Understanding Attitudes to Immunisation in Northern Nigeria: A Research Outline

"It is vital to understand the full range of factors that influence household decision-making on polio. In order to do so, it is important to go beyond assumptions, to systematically collect data from households and to look for patterns in the association between household factors and household polio decision-making."

This report describes the approach developed by a project using participatory research to meet a core challenge for the Global Polio Eradication Initiative (GPEI): the existence of a small number of localised "hot-spots" in the residual transmission zones of the remaining endemic countries - one of which is Nigeria. Funded by the United States Agency for International Development (USAID), this research seeks to respond to the need for more localised, more "granular" data - focusing on the demand-side of household factors shaping attitudes and behaviours around polio immunisation. The project's duration is August 21 2013 to July 30 2014.

Based on findings from the Independent Monitoring Board (IMB) of the PEI, the report notes that the research being undertaken here is premised on the belief that "[t]he key to understanding what causes missed children, and continuing suboptimal programme performance in polio - in general and in Nigeria specifically - is to target research at the very local level at which remaining problems continue to occur." This research goes beyond the population-sampling study approach normally used to assess household attitudes to polio vaccination and immunisation more generally. Instead, it uses a methodology called Qualitative Comparative Analysis (QCA) to assess the specific types and combinations of factors within a household that correlate with that household's likelihood of taking up or avoiding polio vaccination (as well as positive and negative attitudes to routine immunisation). Taking the household as the unit of observation, the research will be able to pinpoint specific factors shaping household thinking and behaviour, and in, so doing, to compare "poor-performing" households and settlements with "well-performing" ones (performance being defined primarily by rates of missed children in the last 3 Immunization Plus Days, or IPDs).

Specifically, QCA provides a systematic case-comparable approach to the organisation of qualitative data. The outcomes (dependent variable/s) that are of interest to the programme are: (i) incidence of missed children in IPDs by household, and (ii) other household attitudinal factors that are likely to eventuate missed children. The core outcome variable is: presence of missed children in a household, over the last 3 IPD campaign rounds. Additional outcome variables include: (i) attitude to/knowledge of routine immunisation and (ii) vaccine delivery preference. The independent variables that may influence household behaviour (and hence the incidence of missed children) are hypothesised to include both indicators of material living conditions as well as perceptions of those conditions (assessed in part through data collected at settlement, ward, and Local Government Area (LGA) levels about wider socio-political institutions like religious, traditional, and government authority).

Following consultations with all partners in Abuja, Nigeria, researchers settled on a 3-state survey, which covers: Sokoto in the northwestern zone, Kano in the north central zone, and Bauchi in the northeastern zone. All 3 states are within the 11 high-risk states as defined by the GPEI. In each state, they will select 2 LGAs (high- and low-performing, based primarily on the rates of missed children in the last 3 IPDs). Within each LGA, they will select 3 wards (again, looking for high- and low-performing on the same criterion). Within each ward, they will choose 4 settlements.

Notably, the survey design actively defers mention of polio until the very end of the interview. "This is a key aspect of the research design - instead of asking directly (or exclusively) about knowledge of and attitudes to polio, the household survey works from broader questions of household livelihood and conditions of living, through perceptions of inclusion (or exclusion) relative to vital services, community decision-making forums, and trusted channels of information and advice, to experiences of health and healthcare seeking, attitudes to immunisation and, finally, knowledge of and attitudes to polio and the PEI programme." At the settlement and LGA level, researchers hope to elicit data about community or wider composition (ethnicity, religion, etc.), developmental trajectory (perceptions of improving/worsening conditions), the ethnic/religious composition of the settlement/LGA leadership, and the processes and mechanisms through which participation (by households in a community, by communities in an LGA) is managed; they will then seek to understand the way settlement and LGA leaders perceive their role.

An excerpt from the report follows:
"As the starting point for this research, we hypothesise that, aside from religious and traditional teachings and communications that may influence households and communities with regard to the polio programme, household decision-making on whether to participate or not in polio vaccination is likely to be influenced by the material circumstances in which they live, including the kinds of vital services they are able to access and benefit from. Moreover, we hypothesise that perceived inequities in material circumstances, including vital services, are likely to influence the political context of households relations with their community leaders, and with wider forms of (primarily local) government. Of course, there are limits to how the polio programme in Nigeria can directly influence the wider socioeconomic conditions of households. But there is a clear need for the programme to have sound intelligence on what stops households and communities from engaging positively with polio eradication, to respond programmatically where it can, and where it cannot, to develop clearer, more evidence based and hence more compelling advocacy with Federal, State and LGA [Local Government Area] government policy and resource provision to change in more than simply symbolic gestures the way households feel they are being served. We hypothesise that collecting data on the perceptions households have of the world around them - government and non-government institutions and levels of progress in socioeconomic development and opportunity - can be used to create a proxy measure of 'trust' between the household and the wider world of administrative authorities, from Settlement, through Ward to LGA. That measure of trust, we hypothesise, may be a significant explanatory factor in differentiating households where vaccination is accepted and sought, and households where it is not.

The objective of the research is to identify, quantify and analyse the combined effects of social and material factors, at the micro-level, that appear to associate with incidence of missed children by household in a given community. The research proposed will strengthen understanding of how factors operate in a composite manner to determine the prevailing level at which households with eligible children drop out of, or are missed in the process of IPDs. At the heart of the project is the proposal to compare, using combined qualitative and quantitative data, communities which may be assumed to share certain macro-level socio-economic and sociocultural characteristics, but which differ in recent IPDs in their respective rates of missed children and, we hypothesise, must therefore differ in other identifiable micro-level characteristics.

This research aims to generate more in-depth, localised analysis of factors leading to missed children, and to produce that analysis in a way that is easily converted back into locally-relevant programme knowledge and practice....

...Understanding barrier and facilitator factors at a much more focused level, comparing areas with good performance against areas with poor performance is critical to operational effectiveness in the residual areas challenging PEI's end-game. This research will be immediately useful for the Nigeria programme and has the potential to be quickly adapted for use in Afghanistan and Pakistan as well as other countries with persistent polio transmission."

Click here for the 8-page report in PDF format.