title: Threats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years.
abstract: BACKGROUND
  Elimination of poliovirus from endemic countries is a crucial step in eradication; however, vaccination programmes in these areas face challenges, especially in regions with conflict. We analysed interviews with caregivers of children living in two polio-endemic countries to assess whether these challenges are largely operational or also driven by resistance or misinformation in the community.
  
  
  METHODS
  We designed and analysed polls based on face-to-face interviews of a random sample of parents and other caregivers of children younger than 5 years in regions of Pakistan and Nigeria at high risk for polio transmission. In both countries, the sample was drawn via a stratified multistage cluster design with random route household selection. The questionnaire covered awareness, knowledge, and attitudes about polio and oral polio vaccine (OPV), trust in vaccination efforts, and caregiver priorities for government action. We assessed experiences of caregivers in accessible higher-conflict areas and compared their knowledge and attitudes with those in lower-conflict areas. Differences were tested with two-sample t tests.
  
  
  RESULTS
  The poll consisted of 3396 caregivers from Pakistan and 2629 from Nigeria. About a third of caregivers who responded in higher-conflict areas of Pakistan (Federally Administered Tribal Areas [FATA], 30%) and Nigeria (Borno, 33%) were unable to confirm that their child was vaccinated in the previous campaign. In FATA, 12% of caregivers reported that they were unaware of polio, and in Borno 12% of caregivers reported that vaccinators visited but their child did not receive the vaccine or they did not know whether the child was vaccinated. Additionally, caregivers in higher-conflict areas are less likely to hold beliefs about OPV that could motivate acceptance and are more likely to hold concerns than are caregivers in lower-conflict areas.
  
  
  CONCLUSIONS
  Beyond the difficulties in reaching homes with OPV, challenges for vaccination programmes in higher-conflict areas extend to limited awareness, negative attitudes, and gaps in trust. Vaccination efforts might need to address underlying attitudes of caregivers through direct communications and the selection and training of local vaccinators.
  
  
  BACKGROUND
  Harvard T H Chan School of Public Health and UNICEF.
authors.affiliation: Harvard T H Chan School of Public Health, Boston, MA, USA. Electronic address: gsteel@hsph.harvard.edu.
authors.forename: Gillian K
authors.initials: GK
authors.lastname: SteelFisher
authors.affiliation: Harvard T H Chan School of Public Health, Boston, MA, USA; John F Kennedy School of Government, Cambridge, MA, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Blendon
authors.affiliation: UNICEF, New York, NY, USA.
authors.forename: Sherine
authors.initials: S
authors.lastname: Guirguis
authors.affiliation: Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Amanda
authors.initials: A
authors.lastname: Brulé
authors.affiliation: Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Narayani
authors.initials: N
authors.lastname: Lasala-Blanco
authors.affiliation: UNICEF, New York, NY, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Coleman
authors.affiliation: UNICEF, New York, NY, USA.
authors.forename: Vincent
authors.initials: V
authors.lastname: Petit
authors.affiliation: UNICEF, Islamabad, Pakistan.
authors.forename: Mashrur
authors.initials: M
authors.lastname: Ahmed
authors.affiliation: UNICEF, Abuja, Nigeria.
authors.forename: Noah
authors.initials: N
authors.lastname: Mataruse
authors.affiliation: UNICEF, Abuja, Nigeria.
authors.forename: Melissa
authors.initials: M
authors.lastname: Corkum
authors.affiliation: Ministry of Health, Pakistan.
authors.forename: Mazhar
authors.initials: M
authors.lastname: Nisar
authors.affiliation: SSRS, Media, PA, USA.
authors.forename: Eran N
authors.initials: EN
authors.lastname: Ben-Porath
authors.affiliation: InterMedia, Washington, DC, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Gigli
authors.affiliation: Oxford Research International, Oxford, UK.
authors.forename: Christoph
authors.initials: C
authors.lastname: Sahm
mesh_terms: D017028:Caregivers; D002675:Child, Preschool; D060740:Disease Eradication; D019353:Endemic Diseases / Q000517:prevention & control; D064868:Ethnic Violence; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic; D008297:Male; D009549:Nigeria / Q000453:epidemiology; D010154:Pakistan / Q000453:epidemiology; D011051:Poliomyelitis / Q000453:epidemiology / Q000517:prevention & control*