Polio remains a critical public health challenge in Afghanistan, despite substantial international efforts and governmental initiatives aimed at its eradication. This study highlights the complex interplay of socio-cultural, economic, and governmental factors that contribute to vaccine hesitancy in Herat Province. The findings underscore how traditional beliefs, religious perspectives, financial concerns, and distrust in foreign healthcare interventions shape public attitudes toward polio vaccination. By exploring these nuanced barriers, this research provides a framework for understanding the persistent resistance to vaccination and emphasizes the importance of culturally sensitive, community-driven strategies to foster vaccine acceptance and protect public health.
Addressing vaccine hesitancy is essential for Afghanistan to meet WHO’s targets for polio eradication, as overcoming local resistance in key provinces like Herat could significantly reduce transmission rates and pave the way toward achieving a polio-free status, contributing to global eradication efforts.
Misconceptions beliefs
Our findings revealed that a substantial number of participants held deep-rooted misconceptions about the effects of the polio vaccine on children’s development. Several participants believed that vaccination could harm a child’s nervous system, reduce intelligence, or even cause sterility. Statements such as “The vaccine harms children, makes them weaker, and shrinks their brains” and “Children become sterile in the future; the vaccine weakens them” highlight the intensity of these beliefs.
These misconceptions appear to be fueled less by scientific information and more by hearsay, social media rumors, and historical mistrust of foreign interventions. While the participants did not cite specific sources, the consistency and emotional tone of these claims suggest that they are part of broader societal narratives—possibly shaped by intergenerational mistrust, low health literacy, and the rapid spread of misinformation through informal networks. In this sense, vaccine hesitancy reflects not only concern for children’s health but also symbolic resistance to perceived external control.
Our study adds to the existing literature by emphasizing how such narratives are not isolated misunderstandings, but embedded within socio-cultural anxieties about bodily harm, fertility, and Western influence. While other studies have discussed belief in adverse effects post-vaccination (e.g., [7, 33]), our findings illustrate how these fears intersect with distrust in medical authority and the prioritization of traditional knowledge over biomedical guidance.
Addressing these fears requires more than simply providing scientific facts. Culturally sensitive health communication strategies, delivered through trusted community figures, are needed to challenge these deeply held beliefs and offer alternative narratives grounded in both science and local context.
A systematic review on barriers and facilitators of polio eradication vaccination programs in less developed countries found that people’s beliefs and fears about becoming ill after vaccination, traditional and experiential beliefs, concerns about children falling ill and experiencing adverse vaccine effects, and distrust in local governments and social and economic conditions were significant barriers to polio vaccination [13].
In Pakistan, polio vaccination faces ambiguities regarding the poor quality of the vaccine, the presence of active virus in the vaccine, and its prohibition from a religious perspective [20]. Another study in Saudi Arabia showed that while many mothers (close to 80%) are aware of the importance of vaccination, a quarter of them are still hesitant about vaccinating their children [4].
Another study conducted in two polio-endemic countries (Nigeria and Afghanistan) indicated that distrust in politicians, societal beliefs, and insecurity are critical obstacles in advocacy programs for polio eradication [13]. A report by The Lancet journal on the state of immunization programs in Afghanistan in 2019 showed that parents, influenced by prevailing beliefs and attitudes, perceive imported vaccines as a cause of infertility in their children as they grow up [8].These findings broadly support the results of the present study.
Štrbac et al. [33] found in Serbia that many parents believe vaccination can lead to rare and unknown diseases. The study revealed that distrust in local and global medical advice, especially in areas with lower literacy levels, is a significant factor in spreading these beliefs [33]. Comparing the present study’s results with Štrbac’s research shows that claims regarding contracting rare diseases post-vaccination are commonly shared across different societies. These concerns stem from distrust in doctors and experts, which necessitates comprehensive educational programs at the community level and collaboration with local leaders to address these worries.
In a multi-country study on the political economy of vaccine financing conducted in six African countries, Nonvignon et al. [28] found that concerns about financial mismanagement and the use of vaccination programs for political influence contributed to declining public trust in immunization effort [28]. While not all participants shared this view, several interviewees expressed concerns that polio vaccination campaigns may be tied to financial corruption or political agendas, citing things they had heard online or within their communities. These narratives reflect broader patterns of institutional mistrust and point to the need for future research to explore the origins and influence of such beliefs. This illustrates a competing priorities model where individuals must make difficult decisions with limited resources, such as choosing between taking time off work to vaccinate their children or securing daily income. In this context, vaccine hesitancy may be better understood as vaccine deprioritization—a strategic, if reluctant, choice in the face of economic hardship.
The present study’s findings align with those of Nanovignon et al., with both studies indicating that concerns over fund misappropriation lead to reduced public trust and, ultimately, lower vaccination uptake. Therefore, transparency in budget allocation and efficient resource management are essential.
Bagateli et al. [7], in a study in rural Brazil, highlighted that many parents believe vaccination weakens the body’s natural immune system, making it more vulnerable to other diseases. This belief was predominantly observed in areas with lower educational levels and limited access to healthcare services [7]. The present study’s findings on distrust in the body’s ability to recover its immunity post-vaccination are consistent with Bagateli’s results. Both studies indicate that these beliefs are more prevalent among individuals with limited access to scientific information, underscoring the need for continuous education and credible information sources to alleviate these concerns.
A study by Mahato et al. [26] in India found that one of the major parental concerns regarding vaccination is the fear of infertility in the future. The study noted that belief in using vaccines as a population control tool is widespread, particularly in densely populated areas with economic challenges [26]. The current study also refers to similar concerns, with some families believing that vaccination could reduce boys’ fertility. Mahato et al.’s findings confirm that such beliefs are more common in regions with lower economic well-being, which highlights the need for effective public communication and scientific clarification on these issues.
Government inadequacies
A recurring theme in our findings was a strong sense of dissatisfaction with the government’s role in supporting families, particularly in relation to their economic struggles. Participants frequently framed vaccination not as a health decision, but as one entangled with unmet socio-economic needs. For example, one participant stated: “I need economic assistance more than the vaccine”, while another remarked: “We have economic issues; the government should help us… and then we’ll vaccinate.”
These statements reveal that refusal to vaccinate may not always reflect distrust in the vaccine itself, but rather a broader frustration with perceived neglect. In this context, families appear to view health interventions such as vaccination as secondary to more immediate priorities like employment, food security, or housing. Vaccine uptake, then, becomes conditional—not on scientific evidence—but on the government’s ability to demonstrate care and support.
Our study builds on existing literature (e.g.,[16, 25]) by showing that economic disenfranchisement can directly shape health behavior. While prior studies have shown that poverty and infrastructure gaps impact vaccine coverage, our findings suggest that vaccine refusal can become a symbolic act of protest, especially when communities feel abandoned or marginalized.
Improving trust in public health requires addressing these material realities. Efforts to boost vaccine uptake must go hand-in-hand with programs that visibly improve living conditions, provide financial aid, or support local livelihoods. Without such parallel investments, even the most well-designed vaccination campaigns may struggle to overcome economic skepticism.
Comparing this study’s findings with Allen et al.’s research on the role of governments in ensuring the success of health and vaccination programs shows that economic weakness and the government’s inability to provide livelihoods lead to public distrust and resistance to vaccination programs in Nigeria. Allen et al. explain that in regions where people face poverty and unemployment, their daily priorities, such as food and work, overshadow government health programs [5].
A study by Kumraj et al. [23] on vaccine production challenges in developing countries highlighted the lack of domestic vaccine production infrastructure. Conducted in South Sudan, the study revealed that, due to the absence of necessary infrastructure, developing countries rely heavily on vaccine imports, resulting in increased costs and logistical problems that ultimately delay vaccination programs [23].
A study by Suman et al. [34] on the relationship between economic conditions, local businesses, and vaccination in parts of India found that economic prosperity and thriving local businesses directly correlate with increased acceptance of vaccination programs. In areas where people feel their livelihoods are supported by government programs, there was also a higher receptivity to health initiatives [34].
Gibson et al. [16], in a study examining the role of local governments in successful vaccination programs, found that the ineffectiveness of local governments in creating necessary infrastructure and providing financial resources increased public distrust toward vaccination programs. In these regions, the absence of strong local leadership and poor government organization posed significant barriers to the success of health programs [16]. The present study’s findings on Herat’s local government’s failure to provide infrastructure and livelihoods align with this research. Both studies demonstrate that local governments’ inability to establish healthcare and economic infrastructure directly impacts the decline in public trust toward vaccination programs. Therefore, improving local government efficiency and strengthening health infrastructure are critical for increasing vaccine acceptance.
A subset of participants expressed strong skepticism toward the financial motivations behind polio vaccination campaigns. Some viewed the program as part of a larger “business” or “mafia,” claiming that donors, governments, or external actors were profiting under the guise of public health. One participant noted: “I’ve seen online that vaccination is a kind of business imposed on the Afghan people”—a statement that reflects how perceptions of corruption and international agendas can erode public trust, even in life-saving interventions.
The origins of these misconceptions remain difficult to trace with precision, but qualitative insights suggest they are largely shaped by informal social networks, interpersonal discussions, and increasingly by content shared on social media platforms such as WhatsApp, Facebook, and YouTube. These channels often circulate unverified information, conspiracy theories, or religious misinterpretations that gain credibility through repetition and community trust. For example, the belief that vaccines are a form of “business imposed on Afghan people” reflects not only economic frustration but also a broader mistrust of foreign agendas and development programs. This skepticism may be further amplified by historical experiences of marginalization or neglect, leading some communities to equate international aid efforts with covert political or economic interests. Similar patterns have been observed in other contexts, such as among minority populations in the United States, where medical distrust is rooted in historical injustices. Understanding the sociocultural pathways through which these beliefs are transmitted is essential for designing effective communication and trust-building strategies.
These beliefs, though not supported by evidence, are socially potent. They are likely shaped by repeated exposure to conspiracy narratives—especially via informal networks, word-of-mouth, or social media—combined with a history of weak financial transparency in public services. In such environments, mistrust becomes a rationalized response to years of exclusion or disappointment, not just fear or ignorance.
While previous studies (e.g., [28]) have shown that vaccine programs are occasionally viewed as vehicles for political gain or financial mismanagement, our findings underscore the emotional and moral tone of such perceptions. In Herat, some families see the polio campaign not as a neutral health effort, but as part of a larger system of unequal power and profit—where their role is passive and exploited.
To counter these narratives, health communication must go beyond education. Transparent reporting of funding sources, clear documentation of how funds are used locally, and visible community engagement in the planning and implementation of vaccination efforts are essential. Without these accountability measures, rumors of exploitation may continue to thrive, even in the face of good intentions.
These perceptions, while not always rooted in concrete evidence, seem to be shaped by a mix of social media influence, hearsay, and historical mistrust of foreign institutions. Participants frequently mentioned “what I’ve seen online” or “people say,” suggesting that informal digital platforms and local rumor networks are powerful sources of information. In the absence of authoritative health messaging, such channels appear to fill the vacuum—often with speculative or conspiratorial content. This dynamic is not unique to Afghanistan; similar distrust in vaccines has been reported among minority populations in other countries, such as the United States, where historical injustices in healthcare contribute to enduring skepticism. These parallels underscore the need for culturally tailored, trust-building strategies that acknowledge past harms while improving access to credible, transparent information.
Cultural barriers
Our findings revealed that cultural and religious concerns—particularly beliefs about haram ingredients and fatwas—play a significant role in vaccine refusal. Participants repeatedly expressed fears about the presence of pig-derived substances in vaccines and referenced statements from religious leaders who declared vaccines as forbidden. These beliefs reflect a deep connection between health behaviors and religious guidance in the region. Rather than being isolated misconceptions, they appear rooted in collective narratives shaped by historical distrust and socio-religious identity. For instance, one participant stated: “It’s haram, made from pig blood, coming from an infidel country.” These sentiments illustrate not just misinformation, but a broader skepticism toward foreign health interventions. These perceptions were shaped not by verified scientific information, but rather by religious interpretations and lived experience. Several participants referred to the good health of their unvaccinated parents as proof that vaccines are unnecessary, reinforcing generational skepticism. Furthermore, the classification of vaccine components as haram was based on widely circulated beliefs and fatwas, even though no direct evidence of forbidden ingredients was known to the participants. This suggests that vaccine hesitancy is grounded as much in cultural memory and social narratives as in any specific doctrine or medical claim.
Numerous studies point to the role of cultural and religious beliefs as significant barriers to immunization in less developed countries [9]. A 2018 report by The Lancet on the immunization status of children under five in Afghanistan revealed that around 600,000 children were deprived of vaccines, with 30% of the refusers being parents influenced by religious beliefs regarding the haram nature of vaccines in Islam. Religious fatwas and the lack of support from ethnic and sometimes political leaders in Taliban-controlled areas were additional influencing factors [31].
Several international studies have also shown how religious perceptions impact vaccine uptake, including findings from Malaysia [11]. However, our study uniquely highlights the emotional and identity-based dimensions of these concerns, showing how vaccine hesitancy can be a form of symbolic resistance. Addressing such deeply held beliefs requires culturally informed strategies and engagement with respected religious authorities who can clarify the halal nature of vaccines and counter religious misinformation in locally trusted ways.
Numerous studies point to the role of cultural and religious beliefs as significant barriers to immunization in less developed countries [9]. A 2018 report by The Lancet on the immunization status of children under five in Afghanistan revealed that around 600,000 children were deprived of vaccines, with 30% of the refusers being parents influenced by religious beliefs regarding the haram nature of vaccines in Islam. Religious fatwas and the lack of support from ethnic and sometimes political leaders in Taliban-controlled areas were additional influencing factors [31].
Another 2020 report on the state of vaccination and polio eradication programs in Afghanistan, according to the Ministry of Health statistics, revealed that religious fatwas declaring vaccines haram from an Islamic perspective were another reason for family refusal to participate. Religious and community leaders in polio-affected areas believed that vaccination teams visit homes for espionage, which further perpetuates cultural beliefs [36].
A 2022 study in Pakistan cited various reasons for vaccine refusal, including beliefs, rumors, religious leaders, parental education, and their conviction against child vaccination. Some participants believed that child vaccination was unnecessary, possibly due to underestimating the disease, low literacy, or other reasons [21]. These studies support the findings of this study in this regard.
A study by Alkhalemi et al. in Malaysia explored religious barriers related to vaccination. The study showed that religious concerns about whether vaccine ingredients were halal or haram were a primary reason for refusal. Specifically, the use of animal-derived gelatin in vaccines raised concerns among Muslims about the religious legitimacy of these vaccines [11]. However, according to the World Health Organization, oral polio vaccines do not contain any pig-derived ingredients, such as gelatin or pork enzymes, and are considered halal. Providing this clarification through credible religious and health authorities may help reduce resistance rooted in such misconceptions [37].
The findings of this study are consistent with those of Alkhalemi et al., with both studies indicating that religious issues and the halal status of vaccine ingredients play a significant role in vaccination refusal among Muslims. Therefore, providing more detailed information on vaccine ingredients and validated religious fatwas can help address these concerns.
A study by Mavundza et al. [27]in Nigeria revealed that local religious scholars’ fatwas had a profound influence on parents’ vaccination decisions. In this research, it was found that in some areas, religious leaders issued fatwas against vaccination for various reasons, including distrust in the government and the influence of rumors, which led to lower vaccination rates among the public [27].
A study by Sophie et al. [32] n Afghanistan found that many parents did not trust the benefits of vaccination due to the health of previous generations who had not been vaccinated. In this study, parents noted that they and their parents remained healthy without vaccination, so they did not see the need for it [32]. This current study also highlights this issue, showing that some parents view vaccination as unnecessary due to the health of previous generations who were not vaccinated. This finding aligns with Sophie’s study and suggests that a lack of trust in the benefits of vaccination is a key factor in vaccine hesitancy. Comprehensive education and accurate information on the role of vaccines in preventing infectious diseases can address this issue.
A study by Habib et al. [18] in Pakistan examined social and cultural attitudes toward vaccination. This research showed that many parents viewed vaccination as unimportant and unnecessary. They believed there were more pressing priorities, such as providing food and daily work, and therefore did not place much importance on vaccination [18].
Based on the findings, targeted strategies could include policies aimed at strengthening trust in healthcare, such as increasing transparency in vaccine sourcing and quality through regular public updates and reports. Additionally, investing in local vaccine production or regional partnerships could address participants’ distrust of foreign-made vaccines, potentially improving uptake. Community-based education programs led by trusted religious and community leaders, tailored to address specific misconceptions about vaccine safety and efficacy, would also be vital in fostering trust and dispelling fears about vaccine-related health risks.
This study has several limitations that may impact the generalizability of its findings. First, the focus on Herat Province, while providing valuable insights into local vaccine hesitancy, may not capture the full diversity of perspectives across Afghanistan’s different regions and cultural contexts. Additionally, the purposeful sampling strategy, though effective in reaching vaccine-hesitant families, may introduce sample bias, as participants with particularly strong views on vaccination were likely overrepresented. Furthermore, the presence of interviewers could have influenced participants’ responses, especially in discussing sensitive topics like distrust in healthcare and government. Future studies would benefit from including multiple provinces and employing methods to minimize interviewer effects, such as anonymous surveys, to build on these findings.
Overall, this study not only confirms themes found in other regions affected by polio—such as religious misconceptions or systemic distrust—but also offers unique contextual insights from Herat. For instance, the framing of vaccination as an economic burden or foreign agenda, as well as localized rumors about its ingredients, show how health decisions are deeply embedded in sociopolitical realities. These insights cannot be treated as mere obstacles; they reflect public reasoning shaped by history, hardship, and competing priorities.
Therefore, addressing vaccine hesitancy in Afghanistan must extend beyond traditional health education. It requires cross-sector strategies that account for economic vulnerabilities, religious leadership involvement, culturally adapted communication, and above all, trust-building measures between communities and service providers. A one-size-fits-all approach is unlikely to succeed in complex settings like Herat.