Beyond the Needle: Understanding Parental Refusal and Pathways to Childhood Vaccine Equity in Akara IDPs, Hargeisa, Somaliland— Advancing SDGs 3, 4, 5, 10 & 16 in Humanitarian Settings

Beyond the Needle: Understanding Parental Refusal and Pathways to Childhood Vaccine Equity in Akara IDPs, Hargeisa, Somaliland— Advancing SDGs 3, 4, 5, 10 & 16 in Humanitarian Settings | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the Needle: Understanding Parental Refusal and Pathways to Childhood Vaccine Equity in Akara IDPs, Hargeisa, Somaliland— Advancing SDGs 3, 4, 5, 10 & 16 in Humanitarian Settings Ahmed A. Keise, Omar M. Omar, Hanaan Hussein Hirsi, Warda Sh. Khalif, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7947813/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Childhood vaccination coverage in Somaliland is one of the lowest in the world, according to the Somaliland Health and Demographic Survey 2020. Only 13% of children aged 12–23 months were fully vaccinated, with 68% having received no immunizations. Despite the availability of routine immunizations, parental refusal and vaccination reluctance continue to impede uptake. To yet, no qualitative studies have addressed the underlying causes for vaccine refusal among parents in Hargeisa. The purpose of this study is to better understand these characteristics and propose context-specific solutions for increasing immunization rates. Methods A qualitative study was conducted using five face-to-face focus group discussions with 31 parents living in the Akara IDP settlement, Ahmed Dhagah District, Hargeisa. Thematic analysis was used to extract essential patterns and insights from participant responses. Results Parental refusal was affected by a variety of factors, including fear of side effects, a lack of awareness of vaccine benefits, previous unfavorable encounters with health personnel, and strong community attitudes and social norms. Physical availability to vaccines was not a big barrier. Participants emphasized the need of culturally relevant communication, regular outreach activities, and the involvement of trusted community figures in addressing vaccine concerns and building confidence. Conclusion Vaccine refusal in IDP camp is driven by fear, misinformation, and social influence rather than a lack of access. Customized public health methods centered on education, trust-building, and respectful participation are critical for increasing childhood immunization coverage in such contexts. Introduction Vaccination is widely considered one of the greatest achievements in public health( 1 , 2 ). Vaccination programs are one of the best and most successful ways to keep people healthy and prevent serious illness and death from diseases that can be passed from person to person. Only clean water is more important than vaccines in keeping people safe. But now, some diseases that used to be rare are coming back because some parents are choosing not to vaccinate their children. Research in the US shows that these decisions to refuse vaccines often happen in certain groups of people, which is why there are more outbreaks of these diseases in those areas( 3 ) Vaccination programs have contributed significantly to the decline in mortality and morbidity from various infectious diseases. Most notably, vaccination has been credited with the elimination of polio in the Americas and eradication of smallpox worldwide( 4 , 5 ) Despite this, millions of children around the world do not receive the recommended vaccines( 6 )In 2020, 23 million children missed out on routine child- hood vaccinations, the highest number since 2009 and 3.7 million higher than in 2019 ( 7 , 8 ). Poor vaccination coverage leads to outbreak of diseases ( 9 )In January and February 2022, more than 17,338 cases of measles were reported around the world, which is higher than the 9,665 cases reported during the same months in 2021( 10 ) In 2018, England and Wales saw a big rise in confirmed measles cases, with 991 cases reported, up from 284 cases in 2017.( 11 ) These developments led to the UK losing its ‘measles-free’ status with the World Health Organization (WHO) barely three years after the measles virus was eliminated from the country ( 12 ). Concern from parents, decision-makers, and the media regarding the safety of recommended immunizations has increased in recent years due to debates regarding the links between vaccines and autism, vaccine ingredients, and the number of injections given during a single office visit or during the first years of life ( 13 – 15 ) An increasing number of people question the safety of vaccines, seek alternative measures such as natural methods and antibiotic use and sometimes delay or refuse vaccination( 16 ) The main reasons for low rates of childhood vaccinations include difficulty in accessing vaccination services, missed chances to get vaccinated during health check-ups, and concerns or reluctance about vaccines( 17 ). Vaccine hesitancy is considered an important driver contributing to low levels of vaccination coverage in many settings( 18 , 19 ). Vaccine hesitancy is defined as a motivational state of being conflicted about or opposed to vaccination ( 20 ). It is affected by things like complacency, where a person doesn't think they need or care about the vaccine, confidence, which is how sure someone is that the vaccine works, and convenience, which means how easy it is for them to get the vaccine( 21 – 23 ). In Somaliland immunization coverage remains among the lowest globally according SLDHS 2020. Only 34% of children under five had got any childhood immunizations, according to the findings( 24 ). Qualitative studies in Somalia, such as focus groups in Galkayo District, identified systemic barriers like inadequate health worker training, vaccine shortages, and community misinformation as drivers of low uptake. Research in Somali immigrant communities in the U.S. revealed measles vaccination rates as low as 54% due to fears of autism and distrust in medical authorities( 25 ). Existing studies in Somaliland have not fully utilized qualitative study employed focus groups to analyze parental vaccination refuse. This study aims to address this gap by conducting focus group discussions with parents in Akara IDPs to identify context-specific barriers. The findings will inform tailored interventions to improve vaccine acceptance, leveraging community leaders and culturally sensitive communication strategies. Materials and Methods Study area and setting The study was carried out in Somaliland, a self-declared post-conflict nation in the Horn of Africa. Hargeisa is the capital city. With a combined wet and dry climate, the nation spans 176,119.2 square kilometers. Awdal, Marodijeh, Sahil, Togdheer, Sanaag, and Sool are the six geopolitical regions that make up Somaliland. There are an estimated 4.2 million people living there, who are Muslims and members of Somali ethnic groupings.( 26 ) The study was conducted in Hargeisa, the capital city of Somaliland and its surrounding districts and villages. The research was carried out in community spaces within the Akara IDP settlements in Ahmed Dhagah District in Hargeisa. Study Design, sample size and participant recruitment The study employed an exploratory qualitative study design to explore the factors that influence parents’ decisions to refuse vaccination for their children. Individuals who supported or believed in vaccination, as well as those who opposed it or had not vaccinated their children who is able to provide representative and relevant information were selected purposively by maximum variation sampling method. The total sample of 31 participants was recruited in the study. The sample size was determined based on saturation of information. Data Collection and tool The data was collected from May to August, 2024. Each participant signed informed consent was obtained from the participants prior to data collection. A semi-structured interview guide was developed to explore the themes of parental refusal and pathways to childhood vaccine equity. This guide was used to facilitate all focus group discussions. Focus group discussions were conducted in face-to-face with parents at Akara IDPs in Hargeisa Somaliland. We conducted included five FGD including five to eight individuals. To enable all members to actively participate in the discussion, an environment conductive to open dialogue was created by composing of focus groups of participants with similar sociodemographic characteristics, shared relevant experience and residing in the same village. Each FGD was facilitated by pair of trained students from team of 10 under supervision of three senior researchers. Ethical considerations Ethics approval of this study was obtained from Public Health Department at The University of Hargeisa with the Ref: CMHS/UoH/145 − 25. All study participants were informed about the aim, purpose, and benefits of the study and that participation was voluntary. Data Management and Analysis All the FGDs were audio recorded and transcribed verbatim. Experts then translated the information from the local Somali language transcription into English. Other experts and investigators reviewed the translation data on the Word document and transcripts several times and double-checked their accuracy. The data were analyzed using Nvivo version 11 to maintain a close connection with the data and to better understanding of the reasons behind parental refusal of childhood vaccination. The process followed an inductive approach to thematic analysis. All transcripts were printed and thoroughly read and re-read by the lead coder for familiarization. Initial coding done to identify key concepts directly from the participants’ words. To enhance the trustworthiness and consistency of the analysis, a second researcher reviewed and coded a portion of the transcripts. The two investigators then compared their coding and worked together to refine the coding framework until they reached agreement. The main themes were ultimately derived from this refined coding framework, ensuring they were grounded in the data gathered during the focus group sessions. Results Demographic of Participants In total, we interviewed 5 groups. First week, we interviewed 3 groups, each consisting of 5 people, making a total of 15 participants. Next week, we interviewed 2 groups, each consisting of 8 people. These participants included both those who opposed vaccination or had not vaccinated their children, as well as those who supported or believed in vaccination. All participants where mothers aged between 45 years old to 20 years old. Most mothers had 6 to 7 Children. The results were categorized five themes, general perception, reason for refusal, Access and Barriers of vaccination, Trust in health care providers and the health system, Community influence and social norms, and potential strategies to improve vaccine uptake General perception and Awareness of Vaccine Theme one looked at how parents make decisions about vaccinating their children. Many factors played a role in whether parents chose to refuse some or all vaccines. These factors included how parents viewed their child's body and immune system, how they saw the risk of diseases compared to the risks of vaccination, their belief in how well vaccines work, the idea that getting sick might have some benefits, past bad experiences with vaccinations, and the influence of their social surroundings. The participants were asked to mention some positive and negative aspects of the immunization program in general. Participants agreed that positive aspect of the immunization program is a protection for children and helps to prevent serious diseases that could harm for children health, another positive is that is freely available, another positive is vaccines protect against illnesses like Measles and polio. “When I had my first child, I didn’t have any information about child vaccination, so I refused to immunize my baby. I was afraid and uncertain because no one had explained to me how vaccines work or why they are important. Later, after receiving proper information from health workers about the benefits of immunization and how it protects children from serious diseases, I understood its importance. Since then, I have ensured that all my other children are fully immunized.” — 30-year-old mother “I believe in vaccination because I have seen how it protects children from many serious diseases. When a child is immunized, the body becomes stronger and can fight infections more easily. Even if the child gets sick, the illness does not reach a severe stage — it only affects them mildly. That is why I always make sure my children receive all their vaccines on time.” — 25-year-old mother Another participant said that vaccines could cause their children to develop high fever and edema. Another negative aspect that participants agreed vaccines could lead to paralysis in their children, giving the example of a child who become ill after being vaccinated. “When I had my first child immunized, he became severely sick afterward, and I was very frightened. At that time, I was living with older people in my community who strongly believed that vaccines cause illness in children. They convinced me that my child’s sickness was because of the vaccine, so I lost trust in immunization and decided not to vaccinate my other children for the next five years.” — 23-year-old mother Reasons for vaccine Refusal This theme explores the personal reasons why some parents hesitate or choose not to vaccinate their children. It aims to understand their fears, misconceptions, and past experiences that shape these decisions. Many parents expressed anxiety about possible side effects, long-term health impacts, or past negative experiences with vaccines or healthcare providers. Others mentioned that their decision was influenced by advice from family members, neighbors, or community elders who discouraged vaccination. Some parents also shared deep mistrust toward vaccines, believing that the vaccine itself could cause illness rather than prevent it. Overall, fear of side effects and misinformation were the most common reasons for vaccine refusal among parents. “I believe that the vaccine itself is a disease and that it causes children to become sick after receiving it. When my first child was vaccinated, he became ill afterward, and I immediately thought it was because of the vaccine. Many people around me, especially elders in my community, also told me that vaccines bring sickness instead of preventing it. Hearing this from people I trust made me more afraid, so I decided not to immunize my other children. I still worry that vaccines might harm them rather than help them.” — 40-year-old mother “I honestly do not understand the importance of vaccination or what specific diseases it protects children from. No one ever explained to me how vaccines work or why they are necessary for a child’s health. When health workers come to our area, they just give the injection without much explanation, so I felt uncertain and scared. Because of that, I was not confident enough to take my children for vaccination, as I didn’t know what was being given or what the benefits were.” — 38-year-old mother “My decision not to vaccinate my children was influenced by the opinions of my family members and neighbors who strongly oppose vaccination. They often said that vaccines are dangerous and can harm children rather than protect them. Since I trusted their advice and did not have much information from health workers, I started believing what they said. Their discouragement made me afraid to take my children for immunization, even though I sometimes wondered if it might actually help them.” — 21-year-old mother “I refused to vaccinate my child because I was worried about the side effects that immunization can cause, such as high fever, swelling, and allergic reactions. I have seen some children in my neighborhood become sick after vaccination, which made me very anxious. I felt that it was safer to avoid the vaccine than to risk my child becoming seriously ill. No one clearly explained to me that these reactions could be normal or temporary, so I remained fearful and decided not to vaccinate.” — 30-year-old mother Access and Barriers to Vaccination This theme explores the barriers that parents may face when accessing vaccines, even in a community where most have relatively easy access. Maternal and Child Health (MCH) centers are located nearby, and frequent outreach programs often provide vaccines directly to households, making immunization services widely available. Despite this accessibility, some parents still encounter challenges that affect their vaccination decisions. These include social pressures, judgment from family or community members, or concerns about being criticized for their choices. Logistical barriers, such as occasional vaccine shortages, inconvenient clinic hours, or negative interactions with health workers, can also discourage parents from vaccinating their children. This theme highlights that access alone is not enough; understanding parents’ experiences, perceptions, and the social context is essential to improving vaccination uptake. “I really don’t face any major obstacles when it comes to vaccinating my children because we have a health center nearby. We don’t have to travel long distances to access services, and this makes it much easier for me to ensure my children receive their vaccines on time. Having the health center close by gives me peace of mind and confidence in the immunization process.” — 36-year-old mother “Even if I don’t personally go to the Maternal and Child Health (MCH) center, they provide door-to-door vaccination outreach programs. These programs are very convenient because the health workers come directly to our homes, and I don’t have to worry about missing any vaccines for my children.” — 25-year-old mother “One time, I had an argument with the healthcare providers at the MCH center, and after that experience, I stopped going there. Now, I only rely on the door-to-door vaccine programs. The problem is, if I’m not at home when the health workers come, my child sometimes misses the vaccines, which worries me a lot.” — 21-year-old mother “In our area, vaccines are the only healthcare service that we receive consistently. They are always available, and we never run out, which makes it easier for parents like me to keep up with our children’s immunization schedule without much difficulty.” — 29-year-old mother Community Influence and Social Norms Parents’ decisions about vaccinating their children are not made in isolation; the opinions and beliefs of the wider community play a significant role. This theme explores how parents’ vaccination choices are shaped by the attitudes, actions, and guidance of people around them. It considers whether most families in the community actively support vaccination or if there is widespread hesitation. It also examines whether parents feel encouraged and supported or criticized and judged by others when making these decisions. Family members, local health workers, religious leaders, and community elders can all influence parents’ choices, either by expressing doubts about vaccines or by reinforcing confidence in immunization. Understanding these social dynamics helps explain how vaccines are accepted or rejected, highlighting the importance of community norms, trusted voices, and collective beliefs in shaping health behaviors. “I didn’t know much about vaccinations at first, but when I saw many other mothers in my community going to the Maternal and Child Health (MCH) center with their children, I decided to follow them. Seeing others take their children for immunization gave me confidence and encouragement. It made me feel that it must be important, and that is why I started vaccinating my children as well.” — 33-year-old mother “I stopped vaccinating my children because of the influence of my older relatives with whom I share a house. They told me that the reason my first child became sick after vaccination was the vaccine itself and that it could cause diseases in children. Hearing this from people I trust made me afraid and lose confidence in immunization, so I decided not to vaccinate my children for some time.” — 27-year-old mother Most mothers in the IDP community were illiterate, so it is not surprising that they heavily rely on the perspectives and advice of their family, neighbors, and community members when making decisions about vaccinating their children. Strategies to Improve Uptake To improve vaccination coverage among children, several strategies were suggested by parents. Many mothers preferred home-based or community outreach services because these approaches save time and effort while providing a more comfortable and supportive environment. Respectful and empathetic communication from health workers during these visits helps build trust and confidence. In addition, providing culturally relevant education, using simple and clear language, and involving trusted community figures such as elders, religious leaders, or local health volunteers encourages open discussion and greater acceptance of vaccines. These strategies are particularly important because many mothers have limited knowledge about vaccines and may hold negative perceptions based on misinformation or advice from others. Tailoring interventions to address these concerns can increase understanding, trust, and ultimately, vaccine uptake. “I have ten children, and in the past, I used to miss a lot of vaccines because the Maternal and Child Health (MCH) center or health facility was far from my home. I didn’t have anyone to take care of my other children while I was away, so it was very difficult to bring them for immunization. This made me feel frustrated and worried that my children were not fully protected. Recently, the community outreach program has been visiting our area occasionally, and it has solved this problem for me. Now, the health workers come directly to our homes, and I can get my children vaccinated without worrying about leaving the others alone.” — 45-year-old mother Discussion This study seeks to find out why some parents in Akara IDPs, Hargeisa, refuse to vaccinate their children. We listened to understand their true ideas and beliefs. The findings revealed that vaccine refusal is often motivated by fear, uncertainty, and community influence rather than a lack of access. Many parents had incorrect information or previous negative experiences that influenced their belief in immunizations. The first theme revealed that parents had conflicting opinions on vaccination. Some people believed immunizations were beneficial and protected their children from dangerous diseases such as measles and polio. This is confirmed by systematic literature Review of the Factors That Affect How Parents Think and Act Regarding Routine Childhood Vaccination in Africa ( 27 ), which found that parental education and awareness boost vaccine acceptability. Others said that immunizations made their children unwell or produced complications such as fever or edema. One mother even though the vaccine itself was a sickness. These findings are consistent with past studies conducted in Somali immigrant communities in the United States, where many parents were concerned that immunizations caused autism ( 28 ). In theme two, several parents expressed concern about potential negative effects. Some have seen or heard of a child becoming terribly ill after being vaccinated. This anxiety led them to avoid vaccination. These types of concerns are not new. According to a WHO reports ( 29 , 30 ), vaccination hesitancy is frequently triggered by concerns about side effects, a lack of trust in health-care systems, and an abundance of bad material on social media or in the community. In our situation, several women had no compelling reason; they were just unsure or swayed by neighbors or relatives. The third theme, concerning access, revealed something interesting. Many parents reported living near health clinics or receiving immunizations through door-to-door initiatives. So access was not the primary issue for them. However, minor hurdles such as fighting with health professionals or not being at home during outreach visits still resulted in children missing immunizations. This study is significant because it demonstrates that even when services are available, trust and communication are more crucial. Similar findings were reported in Ethiopia and Nigeria, when mistrust of health personnel resulted in missed immunizations. The fourth theme explored how much community pressure and norms influence vaccination decisions. Many mothers stated that they made decisions based on what others in their household or area said. Some people followed friends to health clinics without understanding much, while others stopped getting immunizations because elders informed them, they were harmful. This confirms what researchers have shown in similar settings: peer and family influence is a significant impact in vaccine decisions( 31 ). When many people in the community believe vaccines are harmful, it becomes difficult for individuals to challenge that opinion. The fourth determined investigated how community pressure and norms influence vaccination decisions. Many women reported that they made decisions based on what others in their family or community said. Some people followed acquaintances to health clinics without comprehending much, while others stopped obtaining vaccines after elders warned them, they were detrimental. This confirms what researchers have shown in similar settings: peer and family influence has a major impact on vaccine decisions ( 31 , 32 ) When a large number of people in a community believe vaccines are hazardous, it becomes difficult to question that belief. Conclusion This study demonstrates that vaccine refusal extends beyond issues of access—it is deeply rooted in trust, knowledge, cultural beliefs, and past experiences. While our findings align with evidence from low-income, displaced, and migrant communities across Africa, Asia, and Western countries, this study stands out for amplifying the authentic voices of internally displaced persons (IDPs) in Somaliland, where local research remains scarce. The insights gained provide a critical foundation for designing context-specific interventions. Health workers should prioritize empathy, clear communication, and collaboration with community and religious leaders to foster vaccine confidence. Furthermore, outreach programs must be sustained and strategically planned to ensure consistent follow-up and prevent missed opportunities for immunization. Limitations It was conducted in a single IDP community, so the findings may not represent other settings in Somaliland. The small sample size and limited number of focus groups may have excluded important views, especially from fathers and younger parents. Social desirability bias could have influenced participants’ responses, and some views reflected perceptions rather than verified facts. Translation from Somali to English may have caused minor loss of meaning. Recommendations To enhance childhood vaccine uptake, it is recommended that health authorities expand and reinforce door-to-door outreach activities, since many mothers found these services more accessible and convenient than visiting health clinics. Health education should be delivered in simple, culturally appropriate language by trusted community members such as elders or religious leaders in order to instill confidence and correct misinformation. Training healthcare workers in respectful communication is critical, as negative interactions have been reported to discourage future visits. Addressing common fears about side effects through clear, supportive explanations, and using real-life success stories from local mothers who changed their views about vaccination, can also help reduce hesitancy and promote acceptance across the community. Declarations Author Contribution A.A.K. and O.M.O. conceived and designed the study. H.H.H., W.S.K., M.M.A., M.H.O., M.F.A., F.A.D., A.I.H., A.M.M., A.H.A., S.K.C., A.A.M., and M.A.H. participated in data collection and transcription. O.M.O. and K.S.O. conducted data analysis and thematic coding. A.A.K., O.M.O., and S.A.A. interpreted the findings and drafted the manuscript. M.A.H., and S.A.A. critically reviewed and revised the manuscript for intellectual content. All authors contributed to the final version, approved the manuscript, and agreed to be accountable for all aspects of the work. References Centers for Disease Control. Ten Great Public Health Achievements—United States, 1900–1999. 1999. Centers for Disease Control. 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Khalif","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Warda","middleName":"Sh.","lastName":"Khalif","suffix":""},{"id":542206988,"identity":"727a4fb1-4030-435b-827d-0dc1f17c74e8","order_by":4,"name":"Muna Mahamed Abdikadir","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Muna","middleName":"Mahamed","lastName":"Abdikadir","suffix":""},{"id":542206989,"identity":"2921ca7b-ee10-4487-8e1b-974821a20d6c","order_by":5,"name":"Mawlid Hassan Omer","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Mawlid","middleName":"Hassan","lastName":"Omer","suffix":""},{"id":542206990,"identity":"8e138d15-9e50-4ffd-8206-13a88c6790ed","order_by":6,"name":"Mohamed Farah Adare","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Farah","lastName":"Adare","suffix":""},{"id":542206991,"identity":"3ee73d8d-88bc-479f-ba0c-f4b93e388785","order_by":7,"name":"Farah Ahmed Daud","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Farah","middleName":"Ahmed","lastName":"Daud","suffix":""},{"id":542206992,"identity":"cb9afa3d-d17c-4ebf-910c-9b8aee2a67b9","order_by":8,"name":"Abdirahman Ibrahim Hussein","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Abdirahman","middleName":"Ibrahim","lastName":"Hussein","suffix":""},{"id":542206993,"identity":"bf829e9d-05d7-45de-bcc6-9a3bcbfffba6","order_by":9,"name":"Amal Mahamed Muhumed","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Amal","middleName":"Mahamed","lastName":"Muhumed","suffix":""},{"id":542206994,"identity":"0cd5a9fd-d113-435f-9269-477bb8967020","order_by":10,"name":"Amina Hassan Abdi","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Amina","middleName":"Hassan","lastName":"Abdi","suffix":""},{"id":542206995,"identity":"427879eb-5c51-4155-89a2-dc88b4335b77","order_by":11,"name":"Sundus Kh. Cabdi","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Sundus","middleName":"Kh.","lastName":"Cabdi","suffix":""},{"id":542206996,"identity":"9f853f3c-0f38-456f-9dc5-0dce99f6caa7","order_by":12,"name":"Abdishakur Ahmed Mohamed","email":"","orcid":"","institution":"University of Hargeisa","correspondingAuthor":false,"prefix":"","firstName":"Abdishakur","middleName":"Ahmed","lastName":"Mohamed","suffix":""},{"id":542206997,"identity":"faa86255-aac8-49cb-b0c2-7566e0b7afa7","order_by":13,"name":"Mohamed Abdinasir Hashi","email":"","orcid":"","institution":"Haramaya University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Abdinasir","lastName":"Hashi","suffix":""},{"id":542206998,"identity":"6468ed59-4fb6-40a5-afdf-8fbd8e82233b","order_by":14,"name":"Kayse Sacad Osman","email":"","orcid":"","institution":"National Cheng Kung University","correspondingAuthor":false,"prefix":"","firstName":"Kayse","middleName":"Sacad","lastName":"Osman","suffix":""},{"id":542206999,"identity":"9d9f728f-53df-4db0-9121-e891ba9db149","order_by":15,"name":"Saad Ahmed Abdiwali","email":"","orcid":"","institution":"Pan African University Life and Earth Sciences Institute (including Health and Agriculture)","correspondingAuthor":false,"prefix":"","firstName":"Saad","middleName":"Ahmed","lastName":"Abdiwali","suffix":""}],"badges":[],"createdAt":"2025-10-27 10:54:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7947813/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7947813/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95542029,"identity":"9558ca51-b54b-4f4f-bce3-c55f81b9ef6a","added_by":"auto","created_at":"2025-11-10 11:41:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52409,"visible":true,"origin":"","legend":"","description":"","filename":"BeyondtheNeedleUnderstandingParentalRefusalandPathwaystoChildhoodVaccineEquityinAkaraIDPsHargeisaSomalilandAdvancingSDGs3451016inHumanitarianSettings1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/decc24fbf4930f4c6270ce97.docx"},{"id":95654310,"identity":"53fc49da-6bcf-4f2b-a91e-51c1d5a8f077","added_by":"auto","created_at":"2025-11-11 16:10:58","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15331,"visible":true,"origin":"","legend":"","description":"","filename":"bedfb67c14274266b88e285d994153c1.json","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/7a40b6c1184d929514fbc917.json"},{"id":95542030,"identity":"e097b305-7b8f-48f5-ac7a-ce6f1cffe387","added_by":"auto","created_at":"2025-11-10 11:41:57","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75463,"visible":true,"origin":"","legend":"","description":"","filename":"bedfb67c14274266b88e285d994153c11enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/e785a9251ee697e97c045c19.xml"},{"id":95654115,"identity":"4cf62447-386e-4ced-8768-e93be502aeb5","added_by":"auto","created_at":"2025-11-11 16:09:45","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71357,"visible":true,"origin":"","legend":"","description":"","filename":"bedfb67c14274266b88e285d994153c11structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/cfa782be4032d7e5182c8155.xml"},{"id":95542033,"identity":"7739124d-2889-460b-8784-cb20fb048e5d","added_by":"auto","created_at":"2025-11-10 11:41:57","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85436,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/6cf76043e78876020e31accd.html"},{"id":105368237,"identity":"ad46072a-c5c0-4076-bb29-693e6d9fa747","added_by":"auto","created_at":"2026-03-25 08:58:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":688607,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7947813/v1/c61e76bb-4c4a-43da-a4b5-bcd09e17474c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the Needle: Understanding Parental Refusal and Pathways to Childhood Vaccine Equity in Akara IDPs, Hargeisa, Somaliland— Advancing SDGs 3, 4, 5, 10 \u0026 16 in Humanitarian Settings","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVaccination is widely considered one of the greatest achievements in public health(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Vaccination programs are one of the best and most successful ways to keep people healthy and prevent serious illness and death from diseases that can be passed from person to person. Only clean water is more important than vaccines in keeping people safe. But now, some diseases that used to be rare are coming back because some parents are choosing not to vaccinate their children. Research in the US shows that these decisions to refuse vaccines often happen in certain groups of people, which is why there are more outbreaks of these diseases in those areas(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Vaccination programs have contributed significantly to the decline in mortality and morbidity from various infectious diseases. Most notably, vaccination has been credited with the elimination of polio in the Americas and eradication of smallpox worldwide(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Despite this, millions of children around the world do not receive the recommended vaccines(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)In 2020, 23\u0026nbsp;million children missed out on routine child- hood vaccinations, the highest number since 2009 and 3.7\u0026nbsp;million higher than in 2019 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Poor vaccination coverage leads to outbreak of diseases (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)In January and February 2022, more than 17,338 cases of measles were reported around the world, which is higher than the 9,665 cases reported during the same months in 2021(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) In 2018, England and Wales saw a big rise in confirmed measles cases, with 991 cases reported, up from 284 cases in 2017.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) These developments led to the UK losing its \u0026lsquo;measles-free\u0026rsquo; status with the World Health Organization (WHO) barely three years after the measles virus was eliminated from the country (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Concern from parents, decision-makers, and the media regarding the safety of recommended immunizations has increased in recent years due to debates regarding the links between vaccines and autism, vaccine ingredients, and the number of injections given during a single office visit or during the first years of life (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) An increasing number of people question the safety of vaccines, seek alternative measures such as natural methods and antibiotic use and sometimes delay or refuse vaccination(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The main reasons for low rates of childhood vaccinations include difficulty in accessing vaccination services, missed chances to get vaccinated during health check-ups, and concerns or reluctance about vaccines(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Vaccine hesitancy is considered an important driver contributing to low levels of vaccination coverage in many settings(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Vaccine hesitancy is defined as a motivational state of being conflicted about or opposed to vaccination (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It is affected by things like complacency, where a person doesn't think they need or care about the vaccine, confidence, which is how sure someone is that the vaccine works, and convenience, which means how easy it is for them to get the vaccine(\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Somaliland immunization coverage remains among the lowest globally according SLDHS 2020. Only 34% of children under five had got any childhood immunizations, according to the findings(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Qualitative studies in Somalia, such as focus groups in Galkayo District, identified systemic barriers like inadequate health worker training, vaccine shortages, and community misinformation as drivers of low uptake. Research in Somali immigrant communities in the U.S. revealed measles vaccination rates as low as 54% due to fears of autism and distrust in medical authorities(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExisting studies in Somaliland have not fully utilized qualitative study employed focus groups to analyze parental vaccination refuse. This study aims to address this gap by conducting focus group discussions with parents in Akara IDPs to identify context-specific barriers. The findings will inform tailored interventions to improve vaccine acceptance, leveraging community leaders and culturally sensitive communication strategies.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy area and setting\u003c/h2\u003e\u003cp\u003eThe study was carried out in Somaliland, a self-declared post-conflict nation in the Horn of Africa. Hargeisa is the capital city. With a combined wet and dry climate, the nation spans 176,119.2 square kilometers. Awdal, Marodijeh, Sahil, Togdheer, Sanaag, and Sool are the six geopolitical regions that make up Somaliland. There are an estimated 4.2\u0026nbsp;million people living there, who are Muslims and members of Somali ethnic groupings.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The study was conducted in Hargeisa, the capital city of Somaliland and its surrounding districts and villages. The research was carried out in community spaces within the Akara IDP settlements in Ahmed Dhagah District in Hargeisa.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design, sample size and participant recruitment\u003c/h3\u003e\n\u003cp\u003eThe study employed an exploratory qualitative study design to explore the factors that influence parents\u0026rsquo; decisions to refuse vaccination for their children. Individuals who supported or believed in vaccination, as well as those who opposed it or had not vaccinated their children who is able to provide representative and relevant information were selected purposively by maximum variation sampling method.\u003c/p\u003e\u003cp\u003eThe total sample of 31 participants was recruited in the study. The sample size was determined based on saturation of information.\u003c/p\u003e\n\u003ch3\u003eData Collection and tool\u003c/h3\u003e\n\u003cp\u003eThe data was collected from May to August, 2024. Each participant signed informed consent was obtained from the participants prior to data collection. A semi-structured interview guide was developed to explore the themes of parental refusal and pathways to childhood vaccine equity. This guide was used to facilitate all focus group discussions. Focus group discussions were conducted in face-to-face with parents at Akara IDPs in Hargeisa Somaliland.\u003c/p\u003e\u003cp\u003eWe conducted included five FGD including five to eight individuals. To enable all members to actively participate in the discussion, an environment conductive to open dialogue was created by composing of focus groups of participants with similar sociodemographic characteristics, shared relevant experience and residing in the same village. Each FGD was facilitated by pair of trained students from team of 10 under supervision of three senior researchers.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003e of this study was obtained from Public Health Department at The University of Hargeisa with the Ref: CMHS/UoH/145\u0026thinsp;\u0026minus;\u0026thinsp;25. All study participants were informed about the aim, purpose, and benefits of the study and that participation was voluntary.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eData Management and Analysis\u003c/h3\u003e\n\u003cp\u003eAll the FGDs were audio recorded and transcribed verbatim. Experts then translated the information from the local Somali language transcription into English. Other experts and investigators reviewed the translation data on the Word document and transcripts several times and double-checked their accuracy.\u003c/p\u003e\u003cp\u003eThe data were analyzed using Nvivo version 11 to maintain a close connection with the data and to better understanding of the reasons behind parental refusal of childhood vaccination. The process followed an inductive approach to thematic analysis. All transcripts were printed and thoroughly read and re-read by the lead coder for familiarization. Initial coding done to identify key concepts directly from the participants\u0026rsquo; words.\u003c/p\u003e\u003cp\u003eTo enhance the trustworthiness and consistency of the analysis, a second researcher reviewed and coded a portion of the transcripts. The two investigators then compared their coding and worked together to refine the coding framework until they reached agreement. The main themes were ultimately derived from this refined coding framework, ensuring they were grounded in the data gathered during the focus group sessions.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDemographic of Participants\u003c/h2\u003e\u003cp\u003eIn total, we interviewed 5 groups. First week, we interviewed 3 groups, each consisting of 5 people, making a total of 15 participants. Next week, we interviewed 2 groups, each consisting of 8 people. These participants included both those who opposed vaccination or had not vaccinated their children, as well as those who supported or believed in vaccination. All participants where mothers aged between 45 years old to 20 years old. Most mothers had 6 to 7 Children.\u003c/p\u003e\u003cp\u003eThe results were categorized five themes, general perception, reason for refusal, Access and Barriers of vaccination, Trust in health care providers and the health system, Community influence and social norms, and potential strategies to improve vaccine uptake\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eGeneral perception and Awareness of Vaccine\u003c/h3\u003e\n\u003cp\u003eTheme one looked at how parents make decisions about vaccinating their children. Many factors played a role in whether parents chose to refuse some or all vaccines. These factors included how parents viewed their child's body and immune system, how they saw the risk of diseases compared to the risks of vaccination, their belief in how well vaccines work, the idea that getting sick might have some benefits, past bad experiences with vaccinations, and the influence of their social surroundings. The participants were asked to mention some positive and negative aspects of the immunization program in general. Participants agreed that positive aspect of the immunization program is a protection for children and helps to prevent serious diseases that could harm for children health, another positive is that is freely available, another positive is vaccines protect against illnesses like Measles and polio.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I had my first child, I didn\u0026rsquo;t have any information about child vaccination, so I refused to immunize my baby. I was afraid and uncertain because no one had explained to me how vaccines work or why they are important. Later, after receiving proper information from health workers about the benefits of immunization and how it protects children from serious diseases, I understood its importance. Since then, I have ensured that all my other children are fully immunized.\u0026rdquo; \u0026mdash; 30-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe in vaccination because I have seen how it protects children from many serious diseases. When a child is immunized, the body becomes stronger and can fight infections more easily. Even if the child gets sick, the illness does not reach a severe stage \u0026mdash; it only affects them mildly. That is why I always make sure my children receive all their vaccines on time.\u0026rdquo; \u0026mdash; 25-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother participant said that vaccines could cause their children to develop high fever and edema. Another negative aspect that participants agreed vaccines could lead to paralysis in their children, giving the example of a child who become ill after being vaccinated.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I had my first child immunized, he became severely sick afterward, and I was very frightened. At that time, I was living with older people in my community who strongly believed that vaccines cause illness in children. They convinced me that my child\u0026rsquo;s sickness was because of the vaccine, so I lost trust in immunization and decided not to vaccinate my other children for the next five years.\u0026rdquo; \u0026mdash; 23-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eReasons for vaccine Refusal\u003c/h2\u003e\u003cp\u003e This theme explores the personal reasons why some parents hesitate or choose not to vaccinate their children. It aims to understand their fears, misconceptions, and past experiences that shape these decisions. Many parents expressed anxiety about possible side effects, long-term health impacts, or past negative experiences with vaccines or healthcare providers. Others mentioned that their decision was influenced by advice from family members, neighbors, or community elders who discouraged vaccination. Some parents also shared deep mistrust toward vaccines, believing that the vaccine itself could cause illness rather than prevent it. Overall, fear of side effects and misinformation were the most common reasons for vaccine refusal among parents.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe that the vaccine itself is a disease and that it causes children to become sick after receiving it. When my first child was vaccinated, he became ill afterward, and I immediately thought it was because of the vaccine. Many people around me, especially elders in my community, also told me that vaccines bring sickness instead of preventing it. Hearing this from people I trust made me more afraid, so I decided not to immunize my other children. I still worry that vaccines might harm them rather than help them.\u0026rdquo; \u0026mdash; 40-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I honestly do not understand the importance of vaccination or what specific diseases it protects children from. No one ever explained to me how vaccines work or why they are necessary for a child\u0026rsquo;s health. When health workers come to our area, they just give the injection without much explanation, so I felt uncertain and scared. Because of that, I was not confident enough to take my children for vaccination, as I didn\u0026rsquo;t know what was being given or what the benefits were.\u0026rdquo; \u0026mdash; 38-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My decision not to vaccinate my children was influenced by the opinions of my family members and neighbors who strongly oppose vaccination. They often said that vaccines are dangerous and can harm children rather than protect them. Since I trusted their advice and did not have much information from health workers, I started believing what they said. Their discouragement made me afraid to take my children for immunization, even though I sometimes wondered if it might actually help them.\u0026rdquo; \u0026mdash; 21-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I refused to vaccinate my child because I was worried about the side effects that immunization can cause, such as high fever, swelling, and allergic reactions. I have seen some children in my neighborhood become sick after vaccination, which made me very anxious. I felt that it was safer to avoid the vaccine than to risk my child becoming seriously ill. No one clearly explained to me that these reactions could be normal or temporary, so I remained fearful and decided not to vaccinate.\u0026rdquo; \u0026mdash; 30-year-old mother\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAccess and Barriers to Vaccination\u003c/h2\u003e\u003cp\u003e This theme explores the barriers that parents may face when accessing vaccines, even in a community where most have relatively easy access. Maternal and Child Health (MCH) centers are located nearby, and frequent outreach programs often provide vaccines directly to households, making immunization services widely available. Despite this accessibility, some parents still encounter challenges that affect their vaccination decisions. These include social pressures, judgment from family or community members, or concerns about being criticized for their choices. Logistical barriers, such as occasional vaccine shortages, inconvenient clinic hours, or negative interactions with health workers, can also discourage parents from vaccinating their children. This theme highlights that access alone is not enough; understanding parents\u0026rsquo; experiences, perceptions, and the social context is essential to improving vaccination uptake.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I really don\u0026rsquo;t face any major obstacles when it comes to vaccinating my children because we have a health center nearby. We don\u0026rsquo;t have to travel long distances to access services, and this makes it much easier for me to ensure my children receive their vaccines on time. Having the health center close by gives me peace of mind and confidence in the immunization process.\u0026rdquo; \u0026mdash; 36-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Even if I don\u0026rsquo;t personally go to the Maternal and Child Health (MCH) center, they provide door-to-door vaccination outreach programs. These programs are very convenient because the health workers come directly to our homes, and I don\u0026rsquo;t have to worry about missing any vaccines for my children.\u0026rdquo; \u0026mdash; 25-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One time, I had an argument with the healthcare providers at the MCH center, and after that experience, I stopped going there. Now, I only rely on the door-to-door vaccine programs. The problem is, if I\u0026rsquo;m not at home when the health workers come, my child sometimes misses the vaccines, which worries me a lot.\u0026rdquo; \u0026mdash; 21-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In our area, vaccines are the only healthcare service that we receive consistently. They are always available, and we never run out, which makes it easier for parents like me to keep up with our children\u0026rsquo;s immunization schedule without much difficulty.\u0026rdquo; \u0026mdash; 29-year-old mother\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCommunity Influence and Social Norms\u003c/h2\u003e\u003cp\u003eParents\u0026rsquo; decisions about vaccinating their children are not made in isolation; the opinions and beliefs of the wider community play a significant role. This theme explores how parents\u0026rsquo; vaccination choices are shaped by the attitudes, actions, and guidance of people around them. It considers whether most families in the community actively support vaccination or if there is widespread hesitation. It also examines whether parents feel encouraged and supported or criticized and judged by others when making these decisions. Family members, local health workers, religious leaders, and community elders can all influence parents\u0026rsquo; choices, either by expressing doubts about vaccines or by reinforcing confidence in immunization. Understanding these social dynamics helps explain how vaccines are accepted or rejected, highlighting the importance of community norms, trusted voices, and collective beliefs in shaping health behaviors.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t know much about vaccinations at first, but when I saw many other mothers in my community going to the Maternal and Child Health (MCH) center with their children, I decided to follow them. Seeing others take their children for immunization gave me confidence and encouragement. It made me feel that it must be important, and that is why I started vaccinating my children as well.\u0026rdquo; \u0026mdash; 33-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I stopped vaccinating my children because of the influence of my older relatives with whom I share a house. They told me that the reason my first child became sick after vaccination was the vaccine itself and that it could cause diseases in children. Hearing this from people I trust made me afraid and lose confidence in immunization, so I decided not to vaccinate my children for some time.\u0026rdquo; \u0026mdash; 27-year-old mother\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost mothers in the IDP community were illiterate, so it is not surprising that they heavily rely on the perspectives and advice of their family, neighbors, and community members when making decisions about vaccinating their children.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eStrategies to Improve Uptake\u003c/h2\u003e\u003cp\u003eTo improve vaccination coverage among children, several strategies were suggested by parents. Many mothers preferred home-based or community outreach services because these approaches save time and effort while providing a more comfortable and supportive environment. Respectful and empathetic communication from health workers during these visits helps build trust and confidence. In addition, providing culturally relevant education, using simple and clear language, and involving trusted community figures such as elders, religious leaders, or local health volunteers encourages open discussion and greater acceptance of vaccines. These strategies are particularly important because many mothers have limited knowledge about vaccines and may hold negative perceptions based on misinformation or advice from others. Tailoring interventions to address these concerns can increase understanding, trust, and ultimately, vaccine uptake.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have ten children, and in the past, I used to miss a lot of vaccines because the Maternal and Child Health (MCH) center or health facility was far from my home. I didn\u0026rsquo;t have anyone to take care of my other children while I was away, so it was very difficult to bring them for immunization. This made me feel frustrated and worried that my children were not fully protected. Recently, the community outreach program has been visiting our area occasionally, and it has solved this problem for me. Now, the health workers come directly to our homes, and I can get my children vaccinated without worrying about leaving the others alone.\u0026rdquo; \u0026mdash; 45-year-old mother\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study seeks to find out why some parents in Akara IDPs, Hargeisa, refuse to vaccinate their children. We listened to understand their true ideas and beliefs. The findings revealed that vaccine refusal is often motivated by fear, uncertainty, and community influence rather than a lack of access. Many parents had incorrect information or previous negative experiences that influenced their belief in immunizations.\u003c/p\u003e\u003cp\u003e The first theme revealed that parents had conflicting opinions on vaccination. Some people believed immunizations were beneficial and protected their children from dangerous diseases such as measles and polio. This is confirmed by systematic literature Review of the Factors That Affect How Parents Think and Act Regarding Routine Childhood Vaccination in Africa (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), which found that parental education and awareness boost vaccine acceptability. Others said that immunizations made their children unwell or produced complications such as fever or edema. One mother even though the vaccine itself was a sickness. These findings are consistent with past studies conducted in Somali immigrant communities in the United States, where many parents were concerned that immunizations caused autism (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e In theme two, several parents expressed concern about potential negative effects. Some have seen or heard of a child becoming terribly ill after being vaccinated. This anxiety led them to avoid vaccination. These types of concerns are not new. According to a WHO reports (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), vaccination hesitancy is frequently triggered by concerns about side effects, a lack of trust in health-care systems, and an abundance of bad material on social media or in the community. In our situation, several women had no compelling reason; they were just unsure or swayed by neighbors or relatives.\u003c/p\u003e\u003cp\u003eThe third theme, concerning access, revealed something interesting. Many parents reported living near health clinics or receiving immunizations through door-to-door initiatives. So access was not the primary issue for them. However, minor hurdles such as fighting with health professionals or not being at home during outreach visits still resulted in children missing immunizations. This study is significant because it demonstrates that even when services are available, trust and communication are more crucial. Similar findings were reported in Ethiopia and Nigeria, when mistrust of health personnel resulted in missed immunizations.\u003c/p\u003e\u003cp\u003eThe fourth theme explored how much community pressure and norms influence vaccination decisions. Many mothers stated that they made decisions based on what others in their household or area said. Some people followed friends to health clinics without understanding much, while others stopped getting immunizations because elders informed them, they were harmful. This confirms what researchers have shown in similar settings: peer and family influence is a significant impact in vaccine decisions(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). When many people in the community believe vaccines are harmful, it becomes difficult for individuals to challenge that opinion.\u003c/p\u003e\u003cp\u003eThe fourth determined investigated how community pressure and norms influence vaccination decisions. Many women reported that they made decisions based on what others in their family or community said. Some people followed acquaintances to health clinics without comprehending much, while others stopped obtaining vaccines after elders warned them, they were detrimental. This confirms what researchers have shown in similar settings: peer and family influence has a major impact on vaccine decisions (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) When a large number of people in a community believe vaccines are hazardous, it becomes difficult to question that belief.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that vaccine refusal extends beyond issues of access\u0026mdash;it is deeply rooted in trust, knowledge, cultural beliefs, and past experiences. While our findings align with evidence from low-income, displaced, and migrant communities across Africa, Asia, and Western countries, this study stands out for amplifying the authentic voices of internally displaced persons (IDPs) in Somaliland, where local research remains scarce. The insights gained provide a critical foundation for designing context-specific interventions. Health workers should prioritize empathy, clear communication, and collaboration with community and religious leaders to foster vaccine confidence. Furthermore, outreach programs must be sustained and strategically planned to ensure consistent follow-up and prevent missed opportunities for immunization.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eIt was conducted in a single IDP community, so the findings may not represent other settings in Somaliland. The small sample size and limited number of focus groups may have excluded important views, especially from fathers and younger parents. Social desirability bias could have influenced participants\u0026rsquo; responses, and some views reflected perceptions rather than verified facts. Translation from Somali to English may have caused minor loss of meaning.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eRecommendations\u003c/h2\u003e\u003cp\u003eTo enhance childhood vaccine uptake, it is recommended that health authorities expand and reinforce door-to-door outreach activities, since many mothers found these services more accessible and convenient than visiting health clinics. Health education should be delivered in simple, culturally appropriate language by trusted community members such as elders or religious leaders in order to instill confidence and correct misinformation. Training healthcare workers in respectful communication is critical, as negative interactions have been reported to discourage future visits. Addressing common fears about side effects through clear, supportive explanations, and using real-life success stories from local mothers who changed their views about vaccination, can also help reduce hesitancy and promote acceptance across the community.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.A.K. and O.M.O. conceived and designed the study. H.H.H., W.S.K., M.M.A., M.H.O., M.F.A., F.A.D., A.I.H., A.M.M., A.H.A., S.K.C., A.A.M., and M.A.H. participated in data collection and transcription. O.M.O. and K.S.O. conducted data analysis and thematic coding. A.A.K., O.M.O., and S.A.A. interpreted the findings and drafted the manuscript. M.A.H., and S.A.A. critically reviewed and revised the manuscript for intellectual content. All authors contributed to the final version, approved the manuscript, and agreed to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control. Ten Great Public Health Achievements\u0026mdash;United States, 1900\u0026ndash;1999. 1999.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control. Ten Great Public Health Achievements\u0026mdash;United States, 2001\u0026ndash;2010. 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRumetta J, Abdul-Hadi H, Lee YK. A qualitative study on parents\u0026rsquo; reasons and recommendations for childhood vaccination refusal in Malaysia. J Infect Public Health. 2020;13(2):199\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlson O, Berry C, Kumar N. Addressing parental vaccine hesitancy towards childhood vaccines in the united states: A systematic literature review of communication interventions and strategies. Vaccines. 2020;8(4):1\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenwood B. The contribution of vaccination to global health: Past, present and future. Philos Trans R Soc B Biol Sci. 2014;369:20130433.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDub\u0026eacute; \u0026Egrave;, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy. Hum Vaccin Immunother. 2013;9(8):1763\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. COVID-19 pandemic leads to major back-sliding on childhood vaccinations, new WHO, UNICEF data shows. 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnited Nations Children\u0026rsquo;s Fund. UNICEF and WHO warn of \u0026lsquo;perfect storm\u0026rsquo; of conditions for measles outbreaks, affecting children. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnited Nations Children\u0026rsquo;s Fund. Over 20 million children worldwide missed out on measles vaccine annually in past 8 years, creating a pathway to current global outbreaks \u0026ndash; UNICEF. 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. UNICEF and WHO warn of \u0026lsquo;perfect storm\u0026rsquo; of conditions for measles outbreaks, affecting children. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePublic Health England. The wider public health workforce. 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWise J. MMR vaccine: Johnson urges new impetus to increase uptake as UK loses measles-free status. Br Med J. 2019;366:l5219.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiller L, Reynolds J. Autism and vaccination\u0026mdash;the current evidence. J Spec Pediatr Nurs. 2009;14:166\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavidson M. Vaccination as a cause of autism\u0026mdash;myths and controversies. Dialogues Clin Neurosci. 2022;19:403\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGabis LV, Attia OL, Goldman M, Barak N, Tefera P, Shefer S, et al. The myth of vaccination and autism spectrum. Eur J Paediatr Neurol. 2022;36:151\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObohwemu K, Christie-De Jong F, Ling J. Parental childhood vaccine hesitancy and predicting uptake of vaccinations: a systematic review. Prim Heal Care Res Dev. 2022;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams SE. What are the factors that contribute to parental vaccine-hesitancy and what can we do about it? Hum Vaccines Immunother. 2014;10(9):2584\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmes HM, Glenton C, Lewin S. Parents\u0026rsquo; and informal caregivers\u0026rsquo; views and experiences of communication about routine childhood vaccination: A synthesis of qualitative evidence. Cochrane Database Syst Rev. 2017;2:CD011787.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBechini A, Boccalini S, Ninci A, Zanobini P, Sartor G, Bonaccorsi G, et al. Childhood vaccination coverage in Europe: Impact of different public health policies. Expert Rev Vaccines. 2019;18:693\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede la Sant\u0026eacute; O, Organization WH. Understanding the behavioural and social drivers of vaccine uptake WHO position paper\u0026ndash;May 2022. Wkly Epidemiol Rec / Relev \u0026Eacute;pid\u0026eacute;miologique Hebd. 2022;97:209\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Regaiey KA, Alshamry WS, Alqarni RA, Albarrak MK, Alghoraiby RM, Alkadi DY, et al. Influence of social media on parents\u0026rsquo; attitudes towards vaccine administration. Hum Vaccin Immunother. 2022;18:1872340.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJafflin K, Deml MJ, Schwendener CL, Kiener L, Delfino A, Gafner R, et al. Parental and provider vaccine hesitancy and non-timely childhood vaccination in Switzerland. Vaccine. 2022;40:3193\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWirsiy FS, Nkfusai CN, Ako-Arrey DE, Dongmo EK, Manjong FT, Cumber SN. Acceptability of COVID-19 vaccine in Africa. Int J Matern Child Heal AIDS. 2021;10:134.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNFPA, Somaliland Government. The Somaliland Health and Demographic. Somalil Demogr Heal Surv; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdullahi MF, Stewart Williams J, Sahl\u0026egrave;n KG, Bile K, Kinsman J. Factors contributing to the uptake of childhood vaccination in Galkayo District, Puntland, Somalia. Glob Health Action 2020;13(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCentral Statistics Department, Ministry of Planning and National Development SG. The Somaliland Health and Demographic Survey 2020. Somaliland: Ministry of Planning and National Development; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMavundza EJ, Cooper S, Wiysonge CS. A Systematic Review of Factors That Influence Parents\u0026rsquo; Views and Practices around Routine Childhood Vaccination in Africa: A Qualitative Evidence Synthesis. Vaccines. 2023;11(3):1\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed S, Salad F, Ali A. Vaccine hesitancy among Somali parents in the United States: Perspectives from community leaders. BMC Public Health. 2020;20(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. Ten threats to global health in 2019. World Heal Organ; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. Immunization Agenda 2030: A Global Strategy to Leave No One Behind. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBedford H, Attwell K, Danchin M, Leask J, Wiley K, Wiley E. Vaccine hesitancy and the dynamics of trust: an historical perspective. Hum Vaccines \\\u0026amp; Immunother. 2018;14(7):1599\u0026ndash;606.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNICEF, WHO. Progress and challenges with achieving universal immunization coverage. 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7947813/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7947813/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eChildhood vaccination coverage in Somaliland is one of the lowest in the world, according to the Somaliland Health and Demographic Survey 2020. Only 13% of children aged 12\u0026ndash;23 months were fully vaccinated, with 68% having received no immunizations. Despite the availability of routine immunizations, parental refusal and vaccination reluctance continue to impede uptake. To yet, no qualitative studies have addressed the underlying causes for vaccine refusal among parents in Hargeisa. The purpose of this study is to better understand these characteristics and propose context-specific solutions for increasing immunization rates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative study was conducted using five face-to-face focus group discussions with 31 parents living in the Akara IDP settlement, Ahmed Dhagah District, Hargeisa. Thematic analysis was used to extract essential patterns and insights from participant responses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParental refusal was affected by a variety of factors, including fear of side effects, a lack of awareness of vaccine benefits, previous unfavorable encounters with health personnel, and strong community attitudes and social norms. Physical availability to vaccines was not a big barrier. Participants emphasized the need of culturally relevant communication, regular outreach activities, and the involvement of trusted community figures in addressing vaccine concerns and building confidence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eVaccine refusal in IDP camp is driven by fear, misinformation, and social influence rather than a lack of access. Customized public health methods centered on education, trust-building, and respectful participation are critical for increasing childhood immunization coverage in such contexts.\u003c/p\u003e","manuscriptTitle":"Beyond the Needle: Understanding Parental Refusal and Pathways to Childhood Vaccine Equity in Akara IDPs, Hargeisa, Somaliland— Advancing SDGs 3, 4, 5, 10 \u0026amp; 16 in Humanitarian Settings","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 11:41:52","doi":"10.21203/rs.3.rs-7947813/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7201862d-a057-4759-b0d3-e7c40cc43bae","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T08:57:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 11:41:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7947813","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7947813","identity":"rs-7947813","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}