Beyond Hesitancy: Current Multi-Level Polio Vaccine Refusals and Pathways to Acceptance in a High-Risk Region of Pakistan

Background: Pakistan is one of only two countries where wild poliovirus type 1 (WPV1) continues to persist. Vaccine refusals challenge efforts to end the virus, especially in high-risk communities. Methods: A qualitative exploratory study took place from September to November 2025 in three High-Risk Union Councils (HRUCs) of Karachi, Pakistan. The study examined reasons for refusing the polio vaccine and identified specific communication and operational strategies to improve vaccine acceptance. A total of 23 in-depth interviews and 10 focus group discussions were conducted with 71 participants, including parents who refuse the vaccine, polio program staff, physicians, and government stakeholders. Data were analyzed using a sequential inductive and deductive thematic approach, mapping findings onto the Socio-Ecological Model (SEM) with NVivo 15 (Lumivero, Denver, CO, USA). Results: Factors influencing polio vaccine refusals were interconnected and spanned multiple levels. At the intrapersonal level, campaign fatigue, a lack of knowledge about poliomyelitis, concerns about side effects, and rumors about infertility were common. Community-level factors included household gatekeepers, local influencers, and digital misinformation. Institutional barriers included weak communication from the frontline, inadequate supervision, workforce shortages, poor tracking of refusals, and limited involvement of physicians. At the policy level, refusals were linked to distrust in governance, poor municipal services, and dissatisfaction with vertical campaign methods. Recommended strategies included integrating polio services with routine immunization and primary healthcare, strengthening counseling by physicians, engaging trusted local influencers and community leaders, expanding targeted social media campaigns to counter misinformation, implementing quick responses to rumors, enhancing workforce capacity, and using data-driven microplanning, including targeted SNIDs and focused interventions in areas with chronic refusals. Conclusions: Polio vaccine refusals are shaped by social, communication, operational, and structural factors. Improving communication and operational guidelines by reducing the number of campaigns, increasing active engagement at the frontline, integrating polio activities into routine health services, and addressing misinformation with a dynamic communication strategy may enhance vaccine acceptance and support polio eradication efforts.