A Survey Exploring Reasons behind Immunization Refusal among the Parents and Caregivers of Children under Two Years Living in Urban Slums of Karachi, Pakistan

"[I]t is essential to build the trust of parents/caregivers regarding vaccine benefits, vaccine side effects, and vaccination schedules by providing vaccine-related education and information materials."

Compared to routine immunisation activities, Pakistan has historically reported a higher number of immunisation refusal incidents during mass immunisation campaigns and supplemental immunisation activities (SIAs). For this reason, Pakistan is still endemic to certain vaccine-preventable diseases (VPDs), such as polio and measles. This study examines the factors that influence the decisions of parents/caregivers regarding vaccination during SIAs in Pakistan.

A community-based door-to-door household survey was performed among parents and caregivers of children under 2 years of age who were residents of either Pathan Colony or Orangi Town, Karachi, from January 2019 to June 2019. In this study, the research team captured houses marked with an "R" (refusal) on the H-household chalking system used by the Expanded Program of Immunization (EPI) teams to identify vaccination activities performed by each vaccination team. Based on the presence or absence of a vaccination card, the research team identified two different types of refusals: true refusal (households who did not show vaccination cards at the time of visit, which means they were not given a vaccination card because they did not bring their children for routine immunisation) and potential refusal (households who refused child vaccination from the mobile vaccination team during the SIAs but who showed vaccination cards to the research team, meaning that they may have been vaccinated at a health centre).

The "R" households were approached using a 30 × 7 multistage-stratified-cluster random sampling technique and were interviewed using a structured questionnaire. A total of 230 "R" households consented to participate in this study, of which 141 (61.3%) represented true refusals, while 89 (38.7%) represented potential refusals.

The reasons for not vaccinating among true refusals were the cost, side effects and contraindications of vaccines, rumours, and alternative medicines. However, the distance to clinics, limited clinic hours, community/religious leader influence, and a lack of trust in the government were mainly reported by potential refusals. Both true and potential refusals reported that new vaccines are not safe for the health of their children.

After adjusting for confounders, factors associated with lower immunisation refusal odds were: advanced paternal age, a long distance to the clinic (which signifies that parents appreciate the door-to-door vaccination service), and the influence of community/religious leaders (indicating the promotive role of these leaders in effectively implementing the immunisation programme). On the other hand, the use of alternative medicines and a history of adverse events following immunisation (AEFIs) were associated with increasing the odds of immunisation refusals by four-to-five fold.

Thus, an unawareness about self-limiting vaccine-related adverse events, the use of alternative medicines, and an increased concern about the safety and efficacy of vaccines were found to be barriers to immunisation, which can be improved by increasing public awareness through media campaigns and policy reform. In conclusion, the researchers assert that health education could "expand immunization adherence and immunization acceptance among the refusals".