Addressing Community Barriers to Immunization in Rajanpur District, Pakistan: An Implementation Research

"Strong demand for routine immunization across communities of diverse backgrounds is vital to ensure that children are fully immunized."

Global evidence suggests that the refusal to immunise is linked to the absence of clear communication practices at the community level. To that end, the National Communication Strategy for Routine Immunization Pakistan 2015-2018 suggested that some of the country's immunisation barriers can only be addressed with the effective use of communication with the community through group engagement and social mobilisation. The Expanded Program on Immunization (EPI) of Punjab province has faced an implementation challenge: low immunisation coverage in one of the districts, Rajanpur. Implementation research was carried out to explore the reasons for low acceptability for routine immunisation, as well as the appropriateness and relevance of EPI's social mobilisation activities.

As the researchers explain, the Rajanpur district's background characteristics make it distinct from other districts of the Punjab province in various ways. This district is home to the town of Kacha, as well as mix of tribal and rural areas that share a border with the other two provinces, Baluchistan and Sindh. The weather conditions (extreme winters and floods) affect the migration patterns of people residing in the mountainous area and river terrain, and the population migrates during harvesting seasons. Nearly 82% of the population is economically poor, with an average household size of 7. Only 14% of the population resides in urban areas, and the literacy ratio is very low, at 21%.

The researchers used an exploratory qualitative inquiry to explore community perceptions around routine immunisation and social mobilisation. Through a purposive sampling technique, trained interviewers conducted 24 in-depth interviews (IDIs) and 7 focus group discussions (FGDs) with community members/caregivers and healthcare providers in Kacha and in the rural and tribal areas of the Rajanpur district.

Selected findings:

• The level of acceptability for routine immunisation varies among economically poor communities of rural and tribal areas and in Kacha - from complete refusal to dropout. Examples of reasons cited include:
  • Some people said they are not comfortable with their children's fever following vaccination, particularly when the EPI does not provide any medication for that fever. In hard-to-reach areas (tribal areas), to access a health facility, people have to walk or travel by cart to cover a distance of 100 kilometres. After vaccination, when their children get a fever, people find it very difficult to travel back to the centre to seek paracetamol. Instead, parents seek treatment of fever from quacks, who are readily available but who strengthen their misconceptions about vaccination. As a sign of resistance, men lock their houses from outside, so no one can approach them to ask that they vaccinate their children. Mothers in the community believe that carrying a vaccine card is a precondition for immunisation. Therefore, they reason, losing the card can save their children from getting a fever.
  • In Kacha and tribal areas, infants stay inside the house with their mothers. As a norm, a stranger/male vaccinator cannot directly communicate with mothers. Almost every community has an objection to male vaccinators approaching their houses in the absence of male household members. Thus, areas where lady health workers (LHWs) are not appointed face the problem of low coverage. Communities expressed the need for more female vaccinators/staff.
  • In Kacha and tribal areas, social norms hold that women have restricted mobility, and they are not allowed to carry a mobile phone. As a practice, EPI sends a text message of the next due date of vaccination to men's mobile phones. Upon receiving a text message from EPI for the next due date, men who can read the message inform their wives about the next vaccination due visit; otherwise, this information is not communicated to mothers. The LHWs act like a communication channel for women, mobilising communities for immunisation services and providing health education to mothers who have limited schooling. In areas where LHWs are not appointed or not performing their duties, community women remain uninformed. Mainly, tribal areas are facing this problem.
  • Some people have refused vaccination in the Kacha area because the vaccination (e.g., measles, mumps, and rubella - MMR) is made in India.
  • Growing "conservatism" is another reason: Communities in Kacha are influenced by religious elements and, in some cases, blindly follow them. Some people in the Kacha area believe vaccines will cause their children's impotency later in life. They believe vaccination is motivated by genocide/a conspiracy against Muslims.
• Some methods developed to deal with these barriers include:
  • Engaging community leaders, who shape the opinion of parents - The EPI Rajanpur officials always seek their support when communities show resistance to EPI vaccinators. For instance, with the help of a tribal chief, the EPI staff brings the community to their Oatak (a sitting area where the chief holds meetings) for vaccination purposes. This strategy is described as helpful.
  • Engaging people from the "Choto Gang" (a criminal group) in the Kacha area. The EPI has leveraged these people to mobilise economically poor communities in Kacha and to provide protection to the EPI team in their respective areas. The EPI Rajanpur has given them some monetary incentives to encourage their community mobilisation activities.
  • Leveraging vaccinators to communicate and motivate the community regarding the immunisation services, which varies from vaccinator to vaccinator. As a common practice, vaccinators make announcements on loudspeakers to inform the community about the immunisation services. They also visit community members at their workplace to ask them to pass on the vaccination message to their families.
• Community perceptions about appropriateness and relevance of social mobilisation. Sample findings:
  • The community has expressed mixed opinions about the attitude of vaccinators. In areas where vaccinators have displayed a good attitude, people are willing to listen to them and comply with vaccination services, as affirmed by EPI officials from the Rajanpur district. In areas where people were uncomfortable with the attitude of a vaccinator, they refused. The community members attributed their lack of knowledge of vaccination to the behaviour of the vaccinator. They mentioned that the vaccinator's sole communication was to "bring your children for drops/injection", which was not sufficient to meaningfully inform them about vaccination.
  • The absence of community involvement has created a communication gap between the community and the EPI programme. The EPI Rajanpur seeks community support for troubleshooting purposes only. For instance, in rural areas, women who work in the fields generally do not know who comes for vaccination and at what time. There are also no "community sessions" held to inform them about immunisation services or the location of EPI camps. The majority of women do not know about the importance of vaccination.
• Healthcare staff's perceptions about the appropriateness and relevance of social mobilisation - for example:
  • Community mobilisation for vaccination services is an expected function of the vaccinators' job. EPI Rajanpur officials reported that EPI Punjab has facilitated their mobility/ability to perform this function through the provision of a motorbike and 15 litres of fuel per month, as the population is scattered across a large area. They further mentioned that these vaccinators commute on a daily basis to interact with the communities for immunisation coverage, but there are logistical barriers with accessing the intended population.
  • Vaccinators are not skillful in social mobilisation tasks. They are not formally trained on how to communicate with communities and do not know how and what activities to perform for social mobilisation. They have improvised social mobilisation activities by themselves. These activities are mainly centred around approaching decision-makers (e.g., fathers, LHWs, the tribal chief, or other influential people) to seek their support in influencing mothers to vaccinate their infants. The vaccinators find it challenging to mobilise communities for vaccination services by merely relying on these decision-makers.

Thus, these findings indicate that the cultural and social differences among economically poor communities of Kacha, as well as rural and tribal areas of Rajanpur district, have caused low acceptability of immunisation services - from complete refusal to dropout. This problem stems from the absence of adequate communication and social mobilisation activities. Structural issues related to human and financial resources have also compromised demand creation interventions for routine immunisation and result in low coverage of immunisation in the study district.

There is an evident need for vaccinators' capacity-building to strengthen their interpersonal communication skills and provide them with updated knowledge to gain community trust and respect, the researchers stress. Furthermore, there is a need to engage communities systematically, rather than on an ad-hoc basis, and to ensure that women are not left out of social mobilisation activities. Specifically, the researchers recommend:

• Integration of the social mobilisation strategy into EPI planning;
• Structural and partnership support for the social mobilisation into the EPI;
• Capacity-building of field staff;
• Community engagement (to scan their social environment, identify community priorities, study their behaviours, learn their communication channels, and identify a space for EPI communication); and
• Appointment of more female staff/vaccinators.