0115 966 7955 Today's Opening Times 10:00 - 20:00 (BST)

Evaluating Polio and HIV/AIDS Treatment Campaigns

Disclaimer: This dissertation has been submitted by a student. This is not an example of the work written by our professional dissertation writers. You can view samples of our professional work here.

Any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of UK Essays.

Introduction:

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.

Literature review

Health Communication:

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)

HIV AIDS:

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.

Learning:

  1. Locally developed content which has quality entertainment works well
  2. For a multimedia educational model to succeed it should return value to all the stake holders
  3. Media advocacy leads to policy and social change
  4. 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.

Learning:

  1. 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
  2. Use of creative and clutter breaking ideas helps discussion and normalization of sensitive issues like stigma
  3. 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:

  1. Community outreach: Nine outreach sites which were staffed with officers who provided information on safe sexual health practices, condom usage and provided referrals
  2. STI referrals: A non judgemental approach to STI risk patients was followed. STI clinics were set up with a MSM friendly physicians
  3. Social and Group meetings: support groups were formed to help MSM and create a freer environment for information interchange
  4. 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 %

Learning:

  1. Naz foundation realized that in order to reach out to special audiences tailored solutions are necessary.
  2. 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.

Results:

  • 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

Learning:

  1. Political support is necessary for the success of any IEC project on sensitive issues. This can be influenced through strong advocacy
  2. Incorporating feedbacks by outreach workers and IDU can significantly increase the impact of the campaign
  3. 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.

Results:

  1. 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
  2. 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.

Learning:

  1. A high level of motivation should be maintained amongst the peer learning groups.
  2. It's important to have support of all the stakeholders for the success of any ICE program.

Poliomyelitis (polio)

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.

Learning:

  1. It's a challenge to shift the focus of health communication from campaign type to sustainable communication
  2. Advocacy at highest level is instrumental to success of the campaign
  3. Use of local facilities like mosques, bazaars, mobile loudspeakers etc lead to effective social mobilization
  4. Appropriate mix of print and radio can effectively reach mobile population
  5. Establish strong relationship with religious leaders
  6. Promote health education through health facilities as well as private practitioners
  7. 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.

Learning:

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.

Learning:

  1. Polio needs to be incorporated as a part of overall child health program .
  2. 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.

Learning:

  1. New entertaining techniques need to be implemented if communication has to reach children
  2. 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.

Research Objectives:

Through the analysis of the literature review and recommendation of my guide the following research objectives have been identified:

  1. To understand the health communication processes and initiatives undertaken for HIV Aids and Polio prevention/care at a sub-system, grass root level.
  2. To identify factors which lead to an differential impact of these health communication campaigns
  3. To suggest improvements ,if possible, to current health communication practices followed in the geographic sub-system

Research Areas:

Health communication campaigns which will be studied extensively are:

Against HIV-Aids:

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.

Research Methodology:

Phase One

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.

Phase two

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:

  1. It is flexible
  2. It provides in-depth information about areas to be covered
  3. Since the area of study is very specialised it provides scope for clarification
  4. 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:

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.

Analysis

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.

Print

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

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.

Banners:

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.

Human Channel:

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

Television

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

Outdoor Hoardings

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.

Posters:

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:

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.

Pamphlets:

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

HIV-Aids Counselling

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:

Awareness levels:

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.

Media Consumed:

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

Awareness levels:

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

Media Consumption:

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.

Condom Usage:

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:

  1. Dr Rahul Kulshestra - District medical officer
  2. Mr. Rajesh Gupta -Nodal Officer,Aligarh
  3. Mr Kamal Gupta-Auditor and Controller for Pulse Polio Drive Aligarh
  4. Mr Rajeev Singh-Field Level Officer, Aligarh
  5. 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


To export a reference to this article please select a referencing stye below:

Reference Copied to Clipboard.
Reference Copied to Clipboard.
Reference Copied to Clipboard.
Reference Copied to Clipboard.
Reference Copied to Clipboard.
Reference Copied to Clipboard.
Reference Copied to Clipboard.

Request Removal

If you are the original writer of this dissertation and no longer wish to have the dissertation published on the UK Essays website then please click on the link below to request removal:


More from UK Essays

Get help with your dissertation
Find out more