Why is Nigeria one of the last countries with endemic polio?
The World Health Organization's (WHO's) plan to eradicate polio everywhere started in 1988, with an original deadline of 2000 (this was later moved to 2004). In 2011, despite their efforts, polio is still endemic in five countries, including Nigeria. (Renne, 2006.)
Why is this?
In order to answer this question, we have to first look at the vaccination programs that have been put in place. In Nigeria, the focus has been on vertical, top-down vaccination programs. Routine vaccinations are not common; instead, there are National Immunization Days (NIDs), during which oral polio vaccines are given door-to-door. Four doses of the vaccine are needed at different times for it to be fully effective; children rarely receive all doses. To find out more about how the programs are currently working and what is going wrong, we need to examine the country's immunization records and documentation. Unfortunately, record-taking in this area has been indequate and incomplete, suggesting that bureaucratic issues may also be impacting the vaccination program. Without a proper record of who has been immunized and when, and how many doses they have received, it is almost impossible to know who still needs to be vaccinated. Repeated, unnecessary vaccinations are common on NIDs. In addition to creating problems with the program, poor records also make it difficult for us to analyze the effects of the program and address problems. (Renne, 2006.)
Poor record-keeping is a difficult issue for researchers to navigate. One way to address the issue would be to look at other documents, such as those kept by the WHO or UNICEF. Online documents and NID promotional materials are available and contain some information (Renne, 2006). They are no substitute for real records of individual immunizations, however. Mass immunization programs seem to become unorganized easily. This is a structural problem that we will look at again when we ask the question of what type of intervention to use.
Lack of records are clearly not the only problem, and there are other aspects that need to be examined. Low numbers of vaccinations are also a result of parents declining or refusing to immunize their children (Schimmer and Iheweazu, 2006). Why might they do this? In order to find out about their reasoning and how they make their decisions, we have to ask them.
There are several methods for getting this information. Open-ended interviews are one way of gaining large amounts of information, and they can be accesible for people with low literacy or education levels. Renne (2oo6) used snowball-samping to recruit people for interviews. She also found that participant-observation methods were useful, and longitudinal research (over a period of 11 years) garnered the most information. Interviewees included parents who had chosen to immunize their children and parents who had not; several of the parents had polio themselves. Doctors and other members of the community were also interviewed. They chose neighbourhoods to focus on by watching for NID visits and markers. The sample, however, was quite small. Larger samples would be needed for the information to be generalized to the greater population, and there could be logistical problems with getting large samples. Snow-balling is a good technique, but it might not extend very far if people do not wish to participate. This is a problem with all forms of voluntary research. We cannot, however, force people to be interviewed if they do not want to be. Large-scale research is also more costly, and focusing on specific neighbourhoods may be more efficient.
Helman (2007) describes other issues that may arise when using open-ended interviews. Some people may not cooperate with an interviewer who is of a specific gender, race or group. Gender can also be a barrier in communities where women are expected to have a male family member present. Both of these issues can potentially be avoided if the culture of the specific group is researched and planned for, with accomodations made (for example, a possible change of interviewer). Other issues may include an interviewee's need for privacy or fear of information falling into the wrong hands, and problems surrounding informed consent.
While open-ended interviews would likely be the best way of obtaining honest, factual personal information, they may not be the best option on a large scale. They require trained interviewers, time, and participants willing to talk about their private lives in-depth to a stranger. Multiple choice questionnaires (MCQs) are another research option to discover reasons that parents choose or decline immunization for their children. MCQs would be faster and could be administered more efficiently than open-ended interviews, and they would require minimal training and money. (Helman, 2007.) During mass immunization programs such as NIDs, it could even be possible to administer MCQs door-to-door at the same time as the oral polio vaccine; especially if a parent refuses the vaccine, their opinion could be gathered quickly and immediately. There are, however, also problems that could arise with this method. Literacy is a large barrier for taking written questionnaires. In this case, someone could administer the questionnaire orally; this would get around the literacy issue, but it could also cause problems similar to the open-ended interview. If the interviewer or privacy is an issue, an oral questionnaire will probably not be the most effective method. Multiple choice questionnaires also restrict the information that can be given and "impose and artificial framework on human experience" (p. 464, Helman, 2007). One way to attempt to avoid restriction is to look at the research that has already been done on Nigerians' opinions on the polio vaccine, and use that information to create appropriate options for the questionnaire. For example, Renne (2006) found that mistrust of the government and pharmaceutical companies contributed to rejection of polio vaccines. Reasons for this varied, but certain experiences in the country were significant: an earlier trial for a meningitis drug had led to the deaths of 11 children. Some Nigerians believed that this had occurred because of a lack of informed consent, and concluded that they could not trust pharmaceutical companies or the government to have their best interests in mind. Other Nigerians believe that the polio vaccine can cause HIV or infertitlity. We will look at beliefs about the polio vaccine in a further section.
If specific options such as "I do not trust the government to protect my health," or, "I believe the polio vaccine can cause infertility," are included on an MCQ, we might collect a substantial amount of information and opinions.
Socioeconomic and other social aspects of Nigeria must be examined in order to understand polio fully. Polio, like many diseases, flourishes in poverty. We can research this by looking at the prevalence of polio among different groups, education and literacy levels, social and economic statuses. Much of this data already exists but some connections still need to be made. Areas with high levels of diarrhea and low hygeine also have high levels of polio, and these are often areas with the lowest income and education levels. (Roberts, 2004.)
We also have to look at what the conditions in other countries with endemic polio are like. There are only five countries that still struggle with polio, and there are likely similarities between these countries that can tell us about the presence of the virus. Making comparisons between these countries' healthcare services, ethnic and religious groups, Explanatory Models and socioeconomic states could bring us valuable information.
Why is this?
In order to answer this question, we have to first look at the vaccination programs that have been put in place. In Nigeria, the focus has been on vertical, top-down vaccination programs. Routine vaccinations are not common; instead, there are National Immunization Days (NIDs), during which oral polio vaccines are given door-to-door. Four doses of the vaccine are needed at different times for it to be fully effective; children rarely receive all doses. To find out more about how the programs are currently working and what is going wrong, we need to examine the country's immunization records and documentation. Unfortunately, record-taking in this area has been indequate and incomplete, suggesting that bureaucratic issues may also be impacting the vaccination program. Without a proper record of who has been immunized and when, and how many doses they have received, it is almost impossible to know who still needs to be vaccinated. Repeated, unnecessary vaccinations are common on NIDs. In addition to creating problems with the program, poor records also make it difficult for us to analyze the effects of the program and address problems. (Renne, 2006.)
Poor record-keeping is a difficult issue for researchers to navigate. One way to address the issue would be to look at other documents, such as those kept by the WHO or UNICEF. Online documents and NID promotional materials are available and contain some information (Renne, 2006). They are no substitute for real records of individual immunizations, however. Mass immunization programs seem to become unorganized easily. This is a structural problem that we will look at again when we ask the question of what type of intervention to use.
Lack of records are clearly not the only problem, and there are other aspects that need to be examined. Low numbers of vaccinations are also a result of parents declining or refusing to immunize their children (Schimmer and Iheweazu, 2006). Why might they do this? In order to find out about their reasoning and how they make their decisions, we have to ask them.
There are several methods for getting this information. Open-ended interviews are one way of gaining large amounts of information, and they can be accesible for people with low literacy or education levels. Renne (2oo6) used snowball-samping to recruit people for interviews. She also found that participant-observation methods were useful, and longitudinal research (over a period of 11 years) garnered the most information. Interviewees included parents who had chosen to immunize their children and parents who had not; several of the parents had polio themselves. Doctors and other members of the community were also interviewed. They chose neighbourhoods to focus on by watching for NID visits and markers. The sample, however, was quite small. Larger samples would be needed for the information to be generalized to the greater population, and there could be logistical problems with getting large samples. Snow-balling is a good technique, but it might not extend very far if people do not wish to participate. This is a problem with all forms of voluntary research. We cannot, however, force people to be interviewed if they do not want to be. Large-scale research is also more costly, and focusing on specific neighbourhoods may be more efficient.
Helman (2007) describes other issues that may arise when using open-ended interviews. Some people may not cooperate with an interviewer who is of a specific gender, race or group. Gender can also be a barrier in communities where women are expected to have a male family member present. Both of these issues can potentially be avoided if the culture of the specific group is researched and planned for, with accomodations made (for example, a possible change of interviewer). Other issues may include an interviewee's need for privacy or fear of information falling into the wrong hands, and problems surrounding informed consent.
While open-ended interviews would likely be the best way of obtaining honest, factual personal information, they may not be the best option on a large scale. They require trained interviewers, time, and participants willing to talk about their private lives in-depth to a stranger. Multiple choice questionnaires (MCQs) are another research option to discover reasons that parents choose or decline immunization for their children. MCQs would be faster and could be administered more efficiently than open-ended interviews, and they would require minimal training and money. (Helman, 2007.) During mass immunization programs such as NIDs, it could even be possible to administer MCQs door-to-door at the same time as the oral polio vaccine; especially if a parent refuses the vaccine, their opinion could be gathered quickly and immediately. There are, however, also problems that could arise with this method. Literacy is a large barrier for taking written questionnaires. In this case, someone could administer the questionnaire orally; this would get around the literacy issue, but it could also cause problems similar to the open-ended interview. If the interviewer or privacy is an issue, an oral questionnaire will probably not be the most effective method. Multiple choice questionnaires also restrict the information that can be given and "impose and artificial framework on human experience" (p. 464, Helman, 2007). One way to attempt to avoid restriction is to look at the research that has already been done on Nigerians' opinions on the polio vaccine, and use that information to create appropriate options for the questionnaire. For example, Renne (2006) found that mistrust of the government and pharmaceutical companies contributed to rejection of polio vaccines. Reasons for this varied, but certain experiences in the country were significant: an earlier trial for a meningitis drug had led to the deaths of 11 children. Some Nigerians believed that this had occurred because of a lack of informed consent, and concluded that they could not trust pharmaceutical companies or the government to have their best interests in mind. Other Nigerians believe that the polio vaccine can cause HIV or infertitlity. We will look at beliefs about the polio vaccine in a further section.
If specific options such as "I do not trust the government to protect my health," or, "I believe the polio vaccine can cause infertility," are included on an MCQ, we might collect a substantial amount of information and opinions.
Socioeconomic and other social aspects of Nigeria must be examined in order to understand polio fully. Polio, like many diseases, flourishes in poverty. We can research this by looking at the prevalence of polio among different groups, education and literacy levels, social and economic statuses. Much of this data already exists but some connections still need to be made. Areas with high levels of diarrhea and low hygeine also have high levels of polio, and these are often areas with the lowest income and education levels. (Roberts, 2004.)
We also have to look at what the conditions in other countries with endemic polio are like. There are only five countries that still struggle with polio, and there are likely similarities between these countries that can tell us about the presence of the virus. Making comparisons between these countries' healthcare services, ethnic and religious groups, Explanatory Models and socioeconomic states could bring us valuable information.