Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Global Polio Eradication Campaign: A Critique Of The Health Belief Model In Northern Nigeria- Olubunmi Orekoya

Poliomyelitis (polio) is a highly infectious viral disease that can affect people of any age but typically afflicts children aged five years and younger. Among older children and adults, it mainly affects those who have compromised immune systems. Polio is a disease of the nervous system, particularly of the spinal cord, that causes such symptoms as fever, fatigue, headache, vomiting, stiffness in the neck, pain in the limbs, and one in 200 polio infections can lead to irreversible paralysis (1-2). Polio is a contagious, historically devastating disease that was virtually eliminated from the Western hemisphere in the second half of the 20th century. However, the disease still remains endemic in four countries Nigeria, India, Afghanistan and Pakistan (2).
In 1988, the Global Polio Eradication Initiative, spearheaded by the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC) and UNICEF was launched to eradicate polio infection. Its main goals are 1) to interrupt transmission of the wild poliovirus as soon as possible, 2) achieve certification of global polio eradication and 3) contribute to health systems development and strengthening routine immunization and surveillance for communicable diseases in a systematic way (3,4). These goals were to be achieved by having high oral polio vaccine (OPV) immunization coverage rate across countries (4). The program has made remarkable progress in reducing the number of poliomyelitis cases from 350,000 in 1988 to 2,917 in 2000 globally and out of 126 countries only four remain endemic (5).
However, the program has faced many challenges that prevent it from meeting its goals and the projected year of eradication has been postponed about two times (6). In 2003, it suffered a major setback in Nigeria where three states boycotted the immunization program when political and religious leaders endorsed the belief that the immunization was a ploy by the Western countries to reduce the population of Muslims (7). The oral polio vaccine was also believed to be laced with antifertility agents, cancerous agents and the HIV virus (6, 7). Due to this singular act of boycotting in Nigeria, the poliovirus in northern Nigeria has also spread to 20 previously polio-free countries (6-8). In high-incidence states in Nigeria, many children remain under immunized with 40% of children receiving fewer than the full three doses of the OPV (9).
The reported cases of acute flaccid paralysis have increased significantly from 1,937 in 2001 to 5,536 in 2008 while the confirmed cases of paralysis increased from 56 to 860 within the same time period (10). Another major concern for the Global Polio Eradication Initiative (GPEI) is funding. Donors are already getting inpatient, because the set date for eradication has been pushed back twice. What is more, the new set date for eradication (2010) does not look feasible considering the setback in Nigeria. The campaign was estimated to cost the U.S. about $2 billion dollars but presently has gulped about $4.5 billion, and the cost is still growing (6).
Polio Eradication Campaign in Nigeria
The strategies employed in Nigeria typifies the health belief model (HBM) and use mass media to advert to make individuals believe that polio is real, causes severe paralysis and that children are susceptible to the infection. The health belief model was developed to explain health related behavior at the individual level. It assumes that human behavior is rational, planned and within an individual’s control (11, 12). The characteristics of this model are based on four assumptions that for individuals to take action to avoid a disease, they would need to believe that 1) they are personally susceptible to it 2) the occurrence of disease would have moderate severity on their lives 3) taking a particular action will be beneficial to them and 4) taking action would not involve overcoming important barriers like cost, convenience, pain and embarrassment (12).
In accordance with the HBM, the GPEI emphasized that taking OPV is very beneficial explaining that it will reduce an individuals’ susceptibility to the disease and keep children healthy. Generally, the approach tried to sell Health without regard for the cultural context. Although the health belief model was designed primarily for preventive health behavior, it was not helpful in this particular context because of the preceding rumors and negative labeling attached to the vaccine. The following argument explains why the Global Eradication campaign failed in Nigeria resulting in a major setback for the country and the world.
Argument 1
The GPEI focused on the individual level without addressing social and environmental factors
The GPEI initiative in Nigeria based their campaign on individual susceptibility and the severity of polio. They used mass media to emphasize risk and promote their campaign through TV, radio posters and bulletins. They assumed that the advertisements would influence and change people’s behavior. Although this method increased knowledge and awareness of polio, it did not translate into a higher coverage rate of vaccination. Despite the campaign, some individuals did not believe that their children would ever be infected. What is more, some still think that polio is a disease of the past. The campaign reached the masses through the media but the message was targeted towards the individual, emphasizing individual risk.
The program failed to consider the social learning theory, which emphasizes that people are influenced by observing others (11, 15). Social learning theory focuses on the learning that occurs within a social context. It considers that people learn from one another, including such concepts as observational learning, imitation, and modeling. This theory also suggests that the environment reinforces modeling (11). The social context and environment of the northerners in Nigeria in 2003 reinforced the parents’ motivation and beliefs not to take their children for immunization. The parents were already influenced by the actions of their religious leaders and others within their community. The people closest to them in their communities and their leaders upon whose judgment they relied spread rumors of the danger of OPV. Hence, it was not possible to change the perceptions of these individuals by merely increasing their knowledge.
Additionally, the GPEI campaign did not consider the influence of opinion leaders in the diffusion of innovations theory. Opinion leaders have been known to be quite effective in spreading the negative and positive aspects of a program (12). A group of people is more likely to be influenced by leaders within their social context than advertisements on TV that state the facts of polio infection. It was difficult for these communities to relate with the message of the campaign. Also this message may not have reached the intended target group. Many places in Northern Nigeria from where the rumor stemmed do not have access to electricity to listen to these advertisements. Although some of the bulletins were written in the local language, the vast majority of people in rural areas cannot read making it extremely difficult to benefit from the campaign. However, the rumors’ concerning OPV were spread far and wide within their social system, because it was spread by word of mouth in the language people understand.
Argument 2
Failure to recognize the basic needs and core values of the community other than health.
The GPEI failed to utilize the principles of Abraham Maslow’s hierarchy of needs which state that basic needs must be met before higher needs are met. Maslow’s model described various human needs such as physiologic, social and safety needs that influence higher needs of self-actualization (13). For many northern Nigerians, their safety need, which is one of the needs at the base of the hierarchical model, had not been met. The Muslims in Northern Nigeria felt that their safety was threatened, because it has been propagated that OPV contains dangerous agents. These individuals were not able to tackle the higher needs of acceptance of facts or problem solving, because their basic needs of safety have not been met. Obviously, it will be difficult to reduce the prevalence of Polio infection in Nigeria by OPV if OPV is seen as harmful. There are also other factors prevalent in the developing world like low SES whereby many families cannot afford sufficient food or accommodation. It is unrealistic to assume that parents will consider immunization, an act that requires motivation, lack of prejudice and acceptance of fact, if basic physiologic needs are not met. Moreover, the program failed to emphasize or improve other predisposing factors to polio infection that are preventable such as overcrowding, poor hygiene, lack of potable water and poor hand washing.
Additionally, the GPEI tried to sell “health” without considering that people may value health as less important than other assets. In Nigeria, issues such as fertility are more important than severity of polio infection. It is more culturally and religiously acceptable to be lame or crippled from polio infection than to be infertile. Since the OPV vaccine was said to be contaminated with anti-infertility agents, unsafe for young Muslim girls, the practice of immunization was not consistent with their cultural values.
The campaign focused mainly on the benefits of health without acknowledging the advertising theory, which emphasizes that people are influenced by large promises (14). Advertising theory posits that the larger the promise, the more effective the intervention. This theory also emphasizes that the “promise” has two aspects 1) the product 2) the benefits which must be supported by images, stories, or symbols. There is a need for public health advocates to understand the lifestyle of the people whose behavior they are trying to change. Public health advocates need to understand, for example, the core values that are important to the northerners in Nigeria; tradition, families, freedom and control. The GPEI did not offer any large promises other than health. The advertisements’ claims were supported with children on crutches and wheelchairs and emphasis was placed on facts and statistics not on images or stories that promote their core values. The campaign’s emphasis was to prevent polio infection by asking parents to bring their children for immunization i.e. the product is the OPV.

Argument 3
Failure to recognize the cultural context and utilize effective communication strategies that are culturally competent
A successful and effective health promotion campaign must be culturally competent and understand the historical context of the population it intends to serve. Failure to acknowledge the historical and cultural context of the Islamic world in Northern Nigeria also led to the poor OPV coverage rate. The GPEI campaign did not put into perspective the cultural theory, which explains health behavior as part of a pattern of living that integrates action with meanings and values as these are connected to a larger social structure (16). A culturally competent public health program will consider what it means to be healthy, what constitutes illnesses or disease, and how immunization is shaped by the larger social structure of the targeted population (16, 17). In the northern states of Nigeria, if a person falls ill or becomes handicapped, it is accepted as the will of “Allah.” Being crippled is not classified as a shameful condition, but it is assumed that it is one’s destiny. Being healthy does not have to do with whether you can walk or not but if you can afford to eat three meals each day. Furthermore, some communities in northern Nigeria believe that illnesses are related to spiritual causes rather than a biological cause. Therefore, emphasizing the negative effects of polio by paralysis will not influence the target audience’s decision to immunize their children nor will it be easy to persuade community members that immunization can prevent paralysis from polio.
The GPEI program failed to identify or address the beliefs, traditions and cultural norms of northern Nigerians towards immunizations. Unlike the Southerners, the Northerners have not historically been particularly receptive to Modern Medicine which is partly due to lack of infrastructure and lower levels of education. The National Demographic Health Survey in 2003 showed the completed immunization rate for all vaccines in the rural northern state was about 40% lower than the Southern states before the rumors started (8). Hence, it was not a traditional value or cultural norm to go to the health centers for immunization. from the outset immunization campaign, generally, has not been successful in its approach to reach the target population in the northern states because it is not viewed as a traditional value. This fact , coupled with the rumors, made the GPEI unsuccessful in its approach in northern Nigeria.
The time the rumors started also coincides with the period that the USA went to war against Iraq. Since the northerners were predominantly Muslims, it was believed that the USA was trying to find a way to eliminate Muslims from other countries by sending vaccines. (7) However, the campaign failed to use effective communication strategies to stop the spread of the rumors and implement its goals. To get a message across to the population, communication theory emphasizes the following important elements 1) the need to determine the context or setting of the communication 2) the relationship between the sender and the receiver i.e. does one have authority over the other? 3) finding the appropriate channels and the meaning attached to the channel and 4) finding out if the intended target group is receiving the message and interpreting it the way it is intended (16). These four elements take into consideration the need to understand the cultural or historical context of a community before development of a communication strategy.
Studies have shown that mass media and information dissemination approaches used in immunization efforts have contributed to success in India (18, 19). Findings also show that communication strategies have been used effectively in mobilizing social networks and leaders; creating political will; increasing knowledge; ensuring individual and community-level demand; overcoming gender barriers and resistance to vaccination; and reaching out to the poorest and marginalized populations (18, 20-24). The communication strategy utilized in India understood the cultural context of the community and therefore tailored their communication effectively towards the targeted population. The GPEI goal should have been to understand the cultural and historical values of the target population in Nigeria and thereafter tailor the interventions accordingly.

An effective health promotion campaign must not be based solely only on individual change; it must include efforts to change community behavior as well as the physical and social environment of communities (11). The social ecological model would be an effective tool to increase OPV coverage rate in Nigeria, because this model recognizes the interwoven relationship that exists between the individual and their environment. It also emphasizes how the behavior of an individual is influenced not only by the attitudes and practices of that individual but also by their personal relationships as well as community and societal factors (25-27). The social ecological model (SEM) further describes the multiple levels of intervention, beginning with individual level change and culminating with societal change (26). The major flaws and criticisms of the polio eradication campaign previously highlighted will be taken into consideration as the strengths of the social ecological model are reviewed.
There are four major levels of the social ecological model: (25, 27)
Individual level influences are personal factors that influence behavior such as attitudes, knowledge beliefs and personality traits.
Interpersonal relationship level includes factors that influence behavior due to relationships with peers, intimate partners, and family member. This level provides social identity, social support and role definition.
Community level factors includes those factors that influence behavior based on individual relationship with community and social environments such as schools, workplaces, religious homes, and neighborhoods. These include both formal and informal social networks.
Societal level influences are larger, macro-level factors such as policies and laws that regulate or support healthy actions and practices for disease prevention, and health promotion. This level influences religious or cultural belief systems, societal norms, and economic or social policies.
With the above mentioned theoretical framework of SEM, I am proposing a community based approach to increase OPV coverage rate and subsequently eradicate polio infection in Nigeria and globally. This intervention will use the social ecological model, which focuses on the interwoven relationship between the individual and the environment, and the community organization theory which helps community members identify shared problems, plan and carry out solutions to these problems (28). This strategy will utilize existing structures and members in the community including community leaders, schoolteachers, community health worker, midwives and traditional birth attendants. The objective is to implement a program that has tangible impact on the community, is sustainable, economically feasible, and effective. Community capacity strengthening and mobilization will be utilized among existing community groups to allow for a program that will be socially acceptable and culturally competent. A pre-intervention survey will be carried out to access knowledge, attitudes and beliefs of the community on polio infection and immunization and also to assess the prevalence rate in the community. The survey will also aim to assess the cultural norms and beliefs and core values of the community. An initial workshop will be conducted to identify community members who are already empowered to lead this program, organize community dialogue and gain support for the program
Perceived barriers to the program and possible solutions will also be discussed and reviewed. This will provide a framework on how to work within the social system to ensure effectiveness. The target population will be the northern states of Nigeria, since this where the boycott of immunization stemmed from and where the prevalence of polio infection is highest. This will initially serve as the pilot project before it is extended to all communities in Nigeria. The following strategies will be utilized at each level of the social ecological model.
1) Individual education
Preventive strategies at this level are often designed to promote attitudes, beliefs, and behaviors that support health promoting behavior. Specific approaches will include using communication strategies, mentoring and education to promote health seeking and health promoting behavior
This intervention will aim to increase knowledge and awareness of polio infection. One of the aims of the pre-intervention survey is to find out how information is most effectively conveyed in the community. This will influence how the message of the campaign is delivered and what language and wording are used. Based on the findings and what has been learned from listening to the community, we will develop an intervention that is culturally competent. The traditional means of communication include town criers (traditional messengers who convey message across the town by word of mouth and clanking of bells), community meetings and local radio and TV station.
Community health talks will also be given at the market place, community meetings and religious homes emphasizing their core values to increase knowledge and awareness on polio infection. It will use an interactive method and also show videos on local TV and organize role plays. In building knowledge and awareness, our intervention will seek to portray advertisements that will focus on their core values. Emphasis will be placed on the safety of the vaccines. The opinion leaders identified will be fully involved in the interactive sessions. The importance of educating individuals is for them to influence other members of their household linking to the strength of the interpersonal level strategy and thereby initiating a cascade of new adopters of the proposed intervention.
Since polio is transmitted feco-orally, one of the goals at this level is to address other predisposing factors to polio such as poor hand washing, poor environmental sanitation and poor personal hygiene. Health education on polio prevention will be given at prenatal clinics, community meetings and school routinely on personal and environmental hygiene. This will play a significant role in changing the attitudes, behaviors of people and thereby influence health promoting behavior at the individual level
2) Interpersonal factor strategy
A person’s closest social circle—peers, partners and family members—can shape an individual’s behavior and range of experience (11). This level can involve both formal and informal social networks and support. Prevention strategies at this level will include education, peer programs and focus group discussion designed to promote immunization among the target population. If large groups can be influenced at the same time, behavioral change can be faster and immunization will be a way of life in the community. The intervention will encourage friends and families to ask their neighbors if their children had been immunized and if they would like to immunize them. Community health workers will carry out home visits to reinforce positive views against polio infection and counsel other family members. A major strategy here is to emphasize the safety of the vaccine by word of mouth, the exact way the rumor was spread. Friends and families that have taken the vaccine without adverse effect will be encouraged to persuade their neighbors to immunize their children.
Community level strategy
The main strategy here is to use existing structures within the community to ensure adequate community mobilization and capacity building. Prevention strategies at this level are typically designed to impact the social environment, processes and policies in a given system (19, 22). Social norm and social marketing campaigns are often used to foster community climates that promote health-seeking behavior. The intervention will upgrade the community health centers to be equipped for immunization by maintaining the cold chain, providing vehicles and freezers to keep vaccines potent. Community members will be trained to give immunization at home and one community health worker will be responsible for at least 10 households to ensure adequate follow up and completion of immunization. Immunization cards will be given to parents for the next appointment. Also prevention messages will be emphasized at the community level in the religious homes by using the support of leaders who are likely to influence their followers. We will focus on community building and empowering the community especially the women in skills training like basket weaving, bead making, crafts and arts. This will improve their decision making power in the family. Emphasis will also be placed on providing sustainable waste disposal system within the community and also making water safe for drinking to eliminate some of the predisposing factors to polio infection.
Societal level strategy
Prevention strategies at this level will involve collaborations by multiple partners to promote social norms, policies, and laws that support immunization coverage in the intended population. This can be at the local, state or federal government level. The intervention will involve the state government by seeking funds for community health services. Our emphasis will be to equip every facet of the health care system to make vaccine available and accessible. There is a need to implement policy to empower members of the community in skill training. This intervention will advocate for policy to influence the political leaders with incentives to get their local government polio free before the year 2010. This will motivate them to ensure the effectiveness of the program. Collaborations with other partners will be sought to ensure funding for community development. The intervention will also advocate for policy that will require immunization for children starting daycare, preschool and primary school.
How this model addresses group level and environmental and social context.
One of the major flaws of the GPEI is its’ failure to consider the impact of environmental and social context of health behavior and only focuses on the individual level. However, the SEM model is a group level intervention that considers visceral factors that are important in influencing people’s behavior and also identifies and analyzes determinants of health behavior at multiple levels. Since this intervention will utilize a pre-intervention survey, focus group discussion and community dialogue to identify the social norms, cultural and religious beliefs, core values and barriers to immunization, it maximizes the important relationship between the individual and its environment. The different levels of strategy put into perspective the core values of the community and then build on that to organize an effective intervention. By trying to improve the health infrastructure and emphasize personal hygiene, the SEM integrates behavioral and environmental based strategy to influence immunization rate and also prevent polio infection. This intervention uses different forms of communication indigenous to the community to create popularity for the program. Also, since our emphasis is to utilize community members, the intervention focused on capacity building and empowerment for community members using interpersonal relationships to reinforce health seeking behaviors. This intervention accounts for one element of social learning theory; people are influenced by observing others.
How this intervention addresses basic needs and advocating core values
The GPEI initiative has also been criticized for its failure to understand the core values that are more important to people than health and did not consider basic needs of the community that had not been met. The new intervention however emphasizes physiologic and safety needs in the advertisements and at the community meetings. The major cause of concern for the community was the danger associated with the vaccine. Based on the rumors that were spread and basic needs that are unmet, the intervention utilizes interpersonal communication and social mobilization to spread the safety of the vaccines. It uses community members and trusted leaders who know the core values and basic needs of the community to lead dialogues with the people and ensure change. The advertisements and dialogue also focus on safety of the vaccines to allay the fear of the people. Also, the program emphasizes community building and development to address other physiologic needs like food and shelter. It addresses skill building for community members to work and provide for their families and also empower them in the decision making process. Additionally, one of the strategies of this intervention is that, it used the individual level and community factor to promote personal and environmental hygiene, provide potable water and upgrade the health center to reduce the spread of polio infection. The primary aim is not only to immunize children but to address other predisposing factors to polio infection. Emphasis was also placed on selling core values and offering larger promises other than health.
How the intervention addresses the historical and cultural issues of the community.
For an intervention to be successful, it must be culturally sensitive to the population it intends to serve. However, the GPEI did not consider the historical and cultural context of the community, hence its’ failure! By using community dialogue led by trusted leaders and the use of pre-intervention survey, the new intervention was able to understand the historical and cultural context of the community. The intervention utilized community members who identified the problems, planned and proffered solutions that were culturally appropriate. Also, the use of appropriate communication channels such as community leaders, community trained health workers, and town criers ensured that the program was culturally acceptable to the target population. Another means by which this intervention addresses cultural issues is that it used community health workers to vaccinate children and counsel family members during home visits. The involvement of community health worker promoted trust, confidence and sense of belonging within the community, and community members are more likely to allow trusted health workers vaccinate their children than an outsider sent by the government.
Polio infection has affected the lives of many children in the developing world causing severe disability, which could have been prevented. The GPEI is a laudable project which is a step in the right direction. However, it is likely to be ineffective in a country such as Nigeria, because it has failed to account for the group and environmental factors peculiar to the country. It also failed to consider the core values, historical context, social norms, basic needs and cultural beliefs of the targeted population.
An effective intervention program must be culturally sensitive and must promote the core values in the community. It must also utilize appropriate communication channels to convey its message. The social ecological model is an appropriate approach to achieve the goals of the GPEI, because it considers the physical and social environment as well as intrapersonal factors that reinforce health-seeking behavior. Remarkable progress can be made to eradicate polio in Nigeria and increase OPV coverage rate if we can implement new interventions using the framework of the SEM. One of the goals of the Millennium development goals is to improve the health of children globally; this goal is achievable using appropriate social science theory.

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