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74

J Gandhara Med Dent Sci

October - December 2026

ORIGINAL ARTICLE

How to cite this article

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IMMUNISATION STATUS AND DETERMINANTS OF VACCINE HESITANCY AMONG CHILDREN

UNDER FIVE YEARS OF AGE

ABSTRACT

OBJECTIVES

This study aimed to determine immunisation status and identify demographic,

socioeconomic,

access-related,

and

caregiver

factors

associated

with

incomplete immunisation among children under ve years.

METHODOLOGY

This descriptive cross-sectional study enrolled 345 children who presented to

the

Department

of

Paediatrics,

Ayub

Teaching

Hospital,

Abbottabad,

from

October

2025

to

April

2026

using

non-probability

consecutive

sampling.

Parents

or

guardians

completed

a pre-tested

structured

questionnaire,

and

immunisation

status

was

veried

from

Expanded

Programme

on

Immunisation

records

when

available

and

supplemented

with

caregiver

recall.

Children were

categorised

as fully, partially,

or

not

immunised.

We

assessed

associations

using

chi-square

tests

and

Cramer's

V,

followed

by

binary logistic regression for incomplete immunisation.

RESULTS

The mean child age was 28.15 ± 17.19 months. Overall, 212 (61.4%) children

were fully immunised, 103 (29.9%) partially immunised, and 30 (8.7%) non-

immunised. Frequently reported barriers were

fear

of

side

eects

(49.0%),

lack

of

schedule

knowledge

(42.6%),

and

unawareness

of

the

need

for

immunisation (41.2%). Immunisation status was signicantly associated with

residence,

socioeconomic

status,

parental

education,

and

parental

occupation.

After

adjustment,

low

socioeconomic

status,

unawareness

of

follow-up

doses,

misconceptions

about

contraindications,

lack

of

a

nearby

vaccination facility, concern about lost wages, and poor schedule knowledge

independently predicted incomplete immunisation.

CONCLUSION

More

than

one-third

of

children

had

incomplete

immunisation.

Improving

completion

requires

caregiver

education,

clear

counselling

about

contraindications

and

adverse

eects,

reliable

reminders

for

subsequent

doses,

and

practical

service-delivery

measures

that

reduce

geographic and

economic

barriers

for

vulnerable

families.

Targeted

outreach

should

consistently

prioritise

rural

and

socioeconomically

disadvantaged

households.

KEYWORDS:

Immunisation

Status,

Vaccine

Hesitancy,

Children

Under

Five, Expanded Programme On Immunisation, Caregivers, Pakista

n

INTRODUCTION

Immunisation

remains

one

of

the

most

eective

interventions

to

reduce

childhood

morbidity

and

mortality.

Children

are

vaccinated

against

several

serious infections including: tuberculosis, poliomyelitis,

diphtheria, pertussis, tetanus, hepatitis B, pneumococcal

disease, Haemophilus inuenzae type b

infection,

and

measles.

1

Completing

the

recommended

childhood

immunisation

schedule

not

only

protects

vaccinated

children

but

also

supports

herd

protection

in

the

community. Although eective vaccines are available,

incomplete

and

delayed

immunisation

remains

a

significant

issue

in

most

developing

countries,

including

Pakistan.

2

The

Expanded

Programme

on

Immunisation was adopted to provide routine childhood

vaccination

and

reduce

the

burden

of

vaccine-

preventable

diseases.

Nevertheless,

the

uptake

of

vaccines is inuenced by a number of factors other than

access

to

vaccines.

3

Caregiver

knowledge,

parental

education, socioeconomic status,

family income, place

of

residence,

access

to

health

facilities,

and

trust

in

vaccine

safety

all

contribute

to

whether

a

child

completes

the

immunisation

schedule.

Missed

opportunities,

lack

of

awareness

of

follow-up

doses,

inability

to

reach

vaccination

centers,

and

misinformation

can

lead

to

partial

or

complete

immunisation

gaps.

4,5

Vaccine

hesitancy

is

now

understood

as

a

signicant

impediment

to

successful

immunisation

coverage.

It

can

occur

even

when

Ali Maalik

1

, Saima Gillani

2

, Manahil Shamraiz

1

, Aleena Ashraf

1

, Armaghan Ali

1

, Saba Munir

1

Maalik A, Gillani S, Shamraiz M,

Ashraf A, Ali A, Munir S.

Immunisation Status and

Determinants of Vaccine Hesitancy

Among Children Under Five Years of

Age. J Gandhara Med Dent

Sci.2026;13(4):74-79.

Date of Submission:

04-06-2026

Date Revised:

13-09-2026

Date Acceptance:

13-09-2026

2

Head, Department of Pedriatic &

Neonatology, Ayub Teaching Hospital,

Abbottabad

Correspondence

1

Manahil Shamraiz, Trainee Medical

Ofcer, Department of Pedriatic, Ayub

Teaching Hospital, Abbottabad

+92-332-8932799

manihalshamraiz01@gmail.com

http://doi.org/10.37762/jgmds.13-4.946

75

J Gandhara Med Dent Sci

October - December 2026

vaccination

services

are

available

and

may

be

inuenced

by

fear

of

adverse

eects,

misconceptions

about

contraindications,

low

perceived

importance

of

vaccination,

and

doubts

created

by

misinformation.

6

Among

families,

practical

barriers

to

immunisation

include parents' work duties, transport diculties, loss

of

daily

wages,

illness

in

children,

and

a

lack

of

knowledge about the correct schedule, which can delay

or interrupt immunisation. These barriers are especially

important

among

under-five

children

because

missed

early childhood

doses increase

the risk of preventable

infections.

7

Routine

immunisation

coverage

varies

across regions and among people in Pakistan. Children

in

rural

areas,

low-income

families,

and

families

with

poor parental education may be at higher risk of being

under-vaccinated.

8

Understanding

local

trends

in

immunisation

status

and

the

key

causes

of

vaccine

hesitancy is crucial for planning targeted interventions.

For higher-risk families with incomplete immunisation,

evidence

from

a

tertiary

care

setting

can

guide

clinicians,

public

health

teams,

and

policymakers

in

designing counselling strategies, reminder systems, and

outreach

services.

This

study

therefore

aimed

to

determine

the

frequency

of

immunisation

status

and

identify

determinants

of

vaccine

hesitancy

among

children

under

ve

years

of

age

presenting

to

the

Department

of

Pediatrics,

Ayub

Teaching

Hospital,

Abbottabad.

The

ndings

may

highlight

modiab

le

barriers

and

support

practical

strategies

to

improve

childhood immunisation completion.

METHODOLOGY

This

descriptive

cross-sectional

study

aimed

to

determine

the

frequency

of

immunisation

status

and

identify

determinants

of

vaccine

hesitancy

in

children

under ve years of age. The study was conducted in the

Department

of

Paediatrics,

Ayub

Teaching

Hospital,

Abbottabad,

a

tertiary

care

hospital,

over

six

months

from

October

2025

to

April

2026.

The

Institutional

Medical and Ethics Review Committee, Ayub Medical

Teaching

Institution,

Abbottabad,

approved

the

study

with

reference

number

RC-EA-2024/252

on

04/10/2024. In addition, the College of Physicians and

Surgeons Pakistan (CPSP) approved the synopsis under

reference

number

CPSP/REU/PED-2023-010-7578,

dated October 17, 2025. We obtained written informed

consent

from

parents

or

legal

guardians

before

enrollment, and conducted all procedures in accordance

with ethical principles for human research. A sample of

345 children under the age of ve was recruited using a

non-probability consecutive sampling method, in which

all

eligible

respondents

who

presented

themselves

during the study period were included. The sample size

was calculated using a 95% condence level and a 5%

margin of error, assuming a 34% proportion of partially

immunised

children

based

on

previously

published

literature.

9

Children of either gender aged less than ve

years

presenting

to

the

pediatric

department

were

eligible for inclusion. We excluded children older than

five years, those without vaccination records or whose

caregivers

could

not

recall

immunisation

history,

and

those

with

known

medical

contraindications

to

vaccination

(such

as

severe

allergic

reactions).

Additionally,

we

excluded

families

not

permanently

residing in the study area to avoid bias in accessibility-

Immunisation status

was

categorised

as

fully

immunised,

partially

immunised,

and

non-

immunised

according

to

the

national

Expanded

Programme on Immunization (EPI) schedule, based on

vaccination

cards

and

caregiver

recall.

Vaccine

hesitancy determinants included lack of awareness, fear

of

adverse

eects,

misconceptions

about

contraindications,

logistical

barriers,

and

socioeconomic constraints, assessed through structured

questioning.

After

ethical

approval,

participants

were

recruited sequentially as long as they were eligible. We

used a pre-tested structured questionnaire (proforma) to

collect

data.

Data

were

collected

through

face-to-face

interviews

with

parents

or

guardians,

including

demographic

variables

(age,

gender,

residence,

socioeconomic

status,

parental

education,

occupation),

immunisation

status,

and

factors

associated

with

vaccine hesitancy. Whenever available, EPI vaccination

cards

were

used

to

verify

immunisation

status

and

supplemented by caregiver recall where necessary. All

the

variables

were

measured

based

on

operational

definitions. The researcher conducted data collection to

ensure

consistency

and

completeness.

The

data

collection tool

was adapted from previously published

studies and aligned with study objectives. Before data

collection,

subject-matter

experts

reviewed

the

questionnaire

to

establish

content

validity,

and

minor

changes were made to enhance clarity. The pilot testing

phase

was

conducted

to

verify

understanding

and

feasibility,

and

unclear

items

were

reformulated.

To

ensure

reliability,

standardised

questioning

and

standardised data-recording procedures were observed.

All

data

were

entered

and

analysed

using

IBM

SPSS

Statistics version 26. A p-value ≤ 0.05 was considered

statistically signicant.

RESULTS

The

mean age

of the 345

children

was 28.15



17.19

months; 187 (54.2%) were male, and 196 (56.8%) lived

in

rural

areas.

Overall,

212

(61.4%)

were

fully

immunised,

103

(29.9%)

partially

immunised,

and

30

(8.7%) non-immunised. Thus, 133 children (38.6%) had

incomplete immunisation. The most frequently reported

Immunisation Status and Determinants of Vaccine Hesitancy Among Children

76

J Gandhara Med Dent Sci

October - December 2026

barriers

were

fear

of

side

eects

(49.0%),

lack

of

knowledge of the immunisation schedule (42.6%), and

unawareness

of

the

need

for

immunisation

(41.2%).

Residence,

socioeconomic

status,

parental

education,

and

parental

occupation

were

signicantly

associated

with the three-category immunisation outcome, whereas

age group, sex, and monthly-income category were not.

Each measured barrier showed a signicant unadjusted

association

with

incomplete

immunisation.

In

the

multivariable

model,

low

versus

high

socioeconomic

status

(AOR

176.91,

95%

CI

11.622694.40),

middle

versus high socioeconomic status (AOR 58.04, 95% CI

3.75898.36),

unawareness

of

follow-up

doses

(AOR

26.81,

95%

CI

5.14139.96),

misconceptions

about

contraindications

(AOR

41.03,

95%

CI

6.42262.29),

absence of a nearby health facility (AOR 79.13, 95% CI

9.36668.90),

concern

about

loss

of

wages

(AOR

69.59,

95%

CI

7.93610.93),

and

lack

of

schedule

knowledge (AOR 8.07, 95% CI 1.7836.61) remained

statistically

signicant.

The

very

wide

condence

intervals

indicate

imprecision

and

warrant

cautious

interpretation.

Table 1: Participant Characteristics and Immunisation Status

Fully immunised

212

61.4

Partially immunised

103

29.9

Non-immunised

30

8.7

Total

345

100

Panel A. Demographic Charact

eristics

Variable

categories

and

possible

model

instability;

interpret these estimates cautiously. Future community-

based

studies

should

use

age-appropriate

dose

verification,

validated

hesitancy

instruments,

and

adequately powered multilevel models.

CONCLUSIONS

Only 61.4% of children were fully immunised, leaving

38.6%

with

partial

or

no

immunisation.

Incomplete

immunisation

was

associated

with

socioeconomic

disadvantage,

gaps

in

knowledge

about

follow-up

and

schedules,

misconceptions

about

contraindications,

limited

access

to

services,

and

concern

about

lost

wages.

Improving

completion

requires

integrated

caregiver education, reminder-recall systems, accessible

vaccination services, and targeted outreach to rural and

economically vulnerable families.

Immunisation Status and Determinants of Vaccine Hesitancy Among Children

79

J Gandhara Med Dent Sci

October - December 2026

CONFLICT OF INTEREST:

None

FUNDING SOURCES:

None

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Ali

Maalil

-

Concept

&

Design;

Data

Acquisition;

Drafting Manuscript;

Critical Revision;

Final Approval

Saima

Gillani

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Critical

Revision;

Supervision; Final Approval

Manahil

Shamraiz

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Critical

Revision; Supervision; Final Approval

Aleena

Ashraf

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Critical

Revision;

Supervision; Final Approval

Armaghan

Ali

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Critical

Revision;

Supervision; Final Approval

Saba Munir

-

Concept & Design; Data Acquisition; Data

Analysis/Interpretation;

Critical

Revision;

Supervision;

Final Approval

Immunisation Status and Determinants of Vaccine Hesitancy Among Children