BARRIERS TO IMMUNIZATION COVERAGE IN UNDER-FIVE CHILDREN IN RURAL COMMUNITIES: A CROSS-SECTIONAL STUDY FROM RURAL PUNJAB, PAKISTAN

Abstract

Background: Although the immunization program has been working effectively in Pakistan for a long time, the country is still far from meeting the WHO target of immunization coverage of below 100% in rural areas. Determining what specific barriers are present at the household and health system levels is a precondition to designing effective corrective interventions. Objective: To assess the level of under-immunization among children aged 12-59 months in rural areas of Punjab, Pakistan, and the independent factors associated with under-immunization in these areas. Methods: It was a cross-sectional, community-based study conducted in the Faisalabad and Toba Tek Singh districts, across 6 rural union councils, from March 2023 to February 2024. Systematic random sampling of primary caregivers of children aged 12 to 59 months was conducted using a house register; a total of 686 primary caregivers were recruited. Vaccination status was confirmed through vaccination cards and caregiver memory. A pre-tested questionnaire was used to assess the barriers. The independent predictors of incomplete immunization were determined using multivariable logistic regression, and the results are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Key Findings: 64.4% of the sampled children were fully immunized. The strongest independent barrier was geographic distance (aOR 0.24, 95% CI 0.17 to 0.34 if more than 5 kilometers from a vaccination facility). Other independent predictors were maternal non-education (aOR 0.31), household poverty (aOR 0.23), reported vaccine stockout (aOR 0.38), unawareness of the vaccination schedule (aOR 0.41), and paternal refusal (aOR 0.32). Nearly half of respondents (42.2%) reported vaccine stockouts and more than a third (35.2%) reported long waiting times, indicating significant health system vulnerabilities. Conclusion: There are two types of immunization gaps in rural Punjab — both supply-side and demand-side. There is an immediate need to implement targeted interventions to address the coverage gap in rural areas, such as expanding mobile outreach, engaging male caregivers, and strengthening the cold chain.