Understanding Motivating Factors for COVID-19 Vaccination in Families Defaulting from Childhood Immunization: A Mixed-Methods Study in Pakistan

Background: The COVID-19 pandemic significantly disrupted health systems, including the delivery of childhood immunizations. This study assessed COVID-19 vaccination coverage in families of children with incomplete routine immunization and explored why adults accepted COVID-19 vaccines despite skipping routine vaccination for their children in the district of Swat, Khyber Pakhtunkhwa, Pakistan. Methods: A mixed-methods study was conducted in Swat District during March 2022 – April 2023. A cross-sectional survey assessed COVID-19 vaccination in household members of children under 2 years of age for whom vaccination registries showed missed routine vaccinations. In-depth interviews with 18 household members explored motivations for vaccine acceptance through thematic analysis. Results: Among 249 families of children with incomplete immunization found through vaccination records, 237 families (88% response) were interviewed. Among 382 children below 2 years of age in these families, 29.5% (n=113) were fully vaccinated, 67.5% (n=258) were incompletely vaccinated according to age, and 2.9 % (n=11) had not received any vaccine. Data from 237 of the defaulter children—one per household—was included in further analysis. Among household members above 12 years of age, 87% (964/1103) of males and 82% (n=901/1093) of females were vaccinated against COVID-19. Households with at least one fully vaccinated child were significantly more likely to have vaccinated family members. Multivariable analysis showed maternal COVID-19 vaccination (AOR 2.08, 95% CI:1.15–3.76) and urban residence (AOR 2.08, 95% CI:1.14–3.79) were associated with full childhood vaccination. In-depth interviews revealed that key motivators for COVID-19 vaccination included the perception that it was mandatory, house-to-house vaccination, and fear of hospitalization or death. Conclusions: Vaccine requirements and ease of access to vaccination services enhanced coverage with COVID-19 vaccines among families of children with incomplete routine immunization. Ethical use of vaccine requirements and community education to enhance levels of risk perception of vaccine-preventable diseases could potentially improve childhood immunization.