Understanding Structural Determinants of Zero-Dose Children in Urban Slum Communities of Pakistan

Background

Zero-dose children (ZDC) face an unacceptably high risk of illness and death from vaccine-preventable diseases ⁽¹⁾. Pakistan is one of the 10 countries that account for over half of the world’s ZDC ⁽²⁾. In 2023, there were an estimated 396,000 ZDC and 925,000 un- and under vaccinated children in the country ⁽³⁾. While national coverage of diphtheria, tetanus and pertussis-containing vaccine has remained relatively constant ⁽³⁾, coverage is highly variable across urban, rural and peri-urban areas and among marginalized groups ⁽⁴⁾.

Rates of competed childhood immunizations are much lower in low-income urban communities in Pakistan than other areas ⁽⁵⁾. People living in urban slum communities in Pakistan also face multiple deprivations and lack access to basic healthcare services. However, there is limited information on actual estimates of ZDC in these communities, the structural determinants contributing to ZDC and why the system is failing to reach ZDC despite rigorous vaccination campaigns. In this context, structural determinants refer to factors such as vaccine misinformation, community attitudes to vaccination, local norms and traditions, the availability of immunization services, and attitudes of healthcare professionals, in addition to socioeconomic factors that affect access to vaccination.

Consequently, a project was undertaken by the National Institute of Health in Pakistan to understand and characterize the structural determinants of ZDC in urban slums communities in the country.

Research Question and Study Objectives

The study aimed to formulate the conceptual understanding of structural determinants of ZDC in urban slum communities in Pakistan.

Key Objectives: 

• Determine the prevalence of ZDC in children aged 12–23 months in selected urban slum communities in Pakistan. 

• Evaluate the socioeconomic determinants of ZDC in these communities. 

• Assess the political determinants influencing ZDC. 

Study Population 

Target Groups: 

• Parents/caregivers of children aged up to 23 months. 

• Healthcare staff of EPI (Expanded Programme on Immunization) facilities serving these communities. 

• Community influencers. 

• Administrative staff of the respective union councils. 

Methodology

This was a cross-sectional study utilizing a mixed-methods approach to understand the structural determinants of ZDC among urban slum communities in seven cities. The study was conducted over 18 months, from March 2023 to August 2024. Data collection included:

• Semi-structured survey questionnaire targeting social and behavioral drivers of vaccination.
• In-depth interviews with members of the urban slum communities.

Study Tools 

The World Health Organization’s (WHO’s) Behavioural and social drivers of vaccination (BeSD) tool was used to collect qualitative and quantitative data from the respondents, after translation into local languages ⁽⁶⁾. WHO defines the BeSD of vaccination as beliefs and experiences specific to vaccination that are potentially modifiable to increase vaccine uptake ⁽⁶⁾. The BeSD of vaccination are grouped and measured in four domains:  

1. Thinking and feeling about vaccines 
2. Social processes that drive or inhibit vaccination 
3. Motivation (or hesitancy) to seek vaccination 
4. Practical issues involved in seeking and receiving vaccination 

Questionnaires were designed around the BeSD tool to collect information on vaccination coverage, characteristics of the parent/caregiver, characteristics of households and political determinants of vaccination.  

Sampling technique

Two slums from each of the seven cities were identified using simple random sampling. A two-stage cluster sampling technique, as described in the WHO cluster vaccination coverage survey methodology ⁽⁷⁾, was used to select the households from the identified urban slums of the seven cities. The process was facilitated by the official list of urban slum communities from the Expanded Programme on Immunization (EPI) and the available maps of these slums in which all households of the cluster were enlisted and mapped. In addition, healthcare staff of the EPI facilities of these slums and administrative staff of the respective union councils were selected via convenience sampling technique for in-depth interviews.  

Study procedures

After receiving approval from the Ethical Review Board of NIH, the Pilot testing of the quantitative questionnaire was conducted in an urban slum of Islamabad. The field teams were trained on collecting data from the respondents in the local language to standardize data collection. Field teams used the printed questionnaire for face-to-face interviews of the parents/caregivers of children under 2 years of age. The EPI cards of the children were checked to determine immunization status and if cards were not available, then the parent/caregiver was asked to recall this information. Data were collected by field teams after they received formal informed consent from the respondents. Later, trained teams visited each city to train the data collection staff on the tool. The data collectors were identified by the EPI team and included a female health worker and community member.  

In-depth interviews were also conducted to explore the views and practices of healthcare workers, Community influencers and parents/caregivers around vaccination using the qualitative BeSD tools. In-depth interviews with healthcare (EPI Program managers)  and administrative staff were also conducted to understand vaccine demand, availability and factors affecting acceptance, hesitancy and non-acceptance of routine childhood immunization.  

Data Analysis 

Initially, data from each city were compiled into Excel sheets. After data cleaning, the data were exported to SPSS for data analysis. Descriptive analyses were conducted to describe findings, including percentages and frequencies of the key quantitative variables. Thematic analysis of the in-depth interviews was also undertaken by the research team.  

Findings 

A total of 2310 households were interviewed in the urban slums across the seven major cities in Pakistan. The number of respondents by city is shown in Table 1. 

Table 1. Distribution of respondents by city (N=2310)  

Vaccination coverage and prevalence of zero-dose children

Across the study sites, the highest proportion of ZDC was reported in the Karachi urban slum area (54.61%), followed by Peshawar (21.5%) and Gilgit (14.2%). The distribution of ZDC by study city is shown in Figure 1. 

Figure 1. Proportion of immunized and zero-dose children under 2 years of age among urban slum communities in Pakistan  

Across study sites, the majority (69%) of zero-dose children were aged 6–18 months (Figure 2).  

Figure 2. Distribution of zero-dose children by age across study sites 

Among children under 2 years overall, 11.3% were zero-dose, while 29.3% were partially immunized and 59.4% were fully immunized. 

Structural determinants of zero-dose children

Figure 3 shows responses across the priority indicators of the BeSD tool. Around 72% of parents/caregivers reported confidence in the benefits of vaccination. Overall, 82% of parents/caregivers reported that they want their child to receive all recommended vaccines. 

Figure 3. Parent/caregiver confidence in vaccine benefits and intention to get children vaccinated 

In the domain of “Thinking and Feeling”, 72% of parents/caregivers thought that vaccines are safe and beneficial for their children, while 75% of parents/caregivers trusted the health workers involved in vaccination. In the domain of “Social Processes”, 72% of mothers from the slum communities said that they do  need permission to take their child for vaccination. In 96% of cases, health workers recommended that the family get their child vaccinated.  

In terms of practical issues, most parents/caregivers knew where to go to get their child vaccinated (98%), and around 89% of parents/caregivers have taken their youngest child for vaccination. In addition, 82% of parents/caregivers reported that it is easy for them to pay for these services, as healthcare facilities were not far from the slum and the EPI services are free of charge. Overall, 59.4% of parents/caregivers were very satisfied with the vaccination services and 16.5% were moderately satisfied. However, in terms of service quality, 8.2% of parents/caregivers said that a vaccine was not available when they visited the health facility and a further 8.7% reported a long waiting time at the facility.  

In terms of motivation to get the recommended vaccine, around 59% of parents/caregivers were motivated to get all vaccines for their child. Around 29% were in the favor of getting some of the recommended vaccines, while 11.3% of parents/caregivers were not in the favor of getting their child vaccinated. 

Across parents/caregivers of ZDC, none of the respondents thought that vaccines are important for the health of their child, although 80.3% of their close family and friends want their child to get vaccinated. Further, 79.6% of parents/caregivers of ZDC know where to get their child vaccinated. However, only 39.2% reported that vaccination is “moderately” or “very easy” to afford.  

A total of 143 in depth interviews were conducted across different categories of respondents as mentioned in table 2 to understand the structural determinants of zero dose children in urban slum communities

Table 2: Numbers of respondents in different categories 

Insights from qualitative interviews also revealed that parents/caregivers of ZDC do not trust the government and vaccines, and do not think that vaccines are safe for their child. Parents/caregivers reported believing in conspiracy theories and that vaccines are part of a foreign agenda. However, parents/caregivers were found to trust healthcare workers to some extent, as some healthcare workers are from their community and in some cases are related to the parents/caregivers. Across ZDC, 37.3% of parents/caregivers were illiterate, while 28.0% and 17.6% had completed matric and intermediate levels of education. 

Findings from qualitative interviews conducted with healthcare workers and EPI managers highlighted multiple challenges in ensuring vaccination coverage Participants highlighted that when parents are hesitant, engaging community elders often helps encourage vaccine uptake. They also mentioned that in some regions, NGOs providing home-based vaccination services were praised by caregivers, and incentives like mobile balance were seen as effective strategies that should be expanded nationwide as it helped in improving the coverage rate. However, logistical issues such as poor transport, insufficient finances for petrol of field staff, harsh weather, and outdated population data were commonly reported barriers to outreach efforts. According to the EPI managers, Caregivers in remote areas expressed a preference for home visits due to long travel distances to health centers, moreover, misinformation, competing priorities, and concerns about vaccine side effects were the significant challenges. Offering Panadol drops to address pain concerns has helped in some cases, but participants emphasized the need for broader awareness campaigns and systemic support to improve vaccine acceptance. 

Social dynamics were also found to vary substantially across different areas, largely influenced by ethnicity. In some slums, where diverse ethnic groups reside, it was challenging to engage communities due to language and social barriers. To address this, local data collectors were used to help overcome language issues. The highest levels of hesitancy and resistance were observed in Karachi, making outreach in this area particularly difficult.  

Conclusions

This study indicates that there are substantial differences in the attitudes of parents/caregivers of ZDC compared with the overall population among urban slum communities in Pakistan. Targeted interventions to address the identified barriers are required to increase vaccine uptake in slum communities. Importantly, work is also required to sensitize parents/caregivers on the importance of routine immunization and the timely administration of vaccines to protect their children’s health. Efforts should also address misinformation on routine immunization and foster trust in the health system through involving the community in vaccine outreach activities.

Recommendations 

• Targeted interventions are required to address the identified concerns, misinformation and low confidence in vaccines among parents/caregivers of ZDC in urban slum communities.  

• Community-based health workers should be leveraged more effectively to improve vaccine confidence and uptake, as trusted figures in the community.  

• The role of community health workers should be strengthened through enhanced training. They should be equipped with clear and culturally sensitive messaging about vaccine safety, to enable them to address conspiracy theories and bridge the trust gap. 

• Additionally, engaging local leaders and influencers, who share cultural and social ties with the caregivers, in vaccine campaigns can help build credibility. 

• Incorporating community feedback into vaccine outreach programs and ensuring transparency about vaccine development and distribution could also help to dispel misinformation and disinformation. 

References 

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