Unveiling and addressing implementation barriers to routine immunization in the peri-urban slums of Karachi, Pakistan: a mixed-methods study

Abstract

Background Great disparities in immunization coverage exist in Pakistan between urban and rural areas. However, coverage estimates for large peri-urban slums in Sindh are largely unknown and implementation challenges remain unexplored. This study explores key supply- and demand-side immunization barriers in peri-urban slums, as well as strategies to address them. It also assesses immunization coverage in the target slums. Methods Conducted in four peri-urban slums in Karachi, this mixed-methods study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12–23 months, and 155 in-depth interviews (IDIs) through purposive sampling of respondents (caregivers, community influencers and immunization staff). After identifying the barriers, a further six IDIs were then conducted with immunization policy-makers and policy influencers to determine strategies to address these barriers, resulting in the development of an original validated implementation framework for immunization in peri-urban slums. A thematic analysis approach was applied to qualitative data. Results The survey revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated. Demand-side immunization barriers included household barriers, lack of knowledge and awareness, misconceptions and fears regarding vaccines and social and religious barriers. Supply-side barriers included underperformance of staff, inefficient utilization of funds, unreliable immunization and household data and interference of polio campaigns with immunization. The implementation framework’s policy recommendations to address these barriers include: (1) improved human resource management; (2) staff training on counselling; (3) re-allocation of funds towards incentives, outreach, salaries and infrastructure; (4) a digital platform integrating birth registry and vaccination tracking systems for monitoring and reporting by frontline staff; (5) use of digital platform for immunization targets and generating dose reminders; and (6) mutual sharing of resources and data between the immunization, Lady Health Worker and polio programmes for improved coverage. Conclusions The implementation framework is underpinned by the study of uncharted immunization barriers in complex peri-urban slums, and can be used by implementers in Pakistan and other developing countries to improve immunization programmes in limited-resource settings, with possible application at a larger scale. In particular, a digital platform integrating vaccination tracking and birth registry data can be expanded for nationwide use.

Nomadic and Rural Population of Balochistan: Exploring the Pockets of Poor Childhood Immunization in the Most Under-Vaccinated Province of Pakistan

“…Similar picture was seen in a study carried out by Jamal et al, in rural Sindh [11]. Yazdani et al, surveyed peri-urban slums of Karachi and reported that 51% of children had poor vaccination (missed one or more of vaccinations) and 49% were completely vaccinated which is sharply different from our findings [7]. Karachi is the biggest city of Pakistan with easy accessibility and better resources than far flung underprivileged provinces like Balochistan, resulting in better routine immunization uptake in such cities.…”

“…Main reasons held responsible are poor awareness, hesitancy, false beliefs, poor coverage and religious refusals in other studies of Pakistanwith varying immunization coverage rates [2,6]. Great variations in childhood vaccination coverage exist among provinces and also in rural and urban population [7]. Pakistan has poor cumulative vaccination coverage of children reported 66% recently, which is much lower than desired rate [8].…”

Factors associated with accessing and utilisation of healthcare and provision of health services for residents of slums in low and middle-income countries: a scoping review of recent literature

“…Cultural and religious factors: These included religion41 56 59 69 75 114 128; sociocultural influence93 101 such as exposure to media79 97; stigma associated with unplanned/extramarital pregnancy,78 93 postpartum depression129 and other illnesses such as contagious skin disease, barrenness and female sexually related problems101; and use of traditional/home medicine 75 86 99. Women in slums could not go to hospital because they had difficulties in disclosing the symptoms, postponed their health issues because of their responsibilities at home and engaged in self-treatment practices such as home remedies recommended by grandmother and friends because of sociocultural influences towards healthcare-seeking behaviour 77.…”

“…Lack of community-based care (such as school-based education for reproductive health and community support networks for women),132 unreliable immunisation and household data128; and inefficient utilisation of funds,128 affordability (price) and availability of medicine,140 limited medical supplies73 135 and infrastructural facilities,135 inadequate space and equipment,136 139 suboptimal training of staff,139 insufficient availability of logistics and health manpower139 also affected service provision (table 3).…”

Community engagement to increase vaccine uptake: Quasi-experimental evidence from Islamabad and Rawalpindi, Pakistan

“…A prior study on routine immunizations in urban slums of Pakistan found that source of information also plays an important role in shaping trust and risk perceptions of vaccines [44]. Given the social norms and inaccurate information especially in low-income settlements, people might not get vaccinated due to social hesitancy regarding COVID-19 vaccination.…”