Gender Norms, Religious Narratives, and Social Hierarchies as Determinants of Vaccine Decision-Making in Southern Khyber Pakhtunkhwa, Pakistan: A Qualitative Study

Abstract

It is known that socio-behavioral and structural factors relative to Southern Khyber Pakhtunkhwa yield a vaccine-hesitant populace, a public health problem from which arises the need for more documented data about the social dynamics of hesitancy–particularly gender norms, religious authority, social hierarchy, and informal information networks. A qualitative ethnographic design was used in six districts of the left side of KP in Southern region (Bannu, Lakki Marwat, Dera Ismail Khan, Tank, South and North Waziristan), in which the data were collected using 42 in-depth ethnographic interviews (IDIs), 21 key informant interviews (KIIs), and 20 focus group discussions (FGDs). Purposive sampling and snowball sampling resulted in the inclusion of a wide range of vaccination attitudes and social roles. An inductive thematic analysis (Braun & Clarke, 2006) framework was used for data analysis, while triangulation amongst modalities increased credibility. Four foundational patterns emerged in vaccine decision making: (1) gendered authority limiting the agency of women, as fathers and male elders dominated decisions; (2) religious narratives molding the flow and character of information, with imam endorsement significantly enhancing uptake; (3) social hierarchies precipitating cascades of refusals when influential individuals within communities reject vaccination; and (4) informal  rumor networks – mainly WhatsApp groups, hujra conversations, and mosque-adjacent spaces – spreading misinformation while wielding greater emotional impact and speed than formal channels. The four domains were reinforced on a structural level by institutional mistrust, which resulted from conflict history and fluctuating service delivery. Vaccine hesitancy in Southern KP is part of interwoven social designs that are cautious of or oblivious to formal biomedical communication. Social and Behaviour Change (SBC) responses need a paired approach targeting structural governance reforms while addressing gendered authority, religious legitimacy, social hierarchies, and rumour ecosystems.