Assessment of the Prevalence and Determinants of Vaccine Hesitancy in Pakistan

1. INTRODUCTION

The current Coronavirus (COVID-19) pandemic, caused by the virus severe acute respiratory syndrome coronavirus (SARS-CoV-2), is the world's worst public health emergency, causing massive mortality and morbidity as well as enormous economic damage. COVID-19 has already infected over 300 million people globally, resulting in over five million fatalities as of January 2022. In Asia alone, there were approximately 188,455 new cases in January of 2022, with more than 500 fatalities [1]; in Pakistan, more specifically, there were more than 50,000 active cases on this date [2].

The average number of people a single infected person in a completely susceptible population can expect to transmit a virus to has increased from two to three individuals for the original Wuhan SARS-CoV-2 virus and to five to six individuals for the Omicron variant of the SARS-CoV-2 virus [3]. As a result, vaccinated communities are more likely to shift their focus away from preventing SARS-CoV-2 infections and toward recognizing that the virus is endemic in order to reduce major disease, hospitalization, and mortality [4].

When the first batch of COVID-19 vaccines from China arrived in Pakistan on February 3, 2021, Pakistan began its coronavirus immunization campaign. The vaccine was originally given to medical personnel who were treating COVID-19 patients and was later made available to those over the age of 60 through a nationwide campaign. By September 2021, the vaccine was available anyone 12 years or older [5]. Pakistan's overall population is 207.77 million people, with an average household size of 6.45 people and a national population growth rate of 2.4% from 1998 to 2017. The literacy rate in the nation is 58.92%, and 64% of the population is under the age of 30, with 29% between the ages of 15 and 29 [6, 7].

As vaccine hesitancy and confidence are important predictors of vaccine uptake, it is important to understand what causes hesitancy. Vaccine confidence refers to the belief in vaccines, vaccine providers, and the research, protocols, and regulations that underpin them. Vaccine hesitation refers to a fear of vaccines based on a particular belief or underlying principle [8]. Hesitation may also be affected by comorbidities such as pre-existing illness or chronic disease [9, 10]. Vaccine apprehension and low confidence can lead to immunization rejection or postponement. As described by the Strategic Advisory Group of Experts on Immunization working group on vaccine hesitancy, both vaccination hesitation and confidence are complicated and may be impacted by various causes, and are roughly divided into three categories: (1) sociopolitical and cultural elements in the situation, (2) individual and group impacts, (3) vaccine specific factors [11].

Vaccine acceptance is currently a major challenge, raising concerns about public trust in the COVID-19 immunization process, even in developed countries. Similar myths and conspiracies have also been reported for measles, poliovirus, rubella, and mumps, with myths and misinformation leading to decreased vaccination [12, 13]. Vaccine reluctance [14] can be related to misconceptions, disinformation, and conspiracies in vaccination efficacy and practicality or to a complete rejection of vaccination [15]. These are the challenges that plague public trust when it comes to vaccination side effects.

Vaccine beliefs and education levels have been researched in Canada, the United States, and other nations. Concerns about vaccination safety were also prevalent in communities with a high level of education [16]. The most frequently cited beliefs about vaccines include that 1) vaccines can cause disease, 2) that infants' immune systems can be saturated if they are injected with too many vaccines too frequently, 3) that vaccines contain dangerous and that children with underlying health conditions and are more vulnerable to vaccine side effects, 4) that the purpose of vaccines is to make money, and 5) that naturally immunity is more powerful than it can become with vaccines [17].

Pakistan has a tumultuous history with vaccinations for children and adults, as well as public distrust and vaccine apprehension. One significant example is the country's failure to eradicate poliovirus owing to conspiracy beliefs. Pakistanis' cultural and religious views are at the basis of poliovirus and other vaccination debates [18]. Conspiracies and falsehoods, according to research done in Sindh, a large province in Pakistan, are key impediments to vaccination adoption in the region [19]. This is in line with the results of most immunization programs, which are often influenced by public concerns about vaccine effectiveness and safety [20-23]. An estimated 5–10% of people are adamantly opposed to vaccinations, while a considerable majority are “vaccine hesitant” (VH). In many anti-vaccine societies, concerns about vaccine safety are a major factor [24]; however, other research [25] has discovered that reasons behind vaccination rejection are complex and may include factors, such as education level, stigma, perceived and real side effects, as well as information from neighbors and other sources. The goal of this study was to examine knowledge, attitudes, and practices (KAP) through an online study of the general population. To our knowledge, this is the first examination of vaccination hesitancy and predictors in the Pakistani community. This is significant because vaccine uptake varies widely around the world due to social and geographic factors. The goal of this study was to assess the prevalence and risk factors determining COVID-19 vaccine hesitancy (VH) among the Pakistani population.

2. METHODS

3. RESULTS

A total of 688 validated questionnaires were completed online between October and December 2021. The demographic information of the study participants is presented in Table 1. Most of the participants were male (57.4%), 42.6% were female. Most of the participants were from Punjab (50.6%) and had postgraduate education (37.5%) (Table 1). Many of the respondents (51.9%) were students, and nearly all the participants (99.6%) listed Islam as their religion. The typical household surveyed represented a nuclear family (48.3%), with 5 to 10 individuals living in a household (63.1%).

4. DISCUSSION

As it faces a fifth wave of the new coronavirus, Pakistan, a country of 207 million people [6], is seeing a dramatic increase in COVID-19 infections [5]. Pakistan shares its longest border with India, the world's second-most SARS-COV-2 affected country. In reaction to the catastrophic second wave, Indian hospitals are rushing for beds and oxygen, posing a new threat to Pakistan [27, 28]. However, vaccination uptake in Pakistan was delayed due to worries about the vaccine's safety and efficacy [22]. COVID-19 vaccine hesitancy has been studied all around the world [20, 23, 29, 30], and vaccination acceptance and hesitancy rates differ between nations.

Earlier research on vaccine attitudes indicated geographical differences in vaccine safety and efficacy perceptions [8, 31]. Vaccine safety was least certain in higher-income countries, with 72 – 73% of individuals in Northern America and Northern Europe agreeing that vaccinations are safe. Despite significant fluctuation in Eastern European nations, this percentage was much lower in Western Europe (59%) and Eastern Europe (50%), (from 32% in Ukraine, 48% in Russia, to 77% in Slovakia). However, in low-income regions, the majority of people think that vaccinations are safe, with the greatest percentages in South Asia (95%) and Eastern Africa (92%) [32]. In terms of vaccination effectiveness, a similar pattern was seen, with Eastern Europe being the location where individuals are least likely to agree that vaccines are effective, compared to South Asia and Eastern Africa [32].

Another predictor is religion, which is the most commonly researched factor in vaccination reluctance studies worldwide. Greater levels of religiosity have been linked to a higher rate of vaccination refusal in studies [33]. Except for the components used in vaccinations and religious consciousness, this study showed no religious role in vaccine myths, conspiracies, or disinformation that led to vaccine rejection as 59.9% of the participants said that they will not consider religious point of view before getting vaccinated and also many of the respondents have already heard about the rumors like vaccination is a strategy of the non-Muslims against the Muslims and as vaccine is also produced by the non-Muslim countries but still a majority of the participants were ready to have themselves and their children vaccinated even though respondents said that they weigh the opinions of Religious Scholars about vaccines. Although some participants mentioned that they were more concerned about the formulation because of the concept of halal and haram in Islam, this did not affect the view of most of our study participants on the uptake of the vaccine.

Additionally, education level is a critical indication of vaccination rejection, with illiterate and less educated people showing higher rejection and more faith in myths and conspiracies, in line with previously reported data from Canada and other countries [16]. Our findings also demonstrated that less educated participants had objections about the safety of vaccinations and that educated participants were in favor of protection through vaccines, with the results showing that participants were less susceptible the myths about vaccinations as their education level increased.

Despite the ever-increasing responsibility of the media in the public’s vaccination reluctance, these relationships have been relatively understudied. On the one hand, the media is a powerful instrument that has been frequently used in vaccination efforts across the world [34]. In our study, 65% of the survey respondents showed that they were not hesitant toward the COVID-19 vaccine itself; however, many (52.33%) did have a negative attitude toward the presentation of the vaccine in the media. Much of this negative attitude stemmed from the misleading stories and misconceptions emerging from social media sources and political pundits [35]. Negative vaccination-related information communicated through the media, social media, or interpersonal contact, had an influence on the public and contribute to vaccine reluctance. We saw in this study that many of the participants agreed that they had reconsidered the choice to choose to vaccinate themselves and their children, whether they were currently vaccinated or not, due to the reports they had seen or heard on social media, including trends from Twitter, stories on Facebook and Instagram. Despite this, the bulk of the respondents agreed that if they came across a rumor or a misconception, or negative information about COVID-19 vaccination, they would still consider it seriously based on the results of scientific research.

Another factor that has been discussed in this study, government influence. According to our findings, people trust the current government to provide credible information about vaccine products and vaccination campaigns (64.2%). Also, more than half of the participants (52.9%) were convinced that the government would purchase the highest quality vaccines available for COVID-19. In our study, participants were willing to vaccinate whereas participants in cities in the United States who had high or very high confidence in their current national government were less likely to accept the vaccine [36].

A recent study [37] found a 20–25% hesitation rate among Canadian and American adults in May 2020. COVID-19 vaccination hesitancy was reported to be 41% and 26% in Italy and France, respectively [38, 39]. A global poll of 19 nations found that Russia had the lowest acceptance rate (less than 55%) while China had the greatest acceptance rate (90%) [29]; and in Indonesia vaccination acceptance rates of more than 90% were found [40]. According to our study, Pakistan had a lower prevalence of vaccination hesitancy (15-20%) than the United States (20%) [23] and Egypt (27%) [41].

In contrast, vaccination apprehension in our research population was lower than in Australia (41%) [42], and Saudi Arabia (55.3%) [43]. Vaccine acceptance is heavily influenced by one’s beliefs. Our findings revealed major concerns regarding the COVID-19 vaccine’s safety and effectiveness, influence of government and media, gender discriminations and financial factors. Our findings corroborate those of studies done in other countries, which found that the COVID-19 vaccine’s safety and effectiveness were the primary concerns [40, 44-47].

Concerns about effectiveness and safety were among the top reasons given by research participants in surveys looking at the reasons for COVID-19 vaccine rejection [48-51]. One possible explanation for COVID-19 vaccine safety difficulties and vaccination reluctance in Pakistan is the vaccine’s Chinese origin. The Chinese vaccine, which was distributed with other vaccinations from the World Health Organization’s COVAX program, made up the majority of the statewide immunization push in Pakistan. Acording to Kreps et al., respondents were less inclined to accept COVID-19 vaccines developed in countries other than the United States because of vaccine features related to vaccination choice. Following the development of vaccinations in the United Kingdom, the Chinese vaccine was particularly controversial [52]. During our study period, October to December 2021, there were few administrative changes around COVID-19 policy. The vaccine was offered to anyone 12 or older, while travel and other activities were restricted for non-vaccinated individuals. Although these restrictions may have affected the uptake and hesitancy of some of the population, these administrative changes remained in effect after the end of our study.

Shekhar et al. observed a greater proportion of predicted vaccination hesitation among females than men in a recent survey of U.S. healthcare professionals [53]. This contradicts our findings, as our study revealed no link between gender and vaccination hesitancy, despite the fact that males had a higher degree of knowledge than females and females had more positive attitudes. In line with the findings of a 2011 systematic review [54], which found no consistent relationship between participant age and vaccine uptake, our study found a significant relationship between hesitancy rate and participant age, with people in the 18-24 age group being more likely to be vaccinated than those in the other age groups. The belief in conspiracy theories and misleading and inaccurate information regarding COVID-19 vaccinations spread through social media and the internet was the second most common anxiety mentioned by our survey participants. This study result is also in line with the findings of a recent study done in Pakistan’s Sindh province [19]. Multiple COVID-19 pandemic conspiracy theories have been quickly spreading throughout the world [55, 56]. These conspiracy theories are based in part on medical skepticism or a general distrust of and lack of faith in medical institutions and professionals [35]. Other important hurdles to immunization were views that a vaccine could not rescue people from SARS-Cov-2 and that vaccination was unnecessary if preventative measures were adopted [19].

There are several important limitations to the results we present here. First, the limited sample size compared to the size of the overall population of Pakistan. Indicating that the sample may not be representative of the overall population of the country. Also, by conducting this study online, the responses may be subject to potential biases as a result of the time needed to fill out a complex form using a computer or mobile device. Additionally, as with any study, it is difficult to understand how generalizable findings are to the entire population of a country, even with random sampling methods.

This study has identified the key determinants and drivers behind vaccine hesitancy in a variety of demographics in Pakistan, including age and education level. These findings can be used to develop targeted interventions and policies to address the issue of vaccine hesitancy, such as the development of tailored communication campaigns for different segments of the population based on their beliefs, the development of culturally sensitive interventions, investment in Risk Communication and Community Engagement (RCCE), the implementation of behavior change strategies, and addressing access barriers by streamlining vaccination processes, increasing clinic or vaccination site accessibility, and exploring mobile vaccination options.

Furthermore, this study’s findings can be used for a policy that addresses systemic barriers to vaccination, such as expanding vaccination sites, ensuring convenient service hours, and outreach campaigns, particularly in rural areas. Additionally, policies promote the training of healthcare workers on effective communication in order to address vaccine hesitancy and build trust with the public.

CONCLUSION

COVID-19, a pandemic that has wreaked havoc on all aspects of development and affected numerous things around the world, including education, is indescribable. The current study found that the general population in Pakistan has a good understanding of COVID-19, but it also revealed many disparities in public awareness and practices about the disease. The survey further identified the sources of information for the public, which could be used to raise understanding of infectious diseases apart from coronavirus in the same community. However, the findings show that age, education, and gender should be considered while making policies for personalized health promotion programs. Potential areas of future research include exploring these demographics when designing interventions in vaccine uptake.

REFERENCES