Abstract
Introduction:
Vaccine hesitancy is a global barrier to childhood immunization and a significant challenge in fragile health systems like Somalia, making it crucial to identify associated factors for effective interventions.
Objectives:
To identify factors associated with VH among mothers of children under 2 years in Mogadishu
Methods:
A cross-sectional study of 548 mothers in Mogadishu, Somalia
Results:
VH prevalence was 37.4% (n = 205). Mothers without formal education (AOR = 4.31, 95% CI: 2.012-9.109) and fathers without education (AOR = 2.74, 95% CI: 1.514-5.311) were more to report VH. Longer waiting times were associated: 15 to 30 minutes (AOR = 0.40, 95% CI: 0.229-0.699), 31 to 60 minutes (AOR = 0.25, 95% CI: 0.138-0.465), and >60 minutes (AOR = 0.44, 95% CI: 0.230-0.854), compared to <15 minutes.
Conclusion:
VH is common in Mogadishu and is linked to parental education and service-related factors
Introduction
Immunization is one of the most efficient public health tool for vaccine preventable diseases. 1 It has been associated with a reduction of nearly 4.4 million deaths in children worldwide each year. 2 In Somalia, the Expanded Program on Immunization (EPI) policy recommended that all children in Somalia under 2 years of age should receive vaccination against tuberculosis, diphtheria, tetanus, pertussis, polio, meningitis diseases caused by Hemophilus influenzae type B (Hib), measles, and hepatitis B. 3 According to the EPI schedule, all children should receive 1 dose of BCG vaccine, 3 doses of diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type b (DPT-HepB-Hib, Pentavalent) vaccine, 4 doses of oral polio vaccine (OPV), 1 dose of inactivated polio vaccine (IPV), and 1 dose of measles vaccine at 9 months, as well as the second dose of measles and IPV 2 in the second year of life. 4 Globally, the United Nations (UN) set a target of achieving 90% coverage for essential vaccination for children and adolescents, besides halving the number of children completely missing out on vaccines (zero-dose children) in the 2030 Immunization Agenda. 5 Although there has been an overall increase in global vaccination rates in recent years, many lower and middle-income countries (LMICs) still reported suboptimal immunization rates that are below the necessary level to achieve herd immunity. 6 In Somalia, only between 30% and 40% of children receive immunization against the 6 primary childhood infectious diseases, far below the worldwide rate of around 80%. 7 The current vaccine coverage for measles among 1-year-old children is 24% while the coverage for diphtheria, tetanus, and pertussis (DTP3) is 31%. 8 In Somalia. According to Somalia Health and Demographic Survey (SHDS) in 2020, 9 as high as 60% of Somali children did not receive any dose of vaccines. Furthermore, only 11% of children aged 12 to 23 months were fully vaccinated. 3 The poor immunization coverage in Somalia is likely the main contributing factor to the recurrent outbreaks of vaccine-preventable diseases (VPD), such as the measles outbreak during the 2011 famine and the 2017 food crisis. 10 Studies identified various factors such as low socioeconomic status, lack of awareness, rumors and disinformation, cultural attitudes, and low trust as the main culprits of low vaccination rates. 7
Vaccine hesitance (VH) is defined as “delay in accepting or refusing vaccination despite available services.” VH is a significant public health concern globally 11 and one of the main obstacles to the uptake of childhood vaccinations. 12 In 2019, it was ranked among the top 10 threats to public health worldwide. 11 According to a recent study, the prevalence of VH among parent-child pairs between the ages of 0 to 6 years varied among countries with different income levels. In high-income nations, the prevalence ranged from 7.7% in Italy to 41.8% in Israel as compared to 5.9% in Brazil to 34.9% in Bulgaria among higher middle-class income nations. However, lower middle-income countries recorded prevalence rates of 3.4% in Ethiopia to 41.6% in India. 13 In addition, several studies have highlighted factors associated with VH such as religious views, social culture norms, and disinformation through social media, mistrust, and attitude regarding vaccines. 14 To gain a comprehensive understanding of the global implications of VH, it is necessary to understand its complexity within particular social contexts by prioritizing local information to formulate politically informed, ethically sound, and culturally sensitive responses. 15 This study aimed to determine the factors associated with VH in mothers with children up to 2 years in Mogadishu, Somalia.
Methods
Study Setting, Period, and Design
A community-based cross-sectional study was conducted in Mogadishu from March 2024 to May 2024. Mogadishu, the capital city of Somalia, is home to approximately 2 million residents. 16 The Ministry of Health conducted a survey of health facility infrastructure and identified a total of 205 health facilities of various types in Mogadishu. A detailed list of the selected districts is provided in the sampling procedure section. 17
Population
The study population compromises all postnatal mothers of newborn aged less than 2 years selected from the designated districts during the data collection period.
Eligibility Criteria: Postnatal mothers with a living newborn up to 2 years prior to the study period, who are residents of Mogadishu, were included in this study. Mothers who were seriously ill, as well as those who had a baby who died before the data collection period, were excluded.
Sample Size Determination
The sample size was calculated using a single-population proportion formula, assuming a 50% prevalence of vaccine hesitancy, a 95% confidence level, and a 5% margin of error. The formula indicated a minimum sample size of 384 mothers. However, the study ultimately recruited 548 mothers, which exceeds the minimum requirement and provides sufficient statistical power.
Sampling Procedure
A survey was conducted among 548 postnatal mothers with children up to 2 years old, randomly selected from districts in Mogadishu. Using a multistage sampling approach, Mogadishu comprises 20 districts. After applying simple random sampling, 6 districts were selected. Each district contains 4 divisions, except for Deyniile, which has 5 divisions. Using simple random sampling, 2 divisions were selected from each district. Within each selected division, households were identified through simple random sampling, resulting in a varying number of households per district, ranging from 115 to 150. Finally, a simple random sampling method was employed to select the participants. In households with more than 1 eligible respondent, 1 participant was randomly chosen using the lottery method (Figure 1).
Multi-stage sampling procedure.
Data Collection Instrument
Data for this study were collected using a structured, pre-tested questionnaire specifically developed to assess vaccine hesitancy among mothers of children up to 2 years old. The questionnaire was initially written in English and later translated into Somali to ensure better comprehension for both respondents and data collectors. The tool was designed after a thorough review of existing literature18,19 and included items adapted from the WHO SAGE Vaccine Hesitancy Scale, 20 which has been widely used in similar settings. The questionnaire comprised 4 main sections: (1) Socio-demographic and economic characteristics (e.g., age, marital status, education, family income); (2) Prenatal, delivery, and puerperium characteristics (e.g., number of prenatal consultations, guidance from health professionals, breastfeeding, and hospitalization history); (3) Health service access and utilization (e.g., rapport with health workers, place of vaccination, waiting time, participation in campaigns); and (4) Mothers’ attitudes and perceptions toward vaccination, including constructs related to confidence and risk perception measured on a 5-point Likert scale.
Validity and Reliability
The instrument was pretested on a sample of 25 mothers with children under the age of 2, who were not part of the main study. Items in the questionnaire that were found to be unclear or confusing were reworded for better clarity. Additionally, feedback was obtained from pediatric experts, which led to further modifications and refinements to the instrument.
Data Collection Procedure
Data were collected between March 14 and May 21, 2024, through face-to-face interviews conducted in the homes of eligible participants across 6 districts of Mogadishu. A team of 5 trained final-year medical students conducted the interviews. The team approached mothers at their homes, briefly explained the purpose of the study, and invited them to participate. Those who agreed were asked to provide informed consent and were assured that their participation was voluntary, and that they could withdraw from the study at any time without any consequences.
Structured questionnaires were administered in a face-to-face format for caregivers who were able to read and write. In contrast, the questionnaire was initially developed in English and subsequently translated into Somali using the WHO-recommended translation and adaptation process for those who could not read and write English. After completion, the questionnaires were reviewed for completeness and then sealed in envelopes to ensure confidentiality and data integrity.
Data Analysis
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 27. Descriptive statistics were used to summarize participants’ sociodemographic, delivery, and health service characteristics, and results were presented as frequencies and percentages. Associations between categorical variables and vaccine hesitancy (VH) were first assessed using the Chi-square (χ2) test. Univariate logistic regression was then performed to estimate crude odds ratios (COR) with 95% confidence intervals (CI). Also we used multivariate logistic regression model to identify independent predictors of VH, with adjusted odds ratios (AOR) and 95% CI reported. Statistical significance was set at p <0.05.
Ethical Consideration and Informed Consent
Ethical approval for this study was obtained from the Research Ethics Committee of Jamhuriya University of Science and Technology (Reference No. JUREC0093/FMHS00308/052024). Written informed consent was obtained from all participating mothers prior to their inclusion in the study. Mothers were provided with detailed information about the objectives, potential risks, and benefits of the study. The confidentiality of participants was strictly maintained throughout the data collection process, and they were assured that all collected data would be used solely for research purposes.
Results
The result showed that 37.4% of the respondents were experiencing vaccine hesitancy, while 62.6% reported no hesitancy (Figure 2). Significant differences were observed in various factors associated with VH. In the socio-demographic category, there was a significant difference in marital status (P = .041), maternal education (P < .001), paternal education (P < .001), and family income (p < .001) (Table 1). Regarding child’s delivery characteristics, significant differences were observed in parental consultations (P < .045), guidance received (P < .061), child’s sex (P < .001), and child’s hospitalization (P < .001) (Table 2). In terms of health service characteristics, significant differences were observed in the bond with health professionals (P < .001), vaccine center visited (P < .001), the experience of adverse reactions to vaccines (P < .047), waiting time (P < .001), participation in vaccination campaigns (P < .001), and the decision to delay vaccination or not (P < .001) (Table 3).
Indicates the prevalence of vaccine hesitancy among the study participants.
Demographic Characteristics of Participants and Comparison Between Vaccine-hesitant and Non-vaccine-hesitant Parents.
Delivery Characteristics of Participants and Comparison Between Vaccine-hesitant and Non-vaccine-hesitant Parents.
Health Service Characteristics of Participants and Comparison Between Vaccine-hesitant and Non-vaccine-Hesitant Parents.
Factors Associated with Vaccine Hesitancy
After including all the independent variables in the adjusted model, mothers with no formal education [AOR: 4.31; 95% CI: 2.012-9.109] and fathers with no formal education [AOR: 2.74; 95% CI: 1.514-5.311] were significantly more likely to report vaccine hesitancy than parents with higher education levels. Similarly, mothers who reported waiting time between 15 and 30 minutes [AOR: 0.40; 95% CI: 0.229-0.699], between 31 and 60 minutes [AOR: 0.25; 95% CI: 0.138-0.465], and above 60 minutes [AOR: 0.44; 95% CI: 0.230-0.854] at health facilities were more likely to report VH compared to those who waited less than 15 minutes.
Furthermore, not receiving guidance on child vaccination was a strong predictor of VH, as mothers who received no guidance had significantly higher odds of hesitancy [AOR: 7.71; 95% CI: 4.385-11.891] compared with those who received guidance. Poor interactions with health professionals were also associated with increased hesitancy. Mothers describing the bond with health unit professionals as reasonable [AOR: 1.76; 95% CI: 1.095-3.321], bad [AOR: 2.65; 95% CI: 1.211-5.108], and indifferent [AOR: 2.16; 95% CI: 1.123-4.098] showed significantly higher vaccine hesitancy than those reporting an excellent bond.
Additionally, mothers who did not consistently participate in vaccination campaigns had greater odds of VH [AOR: 2.12; 95% CI: 1.781-4.054] compared with those who consistently participated (Table 4).
Factors Associated With Vaccine Hesitancy.
Figure 3 shows that 63.1% of respondents strongly agreed that vaccines are important for their child’s health, 62.6% believed vaccination protects against disease, and 60.8% emphasized the health importance of vaccinating their child, while 40.5% expressed strong concern about adverse effects and 49.3% believed new vaccines carry more risks than older ones.
Shows potential reasons for VH.
Discussion
VH is a global concern due to the serious consequences that it can cause, including poor vaccination uptake and compromised herd immunity among vulnerable populations.
In our study, the prevalence of vaccine hesitancy was 37.4%, which is slightly lower than a previous study in Somalia (38.2%) 21 and systemic review in East Africa (40.4%). 22 These rates are notably high compared to other regions. For instance vaccine hesitancy In United Arab Emirates is (12%), 23 United Kingdom (24.5%) 24 and in turkey it is (13.8%). 25 The higher vaccine hesitancy in Africa may be attributed limited access of health care, lower levels of education, misinformation, and distrust in health authorities. 26 This indicates the urgency for context-specific interventions in Somalia, where structural barriers and misinformation may amplify hesitancy.
Based on our study results, there is a noteworthy percentage of mothers who demonstrated positive behaviors and agreement with most statements on the VH. Additionally, different socio-demographic factors; specifically marital status, parental education levels, and family income were significantly associated with VH. This was in line with a study conducted in UAE in which marital status was also directly linked to VH. 23 Additionally, studies from Australia, the United States, the Netherlands, China, India, Kyrgyzstan, and Nigeria all indicated parental education level as a direct influencing factor of VH.27-31 According to a previous qualitative study, higher levels of education and self-sourced vaccine knowledge contributed to parents of highly educated children believing that they could make responsible decisions with regard to vaccination. 24 Furthermore, Wu et al 32 and Antia et al 33 reported that family income was directly related to VH. In contrast, another study in China reported higher income levels can lead to VH, and this might be because families with higher incomes tend to minimize the negative consequences of illness.
Vaccine-hesitant parents are less likely to have received regular prenatal consultations in this study. This indicates a statistically significant difference in the number of prenatal consultations between vaccine-hesitant and non-vaccine-hesitant parents. Other review also reveals that education and support in vaccine decision making is best provided in pregnancy, and midwives are well placed to provide this. 34 This indicates providing structured consultation can effectively reduce hesitancy and promote child immunization. Globally, 86% of pregnant women have at least 1 visit with a skilled healthcare provider, yet only 65% complete 4 or more visits—with the rate falling to 52% in sub-Saharan Africa 35 and as low as 25% in Somalia. 35 Current study found a significant association between child’s sex and vaccine hesitancy, with mothers of female children showing higher hesitancy than those of male children. In contrast a study in Poland found that parents were significantly more likely to refuse HPV vaccination for boys than for girls10, showing that the child’s sex influenced vaccine hesitancy. 36
In our research, we found a notable link between the level of bond or connection between healthcare staff and parents and vaccine hesitancy. Parents who had a weaker relationship or less communication with healthcare providers were more inclined to be hesitant about childhood vaccinations. Similarly parents in the UK, decided to vaccinate their children based on the information provided by healthcare professionals. 37 This indicates that fostering strong, trusting relationships with healthcare professionals is crucial for promoting vaccine acceptance. Parental decisions regarding childhood vaccination are heavily impacted by vaccine hesitancy. 38 Building trust through better communication, respectful care, and consistent follow-up could be the single most effective approach to reduce VH in Somalia.
Experiencing adverse reactions to vaccines is associated with increased vaccine hesitancy in our study. Which is consistent a recent studies who identified an association between vaccine hesitancy and an increased likelihood of experiencing or adverse event following vaccination.39,40
This research indicates that parents who received structured education or clear guidance about childhood vaccination were significantly less likely to exhibit vaccine hesitancy. In fact, the rate of hesitancy and non-hesitant participants was 5.8% versus 37.1% respectively. WHO SAGE working group dealing with vaccine hesitancy found that community-based educational programs and direct engagement with healthcare professionals were among the most effective interventions. 41 In Somalia, we experienced a civil war that led to the collapse of the healthcare infrastructure, weakening both the guidance and promotion of vaccination efforts. Additionally, the majority of our population lives in rural areas. The Somali National Immunization Policy (NPI) and the Expanded Program on Immunization (EPI) policy offered a strategic framework for guiding, direction, managing, planning, and implementing immunization services across Somalia. 42 Investing in structured, community-based education programs should be prioritized in Somalia’s NPI and EPI strategies. Strengthening rural outreach and rebuilding trust after decades of conflict will be key to sustainable improvement.
Prior hospitalization was more common among non-hesitant parents’ children. A study discovered that parents who had less confidence in their child’s healthcare provider used more informal sources of vaccine information and were less likely to view their child’s pediatrician as their primary source of vaccine information. 43 Our results indicate a highly significant association between consistent participation in vaccination campaigns and the group outcome. This suggests that participation is strongly linked to the observed outcome. 44 Successful outcomes of vaccination campaigns have diminished—if not entirely erased. 45
The study found that 51.8% of parents use public health centers, with a slightly higher proportion of non-hesitant (53.9%). Private clinics were more common among vaccine-hesitant (14.1%), while hospitals were more frequent for non-hesitant (34.1%). Non-hesitant parents often use public and hospital-based vaccination centers due to trust in formal health institutions and access to credible information. Vaccine-hesitant parents use private or “other” centers, which may not offer standardized counseling or government-endorsed messaging, indicating lower trust in public systems. A qualitative study on public trust in Mogadishu’s private healthcare system revealed that it is largely unregulated and costly, making healthcare services financially inaccessible for much of the population. 46
Strengths and Limitations of This Study
This is one of the few studies to assess vaccine hesitancy among mothers in Somalia using the WHO SAGE Vaccine Hesitancy Scale (VHS), providing context-specific data for policy and practice.
The use of multistage sampling enhanced the representativeness of the study population across different districts of Mogadishu.
The cross-sectional study design limits the ability to establish temporal or causal relationships between the identified factors and vaccine hesitancy. Since data were collected at a single point in time, it is not possible to determine whether the observed associations reflect cause-and-effect or are influenced by other unmeasured variables.
Social Desirability Bias: Due to the sensitive nature of vaccine-related questions, respondents might have answered in ways they believed were more socially acceptable rather than sharing their true beliefs or behaviors.
Exclusion of Children above 2 Years: The study did not include data on vaccine administration for children older than 2 years, limiting the comprehensiveness of the findings.
Conclusion
Vaccine hesitancy remains a significant global public health challenge, especially in low-resource settings like Somalia. Our study highlights that maternal vaccine hesitancy is shaped by multiple socio-demographic and systemic factors, including education, income, marital status, healthcare access, and trust in health providers. Strengthening prenatal education, improving healthcare communication, and ensuring equitable access to reliable vaccination services are critical to addressing hesitancy. Community-based interventions and policy support are essential for rebuilding public trust, enhancing vaccine uptake, and ultimately safeguarding child health outcomes.
Supplemental Material
sj-pdf-1-gph-10.1177_30502225251411128 – Supplemental material for Associated Factors of Vaccine Hesitancy among Mothers with Children Up to 2 Years Old in Mogadishu, Somalia
Supplemental material, sj-pdf-1-gph-10.1177_30502225251411128 for Associated Factors of Vaccine Hesitancy among Mothers with Children Up to 2 Years Old in Mogadishu, Somalia by Ahmed Mohamed Dirie, Nur Rashid Ahmed, Shafie Abdirahman Dirie, Hafso Ali Shil, Fadumo Mohamed Jaylani, Fathi Mohamed Omar, Ibrahim Abdikadir Abdirahman, Iftin Mohamed Abdiqaadir and Abdirahman Ali Abdullahi in Sage Open Pediatrics
Footnotes
Acknowledgements
The authors would like to thank the Faculty of Medicine and Health Sciences, Jamhuriya University of Science and Technology, the Faculty of Health Science, Salaam University, the Jamhuriya Research Center, and the Research and Development Office at Salaam University for their invaluable support and collaboration throughout the course of this study. We also extend our sincere gratitude to the participants and data collectors whose contributions were essential to the success of this research.
Ethical Consideration
Ethical approval for this study was obtained from the Research Ethics Committee of Jamhuriya University of Science and Technology (Reference No. JUREC0093/FMHS00308/052024). They were given assurance about the data confidentiality and its exclusive use for this research study.
Consent to Participants
All mothers were signed an informed consent form before study participation.
Consent for Publication
Not applicable
Author Contributions
All authors are equally contributed and approved the final manuscript.
Funding
The authors received no financial support for this research.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research.
Data Availability Statement
Data are available upon reasonable request from the corresponding author.
Open Access
This is an open access article distributed under the terms of the Creative Commons
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References
Supplementary Material
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