Exploring Knowledge and Perceptions of Polio Disease and Its Immunization in Polio High-Risk Areas of Pakistan

"[E]ffective communication and education campaigns are needed to address misconceptions, build trust, and promote vaccine acceptance within the community."

Despite numerous awareness campaigns and initiatives through local and international stakeholders and partners, fears and misperceptions about polio vaccines persist among high-risk communities in Pakistan, one of the few countries where poliovirus transmission still persists. This mixed-method study in high-risk areas for polio in Pakistan sought to identify knowledge and perceptions about polio and its vaccination. In addition, the study estimates the current coverage of routine immunisation and uptake of the oral polio vaccine (OPV).

From January 2020 to March 2020, the researchers collected quantitative data from 3,780, 1,258, and 2,100 households in Karachi, Bajaur, and Pishin, respectively, along with qualitative data from focus group discussions and in-depth interviews.

The findings reflected that most of the respondents had heard about polio in all three site areas: 99% in Karachi, 98% in Bajaur, and 97% in Pishin. However, their knowledge about polio transmission was poor. Over a third of all people (36% in Bajaur, 40% in Pishin) referred to polio as Allah's will; many residential respondents in Karachi believed that the evil eye could cause the disease. The primary information sources about polio were reported to be television in Karachi (47%) and Pishin (39%), along with radio in Bajaur, and lady health workers (LHWs) in Pishin (39%). Polio was considered to be a health problem for 60% to 93% of respondents.

OPV-related knowledge was high, from 97% to 99%, in all three study areas. Its effectiveness for polio prevention was understood, with 69% of respondents in Pishin, 89% in Karachi, and 94% in Bajaur perceiving it as a necessary preventive measure against polio. There are still concerns regarding OPV, which was perceived as being utterly safe by 77% of respondents in Karachi and 63% in Bajaur, but only by 42% of the people in Pishin. Vaccine refusal rates were highest in Bajaur (42%), followed by Karachi (23%) and Pishin (20%). In addition to the belief by some that the vaccine was unsafe, the most-cited OPV refusal reasons were concerns about the vaccine causing sterility (19% in Karachi, 68% in Pishin). This sterility misconception was compounded by other misconceptions that the vaccine was not halal or was impermissible under Islamic laws. This misconception was found to be highest in Pishin (45%). In addition, the proportion of refusals influenced by local/community leaders was highest in Bajaur (21%), with respondents reporting that they had been prohibited by local or community leaders. When specifically asked to cite reasons for not giving polio drops on National Immunisation Days (NID) or campaigns, local respondents cited the absence of the polio team or visits by LHWs.

The researchers compared the data of key indicators from this survey with a comparable survey conducted in 2012. Some of the findings of this analysis are concerning. For example, there was a notable reduction from 49.7% to 41.9% among the respondents in Pishin who believed OPV to be completely safe. The data on OPV refusal rates indicated a significant change in both Karachi and Pishin, with the refusal rates increasing from 5% to 23.1% and 17.4% to 25.0%, respectively. Conversely, there was a substantial increase in the proportion of fully immunised children in all three areas, along with a notable reduction in the proportion of unimmunised (zero doses) children.

The qualitative component findings encompassed the perspectives of various respondents, including doctors, grandmothers, polio health workers, and media sources such as mosque announcements, TV, radio, banners, and posters. The study participants highlighted a culture in which mothers are offered support from grandmothers in child-rearing, child health, and related matters. Members of the community highly admired the rigorous efforts of polio workers as they addressed their queries and concerns and counseled and motivated them to vaccinate their children against polio. However, some people are still against vaccination due to their doubts, fears, religious beliefs, family or cultural norms, limitations, and/or preferences, as well as their suspectibility to fake news and rumours. The respondents highlighted the perception of the adverse effect of vaccines on reproductive health as a prevalent misconception in the community. Notably, in recent years, social media has played an important role in rapidly spreading false rumours about the polio programme.

Reflecting on the quantitative and qualitative findings, the researchers suggest that:

• There is a need to improve community understanding about the importance of childhood immunisations. One approach: comprehensive education campaigns reaching out to parents and healthcare providers that emphasise the importance of vaccination and address misconceptions. The strategy should employ various communication channels and platforms, such as social media, community outreach programmes, and informational materials, in order to reach a wide audience. Furthermore, it should be culturally and contextually tailored to the specific cultural and socioeconomic contexts of countries at high risk of polio. To evaluate the effectiveness of these strategies in enhancing the relationship between parents and healthcare providers, a comprehensive assessment should be carried out.
• Community mobilisation is a cornerstone of vaccine confidence and acceptance. Analysis revealed that these mobilisation activities are very helpful, as, initially, people were rigid and did not have any understanding of vaccination, and even used to refuse to open their doors, but a drastic change was observed after a rigorous and collective effort by all stakeholders. Studies suggest that developing a trusted relationship with parents is the key to influencing parental decision-making about polio and routine immunisation.
• Specifically, there is an utmost need for a coalition campaign involving religious scholars, civil society stakeholders, and the media that could turn the tide against polio disease in Pakistan. Inadequate knowledge, false religious beliefs, and misconceptions are likely to be the source of potential barriers to behavioural change that could help reduce the burden of polio in Pakistan and other high-risk countries.
• Most of the families in these high-risk polio areas are impoverished, underserved, and lack basic needs. Furthermore, weakened essential immunisation services, poor water and sanitation, and lack of maternal and child health care further compound the polio eradication challenge in Pakistan. To overcome these challenges, an integrated approach is required in which all of these services should be given to communities holistically.

"By following these recommendations and continuously evaluating the strategy, decision-makers can develop an evidence-based approach to effectively reduce polio in high-risk countries."