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VACCINATOR’S PERSPECTIVE OF SOCIO-CULTURAL FACTORS
INFLUENCING POLIO VACCINATION CAMPAIGNS
- STUDY FROM SOUTHERN PUNJAB, PAKISTAN
Muhammad Junaid Shafique
Master’s Thesis
Public Health
School of Medicine
Faculty of Health Sciences
University of Eastern Finland
April 2017
ABSTRACT
UNIVERSITY OF EASTERN FINLAND, Faculty of Health Sciences
Public Health
SHAFIQUE, MUHAMMAD J: Vaccinator’s perspective of socio-cultural factors influencing Polio
vaccination campaigns – Study from Southern Punjab, Pakistan
Master's thesis, 80 pages, 2 appendices (3 pages)
Instructors: Sohaib Khan MBBS, MPH, PhD
Professor Tomi-Pekka Tuomainen MD, PhD
April 2017
Key words: Vaccine, Vaccination, Immunization, Vaccinator, Expanded Program on Immunization,
Southern Punjab, Multan, Perception, Socio-Cultural
VACCINATOR’S PERSPECTIVE OF SOCIO-CULTURAL FACTORS INFLUENCING POLIO
VACCINATION CAMPAIGNS - STUDY FROM SOUTHERN PUNJAB, PAKISTAN
Vaccine is a revolutionary tool to fight various diseases. It is made by weakening the disease causing
organism and administrating in to the body. This activates the immunity system which produces
antibodies against the disease and remain in body for life long period. Later exposure to the organism
is then defended by the body due to preexisting antibodies. From public health perspective,
vaccination is the most cost effective and safe method to prevent disease which are life threatening
and require high expenses for treatment and may affect the quality of life by paralysis. In many
underdeveloped countries where public is not well educated and public health concepts are scarce,
the concept of preventive treatment face various challenges. There are wide differences between
people’s perception about vaccination. This study was performed with an aim to understand how
socio-cultural factors affect the perception of people about vaccination from the perspective of
vaccinators.
This study was conducted as a qualitative research in descriptive phenomenographic design
consisting of thematic semi structured in-depth interviews based on an interview guide. The area
chosen for the study was Multan district of southern Punjab region inhabiting mostly lower and
middle class population. To conduct the study, 18 vaccinators were interviewed who were the
government employees under the supervision of Executive District Office of Health. The regional
language of the area is “Saraiki” and all the interviews were conducted in the Saraiki and Urdu
language, Urdu being the national language. As the researcher belong to the same area, there was no
need of a translator to conduct interviews. Interviews were recorded in audio format, transcribed
verbatim and analysis was done. There were seven themes identified form interviews that included,
perception about vaccination, religion, utilization of health care services, parental compliance, family
structure and support, role of stakeholders and socio-economic factors.
Vaccinators perceived a positive attitude of public towards vaccination as now people are well aware
of the benefits of vaccination. Door to door campaign of free vaccination has eliminated various
socio-economic factors. Parents do not have to take their children to the hospitals for vaccination.
Mass media campaigns, involvement of religious scholars and stakeholders have positively
influenced the perception of community about vaccination.
ACKNOWLEDGMENTS
All praises to Almighty ALLAH after that I would like to express my special thanks of gratitude to
my supervisor and examiner Dr. Sohaib Khan who gave me the golden opportunity to do this
wonderful project on this topic. He was very cooperative and with his previous work and knowledge
on the same topic things were very easy for me to understand the core idea that helped me in doing a
lot of Research and i came to know about so many new things about conducting a research.
I would like to extend my thanks to my Parents and my brothers and sisters and friends in Kuopio
who were very supportive to me. My father, especially is worth mentioning who helped me a lot in
collecting data from Pakistan and facilitated me in every possible way.
I wish that this study could serve in improvement of vaccination system and to understand the issues
being coped to eradicate polio form Pakistan. My sincere thanks to all the participants of the study
and the district health officer of my city for cooperating with me to collect the data. Lastly, this
acknowledgment would have been another thesis if I mention everyone so as whole I thank everybody
who provided me support morally or logistically. May Allah’s blessings be with all of us.
Muhammad Junaid Shafique
April 2017
Kuopio, Finland.
CONTENTS
1. INTRODUCTION ........................................................................................................................... 9
2. LITERATURE REVIEW .............................................................................................................. 11
2.1 Poliomyelitis ............................................................................................................................ 11
2.1.1 Etymology ......................................................................................................................... 11
2.1.2 History ............................................................................................................................... 11
2.1.3 Etiology ............................................................................................................................. 12
2.1.4 Geographical Distribution ................................................................................................. 12
2.2 Eradication Strategies .............................................................................................................. 16
2.2.1 Global eradication strategies ............................................................................................. 16
2.2.2 Immunization and Vaccine ............................................................................................... 19
2.2.3 Immunization Strategies ................................................................................................... 20
2.2.4 Immunization Strategies in Pakistan ................................................................................. 22
2.2.5 An overview of Southern Punjab, Pakistan ...................................................................... 26
2.3 Sociocultural factors affecting polio vaccination .................................................................... 28
2.3.1 Perceptions about vaccination ........................................................................................... 28
2.3.2 Rumors and superstitions .................................................................................................. 29
2.3.3 Religious Beliefs ............................................................................................................... 30
2.3.4 Trust on Health Services ................................................................................................... 31
2.3.5 Utilization of Other Health Services ................................................................................. 32
2.3.6 Distance from Health Care Centers .................................................................................. 32
2.3.7 Parental Compliance and birth order ................................................................................ 33
2.3.8 Gender based factors ......................................................................................................... 34
2.3.9 Ethnicity and Influences ................................................................................................... 34
2.3.10 Health Education ............................................................................................................. 35
2.3.11 Stakeholders in the Community ...................................................................................... 36
2.3.12 Family structure and support .......................................................................................... 38
2.3.13 Socio-economic factors ................................................................................................... 38
2.4 Logical framework of the study ............................................................................................... 39
3. AIM OF THE STUDY ................................................................................................................... 41
3.1 General aim .............................................................................................................................. 41
3.2 Specific aims ............................................................................................................................ 41
4. METHODOLOGY ........................................................................................................................ 42
4.1 Study design ............................................................................................................................. 42
4.2 Study Settings .......................................................................................................................... 42
4.3 Subjects .................................................................................................................................... 46
4.4 Data collection ......................................................................................................................... 47
4.4.1 Data collection tool ........................................................................................................... 47
4.4.2 Data collection process ..................................................................................................... 47
4.5 Data analysis ............................................................................................................................ 47
4.6 Ethical considerations .............................................................................................................. 48
5. RESULTS ...................................................................................................................................... 50
5.1 Perceptions about Vaccination – Rumors and superstitions .................................................... 50
5.2 Role of religion ........................................................................................................................ 52
5.3 Health care services utilization – Trust and trends .................................................................. 53
5.3.1 Gender issues .................................................................................................................... 53
5.3.2 Trust .................................................................................................................................. 54
5.3.3 Folk health care sector ...................................................................................................... 55
5.3.4 Distance from health services ........................................................................................... 55
5.4 Parental compliance and health education ............................................................................... 56
5.5 Stakeholders in the community ................................................................................................ 57
5.6 Family structure and support ................................................................................................... 59
5.7 Socio-economic factors ............................................................................................................ 61
6. DISCUSSION ................................................................................................................................ 64
6.1 Discussion of findings and methodology ................................................................................. 64
6.2 Strengths and limitations of the study ...................................................................................... 67
6.3 Implications for research, policy and practice ......................................................................... 68
7. CONCLUSION .............................................................................................................................. 69
8. REFERENCES .............................................................................................................................. 70
9. APPENDICES ............................................................................................................................... 78
9.1 Interview guide ........................................................................................................................ 78
9.2 Vaccination chart ..................................................................................................................... 79
ABBREVIATIONS
AFIX Assessment Feedback Incentives eXchange
AFP Acute flaccid paralysis
AJK Azad Jammu & Kashmir
CBV Community Based Vaccine
CDC Centers for Disease Control and Prevention
CIA Central Intelligence Agency
DCO District Coordination Office
DG Khan Dera Ghazi Khan
DPT Diphtheria-Pertussis-Tetanus
EDO Executive District Officer
EOC Emergency Operations Centre
EPI Expanded Program on Immunization
EPIS Expanded Program Immunization System
FATA Federal Administered Tribal Areas
FIR First Information Report
GAVI Global Alliance for Vaccine and Immunization
GDP Gross Domestic Product
GPEI Global Polio Eradication Initiative
Ig G Immunoglobulin G
IIS Immunization information system
IPV Inactive Polio Vaccines
KPK Khyber Pakhtunkhwa
MMR Measles-Mumps-Rubella
NEAP National Emergency Action Plan
NID National Immunization Days
OPV Oral Polio Vaccine
PPP Purchasing Power Parity
PPW Polio Paid Workers
RNA Ribonucleic Acid
SAGE Strategic Advisory Group of Experts
UC Union Council
UCMO Union Council Medical Officer
UCMO Union Council Medical Officer
UNICEF United Nations Children's Fund
USA United States of America
USD United States Dollar
UV Ultraviolet radiations
VAPP Vaccine associated paralytic poliomyelitis
VDPV Vaccine Derived Poliovirus
WHO World Health Organization
WIC Women, Infants and Children Services
WPV Wild Polio Virus
9
1. INTRODUCTION
Poliomyelitis was a nightmare to industrialized countries in 20th century that resulted in paralysis of
thousands and thousands of children annually. By the mid of 20th century vaccines were developed
which helped in bringing down the huge number of paralysis cases every year. Since then polio has
been considered as a public health issue and it practically eradicated the disease form those countries.
For the developing countries the case was different where food, clothing and shelter were the main
concerns and a lot of population was deprived of those, there health was and still considered as luxury
especially when it comes to preventive health care. However, national immunization programs kept
on working globally with billions of dollars’ investment and cooperation and now more than 2 billion
children have been immunized. Yet, there was not a perfection in achieving the target. Countries such
as Afghanistan and Pakistan and Nigeria are still struggling to get rid of polio (Polio Eradication
Initiative 2017).
Statistics form the recent years suggest that case count for wild polio virus (WPV) in Pakistan has
dropped by 82%. Number of cases are dropping down as seen from 2014 to first half of 2016. In 2014
case count was 306, dropping down to 54 in 2015 and 13 in 2016. These figures suggest 59% decrease
in confirmed cases form year 2015 to 2016. Similarly, confirmed environmental specimens for WPV
dropped down from 35% (2014) to 10%(2016).Community-Based Vaccine (CBV) strategy has been
introduced to cover high risk Union Councils to make sure the delivery of high quality vaccination
services (Polio Eradication Initiative 2017).
Global strategies to eradicate poliomyelitis incorporate vaccination as the key activity. Although
national and international organizations and governmental setups have been struggling hard to
eradicate polio from Pakistan, but the main hindrance is caused by lack of or poor knowledge,
attitudes and perceptions of people about polio vaccination, especially of those living in rural areas
of the country. Socio-cultural influences have been reported by many studies as among the main
concerns for health authorities that are needed to be addressed in order to pursue a successful polio
vaccination campaign (Khan et al. 2015).
Numerous studies have explored socio-cultural factors in different parts of the world and results have
been consistent in identifying their influences but in varying strengths. These studies have mostly
explored the phenomenon from user’s perspective, which are recipients of vaccines. Our study aims
to study the phenomenon from provider’s perspective; Vaccinators are the last part in the chain of
10
providers. Southern Punjab region of Pakistan is a mixed rural-urban setting, with strong tradition
based society, which has been currently labelled as poliomyelitis high transmission zone. This study
will investigate how socio-cultural factors in the society influence the vaccination campaigns,
according to the vaccinators.
11
2. LITERATURE REVIEW
2.1 Poliomyelitis
2.1.1 Etymology
The term Poliomyelitis is derived from Ancient Greek word “polios” meaning “grey” and “myelos”
meaning “marrow” denoting the grey matter of spinal cord and -itis in the end as suffix referring to
medical terminology for inflammation. This condition can extend further to brainstem resulting into
polio encephalitis taking away the ability of patient to breathe (Chamberlin & Narins 2005).
2.1.2 History
Poliomyelitis has a history that dates back to biblical descriptions of the crippled individuals but due
to vague description, the disease could not be defined. However, Egyptian drawings of a priest
thousands of years ago showed that the priest had a deformed (muscle wasted) small leg and he used
a stick to walk which was considered to be the first clear picture demonstrating poliomyelitis. The
disease continued to affect the human race and was hardly defined to give any clear picture till the
epidemics of 18th century when Michael Underwood described the disease as frailty of lower limbs
in children. In 1835, John Badham diagnosed acute paralysis in four children strongly suggesting
poliomyelitis. Further progress was made by Jacob von Heine who termed it as infantile spinal
paralysis differentiating it from other forms of paralysis. However, the lack of medical knowledge
was a main hindrance in understanding the disease until the pathological findings done by Duchenne,
Charcot and Joffroy. They discovered that there was atrophy in the anterior horns of spinal grey
matter due to irritation which causes the cells to lose their function immediately. Erb for the first time
in 1875 used the term “acute anterior poliomyelitis” for this condition (Pearce 2005).
The worst outbreak of poliomyelitis in the history of United States was in 1952 due to which 58,000
case were reported out of which around three thousand died and rest were left with mild to moderate
disability due to paralysis. First milestone in the history of disease cure in United States was
accomplished by Dr. Jonas Salk who developed safe and effective vaccine for poliomyelitis exactly
three years after the outbreak of 1952. Efficacy of the vaccine was proved in 1962 when case drop of
Polio was left to 910 (Polio Eradication 2017).
Polio has always been one of the major problems of developing countries. Surveys held in 1970s gave
a clear picture of prevalence of poliomyelitis in these countries. During the same era routine
immunization was introduced globally as a part of national immunization programmes to control the
12
disease. More than 1000 children per day were being affected due to polio globally in 1988 when a
worldwide polio eradication started. Till now, over 2.5 billion children have been successfully
immunized against polio virus with cooperation of over 200 countries, 20 million volunteers and
international funding of over 11 billion United States Dollar (USD). Certain strains of virus have been
eliminated though, for example, last case of type 2 reported in 1999 was declared as eradicated in
2015 and type 3 in year 2012. With a global decrease of 99% polio cases it is left in only 3 countries
(Afghanistan, Nigeria and Pakistan) which are still unable to eradicate its spread. Remaining 1% of
cases prove to be a challenge as these countries have certain problems like political destabilization,
disputes, elusive population and improper infrastructure (Polio Eradication 2017).
2.1.3 Etiology
Polio virus belongs to Picornaviridae family (Enterovirus subgroup). Enteroviruses are the acid stable
viruses of gastrointestinal tract. Picornaviruses are the Ribonucleic Acid (RNA) viruses, smaller in
size and insensitive to ether. There are three serotypes of polio virus P1, P2 and P3. If any serotype
gets immune it does not affect or cause immunity in other serotypes, a phenomenon known as
heterotypic immunity. Factors that affect the growth of virus are Ultra Violet radiations, heat and
chemicals such as formaldehyde and chlorine (CDC 2015).
2.1.4 Geographical Distribution
A lot of progress has already been made in polio eradication. According to the updates since 1988,
there has been a decrease of 99% in polio cases. In 2015, number of cases reported was 74, which
was 350,000 in 1988. According to a recent update wild poliovirus is endemic in 3 countries only –
Afghanistan, Nigeria and Pakistan details of which are given in the table 1. However, there is still
risk of wild type poliovirus spread form these endemic countries as two different outbreaks were
reported in 2013 in Africa and Israel. A brief comparison is given in figure 1 between two time periods
of 1988 and 2016 about the current status of polio virus eradication success (Polio Eradication 2017).
13
Table 1: Global Wild Poliovirus statistics from 2012 to 2017 (Modified from Polio Eradication 2017).
Country or territory
Wild virus confirmed cases Wild virus reported from other sources
Total 01 Jan – 28
March
Onset
of
most
recent
type 3
Onset
of
most
recent
type 1
Date of
most recent
virus
2012 2013 2014 2015 2016 2016 2017 2012 2013 2014 2015 2016 2017
Pakistan 58 93 306 54 20 7 2 18-Apr-
12
13-Feb-
17
89 66 127 84 62 10 02-Mar-17
Afganistan 37 14 28 20 13 2 3 11-Apr-
10
21-Feb-
17
17 20 2 26-Jan-17
Nigeria 122 53 6 0 4 0 0 10-
Nov-12
21-
Aug-16
15 3 1 05-May-14
Somalia 0 194 5 0 0 0 0 NA 11-
Aug-14
Israel 0 0 0 0 0 0 0 NA NA 136 14 30-Mar-14
Syrian Arab
Republic
0 35 1 0 0 0 0 NA 21-Jan-
14
Ethiopia 0 9 1 0 0 0 0 NA 05-Jan-
14
Kenya 0 14 0 0 0 0 0 NA 14-Jul-
13
1 12-Oct-13
Egypt 0 0 0 0 0 0 0 NA 03-
May-04
2 06-Dec-12
Total 223 416 359 74 37 9 5 106 213 160 104 64 23
WPV type 1 202 416 359 74 37 9 5
WPV type 3 21 0 0 0 0 0 0
In endemic
countries
217 160 340 74 37 9 5
In non-end
countries
6 256 19 0 0 0 0
Countries infected 5 8 9 2 3 2 2
Countries endemic 3 3 3 3 3 3 3
14
Figure 1: Modified from Global Polio Eradication Initiative’s progress for poliomyelitis eradication
from 1988 to 2016 (CDC 2017).
Pakistan is geographically divided in to different provinces such as Punjab, Sindh, Khyber
Pakhtunkhwa (KPK), Federally administered tribal areas (FATA), Baluchistan, Azad Jammu &
Kashmir (AJK) and Gilgit-Baltistan. Since 2009 there has been a marked fluctuation in rise and fall
of polio cased reported. It was highest in 2014 when it was 306 dropping down to 20 in year 2016. In
year 2017 according to recent statistics one new case is reported in Punjab and one in Gilgit-Baltistan.
Table 2 shows the statistics of the case reported and figure 2 is the graphical representation of the
cases reported annually from 2010 to 2017 (End Polio 2017).
15
Table 2: Polio cases in Provinces (End Polio 2017).
PROVINCE 2010 2011 2012 2013 2014 2015 2016 2017
PUNJAB 7 9 2 7 5 2 0 1
SINDH 27 33 4 10 30 12 8 0
KPK 24 23 27 11 68 17 8 0
FATA 74 59 20 65 179 16 2 0
BALOCHISTAN 12 73 4 0 25 7 2 0
GILGIT-
BALTISTAN
0 1 1 0 0 0 0 1
AZAD JAMMU &
KASHMIR
0 0 0 0 0 0 0 0
TOTAL 144 198 58 93 306 54 20 2
Figure 2: Yearly Polio Cases Reported (End Polio 2017).
0
20
40
60
80
100
120
140
160
180
200
2010 2011 2012 2013 2014 2015 2016 2017
Punjab Sindh KPK Balochistan FATA Gilgit-Baltistan AJK
16
2.2 Eradication Strategies
2.2.1 Global eradication strategies
To eradicate a disease, planning and strategies play a vital role. Strategy is designed in such a way
that the immunization provider reaches every single person who need vaccination. Any flaw or
improper planning causes resurgence of certain vaccine preventable diseases such as pertussis. In US
many strategies are being used to increase immunization. One very effective strategy that increased
the demand for immunization was a law according to which a child is given admission in school if
his vaccine/immunization record is complete. Other strategies include door-step service, making the
vaccine cost effective for the consumer and association of immunization to women, infants and
children services (WIC). A strategy is considered to be successful if the current problem is met with
the proposed solution which reflects in high immunization rates. There are different strategies which
include the AFIX Approach and certain other strategies.
The AFIX Approach (Assessment Feedback Incentives eXchange) is a state assisted program in
which healthcare work is mobilized in a way that their knowledge, concerns and motivations are
enhanced to practice immunization more efficiently. This approach focuses on providers and
outcomes and it’s an amalgam of advanced technology and personal interaction. AFIX is an acronym
which can be explained as:
Assessment of immunization coverage providers, evaluation of medical records, targeted
diagnosis providing improvement and increased awareness.
Feedback of the diagnostic information so that the services could be delivered in an improved
manner. Feedback can be provided with feeling and accuracy, confidentiality and without any
judgment.
Incentives, which help in increasing motivation to provide better services and show better
performance and opportunities for collaboration and partnerships.
eXchange of information among service providers which aids in accessing more experience,
provides motivation for improvement. In 2000, AFIX was incorporated with Vaccine for
Children program (VFC) to avoid staff duplication and extra time consumption.
To improve the immunization levels, certain other essential strategies are provided complementary
to AFIX. These include Record keeping which provides current population of patients and their
vaccine history, Immunization information system (IIS), Recommendations to parents about
immunization and verbal, written and calendar linked reinforcement of the need for return visits,
17
Reminder and recall to patients and providers. Reduction of hindrances to immunization like clinical
hours, long waiting time, cost, more travel distance, safety concerns about vaccine and unfriendly
experiences (CDC 2015).
Ever since the anti-polio efforts have been started, 2012 was the year when world witnessed fewest
polio cases in the history of mankind. Afghanistan, Nigeria and Pakistan which are still endemic
started Emergency Action Plans in 2012 to boost up polio vaccination coverage such that the
transmissions must be stopped and these efforts are proving to be fruitful. Global Polio Eradication
Initiative (GPEI) developed a new plan, The Eradication and Endgame Strategic Plan 2013-2018,
aimed to make world polio free by 2018 with strong program partnerships including WHO, Rotary
International, CDC, UNICEF and Bill & Melinda Gates Foundation. The difference form previous
GPEI was the major point that involved scientific experts, donors. National health authorities and
stakeholders. Differences can be seen well elaborated in the figure 3. Strategic plan has four pillar
objectives. Firstly, to detect and interrupt all wild poliovirus transmission by the end of 2014 by
launching emergency plans to improve the anti-polio campaigns. Secondly, Introduction of new
vaccines and withdrawal of oral polio vaccines (OPV) and introduction of Inactive Polio Vaccines
(IPV) to eliminate the risk of vaccine derived poliovirus (VDPV) and strengthening of the
immunization systems which eventually will help in introduction of new polio vaccines. Thirdly, to
get a global certification for being polio free a country or region must pass 3 years’ time period
without any new polio case. Lastly, sharing the success stories of polio eradication in some region
will help modifying the strategies of polio affected areas still fighting against the disease (Polio
Eradication 2017).
18
Figure 3: Global Polio Eradication Initiative plans (Polio Eradication 2017).
To detect wild polio virus circulation in the community surveillance for acute flaccid paralysis (AFP)
is done that includes investigation and specimen collection and sending for the analysis. To be
declared as polio free, a country must perform AFP surveillance with a result of zero cases. Clinical
case definition of acute flaccid paralysis is, “Any child under 15 years of age with AFP or any person
of any age with paralytic illness if polio is suspected.” (WHO 2017).
Case classification is further divided in to suspected case and confirmed case. If a case meets the
definition of clinical case it is categorized as suspected case whereas, confirmed case can be
understood in figure 4.
• Immunity boost up via immunization strengthening
• Introducing new vaccines including polio vaccines.Immunization Systems
• Using a global vaccine switch, addressing both wild and vaccine derived poliovirus to prevent long term
poliovirus riskAll Polio Types Simaltaniously
• Anticipiation and prepration for potential challenges including insecurity to enable repid responses to
hurdles and avoiding delaysRisk Reduction
• Data analysis of the recent acheivments to design a tangible and realistic timeline and budget to reach and
maintain eradicationTangible Timeline and Budget
• Using the recent success stories to provide strateigies to overcome potential hurdles
Learned Lessons
• Transfering of learned lessons and knowledge to benefit other health related goalsLegacy Planning
19
Figure 4: Final classification scheme for AFP cases (WHO 2017).
Acute flaccid paralysis surveillance consists of 4 steps:
Finding and reporting of the AFP affected children.
Transportation of stool samples for analysis.
Isolation and identification of polio virus in laboratory.
Mapping of the virus to determine the viral stain origin.
Environmental Surveillance involves the testing of sewage wastes, drains, stagnant water etc. for the
presence of polio virus. It is beneficial in those areas where there is absence of cases of paralysis but
still a chance of wild polio virus infections (Polio Eradication 2017).
2.2.2 Immunization and Vaccine
Administration of vaccine results in the development of resistance or immunity against that particular
infectious disease. Vaccines act as immunity booster and helps the body’s natural immunity
mechanism to cope with the disease.
20
Vaccines are weakened or harmless agents which are perceived as enemies by the immune system of
the body. Chemical composition of vaccines is usually protein molecules but it’s not necessary to
define a vaccine because of its protein nature. Since these are weakened entities, they provide
protective immunity against a more potent pathogen. Vaccines are proven to be more successful
against viruses (WHO 2017).
2.2.3 Immunization Strategies
Polio Vaccines were developed in 1950 and have been categorized into two types Oral (attenuated)
and Injectable (inactivated). Injectable from is prepared by killing a normal wild type polio virus
using formalin in a monkey kidney cells growth medium. It was discovered by Jonas Salk. It
stimulates humoral immunity (IgG) hence stopping the virus from entering neurons (Hunt 2016).
Advantages and disadvantages of IPV are discussed in table 3.
Table 3: Inactivated Vaccines (Hunt 2016).
Advantages Disadvantages
With booster doses, provides appropriate
humoral immunity
Not 100% results in raising immunity
No back mutation or reversion Boosters are always needed
Can be trusted with immunocompromised
patients
Little mucosal/local immunity IgA
Better performance in tropical areas Expensive
Albert Sabin Developed oral polio vaccine from virus cell cultures. Virus is grown in culture so it
can be mutated not to enter the neuros however it can still replicate like a normal virus eliciting
humoral as well as cell-mediated immunity. Its route of administration is oral hence easy to administer
among children. Since the virus is merely alive still having the capability to replicate in gut, only one
dose is sufficient to develop noble immunity against the disease (Hunt 2016).
One problem that is encountered by using Oral polio vaccine occurs due to recombination of vaccine
viral strain and wild type turning vaccine strain into virulent. Statistics show that paralysis caused by
wild type is 1 in 100 cases of infection as compared to 1 in 2.4 Million due to back mutation. It was
considered acceptable as virus gives gut immunity via IgA (Hunt 2016).
21
Advantages and disadvantages of OPV are discussed in table 4 and a brief comparison of oral polio
vaccines and inactivated polio vaccines are discussed in table 5.
Table 4: Attenuated Vaccines (Hunt 2016).
Advantages Disadvantages
Activate all phases of immune system by
inducing humoral IgG and local IgA
Vaccine virus spread is not always same,
sometimes mutations occur
Raise immune response to all protective
antigens
Easily spread to those who have not shown
willingness to be vaccinated
More cross-reactive and durable immunity Back Mutation
Cost effective Reduced take in tropics
Swift Immunity Problematic for immunity
related/compromised patients.
Easy Administration
Easy Transportation
Eliminate wild type virus
Table 5: OPV and IPV comparison (Polio Eradication 2017).
OPV IPV
Inexpensive Expensive
Safe, effective and long lasting protection Although safe but pre-infected wild polio virus
cases are source of spread even after IPV
administration
Oral administration. Do not need health
professional services for administration
Administered by the experts and health
professionals only
Provides passive immunity to others who are left
unvaccinated
Levels of immunity induction is low
Low yet there a chance of vaccine-associated
paralytic poliomyelitis (VAPP)
No risk of VAPP
Circulating vaccine-derived poliovirus No vaccine derived cases
Different vaccine types for different strains Effective against all 3 types of polio strains
22
2.2.4 Immunization Strategies in Pakistan
Wild polio virus has been restricted to 3 groups of districts in Pakistan. Karachi city, Quetta Block
(Quetta, Pishin, Killah Abdullah), FATA and Khyber Pakhtunkhwa (3 adjoining agencies in FATA
with Afghanistan border and Peshawar). National Emergency Action Plan (NEAP) for polio
eradication 2016-2017 has Strategic focus on:
High quality campaigns to ensure maintenance and increase of population immunity
throughout the country.
Aggressive efforts to stop spread form all reservoirs (endemic zone) and prevention
the circulation of polio virus in the rest of the country.
Detection, containing and elimination of the virus from newly affected areas.
Increase in routine immunization coverage to sustain polio interruption. (EOC 2016)
Since 1994, there are annually two rounds of National Immunization Days (NID), which proved to
be very successful according to coverage survey sponsored by UNICEF measuring more than 95%
coverage by the NID campaign. Later in 2000, door-to-door vaccine delivery strategy was also added
to boost up the eradication in remaining endemic countries (National Surveillance Cell 2001).
Expanded Program on Immunization (EPI) was launched in Pakistan in 1978. Other than kids, it also
included pregnant women to vaccinate them against tetanus toxoid vaccine. With approval of Global
Alliance for Vaccine and Immunization (GAVI Alliance) pneumococcal conjugate vaccine was
planned to be introduced to counter pneumonia and meningitis among children which was later
updated with Rota virus vaccine in 2013 to prevent diarrhea due to rotavirus. These developments in
the programs are capable to reduce childhood mortality in Pakistan by 17% (WHO 2017).
Currently, a child needs 5 visits in 1st year of age and one during 2nd year for complete vaccination
coverage against eight life threatening diseases as mentioned in the table 6 (EPI 2017).
23
Table 6: Immunization schedule according to expanded program on immunization Pakistan (EPI
2017).
Age Vaccine
At birth BCG and OPV-0
6 Week Penta-I, Pneumo-I and OPV-I
10 Week Penta-II, Pneumo-II and OPV-II
14 Week Penta-III, Pneumo-III, IPV and OPV-III
9 Months Measles-I
15 Months Measles-II
The estimate of the vaccine coverage in Pakistan is 88% but practically there are many issues which
affect the coverage percentage e.g. missing vaccination cards, unauthenticity of verbal recall and no
online record of immunization registries. Other influencing factors include socioeconomic
inequalities due to which access to the services are difficult, there isn’t much demand in population
as the basic needs are never met so there is less to worry about vaccination rather than food. Security
to the polio vaccinators is also a big issue in the suburbs of the country. Lack of education and
misinformation about polio that it causes impotency is also a big hindrance (Owais et al. 2013).
Husain & Omer (2016) enlisted work system related challenges and gave recommendations in order
to achieve universal vaccination (Table 7).
24
Table 7: Challenges to achievement of universal vaccination in Pakistan and recommendations
(Husain & Omer 2016).
Theme Challenges Recommendations
Program
structure and
management
Vague division of roles and
responsibilities of EPI activities.
Funneling of funds at district level
making EPI a competitor hence unfair
funds allocation.
Improvement in accountability and
monitoring structures.
Introduction of activity specific funding to
ensure adequate capitalization for target
accomplishment.
Programme
governance and
capacity
Limited managerial capacity and trained
human resources at district and tehsil
level.
Poor accountability due to political
interference
Institutionalized training by district and
provincial health departments.
Improved monitoring and accountability
of managers and frontline workers
Human resources Irrational placement of trained human
resources
Lack of refresher training of health care
providers regarding new vaccines,
communication skills and event
reporting
Poor staff coordination between office
and field workers
Geographic information system mapping
for rational relocation.
Employee development initiatives by
governing authorities
Involvement of community members,
collaborative planning and micro plan
development
Vaccine logistics Faulty demand estimation by central
body based on unreliable data.
Poor maintenance of cold chain
Demand estimation by local facility and
community based data collection.
Regular mapping and identification of cold
chain for any odds and local funds pooling
for its maintenance.
EPI management
information
system
Poor record keeping and utilization for
decision making
Lack of feedback at district level
New data cells at district level to conduct
surveys for accurate data
Revision of paper based data collection
tools
Mobile device based technology for swift
data collection
25
Poor community
uptake of
vaccinations
No significant increase in vaccine uptake
by poor and illiterate people
Poor communication skills of health care
providers
Role of community leaders in spreading
myths about vaccination
Development of evidence based
communication packages targeting
specific foci
Regular training for improved skills and
technical knowledge
Engagement of community leaders and
their education about vaccination
Legible well-lit signboards at EPI centers
26
2.2.5 An overview of Southern Punjab, Pakistan
Southern Punjab is an under developed region of Punjab province form the perspective of health,
education etc. immunization coverage is different in different regions. Overall vaccination coverage
in Punjab is 70%. In Multan it is 92% in Vehari district it is 95% and lowest was found out to be in
District Rajanpur which was almost 29%. These 3 districts are included in lower or southern Punjab
region of Pakistan. The proportion of partially vaccinated children were highest in Rajan Pur (48.3%),
Muzaffargarh and Bahawalpur (44%) whereas the percentage to children remained unvaccinated was
27% in Rajanpur, 10% in Okara and Layyah (UNICEF 2000). A schematic of vaccine delivery system
in Pakistan has been shown in figure 5 (Expanded Program Immunization System 2017).
27
Figure 5: Organization of Immunization Expanded Program by the Federal government of Pakistan
(EPIS 2017)
28
2.3 Sociocultural factors affecting polio vaccination
The main barriers to immunization are low maternal health literacy, poor accessibility to the
immunization services and poor socioeconomic status. Talking about the government responsibility,
less than 2% of the total budget has been allocated to the health sector. As a result, there is poor
infrastructure of health services up to district levels. Natural calamities such as floods and earth
quakes have aggravated the problem and enhanced resistance in mobilization for the vaccination
porgramme.
2.3.1 Perceptions about vaccination
The perception of vaccination about its utility depends upon perceived benefits and perceived risks
related to that vaccine. Greater benefits with lesser risks create a positive perception and people are
facilitated and motivated to get their children. Assurance by the health care professional about vaccine
safety can change the perception of parents so a trust built relationship between the two play a pivotal
role in making a decision for vaccine uptake (Song 2014). Factors that influence the vaccination other
than socio economic reasons include general awareness, impact of controversies in public regarding
vaccine and attitude of the parents. Educating and informing the parents about benefits of vaccination
can help in making a positive decision to get their children immunized. Cultural and religious
controversies like in Nigeria in 2003 and in India in 2006 also affect the immunization campaigns.
Involvement of religious and community leaders can overcome this issue. Parents concerns about
vaccine safety build their attitude towards immunization (Lorenz & Khalid 2012).
Perception of vaccines can be framed positively and negatively for the patients who are free from
vaccine side effects and disease (Positive framing) and patients who get the disease and vaccine side
effects (Negative framing) and it influences the expectations of people depending on the evaluation
for the net gain or loss due to vaccination. Expectation of benefits is raised in positive framing and
of side effects is lessened (O'Connor et al. 1996). Role of health care provider is critical here who can
alter the choice of people who think that vaccine is unsafe and convince them for immunization
(Smith et al. 2006).
Although there is a general belief that vaccines protect from diseases but at the same time people are
concerned about the side effects of the vaccines especially when there is a new vaccine in the market.
An example from a study conducted in US, states that how vaccination coverage against Measles,
Mumps and Rubella (MMR) was affected when parents heard about the relation of autism and MMR
vaccine (Freed et al. 2010). MMR Vaccine was wrongfully reported to have side effects (Autism) by
Wakefield which was published in Lancet after which methodological discrepancies were mentioned
29
by various readers to prove the study wrong but it already had a negative impact on the thinking of
people about vaccination (Leask et al. 2010). As a result, immunization against MMR was rejected
in United Kingdom and there was an outbreak of measles (Jansen et al. 2003).
Whereas, certain other studies like Halsey and colleagues (2001), kept on proving the concept of
MMR and autism relation wrong. According to Tickner and colleagues (2006), it was speculated in
United Kingdom that exposing the child to antigens make them prone to autism due to an idiopathic
cause. Moreover, parents thought that by combining different vaccines it can stress the immunity of
children and also raise the risk of side effects. Past experiences also alter the vaccination trend. It was
found that parents rejected MMR vaccination for their children because they think chronic effects of
autism are far less than those of measles, mumps and rubella.
2.3.2 Rumors and superstitions
Rumors are unauthentic information mostly comprising false news which effect public and society
via negative effects. Nuclear disaster of Japan due to earthquake and tsunami initiated a rumor about
iodized salt to be preventive for radiation damage and sea salt is dangerous as the radioactive material
has polluted the sea water. As a result, there was an increased consumption of iodized salt over sea
salt hence prices of iodized salt were raised that affected the public badly. Similarly, the doomsday
rumor in 2012 led a Chinese man to psychological disturbance due to which he injured 23 school
children. A rumor-spread model explains how the rumors spread via various individuals called
Ignorant, Spreader and Stifler; the one who believes information is outdated. Whereas, the forgetting
mechanism terminates the rumor. The model gets the name SIR where S stand for susceptible
individuals, I stand for infected individuals and R stand for removed individuals. This is
diagrammatically explained in figure 6 (Zhao et al. 2015).
30
In Nigeria, three Northern states boycotted polio vaccination in 2003 due to community pressure and
reason was the circulation of rumor that polio vaccine contains antifertility drugs which is being used
to sterilize Muslim girls (Kaufmann & Feldbaum 2009). Similarly, in India and Pakistan it was
rumored that polio campaigns are planned to limit the growth of Muslims and lower castes of Hindus
(Obregon et al. 2009). An athlete died shortly after the introduction of human papillomavirus vaccine
in Austria and the reason of death was related by people directly to the vaccine hence calling for its
withdrawal (Lower 2008). The link between autism and MMR vaccine rumored quite a lot because
of the increased incidences of autism by increased use of MMR vaccine due to which parents either
became selective in immunization for certain vaccines or totally rejected the immunization process
for their children (Madsen & Vestergaard 2004).
2.3.3 Religious Beliefs
Religion plays an important role in society towards awareness and attitudes of people towards health.
A study conducted in India showed that immunization coverage was increased by the involvement of
religious leaders. One fine example was the involvement of Muslim religious and community leaders
in polio campaign that resulted in drop of children who didn’t get vaccination form 5% to almost 0%
in just 2 years. Similar results were found in Pakistan by the involvement of religious leaders and
noticeable outcomes were seen (Obregon et al. 2009).
Ignorant Spreader
R1
Stifler
R2
Stifler
Spreader
rr
Spreader
Spreader
R2
Stifler
R2
Stifler
Lose interest or forget
Figure 6: SIR rumors spreading model (Zhao et al. 2015)
31
According to a report published by WHO, a Muslim majority area in Nigeria was the major threat to
polio spread because of the false beliefs of the inhabitant Muslims that polio drops cause sterility
(Kapp 2003). In western countries also religious factor has been seen to influence the vaccination
campaigns. In Netherlands polio outbreak was reported among the religious communities who
refused vaccination despite the coverage of 97%. Similarly, in United States (2000-2001) many
families put religious and philosophical reasons to exempt the vaccination (Smith et al. 2004).
Muslim countries like Pakistan and Afghanistan are also facing this issue as a major factor in the
unsuccessful vaccination programs. Tribal areas of Pakistan are of the main concerns in this regard
being one of the biggest hurdles. Areas of Afghanistan bordering with Pakistan are the transmission
areas as well where the local Taliban have issued fatwas that vaccination is a western policy to stop
or control Muslim population. The porous border between the two countries has worsen the situation
further as there is no record of people crossing between these countries. Another false concept used
against the vaccination campaign was that it’s an effort to forfend will of Allah. They assassinated
vaccination staff due to such superstitious beliefs (Warraich 2009).
2.3.4 Trust on Health Services
Developing a trust with the vaccinator boots up the motivation of parents to get the children
vaccinated. In a study conducted by Benin et al. (2006), trust in medical profession was the main
concept and they found out that trust on pediatrician and feeling of satisfaction about vaccines by
discussion with pediatrician that it does not make them going against cultural norms had a positive
influence on the vaccination of children. Similarly, the lack of trust and relationship between new
mothers and their pediatrician gave an alienated feel that prevented them to get their children
vaccinated as they were not motivated. So the development of trust is very important along with the
positive relationships to take the mothers in confidence to get their children vaccinated.
A study conducted to find association between parents’ beliefs about vaccines and their decision to
refuse or delay the vaccination of their children found out that the delay or refusal was because of the
safety concerns and perception of lesser benefits of vaccines. Here the role of pediatrics is important
to educate parents about it as well as taking them in confidence about vaccination. Likewise, trust on
vaccinators also help to boost up the awareness of vaccination (Smith et al. 2011).
In Pakistan, tribal population has a lot of barriers due to lack of education which leads to the thought
of resisting foreign ideas and practices. Affiliation and familiarity of vaccinators play important role
in such areas where a known vaccinator is welcomed and more cooperation is seen by the parents to
32
such vaccinators (Obregon et al. 2009). While designing the health promotion campaigns cultural
factors like a “familiar or known” health care deliverer or vaccinator should be kept and hiring of
locals so they can easily communicate and deliver the services with no or least possible hurdles can
help in successful vaccination campaign (Shaikh & Hatcher, 2004).
According to a research most of the mother’s characteristics are same weather they are educated or
uneducated when it comes to child care. The only distinguishing feature found was education that
makes the difference. It was seen that mothers who were educated had more knowledge and
awareness about health care, location of facilities, kind of coverage that health care center provides
and the limitations of that health care center which decides the trust level and trust development of
mother in specific and parents in general on a health care facility (Streatfield et al. 1990).
2.3.5 Utilization of Other Health Services
For certain disease choice of treatment depend either to visit the doctor or start self-medication at
home and it is directly related to socioeconomic status of the population. In a Kenyan rural setting, a
study showed that to minimize the health expenditure people prefer self-treatment as private health
care costs them too much and only decide to visit health care centers when sickness situation worsens
(Nyamongo 2002).
Prenatal care in developing countries is an issue where not so economically stable families find
difficulty in finding such facilities. In a study in Uganda it was found out that likelihood of child
being fully immunized was higher in those mothers who delivered their children in hospital as
compared to those who gave birth at home. During pregnancy and child birth mother is educated and
motivated about the health concerns of the newly born which results in the follow up of the
immunization (Bbaale 2013).
In 2003, the percentage of Filipino children receiving recommended vaccinations was 69% only. The
data suggested that mothers who paid at least four antenatal visits had their children fully vaccinated
as compared to those who neglected or forgot the antenatal visits (Bondy et al. 2009). Similarly, in
peri-urban area of Kenya 80% of the children who were born at health care centers were fully
immunized suggesting that place of birth plays an important role in immunization (Maina et al. 2013).
2.3.6 Distance from Health Care Centers
In developing countries accessibility to health care centers is a big issue. According to a study in
Uganda where there is a poor infrastructure with unpaved roads and far off distance to the vaccination
booths, reach to the health care centers is limited that leave the chances of higher immunization left
33
outs. Rainy seasons worsen the situation and limits the mobility (Bbaale 2013). Similarly, a study
from China showed that remote areas population found difficulty in reaching the health care centers
and require extra time and effort by the parents (Han et al. 2014).
Conservative societies where there is gender segregation, women are not allowed to go alone to the
health care centers worsen the situation (Shaikh & Hatcher 2004). Mothers on the other hand avoid
taking their daughters for vaccination if the facility is too far and hard to reach moreover urban
dwellers where found to have a better access to the health care services as compared to rural setting
because of the reason of far off locations of health care centers (Choi & Lee 2006).
2.3.7 Parental Compliance and birth order
For Public Health programs and vaccination programs in particular, introduction of vaccine and its
acceptance form the consumer side is influenced by local differences and perceptions of people about
potency and efficacy of vaccine. Individual refusal of the vaccine can be because of many reasons
including vaccine service inadequacy or malfunction, shortage of vaccines, lack of outreach clinics,
timing differences and stubborn or rude behavior of the staff and personal or others past experiences
of the adverse effects (Streefland 2003). Vaccine is potent and efficient only when it is given
according to schedule where age is the prime factor to decide which vaccine works best at which age
(Ota et al. 2002; Breiman et al. 2004). A study form Virginia suggested that chances of missing follow
up vaccination doses were highly related to initial vaccination. Children who missed their first
vaccine were found to miss their later doses as well (Williams et al. 1995). Lopreiato and Ottolini
(1996) assessed the immunization compliance among children and found out that there were delays
in immunization and parents gave certain reasons for that including being unaware of due date of
immunization, coexisting illness, unavailability of immunization, missing the appointment. Other
reasons included travelling, refusal to immunization, misinformation from the vaccinator of child
being vaccinated up to date.
Developing countries have an issue of population. Bigger families with lesser income sources affect
the health care preferences within a family. It was observed that the discrimination of health care
facilities worsens as the family get bigger especially in case of girls. A family with a lot of girls born,
health concerns were found to be less and this discrimination increased with an increase in family
members. However, this phenomenon was also common among the boys where there were more boys
in a family than girls especially those who have only one daughter and lot of male siblings (Pandey
et al. 2002). According to a study conducted, in India, the dropout rate towards oral polio vaccination
was lowest among children of birth order1 and highest in birth order 5 (Nandan et al. 1985). The
34
possible explanation to the phenomenon was described as first born get the major attention and
concern because mother is more conscious about the health of first born and devote most of her time
to child care. This trend drops as the population of family increases (Chen & Liu 2005). Another
study supported the fact that with the increasing birth order, immunization to DPT decreases
(Breiman et al. 2004).
2.3.8 Gender based factors
Parents play a critical role in children health care. Their concern about health is a trigger factor to
increase the chances of getting vaccination. A study conducted by Choi & Lee (2006) showed that
health preference was seen among the children, boys being the preference for vaccination in India.
An analysis made to a hypothesis confirmed that in India the probability of girls being fully
vaccinated was 5% less than for boys (Borooah 2004). Sons’ preference towards immunization in
China migrants was quite visible where girls were neglected to immunization (Han et al. 2014).
Similar results were found in Nepal where girls were ignored as compared to boys (Basel et al. 2012).
In Africa variances were found for the immunization status of boys and girls when same domiciliary
and community were concerned. For the initial age, girls were taken to health care centers for
immunization but later on they were the major dropouts for the follow up vaccines or booster doses
unlikely boys who got full vaccination (Pillai & Conaway 1992).
According to another study in India pre-birth sex determination of child also changes the behavior of
parents which was seen more prominent in urban areas where more care was given to mother if the
child to be born is a boy where as these kind of facilities were not available in rural areas so pre-birth
sex determination related care was not visible there. After birth, in other case, boy was given more
importance in rural areas whereas this factor was comparatively far less important to parents in urban
areas (Choi & Lee 2006).
2.3.9 Ethnicity and Influences
According to a report by UNICEF poverty is associated with child health which is further intensified
by ethnicity. Parents from the minority groups of community do not pay much attention to the children
health (Khan 2010). In a study performed in United States, disparities were found among children of
black, Hispanic and inner city population concerning immunization. Data collected by Centers for
Disease Control and Prevention states that participation by black and Hispanic was more than white
and Asian population (Middleman 2004).
35
In India, caste differences and wealth based inequalities showed discrepancies concerning vaccine
uptake. The children of lower caste were less likely to be immunized as compared to the higher castes
(Bonu et al. 2003). According to Thomas et al. (2012) rural communities of African Americans with
low income and geographic hurdles to access health facilities played critical role in decision making
about the Human Papilloma Virus vaccination for their children.
Local residents and the migrants also show disparities regarding vaccination. In a study performed in
East China, recent migrants were seen less likely to have their children immunized where the
livelihood was insecure and alienation due to migration at new place (Hu et al. 2013).
2.3.10 Health Education
Failure of past failing educational programs for health predict the critical role of health literacy in
health promotion. By facilitating populations towards health education helps in understanding and
developing skills to read the pamphlets in a much better way as compared to the just delivering
information. Improving the access to health information is also helpful in raising the health literacy
level (Nutbeam 2000).
Mass media can also play a vital role to change the perception of people about vaccination (Reluga
et al. 2006). According to a study performed in Uganda, media penetration can play an important role
to deliver the message to parents about how important it is for the healthy future of their children if
they get them immunized fully (Bbaale 2013). Combined with certain others factors education of
parents also play an important role in this regard as depicted by a survey performed in India where
literate parents had a better understanding of health factors and health education due to which there
were found more concerned towards immunization programs as compared to illiterate parents
(Chincholikar & Prayag 2000).
According to a survey education of parents is found to be related to immunization of children. Parents
who are literate tend to have a higher number of children vaccinated as compared to the ones who
were not educated (Marks et al. 1979). Another study conducted among the industrial workers in
Durgapur steel plant India, 8% of the workers were not aware of preventive aspects of health care
among those majority of the groups were illiterate (Mukhopadhyay 1991).
Role of mother in making health related decisions is of prime importance as she spends most of the
time with children in family and as a primary caregiver due to which vaccination of the new born and
follow up of their vaccination along with the written record is managed by her (Bingham et al. 2012).
Studies conducted in United States showed a relation of socio economic condition and parental
36
education directly to the vaccination as parents were not up to date about vaccines due to lower
socioeconomic status and lack of education (Smith 2006). Similarly, Hu et al. (2013) found that
migrants in East China tend to have lesser number of children vaccinated due to lack of maternal
education.
The trend was found to be same in developing countries. According a study conducted on infant
immunization programmes in Matlab (Bangladesh) mothers with higher education (11years or more)
more likely got their children vaccinated as compared to those who were uneducated or under
educated (Breiman et al. 2004). A study conducted by Mahmood & Kiani (1994) determined that
there was positive and significant influence of mother’s education on the child’s health. Mothers of
urban setting who had higher or lower education contributed more towards child’s health as compared
to those who were living in rural areas of the country. Another study by Choi & Lee (2006) concluded
that in India there is a direct relation of maternal education to the immunization of the children as
mothers with better access to information sources like TV and radio tend to get their children
vaccinated. This trend of access to media is seen more among educated mothers.
2.3.11 Stakeholders in the Community
Community plays an important role in health promotion through various media such as electronic
media including television, radio, social media and print media such as newspapers and pamphlets.
These can create either positive or negative sentiments by providing a platform to the groups who are
against or in favor of immunization. Social media in particular is important here because users are
not being controlled and there is no news monitoring as most of the times people share their good or
bad experiences which tend to influence the thinking of others (WHO 2017).
The behavior of community towards immunization comprises a model of 3 C’s that is confidence,
complacency and convenience as seen in Figure 7. On the basis of this model people either accept or
reject the immunization and the evolving term is called Vaccine Hesitancy. Vaccine hesitant may
accept all vaccines or reject all vaccines or become selective for certain vaccines. Various studies
from USA, UK, Canada, Taiwan, Nigeria and Europe suggest that vaccination behavior may be
altered either positively or negatively by the influence of social and professional figures of the
community (Larson et al. 2014). A study form Canada shows that there was encouragement by family
members or friends to the people who were not immunized against H1N1. A negative aspect was also
seen as the people who were not vaccinated were actually discouraged and misinformed about
37
immunization by their family members or friends because of their bad experiences (Boerner et al.
2013. Similarly, another study form India points out certain community factors such as wealth, caste
differences, religion, residence and gender to be affecting immunization of the inhabitants of that
society. The rich and higher caste are privileged to get all the health care facilities where as if a lower
caste poor family try to reach out preventive health facility, they are ridiculed and discouraged
moreover they are not earning enough bread so preventive health care is a luxury for them (Bonu et
al. 2003). Community can show a collective resistance that spreads very fast via electronic and print
media and because of certain religious factors such as fate is predestined and diseases are from God
and they cannot be cured (Streefland 2003).
Figure 7: A model of determinants influencing vaccine acceptance and initiating vaccine hesitancy
(WHO 2017).
Another study form Sweden states the rejection of immunization from parents because children were
already receiving too much vaccines and by declining the vaccination immune system will be stronger
(Alferdson et al. 2004). Another study presented the factors such as parental fear of side effects of
combination vaccines over the immune system, fear of potential complications, negative experiences
with the primary immunization and worsening of genetic disorders (Tickner et al. 2006).
Vaccine Hesitancy
Confidence
ConvenienceComplacency
38
2.3.12 Family structure and support
Even with the good financial stability, family structure and support predicts the concerns towards
health care facilities. Cultures where families are well structured are seen to have a good knowledge
and attitude towards immunization of children (Anderson et al. 1997).
For working class parents it has been seen that primary immunization or booster doses have been
skipped due to tough working schedule or forgetting the dates of immunization. Here potential
barriers as mentioned above and the decision making power of parents play a critical role about how
they manage such situations where health care is put to top priority no matter what (Tickner et al.
2006). Whereas joint family system has an advantage over here. Other than parents there are a lot of
other family members who provide care to the children. Children get more attention in joint family
hence positive effects have been seen on the children health. Grandparents, who have very limited
social activities and are retired from their profession spend more time home with children and
concerned to their daily activities and health (Brenner et al. 2001; Pandey et al. 2002).
According to a study, in rural Mozambique, mothers who give birth to child at home put them at
higher risk of not completing vaccination 2.27 time more than those who deliver at health care
facilities (Jani et al. 2008).
2.3.13 Socio-economic factors
Despite the supporting factors like motivation, heath education, awareness; socioeconomic status of
family is very important when it comes to child health care. According to a study in Mozambique
where the average salary is 33USD, mothers have to spend 2USD for a trip to health care centers to
get their children immunized which is financially a difficult choice to make for them (Jani et al. 2008).
Similar results were found in a study form a British population sample where there was a strong
correlation was found between social class and health behavior (Pill et al. 1995). Parents’ occupation
has a direct effect on attaining the full immunization of children. Those who were doing profession
jobs or white collar jobs were found to have a better attitude towards children immunization as
compared to those who had lower income jobs, farmers, sales persons, daily wage workers because
of having sufficient savings or funds to spend on health care of the family (Bbaale 2013).
Social inequalities, cast systems social classes are quite common in India due to which there is a
variation seen in immunization coverage. Lower cast and socially less sound families were unable to
meet their healthcare needs moreover their economic situation aggravated the factor (Bonu et al.
2003). Similarly, in Pakistan, where majority of population lives in rural areas were found to have
39
the same cast and social inequality system mostly depending on economic status affecting the
accessibility to health care services (Sathar 1987). Families with a better socioeconomic status have
access to better health care services and it has been seen that they prefer to go to private health care
sectors to avoid queues and lengthy appointments (Topuzoglu et al. 2005). Similarly studies from
Bangladesh and Nepal showed the highest dropout number for immunization among the families with
poor socio economic status (Breiman et al. 2004; Basel et al. 2012).
According to Choi & Lee (2006) mothers having better social and economic status responded better
towards children immunization. Lower socio economic status along with lower parental education
and deprivation from private health insurance leaves them with less knowledge about new vaccines,
vaccination records and up to date information (Smith et al. 2011).
2.4 Logical framework of the study
Based on the literature review, it is clear that socio-cultural influences play a unique and vital role in
how the public generally and parents specifically respond to and uptake the vaccinations. However,
since most studies have been conducted from the recipient’s point of view, there is need to see and
understand the phenomenon from provider’s (vaccinator) stance. Figure 8 displays the general
domain of the study theme.
40
Figure 8: Logical framework of the study
Vaccination
Religion
Socioeconomic
Perceptions
Health care services
Compliance
Stakeholders
Family structure and support
41
3. AIM OF THE STUDY
3.1 General aim
The main objective of the study is to analyze the effects of sociocultural factors influencing the
vaccination campaigns from Vaccinators point of view, form southern region of Punjab province
Pakistan.
3.2 Specific aims
Specific aim is to explore the following points:
Perception of public about vaccines
Gender issues, specifically inequality in vaccine uptake
Role of religion
Effect of socio economic conditions on vaccination campaigns
42
4. METHODOLOGY
4.1 Study design
This study was conducted as a qualitative research in descriptive phenomenographic design.
Qualitative research explores the “why and what” questions to understand the phenomena. It helps to
explore the explanations of how these explanations develop by getting into people´s behavior, beliefs,
attitudes, concerns, culture, lifestyles and motivations. The data collected via this method is often not
strictly structured and the sample size is smaller as compared to quantitative research (Joubish et al.
2011).
4.2 Study Settings
The study was conducted in southern Punjab province region of Pakistan. Pakistan is located in South
Asia divided into three major geographic areas including highlands in northern region, center and
east as river Indus plain and south and west comprising Baluchistan plateau. Pakistan shares borders
with India on east, China in the north and eastern border with Iran and Afghanistan. Arabian Sea is
located in south of the country as shown in figure 9. Total country area is 796,095 square kilometers
with a population of 200 million and 1.45% population growth rate. Urdu is the official language of
Pakistan while English being second official language in most government ministries. Other regional
languages with a descending order of majority speakers include Punjabi, Sindhi, Saraiki, Pashtu,
Balochi, Hindko, Brahui and Burushaski. Pakistan is officially a Muslim majority country comprising
96.4% Muslims, 3.6% Christians and Hindus (Central Intelligence Agency 2017).
43
Figure 9: Geographical location of Pakistan (Central Intelligence Agency 2017)
According to World Health Organization (2017), general health statistics of Pakistan for the year of
2015 are tabulated below.
Table 8: WHO's Health statistics of Pakistan of year 2015 (WHO 2017).
Population (2015) 188,925,000
Urban Population 38%
Fertility rate 3.2 per women
Live births 4599.4 thousand
Population under 15 years of age 34%
Population over 60 years of age 7%
Median age 23 years
Mortality 1329.3 thousand
Gross national income per capita 4(PPP international $, 2013)
Total expenditure on health per capita 129(Intl $, 2014)
Total expenditure on health as % of GDP 2.6(2014)
44
Multan is one of the major cities of southern Punjab, separated form Bahawalpur district by Sutlej
River and from Muzaffargarh district by Chenab River. Multan is surrounded by Khanewal district
on north and north-east, Vehari district on east and Lodhran on the south. It has 4 tehsils and is spread
over the area around 3,721 square kilometers with population of five million. There are six
administrative divisions of the city into towns as Bosan town, Shah Rukne Alam town, Mosa Pak
town, Sher Shah town, Shujabad town, Jalapur Pirwala town. This district is a fertile plain except the
areas near river Chenab which are flooded during rainy seasons. Climatic conditions are extreme as
in summers temperature raises as high as 50°C to as low as 1°C in winters (Multan Development
Authority 2017).
Multan district is an amalgamation of different ethnic communities, religion and casts. It has been
famous for Sufism. Islam being the major religion, other religions include Hinduism and Sikhism.
Multan is the only ancient surviving city of Pakistan famous for a huge number of tombs and shrines
with vast ethnic diversity including Punjabi, Sindhi, Balochi and Pashtuns (Historypak 2017).
Location of Multan is critical and high risk zone in special reference to polio vaccination campaign
as many people visit this city from all across the country due to many reasons. One of them is that
Multan is famous for its Tombs and Shrines called as “city of saints”. People come to attend the “Urs”
and religious festivals form different regions especially Sindh province and bring their children along
so special measures are needed to get every child vaccinated. Other than this, it is the hub for
travelling and a very important transient zone for many people. Roughly located in center of Punjab,
people from other cities like Dera Ghazi Khan (DG Khan), Kot Addu, Jampur, Rajanpur, Kot Mithan,
Khanewal, Vehari, Lodhran, Bahawalpur etc. travel to other bigger cities like Lahore, Islamabad, and
Rawalpindi etc. via this city for their jobs or other errands. Out of total 36 districts of Punjab people
of 18 districts travel through Multan daily.
Nishtar hospital is the only tertiary care hospital of southern Punjab and there is only one Cardiology
center and Kidney center for the whole southern Punjab region located in Multan. So throughout the
year people keep on visiting the city either to attend URS or medical treatment. Visitors stay here and
sanitary conditions are not so good here so it is also a potential source of virus spread. Moreover,
Multan is at center location to other small cities like DG Khan, Kot Addu, Jampur, Rajanpur, Kot
Mithan, Khanewal, Vehari, and Lodhran. People from these cities travel to other big cities via Multan.
Figure 10 represents Multan geographically with its adjoining cities.
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Figure 10: Geographic location of Multan District (Humanitarian Response 2017).
46
4.3 Subjects
Study subjects were the vaccinators and were selected by using Purposive Sampling which is a
technique of non-probability sampling that effectively covers the study of a particular cultural domain
with knowledgeable experts within and the efficiency of the method is well contributed by inherent
bias due to which random probability sampling does not affect the study. Figure 11 explains the steps
in purposive sampling. Quality of the data is dependent on the reliability and competence of the
subjects which must be considered as of prime importance for quality data collection (Tongco 2007).
Figure 7: Steps in purposive sampling (Tongco 2007).
Total 18 vaccinators were interviewed to conduct the study with the following eligibility criteria:
Currently employed vaccinator
Fluent in the local language of the area
Availability
Anonymity to avoid any social or political influence
Field experience sufficient enough to respond the interview questions in special reference to
socio-cultural factors.
Working under the domain of Executive District Officer (EDO) Health of the district.
Decide on the research problem
Determining the information type
needed
Defining informants qualities
Use of appropriate data collection
techniques
Considering reliability and competency of
informants
Finding informants based on defined
qualities
Using inhernent biasing as a critera to analyze data and results interpretation.
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4.4 Data collection
4.4.1 Data collection tool
Data was collected through thematic semi-structured in-depth interviews with the help of an interview
guide questionnaire consisting of open ended questions. Questions of the interview guide were aimed
to probe and explore the socio-cultural factors that affect the vaccine uptake in special reference to
vaccinators’ point of view/perspective. Interview guide was designed to be flexible enough so that it
can result in in-depth responses of people about their perceptions and experiences along with their
knowledge, opinions and feelings. Additionally, probing was used as atool of choice to further expand
on a theme or sub-theme based upon the subject’s response (Patton 2002).
Before conducting the interviews, interview guide was piloted on 5 individuals who met the inclusion
criteria. This piloting led to improvement in the interview guide and aided in clarifying certain
logistics involved. Primary researcher gained specific experience of handling the interview process.
4.4.2 Data collection process
Data collection process was started in the month of September 2016. EDO Health of Multan district
was approached to get the official permission and contact details of the vaccinators were acquired. A
total of 25 vaccinators were contacted, out of which 18 gave a positive feedback with no hesitation
knowing that their identity will be kept confidential. All the interviews were conducted in evening
timings as the campaigns keep them busy in working hours. Locations of the interviews were casual
public meeting places such as tea stalls, public parks and sometimes vaccinator’s homes. Most of the
participants were males, because females found it hard to give an appointment in evening times as
they were busy with children and home chores. Average time of interview was about 1 hour. No
incentives of any kind were offered to the study subjects.
4.5 Data analysis
All the recorded interviews were transcribed from audio to text form in the original language of the
interviews. Since the interviews were conducted in Urdu language, they were translated into English
by a professional language expert with a good command over both Urdu and English languages.
Translation was double checked and corrected.
All the themes were identified from the interviews and data was analyzed by using thematic
descriptive content analysis which is a form of analysis used in qualitative research. It helps to track,
examine and record data patterns or themes associated to the research question. Phases and stages of
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theme development in qualitative content and thematic analysis are tabulated below in table 9
(Vaismoradi et al. 2016).
Table 9: Phases and stages of theme development in qualitative content and thematic analysis
(Vaismoradi et al. 2016).
Phases Stages
Initialization Reading transcriptions and highlighting meaning units
Coding and looking for abstractions in participants’ accounts
Writing reflective notes.
Construction Classifying
Comparing
Labelling
Translating & transliterating
Defining & describing
Rectification Immersion and distancing
Relating themes to established knowledge
Stabilizing
Finalization Developing the story line
4.6 Ethical considerations
Making an ethical guideline is very essential considering the nature of studies. Researcher is the data
collection tool, and in qualitative studies, there are different stages where the researcher interacts with
the participants which is ethically challenging for the researcher due to the concerns of the
participants. Since there is no statistical analysis, researcher has to carefully evaluate his observations
and interpretations. Ethical challenges of the study include informed consent of the participant,
confidentiality and anonymity, impartiality and potential impact of researcher and participant on each
other (Sanjari et al. 2014).
Permission to collect the data was obtained from Executive District Officer of Health Multan as all
the vaccinators fall under the domain of EDO Health. Consent was taken from the vaccinators
verbally before interview and all of the participants voluntarily accepted to participate in the interview
49
process. Privacy was ensured as well and there was no pressure to answer any or every question if
they feel uncomfortable about anything.
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5. RESULTS
5.1 Perceptions about Vaccination – Rumors and superstitions
All the vaccinators had almost the same reply to the question about people’s perception about
vaccination. A positive attitude has been seen form the society towards the vaccination. Most
vaccinators who had been working for over a decade described that in previous years, it was difficult
to convince parents for the vaccination, but in recent years, the attitudes have changed. Vaccinators
reported different reasons for this change towards positive attitude in parents.
One vaccinator said:
“… It is almost impossible to miss a child in my Union Council (UC) but even then if any child is
missed, parents know where the polio vaccination centers are, they rush towards us asking for their
child’s dose…”
Another vaccinator of main city area commented on people’s perception that most people consider it
to be a good thing for their children health. He stated:
“… In my Union council of population of 35000, I have seen one refusal 3 years back but now parents
are convinced for two reasons. One being educated about the vaccine importance and secondly,
feeling a social isolation form his community people as they got to know that they do not get their
child vaccinated. It persuaded them to be convinced…”
One vaccinator commented on the change concerning time:
“… I am working since 1992. People did not know in the beginning times when I came into this field.
Now people are well aware and because of it, there is a drop in polio cases. Polio Campaigns are now
happening every month throughout the year but still elite class do not trust our vaccinators. They say
that it is hard to maintain the vaccine temperature at the recommended level especially in the months
of July, August and September when temperature raises as high as 50℃ due to which it is hard to
maintain the vaccine temperature between +2 to +8.…”
Another vaccinator who has been working since 1984 said:
“…this year total 14 cases are reported in 2016 in which Punjab is polio free which houses almost
60% of total population with no refusal in my area”
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Rumors and superstitions had always been a strong influencing factor on Pakistani society, due to
many incidents that mislead people to the conclusion that polio vaccination is not a healthy thing for
their children. Different aspects to this topic were reported.
A vaccinator stated:
“…I have a friend who is a doctor and had been working with WHO, he told me that his grandson
got allergy from vaccine and it happens sometimes...”
This information is important as he is quoting a doctor, thus adding a certain authenticity element to
the belief.
Another view that is quite common among the people is that the vaccination is a western conspiracy
to control population and something is inside the vaccine to make them impotent. One vaccinator told
about it:
“… I have been working since 1995 for polio vaccination campaign. If this were true, population
would have been dramatically affected but ever since population is increasing. Sometimes I quote my
example that I had these drops in my childhood and now I have my kids so if it was true I would not
have any children by now…”
The breach to the trust of people on health services affects the public health projects drastically. One
vaccinator said:
“… Fake vaccination campaign was used to locate Osama bin laden by American agencies. This
incident had a profound effect on the public due to which rumors about western conspiracy got even
stronger…”
Another vaccinator pointed to the practice of repeated vaccination, which adds an uncertainty and
concern for the parents:
“… They have reservation that repetitive vaccination is not good and in this case especially more
concerned about boys as it might cause impotency in them…”
Since there are many campaigns other than National Immunization Day at district levels, sometimes
parents are concerned about it too. One of the vaccinators narrated:
“…Campaign is repeated after every 28 days. Sampling of the sewerage is done regularly and if wild
type virus is detected then aggressive campaigns are started usually four times a month. This is also
questioned by people that why so many campaigns? Then we have to explain them that we have
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detected virus in the region and this region is high risk zone so we have to vaccinate children
repeatedly…”
One of the vaccinators had another explanation about the rumors:
“…there are some rumors about vaccination that it is related to some disease. For example, if the
child gets diarrhea or fever, mothers think that it is because of vaccination. For that we reply them
with an answer that one ampule of polio vaccination is for 20 children. If it causes any fever or other
disease, then how could it be selective? Either all 20 should get sick or none. It helps us in convincing
them that the disease is not due to polio drops but some other reason and it should further be evaluated
by contacting a doctor…”
Sometimes parents are seemed to be influenced by certain misleading incidents due to which they
avoid getting their children vaccinated. A vaccinator quoted one such example:
“… Few children died in Faisalabad city during the campaign and it was highlighted as a result of
polio vaccination due to which number of refusals was increased…”
Another vaccinator told:
“… We see a feeling of satisfaction among the parents with many children as there is no history of
older children getting sick due to vaccination or any other complication so the trend follows to the
younger ones…”
Another vaccinator talked about how he replies to the people about rumors related to population
control:
“…to convince them, I tell them that this campaign started in 1990’s, kids at that time got vaccinated
and they are adults now and they are living a normal life having kids. So if the rumor is correct about
population control conspiracy, then why the population is still increasing? ...”
5.2 Role of religion
Pakistani society is conservative by nature and has a very visible presence of religion. Majority of the
population comprises of Muslims. Religious leaders and scholars have a very influential role on the
mindset of common public. To run a campaign like polio vaccination, involvement of religious
leaders and scholars has a pivotal role for the success of such campaign. In the beginning when the
campaign started, it was very difficult to convince the religious leaders and scholars to help mobilize
the public for vaccination. The vaccinators gave different perspectives about it.
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One vaccinator said:
“… almost 2 decades ago we had a large number of refusals just on the basis of a wrong concept that
it is an agenda by non-Muslims to control Muslim population. In old times when there was no such
thing as vaccination, we were quite all right and so will be now. We don’t need something from west”
Another vaccinator explained:
“…community leaders and religious leaders cooperate with us. We go to the religious leaders and ask
them to help conveying the importance of vaccination and they announce it in larger weekly prayer
gathering in mosques on Fridays so the message could reach to maximum number of people and they
are aware of the dates of vaccination in their area. However, some religious sects are still strictly
against polio vaccination and they are not even willing to listen. In Rashidabad colony Multan there
were many refusal, we contacted the District Coordination Office (DCO) Multan about the situation.
Police intervened but the matter got even worse. We contacted the famous religious scholar of that
sect and asked him to come and convey the message on Friday prayer. Even though, he was a well
renowned religious scholar but in this case, they even rejected his message about vaccination. 10%
people in that area still refuse to get their children vaccinated…”
One vaccinator told:
“… We have fatwas issued by the religious scholars of every sect for example Shia and Sunni. We
know the religious orientation of people of our area so if there is any objection related to religion we
simply show them the fatwa issued by the scholar of their sect and they are convinced…”
5.3 Health care services utilization – Trust and trends
5.3.1 Gender issues
Bad experiences and tragic stories told by friends and other family members about incidents related
to health care services widely influence the development of trust. As mentioned earlier, Pakistani
society is conservative and this conservativeness involves the gender norms and positioning. Females
prefer to go to female doctors and feel more comfortable about discussing their health problem. This
element is more common in villages but exists in cities as well to some extent. Lower and middle
class families and religious oriented families still prefer a female health worker or doctor when it
comes to health issues. This phenomenon has extension into the vaccination services as well, as a
vaccinator explained:
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“…when we are working usually its mother who opens the door who hesitates to talk to strange male
person. To address this gender gap we always have one female vaccinator in the team with whom
mother can easily discuss and she trusts the female vaccinator and there is no problem in letting her
go inside and vaccinate children…”
Usually mothers accompany the children during vaccination so there hesitate to talk to male
vaccinator. One of the vaccinators described:
“…As the society is conservative it is difficult for the male vaccinators to interact with the ladies for
that reason we are now having more female vaccinators who visits home. Female to female interaction
is much easier in comparison to opposite gender interaction. Sometimes when male representative of
the family is not home, females hesitate to allow vaccinators to come in home but they do not have
any problem in letting in the female vaccinators. Male member waits outside and female worker goes
in home and vaccinate the children…”
Gender of child was an influential on the vaccination campaign few decades ago but now a days
parents equally prefer daughter and sons to get them vaccinated even sometimes parents are more
concerned about daughters. One vaccinator told:
“…It’s very rare that I have seen gender difference but very few where there are more daughter. Even
in such cases, counseling is helpful in convening them. Now a day’s focus is more on daughters.
Parents are even concerned that at births while injecting vaccines like BCG, special care should be
taken so there is no scar on that part of body. This thing is seen more in case of daughters than sons…”
5.3.2 Trust
Developing the trust in polio vaccination was a big issue in the beginning. One vaccinator described:
“… It is hard to convince some people about benefits of vaccination in the beginning, but when they
see their neighbors and other people in the area showing trust on us, they are at least ready to talk
about it. Then we explain them everything and this is easy if done in their own regional language.
Because of this reason, most of our works belong to the same area where they are working and speak
the same language…”
Private family doctors are trusted more as they are often treating a family for years. Parents duly note
their suggestions and act accordingly. A vaccinator described an issue related to such scenario:
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“…Some families consult private health care and doctors working there forbids the families out of
greed not to get their children vaccinated by government hospitals or workers as they are expensive
when purchased privately but government provide these for free. Such doctors tell them that since it
is free, it is not of good quality…”
Developing the trust is a slow and steady process. People do not accept strangers as health care
workers especially when it comes to child health care. Because of this reason, specific areas are
assigned to polio vaccinators permanently so that people get to know them and develop trust in them.
One vaccinator explained it as:
“… sometimes people ask us to have a drink or tea and even they offer us food as they see we are
working in extreme hot weather. This act of morality boosts our energy and we work even harder to
vaccinate every child in our area…”
5.3.3 Folk health care sector
In general, various trends have been seen while seeking folk health services. In villages, government
health facilities are inadequate due to which people look for alternate. Quackery is quite common in
villages, for various reasons. A vaccinator told about this phenomenon:
“…few decades back people used to use other health services like homeopathy or herbal. People also
used to visit quacks which is still common but now trend has been changed to allopathy
medicine…”
Another vaccinator from the rural setting said:
“…lower class preferably approach quacks for sickness as they are very cheap…”
5.3.4 Distance from health services
Distance from health care centers is not an issue in polio vaccination as government launched door-
to-door campaign to avoid any chance of missing any child from vaccination. Multan is a zone of
high mobility as it acts as a transit zone for people travelling from smaller cities around to bigger
cities. So special polio booths are setup at bus stops and railway stations. Travelling is not allowed
without polio card. Later on, it was compulsory for all the international flight passengers who are
travelling out of the country to get polio vaccination and a carry its documentary proof.
In urban setting, a vaccinator presented another picture:
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“…Trend of vaccination center is not so much productive now. Door-to-door campaigns of polio
vaccination has left an impression on peoples mind that it is the duty of government to provide
services at doorstep so even if we make vaccination centers to limit the chances of spoiling vaccine
due to heat and maintain efficacy people do not respond…”
One vaccinator told about problems related to change in vaccination strategies like booth location,
preferred disease vaccination, mother childcare:
“…Too many changes in strategies also affect the immunization program for example if someone has
a child after 2 or 3 years. He needs to be described each and every thing in detail about the child
vaccination as he complains that everything in hospital has been changed since his or her last visit to
hospital years back…”
5.4 Parental compliance and health education
In Pakistan, joint family system is very common especially in rural areas whereas in cities nuclear
family system is also seen. In bigger families, there are many persons to take care of children
especially the grandparents who spend most of their time with children if parents are working.
Parental concerns about the health of children matter because if they neglect the vaccination schedule
and miss their children’s doses, they might put them at risk. A vaccinator told:
“…Door is opened mostly by children in a poor class. Rich families usually send their servants at
door. However, our teams insist on talking to the family representatives like father or mother. Usually
mothers accompany the child while he or she is being vaccinated and to cover the gender gap we have
more female vaccinators so it’s easy to talk to the females of the family…”
To look out for number of children living in a home, a questionnaire comprising seven question is
made and teams are well trained to explore the details in lesser time by asking questions verbally.
One vaccinator was telling about it:
“… To explore the total number of children under 5 years of age we start questioning about how big
family is and how many members are living and how many are married and out of those how many
have kids and how many kids are under 5 years of age. Usually people do not take their newly born
child out of home unless he or she is 40 days old. To cope such situation, we have female team
members who can go inside and do the job…”
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The vaccinators concerning the birth order saw no differences. A vaccinator quoted:
“… in families where there are many children, older ones are more excited to bring the young ones
to get them vaccinated as some kind of fun and getting a vaccination mark on the thumb nail…”
Health education of a society is very important to prevent or cure any disease outbreak. Knowledge
and understanding of poliovirus and its spread is not very well known in Pakistan. Mostly, people
consider polio vaccination as a routine campaign not concerning to what benefits it can bring. With
the passage of time refusals have become far less but still there is a need to make people aware of the
disease so that the facilitation becomes easy for the success of vaccination campaign. One of the
vaccinators was talking about the role of media. He said:
“…Media advertisement is not sufficient. Polio related documentaries and advertisements are rarely
seen on NID but other times even when the campaigns are running at district level no advertisements
are seen at all on print or electronic media…”
Another vaccinator quoted:
“…India successfully ran media campaigns by involving very famous actor in the ads whom people
love to watch on screen as a result those ads became catchy for them and information was transferred
successfully to the families…”
5.5 Stakeholders in the community
Various stakeholders include financing bodies, health department, physicians, health care
professionals who ensure vaccine delivery and safety and inoculations, parents of children who
receive vaccines. There are two types of field workers, polio paid workers (PPW) and government
workers. In villages where there is mostly landlord, system who is the influential and dominant figure
of the village offers his drawing room, also called “Bethak” as a vaccination center. A vaccinator told
about it:
“…In villages sometimes we make a vaccination booth at some Bethak of an influential person like
landlord and announcement is done in mosque loud speakers and people bring their children for
vaccination. Since the villages are small so it can be tracked easily who didn’t bring their child for
vaccination…”
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The vaccinators described certain factors related to stakeholders. One Vaccinator told:
“…Currently scenario has been changed due to mass media campaigns and general public
awareness.15 days prior to campaign a meeting is held at Union council level. Members of the
meeting include UC secretary, religious scholars, mosque in charge, headmaster/mistress of the
school, teachers, Union Council Medical Officer (UCMO), vaccinators, area in charge. Problems are
discussed and resolved. Now we have a very positive feedback from religious leaders too and they
are integral part of our campaign planning…”
A vaccinator explained about the refusals:
“…DCO heads the campaigns. He takes the necessary actions to make sure every child is vaccinated.
National Emergency Action Plan (NEAP) is made bearing no tolerance at all in vaccination
campaigns. If anyone refuses a case is filed against him for meddling in government matters…”
Another vaccinator narrated:
“…Refusal are attended by UCMO to convince, if they are still not convinced then influential persons
of area like political leaders, social workers or religious leaders and DCO intervene. If problem
persists a First Information Report (FIR) is launched against them…”
One vaccinator told about the dedication of field workers:
“…we always keep a record of each and every home so if sometimes child is not at home we track
the kid to the school or playground and vaccinate him there. Revisits are our routine for the missed
children and sometimes even 5 times a day till we vaccinate the child…”
One of the vaccinator said:
“…If the child is sick we try to evaluate through history and sometimes we have to ask them to consult
the doctor about the vaccination rather than deciding by ourselves but we keep the record of that child
and give that home a follow up visit again…”
Another vaccinator told about religious oriented people:
“…People prefer the words of a religious leaders as compared to social workers or political leaders.
So we ask the “Imam” to accompany us if needed and he always join the team to talk to families if
and when needed and I can proudly and happily say that in my area everybody is very cooperative…”
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There were however, certain issues reported by the vaccinators regarding the higher-level authorities.
One vaccinator replied to the question:
“…Salaries bonuses and facilities are much more for the people working at higher end. I saw myself
two doctors working in WHO congratulated each other when a new case was reported reason behind
that their contract is extended for 3 more years…”
Another vaccinator said:
“…Fear of losing the job keeps us from reporting complaints against higher authorities. Anonyms
complaint system should be introduced so that the identity can be hidden and flaws can be reported
well in time and foreign doctors should be in charge of the whole campaign to eliminate corruption
element…”
5.6 Family structure and support
In bigger cities, most people are those who have moved there for the livelihood from the smaller
cities. Hence, most of them are living in rental houses and apartments. One vaccinator was telling
about the issues concerned to such cases:
“…In bigger cities people usually live in rental houses. For team members it’s a little difficult to keep
the record as these families are not permanently living there and keep on changing…”
Urban lifestyle has its own drawbacks as described by one of the vaccinators:
“…Every family has a different lifestyle so catching everyone at perfect time is difficult. Some
families wake up late and when team comes, they are told that kids are sleeping so team has to come
later in evening. In some cases, we have visited one family multiple times in a day…”
In cities like Multan, many people from adjoining smaller cities come to work and stay there in rental
houses. This keeps on changing with time so the population record varies continuously. One of the
vaccinator suggested an idea of “District Polio Emergency Plan”. He said:
“…There should be an ordinance that nobody can leave their residence during the vaccination
campaign just like in China when they were fighting polio they used to have a national holiday
followed by a curfew to minimize the chances of missing any child form vaccination…”
Families where both parents are working usually have a relative or a servant living with them in house
to take care of the child. The responsibility of getting the child vaccinated is least understood in such
cases. According to one vaccinator:
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“…Families living in bigger houses or rich families when approached usually send servants at the
gate who sometimes misinform about the children and do not let the team to come in so team is unable
to meet the parents or vaccinate children…”
Another vaccinator told:
“…Negligence is seen in big families. For example, if the children are sleeping, they do not allow us
to vaccinate them as mothers say it will be difficult for them in doing household chores because if
the kids get up they will disturb them. In such cases we have to visit the house again…”
In villages, however situation is different. Big families are living together in same house where
grandparents and grandchild usually have a special bond and they always look after them whenever
parents are not around. Moreover, landlords and other influential persons of village help teams to
vaccinate every child as the villagers always listen to them.
One of the vaccinators narrated this:
“…Villages follow trends. They ask their influential people like landlords and religious leaders in
making the decision to decide whether to get their children vaccinated or not. We find no problem in
approaching such people and they are cooperative enough that sometimes they join the team and go
door to door with us…”
Federally Administered Tribal Areas or FATA consists of tribes who have their own culture and
traditions and even they have their own law system. Majority of people are of conservative nature
and for the past decade, the area was unstable and insecure for the polio teams and was considered
hard area. One vaccinator who was a government employ with an experience more than 20 years was
sharing his experience:
“…FATA was polio free in 2007 but due to terrorism vaccination activities were not that efficient
and as a result now there are new 7 polio cases in fata. Other than terrorism, reasons are remote hilly
areas providing hindrances due to which polio teams cannot reach those places and tribal system in
which if the tribe decides not to allow teams to work refusals are form the whole population of that
area and people are mostly uneducated so they do not know the importance of vaccination…”
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5.7 Socio-economic factors
Education has always played an important role in decision making about vaccination. Illiterate people
have lesser information about the vaccination and its benefits and how it works and it is difficult to
convince them according to different vaccinators. A vaccinator said:
“…we do not have any refusal from educated families they are cooperative and have more knowledge
about vaccination through media and other awareness campaigns. Approach to media for poor is very
less and usually they work really hard that they have to stay out all day and come home at night so
they don’t have time to catch such campaigns and information...”
Illiteracy shifts the priorities of people. One vaccinator was telling a unique and interesting incident
about a rich but illiterate person living in a big luxurious house:
“… To keep the record we usually mark the door of house and put some numerical information about
number of children living and number of children vaccinated etc. For some people wall chalking or
marking the door is an issue. During the campaign in posh area of the city, a person came out of house
speaking harshly and complaining that we have marked his expensive gate all over making it look
dirty bashing and threating to shoot us and told us to go away. But to handle the situation we called
emergency number and he was arrested for not getting his children vaccinated and interfering in
government matters…”
One vaccinator was telling an example about health education:
“…Education has ha role in people’s decision making. Uneducated people rely on rumors such as
one person told a family that a kid died due to these polio drops and they refused to get their children
vaccinated without inquiring about the news or the details about the death…”
One other vaccinator presented a different picture:
“...Message is easy to convey to the educated but sometimes it becomes difficult to convince them as
they ask too many questions that may also be irrelevant. Uneducated people are mostly addressed in
their own regional language that is helpful in convincing them…”
Income was found to have almost no direct role on the campaign as vaccines are provided free of
cost. However, rich people prefer to visit the private hospitals for vaccination. One vaccinator told
about this. He said:
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“… Not much but a small percentage of rich people prefer to go to the private hospital for vaccination.
We have seen two main reasons for that. First, they have a concept in mind that if vaccine is free and
from government then it will be of low quality. Second, they usually have their own family doctors
who work in private hospitals; these doctors recommend them to get their children vaccinated from
hospital. Since, money is not an issue for them they happy take the advice and pay heavy prices to
get their children vaccinated form those hospitals…”
Another vaccinator told:
“…Rich people few years back used to prefer private health sectors for vaccination but we kept on
counseling that it’s just a waste of money as we provide them for free. Because of it, many were
convinced any now they get vaccinated by government polio vaccination teams…”
One vaccinator was talking about the issues related to rich families:
“… People living in big houses usually send servants at the door who do not let the team to go in the
house and most of the time they try to put off saying parents are not home come when there are here
or children are not home or sleeping. So we find it difficult to know how many children are there and
how many need vaccination…”
One vaccinator was talking about the offered incentives to the poor class:
“…Sometimes it happens that children get fever for 2 days due to the vaccination but for that our
centers provide free antipyretics. People who are poor are benefited from this service as they get free
medicine…”
Another vaccinator who was working in an area of nomads told:
“…These people have no concern at all if their children get vaccinated or not. When we visit them
and ask about it, they usually reply with a question that what benefit we get from it financially. We
tell them that get your children vaccinated and after your child gets 5 years of age government will
provide you incentives and benefits. This is usually sufficient to convince them…”
Prevailing poverty among the majority of population has restricted them to fulfil their basic needs
due to which heath is the least important thing to take care of. Trend of self-medication and going to
quacks for treatment is the cheap way to escape heavy health expenditures. This whole picture
describes general routine health check-up as a luxury. People visit hospital only when they think
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things are pretty worse and out of control due to these rare visits to hospitals keep them unaware of
the hospital related activities and currently targeted goals.
In a society of mixed cultures and ethnicity, usually difference of opinion regarding a certain issue is
seen. In case of polio vaccination, there were no variations found. Only one vaccinator told about his
area where there were some slum dwellers:
“…Nomads hesitate but their hesitation is far gone when they are offered incentives for a successful
vaccination of their children. Covering them is also a major task as they do not settle in a certain place
for longer duration hence can act as potential virus carriers…”
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6. DISCUSSION
6.1 Discussion of findings and methodology
This study was intended to get an insight of the vaccinators’ experiences about how the socio cultural
factors have affected the polio vaccination campaigns. Since Multan district and its adjoining tehsils
are located in southern Punjab which is comparatively less developed region of Punjab comprising
majorly of a rural population, this area was of special interest to perform the study to understand
factors such as religious influences, gender differences, superstitions and beliefs about vaccinations
and socio economic factors from vaccinator’s perspective.
This study shows a change in trend in people’s attitude towards polio vaccination from few years
back and now. Factors which were big issues in past years, are either not issues any more or have
diluted down in majority of the population (Khan 2010). Parental attitudes towards the polio
vaccination have changed in this population and setting, unlike reported by Lorenz & Khalid’s study
on Nigerian and Indian parental attitudes (Lorenz & Khalid 2012). Earlier, it was very difficult for
vaccinators to convince parents about the safety of vaccine as explained by Smith and colleagues
(2006), but now due to massive media campaigns and awareness programs, parents are well informed
and quite up to date about the vaccine safety and its importance. Only few exceptions were narrated
by the vaccinators where parents had concerns due to rumors, but such concerns were also
successfully addressed by counseling. Various studies which covered the parental concerns about
relation of MMR with autism (Jansen et al. 2003, Tickner et al. 2006, Freed et al. 2010) were not seen
in this study.
Pakistani society is conservative society and gender gap is very prominently seen there in everyday
life scenarios. Women hesitate to interact with the stranger men, even in health matters. It was very
hard in the beginning of the vaccination campaigns when teams consisted of men vaccinators only.
During door to door visits, women were not allowed to come to the door or they used to communicate
while standing behind the closed door. Later, to cope with the issue, a study conducted in southern
Punjab recommended employing women vaccinators (Khan 2010). Government uptook this
recommendation and women vaccinators were introduced as regular members of vaccination
campaigns in many different parts of the country. Additionally, it is now made compulsory for the
health department to include at least one woman vaccinator in every vaccination team. This has led
to an easier and more fluent interaction with the mothers and the vaccinators. They can now freely
discuss their concerns and vaccinators get a chance to answer to these concerns.
65
Another issue in the society is the gender discriminatory practices. Girls are often less preferred in
family as compared to boys and this discriminatory trend often creeps into the everyday health matters
and decisions as well (Pillai and Conaway 1992, Borooah 2004, Choi and Lee 2006, Khan 2010,
Basel et al. 2012, Han et al. 2014). Contrastingly, in this study, it was seen that parents were showing
more care and affection to girls in comparison to boys as told by the vaccinators, however, gender
gap is still there, though to a much lesser extent than previously reported.
Since Pakistani society is predominantly a religious society, hence religion has a strong effect over
the thinking and reasoning of the people and it has always been a great debate if the polio vaccine is
allowed in Islam or not, as described in various studies (Kapp 2003, Smith et al. 2004, Obregon et al.
2009, Warraich 2009). If a comparison is made between the previous decades and now, overall a
positive response is seen in vaccination campaigns, potentially owing to the involvement of religious
leaders in many stages of the campaigns, especially in the planning. Announcements are made by
religious leaders in mosque gatherings and media as well and sometimes they are even willing to join
the vaccination teams for the door to door visits during the campaigns. In rural areas, there are still
some cases where families resist vaccination based on false religious beliefs but according to
vaccinators, government has made new laws against refusing vaccination, so overall negative effect
is almost negligible.
Developing and maintaining trust helps in providing the health care services. It applies to the
vaccination campaigns as well. Vaccinators, who are well known to the people of that particular area,
can easily conduct a campaign and counter the difficulties. The trust issues are mentioned in many
studies (Streatfield et al. 1990, Shaikh and Hatcher 2004, Benin et al. 2006, Obregon et al. 2009,
Khan 2010, Smith et al. 2011). Trust influences in various ways and the local societal norms and
practices govern this development of trust. Society is very social by nature in these southern Punjab
areas. People living in a neighborhood know each other very well and these small communities stay
in a very close social cohesion. Any stranger arriving to the area is easily spotted. For vaccination
campaigns, it was a big issue as in the beginning, people hesitated to have health related contact with
such “strangers”. Later on, health department adopted the policy and preference of assigning the
health workers who belong to the area or at least keeping the workers for a longer period of time at
one posting, in order to counter any trust issues being a negative influence on the vaccination
coverage. Years after years, seeing the same faces developed trust and repute, thus resulting in an
increase in the vaccination coverage figures.
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In poverty ridden parts of the world where necessities of life are scarce, health care is usually far from
the reach of people. Higher costs of health care system, especially fees of doctors and prices of
medicine push people towards folk health care sector, which is cheaper and more accessible in nature
(Kleinman 1980). Self-medication is also a common practice in such societies. Various examples
have been quoted in different studies (Nyamongo 2002, Bondy et al. 2009, Bbaale 2013, Maina et al.
2013) where people seek alternative health care due to various reasons. In this study, people of
southern Punjab are seen consulting alternative health care sectors. Homeopathy and herbal medicine
also have the strong impact on people and are commonly used healthcare options.
Distance from the health care centers has no impact on these polio vaccination campaigns as these
are run primarily as a door-to-door activity. Parents do not have to take their child to the hospital
hence eliminating the factors such as laziness, carelessness and busy schedule which were reported
to be important issues in earlier studies (Shaikh and Hatcher 2004, Choi and Lee 2006, Bbaale 2013,
Han et al. 2014).
Parental compliance has increased with time. Parents are more concerned about the health of their
children due to repeated mass campaigns and media awareness. In Pakistani society, joint family
system is common, so the health concerns of the children are not only with the parents but also with
the other members of the family, like grandparents. If the family is away or if children are not at
home, neighbors often help by informing the vaccinators about when the family is coming back. In
short, the socio-cultural influence on the vaccination campaigns is positive. This improvement in
compliance has roots in parental education about the polio vaccination. There are also cases when
children are missed from vaccination but parents know the next step. They either inform the
vaccination centers or take kids there themselves to get them vaccinated. Earlier studies have reported
that parents had less knowledge about polio vaccination, which seems to have improved according to
our study (Williams et al. 1995, Lopreiato and Ottolini 1996, Ota et al. 2002, Pandey 2002, Streefland
2003, Breiman et al. 2004, Chen & Liu 2005).
Stakeholders augment the process of vaccination and their involvement in the vaccination process is
clear by comparing the results from last few decades and now. Religious leaders, landlords, financing
bodies and others, are now more involved during different phases of the campaigns. Again, the role
of media as a stakeholder is valuable here because rumors and misinformation had affected the
vaccination campaigns in past. Religious leaders are now better informed and they take part in
planning and running the campaigns. Landlords, in villages, take responsibility to conduct the
campaigns under their supervision, as they know almost all the people of the village so their
67
involvement and social influence increases the chances of an improved vaccination coverage. It is
quite contrary to the past when vaccinators struggled to influence people of a neighborhood and
stakeholders were part of the resistance (Streefland 2003, Alferdson et al. 2004, Tickner et al. 2006,
Boerner et al. 2013, Larson et al. 2014).
Socio economic factor are found to be less prominent here as the polio vaccination is free of cost for
every individual and provided at the doorstep. People who do not have any access to basic health
services due to poverty are not left out of these vaccination campaigns. Economic status of the
families was one of the commonly reported hindrances according to previous studies, where the poor
did not have enough money to travel to far off vaccination centers and/or to pay for the vaccination
(Pill et al. 1995, Jani et al. 2008, Bbaale 2013).
Social inequalities based on caste system and social classes, are still an issue to the developing and
poor countries. Previously conducted studies (Sathar 1987, Bonu et al. 2003, Breiman et al. 2004,
Toopuzoglu et al. 2005, Choi and Lee 2006, Smith et al. 2011, Basel et al. 2012) presented various
socioeconomic factors such as income, ethnicity, family structure, gender, rural-urban lifestyle, which
affected vaccination. This study, however, reports that the vaccinators in southern Punjab do not see
these socioeconomic factors as of much influence on the vaccination campaign activities and results,
due to an improved government policy and planning.
6.2 Strengths and limitations of the study
This study is based on descriptive phenomenographic design that includes thematic semi-structured
in-depth interviews, with help of an interview guide questionnaire, consisting of open-ended
questions. It encompasses a wide range of socio cultural factors influencing the vaccine uptake, and
the data collection was designed to offer a very flexible and neutral environment to the subjects.
Using the local language, and even the local dialect helped in improving the flow of the ideas. This
study was conducted from the vaccinators’ perspective, so the research angle was different from past
studies, which were mostly conducted on the parents. All the vaccinators had job experience of more
than a decade, so their understanding and experiences of socio cultural factors were considered to be
quite comprehensive.
Southern Punjab region, especially Multan city is a central hub that joins many small cities and towns
to the major cities of the country irrespective of the provinces, and hence it is a region of high mobility
of people and poliovirus. Additionally, Multan is famous for its shrines and religious festivals (Urs)
due to which people from across the country visit this city throughout the year. Previously, there has
68
been no such study conducted specifically in Multan city. Moreover, major hospitals of southern
region are also located in this city and patients form other province (Baluchistan) and tribal areas also
visit the city to seek these health facilities. These factors make this city a high mobility zone and
critical in special reference to poliovirus spread.
Interview guide was piloted and improved prior to conducting the study by interviewing 5 sample
entrants. This eliminated the unnecessary elements form the questionnaire and made it precise and to
the point. This piloting also helped the Interviewer in improving his interview skills.
The interviews were conducted in local language, which is also the mother-tongue of researcher due
to which communication was direct, precise and accurate between the researcher and the subjects.
Additionally, the researcher belongs to the same city where study was conducted, which added a
clearer understanding and familiarity with the local customs and communications.
Since it was a direct face-to-face interview between the researcher and the subject, there is a chance
of social desirability bias, potentially limiting the quality of the data.
At times, the interview process was cut short due to the logistics involved. Due to the active
vaccination campaigns, subjects were always busy in the working hours so all the interviews were
conducted in the evening times, according to the availability and ease of the subjects. Even then, they
had their family responsibilities and similar issues.
6.3 Implications for research, policy and practice
Area where the research has been conducted is under developed part of Pakistan in terms of public
health. The analysis made through the results can help in understanding the socio-cultural phenomena
attached to vaccination, and thus making district specific plans and implementation to interrupt polio
virus transmission can be further improved.
Furthermore, vaccinators from other parts of the country, especially those pockets which are reporting
polio cases, can be interviewed in order to point out any specific socio-cultural features as challenges.
69
7. CONCLUSION
This study gives a detailed view of vaccinators’ perspective to see how sociocultural factors influence
the vaccination and campaigns. For the last few years, pressure and concern from the international
community has motivated the government to increase its focus on polio eradication aims. Aggressive
vaccination campaigns, updated information and reporting system and an increased awareness in
public about polio, its effects and vaccination needs, are collectively presenting a positive picture.
However, there is a need to further involve the society. Recent statistics of polio cases are showing a
drop in numbers, globally and in Pakistan, which should continue. Understanding these socio-cultural
factors in different societies and settings will contribute to this progress.
70
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9. APPENDICES
9.1 Interview guide
Interview Guide for thesis topic- Vaccinators perspective of sociocultural factors affecting Polio
vaccination campaigns in southern punjab Pakistan.
1. What do people, in general, think about vaccination program (Perception/compliance)? Is it
uniform throughout the community- if not how? (Education (maternal education and health
education), income, ethnicity, religion, family structure, gender, rural-urban…)
2. When you go for vaccinations, who do you encounter most? With the children/who opens the
door mostly? When children are brought for vaccinations who accompany them mostly?
(Individual/family setup-support/single parent) Do you talk to these people? Is it easy or
difficult to relay to them messages about vaccination? Why? How? What? Do you think
there’s a difference in uptake of vaccines or immunization related message by them? How?
Why? (Education, income, ethnicity, religion, family structure, gender, rural-urban…)
3. How about other health services? Utilization and belief in other health services (Folk sector),
trust and belief in your health services (professional)
4. Are there particular people (leaders) that the people listen to? (Community) Do they listen
when approached by these leaders? How are they influenced by community leader/religious
leaders?
5. Are there any rumors about vaccines? What? How have they affected vaccination? Trends in
change of immunization uptake pattern? (Education, income, ethnicity, religion, family
structure, gender, rural-urban…)
6. What do you think should be done to improve immunization? What are the loop-holes? How
can it be changed? Has this been discussed before, if yes, by whom/has it been implemented?
79
9.2 Vaccination chart
قومی توسیعی پروگرام براۓ حفاظتی ٹیکہ جات
کوآرڈینیشن۔ حکومت پاکستانوزارت ہیلتھ سروسز ، ریگولیشن اور
کارڈ حفاظتی ٹیکہ جات براۓ اطفال
-------------------------------------------------------------------------نام :
----------------------------فون نمبر: --------------------------والد کا نام :
--------------------------------------------------------:تاریخ پیداؑیش / عمر
---------------------------------------------------------------یونین کونسل :
------------------------------ضلع : ------------------------تحصیل / تعلقہ :
-----------------------------------------------------ای۔پی۔آئی سینٹر کا نام :
----------------------تا ر یخ اجرؑا : -----------------------------کارڈ نمبر :
--------------------------فون نمبر: ---------------ٹیکہ لگانے والے کا نام :
-------------------------------------------------------------ھیلپ الؑین نمبر :
آؑیندہ ٹیکہ لگوانے کی تاریخ
/ / 3 / / 2 / / 1
/ / 6 / / 5 / / 4
/ / 9 / / 8 / / 7
15
.5 C
M
11.5 CM
80
ریکارڈ حفاظتی ٹیکہ جات
ٹیکہ لگنے کی عمر حفاظتی ٹیکہ کا نام ٹیکہ لگنے کی تاریخ ٹیکہ لگانے والےکے دستخط
/ / BCG پیداؑیش کے فورا بعد
/ / OPV-0
/ / OPV-1
ہفتے کی عمر میں 6 / / Penta-1
/ / Pneumo-1
/ / OPV-2
ہفتے کی عمر میں 10 / / Penta-2
/ / Pneumo-2
/ / OPV-3
ہفتے کی عمر میں 14 / / Penta-3
/ / Pneumo-3
/ / IPV
/ / Measles-1 9 ماہ کے فورا بعد
/ / Measles-2 15 ماہ کے فورا بعد
ہدایات:
پیداؑیش کے بعد جتنا جلد ممکن ہو سکے فورا بچے کو ٹیکوں کے حفاظتی مر کز میں الؑیں۔
حفاظتی ٹیکہ جات کے شیڈول کے مطابق ٹیکوں کا کورس وقت پر مکمل کراؑیں۔
اگر ٹیکے کے بعد معمولی بخار ہو تو پیراسیٹامول دیں۔ اگر بخار تیز ہو تو قریبی ڈاکٹر سے رجوع کریں۔
ہ، کھانسی، دست اور معمولی بخار میں بھی حفاظتی ٹیکے لگواۓ جاسکتے ہیں۔نزل
اس کارڈ کو سنبھال کر رکھیں۔ سکول میں داخلہ کے وقت اس کی ضرورت پیش آ سکتی ہے
آؑیندہ ٹیکہ کے لئے دی گئ تاریخ پر اپنے نزدیکی حفاظتی ٹیکوں کے مرکز پر تشریف الؑیں۔
صورت میں ھیلپ الین نمبر یا حفاظتی ٹیکہ لگانے والے کے نمبر پر رابطہ رہنماؑلی یا مدد کی ضرورت کی
کریں۔