Perceptions Toward COVID-19 Vaccines and Factors Associated with COVID-19 Vaccine Acceptance in Peshawar, Pakistan

Abstract

COVID-19 vaccine hesitancy in Pakistan is a barrier to optimal vaccine uptake and has been situated within a context of hesitancy towards other vaccines. A mixed-methods study was conducted during the initial COVID-19 vaccine roll-out in 2021 in four union councils in Peshawar, consisting of a cross-sectional survey, eight focus group discussions (FGDs) with community members and eight in-depth interviews with healthcare workers (HCWs) to assess perceptions toward vaccines. Multivariable logistic regression was used to assess factors associated with COVID-19 vaccine hesitancy. Of 400 survey participants, 57.3% were vaccine acceptant and 42.8% vaccine hesitant. Just over half (56.8%) perceived COVID-19 vaccines to be safe. Most (88%) reported trust in HCWs to provide accurate vaccine information. FGDs revealed that women received less information about the vaccine compared to men and cultural restrictions were barriers even for those willing to be vaccinated. Correlates of vaccine acceptance included male sex (aOR 2.25; 95% CI 1.29–3.91), age 50 years or greater (aOR 1.74; 95% CI 1.19–6.31), social network support (e.g., vaccine acceptance among an individual’s social network) in receiving COVID-19 vaccines (aOR 2.38; 95% CI 1.45–3.89), community concern about COVID-19 spread (aOR 2.84; 95% CI 1.73–4.66), and trust in HCWs to provide vaccine information (aOR 3.47; 95% CI 1.62–7.42). Future vaccine promotion should prioritize engaging community leaders, sharing transparent information, combatting misinformation and rumors, and implementing household-based interventions especially targeting the importance of vaccination among women and young people to increase uptake.

1. Introduction

Safe and effective vaccines and booster shots have been vital tools in controlling the spread of COVID-19, mitigating severe disease, and decreasing death. However, despite the well-established efficacy of COVID-19 vaccines in reducing morbidity and mortality, actual vaccine uptake has varied widely between countries worldwide. While inequities in vaccine access and distribution play a role in vaccine uptake, vaccine hesitancy and public opinion surrounding vaccination continue to greatly affect vaccine acceptance and uptake. Vaccine hesitancy is defined as the “delay in acceptance or refusal of vaccination despite the availability of vaccination services” [1,2].

Pakistan is unique due to historically high levels of general vaccine hesitancy. Despite a 99% global decline in the incidence of polio since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, Pakistan remains one of only two polio-endemic countries, largely due to resistance to vaccination in certain regions. Misinformation and distrust, especially in tribal and rural areas, have contributed to increased hesitancy and low vaccine uptake [3]. This anxiety and distrust, at times, has escalated into harassment and attacks on polio vaccination teams, resulting in the deaths of over 200 vaccinators and healthcare workers between 2012 and 2013 [4].

Pakistan launched its COVID-19 vaccination campaign in February 2021, initially prioritizing healthcare workers and the elderly, before expanding eligibility to all individuals over 18 years of age [5,6,7]. The rollout faced several early challenges, including the spread of misinformation and conspiracy theories through mass media [8]. Politicization and religious factors further fueled public confusion and impacted vaccine uptake. Logistical barriers, such as the appointment booking process, also complicated access to vaccines [8].

Reported COVID-19 vaccine acceptance rates in Pakistan range from 40.5% to 72% [9,10,11,12]. Demographic factors such as urban residency and lower education levels have been associated with increased hesitancy, while higher vaccine acceptance was associated with respondents who had chronic diseases and those who received information directly from healthcare workers (HCWs) instead of social media [10,13]. Gender was also found to be a significant factor, with men having higher vaccine acceptance [10,11,14].

Reasons for COVID-19 vaccine hesitancy in Pakistan include concerns surrounding side effects, perceived inefficacy of the vaccine, belief in protection through other precautionary measures, distrust of foreign COVID-19 vaccines, and concerns about the vaccine’s halal status [8,13,15,16,17]. One study indicated that 20.1% of surveyed individuals believed in conspiracy theories and rumors, and another conducted in the surrounding region stated that 27.7% of respondents believed that western-manufactured vaccines contained nanochips, while 23.4% believed they caused infertility in Muslim women [10,11,12,14]. Multiple studies have found that individuals who rely primarily on social media for information on COVID-19 exhibit higher levels of vaccine hesitancy, whereas those who rely on physicians or healthcare professionals showed lower rates of hesitancy [8,14].

The success of COVID-19 vaccination depends on high vaccine acceptance in a community [18]. Given the considerable regional variation in vaccine perceptions across Pakistan, further research is needed in the Peshawar District, which has faced a high incidence of poverty, unemployment, and poor access to social services [19]. Insights from this context could inform interventions to increase vaccine uptake, ensure equitable access to future booster shots and emerging variant vaccinations, and address prevailing misinformation and distrust. This cross-sectional mixed-methods study aimed to evaluate perceptions towards COVID-19 vaccines, identify determinants of vaccine hesitancy and acceptance, and explore the views of community members and HCWs in Peshawar, Pakistan.

2. Materials and Methods

2.1. Study Design and Setting

A mixed-methods study was conducted in May 2021 by International Medical Corps (IMC) in collaboration with the Department of Health Khyber Pakhtunkhwa and Khyber Medical University (KMU) in Peshawar, Pakistan. Peshawar is one of seven administrative divisions within the province of Khyber Pakhtunkhwa in Northwestern Pakistan and has a population of 4.3 million people. IMC has been working in Pakistan since 1985 and currently provides services primarily to Afghan refugees and vulnerable Pakistanis in several districts of Khyber Pakhtunkhwa. Services include community health education, capacity-strengthening of healthcare providers on COVID-19 response, and a risk communication and community engagement (RCCE) campaign that provides information through radio and television on COVID-19 related services and counseling.

2.2. Study Population and Sample Selection

For the quantitative component of the study, a cross-sectional survey of adult community members residing in four union councils (two rural and two urban) of the Peshawar District was conducted. The four union councils were purposively selected in consultation with the Department of Health and the Expanded Program of Immunization (EPI), based on IMC’s operational presence in the two rural union councils and the Department of Health’s selection of two urban councils. The selected sites included the following: Urmar Payan (rural, population: 32,403), Musazai (rural, population: 63,000), Shaheen Muslim Town-1 (urban, population: 80,499), and Gunj (urban, population: 14,238).

A systematic random selection of households in the selected union councils was employed, beginning from the farthest household from the center and moving inwards, with every third household being selected to be interviewed in order to reduce selection bias. One adult over 18 years of age per household was invited to participate in the survey. If eligible household members were unavailable or declined to participate, the next household was selected until the target number of households was reached. The total number of households included per union council was proportionate to the council’s population size. The sample size assumed a design effect of 1, precision of 5%, and α value of 5% (corresponds to 95% confidence level) to obtain a target sample size of 384. To account for missing data, an additional 5% of the target population was added to give a final target sample size of 404 individuals.

For the qualitative component, participants over 18 years of age were identified through purposive and snowball sampling. Two focus group discussions (FGDs) were conducted in each of the four union councils, for a total of eight FGDs (four groups with women, four groups with men) each comprising 6–10 participants. Additionally, two in–depth interviews (IDIs) were conducted in each of the four union councils, totaling eight IDIs with HCWs who were directly engaged with the communities in conjunction with IMC.

2.3. Data Collection Tools

For the quantitative survey, a 30-item structured questionnaire was developed which included the following topics: participant demographics, intentions to receive a COVID-19 vaccine, individual and community perceptions toward COVID-19 vaccines, information sources and vaccine communication preferences, and barriers to vaccination. The questionnaire was developed by adapting questions from the World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) vaccine hesitancy matrix [2]. The survey was pilot tested in one of the survey locations prior to data collection with the questionnaire modified and contextualized based on the results (pilot data were not included in the final analysis as the pilot test was conducted solely to refine the survey tool). For the qualitative component, FGDs and IDIs were conducted using a semi-structured interview guide led by trained data collectors with experience in qualitative research methods.

2.4. Data Collection

For the quantitative survey, participation was anonymous, voluntary, and uncompensated. Data collection teams were required to follow COVID-19 mitigation measures. For the FGDs and IDIs, male participants were identified by local leaders or nazims (local government officials), and female participants were identified by female health workers familiar with the local communities. FGDs were separated by gender according to local cultural norms. Despite the challenges of data collection during the COVID-19 pandemic and local insecurity, emerging themes were reviewed throughout the process and showed consistent patterns across responses, indicating that thematic saturation was likely reached.

2.5. Quantitative Data Analysis

Descriptive statistics were used to assess responses to survey questions. The ‘svyset’ command in STATA was used, applying sampling weights to account for the survey design. Stratification of union councils as rural or urban was included in the survey sampling design. For all analyses, a two-tailed p-value of 0.05 was considered statistically significant. STATA Version 16 (Stata Corp, College Station, TX, USA) was used for all analyses.

Multivariable logistic regression was performed to assess for associations between the independent variables and the primary outcome. The primary outcome was defined as “vaccine acceptance” with individuals categorized as “vaccine acceptant” if they responded “yes” or “already received a vaccine” in response to the question, “Would you take a COVID-19 vaccine if available now?”; individuals were categorized as being “vaccine hesitant” if they responded “unsure” or “no.” Variables were selected for inclusion in the model based on expert consensus informed by the literature review and theory and included sociodemographic variables including the following: sex, age, educational level, rural versus urban location, and presence of a high-risk person in the household. Additional variables included in the model were as follows: having sufficient COVID-19 vaccine information, belief in COVID-19 vaccine safety, concern about COVID-19 risks/side effects, social network support of COVID-19 vaccination (“Are most people you know interested in receiving a COVID-19 vaccine?”), community concern regarding COVID-19 spread, and trust in HCWs to provide vaccine information. Likert scale responses were dichotomized with “yes” and “somewhat” coded as positive responses, and responses of “unsure,” “don’t know,” and “no” were coded as negative responses to simplify interpretation. Community concern about COVID-19 spread (“How many people in your community are concerned about the spread of COVID-19 in the community?”) was dichotomized with “most people” and “more than half of community” coded as positive responses, and responses of “less than half of community,” “none or few people,” coded as negative responses. Magnitudes of effect were reported as unadjusted and adjusted odds ratios (OR) and their respective 95% confidence intervals (CI).

2.6. Qualitative Data Analysis

Audio-recorded interviews were transcribed and translated from Pashto to English. Deductive analysis was performed using a framework analysis to develop a matrix to sort data. Three pre-defined themes were identified as follows: 1. Perception and knowledge about COVID-19 vaccines, 2. Enablers for taking a COVID-19 vaccine, 3. Barriers for taking a COVID-19 vaccine. Data were manually analyzed and when discrepancies arose, they were discussed and resolved.

2.7. Ethical Considerations

Ethical review board approval was granted by the Khyber Medical University Ethics Committee (No. DIR/KMU–EB/CV/000107). The purpose of the assessment was explained to all participants and verbal informed consent was obtained and documented by trained research staff.

3. Results

3.1. Survey Respondent Characteristics

A total of 405 individuals completed the survey; five individuals were excluded due to missing demographic information, leaving 400 respondents for further analysis. Females comprised 55.8% of the population; 28.0% of respondents were aged between 18 and 29 years, 33.3% between 30 and 39 years, 19.8% between 40 and 49 years, and 19.0% were 50 years or older. Half (51%) of the respondents were from rural areas and 38.8% had no formal education. Two-thirds (68%) had at least one high-risk person (i.e., pregnant/lactating woman, elderly person, or person with chronic illness or disability) living in their household. Further characteristics of the study population are shown in

Table 1. Respondent characteristics.

	n (N = 400)	(%) 95% CI
Gender
Female	223	55.8 (50.8–60.6)
Male	177	44.3 (39.4–49.2)
Age Category
18–29 years	112	28.0 (23.8–32.6)
30–39 years	133	33.3 (28.8–38.0)
40–49 years	79	19.8 (16.1–24.0)
≥50 years	76	19.0 (15.4–23.2)
Marital Status
Married	333	83.3 (79.4–86.8)
Living Together	1	0.3 (0.0–1.8)
Separated/Divorced	2	0.5 (0.1–2.0)
Widowed	9	2.3 (1.2–4.3)
Single	54	13.5 (10.5–17.3)
Missing/Declined	1	0.3 (0.0–1.8)
Level of Education
None/Never attended school	155	38.8 (34.1–43.6)
Primary	80	20.0 (16.4–24.2)
Secondary	59	14.8 (11.6–18.6)
College/Vocational/University	63	15.8 (12.5–19.7)
Other */Missing/Declined	43	10.8 (8.1–14.2)
Location
Gunj (Urban)	30	7.5 (5.3–10.6)
Musa Zai (Rural)	130	32.5 (28.1–37.4)
Shaheen Town (Urban)	168	42.0 (37.3–47.0)
Urmar Payan (Rural)	71	17.8 (14.3–21.9)
Missing	1	0.3 (0.0–1.8)
Primary Language Spoken
Pashto	356	89.4 (86.0–92.1)
Hindko	35	8.8 (6.4–12.0)
Farsi	2	0.5 (0.1–2.0)
Urdu	5	1.3 (0.5–3.0)
Missing/Declined	2	0.5 (0.1–2.0)
High Risk Household Members †
None	128	32.0 (27.6–36.7)
Pregnant or Lactating Women	103	25.8 (21.7–30.3)
Elderly	193	48.3 (43.4–53.2)
Persons with Chronic Illness	60	15.0 (11.8–18.9)
Persons with Disabilities	36	9.0 (6.6–12.2)

* Other education included adult literacy school (n = 3) and madrasa (n = 1); ^† Multiple selections allowed; proportions do not sum to 100%.

.

3.2. COVID-19 Vaccine Acceptance, Hesitancy, and Barriers

More than half of survey respondents (55.8%) would take a COVID-19 vaccine, while 27.8% would not, and 15.0% were unsure (

Table 2. Receipt and intention to receive a COVID-19 vaccine.

	n (N = 400)	(%) 95% CI
Would you take a COVID-19 vaccine if available now?
Yes	223	55.8 (50.8–60.6)
No	111	27.8 (23.6–32.4)
Unsure	60	15.0 (11.8–18.9)
Already Received	6	1.5 (0.7–3.3)
Have you or anyone in your household already received a COVID-19 vaccine?
Yes	18	4.5 (2.8–7.0)
No	381	95.3 (92.7–97.0)
Unsure	1	0.3 (0.0–1.8)
Would you delay vaccination with a newly developed COVID-19 vaccine?
Yes	93	23.3 (42.4–52.2)
No	189	47.3 (42.4–52.2)
Unsure	114	28.5 (24.3–33.1)
Missing/Declined	4	1.0 (0.4–2.6)
What barriers do you face (or foresee) for receiving the vaccine?
Lack of information about how/where to receive vaccine	112	28.0 (23.8–32.6)
Availability	91	22.8 (18.9–27.1)
Distance to vaccination site	67	16.8 (13.4–20.7)
Cost	58	14.5 (11.4–18.3)
Not being in a priority group	18	4.5 (2.8–7.0)
Other responsibilities	17	4.3 (2.7–6.7)
Staff attitude	10	2.5 (1.3–4.6)
Other	32	8.0 (5.7–11.1)
None	125	31.3 (26.9–36.0)

). Only 1.5% had already received a COVID-19 vaccine. More than half 229 (57.3%) were categorized as “vaccine acceptant” (i.e., intended to receive a vaccine or had already received one) and 171 (42.8%) as “vaccine hesitant.” One-quarter (23.3%) reported they would delay vaccination with a newly developed vaccine, while 47.3% would not delay, and 28.5% were unsure (Table 2). The most common barrier to vaccination was lack of information about how/where to receive the vaccine (28.0%) and vaccine availability concerns (22.8%); 31.3% reported they anticipated no barriers to vaccination (Table 2).

3.3. Individual Perceptions Toward COVID-19 Virus and Vaccines

While more than half of survey respondents (227; 56.8%) perceived COVID-19 vaccines to be safe or somewhat safe, nearly one-third (31.0%) were unsure, and 11.8% did not feel they were safe (Table S1). In IDIs, all HCW participants indicated they felt the vaccine was safe and effective against COVID-19. Approximately one-third (150; 37.5%) of survey respondents were concerned about vaccine risks or side effects; the most frequent concern was that the vaccine could cause death (53; 13.3%). Half of respondents (201; 50.3%) felt it was preferable to develop natural immunity to COVID-19 than to receive a vaccine (Table S1). Two-thirds of respondents (266; 66.5%) felt prioritization of groups during vaccine roll-out was equitable.

3.4. Community Perceptions Toward COVID-19 Virus and COVID-19 Vaccines

Regarding the perceptions of their communities, over half of respondents (231; 57.8%) reported that most people they knew were interested in receiving a COVID-19 vaccine (Table S2). One-third (33.5%) reported that most people in their community were concerned about the spread of COVID-19, while 25.8% reported that no or few people were concerned about COVID-19 (Table S2). Half of respondents believed that at least half of their community would want a vaccine for themselves (207; 51.8%) as well as for their children (201; 50.3%). The most frequently given reason for which people in their community would not want a COVID-19 vaccine was concern about COVID-19 vaccine side effects (42.8%), followed by general mistrust of any vaccine (25.0%) as shown in Table S2.

Most HCWs interviewed in the IDIs explained that people are hesitant to take the vaccine due to rumors and lack of information. Rumors circulated about the vaccine, including reports of death caused by the vaccine, which propelled public fear and distrust. Common rumors heard by HCWs and community members include the following: the vaccine itself causes COVID-19; the vaccine causes death and serious side effects (ex: paralysis, disability, infertility, early puberty, DNA changes in the body, gender transformation); the vaccine is a form of birth control; the vaccine is an international conspiracy; vaccines are only for the elderly and that diabetes and cardiac issues were contraindications for vaccination. Some community members believed the government is directly benefiting from the COVID-19 vaccination campaign through international donors.

It is our nature that we accept negative things quickly. People sometimes spread rumors about the vaccines and COVID-19. I personally don’t believe it. I believe in what I see and never pay attention to other things.

(Rural Males, FGD)

I have heard that one of the ladies in a neighboring village took the vaccination and died the next day. That news created fear in my mind and is preventing me from taking the vaccine. I prefer for my family not to be vaccinated.

(Urban Males, FGD)

Several participants recalled an unpleasant experience with a previous vaccine in a rural village, where several school children had an adverse reaction and were hospitalized following the administration of a polio vaccine. This incident resulted in high vaccine rejection rates within their community and generated anger towards the vaccination team. One HCW described a case in which an adverse reaction to a measles vaccine led to a large dispute and high vaccine hesitancy in the area.

One incident happened in our area; a child was taken to the hospital after getting a polio vaccine and died. After this incident, the situation got worse, and people got incredibly angry with the polio team. It was even reported to our village elders (jirga); whenever the polio team tried to approach us after this mishap, men used to insult the team members.

(Rural Females, FGD)

3.5. Vaccine Communication

Half (52.8%) of survey respondents felt they had sufficient information about COVID-19 vaccines and most (352; 88%) trusted healthcare providers or community health workers (CHWs) to provide accurate COVID-19 vaccine information (

Table 3. COVID-19 vaccine-related information and communication sources.

	n (N = 400)	(%) 95% CI
Do you feel that you have sufficient information about COVID-19 vaccines?
Yes	87	21.8 (18.0–26.1)
Somewhat	124	31.0 (26.7–35.7)
No	141	35.3 (30.7–40.1)
Unsure/Don’t Know	46	11.5 (8.7–15.0)
Missing/Declined	2	0.5 (0.1–2.0)
Do you trust your healthcare providers/community health workers to provide accurate COVID-19 vaccine information?
Yes	293	73.3 (68.7–77.4)
Somewhat	59	14.8 (11.6–18.6)
No	21	5.3 (3.4–7.9)
Unsure/Don’t Know	26	6.5 (4.5–9.4)
Missing/Declined	1	0.3 (0.0–1.8)
Most common source(s) of information for health including vaccines *
Television	162	40.5 (35.8–45.4)
Social media	137	34.3 (29.7–39.1)
Neighbors, friends, colleagues	136	34.0 (29.5–38.8)
Healthcare workers at health facilities	135	33.8 (29.3–38.5)
Family	115	28.8 (24.5–33.4)
Community health workers	96	24.0 (20.1–28.4)
Radio	54	13.5 (10.5–17.2)
Newspapers	46	11.5 (8.7–15.0)
Religious leaders	18	4.5 (2.8–7.0)
Local leaders	7	1.8 (0.8–3.6)
Mass events	3	0.8 (0.2–2.3)
Organizations	3	0.8 (0.2–2.3)
Which source(s) of information for health including vaccines do you trust the LEAST? *
Social media	115	28.8 (24.5–33.4)
Television	87	21.8 (18.0–26.1)
Neighbors, friends, colleagues	46	11.5 (8.7–15.0)
Newspapers	28	7.0 (4.9–10.0)
Radio	29	7.3 (5.1–10.2)
Family	24	6.0 (4.0–8.8)
Healthcare workers at health facilities	22	5.5 (3.6–8.2)
Organizations	13	3.3 (1.9–5.5)
Local leaders	12	3.0 (1.7–5.2)
Community health workers	11	2.8 (1.5–4.9)
Religious leaders	4	1.0 (0.4–2.6)
Mass events	3	(0.2–2.3)

* Multiple selections allowed; proportions do not sum to 100.

). Respondents most preferred to receive COVID-19 vaccine information from HCWs at health facilities (58.2%), followed by CHWs (21.8%), and television (17.8%). The most common sources of health and vaccine-related information were television (40.5%), social media (34.3%), neighbors, friends, and colleagues (34%), healthcare workers at health facilities (33.8%), and family (28.8%); the least trusted sources of information were social media (28.8%) and television (21.8%) (Table 3). In FGDs, community members’ attitudes toward the COVID-19 vaccine varied depending on their primary sources of information. While many community members considered HCWs as the most knowledgeable and trusted source, only a few participants reported receiving information from them. HCWs were perceived as more knowledgeable or informed about vaccines especially since they had already been vaccinated and thus could provide more accurate information. Rural participants expressed greater trust in doctors compared to urban participants. HCWs reported receiving information from other healthcare staff, social media, and news channels. All HCW participants indicated that they trusted the information provided by other healthcare personnel and perceived the information to be accurate. However, several acknowledged that false information about the COVID-19 vaccination was circulating on social media.

I don’t trust the social media because every day there is a new video by doctors individually, one saying something and the other one saying something else. They contradict one another on a daily basis on social media, so we are puzzled. Which one should we trust?

(Rural Males, FGD)

I do not search on the internet about vaccines as I do not believe in internet sources.

(Female Health Worker, IDI)

Among religious leaders, 50 percent of them say that this all is a conspiracy, and 50 percent of leaders say that this is the punishment from Allah due to our deeds.

(Medical Technician, IDI)

Due to cultural restrictions, women are less exposed to those outside their family and therefore have fewer and limited sources of information. In FGDs, women indicated that television and social media were their primary source of information. Female participants almost always mentioned friends, family members, relatives, and neighbors as primary sources of information.

I trust my husband. Whatever he says, it is right.

(Urban Female, FGD)

Among survey respondents who reported having heard about COVID-19 vaccines (i.e., had knowledge about the COVID-19 vaccines), the information most desired was about risks and side effects (48%) followed by vaccine efficacy (32.4%), and eligibility criteria (24.4%). FGD participants reported having little concrete information about the vaccines themselves, and mostly only had knowledge about the process of vaccination. Despite many HCWs feeling as though they had sufficient information regarding the COVID-19 vaccines, none had any information about the types of vaccines, and each had a different response on dose rates. Almost all community members suggested that they need more accurate information about the vaccines.

I do not have much information about the types of COVID-19 vaccines, but I will prefer vaccines imported from countries other than China because we have seen those other vaccines (chickenpox, MMR, etc.) from China, and they are less effective than those imported from some other countries.

(EPI Technician, IDI)

3.6. Enablers of Vaccination

IDI and FGD participants identified several factors that could encourage the general population to get vaccinated, including more accurate information on vaccine side effects, safety, effectiveness, and affordability. Community members suggested that vaccination campaigns and awareness activities (e.g., displaying banners, distributing pamphlets, and other advertising materials) could help inform and enable people to get vaccinated. HCWs stressed the need for training healthcare staff to provide more accurate information to the community. Most community members felt vaccination was acceptable if they saw an influential person take the vaccine. Additionally, most HCWs mentioned that influential people (e.g., religious leaders, community leaders, and HCWs) could educate the community about vaccines and encourage them to get vaccinated. HCWs also suggested that vaccinating in public or making the vaccine available at their facility will make the community more aware of the vaccine and motivated to vaccinate.

If religious and community leaders are given enough information about COVID-19 vaccines, and they are ready to get vaccinated, then it is extremely easy to convince this community to get vaccinated. Otherwise, it will be a challenging task to convince people of this area. Once there is public awareness and satisfaction, then they will be ready to take this vaccine.

(Medical Technician, IDI)

I personally might agree with the doctors if they say the vaccine is safe, but for most people, I will say that the government should regain the confidence of the people by practicing preventive measures like wearing masks and social distancing in their own environment. Religious leaders should take part in it as people follow them due to religious beliefs. Doctors should show people that they are their helpers, not the harmers.

(Rural Males, FGD)

Female participants highlighted that gender dynamics within their communities often limit women’s ability to make independent health decisions. One participant explained that in their male-dominated society, men are the primary decision-makers in the family, and women are expected to obey their partners or other male relatives. Although women expressed willingness to receive the COVID-19 vaccine, they indicated that they are required to obtain permission beforehand. If their husbands or family members are reluctant to vaccinate, they act as barriers for women’s vaccination. As a potential solution, female participants suggested that educating their family members, especially husbands, could help overcome these cultural constraints and improve vaccine uptake among women.

3.7. Correlates of Vaccine Acceptance

Multiple correlates of vaccine acceptance were found in multivariable logistic regression analysis. Correlates of vaccine acceptance included male sex (aOR 2.25; 95% CI 1.29–3.91), being 50 years or older (aOR 1.74; 95% CI 1.19–6.31), social network support of COVID-19 vaccines (aOR 2.38; 95% CI 1.45–3.89), community concern about COVID-19 spread (aOR 2.84; 95% CI 1.73–4.66), and trust in HCWs to provide vaccine information (aOR 3.47; 95% CI 1.62–7.42) (

Table 4. Correlates of COVID-19 vaccine acceptance versus hesitancy in multivariable analysis.

	Vaccine Acceptant n (%) (N = 229)	Vaccine Hesitant n (%) (N = 171)	OR, [95% CI]	aOR, [95% CI]
Gender
Female	104 (45.4)	119 (69.6)	Reference	Reference
Male	125 (54.6)	52 (30.4)	2.75 (1.81–4.18)	2.25 (1.29–3.91)
Age Category
18–29 years	62 (27.1)	50 (29.2)	Reference	Reference
30–39 years	67 (29.3)	66 (38.6)	0.82 (0.49–1.36)	1.19 (0.65–2.19)
40–49 years	45 (19.7)	34 (19.9)	1.07 (0.60–1.91)	1.23 (0.62–2.44)
≥50 years	55 (24.0)	21 (12.3)	2.11 (1.13–3.96)	1.74 (1.19–6.31)
Level of Education
None/Never attended school	84 (36.7)	71 (41.5)	Reference	Reference
Primary	46 (20.1)	34 (19.9)	1.14 0.66–1.97)	0.97 (0.49–1.92)
Secondary	34 (14.9)	25 (14.6)	1.15 (0.63–2.11)	1.03 (0.49–2.17)
College/Vocational/ University	48 (21.0)	15 (8.8)	2.70 (1.39–5.25)	2.18 (0.88–5.37)
Missing/Declined/Other	17 (7.4)	26 (15.2)	n/a	n/a
Union Council Type
Rural	126 (55.0)	76 (44.4)	Reference	Reference
Urban	103 (45.0)	95 (55.6)	0.65 (0.44–0.98)	0.65 (0.40–1.04)
High-risk household member †	155 (67.7)	116 (67.8)	0.99 (0.65–1.52)	1.03 (0.61–1.76)
Have sufficient information about COVID-19 vaccines	131 (57.2)	80 (46.8)	1.52 (1.02–2.27)	1.19 (0.62–2.29)
COVID-19 vaccines are safe *	162 (70.7)	81 (47.4)	2.69 (1.77–4.07)	1.61 (0.83–3.13)
Concern about COVID-19 vaccine side effects/risks *	79 (34.5)	71 (41.5)	0.74 (0.49–1.12)	0.58 (0.34–0.99)
Social network support of COVID-19 vaccines *	166 (72.5)	65 (38.0)	4.30 (2.81–6.57)	2.38 (1.45–3.89)
Community concern about COVID-19 spread *	160 (69.9)	75 (43.9)	2.97 (1.96–4.49)	2.84 (1.73–4.66)
Trust healthcare workers to provide vaccine information *	216 (94.3)	136 (79.5)	4.28 (2.18–8.39)	3.47 (1.62–7.42)

aOR = adjusted odds ratio. ^† High-risk: Chronic illness, pregnant, disabled, or elderly. * Likert scale responses dichotomized to binary responses.

). Being concerned about COVID-19 risks/side effects (aOR 0.58; 95% CI 0.34–0.99) was negatively associated with vaccine acceptance. While those residing in urban areas were less vaccine acceptant in unadjusted analysis, there was no association found in multivariable analysis. Having a high-risk person in their household and having sufficient information about COVID-19 vaccines were not associated with vaccine acceptance.

4. Discussion

Research on COVID-19 vaccine hesitancy in diverse and marginalized communities has provided new insights relevant to current and future outbreak responses. This mixed-methods study provides a nuanced, in-depth understanding of COVID-19 vaccine perceptions and hesitancy in the Peshawar District during the early roll-out period in May 2021. These findings were subsequently used to inform vaccine promotion efforts in the region. Substantial vaccine hesitancy among community respondents was found, with nearly half of respondents (42.8%) hesitant towards COVID-19 vaccines during this period; this is slightly higher than other statistics from Pakistan (29.2–36.9%), possibly due to the study timing in relation to vaccine roll-out and contextual differences [10,11,12,13,14]. As this survey was conducted just a few months after vaccine roll-out, actual vaccine uptake was low with only 1.5% of respondents having received a vaccine dose at the time of the survey. This was likely due to difficulties with vaccine access during the early phase of vaccine availability, prioritization of HCWs over community members, in addition to vaccine hesitancy; of note, planned vaccine delay was fairly common with nearly one-quarter of respondents planning to delay vaccination given how new the vaccines were. Perceptions towards vaccines were mixed, with over half of respondents perceiving COVID-19 vaccines to be safe and believing that most people they knew were interested in receiving a COVID-19 vaccine, while others reported concerns regarding vaccine risks and side effects.

We found that a majority (88%) of participants trusted HCWs to provide accurate COVID-19 vaccine information. Participants emphasized the importance of HCWs, as well as religious or community leaders being actively involved in vaccine campaigns to increase uptake. Other studies support these findings and suggest that physicians and scientists are trusted sources when it comes to vaccination knowledge [14]. This high level of trust demonstrates that HCWs could play a pivotal role in vaccination health initiatives. However, HCWs in Pakistan experienced significant physical and psychological stress during the COVID-19 pandemic due to inadequate infrastructure and resources, which could affect their capacity to disseminate vaccine information effectively [4]. Our findings show that while HCWs are trusted, participants are more likely to receive vaccine information from television and social media. As a result, fewer individuals rely on HCWs for vaccine knowledge and guidance. The combined impact of pandemic-related stress, limited access to accurate information, and insufficient training has further constrained HCWs’ ability to educate the public. This underscores the need for HCWs to be supported with accurate, transparent information, and trained to lead educational efforts within their communities. To combat misinformation, targeted HCW-led interventions, transparent communication on vaccine side effects, and community-based fact-checking initiatives must be put in place.

Respondents cited a lack of accurate information as a major barrier to vaccine acceptance, with widespread rumors and conspiracy theories fueling vaccine hesitancy. These rumors included claims that vaccines could cause infertility, paralysis, DNA changes, and even death. These types of misinformation are not new, as similar myths have surrounded previous vaccination campaigns, such as polio vaccination efforts in Pakistan [16]. The suspicion regarding the polio and COVID-19 vaccines causing infertility is persistent and has been circulated previously [20]. These misconceptions are often deeply rooted in cultural and societal beliefs and have been influenced by mistrust of foreign aid and external entities [3]. This persistence of misinformation is concerning, as widespread false narratives led to violence during the polio vaccine campaign [18]. This type of rhetoric further entrenches vaccine hesitancy, particularly in rural areas where misinformation spreads more easily due to limited access to reliable information and the increasing use of social media [21]. Mass media and television can also exacerbate these rumors. Researchers and healthcare workers should actively engage in public communication and provide factual, transparent information to counter these rumors [16].

Our study also demonstrated that male gender, older age, acceptance of COVID-19 vaccines among individuals’ social network, community concern over the spread of COVID-19 and trust in HCWs to provide vaccine information were associated with COVID-19 vaccine acceptance. Our findings are consistent with several other studies in Pakistan whereby male gender was positively associated with vaccine uptake [11,22,23].

Restrictive social and cultural norms have critical implications for women accessing COVID-19 vaccines in our study location. In Peshawar, especially among Pashtun families, women are expected to abide by strict gender roles that influence their decision-making, mobility outside the household, and interactions in public [24]. Women rarely leave their homes, and when they do, they are typically accompanied by their husband or a male relative [24]. These constraints, along with limited exposure to individuals outside the household and restricted access to sources of information about COVID-19, strongly influence female vaccination rates in this population. Similar findings across Pakistan show that women often lack autonomy in vaccination decisions, and in some cases, face pressure from husbands or close relatives not to receive the vaccine [25,26,27]. Notably, in the southern province of Sindh, the government recruited and trained female health workers to go door-to-door to target women from conservative families with COVID-19 vaccines, as they were more likely than male vaccinators to be allowed entry into homes [28]. Similarly, UNICEF Pakistan’s intervention of recruiting locally based female vaccinators in multiple locations, including Khyber Pakhtunkhwa, proved instrumental, especially in rural and semi-urban areas. These vaccinators carried out extensive community mobilization and awareness-raising efforts, delivering culturally appropriate health education through door-to-door visits and community gatherings. They also engaged men directly, addressing their concerns and misconceptions about the vaccine while emphasizing the importance of protecting their family’s health. This resulted in a notable increase in vaccination rates among both women and men [29]. This highlights the importance of not only targeting women with vaccination messaging but also engaging their family members. Tailored messages delivered by trusted HCWs, in accessible and understandable formats, can help improve vaccine uptake. Community outreach activities that specifically reach women (e.g., door-to-door campaigns or outreach conducted in locations where women are likely to visit or gather publicly) are essential. Finally, involving existing women-led groups in the design and implementation of these efforts is crucial, as they bring valuable insights into community needs and norms and can help promote more equitable access to COVID-19 vaccination for women.

The positive association found in our study between older age and COVID-19 vaccine uptake has been similarly demonstrated in other studies in Pakistan [16,23,30,31]. Higher acceptance among older adults may reflect greater perceived susceptibility due to their increased likelihood of severe complications and mortality from COVID-19 as a result of increasing age and association with comorbidities [32]. The positive influence of social networks who support vaccination and having high community concern over the threat of COVID-19 emphasize the importance of community engagement in understanding the risks of COVID-19 spread in communities, and normalizing COVID-19 vaccination to increase uptake among the social network of those already vaccinated or intending to receive a vaccine.

Impact, Future Directions, and Limitations

After the initial vaccine roll-out, the results of this study were used to inform IMC’s vaccination efforts in the Peshawar District. Mobile vaccination teams were used to address barriers related to difficulties in access especially for women who were unable to travel unescorted to vaccine sites, those with physical disabilities, rural residents, and those with financial constraints. Mobile teams were also positioned to meet people at commonly visited locations such as transportation centers, bus stations, mosques, schools, and markets. To address concerns about lack of accurate information about vaccines, community education sessions were held to reduce misinformation and dispel rumors, in conjunction with campaigns to increase overall vaccine awareness. Between August and December 2021, the number of people in the Peshawar District who had completed vaccination series increased from 360,000 to 1,007,000 individuals. Door-to-door vaccination was not utilized due to security concerns, which may have contributed to continued disparity in female vaccination rates (32% female versus 68% male as of December 2021), as women were often not permitted to leave the home. To address this, special efforts were made to vaccinate women in antenatal, postnatal, and basic health units [33]. Following our study, IMC began advising vaccine advocates to directly target men about the importance of vaccinating women and other members of their household, since most of the awareness raising was performed in locations not frequented by women.

While this study was not designed to directly evaluate the impact of the survey on vaccine uptake, the use of many of the findings of this study on what was eventually a successful vaccination campaign in Peshawar may be useful for future vaccine efforts for COVID-19 or other emerging infectious diseases in this region. Further research to understand current perceptions to COVID-19 vaccines in Peshawar after the conclusion of intensive vaccination campaign efforts are needed to understand long-term effects on overall vaccine hesitancy in this region. This study is limited due to its focus on the Peshawar District and non-random sampling of union councils which limits generalizability to other parts of Pakistan or other countries. As with all self-reported data, there is a potential for social desirability bias, particularly in responses related to COVID-19 vaccine attitudes and behaviors. Efforts to minimize this included ensuring participant confidentiality and using trained local interviewers. Other minor limitations include initial hesitation to participate in the survey in several rural communities. However, with the help of community elders and comprehensive presentations on the importance of the survey, the study was accepted by these communities. Notably, the study was conducted during Ramadan, which meant that people were fasting and busy with religious activities which may have limited participation in the study and may have led to bias towards individuals with fewer religion-related obligations. Researcher positionality may have influenced the analysis; however, this was mitigated by the involvement of local researchers who contributed to data interpretation and provided critical contextual insights throughout the study.

5. Conclusions

Vaccine hesitancy must be actively addressed through strategies that promote accurate and accessible vaccine information to ensure high vaccine acceptance and uptake in Peshawar, Pakistan. Targeted and transparent communication, combatting misinformation and rumors, and community-based interventions should be employed to increase uptake. Future vaccination efforts should be specifically directed towards groups with relatively high vaccine hesitancy, such as young people and women, as cultural norms and restrictive gender roles have been shown to significantly impact vaccine access and acceptance. Facilitators to vaccine acceptance include overall trust in HCWs and community leaders, which should be effectively utilized to counter misinformation and guide vaccine education efforts. Community engagement through the employment of female vaccinators and the use of door-to-door or mobile vaccinators may be especially effective in reaching underserved populations, especially in rural areas. This study highlights the importance of conducting localized research on vaccine perceptions during outbreaks. To overcome cultural limitations and ensure high vaccine uptake and acceptance, it will be necessary to improve information-sharing and build community trust in healthcare initiatives during future infectious disease vaccine efforts.