{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,4]],"date-time":"2026-10-04T23:58:14Z","timestamp":1791158294446,"version":"4.1.0"},"reference-count":48,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2022,9,15]],"date-time":"2022-09-15T00:00:00Z","timestamp":1663200000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>This study assesses the experiences of parents\/caregivers regarding the refusal to childhood immunization. A cross-sectional study was conducted among the parents\/caregivers of children under two years old from January 2019 to June 2019 who were residents of either Pathan Colony or Orangi Town, Karachi. In this study, the data collectors targeted parents\/caregivers of 440 households who showed a refusal mark \u201cR\u201d in the Expanded Program of Immunization (EPI) H-chalking system. These households were approached using a 30 \u00d7 7 multistage-stratified-cluster random sampling technique and were interviewed using a structured questionnaire. The study sample produced two different types of refusals: true refusal (absence) and potential refusal (presence), based on the absence and presence of a vaccination card at the time of the survey. Multivariate logistic regression was used to analyze the data using Jamovi (V-1.6.13). A total of 230 households consented to participate in this study, of which 141 (61.3%) represented true refusals, while 89 (38.7%) represented potential refusals. More than half of the participants from both groups complained about fever and pain at the injection site following immunization. The use of alternative medicines and a history of adverse events following immunization (AEFI) were associated with increasing the odds of immunization refusals by four-to-five fold. However, advanced paternal age, a long distance to the clinic, a lack of trust in government, and the influence of community\/religious leaders were associated with lower immunization refusal odds. Thus, an unawareness about self-limiting vaccine-related adverse events, the use of alternative medicines, and an increased concern about the safety and efficacy of vaccines were found to be barriers to immunization, which can be improved by increasing public awareness through media campaigns and policy reform.<\/jats:p>","DOI":"10.3390\/ijerph191811631","type":"journal-article","created":{"date-parts":[[2022,9,15]],"date-time":"2022-09-15T22:11:10Z","timestamp":1663279870000},"page":"11631","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["A Survey Exploring Reasons behind Immunization Refusal among the Parents and Caregivers of Children under Two Years Living in Urban Slums of Karachi, Pakistan"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5284-7014","authenticated-orcid":false,"given":"Asif","family":"Khaliq","sequence":"first","affiliation":[{"name":"Department of Health & Hospital Management, Institute of Business Management, Karachi 75190, Pakistan"},{"name":"School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD 4059, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alfaraz Ashraf","family":"Elahi","sequence":"additional","affiliation":[{"name":"Department of Health & Hospital Management, Institute of Business Management, Karachi 75190, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asima","family":"Zahid","sequence":"additional","affiliation":[{"name":"Department of Health & Hospital Management, Institute of Business Management, Karachi 75190, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zohra S.","family":"Lassi","sequence":"additional","affiliation":[{"name":"Robinson Research Institute, The University of Adelaide, Adelaide, SA 5005, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,9,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"94","DOI":"10.3329\/icpj.v5i11.29901","article-title":"An overview of immunization practices in Pakistan","volume":"5","author":"Wain","year":"2016","journal-title":"Int. Curr. Pharm. J."},{"key":"ref_2","unstructured":"World Health Organization (2021, March 11). Immunization: The World Health Organization. Available online: https:\/\/www.who.int\/news-room\/facts-in-pictures\/detail\/immunization."},{"key":"ref_3","first-page":"1800004","article-title":"Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks, Jerusalem, Israel","volume":"24","author":"Israeli","year":"2019","journal-title":"Eurosurveillance"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"4031","DOI":"10.1073\/pnas.1704507114","article-title":"Simply put: Vaccination saves lives","volume":"114","author":"Orenstein","year":"2017","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"140","DOI":"10.2471\/BLT.07.040089","article-title":"Vaccination greatly reduces disease, disability, death and inequity worldwide","volume":"86","author":"Andre","year":"2008","journal-title":"Bull. World Health Organ."},{"key":"ref_6","unstructured":"European Centre for Disease Prevention and Control (2021, March 26). Immunisation and Vaccines. Available online: https:\/\/ecdc.europa.eu\/en\/immunisation-and-vaccines."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"4161","DOI":"10.1016\/j.vaccine.2015.04.036","article-title":"Vaccine Hesitancy: Definition, Scope and Determinants","volume":"33","author":"MacDonald","year":"2015","journal-title":"Vaccine"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"The Lancet Child Adolescent Health (2019). Vaccine hesitancy: A generation at risk. Lancet Child Adolesc. Health, 3, 281.","DOI":"10.1016\/S2352-4642(19)30092-6"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"32","DOI":"10.4103\/2230-8229.172231","article-title":"Determinants of nonimmunization of children under 5 years of age in Pakistan","volume":"23","author":"Murtaza","year":"2016","journal-title":"J. Fam. Community Med."},{"key":"ref_10","unstructured":"Everist, L. (2022, September 11). The Impact of Vaccine Hesitancy on the Polio Vaccine in South Asia. Available online: https:\/\/digitalcollections.sit.edu\/isp_collection\/2106\/."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.jiph.2017.09.007","article-title":"Outbreak of vaccine-preventable diseases in Muslim majority countries","volume":"11","author":"Ahmed","year":"2018","journal-title":"J. Infect. Public Health"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3163","DOI":"10.1080\/21645515.2020.1753439","article-title":"Vaccine hesitancy and its determinants among Arab parents: A cross-sectional survey in the United Arab Emirates","volume":"16","author":"Alsuwaidi","year":"2020","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"6649","DOI":"10.1016\/j.vaccine.2014.09.039","article-title":"Mapping vaccine hesitancy\u2014Country-specific characteristics of a global phenomenon","volume":"32","author":"Gagnon","year":"2014","journal-title":"Vaccine"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"984","DOI":"10.1016\/j.vaccine.2018.12.062","article-title":"Parent perspectives on childhood vaccination: How to deal with vaccine hesitancy and refusal?","volume":"37","author":"Bianco","year":"2019","journal-title":"Vaccine"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1016\/j.ijid.2020.12.029","article-title":"Prevalence of Parental refusal rate and its associated factors in routine immunization by using WHO Vaccine Hesitancy tool: A Cross sectional study at district Bannu, KP, Pakistan","volume":"104","author":"Khattak","year":"2020","journal-title":"Int. J. Infect. Dis."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1186\/s12992-016-0195-3","article-title":"Eradicating polio in Pakistan: An analysis of the challenges and solutions to this security and health issue","volume":"12","author":"Hussain","year":"2016","journal-title":"Glob. Health"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"D80","DOI":"10.1016\/j.vaccine.2011.10.005","article-title":"The global polio eradication initiative: Lessons learned and prospects for success","volume":"29","author":"Aylward","year":"2011","journal-title":"Vaccine"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"822","DOI":"10.2471\/BLT.12.106260","article-title":"Parental perceptions surrounding polio and self-reported non-participation in polio supplementary immunization activities in Karachi, Pakistan: A mixed methods study","volume":"90","author":"Khowaja","year":"2012","journal-title":"Bull. World Health Organ."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1093\/inthealth\/ihx067","article-title":"Routine immunization in Pakistan: Comparison of multiple data sources and identification of factors associated with vaccination","volume":"10","author":"Imran","year":"2018","journal-title":"Int. Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.puhe.2018.07.008","article-title":"What is causing high polio vaccine dropout among Pakistani children?","volume":"164","author":"Imran","year":"2018","journal-title":"Public Health"},{"key":"ref_21","unstructured":"National Institute of Population Studies (2019). Pakistan Demographic and Health Survey 2017\u201318, NIPS\/Pakistan and ICF."},{"key":"ref_22","unstructured":"Open Epi (2019, July 27). Sample Size Calculator. Available online: http:\/\/www.openepi.com\/SampleSize\/SSPropor.html."},{"key":"ref_23","unstructured":"Raosoft, I. (2019, July 27). Sample Size Calculator. Available online: http:\/\/www.raosoft.com\/samplesize.html."},{"key":"ref_24","first-page":"645","article-title":"Missed Immunization Opportunities among Children under 5 Years of Age Dwelling in Karachi City","volume":"29","author":"Khaliq","year":"2018","journal-title":"J. Ayub Med. Coll. Abbottabad JAMC"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"195","DOI":"10.4103\/1117-1936.173959","article-title":"Principles and methods of validity and reliability testing of questionnaires used in social and health science researches","volume":"22","author":"Bolarinwa","year":"2015","journal-title":"Niger. Postgrad. Med. J."},{"key":"ref_26","unstructured":"(2021, March 11). Project. Tj. Jamovi (Version 1.6). Computer Software. Available online: https:\/\/www.jamovi.org."},{"key":"ref_27","first-page":"104","article-title":"Exploring the Reasons behind Parental Refusal of Vaccines","volume":"21","author":"McKee","year":"2016","journal-title":"J. Pediatr. Pharmacol. Ther."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"4747","DOI":"10.1016\/j.vaccine.2020.05.018","article-title":"Low vaccination in rural Sindh, Pakistan: A case of refusal, ignorance or access?","volume":"38","author":"Jamal","year":"2020","journal-title":"Vaccine"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"5288","DOI":"10.1016\/j.vaccine.2018.07.024","article-title":"Reasons for non-vaccination and incomplete vaccinations among children in Pakistan","volume":"36","author":"Riaz","year":"2018","journal-title":"Vaccine"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Torun, S.D., and Bak\u0131rc\u0131, N. (2006). Vaccination coverage and reasons for non-vaccination in a district of Istanbul. BMC Public Health, 6.","DOI":"10.1186\/1471-2458-6-125"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Mutua, M.K., Kimani-Murage, E., and Ettarh, R.R. (2011). Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated?. BMC Public Health, 11.","DOI":"10.1186\/1471-2458-11-6"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1215","DOI":"10.1542\/peds.111.S1.1215","article-title":"Maternal characteristics associated with vaccination of young children","volume":"111","author":"Luman","year":"2003","journal-title":"Pediatrics"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1177\/1010539519889765","article-title":"Role of Maternal Education and Vaccination Coverage: Evidence from Pakistan Demographic and Health Survey","volume":"31","author":"Asif","year":"2019","journal-title":"Asia Pac. J. Public Health"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e013853","DOI":"10.1136\/bmjopen-2016-013853","article-title":"Maternal education, empowerment, economic status and child polio vaccination uptake in Pakistan: A population based cross sectional study","volume":"7","author":"Khan","year":"2017","journal-title":"BMJ Open"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Bertoncello, C., Ferro, A., Fonzo, M., Zanovello, S., Napoletano, G., Russo, F., Baldo, V., and Cocchio, S. (2020). Socioeconomic Determinants in Vaccine Hesitancy and Vaccine Refusal in Italy. Vaccines, 8.","DOI":"10.3390\/vaccines8020276"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Forshaw, J., Gerver, S.M., Gill, M., Cooper, E., Manikam, L., and Ward, H. (2017). The global effect of maternal education on complete childhood vaccination: A systematic review and meta-analysis. BMC Infect. Dis., 17.","DOI":"10.1186\/s12879-017-2890-y"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1459","DOI":"10.26719\/2007.13.6.1459","article-title":"Women\u2019s empowerment and health: The role of institutions of power in Pakistan","volume":"13","author":"Qureshi","year":"2007","journal-title":"EMHJ-East. Mediterr. Health J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.sbspro.2015.02.321","article-title":"Assessing the Socio-economic Determinants of Women Empowerment in Pakistan","volume":"177","author":"Bushra","year":"2015","journal-title":"Procedia Soc. Behav. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"4293","DOI":"10.1016\/j.vaccine.2013.07.013","article-title":"A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy","volume":"31","author":"Sadaf","year":"2013","journal-title":"Vaccine"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1001\/archpedi.159.5.470","article-title":"Factors associated with refusal of childhood vaccines among parents of school-aged children: A case-control study","volume":"159","author":"Salmon","year":"2005","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"3694","DOI":"10.1016\/j.vaccine.2019.05.029","article-title":"\u201cThis is a Pakhtun disease\u201d: Pakhtun health journalists\u2019 perceptions of the barriers and facilitators to polio vaccine acceptance among the high-risk Pakhtun community in Pakistan","volume":"37","author":"Shah","year":"2019","journal-title":"Vaccine"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"ofx146","DOI":"10.1093\/ofid\/ofx146","article-title":"Vaccine Rejection and Hesitancy: A Review and Call to Action","volume":"4","author":"Smith","year":"2017","journal-title":"Open Forum Infect. Dis."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1992","DOI":"10.1007\/s10943-020-01122-4","article-title":"\u201cI Took the Trouble to Make Inquiries, So I Refuse to Accept Your Instructions\u201d: Religious Authority and Vaccine Hesitancy among Ultra-Orthodox Jewish Mothers in Israel","volume":"60","author":"Keshet","year":"2021","journal-title":"J. Relig. Health"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"3288","DOI":"10.1016\/j.vaccine.2015.05.023","article-title":"Deaths following vaccination: What does the evidence show?","volume":"33","author":"Miller","year":"2015","journal-title":"Vaccine"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"3518","DOI":"10.1016\/j.vaccine.2020.03.028","article-title":"Adverse events following immunization with typhoid conjugate vaccine in an outbreak setting in Hyderabad, Pakistan","volume":"38","author":"Qamar","year":"2020","journal-title":"Vaccine"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"5617","DOI":"10.1016\/j.vaccine.2018.07.042","article-title":"Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka, Zambia","volume":"36","author":"Heyerdahl","year":"2018","journal-title":"Vaccine"},{"key":"ref_47","first-page":"48","article-title":"Immunization Coverage in a Rural Area","volume":"20","author":"Shaikh","year":"2016","journal-title":"J. Rawalpindi Med. Coll."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Marti, M., de Cola, M., Macdonald, N.E., Dumolard, L., and Duclos, P. (2017). Assessments of global drivers of vaccine hesitancy in 2014\u2014Looking beyond safety concerns. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0172310"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/18\/11631\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:32:10Z","timestamp":1760142730000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/18\/11631"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,9,15]]},"references-count":48,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2022,9]]}},"alternative-id":["ijerph191811631"],"URL":"https:\/\/doi.org\/10.3390\/ijerph191811631","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,9,15]]}}}