Socio-behavioral barriers and drivers of typhoid conjugate vaccine uptake in Pakistan: a qualitative study using the WHO BeSD framework

Objective The objective of the study is to explore the socio-behavioral drivers of Typhoid Conjugate Vaccine (TCV) and to understand the barriers and facilitators of Typhoid vaccine uptake in Pakistan. Methods We conducted a descriptive exploratory study in Karachi, Hyderabad, and Lahore from March–August 2024. In-depth interviews (IDIs) were conducted with lady health workers (LHWs), vaccinators, physicians, community influencers, and program managers from the Expanded Program on Immunization (EPI). Focus group discussions (FGDs) were conducted with parents of children aged 10 months–15 years, LHWs and vaccinators. The interview tool, guided by the WHO Behavioral and Social Drivers (BeSD) framework, used semi-structured questions. Data were analyzed using consensual qualitative research to identify themes influencing vaccination behaviors. Results We conducted 63 IDIs and 21 FGDs. Four overarching themes emerged from the data: Thinking and Feeling About Typhoid Disease, Social Processes, Practical Issues and Motivation. Caregivers' decisions were influenced by perceptions of disease severity, concerns about side effects, and widespread mistrust, including conspiracy theories about infertility and foreign agendas. Patriarchal authority limiting maternal decision-making and trusted community leaders either facilitating or hindering acceptance. Practical barriers included poor accessibility, long waiting times, fragmented immunization records, and gaps in provider communication, while school-based delivery proved effective. Motivation was strengthened by incentives, skilled vaccinators, and community mobilization, though misinformation and weak systemic coordination undermined confidence. Conclusion This study highlights communication, cultural, and systemic barriers to TCV and other vaccines delivered under EPI program in Pakistan. Framing TCV as protection against antimicrobial resistance, engaging community leaders and male decision-makers, incentivizing vaccinators, and leveraging social media can build trust. Tailored, sustainable interventions are essential to optimize uptake in Pakistan and other similar setting.