COVID-19 vaccine hesitancy and social contact patterns in Pakistan: results from a national cross-sectional survey

Abstract

Background: Vaccination is a key tool against COVID-19. However, in many settings it is not clear how acceptable COVID-19 vaccination is among the general population, or how hesitancy correlates with risk of disease acquisition. In this study we conducted a nationally representative survey in Pakistan to measure vaccination perceptions and social contacts in the context of COVID-19 control measures and vaccination programmes.

Methods: We conducted a vaccine perception and social contact survey with 3,658 respondents across five provinces in Pakistan, between 31 May and 29 June 2021. Respondents were asked a series of vaccine perceptions questions, to report all direct physical and non-physical contacts made the previous day, and a number of other questions regarding the social and economic impact of COVID-19 and control measures. We examined variation in perceptions and contact patterns by geographic and demographic factors. We describe knowledge, experiences and perceived risks of COVID-19. We explored variation in contact patterns by individual characteristics and vaccine hesitancy, and compared to patterns from non-pandemic periods.

Results: Self-reported adherence to self-isolation guidelines was poor, and 51% of respondents did not know where to access a COVID-19 test. Although 48.1% of participants agreed that they would get a vaccine if offered, vaccine hesitancy was higher than in previous surveys, and greatest in Sindh and Baluchistan provinces and among respondents of lower socioeconomic status. Participants reported a median of 5 contacts the previous day (IQR: 3-5, mean 14.0, 95%CI: 13.2, 14.9). There were no substantial differences in the number of contacts reported by individual characteristics, but contacts varied substantially among respondents reporting more or less vaccine hesitancy. Contacts were highly assortative, particularly outside the household where 97% of men's contacts were with other men. We estimate that social contacts were 9% lower than before the COVID-19 pandemic.

Conclusions: Although the perceived risk of COVID-19 in Pakistan is low in the general population, around half of participants in this survey indicated they would get vaccinated if offered. Vaccine impact studies which do not account for correlation between social contacts and vaccine hesitancy may incorrectly estimate the impact of vaccines, for example, if unvaccinated people have more contacts.

Keywords: COVID-19; Physical distancing; SARS-CoV2; Social contacts; Vaccine perceptions.

Fig. 1

Stringency of COVID-19 control measures in Pakistan during COVID-19 pandemic. A shows ln(Total SARS-CoV-2 cases) on the first day of the survey, 29 May 2021, plotted against the average stringency index over the survey period. B plots Pakistan's stringency index over time during the COVID-19 pandemic. C plots the stringency index during the survey period, note that the scale of this panel differs from (B)

Fig. 2

Description of (A) perceived threat from COVID-19 to respondents and groups to which they belong, B the proportion of respondents from different groups who reported not knowing where to obtain a COVID-19 test, C percentage of respondents reporting knowledge and self-reported adherence to self-isolation with COVID-19 symptoms, and (D) self-reported household hunger

Fig. 3

Median number of direct contacts (physical and non-physical) by (A) socioeconomic status, B gender, C respondent age, D education level, E household size, F living in an urban or rural area, and (G) province. Each panel shows the median, hinges (25th and 75th percentiles), and whiskers representing upper and lower adjacents. Outliers are not displayed in boxplots for scale, these are plotted in (H) showing the distribution of the number of direct contacts reported

Fig. 4

Characteristics of (A) household and (B) non-household contacts for which full information was gathered

Fig. 5

Mean number of contacts by those responding that they strongly agree with vaccine hesitancy questions. Asterisks represent difference in t-tests of mean contacts between groups: *** p < 0.01, ** p < 0.05, *p < 0.1

Fig. 6

Age-stratified mean number of reported contacts from survey respondents, where (A) is the unadjusted contact matrix, B the mixing matrix produced when estimates from Prem et al. are used to impute contacts between children, and reported adult–child contacts are used to impute child–adult contacts, and (C) the mixing matrix produced when matrix (B) is adjusted for reciprocity using the age structure of Pakistan in 2020