Low vaccination in rural Sindh, Pakistan: A case of refusal, ignorance or access?

Introduction: Pakistan is suffering from low routine childhood immunization (RI) coverage, meriting a systematic examination of community acceptance and barriers towards vaccination with a view to inform responsive strategies. We examine community perspectives on RI for children 0–23 months of age, unveiling community beliefs, health systems barriers and willingness to actively seek immunization services. Methods: A qualitative study was conducted in the rural under-resourced district of Tando Muhammad Khan of Pakistan's Sindh province. 12 focus group discussions were conducted to probe immunization perceptions and experience: 6 with female caregivers of children <2 years and 6 with Lady Health workers (LHWs). An adapted Health Access Livelihood Framework guided data collection, qualitative data were thematically coded using inductive analysis and findings were triangulated across caregivers and LHWs. Results: Caregivers were either indifferent to vaccination or had an unmet need to know more, with few reporting outright refusals to vaccinate. Caregiver beliefs were characterized by a lack of awareness and a confusion of RI with Polio and a fear of side effects. Religious beliefs were not major considerations. Second, health systems issues of hurried and infrequent vaccination encounters, driven by LHWs’ poor capability to handle the vaccine counter-narrative, interrupted vaccine delivery to villages. These challenges were exacerbated by interruptions due to the Polio campaigns. Third, time and public transport constrained access to the Extended Program on Immunization centers. However, female caregivers usually took decisions on vaccination without recourse to male household members, with child's health viewed to be the main concern. Conclusions: An ineffective vaccination narrative, low LHW capability and prioritization of RI, intermittent outreach vaccination encounters, and overshadowing of RI activities by Polio campaigns limit the uptake of childhood RI services. We contend that critical attention is required for post-immunization messaging, client-centric services, positive immunization experiences and the availability of vaccination encounters.