12,544 The Communication Initiative, Understanding Attitudes to Polio Vaccination and Immunisation in Northern Nigeria, The Drum Beat 694

The Drum BeatResearch Findings: Understanding Attitudes to Polio Vaccination and Immunisation in Northern Nigeria – The Drum Beat 694
A sample of the results:

  • Vaccine refusal is clustered: Approximately 20% of the sample communities accounted for almost three-quarters of refusal risk…
  • Household religious orientation does not appear to correlate with OPV refusal…
  • Trust in government appears strongly associated with attitude towards vaccine compliance…
  • Vaccine programmes need a clearer gender strategy for building communication and engagement between men and women within households…
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The Drum Beat 668 – A Brief Chronology of a Polio Communication Research Initiative described a research process The CI has been engaged in under the auspices of the National Primary Health Care Development Agency (NPHCDA) of Nigeria’s Federal Ministry of Health, led by principal investigator (PI) Dr. Sebastian Taylor and with the generous support of the United States Agency for International Development (USAID) through its Mother and Child Survival Program (MCSP). The research was designed to support the Nigerian government and Global Polio Eradication Initiative (GPEI) partners in developing evidence-led strategies to understand the factors behind household demand (or lack thereof) for immunisation services in Nigeria.

As Dr. Taylor explains in the main research report, the purpose of the research is to develop an in-depth understanding of the underlying family- and community-based issues that influence Nigerians’ attitudes towards immunisation – attitudes that, in spite of the recent and very important July 24 2015 milestone which marked 12 months without detecting a single wild polio virus (WPV) case in Nigeria, continue to impact on the success of the effort to eradicate polio in Nigeria and other parts of the world. Though the research focused on polio vaccination and routine immunisation (RI), it also offers insight into how household demand operates across a range of health and development issues.

This issue of The Drum Beat provides you with an advance overview of the findings and implications as presented in the soon-to-be-released final report. We hope it will be useful to your work and spark discussion on the importance of perception and community priorities in localised decision making. To share your questions and observations on this research and/or to request a copy of the full report, please use the Development Conversations Comment facility at the bottom of this page, which summarises the research results and their strategic implications.

Drawing on Qualitative Comparative Analysis (QCA) – see below – to create a research protocol combining qualitative and quantitative data, the research randomly sampled 30 households per settlement in 60 settlements within wards and local government areas (LGAs) in Sokoto, Kano, and Bauchi states of northern Nigeria. Settlements were not randomly sampled but were instead selected because: (i) they were characterised as high- and low-performing, according to the national government programme’s risk for transmission of WPV and (ii) they had certain “performance” characteristics in terms of supplementary immunisation activity (SIA) coverage. Logistical and security considerations allowed for inclusion of rural and urban settlements in Sokoto, rural and semiurban settlements in Kano, and rural settlements in Bauchi. A representative sample of 480 households was selected per state. Allowing for attrition and substitutions, a total of 3,306 respondents (male and female) in 1,653 households were interviewed using a questionnaire designed to gather information on quantitative and qualitative dimensions of family life: general developmental conditions, household perceptions of (and trust in) external actors, health and healthcare experiences, and knowledge of/attitudes to RI and polio eradication.

The research focused on 2 primary outcome variables – (i) households reporting missed children in past polio SIAs and (ii) households reporting the possibility of refusing oral polio vaccine (OPV) in the future (“propensity to refuse”) – with 2 secondary outcome variables: (i) approval/disapproval of the Polio Eradication Initiative (PEI), and (ii) approval/disapproval of RI.

  • A significant minority of sampled households reported having missed children (16-17%); a similar proportion reported considering OPV refusal in the future (14-17%). Households reporting missed children in the past were significantly more likely to consider refusing OPV in the future, a finding that is likely reflective of intentional caregiver behaviour. “The fact that 0-dose children have a substantially higher chance of being missed in northern Nigeria suggests, further, that a substantial part of household refusal is continuous over multiple SIAs, and hence ‘chronic’. This also suggests that behaviour-change communication [BCC] interventions are not having the required effect for all risk groups, in particular entrenched refusal.”
  • Propensity to refuse OPV was found to be clustered in specific settlements: Approximately 20% of the sample communities accounted for almost three-quarters of refusal risk (and over half of all reported missed children). “This clustering suggests that refusal may be at least partially a collective, community-level effect, requiring a collective, community-level response.” The researchers found that “urban households (who do not fit the conventional risk profile of poor, poorly educated, illiterate and susceptible to anti-vaccine rumours) require strategic attention”. The MRR further notes that urban refusal has been found in other eradication programmes, notably Greater Cairo, Egypt, where urban families, at higher levels of wealth and education, viewed private health practitioners as preferable to mass-delivered public health services.
  • Knowledge of immunisation practices and vaccines – including but not limited to OPV alone – is strongly associated with reduced risk of refusal in urban, semiurban, and rural households across all states. “[E]xpansion of routine immunisation (awareness, understanding and service provision) may be a primary, rather than ancillary, strategy for enhancing OPV uptake.”
  • “[I]nterventions that can build alignment between male and female caregivers (e.g. on vaccination) may be helpful in improving acceptance….PEI (and wider health system strengthening) need a clearer gender strategy – building communication and engagement between men and women within households, but also through their mutual participation in the planning and management of community health activities, and integrating female health workers more closely in institutional processes of service planning and delivery.”
  • The intensity of household religious orientation does not appear to correlate with OPV refusal. Thus, “[w]hilst there are many reasons to engage with religious and traditional leaders for public health, a predominant emphasis on religious and traditional leaders as principal interlocutors for polio vaccination (and their interlocution as the primary mechanism for addressing OPV refusal) does not appear justified.”
  • “A combination of higher expectations from government and lesser belief that government is responsive to community needs was strongly correlated with higher risk of OPV refusal. It may be disappointment in government that shapes negative attitudes to a programme like polio eradication….However, it is clear that high-risk settlements trust government in some areas. A critical objective (both for PEI and longer-term expansion of RI) may be to “extend that trust into the field of public health, but to do so in ways which are consistent with public perceptions of legitimate state intervention.”
  • Settlements at higher risk of refusing OPV have systematically lower levels of households reporting participation in community meetings.
Polio Eradication – Using Qualitative Comparative Analysis to Strengthen Understanding of Social Factors in Programme Effectiveness by Dr. Sebastian Taylor.

Dr. Taylor has also given presentations on the methodology he used for this research – one of which was at a meeting in London, United Kingdom (UK) in March 2015 entitled “Local and Household Decision Making on Health in Northern Nigeria, Polio/Routine Immunization Research Insights. An Innovative Use of QCA methodology for Health Communication”, which can be found by clicking here.

Strategic implications of health camps:
  • “State programmes should strengthen capacity (including developing qualitative and quantitative data-gathering methods) to analyse programme performance at settlement level, to identify persistent localised gaps in SIA performance.”
  • “…State programmes should investigate PEI performance and RI uptake in urban and semiurban settlements to assess the extent of a new/emerging urban set of OPV/RI risks.
  • Programmes should re-balance the current focus on poor/poorly-educated, rural households, to develop capability to respond to urban dynamics of OPV, RI and wider health demand.
  • Programmes in Sokoto and Kano should conduct targeted investigations in VHR [very high -risk] settlements (for example using ‘social network analysis’) to analyse how households develop and share information/attitudes to PEI/RI…
  • State programmes should strengthen information and communication on the benefits of routine immunisation as a general practice, focusing on mitigating negative perceptions (e.g. AEFI [adverse events following immunisation)…
  • State programmes should focus on building health communication between men and women within communities, strengthening shared commitment by male and female caregivers to health and education as community development priorities.
  • A gender strategy should build male-female engagement at household, but also at community participation and service-provision levels.
  • State programmes should maintain networks and relations with religious and traditional leaders to create a supportive ‘background’ environment of cultural norms for PEI and RI.
  • But strategic focus and resources should be rebalanced in favour of promoting local government leadership on public health provision, and community-level engagement…
  • State programmes should re-balance current emphasis on individual behaviour change, to build a stronger community context of public health within which PEI (and RI) happens.
  • …[O]ur research suggests that the ‘health camp’ concept may have considerable potential as a strategic intervention – primarily for PEI in the short term, but with positive cross-over effects for RI. Health camps constitute a practical way forward to build ‘public health under one roof’…[b]ut the health camp concept needs to be developed, and the quality of implementation strengthened (with a potential pilot in Sokoto).
  • Health camps should be run alongside SIAs. They should offer a way of accessing OPV and other antigens/health services which complements house-to-house campaign vaccination. Health camps should be regular and more substantial in scale, offering a consistent, publicly desired suite of public health and nutritional interventions within which OPV/IPV are delivered. They should be situated in well-known public spaces and where possible attached to publicly-valued and trusted institutions/activities (such as education or therapeutic feeding centres)…”
A pre-view summary of the annexes can be found here.
  • Annex a: Research Governance and Participation
  • Annex b: Detailed methodology
  • Annex c: Demographic and socioeconomic profile of sample
  • Annex d: State-specific analysis breakdown
  • Annex e: Ethical approval from the Nigerian Health Research Ethics Committee (NHREC)
  • Annex f: Composite variables indices
  • Annex g: Data analysis and analytical methodology (pages 36-37)
The World Health Organization (WHO), in partnership with non-governmental organisations (NGOs) and civil society organisations (CSOs), is hosting a global consultation to discuss WHO’s new End tuberculosis (TB) strategy, with a focus on the role of collaboration and cooperation between governments, NGOs, CSOs, and community members in reducing TB deaths by 95% and the incidence of TB by 90% by the year 2035. These organisations, which include faith-based organisations (FBOs), patient-based organisations, professional associations, and others, engage in activities that range from community mobilisation, service delivery, and technical assistance to research and advocacy to combat TB, including through what WHO describes as a tool that needs to be made available by 2025: “a new vaccine that is effective pre- and post-exposure.”

In advance of the November 11-13 2015 consultation in Addis Ababa, Ethiopia, you are invited to take a brief online survey to identify critical areas and main challenges that need to be discussed during November’s workshop, as well as to select national and indigenous NGOs and CSOs to submit a 500-word proposal to compete for WHO financial support to attend the workshop in Ethiopia.

The online survey, which is available in English, French, and Spanish, will run until August 31 2015. Please click here to participate and to find more information on the WHO End TB Strategy.

This issue of The Drum Beat was written by Kier Olsen DeVries and Chris Morry.
The Drum Beat is the email and web network of The Communication Initiative Partnership – Partners: ANDI, BBC Media Action, Bernard van Leer Foundation, Breakthrough, Calandria, Citurna TV, DFID, FAO, FundaciÛn Imaginario, FundaciÛn Nuevo Periodismo Iberoamericano (FNPI), Inter-American Development Bank, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, MISA, Oxfam Novib, PAHO, The Panos Institute, Puntos de Encuentro, The Rockefeller Foundation, SAfAIDS, Sesame Workshop, Soul City, STEPS International, UNAIDS, UNDP, UNICEF, USAID, The Wellcome Trust, World Health Organization (WHO), W.K. Kellogg Foundation.

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