The Central Role of Women in Polio Vaccine Acceptance Among the Pashtun in Pakistan

"A nuanced understanding of the intersectionality of poverty, ethnicity, and location with gender and gendered power dynamics within Pashtun households and communities helps to understand better the context in which vaccination against polio is received or refused."

Despite forming only a part of Pakistan's population, Pashtun households contribute the biggest number of polio cases to the country's caseload. Pashtuns are a nomadic, pastoral, Eastern Iranic ethnic group primarily residing in northwestern Pakistan and southern and eastern Afghanistan. The lack of understanding of ethnic/social constructs of refusals, as well as that of population dynamics that may limit effective coverage of Pashtun diaspora, are significant problems that limit efforts to eradicate polio from Pakistan. This chapter explores the intersection of gender norms and power relations with cultural norms, the marginalised social location of Pashtuns, geographic location, and age through the lens of polio vaccination. The study on which this chapter is based was conducted from June to December 2021 at the request of the National Emergency Operations Centre for Polio Eradication (NEOC) to understand refusals to polio vaccination, specifically among Pashtun communities.

Prior to sharing the results of the study, opening sections of the chapter provide context.  Refusals by parents of vaccine-age children are often fueled by misconceptions regarding the purpose or effectiveness of immunisation. Many believe that vaccines can harm or sterilise children or contain monkey- or pig-derived products that are forbidden in Islam. Pashtun communities in Pakistan have resisted polio vaccination owing to distrust of the state machinery, which is perceived as falling short of its obligations to provide for its citizens. In some of these refusal homes, the state has used coercion, including the use of police, to enforce vaccination. In the highly honour-sensitive Pashtun communities, having the police appear at one's door is highly embarrassing. It has resulted in backlash from the communities and recast polio vaccination as a political issue.

As noted above, Pashtun communities share some aspects of "honour cultures" with other communities with similar historical contexts. Intrinsic to these cultures is an understanding of women (and children) as a productive household asset, not just for the work they can contribute but also for their ability to bear children, who would be productive assets. These assets are guarded from outsiders. Thus, in its most traditional form, a Pashtun woman from a typical village may not step outside her home without permission or chaperone and must wear conservative clothing. In their households, Pashtun men are expected to have complete control and decide everything for women. After marriage, in-laws also make most life decisions for women, often leaving them out of these discussions.

The one norm that is never violated is that women talk to women; men are seldom allowed to meet household women, whether from the community or not. A male health worker visiting a household is unacceptable, more so in distant rural Baloch or Pashtun communities. This prohibition is sometimes a problem for polio vaccination campaigns. Since local women are not allowed outside homes, not many women are available to work, and only male vaccinators must go from door to door for vaccination.

For the study, the NEOC identified locations as communities with households in clusters of refusals with persistently missed children. Interviews with a total of 153 caregivers (male and female parents and grandmothers) were conducted. Most households refusing polio vaccination (hereafter, "refusing households") were indigent. Female caregivers live with limited mobility and exposure to outside information. None of the mothers interviewed were formally employed. Fathers also had low levels of education (most were not educated at all) and were engaged in manual labour or non-skilled jobs.

The research found that refusals of polio vaccination were concentrated in Pashtun households that were extremely economically poor and socially excluded. With regard to exclusions, limits on Pashtun women's mobility outside their homes were a norm in rural and some urban migrant communities. For women in villages, the limited mobility restricts access to information sources, including conventional and social media or phones. Limits on exposure and mobility to interacting with outsiders and outside messages prevent many Pashtun women from attending counseling and awareness sessions arranged for caregivers of persistently missed children by the polio programme.

However, the stature of all women in the household is not the same. Mothers-in-law are an important source of influence, given that they are respected and listened due, having brought up children. When they are pro-vaccine, they sometimes go against their sons, who may have opposed vaccination. The reverse is also true. So, while traditionally, men have always had the final say in decision-making, gender norms appear to be evolving, with mothers-in-law exerting agency in different ways to get their children vaccinated or to refuse vaccination. 

Both acceptance and refusal are grounded in concerns about the safety of children. This means that in rare instances if the mother was adamant, she refused vaccination, even when the husband was in favour. For example, after an April 2019 incident in the Mashokhel village near Peshawar, when social media misreported that several children had fallen ill after receiving polio vaccine and claimed the vaccines were poisonous, many households that were open to vaccines reversed their position. One such mother was very adamant about refusing polio vaccination and even fought with her husband to allow the team to vaccinate their son. The finding that some mothers could play a crucial role in both refusals and acceptances suggests the previously unrecognised agency of these women.

While boys may get taken to clinics or hospitals for illnesses or injuries, girls are mostly tended to at home and through totkas (home remedies) to limit their exposure to outsiders. However, all caregivers (mothers as well as fathers) interviewed felt that this was to protect girls from outsiders and the outside world, and none felt it was discrimination, hence the perception of lack of differences in health-seeking for boys and girls.

Vaccine hesitancy is similar for boys and girls in all refusal households. The reasons for refusal are driven by fears of sterility and infertility from the vaccine, for boys because they are responsible for carrying on the bloodline, and for girls because they cannot be married off if they lose their reproductive potential.

Finally, acceptance of the vaccine is often linked to whether the vaccinator is seen as an insider or an outsider. Some chronically refusing households reversed their stand and allowed vaccination when approached by an insider (someone familiar and trusted). In rural settings, an insider was somebody who was native to the area, but in urban locales, an insider was anyone who could speak their language. Some respondents even said they might be hesitant but had sometimes allowed a polio worker to vaccinate their children if she was Pashtun, if only to not refuse someone from their community. In this way, women could indeed be said to "play a core role as 'community insiders' facilitating polio vaccination."

The researchers conclude that "polio campaigns in Pakistan would benefit from conceiving a more central role for mothers and other women caregivers. Polio (or other vaccination) teams must understand the nature of women's agency and internalize its implications for campaigns and communication in their work. For example, mothers and mothers-in-law must be key audiences for all polio-related communication. Further, at least some women may be included as local influencers in the social mapping of communities, while others may be included (or trained) as peer influencers. Such a strategy is likely to effectively reduce immunization refusals..."