Parental Perceptions Surrounding Polio and Self-Reported Non-Participation in Polio Supplementary Immunization Activities in Karachi, Pakistan

"Lack of knowledge about polio, lack of faith in the vaccine’s effectiveness, misperceptions about vaccine-related adverse events (e.g. infertility) and mistrust among Pashtuns make it highly likely that poliovirus transmission will continue in this population unless specific targeted activities are undertaken to promote vaccination."

Given Karachi, Pakistan's cultural and ethnic diversity, the authors of this paper studied a large representative sample of individuals living across the city, their objective being to assess parents' knowledge about polio, rates of non-participation in polio supplementary immunisation activities (SIAs), and reasons for non-participation in these activities. The researchers sought to ensure adequate representation of the Pashtun community, a group that comprises an estimated 35-40% of Karachi's population and yet has suffered 90% of recent polio cases in the city. This community has high rates of migration and displacement and low rates of polio vaccination.

Data collection for the study, which had a mixed methods design, was carried out from November 2011 to January 2012. The quantitative component of the study involved a cross-sectional cluster survey in Karachi. The questionnaire included questions on demographics, knowledge about the symptoms of polio, and number of polio SIAs in which parents had participated in the 2 most recent months. Participants included parents of a child < 5 years old. For the qualitative assessment, parents who refused to have their children receive the oral polio vaccine (OPV) or who reported that their eligible children did not participate in the 2 most recent polio SIAs were purposively selected from the Pashtun population and invited for in-depth interviews. A native Pashto-speaking male medical student was trained to conduct these interviews. Data saturation was reached after 30 in-depth interviews.

Selected communication-related results:

• Pashtun parents cited the primary reasons for refusing to have their children vaccinated as fear of potential harm from the OPV (16%) and lack of permission from family elders (77%).
• Among high-income respondents interviewed in malls, the main reason given was the belief that the vaccine was harmful (72%) or unnecessary (8.5%)
• The odds of knowing nothing about polio were 2.2 times greater among low-income Pashtun parents than among low-income non-Pashtuns. Low-income Pashtun parents were 6 times more likely to have never heard about a polio SIA campaign in their area than low-income non-Pashtuns.
• Children of low-income Pashtun parents were 7 times more likely to have failed to participate in polio SIAs than children of low-income non-Pashtun parents.

In-depth interviews revealed parental perceptions surrounding polio and polio vaccination and why some children did not receive the OPV during the 2 most recent polio SIAs. Most of the parents thought that the polio vaccine caused sterility in adulthood. Some also considered polio vaccination campaigns to be part of a Western conspiracy against Muslim nations, including Pakistan. Moreover, about one-third of the parents reported "no belief" in the polio vaccine and considered it useless or ineffective against polio. Other parents felt that since their children had received several doses of polio vaccine in the past, they did not need to get vaccinated again. Some voiced doubts about the government's motives; one respondent asked: "Why do the government and health system give so much emphasis to polio vaccine? There are so many other diseases that should be addressed first. There must be some other reason (negative reason) for their giving so much importance to polio vaccine." Another theme was concern that the vaccine could contain religiously forbidden "non-halal" ingredients. A few parents also mentioned other reasons, such as difficulty in communicating with the polio vaccinator because of a language barrier.

An excerpt from the Discussion section of the study follows (footnote numbers have been removed):

"This study was undertaken in the wake of extensive media reports of an allegedly fake vaccination campaign organized by the United States Central Intelligence Agency to try to track down Osama Bin Laden by surreptitiously obtaining blood samples from his family members for deoxyribonucleic acid (DNA) testing. The campaign was run by a Pashtun government physician from the tribal area of Khyber Agency who had worked in polio vaccine campaigns....several Pashtun families gave distrust of government-run programmes as the reason for having refused to get their children vaccinated....[R]eports of the incident may have reinforced or perpetuated negative perceptions...

At the community level, conventional communication efforts surrounding polio are largely conducted by female workers or mobilizers who primarily target adult females in the households....Our interviews showed that religious authorities of two or three of the main religious institutions (madrassahs) heavily influence the opinions of Pashtun men in Karachi. To enhance social mobilization, integrated participatory interventions targeting communities at high risk for polio need to be implemented....These interventions should include parental counselling, targeted particularly at male decision-makers; the creation of community networks involving trusted religious authorities, and role modelling by parents who approve of the polio vaccine. The strategy of involving religious opinion leaders in efforts to increase acceptance of polio immunization has already been employed in northern India and Nigeria...

...Although children from high-income families are at little risk of contracting polio, the widespread belief in this social group that repeat doses of OPV are harmful may undermine the overall success of the polio eradication programme, since the wealthy are often opinion leaders and trendsetters...

This is the first study to identify the main perceptions associated with lack of participation in polio SIAs in the ethnic group with the highest polio incidence in Pakistan. This high-risk group needs targeted educational messages and we believe that our findings will contribute to their development...[consider that even] outside Karachi endemic polio transmission is primarily restricted to Pashtun majority areas."