THE LAST FRONTIER OF RESISTANCE: REFUSALS TO ORAL POLIO VACCINATION IN SIX DISTRICTS OF KANDAHAR PROVINCE OF AFGHANISTAN

Received: 15 June 2017 Final Accepted: 17 July 2017 Published: August 2017 Background: Refusal to the Oral Polio Vaccine (Henceforth referred to as OPV) is a difficulty faced by the Polio Eradication Initiative (PEI) in the most dangerous and highly endemic areas, in Kandahar, Afghanistan. Through our survey during the period of 2015-2016, we investigated community perceptions of the OPV and estimated the prevalence of OPV refusal in 6 Very high risk districts (VHRDs) of polio-endemic areas in the province of Kandahar. Methods: Cross-sectional survey was conducted among the caregivers of refusal families with children aged <5 years. The study was conducted at the community level of 6 very high risk districts of Kandahar province. For the first section of the study, multistage cluster sampling technique was adopted. The primary sampling units were families obtained by the Polio vaccination team. At the first stage, a total of 400 households were randomly selected from 4000 refusal families in 6 districts, using Probability Proportion to Size (PPS) technique. The sample consisted of 400 households selected for the survey. All target houses were interviewed in the survey. Discussion: The survey identified the reasons behind refusals to OPV. There are numerous reasons given by the respondents, where some had only one reason for refusing OPV whilst others had multiple misconceptions. These misconceptions include, vaccines will cause impotence because it is a western conspiracy, and that the vaccine is not safe. Others did not even believe in the effectiveness of the vaccine provided. Some were against it for cultural reasons such as the prohibition of bringing out a new-born outside of the house. While others thought it was not allowed by the religion. Other reasons included too many campaigns, political differences with the government and males members of the family not at home at the time of immunization. In the 6 districts, the rate of refusal ranged from 20% up to 60% (WHO, 2009). Recommendations: The approach has to be modified by the PEI to reflect ground realities considering the local value system in the path to polio eradication in the surveyed districts. During this article we have established that the awareness level of the caregivers is high. Almost 80% of the residents know about the campaigns. Even though the caregivers know about the timing of immunization there is a lack of knowledge of potential risk associated with retracting the virus. The

In order to vaccinate all children below 5 years of age and bring the transmission of poliovirus to a complete stop, Supplementary Immunization Activities (henceforth referred to as SIAs) such as National Immunization Days (NID), Sub National Immunization Days (SNID), Short Interval Additional Doses (SIAD) and mop-ups are being conducted regularly in Afghanistan. While the campaigns are reaching and vaccinating majority of children, a reasonable number of children are still repeatedly missed, especially in the security compromised areas of the country.
Afghanistan is still on the list of polio endemic countries due to the protracted insecurity, mass population movement, low level of awareness about polio campaign and community beliefs, attitudes and practices regarding polio vaccination. To enhance knowledge of the community about polio vaccine and generate demand for vaccination, a variety of communication/social mobilization activities are taking place in the whole country, with special focus on the high risk districts of South Region. During different phases of the polio campaigns, a variety of data is collected regularly. It captures the process and output indicators, related to the operational and communication aspect of the program. The data is collected from across the country, during and after every polio campaign at the cluster level, the smallest geographic unit. The existing system collects data on a number of refusals, as part of the missed children without any explanation of the refusal.
Southern region especially Kandahar province of the country is a high priority region for polio eradication in the country. It is a reservoir of polio cases and possibly exporting the cases to other parts of the region. According to the post campaign assessment (PCA) data and intra campaign data, on the average 11% of the target children are missed during the campaign (Survey: 2013, PCA data). Out of these total missed children, 49% were missed due to 1260 the absence of child during the campaign, while another 5% did not receive vaccine due to refusals (PCA data). So far, through the existing data collection system, no data is available on why these people refuse to get their children vaccinated by OPV during polio campaigns and there are none real solutions suggested.
Therefore it is the need of the hour to further supplement the polio eradication efforts with a strong communication component that is based on quality information and understanding of the local knowledge, concerning polio vaccination. To address this need for information, a research needs to be carried out in the district of Kandahar of south region, showing an increased trend in refusals, hence it is targeted by this research thesis. Findings of this research will be used for evidence based communication planning to stem the rising trend of refusals in the southern region as a whole and specifically in 6 very high risk districts helping to reduce chronically missed children and ultimately filling existing gaps.

Epidemiologic situation:-
The current global goal to completely stop transmission of polio by the end of 2012 was declared a programmatic emergency for global health by the Executive Board of the World Health Organization (WHO, 2017). The circulation of indigenous Wild Poliovirus (henceforth referred to as WPV) continues in three countries, Afghanistan, Nigeria and Pakistan (WHO, 2017). India has not reported a polio case since January 2011 and was considered polio free since February 2012 (UNICEF, 2014).
Afghanistan is now one of the only three countries where polio remains endemic, collectively accounting for 60 per cent of all new cases of poliomyelitis (WHO, 2017). The remaining 40 per cent of cases occurred in Pakistan. In Afghanistan, 5 WPV poliomyelitis cases were reported during 2017, hitherto, compared with 7 WPV cases in 2017 (Annual report). 4 out of 5 cases are from the southern region of the country. Most of these cases are zero dose and refusal patients.

Afghanistan Polio Eradication Initiatives (PEI):
Most parts of Afghanistan is polio-free and persistent wild poliovirus transmission is now restricted to 28 securitycompromised districts in the provinces of Helmand, Kandahar and Urozgan in the conflict zone in the south and Farah province in the west.
The main elements of the polio eradication initiative (PEI) in the country are to: strengthening routine EPI, including OPV4 dose at 9 months of age Supplementary immunization activities, including national immunization days using trivalent vaccine, subnational immunization days (SNID), using either trivalent or monovalent vaccine, and cross-border vaccination Acute Flaccid paralysis Surveillance

PEI priorities and Polio High risk districts Afghanistan
Polio eradication team has developed the list of 29 out of 49 high-risk districts (Table) located in the southern region of the country. The first priority was to improve quality of campaign in these 29 high-risk districts of the southern region. These districts are labeled as high risk due to: 1) districts having reported confirmed polio cases 2) districts having reported 0 dose AFP cases.
3) districts facing security and accessibility issues (Reports from the field number of missed children, clusters, villages during the campaign) 4) districts situated in the epidemiological block of high risk districts for polio, (Geo graphic situation of the areas) and 5) low awareness levels about the campaign.

Chapter TWO:-Review of available Literature and Information:
Revision of the information for developing the research is one of the important steps in acquiring resources/data and obtaining information to support the objective of the research. Polio Eradication report, WHO, UNICEF and MOPH monthly quarterly and annual reports are good resources, which I have access to, through my work for the purpose of this research. In addition the university primers and technical notes and also the WHO training manual on Health System Research Training are good references, which helped me in the following steps and processes systematically. 1262 me in acquiring the updated knowledge on the topic. In addition the previously mentioned sources 10 facts on polio eradication, Global Polio Eradication Initiative. Wild poliovirus (WPV) cases: case breakdown by country, Situation analysis-polio situation worldwide: the game changer. UNICEF, immunization communication network data, national coverage survey, Surveillance report of WHO and coverage report NEPI/MoPH have also been a tremendous help in formulating the thesis. To give an overall perspective on the literature I will be mentioning some excerpts from the research material I have gone through in the following examples.
In the southern region of Afghanistan, the proportion of missed children has hardly changed in two years. The proportion of refusals continues to be the highest of all polio affected countries and this situation has persisted for four years. (Country Program review Independent monitoring board London 2016). The review also notes that "refusal" is still important especially in highest risk areas and that strategy for conversion of soft refusals should be reviewed. Where communications strategy seeks to build wider community support for PEI, as a means to improve household OPV uptake, emphasis should be given to engaging local level influencers and caregivers to address identified issues; including sustained engagement of religious leaders in the Very high risk districts (VHRDs), rather than at the national level (Technical Advisory Group on Polio Eradication for Afghanistan 2016). Still we are anxious for wrong information that spreads regarding polio vaccine. Therefore, we request media, clergies and others who have a role in making the public opinion to endeavor for reconstruction of public opinion regarding Polio vaccine and to uproot the wrongful fear of concerned people (international-ulama-conference-on-polio-eradicationand-childhood-vaccination Kabul -2015).
The GPEI Community Engagement Strategy considers three main phases:  Before the Knock -Pre-campaign awareness and community mobilization  The Interaction -Supporting interpersonal communication and training so that the interaction at the door is the most effective it can be.  After the Knock -Building toward constant improvement and increased levels of trust, seeking caregiver feedback is critical (PEI End game strategy).
The revised approach to communication for PEI will focus on increasing correct knowledge about polio to address misperceptions and false rumours, and to provide facts on polio and PEI activities (National Emergency action Plan 2016). Caregivers refuse OPV largely because of poor polio risk perception and religious beliefs. Communication strategies should, therefore, aim to increase awareness of polio as a real health threat and educate communities about the safety of the vaccine (An assessment of the reasons for oral poliovirus vaccine refusals in northern Nigeria). Strive to educate parents and patients about the importance of eradicating polio, not just in the United States but worldwide. Ensure that patients are vaccinated against polio. Ensure that patients traveling internationally receive all recommended vaccines, including a booster dose of IPV when appropriate (American academy of pediatrics).
Chapter Three Objectives of the research: Purpose of the study The main purpose of this research is to determine factors associated of the caregivers of children, who refused to vaccinate their children with polio vaccine in Kandahar province of Afghanistan.
Specific objectives of this research are:- To estimate personal factors (including knowledge, beliefs and attitudes, of refusals to the polio vaccine, reported in 2016 SIAs, in the Kandahar Province).  To uncover patterns, trends or associations contributing as factors among caregivers leading to refusals towards polio vaccination.  What are the child care takers/mothers/parents" concerns in connection with immunization of their children.  What are the communication, knowledge /exchange issues resulted into demotivation of service providers and families who are not fully participating in the EPI program  How families and service providers are seeing the adverse effect to immunization as a limitation for next session follow up and completing the course of immunization.  What are the limitation in training of service providers and community awareness that resulted into in low immunization coverage? 1263 Geographic scope:-The study covered 6 polio high risk districts of kandahar province, which include: Kandahar city/Dand, Spin blodak, Panjwai, Maiwand/Zahray, Daman/Takhtapol and Arghandab.

Hypothesis:-
There is an association between specific socio-demographic factors and chronic refusals of OPV. Study design: Cross sectional study (community base) Survey methodology 2.

Study design
This study is a cross-sectional survey targeted at caregivers of refusal families with having children aged under 5.
The study was conducted at the community level of 6 very high risk districts of Kandahar province. For the first section of the study, multistage cluster sampling technique was adopted. The primary sampling units were families obtained by the Polio vaccination team. At the first stage, a total of 400 house hold were randomly selected from 4000 refusal families in 6 districts, using Probability Proportion to Size (PPS) technique. The sample consisted of 400 households were selected for the survey. The study was conducted between 23 June 2016 and Sep 2017. All target houses were interviewed in the survey. The questionnaire consisted of the following sections: 1. Socio-demographic characteristics of the household and the main caregiver: -Age, -Education, -Ethnicity, -Occupation of the caregiver -Number of families and children under 5 living in a compound.
-Material of boundary wall of the house and basic household 2 Reason of objecting/rejecting vaccination Why they are refusing vaccine? 3 Routine Immunizations (RI) -What is the RI immunization status of these chronic refusal families? -Awareness Level -Source of Information

1.5.2
Sample size:-The sample size for quantitative data was calculated based on WHO 30 by 7 random cluster methodology 11. Selection of respondents Inclusion criteria Married (women/Men): The caregivers including mother, Grandmother, Aunt, Father, Grandfather, and Brother of the youngest child in a household were interviewed.

Study sampling procedure two stages cluster sampling technique
In this study the Probability Proportion to Size (PPS) technique was used for the sampling through a two-stage cluster sampling technique.
The primary sampling units and households were selected based on below two stage sampling technique: First stage: all the villages of the survey districts were obtained from the Immunization Communication Network (ICN) Second stage: Selection of household. The households were randomly selected by visiting each PSU, identification of a central point, random selection of a direction from central point, identification/numbering of houses and selection of first house between 1 and total number of refusal houses in the area through using lottery technique. 1264

Survey implementation:-
The implementation process included the development of the household questionnaire, plan of action showing the timelines for all activities, pre testing of tools, selection of supervisors and data collection teams, their training, data collection from the field, data entry and cleaning/processing and report development.
All the instruments were prepared in English and translated to Pashto. Selection and training of field staff. The field personnel, 3 supervisors and 20 local data collectors were selected locally at the /district level. 3 supervisors trained for one days centrally at Kandahar city, Supervisors organized a one-day orientation on the questionnaire for the locally selected female/male data collectors at the district level.
Data management/data Collection: Quantitative data were entered into the computer using Excel especially. A number of controls were incorporated in developing data entry software to minimize entry errors.
Limitation of the study: In some districts of the province, finding female surveyors in these districts because of insecurity and cultural and social barriers. The use of male interviewers posed challenges as typically; the survey respondents were females, resulting to have some interviews with male caregivers as well.
Chapter Four:-Socio-Demographic Information A total of 400 primary caregivers were interviewed from 6 districts of Kandahar provinces. A total of 183 caregivers were interviewed from Kandahar city, 37 from Panjwai, 40 form Damn, 40 from Arghandab, 40 from Zehrai and 60 from Spinboldak province. Only 8% of mothers were ready for an interview, the lowest was in Daman and Arghandab were the percentage was zero.   Zehrai  Total  1-2  35  8  18  33  35  30  29  3-4  40  42  55  46  49  60  45  5 or more  25  49  28  21  16 10 26 It was revealed that 19 percent respondents attended formal school and another 15 percent educated from Madrassas (mainly religious school) while 1 percent completed their Grade-X or above, The rate of illiteracy of the caregivers was highest (82) in Daman, followed by Zehrai (75%), Spinboldak (74%), Arghandab (68%), Kandahar city (62%) and Panjwai (58%).  Total  Uneducated  62  74  58  82  68  75  67  Primary  13  3  23  5  16  0  11  Secondary  12  3  0  3  0  3  7  High education  1  2  5  0  0  0  1  Islamic Education  13  18  15  10  16  23 15 Out of total respondent 32% were farmers, 10% jobeless, 11% mullah Imams, 2% were medical practitioners, 22% had private services, 7% drivers and 6% skilled labours.  Total  Private service  33  25  3  8  16  8  22  Jobless  13  16  3  0  0  8  10  Farmer  11  21  67  66  59  53  32  Mullah Imam  9  8  15  13  8  21  11  Skilled Labor  8  7  8  3  3  3  6  Unskilled Labor  8  7  0  3  3  0  5  Driver  7  13  0  8  8  3  7  Health practitioner  3  0  5  0  0  0  2  Teacher  2  2  0  0  0  3  2  Police  2  Chapter Five:-Reason of not vaccinating the children with OPV If was found that 9% of respondent from refusal families have a concern about getting their children polio vaccine the highest number was in Panjwai 14% and the lowest number was in Daman 5% while It was 9% in each of three districts (Kandhar city, Spinboldka, and Zehrai. It was found that 9 % of caregivers thinking that their children receive more doses of OPV and there is no need and 12 % of respondent have no trust on vaccinators  It was found that 12% of respondents in Zehrai reported that it is culturally not allowed to bring new born babies outside the house while 2% each in Panjwai and Kandahar city/Dand, and in Spinboldak 1%. And 8% of responded in Arghandab reported that during the appearance of vaccination teams the males are not available at home, 2% reported each from Daman, Kandahar city/Dand, and Panjwai districts and 1% from Zehrai district. 8% of respondent in Daman is not given a reason, while 2% in Arghandab and 1% each in Spinboldak and Kandahar city/Dand not given a reason.   We have also seen, during the course of this article that, although the families might know about the polio vaccine but they do not comprehend entirely what it means in the sense of the dangers polio virus possess. According to the 1269 response of caregivers community elders are not engaged properly to convince the refusal families (Survey, 2013). Most of respondent are feeling the OPV is not needed to their children highest in Zehrai district 30% (Survey, 2013). Over all 9% of the respondent disagree with usefulness of polio vaccination campaign especially in Panjwai (14%). 3% of respondent believed that OPV is not allowed in religion especially in Spinboldak 9% and 11% in Zehrai district of the caregivers reported that it is western conspiracy (Survey, 2013). In this regard other decision affecters such as elders in the villages and religious clerics should be convinced to engage their communities in changing the mind-set of the people. Changing the mind-set of the people in this era is done exclusively through digital media and it can be used for a very positive impact in the fight against polio eradication. Whether it is the radio advertisements or Afghanistan cricket players enlightening and educating people through simple ads. Other argue that the most important reason given by the caregivers is the safety of the as 9% of respondents in Daman and Kandahar city/Dand districts have exhibited fears about (Survey, 2013). Quality information about understanding of chronic refusal to polio vaccination in needed to further supplement the polio eradication efforts with strong communication component. Therefore the topic was chosen to identify the reasons of chronic refusals in sixVHRDs of Kandahar where number of refusal is high (Survey, 2013).
Cross section survey conducted among list of 4000 of refusal families in these districts. 20 surveyors and 3 supervisor conduct the survey. On average 3-4 children below the age of 5 are found in a household in the six districts. It was revealed that 19 percent respondents attended formal school and another 15 percent educated from Madrassas (mainly religious schools), while 1 percent completed their Grade-X or above studies (Survey, 2013). The rate of illiteracy of the caregivers was highest (82) in Daman, followed by Zehrai (75%), Spinboldak (74%), Arghandab (68%), Kandahar city (62%) and Panjwai (58%) (Survey, 2013). As mentioned earlier there are on average, 3-4 children below 5 years of age in most compounds, while in 26 % there are 5 or more and in of 29% cases 1-2 children were living in one household (Survey, 2013).Out of the total 42% respondents were farmers, 10% jobeless, 11% mullah Imams, 2% were medical practitioners, 22% had private services, 7% drivers and 6% skilled labours (Survey, 2013). It was found that 9% of respondents from refusal families have a concern about getting their children polio vaccine the highest number was in Panjwai 14% and the lowest number was in Daman 5% while it was 9% in each in three districts Kandahar city, Spinboldak, and Zehrai (Survey, 2013). 1270 Engagement of female vaccinators and social mobilizers as they have direct access to mothers and will reduce the number of refusals.

CHAPTER Eight:-Recommendations:-
Based on findings of the survey, following is recommended to convince the caregivers of refusal families of the community to facilitate and increase vaccination coverage among the target children. Strategy:  Increase and sustain awareness levels about the disease and benefits of OPV as an effective tool for its prevention.  Involve the community influencers (Community elders, Mullah Imams), male heads of the families, at the grass root level being a rich resource for Inter Personal Communication to remove misconceptions and counter rumors against vaccination. This is a very important point because in a society like Afghanistan males are the decision makers and if they are not convinced properly it will most definitely lead to refusal.

Capacity Building:
Social mobilizers need to be trained especially to improve their IPC ad technical skills to remove concerns as shared by the respondents and restore confidence of the community on the delivery of the program. The respondents were found concerned about their children contracting polio. The messages needs to be focused on awareness about the disease, its mechanism of spreading, symptoms and threats about the consequences as a result of paralysis Community mobilization:  The Immunization Communication Network can sustain and further involve them to ensure that polio messages reach within the households.  The most important category of most effective source for health information came out as Health practitioners and religious scholars. Capacity of the health practitioners and religious elders need to be further developed to use them more effectively to increase knowledge of the community and positively change their attitudes towards vaccination.  It has clearly came out that engaging community influencers (mullah, elders teachers, CHWs) can play a vital role for reaching and vaccinating all target children. They need to be involved through social mobilization activities.  As most of the refusals are from formers, drivers and jobless individuals, therefore establishing a special team consisting of Mullah imams and community elders can play vital role to convince this category for polio vaccination.  Engagement of female in refusal community can make a difference as they have an access to mothers and children inside the house to convey the message and vaccinate their children.
Strengthening of the Media involvement:- More than 42% of the respondents reported Radio as the most effective source of information for health information, knowledge about polio disease as well as polio campaign. It can reach to all those areas where messages dissemination through IPC channels is not possible. Involvement of radio needs to be intensified using specific targeted messages Inter Personnel Communication:- The knowledge of refusal community about polio is very low and they do not trust on vaccine, therefore Mullah Imams, and health practitioners are effective sources of information about the campaign. Their engagement at local community level needs intensification to enhance the awareness and build trust of the refusal community. Besides other activities from the provincial and district level, ICN is an effective tool at the grass root level to map and involve them.  Cultural sensitivities are other barriers reported in some districts especially 12% in Zehrai and 8% in Arghandab districts (Survey, 2013). Employing female vaccinators will improve this situation as they are more accepted by both the males and female caregivers. The necessity of female caregivers coming out of their home to meet strangers is diminished as the female workers can go into the houses of the families and vaccinate them inside of the house. As some of the families members are saying that the decision makers are not at home during the visiting of vaccination team indicating that the need for female personal is paramount. And if it is not possible 1271 to recruit female workers because of cultural sensitivities, then visiting time of the vaccinators should be changed to calculate the factor the male caregivers are at home so they can be engaged if they have any doubts and to convince them at the time of vaccination. Area/issue specific approaches  While planning communication/social mobilization activities, situation of those specific areas needs to be taken in to account.  For instance it is a belief of the community that if the vaccine is given to the children, they will become unhealthy and develop genetic defects as well as impotence in the future. As we mentioned earlier most of the caregivers/respondents are farmers, drivers and unskilled laborers, who cannot be convinced with scientific data and studies. To deal with this group of people UNICEF signed a contract with the Afghanistan Cricket Board (ACB), which is loved by one and all. In the advertisement video promoted by ACB the players are convincing the people by advocating the safety with phrases like "if you want you kids to grow strong and healthy like us, do not forget to vaccinate your children" (UNICEF Promo Video). This is an example for the people who do not trust the vaccinators but they will trust the crickets, whom are seen as role models and looked up to. There is another group who are educated and might be even doctors who oppose the effectiveness of the vaccine and propagate negative about it. These people can be dealt with scientifically as they reason with you and since there is an overwhelming scientific data to back the vaccine it should be easy.
Conclusively awareness level regarding polio campaign is good but regarding the Polio disease is far behind the target set by the program. Community awareness and trust is crucial for success of the polio eradication initiatives.
Efforts are needed to enlighten the thus far unwilling segment of the community about the benefits, availability of vaccination services and the potential risks of not vaccinating children. Electronic media and IPC is rich and trusted source to improve the coverage for more vaccinated children. Based on the findings of the survey, usefulness of effective sources of information needs further intensification. Keeping in view literacy status of the community in this specific area, the use of print media and printed material may not be useful. However use of simple and carefully designed pictorial printed material may work to make the community aware. The area and issue specific approach will work well to reduce number of missed children if the reasons behind missing children are addressed.
No trust on vaccinators, cultural barriers to bring the children outside the houses and no direct communication with caregivers especially in urban area need to involve more female as a social mobilizers and vaccinators to convince the refusal families and reduce number of missed children. I end my thesis with the ambition and hope in heart that we will one day have a polio free world.