Vol. 12(1), pp. 40-49, January - March 2020
DOI: 10.5897/JPHE2019.1194
Article Number: 594555C62869
ISSN 2141-2316
Copyright © 2020
Author(s) retain the copyright of this article
http://www.academicjournals.org/JPHE
Journal of Public Health and Epidemiology
Full Length Research Paper
A mixed method approach for the assessment of
demand creation intervention strategy for polio
eradication on exclusive breast feeding in
Northern Nigeria
Oladele Akogun1*, Omolola Olojede2, Adedoyin Adesina1 and Sani Njobdi3
1
The Health Programme, Common Heritage Foundation, Abuja, Nigeria.
2
Federal Ministry of Health, Abuja, Nigeria.
3
Institute of Infectious Diseases of Poverty, Modibbo Adama University of Technology, Yola, Nigeria.
Received 19 November, 2019; Accepted 30 January, 2020
The Federal Ministry of Health, Nigeria introduced incentives such as sachets milk powder to increase
demand for oral polio vaccine (OPV). This study assessed whether the milk encourages the use of
breast milk substitutes thereby dis-incentivising exclusive breastfeeding (EBF) in children during the
first six months of life. A cross sectional design with mixed method was used for collecting quantitative
and qualitative data in Borno and Kaduna states. Questionnaire was administered to 808 caregivers.
There were focus group discussions, in-depth interviews and observations of an ongoing OPV+
intervention campaign. Quantitative and qualitative data were analysed using STATA 10 and MAXQDA,
respectively. Milk was an infrequent component of the incentive package and accounting for only 4.6
and 1.5% in the 3 most recent immunisation campaigns. The high EBF awareness (82.4%) was
associated with the demand creation campaign which the health service providers used to reinforce
EBF messages. Breastfeeding decisions were mainly influenced by family and group norms and not by
the sachet of milk powder that was given during the OPV+. There were no indications of inappropriate
promotion of foods or any of the incentives. The inclusion of sachet milk in OPV+ kit did not
compromise EBF but further enhanced it since the same service providers were responsible for all
health interventions in the local government. Using milk powder and other incentives are effective for
increasing participation and compliance with uptake of OPV in both states.
Key words: Polio eradication, incentive, exclusive breastfeeding, demand creation.
INTRODUCTION
Infant and child health remains a priority in many
developing countries and is considered critical to the
attainment of child related Sustainable Development
Goals (SDG3.2) and national development in Nigeria
*Corresponding author. E-mail: akoguno@yahoo.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
Akogun et al.
(WHO, 2019; Oleribe and Taylor-Robinson, 2016).
Several health interventions programmes (including
nutrition, immunization and education) are directed at
children that are less than five years old due to their high
level of vulnerability (Onwujekwe et al., 2019).
Implementation of such health interventions criss-cross
and unless operational care is taken, the advantages that
accrue to a programme may be a concern to or
undermine the other intervention. There are two major
interventions that are given high priority for improving the
health of the Nigerian child. One of it is the eradication of
poliomyelitis (NPHCDA, 2016; McArthur-Lloyd et al.,
2016; Oyo-Ita et al., 2016; Warigon et al., 2016). The
other is promotion of exclusive breastfeeding (EBF) for
infants (WHO, 2000).
The World Health Assembly at its sixty-fifth session of
May 2012 declared polio eradication as a public health
emergency of global significance (Warigon et al., 2016a).
In response, Nigeria which is one of the three polio
endemic countries that is yet to interrupt its transmission
developed the National Polio Eradication Emergency
Plan (NPEEP) as a strategic priority for 2013, 2016 and
2018. The main goal was to intensify “efforts to scale up
communication and advocacy in the high-risk areas to
contribute to a reduction in the percentage of missed
children’’, while sustaining the gains existing initiatives
(NPHCDA, 2013, 2016, 2018). In 2014, although polio
intervention efforts had improved significantly in Nigeria,
persistent poliovirus transmission underscores the urgent
need to reach the 5% children that are missed and who
may be responsible for sustaining polio virus
transmission (WHO, 2019; Tobin-West and Alex-Hart,
2011; Johri et al., 2015; Machingaidze et al., 2013).
Independent monitoring data from previous immunisation
rounds showed that children continue to be missed even
after several campaigns (WHO, 2019). Outright rejection,
of oral polio vaccine (OPV), among other factors, was
identified as a central problem in interrupting polio
transmission in Nigeria, making Nigeria the only polio
endemic country in the African Region for a considerable
period of time (Oku et al., 2019).
The negative anti-intervention campaigns that were
launched by influential individuals in Northern Nigeria
which had a devastating effect on the eradication effort
made the creation of demand for OPV a necessity
(Warigon et al., 2016b). The strategy comprised activities
that attract the children from high-risk communities to the
polio vaccine. Health providers worked in collaboration
with local government officials, community leaders and
caregivers to build trust and confidence in immunization
programme (NPHCDA, 2016). The most popular
approach is the oral polio vaccine plus (OPV+) which
consisted of child-friendly gifts of whistle, toys, biscuits
and 12 g sachet of milk powder to reinforce child
acceptance of the immunization (Korir et al., 2018).
Caregivers who presented their children for immunization
41
received a gift with some health value, such as soap,
sachet of detergent or similar article. An OPV+ campaign
was heralded by announcements in the health facility
catchment area. The rapid decline in polio cases in some
states was attributed to this change in strategy.
Exclusive breastfeeding (EBF) on the other hand is the
feeding of infants with only breast milk, be it directly from
breast or expressed, with no addition except drops of
syrups consisting of vitamins, mineral supplements or
medicine (WHO, 2001, 2002; Setegn et al., 2012). EBF of
infants for the first six months and the continuing
breastfeeding of children for up to two years of age with
appropriate
complementary
feeding,
are
highly
recommended by WHO and UNICEF in preventing
childhood illnesses and maximizing the growth of children
(WHO, 2016). However, multiple factors contribute to
poor breastfeeding practices including the inappropriate
promotion of breast milk substitutes (Piwoz and Huffman,
2015; Hadihardjono et al., 2019). Inappropriate promotion
of breast milk substitutes such as snack foods targeted at
infants are said to be common in countries like Indonesia
and have contributed to stunted growth in children (Green
et al., 2019; Purwestri et al., 2018; Hadihardjono et al.,
2019).
In 2008, only 17% of Nigerian infants receive
appropriate breastfeeding and the duration of exclusive
breast feeding is 15 days and 50% of infants are denied
exclusive breastfeeding for up to one month (Victora et
al., 2011). Nwankwo and Brieger (2006) associate the
problem with cultural practices, ignorance and beliefs as
well as corporeal cosmetic preservations. Yet EBF is
intensely promoted at all levels of the health
administration as the main strategy for preventing
childhood illnesses and maximizing the growth of children
(WHO, 2016). Antenatal care health education
campaigns and social gatherings are used as forums for
promoting the benefits of the EBF (UNICEF/WHO, 2003).
Both the OPV+ which includes gifts of sachets of milk
powder and the EBF campaigns are co-implemented in
same communities. However, it is unclear whether the
inclusion of the provision of sachet milk as an incentive in
the OPV+ campaigns unintentionally encourages the use
of breast milk substitutes in areas where both
interventions are co-operational in Northern Nigeria.
This study reports an assessment of the EBF practices
in an area where polio eradication campaign using a
sachet milk powder as an incentive for creating demand
is co-implemented with exclusive breastfeeding
promotion.
METHODOLOGY
A cross sectional study design using mixed methodological data
collection technique was employed to assess the factors associated
with the co-implementation of OPV+ (oral polio vaccine incentivised
with sachet of milk) and EBF interventions. Quantitative and
42
J. Public Health Epidemiol.
qualitative data were collected from mothers who have children less
than 5 years and living in a community where demand creation
interventions have been implemented for polio eradication in
Northern Nigeria for at least three years.
Study site and sample size
The study was carried out in Northern Nigeria states of Borno and
Kaduna. A 50% chance of every child accessing OPV+ was
assumed at 95% confidence to give a sample size of 384 per state.
A sample of 400 per state was considered more appropriate to
compensate for cluster effect in respondent selection and losses.
A rural and an urban LGA were selected from Borno and Kaduna
states for the study. Only LGAs that have an ongoing OPV+
component (sachet milk powder intervention), with consistent
implementation in the preceding three years, that has attained 80%
compliance coverage and have coverage rate data for all
communities within it. Sample selection was multi-stage and
received the assistance of the local government personnel. Two
wards (one urban and one rural) were selected from each of the
LGAs and ten communities/neighbourhoods were selected in each
of the wards. Ten households were selected in each community for
the quantitative survey. Qualitative data collection was purposive,
and sampling depended on the attainment of saturation point.
Data collection
For household selection, the researcher moved to the centre of the
community which served as reference point and rotated a pencil
and let it freely fall. The team selected the households in the
direction of the pencil tip and then continued until the number of
required households was obtained. Where there is a cul-de-sac, the
step is retraced, and a turn in the opposite direction to the tip of the
pencil was taken to continue the sampling process.
It was assumed that at least one woman with a child who is less
than five years would be in such household. Once in a selected
household, a mother (15-49 years) with a child less than five yearold, was identified for inclusion as a participant. In the absence of
the mother, any other individual caregiver that fulfilled the inclusion
criteria was substituted. A researcher-administered household
questionnaire was used for collecting quantitative information from
selected households.
An observation guide was used to follow up a Supplementary
Immunisation Activities (SIA) event in the communities and to
record the use by beneficiaries of the gifts they received during the
OPV+.
Focus group discussions (FGDs) were held with both male and
female groups to obtain the perspective of fathers of U5 children
(male group), in addition to that of mothers (female groups), about
breast feeding practice, the polio plus incentives and the use of the
intervention components. Mothers of U5 children that received the
sachet of milk powder were also interviewed about their breastfeeding behaviour and the use of the sachet of milk powder that
they received. The FGDs were complemented with in-depth
interviews with purposefully identified community and opinion
leaders as well as individuals involved in the polio eradication
programme at the state, LGAs, communities and facility levels. Five
individuals that shunned the programme were traced and also
interviewed to understand the reasons for rejection.
Data analysis
The quantitative data were entered using Epidata version 3.1
(Odense, Denmark) and processed using STATA v 14 (StataCorp).
Descriptive statistics was used to determine proportions of various
categories of respondents, and for comparison. Qualitative data
were transferred into MAXQDA 12 software package (Verbi
Software) and analysed. The themes from the qualitative data
aligned with the variables of interest in the quantitative data to
ensure data harmony, triangulation and to enable complementary
and analogous interpretation.
Ethical clearance
The National Research Ethics Commission (NREC) reviewed the
study protocol and granted an ethical clearance for its conduct.
RESULTS
Study population
Kachia (rural) and Kaduna North (urban) LGAs from
Kaduna and Biu (rural) and Maiduguri Metropolitan
Council (MMC) (urban) LGAs from Borno were used for
the study. A total of 808 mothers and caregivers were
interviewed. Seventy-four (74) in-depth interviews and
group discussions were conducted. The similarities in the
samples irrespective of their locations, culture, religion
and states were striking (Table 1) thus allowing our
conclusions to be highly representative of the study
communities and states. More than 60% of the caregivers
in the household survey had a child less than 24 months
and only 9.3% had children between age 37 and 60
months.
Awareness of polio disease and vaccination
Awareness about polio disease is very high in the two
states (92.9%) but the proportion of those that have seen
a polio case was relatively low (27%). Almost all
caregivers know that polio vaccine or a visit to a health
facility can protect a child from polio disease. 99.7% (last
child) received polio vaccination during the last polio
vaccination exercise (Table 2).
Respondents in qualitative interviews are also aware
about the disease and vaccination although some have
seen cases while others have never seen a case.
I know of a woman called …… whose child is a victim of
polio. Polio has been here long before I was born. My
grandparents also had the issue but then no one knew
what to do. We thought it was iska (bad omen). Female
community leader, Biu, Borno State.
Since we grew up to know our community, we have not
seen any case of polio, we only hear about it. But the
vaccine is given to the children despite our awareness
that polio is not one of the health challenges the
community. FGD Mothers, Kachia, Kaduna.
Akogun et al.
43
Table 1. Description of study population1.
Settlement type
Urban
Rural
Total Sample
Caregiver has child aged
Less than 6 months
6 to 24 months
25 to 36 months
37 to 60 months
Last child’s median age (months)
State (%)
Borno
Kaduna
50.3
50.1
49.7
49.9
403
405
No difference
-
Total (%)
417
391
808
-
157 (19.4)
374 (46.3)
202 (25.0)
75 (9.3)
14
21.6
49.1
24.3
5.0
18
17.3
43.5
25.7
13.6
17
Religion (%)
Moslem
Christian
52.9
47.2
47.1
52.8
628
180
No difference
-
21.0
45.7
24.0
9.2
17
13.9
48.3
28.3
9.4
-
1
Household survey respondents were strictly mothers of U5 children. Vertical comparison only.
Table 2. Caregivers’ awareness about polio disease and vaccination.
Polio Awareness
Seen child with polio
Aware vaccine prevents
Monthly campaign
Borno (403)
42.1
99.7
96.8
Kaduna (405)
13.2
96.2
75.6
Total (808)
202 (27.0)
739 (97.9))
696 (86.1)
99.7
100
100
100
99.8
100
100
100
794 (99.7)
524 (100.0)
154 (100.0)
13 (100.0)
Last child received polio vaccine
2nd child received polio vaccine
3rd child received polio vaccine
4th child received polio vaccine
Awareness and practices of exclusive breastfeeding
Participants’ awareness of EBF among caregivers is
82.4% (Table 3). Awareness about EBF was higher in
Kaduna (96.8%) than in Borno State (68%). The local
health personnel were the main source of information
about exclusive breast feeding (90.5%) through antenatal
health education and home visits. Only 3.6% attributed
awareness of EBF to campaigns.
Local health personnel display messages about
exclusive breast feeding in health facilities and provide
health talk at health events and particularly during
antenatal meetings.
The information on exclusive breast-feeding was passed
to us at the health facility by the officer in-charge who
came here this morning. It was during ante-natal care.
We were told about the importance of breast milk without
water or any other processed milk or food. We were also
told to exceed the six months if we want. ... believe me,
you would love this method of breast feeding because …
the child will be active and agile. Female community
leader, MMC, Borno State.
The in-charge told us to breast feed our children for at
least six months of life before giving them water and
other food. FGD Mothers, Biu, Borno State.
Participants (32.6%) confirm practising exclusive
breastfeeding (22.4% in Borno and 42.7% in Kaduna
State). Processed milk (infant food formula is introduced
before the age of 6 months by 14.9% while solid food is
introduced by 11.8% (Table 4).
Caregivers with only one child were more likely to be
exclusively breastfeed (35.4%) than those with more than
one child. From the results, the first child received less
exclusive breast milk than those born later. Irrespective of
the birth order, the proportion of children that were
exclusively breastfed was higher in Kaduna than Borno
State. Overall, 49.5% of 283 caregivers had exclusively
breastfed at least one child.
Mothers start giving water at birth and may then resort
44
J. Public Health Epidemiol.
Table 3. Awareness and source of information about EBF (multiple responses allowed)
State
Awareness
Source of information about EBF
Health worker
Health campaign
Relative/Family
Friends
Poster/advertisement
Others
Total
Borno
68.0
Kaduna
96.8
Total
666 (82.4)
85.3
7.0
2.2
5.1
0.4
0
273
94.1
1.3
1.5
1.3
1.0
0.8
392
602 (90.5)
24 (3.6)
12 (1.8)
19 (2.9)
5 (0.8)
3 (0.5)
665 (100)
Table 4. Exclusive breastfeeding practices among caregivers (%)
Parameter
Before age 6 months, caregiver
Exclusively breastfed child
Gave breast milk+ processed milk
Gave breast milk+ processed milk + Solid food
Gave other
Borno
Kaduna
Total
90 (22.4)
90 (22.4)
90 (22.4)
132 (32.8)
173 (42.7)
30 (25.0)
5 (1.2)
197 (48.6)
263 (32.6)
120 (14.9)
95 (11.8)
329 (40.8)
Caregivers that
EBF all 4 children
EBF all 3 Children
EBF all 2 children
EBF the only child
7 (14.3)
101 (21.8)
189 (18.0)
105 (24.8)
1 (0)
43 (20.9)
178 (41.0)
183 (41.5)
8 (12.5)
144 (21.5)
367 (29.2)
288 (35.4)
Caregiver exclusively breast fed
1st Child
2nd Child
3rd Child
Last child
12 (16.7)
294 (20.7)
111 (20.7)
12 (16.7)
1 (0)
224 (40.2)
43 (23.3)
1 (0)
13 (15.4)
518 (29.2)
154 (21.4)
13 (15.4)
to only breast milk in addition to water before introducing
adult meals at a later age and finally weaning the child.
Even though awareness of EBF is high, community
members were concerned about denying a new-born
water considered giving water as integral component of
exclusive breast feeding.
I usually give my child other food like pap and spaghetti
at twenty months. As for the child before the last child, I
breastfed him exclusively for the first seven months
before I started giving him water and later, I added pap,
and it continued until he could eat food by himself, then I
weaned him off breast milk. Female community leader,
Biu, Borno State.
Frankly speaking, I know of this exclusive breast feeding,
but I do not practice it because I cannot deny my child of
water for six months. I do not give any other food but
breastmilk and water until after six months. FGD mothers,
MMC, Borno State.
In Borno, Moslem women would give holy water, zamzam from Mecca to infants as soon as they are born. The
water is assumed to have spiritual cleansing and it is
believed to make children brilliant and healthy.
However, others comply with EBF.
Some mothers dropped zam-zam (water from Mecca
Akogun et al.
45
Table 5. Age (months) at which breast feeding is stopped.
Parameter
Age (months) when last child stopped breastfeeding
Sample
Mean age
Median age
Mode
Borno
Kaduna
Total
157
19.17
19.00
18
201
18.67
18.00
18
358
18.89
19.00
18
Age when first Child stopped breastfeeding
Sample
Mean
Median
Mode
12
19.42
20.00
20
1
20.00
20.00
20
13
19.46
20.00
20
Reasons for stopping to breast-feed the child (multiple responses allowed)
Sample
Tired (%)
Usual/normal time to stop (%)
Prefer powdered milk (%)
Child old enough (%)
Other reasons1 No breast milk (%)
157
1.3
76.4
0
14.6
0.6
204
13.7
28.4
0.5
53.9
9.9
361
8.3
49.3
0.3
36.8
4.7
1
No breastmilk, not my child. Vertical comparison only.
which is believed to be holy water for the Moslems) in the
baby’s mouth to make the child brilliant and to prevent
diseases. If the mother lacks breast milk, we give
zamzam to the child to drink. Female community leader,
MMC, Borno State.
Breast feeding duration varied and the interpretation of
EBF had different interpretations depending on the
caregivers. The mean age of weaning is 19 and 18.7
months in Borno and Kaduna states, respectively (Table
5). Children are introduced to adult food after weaning
between 18 to 20 months.
In both states, the age at which a child was weaned
seemed to decline from the first (Mean 19.42, mode 20.0)
to the last child (Mean 19, Mode 18) indicating that the
first child had more breastmilk than the successive
siblings. The most commonly cited reason for stopping to
breast feed were compliance with culturally appropriate
time for stopping (76.4% in Borno) and when the child
was old enough (53.9%, Kaduna). The introduction of
supplementary milk feeding was the least important
reasons (0.3%) for stopping to breast feed the child.
Impact of demand
immunization
creation
strategy
on
polio
A mobile “road show” is conducted by a team which has
health personnel, recorder, vaccinator, mobiliser as well
as entertainer that led the street-to-street show. The
entertainer used various theatrics, music and acrobatic
displays to draw children to a central location.
During the first two days, we focus on entertaining the
community by organising street shows, dances, and
revelry often on their market days. As the children come
out to enjoy the shows, the team would give the vaccine
and present gifts to those that had received the
vaccination. Those who receive the presents would then
go to bring other children. This creative approach proved
to be a highly effective mobilisation strategy in all the
communities that we visited. Senior Health Management
official, Kaduna State.
Caregivers are presented with some gift of soap, noodles
and other items of value to the household. In addition,
children between the ages of 24 to 60 months who are
attracted to the road shows, are given toys, whistles and
sachets of milk powder.
The gifts that the nurses give our children is like magic.
The nurses now have absolute control on the children
during the vaccination. No parent can prevent the child
that can walk from rushing off into the streets to receive
the vaccine and the gift that comes with it from a smiling
nurse. No one. The children love the nurses now more
46
J. Public Health Epidemiol.
Table 6. Motivational items that caregivers received in the last campaign.
Parameter
Sample
I and, or my child received nothing
Borno
403
0.7
Kaduna
405
23.5
Total
808
12.0
I and, or my child received:
Vitamin A
Deworming medicines
Sachet milk powder
Others
The items motivate me
0.5
1.2
70.5
86.8
100.0
23.5
20.0
57.0
20.5
100.0
12.0
10.6
63.7
53.6
100.0
Table 7. Receipt and use of the sachet of milk.
Parameter
Received milk sachet at least once in three campaigns
Children less than 6 months that consumed sachet milk at least once in three campaigns
Received milk in campaign before last
Children less than 6 months that consumed the sachet of milk powder at least once
Received milk in campaign last campaign
Children less than 6 months that consumed the sachet of milk powder at least once
How the milk was used
made tea with it.
gave to a child that is breast feeding who is OLDER than six months
gave to a child who is NO LONGER breast feeding
gave to a child that is breast feeding who is YOUNGER than six months
It makes women to start buying sachet milk for the bf children
Borno
(403)
49.4
6.0
37.5
2.0
32.0
1.6
Kaduna
(405)
57.3
3.4
2.2
11.1
0.2
0
Total
(808)
53.3
4.6
19.8
2.5
16.1
1.5
119 (32.3)
75 (20.4)
170 (46.2)
3 (0.8)
1 (0.3)
136 (32.2)
107 (25.3)
175 (41.4)
2 (0.5)
3 (0.7)
155 (32.2)
182 (23.0)
145 (43.6)
5 (0.6)
4 (0.5)
1
These relate to the caregiver and excludes milk that is given to children during the road shows. Vertical comparison only.
than their teachers because of this. Female community
leader, Biu, Borno State.
Collection and consumption of the demand creation
incentive (sachet milk powder)
In Borno and Kaduna states, 70.5 and 57% of the
caregivers, respectively received a sachet of milk powder
and other items such as sweet (19.9%), soap and sweet
(11.4%), soap (10.6%), sweet (4.7%), and biscuit (3.6%)
during the polio campaigns. Every community member
attested that the gifts influenced the acceptance of the
vaccine (Table 6).
In the three campaigns before the last, 53.3% of the
caregivers received sachets of milk powder at least once
in both states while 16.1% of the caregivers received it
during the last campaign thus showing a decline in
sachet milk distribution (Table 7).
Less than 50% of caregivers in Borno State received
the sachet of milk powder during the three polio vaccine
campaigns considered with the proportion of caregivers
given milk reducing it from the previous to the most
recent campaigns. Only 1.5% of the children less than 6
months old were given the milk received by caregivers.
There was a reduction in the proportion of children less
than six months that received the sachet milk from the
previous polio campaign to the most recent one.
Neither caregivers nor community members gave the
milk powder to children that were breastfed. Reasons for
not giving babies include: the powder will choke them,
milk only for grown-ups, it was not enough.
We don’t give the milk to the children and babies
because you know they can’t take it and the milk can
cause choking since it is in powder form. FGD Fathers,
Akogun et al.
consequence should they be removed by fiat.
Miringa, Biu, Borno State.
It is only the grown-up children who were not breastfed
that got the milk and they gave me soap or detergent for
bringing my youngest child and I use it to wash her
clothes. She is now one year old. There was no time I
gave the milk to my breast feeding baby. Female
participant, Biu, Borno State.
There was not any instance where it was reported to us
that a mother gave our milk to anyone less than two
years. The older children like milk and sometimes insist.
The milk has resolved most of the issues of
noncompliance. Health Personnel interview, MMC, Borno
State.
I do not think any mother that has chosen to exclusively
breastfeed will interrupt it because of this small thing that
you get once in many months. A woman will not stop her
exclusive breast feeding just because she was given a
sachet of milk. Female Community leader, Kachia,
Kaduna State.
In my community we practice exclusive breast feeding. It
is cheap, and we are poor. Community leader, Kachia,
Kaduna State.
DISCUSSION
Influence of
vaccination
gifts
and
47
entertainment
on
polio
The study shows that the mothers and caregivers are
well aware of, and accept polio vaccine. The high level of
awareness is largely influenced by the demand creation
strategy through the distribution of incentives to children,
mothers and caregivers.
The gifts and entertainment motivate participation and
compliance. In 2003, the polio vaccine was widely
rejected in Northern Nigeria causing a setback to the
previous accomplishments and a global health crisis. The
gifts (and entertainment) resulted in significantly higher
uptake of the vaccine in hitherto non-compliant
communities (Warigon et al., 2016).
There is a high dependence on the gifts in Borno State
as a motivator for compliance where traditional noncompliance had been the norm. The children were
particularly motivated to come outdoors bringing their
siblings and friends to receive the gifts and the vaccine.
Stakeholders’ opinion including representatives of
international development partners and project managers
attest to the influence of the incentive approach on local
participation particularly where compliance is low. The
incentives are a major motivating factor that could only be
withdrawn gradually to
avoid
the
unpleasant
Awareness and practices of exclusive breastfeeding
Awareness of EBF among caregivers in both states is
also high and mainly influenced by the health personnel
at the local health facilities whose responsibility include
the coordination of all health education and intervention
campaigns in their areas. The same health personnel that
promotes polio immunization uptake, is also responsible
for the promotion of EBF. That the high level of
awareness has not translated to practicing exclusive
breastfeeding especially for children under 6 months is
much more complex and will require further study of
culture, economic and other social factors.
Influence of the demand creation (sachet milk
inclusive) on breastfeeding practice
The road shows attract children between 36 and 60
months who could join in the fun outside and follow up
the vaccination team and makes it extremely difficult for
children who are less than 24 months old to receive the
sachet of milk powder. Incentives for mothers to bring
children below twelve months of age focus on gifts that
are of domestic value to mothers (wash soap, spoons)
while gifts such as milk powder are used to attract the
older children who may more easily avoid the vaccination
teams.
The quantity of the milk powder and the distribution is
too little and infrequent to cause any behaviour change
that will make caregivers and mothers develop appetite
for replacing breast milk with sachet milk powder. The
milk powder costs about five US cents which is expensive
for its value in the household priority list. Caregivers are
also aware that the milk is not formulated for infants and
could not be a substitute for breast milk.
The same health personnel that promote EBF also
promote compliance with polio vaccine acceptance and
use every opportunity for an outreach to pass the same
information to the community members. For example, the
house to house polio vaccine campaign was used to
reinforce the exclusive breastfeeding message.
The study did not find any promotion (advertising,
endorsing or preferment or advancement, encouragement
in any form) of the gift items. All the motivational add-ons,
although bearing trade names were procured using the
WHO procurement processes and were neither donated
nor branded for use thus excluding the likelihood of
external influence.
The scope of the study was limited to Borno and
Kaduna states and although a wider exploration would
have been useful, it does not in any way diminish the
quality of the evidence. The results were shared with a
48
J. Public Health Epidemiol.
cross section of the stakeholder community (UNICEF,
WHO, Federal Ministry of Health) which recommended
further use of the incentives approach to target areas with
persistent low OPV uptake.
United Nations Children’s Emergency Fund; WHO, World
Health Organisation.
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Conclusion
These findings show community entertainment and
incentives were an effective strategy for increasing
participation and compliance with OPV campaigns in
Northern Nigeria. The involvement of the same local
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CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
ACKNOWLEDGEMENTS
The authors are grateful to the Federal Ministry of Health,
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the participants who were generous with their time and
insights. The study received financial assistance from the
Common Heritage Foundation through the World Health
Organisation and logistical support from the Federal
Ministry of Health, Nigeria.
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