A Situational Analysis of the Contextual Factors Influencing Vaccine Uptake on Koome Island, Lake Victoria, Uganda
WinnieEoju2✉Emailweoju@uvri.go.ug
FlaviaZalwango2,5Emailfzalwango@uvri.go.ug
EstherAOwino6EmailEAwuor@kemri-wellcome.org
LaureenKahunde2Emaillkahunde@uvri.go.ug
DenisNsubuga3EmailDenis.Nsubuga@mrcuganda.org
NoniMumba6EmailNMumba@kemri-wellcome.org
LudovikoZirimenya3,7EmailLudoviko.Zirimenya@lshtm.ac.uk
HenryLuzze8Emailluzzehenry@hotmail.com
AnnetteKezaabu5Emailakezaabu@gmail.com
PontianoKaleebu2Emailmbchibita@gmail.comEmailpkaleebu@uvri.go.ug
AlisonElliott2,3,7EmailAlison.Elliott@lshtm.ac.uk
DorcasKamuya6EmailDKamuya@kemri-wellcome.org
Primus Chi6EmailPChi@kemri-wellcome.org
DavidKaawa-Mafigiri4Emailmafigiridk@yahoo.com
1Monica Chibita4
2Uganda Virus Research InstituteEntebbeUganda
3MRC/UVRI & LSHTM Uganda Research UnitEntebbeUganda
4Department of Social Work and Social Administration, School of Social SciencesMakerere UniversityKampalaUganda
5School of Journalism, Media and CommunicationUganda Christian UniversityMukonoUganda
6Centre for Geographic Medicine Research (Coast)KEMRI Wellcome Trust Research ProgrammeKilifiKenya
7Department of Clinical Research, London School of Hygiene and Tropical MedicineLondonEngland, UK
8National Tuberculosis and Leprosy ProgramMinistry of HealthKampalaUganda
1. Winnie Eoju1, weoju@uvri.go.ug
2. Flavia Zalwango1,4, fzalwango@uvri.go.ug
3. Esther A Owino5, EAwuor@kemri-wellcome.org
4. Laureen Kahunde1, lkahunde@uvri.go.ug
5. Denis Nsubuga2, Denis.Nsubuga@mrcuganda.org
6. Noni Mumba5, NMumba@kemri-wellcome.org
7. Ludoviko Zirimenya2,6, Ludoviko.Zirimenya@lshtm.ac.uk
8. Henry Luzze7, luzzehenry@hotmail.com
9. Annette Kezaabu4, akezaabu@gmail.com
10. Monica Chibita4, mbchibita@gmail.com
11. Pontiano Kaleebu1, pkaleebu@uvri.go.ug
12. Alison Elliott1,2,6, Alison.Elliott@lshtm.ac.uk
13. Dorcas Kamuya5, DKamuya@kemri-wellcome.org
14. Primus Chi5, PChi@kemri-wellcome.org
15. David Kaawa-Mafigiri3, mafigiridk@yahoo.com
1Uganda Virus Research Institute, Entebbe, Uganda
2MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
3Department of Social Work and Social Administration, School of Social Sciences, Makerere University, Kampala, Uganda
4 School of Journalism, Media and Communication, Uganda Christian University, Mukono, Uganda
5Centre for Geographic Medicine Research (Coast), KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
6Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, England, UK
7National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda.
Corresponding author: Winnie Eoju, weoju@uvri.go.ug
Abstract
Background
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Vaccine uptake in Uganda remains below target, especially in hard-to-reach places such as Koome Island, a fishing community in Lake Victoria’s Mukono District. Although national immunization efforts have made progress, social and structural barriers limit access to and trust in vaccines. A
As part of the NIHR Global Health Research Group on Vaccines for Vulnerable People in Africa (VAnguard), we conducted a situational analysis to understand the local factors influencing vaccination attitudes and practices on Koome Island.Methods
Using the socioecological model as a framework, we employed qualitative methods, including community dialogues, stakeholder consultations, transect walks, informal conversations, and field observations, from November 2022 to October 2023. The participants included community members, health workers, local leaders, and district officials. The data were thematically analysed to capture influences on vaccine uptake across multiple social and structural levels.
Findings:
Despite longstanding Ministry of Health efforts, vaccine uptake remains limited in remote areas such as Koome Island. Structural challenges such as long distances to health centres, poor infrastructure, and frequent vaccine stockouts restrict access. These are worsened by high transport costs, gendered caregiving roles, limited awareness of the full immunization schedule, and persistent myths and misinformation, for example, fears that vaccines cause infertility or goitre.
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These findings shaped the stakeholder mapping and community engagement approaches for VAnguard and guided the design of a follow-up survey in three districts to further explore the complex social, biological, and structural factors affecting vaccine equity.Conclusion
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The analysis underscores the need to ground vaccine research and interventions in local realities. It informs culturally sensitive, systems-aware strategies and supports participatory approaches aimed at strengthening vaccine uptake in underserved communities.Keywords:
Community engagement
Koome Island
Qualitative research
Situation analysis
Socio-ecological model
social barriers
Structural barriers
Vaccine uptake
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Background
Vaccination is widely recognized as one of the most cost-effective and impactful public health interventions, preventing the spread of infectious diseases and saving millions of lives [1]. Despite this, global vaccine coverage has plateaued, and large disparities persist, particularly in low and middle-income countries (LMICs) [2]. These disparities are driven by a complex interplay of structural, social, and biological factors. Common challenges include geographic inaccessibility, weak health systems, poor sanitation, and prevalent myths, disinformation, and misinformation about vaccines [3]
Uganda, like many LMICs, has made important progress in immunization through the efforts of the Uganda National Expanded Program on Immunization (UNEPI). The introduction of vaccines such as the pentavalent, pneumococcal conjugate (PCV), and rotavirus vaccines demonstrates the country’s commitment to improving public health. However, significant barriers remain, particularly in underserved and hard-to-reach communities [4–6].
Different studies highlight the specific factors affecting vaccine uptake in Uganda [7] found that many caregivers lacked adequate information about immunization schedules, leading to missed follow-up doses. These findings mirror global evidence that caregiver education is a strong predictor of full immunization [8, 9]. Infrastructural and logistical barriers including poor road conditions, limited transport options, and vaccine stockouts have also been identified as major obstacles [10]. Similar patterns have been reported in other countries with comparable contexts, such as India, Nigeria, and Pakistan [11].
Both globally and in Uganda, myths, disinformation, and misinformation significantly impact vaccine acceptance, as shown in [12], which reported that widespread rumours about the COVID-19 vaccine in Kampala, such as claims that the vaccine causes infertility led to significant public hesitancy. These concerns echo global trends in vaccine confidence and hesitancy, as documented in large-scale reviews and international analyses [13–15]. Cultural and religious beliefs also influence health behaviours and vaccine decisions across diverse settings [16, 17].
Gender roles further affect vaccine uptake worldwide. While women are often the primary caregivers, they may lack decision-making power in male-dominated societies, limiting consistent follow-through with childhood vaccinations [18]. Evidence shows that involving fathers in child health initiatives improves immunization outcomes [19, 20].
Concerns about specific vaccines, such as the human papillomavirus (HPV) vaccine, have been especially notable [21]. Fears around infertility have discouraged uptake in South Africa, Nigeria, and Uganda [22–24]. Effective strategies to counter such fears include the use of relatable community stories and trusted messengers to rebuild confidence [25, 26].
Environmental factors such as poor sanitation and water access further compound health risks. Schistosomiasis, for example, is prevalent in Uganda’s lake regions [27] and remains a global neglected tropical disease with millions affected worldwide, particularly in Sub-Saharan Africa [28–30]. Notably, emerging evidence suggests that infection with Schistosoma mansoni may impair immune responses to vaccines, adding a biological dimension to the disadvantage experienced by affected populations [31–33]. These intersecting health burdens underscore the need for vaccine delivery approaches that are sensitive to structural, social, and biological vulnerabilities.
In response to persistent global and local challenges surrounding vaccine access and uptake, the NIHR Global Health Research Group on Vaccines for Vulnerable People in Africa (VAnguard) was setup to explore the structural, social, and biological factors influencing vaccine responses in vulnerable communities in Kenya and Uganda. The project is organized around a set of thematic and cross-cutting work packages that examine vaccine response mechanisms, barriers to uptake, and co-designed solutions. Full details of the VAnguard project structure and methodology are published elsewhere [34].
As part of the project’s formative phase, a situational analysis was conducted on Koome Island, Uganda, to inform the ethnographic and participatory components of the broader study.
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This early engagement aimed to identify local challenges to vaccination, map key stakeholders and shape the design of a follow-up community survey in subsequent phases of the VAnguard study.The situational analysis was guided by the socioecological model (SEM) [35], a framework that recognizes multiple, interacting levels of influence on health behaviors such as vaccine uptake. SEM allows for an in-depth exploration of factors across five domains: individual-level barriers (e.g., limited knowledge, fear of side effects), interpersonal dynamics (e.g., household roles and decision-making), community norms and beliefs, health system constraints (e.g., service delivery gaps, communication breakdowns), and structural factors (e.g., geographic isolation, transport limitations, seasonal mobility, and poverty).
Grounded in these interconnected layers of analysis, the situational analysis provided contextual insight into how communities experience and respond to vaccination services.
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These findings informed the refinement of the data collection tools, guided the selection of field sites, and supported culturally responsive strategies for community engagement and stakeholder collaboration in later phases of the VAnguard project.Methods
Study Design
This study employed a qualitative situational analysis design, forming part of the formative phase of the NIHR) Global Health Research Group on Vaccines for Vulnerable People in Africa (VAnguard) project.
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The aim was to launch the VAnguard project on Koome Island through community introduction, stakeholder engagement, and mapping of local health and social infrastructure. A situational analysis approach was selected to gain an in-depth understanding of community lived realities, identify key stakeholders, map barriers and enablers to immunization, and guide the design of the subsequent ethnographic and participatory research phases.A
Data were collected in phases between November 2022 and October 2023 as part of the preparatory phase. This included an initial scoping visit to Koome Island and stakeholder consultations with national and district, community dialogues, field observations, transect walks, and participatory mapping focusing on identifying local challenges and informing subsequent study phases. These approaches enabled the triangulation of data across various sources and levels of influence, enhancing the credibility and depth of findings. To support the situational analysis, the research team used two supplementary materials. First, a discussion guide (Supplementary File 1) was developed by the research team to help steer community dialogues and stakeholder consultations. Second, a PowerPoint summary of the VAnguard Social Science and Engagement Protocol (Supplementary File 2) was used during stakeholder consultation meetings with gatekeepers to present the study objectives and engagement approach. A
The study was guided by the socioecological model (SEM), which allows for the systematic exploration of factors at the individual, interpersonal, community, health system, and structural levels.The study was implemented in three purposively selected villages on Koome Island, Busiro, Kitosi and Zingoola, to reflect variations in geographic location, access to services, and community dynamics. The research team included public health researchers, social scientists, and local field assistant.
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We worked closely with Village Health Team members (VHTs), local leaders, and district health authorities throughout the process.Study setting
Koome Island is in Mukono District, approximately 51.8 km from Kampala city (Fig. 1). It is part of the Lake Victoria Island region, with an estimated population of approximately 20,806 people, according to the Uganda Bureau of Statistics projections [40]. This vibrant community primarily consists of fishing households that heavily rely on Lake Victoria's resources for their livelihoods [36]. The island's demographic diversity contributes to its rich cultural composition. However, Koome is also characterized by poverty and limited access to essential services. The island has only three public health facilities, two Health Centre IIs and one Health Centre III, and is served by 19 primary schools (7 private and 12 public) alongside a single public secondary school [37]. These limitations significantly impact healthcare delivery and educational opportunities for residents.
Fig. 1
Map of Uganda showing the location of Koome Islands in Mukono District, highlighted within Lake Victoria. The inset provides a detailed view of Koome Islands.
Participants
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The participants for the community dialogues, transect walks, participatory mapping, and informal conversations for this situational analysis were purposively selected from the three villages of Busiro, Kitosi, and Zingoola on Koome Island. The stakeholder engagement participants included community leaders from all fifteen villages within Koome Main Island, whereas the district-level consultation meetings involved officials from Mukono District. The selection aimed to capture a wide range of perspectives across gender, age, occupation, and social roles to ensure that the data reflected the diverse realities of the community.The participants included caregivers (primarily mothers, fathers and grandmothers responsible for child health), youth (both male and female, aged approximately 18–35), District Counsillor, LC1 and LCIII, Village Health Team (VHT) members/community health workers, religious and cultural leaders, subcounty and local council leaders, health workers, including the Expanded Program for Immunization (EPI) focal person and a laboratory technician based at Koome Health Centre III, fisherfolk, traders, and other residents encountered during informal conversations and community observations.
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In total, approximately 107 individuals participated in the three formal community dialogue sessions (34 in Busiro, 25 in Kitosi, and 48 in Zingoola). A
An additional 5–10 individuals were engaged through informal conversations and transect walks, whereas 77 stakeholders, including district and subcounty officials, local council leaders, religious leaders, Village Health Team members (VHTs), and cultural leaders, participated in stakeholder meetings. The selection process was supported by local leaders and VHTs, who helped identify individuals actively involved in community health or those with relevant lived experiences related to vaccine uptake and health-seeking behaviours. This diverse mix of participants enabled a multidimensional understanding of vaccine-related attitudes, barriers, and enablers in the context of constrained island livelihoods.Data collection
To gain a complete understanding of the situation, we used several methods. This situational analysis was carried out between November 2022 and September 2023 and employed a range of qualitative approaches to gather rich, contextual insights into the social, structural, and biological factors shaping vaccine uptake and broader health-seeking behaviours on Koome Island. This ensured inclusivity of perspectives and triangulation of findings.
The data collection methods included community transect walks, which allowed researchers to observe environmental conditions, infrastructure, and service availability firsthand. Stakeholder discussions were conducted with a range of actors, including health workers, VHTs, also known as community health workers, subcounty officials, and local leaders, to understand systemic and policy-level influences. In addition, meetings were held with district-level health officials to explore institutional perspectives and policy implementation challenges.
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Community dialogues and informal conversations with residents provided further depth and grounded the findings in lived experiences. These engagements offered insights into community beliefs, perceptions, and behaviours related to vaccination, as well as broader health concerns.A
Due to the informal and participatory nature of many of these interactions, no audio recordings were taken to allow for maximum spontaneity. Instead, the research team relied on detailed field notes, reflective journals, and minutes captured in real time. These were carefully reviewed and synthesized into narrative accounts and thematic findings for this report. A
Discussions with local leaders, community dialogue, and informal conversations were conducted primarily in Luganda, while English was used in engagements with district health officials. All members of the research team were fluent in these languages, which facilitated effective communication and ensured accurate interpretation of community perspectives.Stakeholder Consultations
District Health Management Team Meetings
As part of the VAnguard study, two key meetings were held with the Mukono District Health Management Team (DHMT) to support the situational analysis activities. The first meeting took place on 6 December 2022, and the second took place on 23 August 2023.
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Both meetings were held at the district health offices in Mukono and lasted between two to three hours, and involved approximately 30 participants, including key district health staff led by the District Health Officer (DHO), along with senior administrative officials headed by the Chief Administrative Officer (CAO).The main objective of the first meeting was to formally introduce the VAnguard study to the DHMT. The meeting was secured through the designated district contact person. During the discussion, the research team presented the study aims, research design, and focus areas. The DHMT shared useful insights into health service delivery challenges in hard-to-reach communities, particularly on Koome Island. These included limited transport, challenges with cold chain management, shortages of health workers, irregular vaccine supplies, and past experiences with outreach activities. The meeting created a foundation for collaboration and provided important background information for shaping the study.
The second meeting was held as part of a scheduled district health planning session that included other implementing partners. The aim of this engagement was to inform the DHMT of the team’s plans to begin data collection activities on Koome Island. The meeting also offered an opportunity to seek guidance on how to coordinate fieldwork with existing health services. The DHMT provided helpful input on community entry strategies, recommended engagement with local health workers and Village Health Team members (VHTs), and advised on the timing and logistics of working with island communities.
These meetings contributed significantly to the development of the study. The information gathered from the DHMT helped the research team refine the interview guides by highlighting key issues such as vaccine stockouts, staffing shortages, and the timing of outreach and shaping community entry plans. In addition, the discussions helped validate findings from the literature review and earlier field observations. Overall, these engagements ensured that the study was grounded in both community realities and district-level health system perspectives.
Consultations with Subcounty officials, Religious and Cultural Leaders, and Health Workers
A consultative meeting was held on 6th September 2023 with subcounty-level administrative officials, religious and cultural leaders, and health workers from Koome Health Centre III. The meeting lasted approximately two and a half hours and was conducted at the subcounty community hall. The meeting was moderated by the local Council III chairperson. The subcounty chief gave the opening remarks, and the VAnguard team member introduced the project to the stakeholders.
The primary aim of the meeting was to formally introduce the study to key local stakeholders, present its objectives and proposed procedures, and obtain feedback on the planned research activities.
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The session also sought to strengthen local collaboration by requesting support in linking the research team with relevant village-level leaders and by inviting some participants to take part in follow-up key informant interviews.In addition to sharing information about the study, the team facilitated discussions to gather background information about the local health context, the topics included and not limited to; common health conditions in the area; patterns of vaccine coverage, including areas with relatively high or low uptake and associated delivery challenges; and recommendations for villages or sublocations that would be relevant for inclusion in the study.
An open discussion followed the presentation, during which stakeholders raised questions and shared reflections that were related to the study for how households would be selected for participation.
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This engagement provided critical insights into the community context and facilitated alignment between the study team and local leadership, helping to inform both the methodological approach and the broader community entry strategy.Community Dialogues
Between September and October 2023, we conducted three community dialogue sessions in Busiro, Kitosi, and Zingoola on Koome Island.
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These sessions were organized in close collaboration with local council leaders and VHTs, who played an essential role in mobilizing participants and identifying suitable, venues for the discussions. The meetings were held in familiar and trusted spaces within each village. In Busiro, the session took place on 9th September in an open-air village meeting area, sheltered by makeshift tarpaulins, and was attended by 34 participants. In Kitosi, the dialogue was held at a Born Again community church on 11th September and was attended by 25 participants. In Zingoola, the meeting took place under a large fig (mukoko) tree, a common gathering point, on 31st October with 48 participants. These accessible and locally respected venues created a welcoming environment that encouraged open dialogue and strong community ownership of the sessions. The participants included a diverse mix of caregivers, youth, informal opinion leaders, community health workers/VHTs, and other residents.The sessions were facilitated by members of the research team, with active participation from VHTs and health workers, including the EPI Focal Person and the local field worker, who also serves as a laboratory technician at Koome Health Centre III. We began each session by introducing the objectives of the formative phase and explaining its relevance to the community.
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These introductions were delivered in Luganda, the commonly used local language, to ensure inclusivity and clarity. A
Following the presentations, the participants were encouraged to ask questions and share their experiences in an open discussion format. The presence of health workers and VHT members allowed for real-time responses to community concerns and helped address any myths, disinformation and misinformation or confusion around vaccination.A
The conversations were guided by broad thematic areas aligned with the socioecological model. At the individual level, discussions explored beliefs, attitudes, and concerns about vaccines, including safety, effectiveness, and perceived necessity. Interpersonal factors such as household decision-making and the influence of family members and peers were reflected in discussions on sources of health information and social norms. At the community level, the themes included local knowledge, myths, disinformation and misinformation, as well as the role of influential figures such as religious and cultural leaders. Health system-level challenges emerged around experiences with health services, trust in health workers, and perceptions of service quality. Structural-level barriers such as distance to health facilities, transport issues, and the availability of services were also key topics.The dialogues provided rich insight into how vaccination is understood and negotiated within the context of constrained livelihoods and limited healthcare infrastructure. They also became an iterative space where community questions informed our evolving lines of inquiry. Importantly, the presence of health workers and VHTs allowed for immediate clarification of myths, disinformation and misinformation and contributed to building trust through face-to-face engagement.
Field observations and participatory community mapping
The observations were carried out through community transect walks, where researchers travelled across the villages of Busiro, Kitosi, and Zingoola. During these walks, the team observed the physical and social environment, including healthcare infrastructure, transport options, and everyday community activities. We paid close attention to vaccination sites, population movement patterns, and how people interact in their social settings. The team noted potential barriers to vaccination, such as long distances to health centres, lack of transport, and community gathering spaces where health information is shared.
Following the walks, we engaged with community leaders and selected members in a participatory mapping exercise. Together, we co-created a community map (Fig. 2) highlighting key landmarks, movement routes, health service points, and social gathering points. This process provided a spatial lens to the data and informed the interpretation of structural barriers.
Fig. 2
Participatory mapping exercise with community members to identify key village landmarks and resources relevant to vaccine access.
Informal Conversations
Informal conversations were an integral part of our fieldwork, allowing us to engage with community members in natural, everyday settings. Over the course of engagement activities, we engaged in approximately 10 informal conversations with community members across the villages of Busiro, Kitosi, and Zingoola. These interactions were spontaneous and unstructured, taking place during routine activities such as offloading boats at docking areas, buying or selling goods at trading centres, drying and sorting silver fish and gathering in communal spaces such as church compounds and roadside stalls. The people we spoke with included caregivers, fisherfolks, youth, elders, and individuals seeking care at Koome health centre III.
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These conversations were not guided by formal questions but instead emerged organically as we moved through the communities and participated in daily routines. This approach created space for participants to speak openly and candidly, often sharing personal stories, reflections, and concerns about vaccination and general health without the pressure of a structured interview setting.The participants shared a variety of concerns, including logistical difficulties in accessing vaccines, such as long travel distances and irregular outreach services; we also noted some of these challenges during field observations. They also spoke about deeply rooted beliefs, fears, and misconceptions regarding vaccine safety and necessity. Some participants reflected on their past experiences with healthcare workers, rumours about vaccine safety and side effects circulating within the community, and how decisions about vaccination were often made collectively within households or influenced by peer networks. These interactions provided rich, contextually grounded narratives that offered a window into how people navigate health decisions in relation to their livelihoods, beliefs, and social ties.
While these conversations were informal, the research team remained intentional in listening for recurring themes and capturing emerging insights.
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Field notes were written shortly after each interaction to document key points, emotional tones, and relevant contextual details. These notes later contributed to broader thematic analysis and helped validate and expand on findings gathered from different sources.Data analysis
The data gathered throughout the data collection process included field notes, summaries from observations, activity reports, and meeting minutes, as no audio recordings were taken during the situational analysis. All the notes and summaries were stored securely and reviewed by the core research team. Each engagement (e.g., community dialogue, observation, informal conversation) was dated, and the location was referenced. Researchers compiled narrative accounts from each session, organized according to source and date, to allow for traceability during the analysis. We used the thematic approach for data analysis [38].
The research team first familiarized themselves with the field notes and observation summaries through repeated reading. Open coding was applied manually, assigning descriptive labels to key points. These codes were then grouped into broader themes aligned with the study objectives.
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Through iterative team discussions, themes were reviewed, refined, and finalized, ensuring consistency and triangulation across all data sources. Finally, the identified themes were mapped onto the SEM to capture influences at the individual, interpersonal, community, health system, and structural levels.A
The approach emphasized capturing participants’ voices and the context of Koome Island while acknowledging the limitations of using notes instead of audio-generated transcripts. Regular team discussions helped check interpretations and reduce bias.Results
The analysis identified seven interrelated themes shaping vaccine uptake and health-seeking behaviours on Koome Island. These findings are organized according to the socioecological model, highlighting the multiple levels of influence on vaccination practices.
Individual-level factors: Knowledge and perceptions of vaccines
During informal conversations and dialogue with community members, we noted that routine childhood vaccination was commonly referred to as “okutwala omwana ku polio” (taking the child for polio vaccination), suggesting that polio immunization, likely due to historic campaigns such as Kick Polio Out of Uganda, remains the most recognized aspect of vaccination. This reflects the limited understanding of other vaccines in the routine schedule.
As one male participant explained, “People often don’t participate in vaccine discussions due to limited information” (Community dialogue, Kitosi, 2023).
Other participants questioned the differences between past and present vaccines. For example, an elderly woman asked, “I lost my child many years ago after a vaccination. Are these vaccines different now?” (informal conversation, Busiro, 2023).
Interpersonal-level factors: household dynamics and decision-making
Decision-making around child health and immunization was often male dominated, despite caregiving responsibilities falling primarily on women. As one caregiver observed, “Men think they should just provide money. Only one man helps his wife with vaccination in our village” (male participant, Community dialogue, Busiro, 2023).
Others noted that fear of side effects led some family members to discourage vaccination. For example, a woman shared, “I was told that if a child finishes the polio vaccine [routine childhood vaccination], they might get goiter” (Community dialogue, Kitosi, 2023).
Community-Level Factors: Cultural Beliefs, Social Norms, and Leadership Influence
Cultural beliefs and norms shaped vaccine decisions across all the study sites. In one community dialogue meeting, a male participant voiced concerns tied to religious or cultural interpretations: “Telling someone to get the HPV vaccine is like telling them to remove their uterus” (Community dialogue, Kitosi, 2023).
Others emphasized the importance of community-level proof in decision-making: “Show people examples of girls who benefited or suffered because of not getting vaccinated” (male participant Community dialogue, Busiro, 2023).
The influence of local leaders and churches was significant. As one male participant explained, “If the LC [Local Council] get vaccinated when I am seeing or a church leader tells us it’s okay, we go” (informal conversation, Zingoola, 2023).
Health System-Level Factors: Access, Communication, and Responsiveness
Access was limited by poor infrastructure and service availability. As one community member noted, “To get to the health centre, we need to hire a boat or motorcycle; it is too expensive for some people” (Male participant Community dialogue, Kitosi, 2023).
A health worker echoed the logistical constraints: “Sometimes we don’t have the vaccines for example the Hepatitis B vaccine, or fuel to take us to the landing sites” (Stakeholder consultation, 2023).
The participants also described poor communication around side effects: “Why are caretakers not educated about side effects, like swelling after the shot just like in antenatal clinics?” (Female participant Community dialogue, Kitosi, 2023). The community dialogue and informal conversation revealed that many caregivers were not informed about common postvaccination reactions, such as swelling at the injection site. This gap in pre- and postvaccination counselling led to increased caregiver anxiety, misinterpretation of normal side effects as signs of serious illness, and mistrust of vaccination services.
In addition, the perceived attitudes and communication styles of health workers negatively impacted community trust. Community members described the behaviour of health staff at times as “militaristic,” characterized by a lack of sensitivity, confidentiality, and patient-centred communication. This perception discouraged some caregivers from seeking services or following vaccination schedules. “People don’t talk about vaccines because they lack information. “The health workers act like the military there’s no confidentiality, and that stops people from opening up” (Male participant, community dialogue, Kitosi, 2023).
Trust in vaccine campaigns was also shaped by collective memory and past experiences. One male participant recalled an incident from the early 2000s, where a vaccination campaign reportedly used the “wrong drug,” which deeply affected community perceptions of vaccine safety: “Communication about vaccines should be done with some sensitivity” (Male participant, Community dialogue, Busiro, 2023).
Similarly, a female participant linked low uptake of Hepatitis B vaccines to rumours about expired doses:
“They said the government brought expired vaccines that’s why people didn’t go for it” (Female participant, Community dialogue, Kitosi, 2023).
These accounts highlight how past communication failures and vaccine delivery errors real or perceived continue to shape present-day hesitancy, reinforcing the need for consistent, transparent, and culturally attuned vaccine messaging.
Structural-level factors: transport, geography, and livelihood constraints
Structural barriers such as poverty, long travel distances, and limited infrastructure constrained access to vaccination services. During transect walks, researchers observed that many residents lived in temporary wooden structures and lacked land ownership, reflecting economic hardship. The absence of shared markets and reliance on small-scale livelihoods such as fishing and farming have limited household income and made it difficult to prioritize healthcare over daily survival needs.
Stakeholders also acknowledged the presence of a government boat ambulance intended to support the referral system. However, they noted that the ambulance is often non-operational due to a lack of fuel. In emergency situations, patients and their families are typically asked to cover fuel costs, which many community members cannot afford.
Seasonal migration due to fishing disrupted the continuity of care. A health worker explained, “Service demand spikes during fish harvest months (March–June) and declines when fishmongers migrate (August–September)” (Stakeholder consultation, 2023), overwhelming the limited health infrastructure and workforce and leading to interruptions in vaccination schedules and follow-up care, respectively. These fluctuations in service demand make planning and consistent service delivery extremely difficult, often resulting in gaps in vaccine coverage and follow-up.
One male participant also described the trade-offs between health and survival: “We think about what to eat first. Vaccines are not urgent when children are not sick” (Community dialogue, Kitosi, 2023).
Environmental and Biological Contexts: Disease Burden and Unmet Needs
Koome Island suffers from poor sanitation, reliance on untreated lake water, and limited access to diagnostic services. A local leader highlighted, “Typhoid is misdiagnosed because clinics don’t have the tools for proper tests” (Stakeholder consultation meeting, 2023).
Communities also reported the resurgence of schistosomiasis following a mass drug administration campaign, with no medicines currently available. “All conditions here are serious because people cannot easily access care,” summarized one local leader (Stakeholder consultation meeting, 2023). Local leaders mentioned a previous mass drug administration programme in which praziquantel was distributed, which temporarily reduced the incidence of schistosomiasis. However, they reported that the disease has since re-emerged, and no medications are currently available at the Health Centre III to manage new cases.
System-level progress and gaps in immunization
People in the community shared that even though the government has added new vaccines, such as those for pneumonia and diarrhea, there are still many challenges. From the community feedback, these gains have not fully addressed the challenges faced in remote settings such as Koome Island. The participants described persistent gaps in outreach, communication, and trust in vaccination efforts. Reflecting on the COVID-19 vaccine, one participant explained, “It was the silent law. People wouldn’t have taken it otherwise. That’s why booster uptake is low now” (Community dialogue, Busiro, 2023). This response illustrates how perceived coercion, rather than trust or understanding, can drive initial vaccine uptake, undermining longer-term acceptance.
Discussion
The situational analysis of Koome Island reveals complex and interconnected factors that shape vaccine uptake and health-seeking behaviours within the community. These findings align with both local realities and broader public health frameworks, offering valuable insights into the challenges and opportunities for improving vaccination rates and overall health outcomes. Using SEM was particularly appropriate for this formative phase of the VAnguard study. It enabled us to map and interpret emerging patterns across different levels of influence, i.e., individual, interpersonal, community, health system, and structural, and to identify leverage points for future community-based interventions.
At the individual level, the study revealed that while awareness of polio vaccines was relatively strong, likely due to past national campaigns, knowledge of the full childhood immunization schedule remained limited. This aligns with a study conducted in Kampala District, Uganda, which revealed that caregivers' lack of information about immunization schedules is a significant barrier to vaccine uptake. The study revealed that nearly all parents cited a lack of information on when their children should receive subsequent vaccines as the reason for missing some or all scheduled vaccinations [7]. The participants on Koome Island also expressed concerns about vaccine safety and misconceptions, such as the belief that completing certain vaccines may cause goiter or infertility. These individual-level knowledge gaps, combined with fears of side effects and limited access to reliable health information, contribute to vaccine hesitancy and underutilization.
At the interpersonal level, household dynamics, particularly gender roles and caregiving responsibilities, also shaped vaccine uptake. Women were primarily responsible for ensuring that children’s health needs were met yet often lacked decision-making autonomy within households. This gendered division of labour constrained access to vaccination services, especially when women faced competing demands on their time or lacked support from male partners. These findings are consistent with research indicating that engaging fathers in child health improves immunization coverage and broader health outcomes [11]. Concerns about the HPV vaccine were also pronounced, with some community members associating it with infertility, an association that mirrors findings from other African settings, including South Africa and Nigeria [22, 23].
At the community level, social norms, religious beliefs, and collective memory play significant roles in shaping vaccine attitudes. Myths, disinformation, and misinformation are commonly shared through social networks, and these narratives often reinforce fear and mistrust. This finding is consistent with a recent study from Kampala, which revealed that widespread rumours about COVID-19 vaccines were a key driver of hesitancy [12]. On Koome Island, historical perceptions of vaccine errors such as the administration of the “wrong drug” or expired vaccines persisted in community memory and continued to shape attitudes. The participants also expressed the need for “real-life examples” of people who had benefited from vaccines to reinforce trust. This approach aligns with findings from [39], who argue that community engagement and relatable storytelling are effective ways to counteract misinformation and build vaccine confidence.
Health system constraints such as vaccine stockouts, limited cold chain storage, and poor outreach capacity continue to undermine trust in vaccination programs. These challenges, also documented in rural districts such as Hoima [10], were reported on Koome Island. Health workers reported logistical limitations, including fuel shortages and transport difficulties, especially during peak fish harvesting seasons when the demand for services spikes.
Moreover, caregivers highlighted inadequate pre- and postvaccination communication, particularly regarding side effects, which led to increased anxiety and reduced confidence in vaccination services. The authoritarian or “militaristic” communication style of some health workers further discourages service use, underscoring the importance of patient-centred approaches.
Structural barriers, particularly those related to geography, transport, and livelihoods, further complicate vaccine access. Like other remote Ugandan settings [10], the Koome Island population faced long travel distances, poor terrain, and seasonal migration patterns that disrupted continuity of care. These constraints make it costly or logistically impossible for some households to reach health centres, especially during the rainy season. Additionally, the transient nature of fishing livelihoods means that families are often mobile, making it difficult to adhere to scheduled immunizations.
The health challenges on Koome Island are compounded by poor environmental sanitation and high disease burden. Residents relied heavily on untreated lake water, and many lacked access to functional latrines. Such an environment increases the prevalence of waterborne diseases and helminth infections, including schistosomiasis, which is an ongoing concern in Uganda’s lake regions [27]. A nationally representative study reported a schistosomiasis prevalence of 25.6%, with young children being particularly affected [28]. These environmental health risks, combined with drug stockouts and a lack of diagnostic capacity, have placed significant pressure on the local health system and diverted attention from preventive services such as vaccination.
Implications for Policy and Practice
This situational analysis provided valuable insights that contributed significantly to the strategic progression of VAnguard study. As a key component of the formative phase conducted on Koome Island, it served as an essential groundwork for understanding the local realities shaping vaccine uptake in hard-to-reach settings. These insights played a foundational role in refining the design of the ethnographic and participatory components of the broader VAnguard project. The situational analysis directly informed the stakeholder mapping and analysis, community engagement strategies, identification of priority themes for deeper inquiry (e.g., trust, household decision-making, access barriers, health worker communication), and selection of communities to engage in the formative phase of the study.
Importantly, the findings from Koome Island were also instrumental in shaping the VAnguard community survey, which was subsequently conducted in the Namayingo, Kawaala, and Kikuube districts as well as in Kenya. This learning has influenced the formulation of survey tools, question wording, and domains of interest, particularly concerning livelihood constraints, health-seeking behaviour, perceptions of vaccine safety, and structural access issues. The situational analysis also helped determine sampling strategies that accounted for geographic isolation, mobility patterns, and local social dynamics, ensuring that the survey was both context responsive and inclusive.
From a policy and practice perspective, this study underscores the value of embedding situational assessments early in complex health interventions, particularly in under-researched or hard-to-reach communities. This highlights the need to strengthen infrastructure and health worker support, improve vaccine supply and delivery mechanisms, engage local leaders and informal opinion networks to build trust, and address misinformation through trusted, community-based communication channels.
By grounding subsequent phases of the study in lived experience, the situational analysis ensured that the research instruments were ethically appropriate, locally relevant, and systematically informed.
Strengths and Limitations
A
This situational analysis used a participatory and multi-method approach combining stakeholder consultations, community dialogues, transect walks, participatory mapping, informal conversations, and observations. This enabled us to capture diverse perspectives and contextual factors influencing vaccine uptake across different levels of the socio-ecological model. Involving local leaders and Village Health Teams strengthened trust and helped to ensure culturally appropriate engagement.However, the study has some limitations. First, much of the engagement was documented through field notes and summaries rather than audio-recorded transcripts, which limited verbatim quotations. This choice was made to promote participant comfort and openness but constrains the depth of textual data. Second, because the situational analysis was exploratory and preparatory in nature, the findings are not statistically generalisable. Finally, logistical challenges, including the remoteness of Koome Island and limited time for community engagement, may have affected the breadth of perspectives captured. Despite these limitations, the systematic use of reflective journaling, note-taking, and team-based coding helped strengthen the reliability of the findings.
Conclusion
The challenges identified in Koome Island align with broader findings from other hard-to-reach populations. Studies in similar remote, fishing, and island communities [3, 27] have noted that physical access barriers, myths, disinformation and misinformation, distrust in the health system, and health worker communication styles are recurring determinants of low vaccine uptake.
A
While these findings largely reinforce the literature, this study underscores the particularly strong influence of local community structures, such as VHTs and religious leaders, in shaping vaccine uptake. Additionally, the pronounced mobility of the fishing population and the importance of culturally sensitive, locally tailored communication emerged as areas where targeted, context-specific interventions may be especially effective. These insights suggest that although the barriers are well documented, focused efforts to empower local actors and adapt service delivery models to community rhythms could be especially useful in improving vaccine coverage in similar settings.List of abbreviations
CAO
Chief Administrative Officer
COVID-19
Coronavirus disease 2019
DHO
District Health Officer
DHMT
District Health Management Team
EPI
Expanded Program on Immunization
HPV
Human Papillomavirus
LC1
Local Council Chairperson 1
LCIII
Local Council Chairperson III
LMICs
Low- and Middle-Income Countries
KEMRI
Kenya Medical Research Institute
NIHR
National Institute for Health and Care Research
PCV
Pentavalent, Pneumococcal Conjugate
REC
Research Ethics Committee
SEM
Socioecological Model
UNEPI
Uganda National Expanded Program on Immunization
UVRI
Uganda Virus Research Institute
VAnguard
The (NIHR) Global Health Research Group on Vaccines for vulnerable people in Africa
VHT
Village Health Teams
WHO
World Health Organization
Declarations
Ethics approval and consent to participate
A
A
The situational analysis was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and adhered to national and institutional guidelines for research involving human participants. A
Ethical approval for study activities was obtained from Uganda Virus Research Institute Research Ethics Committee (UVRI-REC), Ref: GC/127/966, the Uganda National Council for Science and Technology (UNCST, Ref: HS2901ES), and LSHTM-REC (Ref: 29672). Written consent was waived by the UVRI-REC (Ref: GC/127/966). However verbal informed consent in line with the Uganda National Guidelines for Research Involving Humans as Participants [41], was sought from participants who were engaged during community dialogues, transect walks, participatory mapping, stakeholder consultations, and informal conversations.Consent for publication
Not applicable.
A
Data Availability
The data generated and analysed in this study are not publicly available to protect participant confidentiality and to comply with the ethical requirements of the Uganda Virus Research Institute Research Ethics Committee (UVRI-REC). However, de-identified data may be made available upon reasonable request to [regulatory@mrcuganda.org] and with approval from the UVRI-REC.
A
Funding
This work was funded by the National Institute for Health and Care Research (NIHR), Award No. 134531, through UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care.
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Author Contribution
WE actively involved in the investigation, project administration, and supervision of fieldwork. She contributed to the methodology, validation, and visualization, and was responsible for the original draft preparation and review and editing of the manuscript. FZ contributed to the conceptualization of the study and was actively involved in the investigation, methodology development, and resource coordination. She also supported visualization, original draft writing, and critical review of the manuscript. EAO participated in methodology development and validation and contributed to the original draft and manuscript revisions. LK supported investigation, project administration, methodology, and validation. She contributed to the visualization and drafting of the manuscript. DN contributed to investigation, methodology, validation, and visualization, as well as to the original drafting and review of the manuscript. NM provided supervision and project administration support and contributed to validation, methodology, and manuscript review. LZ was involved in conceptualization, resource provision, project administration, and supervision, as well as validation and critical manuscript review. HL supported investigation, validation, and reviewing and editing the manuscript. AK supported the investigation and supervision, contributed to methodology and validation, and participated in original draft preparation and review. MC contributed to conceptualization, funding acquisition, supervision, and validation, and was actively involved in reviewing and editing the manuscript. PK supported conceptualization, funding acquisition, and resource mobilization, and contributed to supervision and manuscript review. AE contributed to conceptualization, funding acquisition, project administration, and supervision, and participated in manuscript review. DK supported conceptualization, funding acquisition, and project administration, and was involved in supervision, validation, and manuscript review. PC led data curation and formal analysis, and contributed to conceptualization, funding acquisition, investigation, methodology, project supervision and writing the original draft and reviewing the manuscript.DKM led data curation and formal analysis, and contributed to conceptualization, funding acquisition, investigation, methodology, and project supervision. He also played a key role in writing the original draft and reviewing the manuscript.
All authors read and approved the final manuscript.
A
Acknowledgement
We extend our sincere gratitude to all members of the NIHR Global Health Research Group on Vaccines for Vulnerable People in Africa (VAnguard) for their invaluable support throughout the design and implementation of the situational analysis. We deeply appreciate the dedication of the management work package whose efforts were instrumental in facilitating data collection. Our heartfelt thanks also go to the district and subcounty leaders in Mukono, as well as the communities of Busiro, Kitosi, and Zingoola, for their time, trust, and meaningful collaboration.
Competing interests
The authors declare that they have no competing interests.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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