A Mixed Method Approach for the Assessment of Demand Creation Intervention Strategy for Polio Eradication on Exclusive Breast Feeding in Northern Nigeria

"There is a high dependence on the gifts in Borno State as a motivator for compliance where traditional non-compliance had been the norm. The children were particularly motivated to come outdoors bringing their siblings and friends to receive the gifts and the vaccine."

There are two major interventions that are given high priority for improving the health of the Nigerian child: the eradication of poliomyelitis and the promotion of exclusive breastfeeding (EBF) for infants. Outright rejection of oral polio vaccine (OPV), among other factors, has been identified as a central barrier to interrupting polio transmission in Nigeria, making Nigeria the only polio-endemic country in the African region for a considerable period of time. 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. Health providers have worked in collaboration with local government officials, community leaders, and caregivers to build trust and confidence in the immunisation programme. One approach is OPV plus (OPV+), which involves giving incentives such as a 12-gram sachet of milk powder to reinforce acceptance of the vaccine. This study assessed whether the inclusion of the provision of sachet milk as an incentive in OPV+ campaigns unintentionally encourages the use of breast milk substitutes in areas where both interventions are co-operational in Northern Nigeria.

The study was carried out in the Northern Nigeria states of Borno and Kaduna, in both a rural and an urban local government area (LGA) that have had an ongoing OPV+ component (sachet milk powder intervention), with consistent implementation, in the preceding three years. A total of 808 mothers and caregivers of children under five years of age were interviewed, and 74 in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted - the former (IDIs) with purposefully identified community and opinion leaders and individuals involved in the polio eradication programme at the state, LGA, community, and facility levels, and the latter (FGDs) with fathers and mothers (separately) of children under five.

The results show that:

• Awareness of polio disease is very high in the two states (92.9%), and almost all caregivers know that polio vaccine or a visit to a health facility can protect a child from polio. Almost all (99.7%) of the last child had received polio vaccination during the last polio vaccination exercise.
• Awareness of EBF among caregivers is 82.4%, with local health personnel the main source of information (90.5%) through antenatal health education and home visits. About one-third of participants (32.6%) confirm practising exclusive breastfeeding (22.4% in Borno and 42.7% in Kaduna state).
• As the IDIs revealed, the demand creation strategy on polio immunisation involves, for example, a mobile "road show" conducted street to street by a team that includes health personnel, a recorder, a vaccinator, a mobiliser, and an entertainer who uses various theatrics, music, and acrobatic displays to draw children to a central location. In Borno and Kaduna states, 70.5% and 57% of the caregivers, respectively, received a sachet of milk powder and other items (e.g., soap - 10.6%). Every community member attested that the gifts influenced the acceptance of the vaccine.
• Neither caregivers nor community members gave the milk powder to children that were breastfed. Reasons for not giving it to babies include: the powder will choke them; milk is only for grown-ups; it was not enough.

Thus, the researchers find that the quantity of the milk powder and the distribution is too little and infrequent to cause any behaviour change that would make caregivers and mothers develop an appetite for replacing breast milk with sachet milk powder. Caregivers are aware that the milk is not formulated for infants and could not be a substitute for breast milk. It helps that the same health personnel who 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." Furthermore, the study did not find any promotion (advertising, endorsement, or encouragement in any form) of the gift items. All the motivational add-ons, although bearing trade names, were procured using World Health Organization (WHO) procurement processes and were neither donated nor branded for use - thus excluding the likelihood of external influence.

In conclusion, this study found that "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 health personnel for the promotion of exclusive breast feeding and polio eradication campaigns at the community reinforced and complemented both health interventions. The use of OPV+ campaign for reinforcing EBF messages increased EBF awareness and could be extended to other interventions."

The researchers suggest that a comparison of the nutritional status of children receiving the OPV+ incentive with those receiving OPV without incentive, as well as an assessment of the influence of the strategy on child-friendly health facilities, could be a valuable complement to the present study.

The results of the study were shared with a cross-section of the stakeholder community (the United Nations Children's Fund (UNICEF), WHO, Federal Ministry of Health), which recommended further use of the incentives approach to target areas with persistent low OPV uptake.