Findings In Eradication Of Polio Health And Social Care Essay
This chapter presents the discussion of the findings of this review which aims at examining the factors that help improve or impede the eradication of polio by immunization in Nigeria as stated earlier in Chapter One.
The findings from the study suggest that the following theme of factors affect polio immunization in Nigeria: socio-demographic factors, culture, poor health infrastructure, public confidence and trust, accessibility and poor vaccine coverage, political commitment, vaccine availability and efficacy, health inequity, and rural-urban migration.
Socio-demographic factors are one of the issues identified by the review which impedes polio eradication in Nigeria by immunization. These factors play significant roles in the uptake or acceptance of health interventions such as immunization in populations (Porta, 2008). In the findings of this review, the socio-economic and demographic factors were enumerated together by most studies, hence, the rationale behind merging them together as a single theme by the author. However, socio-demographic factors are factors such as poverty, religion, place of residence, literacy level, occupation, or employment status as described by Porta (2008). In relation to this description, the sub-themes listed under this theme include: low literacy level, religion, place of birth, poverty, and area of settlement (refer to table 4.5).
These sub-themes will be explained in more detail as they affect the eradication of polio by immunization in Nigeria.
Literacy level; Berkman et al (2004) highlighted that the lower the literacy level of a population, the poorer the health and well-being of that population. This was affirmed by Weiss (1991) who stated that; in developing countries, those with the poorest health status are those who have low levels of education. The literacy of the total population of Nigeria is 68% as stated by the CIA-World Fact Book (2010), the World Bank (2010) also stated that female literacy level was 64.6% as opposed to that of males 75.7%. This is a regrettable situation because the education of women is a potential determinant of the health of children.
Furthermore, the role of literacy in immunization uptake cannot be overemphasized, as literacy is required in all facets of life from communication, to interaction, and above all in making judgement particularly informed decisions about health. A study carried out by Lindeboom et al (2008) reiterated that educated mothers tend to have their children immunized than otherwise.
Surveys carried out in Nigeria report variation in literacy levels among the populace (Renne, 1996; Odutola, 2004) and this is a barrier affecting immunization uptake in different regions of the country. Low literacy level leads to low level of awareness, the official language of Nigeria is English and it is the language of instruction in all levels of education as well as the language used in the media.
With this regards, an uneducated or less educated Nigerian will not be able to communicate or interact effectively neither will he/she appreciate the awareness campaigns on immunization in the media. This will in turn enable them lack cues to action which are factors that will facilitate taking preventive action on their health as mentioned in the Health belief model in Chapter 2. Furthermore, with reference to the literacy ratio of the total population of Nigeria which is 68% as stated earlier, it will be difficult to achieve a level of immunization which can be considered as herd immunity in the country because the total population of Nigeria as stated by World Bank (2010) in Chapter One is 154,729,000, so obviously 32% of this figure are either uneducated or less educated which will in turn affect their informed decisions.
Religion on the other hand is considered to be among the socio-demographic factors hindering the polio immunization uptake in Nigeria. The CIA-World Fact Book (2010) stated that Nigeria is made up of 50% Muslims, 40% Christians and 10% Unbelievers. Of this statistics, majority of the Muslims reside in the Northern part of the country and the South is predominated by Christians, though, there is inter-residence of both religions in all parts of the country (United States of America-Department of State, 2010). There are occasional interreligious tensions erupting in parts of the country and the Muslims tend to perceive the Christians as advocates of the Western world partly because the West first made contact with the southerners when they arrived at the country and partly due to political or socio-economic reasons (United States of America-Department of State, 2010). This tensions or divide between followers of the two religions tend to affect the acceptance of Western medicines particularly in the Northern part of the country and Vaccines are no exception. This is among the reasons why polio immunization faces challenges in some parts of the country as evidenced by literature reviewed in this research.
Area of settlement or places of birth are among the socio-demographic factors affecting polio immunization uptake in Nigeria. This refers to either urban or rural settlements. The urban settlements tend to have more basic amenities and immunization uptake. The CIA-World Fact Book (2010) stated that 48% of the total population of Nigeria resides in the urban areas. This means 52% reside in either rural or sub-urban areas and will not have adequate basic amenities, education, infrastructure, sanitation and health services which will in turn affect the level of polio immunization uptake, and as evidenced by the literature such settlements produce pockets of unimmunized children during immunization campaigns and the compromised sanitation further enables easy transmission of polio virus among the inhabitants.
Poverty was also listed to be one of the socio-demographic factors affecting polio immunization uptake in Nigeria. Long-term deprivation of essential material and non-material aspects of well-being necessary for a good living is described as poverty by the United Nations Development Program (UNDP, 2010). Presently, the official poverty prevalence in Nigeria is 54.4% and this translates to about 70 million poor people (UNDP, 2010). It was also reported by the UNDP (2010) that poverty in Nigeria is more intense in the Northern geographical zones than in the South and stated that residing in the rural areas or the Northern part of the country increases the chances of being poor. In addition, 18 out of the 36 States and 1 Federal Capital Territory of the country have lower per capita income than the $1.25 per day global standard poverty benchmark (UNDP, 2010).
With respect to polio immunization uptake, findings from the literature reviewed, insinuated that polio immunization uptake face severe challenges in the rural areas and the Northern part of the country. However, there is no doubt that poverty plays a significant role in hindering polio eradication by immunization in the country because considering the total population (154,729,000) and the total number of poor people (about 70 million) as mentioned earlier, there is the tendency of not perceiving susceptibility to polio as stated in the Health belief model and not complying to immunization uptake due to struggling and competition for survival which is a consequence of poverty.
Culture is among the themes identified by the findings of this review to be hindering polio eradication by immunization in Nigeria. In terms of culture which is a shared set of beliefs or group values, Nigeria has over 250 ethnic groups which are further broken down due to the most populous and politically influential as follows: Hausa and Fulani 29%, Yoruba, 21%, Igbo 18%, Ijaw 10%, Kanuri 4%, Ibibio 3.5%, and Tiv 2.5% (CIA-World Fact Book, 2010). Of these ethnic groups, each have their own specific set of beliefs and sources of traditional medicines. Such beliefs serve as barriers to accepting or appreciating the efficacy of western medicines which polio immunization is not an exception. While some people do not even believe in disease causing organisms, rather, they attribute diseases to non-living things or even Jinni (super-natural creatures). For instance, some northerners attribute polio paralysis to be caused by Jinni not a living microorganism.
Poor health Infrastructure is one of the factors affecting polio immunization identified by this study. This is evidenced by the WHO (2010) who reported that the total expenditure on health as % of Gross Domestic Product (GDP) of Nigeria as at (2006 estimate) is 4.1. This is further highlighted by UNDP (2010) which reported the human development index (HDI); an indicator of life expectancy at birth, adult literacy rate, and GDP per capita (Porta, 2008) of Nigeria to be 0.499 which places Nigeria in the lead of the group of countries with low HDI since 1990’s. The sub-themes identified under this theme include: poor primary health care and routine immunization, lack of motivation from health personnel, long waiting queues at health centers and payment at private centers. This is no surprise as the country is ranked 187 out of 191 on poor performances of health care systems (UNDP, 2010). Generally, infrastructure in Nigeria is considerably poor leading to its slow corporate development (UNDP, 2010) and health infrastructure is not an exception. Apparently, investment in the health sector of the country is low as evidenced above and therefore much irregularities due to lack of enough qualified professionals or poor health services including poor routine immunization are anticipated.
Public confidence and trust is among the issues identified by the review to be hindering polio immunization uptake in Nigeria. Lack of enough education, abject poverty, cultural beliefs, ethnic differences, interreligious tensions, and lack of delivering campaign promises by the politicians all culminate in losing confidence and trust in the Government. Therefore, the persistent rejection of polio immunization and other health interventions by some populace of the country is no surprise.
Accessibility and poor vaccine coverage is another salient issue identified by the review to be a barrier of adequate polio immunization uptake. Accessibility in this context refers to bad road networks and other means of travel, whereas, poor vaccine coverage connotes inadequate coverage of vaccines during immunization campaigns. The major means of transportation in Nigeria is road transport and the total roadways of the country as documented by the CIA-World Fact Book (2010) is 193,200 km of which only 28,980 km is paved while 164, 220 km is unpaved. This factor poses significant threats to outreach during mass immunization campaigns which results to leaving pockets of unimmunized children in areas that cannot be easily assessed, particularly the rural areas (villages and hamlets) in all parts of the country and the riverine areas of the South-south geopolitical zone.
Political commitment is among the list of themes pointed out by this review to be affecting polio immunization in Nigeria. Lack of political will and inadequate spending on health services by the government were the sub-themes identified under this topic. With respect to lack of political will, two major obstacles play a role in hindering good governance which then translates to lack of proper functioning of the institutions of the country and these obstacles are corruption and mismanagement of resources by the politicians. UNDP (2010) also affirmed that corruption has under-developed Nigeria. Inadequate spending on health services on the other hand is evidenced by WHO (2010a) which stated that the total expenditure on health per capita of Nigeria is $50. There is no doubt such amount is less significant compared to $6714 health expenditure per capita of the United States of America, $2784 health expenditure per capita of the United Kingdom, and unfortunately even lower than that of neighbouring Cameroon which spends $80 per capita on health (WHO, 2010b; 2010c; 2010d) despite Nigeria’s abundant resources. Therefore, with less political commitment and willingness on the part of the politicians to serve and deliver good governance by implementing policies and investments in all sectors of the economy, there is no tendency for health of the country to be improved talk more of immunization which targets children at their early stage of life.
Vaccine availability and efficacy is another theme emerged from the findings of this review. The sub-themes outlined under this subject are: vaccine supplies, vaccine availability, and efficacy. In the context of polio immunization in Nigeria, this theme is dependent on accessibility and proper health infrastructure. Poor accessibility as a result of bad road networks affects the condition of storage of the vaccines leading to disruption of the cold chain during immunization exercises which will in turn affect the efficacy of the vaccines. Poor health infrastructure or inadequate health expenditure as stated earlier results to scarcity of health resources in which vaccines are no exceptions. Furthermore, the low compliance of parents during immunization days in some parts of the country is as a result of the fear of the vaccines’ safety (Sutter & Cochi, 2008).
Health inequity is another important factor outlined by the findings of the review to be affecting polio eradication by immunization negatively. Health inequity is defined by Donald (2001) as the lack of fairness or justice in distributing health care goods and services for people with the same health needs. In relation to this, the UNDP (2010) reported that Nigeria ranks 100th out of 128 countries in health and survival, and also highlighted that there is a wide margin between the two regions of the country (South and North) in terms of health care access and health infrastructure. With this regards, the inequity in Nigeria is a salient issue that hinders immunization uptake in parts of the country and evidenced by the literature the Northern States of the country suffer more burden of poliomyelitis than the Southern part of the country partly due to health inequity and partly due to inequity in the distribution of health resources in the country.
Rural-Urban migration is part of the themes identified by the study that present difficulties to polio immunization in Nigeria. As mentioned above, due to poor road networks, pockets of unimmunized children are left out during mass immunization campaigns and poverty is more endemic in the rural and Northern part of the country. The migration to urban areas in search of livelihoods as a result of poverty by these rural communities who remain unimmunized due to poor access interrupts the chain of immunity in these urban cities. Furthermore, while in the urban areas the migrants do not usually have a permanent place of residence and therefore cannot be reached during mass immunization campaigns. This is why migration poses a threat to successful polio eradication in Nigeria.
Having discussed all the themes of the findings of this study, the author thought it is not enough to conclude that these factors are impeding polio eradication by immunization. With this regards, the author considered measures of effect; causation and association (Adetunji, 2010) where the following pertinent questions were asked:
Could these findings be due to selection or measurement bias? Based on the critical appraisal of the articles, No
Could they be due to confounding? No
Could they be as a result of chance? Probably not
Could they be causal?
In order to make judgements, the Bradford Hill Criteria (1965) of causality (Adetunji, 2010) was employed and the following stances which were relevant to this study were reviewed.
Consistency: in the findings of this study, there is evidence of similar findings from different studies applied in different populations of Nigeria; for instance, in the table of findings (table 4.5); Adeyinka et al (2009) was a quantitative study conducted in Oyo State, South-western Nigeria which aimed at determining the awareness and attitude of mothers of under-5 towards immunization, Renne (2006) conducted a qualitative study in Zaria town, Northern Nigeria and examined the reason for the difficulties in eradicating polio in Northern Nigeria, Lastly, Jenkins et al (2008) conducted a case-control study and examined the effectiveness of immunization against paralytic poliomyelitis in Nigeria which estimated the field efficacies of oral polio vaccines among a represented sample of Nigerian children who were randomly selected- and all these studies came up with similar findings which were then put into themes all of which were discussed above.
Similarly, comparisons were made with other studies for instance Paul (2009) conducted a qualitative study in India (another polio-endemic country) on why polio has not been eradicated in India despite many remedial interventions? And came up with the following factors as findings; poor health infrastructure, social factors such as religion and ethnicity, and vaccine failure which are all similar to the findings of this study.
Furthermore, Mushtaq et al (2010) conducted a qualitative cross-sectional study using focus group discussion and in-depth interviews in understanding of the perception of health workers towards the constraints of polio eradication in Pakistan and came up with poor health services and lack of enough knowledge of health personnel as their findings.
Therefore, there is evidence of consistency from the findings of this study with other studies.
Strengths of association: determines the likelihood of a strong association to cause the outcome under investigation (Adetunji, 2010). With respect to the results of this review all findings are likely to cause low uptake of polio immunization in many parts of the country. For instance, bad road network hinders access to rural areas and the inhabitants of these rural areas are likely not to be immunized, low literacy level, a socio-demographic factor explained earlier contributes significantly to low polio immunization uptake.
Reversibility: this determines the strength of causality by removal of a possible cause (Adetunji, 2010). For instance in the context of the results of this study, constructing good road networks will enhance accessibility thereby enabling the immunization of almost all children against polio, likewise, improving the levels of education will improve polio immunization uptake, because as stated earlier more educated mothers tend to have their children immunized than otherwise (Lindeboom et al, 2008).
The findings of this study were discussed in detail as they affect polio immunization uptake in Nigeria. Furthermore, measurement of effects; causation and association was carried out to ensure consistency of the findings and rigour in this research.
Therefore, recommendations on the aforementioned factors as they affect polio immunization uptake will be proposed in the next chapter followed by a concise conclusion along with limitations and reflection of the study.