Low vaccination in rural Sindh, Pakistan: A case of refusal, ignorance or access? Durenaz Jamal a , Shehla Zaidi b,⇑ , Sara Husain c , David W. Orr d , Atif Riaz b , Asif A. Farrukhi e , Rabia Najmi e a Expanded Program on Immunization-WHO Sindh, Pakistan b Department of Community Health Sciences and Women & Child Heath Division, Pakistan, Aga Khan University, Karachi, Pakistan c Department of Paediatrics and Child Health Aga Khan University, Karachi, Pakistan d Mott MacDonald, London, United Kingdom e Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan article info Article history: Received 3 December 2019 Received in revised form 18 April 2020 Accepted 6 May 2020 Available online 25 May 2020 Keywords: Vaccine hesitancy Access Routine immunization Community perceptions Polio Pakistan abstract 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 work- ers (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 chal- lenges 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 usu- ally 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, intermit- tent 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. Ó 2020 Elsevier Ltd. All rights reserved. 1. Introduction An estimated 21.8 million children worldwide are not fully immunized, with the majority of these children residing in low-income countries, including Pakistan [1]. Pakistan’s routine childhood immunization rate remains sub-optimal as only 66% of 12–23 months of age children are fully immunized, 4% are unimmunized and the remainder have incomplete vaccinations. The figures also mask significant inter-provincial variability with incomplete vaccinations being the norm in several geographical clusters [2]. Pakistan has experienced recent repeated outbreaks of vaccine preventable diseases (VPDs) such as measles as well as a rising number of Polio cases, raising serious concerns about the ability of the Expanded Program of Immunization (EPI) to deliver timely vaccinations to eligible children. This is also a cause for https://doi.org/10.1016/j.vaccine.2020.05.018 0264-410X/Ó 2020 Elsevier Ltd. All rights reserved. ⇑ Corresponding author at: Department of Community Health Sciences and Woman & Child Health Division, Aga Khan University, National Stadium Road., Karachi, Pakistan. E-mail address: Shehla.zaidi@aku.edu (S. Zaidi). Vaccine 38 (2020) 4747–4754 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine