Addressing community barriers to immunization in Rajanpur district, Pakistan: an implementation research

# Background The Expanded Program on Immunization (EPI) of Punjab province faced an implementation challenge of the lowest immunization coverage in one of the districts, Rajanpur. In the Rajanpur district, low acceptance of immunization for poor communities of tribals, Kacha, and rural areas is unknown. Implementation research was carried out to explore the reasons for low acceptability for routine immunization, appropriateness, and relevance of social mobilization activities. # Methods To understand the low acceptability of immunization we used ‘exploratory qualitative inquiry’ to explore community perception of immunization services, appropriateness, and relevance of EPI social mobilization activities. With purposive sampling technique, trained interviewers conducted 24 in-depth interviews and 7 focus group discussions with community members/ caregivers and health care providers in the communities of Kacha, Rural and Tribal areas of the Rajanpur district. The data was collected in Urdu and Siraiki languages, which were transcribed in Urdu and translated into English for content analysis purposes. # Results Level of acceptability for routine immunization varies among poor communities of rural, Kacha and tribal areas, from complete refusal to drop out. Factors related to health system for EPI that is influencing the demand at the community level are the insufficient deployment of female staff, the capacity gap of the current field staff, provision of need-based transportation and funding to field staff, and lack of community engagement in EPI planning for service delivery. These factors are resulting in low coverage of immunization in the Rajanpur district. The support of the tribal chief was identified as a factor that appeared to facilitate the EPI Rajanpur by mobilizing communities for immunization services. Lack of community engagement has implications for an integrated social mobilization strategy into EPI planning. # Conclusions Immunization communication in general and social mobilization, in particular, is unsatisfactorily given the least priority by policymakers in creating demand for immunization in the Rajanpur district. Health system barriers for EPI need to overcome to increase demand among poor communities of rural, Kacha, and tribal areas of the Rajanpur district