Sitting in my apartment in Geneva, my thoughts inevitably return to the streets of Quetta, Balochistan (Pakistan) where I led a network of community health workers in Quetta Block who went door to door to raise awareness and immunize children against poliomyelitis. Polio is 99% eradicated but remains endemic in Pakistan and Afghanistan. Following the COVID-19 pandemic, vaccine hesitancy and refusals have become a worldwide phenomenon. Based on my experience in Balochistan, here is my take on why people refuse vaccines:
Perceptions
Although fear can, to some extent, influence attitudes, intentions, and behaviors in the short term, it is debatable whether fear is a driving force of vaccine acceptance in the long-term . Let us consider constructs from the health belief model; in my experience, the key is understanding that the perceived severity and susceptibility of a disease is different for everyone. For example, parents in the rural district of Killa-Abdullah (who typically have more than 7 children) did not perceive a disease leading to lifetime paralysis as severe as compared to an urban parent (who typically have 2-3 children), or it was commonly observed that the perceptions on severity varied for a male and female child. Similarly, perceived disease susceptibility plays a role in determining the likelihood of action. For example, in urban communities, particularly in affluent areas, mothers didn’t really believe their children were at immediate risk of polio and were hence hesitant to vaccinate.
Perceived benefit of a particular behavior (such as vaccination) is also an important predictor of the intention to engage in that desired behavior. I observed that some refusal families believed their children were at risk of polio but did not believe the vaccination was beneficial because multiple doses must be administered. Some parents frequently weighed the benefit of a vaccine against its perceived harms, such as paralysis vs infertility, resulting in hesitancy and refusals.
In sum, the communication strategies must consider several factors for promoting individual and community behaviors around vaccination. This may require a quick qualitative assessment on perceptions and a behavioral analysis which will provide us an evidence base for developing targeted messages, content, and tactics for communication interventions.
Misconceptions and mistrust
Rumors spread like wildfire, generating misconceptions, misinformation, and fuel distrust in vaccines. It is my experience that misconceptions take root and become more complex if not addressed timely and efficiently. Among key misconceptions about polio vaccination in Balochistan are that vaccines cause infertility or contain ‘haram’ ingredients; misconceptions that vaccination programs are used for espionage, and that the program is a foreign political agenda aimed at harming Muslim populations. All these notions, while may not be widely prevalent, were persistent in some communities and fueled by context beyond the polio programme.
Another key obstacle to eradicating polio is the spread of misinformation and rumors. Social media has been used as a key tool in spreading this. The case of Peshawar in 2019 can be viewed as an example when disinformation on the adverse effects of polio drops was spread throughout the city using social media channels resulting in thousands of refusals across Pakistan.
Misinformation spreads further, faster, and deeper than facts; therefore, in addressing vaccine hesitancy time is of the essence. Rumors can be handled effectively by monitoring traditional and social media channels (social listening); dispelling rumors by providing accurate and credible information through appropriate trusted channels (pre-bunking/debunking); creating two-way communication avenues (including and beyond social media), and responding to community concerns.
Social determinants
Health behaviors are multidimensional, and influenced by a wide range of factors such as socioeconomic status, geography, education, and cultural norms. According to demographics, more than 70 % of polio cases in Pakistan reside in multiple family dwellings, are predominantly Pashtuns, and are from low-income groups.
In Balochistan, e.g., access to children inside the house by male vaccinators is limited due to social norms; they are not allowed to enter the home and interact with the mothers, resulting in children being missed. The reluctance is not due to the vaccine, but to cultural norms associated with gender segregation.
Many households refused vaccinations because of demands. It was a kind of give-and-take broadly divided into two categories: 1) genuine demands for other services, and 2) using vaccination as a bargaining chip for political gains.
These refusals tend to be easier to deal with because they primarily have no trust issues with the vaccine, so negotiating with them is easier. In addition, we were able to establish health camps as well as advocate for water installations, and sanitation efforts within the areas. In areas as impoverished as Balochistan, these demand-based refusals are never going to disappear but the key is to identify their needs, to hold open dialogues, to listen to their concerns, and to truly advocate for services that will improve their quality of life.
Vaccine hesitancy and refusal is one of the emerging challenges to global health, where the reasons are multifaceted and complex, ranging from individual perceptions to political dynamics and sociocultural influences. Thus, rather than concentrating solely on knowledge, efforts to address the phenomenon must be based on social research, be proactive, and focus on tailored community engagement.
About the author: Jawahir Habib holds a master’s degree in health communication and is currently working with the UNICEF Global Polio Outbreak Response based in Geneva.
Disclaimer: The information of this document expresses the author’s personal views and opinions and does not necessarily represent the views or positions of any organization.
Competing interests: None
Handling Editor: Neha Faruqui