Developing an Attitude Toward Polio Vaccination Scale and Establishing Its Psychometric Properties in Pakistani Context for Indigenous and International Researchers

"The attitude differences observed through the use of this instrument can help identify groups where negative attitudes are prevalent so they can be targeted for interventions."

In Pakistan, anti-vaccination propaganda widely spreads through social media and poses a significant hurdle in the eradication of polio by peddling various conspiracy theories, such as rumours that the vaccine contains pig fat, which Muslims are forbidden to consume, or that polio vaccines cause infertility. The present research is rooted in the conviction that statically testing the links of these variables with attitudes towards polio vaccination can help inform efficacious intervention designs. Specifically, the research explores the underlying dimensions of these attitudes and their correlates: (i) belief in conspiracy theories and (ii) uncertainty, which can stem from the immediate situation or the overall social environment.

The first step in this endeavour requires a psychometrically sound instrument for measuring attitudes toward polio vaccination as they exist in Pakistan. This process began with the development of an item pool generated with the help of an open-ended survey of university students (n = 44). Face and content validity assessment by subject experts (n = 9) led to an initial version of the 28-item attitude toward polio vaccination scale (ATPVS). This scale was administered to a sample of Pakistani adults (n = 620) through a paper-and-pencil survey and an online survey.

The ATPVS consisting of 22 items was finalised as consisting of two dimensions or factors. Factor I was named Scepticism, while Factor II was named Advocacy. Scepticism reflected doubts about the safety of polio vaccines, concern about their harmful effects, and belief in conspiracy theories about polio vaccines. Items of Advocacy indicated belief in the effectiveness of polio vaccines and support for the vaccination campaign. This aspect is unique in the sense that it covers advocacy of polio vaccination on a country-wide level (e.g., "polio workers should be facilitated during polio vaccination campaigns" and "outreach of polio vaccines should be increased all over the country"). This aspect reflects the social welfare aspect of vaccination: something that goes beyond personal concern. This analysis suggests that an effective campaign can benefit from a two-pronged approach: tackling misinformation about polio vaccination and appealing to concern for social welfare.

It was observed through a frequency analysis of responses to ATPVS by the combined sample that most participants tended to agree with items of the advocacy subscale, thereby indicating their support for polio vaccination campaign and their willingness to participate in it. This finding could have occurred due to certain sample characteristics - being young, single, and mostly hailing from Punjab - associated with positive attitudes towards polio vaccination. For the Skepticism scale, it was observed that participants disagreed with statements of most items, thereby, indicating their positive attitudes. However, participants showed agreement with two items: Item 1 that states that the problem of polio has been exaggerated, and item 7 that states that the vaccine process is repeated so it can provide financial benefit to the vaccine developers. This finding provides proof for the two-factor structure of ATPVS in which Scepticism and Advocacy are not simply opposite constructs. Thus, participants who might be showing more advocacy of polio vaccination can also hold certain skeptical attitudes. Even a few such doubts can indicate vaccine hesitancy, which can soon turn into refusals.

Furthermore, hypothesis testing for convergent validity on the total sample (n = 620) revealed that self-uncertainty about self, world, and future was positively related to scepticism and negatively related to advocacy. The need to assess vaccine decision-making in the presence of uncertainty has significant implications for Pakistan because uncertainty prevails in low-income emerging economies. Conspiracy mentality had a positively significant relationship with both components of ATPVS; therefore, an increase in conspiracy mentality is associated with increases in both scepticism and advocacy of polio vaccination. The researchers suggest that dealing with individual characteristics that make people susceptible to negative attitudes should be a greater priority for the government than curbing few factions peddling anti-polio vaccination propaganda.

Per the researchers, the satisfactory results of almost all validation procedures suggest that ATPVS has displayed sufficient psychometric properties and can be used as a valid and reliable measure of attitudes towards polio vaccination across Pakistan. For instance, descriptive cross-sectional surveys can use ATPVS to gain a more psychometrically sound assessment of attitudes across different regions of Pakistan. "Such data can help inform vaccination policies as a detailed understanding of people's attitudes and opinions can lead to more effective health promotion practices." Furthermore, ATPVS also be used in Afghanistan, a country that forms a common epidemiological block with Pakistan. Translation of this instrument can be taken up in future studies.

In conclusion: "The insight gained from this study can help in identifying individuals and contexts that increase susceptibility to anti-polio vaccination propaganda. In the long run, more individualized campaigns can be designed and implemented to help in achieving the complete eradication of polio from Pakistan."