The interest in this dissertation could not have resulted in a successful research without the help of my guide Dr. Arbind Sinha. A constant source of guidance and inspiration he helped me tackle difficult issues and showed me a way out when I was stuck.
I would also like to thank all officials i met during my primary research in Aligarh. I would especially like to thank Dr Rahul Kulshestra (District medical officer),Mr. Rajesh Gupta(Nodal Officer),Aligarh,Dr Abdul Gaffar(Head Integrated Counselling and Testing Center,ICTC), Aligarh Muslim University and Dr Kavita Gaur (CMS, Female general Hospital),who took out their time to not only give me interviews but directed me with further contacts.
A special mention to all the counselors and field officers who gave me valuable insights and were extremely co-operative in sharing their opinion with me.
I also thank Dr. Beena Saxena for helping me out with the initial set of contacts and helping me find my way out in a new city like Aligarh.
Lastly I thank my very supportive friends who cheered me on when I was depressed and gave me the necessary motivation to carry on with a topic which made me realize the complexities of real life. A special mention to Mr Anshuman Wanchu, Mr Kunj Sanghvi ,Ms Saloni Handa, and Ms Mansi Saxena for being a constant support during this entire dissertation.
Last two decades of the century has seen a renewed interest in the field of health communication, disease prevention and health promotion. This was because it was realized that continued investments in clinical health research brings diminishing returns if it is not accompanied with strategic information, education and communication(IEC) efforts. (Pencheon, Guest, Melzer, & Gray, 2004)
Public and government health departments are rich with tacit knowledge regarding health communication practices and the problems encountered with the population in their geographical area. However this information is rarely collected and written down due to lack of resources.
Effective communication can spread knowledge, value and social norms. This can be instrumental in affecting behaviour and improving the over-all health status of the population.
India faces a dual challenge in tackling the problem of HIV Aids and Polio. First is the overall high population and poor living conditions of people living in small towns and villages, and second is the complex socio- cultural factors which lead to poor awareness and stigma attached to these diseases.
It is important to understand these factors which affect the impact of health communication campaigns in a particular geo-graphical sub system if a comprehensive micro understanding of this field has to be generated. Moreover there always exists a gap between the people who design health communication campaigns and the campaign implementers. An assessment and feed-back from the grass root level implementers needs to be taken if this gap has to be effectively filled.
This research hopes to uncover these insights which will be useful not only to the academics but also to the practitioners.
Health communication involves the use of communication strategies by experts in public health domain to influence the health behaviour of people.
It is a link between health care practices and communication which has a significant impact on influencing individual and community behaviour towards health and thereby a huge potential to significantly improve their life. (Neil Mckee, 2004)
The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to infections. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS). It can take 10-15 years for an HIV-infected person to develop AIDS; antiretroviral drugs can slow down the process even further.
HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of contaminated blood, sharing of contaminated needles, and between a mother and her infant during pregnancy, childbirth and breastfeeding.
Global Case load: HIV - Aids
In countries most heavily affected, HIV has reduced life expectancy by more than 20 years, slowed economic growth, and deepened household poverty. In sub-Saharan Africa alone, the epidemic has orphaned nearly 12 million children aged less than 18 years. The natural age distribution in many national populations in sub-Saharan Africa has been dramatically skewed by HIV, with potentially perilous consequences for the transfer of knowledge and values from one generation to the next. In Asia, where infection rates are much lower than in Africa, HIV causes a greater loss of productivity than any other disease, and is likely to push an additional 6 million households into poverty by 2015 unless national responses are strengthened (Commission on AIDS in Asia, 2008). According to the United Nations Development Programme (UNDP), HIV has inflicted the "single greatest reversal in human development" in modern history (UNDP, 2005).
Global Health Communication initiatives for HIV Aids:
Education Entertainment Approach: The Soul City, South Africa (Goldstein, Japhet, & E.Scheepers, 2004)
South Africa even though a developed country had a wretched health care system, mainly due to long years of apartheid practices. In late 1990's Dr Garth Japhet, a young doctor observed this at Alex clinic.
He observed that the health communication efforts in South Africa where very "slogan based "and not sustainable. Bursts of activity like "National Aids day" were not enough. There was no formative research before planning these campaigns. More over the campaigns followed a "Top Down" approach, and lacked synergies between medical community, government and media.
Soul City was an extensive multi media campaign started in South Africa, due to the efforts of Dr Garth Japhet.
The whole campaign was a collection of mass media campaigns which were connected and implemented year on year. There was a 13 part prime time- television series called "Soul city", which was accompanied by a 60 episode radio show. Even though content of both these shows was not similar yet they both highlighted same health issues. Later on printed IEC material was also developed and distributed based on the characters of Soul City. These booklets were also reviewed by 11 top newspapers of the country. Through 1994 to 1999 five series of Soul city were broadcasted. These were consisted rated as top three most watched drama series in South Africa.
The Radio program also got very high listenership ratings. Formative research and high creative input went into designing the IEC material which was targeted uniquely to adults and young population.
The key to success of Soul City multimedia program was use of media conversion, from print to radio to television. This encouraged inter-personal discussions about health issues.
- Locally developed content which has quality entertainment works well
- For a multimedia educational model to succeed it should return value to all the stake holders
- Media advocacy leads to policy and social change
- A continual and integrated multimedia strategy is necessary if the effect of communication has to be sustained.
Against Stigma: ACT UP, United States of America (Documents archive/Act Up explained)
Stigma is a problem which plaques every country and becomes a very important factor in HIV + people seeking help and coming out in public .The Aids Coalition to unleash power , is one such organisation which attempts to remove this stigma through bold and creative action. They boldly use their slogan Silence = Death which urges people to speak up about HIV and Aids.
They seek to normalize talks about condoms and Aids by radical action like sticking posters on telephone booths which say "this telephone has been touched by a person with Aids"
Public demonstrations at churches, baseball fields, Wall Street etc are held to imply that Aids is everybody's business. Once during a Sunday sermon session in New York the ACT UP activists did staged a mass die in outside to highlight the bishop's silence on Aids.
ACT UP activists use linguistic symbols to make strong statements like -"No, Glove No Love" and "Aids is no ball game". These were used as places like Shea baseball stadium.
- ACT UP founder Larry Kramer studied the fight against stigma by Mahatma Gandhi and Dr Martin Luther King and suitably adapted it for modern day audience
- Use of creative and clutter breaking ideas helps discussion and normalization of sensitive issues like stigma
- Use of public demonstration, Sit ins and Die ins helps create buzz and social change.
Health communication efforts for HIV Aids in India:
The National Aids Control Program (UNAIDS, 2008):
Every State in India has an Aids prevention and Control Society which under supervision from NACO carries out local initiatives.
The second Stage of National Aids control program (NACP) ended on March 2006.This focussed on various platforms to promote youth education about safe sex, safe blood donation and HIV testing. Various platforms like Street plays, concerts, national aids day, TV and radio spots, and celebrity endorsements were utilised.
Use of teachers and peer group influencers was done to disseminate knowledge about HIV aids
The third stage of NACP will have a strong focus on condom promotion. The installation of over 11,000 condom vending machines in colleges, road-side restaurants, stations, gas stations and hospitals has been done. With support from the United States Agency for International Development (USAID), the government has also initiated a campaign called 'Condom Bindas Bol!', which involves advertising, public events and celebrity endorsements. It aims to break the taboo that currently surrounds condom use in India, and to persuade people that they should not be embarrassed to buy them. (Shhhh...not anymore!)
Various multi-media campaigns have been implemented in India to create awareness about HIV.
These include special communication programs to target special audience like sex workers, truck drivers, and street children. Radio programs are broadcasted on a regular basis to disseminate information. Field publicity units, Drama and song division has been set up to target rural India. Aids hotlines with around 1097 toll free numbers have been set up in major cities of India.
A very successful program has been the University Talk Aids (UTA program), which covered 4,044 institutions in India and reached out to 3.5 million students. The program was implemented by National Service Scheme with assistance from WHO and NACO.Independent evaluation suggested that the program was highly successful in creating a healthy attitude about sex among young children
Communication regarding Condom promotion:
Social marketing of Condoms combined with free distribution has been used to promote usage among general public as well as high risk groups. Department of Family welfare has been instrumental in distribution and supply of condoms.
Family Health Awareness Campaign
This campaign was focussed on creating awareness about RTI and STI among the general public as well as the field level functionaries. This campaign is organised annually in rural as well as urban slum areas. (Shaukat Mohammed, 2003)
Reaching Special Audiences:
Reaching Men who have Sex with men (MSM): Case Study Naz foundation Trust of India: (Rakesh, 2002)
Background: India with a very high population runs the risks of very high PLHA even if a low prevalence rate of HIV is present. Even though most sources of infection are through hetero-sexual sex yet in certain areas like north -eastern India, IDU becomes a dominant factor for HIV transmission.
Strategy: The Naz foundation was set up in 1994 to address sexual health issues of MSM, women, truck drivers and PLHA.
The key communication objectives were:
- Communication about modes of transmission
- Prevention and risk reducing strategies
- Means of accessing treatment
The intervention strategies utilised were:
- Community outreach: Nine outreach sites which were staffed with officers who provided information on safe sexual health practices, condom usage and provided referrals
- STI referrals: A non judgemental approach to STI risk patients was followed. STI clinics were set up with a MSM friendly physicians
- Social and Group meetings: support groups were formed to help MSM and create a freer environment for information interchange
- Counseling:Telephone hot lines and personal counselling was set up to address MSM concerns
Results: The implementation of Naz foundation strategies was evaluated and it showed a number of positive results. An increase from 11 % to 43% for "all time " condom usage ,the STI clinic visits increased from 24% to 56%, and condom usage by male sex workers increased from 20% to 43 %
- Naz foundation realized that in order to reach out to special audiences tailored solutions are necessary.
- Some risk groups like female partners of MSMs are very difficult to reach and hence intensive efforts are needed in this area.
Reaching out to Injecting Drug Users (IDU): Case Study IDUs in New Delhi India (Dorabjee, 1998)
Background: In some cities of India like New Delhi the HIV prevalence rate among IDU users is as high as 85%.The Indian NGO Sharan has been working for IDU since 1979,and has done some breakthrough work in this area.(AIDS Analysis Asia ,1996).
Strategy: IDU were motivated to join either drug substitution therapy which involved substituting drug injections to oral drug usage or needle exchange program where the registered IDU users vouched to stop exchanging needles during drug usage.
The reason behind the success of this program was that it managed to develop a strong trust among IDU users because it employed recovering drug users as outreach workers. Constant feedback was sought from them and the program was modified accordingly.
The IEC approaches used were counselling, peer education, information on sexual transmission of HIV aids, condom distribution and drug use prevention programs.
- 33 % of registered IDU started taking oral drugs instead of Injections
- 21% stopped sharing needles
- Use of advocacy resulted in government accepting the use of harm reduction strategies for IDU users
- Political support is necessary for the success of any IEC project on sensitive issues. This can be influenced through strong advocacy
- Incorporating feedbacks by outreach workers and IDU can significantly increase the impact of the campaign
- A range of clinical, social and communication services are required to meet the purpose of HIV prevention among IDU users
Addressing the mobile population: Case Study the Trucker Population of India (Bhoruka, 2001)
There are about 50 million trucker population in India, who spend around ten months away from home. Around 70% of these engage in unprotected extra marital sex (UNAIDS, 2006).HIV infection is high in this segment along with a high STI danger. A major obstacle is that these truck drivers do not use condoms for "road side sex" as it regarded as a re-creational activity.
Strategy: The Bhoruka public welfare trust (BPWT), attempted to reach these truck drivers through free tea parlours set up at 5 main route stops in India. These tea parlours offered a meeting ground for the truck drivers and offered tea, newspaper, TV and other forms of entertainment. However no prostitution or drugs were encouraged. Condoms, clinical counselling and STI medical referrals were offered at a subsidised rate.
The most important aspect was focus on peer education and counselling. As these truck drivers discussed about their life, peer educators gave them counselling and information. Parking lots were used as another reaching stop where peer educator gave out condoms and IEC material.
This program became so successful that various truck drivers themselves became informal peer educators. The tea-shops were also managed by truck drivers or sex workers. Informal truck driver peer educators were later trained and given certificates to become formal peer educators and work in these tea shops.
Small motivational incentives like bags and pens were also offered to these truck drivers as well as informal peer educators.
- Every tea centre reaches out to close to 48,000 people annually, provides subsidised treatment to 2,200 patients .Fifty percent of these patients are treated for STIs
- Around 200 truck drivers had been trained as peer educators by the year 2000
The condom social marketing component of this program was very successful, with steady increase in condom sales. Till 2000 there were 104,832 sold and 162 active condom distribution set up.
- A high level of motivation should be maintained amongst the peer learning groups.
- It's important to have support of all the stakeholders for the success of any ICE program.
Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young children. The virus is transmitted through contaminated food and water, and multiplies in the intestine, from where it can invade the nervous system. Many infected people have no symptoms, but do excrete the virus in their faeces, hence transmitting infection to others.
Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. Polio can only be prevented by immunization (World Health Organisation)
Global Case load: Polio
Polio cases have decreased by over 99% since 1988, from an estimated 350 000 cases in more than 125 endemic countries then, to 1997 reported cases in 2006. In 2008, only parts of four countries in the world remain endemic for the disease - the smallest geographic area in history.
In 1994, the World Health Organization (WHO) Region of the Americas (36 countries) was certified polio-free, followed by Western Pacific Region (37 countries and areas including China) in 2000 and the WHO European Region (51 countries) in June 2002.
In 2007, more than 400 million children were immunized in 27 countries during 164 supplementary immunization activities (SIAs). Globally, polio surveillance is at historical highs, as represented by the timely detection of cases of acute flaccid paralysis.
Persistent pockets of polio transmission in northern India, northern Nigeria and the border between Afghanistan and Pakistan are key epidemiological challenges.
As long as a single child remains infected with polio, children in all countries are at risk of contracting the disease. The poliovirus can easily be imported into a polio-free country and can spread rapidly among unimmunised populations. Between 2003 and 2005, 25 previously polio-free countries were re-infected due to importations.
The four polio-endemic countries are Afghanistan, India, Nigeria and Pakistan.
Global Health Communication efforts for Pulse Polio:
Strategic communication efforts in Afghanistan (Rafiqi, 2004)
The Pulse polio eradication program of Afghanistan faced stiff challenges due to illiteracy, resistance, inaccessibility and worsening security conditions.
Strategic approach for Polio health communication in Afghanistan focussed on advocacy, social mobilization, communication to support the program and training.
Advocacy was achieved by involving top leaders at every program launch, and getting them involved at all levels by sharing epidemiological data. Social mobilization through involvement of religious leaders, mosque and prayer announcements, and inter-personal communication. Television and Radio was also utilized. Communication to support the program was achieved through district and community based forums which encouraged discussions, dedicated community specific social mobilization workers were employed and training was given to Imams and other religious leaders. Print media was used effectively for brochures, banners and leaflets.
- It's a challenge to shift the focus of health communication from campaign type to sustainable communication
- Advocacy at highest level is instrumental to success of the campaign
- Use of local facilities like mosques, bazaars, mobile loudspeakers etc lead to effective social mobilization
- Appropriate mix of print and radio can effectively reach mobile population
- Establish strong relationship with religious leaders
- Promote health education through health facilities as well as private practitioners
- Ensure all factions of community are involved including women
Polio immunization efforts through public health education efforts in West Africa. (African Science Academy Development Initiative (ASADI), 2005)
Nigeria faced a major challenge when polio vaccination was stalled in northern areas due to huge negative controversy in local as well international media regarding the safety of these oral medicines. Moreover allot of trusted religious leaders also spoke out against the vaccine.
To fight this drastic loss of acceptance of Oral Polio Vaccine (OPV), a strong communication plan was developed with the objective that each child should get OPV drops.This was achieved through heightened advocacy through large scale public flag offs of campaigns, direct involvement of the president, working with the private companies including telecom companies, and engagement of religious as well as community networks.
To focus on community education community mobilizers were assigned to high risk area, traditional media like street theatre, town criers, mobile cinema and folk songs were utilized. Mass media like TV spots and radio jingles were also integrated
Effective use of Media for behaviour change was used. This included broadcasting in national languages, special programs for minority groups, projection of human interest stories to create positive dialogue, folk media, community theatre and mobile cinema followed by dialogue.
Success of this campaign can be determined by the fact that the demand for immunization and OPV drops substantially increased. The OPV controversy was effectively resolved, along with support from key stake holders.
Behaviour Change through public education and integrated mass and traditional campaigns can effectively result in more demand and acceptance of polio immunization.
Health communication efforts for Polio: India
Reducing resistance and increasing community dialogue: Meerut, Uttar Pradesh (United Nations Children's Fund (UNICEF) India, 2007)
Meerut is one of the regions of Uttar -Pradesh which is seen as high risk for the polio endemic. A highly innovative social mobilization campaign was implemented in Meerut, which involved:
Use of distinct influencers; Three teams of 35 Urdu teachers,24 kirana store owners and Haji's (people who have completed Haj pilgrimage )were involved in these teams.
Close to 25,000 primary schools were approached on republic day, to educate the children, inform them of the dates of immunisation so that better participation is achieved. Mosques were approached to educate the community. Their participation increase from 61% in January 2007 to 74% in February 2007.
Meetings on a regular basis were conducted with mothers and daughter in laws, to discuss polio and child health issues.
Booklets were published which contained poems written by local influential poets. These boosted the morale of health workers and also worked as strong advocacy measure.
Due to these innovative techniques Meerut recorded the lowest no. of resistant households in Uttar Pradesh in 2007.
- Polio needs to be incorporated as a part of overall child health program .
- Consistent, open and on-going dialogue with all factions of community is necessary.
Use of innovative techniques to create interest: Polio Joker (Kher, 2007)
Brihanmumbai Municipal Corporation (BMC), hired Manchanda Jha to dress up as a joker and attract kids to polio booths .He sings songs about polio, does tricks, engages children and gives information about the importance of polio drops alongside.When dances and sings "Chal chale polio boothpe hum sathiyoon, chalke do boondh jeevan ke le sathiyon" the children are not only humoured but also an important message has been delivered.
He became so successful that he came to be called "Polio Joker" popularly. He has been instrumental in reaching out to care-givers and kids in slum areas. This program was implemented for three years and has very high recall value.
- New entertaining techniques need to be implemented if communication has to reach children
- Communication methods should be tailored to meet the needs of high risk areas.
Rationale of the research and Knowledge gap
Health status of a country is influenced by a number of factors like food, water, income, sanitation, education and accessibility to health care services. Health communication campaigns and health services don't exist in a vacuum but are influenced by external socio-economic, cultural and factors.
These factors play an important part on how health information education and communication campaigns are designed, implemented and finally received by the target audience.
These factors also influence policies, resource allocation, technology, training of medical staff and communication strategies used. These in turn shape the health services system of a particular region.
Studies which have documented the health communication efforts have restricted themselves to an analysis at national level. It will be not surprising to find that in a complex nation like India various sub-systems exist, and every sub-system might influence the message in its own way.
HIV AIDS and Polio are two major health concerns faced by Indian population. On-going and consistent efforts are made to educate people regarding these. However again within a geographic sub-system people might react and respond both these campaigns in a differential manner owing to a variety of factors like sensitivity of the issue, complexity of the message and stigma.
Through this study I wish to explore these factors which affect the impact of health communication campaigns of HIV Aids and Polio, in a geographic sub-system.
Through the analysis of the literature review and recommendation of my guide the following research objectives have been identified:
- To understand the health communication processes and initiatives undertaken for HIV Aids and Polio prevention/care at a sub-system, grass root level.
- To identify factors which lead to an differential impact of these health communication campaigns
- To suggest improvements ,if possible, to current health communication practices followed in the geographic sub-system
Health communication campaigns which will be studied extensively are:
These will include the communication efforts in the area of prevention (transmission through mother to child, sexual transmission and primary prevention) and general awareness.
Against Pulse Polio:
Campaigns for polio education and routine immunisation will be studied.
This study aims to understand the use of traditional media, electronic and human channel employed at the grass root level. What are the problems faced in implementation, what are the intermediary factors which affect them, and what measures are taken to combat these problems.
An evaluation of these campaigns will also be conducted based on how much has the target audience been receptive to them, and responded by either positive action or behaviour change.
Ultimately both these campaigns will be compared and contrasted to arrive at the differentiating factors which impact the outcome of these.
An extensive secondary research will be done to establish a foundation for the primary research.
The literature review provides certain learning about different methods of strategic health communication. This learning will be taken forward to primary research where the focus will be kept on the grass root health communication initiatives undertaken in the chosen sub-system.
This phase will consist of primary research will be essentially qualitative and exploratory in nature. The purpose of this type of research methodology is to generate basic knowledge on relevant areas, discover associated factors, and identify information gaps.
Data collection and Analysis:
Primary data collection will be from performance reports and internal documents which are generated at the primary sub-system .
Expert In-depth interviews will be conducted to gain more understanding on the subject. It is important to note that the interviews will be open -ended and flexible to generate maximum insights.
These interviews will involve extensive probing and will utilize the technique of laddering, An interview guideline will however be prepared for a comprehensive and systematic execution.
Similar technique of in-depth interviews will also be employed to collect information from beneficiaries to judge the effectiveness of the campaigns.
The reason why in-depth-interviews will be used over other methods of data collection is:
- It is flexible
- It provides in-depth information about areas to be covered
- Since the area of study is very specialised it provides scope for clarification
- Some of the issues which needs to be discussed are personal in nature, a face to face and private discussion is necessary
Like other techniques, this tool also suffers from certain limitations. In-depth interviews require skill at the part of the interviewer and it is prone for bias if not conducted properly. The responses may be difficult to interpret and due to its flexible nature it is not neccary that all the respondents are asked the same questions.
Area of Study:
The chosen geographical sub-system for the primary research is Aligarh in UP. The reasons behind this are the following:
- UP has a relatively high prevalence rate of HIV AIDS
- It's one of the few areas in India which is still Polio Endemic
- Familiarity with the local language
- Initial contacts are available
Timeframe of the study:
Phase one-: November till mid-December 2009
Phase two/primary research: Mid December to January 2010
Phase Three-(Data analysis and Dissertation report completion):January 2010 to February 2010
Sampling universe consists of all the experts in the area of the study, and the population to which the health communication campaigns are targeted.
The sampling technique would be Purposive Sampling. This is because it is difficult to obtain appointments and approach the working professionals and experts in this field. It will also be more convenient and inexpensive because I am the only one involved in the study and selection. This technique is non random and most appropriate because I need to interview the experts in the field to fulfil the research objective. Here the interviewers will become the key to shaping up the research. These would be the people directly or indirectly connected to the research areas taken up for study.
Further to approach the experts the Snowballing technique will be employed. Snowball sampling uses recommendations to find people with the specific range of skills that has been determined as being useful, as such, snowball sampling aims to make use of community knowledge about those who have skills or information in particular areas .Therefore this method will help me in identifying interested and knowledgeable professionals required for my study. These participants would then be asked for referrals based on their contacts already established.
Why it is being used over any other technique?
- Convenient and easy method
- Increases the number of participants in process.
- Builds on resources of existing networks
For the beneficiary interviews simple convenience random sampling technique will be used to get an unbiased representation of general population. However a screening criteria will be used to ensure that the respondents are the target audience of the Polio and HIV/Aids Campaign.
The screening criteria will be respondents of the age group of 15-49 and with children of less than five years of age or with family which has children less than five years of age.
Sample size and Limitations
At least 10 expert (medical and field officers) and 30 beneficiary (of the campaigns currently being implemented) interviews in total will be conducted to obtain their views, opinions and beliefs on the subject under study.
The sampling unit would be individual because the method of research involves in-depth interviews.
The primary research will be limited to the geographical area of Aligarh, U.P; however the leanings can be extrapolated for cases with similar socio-economic and cultural factors.
In depth interview is a data collection technique and provides a basis for future research areas.
Therefore, the data collected through interviews will be organized to arrive at some sort of an understanding of the field. The data collected will be analysed to develop a comprehensive review of the health communication activities under-taken in Aligarh,U.P.Further on both these campaigns will be developed as cases to be compared and analysed. Finally underlying factors and insights will be generated to fulfil the research objectives.
Aligarh: An introduction
Aligarh district located in Uttar Pradesh, has a population of around 8 million. Main industries are brassware and cottage industries. Aligarh Muslim University is the centre for higher education in Uttar Pradesh. This attracts a lot of migrants and students to the city. The population of the congested urban city is 3.5 million, with around 500,000 slum dwellers.
Countless slum areas have cropped up in the city and have become home of these migrants. These areas have no sanitation services, waste disposal or sewerage cleaning services.
Due to this reason Aligarh is a ripe bed for diseases and illness. Main issues are child and family healthcare, tuberculosis, Polio and HIV/Aids.
High Risk areas in Aligarh include Masal Gunj,Rafala ,Shahjamal ,Bhais wali gali. These areas are mainly slums pockets, inhabited by daily wage earners. Literacy levels and concern for health is low in these areas. These areas are pre-dominantly dominated by the marginalised Muslim community of Aligarh.
Another high risk area is near Majhaar gate in Aligarh where prostitution flourishes. Migrant population has boosted the sex industry in Aligarh. Moreover its proximity to the Delhi highway attracts a lot of truck drivers to the sex workers of this area. These sex workers are low on resources and hold little knowledge or bargaining power leading to high risk behaviour towards sexually transmitted diseases and Infections,HIV and Aids.
Health Infrastructure in Aligarh:
Government health care infrastructure constitutes two general government hospitals Dindayal Hospital and Mohanlal Gautam Hospital.Malkhan District Mahila hospital is a Female and Child healthcare hospital. Another center of healthcare in Aligarh is Aligarh Medical College's Jawahar Lal medical college. Main healthcare staff includes chief medical officers, specialists and senior consultants. These are aided by auxiliary nurse and mid-wife or ANMs .A team of medical field officers are appointed for door to door administration of health services in urban as well as surrounding rural areas.
Polio Case Load ALIGARH :( BASED on an Interview of Dr Rahul Kulshestra - (District medical officer))
Over the past year 8 cases of Polio Type one virus and 15 cases of Type three virus were reported in the district. The conversion rate of X,R houses(Houses where inhabitants had left or children were not at home) to P houses(were polio drops were administered) was 32% which is a significant improvement over 44% last year.
Immunization rounds in the month of December resulted in an 88% coverage of urban and rural households which was a significant improvement over an average 74% coverage being achieved (Including rural areas of the district and mobile population).
This improvement can be attributed to an aggressive attempt to fully eradicate polio under the aegis of UNICEF, WHO and Ministry of Health and Welfare India.
HIV/Aids Case Load :( Based on an interview of doctor Abdul Gaffar Integrated counselling and Testing center, ICTC head, ALIGARH Medical College)
Uttar Pradesh is considered a low risk state with a below 5% prevalence in high risk groups and 1% under general population. However severe underreporting of positive cases and high risk factors like low literacy, slums dwellers, mobile population and prostitution makes it a highly vulnerable state.
The number of HIV positive cases reported in Aligarh increasing. In 2003 there were three reported cases while in 2008 a confirmed number of 120 were reported. However experts indicate that there are more positive cases among the population who don't come for voluntary testing due to fear, stigma or neglect.
Other target groups include Men who have sex with men, Intravenous drug users and sex workers. Data on these groups was not available mainly due to less focus in these target groups.
Overview of the Polio Campaign in Aligarh:
Polio Education and Immunization CAMPAIGN ((based on interviews Dr Rahul Kulshestra (district Medical OFFICER) AND MR. Rajesh GUPTA (Nodal officer in Aligarh)
Polio Education and Immunization Campaign is the most aggressive campaign run in Aligarh. In effectively utilizes mass media as well as human channel. Polio immunization is conducted every month and campaigning is done to create awareness about importance of polio drops and dates of pulse polio drive.
This campaign is run under the direct administration of the District Magistrate of Aligarh.Main officials involved are the District Medical Officer, the nodal officers, the community health care (CHC) officers and primary health care (PHC) officers. This campaign is also supported by an extensive network of field officers, volunteers and informers. The main agencies involved are the State ministry of Health, UNESCO and the rotary club of india
Use of Mass Media:
Television And Radio:
Information in forms of Ads and Tickers are run on local channel like City Cable at least ten days before the stipulated dates. Similarly All India Radio is used to target the rural areas. The message aired is simple and it informs about the date of the upcoming polio immunization dates and the location of booths.
Even though there is no media cell, yet during the days of National Immunization days (NID), the papers are filled with filled with articles about Polio immunization. This happens because the polio immunization rallies get a lot of coverage from local news papers, due to the presence of politicians and officials in the rally which attract a lot of crowd. However no press releases are sent by the government. Journalists normally get the data and statistics from the office of District Magistrate.
Use of Traditional Media
Posters are visible throughout the city and near the hospital areas. Use of Cricketers has been done to attract attention and provide credibility. These posters seem to be new has they are talking about the upcoming date of the polio drive. Officials confirmed that these posters are provided regularly to them to be put up before every polio drive.The hugely popular slogan"Do boond zindagi ke Pilaye har baar "is clearly visible.
Similary banners are put up,wich seem to be targeting Muslim community.Use of Urdu is visible.The banners are locally made by the district hospital administration.
Huge rallies are taken out to create awareness about polio. Important politicians and famous personalities of the town as well as head medical officers come to inaugurate these rallys.
Slogans like "Haay Haay Polio", "Do boond Zindagi ke" and "Hum polio mita ke rahenge "are chanted.These rallies are organized to create a sense of excitement about the upcoming polio immunization dates and urge people to come to the appointed booths.
The ralleys start at the main circle of the city and cover all the major areas of Aligarh.The ralley is preceded by speeches where the district medical officer addresses the crowd and urges people to help eradicate polio from their lives.
Overview of HIV /Aids Campaign in Aligarh:
The HIV Aids Campaign in ALIGARH (Based on an interview of Professor Abdul Gaffar Integrated counselling and Testisting center, ICTC head, ALIGARH Medical College)
The HIV/AIDS campaign in Aligarh is under the direct control of the Union ministry of Health and Family welfare. It is assisted on a district level by the district magistrate. However the main onus lies on the HIV Aids integrated counseling and testing division of the Aligarh Medical college. The Vice Chancellor of AMU is actively involved in HIV/Aids campaigning. An important component of HIV/Aids campaigning is the work counselors and local NGO's inclusing social workers. The main agencies involved are Union Ministry of Health and Family welfare and National Aids Control Organization (NACO).
Use of Mass Media
A joint effort of Development communication division, Union Ministry of Health and Family Welfare and Doordarshan resulted in an education-entertainment program called "Kalyani".It is broadcasted in nine states of India including Uttar Pradesh.
It's broadcasted at 8 pm on Saturday and Sundays. The content includes giving information on family health issues including HIV Aids and Tuberculosis. The information content is weaved into the story line to make it interesting and appealing.
According to counselors this program is highly popular in Aligarh and helps in spreading awareness about HIV and Aids.
Use of Print Media
Occasionally articles appear in local newspapers like Umar Ujala and Dainik Jagran giving information about HIV- Aids and the testing centers.
"Paper mein article nikalte hain kabhi kabhi..Abhi national aids day par Umar Ujala mein article nikala tha. Kuch log article pad kar khud testing karwane aaye ,paper mein article padne se logon ko lagta hain ke mere jaise aur bhi log hain, mein bimaari se marna nahi chahta..mujhe kuch karna chahiye."- Ms Nirmala Shankar the HIV counsellor at the Aligarh Government Deen Dayal District Hospital
Use of Traditional Channel
Hoardings have been put up in high visibility areas of the city like bus-stops, shopping centers as well as the hospitals. It was observed that most of these posters were old and were in a damaged condition.
Various posters giving information about transmission and prevention of the disease are put up on walls, and distributed in the hospitals, medical college. To target mobile population posters are also put on city centre crossing as well as truck and bus stops.
Another point of contact is the Tuberculosis testing center. Since HIV positive people have a higher risk of contracting tuberculosis ,HIV information and referrals are conducted there.
Videos have been made by Union Ministry of Health and Family Welfare and NACO to be broadcasted in Hospitals. Government has provided TV and Video players in the main hospitals of Aligarh where HIV counseling and testing is done. In Aligarh the hospitals have been provided with two videos namely"Aap HIV ke saath Je sakte hain" which narrates true stories of HIV positive people and how they have learnt to cope with their positive status and "Josh mein Hosh" which promotes condom usage.
However it was observed that these video playing facilities were in not in working conditions or they were not utilized properly.
When asked to demonstrate a video playback the counselor said that the TV has not been working since past three months as rats had nibbled on the cables. Even when the compound is full and she feels that the videos can be used to give information she feels helpless as she doesn't have the necessary facilities.
Even though pamphlets are available in hospitals they are distributed rarely in the city. According to hospital staff these pamphlets are good in content but due to limited availability they are not able to distribute them freely
According to experts the most important aspect of HIV-Aids education is counseling. Counseling in this field includes handling general clients, mobile population and Antenatal care.
Anyone who suspects STD infections or HIV can walk in get proper counseling done by trained experts. The meetings are confidential and trust between the counselor and the patient is of prime importance.
These counselors work in the VRT, PPCTC and ART centers based in the government general hospitals, female health hospital and the medical college of Aligarh.
Work of local NGO-The Udaan Society
Udaan society is a non-government organization with its head quarters in Aligarh itself. The society specializes in supporting government programs like HIV/Aids campaigning, focusing on community outreach activities. The NGO organizes awareness camps, street plays , group meeting and counseling activities with emphasis on dissemination of knowledge about health services, health and legal rights, and social awareness about Aids. The goal of the NGO is to create a social and behavior change towards HIV positive people, improve living conditions and create empathy towards HIV positive people . The society also focuses on counseling dissemination of health education about HIV/aids to high risk groups like men who have sex with men (MSM), prostitutes, moblile population (truckers)and injecting drug users(IDU).
The Udaan society gets funding from the state health department to carry out its field activities in Aligarh and surrounding rural areas.Infact this NGO has been the main touch point with the high risk groups of Aligarh.
The society operates on the principle of becoming friends and counselors of these high risk groups. The trust and credibility enjoyed by the social workers is much more than the government field officers. This is the reason that the government and the NGO work in close co-operation for HIV/Aids campaigning in Aligarh.
In fact a lot of IEC material distributed in the hospitals is conceptualized and created by the Udaan Socitey.These materials include pamphlets and booklets printed in the local language Hindi.
Evaluation of the Campaigns:
To evaluate the effect of the health communication efforts one of the methods used were beneficiary interviews. The key areas of investigation attempted to understand the awareness and knowledge about the diseases, the kind of media used to get that knowledge and if the communication has led to any behavior change.
Evaluation of the Polio Health communication campaign:
The overall awareness level of Polio is very high. All the beneficiary respondents had heard about the disease polio. When asked about what have they heard about polio the beneficiaries responded with remarks like "Pairon ki bimaari hai,pair kharaab ho jaate hain"(it's a disease of the legs ,where the legs stop working"),"Teeka na lage to ,pairon se jaan nikal jaati hai"(if vaccination is not done the legs become lifeless) and "sharer mein kamzoori ki wajah se pair chalne band ho jaate hain"(due to some deficiencies in the body the legs stop working) ,"Polio aisi buri bimaari hai ki agar ek baar lag jaaye to haath pair katne padte hain"(Polio is such a bad disease that once you contract it the limbs have to be amputated).
Only 26% of the respondents had knowledge that the disease affects the limbs. Most the description invariably left out some of the aspects of the disease. For instance most of the respondents failed to include that the disease affects children less than five years of age.
This indicates that even though the respondents have heard about the disease from various sources yet they do not fully understand the effects of the disease. The communication has been heard but it's not comprehensive enough for a full understanding to the general population.
Human Channel like propaganda efforts through rally's, loudspeaker announcements and door to door polio immunization workers were cited as their source of information by 76% of the respondents.
"Loudspeaker par announce karte hain hamri colony mein wahin suna tha"(Have heard through the loudspeaker announcements made in my colony)-Male respondent, Age 34
Woh polio pilane ke liye ghar ghar log aate hain na unhi ne bataya tha.Booth par bhi log baithte hain woh bat ate hain (Door to Door Polio immunization workers told me)-Female respondent, Age 33
The second most effective medium which emerged was Radio. Around 63% of the respondents remembered hearing information about polio or upcoming polio immunization dates on Radio.
Others had seen Posters (53%) in and around their colonies, booths and railways stations. TV emerged as another medium .Around 28% of them remembered seeing polio information programs.
Only 8 % of the respondents cited newspapers as their source of information.
"Haan woh TV mein Dikhate the na Amitabh Bacchan aur Shahrukh Khan Polio ke bare mein baat karte the "(There was a program on TV with Amitabh Bacchan and Shahrukh Khan)"-Female respondent, Age 35
"Raveena Tandon ka koi program aata tha TV par waheen suna tha"(I heard it on a program on television where Raveen Tandon spoke about Polio)-Male respondent, Age 40
Most of the respondents said that they had heard about polio from more than one media. The pulse polio communication program has managed to create multiple touch points with the beneficiaries the most aggressive being the human channel in terms of the propaganda vehicles and mass mobilization vehicles utilized .
Knowledge about the disease:
How does Polio occur/spread?
"Pata nahin kyun hoti hai,sharer min kamzoori ho jaye to ho jaati hogi"(That i don't know,maybe if the body is too weak polio happens)-Male respondent ,Age 21
"Ab yeh to pata nahi, kharab khane peene se, gandi jagah rahne se hota hai"(Maybe it is caused by living in unhygienic places)- Female respondent, Age 36
"Bacche ko vaccination na lagao to phalta hai"(if the child is not vaccinated then he can spread polio)- Male respondent,Age 33
"Polio phalta nahi hai,yeh to bachpan ki bimaari hai, insaan nasseb mein likha lar aata hai ki usse polio hoga ,shayad gharbh ke dauran kuch kamee ke karan hota ho"-(Polio doesn't spread ,maybe it's a congenital disease caused due to deficiencies during pregnancy.
More than 80% of the respondents didn't know what the reasons for the occurrence of the disease are and how it spreads. This means that there is an essential gap in the communication message being communicated and hence understood by the respondents. Understanding that Polio is a highly communicable disease is an instrumental aspect of Polio Health communication and this doesn't seem to be understood clearly by the general population.
Why repeated immunization is necessary.
Only 53% of the respondents could explain that until every child is immunized the rounds will have to be repeated.
"pata nahin itni baar kyun pilate hain, humein to bataya tha ki ek baar pilal to baccha kabhi polio nahi khayega,kya galat dawai pilate hain,ya dawai asardaar nahi hai"(i don't know why repeated doses are necessary , we were told that once the child is vaccinated he is safe, is the vaccine incorrect or is it not working)"-Female respondent ,Age 36
"Shayad baccha jaise jaise bada hota hai use lagatar dawai pilani badti hai..aakhir baccha bhi to bad raha hai"(Since the child is developing maybe he needs regular vaccination)-Male respondent, Age 30
Hence it's clear that there is a gap in terms of details of the disease, why it's transmitted and why frequent immunization is necessary. Either this message has not being communicated clearly or is absent from the Polio Health Communication campaign being run.
Understanding if Communication has led to any behavior change:
Do they take the child for all the immunization rounds?
Around 93% of the respondents take the child regularly for Polio immunization rounds.
"Bade logon ne kahan tha ki polio ki dawai baar baar pilani ki zaroorat nahi hai,isi liye nahi pilwayi thi ek baar, ek baar pilana kaafi hota hai"(elders had said that there is no need to give vaccination again and again, vaccinating the child once is enough that's why i didn't take him to the booth)-Female respondent ,Age 32
Some respondents commented that even though they did not take the child to the booth due to lack of money or time when the door to door immunization rounds were conducted they got the child vaccinated.
Do they want to know more about Polio?
Almost 80% of the respondents said that they are willing to learn more about polio and why repeated immunization is necessary. Main reasons were concern for their child.
"Haan haemin pata to hona chahiye,agar bimaari phelti hai to hamare bacche ko na ho jaaye, agar mujhe pata ho ki kuch khilane se ya kuch bachaav karne se baccha surakshit rehega to mein zaroor karungi"(yes I would like to know more about Polio,if i know then i will be able to protect my child ,maybe some proper diet or precautions will protect my child)-Female,Age 26
Overall the Polio campaign seems to have generated a high level of awareness with positive intent for more information seeking behavior. The actionable behavior change is also observed to be high as even though the there is lack of information about the need of monthly immunization the beneficiaries seem to recognize it as a necessary health immunization activity.
Evaluation of health communication program regarding HIV/Aids
The awareness level of HIV/Aids is medium to low. Only 57% of the respondents said that they had heard about HIV/Aids .Even if they were aware there was a significant lack of knowledge as to what the disease it. A marked discomfort in tone and composure of the respondent was also observed while talking about HIV/Aids.
"Jaanlewa bimaari hai..jo log apni biwi ko chod kar doosri aurtoon ke paas jaate hain unhe hoti hai"-(It's a life threatening disease ,people who have extra- marital sex get infected by it)-Female respondent ,Age 25
"HIV/Aids to raakshas hai jo insaan ko kha jaata hai..jo ek baar ho jaaye to aadmi khatam.Jeene ka koi matlab nahi."(HIV/Aids is like a monster which eats up the person, once you get HIV/Aids there is no point in living)-Male respondent, Age 36
None of the respondents could define the disease as which attacks the immune system.
Awareness about HIV aids was skewed in favor of males between both the sexes. Female respondents were less aware and also less willing to talk about it. Of the people who said that they had not heard about HIV Aids 80% were women.
"Jee suna to hai HIV aids ke bare mein ,magar hemein jyaada pata nahi..hamare aadmi to hain nahin isliye haemin samjhne ki kya zarrorat hai"(yes I have heard about HIV-Aids but since I don't have a husband ,I don't need to know much about it)-Female, Age 19
Only 16% knew the difference between HIV and Aids. Most of them considered them to be the name of the same disease.
"Je eek hi baat hai,doctor log HIV kehte hain aur hum log Aids"-(Its one and the same thing doctors call it HIV while we call it Aids)-Male respondent, Age 40
"HIV to keetadun ka naam hai,jab insaan ko ho jaati hai to Aids kehte hain"-(HIV is the name of the germs/virus ,when the disease occurs in the human body it's is called Aids)-Male respondent ,Age 34
Human Channel emerges as the main source of information about HIV-Aids.76% of the respondents had heard about it through counsellors or NGO workers.
58% of them had their knowledge about HIV Aids through pamphlets and posters which have been distributed to them. Around 52% had seen program about HIV Aids on TV.
"Jee Hiv Aids ke bare mein Tv par suna hai, woh doordarshan par Kalyani karke program aata haina usi mein suna tha. Woh bahut acche se batate hai,har shukrawar aur shaniwar ko sham mein aata hai.Hum sab dekhte hain"- "(I have heard about Aids on television through a program called Kalyani.They tell about it in a very interesting way. All of us watch it every Saturday and Sunday.)-Female respondent, Age 22
Around 29% had read about Aids in local news-paper.(This can however be skewed on account of recency of exposure as recently articles had been published in the newspaper about Aids ,due to National Aids day in December. This result may not be the same if perhaps the interviews were taken during some other month when articles do not appear regularly)
Use of Radio as a communication medium was missing from the HIV/Aids communication program in Aligarh
Knowledge about the Disease
How does the disease spread?
Most of the respondents, around 88% identified sexual activity as the reason for the spread of the disease. However it was observed that the understanding was that people get Aids due to extramarital affairs, having multiple partners or indulging in sex with prostitutes. Only 32 % of the respondents could identify unprotected sex as the cause of HIV virus transmission
A significant number respondents (15%) indicated misconceptions about the spread of the disease.
"Agar kisi ko HIV Aids hai to uske saath rahne se,khane peene se Aids phal sakta hai"(If someone has HIV aids then it can spread to people living around them.)-Male respondent Age 44
"Galat kam, jaise bahut aurtoon se sambandh banana se,Aids phailta hai,Kharaab khun chad jaye to bhi ho sakta hai,shayad HIV jhuta khane se bhi hota hai"(Aids is spread due sexual contact with a number of women,infected blood and perhaps infected food)-Female Respondent ,Age 39
"Shaadi se pehle yaun sambandh banana se aids ho jaata hai"(Aids happen if you have sex before marriage)-Female respondent, Age 22
28 % of the respondents identified blood transfusion as another cause of HIV spread. Some of these included respondents who said that infected needles can spread the disease. Around 12% said that the disease can also spread from mother to child.
Homosexual sex and spread due to Injecting drug users were not identified by any respondents as the cause of spread of the disease.
Understanding if Communication has led to any behavior change:
Behavior towards HIV Testing:
86% of respondents knew where HIV testing is done. In response to whether anyone has got HIV testing done 73% of the respondents said that they have never got it done.
Reasons like "meri aadatein kharaab nahi hai,isliye kabhi zarooorat nahi padee"(i don't have bad habits that's why i don't need to get it done)-Male ,Age 32
No substantial reason was given as to why they have never got testing done. Mostly the reason was denial or extreme faith that the disease cannot happen to them.
"aisi bimaarian Hamare ilaake mein nahin hoti,hum to shareef log hain"-(These diseases don't happen in our locality, we are very simple people)-Female, Age 36
It's surprising that married women with children said that they have not got HIV testing done. Either they were not aware that these tests are being conducted before delivery or they have had delivery at quacks or unauthorized clinics, which fail to conduct these tests before delivery.
46% of married male respondents said that they use a condom regularly.66% of unmarried men said that they used a condom regularly. However only 33% of female respondents said that they use a condom. In fact the women were hesitant to talk about this topic. This question evoked a visible feeling of discomfort among the respondents. The answers to this question can be biased as it was observed that respondents were giving non-committed answers.
"Haan Nirodh istmaal to karta hun,matlab mujhe pata hai karna chahiye,vaise hum to ghar parivar waale log hain haemin nirodh ki itni kya zarroorat"(yes I do use condoms ,I know we should use them but we are family men we don't really don't need to use condoms all the time),Male Respondent ,Age 40
Attitude towards HIV+ People:
"haemin pata hai ki jin logon ko aids hain woh achoot nahi hain,unse darna nahi chahiye magar darr to lagta hai..log kehte hai ki baat cheet karne se aids nahi failta magar agar humein ho gaya to..kal ko pata chala ki Aids aise bhi phailne laga hai to hum to museebat mein pad jaayenge"-(I know that people with Aids are not untouchable, but still I feel afraid, we are told that Aids doesn't spread just by meeting and talking to the person but what if I find out later that it is spread like this also. I will be in trouble then)-Male Respondent, Age 40
86% of the respondents said they will be willing to shake hands with a person with Aids. Only 53%respondents agreed that they will be willing to eat food with a HIV positive person. 40%respondents would be ready to share toilets with a HIV positive person.
This indicates that the information conveyed about the modes of HIV transmission is very limited or is not received by the target audience. These misconceptions lead to negative attitude towards people living with HIV and Aids. The efforts of the campaign to create positive social awareness about the disease seem to be lacking in its affect.
Findings: FACTORS affecting the Health Communication Programs:
An analysis based on and Beneficiary Interviews and Expert Interviews OF:
- Dr Rahul Kulshestra - District medical officer
- Mr. Rajesh Gupta -Nodal Officer,Aligarh
- Mr Kamal Gupta-Auditor and Controller for Pulse Polio Drive Aligarh
- Mr Rajeev Singh-Field Level Officer, Aligarh
- Mr.Khaled Rizwan- Field Level Officer, Aligarh
The Polio Health Communication Campaign:
Social and Cultural Factors: Community beliefs- Leading to resistance and avoidance
"Majar Gunj mein muslim abadi rehti hai..hamare liye woh problem area hai. Ghar Ghar ja kar OPV drops detein hain magar kuch galat dhadnaon ke chalte woh drops lena nahin chahte"(Mazjar Gunj a muslim inhabitant area is a critical area for OPV administration. lot of misconception leads to people resisting the administration of the vaccine)- Kamal Gupta,Auditor and Controller for Pulse Polio Drive Aligarh.
Resistance to any drug treatment can be influenced due to one's own religious or community beliefs. Post 1999 the routine polio immunization program started very aggressively, however due to lack of proper information a lot of hearsay about the side-effects of the vaccine started. Even though today there is a high awareness level about Polio and the fact that it's preventable, yet there is resistance from Muslim community in Aligarh.
"Maulvi ne bola tha ke polio drops pilane se baccha beemaar ho jayega.Isiliye mein booth nahin le ke gayi"(The Muslim Cleric said that polio drops make the child sick that's why i didn't take him to the polio booth)- Muslim female respondent, Age 34
"Muhalle mein log kehte to hain ki zabardasti humein polio drops kyun pilayee jaati hain.Hamaari aabadi itni zyada bad gayi hai to us ko kaboon mein rakhnein ke liye"?(People in my colony do comment that since our population is increasing the government wants to control it by giving these drops) -Muslim male respondent,Age 30
"Polio Drop pilane se ek hi baccha hota hai, ya nahi hota."-(Polio drops make the child sterile or he has only one child.)-Muslim male respondent, Age 40
The Experts are of the opinion that even though this resistance is reducing yet critical areas never reach hundred percent immunizations with ease.
"Mein do ghantein tak darwaze ke bahar intezaar karta raha..Ghar mein baccho ko chuppa diya aur bola ke hamare bacche nahin hain.."(I waited for two hours to administer a dose, and the family hid the children"- Field Officer, Pulse Polio
"Kabhi Kabhi to bahut pareshani hoti hai, ya to woh baccho ko chuppa dete hain, ya bol dete hain ki Hamare bacche paanch saal se jyaada ke hain.Puri ki Puri colony kabhi kabhi vaccinate nahin ho pati hai..Saamne se ab koi nahin bolta ki drop nahin leni , magar unhe ab bhi dawai per shak hai"-(They cause a lot of problems, sometimes the whole colony is not immunized because everyone makes excuses that the child is not at home.Even though no one says it aloud now but the reason is still that they think that the vaccine will sterilize the child)- Field Officer ,Pulse Polio
According to the Officer in Charge of District Task force of Polio Drives, the fear in the Muslim community that these drops will make the child infertile is reducing. Some of the people who actually want to take these medicines are threatened by the Muslim community that they will be denied access to the village resources. This problem is compounded by the fact that the field officers are the same who also supply family planning healthcare to those areas.
Moreover this is the most visible program in the Family health program, which makes them suspicious of its motive.
Polio communication program has to fight a lot of these misconceptions raised over years of rumors like different type polio medicines being given to Hindus and Muslims, and that it's an attack of Hindus on Muslim.
Social Mobilization efforts like including the Muslim University and other educational and religious institutes have been roped in to develop a network of grass root level advocacy and outreach program. Advocacy efforts to include Muslim opinion leaders talk about the safety of the medicine have been undertaken.
Campaign Specific Factors: FATIGUE and Lack of Information
According to experts the frequency and repetititive nature of the Polio drive, people are developing a sense of fatigue from the system. The field level functionaries are forced to deliver 100% door to door immunization, while encountering resistance.
"logon ko samajh nahi aata hai ki virus badal raha hai..isliye type one or type two vaccine pilani zaroori hai.Gaon mein log sochte hain ki e kya do baar vaccine pilane se baccha surakshit ho gaya.Magar bimari aise nahi khatam hogi.Har mahine naye cases report hotein hain, aur jab tak naye cases report hongein har paanch saal tak ke bacche ko dawai pilana zaroori hai."(People don't understand that till every child is immunised the disease will not be eradicated ,they feel if their child has been immunised once their job is done)-Dr, Rahul Kulsheshtra, District Medical officer, Aligarh
"Mein logon ko samjahane ke koshish karta hun ,magar woh mante nahi hain.Kah dete hain mere bacche ko polio ki drop mil chuki hai,ab mere paas time nahi booth par aane ka"(I try and convince people to get their children to the booth ,but they are reluctant as to come again and again citing lack of time)
" Kuch log to saaf mana kar dete hain kehte hain ,Har Mahine Bees rupees kharch karke booth nahi aa sakte,itne paise nahin hain Hamare pass"(They say they can't spend twenty rupees every month to get their children to the booth.) -Field Level Officer,Pulse Polio
Beneficiary interviews also revealed a lack of knowledge of cause of Polio spread and the importance of regular immunization of every child.
"Polio kharab khane peene se hota hai" (Polio happens due to bad food consumption)-Female respondent, Age 25
"Jab Baccha ko khane se shakti nahin milti aur sharer kamzor ho jata hai to Polio ho jata hai"-(The child gets polio when he doesn't get enough strength from food)-Women Respondent, Age 33
"Vaccine baar baar pilane ki kya zaroorat hai yeh to pata nahi,haemin to yahi bataya gaya tha ki ek baar pilane se bimaari nahi hoti, to baar baar pilane ki kaya zaroorat" (Whats the use of getting vaccination done again and again , we were told getting it done once is enough,so what's the point of asking us again and again)-Male Respondent ,Age 44
"Mere bacche ko dawai acchi nahi lagti, woh rota hai,har mahine dawai peyega to bimaar nahi ho jayega"(My kid doesn't like taking the medicine again and again ,he cries, wont he get sick if he takes it every month)-Female Respondent, Age 33
An analysis of the IEC material distributed and the posters and banners put up also indicate that the message itself doesn't contain any information on areas like why polio occurs, why repeat immunization is necessary etc.The focus seems to be only on the communication of the polio drive dates. Although the IEC material is plenty yet it is lacking in addressing these issues which are affecting the outcome of the polio health communication campaign
MISTRUST and Use of Force
Hum door to door polio pilane jaate hain to log darwaze band kar lete hain. Ek baar haemin kuch logon ne ek gali mein jaane se maana kar diya tha.Ghar ke mard hamara rasta rokne ko aagaye the. Isliye humne police bulwali.kabhi kabhi police ko to bulana padta hai ,warna log mante nahin hain.Us din colony ki electricity kaat di thi,taki log gharon se bahar aaye.( Once during door to door administration of polio drops some men blocked our way from entering a colony, we had to call police force.That day we cut the electricity of the colony so that people come out of their rooms)-Sneha Devi,Aasha Volunteer and Field Officer.
Upon probing it was found out that earlier force and coercion were employed by the health officials to meet the elusive targets of Polio immunization. This coupled with rude behavior of health officials has resulted in a lot of mistrust and hostility towards field officers.
This hostility has now reduced over time due to systematic efforts like employing same community field officers, training towards better persuasion techniques and use of same field officers for other routine health checkups. However the angst of these incidents still remains and causes a strong lack of credibility in the message being communicated by these officers.
Resources and Monetary incentives: BASED on an interview with Dr Rahul Kulshestra District medical officer, Aligarh
Polio Immunization program is the most efficiently and aggressively run health communication and service campaign run in Aligarh. The funding and resources for the campaign are allotted directly by Uttar Pradesh Health Care Ministry, and the reporting is done directly to them, along with a close association with UNESCO.
Eradication of Polio from India especially from Uttar Pradesh and Bihar is one of the millennium development goals for the Ministry of Health and Family welfare.
Hence the resources available for the program are abundant. Approximately 35 lakh Rs are allocated to every round of Polio immunization, which happens on a monthly basis. Funds are utilized to create new banners, posters and conduct mass mobilization programs like rallies.
Moreover volunteer field officers are engaged for door to door counseling. These officers are paid 75 Rs over and above their stipulated salaries for polio counseling. According to a field officer sometimes monetary incentives are also given to beneficiaries to come to the booth. These range from 10 Rs to 20 Rs.
Strong administrative and political support like this has resulted in an effective Polio campaign. An hundred percent coverage of all the households of Aligarh district is achieved in every immunization round.
Goal driven procedural efficiency:
Polio Program in Aligarh is extremely goal driven .A house map is made for every area and marking is done for every house where immunization is done and where it is needed. In case there is resistance or families are not able to be contacted, a network of informers is used to target these mobile families. These informers are trained to develop contacts with resistant communities and persuade them about Polio immunization. Reports about the progress are made every day under the DMO and Auditor and the programs are evaluated. Team A and Team B district task force is formulated consisting of field officers which administer door to door immunization. Finally all reporting is done toLucknow and extreme importance is given to meetings the goals charted out for every immunization rounds.
This kind of procedural efficiency ensures a straight line of command, high level of motivation and overall high effectiveness of Polio education as well as delivery of service.
The HIV/Aids Health Communication Campaign:
An analysis based on and Beneficiary Interviews and Expert Interviews OF:
- Dr Kavita Gaur-CMS, Female general Hospital
- Ms Namrata Kumar- HIV/Aids Counsellor Voluntary Testing Center,Deen Dayal Hospital
- Ms Harsha Saxena- HIV/Aids counselor PPCTC Center, Female Hospital
- Dr Abdul Gaffar -Head Integrated Counselling and Testing Center,ICTC, Aligarh Muslim University
- Ms Sneha Devi -Field Officer and Aasha voluteer
Social and Cultural Factors: Stigma and Denial
Stigma is perhaps the biggest factor which affects the effectiveness of HIV/Aids campaign. It stems from the assumption that contracting HIV/Aids is a result of mistakes of the PLHA, and he is looked down upon by his community members. Moreover the problem is compounded as cases of stigma and discrimination are reported on a daily basis and any overt act of stigma dramatically increases the perception about stigma.
The main reasons why stigma is so strong against HIV/Aids is because the disease is firstly considered to be highly lethal and dangerous and secondly it is supposed to be the responsibility and mistake of the patient.
The health communication program of HIV Aids attempts to inform the community about these issues and the social campaign attempts to reduce this stigma and create empathy towards Aids patients. However strong social and cultural beliefs and fear of the disease have been hampering the behavior change the program wishes to achieve.
HIV+ logon ka asar bas patient par nahi magar uski puri family par padta hai,hamara yahaan hi kitne cases huen hai jab log hiv ka test nahi karwate, kyunki unhe darr lagta hai ki log kya sochein gein,Hamare ek patient ko abhi Aids diagnose hua tha.Pata nahi kaise par us patient ke bacche ke school mein pata chal gaya ki uske pita ko Aids hai..school to kuch nahi kar sakta tha magar logon ne use utna kharaab bola ki uska us school mein jaana mushkil ho gaya..bacchon ke maa ne bola ki usse baat mar karo. Logon ko pata nahi hai Aids kaise phelta hai, isliye us bacche ke saath aisa vyavahar kiya.Abhi mujhe kuch dino pata chala hai ki us bache ne school chod diya hai..Hum logon ke samjhate hain ki aisa nahi karna chahiye magar,Aids bimaari hi aisi hai..log bahut darte hain.."-(Fear of Aids is so strong that its effect is felt not only on the patient but on his entire family, one of my patients was diagnosed with Aids. The child of that patient was in a school where somehow people found out that his father has Aids. After that the children misbehaved with him so badly that his life became very difficult. The mothers told their kids not to speak to the child. Finally I heard he has left the school.)- Ms Namrata Kumar- HIV/Aids Counsellor Voluntary Testing Center,Deen Dayal Hospital
"Ek Aids grasit aadmi ko ghar se nikal diya.. uski tabiyat itni kharaab thi,woh apna khayal nahi rakh sakta tha magar uski family ne us par taras nahi khaya,socha uske bure kamoon ki saza woh kyo kate.Hamien use hospital mein admit karna pada"-(One Aids patient was thrown out of his house,he was was very sick and couldn't take care of himself, yet the family showed no sympathy. They tend to think that he is sick because of his wrong doings and why should the family suffer because of that. Finally we had to admit him in the hospital)- Dr Kavita Gaur-CMS, Female general Hospital,
This strong stigma prevents social dialogue and information dissemination. The patients are fearful of getting HIV testing done and seeking medical help. The families are discriminated against and they blame the patient making it a complex social cycle, with to respite to the patient. The communication program suffers because people don't seek information or are not receptive when it is imparted. This is especially high among female population where other social factors add to the problem. These are position of women and low literacy factors. People do not talk about safe sex practices and condom usage, leading to a lack of information about risk factors as well as legal rights.
Another factor which emerged was denial that Aids is a disease which is foreign and affects only high risk groups and not the general population. The beneficiary interviews revealed that the people believe that Aids cannot happen to them because they do not engage in sex with multiple partners or take service from prostitutes. The knowledge about other methods of Aids transmission is minimal and this puts the beneficiaries in a highly vulnerable state.
"Log to yahi sochte hain ki Aids prostitutes ke paas jaane se hua hai..family samajhna hi nahi chahti ki koi aur wajah bhi ho sakti hai..Hum family counselling mein batate hain ki yahi ek wajah nahi hai,inflected blood,needles se bhi ho sakta hai magar log nahi mante"-(People think that Aids happen due to sex with prostitutes, the family refuses to understand that it can happen due to other reasons also. Even during family counseling we try and explain that it can happen due to infected blood transfusion or infected needles, but people don't accept that)- Ms Harsha Saxena- HIV/Aids counselor PPCTC Center, Female Hospital
This factor affects the campaign in a way that it hampers active information seeking behavior and increases the risk of general population. If the beneficiaries do not perceive Aids to be a problem that can concern them the objective of the campaign is definitely not being met.
Poor social and economic conditions of High Risk groups: Dejection and Helplessness
"Sex workers ko samjahana bahut muskhkil hai,utnki apni problems hai. Abhi ek case hua tha Hamare PPCTC center mein,ek sex worker pregnancy abort karwane aayi thi,to uska test HIV positive nikala. Hamne use samjhaya ki woh kitne logon ko risk mein daal rahi hai,magar uska kehana tha ki agar who yeh kam nahi karegi to paisa kaise kamayegi. Uske dewar ne use yahaan kam mein laga diya tha,jab uspar kissi ne taras nahi khaya to who kyun logon par taras khaye.Woh to sabko Aids phelayegi."(It's difficult to make the sex workers understand about safe sex practices and risky sexual behavior. They have their own problems.Some days ago a sex worker has come to our clinic for an abortion. She was tested HIV positive. We tried to convince her that's she is putting a lot of people at risk by continuing. But if she doesn't do that she has no means to earn a livelihood.Infact she was so dejected that she said that no one cared when she was put into prostitution. Her family herself forced her into this, now she will spread the disease to everyone."- Dr Kavita Gaur-CMS, Female general Hospital
Counsellors who work with sex workers reported that condoms are provided free of cost to brothels in Aligarh. However their usage remains a question. Even though the sex workers now know the risk of unprotected sex with clients, yet their economic and social conditions deter them from practicing them. In fact it is perceived that a sex worker who enforces a client to use condoms is delivering a lesser "service". Normal charges are Rs 35 to Rs 40 per service which reduces to Rs 10 to Rs 15 if the client uses a condom. A major cut of this goes to the brothel owner and the pimp and the sex worker is not left with any choice to negotiate condom usage.
Hence HIV/ Aids communication and behavior change becomes a complex social problem. Awareness and even desire to action doesn't necessarily lead to action because of poor economic and social position.
Similarly the Injecting Drug Users are so dependent on drugs that communicating to them becomes a problem. Even if the volunteers try and convince them not to share needles, their economic condition does not allow them to buy new ones hence they end up sharing infected needles.
"Drug users ko naukri to milti hai nahi, ghar se nikaal diye jaate hain, aakhir kuch chota mota kam kartein hain,jaise kuda beenana,Usmein unhe syringes mil jaatein hai, kuch dus rupess jaise hi ekhatta hotein hain,vaise hi drugs khareed ke jaldi se laga lete hain. Who groups mein hi drug use kartein hain, aur needles hare karte hain kyunki unke paas paise hi nahi hai ki who nayi kahreende ya,bleech se saaf karein.Aur agra khareendein bhi to kahaan se, duniya se uhhe darr lagta hai. Ab kaunse chemist par ja kar khareendenge.Police ka dar hamesha unhe underground rakhta hai"-(The drug users are jobless and homeless. They do petty jobs like collecting waste. Sometimes they find syringes in the waste .As soon as they are able to collect Rs ten to Rs fifteen they buy drugs and call everyone to have them. They normally take drugs in groups as they do not have enough money to buy new needles. So they end up sharing them. Even if they want to they can't go to a chemist to buy syringes. They are always afraid of the world and the police; hence they tend to remain underground.)- Dr Abdul Gaffar -Head Integrated Counseling and Testing Center, ICTC, Aligarh Muslim University.
Thus the plight and addiction of high risk groups makes them insensitive towards their own HIV/Aids risk and health issues. The health communication program suffers because only communication and understanding is not enough to change habits. A stronger support system is needed to bring about such complex behavior change.
Campaign Specific Factors: THE Gaps in IEC campaign
HIV Aid campaign in Aligarh is heavily dependent on social and community dialogue, and human channel. Information about comprehensive Aids knowledge was lacking as observed from beneficiary interviews. Mass media is rarely utilized, which is an essential medium to spread widespread knowledge and break social taboo regarding Aids.
A review of the IEC material distributed revealed the following gaps:
The pamphlets distributed are low in quality as well as limited in number. They have been designed by local NGOs and hence suffer from serious limitations. They do not speak to the semi-literate and illiterate population. The language used is not very easy to understand as scientific terms are used to describe the disease and its effects.
The graphics are minimal and the pictures are of couples dressed in western clothing. This can only add o the perception of Aids being a "foreign" disease which cannot affect the general population.
The materials are cluttered and are not reader friendly or attractive enough for the delivery of the message to the beneficiary.
Political and Administrative Factors: RESOURCES and Training
"Vaise to hamein mahine mein do baar meetings karni hoti hai,zile ke gaon mein mahila samiti ke saath group meetings honi hoti hain..Magar aisa hota nahi hai. Ab hamein agar gaon mein jaana hai to hum kaise jayein,government ne koi suvidha to di nahi hai.Na to koi van hai,na hamein allowance milta hai."(Actually we are supposed to have bi-monthly community meetings,in villages as well with Mahila Samiti's.However this doesn't happen. The government has provided us no conveyance, or gives us any allowance to travel to these remote villages) - Ms Sneha Devi, Field Officer and Aasha voluteer
The training of the counselors is another issue. Even though comprehensive manual to conduct counseling is available in the centers yet the counselors indicated that no formal training has been imparted to them in months. The problems faced by them are not addressed, and the material distributed to them is limited.
While interviewing the field officers it was observed that they themselves had incomplete knowledge about Aids. For instance one of them remarked that Aids can be spread because in villages people share toilets.
This problem is occurring because HIV/Aids is not a top priority of government health officials in Aligarh. The community outreach meetings which are conducted by volunteers are for general family health and child health. It become the choice of volunteers to talk about HIV/Aids in these meeting, however no separate social communication program is run for this cause
Dependence and Lack of NGO's
Due to above mentioned constraints the HIV/Aids program in Aligarh has become severly dependent on the work of NGOs. Especially to target high risk groups like injecting drug users who are apprehensive in talking to government workers.
According to counselors the IDU's run away if any government workers even tries to approach them. Moreover as government workers they can support prostitution(by providing monitory support) or provide syringes to the IDU's while the NGO workers can. These policies become a big hindrance in HIV behavior change.
According to Ms Namrata Kumar - (HIV/Aids Counsellor at Voluntary Testing Center,Deen Dayal Hospital )The Udaan Society was the only NGO working in Aligarh ,and was doing an effective job.Infact they had developed contacts with the mechanics to target trucker population and also identified groups of IDU's in Aligarh. However due to some political reasons the project has been taken away from them and they are now receiving no funding to carry out their efforts. She used to get 25 cases per day that came through Udaan referrals, however since past six months no such referrals have come.
This is a big blow to the HIV/Aids campaign in Aligarh as there are currently no efforts being taken to target high risk groups .Any new agency which starts work will have to start from scratch as developing trust with high risk groups takes a lot of time and commitment..
Thus there is an obvious lack of focus and support for HIV/Aids campaign in Aligarh. This can be because of variety of reasons like no direct control from the state government and Uttar Pradesh being a low risk state. However this is a vicious cycle as lack of efforts mean, low HIV awareness and hence testing and case count. This leads to incorrect reporting and false assumption of low prevalence of HIV Aids in the state.
Some of the recommendations which emerge out of this research are as following:
Polio Health Communication Campaign:
- The door to door field officers should be trained in persuasion techniques so that they refrain from using coercion in meeting their specified number of converted households. As far as possible these field officers should be allocated same areas every month so that they are able to identify resistant households, develop relationships and hence credibility.
- Even though in the main city spiritual leaders of the Muslim community advise the people to take the polio vaccination drops, such advocacy methods should be extended to interior rural regions of the district in order to effectively tackle the misconception and resistance against the vaccination.
- The communication campaign has delivered it's first goal of creating awareness about the disease. The beneficiary interviews revealed that the population understands that the vaccination is important to prevent polio. However the lack of information area is the need for regular vaccination. The program should focus on areas like the communicability of the disease, the changing nature of the virus, and the ultimate goal of 100% eradication. Until the beneficiaries realize that till every child is vaccinated, their children will not be safe, they will not understand the importance of regular immunization and the authorities struggle will door to door immunization rounds. This should also reflect in the IEC material being distributed, and the mass media campaigns which are run on television as well as print medium.
- A separate media cell should be set up so that proper press release are sent out, containing authenticated data and information regarding polio and immunization drives.
- The program should be a part of overall child healthcare program. The IEC material should be integrated with other child healthcare material distributed. The communication should not be focused just on immunization rounds but should run all year round as a part of child and family welfare.
HIV/AIDS HEALTH Communication Campaign:
- This campaign suffers from serious limitations and complexities as compared to the Polio campaign .More focus and resources are required to make it a success. A proper chain of responsibility, and feedback should be developed to make it more goal oriented. The program cannot sustain on the basis of volunteers and sporadic communication efforts.
- The program needs to be more aggressive. Social and community dialogue has been seen as an effective way to break social taboo related to HIV aids. Communication regarding condom usage is scant and people do not talk about it openly. Television and Radio can be exploited to talk about condom usage and risky sexual behavior. The behavior change regarding these practices starts with an understanding that talking about healthy sexual practices is not taboo and this can only happen if mass media campaigns trigger such talks among peer and community groups.
- Comprehensive knowledge about HIV/AIDS limited. A review of IEC material has revealed that it suffers from serious design limitations . Either assistance should be given to develop more effective IEC materials or more material should be procured from NACO.
- The program should focus on social change through storytelling, street plays and peer education. Attitude and behavior towards HIV/ Aids can only change through sensitizing people that the patient is not the only one to be blamed for the disease and that he doesn't put the community at risk, hence discrimination and stigma is uncalled up. Real life stories of struggle and sustenance of HIV/Aids patients can be narrated in these peer group meetings. Ultimate goal should be to create empathy so that their social and living conditions are improved.
- There is a need to encourage active information seeking behavior towards HIV/Aids.The message should be that everyone is at risk. Sexual transmission is not the only way HIV/Aids is spread.
- Women should be educated and informed about safe sexual practices. The status of women deters them to negotiate any condom usage. Lack of knowledge compounds this problem. Women self help groups can help improve this situation.
- High risk groups need strong support if any behavior change is to happen. NGO's should be encouraged and supported. Alternative employment option, monetary and social assistance is necessary for the success of this campaign among high risk groups.
- Ultimately the field officers need to be properly trained. They have to be given enough motivation and support to regularly go on outreach programs and educate the rural population.
- Advocacy has not been utilized by the communication program. Beneficiaries still remember the Amitabh Bachhan campaign. Similarly such new campaigns should be developed. Local artists can be roped in for this purpose.
- Hotlines should be set up, and the contact details should be communicated through mass and traditional media.
The analysis of the Health Communication Campaigns of Polio and HIV/Aids has resulted in identification of factors which lead to a differential effect of the same. Contrasting the campaigns resulted in identifying that Polio program has reached a larger audience and has led to a more effective behavior change ,while HIV-Aids campaigns seems to be lacking not only because of campaign deficiencies but other social and political factors.
The health care system and delivery in India is marred by many such factors and an on-ground check resulted in identifying gaps between the ideal and the real practice followed in the geographic location of Aligarh.
Both HIV/Aids and Polio campaigns are affected by certain social, cultural, campaign specific and political factors. However the way they are dealt with are substantially different. The community resistance against Polio has been identified and steps are taken to address those. Similarly Aids campaign can also learn from these efforts.
It is also identified that the behavior change regarding HIV/Aids is a more complex action as it involved not only action and attitude change as with polio but a more deep social change regarding attitude towards people with HIV/Aids. The target groups of both the campaigns also play a major role in creating this differential effect.
The suggestions outlined in this research are comprehensive and address every factor identified. An application of those will result in more strategic and efficient health communication campaigns for both HIV/Aids and Polio.
Scope of further research:
Scope of further research exists in developing comprehensive campaigns based on the factors and limitations identified in the existing ones. The suggestions given can be indications and starting points for capacity building and campaign improvement.