The mirage of community participation in Nigeria’s response to COVID-19

Adanma Ekenna, Chinyere Mbachu, Uju Agbawodikeizu and Obinna Onwujekwe

Background

Community participation is a foundational principle of primary health care and it is recommended that policy makers consider participatory mechanisms of engaged and developmental processes where people are actively involved in determining priorities as well as implementing solutions(1). When these are in place, communities may begin to understand their health status objectively rather than fatalistically and moved to take a series of preventive measures(2). Community participation exists in degrees; co-option, compliance, consultation, cooperation, collective action and co-learning(3). In co-option, local representatives are chosen, but have no real input or power. In compliance, tasks are assigned with incentives, but outsiders decide the agenda and direct the process.

In consultation, local opinions are asked for, and outsiders analyse and decide on a course of action. In cooperation, local people work together with outsiders to determine realities; responsibility remains with outsiders for directing the process(3). In collective action, local people set their own agenda and mobilise to carry it out, in the absence of outside initiators and facilitators. Finally, co-learning is when local people and outsiders share their knowledge to create a new understanding, and work together to form action plans, with outsiders facilitating(3). At the peak of community participation is community ownership and sustainability of public health. The degree of community participation or lack thereof in Nigeria was exposed in the societal responses to control measures against the COVID-19.

Method

This was a scoping review of official documents, journal articles and media reports published from December 2019 to December 2020 highlighting processes of government institutionalized responses, evidence-use in stakeholders’ decision-making and community response to COVID-19. Research articles were sourced from online journals and media articles written in English language. The geographical scope was national and sub-national levels in Nigeria. The search was performed in Factiva, PubMed, Google, Google Scholar and Scopus.

Findings

Non-pharmaceutical preventive measures were instituted by the Federal and state governments. The use of face masks in public spaces, the use of alcohol hand sanitizer, physical distancing, washing of hands with soap and water, disinfecting frequently touched surfaces, and avoidance of crowded places are some examples. Discussions of development of vaccines were on-going amidst scientific controversies. Policies, protocols and guidelines were developed and produced by the Nigeria Centre for Disease Control and the Presidential Task Force committee on COVID-19.

Community involvement in decision making

The primary decision for the Coronavirus response in Nigeria was based on international guidelines from the World Health Organization and advisory from the many expert committees that were set up at national and sub-national levels. The community at the sub-national level was not part of this part of the response(4). However, when the national guidelines were established, the community leaders were engaged in community mobilization.

Community support for national efforts

The discussion of community support for national effort starts with the issue of large-scale political distrust. The Nigerian society undermined public compliance to government protocols limiting the outcomes of government responses to COVID-19(5) and facilitated the spread of the virus in Nigeria(6).  Female respondents and those less than 40 years generally rated the government’s response as poor with the largest rating for Federal President’s Office (57.5%). Communication (50.0%) and prevention messages (43.7%) received the highest perception good rating(5).

At the onset of the outbreak, researchers found that the community was not aware of the pandemic(4). “While some felt it was a made-up story, others felt it was a usual transitory disease outbreak that would come and go. A few others expressed knowledge of the disease but sounded nonchalant about the preventive measures. Some respondents felt that the virus is not in the village and therefore they do not need to worry about anything. Many were more concerned with how to sustain their daily income in the face of the lockdown rather than worry about a COVID-19, which to them is not even real”(4). Likewise, mothers were not enthused about their children wearing the facemask (7).

By June 2020 in the South-western region of Nigeria, the use of face masks by 64.5% and social distancing (48%) were the most frequently reported practices for prevention(8). Only 71 (20.8%) demonstrated good hand-washing practices. The perception of the likelihood to contract COVID-19 and practices to prevent COVID-19 had a weak correlation of 0.239 (p < 0.001)(8).

With the prevailing low perception of risk, a study in South-east, Nigeria found preventive measures practice as the use of alcohol hand sanitizer (86.6%), physical distancing (85.6%), washing of hands with soap and water (81.6%), and disinfecting frequently touched surfaces (80.9%). The non-pharmaceutical interventions (NPIs) the respondents practiced poorly were the use of face masks (33.8%) and avoidance of crowded areas (47.2%)(9). Having good knowledge (AOR: 3.2; 95% CI: 1.65 – 6.05) and attaining secondary education or less (AOR: 2; 95%CI: 10-3.13) were the only predictors of good practice of preventive measures(9).

Healthcare workers complied with precautionary measures, though only 3 out of 5 used a face mask when leaving home(10). They expressed confidence that Nigerian medical scientists would win the war against COVID-19(10).

The situation is not all gloomy. Religious and traditional leaders supported government efforts at the Ogun state border to curb the importation of COVID-19(11). The Federal government has therefore been making efforts to inform and empower populations to protect themselves by taking measures at the individual and community level that will reduce the risk of transmission(12).

Community mobilization

In its pandemic response plan, the government aimed at controlling community transmission positing that ‘we must ensure that communities, including the most hard-to-reach and vulnerable groups, have a voice and are part of the response’, though this is yet to be evidenced(12).  Community members felt that there was a gap between the government and the people which is needed to be breached through the community leaders(4) who should be involved in decision making. The importance of the voice and face of community members lending credibility to the message of changing health behavior has been underscored(13).

Mobilization was focused on areas of importance. In Borno state, the epicenter of the humanitarian crisis in Northeastern Nigeria, sensitization campaigns on hand-washing was followed by the distribution of soaps to more than one hundred thousand internally displaced persons (14). In the border towns of the south-western border, Port health officers were trained(11). Social and traditional media were employed in the mobilization of Nigerian society through different ministries, departments, and agencies(15).

Discussion  

The events in the world in 2020 put a strain on man’s emotional, physical, mental and social well-being. World economies groaned under the weight of the Coronavirus pandemic. Health systems were overwhelmed, with rising number of infected persons and surge capacity in laboratory medicine and intensive care. Policies and guidelines from international agencies were developed and adapted by governments. At the containment phase, lockdowns and non-pharmaceutical measures were advocated for and met with little societal compliance in some countries, including Nigeria which felt the brunt of the pandemic in a lot of spheres. The compliance in the communities was worse in countries with weaker health systems. There seemed to be lack of trust between the government and the public which adversely affected compliance to these non-pharmaceutical measures.

Conclusion and recommendation

Public health practice in Nigeria must get past a top-bottom approach to a bottom-up approach. This can be implemented by establishing town hall meetings between the NPHCDA and ward health committee leaders in a transparent manner for decision-making.

References

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3. Digital Campus Moodle. Levels of community participation [Internet]. Internet. 2014 [cited 2021 May 11]. Available from: https://moodle.digital-campus.org/mod/page/view.php?id=19437
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5. Oleribe O, Ezechi O, Osita-Oleribe P, Olawepo O, Musa AZ, Omoluabi A, et al. Public perception of COVID-19 management and response in Nigeria: A cross-sectional survey. BMJ Open. 2020.
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Adanma Ekenna, MBBS, MPH, MWACP is a public health and community physician whose passion is in strengthening health systems in low and middle-income settings especially at the primary health care level to be more responsive to population needs, particularly for vulnerable groups. Accordingly, her research interest is targeted at identifying weaknesses in the HS, and mitigating strategies. One of her most recent research demonstrated a gap in the availability and readiness to provide non-communicable disease service at the primary health care level in south-east Nigeria and recommended strategies for improving service availability in rural settings. She is a member of West African Network of Emerging Leaders in Health Policy and Systems Research (WANEL) and Health Systems Global (HSG).

Patricia Uju Agbawodikeizu has been at the University of Nigeria, Nsukka since 2010 as an academic staff of the Department of Social Work and is currently a lecturer I. She currently rounded-off her Ph.D programme in Social Work with specialty interest in Social Gerontology. She holds an O.N.D, a B.Sc and M.Sc in Social Work. Her primary research interests are in the area of Social Gerontology, Gender studies and Public Health. Uju’s publications include articles in End-of-life planning, Ageing, Development studies, Gender, Maternal Health Issues and COVID-19 & Older adults.

Dr. Chinyere Ojiugo Mbachu is a community health physician in the University of Nigeria Teaching Hospital, and a senior lecturer in the University of Nigeria Nsukka. She is currently the grants officer of the Directorate for Research in the University.
Ojiugo is a fellow of the West African College of Physicians and a founding member of the West African Network of Emerging Leaders in Health Policy and Systems Research (WANEL).
She has published numerous articles in reputable journals, in the areas of health services, policy and financing.

Professor Obinna Onwujekwe is a Professor of Health Economics and Policy, and the Director of the Directorate for Research in University of Nigeria, Nsukka. He established the Department of Health Administration and Management in the University. He is the founder and Director of the Health Policy Research Group, which is a renowned and reputable research organization. Obinna has led the development of health policies in Nigeria, including the National Health Policy (2016) and the National Health Financing Policy (2016). He has served on the scientific and advisory boards of the African and International Health Economics Associations, and is the foundation president of the Nigeria Health Economics Association. He currently chairs the health systems research subcommittee of the Ministerial Expert Advisory Committee on COVID-19 Health Sector Response (MEACoC). He is also a Fellow of the Nigerian Academy of Science and Nigerian Academy of Medical Specialities.