Prevalence and Associated Factors of Parental Refusal Rates for Routine Immunisation: A Cross-sectional Study in Peshawar, Khyber Pakhtunkhwa, Pakistan-2024

"[V]accine hesitancy has emerged as a significant barrier to achieving optimal vaccination coverage, especially in areas with deep-rooted cultural, religious, and socio-economic influences..."

Vaccine hesitancy is a serious public health problem globally, particularly in low- and middle-income countries (LMICs) like Pakistan. Peshawar, a district in Khyber Pakhtunkhwa, Pakistan that is categorised as having the highest number (n=18) of super-high-risk union councils (SHRUCs) by the polio eradication initiative, exhibits low levels of immunisation, despite the availability of vaccines and active promotion efforts by health authorities. High refusal rates in these areas continue to hinder progress in combating vaccine-preventable diseases (VPDs) in the region. This study aims to determine the vaccination refusal rate, associated factors and perceptions of parents who refused routine immunisation in Peshawar.

A cross-sectional study was conducted in July 2024 among parents of children aged 0-59 months. Data were collected using a structured vaccine hesitancy survey tool developed by the Strategic Advisory Group of Experts (SAGE).

Among 340 participants, 22% (n=74) refused vaccines for their children. The highest refusal rate was in Shaheen Muslim Town, where 41% of parents refused vaccination (p = 0.035). Parents who refused were less inclined to believe that vaccines protect children from vaccine preventable diseases (77% vs. 98%, p < 0.001) and expressed higher rates of vaccine hesitancy (47% vs. 29%, p = 0.003). Notably, 38.5% of parents in the study reported fear of adverse effects as a primary reason for vaccine refusal. This fear is particularly prominent in conservative and low-literacy communities where vaccine hesitancy is more widespread. 

A total of 15% employed mothers refused vaccines compared to only 4.5% unemployed mothers (p = 0.004). Multivariable logistic regression revealed that employed mothers were over 3 times more inclined to refuse vaccination (adjusted odds ratio (AOR): 3.11, 95% confidence interval (CI): 1.25, 7.67), while no significant association was found with the father's employment status.

Barriers, including distance from health facility and associated cost (AOR: 1.82, 95% CI:1.10,3.02), and concerns about the necessity of vaccines (AOR: 2.50, 95% CI: 1.45, 4.30) were significantly associated with vaccine refusal. Furthermore, the group that refused vaccination has a more concentrated distribution of lower food security scores, potentially indicating that food insecurity may contribute to the decision to refuse vaccination.

The results also showed that 84% of parents believe that community leaders support vaccinations, reflecting the significant role of social influence on health behaviours. This finding aligns with existing research suggesting that active community involvement, especially through leveraging support from both religious and non-religious influencers, enhances vaccine acceptance. Pakistan's National Immunisation Policy of 2022 outlines strategies to further involve community and religious leaders, philanthropists, and local influencers in supporting vaccination efforts. The policy emphasises the importance of interpersonal communication to encourage families to complete immunisation schedules.

Reflecting on the findings, the researchers note that, in SHRUCs, socio-cultural factors such as mistrust of government programmes, deeply rooted traditional beliefs, and susceptibility to misinformation often compound logistical challenges. For instance, religious interpretations that associate vaccines with foreign agendas have been reported in both Pakistan and other conservative LMICs, such as Afghanistan and Nigeria, where polio eradication efforts have faced resistance. Global health strategies must integrate culturally sensitive approaches to counteract these challenges effectively.

To address the gaps identified in the study, the researchers recommend that national immunisation policies focus on addressing vaccine hesitancy and improving access to vaccines. For example:
 

• Educational campaigns targeting parental concerns about vaccine safety and effectiveness to dispel misconceptions;
• Engaging community leaders, religious influencers, and healthcare professionals to build trust and foster acceptance of immunisation;
• Flexible vaccination services, such as extended clinic hours and mobile immunisation units, to reduce logistical barriers, especially for working mothers; and
• Workplace vaccination programmes to provide convenient options for employed parents, minimising missed opportunities for child immunisation.