Module 2: Rumors and Word of Mouth in Developing Countries

Many attempted health interventions are resisted and hindered due to circulating rumors and misconceptions.  It is important that healthcare delivery programs understand the rumors and their context. These case studies provide insight into why rumors arise and the lasting consequences that they can have.

Eyecare in Kenya

Even when eye care is provided free of charge, patients sometimes refuse to receive surgery and other treatment. A recent study by Briesen et. al. explored this issue. Ninety individuals were interviewed in the Kwale District of Kenya during routine eye screening assessments, 48 of whom accepted the surgery and 42 of whom rejected the offer.  Those who elected to have the free surgery usually had heard of a good outcome from another person, whereas those who declined the surgery commonly claimed to know someone whose sight had worsened or who had been blinded by eye surgery.  Upon being re-interviewed, it was revealed that some of these people had only heard rumors through word of mouth that the eye surgery “makes you blind,” and did not actually know anyone personally who had experienced this.  Also, some individuals had apprehensions about surgery, and the study reported that the rumors were sometimes used as an excuse not to undergo surgery.(1)

A closer look was taken at the “failed cases,” and it was determined that several of the interviewees mentioned the same instance of a well-regarded town elder who had experienced surgery-gone-wrong.  However, it is important to note that this man had undergone surgery at an advanced stage of glaucoma, and after going completely blind he held the hospital responsible for his worsening condition even though the hospital was reportedly not at fault.  Glaucoma progressively and permanently causes blindness. Glaucoma surgery is not able to restore sight, but instead helps to reduce intraocular pressure in an effort to prevent further blindness from glaucoma. In contrast, cataract surgery is a different type of operation that restores sight. The community members were not aware of the difference between glaucoma and cataract surgery, and they incorrectly believed that the town elder had undergone the same type of surgery that was being offered to them.(2)

The study also reported that many in Kenya believe that surgery entails the replacement of the human eye with the eye of an animal, such as that of a goat or sheep. Another common rumor is that patients’ vision will be ruined by students who are not properly trained. Also, when the doctors are not local, there are sometimes alarming rumors amongst the townspeople that the outside physician may try to intentionally ruin vision because they are from a different tribe.(3) These last two rumors may have been derived from students who practiced beyond their abilities in the community, or by visiting "surgical safaris" that caused poor surgical outcomes. See The Significant Harm of Worst Practices for additional details about these global health issues.

In order to stop free surgeries from being refused due to misconstrued rumors, several interventions are vital.  Within the general population, knowledge about eye illness and treatment should be improved.  The cataract surgeries that are performed should be high quality so that all will have good outcomes, therefore building a good reputation in the village for eye surgeries.  Also, social assistance for the elderly should be improved.  Blind people are often considered a burden by their families and therefore do not want to inconvenience loved ones by asking for the surgery, therefore letting themselves go fully blind.  Patients who have been operated on should help provide this support and endorse the successful surgery to their peers.(4)

Polio Eradication in Nigeria

While the goal of completely eradicating polio from the world is within reach, it has not yet been achieved.  This is a very challenging goal to achieve since a new pocket of infection can result from a single child who is without a vaccination.  Countries must be extremely diligent about ensuring that every single person is vaccinated, and the breakdown in Nigeria’s motivation to vaccinate polio has transformed into a classic example of how eradication campaigns can go wrong.  As Dr. Stephen L. Cochi, senior advisor in Centers for Disease Control and Prevention’s immunization program, states, “Nigeria is clearly far and away the greatest risk to the eradication effort.  They’re just missing lots and lots of kids.”(5)

While the president from the Christian, Yoruba-speaking south expresses regrets for the country’s contribution in restarting the disease, the conservative officials in the Muslim north defend their decision, claiming that Kano residents were highly mistrustful and apprehensive of the health employees and were declining vaccinations.  According to a New York Times article in 2006, “as is often the case with rumors, they appeared based on distortions of fact amplified by an alarmist media and by politicians and clerics absorbed in a religiously divisive presidential election campaign.”(6)  Many persuasive arguments against polio vaccinations began to formulate, convincing great numbers of Nigerians that the vaccine was evil.(7)

A book published in 1999, entitled The River, argued that AIDS was derived from an early polio vaccine implemented in the Belgian Congo during the 1950s.  The science behind this claim was that the vaccination had been developed on chimpanzee cells comprising the monkey virus known to be the forerunner of human AIDS.  While most scientists did not accept the theory, and even the author himself did not believe that the AIDS virus still existed in current polio vaccines, many Nigerians were confused and started to believe that it did. (8)

Many Nigerians were also under the belief that the polio vaccine contained the hormone estrogen, which is considered highly scandalous since “estrogen” was interpreted as being synonymous with “birth control.”  Others circulated false rumors about the harm of vaccines during political campaigns. (9)  Although official hostility and disapproval for the vaccine has ended in Nigeria, resistance efforts and many obstacles still exist.  The rumors created a harmful lasting impact, and reigniting the campaign for eradication has proven to be a difficult struggle.

Neonatal Tetanus in Cameroon

In 1990, a rumor circulated throughout Cameroon that public health employees were overseeing a vaccine to women and girls that would sterilize them.  In reality, the vaccine was aimed at diminishing neonatal tetanus.  Opposition groups and movements sprung up to strike against the vaccination.  Additionally, the vaccination campaigns occurred at the same time that contraceptives were being legalized, which further raised apprehensions and rumors that the public health sector was a threat to human fertility.  The reaction to this rumor was enormously dramatic, as the Cameroonian schoolgirls “squeezed through doorways and leapt from windows” in order to escape from the allegedly evil teams of vaccinators.(10)

A study was conducted to explore this 1990 rumor regarding the vaccines.  In order to better understand the rumor and why it was so widespread, women who were present at the institutions during the scare were interviewed.  One way to better understand the rumor is to contrast the perspectives of public health employees with those of the fleeing girls.  From the eyes of the public health workers, the situation was merely an attempt to help with vaccination coverage by straightforwardly implementing the vaccines to as many women and girls as possible.  From the girls’ perspective, no background information about the vaccination was provided before implementation, causing them to feel unsure of its purpose and forced to acquiesce to the people in power.  It is important to keep in mind that the technologies being used were novel and unfamiliar to these women.  This rumor about the sterilizing vaccines provides a window into the social issues and changes taking place at the time.  The vaccinated girls viewed themselves as being victimized against their own will and began to blame any health problems they encountered down the road as being the fault of the vaccines.  It is critical that public health workers thoroughly consider the best way to implement their interventions on a local level, taking into account that the community members must be well-informed and comfortable with the procedure in order for it to be successful.  A stronger health education process could prompt women to pursue the vaccination themselves, whereas a lack of knowledge caused women to feel coerced by the vaccination campaign.(11)

The occurrence in Cameroon is just one example of the many rumors about sterility that have spread throughout Africa.  “Collective survival” is a fixation in many African cultures, and anxious feelings frequently arise that an entire community’s identity will be terminated.  While comprehensive health education can be effective and successful, complex social and political realities can make it difficult to completely eradicate rumors.(12)

Family Planning in Uganda

In Uganda, there is widespread distortion and misrepresentation of information regarding contraceptives.  On a broad scale, it is believed that contraceptives lead to nausea, cause women to be promiscuous, and are overall publicly offensive.   Explicit rumors exist as well, such as the fear that contraceptives “burn up” all of the women’s eggs or raise blood pressure to dangerous levels.  Horror stories of the condom circulate, causing worries that it commonly falls off and gets stuck inside of the woman.  The vasectomy is thought to render men powerless or mentally ill.(13)

In order to correct these misconceptions and intensify the practice of family planning in Uganda, a standard method of family planning implementation must be established, workers must be better trained, counseling services should be offered to patients, successful users should distribute encouraging evidence and materials to their villages, and educational programs should be improved and increased. 

Conclusion

In summary, false information traveling through rumors or word of mouth can be extremely challenging to the successful implementation of global health delivery.  The examples of eye care in Kenya, polio eradication in Nigeria, neonatal tetanus in Cameroon, and family planning in Uganda provide us with just a small glimpse at the way in which facts and anecdotes can be easily misconstrued.  Programs must remain conscious of the social, political, and cultural forces that play a role in any given area, and try to offer as thorough of an education as possible.  When patients are well-informed about the services being provided, it will be easier for them to fully understand and appreciate the intervention.

Footnotes

(1) Briesen et. al.  “Understanding why patients with cataract refuse free surgery: the influence of rumours in Kenya,” Tropical Medicine and International Health, Vol. 15 No. 5, 534 – 539 (May 2010).

(2) Ibid.

(3) Ibid.

(4) Briesen et. al.  “Understanding why patients with cataract refuse free surgery: the influence of rumours in Kenya,” Tropical Medicine and International Health, Vol. 15 No. 5, 534 – 539 (May 2010).

(5) Dugger, C. & McNeil, D.  “Rumor, Fear and Fatigue Hinder Final Push to End Polio,” New York Times, (20 Mar 2006). 

(6) Ibid.

(7) Ibid.

(8) Ibid.

(9) Dugger, C. and McNeil, D.  “Rumor, Fear and Fatigue Hinder Final Push to End Polio,” New York Times, (20 Mar 2006). 

(10) Feldman-Savelsberg, P., Ndonko, F., and Schmidt-Ehry, B.  “Sterilizing Vaccines or the Politics of the Womb: Retrospective Study of a Rumor in Cameroon,” Medical Anthropology Quarterly, New Series, Vol. 14, No. 2, 159-179, (Jun 2000). 

(11) Ibid.

(12) Kaler, A.  “Health Interventions and the Persistence of Rumour: The circulation of sterility stories in African public health campaigns,”  Social Science & Medicine, 68, 1711-1719 (2009). 

(13) Nakato, L.  “Have you heard the rumour?”  African Women Health, 2(3):23-7, (1994).