersonal level factors

At the interpersonal level, we identified key barriers arising from interactions between health professionals and caregivers that hinder effective child vaccine communication. Caregivers’ limited time for discussion, administrative conflicts related to documentation (child birth registration as a requirement for getting vaccination services), and disruptions caused by the COVID-19 pandemic all influenced the quality and depth of dialogue during immunization encounters.

First, caregivers’ time constraints emerged as a significant barrier to meaningful interaction with health workers. Despite efforts by providers to offer education during home visits and clinic appointments, caregivers often prioritized quick vaccine administration so that they could return to their homes or workplaces. As one health worker explained: “They did not have enough time to sit and talk with us about their family’s health. They push us to administer the vaccine/s and go back to their home or workplace” (health worker number 9).

This finding is consistent with research showing that time pressure in health consultations often limits opportunities for in-depth vaccine communication, with providers feeling compelled to be efficient at the expense of fully addressing questions or concerns. For example, studies on vaccine communication in other settings have found that high throughput environments and time constraints reduce the ability of providers to explore caregivers’ information needs, potentially undermining caregivers’ understanding and confidence in vaccines[22].

Moreover, limited time during clinic or home visit interactions can weaken the role of communication as a tool for promoting routine vaccine uptake. Qualitative evidence from Ethiopian communities emphasizes that poor interpersonal communication, including rushed encounters and inadequate explanation, is a recognized barrier to caregiver engagement with immunization services[17].

A second interpersonal barrier was conflict between mother and health professional resulting from administrative requirements, specifically the demand for a birth certificate before vaccination. Caregivers reported that obtaining the document was difficult, particularly when both parents were required to appear in person, leading to tense interactions with health workers. One participant described this experience: “When we are asked to have birth certificate to vaccinate our children, we quarreled with the nurses. It is impossible to get it unless both I and my husband can come in person” (focus group discussion 3, participant 2).

Such administrative obstacles can create frustration and may discourage caregivers from fully engaging with health services, particularly when requirements are perceived as unrealistic or insensitive to household realities. Although research on administrative barriers to immunization in Ethiopia is limited, broader studies have linked procedural hurdles, such as strict documentation requirements or inconvenient service policies, to reduced access and caregiver dissatisfaction[17].

Finally, the COVID-19 pandemic disrupted interpersonal communication by limiting face-to-face contact due to physical distancing measures. This reduced providers’ opportunities to counsel caregivers effectively about vaccines: “It was preached that people should keep their distance. As a result, I could not sit with mothers and communicate about child vaccines” (health worker number 1).

Global evidence shows that COVID-19 safety protocols, including distancing and reduced in-person consultations have challenged traditional provider–patient interaction patterns, weakening communication channels and potentially impacting service quality. In the context of immunization, decreased interpersonal engagement may contribute to gaps in caregiver understanding, trust, and follow-up behaviors, particularly in settings where in-person dialogue remains a primary source of health information[23].

Collectively, these findings highlight that interpersonal interactions in immunization contexts are shaped not only by the content of communication but also by practical and systemic constraints. Time limitations, administrative friction, and pandemic measures all reduce the opportunities for caregivers and health workers to engage in meaningful dialogue about the purpose, benefits, and potential concerns related to child vaccination. These barriers must be addressed alongside broader efforts to strengthen immunization programs if routine vaccine uptake and caregiver satisfaction are to be improved.

Health system-level factors

At the health system level, several structural and organizational factors were identified as barriers to effective child vaccine communication. These include facility capacity, staffing, workload, resource availability, and infrastructure, all of which shape the ability of health workers to provide thorough counseling and education to caregivers.

Workload and competing responsibilities are mentioned as the factor jeopardizing child vaccine communication at health system level. Health workers reported that performing multiple clinical and administrative tasks simultaneously limits their ability to focus on health communication. One participant emphasized: “Health communication needs a person who should freely focus and work on it regardless of having any other task. I give priority to administering vaccines for children instead of giving emphasis for health education first” (health worker number 7).

Another health worker described balancing multiple roles during home visits and clinic activities: “I was busy doing different activities related to the health insurance card renewal. I was busy and could not communicate about child vaccines with mothers” (health worker number 8).

These findings are consistent with studies in low-resource settings showing that high workload and task multiplicity reduce the time available for patient education, often prioritizing immediate clinical tasks such as vaccination over counseling[24]. When health workers are overburdened, the delivery of preventive health education suffers, which can reduce caregivers’ understanding and uptake of immunization services.

Participants also highlighted a shortage of communication materials, including brochures, flipcharts, vaccine cards, and audiovisual equipment, which hampers effective communication: “Sufficient education materials to communicate about vaccines are needed, depending only on oral descriptions made my effort ineffective” (health worker number 4).

This finding aligns with evidence that availability of visual aids and educational materials enhances caregiver comprehension and engagement in vaccination programs[25]. In contrast, lack of such resources forces health workers to rely solely on verbal explanations, which may be less effective in ensuring that caregivers understand the purpose, schedule, and potential side effects of vaccines[17].

Transportation and infrastructure challenges have been identified in the study as the barrier that hamper child vaccine communication. Poor road infrastructure and limited transportation options further reduce the time available for health education and vaccination services. One health worker explained: “In some places, there is road unavailability. I go on foot which takes increased travel time. I would have sufficient time to stay with mothers in a settled manner if there were cars” (health worker number 1).

This finding echoes studies showing that geographical and transport barriers in low-resource settings impede service delivery, forcing health workers to reduce time spent with caregivers, sometimes leading to rushed consultations[26]. Infrastructure constraints not only limit access but also compromise the quality of interactions between providers and caregivers.

Overall, health system–level barriers demonstrate that structural and organizational constraints can significantly reduce the effectiveness of vaccine communication, even when health workers are motivated and knowledgeable. Heavy workloads, multitasking, inadequate educational materials, and transportation challenges interact to limit opportunities for caregiver counseling and engagement. Addressing these systemic barriers is critical for improving the quality of immunization services and promoting routine vaccine uptake. Potential strategies include dedicated staff for health communication, provision of adequate educational materials, improved transport infrastructure, and updated task allocation to allow health workers sufficient time for counseling[27].

Community-level factors

At the community level, effective child vaccine communication is influenced by the degree of community participation and support. In this study, limited involvement of community volunteers and political instability were identified as key barriers that undermine health education and vaccination promotion efforts.

Participants reported that collaboration with community health volunteers, such as the Women's Development Army, had previously enhanced maternal and child health services. Volunteers played a critical role in health counseling and promotion of routine vaccination, with one volunteer responsible for providing health services to 30 households. As a health worker explained: “Their involvement has a noticeable positive change in maternal and child health. However, it is not working with us because the members are recognized as politicians, and they are not getting different incentives unlike the trend before” (health worker 6).

This highlights that the absence of active community volunteers reduces the reach and effectiveness of health promotion efforts, which is consistent with evidence from low-resource settings where community health workers and volunteers are key facilitators of vaccination uptake[28]. When incentives are removed or political recognition interferes with volunteer engagement, the capacity to educate caregivers and support maternal follow-up diminishes, potentially contributing to lower immunization coverage[29].

We found that political instability hindered child vaccine communication in the study area. It further disrupted collaboration with local leaders, which negatively affected health workers’ ability to conduct outreach and community counseling. One participant noted: “Before the escalation of political instability, we were working with kebele leaders, they stopped going with us to the community because they fear their opponents. For this reason, we are not freely going to the community and counsel them about their child’s health” (health worker number 6).

This demonstrates that fear associated with political conflict reduce community-level support, limiting the opportunities for health workers to provide vaccine education and counseling. Similar findings in other contexts show that political unrest can interrupt health programs by restricting mobility, weakening community networks, and reducing trust between health workers and community members[30]. The inability to engage with local leaders and volunteers compromises not only outreach but also caregivers’ access to timely and accurate vaccine information.

Together, these findings signify that sustaining community-level engagement is critical for effective vaccine communication. Health systems should consider strategies to maintain the motivation and involvement of community volunteers, including appropriate incentives, recognition, and depoliticized structures for participation. Strengthening partnerships with local leaders and ensuring continuity of community engagement, even in contexts of instability, is essential for promoting routine immunization and maternal-child health services.

Policy-level factors

The findings under this theme highlight how national and regional policies, governance structures, and broader health system organization shaped the environment in which routine child immunization services were delivered. Participants’ accounts point to multiple system-level barriers that constrained immunization promotion and service delivery, illuminating both the direct and indirect effects of policy decisions and health system functioning.

In line with policy level factors, pandemic-driven reprioritization of services, such as COVID-19 pandemic, has a pivotal disruption in health sector priorities: “The occurrence of COVID-19 pushed me to abandon routine child immunization and other public health services… instead of promoting child vaccines, every health professional’s attention was on the care and cure of the individuals caught by the pandemic” (health worker number 1).

This idea corroborates a system-wide shift in focus from preventive services toward urgent pandemic response. Such reprioritization is consistent with evidence from other settings where routine immunization was disrupted as health workers were reallocated to COVID-19 activities, and routine services were postponed or deprioritized. For example, studies across multiple countries documented that healthcare worker deployment to pandemic relief and concerns about COVID-19 risk reduced the delivery and uptake of routine immunization services. Interruptions in staffing, service availability, and client communication during the pandemic were common contributors to reduced routine vaccination coverage[31].

Although some quantitative studies in Ethiopia found mixed statistical effects of COVID-19 on immunization coverage, qualitative evidence underscores how the pandemic influenced provider behavior, client access, and service emphasis[32]. The account from this study’s participants thus adds local qualitative depth to these broader patterns, showing how policy-driven crisis response can inadvertently weaken preventive services like child immunization when health systems lack surge capacity.

Misaligned administrative requirements as structural barriers, specifically the linkage between child birth registration requirements and receipt of vaccination services, is another policy-related barrier: “Even if important, a birth certificate should not be connected with child vaccination. The nurses were told not to provide vaccines for children who do not have a birth certificate. To have the certificate, there should be a renewed kebele ID of the father and the mother” (focus group discussion 3, participant 2).

This highlights how administrative policies can unintentionally create barriers to vaccination services when they intersect with service delivery. Although birth registration has value for legal identity and population planning, requiring it as a precondition for immunization can delay or deter caregivers from presenting for vaccination, especially when obtaining the documentation involves additional logistical or time burdens.

While specific studies on birth certificate requirements and immunization access in Ethiopia are limited, a previous study found a contrasting result that suggested that vital statistics and civil registration benefits child immunization in providing population estimates to target vaccination efforts and monitor the reach of immunization programs[33].

Additionally, broader health systems research emphasizes that supply-side structural factors, including overly rigid service policies, documentation requirements, and poor coordination across government sectors, can undermine vaccination services. Poor integration of health services and administrative systems can exacerbate this problem[17]. This finding underscores the importance of policy alignment across sectors to ensure that essential preventive health services like immunization are accessible without unnecessary bureaucratic hurdles.

The other policy-related barrier influencing child vaccine communication is excessive workload, reducing the health professionals’ ability to engage in effective vaccination communication: “The standard for one health extension worker (HEW) is 500 households… in practice, I have been assigned up to 1000 households… I spent a short time educating the family about child immunization… I could not effectively promote immunization through communication” (health worker number 7).

This finding demonstrates that health workforce allocation policies directly influence the effectiveness of child vaccine communication. HEWs reported being responsible for a number of households far exceeding national standards, which substantially reduced the time available for health education and immunization promotion.

In Ethiopian health extension programs, HEWs are mainly expected to serve a defined number of households. In theory, standards suggest one HEW should cover around 500 households (about one kebele) and conduct outreach, such as health education and immunization promotion at health facilities and in the community’s homes[34].

However, in practice, assignment to more households than recommended extends the time needed to complete home visits and reduces opportunities for quality engagement about vaccine communication and other preventive services. Evidence suggests that workload impacts preventive health service quality. When HEWs manage far more households than planned, the time available for each home visit decreases, making it difficult to spend adequate time on counseling and vaccination promotion, as opposed to simply completing household rounds. This leads to abbreviated communication about the benefits and schedule of immunization. This aligns with qualitative insights where staff describe spending short, rushed periods with families because of limited time available per household[34].

Time-motion studies in Ethiopia show that while HEWs provide health counseling services, the proportion of time spent directly on such activities is relatively low compared to all their duties, signaling that under heavy workload conditions, health promotion tasks (including vaccination education) may be compromised[35].

CONCLUSION

This study aimed to explore the factors that hinder child vaccine communication practice in the town of Gondar. The findings highlight that child vaccine communication is negatively affected by multi-level factors, including individual, interpersonal, health system, community and policy level factors that interact with each other. Key barriers, such as insufficient training, limited communication materials, and language-related challenges, reduce the effectiveness of existing immunization communication interventions. These findings imply that efforts to improve child vaccination outcomes should go beyond making interventions that focus only on one factor; rather, attention should be paid to design integrated strategies, including strengthening health worker communication skills through targeted training, ensuring the availability of linguistically appropriate communication materials, and improving health system support. Policy makers, program implementers and health administrators should address structural constraints, like allocation of health workers based on their professional roles, addressing security issues and coordination and working with the health system. Adopting such a holistic approach is essential to foster consistent and meaningful dialogue on child vaccines and to enhance vaccination uptake.

ACKNOWLEDGEMENTS

The authors would like to express their heartfelt gratitude for those who contributed to this research article.