Strength:

- use of matched-controlled design might give a higher level of evidence.

Limitation:

- although subgroups analysis data for polio vaccine was provided, conclusions and recommendations were targeted at routine vaccine as a group.

Paper 2

Strength:

- nil when compared to Paper 1 and 3.

Limitation:

- the study was targeted the adherence to routine vaccine as a group and not to polio vaccine. Conclusions drawn might hence not represent that of polio vaccine, although it might be argued that factors hindering the acceptance of different vaccines might not be different.

Paper 3

Strengths:

- most update study period of 2020 when compared to 2017 of Paper 1 and 2017-18 of Paper 2.

- the qualitative component of the mixed methodology allows for exploration into experience and perceptions of the participants on polio vaccine. This cannot be achieved with a pure quantitative approach as in Paper 1 and 2.

- the research addressed the issue of adherence to polio vaccine only. Conclusions drawn would hence be most appropriate to answer the RQ.

- this paper recruited over 8,000 participants, the highest amongst the three. And hence might yield data most representative of the population under study.

Limitations:

- as participants were recruited using convenient purposive sampling, the finding might not be generalized.

- the cross-sectional survey design renders temporal relationships impossible.

Did the papers answer the RQ?

Paper 1

Yes. ⭐⭐

The paper was relatively outdated and the sample size was relatively small. However, the adoption of a matched-control design might potentially yield more reliable results. Data for the polio sub-group was provided, which was most relevant to the RQ. Although subsequent conclusions and recommendations were based on routine vaccines as a group only, they might still be valid as it would be likely that factors related to refusal of routine vaccine as a group and to polio vaccine alone would be no different.

Paper 2

Yes.⭐

The paper was relatively outdated. In particular, the paper mentioned on the provision of easier access to health facilities. However, this factor might have scientifically changed after a period of 6 years. The main limitation of the paper is that it addressed on routine vaccine as a group and not to polio vaccine alone. One might argue that there would not be a significant difference in the factors responsible for refusal of polio vaccine and routine vaccines as a group. However, polio is an oral vaccine at the time of the study while other vaccines were injections. Needle phobia might be a factor for refusal of other vaccines, which would not be a factor for polio vaccine. Also, there were previous reports of serious neurological sequelae after the older-generation polio vaccines. Mothers might have misconceptions about the same for current polio vaccines. This concern would not apply to other routine vaccines. It is hence best to identify papers addressing issues onto polio vaccine.

Paper 3

Yes. ⭐⭐⭐

This is the most update paper with a large number of participants. The qualitative element of the paper contributed to valuable data in relation to the expectations and experience of the participants, which would not be provided in quantitative research. Due to engagement of healthcare workers during the focus group discussions and in-depth interviews, the paper came to the conclusion that education campaigns and rectifications of misconceptions should be targeted not only to parents, but also to healthcare workers. This might be a crucial factor to be in-cooperated into policymaking for the public health issue under discussion.

The paper provides some useful insights to the research question, with the limitation that polio vaccine is grouped under multiple routine vaccines.

However, the sample used may not be generalisable to the Pakistan population as a whole. It provides up-to-date information on knowledge and perception of polio vaccine, and the findings useful for the research question around factors influencing polio vaccination adherence.

The study identifies factors associated with incomplete immunization, however, it may not establish causality between these factors and poor adherence to polio vaccination. There could be other underlying variables or complex interactions that are not fully captured.

In contrast, the reliance on self-reported data for identifying factors associated with vaccine refusal could introduce recall bias or social desirability bias, leading to inaccuracies in reporting.

The paper answers the research question as it uncovers the factors that are associated with incomplete immunization of children. what came out clearly were mother`s leteracy level and access to healthcare services.

A menthod used for data collection (Pakistan Demographic and Health Survey (PDHS) 2017–2018) was reliable as it has potential to produce generalizable results for Pakistan.

But apart from knowledge and accessibility which came out clear in this study, decisions about people`s health are affected by many factors including beliefs, experiences, social economic status and many more. So surveys which normaly use standardized questions with no flexibility of probing, may not give out in depth understanding of the issue at hand. Therefore it would be great if a mixed method was used.

Maguy Makusudi

The study was relevant to respond to the research question. The use of a mixed method approach provided a holistic understanding of factors behind poor adherence of polio vaccine. The triangulation of quantitative data from a cross-sectional study with qualitative data from focus groups + in-depth interviews offered more insights on the issue and identified knowledge gaps. For instance, it has revealed the role of grandmothers in child caring. Mixed methods are appropriate in reducing bias inherent in the use of a single method.  However, the study was limited to the polio high-risk areas and would not be generalised to the whole country.

The paper is secondary study based on Pakistan DHS findings, to understand factors for incomplete child immunisation in Pakistan. Researchers have employed a cross-sectional approach to gather data from both urban and rural regions, hence offering a representative sampling for findings to be generalised across the country. The study has identified demographic and behavioural factors that denote inequalities in adherence to child immunisation, substantiated by other studies in Pakistan and other countries, with key ones being maternal literacy and accessibility to health facilities.

The study was relevant to respond to the issue of adherence to childhood immunisation and to inform decision making. However, it was limited to prove the causality between the factors and adherence to polio vaccination amongst other vaccines.

While the results can be generalized, the study is not the most appropriate for the research question as it does not pertain solely to the poliovirus vaccine.

The study is relevant to the research question as it provides up-to-date information on factors that affect polio vaccine adherence, such as knowledge and perception.

1.       The study utilizes data from reputable source i.e. Pakistan’s Demographic and Health Survey which enhances reliability of the findings. It clearly outlines its objective providing a specific research goal.

2.       It addresses a critical and relevant public health concern i.e. issue of incomplete immunization in a developing country.

3.       The study discusses global immunization efforts i.e. WHO’s Expanded Program of Immunization.

4.       References local studies and utilizes regional data.

Weaknesses

1.       The study lacks detailed information on specific methods employed for data analysis and selection of determinants.

2.       The paper does not elaborate on the extent to which each sociodemographic and behavioral factors influencing vaccine uptake

3.       There is lack of detailed discussion on practical implications of findings for healthcare policy.

4.       It would have been beneficial to discuss any ethical considerations related to the original data collection.

1.       Study employs a mixed-methods approach, combining quantitative and qualitative data collection method.

2.       Study involves a comparative analysis with previous survey conducted in 2012 which allows for identification of trends and assessment of effectiveness of interventions implemented.

3.       Qualitative component involves diverse representation i.e. various stakeholders, including healthcare providers, parents, and community leaders. It provides a well-rounded understanding of the factors influencing polio knowledge and vaccine acceptance.

Weaknesses

1.       The study focuses on specific high-risk areas, it limits generalizability of the findings to the broader population.

2.       The cross-sectional design restricts establishing a temporal relationship between variables.

3.       Self-reported data through surveys and interviews introduces bias e.g. recall bias