Attitude and Perception towards Vaccination against Poliomyelitis in Peshawar, Pakistan

"...communication officers and mobilization teams struggle to convince people that repeated polio vaccinations are safe, and that complete immunization is needed for children's immune system to cope with the virus, yet this message is still not effectively communicated..."

In contrast to global trends, the number of polio cases has increased at an alarming rate in Pakistan. The condition can be efficiently prevented by the administration of a vaccine in childhood. In Pakistan, clinical camps and door-to-door oral vaccination of every child under the age of five are implemented to ensure widespread access to the vaccine. Awareness campaigns, counselling exercises for parents in high-risk areas, and media campaigns have been planned and executed to try to make Pakistan polio free. Despite all the government's effort, barriers to eradication clearly remain, including in Peshawar city, Khyber Pakhtunkhwa (KPK), deemed a "conveyor belt" for polio transmission by the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI). This paper describes a pre-tested questionnaire-based study conducted in 2019 to assess the attitude and general perception of residents of Peshawar towards polio vaccination.

Data on polio-positive patients from 2015-2019 were collected from the National Surveillance Cell, Islamabad. Of 241 country-wide polio cases during that time, 63 (26.1%) were reported in Peshawar city. A convenience non-probability sampling approach was used in the surveillance study, which ran from March 2019 to September 2019 and involved 384 participants in Peshawar aged 18 and over. Another questionnaire was designed to interview polio health workers to assess the difficulties they face in the field during polio campaigns, such as coping with community resistance. The 178 polio workers were interviewed during the polio campaign held in April 2019.

By assessing participants' knowledge, the researchers observed that people were aware of the polio disease due to the polio campaign, but most of the people were unaware of the clinical symptoms and of post-polio syndrome. The questionnaire revealed that individuals between 18-30 years of age had sufficient knowledge (65.1%) about polio. Male and female participants had equal awareness (approximately 43%). Participants with higher education (45.9%), those with better financial status (49.5%), those with children under 5 years of age (46.4%), and those who knew someone with polio (63.1%) had better knowledge. Participants inhabiting the central city were more aware (50.5%) of polio than individuals living in the outskirts (35%).

With regard to attitudes, 15.8% of participants still did not consider polio to be as a severe disease. About 21% of individuals strongly disagreed that children should be vaccinated, and 14.5% strongly disagreed that communities should actively participate in the effort to eradicate polio from the country. Approximately 10.9% of participants strongly rejected the statement that polio patients are less productive than those who are physically normal and healthy.

Most of the people surveyed believe that the polio vaccine has some contents that are not halal (permitted by Islam) to consume. People also showed concern about the quality of polio vaccine. Many participants had a false belief that there is some hidden agenda behind the polio eradication programme to target religious communities or coloured races. Others had misconceptions about the vaccine - e.g., that it could cause HIV or sterility - which is why they were reluctant to immunise their children.

In that vein, the polio workers who were interviewed suggested that religious constraints - i.e., the belief that polio vaccine has some content that is unlawful to consume (as some uneducated religious leaders argue) - is the biggest hurdle to immunisation (43.2%). As noted here: "Most people in Pakistan blindly believe preachers' opinions about specific products; therefore, altering their mindset is difficult." Lack of knowledge is the second-biggest problem (35.4%) in the way of polio eradication from Pakistan, according to the respondents.

Reflecting on the findings, the researchers note that, thanks to the government's social mobilisation efforts, people are getting familiarised with the disease name and cause, but knowledge about transmission and dosage of vaccine needs to be conveyed. Though most of the individuals agreed that polio is a severe disease, some were reluctant to get their children immunised due to the lack of awareness about the possible threats. One of the reasons why older people had poorer knowledge than those below age 30 is they are less familiar with social media and are mostly illiterate. Thus, ignorance is a significant factor influencing the vaccination rate in Pakistan.

Some of the other issues the researchers cover in the paper's discussion section include:

• People said they usually get uncomfortable because of frequent visits of the male polio workers; mothers at home avoid the interaction. Considering this issue, the government of Pakistan specifically trained female health workers. However, some criminals have taken advantage of this campaign to loot, making people distrust the polio teams. Polio team worker backgrounds should be checked before field visits.
• The study found that some parents believed vaccines could make their children sick. The belief was strengthened after an April 2017 incident in Peshawar when, on the second day of the polio vaccination campaign, hundreds of children were rushed to hospitals complaining of abdominal pain, diarrhoea, and vomiting. Consequently, parents in rural and urban areas of Peshawar and the capital of Islamabad refused to have their children vaccinated the next day.
• Polio workers also noted that political and religious leaders' negative attitudes prompt security issues, which might interfere with their performance. For example, a policeman was gunned down while protecting polio workers during a polio campaign in Bannu region of KPK in 2019.
• Other factors behind the polio campaign's failure not covered above include lack of health facilities and unchecked migration between Pakistan and Afghanistan (the other remaining polio-endemic country in the world).

In conclusion: "To eradicate polio from Pakistan, we must overcome the religious, political and socio-economic obstacles to immunisation, including vaccination coverage gaps, inadequate health facilities and tensions in the country's polio-endemic areas....The scholars or religious leaders should be sensitized to the severity of the disease and its control to clear their insecurities. In that way, we could change the mindset of a vast mass."