Exploring the Reasons for Defaulting from Childhood Immunization: A Qualitative Study in Pakistan

"Addressing the reasons behind defaulting is crucial to improve vaccination rates."



Data from Pakistan reveal that only 66% of children aged 12-23 months receive complete immunisation, marking the lowest rate among the countries in the subcontinent. There are multiple factors contributing to low vaccination rates among children. This study explores the reasons for defaulting from the expanded programme on immunisation (EPI) in district Swat, Pakistan. District Swat, being a neglected and marginalised region in Khyber Pakhtunkhwa, faces unique challenges due to its rugged terrain, hilly areas, and freezing weather, making it difficult for vaccinators to conduct outreach sessions and for the community to visit the health facility for vaccination. The district was previously hit by terrorism and militancy, which severely affected the functioning of the health system. Vaccinators and lady health workers (LHWs) were threatened to be killed if they conducted field visits for vaccination.



From March to September 2022, researchers conducted 36 in-depth interviews with caregivers with children under the age of two who had not completed their children's vaccination. The collected qualitative data were analysed thematically to identify key patterns and themes related to the reasons for defaulting from the childhood vaccination schedule.



The study identified six main themes and four subthemes as reasons for defaulting, which are described in detail in the paper. In brief, they include:

1. Illness of the defaulter child at the scheduled time: Participants believed that administering vaccines during illness might exacerbate the child's discomfort. The interviews revealed that malnourished children were not given vaccines, but proper counselling could have led to timely vaccination. Per the researchers, health workers should address parents' concerns and provide information about vaccine contraindications to reduce missed vaccination opportunities.
2. Perceived side effects of the vaccination: Most of the participants were worried about adverse events following immunisation (AEFIs). Participants were asked whether their child or any other child they knew had experienced any side effects following vaccination. Thirteen out of the 36 participants responded affirmatively. The most commonly reported AEFI was fever. "Poor counselling by the vaccinator regarding these adverse effects resulted in participants leaving the program."
3. Factors related to caregivers: Among the majority of participants (23 out of 36), incomplete vaccination was acknowledged as a result of parental neglect rather than deliberate refusal. The interviews revealed four subthemes here:
   • Lacking a clear understanding of the completion of vaccination: Despite being aware of the significance of vaccination and its timely completion, the parents' carelessness resulted in their child not receiving a complete schedule of vaccinations.
   • Low priority for child's vaccination: Some participants said they were unable to take their child to the vaccination centre due to other competing priorities, such as work obligations.
   • Cultural restrictions on mothers: Four participants highlighted that mothers of children were required to be accompanied by a male family member when visiting vaccination centres, as per cultural norms. This restriction posed a barrier to mothers accessing vaccination services independently and contributed to their inability to comply with the vaccination programme.
   • Loss of vaccination card: Incomplete documentation confuses caregivers and parents about the vaccination schedule, leading to children missing doses. Two participants mentioned their children's vaccination cards being with the local LHW, leaving them unaware of the next vaccination date. Proper documentation and communication are vital to avoid such issues and ensure timely vaccinations.
4. Myths and misconceptions: Six out of thirty participants expressed reservations about the vaccination programme. Despite receiving the initial doses of vaccines for their children, they were uncertain about continuing the vaccination process due to misconceptions and doubts, such as being unsure about the undisclosed motives foreign countries might have in children's vaccination. Lack of awareness about vaccine constituents also negatively impacted community trust in vaccinations. Some participants believed vaccines could cause sterility or early puberty in the future.
5. Vaccinators' attitudes and crowded vaccination centres: People avoided visiting vaccination centres because of negative experiences with vaccinators, including rude behaviour and inappropriate injection techniques. Long waiting times and overcrowded vaccination centres were also cited as factors contributing to child defaulting from the immunisation programme.
6. Poor immunisation service arrangements: Three participants reported that their children were not at home on the scheduled vaccination dates. When asked why they did not vaccinate their child in the adjacent union council (UC), two of them were unaware that vaccination could be done in another UC. The lack of proper and timely conduction of outreach sessions was another factor: Community members reported waiting for the next outreach session but were unaware of the date for the upcoming session.

According to the study's findings, caregivers in Swat, Pakistan have their own perceptions regarding the non-completion of their children's vaccination schedule. The vaccination completion rate may be increased if the concerns of the caregivers are appropriately addressed.