Prevalence of Parental Refusal Rate and Its Associated Factors in Routine Immunization by Using WHO Vaccine Hesitancy Tool: A Cross Sectional Study at District Bannu, KP, Pakistan

"The parental vaccination refusal rate in this study was high."

Although the Expanded Program on Immunization (EPI) has been in place in Pakistan since 1978, the national immunisation rate is consistently low. Vaccine hesitancy, due to factors such as a low literacy rate, socioeconomic disparities, cultural and religious beliefs, and belief in conspiracy theories (e.g., that vaccines may damage or sterilise children), is one of the main reasons for reduced vaccination coverage in this low- and middle-income country (LMIC). This study used the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy Survey Tool to determine the vaccination refusal rate, associated factors, and perceptions of parents who refused routine immunisation for their children in Bannu District, Khyber Pakhtunkhwa (KP) Province, Pakistan.

A cross-sectional survey was conducted using multi-stage cluster sampling in Bannu District from March 2019 to July 2019 among 610 parents, the majority of whom were male [n = 323 (53%)], of children aged 0-59 months. Logistic regression was performed for associations, and multi-regression was applied to identify any confounders.

Of the 610 parents, 68.2% believed that vaccination would protect their children from serious diseases, and distance to clinic, time, and cost did not deter them from immunisation [n = 346 (56.7%)]. One hundred seventy of them (27.9%) reported they had ever refused vaccination of their children. The majority [n = 103 (60.6%); p = 0.005] of parents who refused vaccination of their children believed vaccination has serious adverse effects. As a result, 19.4% of parents disagreed with doctors' recommendations to vaccinate their children. However, the majority [n = 152 (89.4%); p = 0.005] of those parents who refused vaccination of their children believed vaccination would protect their children from serious disease. One hundred and fifty-six (91.8%; p = 0.005) reported that parents who are "like them" do not vaccinate their children, and 146 (85.9%; p = 0.005) parents reported they had ever hesitated about vaccination of their children.

Vaccination refusal rate was associated with inability to read or write, lack of education, owning a mobile phone, unemployment, and food security. For example:

• Using univariate logistic regression analysis, mothers who were able to read or write were found to be less likely to refuse vaccination of their children [unadjusted odds ration (OR) 0.61, 95% confidence interval (CI) 0.38-0.98, p = 0.04; adjusted OR 0.74, 95% CI 0.05-9.3, p = 0.81]. The researchers explain that a low level of education could result in a lack of, or low, understanding of information about the benefits of vaccination. Such parents may also be easy targets for rumours and false information.
• On multi-variate logistic regression, parents with high food insecurity were more likely to refuse vaccination of their children (adjusted OR 2.2, 95% CI 1.0-0.50; p = 0.04) compared with parents with minimal food insecurity (adjusted OR 1.6, 95% CI 1.0-2.5; p = 0.02). A possible reason could be that "a high degree of food security is directly associated with higher social class, so these people are more likely to be influenced by the media and conspiracy theories relevant to vaccination."

The researchers explain that it was difficult to establish the role of polio campaigns in vaccination refusal (in Pakistan, polio campaigns for children aged under 5 years of age are held almost every month); thus, it remains to be determined whether polio campaigns have a positive or negative effect on vaccination refusal. It may be worth noting that, in 2019, 25,000 children were brought to hospital in Peshawar, Pakistan, over a matter of hours, reporting adverse reactions attributed to the polio vaccine. In reality, there were no adverse reactions, and the response was based on a rumour; on the same day, two police officers and polio workers were shot dead to stop the vaccination drive. Such an example illustrates why it may be useful to understand the reasons behind parental refusal and also hesitancy around vaccination in Pakistan, as "even parents who are willing to have their children vaccinated are also 'on the edge' and easily cave in to negative rumours about vaccination."