1 APPLICATION OF UNICEF’S COMMUNICATION MODEL FOR BEHAVIOUR CHANGE: MOTHERS’ RESPONSE TO POLIO ERADICATION CAMPAIGN IN SELECTED NIGERIAN STATES BY ADEWUMI OLUBUNMI AJIBADE MAT. NO 840902040 B. Sc. (Mass Comm., UNILAG), M. Sc. (Mass Comm., UNILAG) Department of Mass Communication, School of Postgraduate Studies, University of Lagos, Lagos, Nigeria September, 2010 APPLICATION OF UNICEF’S COMMUNICATION MODEL FOR BEHAVIOUR CHANGE: MOTHERS’ RESPONSE TO POLIO ERADICATION CAMPAIGN IN SELECTED NIGERIAN STATES BY AJIBADE, ADEWUMI OLUBUNMI MAT. NO 840902040 2 B. Sc. (Mass Comm., UNILAG), M. Sc. (Mass Comm., UNILAG) Department of Mass Communication, University of Lagos, Lagos, Nigeria THESIS SUBMITTED TO THE SCHOOL OF POSTGRADUATE STUDIES, UNIVERSITY OF LAGOS, IN PARTIAL FULFILMENT OF THE REQUIREMNETS FOR THE AWARD OF THE DEGREE OF DOCTOR OF PHILOSOPHY (Ph. D.) IN MASS COMMUNICATION SEPTEMBER 2010 ABSTRACT Numerous studies have investigated the general and specific effects of the media of communication on attitude and behaviour modification or change, using different theoretical approaches. Since polio cases assumed worse dimensions in Nigeria between 2003 and 2006, the UNICEF-developed ACADA communication planning framework for behaviour change has been consistently used to address the communication issues related to the problem. This study was conceived to provide data for policy makers, advocacy groups, development agencies and communication scholars on how the ACADA model for behaviour change has been applied and how mothers in study locations have responded to the polio eradication campaign in selected states in Nigeria. The social marketing theory, of which the ACADA model is a sub-set, formed the theoretical framework for the study. Triangulation research method consisting of survey, focus group discussion and interview were used to obtain data for the study. Multi-stage random sampling technique was used to select 800 mothers of child-bearing age from four states in the country. From two polio-free South-West states, 400 mothers were selected, made up of 100 each from Ikere and Ido-Osi LGAs in Ekiti State, Ayobo-Ipaja and Yaba Local Council Development Authorities in Lagos State. From two polio- endemic North-West, another 400 mothers chosen, comprising of 100 each from Kaduna North and Chikun LGAs in Kaduna State and Gwale and Rimin-Gado LGAs in Kano State. Focus group discussion was used to obtain additional data from mothers while interview method was used to obtain information from polio programme officers in the local governments. Data collection instrument was the structured questionnaire. Of the 800 questionnaire administered to respondents, 716 were returned, only 654 were correctly filled. Data were analysed at univariate, bivariate and multivariate levels using the Statistical Package for Social Sciences (SPSS). Eight research questions were raised and eight hypotheses formulated for the study. This shows there is relationship between the application of ACADA model for behaviour change and the positive response of mothers to the polio eradication campaign in the four selected states. It further reveals 3 that though most mothers were exposed to ACADA-related messages from the mass media, their decisions on polio immunisation were largely influenced by family members (43.9%), friends (11.9%), village or community leader (8.7%), religious leaders (6.2%), and traditional rulers (3.5%). The mass media altogether contribute only 12.3% of the influence of mothers. Data indicate that socio-psychological factors such as respondents’ knowledge, beliefs, values, and practices as well as their demographic attributes influenced their responses to the campaign. The study recommends that government and development agencies should identify and work closely with major influencers in each community in every social change programme. It further recommends that thorough formative research be carried out before embarking on any intervention in the society. Finally, the study recommends that the ACADA model for behaviour change be included in the curricula for communication studies in Nigeria. DECLARATION I, Adewumi Olubunmi Ajibade, declare that this thesis was originally written by me, and that, to the best of my knowledge, this research has not been submitted to any other school or university for any other degree. I also declare that both published and unpublished materials used in this study are appropriately acknowledged. Name: Adewumi Olubunmi Ajibade Signature………………………………….. Date: 4 CERTIFICATION This Ph.D. thesis has been examined and found acceptable in meeting the requirements of the Postgraduate School of the University of Lagos, Akoka, Lagos State, Nigeria. ………………………………… ………………………. Prof. Ralph A. Akinfeleye Date Supervisor ………………………………… ………............................ Dr. Abayomi Daramola Date Second Reader ………………………………… ………………………… Dr. Victor Ayedun-Aluma Date Departmental PG Coordinator ………………………………….. ……………………….. Prof. Ralph A. Akinfeleye Date Head, Dept of Mass Communication …………………………………… ………………………. External Examiner Date DEDICATION 5 This work is dedicated first and foremost to the Almighty God, the only source of true knowledge, understanding and wisdom. He is truly my strength, my stronghold, my shield and my defender, my fortress and my refuge at all times. He kept me by His power and gave special ability and grace to start and to complete this work. Without Him l could not have carried out this research. To Him alone be all the glory, honour, power, dominion, adoration, praise, and splendor forever. I also dedicate the work to the living memories of my late parents—Prince Reuben Ajibade and Princess Beatrice Ajibade—whom God used as worthy vessels to bring me to this world and to nurture me physically, spiritually, mentally, materially, and in other areas of life. ACKNOWLEDGEMENTS Numerous people contributed immensely to the success of this research. But first, l want to acknowledge the generous help of the Almighty God, who was my backbone throughout the duration if the programme. But for His intervention this work could never have been completed. I ascribe all the glory and praise to His holy name. 6 I also owe a lot of gratitude to my supervisor, lecturer and mentor, Professor Ralph Afolabi Akinfeleye, who inspired me to come to the academia and to enroll for the doctoral programme. I remember his several ―yellow, red and infra-red cards‖ which he issued orally and in writing when l seemed to be distracted from the work. In fact, for me the fear of his uncompromising attitude to deadlines was the beginning of wisdom. In class, Professor Akinfeleye was a motivator. His wealth of teaching experience guided us and enriched the programme. I am very grateful to him for his investments in my life. My gratitude also goes to my second reader, Dr. Abayomi Daramola for his candid advice, encouragement and support. May your labour be richly rewarded. It is also in order to appreciate Dr. Victor S. Ayedun-Aluma, the Departmental Postgraduate Coordinator. He devoted so much time attending to my needs, offering frank advice where and when necessary. He was a great encouragement to me, raising alarm when my pace appeared to be slow. I deeply appreciate the invaluable contributions of my lecturers during the doctoral programme. Specifically, l thank Professor Ralph A. Akinfeleye, Dr. Adidi Uyo, late Professor Segun Odukomaiya. I am greatly indebted to Dr Innocent E. Okoye who gave me useful advice on theoretical and methodological issues surrounding my thesis. His advice was valuable during my field work and report writing. Other lecturers in the Department of Mass Communication, University of Lagos, deserve my appreciation for their encouragement and support throughout the period of my programme. They include Dr, Abigail Ogwezzy-Ndisika, Dr. Oloruntola Sunday, Mr. Soji Alabi, Mr. Teslim Lawal, Mr. Tayo Popoola, Mrs Joy-Rita Mogbogu, Mr. Akinyemi Taiwo, Mrs. Rhasidat Hassan, Mrs. Adepeta Mustapha-Koiki, and Mrs. Khadijat Aledeh, to mention a few. 7 I am greatly indebted to the Dean, School of Postgraduate Studies, Professor Toyin Ogundipe, under whose tenure l completed my thesis. His dynamic style of administration and great vision for the School of Postgraduate Studies and the University of Lagos as a whole made it possible for all hindrances to early completion of my programme to be removed. I thank Prof. Modupe Olusakin, former Sub-Dean, School of Postgraduate Studies, who evaluated my work critically and other distinguished scholars in the Academic Programme Committee (APC) of the School of Postgraduate Studies of the University of Lagos for their intellectual contribution to the refinement of my thesis Many of my friends contributed in no small measure to the success of my thesis. They include Dr Bolu John Folayan, Dr. Onjefu Okidu, Dr. Chidinma Onwubere, Mr Benjamin Nwanne, Mr. Jimi Kayode, Mr. Charles Owunali, Mr. Adepoju Tejumaiye. Their advice inspired me to move ahead when the going was tough. I greatly appreciate the support, love, understanding of my darling wife, Mrs. Yetunde Adeola Ajibade and our wonderful children, Temiloluwa Oluwagbotemi Ajibade, Ayobami Oluwadamilare Ajibade, and Oluwadolapo Eniola Ajibade. May God Almighty bless you all richly in Jesus name (Amen) Olubunmi Ajibade September, 2010 TABLE OF CONTENTS Content Page First title page ……………………………………….. …………………….……..............i Second title page ….………………………………………. ………………………………....ii Abstract ……………………………………. ……………………………………………..iii Declaration …………………………………. ……………………………………………iv 8 Certification …………………………………………………................................................v Dedication…………………………………………………...................................................vi Acknowledgements ………………………………………………………………….............. vii Table of contents ………………………………................................................... ……..ix List of tables ………………………………………………………………........ ……..x List of Figures …………………………………………………………………………………xiii List of Appendixes ………………………………………………………………………..xiv List of Abbreviations……………………………………………………………………...........xv Chapter One: INTRODUCTION... ….....................................................................................1 Chapter Two: LITERATURE REVIEW…......................................................................22 Chapter Three: RESEARCH METHODOLOGY……………………………………………..59 Chapter Four: DATA PRESENTATION AND ANALYSIS…………………………………...80 Chapter Five: FINDINGS AND DISCUSSION……………………………………………….130 Chapter Six: CONCLUSION,&RECOMMENDATIONS/CONTRIBUTIONS TO KNOWLEDGE………………………………………………………………….. 141 Bibliography …………………………………………………………………………………...147 Appendices……………………………………………………………………………………... 155 9 LIST OF TABLES Table No Title Page 1. Wild Poliovirus Cases in Four Polio Endemic Countries 4 2. Selected Sates and their Local Government Areas 66 3a. Application of ACADA Model By selected LGAs 81 3b. Application of ACADA-related Communication Strategies By Selected LGAs 81 4. Information Officers’ Rating of the Effectiveness of ACADA Model 84 5 Major Sources of Mass-Mediated Health Information to the Respondents 85 6. Respondents Most Frequently Used Interpersonal Health Information Source 86 7. Mothers’ Exposure to ACADA-related Message and their Response 87 8. Major sources of Polio Information by Respondents 89 9. Respondents’ Answer to the Question: Immunisation against polio is the right of every child 91 10. Mothers’ Attitude to Immunisation Appointments 92 11. Mothers’ Opinion about the safety of OPV 93 12. Mothers’ Opinion about Extra Doses of OPV during NIDs 94 13. Mothers’ Belief about the danger of poliovirus 95 14. Persons, Institutions, things that Influenced Respondents most on Polio Decisions 97 .15. Respondents by Age 98 16. Respondents by Education 99 17. Respondents by annual income 100 18 Respondents by Religious affiliation 101 19. Respondents by Ethnic Groups 101 10 20. Respondents by Occupation 102 21. Respondents by marital status 102 22 Respondents by number of children 103 23a Application of ACADA Components by Selected LGAs 104 23b Application of ACADA Communication Strategies by selected LGAs 105 24 Information Officers’ Rating of the effectiveness of the ACADA model 106 25. Respondents’ Exposure to Information sources on Polio 108 26. Cross tabulation of Respondents’ Exposure to Information Sources On Polio Immunisation and Compliance with the Campaign 110 27. Respondents’ Most Frequently Used Mass Medium Source for Health Information 112 28 Respondents’ Most Frequently Used Interpersonal Source for Information 113 29. Respondents Most Frequently Used Information Source on Polio Immunisation 114 30. Respondents’ Answer to the Statement :‖ Immunisation against Polio is the right of every child‖ 115 31. Respondents’ Answer to the statement: ― It is not important to keep all Immunisation Appointments‖ 116 32. Respondents’ answer to the statement: ―Overdose of OPV is dangerous‖ 117 33. Respondents’ Belief about the danger of Polio 118 34. Respondents’ Belief about Extra Doses of OPV during NIDs 119 35. Respondents’ Opinion about whether Extra Doses of OPV during NIDs boost the child’s Immunity against Polio 120 36. Relationship between The States and the Person, thing or institution or place that influenced Mothers most on their Children’s Immunisation 122 37. Cross tabulation of Respondents’ Age and their Response to the Polio campaign 124 11 38. Cross tabulation of Respondents’ Educational Qualification and their Response to Polio Campaign 125 39. Cross tabulation of Respondents’ Income and their Response to Polio Eradication Campaign 126 40. Cross tabulation of Respondents’ Religion and their Response to Polio Eradication campaign 127 41. Cross tabulation of Respondents’ Ethnic Groups and their Response to Polio Campaign 128 42. Respondents’ Occupation and their Response to Polio Campaign 129 43. A matrix of Responses from Interviews with Mothers in Selected States 131 12 LIST OF FIGURES S/No Title Page 1. Lassweell’s Communication Effects Model 20 2. UNICEF’s ACADA Model for Communication Planning 29 LIST OF APPENDICES S/No Title Page I. Questionnaire for Mothers in Selected States 158 II. Map of Kaduna State showing Study sites 171 III. Map of Ekiti State showing Study Sites 172 13 IV. Map of Kano State showing Study Sites 173 V. Map of Lagos State showing Study Sites 174 VI. Interview Schedule for Mothers 175 VII. Interview Schedule for LGA Health Officials 177 VIII. Full text of Interview with Mothers at Gwale LGA 178 IX. Full text of Interview with Lawan Japha (Health official at Gwale LGA) 182 X Full text of Interview with Sambo Sabo Abba (Information Officer for Kaduna North LGA) 187 XI Full text of Interview with Mothers at Chikun LGA 193 XII Full text of Interview with Mothers at Rimin-Gado LGA 203 XIII Full text of Interview with Mothers at Ayobo Ipaja LCDA 212 XIV. Example of UNICEF’s ACADA Communication worksheet used For Polio Intervention Programme 223 XV. Sample Immunisation Messages 253 14 XVI Emir of Kano Immunising a Child 256 LIST OF ABBREVIATIONS ACADA Assessment, Communication Analysis, Design, Action AFP Acute Flaccid Paralysis BASICS Basic Support for Institutionalizing Child Survival CDC Centers for Disease Control and Prevention CVDPV2 Circulating Vaccine-Derived Polio Virus2 EPI Expanded Programme on Immunisation GPEI Global Polio Eradication Initiative HIV/AIDS Human Immuno-Deficiency Virus/Acquired Immune Deficiency Syndrome IPDs Immunisation Plus Days LCDA Local Council Development Authority LGA Local Government Authority NIDs National Immunisation Days NPHCDA National Primary Health Care Development Agency OPV Oral Polio Vaccine SIAs Supplementary Immunisation Activities SNIDs Sub-National Immunisation Days UNICEF United Nations Children’s Fund 15 WPV Wild Polio Virus WHO World Health Organization CHAPTER ONE INTRODUCTION BACKGROUND TO THE STUDY Eradication of poliovirus has remained one of the most challenging international public health issues in the last 60 years. Until 2003, there was hope that poliomyelitis (polio for short), which had crippled or killed millions of children worldwide, would be wiped out from the surface of the earth by 2005. But as Cathcart (2005) has observed, the number of countries where children under five years are infected with poliovirus has instead soared, raising fears in the international health community that polio eradication which has so far cost more than USD 9 billion (WHO, 2010a: 38), might be prolonged a little longer. 16 Wild polio virus(WPV) is the agent that causes Acute Flaccid Paralysis (AFP), i.e. weakness of the limbs – hands and legs – in children who are less than five years old (WHO, 2001:8). It attacks and paralyses or kills children. It spreads from one person to another mainly through contaminated fingers, foods, drinks and faecal matter from an infected person. It has been reported that polio paralysed about 25 million children in the first half of the 20th century. The communicable disease, which has no cure, according to the World Health Organisation (WHO), can only be prevented through immunisation (WH0, 2010a). Historically, global effort to fight polio received its first significant breakthrough in 1954, when Dr. Jonas Salt developed an effective vaccine against polio, and this was followed in 1957 by a vaccine developed by Dr. Albert Sabin that could be taken orally (Piller, 2005). By 1991, vaccination virtually eliminated polio in the Western Hemisphere. The last case of polio was found in that year and by 1994, the region was certified polio-free after a three year period of intensive surveillance. So far, Oral Polio Vaccine (OPV) has been administered to more than two billion children across 125 countries around the world as part of the polio eradication programme and as part of routine immunisation services in more than 200 countries (WHO, 2010b). Due to the effectiveness of the worldwide campaign against polio, regarded as one of the most successful in medical history, the infection rate has been reduced by 99% (WHO, 2008: 7) 17 In 1988, there were 350,000 cases of Polio infection reported annually (Cathcart, 2005). That same year, a coalition of the World Health Organisation (WHO), United Nations Children’s Fund UNICEF), Rotary International and the United States Centres for Disease Control and Prevention (CDC) launched the Global Polio Eradication Initiative (GPEI), aimed at eradicating polio from the surface of the earth by the year 2000 and certifying the world polio free by the year 2003 (Branswell, 20005a). This deadline, as Branswell has noted, was missed and another deadline which targeted interruption of poliovirus circulation by 2005 and certification by 2008 was also missed due to the inability of the four polio endemic countries, including Nigeria, to stop the circulation of polio. The most recent deadline aims to interrupt the virus by 2012 and certify the world polio-free by 2013 (WHO, 2009). According to GPEI’s new strategic plan for 2010-2012, polio will be eradicated as follow (WHO, 2010b:17): Middle of 2010: Interruption of all new importations (i.e. virus imported from other countries) End of 2010: Interruption of all re-established viruses End of 2011: Interruption of virus circulation in two of the four endemic countries End of 2012: Interruption of poliovirus in the other two endemic countries End of 2013: Certification Though Polio was almost extinct in 2003, the vision of a polio-free world is now being threatened by its re-emergence in parts of Africa and Asia (Richardson and Saginur, 2005). Immunisation against polio has been implemented in all parts of the world for 18 about 60 years, according to UNICEF et al (2000). However, many countries, as UNICEF et al note, had only low-key and often unstructured programmes. To stimulate re-organisation and strengthening of immunisation programmes – throughout the world, the WHO, in 1974, launched the Expanded Programme on Immunisation (EPI). And in 1988, the World Health Assembly – the governing body of the WHO – set the target of the year 2000 for the eradication of polio. The goal was to be achieved through three main strategies:  Establishing high-level national commitment to the programme to ensure adequate personnel and financial resources are made available  Increasing and sustaining routine immunisation coverage through the administration of at least three doses of Oral Polio Vaccine (OPV) - Conducting of supplemental immunisation campaigns, through National Immunisation Days (NIDs) and sub National Immunisation Days (SNIDs); and - Reaching process of transmission of the wild polio virus by conducting mop-up immunisation.  Implementing action-oriented surveillance for all possible cases of poliomyelitis (UNICEF) et al, 2000:1-2) The fear in the international health community is that if only one case of the highly infectious polio is left in any country in the world, it may lead to its resurgence even in countries, which have been certified polio-free. In fact, as Piller (2005) has noted, each case (of polio) typically represents up to 200 undetected infections, meaning that the virus is more widely distributed than the figures indicate. This is probably why many 19 resources are being deployed towards the elimination of the last case of polio in the world. Today, polio is reported to be endemic in only four countries: Nigeria, India, Pakistan and Afghanistan (Branswell, 2005b). In fact, Nigeria, regarded as the largest reservoir of polio virus in Africa, is said to be the epicentre of the recent polio outbreak that has so far spread to 16 polio-free countries and re-established transmission in six others (Piller, 2005). For example, DNA fingerprinting of viruses allowed scientists to track the spread from Nigeria to a number of countries that had succeeded in wiping out polio, including Yemen and Indonesia (Branswell, 2005b). Table 1 gives a 10-year case count of polio in the four endemic countries. Table 1: Wild Poliovirus Cases among Four Endemic Countries (2000-2009) Year Nigeria India Pakistan Afghanistan Total Annual Cases 2000 28 265 199 27 519 2001 56 268 119 11 454 2002 202 1600 90 10 1902 2003 355 225 103 8 691 2004 782 134 53 4 973 2005 830 66 28 9 933 2006 1122 676 40 31 1,869 2007 285 874 32 17 1,208 20 2008 798 559 117 31 1,505 2009 388 741 89 38 1,256 Total 4,846 5,408 870 159 11,283 Source: WHO, (2010) Geneva: http://www.polioeradication.org/casecount.asp The problem began in Nigeria in 2003, when vaccination was suspended by 14 northern states of Kano, Sokoto, Katsina, Zamfara, Kaduna, Bauchi, Benue, Gombe, Jigawa, Kebbi, Nasarawa, Niger, Borno and Taraba. This followed rumours that the polio vaccines cause sterility, and Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), and that immunisation against polio was a plot by the western world to control the population of Northern Nigeria (Nasher, 2005). Stopping the transmission of polio virus in Africa, particularly in Nigeria, according to Piller (2005), is said to be critical to protecting children on the continent and in polio-free countries around the world. However, despite efforts being made by the United Nations Children’s Fund (UNICEF), the World Health Organisation (WHO), as well as their global partners in the polio- eradication campaign, problems still remain in some countries, including Nigeria. Worst cases of wild polio virus have been narrowed to 13 northern states in Nigeria. According to a recent report by the National Primary Health Care Development Agency (NPHCDA, 2007:12-13) the states are Bauchi, Borno, Benue, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Niger, Sokoto, Yobe and Zamfara. They have been classified by the agency as ―Polio High Risk States‖. As at 2007, eight states: Bauchi, Borno, Jigawa, 21 Kebbi, Kano, Katsina, Sokoto, and Yobe accounted fo 88% of all confirmed polio cases in Nigeria (NPHCDA, 2007: 4). According to NPHCDA, 64% of all 2007 confirmed polio cases occurred among children below three years old, and about 74% of all cases occurred among either incompletely vaccinated children (46%) or children never vaccinated before (28%). Effective implementation of the campaign against polio had depended largely on one form of communication or the other. However, by 1997, UNICEF et al (2000:4) and its partners in the war against polio noticed apparent weakness in the communication activities, aimed at achieving the goals of EPI. A programme review meeting by the polio partners held in Kampala, Uganda Capital, that year found that though social mobilisation, through communication, had made important contributions to the success of NIDs, it remained weak in supporting routine immunisation and disease surveillance. Besides, the meeting noted that while much time was spent on advocacy, public events and dissemination of information through the mass media, little time was devoted to other communication components, such as programme communication and the use of interpersonal communication. A workshop of senior communication officers from ministries of health across Africa, WHO, UNICEF and Basic Support for Institutionalising Child Survival (BASICS), subsequently, in 2000, developed a Communications Handbook for the implementation of Polio eradication and routine EPI. The handbook incorporated the UNICEF- developed ACADA, an acronym for Assessment, Communication Analysis, Design and Action. The 22 ACADA communication model for behaviour change was developed based on the premise that influencing and modifying human behaviour is a complex process that needs to be planned carefully (UNICEF et al, 2000:8). The goal of the ACADA communication model is to achieve sustained behaviour change through the strategies of advocacy, social mobilisation and programme communication. As it relates to polio immunisation, it envisages that all mothers will always take all their children under five years for routine and supplemental polio immunisation. The development and application of a new communication model, designed to persuade mothers to take their children for polio immunisation, against the backdrop of intensified international effort to remove the last case of polio from the earth, spurred the interest in this study. The researcher was particularly interested in the subject because Nigeria is reported to be responsible for the recent outbreak of polio, which is re-infecting countries that had earlier been declared polio-free. STATEMENT OF THE PROBLEM Nigeria is the only polio endemic country in Africa. It is the only country in the continent which continues to have circulation of indigenous Wild Polio Virus (WPV), and as of 2009, the only country in the world with ongoing transmission of all three poliovirus serotypes: WPV1, WPV3 and circulating Vaccine-derived Poliovirus 2 (cVDPV2) (WHO, 2010: 17). This has made Nigeria a major focus of global polio eradication effort. 23 Poliomyelitis has killed more than 25 million children worldwide and the World Health Organisation (WHO) estimates that 10 to 20 million people live with permanent paralysis that accompanies polio attack (WHO, 2010). The highly infectious disease has no cure but is preventable through oral vaccination. With consistent use of polio vaccine, poliomyelitis was almost extinct in the world in 2003. The year, with only 784 reported cases of polio infection, recorded the lowest figure since the initiative began (WHO, 2006). But the figure jumped to 1,263 in 2004, with increase driven primarily by Nigeria as a result of rumours that OPV could damage fertility and that it was been used to spread HIV/AIDS. This misinformation led to the suspension of the polio immunisation campaign in northern states of Nigeria. The boycott triggered the re-emergence of polio in Nigeria and its spread from there to 21 polio-free countries by the 2006 (Ogden et al, 2006). Between 2001 and 2009, Nigeria had 4,846 reported cases of polio (WHO, 2010). The bulk of the cases (3,089 or 64%) were recorded between 2003 and 2006, the period that coincided with the polio immunisation boycott in northern Nigeria. Today, Nigeria is the only polio endemic country in Africa and one of four remaining polio-endemic countries globally, according to the National Primary Health Care Development Agency- the federal agency responsible for immunisation programmes in Nigeria- (NPHCDA, 2007:3). The other three are India, Pakistan and Afghanistan. Of the four polio endemic countries, three (India, Pakistan and Afghanistan) consistently have socio- political crises leading sometimes to military confrontations that make polio campaigns difficult. Nigeria 24 is the only country of the four that does not experience political crisis that make immunisation difficult. While most of the southern states in Nigeria are polio-free, 12 states in northern Nigeria are designated as polio high risk states. The states are: Bauchi, Borno, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Niger, Sokoto, Yobe and Zamfara (NPHCDA, 2007:12). In fact, five of the states- Borno, Jigawa, Kano, Katsina and Sokoto- have been further classified as ―very high risk‖ in terms of polio infection (WHO, 2008: 21). Following the re-infection of polio-free states of southern Nigeria and neighbouring countries by poliovirus originating from Nigeria and a strong statement of international concern by the World Health Assembly in May 2008, federal authorities in Nigeria established an emergency task force to address the situation. This resulted in the signing of the ―Abuja Commitments to Polio Eradication‖ by all the 36 state governors in February 2009 (WHO, 2010:17). In 2009, polio cases dropped to 388, down from 798 in 2008 (WHO, 2010). The 51% drop in polio cases in one year is significant, and the success is attributable to the seriousness the government at all levels attached to the campaign. The period of this significant drop in polio cases in Nigeria coincided with the time of greater involvement of all the 36 state governors, frontline traditional rulers on northern part of Nigeria and local government chairmen. UNICEF, which developed the ACADA model for behaviour change communication, is the lead Global Polio Eradication Initiative (GPEI) partner on social mobilisation and 25 communication. It is leading a strengthening of technical assistance for communication in the highest-risk states in Nigeria in order to enhance community awareness and engagement (WHO, 2006). The ACADA framework for communication planning has been applied, through the technical assistance of UNICEF, in the campaign for polio eradication in Nigeria, particularly during the intensified campaigns that have followed the re-emergence of polio in the country between 2003 and 2006. The question, therefore, is: How has UNICEF’s ACADA model for communication planning and behaviour change been applied in polio eradication campaign in Nigeria? What lessons have been learnt from the application of ACADA model in polio eradication communication in Nigeria? What are the sources of information on polio immunisation in the study locations? What communication channels are been used to disseminate polio immunisation messages to the target populations? What communication challenges face polio eradication campaign in the selected states? What are the attitudes of mothers towards polio immunisation? The purpose of this study, therefore, was to examine the relationship between the application of UNICEF’s ACADA communication model in polio campaign and the response of mothers to the eradication campaign in Lagos and Ekiti States, in South West Nigeria and Kaduna and Kano States in the North West. 26 OBJECTIVES OF STUDY The objectives of the study were: 1. To find out how the ACADA model for communication planning has been applied in the selected states 2. To determine whether information officers in the study sites would differ in their rating of the effectiveness of ACADA-related communication strategies? 3. To identify the major sources of health information for mothers in the study locations 4. To investigate the relationship between mothers’ exposure to ACADA-based messages on polio and their compliance with polio immunisation 5. To determine whether mothers in study locations would depend more on interpersonal channels than mass media channels for information polio immunisation 6. To find out whether socio-psychological factors such as knowledge, attitudes, practices, values and beliefs of mothers would have influence on their response to ACADA-based messages on polio eradication 27 7. To identify the major factors responsible for mothers’ response to the polio eradication campaign 8. To examine the relationship between mothers’ demographic attributes and their response to the polio eradication campaign RESEARCH QUESTIONS This study was guided by the following research questions: 1. How has the ACADA model for communication planning been applied in the study locations? 2. Do information officers in the study sites differ in their rating of the effectiveness of ACADA-related communication strategies for polio information? 3. What are the major sources of health information for mothers in the study locations? 4. Is there a relationship between mothers’ exposure to ACADA-related messages on polio and their response to the polio eradication campaign? 5. Do mothers in the study locations depend more on interpersonal communication channels than mass media channels for information on polio eradication? 6. Do socio-psychological factors such as knowledge, attitudes, practices, values and beliefs influence mothers’ response to the polio campaign? 28 7. What are the major factors responsible for mothers’ response to the polio campaign? 8. What is the relationship between the demographic attributes of mothers in the study locations and their response to the polio immunisation campaign? HYPOTHESES The study tested the following hypotheses: H1 There is no significant difference in the application of the ACADA model across the study locations H2 Information officers will not differ in their rating of the effectiveness of ACADA- related communication strategies for polio information H3 There is no significant relationship in major sources of health information among mothers in the selected states H4 There is no relationship between mothers’ exposure to ACADA-based messages on polio and their response to the polio eradication campaign H5 Mothers in the study locations will not depend more on interpersonal communication channels than mass media channels for information on polio eradication H6 Socio-psychological factors such as knowledge, attitudes, practices, values and beliefs will not influence mothers’ acceptance or rejection of polio immunisation 29 H7 There is no significant difference in the major factors responsible for mothers’ response to the polio campaign in the study sites H8 There is no relationship between mothers’ demographic attributes and their response to the polio eradication campaign PURPOSE OF STUDY Implicit in the UNICEF’S ACADA communication model is the assumption that communication can be used as a tool for attitudinal and behaviour change as well as to promote development. The purpose of this study, therefore, was to ascertain how far the goal of sustained behaviour change through the application of UNICEF’s ACADA communication model has been achieved in the polio eradication campaign. SIGNIFICANCE OF STUDY The findings of this study are important to groups, individuals and institutions in the society. First, an understanding of the impact of the ACADA model is important to UNICEF and other local as well as international agencies that are promoting one form of behaviour change or the other. Since the goal of ACADA model is sustained behaviour change through communication (at individual, family and community levels), other health communication interventions can benefit from its methodology it if is found to be effective. 30 Second, the study adds to the growing scholarly research and literature in the field of development communication. Since the end of the Second World War researchers have conducted hundreds of research on the effect of communication, particularly about the role communication plays in national development. So many resources- financial, material, manpower and time – have been committed to the polio eradication campaign by the Federal Government of Nigeria, state governments and donor agencies. A study on the effectiveness of the campaign is, therefore, important to scholars and development communication professionals. Third, policymakers at local, regional and international levels will benefit from the findings of this study. Since knowledge, beliefs and attitudes underlie behaviour and practices, an understanding of the factors that influence mothers’ response or non- response (behaviour) to the polio eradication campaign is important for policy makers. The findings of this study underscore the need to reinforce or re-adjust strategies for communicating polio eradication messages with mothers. DELIMITATIONS AND LIMITATIONS In terms of scope, this study was concerned itself with obtaining information on the response or non-response of mothers, through questionnaire and as well as interviewing health and information officers in Ekiti, Lagos, Kaduna and Kano States, which have been systematically chosen for this study. The study was limited to only mothers with any child less than fire years old. This was because wild polio virus attacks only children less than five years old. This group of children is the target of the immunisation campaign. Because this study was limited only to the south-western and north-western 31 parts of Nigeria, a major weakness is that it will not be generalisable to all parts of Nigeria. Since cultural values, beliefs and practice vary in different parts of the country (Akinfeleye et al, 1995), it was expected that response to the immunisation campaign would differ in different parts of Nigeria. These differences in cultural values, beliefs and practices among different ethnic groups in Nigeria, therefore, decrease the generalisability of the findings of this study. OPERATIONAL DEFINITIONS OF TERMS A number of terms used in this study are hereby operationally defined as follow: ACADA ACADA is the acronym for Assessment, Communication Analysis, Design and Action. Monitoring and evaluation are central to all the stages. It is the model of development communication planning that utilises three main strategies of advocacy, social mobilisation and programme communication. It was developed by UNICEF, which is the lead partner in its application under the Global Polio Eradication Initiative (GPEI). Attitude: This refers to the belief and feelings that predispose mothers to respond in a particular way to the polio immunisation campaign. It has cognitive (knowledge), emotional (feelings) and behavioural 32 components. Most attitudes are the result of direct experience or observational learning from the environment. Attitudes are positive, negative or neutral views of an attitude object—polio immunisation, in the case of this study. Attitude Change: This is modification of an earlier attitude. Attitude change is basically a response to communication. It is influenced by three major factors: target characteristics, source characteristics and message characteristics. Attitude can be changed through persuasion, which is essentially a communication process. Belief: This is a thing, information or an idea that mothers accept to be true or real concerning polio and immunisation. It deals largely with their opinions and convictions about polio and immunisation against it. Behaviour: This is mothers’ acceptance or rejection of immunisation for their children who are under five years of age. Behaviour Change: This is modification of old behaviour in the light of information, new belief and a change in attitude. Within the context of this study, this means a decision by mothers to take their children for immunisation after initial refusal. 33 Advocacy: This is a continuous and adaptive process of gathering, organising and formulating information into arguments to be communicated through various interpersonal and media channels, with a view to raising resources or gaining political and social leadership acceptance and commitment for a development programme, thereby preparing a society for acceptance of the programme Communication: This refers to exchange of information and ideas on polio between those promoting mass immunisation and mothers with children below five years. It could be through interpersonal or mass media channels. Communication for This is a research and planned process, crucial for Development: social transformation, operating through three main strategies of advocacy, social mobilisation and programme communication. Campaign: This is a series of planned communication activities directed at stakeholders with the specific aim of persuading them to get involved in eradication of polio through routine, supplemental and mop-up immunisation. Immunisation: This is the process of administering few drops of oral polio vaccine to children’s bodies in order to boost their immunity against poliovirus. Poliomyelitis: This is a disease caused by the wild polio virus. It attacks and paralyses children. It enters the victim’s body through the mouth. 34 It spreads from one person to another mainly through contaminated fingers, foods, drinks and faecal matter from an infected person. Knowledge: This refers to mothers’ awareness of a fact or situation about polio and immunisation. It also means the facts, information, understanding and skills that mothers have acquired through experience or education about polio and immunisation against polio. Mother: Mothers, as used in the context of this study, means a woman of child-bearing age with any child less than five years old. Opinion: This is mothers’ evaluation or judgement about polio immunisation and polio immunisation teams. Opinion is not necessarily based on fact or knowledge. For instance, rumours which slowed down immunisation in northern Nigeria between 2003 and 2004 were, in most cases, not based on facts about polio vaccines and their chemical properties. Programme Communication: This is research-based communication process of addressing knowledge, attitudes and practices through identifying, analysing and segmenting audiences and participants in programmes and by providing them with relevant information and motivation through well-designed strategies, using appropriate mix of interpersonal, group, and mass media channels. 35 Persuasion: This is the process of convincing or leading mothers to take their children for every immunisation through reasoning or argument. Practice: This is what mothers commonly do regularly about the immunisation of their children. It is usually determined by cultural beliefs, norms and values. National Immunisation Days (NIDs): These are special days when all children below five years in the country are given a dose (two drops) of Oral Polio Vaccine (OPV) in each round, irrespective of their previous immunisation status. This dose helps prevent the polio virus from circulating among children. Routine Immunisation: This is immunisation given to children at health centres from birth and at various ages till they are nine months old, to prevent them from serious disability or possible death from the six childhood diseases – tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles. Social Change: This refers to a transformation within a society from an old practice to a new that improves living condition or quality of life Social Mobilisation: This is a process of bringing together all feasible intersectional social partners and allies to identify needs and raise awareness of and demand for, immunisation against polio. It involves enlisting the participation of such actors in identifying, raising and 36 managing human and material resources, thereby increasing and strengthening self-reliance and sustainability of achievement made. CHAPTER TWO LITERATURE REVIEW This chapter reviews literature that is pertinent to this study in three parts. The first part deals with conceptual literature i.e. a review of concepts that have direct bearing with this study. The second part deals with theoretical review and the third part details a review of empirical studies. Much has been written by scholars in different fields on the role of communication in social change or development, especially since the end of World War II. Melkote and Steeves (2001:47-48) remark that this period coincides with the birth of the United Nations and its multilateral agencies as well as numerous bilateral aid agencies established by the Western industrialised countries, following the belief then that aid to 37 the less developed countries was important in the prevention of future wars. Invariably, most communication scholarship and practice are consistent with modernisation theory because, as Melkote and Steeves (2001:130) further note, early communication scholars and development communication professionals viewed communication as a product and reinforcer of economic growth and development. CONCEPTUAL REVIEW The following concepts are reviewed in this section: development, social change, information and communication, and development communication. . DEVELOPMENT Early development Communication scholars saw the concept of development within the concept of economic growth. Their view of development and the role that communication should play in it was largely influenced by the development strategy of post-World War II era. The United States of America, Moemeka(2000a:1-2) has noted, had developed a plan to rebuild war devastated Europe. The plan, known as ―Marshall Plan‖, was a huge success. It was characterised by the infusion into the economy of large sums of money and modern technology, which made establishment and growth of industries possible. This, in turn, led to large profits for investors and industries as well as economic incentives for workers. About this same period, Everett Rogers, one of the renowned early scholars in development communication, published, in 1962, his influential book The Diffusion of Innovation. The book, as Moemeka (2000a:2-3) has observed, presented and discussed in 38 great detail how new and development – oriented ideas could be spread through a social system. Moemeka further notes that Rogers’ work seemed to have been specifically geared towards economic improvements, especially of the very poor, through the use of the diffusion process. Wilbur Schramm, another well-known development communication scholar, in 1964 published his book Mass Media and National Development: The Role of information in Developing Countries. Schramm’s idea was concerned with the role the mass media of communication could play in national development. Moemeka (2000a:3) observed that the book was so influential that for many years after its publication it served as the guide book on how to use information in development projects. Mowlana (2000:20) notes that the concept of development was not used extensively in the literature until after the end of World War II. The term, he said, became synonymous in the 1940s, 1950s and 1960s, with (economic) growth, modernisation, industrialisation, productivity, change, democracy, etc. Mowlana (2000:24) identifies four main elements of this model of development: 1. Economic growth through industrialisation and accompanying urbanisation; 2. Capital-intensive technology mainly imported from the more developed countries; 3. Centralised planning, mainly by economists and financial experts to guide and speed up the process of development; and 39 4. Assertion that the causes of under-development are mainly within developing countries themselves. However, this ―economic growth-only‖ view of development, referred to as the dominant paradigm, has been rejected by many scholars (Inayatullah, 1975; Rogers, 1976; Moemeka, 1989; Mowlana, 2000). Inayatullah (1975), for instance, defines development as ―Changes towards patterns of society that allows better realization of human values; that allows a society greater control over its environment, and over its own political destiny; and that enables its individuals to gain increased control over themselves.‖ Though this definition is not as specific as one would expect, it represents one of the earliest attempts to view development from angles other than the economic growth only. Rogers (1976) also defines development as – ―A widely participated process of social change in a society intended to bring about both social and material advancement including greater equality, freedom, and other valued qualities for the majority of the people through gaining greater control over their environment.‖ One of the most useful contributions of Roger’s definition to the understanding of the concept of development is the idea of wide ―participation‖, meaning that beneficiaries of development programmes must be involved at every stage of the process. Moemeka (1989) defines development as ―a positive change (for the better) from conditions (social, economic, political, cultural and human) that are no longer considered good enough for the goals and aspirations of a society to those that are most likely to meet those goals and aspirations.‖ 40 A major contribution of Moemeka’s definition of development is the link between development and society’s goals and aspirations, which are determined by the people themselves. Dissayanake (2000:39) d n his own definition, describes development as ―The process of social change which has as its goal the improvement in the quality of life of all or the majority of the people in a given society without doing violence to the natural and cultural environment in which they exist and which seeks to involve the generality of the people (participation) as closely as possible in this enterprise, making them the masters of their destiny.‖ The key ideas in this definition are improved quality of life, sustainable development, participation and self-reliance. From current literature, it is obvious that development in society is no longer viewed from economic angle alone. It also covers social, cultural, political, environmental and technological issues as well as issues bothering on health (personal, community or public), freedom, equality, women empowerment, poverty reduction, literacy, sanitation, social justice, child survival, democracy, and so on. SOCIAL CHANGE 41 Rogers (1983:6) posits that social change is ―the process by which alteration occurs in the structure and function of a social system.‖ Implicit in this definition is both positive and negative change, i.e. change can be from bad to good or from good to bad. But Moemeka (2000b:69) defines social change as ―action taken to reduce or eliminate the non- conducive or negative side-effects of social or physical development.‖ Moemeka (2000a:10) argues that while development ―is directed mainly at replacing identified retrogressive attitudes, behaviours and outmoded methods, structures and systems, social change is aimed at restructuring, that is, removing the undesirable effects and consequences of otherwise good and desirable attitudes, behaviours, structures and systems.‖ He concludes by saying that both concepts are ultimately geared towards the same goal – the improvement of the social, economic, political, cultural and environmental conditions under which human beings…live.‖ INFORMATION AND COMMUNICATION Related to the concepts of development and social change are the twin concepts of information and communication. The later concepts have played critical roles in development or social change programmes from the onset. But Moemeka (2000a:3) makes a distinction between information and communication. Information, he posits, is the provision (dissemination) of facts and figures on 42 development issues. According to him, information deals with ―talking to‖ the people- beneficiary of development programmes. It is essentially top-down, one-way strategy for transferring information. Communication, on the other hand, deals with exchange of information, ideas, feelings, opinions etc. It is two-way, and it is horizontal in structure. It is ―talking with‖ the people (Moemeka, 2000a:3). There is element of interaction in communication, as the process is all about sharing of meaning. DEVELOPMENT COMMUNICATION/ COMMUNICATION FOR DEVELOPMENT Moemeka (2000a:12) defines development Communication as ―the application of the principles and practices or exchange of ideas towards the achievement of development objectives.‖ Moemeka (1989c:50) explains the nature and purpose of development communication: ―Development communication is not persuasion-oriented in that it is not geared towards persuading people to change. It is interaction-oriented in that it tries to create opportunities for dialogue that would lead to understanding the issue involved in a particular change situation, and to freely accepting or rejecting the demand, depending on the ratio of the reward / punishment mechanism associated with the projected change.‖ UNICEF et al (2000:6) define communication for development as ―a researched and planned process crucial for social transformation and operating through three main strategies: advocacy to raise resources and political and social leadership commitment for 43 development goals; social mobilisation for wider participation and ownership; and programme communication for bringing about changes in knowledge, attitudes and practices among specific participants in programmes.‖ The definition of UNICEF et al makes communication crucial at every step in the process of change. 44 THEORETICAL REVIEW This section reviews theories that are relevant to this study Melkote and Steeves (2001:104) classify the various communication approaches used for development since the end of World War II into four interrelated theoretical and operations areas, that is: communication effects approach, mass media and modernization approach, the diffusion of innovation approach and the social marketing approach. According to the two communication scholars, the scholarship of communication effects helped lay the groundwork for the use of mass media in support of development projects. The diffusion of innovations research, on the other hand, provided a model for communication interventions in local-level projects. But as these models increasingly proved inadequate, development agents turned to social marketing approach to guide communication projects. COMMUNICATION EFFECTS APPROACH The successful use of propaganda to mobilise people in the Western World to fight and to maintain their morale during adverse conditions provided the impetus for mass communication theory and research. Lasswell (1948) came up with his famous mass media effects model during this period. His model suggests the following question: Who says WHAT in which CHANNEL to WHOM and with what EFFECT? Melkote and Steeves (2001:105) outline a graphic presentation of Lasswell’s formula in the following figure: 45 Figure 1: Lasswell’s Communication Effects Model Source: Melkote, S.R. and Steeves, H.L. (2001). Communication for Development in the Third World: Theory and Practice for Empowerment (2 nd ed.) New Delhi: Sage Publications India Pvt Ltd. Lasswell’s conceptualisation later provided the framework for the emergence of the Bullet Theory of mass communication effects. This phenomenon has been given various names. Berlo (1960) refers to it as the Hypodermic Needle Theory. Schramm (1971) calls it Bullet Theory while Defleur and Ball-Rokeach (!975) label it Stimulus-Response Theory These earliest theoretical models on mass media effects conceptualised the influence of mass media in individuals as direct, powerful and uniform. The models assumed an all – powerful source and passive receiver. Katz (1963:80), in a critical review of the earliest model of communication effects, notes that ―the model in the minds of the early researchers seems to have consisted of (i) The all-powerful media, able to impress ideas on defenceless minds, and (ii) atomized mass media but not connected to each other.‖ Melkote and Steeves (2001:107) also remark that between the two World Wars, ―the mass media were viewed as powerful instruments that could be successfully used to Who Says What In which channel To whom With what effect 46 manipulate people’s opinions and attitudes, and thereby their behaviours in a relatively short period of time‖ It is clear, therefore, that the earliest models of mass communication effects conceptualised communication as a linear and one way process always flowing from the source of communication to a passive receiver (Melkote and Steeves, 2001:108). A major defect of these earliest models was their over-emphasis on the effects of message, of the several elements of the communication process. Other elements like the source, channel, noise and context (environment) of communication were largely neglected in communication scholarship. Perhaps one reason for the major concern with message effects is the view among scholars that message is the central element in mass communication. For instance, Uyo (1987:1-2) contends that every other element of the process of mass communication tends to revolve around it. He believes it is through messages that mass media organisations fulfil their functions to society or mankind. However, this tendency to concentrate on message effects, without due considerations to the other elements of the communication process, may delay a full understanding of the individuals and society. Defleur and Ball-Rokeach (1989:27-29) write about the controversies that continue to surround studies on the impact of the mass media on their audiences. On one hand, the different media, the authors say, have been charged with responsibility for lowering the public’s cultural tastes, increasing rates of delinquency, contributing to general moral 47 deterioration, lulling the masses into political superficiality and suppressing creativity. On the other hand, the media have been credited with: exposing sin and corruption, acting as guardians of precious free speech, bringing at least some culture to millions, providing harmless daily entertainment for the tired masses of the labour force, informing people of the world’s events and making more bountiful people’s standard of living by their unrelenting insistence that they purchase and consume products to stimulate the economic institutions. Perspectives on Minimal Effect of the Mass Media In the post World War II era, the theory of dominant mass media effects began to give way to that of limited effects. Many inter-disciplinary studies (Lazarsfeld et al 1948, Katz and Lazarsfeld, 1955; Hovland et al 1949; 1953; Klapper, 1960; Allport and Postman, 1947; Jones and Kohler, 1958; Levine and Murphy, 1958; Severin and Tankard, 1987; and Lowery and DeFleur, 1988) suggest a relative warmness for the mass media in directly influencing individual personal decision. For instance, Lazarsfeld et al (1948) discovered that individuals were more influenced in their political decisions by members of their primary and peer groups than the combined mass media. Katz and Lazarsfeld (1955) also found that one segment of studied population was more exposed to the mass media than the other. They called the more exposed individuals influentials or opinion leaders. They discovered that the opinion leaders influenced other people in their community. According to Melkote and Steeves (2001:109), their notion was described in the Two-step Flow Theory and suggested that the first step of influence is from the mass 48 media to opinion leaders, while the second step is from their leaders to others in the community. Hovland et al (1949) who carried out a baseline study in the area of communication and persuasion found that people defended themselves against persuasive messages in three ways: selective exposure, selective perception ad selective retention. The researchers’ work on war propaganda films examined how and why individuals responded to persuasive messages, showing that the mass media were ineffective in improving the attitudes of soldiers towards their allies and increasing their motivation to fight. Rather, they discovered that the social categories (e.g. level of education) to which people belonged and individual differences were more predictive of certain effects than mass media exposure. Klapper (1960) suggests that exposure to media messages and the individual’s perception of those messages are influenced by their beliefs, ideas, values, attitudes, wants, needs, and other factors. Klapper argues further that the mass media were more agents of reinforcement than causal agents of behaviours change in individuals. The demographic categories to which people belong, their individual characteristics and their social relationships, Lowery and DeFleur (1988) conclude, have a far greater influence than the combined mass media. The major lesson learnt from the selective processes is that the individual is not a defenceless target for persuasive communication. He or she is very active in receiving, processing and interpreting information (Melkote and Steeves, 2001:110). 49 The theory of minimal mass media effects, Melkote and Steeves (2001:111) remark, has contributed to the refinement of theories and methods in communication studies. They explain that the survey sampling of Paul Lazarsfeld and colleagues at Columbia University, the experimental designs of Carl Hovland and colleagues at Yale, the functionalistic and middle-range theories of Merton , Klapper and others have made significant contributions to researchers’ conceptualisations of communication effects. Researchers are now able to discover and explain more adequately the role of interpersonal influences and other social-psychological variables on media diffusion and impact. Despite the findings of minimal effects research, the mass media have been continuously used for information delivery, persuasion and social change programmes, particularly in the less development countries of the world (Melkote and Steeves, 2001:112). Administrators and policy makers in those countries apparently still perceive the mass media as potent vehicles or tools for achieving rapid development or effecting behaviour change. One conclusion that is apparent from this practice is that preoccupation with effects suggests that the mechanistic stimulus – response model has not vanished entirely. It still appears to underlie much thinking about the nature and role of mass communication in development. MASS MEDIA AND MODERNISATION APPROACH Under this approach, the mass media were thought to have powerful and direct effects on individuals and society. In fact, as Melkote and Steeves (2001:118) have pointed out, the 50 media of mass communication were considered to be magic multipliers of development benefits to the developing nations of the world. This approach was popular in the 1950s up to the first half of the 1970s. The scholarship and practice of development communication during this period focused on the use of the mass media, in a one-way, top-down flow, to disseminate information on development or social change. Much thinking about the role of communication in development was heavily influenced by the works of sociologists, political scientists, economists and social psychologists, who were interested in studying the role of communication in modernisation. Generally, they identified the functions of the mass media and measured their influence in the modernisation of developing countries. Such influential works include those of Lerner (1958), Neutrath (!962), Rao ((1963), Rogers (1965, 1969), Frey (1966), Inkeles and Smoth (1974), and (Fjes 1976) Lerner identifies the major ideas of the early mass media and modernisation approach in his book, The Passing of the Traditional Society. His generalisation was based on data collected from The Middle East. Lerner’s model of social development includes a view of an all-powerful mass media system that reinforced and accelerated social and individual change by disseminating the new knowledge and attitudes conducive to modernisation. A major element in Lerner’s model is that development of a psychological pattern, termed empathy, by the individual. Empathy, he insists, is both required and reinforced by modern society (Melkote and Steeves, (2001:115). Empathy was viewed as capacity to 51 see oneself in the other fellow’s situation. According to Lerner, empathy performs two important functions. First, it allows the individual to operate efficiently in a constantly changing modern society. Second, it helps him/her to desire movement out of his/her traditional settings. Fjes (1976) explains that empathy ―allows the individual to internalise the process of modernisation by not only being able to cope with change, but (by) expecting and demanding it…, It is the psychic nexus of all the attitudes and behaviours necessary in a modern society.‖ The second element in Lerner’s model was the mass media. According to him, the media expose individuals to new people (especially people in the developed nations of the Western World), ideas and attitudes, thus accelerating the process of modernisation. Generally, he ascribed to the mass media the inherent capacity to blow the winds of modernisation into isolated traditional communities and to replace the structure of life, values and behaviour in those communities with ones seen in the modern Western society. Lerner’s idea was further reinforced by the work of Rao (1963). Rao suggests that communication was the major catalyst in the development process. The conclusion came from a study of two Indian villages – Kothooru and Pathooru. The former was on the verge of modernisation, and the latter was still enmeshed in traditional beliefs and customs. Rao observed that the construction of new road to Kothooru from a nearby city began the process of modernisation. The road, he suggests, brought new people, idea and the mass media, and allowed the villagers to visit the urban centres. All this new 52 information, he reasons, opened the people’s minds, concluding that it was the quality of information that triggered the change in Kothooru. It is, therefore, very clear that the role of the mass media, under this approach, was accorded a central position. The mass media were seen as agents and indices of modernisation. The period was characterised by a number of research activities to demonstrate the correlation between exposure to mass media and modernisation. Studies by Neutrath (1962), Rogers (1965), Frey (1966), Inkeles and Smith (1974) showed a positive correlation between the availability of mass media and national development – economic, social and political. However, by the mid-1970s, the optimism about the crucial role of the mass media in development had started to wane. Researchers and administrators began to realise that the development process was not as straight forward as it was earlier conceptualised. Many critics (Golding 1974), Betran 1976, Fjes 1976, Diaz-Bordenave, 1977; Samarajiwa, 1987) have identified the serious problems with the conceptual underpinning and underlying assumption of the mass media and modernisation approach. For instance, they argue that the approach or model was a recreation of the bullet theory of communication, which assumed a direct and powerful effect on defenceless receivers. But research evidence in the United States in the 1940s and 1950s had led to the overwhelming rejection of the same model, which is now being recycled in the analysis of effect of mass media in developing countries. 53 DIFFUSION OF INNOVATIONS APPROACH The diffusion of innovations was the model of development communication in use before the advent of the social marketing model. Everett Rogers was credited with the development of this model, with release or his book The Diffusion of Innovation in 1962. The approach rests on the implicit assumptions of exogenous change theory. According to Golding (1974:43), the approach ―suggests that static societies are brought to life by outside influences, technical aid, knowledge, resources and financial assistance and (in a slightly different form) by the diffusion of ideas‖. The conceptualisation of diffusion of innovations followed closely the earliest definitions of development at both individual and societal levels. Rogers (!969:18) defines development as ―a type of social change in which new ideas are introduced into a social system in order to produce higher per capital income and levels of living through more modern production methods and improved social organisation‖. At individual level, Rogers (1969) sees development as ―the process by which individuals change from a traditional way of life to a more complex, development technologically advanced, and rapidly changing style of life‖. The route to this change from traditional to a modern person was identified as communication and acceptance of new ideas from sources external to the social system. According to Melkote and Steeve (2001:122), Everett Rogers, whose work has been central in the diffusion model, identified the key elements in any analysis of diffusion of an idea or information. These include (a) the innovation, which is any idea considered new by the recipient, (b) its communication through certain channels (c) among members of a social system and (d) over time. Katz (1963:71) had earlier offered good definition of 54 diffusion as ―the process of spread of a given new idea or practice, over time, via specifiable channels, through a social structure such as neighbourhood, a factory, or a tribe‖. It is important to point out that the predominant model that guided local-level development communication planning from the 1950s into the early 1970s was the diffusion of innovations model (Melkote and Steeves, 2001:222). However, many scholars have picked holes in the diffusion theory, pointing out many of its conceptual, theoretical or methodological shortcomings. For instance, Golding (1974), Steeves and Arbogst (1993), Shings and Mody (1976) have argued that the communication effects orientation of the diffusion model gave undue importance to the question of exposure to mass media. No attempt was made to discover the types of media messages the audience were exposed to. Little or no attempt was given to content and quality of information, or knowledge and skills emanating from the messages (Melkote and Steeves (2001: 223). Besides, the element of participation by the intended beneficiaries of development programmes was absent from the diffusion model. SOCIAL MARKETING APPROACH The failure of the diffusion theory to sufficiently account for audience behaviour in communication planning for development gave rise to science-based commercial marketing strategies for the dissemination of ideas to promote social change, called social marketing. The concept of social marketing, first introduced in 1971, was defined by Kotler and Zalman (1971:5) as ―the design, implementation, and control of programmes 55 calculated to influence the acceptability of social idea and involving consideration of product, planning, pricing, communication, distribution, and marketing research.‖ However, Andreason (1995:7) has refined the definition of social marketing, describing it as ―the application of commercial market technologies to the analysis, planning, execution and evaluation of programmes designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of their society‖. The social marketing theory has introduced such concepts as audience segmentation (targeting), market research, product development, incentives and facilitation. According to Melkote and Steeves (2001:128), market research is defined as the detailed investigation of the market for the specific products, idea or service; the segment within the broad audience group; behavioural and knowledge characteristic of the audience segments; and the cost-benefit analysis of reaching and influencing the different groups through communication campaigns. They see product development as the development of not just one product, but a host of other products that will appeal to the different market segments in terms of their varied needs. Incentives, according to the two authors, offer the target audience monetary or psychological incentives to increase the level of motivation in the adoption and use of the product or service while facilitation makes it relatively easier for the target group to adopt the innovation by reducing the effort or time required on the part of the user. Melkote and Steeves (2001:128-138) state that it is the social marketing techniques that have been used for behaviour change in such health-related issues such as family 56 planning and Human Immuno-Deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) campaigns. Clearly, the UNICEF's ACADA communication model for behaviour change, which is the concern of this study, utilises the social marketing techniques. In the social marketing model, a great deal of formative research is used to identify and define problems from the perspective of those affected by the problems to properly segment the target audience, to determine appropriate messages for the various target groups, to assess communication channels, as well as to assess audience uses of the channels and develop campaign strategies. Much emphasis is placed on evaluation and feedback throughout the process of planning, execution and monitoring of campaigns. But the social marketing model or approach has its own flaws. For instance, the approach focuses on the individual as the unit of analysis. Besides, the model has adopted top- down communication approach with receivers treated as targets for persuasion and change. ACADA INTEGRATED COMMUNICATION PLANNING MODEL The UNICEF-developed ACADA communication planning model is a four-stage process that includes: Assessment, Communication Analysis, .Design and Action. It is research- based, people-oriented and participatory. Below is the pictorial representation of the ACADA model: 57 Figure 2: UNICEF’s ACADA Model for Communication Planning Source: Communication for Development. New York: UNICEF (2008) 58 ASSESSMENT This is the first stage in the ACADA communication, planning model. The main activity is to identify what information is missing or needed and to design and carry out research to fill the information gaps. It is concerned with research to understand the situation, its nature, characteristics, history and current status, those involved and the socio-cultural environment (Oso, 2005 :2). In essence, the assessment stage in ACADA communication planning model is the same as research - driven situation analysis. It is intended to identify all real issues that need to be addressed in an intervention programme. In the case of the polio eradication programme, effort is made at this stage, to document the status of the existing communication programme as a whole in a community by identifying its successes, weaknesses, lessons learnt, issues, problems, participants (i.e. people involved), behaviours, credible communication channels, and so on. Usually, formative research is conducted at this stage. This is because research is critical in all forms of planning, including communication planning. Research, for instance, provides very useful information, which facilitates the development of relevant focused plans. Besides, research enables managers of intervention or social change programmes to assess and revise their strategies, if initial strategies do not work as planned. Research, as conceived under the ACADA Model, is a participatory process, which involves community members in data collection and analysis, giving them an opportunity to interact firsthand with critical issues concerning a particular intervention programme. 59 At the assessment stage, research findings are to be summarised and their implications for polio eradication campaign stressed. A critical activity at this state is the determination of the problem(s) to be addressed. Some of the problems of immunisation identified by UNICEF (2000:18) include: low immunisation coverage, decrease in turnout of target audience during NIDs,s decreasing political support for NIDs, lack of conviction about the value of immunisation by caretakers, and so on. Assessment, under the ACADA Communication Model, is not limited to communication aspects alone. It looks at all aspects of the intervention programme. COMMUNICATION ANAYLSIS UNICEF and WHO (2000:5) have identified five pertinent questions that are frequently asked by parents and guardians. They are: • Why should children be again immunised when they have had all immunisations in the routine immunisation programme? • Does this mean that immunisations given during the routine immunisation are not effective? • Will additional immunisations hurt children? • Are additional immunisations given with ulterior motive? • Are the immunisations safe? According to the two international agencies, which have been in the forefront of the sustained campaign for polio eradication worldwide, when the above questions are 60 inadequately answered or left unanswered, both routine and supplementary immunisation activities lose out. Integrated communication approaches, they argue, are, therefore, designed to address these questions. Writing on the role communication can ay in the global initiative to wipe polio virus, UNICEF and WHO (2000:6) identify 10 specific contributions effective communication can make towards the achievement and maintenance of high immunisation coverage. They believe communication can: • Stimulate the development of structures (such as health facility committees) that can improve relations between health facilities and communities. • Promote use of participatory learning and decision-making methods to improve community involvement and ownership of health programmes. • Support communities to develop strategies for identifying and tracking immunisation defaulters • Identify and train volunteer motivators to disseminate health messages, facilitating discussion and supporting action in the community. • Improve the interpersonal communication skills of health workers to disseminate appropriate information, hold discussions and provide counseling services for caretakers. • Strengthen interpersonal skills of trainers and supervisors in order to improve their training and supportive supervision skills at all levels. • Develop appropriate communication materials to support message dissemination to key target audiences. 61 • Publicise immunisation achievements to give encouragement to partner agencies, volunteers and other stakeholders. • Help to strengthen partners and community participation in EPI programmes, and • Support communities to identify and report cases of acute flaccid paralysis (AFP). Oso (2008:2) summarises the series of activities normally undertaken during communication analysis. These include problem identification and analysis, behaviour analysis i.e. determination of behaviours associated with the problem, barriers to desired behaviour, factors encouraging desired behaviour, identification of beliefs, knowledge and current practices of the participant or target groups related to the problem (participants or stakeholders analysis). Specifically, communication analysis, under the ACADA model, involves eight activities (UNICEF and WHO, 2000:19-33):  Analysis and formulation of problem  Determination of problem behaviours to address  Behaviour analysis  Participant analysis  Channels/media analysis  Statement of communication objectives  Identification of communication strategies and activities  Development of monitoring and evaluation indicators 62 Communication analysis seeks to find answers to the following questions: • What is happening (are people doing/not doing) that is problem • Where and when does it usually take place? • Whom does it affect? • What are the primary effects of the problem? • What are the possible causes? Problem Behaviours to Address • How strong is the relationship between the (i.e. relevance) behaviour and the health problems? • How frequently or rarely does the behaviour occur (i.e. occurrence)? • Does the behaviour have a demonstrable effect on the health problem (i.e. impact)? • Is behaviour in a developmental stage or is it already established (i.e. stage of behaviour)? • Is the ideal (desired) behaviour that should replace the current behaviour compatible with acceptable socio-cultural norms and practices (i.e. cultural acceptability)? • What successes/failures have been realised in efforts to change this behaviour in other programmes in the past (i.e. past successes/failures)? • At what cost (in time, energy, social status, money and materials) will the ideal behaviour come about? Is the cost acceptable or too high (i.e. costs)? • Will the new behaviour yield positive or negative consequences for the person performing it (i.e. consequences)? 63 • Does the new behaviour require compliance over an acceptable or an unrealistically long period of time (i.e. persistence)? • Is the behaviour too complex or can it easily be divided into a small number of elements or steps to facilitate adoption (i.e. complexity)? Behaviour Analysis After determining problem behaviours to focus on, the next stage is to analyse the identified or chosen problem behaviours in order to understand them better and determine the behaviours to promote in their place. Hence, the following questions are important in behaviour analysis: Who does not take children for immunisation (i.e. primary target audiences/participants who must take action for children to get immunised)? - Who is in a position to influence those who do not take children for immunisation (i.e. secondary target audiences in the immediate environment of primary target audiences e.g. family and friends)? - Who will inform, support, and persuade primary target audiences to take children for immunisation (i.e. the motivators)? Participant Analysis This deals with the identification of other individuals and institutions that may be enlisted to support behaviour change and behaviour development in the community. These partners may be required to play advocacy, social mobilisation or programme communication role. Critical questions to be answered under this segment of communication analysis include: • Who holds the key to programme acceptance in the community? • Which agency or individuals are interested in or working for immunisation? 64 • What facilities do they have (networks in the community, personnel, experience training, facilities, funds, transport, etc)? • What is their reputation in the community? • What influence do they have with the authorities as well as with the primary and target groups? • Who can motivate target audiences to adopt the behaviour being promoted? Channel/media Analysis Questions to which answers must be provided under this segment include: - What channels of communication are available for reaching the identified target audiences? - What are the strength and weaknesses of each channel? - How effective are the channel in reaching the target audiences we wish to reach with the messages planned to be delivered? - Where do people seek information on health or immunisation? Why do they go to this particular place or individual? How can the place or individual be integrated in promotion of immunisation messages? Statement of Communication Objectives An objective is a statement of the desired end result, usually expressed in terms of change from problem behaviour to desired behaviour. According to UNICEF and WHO (2000:282) communication objectives in intervention programmes must be SMART, an 65 acronym for the requirements of good objectives. It means that objectives must be specific, measurable, appropriate, realistic and time-bound. Strategy Selection and Detailing of Activities The next thing after stating objectives that are SMART is to identify the best communication strategies and identify the activities that need to be undertaken. While an objective is a statement of what we want to achieve or the destination where we are going, a strategy is a clear statement on how the objective will be achieved or a road map that guides to the clearly identified destination. The WHO (2001: 14-16) defines communication strategy as "a researched and planned process, crucial for social transformation, operating through three main strategies: • advocacy to raise resources, political and social leadership commitment for development goals • social mobilisation for wider participation and ownership by targeted institutional partners • programme communication for changes in knowledge, attitudes and practices of targeted participation" Monitoring and Evaluation Indicators The last activity under communication analysis is the development of monitoring and evaluation indicators. The indicators enable programme managers to track the performance and impact of their programmes. These indicators may measure short-term, medium-term or long-term impact process indicators, impact indicators and outcome indicators respectively 66 DESIGN The third step in the ACADA Model of Communication planning for behavioural change is design. At this stage, messages and materials meant for the different target groups are designed and developed based on the information obtained from the assessment and analysis stages. Design involves five levels of activities (UNICEF et aI, 2000:33-38): - Message development - Materials development - Message dissemination plan - Training plan - Development of Integrated communication planning matrix Message Development This activity is threefold. • Determination of basic message concepts that will bring about the desired behaviour change. • Selection of the communication approach. For instance, will the message aim at informing, entertaining, persuading, educating, empowering the target audiences? • Selection of the message appeal and tone. Planners choose from the following message appeals and tones: positive or negative, rational or emotional, mass or individual, humour or serious, one-or two-sided, direct or indirect, and definite or open-ended. 67 Material Development Materials to be developed to enhance communication include: posters, handbills, T-shirt, Fez caps, calendars, booklets, manuals, audio-visual aids, etc. But these materials, UNICEF et al (2000:35) suggest, must be appropriate to the topic and target audience. Besides, they must be appropriate to the context or setting in which they will be used. Message Dissemination Plan This involves providing answers to the following questions: - How will the message reach the intended audiences? - How will the educational materials be distributed? - How will the educational materials be used? - Are there activities in all three communication settings (i.e. advocacy, social mobilisation and programme communication)? - Are the activities mutually supportive? - Are the proposed educational materials the right road to support activities in their different settlings? Development of Training Plan The ACADA Model makes provision for the training of volunteers in order to: • acquaint themselves with the objective strategies and activities of the programme • know the roles they are expected to play • acquire information and skills needed to perform assigned roles. 68 Development of Integrated Communication Strategy Planning Matrix This involves the integration of all the different segments of the communication plan under the three strategies of advocacy, social mobilisation and programme communication. The integrated communication strategy planning matrix consists of clear and concise statements on the following 13 items: problem behaviour, behaviours to promote, target audience, communication objective, communication strategies, activities, monitoring and evaluation indicators, message areas, communication approach, message appeal, message tone, channels of communication; and communication materials. In the matrix, the three communication strategies of advocacy, social mobilization and programme communication occupy three rows while the 13 items listed above occupy 13 columns in front of the strategies. ACTION This is the last stage in the ACADA Model in which all activities to be undertaken are clearly identified and stated. In other words, this stage provides information on the implementation schedule for all activities. The information contains, specifically, the type of activity to be undertaken, the implementation time frame for the activity, the name of officer or organisation responsible for the action and the source(s) of funds for the activity. This study focuses mainly on the communication analysis component of the ACADA model. On the whole, the ACADA has several strengths, which make a better model than 69 the previous ones such as the Diffusion and the P-Process models. For example, the ACADA model is evidence-based, i.e. its planning is based on research evidence. Secondly, it emphasises the involvement (participation) of relevant stakeholders in intervention programmes. Thirdly, its planning and implementation are localised to give room for the peculiarities and particularities of the communities. Besides, the model is highly structured and its approach to implementation is systematic. From conceptual and theoretical literature on approaches for development communication, it is clear that the basic principles of the dominant paradigm of development are yet to disappear. For instance, there is still over- emp