Monday, May 10, 2010

A World With(out) Polio: A Critique of the Polio Eradication Campaign in Nigeria – Alix M. Wilson

For much of the western world the crippling effects of polio remain only as a mere memory from the lives of our ancestors. We categorize poliomyelitis as a disease of the past, yet polio remains a serious concern in other areas of the world. The virus remains active in four endemic countries including India, Afghanistan, Pakistan, and Nigeria (3). As of 2010 these countries accounted for 85% of all new polio cases worldwide (7). Although significant progress has been made, there is still much work to be done in areas where poliovirus still infects populations. As the World Health Assembly turned their attention and energy to eradicating polio, they were committed to global eradication by the year 2000 (6). Today, exactly one decade later polio has not disappeared from the global agenda. However, more than any other endemic area, Nigeria’s eradication movement has demonstrated the dangerous effects and setbacks that can come of a failed campaign. The lessons learned in Nigeria are of grave importance for future efforts towards polio eradication. Without careful examination and remediation of Nigeria’s campaign, a world without polio will remain out of reach.

Although the effects of poliomyelitis had been known throughout the 20th century, the virus gained worldwide attention in 1955 with the announcement of the first vaccine against polio by Dr. Jonas Salk (6). During the early 1900’s polio was being referred to as the most serious and most frightening public health problem of the postwar era. (14). By 1952, polio was responsible for killing more children than any other disease at the time worldwide (15). The symptoms of the disease are often not fatal, however polio is an acute viral disease that is highly contagious and frequently passed through the fecal-oral route (7). Most commonly, people acquire the infection from ingesting contaminated food or water. Infection with poliovirus may result in different outcomes. In most cases, polio infections are asymptomatic. However, in 1% of cases, the virus enters the central nervous system and selectively destroys motor neurons resulting in paralysis, permanent loss of limb function, and often death (7). Furthermore, once paralytic damage has occurred there is no treatment to reverse the polio paralysis (6). This muscle paralysis can sometimes result in permanent skeletal deformities, joint tightness, clubfoot, and severe movement disability (14).

As Salk’s announcement to the world brought hope and optimism into the picture of despair created by polio, nations were in dire need of vaccination campaigns. With polio spreading among populations in developing nations where sanitation was lacking, the devastation was even more evident. Finally, in 1988 as the World Health Organization (WHO) launched the global eradication program, Nigeria became one of many countries flooded with health care workers bringing Salk’s vaccine to stop the spread of a disease that had claimed thousand of innocent lives (9). The eradication endeavor around most of the world was achieved, but by the year 2000 Nigeria remained one of four countries still endemic with poliovirus. With success having been achieved in a multitude of different cultures and among all sects of governments around the world one has to ask – why did the campaign falter in Nigeria?

The failure of the public health intervention to eradicate polio in Nigeria can be attributed to three distinct factors. First and most importantly, health workers were not prepared on how to effectively address resistance to vaccination stemming from a lack of perceived susceptibility and unfounded beliefs surrounding the treatment. Second, the campaign efforts failed to fully take into account the viewpoints and core values of Nigerian citizens. Lastly, in conjunction with sociopolitical context, the approach to vaccinate children was too reliant on a top down, vertical strategy with little to no community involvement. Each of these setbacks presented unique challenges and extended the initial deadline past its goal set for the year 2000.

Propelled by the incredible success of smallpox eradication, the case for polio eradication seemed the next feasible step in a global effort to limit infectious disease. The donor world gave billions of dollars to scale up polio eradication efforts, just as it had done previously for smallpox (20). As health workers were sent to Nigeria to scale up vaccination efforts as a part of the global polio eradication campaign, they had one goal in mind: to eradicate polio through vaccination by the year 2000. However they were quickly met with increasing resistance that they were not prepared to resolve. As vaccination campaigns spread throughout Nigeria there was an increasing resistance encountered to accepting the vaccination (21). Without adequate knowledge or any perceived susceptibility, parents were unwilling to allow health care workers to administer the vaccine to their children. As the Health Belief Model indicates, people who have a low perceived susceptibility to a disease or fail to understand the consequences of being infected with a particular disease will be highly unlikely to adopt any behavior targeted to prevent infection (5). Unlike smallpox, the majority of those infected with poliovirus were unaware they had the infection. In fact, polio only results in paralysis in 1 in every 200 of the people who are infected (8). Consequently, if one person is discovered to have polio after displaying signs of paralysis, they have likely already passed along the infection to others who can remain asymptomatic (10). These victims are the most dangerous in the realm of public health. They pass along the disease unknowingly and simultaneously increase the notion of low perceived severity.

The detrimental impacts of perceived susceptibility and perceived severity as defined by the Health Belief Model were extremely underestimated in the vaccine campaigns designed to eradicate polio in Nigeria. In a study conducted in Gombe State, Nigeria, a total of 216 parents out of 422 of those interviewed believed that their children were not susceptible to poliovirus (15). In other words, less than half of these parents had any degree of perceived susceptibility. Moreover, 55.7% of these respondents did not know the route of transmission for poliomyelitis (15). Furthermore, misconceptions about the vaccine’s safety were rampant throughout much of Nigeria (15). In Between 2003 and 2004, the oral polio vaccine was withdrawn from use in the State of Kano due to strong beliefs that the polio vaccine was more harmful than beneficial (16). These barriers are defined in the Health Belief Model as perceived benefits of taking action (5). If parents do not believe there are any perceived benefits to taking action, or worse yet, those results will be harmful, they will be highly unlikely to take up the behavior (5). Without proper evaluation of the low levels of perceived susceptibility, severity, and or benefits to taking action that existed in Nigeria, health care workers were fighting a loosing battle from the very beginning of the campaign. Regardless of the access to and availability of the vaccine for children in this area, immunization days were unsuccessful in vaccinating a large percentage of children (11). Research that led to the development of the Health Belief Model in the 1950’s was based around findings similar to these. At the time free tuberculosis screenings were being offered, but despite easy access turnout was extremely low. Investigation by Hochbaum and his collegues led them to the conclusion that people are more likely to engage in a preventive behavior if they thought they were at risk and believed they would benefit from that behavior (5). These findings are congruent with those in Nigeria. Regardless of whether the other components of the Health Belief Model were addressed, without any perceived susceptibility or need to change their behaviors, parents in Nigeria were not motivated to adopt the behavior being promoted by the vaccine campaigns. Although the Health Belief Model may not be the entire story behind the breakdown of the eradication campaign, it certainly points out the failure in addressing the populations’ attitudes and beliefs regarding vaccination.

However, not all parents were unaware of the serious consequences polio infection or of the intended benefits vaccination could bring to their child and thousands of others. In fact, despite those who were not motivated to participate and remained passive to the campaign, there was a large outcry against the vaccine campaign as well (11). As the polio vaccine eradication went into full swing in Nigeria, people began to question Westerner’s intentions. With a country still suffering from a multitude of preventable diseases, such as diphtheria, pertussis, typhoid fever, and hepatitis B, polio is just one of the many challenges remaining in the battle of childhood survival (8). Consequently, when free polio vaccines began pouring into the country, Nigerian citizens began to question the Westerner’s approach of focusing all their efforts on one problem. They were well aware of the ongoing threat of other treatable diseases that were killing even more children than polio. From their perspective, fighting the battle against polio was important, but was only a small piece to improving childhood survival rates (11). As a result, frustrations arose and Nigerians began to actively resist vaccination efforts (17).

As this active resistance increased throughout the country it became clear that the approach being taken by Westerner’s, although good intentioned, was faltering. In 2004, Nigeria’s head of primary health care, Dr. Muhammad Ali Pate expressed concerns that the gains made by polio eradication will never hold without a broader health-care system (8). He shared common beliefs held by many Nigerians that vertical attacks on single diseases are ineffective and ultimately ignore the larger problem of stopping infectious diseases. In public health promotion in developing nations, donors tend to ignore the wants and needs of the population they will be serving (8). The polio eradication campaign in Nigeria did exactly this, falling into the dangerous pattern of formulating public health interventions based around intuition rather than research. Too often in public health, practitioners base their campaigns or interventions on what they feel people should want (18). As marketing theory has demonstrated, public health practitioners can be much more effective in achieving their goals by first identifying what it is the people actually desire before designing their intervention (18). The key to establishing an effective campaign is creating a program that addresses the core values of the target population (18). The polio eradication campaign in Nigeria did not address the main concern of the audience it was trying to serve. Nigerians wanted a broader approach. They wanted to eradicated polio, but not at the expense of allowing other diseases to continue to ravage their population. The eradication campaign failed to address the core values of the audience they were serving. Nigerians shared the same concern of controlling the spread of polio, but what they really wanted was control and autonomy over where efforts were being focused. They watched donor money being poured entirely into the polio fight while their sons, daughters, and grandchildren died of a multitude of other diseases that were entirely preventable. As time went on and polio continued to be a problem, Nigerians became frustrated with the narrow approach underway and became resistant to, what they felt, was a loosing battle.

In addition to the failure of the polio campaign to address the core values and desires of those it was meant to serve, the campaign also lacked community involvement. As a result, Nigerians felt no sense of ownership to the campaign efforts or impacts and thus were not invested in the programs. As the World Health Organization (WHO) developed the implementation strategy for polio eradication efforts in Nigeria they stressed the inclusion of political, community, and religious leaders, but evidence demonstrates that none of these players were involved effectively (11). When WHO was ready to role out the eradication campaign, they met with the Minister of Health, but did not include political or religious leaders in gaining support for immunization programs (11). Consequently, the polio eradication campaign in Nigeria transformed into a top-down approach with little to no involvement of community leaders and influential citizens.

This lack of community involvement likely weekend the campaign efforts. Specific theories address the importance of community involvement and are applicable to public health approaches. As Rothman and Tropman stated in their theory of community organization developed in 1987, community change is most effectively accomplished through the involvement of a broad cross-section of members in the community (1). They expand upon this definition by stating that community change is most likely to occur through consensus building, cooperation, and a coordinated effort by the community to address its own concerns (1). Without a sense of involvement in the campaign efforts, Nigerians became subjects of the intervention rather than agents of change. They were simply being vaccinated to fulfill the eradication goal, rather than participating in making this goal a reality. Moreover, there was no involvement on the part of their influential superiors, both religious and community members, to incite motivation. Lastly, the intervention lacked a key component of community organization theory, which was empowerment. According to the theory, empowerment is defined as a process by which communities gain mastery over their lives by being enabled to effectively transform or change their environments (12). Essentially, individuals gain self-efficacy on the community level and these gained confidences and skills are essential to bring about behavior change on a large scale. However, the lack of empowerment in conjunction with few influential and respected leaders at the helm, Nigerians felt no sense of ownership to the cause. With a top-down approach in full scale, the polio eradication in Nigeria continued to suffer further setbacks.

As the campaign was continuing to face further challenges, it became clear that the original goal set for the year 2000 would have to be pushed back. Many people questioned how smallpox eradication could have been so quick and so effective, while polio was proving to be more challenging as each day of the campaign went on. Although smallpox had encountered challenges along the way, the vertical campaign approach along with compulsory vaccination ultimately proved to be successful when the last case of smallpox was reported in 1979 (20). However, the eradication of polio has proved to be more complicated. With increasing opposition and lack of motivation on the part of Nigerians to comply with polio vaccinations, it will be necessary for the campaign to adopt a new strategy. In order to overcome the variety of obstacles encountered in the Nigerian polio eradication campaign, the intervention approach must be altered. Namely, several health behavior models in combination with marketing theory must be understood and applied to meet the resistance being faced to create a solution, rather than a mandate for compulsory vaccination or a continuation of strict vertical strategies.

First, the campaign must address the issues of perceived susceptibility and severity. By increasing the awareness and knowledge about poliomyelitis, parents will understand the importance of getting their children vaccinated. Furthermore, they will appreciate the potential consequences of this infectious disease for their own child as well as other children. In order to accomplish this goal, the campaign workers should collaborate with community leaders to develop information cards. Information cards have been utilized successfully in childhood nutrition programs through South America, where a lack of knowledge about breastfeeding and complimentary feeding have left thousands of children malnourished (22). These cards contain pictures on the front side depicting the message being relayed, while the backside of the cards contain simple words, guidelines, or messages about the public health intervention. These cards can be carried by health workers and posted throughout the community. In the case for polio, the cards could display a picture of a child suffering from polio on one side with information and pictures on the back indicating how the disease is transmitted, what health effects it causes, and how vaccination prevents transmission and infection. These cards will serve to accomplish barriers identified by the Health Belief Model. Many parents do not know how crippling the effects of polio can be. The picture and listed health effects will serve to increase the parent’s perceived severity. Also, the information on the mode of transmission will influence parents’ perceived susceptibility as they learn how infectious poliovirus is among the population. Lastly, the utilization of pictures in combination with words to display messages about the health effects and transmission of polio makes these cards a quick and easily viewable device that transmits a powerful message. Moreover, even though Nigeria has a 72% literacy rate (13) and most citizens will be able to read the accompanying messages, those who are illiterate will not miss out on the message. As the cards a distributed by health care workers and spread throughout communities, the messages can transform the views concerning perceived susceptibility and severity and break down these harmful barriers to vaccination.

With this first step underway, the Nigerian community can begin to see the benefits of taking action. However, in order to motivate people to act, it will be necessary to address the needs and desires of community members. Many people in Nigeria feel that polio eradication efforts ignore the larger issues concerning health care and childhood diseases rampant in the country (8). In order to better quantify and qualify these concerns, campaign workers should be deployed to hold focus groups in collaboration with influential community members throughout Nigerian states. At these focus groups, citizens can have their voices heard about what issues they feel need to be addressed immediately, where they believe resources should be allocated, and in addition to polio, which diseases they feel are of most importance for donors to address. Once these focus groups have been conducted, community leaders and campaign workers can combine their findings for submission to the donor agencies. Given that polio is the mission of this eradication campaign, citizen feedback will serve to increase multiple vaccination efforts or other sanitation projects that will directly address the desires of the people as an extended portion of the eradication campaign. By recognizing the core values of the Nigerian people, mainly their desire to surmount the multitude of diseases currently affecting them, the campaign can redefine and repackage its goals towards these desires. As marketing theory predicts, if public health practitioners offer programs that the target population values and demands, they can more effectively face the challenges of inciting behavior change (18). Instead of working against the Nigerians to incite change, they will be able to work with them. If donor agencies can adopt this strategy, their implementation of polio eradication will be more well rounded and successful.

To bring the campaign full circle, another component for a successful strategy is to incorporate community members as well as influential political, and religious leaders. The polio eradication campaign is too focused on a top-down strategy that disregarded the importance of involvement and community leadership throughout Nigeria. It has become evident throughout the global campaign that wherever community involvement has been low, vaccination coverage has also remained low, directly resulting in the failure to eradicate polio (9). There is no question as to whether community involvement will be beneficial; the only question remaining is how to implement these strategies.

To incite and propagate community involvement health care workers should seek out influential leaders in the political and religious sectors. Health care workers should seek out many of these leaders in every state to ensure all parts of Nigeria are initiating community leadership and involvement. Moreover, once these relationships are established, responsibilities must be defined and shared between the health care worker and the community advocate. They should not simply serve as a voice, but also an agent of change. Research has indicated that active community leadership and community involvement in planning and implementing your own health care is vital to successful health projects (1). If Nigerians can be incorporated into the eradication campaign strategy, they will have the leverage to encourage their counterparts to do the same. In addition, it is generally accepted that people are more willing to follow the advice of those they feel a connection or similarity with (2). Furthermore, religious leaders can be utilized to dispel misconceptions surrounding the dangers of the polio vaccine that surfaced among religious groups in 2003. Again, those who were influenced by these misconceptions are more likely to listen to their own leaders who share common morals and values, than they are to Westerner’s attempts at dispelling these delusions (2). The involvement at the community level is expected to have drastic implications in inciting behavior change by encouraging Nigerians to take an active part in creating a polio-free world. With the increased awareness being created through cards and media to address perceived susceptibility, they will have the tools and a reason to join the cause. Finally, with attention paid to their own needs in the realm of global health initiatives, they will have a more genuine commitment to the cause.

The set backs that have been encountered in the Nigeria are not by any means entirely avoidable. However, with the proper planning and evaluation through known public health strategies such as the Health Belief Model, Marketing Theory, and Community Organization Theory, these set backs can be overcome in a systematic way. Today the world is a decade past its original goal set for polio eradication. Polio has dodged a 20-year effort to eliminate it along with the disbursement of $8.2 billion dollars supplementing the ongoing human effort worldwide (8). Cleary, a new approach is in order. It is expected that the major leaders in polio eradication including WHO, UNICEF, and the CDC will announce a reorganized plan and strategy to address the failures of campaigns like those in Nigeria this week (8). The world can only hope that these strategies address the roots of the problem, taking into consideration the beliefs and viewpoints of those on the ground and the involvement of community and religious leaders in creating new, effective strategies. If these strategies are implemented effectively the world may finally be free of polio once and for all.

(1) Asthana S., Oostvogels R. Community participation in HIV prevention: problems and prospects for community-based strategies among female sex workers in Madras. Social Sciences and Medicine 1996; 43:133–148.

(2) Bolden R., Gosling J., Marturano A., Dennison, P. A Review of Leadership Theory and Competency Frameworks. Centre for Leadership Studies 2003: 6-17.

(3) Centers for Disease Control and Prevention. Progress toward poliomyelitis eradication – Nigeria, January 2008-July2009. Morbidity and Mortality Weekly Report 2009; 41:1150-1154.

(4) Chen C. Rebellion against the polio vaccine in Nigeria: implications for humanitarian policy. African Health Sciences 2004; 3:205-207.

(5) Edberg, M. Social and Behavioral Theory in Public Health. Essentials of Health Behavior. Washington D.C. 2007.

(6) Global Polio Eradication Initiative. The History. WHO, CDC, UNICEF.

(7) Global Polio Eradication Initiative. The Disease and the Virus.

(8) Guth R.A. “Gates Rethinks His War on Polio”. Wall Street Journal 23 April 2010.

(9) Lahariya C. Global Eradication of Polio: The Case for “Finishing the Job”. Bulletin of the World Health Organization 2007; 6:421-500.

(10) Miyamura T. Global polio eradication program: fundamental lessons for the control of infectious diseases. National Institute of Infectious Diseases 2009; 2:277-286.

(11) Mohamed A.J., Ndumbe P., Hall A., Tangcharoensathien V., Toole M., Wright P. Independent evaluation of major barriers to interrupting poliovirus transmission. Wild Poliovirus 2008 – 2009 Executive Summary 2009;

(12) Ndiaye S.M., Quick L., Sanda O., Niandou S. The value of community participation in disease surveillance: a case study from Niger. Health Promotion International 2003; 2:89-98.

(13) UNICEF. At a glance: Nigeria. Adult literacy rate 2003 – 2008.

(14) O'Neill, William L. American High: The Years of Confidence, 1945-1960. Glencoe, Illinois: The Free Press, 1989.

(15) Osowole O.S., Obute J.A. Parent’s awareness and perception of the polio eradication programme in Gombe local government area, Gombe State. Department of Health Promotion and Education. 2005.

(16) Renne E. Perspectives on polio and immunization in Northern Nigeria. Social Science and Medicine 2006; 63:1857-1869.

(17) Rey M., Girard MP. The global eradication of poliomyelitis: Progress and problems. Comparative Immunology Microbiology & Infectious Diseases 2008; 31:317-325.

(18) Siegel M. Marketing Public Health: An opportunity for the public health practitioner. (pp. 127-152) In: Seigel M and Lynne Doner, ed. Marketing Public Health- Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett, 2007.

(19) Stephens C. Participation in different fields of practice: Using social theory to understand participation in community health promotion. Journal of Health Psychology 2007; 12:949-960.

(20) World Health Organization. Smallpox. Factsheet. 2010.

(21) WHO, UNICEF, USAID. Engaging Communities. Nigeria’s Campaign to Increase Acceptance of Routine and Polio Immunization Services. 2006.

(22) Linkages Projects. Ghana. 1998-2004.

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