Beyond Hesitancy: Designing Multi-Level Responses to Polio Vaccine Refusal in High-Risk Karachi, Pakistan

Pakistan remains one of the few settings in which wild poliovirus type 1 continues to circulate, and repeated vaccine refusals in high-risk communities threaten the final stages of eradication. This case study examines research conducted in three High-Risk Union Councils in Karachi, selected because they were persistent hotspots for refusals and poliovirus detection. Using the Socio-Ecological Model, the study drew on 23 in-depth interviews and 10 focus group discussions with vaccine-refusing parents, polio programme staff, physicians and government stakeholders. The findings show that refusal cannot be explained by “hesitancy” alone. At the intrapersonal level, limited knowledge, fear of side effects, infertility rumours and campaign fatigue were important. Community-level influences included household gatekeepers, language and social identity, trusted local figures and digital misinformation. Institutional barriers included weak frontline training, workload pressures, poor refusal tracking and limited physician involvement, while policy-level concerns centred on distrust of government, unmet municipal needs and the vertical structure of the polio programme. The study translated these findings into communication and operational recommendations that were subsequently discussed with provincial and national Emergency Operations Centres. The case illustrates how multi-level analysis can move vaccine refusal research towards context-specific, trust-centred programme design, while highlighting the need to evaluate whether these recommendations improve acceptance in practice.