Polio Immunization Social Norms in Kano State, Nigeria: Implications for Designing Polio Immunization Information and Communication Programs for Routine Immunization Services

In light of concerns about the sustainability of acceptance of polio vaccines as a routine exercise to sustain the gains of the Global Polio Eradication Initiative (GPEI) programmes, this study presents a conceptual model of polio immunisation social norms in Kano State, Nigeria, which was at the time of this writing one of the last polio-endemic regions in the world.

The framework is grounded in social norms theory, which posits that people's behaviour is prejudiced by misperceptions of the thinking, action, behaviours, and practices of their peers and significant others. For example, parents may be predisposed to accept polio vaccine and will want to submit their children for polio immunisation but incorrectly assume that other parents are resistant to the vaccines. When this occurs, parents suppress their healthy polio immunisation attitudes and behaviours that are incorrectly thought to be nonconforming and instead to engage in the behaviours that are incorrectly thought to be normative. Social norms theory consists of descriptive norms (how commonly (un)healthy behaviours are practiced in a given social context and situation), injunctive norms (expectations and/or perceptions about what people ought to do or ideally would do), and personal norms (an individual's norms related to the acceptability of a behaviour). Descriptive, injunctive, and personal norms influence attitude (a mindset or a tendency to act in a particular way because of prior beliefs and experiences) and perception (relates to information and/or knowledge). Information is described as anything that can change a person's knowledge. "Information communicated to parents about polio either through communal intersubjective discourses with peers, friends, and significant others or through formal channel by agencies helps in building the internal scheme for either acceptance or rejection of the polio vaccine." Another concept applied within this research context is that of "pluralistic ignorance", defined here as a situation when individuals in a social context have similar beliefs and attitudes, but all act contrary to the beliefs and attitudes because they wrongly accept as true that everyone else in the group has a conflicting stance."

An interpretative research paradigm and qualitative method guided data collection, data analysis, data interpretation, and discussion of findings. Twenty-six parents in Sumaila Town, Kano State, Nigeria were interviewed using a semi-structured questionnaire. The author used an analytic inductive process to identify 234 narratives explaining polio immunisation social norms. The narratives are organised into 10 recurring topics and further collapsed into 3 emergent categories to explain the polio immunisation social norms. In sum:

• Personal norms of parents about polio immunisation - Two opposing norms prevail: parents who believe that polio immunisation is very important (healthy polio immunisation behaviour), and those that believe polio immunisation has no value (unhealthy polio immunisation behaviour). Those that believed in the importance of polio immunisation considered the vaccine a good byproduct of 21st-century development in medicine to improve the quality of life of children. They also believed that polio immunisation health workers should be given a welcoming reception during polio immunisation rounds. The second category of polio immunisation personal norms includes parents who do not believe in the importance of polio immunisation. Negative polio immunisation beliefs leads to polio vaccine hesitancy. For example, parents that resisted polio immunisations during the GPEI are particularly unlikely to receive the polio vaccine during routine immunisation after the GPEI.

   

  The author argues that there is an urgent need to redesign polio immunisation communication to focus on changing negative and unhealthy personal beliefs about polio immunisation. In this sense, routine polio immunisation information programmes must be rooted in healthy polio beliefs. An example of a communication message would be: "As a father/mother, I believe polio immunisation is a potent medicine against polio" or "As a father/mother, I have immunised my children against polio. What about you?" Similarly, by applying the personal norms construct, polio communication officials can design information programmes by identifying real parents of victims of polio regretting their actions of not submitting their children for immunisation.

• Injunctive norms of parents about polio immunisation - Three major polio immunisation descriptive norms are identified in this study: Parents are accepting polio vaccines, parents do not accept polio immunisation (e.g., because they believe that it is a family planning strategy), and wives need encouragement from husbands to accept polio vaccines. These descriptive norms are potentially useful for designing routine polio immunisation information programmes. For example, polio communication officials can identify a healthy polio immunisation descriptive norm and publicise it as the prevalent and appropriate group norm. The objective is to get parents who are chronically resistant to polio immunisation to want to conform to the publicized group norm.
• Polio immunisation injunctive norms - This study also identified approval by some parents to submit children for immunisation and a conflicting injunctive norm that it is fine for parents to refuse polio immunisation. Another injunctive norm relates to the fact that parents do not approve of the use of force and intimidation on those that resist polio immunisation. Injunctive norms have implications for designing routine polio immunisation information services; they should focus on highlighting healthy injunctive norms in the community.

Findings interpreted using social norms theory suggest that for there to be a sustained acceptance of polio vaccines through routine immunisation, polio information programmes must take account of the social norms of parents who are resistant to polio immunisation in polio-endemic regions. The author argues that future research on social norms in this context is needed. For example, there is the need for research to identify "important" individuals in subgroups that have social influence in polio-endemic locations in Pakistan and Afghanistan. "This is critical because behaviors and beliefs are influenced by community members through intersubjective discourse with people that the social group regards as important. Most important, there is a need to determine in what way parents' polio immunization behavior in public (injunctive norm) does/or does not correspond to their private personal belief (pluralistic ignorance)." In conclusion, the author states that understanding personal, descriptive, and injunctive norms can inform the design of polio immunisation information and communication programmes for parents that are chronically resistant to polio immunisation in the last remaining polio endemic areas.

Editor's note: This paper has been published as part of a United States Agency for International Development (USAID)-funded initiative to increase the number of peer-reviewed papers on routine and polio communication and to ensure that academics from a range of countries, including those facing the greatest polio and routine immunisation challenges, are supported in getting their research peer reviewed, published, and widely disseminated through The CI and the new journal Global Health Communication.