Background: Pakistan has subpar childhood immunization rates and immunization activities have faced several challenges over the past years. We evaluated the social-behavioral and cultural barriers and risk factors for refusal of polio, Routine Immunization (RI), or both in high-risk areas of poliovirus circulation. Methods: A matched case-control study was conducted from April to July 2017 in eight super high-risk Union Councils of five towns in Karachi, Pakistan. A total of 3 groups, each with 250 cases, including refusals for the Oral Polio Vaccine (OPV) in campaigns (national immunization days and supplementary immunization activities), RI, and both, were matched with 500 controls and identified using surveillance records. Sociodemographic characteristics, household information, and immunization history were assessed. Study outcomes included social-behavioral and cultural barriers and reasons for vaccine refusal. Data were analyzed in STATA using conditional logistic regression. Results: RI refusal was associated with illiteracy and fear of the vaccine’s adverse effects, while OPV refusals were linked to the mother’s decision authority and the assumption that the OPV caused infertility. Conversely, higher socioeconomic status (SES) and knowledge of and willingness to vaccinate with Inactivated Polio Vaccine (IPV) were inversely associated with RI; and lower SES, walking to the vaccination point, knowledge of IPV, and an understanding of contracting polio were inversely associated with OPV refusals, with the latter two also inversely associated with complete vaccine refusal. Conclusion: Education, knowledge and understanding of vaccines, and socioeconomic determinants influenced OPV and RI refusals among children. Effective interventions are needed to address knowledge gaps and misconceptions among parents.

Pakistan is one of the few countries where poliovirus transmission still persists, despite intensive efforts to eradicate the disease. Adequate vaccination coverage is essential to achieve polio eradication, but misconceptions about polio vaccines have hindered vaccination efforts. To address this issue, we conducted a mixed-methods study to explore knowledge and perceptions regarding polio disease and immunization in high-risk areas of Pakistan. We collected quantitative data from 3780, 1258, and 2100 households in Karachi, Bajaur, and Pishin, respectively, and supplemented this with qualitative data from focus group discussions and in-depth interviews. Our findings reveal a high level of awareness about polio and its immunization; however, misperceptions about the polio vaccine persist, leading to refusal for both polio vaccines and routine immunizations. Our study provides up-to-date data on knowledge and perceptions of polio and its immunization and identifies critical gaps. These findings can inform the development of future strategies and innovative approaches to improve the success of the polio program in Pakistan.

Poliomyelitis is a condition of great concern and is endemic in only two countries of the world: Pakistan and Afghanistan. Community mobilization plays a vital role in raising awareness and can help reduce polio vaccine refusals. The objective of this study will be to decrease polio vaccine refusals and zero-dose vaccines by motivating behavior change through the provision of conditional–collective–community-based incentives (C3Is) based on a reduction in polio vaccine refusals. The project will adopt a pretest/post-test quasi-experimental design with two intervention high-risk union councils (HRUCs) and two control union councils (UCs) of peri-urban (Karachi) and rural (Bannu) settings in Pakistan. A participatory community engagement and demand creation strategy with trust-building community mobilization with C3Is, to reduce vaccine refusals and improve polio immunization coverage in two HRUCs, will be used. These UCs will be divided into clusters based on the polio program framework and community groups will be formed in each cluster. These community groups will carry out awareness activities and will be given serial targets to reduce vaccine refusals and those who qualify will be provided C3Is. The project intends to create a replicable model that the government can integrate within health systems for long-term sustainability until the goal of eradication of poliovirus is achieved. The evaluation will be carried out by an independent data collection and analysis team at baseline and endline (after 12 months of intervention). The trial is registered with linicalTrials.gov with number NCT05721274.

Background: Pakistan is one of only two countries where wild poliovirus type 1 (WPV1) continues to persist. Vaccine refusals challenge efforts to end the virus, especially in high-risk communities. Methods: A qualitative exploratory study took place from September to November 2025 in three High-Risk Union Councils (HRUCs) of Karachi, Pakistan. The study examined reasons for refusing the polio vaccine and identified specific communication and operational strategies to improve vaccine acceptance. A total of 23 in-depth interviews and 10 focus group discussions were conducted with 71 participants, including parents who refuse the vaccine, polio program staff, physicians, and government stakeholders. Data were analyzed using a sequential inductive and deductive thematic approach, mapping findings onto the Socio-Ecological Model (SEM) with NVivo 15 (Lumivero, Denver, CO, USA). Results: Factors influencing polio vaccine refusals were interconnected and spanned multiple levels. At the intrapersonal level, campaign fatigue, a lack of knowledge about poliomyelitis, concerns about side effects, and rumors about infertility were common. Community-level factors included household gatekeepers, local influencers, and digital misinformation. Institutional barriers included weak communication from the frontline, inadequate supervision, workforce shortages, poor tracking of refusals, and limited involvement of physicians. At the policy level, refusals were linked to distrust in governance, poor municipal services, and dissatisfaction with vertical campaign methods. Recommended strategies included integrating polio services with routine immunization and primary healthcare, strengthening counseling by physicians, engaging trusted local influencers and community leaders, expanding targeted social media campaigns to counter misinformation, implementing quick responses to rumors, enhancing workforce capacity, and using data-driven microplanning, including targeted SNIDs and focused interventions in areas with chronic refusals. Conclusions: Polio vaccine refusals are shaped by social, communication, operational, and structural factors. Improving communication and operational guidelines by reducing the number of campaigns, increasing active engagement at the frontline, integrating polio activities into routine health services, and addressing misinformation with a dynamic communication strategy may enhance vaccine acceptance and support polio eradication efforts.

Worldwide, pneumonia, diarrhea, and malaria remain leading causes of death for children under the age of five, even though these diseases are preventable and can be treated. In public health, complex behavioral change interventions are often used. These interventions employ multi-component strategies and work on domains, such as education, policy, and environmental change, to promote prevention, control, and management of childhood diseases. In Tando Muhammad Khan (TMK), the Community Mobilization and Community Incentivization (CoMIC) trial employed a complex, participatory community engagement strategy and included conditional community-based incentives and showed promising results by improving child health related behaviors. A study was conducted to explore the experiences and perceptions of community members regarding the implementation and engagement processes of the CoMIC trial. A total of 13 IDIs and 16 FGDs were conducted to understand the factors behind the community engagement and behavior change that led to the success of the CoMIC trial and its adaptability for wider scale-up. The study identified four key motives for driving community engagement: egoism, altruism, collectivism, and principlism. The community’s close-knit social structure and shared sense of collective growth played a crucial role in encouraging participation and adapting to required behaviors. The trial focused on empowering the community by reinforcing health-seeking behaviors as a community responsibility, promoting cost-sharing to ensure long-term sustainability, and creating collective ownership through active community engagement and Conditional, Collective, Community-based Incentives (C3Is). By strengthening WASH and IYCF practices, increasing immunization uptake, promoting care-seeking behaviors, the intervention aimed to reduce the burden of childhood illnesses such as diarrhea, pneumonia, and malaria, ultimately improving child health outcomes.

Pakistan is one of the few countries where poliovirus transmission still persists, despite intensive efforts to eradicate the disease. Adequate vaccination coverage is essential to achieve polio eradication, but misconceptions about polio vaccines have hindered vaccination efforts. To address this issue, we conducted a mixed-methods study to explore knowledge and perceptions regarding polio disease and immunization in high-risk areas of Pakistan. We collected quantitative data from 3780, 1258, and 2100 households in Karachi, Bajaur, and Pishin, respectively, and supplemented this with qualitative data from focus group discussions and in-depth interviews. Our findings reveal a high level of awareness about polio and its immunization; however, misperceptions about the polio vaccine persist, leading to vaccine refusal for both polio and routine immunization. Our study provides up-to-date data on knowledge and perceptions of polio and its immunization and identifies critical gaps. These findings can inform the development of future strategies and innovative approaches to improve the success of the polio program in Pakistan.