Vaccination‐hesitancy and vaccination‐inequality as challenges in Pakistan's COVID‐19 response

Abstract

This study explores the mechanism for timely and equitable distribution of coronavirus disease 2019 (COVID‐19) vaccination among the various communities in Pakistan. It examines the factors that support and/or impede peoples' access and response towards COVID‐19 vaccination in Pakistan. The study uses a literature synthesis approach to examine and analyze the situation of the COVID‐19 vaccination in Pakistan. The research results show “hesitancy” and “inequality” as two fundamental challenges that hinder the successful delivery of COVID‐19 vaccination in Pakistan. People are reluctant to use vaccines due to conspiracy theories and religious beliefs. However, inequality, especially unequal accessibility to all social groups appears to be a more significant barrier to getting a vaccine. We argue that there is a need to mobilize community influence, social media, and mass media campaigns for public education on vaccination programs along with the engagement of religious leaders to endorse the vaccination for the masses. The area of this study is underdeveloped; thereby, future studies are recommended to investigate the possible way for equitable distribution of vaccines in multiple regions.

Full text

J Community Psychol. 2021;1–18. wileyonlinelibrary.com/journal/jcop © 2021 Wiley Periodicals LLC
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1
Received: 24 May 2021
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Accepted: 5 June 2021
DOI: 10.1002/jcop.22652
RESEARCH ARTICLE
Vaccination‐hesitancy and vaccination‐
inequality as challenges in Pakistan's COVID‐19
response
Shama Perveen
1
|Muhammad Akram
1
|Asim Nasar
2
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Adeela Arshad‐Ayaz
3
|Ayaz Naseem
3
1
Center for Justice and Peacebuilding,
Eastern Mennonite University, Harrisonburg,
Virginia, USA
2
Azman Hashim International Business
School, Universiti Teknologi Malaysia,
Kuala Lumpur, Malaysia
3
Department of Education, Concordia
University, Montreal, Quebec, Canada
Correspondence
Muhammad Akram, 1001‐B, Chicago Ave,
Harrisonburg, VA 22802, USA.
Email: akramuhammad1@gmail.com
Abstract
This study explores the mechanism for timely and equi-
table distribution of coronavirus disease 2019 (COVID‐19)
vaccination among the various communities in Pakistan. It
examines the factors that support and/or impede peoples'
access and response towards COVID‐19 vaccination in
Pakistan. The study uses a literature synthesis approach to
examine and analyze the situation of the COVID‐19 vac-
cination in Pakistan. The research results show “hesitancy”
and “inequality”as two fundamental challenges that hinder
the successful delivery of COVID‐19 vaccination in Paki-
stan. People are reluctant to use vaccines due to con-
spiracy theories and religious beliefs. However, inequality,
especially unequal accessibility to all social groups appears
to be a more significant barrier to getting a vaccine. We
argue that there is a need to mobilize community influence,
social media, and mass media campaigns for public edu-
cation on vaccination programs along with the engagement
of religious leaders to endorse the vaccination for the
masses. The area of this study is underdeveloped; thereby,
future studies are recommended to investigate the possi-
ble way for equitable distribution of vaccines in multiple
regions.
KEYWORDS
COVID‐19, hesitancy, inequality, Pakistan, vaccine

1|INTRODUCTION
Coronavirus disease 2019 (COVID‐19) outbreak started in Wuhan city in China in mid‐December 2019. The
first case of COVID‐19 in Pakistan was reported in Karachi on February 26, 2020. The patient‐zero in
Pakistan had traveled from Iran (Saqlain et al., 2020;Yousafetal.,2020). The World Health Organization
(WHO) declared it as public health emergency of international concern (PHEIC) on January 30, 2020 (Saqlain
et al., 2020), but due to its rapid spread throughout the world and severity of illness, the WHO named it as a
global pandemic on March 11, 2020 (Abid et al., 2020). A variant of severe acute respiratory syndrome
coronavirus 2, characterized as VOC‐202012/01, emerged in the UK on December 14, 2020, which by
January 27, 2021, had quickly spread to over 64 countries (Umair et al., 2021). The WHO estimates that
different vaccine programs, in general, across the world prevent 2–3 million deaths every year (Robertson
et al., 2021). If vaccine coverage is increased with effectiveness, it can save a further 3.5–4.5 million deaths
globally. The 34 billion USD investment on the expansion of global outreach for vaccinations could save 586
billion USD against direct costs of illness, which could benefit further 1.5 trillion USD in larger economic
benefits (Khattak et al., 2021). RAND Corporation estimates a USD 3.4 trillion annual worldwide economic
impact of COVID‐19 and a USD 1.2 trillion annual loss to the global economy due to unequal distribution of
COVID‐19 vaccine (Hafner & Stolk, 2020).
The COVID‐19 pandemic has caused multiple socioeconomic problems in Pakistan due to the country's
fragile politics, struggling economy, and unstable healthcare system (Haqqi et al., 2021). Asian Development
Bank (ADB) estimated that Pakistan's economy has lost around USD 4.95 billion due to COVID‐19 pandemic
and triggered 946,000 job losses (Ilyas et al., 2020). Furthermore, the COVID‐19 related lockdowns could
cause the layoff of 12.3 to 18.53 million Pakistanis, which will destroy the country's already struggling
economy (Yousaf et al., 2020). However, according to Haqqi et al. (2021), lack of capacity and resources for
testing COVID‐19 and inequitable vaccination may put the country at an even greater risk than the socio-
economic impacts of this pandemic. Haqqi et al. (2021) observations support the speculations that the actual
number of cases is way higher than what is reported. Initially, Pakistanis believed that their stronger immune
system and hot weather in the country would prevent them from severe impacts of COVID‐19 as compared
with other countries like Italy, Iran, and United States. But the fear in Pakistan was sparked by the strict
measures for the funerals of those who died of COVID‐19 infections whose funerals happened without
physical contacts and gatherings. (Shoukat & Jafar, 2020).
There has been intense global competition among vaccine developers followed by a similar trend in
nations racing to get vaccinated first. However, despite WHO's warnings, less attention and debate have
gone into making vaccines available to developing countries. Another question that has not been given
enough attention is how the COVID‐19 vaccine would be distributed equitably among communities once
made available to developing countries. Therefore, there is an urgent need for further research on equitable
distribution of COVID‐19 vaccine globally between the core and peripheral countries but also within the
peripheries, which are usually marked by power differentials and corrupt political systems.
In this backdrop, our study looks at the issue of the equitable delivery of the COVID‐19 vaccination in
Pakistan and people's response to the COVID‐19 vaccination. In particular, the study explores what socio‐
cultural, religious, and economic factors support and/or impede equitable access to COVID‐19 vaccination.
We use a literature synthesis approach to highlight the accessibility issues and people's response towards
the COVID‐19 vaccination in Pakistan. The article is organized in three sections, namely, synthesis of the
literature on COVID‐19 vaccination in Pakistan, thematic content analysis, and discussion on tackling the
issues of hesitancy and equality towards COVID‐19 vaccination. These are then followed by conclusions and
recommendations for future research.
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2|COVID‐19 VACCINATION WORLDWIDE: AN OVERVIEW
The first human clinical trial of a COVID‐19 vaccine commenced on March 03, 2020, in the United States (Murphy
et al., 2021). As of May 2, 2021, 60 vaccines were at the different phases of their trial, and 13 vaccines (Table 1)
had already been authorized to vaccinate people in different countries (Craven, 2021). Among major manu-
facturers, Pfizer planned to make two billion COVID‐19 vaccine doses in 2021, AstraZeneca three billion, and
Moderna one billion (Baraniuk, 2021). These counts are in addition to the other authorized vaccines manufactured
in China, India, and Russia. Among authorized ones, five were available in Pakistan as of May 2, 2021.
Figure 1(below) depicts COVID‐19 vaccine doses administered per 100 people worldwide. Even though there
is considerable scientific evidence that vaccines reduce mortality and morbidity rates, there is a significant number
of Anti‐vaxxers and vaccine “hesitants”in every country (Dubé et al., 2013). Anti‐vaxxers are those individuals or
groups of individuals who oppose the vaccinations, and vaccine‐hesitants are those who “delay in acceptance or
refusal of vaccination despite availability of vaccine service”(Boodoosingh et al., 2020; MacDonald & SAGE
Working Group on Vaccine Hesitancy, 2015). Thus, the COVID‐19 vaccine acceptance is not the same among
people living in different countries, as vaccine hesitancy is a global phenomenon (Biddle et al., 2021; Macpherson,
2020). The people who hesitate to be vaccinated are often more than those who just resist the roll‐out of
vaccination programs. For example, 31% of the surveyed population in the United States were hesitant to have the
COVID‐19 vaccine, 25%–27% in the UK, 14% in Canada, 9% in Australia, and an average of 19% were hesitant in
seven European countries (Dube et al., 2013; Murphy et al., 2021). Though vaccines are the most efficient method
of preventing and controlling the pandemics like COVID‐19 (Wong et al., 2020), vaccine hesitancy is a global
phenomenon derived from various factors, not merely linked to religion (Seifman & Forthomme, 2020). For in-
stance, in the United States, millions of white evangelical adults do not want to be vaccinated against COVID‐19
due to various reasons, including a belief that the COVID‐19 vaccine contains the tissues of aborted cells (Pew
Research Center, 2021).
3|COVID‐19 VACCINATION IN PAKISTAN
As of May 2, 2021, the WHO (https://COVID19.who.int/) reported that the world has 150,989,419 confirmed
cases of COVID‐19, and 3,173,576 deaths. Figure 2presents the official statistics of the COVID‐19 situation in
Pakistan. Figure 3depicts COVID‐19 vaccine doses administered per 100 people in and around Pakistan.
Pakistan's geographic location was critical due to its border with China, the country of COVID‐19 origin, and Iran,
the first Islamic epicenter of COVID‐19 among the Muslim countries (Yousaf et al., 2020). The major sources of the
COVID‐19 outbreak in Pakistan were the unscreened return of over 7000 pilgrims from Iran and the careless
week‐long religious gathering of 1,250,000 followers of the Tablighi Jama'at (an Islamic proselytizing group) in
Lahore (Farooq et al., 2020). Furthermore, the religious leaders continuously defied the implementation of socially
distanced religious activities in mosques and shrines. The government could implement the lockdown for most
businesses and schools, except mosques where religious gatherings take place multiple times a day (Shoukat &
Jafar, 2020). These social and religious attitudes towards the pandemic led to a rapid increase in COVID‐19
infection rates in Pakistan. As of May 22, 2021, there were 20,177 deaths against 897,468 confirmed cases of
COVID‐19 in Pakistan (see Figure 2).
On the other hand, once the vaccines became available in Pakistan these very attitudes and practices can be
seen behind the rising vaccination hesitancy in the country. The COVID‐19 knowledge, attitude, and practice study
by the Center for Communication Program at John Hopkins University found the COVID‐19 vaccine acceptance in
Pakistan was 67%. Whereas the Vaccine Confidence Project found the growth of anti‐vaccine sentiments in
Pakistan from 2% to 4% due to instability and anti‐vaccine religious leadership (MacPherson, 2020). In this
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TABLE 1 Details of vaccines approved or authorized to vaccinate people
No Name Vaccine type Primary developer Country of origin
Authorized in
Pakistan
1 Comirnaty (BNT162b2) mRNA‐based vaccine Pfizer, BioNTech; Fosun Pharma Multinational No
2 Moderna COVID‐19 Vaccine (mRNA‐1273) mRNA‐based vaccine Moderna, BARDA, NIAID US No
3 COVID‐19 Vaccine AstraZeneca (AZD1222);
also known as Vaxzevria and Covishield
Adenovirus vaccine BARDA, OWS UK Yes
4 Sputnik V Recombinant adenovirus vaccine
(rAd26 and rAd5)
Gamaleya Research Institute, Acellena Contract Drug
Research, and Development
Russia Yes
5 COVID‐19 Vaccine Janssen (JNJ‐78436735;
Ad26.COV2.S)
Non‐replicating viral vector Janssen Vaccines (Johnson & Johnson) The Netherlands, US No
6 CoronaVac Inactivated vaccine (formalin with
alum adjuvant)
Sinovac China Yes
7 BBIBP‐CorV Inactivated vaccine Beijing Institute of Biological Products; China National
Pharmaceutical Group (Sinopharm)
China Yes
8 EpiVacCorona Peptide vaccine Federal Budgetary Research Institution State Research
Center of Virology and Biotechnology
Russia No
9 Convidicea (Ad5‐nCoV) Recombinant vaccine (adenovirus
type 5 vector)
CanSino Biologics China Yes
10 Covaxin (BBV152) Inactivated vaccine Bharat Biotech, ICMR India No
11 WIBP‐CorV Inactivated vaccine Wuhan Institute of Biological Products; China National
Pharmaceutical Group (Sinopharm)
China No
12 CoviVac Inactivated vaccine Chumakov Federal Scientific Center for Research and
Development of Immune and Biological Products
Russia No
13 ZF2001 Recombinant vaccine Anhui Zhifei Longcom Biopharmaceutical, Institute of
Microbiology of the Chinese Academy of Sciences
China, Uzbekistan No
Abbreviation: COVID‐19, coronavirus disease 2019.
Source: (Craven, 2021).
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backdrop, it becomes important to examine what sociocultural, religious, and economic factors support and/or
impede equitable access to COVID‐19 vaccination.
4|METHODOLOGY
A systematic literature synthesis was undertaken to examine the COVID‐19 vaccination situation in Pakistan. The
synthesis of the systematic review was based on two approaches. The first approach was to check the Web of
Science database from 2020 to May 2021 using four indexes, that is, Science Citation Index Expanded, Arts and
FIGURE 1 COVID‐19 vaccine doses administered per 100 people in the world. Source:https://ourworldindata.
org/coronavirus‐as of May 22, 2021. COVID‐19, coronavirus disease 2019
FIGURE 2 COVID‐19 situation in Pakistan as of May 22, 2021. Source: Government of Pakistan, Retrieved
from https://COVID.gov.pk/stats/pakistan. COVID‐19, coronavirus disease 2019
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Humanities Citation Index, Emerging Sources Citation Index, and Social Sciences Citation Index. The research on
COVID‐19 vaccination is emergent, and the concept of COVID‐19 is still evolving in Pakistan. In total, we identified
27 articles from the research database, namely Web of Science, Scopus, EBSCO, and others from related disciplines
(see Table 2). The second approach was to analyze policy reports, news briefs, and public announcements by
Pakistani officials on COVID‐19 vaccination in Pakistan. We decided to use this approach as it had a greater level
of significance of the COVID‐19 vaccination in Pakistan. This approach helps us analyze and review the public and
institutional responses to COVID‐19 Vaccination in Pakistan. We present the summary of key findings along with
the remedial actions in the subsequent sections.
5|ANALYSIS AND DISCUSSION
By synthesizing the literature, we identified salient themes and categories (see Table 3). The dominant theme, that
is, “the situation of COVID‐19 vaccination in Pakistan”emerged along with two sub‐themes, that is, hesitancy and
inequality. Peoples' hesitation in getting vaccinated is further broken down into two categories, namely conspiracy
theories and religious beliefs. Inequality in terms of unfair distribution of the COVID‐19 vaccine is generally
associated with policy implications and accessibility. We present the description of thematic analysis in the sub-
sequent sections.
6|COVID‐19 VACCINE HESITANCY IN PAKISTAN
Vaccine hesitancy is a universal phenomenon that exists in both developed and developing countries (Khattak
et al., 2021). About 90% of the countries reported some degree of vaccine hesitance (Murphy et al., 2021). The
WHO declared vaccine hesitancy as one of the 10 major threats to public health worldwide. Though the current
literature on vaccine hesitancy is helpful to understand the reasons, it is quite early to understand the attitudes
and behaviors for the COVID‐19 vaccine in the longer run. Identifying COVID‐19 vaccine hesitation could help the
effective design of public education campaigns aiming to improve vaccine acceptance behaviors (Murphy
et al., 2021).
FIGURE 3 COVID‐19 vaccine doses administered per 100 people in and around Pakistan. Source:https://
ourworldindata.org/coronavirus‐as of May 22, 2021. COVID‐19, coronavirus disease 2019
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TABLE 2 Summary of selected papers from research database
No Authors Title
Year
published
1 Mehmood, K; Bao, YS; Petropoulos, GP; Abbas,
R; Abrar, MM; Saifullah; Mustafa, A; Soban,
A; Saud, S; Ahmad, M; Hussain, I; Fahad, S
Investigating connections between COVID‐19
pandemic, air pollution, and community
interventions for Pakistan employing
geoinformation technologies
2021
2 Khan, MT; Ali, S; Khan, AS; Muhammad, N;
Khalil, F; Ishfaq, M; Irfan, M; Al‐Sehemi, AG;
Muhammad, S; Malik, A; Khan, TA; Wei, DQ
SARS‐CoV‐2 genome from the Khyber
Pakhtunkhwa Province of Pakistan
2021
3 Singh, J; Malik, D; Raina, A Immuno‐informatics approach for B‐cell and T‐cell
epitope‐based peptide vaccine design against
novel COVID‐19 virus
2021
4 Oud, MAA; Ali, A; Alrabaiah, H; Ullah, S; Khan,
MA; Islam, S
A fractional order mathematical model for COVID‐
19 dynamics with quarantine, isolation, and
environmental viral load
2021
5 Shahzad, F; Du, JG; Khan, I; Ahmad, Z;
Shahbaz, M
Untying the precise impact of COVID‐19 policy on
social distancing behavior
2021
6 Qiang, XL; Aamir, M; Naeem, M; Ali, S; Aslam,
A; Shao, ZH
Analysis and forecasting COVID‐19 outbreak in
Pakistan using decomposition and Ensemble
model
2021
7 Khan, A; Bibi, A; Khan, KS; Butt, AR; Alvi, HA;
Naqvi, AZ; Mushtaq, S; Khan, YH; Ahmad, N
Routine pediatric vaccination in Pakistan during
COVID‐19: How can healthcare
professionals help?
2020
8 Kazi, AM; Qazi, SA; Khawaja, S; Ahsan, N;
Ahmed, RM; Sameen, F; Mughal, MAK;
Saqib, M; Ali, S; Kaleemuddin, H; Rauf, Y;
Raza, M; Jamal, S; Abbasi, M;
Stergioulas, LK
An artificial intelligence‐based, personalized
Smartphone App to improve childhood
immunization coverage and timelines among
children in Pakistan: Protocol for a randomized
controlled trial
2020
9 Chandir, S; Siddiqi, DA; Mehmood, M; Setayesh,
H; Siddique, M; Mirza, A; Soundardjee, R;
Dharma, VK; Shah, MT; Abdullah, S; Akhter,
MA; Khan, AA; Khan, AJ
Impact of COVID‐19 pandemic response on
uptake of routine immunizations in Sindh,
Pakistan: An analysis of provincial electronic
immunization registry data
2020
10 Naik, PA; Yavuz, M; Qureshi, S; Zu, J;
Townley, S
Modeling and analysis of COVID‐19 epidemics
with treatment in fractional derivatives using
real data from Pakistan
2020
11 Ullah, S; Khan, MA Modeling the impact of non‐pharmaceutical
interventions on the dynamics of novel
coronavirus with optimal control analysis with
a case study
2020
12 Kakakhel, MA; Wu, F; Khan, TA; Feng, H;
Hassan, Z; Anwar, Z; Faisal, S; Ali, I;
Wang, W
The first two months epidimiological study of
COVID‐19, related public health preparedness,
and response to the ongoing epidemic in
Pakistan
2020
13 Yousaf, M; Zahir, S; Riaz, M; Hussain, SM;
Shah, K
Statistical analysis of forecasting COVID‐19 for
upcoming month in Pakistan
2020
(Continues)
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TABLE 2 (Continued)
No Authors Title
Year
published
14 Anjum, FR; Anam, S; Rahman, SU Novel coronavirus disease 2019 (COVID‐19): new
challenges and new responsibilities in
developing countries
2020
15 Zubair, K; Luqman, M; Ijaz, F; Hafeez, F;
Aftab, RK
Practices of general public towards personal
protective measures during the coronavirus
pandemic
2020
16 Iqbal, Z; Aslam, MZ; Aslam, T; Ashraf, R; Kashif,
M; Nasir, H
Persuasive power concerning COVID‐19
employed by premier Imran Khan: A socio‐
political discourse analysis
2020
17 Abbas, Q., Mangrio, F. and Kumar, S. Myths, beliefs, and conspiracies about COVID‐19
vaccines in Sindh, Pakistan: An online cross‐
sectional survey
2021
18 Abid, K., Bari, Y. A., Younas, M., Tahir Javaid, S.,
& Imran, A.
Progress of COVID‐19 epidemic in Pakistan 2020
19 Farooq, F., Khan, J., and Khan, M. U. G. Effect of lockdown on the spread of COVID‐19 in
Pakistan
2020
20 Haqqi, A., Awan, U. A., Ali, M., Saqib, M. A. N.,
Ahmed, H., & Afzal, M. S.
COVID‐19 and dengue virus coepidemics in
Pakistan: A dangerous combination for an
overburdened healthcare system
2021
21 Khalid, A. and Ali, S. COVID‐19 and its challenges for the healthcare
system in Pakistan
2020
22 Khan, Y. H., Mallhi, T. H., Alotaibi, N. H.,
Alzarea, A. I., Alanazi, A. S., Tanveer, N., &
Hashmi, F. K.
Threat of COVID‐19 vaccine hesitancy in Pakistan:
The need for measures to neutralize
misleading narratives
2020
23 Khattak, F. A., Rehman, K., Shahzad, M., Arif, N.,
Ullah, N., Kibria, Z., Arshad, M., Afaq, S.,
Ibrahim, A. K., & ul Haq, Z.
Prevalence of parental refusal rate and its
associated factors in routine immunization by
using WHO Vaccine hesitancy tool: A cross‐
sectional study at district Bannu, KP, Pakistan
2021
24 Saqlain M, Munir MM, Rehman SU, Gulzar A,
Naz S, Ahmed Z, Tahir AH, Mashhood M.
Knowledge, attitude, practice and perceived
barriers among healthcare workers regarding
COVID‐19: A cross‐sectional survey from
Pakistan
2020
25 Shoukat, A. and Jafar, M. Scarce resources and careless citizenry: Effects of
COVID‐19 in Pakistan. International Journal of
Innovation, Creativity and Change, Special
Edition: COVID‐19 Life Beyond
2020
26 Umair, M., Ikram, A., Salman, M., Alam, M. M.,
Badar, N., Rehman, Z., Tamim, S., Khurshid,
A., Ahad, A., Ahmad, H., & Ullah, S.
Importation of SARS‐CoV‐2 variant B. 1.1. 7 in
Pakistan
2021
27 Zakar, R., Yousaf, F., Zakar, M., & Fischer, F. Socio‐cultural challenges in the implementation of
COVID‐19 public health measures: Results
from a qualitative study in Punjab, Pakistan
2020
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The conspiracy theories contradict the norms, believed to be influenced by those in power, followed by the
minority, and have no scientific evidence to be supported (Freeman et al., 2020). Amidst various conspiracy
theories, vaccine hesitancy remains a critical challenge for Pakistan. The country has been facing a similar hesi-
tancy for decades in the case of polio eradication. The factors perceived for hesitation include, but are not limited
to, the poor quality of vaccine, perception of vaccine by the clergy as “infidel vaccine,”rumors about active virus
within the vaccine itself and the theory that the vaccines are a Western conspiracy to eradicate Muslim popula-
tions. The conspiracy theories around the COVID‐19 vaccine are widespread on popular media and reach millions
of Pakistanis. For example, a renowned political analyst in Pakistan claimed that the COVID‐19 vaccine has nano‐
chips to control human bodies through the 5G internet. Ex‐foreign ministry of Pakistan also made similar disin-
formant comments accusing the United States of inventing the Coronavirus in the UK labs and then transferring it
to China for spread. In Pakistan, social media feeds such conspiracies about the COVID‐19 vaccine every day. This
builds a public narrative defying the reality of the COVID‐19 virus and denial of vaccine safety and efficacy (Khan
et al., 2020a).
Gallup Pakistan found that 49% of Pakistanis were hesitant to get vaccinated against COVID‐19 (Gallup
Pakistan, 2020). This hesitancy was mainly because the vaccines were developed in Western countries. 42%
among 46% who were willing to be vaccinated said they would prefer not to take Western‐made vaccine. The
5% of the respondents either not responded to this question or were not sure about. Similarly, the con-
spiracies associated with Bill Gates trying to put a surveillance micro‐chip in human bodies for tracking and
controlling them (Hadid, 2021) also contribute to the hesitancy in getting vaccinated. Another major factor
in the rejection of the Western vaccine is the sense of betrayal resulting from the 2011 CIA operation, which
targeted Osama bin Laden whose presence in Abbottabad city was identified using a polio vaccine drive as a
cover. Such serious factors would risk the security of health workers administering COVID‐19 vaccine as
previously the polio vaccine drive has been life‐threatening for them particularly in northern areas of
Pakistan (Jaafari, 2021).
The fake news about Coronavirus misleads the public understanding of the pandemic resulting in challenges to
contain the virus and achieve public confidence in being vaccinated. Many in Pakistan believed that the virus
only affects older people. This misconception will lead to ignorance of preventive measures by younger people
TABLE 3 Thematic analysis based on the literature synthesis
Theme Sub‐themes Categories Sub‐categories
The situation with respect to
COVID‐19 vaccination in
Pakistan
COVID‐19 vaccine
hesitancy
Conspiracy
theories
•Fake news about vaccine
•Misinformation about vaccine
•Lack of awareness on public health
education
•Potential side effects
Religious beliefs •Forbidden by religion (Harram)
vaccine
•Infidel vaccine
•Religious sect “Shia”virus
•Western‐made vaccine
COVID‐19 vaccine
inequality
Policy implications •Lack of policy for public and
private health center
Accessibility •Socio‐political influence to get the
vaccine
•Inability to buy the vaccine at
private health centers
Abbreviation: COVID‐19, coronavirus disease 2019.
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(Zakar et al., 2020). The politicization of the virus by connecting it to serving Pakistani Prime Minister Imran Khan's
and Western countries interests further created confusion and misinformation, which led to the denial that there is
no Coronavirus. Especially the rumors claiming that government receives a certain amount of money by declaring
each death due to COVID‐19 fueled the idea among some groups that the virus is a means for the government to
ask for funding from the United States and other Western countries. The widespread comments made by Pakis-
tanis include: “There is no coronavirus,”“Is the coronavirus a reality?,”“I have not seen any coronavirus infected
person anywhere,”“Coronavirus cannot harm Muslims,”“What coronavirus can do to us?,”“Is the coronavirus a
reality or conspiracy of America for selling vaccine and medicines?”The conspiracies about coronavirus were
common in rural areas of Pakistan, where a limited number of cases were reported (Shoukat & Jafar, 2020).
Malik et al. (2021) argue that some religious leaders have hijacked religion in a predominantly Muslim
country and used their interpretation to claim that Sharia law does not allow vaccination against COVID‐19
and other chronic diseases. Yet another significant religion‐related challenge for Pakistanis is the concept of
“Halal.”Just as kosher is important to Jewish people, Halal is essential for Muslims. Muslims do not use
ingredients forbidden in Islam, such as pork. Many people are concerned about the ingredients used in the
production and development of vaccines. It is precisely, for this reason, the representatives of the high
clerical council in Indonesia—a country with the largest Muslim population, visited China's Sinovac
COVID‐19 vaccine factory to conduct a halal audit and declared that vaccine as halal, permitting Muslims to
take the Chinese Sinovac COVID‐19 vaccine.
A 2019 non‐COVID vaccination study found Pakistan among 10 countries with the least acceptance to
the vaccines (Shah, 2021). As quoted by Zakar et al. (2020) one participant in the survey said: “If it is in my
kismet [fate] written that I will get infected with the virus, then nothing can stop it. So, we must trust in Allah.
Nothing will happen.”Another participant in the same study said: “Allah is not happy from us. This is a wrath
of Allah. We need to give more sadaqa [spend money on poor to make Allah happy].”
Experts identify the misinformation and hardline religious beliefs among significant factors of people's
mistrust in vaccines like COVID‐19. Apart from myths about the COVID‐19 vaccine for not being halal
(denoting or relating as prescribed by Islamic law) due to the potential use of pork gelatin and human fetus
tissues, many Pakistanis do not want to take Chinese vaccines due to the conspiracies of the vaccine being
not effective. Others do not want to take the AstraZeneca vaccine as it is being manufactured in India. Social
media, particularly WhatsApp, has been the major source of such misinformation around the COVID‐19
vaccinationinPakistan(Maryam,2021). The vaccine hesitancy in Pakistan is spread through inauthentic
information spread on social media, which has become the source of news for millions in the country. The low
level of critical social media literacy has been contributing factor of info‐demic in the country about
COVID‐19 and its preventive measures like vaccination (Malik et al., 2021).
In addition to limited awareness/knowledge and religious beliefs, another major factor hindering the
acceptance of explanation is the preference for traditional methods of cure and reliance on spirituality and
prayers (Larson et al., 2015). Dube et al. (2013) also included limited awareness as one of the six key factors
causing vaccine hesitancy. The other five factors are the nature of an experience with a vaccine, perceived
importance of being vaccinated, the level of trust in vaccine, subjective norms related to a particular vaccine,
and religious or moral convictions. Khan et al. (2020b) argue that in a country with a fragile healthcare
system and economic turmoil of lockdown, vaccinating the masses could be the only way to limit the spread
of the COVID‐19 pandemic. Yet others potential reasons for vaccine hesitancy could be fears of potential
side effects in the future, limited supply of vaccine, lack of trust in vaccines' effectiveness, misconceptions of
not being affected by COVID‐19, and inability to afford the vaccine (Robertson et al., 2021). The video of a
nurse collapsing after vaccination and the news about death after vaccination fueled the conspiracies against
COVID‐19 vaccine but there was no reality in those videos (Asghar, 2021).
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7|COVID‐19 VACCINE‐INEQUALITY IN PAKISTAN
Like many other developing countries, Pakistan lacks pharmaceutical infrastructure and purchasing power, thus, it
relies on its allies and other humanitarian programs to get vaccination support. It is evident that the allies tend to
harvest political influence and solidarity from such support to the poor nations. In the case of Pakistan, the Chinese
vaccine companies agreed to supply the vaccine for one‐fifth of the population on the condition that Pakistan
allows vaccine trials for the Chinese vaccines. It is unclear whether Pakistan would have to pay any additional
costs, but vaccine provision certainly enhanced the Chinese diplomatic interests in Pakistan (Shah, 2020). Ap-
proximately 17,500 Pakistani volunteers were recruited for the trials of China's CanSino vaccine (Mangi, 2021).
Though Pakistan has started receiving the COVID‐19 vaccine, an inclusive vaccination rollout strategy is still
missing. Also, educational drives associated with vaccine rollouts, which could educate the masses for its wider
acceptability are also missing (Umair et al., 2021). In a country marked by economic disparities, various margin-
alized and vulnerable groups are at a greater risk of contracting COVID‐19. People at the bottom of the hierarchy
are forced to work extra hours to serve those in power, pushing them for enhanced interactions and reduced
chances of social distancing (Kelly, 2020).
In an interview on April 27, 2021, Health Advisor to the Pakistani Prime Minister confirmed that China had
donated 1.7 million doses of the COVID‐19 vaccine to Pakistan. The country expects to import about three million
doses purchased from another Chinese company named CanSino Biologics (Farooq et al., 2021). The health advisor
further confirmed that different deals had been secured to import 30 million purchased doses from other vaccine
manufacturers (Sultan, 2021). The country is two million doses from Sinovac, a Chinese vaccine manufacturer,
during the last week of May 2021 (APP, 2021). Pakistan is also expecting 45 million doses from the COVAX
alliance, 1.2 million of which were received on May 8, 2021 (Baig, 2021; WHO, 2021). The challenge with Chinese
and Russian vaccines is their lower level of efficacy compared to Pfizer and Moderna, which have more than 95%
efficacy (Umair et al., 2021). It was critical to select the best efficacy vaccine for the Pakistani people to control the
pandemic, but the government has leaned towards its political ally China whose vaccines' lower efficacy may
prolong the pandemic in Pakistan.
The lockdowns to control the COVID‐19 in Pakistan have seriously effected the masses' economic capacities,
which has become a key factor restricting the affordability of the COVID‐19 vaccine. The poverty and economic
disparities played a significant role in people not following the lockdown orders and social distancing guidelines.
Additionally, denial of the virus was another major factor that hindered preventive measures, which caused the
spread of COVID‐19 in Pakistan (Zakar et al., 2020).
Pakistan is among a few countries that have allowed the private sector to import and sell the vaccine. AGP Pharma,
a private pharmaceutical company, imported 50,000 doses of two‐shot Sputnik vaccine from Russia, which was sold
quite rapidly (Yeung & Saifi, 2021). The Drug Regulatory Authority of Pakistan (DRAP) fixed the price of privately
imported COVID‐19 vaccine as PKR 8449 for two doses of Russia's Sputnik V vaccine and PKR 4225 per jab for China's
CanSino Biologics vaccine (Wion, 2021). Contrary to the prices fixed by DRAP, the first round of commercial sale, which
was of Russian Sputnik V vaccine, went for PKR 12,000 (around USD 80) for two doses. The pharmaceutical company,
which imported the first shipment of the COVID‐19 vaccine, took the government to the court for not being allowed to
charge the maximum price for the Sputnik V vaccine; it won the case. Young Pakistanis who did not fall into eligibility
criteria for the free vaccine queued up for the purchase of the vaccine, and 50,000 doses went in a few days. Though
private vaccines are available in the market, not everyonecanaffordtogettwoshotsforUSD80,whichisfourtimes
higher than the international market. (Hassan, 2021). The cost for an average family of five will be USD 400 which
mightbemorethanmanyfamiliesinthelowerstrataearninamonth.
Baraniuk (2021), while analyzing the situation of global vaccine allocation for developing countries, argues, “by
the time we board, they were already seated, with champagne in their hands.”He expressed concern over global
vaccine inequality. While most Western nations started being vaccinated, the global South neither had the
COVID‐19 vaccination nor strategies for the procurement of the vaccine. As per the current manufacturing plans
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of 13 authorized COVID‐19 vaccine companies, a quarter world's population will remain unvaccinated until the
end of 2022. Although Covax, the global vaccine alliance for COVID‐19, has secured two billion doses for 2021,
vaccine nationalism has significantly affected the supply and timeline targets for the potential beneficiary
92 low‐and middle‐income countries.
Other significant factors for delayed vaccination of people in the Global South include but are not limited to
the influence of conspiracy theories against COVID‐19, hesitation based on religious factors, fear of side effects,
lack of education, and above all, inadequate infrastructure to store and roll out the vaccine (Figure 4).
The corruption of some members of the Pakistani elite has posed a significant challenge in the equitable
distribution of the COVID‐19 vaccine. Those in power have either used money as bribes or political pressures or
threats to the health officials administering the COVID‐19 vaccine to gain access to the COVID‐19 vaccine doses
for themselves and their loved ones (Hadid, 2021). Dawn News leaked one such story where the family and friends
of the Federal Ministry of Housing (Tariq Bashir Cheema) received the COVID‐19 vaccine at the minister's home
when the first shipment of free vaccine arrived in the country (Dawn News, 2021).
Moreover, the already marginalized religious minorities in Pakistan are further away from getting COVID‐19
vaccinated. They have been experiencing allegations and discrimination during the pandemic. Since the COVID‐19
reached Pakistan with Shia pilgrims returning from Iran, people named the Coronavirus as “Shia virus.”There also
have been rumors about incidents of Muslim aid workers mobilizing Hindus to convert to Islam if they want to
receive humanitarian aid in the pandemic. Such incidents push the religious minorities farther away from the
equitable supply of COVID‐19 vaccine if/when it becomes available for the public in Pakistan (Mirza, 2020).
8|STRATEGIC IMPLICATIONS
Initially, the British Pakistanis were hesitant to take the COVID‐19 vaccine due to fears of potential current or
future side effects. However, once their confidence was restored in the vaccine's efficacy, they expressed will-
ingness to take the vaccine. We argue that awareness and education can lead to enhanced acceptance of the
FIGURE 4 Some Tweets of Pakistani journalists on Minister's family being vaccinated. Source:www.dawn.com/
news/1615465
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vaccination against COVID‐19 in Pakistan. It is critical for a successful vaccine rollout plan to understand who
intends to take the vaccine and who has hesitance or concerns. According to the expert advice, the control of the
COVID‐19 pandemic requires somewhere from 67% to 80% vaccine uptake. Vaccine hesitancy can be a major
hindrance in controlling the pandemic (Robertson et al., 2021). The WHO acknowledged and defined vaccine
hesitancy as “delay in acceptance or refusal of safe vaccines despite availability of vaccination service.”Vaccine
hesitancy can play a crucial role, given the novel nature of COVID‐19 makes it unclear when this disease will
disappear (Yousaf et al., 2020).
Demographic and contextual factors play an important role in vaccine acceptance rates. Malik et al. (2021)
found that the COVID‐19 vaccine acceptance was influenced positively by age, female gender, and single marital
status. Among different ethnic groups in Pakistan, Pashtuns had the highest acceptance for the COVID‐19 vaccine,
and Balochi has the lowest. Among vaccine‐hesitant, the females were more likely to give religious reasons
whereas the males were concerned with the vaccine's effectiveness and its potential side effects.
Abbas et al. (2021) found lower education levels as a significant factor in believing in myths related to
COVID‐19 vaccine in Pakistan, such as believing that the vaccine is a ploy to make Muslims infertile. Since public
confidence is vital to the success of any immunization program, the increased public awareness is critical for
vaccine acceptance. The vaccine acceptance behaviors are contextual; they rely on the level of public education
campaigns led by the vaccine providers, government institutions, politicians, and civil society activists. When the
vaccine‐hesitant individuals do not receive enough attention or knowledge from health authorities, their level of
hesitancy multiplies with everyday conspiracy theories. It results in public denial of the vaccine and hence creates
severe challenges for the vaccine rollout. Examples include the resistance to the polio vaccine in Pakistan's Khyber
Pakhtunkhwa province and neighboring Afghanistan (Larson et al., 2015). The Pakistani government must take
public education as the primary measure of prevention from the rapid increase of COVID‐19 and increased vaccine
acceptability (Khalid & Ali, 2020). Researchers and sociologists can play an essential role in informing the gov-
ernment and policymakers about public attitudes related to COVID‐19 vaccination (Eskola et al., 2015).
While the importance of education and research is undeniable, another neglected but critically important
avenue is proper religious education. Pakistan is a predominantly Muslim country, but unfortunately, religious
education has mostly been hijacked by those who have not studied religion. While masses are provided disin-
formation by quack religious scholars about Halal versus Haraam (what is allowed in Islam vs. what is forbidden),
they do not mention that in actuality, Islam promotes taking strict measures to prevent the spread of chronic
diseases. Prophet Muhammad (SAW) preached for social distancing, quarantine, and travel bans during pandemics
and asked for frequent handwashing during the day. There are numerous examples of quarantine and hygiene in
the Islamic religion. Such Islamic measures complement current medical advice for the prevention of COVID‐19.
Religious education can teach its followers that Islam obliges them to protect themselves from chronic diseases like
COVID‐19 and prevent the spread by adopting the necessary measures (Hussain, 2021).
Traditional media outlets and social media platforms can also help overcome vaccine hesitancy by engaging
medical professionals rather than airing biased commentaries or political views on COVID‐19. The government and
civil society activists should educate the masses to question the authenticity of information they receive when they
refuse the COVID‐19 vaccine (Khan et al., 2020a). There is a need for the Pakistani government to launch an
expanded public educational outreach campaign to disseminate accurate and honest information about the spread
of Coronavirus to encourage vaccine acceptance for public safety. The PEMRA, Pakistan Electronic Media Reg-
ulatory Authority, could issue guidelines for media platforms to share and promote reliable information on the
COVID‐19 vaccine (Yousaf et al., 2020). The government must take strategic and prioritized steps to counter the
misinformation and disinformation against the COVID‐19 vaccine; and educate the masses against myths and
false assurances, not affirming misperceptions, and connecting to the common good of public health
(MacPherson, 2020).
Medical professionals and social researchers should come forward to counter the vaccine‐defying narratives
and educate the masses with scientific evidence. It can help counter the falsehood about the COVID‐19 vaccine,
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rumors, and disinformation and challenge the misleading narratives. There is an urgent need to engage religious
scholars who have considerable influence on the Pakistan masses to create awareness about the severity of
Coronavirus and encourage COVID‐19 vaccination. Religious scholars can draw on religious arguments to creating
awareness which may help in defying the hesitant behaviors resulting from conspiracy theories. Lessons learned
from incorporating religious scholars in promoting the polio vaccine in Pakistan can be applied to endorsing the
COVID‐19 vaccine (Zakar et al., 2020).
Furthermore, the field staff of the Expanded Program on Immunization (EPI) in Pakistan, in collaboration with
UNICEF and WHO, can play a vital role in educating the grassroots communities on COVID‐19 vaccination's
importance for individuals, their families, and the country (World Health Organization, 2013). Jarrett et al. (2015)
conducted a systemic review of the literature and found similar recommendations to overcome vaccine hesitancy
among the masses. The most successful strategies listed by Jarret et al. (2015) included the prioritized reach to the
unvaccinated or under‐vaccinated populations and educating the masses on vaccine importance for the public
good. They further suggested the mobilization of community influence, utilization of social media and mass media
for public education on vaccination program, and engagement of religious leaders to endorse the vaccination for
the masses. Malik et al. (2021) also confirmed that anti‐vaccine religious narratives can only be countered through
the engagement and public support by like‐minded religious leaders. Since the major COVID‐19 vaccines devel-
oped in the Western countries and with the highest efficacy—Pfizer, Modern, and AstraZeneca—also confirmed
that their vaccines do not contain pork products (Times of India, 2020), the government of Pakistan should engage
like‐minded religious leaders, social media influencers, and celebrities to disseminate the knowledge for COVID‐19
vaccine confidence among Pakistanis (Hadid, 2021). The suspicion of COVID‐19 vaccine for not being halal should
balance with fact that “protecting others is an obligation”(Kadri, 2021).
9|CONCLUSION
After conducting a thorough review of the literature, our conclusions are in sync with the nascent available
literature on this current but important topic. For example, we agree with Jarrett et al. (2015) recommendations to
counter vaccine hesitancy among the masses especially prioritizing reach to the unvaccinated or under‐vaccinated
populations. We also emphasize educating the masses on vaccine importance. Several other strategies such as
mobilization of influential people in communities, availing social and traditional media for public education on the
vaccination program can also play a vital role in encouraging vaccination acceptance levels. Another under‐
researched area that can play an important part is the engagement of religious leaders to endorse the vaccination
for the masses. We agree with Malik et al. (2021) that anti‐vaccine religious narratives can be countered most
effectively by engaging religious leaders and scholars in the country.
Major vaccine producers such as Pfizer, Moderna, and AstraZeneca have confirmed their vaccines do not
contain pork products (Times of India, 2020). The Pakistani government needs to engage religious leaders/scholars
to disseminate the knowledge of the Halal/kosher nature of the COVID‐19 vaccine to restore confidence among
Pakistanis (Hadid, 2021). The suspicion of the COVID‐19 vaccine for not being halal should balance with the fact
that “protecting others is an obligation”(Kadri, 2021). We noticed a significant gap in the literature when it comes
to highlighting the problems associated with the use of imported terminology related to the spread COVID‐19
virus in the context of Pakistan. Most laboratories and doctors continue to use Western terminology such as
positive tests and negative tests when providing information to the public. This has given rise to much confusion
amongst people as a positive test is sometimes taken to indicate everything “being good.”In some instances, when
people received a positive test report, they continued mingling with others, thinking that all was good. Perhaps
more research is needed on the use of context‐bound terminology to deal with global pandemics.
Our study reviews the mechanism for equitable distribution of the COVID‐19 vaccination among the com-
munities in Pakistan. The literature is limited as this is a new area of research. A synthesis of literature indicates
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that people are reluctant to use vaccines due to conspiracy theories and religious beliefs. Inequality appears as a
barrier to getting a vaccine due to ineffective policy implications and lack of accessibility to all social groups.
Further research is required to empirically examine the factors that support and impede the equitable distribution
of the COVID‐19 vaccine to ensure equality among all social groups in multiple regions.
ACKNOWLEDGMENTS
Authors acknowledge institutions, researchers, blog writers and news portals who have published content related
to topic of study. This study received no external funding.
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
AUTHOR CONTRIBUTIONS
All authors made equal contributions.
PEER REVIEW
The peer review history for this article is available at https://publons.com/publon/10.1002/jcop.22652
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
ORCID
Muhammad Akram http://orcid.org/0000-0002-0379-7030
Asim Nasar https://orcid.org/0000-0003-0053-2595
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How to cite this article: Perveen, S., Akram, M., Nasar, A., Arshad‐Ayaz, A., & Naseem, A. (2021).
Vaccination‐hesitancy and vaccination‐inequality as challenges in Pakistan's COVID‐19 response. Journal of
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