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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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