The Cultural and Political Dynamics of Technology Delivery ......In Yoruba terms the concept of care...
Transcript of The Cultural and Political Dynamics of Technology Delivery ......In Yoruba terms the concept of care...
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The Cultural and Political Dynamics of Technology Delivery: The Case of Infant Immunisation in South western Nigeria
Dr. Ayodele Samuel Jegede
Department of Sociology University of Ibadan, IBADAN
West African Social Science and Immunisation Network (WASSIN) paper 3
Introduction1 Immunisation coverage is low in Nigeria. The 2003 Nigeria Demographic and Health
Survey reports that 'only 13 percent of the Nigerian children aged 12-23 months can be
considered fully immunised,2 the lowest vaccination rate among the African countries in
which Demographic and Health Survey (DHS) rates have been concluded since 1998'
(National Population Commission, 2004). Despite the creation of the National
Programme on Immunisation (NPI), the situation over the years has not improved;
rather, it has deteriorated. For instance, the 1999 DHS found that full immunisation
coverage had dropped to 17 percent from 30 percent in 1990 (Measure 2004), with a
particularly marked decline in the north of the country (1999 coverage was 7.5 percent
in the north east and 4.3 percent in the north west). In 2003, coverage was found to be
approximately 13 percent.
In the 2004 report on the State of the World's Children, the United Nations Children’s
Fund (UNICEF, 2004) rated Nigeria as the 15th nation with the highest under five (U-5)
mortality rates. Many babies lose their lives before their first birthday to six childhood
killer diseases which are preventable by immunisation (measles, tuberculosis, 1 The study on which this working paper draws was funded by the Committee on Social Science Research of the UK Department for International Development; however opinions and views represented here are those of the author and not of DFID. 2 “Full immunization” is defined as BCG, measles and 3 doses each of DPT and OPV
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diphtheria, whooping cough, tetanus and poliomyelitis), while many of those who
survive are maimed for life, blind or deaf, or weakened by heart and lung diseases
(Nakajima, 1995). Indeed, about one third of all deaths in children less than five years
of age are attributed to these diseases (UNICEF, 1993, 1999, 2000). In Nigeria the
infant mortality ratio due to the prevalence of these diseases is still as high as 112
deaths per thousand births, one of the highest in Africa (UNICEF, 2003, 2004; UNFPA,
2003).
Efforts to prevent these childhood diseases go back at least as far as 1979 when the
Federal Government established the Expanded Programme on Immunisation (EPI). In
1997 this programme was renamed the National Programme on Immunisation (NPI)
and was charged with the responsibility of effectively controlling, through immunisation
and provision of vaccines, preventable diseases by the end of 2005. However, the
realization of these goals has faced many setbacks. More than half of children aged 12-
23 months have never been vaccinated and the ratio of immunised children is declining
(Onwu, 2004). Less than 50% of children have been vaccinated against measles, and
Nigeria is rated one of the seventh polio endemic nations (Onwu, 2004).
The continued decline in routine immunisation coverage, coupled with a dramatic
resurgence of measles in 2004, suggests that current strategies are failing. For
instance, two new strains of the measles virus found circulating recently in Lagos and
Ibadan have been isolated and deposited at the world database on viruses in
Luxembourg for incorporation into future vaccine production3. The appearance of these
new strains dashed the hope that measles might be eradicated in Nigeria. At the same
time, crises in the uptake of oral polio vaccines in the northern part of the country during
2003-4 linked to a resurgence of polio (see Yahya, forthcoming), raise further questions
about vaccine delivery and uptake, and whether in the Nigerian context this technology -
supposed to be key in preventing disease - is really meeting its goals.
3 Punch Wednesday, June 22, 2005 Page 4
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Many current policy debates about low vaccination coverage in Nigeria focus on issues
of vaccine supply. They point to problems of finance, procurement, cold chain
maintenance, staffing and management, linked to what is argued to be a wider collapse
in Nigeria's primary health care system (FBA 2005). Others focus on issues of demand.
For example, it is argued that the least protected children are those whose mothers
have no education, of which more than half have not been vaccinated against polio
(Onwu 2004). However, as in this argument, discussion of vaccination demand is often
reduced to narrow issues of knowledge and education. Missing is a deeper
understanding of the social and cultural influences on vaccine demand, acceptance or
non-acceptance. In turn, how these social and cultural dimensions shape people's
interactions with vaccine delivery services and institutions is poorly understood. This
study aimed to fill these gaps in the south-western Nigerian context by examining socio-
cultural aspects of immunisation demand and supply-demand interactions at the local
level.
Goals and methods
The study took an anthropological approach to documenting current demand and use of
vaccinations, and local interactions with delivery services (see Fairhead, Leach and
Small 2004). Specifically, it aimed:
1. To examine cultural beliefs, concepts and practices around child health
protection and immunisation
2. To understand the nature of demand for immunisation
3. To explore local interactions with immunisation services.
4. To identify how community members' experiences with immunisation delivery
and staff influence these interactions.
The anthropological research on which this paper is based was conducted in July 2005,
and focused on two contrasting sites in Oyo State in Yoruba-speaking south-western
Nigeria. Moniya is a peri-urban area with a fast growing population and relatively strong
infrastructure while Onidudu is a rural community about five km away with comparative
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serenity, but a lack of infrastructure. The aim of choosing Moniya was to see how
immunisation is affected by cultural changes linked to urbanization. The two sites are
within the areas covered by the author's on-going and past health research activities: he
conducted his PhD thesis research on immunisation in the area in 1993 (Jegede, 1995)
and has maintained a research base in the area since then. The present study provided
an opportunity to follow up on specific issues explored in 1993 and to see whether, a
decade later, they have changed.
In each of the sites, the research consisted principally of detailed narrative interviews
taking the form of vaccination and research engagement ‘biographies’. These traced
parents’ unfolding experiences with each child, and took an open ended format that
enabled the narrative to follow the issues most important to them. The 18 biographies in
both sites built on 8 focus group discussion held with men and women grouped by age
category, and 10 key informants including traditional healers, traditional birth attendants,
health workers, community leaders, religious leaders, adult men and women. The
biographies were complemented by observation to explore issues surrounding infant
health, and the social dynamics shaping health practices.
Existing studies of parents’ engagement with vaccination in the study area have been
based mainly on questionnaire surveys (NDHS 1990, 1999; Jegede 1995). In contrast,
this study's ethnographic approach helps to consider how people’s engagement with
vaccination unfolds, and how this is linked to broader contexts of infant care and of
people’s social worlds.
During this research, conducted as it was over a short time period, it was difficult to
have direct observation of mothers' interactions with immunisation services. This clearly
places limitations on the ability of the study to describe delivery and uptake practices.
Rather the focus is on representations of these practices as given in the narratives of
both 'frontline' health workers (e.g. nurses) and community members.
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The paper first explores how Yoruba parents reflect on immunisation in the context of
broader beliefs and practices around child protection. It then examines particular
concepts of immunisation and immunity. These concepts and beliefs, it is shown,
underlie strong demand for immunisation. However, as the paper shows, some people
have anxieties about immunisation, while there are certain mothers who despite this
demand, 'default' on immunisation for practical reasons. The paper goes on to look at
people's interactions with immunisation services. It highlights the significance of visits to
the clinic as a social event, of gender dynamics in clinic visits, and of peoples'
interactions with staff as key supply-demand interactions that shape immunisation
uptake.
Cultural beliefs and practices around child health protection and immunisation
Immunisation in the study area takes its place amidst a broader set of beliefs and
practices used to care for children and protect their health. In Yoruba culture, parents
explore different ways of protecting their children against diseases. This is exhibited in
their day-to-day behaviour. As a result childcare sometimes appears like ritual.
Culturally, child health protection is viewed as a form of investment. Protection is
encapsulated in the concept of 'itoju' which means 'care'. In Yoruba terms the concept
of care involves paying attention (ito means paying attention while ju is a short version
of oju, literally meaning 'eye') - in this case to the health of the child.
Itoju in Yoruba culture is reciprocal in the sense that investment in children would bring
about social security for parents at old age (Jegede 1999). This is expressed in the
adage bi okete ba dagba tan omu omo re nii mu, literally meaning 'a rabbit sucks from
its offspring at old age', a metaphor indicating parents’ dependence on children at old
age. This child/parent relation shapes attitudes towards the care of children: a child
whose health is protected suggests a promising future for the parent. But how this is
done is a matter of cultural perceptions of protection itself.
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Practices around child health protection and immunisation in the study area involve day-
to-day routine care. In many cases, mothers use common hygiene practices including
bathing the child. Most of the respondents indicated that an early morning bath is very
important for a child. In Onidudu, an uneducated young woman participant said than “I
know when I wake up in the morning I bath for my child”. Similarly an uneducated male
FGD participant in Moniya revealed that “we keep babies healthy by giving them good
baths”.
Bathing to Yoruba culture is both preventive and curative, as indicated in the concept of
iwe. This connotes “removal” which in this case means removal of 'dirt'. Dirt has both
literary and philosophical meaning. Philosophically it may mean ill-health which must be
cleansed. Therefore, removing dirt from a child takes care of both physical dirt and the
washing away of potential illnesses. A traditional healer suggested that 'The body is full
of “oil” which constitutes danger to the human health. There are herbs that can be used
together with ‘black soap’ to wash and remove all the oil. If this is done regularly for a
child he/she will be in good health'. This suggests excess fat in the body, and
corresponds to a biomedical view that the reduction of body fat will definitely promote
good health since the level of cholesterol in the body will be reduced.
Nutritional practices are common methods of keeping a child in good health as indicated
in the phrase omo ti ko jeun ko see toju, meaning 'it is difficult to care for a child who
does not eat'. Eating is generally considered as both preventive and curative, for male
and female respondents in both sites alike. For instance, an elderly woman from Moniya
said that iyan ni onje oka ni ogun, meaning 'food is medicinal'. This suggests that
respondents are able to identify food substances as therapeutic. An important thing
about the food one must give to a child is that it must be warm. This is because it is
generally believed that cold food can harbour germs that may cause stomach or
gastrointestinal respiratory infections (RTIs).
Breastfeeding practices are understood as protective for children. An uneducated
elderly woman in Moniya, for instance, stated that “breastfeeding is important to
children’s health”. It is generally believed that a child must be properly breastfed in other
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to be strong. As indicated earlier, 'strength is synonymous with the ability to resist
diseases”. This provides a local interpretation of immunity. In these terms, therefore,
breastfeeding is understood as a source of natural immunity.
Clothing is another way of keeping a child healthy, emphasised the respondents. This is
important to ensure that a child is not exposed to harsh weather conditions. For
instance, an uneducated elderly man from Onidundu stated that “we need to clothe our
children very well especially during the cold weather in order not to expose them to
certain diseases”. Similarly, a young educated woman from Moniya said that “when
children are not properly clothed they can be exposed to respiratory tract infections
(RTI) like bronchitis and pneumonia”. In a related statement an educated elderly man in
Moniya was of the opinion that clothing a child is very important saying that “a child
needs proper care especially when there is cold. If a child is not properly clothed during
cold season, such a child may catch cold and die. That is why mothers are advised to
look after their children properly”.
In addition to these everyday practices, health centres and hospitals are also a major
source of care for the child. For instance, an educated young woman from Moniya
stated that “we also take our children to the hospital to see the nurses so that they do
not get sick”. An uneducated man from Moniya stated similarly that “we keep our
children healthy by taking them to the hospital”. Respondents from Onidudu shared
similar opinions.
Behaviour change in children is an important way in which people gauge their health
status. Respondents view a healthy child to be a playful and cheerful one. According to
an educated elderly man in Moniya “there is need for proper monitoring of children in
order to detect unusual behavior that can reveal the emergence of ill-health. Prompt
detection of such behavior and intervention has proved to be a good method of ensuring
good health for a child”. A health child is expected to be active and not dull. He or she
should eat well and interact with peers actively. Observation provides proper monitoring
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of a child’s behaviour. If a child is not properly monitored such a child may run into
complications any time he or she is sick.
Aside from these general views and practices that apply to all children, people
distinguish certain categories of children by the special care and protection that they
require. For example, a herbalist from Onidudu was of the opinion that: “it is not all
children that use warm water. There are some children that are allergic to warm water.
Cold water is used for them and they do not usually get sick. In fact, they do not have
similar health problems like other children”. This is a general consensus among
uneducated elderly women in Onidudu, who said such children are named Olomitutu4
meaning 'A child allergic to warm water'. This can also be interpreted literally as “the
owner of cold water”. The word olomitutu has three syllables: olo is a possessive word
meaning ‘owner’ and in this context depicting identity ‘mi is a short version of omi
meaning, ‘water’ and tutu means ‘cold’. It was explained that such children are
considered to be a blessing from the river goddess. As a result to react negatively to
warm water. Indeed the care of such children rests primarily on the use of cold water
without much medicine, as illustrated in a song seleru agbo iyeru agbo l’osun fi nwe ‘mo
re ki dokita o to de, a bi ‘mo ma d’ana osun l’aa fii bu. This means that 'the abuse of
Osun5 goddess is that she did not cook nevertheless she cared for her children even in
the absence of modern medicine'. This song emphasizes the importance of traditional
child care practice in Yoruba culture.
Special water drawn from a designated river site would usually be used for these
children. Narrating the water collection event, an educated woman in Onidudu explained
4 This practice appears no longer to be popular though some elderly women still refer to it. Observations did not reveal it and the majority of young women did not mention it. Many of these names are no longer used. The elderly women's response could therefore be due to how the question was posed as an exploration of child care practice in the area; somebody wanted to note an exception. 5 Osun is a river goddess worshipped in Yorubaland. Its influence cuts across the length and breadth of the Yoruba society. Yorubas believe that Osun is a goddess that blesses people with children because she has many of them. As a result barren women usually seek children through her. The goddess is venerated resulting in annual celebration at its shrine in Oshogbo the capital city of Osun State. In recent times the Osun festival has assumed an international recognition which attracts people from across the world. However, it is not clear whether the current renewed interest and international participation in the worship of Osun will reinvent widespread child care practices and naming patterns as described above.
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that “very early in the morning before dawn mothers of such babies would go to the river
to fetch the water in a mud pot covered with a particular leaf omu”. This suggests a kind
of social event, which parallels - and may sometimes be translated into - the social
event of a visit to an immunisation centre.
Indeed, as such parallels suggest, people use a combination of both traditional and
modern medicines. For instance, a herbalist from Moniya said: 'We do go there
(immunisation centre) but at the same time we go for herbs to complement modern
drugs. There are certain ailments like oka and jewo that herbs can effectively address.
That is why we use both.' Another herbalist, also from Onidudu, stated that “They
complement each other. The combination has no bad effect”. This suggests that
prevention of children against diseases involves shuttling between traditional and
modern medicine as earlier observed by Erinoso (1981) in his study among the Yoruba.
Jegede (1995) also made similar arguments a decade ago about the use of EPI in the
study area. This is contrary to other studies, especially in developed country settings,
which suggest that alternative health care providers may harbour anti-vaccination
attitudes (e.g. Wilson et. al., 2004).
In Nigeria, studies have indicated multiple pathways to health care utilization (e.g.
Erinoso 1981). This also promotes choices of protection against childhood diseases. A
combination of both modern and traditional medicine is usually considered as the best
way to protect a child’s health. Traditional healers indicated that traditional medicines
complement modern immunisation, saying that “there are diseases that modern
medicine cannot cure”. According to them, “those who use traditional medicine and later
go for modern medicine do so in order to fulfill all righteousness”. For modern health
care practitioners, in contrast, modern immunisation is the ultimate method of protecting
children.
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Concepts of Immunisation Immunisation as a health technology is central to child health care practices in the study
communities. Various everyday child care practices by themselves are seen as ways of
protecting children against childhood diseases. However, formal methods of prevention
also exist and are widely used. Generally, although there are some rural-urban
differences in the perception of immunisation, it is believed that immunisation
strengthens the child and prevents diseases. As the uneducated women participants in
a FGD from Moniya put it: were of the opinion that “it enables a child to be strong and
avoid diseases”.
A common concept of immunisation in the study communities is ajesara. This literally
means something absorbed into the body. Absorption is not the key issue as this
happens frequently with other substances, such as food nutrients. Rather, the emphasis
is on things of a particular content or properties made specifically to prevent diseases.
The prevention of diseases through absorption of certain properties may happen in
different ways. First, the substances may be taken orally, like oral polio vaccine (OPV).
The administration of OPV is described as atola. Ato means droplet and la means
'licking'. Droplet in this sense explains issues of volume and size, referring to a minute
volume of liquid at a point in time. The perception that this small volume allows disease
prevention runs contrary to Yoruba views on volume and efficacy in other contexts.
Thus for example there is a Yoruba saying that a kii wa l’odo ki a maa fi ito san owo,
literally meaning 'one does not use saliva to wash hand at the river bank'. This implies
that one should not suffer in the midst of plenty. Equally, licking (la) is seen as different
from drinking or eating, involving a much slower digestive process. This means that
whatever is licked may take some time to be absorbed. The two syllables combined
together, suggesting that droplets might be ineffective, might be seen to explain parents'
preference for alternative preventive care.
Nevertheless in the case of oral polio vaccine, everyone agrees that despite the small
volume and the licking, it is efficacious. As an uneducated elderly woman from Moniya
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explained: “it is very effective! It ensures growth”. Even men agreed that immunisation is
good, thus supporting the view that people should take the droplets. This is contrary to a
Yoruba adage saying opo oro ko kun agbon meaning “many words do not fill a basket”,
referring to the quantity of words. It shows that changes are taking place in Yoruba
worldviews and perceptions of health technologies such as immunisation.
Another concept used to refer to immunisation is abere iwosan meaning 'healing
injection'. The word “injection” is central to all drugs administered using syringes and
needles in health care delivery in the study areas. This is likely to cause confusion
between vaccines administered through intra-dermal processes and curative medicine
administered through the same process. Therefore, referring to immunisation as abere
ajesara, or injection absorbed into the body, provides a different meaning distinct from
the utilization of services for iwosan, meaning ‘healing’. This is different again from the
common concept abere ilera which is more closely related to 'health'. Another concept
used by respondents is abere agbomola, meaning an injection that saves children.
Immunisation as a social event
A visit to an immunisation assembly point is usually an event associated with group
movement, singing and dancing, and social networking. Nursing mothers engage in
group visits to immunisation centres as they sometimes come in company of those
living in the same neighbourhood, or with friends. Sometimes it is those who delivered
in the same place at the same time. This behaviour promotes compliance in that
mothers tend to remind one another about the need to go, while everyone sees it as an
opportunity for relaxation and an outing. Women dress themselves and their babies in
their best clothes, suggesting a degree of competitive behaviour amongst mothers, as
well as an attempt to demonstrate to the nurses how well they comply with clinic
instructions about hygiene. For instance, a nursing sister stated that “we usually
educate them that they should give their babies warm food, especially during cold
weather. It is also important to cover their babies well in order to protect them from cold
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weather”. Corroborating this view an educated elderly woman in Moniya stated that “a
good mother will use warm water to bath the child and also cover him/her very well”.
Singing and dancing at immunisation centres arouses the interest of nursing mothers in
attendance as a social activity. Even some who may have defaulted on immunisations
continue to come to the clinic as an occasion for relaxation. An educated woman in
Moniya captured this vividly, saying that “before they start giving the injection we will
sing many interesting songs while people will dance. That alone is enough to let one
say I am going the next time”. This suggests that not only does the singing and dancing
prepare the women for the vaccination while the procedure is been prepared, it also
promotes demand for it. For a few, this social aspect is a waste of time. For example an
educated elderly woman in Moniya said “One of the reasons why some people do not
want to come is that they waste a lot of time singing and dancing. Therefore, those who
have much to do at home may not want to come”. But most of the women indicated that
they enjoy the event.
Among men, the situation is a little different. They tend to claim ignorance of what
happens at the clinic. However immunisation events also promote social networking
among married men. Sometimes a husband may contact a neighbour whose wife has
been going for immunisation, and inquire about his experience. This, most of the time,
creates a type of relationship founded on a common factor, as revealed by an educated
man in Moniya saying “we men do discuss these things and share experiences”. An
uneducated young man from Onidudu revealed that “initially I didn’t want my wife to go
for this immunisation but a friend convinced me”.
Social networking is another important feature of visits to immunisation centres. Some
women indicated that they make new friends at the centres. At Onidudu an educated
young woman said that “it is a place to make new friends. This is a small community;
people going for immunisation know one another”. Similarly at Moniya an uneducated
young woman stated that “it helps people to make new friends”. This may in turn lead
to mutual assistance. For example an educated woman in Moniya explained that
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“sometimes people engage in common spending especially when they board same
public transport”. This suggests that those who could have defaulted on the basis of
transport fare may receive assistance from co-nursing mothers who may not necessarily
be close friends, whom they know at immunisation centers.
Mother-in-law/daughter-in-law relationships sometimes come to the fore in visits to
immunisation centres, especially for the first three vaccinations. It is a common practice
in the study area for mothers-in-law to assist their daughters-in-law immediately after
delivery. Most young women having their first child have their mother-in-law carrying
their babies while they follow to immunisation centers. Sometimes the mothers-in-law
remind their daughters-in-law about immunisation. This is significant as mothers-in-law
play important roles in household decision-making in the study areas, sometimes able
to influence their sons. Therefore, acceptance of immunisation by mothers-in-law is
likely to help create good demand for it.
Gender dynamics in immunisation uptake
The research revealed that both men and women in the study area are receptive to
immunisation, contrary to the researcher's earlier work (Jegede 1995). At that time, the
researcher suggested the need for a public enlightenment programme and it seems that
this has been effective, with public knowledge about the importance of immunisation
now widespread.
However husbands and wives differ in their knowledge of immunisation schedules. An
educated man in Moniya stated that “Most men do not know when their babies should
take the next immunisation”. Similarly an uneducated young woman in Onidudu said
“my husband has never asked me what type of immunisation I go for. All he knows is
that I take the child for immunisation”.
The study found no evidence of different attitudes towards male and female children
when parents thought about immunisation. Although a child's gender plays important
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roles in such practices as breastfeeding, nutrition, and education, there is no gender
preference in terms of which child to take for immunisation. Most respondents insist
that they do not discriminate against any child due to gender. An educated young
woman in Moniya argued that “there is no special care for any child. As soon as a baby
is born he/she starts receiving attention. A mother or father will not say that because a
child is a female, he should not be given BCG after delivery”. Most men also shared
this view with one young man in Onidudu saying that “it is true that male and female
children are desired differently but when it comes to immunisation there is no
difference”. It is also a common practice within certain religions that gender segregation
is the basis of interaction. As a result mothers may not allow male health workers to
attend to them or to vaccinate their female children. However such practices were not
observed in the study area where both male and female staff members vaccinate both
genders, as well as people of diverse religious backgrounds. This suggests that
demand for immunisation may not be hindered by gender.
Child health protection and immunisation requires the attention and cooperation of both
parents. As a result household decision-making about it becomes important. 6 It is
common in the study area for men to express a dominant role. In practice, however,
most women revealed that they have the cooperation of their husbands. Indeed an
uneducated young woman from Onidudu stated that “if our husbands do not support us
we will not be here”.
Gender dynamics thus remain important to immunisation decision-making, even though
most Yoruba women earn their own income (Mabogunje 1961). An educated young
woman FGD participant from Moniya explained that “although most men will not say no
to immunisation but they still want their wives to take permission from them”. This
suggests that men want to express responsibility as ultimate decision maker. This is 6 The earlier study (Jegede 1995) demonstrated clearly that household decision making is a major factor in child immunization as many women take permission from their husbands. This is not only in terms of financial support but fulfilling normative value of the society in matters relating to marriage relationship husband being the ‘head’ even though he may not be the breadwinner. The changing economic situation has demonstrated the role of women as breadwinners in some household or at least contributing to house household budget but the concept of ‘headship’ has not changed, as expressed in a Yoruba phrase ‘oko lori aya’ (meaning husband is the head of the wife).
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explicit in a response of an uneducated man from Onidundu saying “oko no olori aya, ibi
ti a ba fi se ori, a kii fi ibe tele” meaning “the husband is the head of the wife, the head
cannot be used to walk”. An educated woman from Moniya buttressed this by saying
that “civilization does not mean that a wife should dishonour her husband”. She argued
further that “should anything happen to the child in the process of immunisation, how
would the woman explain it? That is why the husband should be taken along”.
The question therefore arises: what should be the role of men in supporting the
demand for immunisation? These should include receptivity to the technology, finance
and adequate knowledge of the vaccination. The research revealed that a good
number of men are highly receptive to immunisation and child health protection, with
many saying “immunisation is the best way to protect children’s health”, while also
engaging in normal child care practices at home. As the nominal breadwinner of their
families men are expected to provide money for their wives to buy good clothes for
themselves and their children, since this is a social aspect of the immunisation visits.
An educated young woman in Moniya stated that “if a woman is not well dressed or she
has no good clothes to wear for her child she will not come to this place because she
will feel ashamed”. Another educated young woman in Moniya expressed similar
opinions, saying “if my husband does not give me money to buy good clothes for the
baby I will not come here. The problem is that all eyes will be on you and the nurses
will even talk to you. But if you and your baby come in neatly they will respect you”. An
elderly woman from Onidudu said that “men should see that people determine their
status by how they see their wives and children. Therefore they must care for them
very well”. An uneducated young man in Onidudu revealed that “seeing those women
going for immunisation will encourage one to want to care very well for one's wife and
baby”. Since the women sometimes spend a long time at immunisation centres, they
may want to buy snacks or light food. Equally, on their way back home they may want
to buy certain household effects in the company of others, in order to compare prices.
Men are expected to make adequate provision for their wives and children in this
regard.
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Finally, men's understanding of the immunisation schedule is very important, because
most men tend to remind their wives of the next appointment; if they are able to do this
accurately the effect on immunisation uptake is positive.
The nature of demand - and anxieties about immunisation
Given the above discussion, how should the nature of immunisation demand in the
study areas be described? Jegede (1995) concluded that mothers have adequate
knowledge of immunisation due to the public enlightenment programme in the area.
The present study confirms these findings and emphasizes further that health education
has neutralized any effects of formal education on immunisation demand, as also
observed by Elo (1991). Through experience, too, immunisation has demonstrated the
efficacy of child protection against diseases, as indicated by a woman saying
“immunisation has reduced infant death that used to be a common phenomenon in
those days making people to give special names as Kokumo7 to children whose
mothers have experienced successive infant deaths'. Such names have disappeared in
the naming list of Yoruba people today. Current views therefore exemplify “active
demand” as observed in existing literature on immunisation (e.g. Nichter 1995).
Secondly, the research also suggests that clinic attendance is also a matter of
“routinised” or “community demand”, as a phenomenon that has now become a normal
part of child care, and with visits to immunisation centres having become a social event.
Despite this strong active and social demand for immunisation, parents sometimes
express worries about it. These focus on two issues: the perceived objective of
immunisation, and perceived side effects.
7 Kokumo means ‘s/he is not going to die again’. Such name are given to children whose mothers have experienced frequent infant deaths in succession believing that it will help to sustain the child and also to indcated the antecedent of the child’s birth. This is because fertility is highly valued in Yoruba culture while barreness is abhorred. Therefore, every woman is expected to be fruitful. Hence, infant death is considered evil and such children are considered to belong to the evil spirit thus referring to them as ‘abiku’ (literally meaning ‘born to die’).
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For some, immunisation is perceived as means of fertility control. For instance, an
uneducated man in Moniya stated that “people do carry rumour that immunisation is a
secrete way of controlling population”. Another uneducated man in Onidudu said that “I
hear people saying that immunisation is another method of birth control, but I don’t
know how far that may be true”. Similarly a young uneducated woman from Onidudu
said “some people say that immunisation is part of the methods used to check the
number of children a woman can bear”. This is similar to the finding of an earlier study
in the northern part of Nigeria (Odumosu et al 1996), and to current rumours in that
region. It s suggests that rumours about immunisation still go around, and are relevant
throughout Nigeria, not just in the north.
On perceived side-effects, some women are quick to mention swelling at the point of
injection while others emphasise body temperature. According to a woman from
Moniya, “after my child was immunised the spot began to swell up and the body
temperature starts to increase”. Another educated woman from Onidudu stated that
“each time my baby gets immunisation she always develops body temperature”.
Corroborating this fact a nurse explained how they respond to mothers' complaints
about such reactions, saying that “immediately a child is immunised we usually tell the
mothers to rub the point of injection where needle entered the body very well especially
when the baby takes DPT because it combats three diseases together”. She stated
further that “after being immunised, the common thing to note is that the baby will start
running temperature. As a result, mothers are always advised to give their children
paracetamol to help relieve the baby”. The nurse also explained that when a mother
fails to rub the point of injection it will swell up but “we usually advice them to use ice
block to reduce the pain and the swollen”. Nurses thus affirm the views expressed by
mothers about immunisation side-effects, but whereas in the nurses' perspective they
are normal, for some mothers they are worrying, which may affect demand significantly.
Indeed over the years fear of side effects has been a major contributory factor to non-
use of new medical technologies. Vaccines have not been spared this perception. In an
earlier study (Jegede 1995) the majority of respondents reported fear of side effects as
18
a reason why they did not take their children for immunisation. The present study, a
decade later, still finds traces of such bias against immunisation but with variation
between urban and rural settings. Thus in the rural areas, rumours about serious side
effects remain a powerful influence on human behaviour. In Onidudu most male and
female participants have heard of one rumour or the other about immunisation. For
instance, a young woman FGD respondent suggested that “immunisation is dangerous
because it can lead to complications” while an educated male rural respondent from
Onidudu says that “people carry a lot of rumours about immunisation saying negative
things about it”. But in the urban areas, cultural beliefs about immunisation are not very
strong among the study population regardless of their gender and educational status.
For instance, an educated young female respondent said that “there is no side effect of
immunisation and people now realize that it serves useful purpose for child health”. A
young educated male respondent in Moniya also explained that “it is true that people
carry a lot of bad information about immunisation but there is no doubt it is still the best
means of child protection”. This suggests that especially in the urban setting, people
use immunisation regardless of the negative rumours about it.
Interactions between immunisation supply and demand
Turning to the supply of vaccines, research in the health centres in the study area
revealed that vaccines are supplied in large quantity - even more than is required in
each centre. This suggests that at least during the period of the research, the study
area was not experiencing the same degree of supply breakdown reported for some
other parts of Nigeria (FBA 2005). However, the problem is utilization. Although the
health workers reported good patronage, they said that the number of people coming
does not justify the supply. For instance, a nurse in Onidudu Health Centre explained
that “because we are in rural area, people trickle in. Therefore a vaccine that is meant
for 10 people if it is used for only 2 people the remaining vial will waste. If one decide
not to attend to these two people that come in order not to waste the vaccine that is
going to remain they may stop coming”. This shows that low patronage still occurs in
19
the rural areas, due to a combination of worries about immunisation among some
mothers, and a variety of reasons for default, discussed below.
Another problem concerning immunisation supply is power failure. The Community
Health Officer of Moniya Health Centre explained that “we usually record large turnout
but there is problem of storage due to power failure. Electricity is not stable and as a
result it becomes difficult to meet demand”. In these circumstances, mothers may be
turned away and this in turn has repercussions for demand. Thus the officer explained
further that “because we are asking the mothers to come today, come tomorrow, they
often feel discouraged and some may not come back”.
The research also revealed a wide distance between source of supply and point of
delivery. Given pervasive problems in maintaining the cold chain in Nigeria, this raises
questions about the potency of the vaccines received by the children. The Office at
Moniya Health Centered revealed that “we get our daily supply from Jericho and
somewhere else. Jericho is a long distance from here”. The situation is even worse in
the rural areas. This calls for re-assessment of the modes for transporting vaccines in
Nigeria in order to ensure the potency of the vaccines at the point of use.
Local interactions with immunisation services
At the routine immunisation days at the primary health centres (PHC), a team of
community nurses registers new babies and assigns them green clinic cards, weighs
each baby, examines the card to see whether and which vaccinations are due, and
administers the vaccination appropriately. In Onidudu, a nursing sister plays a
supervisory role and sometimes gives health talks. In Moniya clinic, a matron who is the
head of the PHC plays this role. They engage the mothers in choruses. The goal of the
choruses is to enlighten the mothers more about their children and why they must bring
their children for immunisation. The exercise will continue until a nurse appears to give
the health talk. A question and answer session follows before the commencement of
vaccination. For all the health workers a key objective is to ensure that mothers
20
complete the schedule of vaccinations on time and to facilitate that, the regular monthly
weighing is sustained at least until a child is eighteen months old or 60 months in most
cases.
Those mothers who do not fulfill the overall EPI objectives and fail to fulfill the
prescribed schedule are generally referred to as “defaulters”. This strong term with its
condemning overtones group a large variety of particular ‘failures’ including being (a)
late for first vaccination, ideally given few days after delivery; (b) missing one or more of
the diptheria, pertussis and tetanus (DPT) vaccinations supposed to be given at 2, 3
and 4 months, (c) missing measles vaccination at 9 months; (d) being late for any of
these; and (e) showing a gap in weighing records of more than about 2 months.
Generally, health workers describe the attendance rate good, with the defaulters being
an exceptional and problematic few. An earlier study in Moniya found a low rate of
defaulting (Jegede 1995) and the author was able to explain this through the importance
mothers attached to immunisation. The present study confirms these findings.
Reasons for default
The research explored the reasons why some mothers default on immunisation, since
no action can be understood without its latent meaning. Generally women in the study
area know the importance of immunisation but they are constrained by certain factors,
leading them sometimes to miss scheduled immunisations. Defaulters can be
categorized into the following groups: those who travel a lot, those who forget
immunisation days, those whose schedules are tight and those who need the
permission of their husbands. Some of the defaulters are itinerant traders who shuttle
between Ibadan city about 20km away and their communities, engaging in trading.
They are not against immunisation, but often claimed to have forgotten their child's
immunisation card at home. Second, there are those who forget the date when their
children are due for the next immunisation. This is particularly common among illiterate
mothers in Onidudu. For them, reminders are important, yet these are not available.
21
Third, many of the defaulters have tight economic schedules since many of them are
petty traders. According to a respondent, “I usually miss the appointment for
immunisation because of my trade. Sometimes I find it difficult to leave market
especially on market days.” Fourth, some others need to take permission from their
husbands (Jegede 1995), and as a result fail to meet immunisation schedules.
Therefore, gender factors are very important in understanding the utilization of EPI
services in the study area, as discussed in the section on gender dynamics above.
Interactions between clinic staff and community members
One of the major factors contributing to the low patronage of immunisation services in
the past was the attitude of clinic staff (Jegede 1995). In this study we tried to examine
this in order to assess the extent to which staff attitudes have changed over the years.
The present study suggests that community members now have different views about
staff. Staff/mother relationships have developed positively, so that they now contribute
to the demand for immunisation. It appears that both experience with routine
immunisation and public enlightenment programmes have contributed to these
improvements. For instance, an educated young woman in Moniya argued that “When
there was no campaign many people were ignorant about the whole thing. But with the
ongoing campaign people are now more enlightened”.
Certain staff members sometimes appear to mothers to behave in ways that make them
feel discouraged about coming for immunisation. However, such behaviour often
reflects aspects of the immunisation supply process that is opaque to mothers. For
instance, mothers complain that staff do not turn up, and make them wait for long
periods in the clinic. In reality, those staff may be in the process of procuring the
vaccines from a distant location in Ibadan city, which can take an hour or more
depending on traffic flow. Nevertheless many of the mothers are able to understand the
delay and conclude that “all things work for good of their children”. In fact, an
uneducated elderly woman from Onidudu argued that “even though we spend much
time here the staffs are taking good care of the children”. Another educated woman
22
from Moniya was of the opinion that “the staff are not to blame for some of these things
because the government is not doing what it is supposed to do”. Indeed, it seems that
as a result of the public enlightenment programme about immunisation, parents
increasingly see it as a government activity, shifting perceived responsibility from clinic
staff to the government. The implication of this is a lowering of the level of community
participation in vaccination delivery.
The issue of community participation is central to the acceptance of any new technology
or innovation. The research suggested that currently, immunisation is less a
community-centered event than one 'of the clinic'. Some respondents were of the
opinion that this should change, and that immunisation scheduling, for instance, should
come to be a joint decision between the community and the vaccination providers. For
example, an uneducated young woman from Moniya highlighted how “sometimes the
immunisation days fall on market days and as a result some mothers may not be able to
come. Such things must be taken into consideration before fixing date”.
For men, problems with staff tend not to arise as they have little or no direct interaction
with them. Nevertheless, they tend to form opinions based on reports from their wives
and thus some men perceive clinic staff negatively. In general, such negative attitudes
are limited and do not really affect demand for immunisation services, outweighed as
they are by the perceived benefit of immunisation. As an educated young man from
Onidudu put it: “there is nothing that has advantage without disadvantage. Though
people complain about the staff but the immunisation is working very well. In fact, that
is why I have not stopped my wife from taking my child there”. Another uneducated
man from Moniya said that “I have seen the good side of the exercise and so I do not
listen to the bad news about the behaviours of the staff because they too are human
beings who can make mistakes anytime”. In general, then, it can be said that attitudes
towards staff no longer have any negative effects on demand for immunisation services
in the study areas.
Conclusions and implications
23
Cultural beliefs and concepts around immunisation in this part of south-west Nigeria
provide two meanings for vaccination. First, it is seen as an injection for preventing
diseases; and second, it is seen to enhance treatment. These meanings influence
responses to vaccination, as those who view it as disease prevention use it for that
purpose, and those who see it as treatment behave as such. Different concepts also
affect perception of the diseases prevented by immunisation. But whether for prevention
or cure, most respondents affirmed the efficacy of the technology.
The study has shown that people shuttle between traditional and modern
methods to protect children’s health. In this context traditional practitioners support and
recommend the use of immunisation as one among many forms of protection. Hence
the use of traditional medicine does not hinder demand for immunisation; rather, it
complements it.
Socially, immunisation provides an important platform for social interaction and
relationships in both urban and rural settings. Visits to immunisation centres promote a
sense of competition between mothers in how they dress themselves and their babies,
at the same time as they stimulate social networking. In turn, social networking is
important in supporting immunisation demand and uptake, as mothers visit together and
remind each other of the next immunisation day. The roles of men as stakeholders in
demand for immunisation becomes obvious both in household decision-making about
visits to immunisation centres, and in provision for mothers' financial needs for such
visits. Male involvement also promotes social networking among men who want to
learn from one another about the technology their wives and children use.
The study has therefore shown that there is both strong social demand, and culturally-
grounded active demand, for immunisation in this part of Nigeria. Nevertheless, there
are some mothers who default. It is not that defaulters do not accept vaccination; rather,
most start the use of the technology but dropout for particular reasons, whether linked to
time constraints, forgetting appointments, travel, economic activities or gender
dynamics. All these factors thus play significant roles in immunisation uptake.
24
The study found no gender bias in demand for immunisation. It does not matter whether
a child is a male or female; parents view it a responsibility to protect their health. Also it
does not matter whether one is a man or woman; everyone considers immunisation as
good. Nevertheless fathers never take their children to the centres to assist mothers
when they are unable to go. This confirms that immunisation practices entail gender
roles. Especially in the face of changing economic conditions, there is a need for male
engagement in child care practices such as immunisation, to compensate for the
changing roles of women in the household, not as housewife but as increasingly
important, economically productive partner contributing to the household budget
(Orubuloye 1991).
Community members view immunisation as generally good, with many denying the
existence of any side effects. Some people observe negative effects such as swelling
and fever - reactions confirmed by health workers as common - but these side effects
barely hinder demand for immunisation since mothers, today, have been taught how to
treat them. At the same time, however, rumours circulate that immunisation inhibits
fertility, while some people view it as a method of family planning.
Although mothers are sometimes displeased with the attitudes of staff this is generally
outweighed by their perception of the positive benefits of immunisation for their children.
Generally, public enlightenment programmes have helped mothers to look beyond the
behaviour of particular staff to broader issues concerning vaccine availability and
governmental responsibility for it. Nevertheless, mothers' repeated experiences of delay
due to the length of time it takes to get immunisation supplies from Ibadan, and
uncertainty of those supplies, threatens to increase the rate of dropouts. Mothers may
be discouraged from coming for immunisation if they are not sure whether vaccines will
be available or not. The consequence of such drop-outs are very important. Declining
vaccination rates have been associated with outbreaks of preventable diseases,
especially measles and polio, in many places (Ritvo et. al. 2005)
25
Generally, the research revealed that demand for immunisation is good in the study
areas but that uptake is hindered by irregularity in the supply of vaccines. Therefore,
there is a need to supplement an understanding of demand and demand-supply
dynamics with efforts to address problems associated with vaccine supply, and its links
with the wider context of primary health care financing and delivery in Nigeria.
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