Knowledge, Attitudes and Practices regarding the Oral Polio Vaccine ...

Title: Knowledge, Attitudes and Practices regarding the Oral Polio Vaccine in a slum area of Karachi PHC Project by Group 1A Alina Ghani Emmon Raza Abeer Sami Mohammad Usman Ali Sobia Nizami Arslan Mirza Umar Hayat Marvi Bikak Saad Siddiqui

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Introduction Poliomyelitis is an infectious disease that can lead to drastic results in afflicted individuals. It is caused by an RNA virus and is spread via the fecal oral route or through aerosol secretions of those affected. The virus primarily targets the central nervous system and in its most severe form can lead to irreversible flaccid paralysis. Frequent polio epidemics have occurred throughout the 20th century at an alarming rate and by 1910, the race to develop an effective vaccine was underway. The first successful vaccine, the injectable Salk, was developed in 1950, leading to a drastic reduction in the incidence of polio worldwide. Later on the oral live attenuated vaccine Sabin was also introduced. Encouraged by the successful eradication of smallpox in 1980, the WHO launched the Global Poliomyelitis Eradication Initiative in 1988 with the goal of eliminating the disease by the year 2000.(1) The success of this initiative is apparent by the global decline in the incidence of polio from approximately 350,000 cases in 1988 to less than 2000 cases in 2005.(2) Current estimations suggest that the global incidence of polio has decreased by more than 99% to less than 1000 cases per year.(3) However, this drastic reduction has been seen primarily in industrialized nations and polio still remains an endemic disease in Nigeria, India, Afghanistan and Pakistan.(4) In 1997 Pakistan constituted 22% of the global cases of polio.(5) More recent studies show a rising trend in the incidence of polio as is evident by the fact that the number of cases increased from 32 in 2007 to 118 cases in 2008.(6) Consequently, eradication of this disease remains a significant priority for public health officials in Pakistan. In an effort to combat its spread, mass public education campaigns have been carried out on numerous occasions. The public health ministry started conducting National Immunization Days in 1994 in an attempt to address this growing concern. The first implementation of NID was conducted in two rounds (27-30 April and 28-31 May) and aimed towards immunizing all under-5 children living in the four provinces and all federally administered areas regardless of prior immunization.(7) This effort was subsequently increased in 2009 when it was decided that NID rounds should be conducted every 2 months.(2) Other attempts at eradicating polio have also been met with success. Recent involvement of the National Database and Registration Authority (NADRA) in administration of polio vaccines resulted in the successful vaccination of 20,000 children, a significant increase from the initial target of 12,000.(6) Despite these efforts, there are substantial obstacles that must be overcome before complete eradication of polio can be achieved. These obstacles include the lack of accountability and

resources among public health officials, inaccessibility of communities in far-flung areas and difficulty maintaining cold-chain storage of the vaccine. Of special concern is the lack of awareness among rural communities regarding the importance of vaccination, which often results in negligence. Low level of maternal education is a particularly important factor, as maternal education status has been shown to have a significant association with a child’s immunization status in peri-urban settings (Siddiqi N et al., 2010). Furthermore, suspicion against the vaccination is especially prevalent in NWFP and areas close to the Afghanistan border, which make it particularly difficult to implement vaccination campaigns.(2) Prevailing attitudes indicate a reluctance towards administration of the polio vaccine due to religious misconceptions, ignorance and mistrust of modern medicine, especially persistent beliefs that administration of the vaccine will further worsen the condition of the child. Religious misconceptions regarding the polio vaccine have lead to the denouncement of the vaccine in certain areas of Pakistan and Afghanistan as an American ploy to sterilize Muslim populations.(4) The severity of this issue is highlighted by the numerous incidences involving kidnapping and assault of vaccinators that have occurred in the country.(4) Lastly, it has been observed that unvaccinated children tend to be clustered geographically and thus increase the risk of transmitting the disease to other unvaccinated children (Smith P.J. et al., 2004). In light of this, it is important to vaccinate a substantial number of children and achieve at least 90% coverage in order to provide herd immunity and successfully break the transmission cycle. Considering this scenario, it is important to assess the level of knowledge and attitude of members of rural communities regarding polio vaccination, and to determine the proportion of children being vaccinated. This information will shed light on the importance of public awareness and attitude towards vaccination, and will help explain the significance of these factors in the failure to eradicate polio. The aim of this study was to determine the level of knowledge regarding the disease as well as attitudes towards the oral polio vaccine by interviewing visitors to a child health care clinic situated in a slum area of Karachi. It is hoped that the knowledge gained from this study will allow us to better evaluate the various factors that must first be addressed in order to eradicate polio.

Methods: This was a questionnaire based cross-sectional study done at Bilal Colony. The study population was the parents/guardians of children presenting to mother and child care clinic at Bilal Colony. The respondents were explained about the purpose of the questionnaire and there consent

was taken before subjecting them to a short interview which was conducted by the 4 th year medical students. The questionnaire was adapted from a similar study done in Egypt; the reference for which has been quoted at the end. 119 questionnaires were filled out. The data was entered and analyzed in spss version 17.0. Descriptive statistics which mainly involved frequencies were calculated. The individual responses were cross-tabulated against the variables that were thought to have an effect on the level of knowledge, attitude and practices. These variables included age, educational status and monthly income which is a predictor of socio-economic status. The data has been tabulated in form of charts and graphs.

Results A total of 119 respondents were questioned on their knowledge about polio disease and its vaccination. Their attitude and practices regarding polio vaccination were also assessed. Age of the respondents ranged from 12 to 40 years with mean age of 25.17 ± 5.72 years. The relation of the respondent to the child and their educational status is displayed in Figure 1 and 2 respectively. Knowledge about Polio disease Table 1 demonstrates the respondents’ knowledge about polio disease. 7 5.6% of the respondents had heard about polio. Among them 91% correctly identified that polio makes child unable to walk. 41.1% were of the view that polio is a life threatening condition while 77.8% viewed as a life threatening condition. Only 27.8% considered polio an infectious disease. 54.4% of respondents thought that polio can also affect adults and 82.2% knew that it can be prevented by polio vaccination. Responses to each question were stratified according to age, socio-economic status and educational level of the respondents. However, none of these variables were found to be significantly associated with the responses to each question. Knowledge about polio vaccination and NID (National Immunization Day) Table 2 represents the respondents’ knowledge about polio vaccination and NID. 94.1% of the respondents had heard about polio vaccination and were further questioned on their knowledge. 91.6% of the respondents were aware of NID and were further questioned regarding their knowledge. Among them 15.9% thought that NID dose was different from OPV. When inquired about number and sequence of doses, the response obtained was poor. Only 7 respondents were able to correctly identify the correct number of OPV vaccination according to EPI schedule. However, only 2 were able to recall the correct sequence. 91.6% were of the opinion that breastfed child needs immunization while 75.6% of the respondents thought that children with fever can be immunized. 85.7% were of the view that child can be vaccinated shortly after eating and 52.1% considered re-immunizing their children with diarrhea. Individual

responses were stratified according to age socio-economic status and educational level of the respondents. However, none of these variables had any significant association with the responses. When asked about the purpose of NID, the individual responses received are shown in Figure 3. Table 3 shows the participants’ responses when given the situation in which the child was not vaccinated or missed a dose. Out of these, 48.2% thought that the child might develop polio if not vaccinated whereas 33% thought that the child will surely develop polio. 60.7% were of the opinion that missing the dose might cause polio while 14.3% were of the view that polio will develop for sure. Again the stratification with the above mentioned variables failed to achieve any statistical significance. Attitude and practices regarding Polio vaccination Again an overwhelming majority i.e. 95% considered polio vaccine to be beneficial in terms of protection and only 7.6% thought that can be harmful in some way. Among them, the most commonly quoted harms caused by OPV were fever, infertility and chance of contracting polio. 93.2% advised others to get their children vaccinated as well. Rest of the responses along with stratification is shown in Table 4. Statistical significance for the tabulated responses was not reached. Table 5 depicts the practices of the respondents with regards to polio vaccination. 91.5% of the respondents had their child vaccinated against polio according to EPI schedule and 97.5% had their child vaccinated by NID teams coming to their homes. The most common reason quoted by the guardian for not getting their child vaccinated was lack of awareness regarding OPV at birth.

Discussion As emphasized it has been a great tragedy that polio has not been eradicated despite numerous efforts. This failure strongly highlights the short comings in the health care infrastructure but on a more preliminary level, on the public awareness. The knowledge, attitude and perception analysis in our study involved 119 respondents coming to a health care service which already had an established EPI based vaccination setup. These individuals were mostly the mothers of the children being brought to the centre, 75.6% had heard about polio while 82.2% had heard about the vaccine. This showed that the knowledge about polio rather came from vaccination campaigns held by NIDs heralded by the stronger number (97.%) who had their children vaccinated under the provision by NID. The strong need for active Communication and interpersonal skills to create awareness in the female caregivers i.e. mothers through NID teams about the burden of polio as a disease on our nation has previously been discussed(8) yet forgotten with time. Further more as 94.6% knew about NID, this shows that coverage by the teams plays a significant role on the awareness of the community. However it was surprising to see only 15.9% identified a difference between OPV of EPI versus NID polio vaccination dose. The knowledge regarding the schedule of OPV was extremely poor harbingering the need for more awareness in this area. It must be again emphasized that this was the baseline knowledge that we were able to look into in an EPI based centre where OPV along with other vaccines are being provided to these individuals yet only 2 out of 119 could recall the correct sequence of the OPV doses. This shows provision of vaccine is not the mere mechanism towards awareness as it takes a communication and as well community sensitive approaches(9). On contrary to the poor knowledge, 93.2% supported the idea of Polio vaccination by advising others in their family to get it for their children too. At grass root levels, the community itself has the power to drive itself towards the eradication of polio hence there is a need for creative and innovative ways to be explored through which people to people awareness can be effectively transferred(10). This will surely help combat the train of obstacles of social and behavorial issues as only the aware elements within the community are the true means of clarifying their own concerns. Regarding the misconceptions 7.6%, seemingly a small number but considering the sample of 119 a significant number of people considered the vaccine was harmful expressing their concerns. Dealing with this problem again a lot more than media or public campaigns is required. There is a need for health care providers in conjunction with the house to house teams to address these concerns by using community sensitive empathetic interpersonal

skills(11). This may include activities and involvement of significant community figures like political or religious leaders to drive social mobilization(12). A multi faceted and multi partnered awareness strategy is the best way to penetrate the barriers in polio eradication the community rather than just provision of facility(13). The short comings in this study have been first of all the small sample size hence inability to demonstrate or identify the causal role of age, social status or relationship of the interviewee in the knowledge, attitude or perception. As this study was limited to an EPI setup, the baseline knowledge cannot be generalized hence heralding the need to conduct a further survey in centres or communities where NID aren’t providing. This will help visualize the true picture of our community awareness so that strategies can be directed keeping in view of hard to reach underserved regions. An automated response was commonly encountered especially regarding indications and contraindications of the vaccine. Further more most of the participants were females who lack insight due to being restricted at homes. Keeping in view that a large number 97.5% received vaccination for their children via NIDs, the need of the time is that more teams are a structured trained and mobilized towards underserved areas of Pakistan. With the advantage of direct communications these teams should provide knowledge about OPV as well along with the schedule and the locations of centers easy for them to reach accordingly. Since the knowledge regarding the benefit of Polio vaccine against disease is fairly good because of NIDs continued efforts it makes hope that with further focus on specified awareness provision would help change attitudes and perceptions.

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8. Islamabad. Evaluation of social mobilization activities for polio eradication. United Nations Children fund. 2005. 9. Haider M. Global public health communication: Challenges, perspectives, and strategies: Jones & Bartlett Learning; 2005. 10. Waisbord S. Assessment of communication programs in support of polio eradication: global trends and case studies. Washington, DC: The CHANGE Project Academy for Educational Development/The Manoff Group. 2004. 11. Dehli N. A critical leap to polio eradication in India. United Nations Children's Fund Regional Office for South Asia. 2003. 12. A. J. Jabbar A. Religious leaders as partners in polio eradication [NWFP/FATA]. In: Technical Advisory Group on poliomyelitis eradication in Afghanistan and Pakistan. Cairo. 2008. 13. Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M, et al. Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan. Bulletin of the World Health Organization. 2009;87(8):624-30. Reference for questionnaire: El-Zanatay & associates, UNICEF. Support to National Communication Polio Plan Baseline Survey.2002/005