Refusal of oral polio vaccine in northwestern Pakistan: a qualitative and quantitative study.
BACKGROUND
Refusal of the oral polio vaccine (OPV) is a difficulty faced by the Polio Eradication Initiative (PEI) in multiple endemic areas, including the Khyber Pakhtunkhwa Province (KPP), Pakistan. In 2007, we investigated community perceptions of the OPV and estimated the prevalence of OPV refusal in three districts in Swat Valley, KPP, a polio-endemic area.


METHODS
Qualitative data concerning community perceptions were collected by focus group discussions among lady health workers (LHWs) and mothers with children <1 year old and by key informant interviews with local health managers and officials. Quantitative data collection followed using a questionnaire survey of 200 LHWs and a cluster sampling survey of 210 mothers (per district) with children <1 year old.


RESULTS
The qualitative assessments identified the grounded theory of OPV refusal involving facts known by the residents that are related to the OPV (too frequent OPV campaigns, an OPV boycott in northern Nigeria in 2003 and that birth control is viewed as is against Islam), the local interpretations of these facts (perceptions that OPV contained birth control or pork, that OPV was a foreign/central plot against Muslims, and that the vaccination was against the Hadith and the fate determined by God) and different manifestations of OPV refusal. Among the three districts studied, the proportion of LHWs who encountered OPV refusal ranged from 0 to 33%, whereas among the districts, the proportions of mothers unwilling to give OPV to their children ranged from 0.5 to 5.7%. Refusal of other injectable vaccines was almost equally prevalent for reasons that were very similar.


CONCLUSIONS
The PEI needs to reflect local value system in the path to polio eradication in the studied districts in the Swat Valley. The religious and cultural values as well as the interpretation of the international political situation are of particular importance.
Expert Services Division, Department of International Medical Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Electronic address: murakami@it.ncgm.go.jp.
Hitoshi
H
Murakami
Expert Services Division, Department of International Medical Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Electronic address: koba98@mwb.biglobe.ne.jp.
Makoto
M
Kobayashi
Expert Services Division, Department of International Medical Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Electronic address: m-hachiya@it.ncgm.go.jp.
Masahiko
M
Hachiya
The United Nations World Food Programme (WFP) Office for Pakistan, Islamabad, Pakistan. Electronic address: khanzahir_shah@hotmail.com.
Zahir S
ZS
Khan
The United Nations World Food Programme (WFP) Office for Pakistan, Islamabad, Pakistan. Electronic address: syedqamarulhassan@yahoo.com.
Syed Q
SQ
Hassan
Expert Services Division, Department of International Medical Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Electronic address: ssakura@mti.biglobe.ne.jp.
Shinsaku
S
Sakurada
D060740:Disease Eradication; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D009035:Mothers / Q000523:psychology*; D010154:Pakistan; D011051:Poliomyelitis / Q000517:prevention & control; D011055:Poliovirus Vaccine, Oral / Q000008:administration & dosage*; D012067:Religion; D016312:Treatment Refusal; D014611:Vaccination / Q000523:psychology*
D011055:Poliovirus Vaccine, Oral
Oral polio vaccine; Pakistan; Polio eradication; Poliomyelitis; Vaccine refusal