Challenges to health workers and their opinions about parents' refusal of oral polio vaccination in the Khyber Pakhtoon Khawa (KPK) province, Pakistan.

A qualitative study design was adapted to explore the challenges faced by health workers (HWs) during the polio health campaign. In addition, HWs' opinions about the factors causing parents to refuse oral polio vaccination (OPV) were also explored. Four focus group discussions (FGDs) were held (from 1st January 2015-31st March 2015) with the HWs who participated in the OPV campaigns in the polio red zones of Khyber Pakhtoon Khawa (KPK) province of Pakistan, namely Kohat (FG 1), Domel and Bannu (FG 2), Hangoo (FG 3), and Peshawar (FG 4). A total of N=42 HWs (10-11 in each FG) agreed to participate in this study. Overall, HWs disclosed that public attitude and harsh behaviour towards the HWs and security threats are the two main challenges they face. Common issues hindering parents' willingness to vaccinate their children against OPV are: OPV is seen as haram and not permitted in Islam, it is said to contain the blood of pigs (Khinzir) and monkeys, and parents are afraid that it is done to induce sterility among their children. HWs also shared that parents have a strong belief in the conspiracies that are associated with OPV, i.e. the USA and CIA, are spying on us and our government is helping them to achieve their agenda. Furthermore, HWs revealed that frequent visits may further strengthen parents' perceptions and make them more resistant to OPV. The common side effects of OPV reported by parents were mainly gastro-intestinal problems and in some cases mild to moderate fever with some respiratory symptoms. There is a great need to improve the logistics and facilities for HWs assisting in vaccination programmes. Furthermore, it is necessary to improve education, so people understand the basic concept of revaccination and booster doses, thereby assisting in creating a basic understanding of vaccinations, which may trigger changes in attitudes and make people believe in the benefits of OPV rather than following the conspiracies that lead them to refuse it.