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This research set out to study the communication approaches used by Viral Hepatitis Association of Nigeria (VHAN), an organization that is at the forefront of the fight against viral hepatitis in Nigeria, in its hepatitis interventions in Kaduna State. The population of the study included teachers and students of ECWA Goodnews School, Narayi High Cost, Kaduna which is one of the schools that the organization has been interacting with on hepatitis issues for years. This is because the school is popular for academic excellence in Kaduna metropolis. People infected by viral hepatitis, and are receiving treatment from VHAN were also engaged in this study. The theory that underpins this research is Health Belief Model (HBM). Through the use of in-depth interview, focus group discussion and documentary observation the study found out that although the organization has made some progress, especially in engendering behaviour change amongst its patients. The study revealed that they do not involve their target audience in the conception and design of hepatitis interventions. More so, the organization does not have an organized feedback mechanism in place to accommodate its audience contributions in its activities. The study, therefore recommended the use of participatory communication approaches such as TFD, PLA tools, Volunteer Community Mobilizers to enhance community participation in VHAN‟s hepatitis intervention. The study further suggested the use of social media platforms and the establishment of hepatitis clubs in schools as necessary measures to be adopted by the organization in order to strengthen its existing communication approaches and achieve sustainable result.



Title Page – i
Declaration – ii
Certification – – iii
Dedication – iv
Acknowledgements- v
Abstract – vii
Table of Contents – viii
1.1 Background to the Study- – 1
1.2 Statement of the Research Problem – 12
1.3 Aim of the Study — 13
1.4 Objectives of the Study – 13
1.5 Research Questions — 14
1.6 Significance of the Study – 15
1.7 Scope of the Study – 15
2.0 Introduction – 18
2.1 A Brief Historical Overview of Development Communication – – 20
2.2 Health Communication – – — 22
2.3 Factors that Influence Attitude to Health Communication   – 26
2.4 Theories that Influence the Practice of Health Communication- – 33
2.5 Types of Media in Health Communication – 36


2.6 A Review of Hepatitis Prevalence in Nigeria – 38
2. 7 Theoretical Framework – 45
3.0 Introduction – 49
3.1 Research Design – – 49
3.2 Research Approach – 50
3.3 Study Population- – 50
3.4 Research Instrument for Data Collection – 51
3.5 Method of Data Analysis – 58
4.0 Introduction – 59
4.1 Data Presentation and Discussion – 59
4.2 Factors Militating Against Effective Hepatitis Communication by VHAN – 82
4.3 Towards a Virile Hepatitis Communication – 94
5.0 Introduction – 99
5.1 Summary – – 99
5.2 The Study Major Findings – 100
5.3 Recommendations — 102
5.4 Contribution to Knowledge- 103
5.5 Conclusion- 104
References –  – 106
Appendices — – 115











1.1. Background to the Study


Diseases are among the challenges confronting the human population today. The pace at which diseases have continued to spread across the globe is a pointer to the fact that the world is under a serious threat. From time to time, new diseases emerge and old ones develop new strains that task the resources, patience and knowledge of individuals, national governments, international agencies and non-governmental organizations (NGOs). This is why stakeholders have continued to map out strategies that can successfully confront them. Besides disseminating vital information about a particular disease or health threat, health communication has also been concerned about influencing people‟s behaviours.


However, over the years, health communicators have continued to face a lingering challenge on how to influence people to adopt positive health behaviour in a bid to combat diseases or any related health problem because of the complexity of human beings. For instance, it is not unusual to encounter an individual today with a positive disposition towards an idea or object, only to discover the following day that the same individual is at war with that same idea or object. Therefore, it is important for us to understand that this complexity of human behaviour does not emerge from a vacuum; it is usually a manifestation of a long established attitude, which is in turn being influenced by the entire human environment. Behaviour is viewed as the range of actions and mannerisms made by organisms, systems, or artificial entities in conjunction with other systems or organisms around, as well as the (inanimate) physical environment (Jegede,2014).

Wilma and Allen (2000) further reveal that Behaviour is the way an individual acts towards people, society, or objects. It can either be good or bad. It can be normal or abnormal according to societal norms. Therefore society will always try to address bad behaviour and try to bring abnormal behaviour back to normal. From this view, it is understood that one of the enduring challenges in human society is how to address attitudes and behaviours that are inimical to the collective well-being of the people. It is also important to note that in most cases, people‟s behaviours are the manifestations of their culture and norms, which might have been acquired over a long period of time through socialization processes. Existing societal values and norms make individuals in a particular community different from other people in different communities who also have values and mores peculiar to them.


In respect of the foregoing, any health communication strategy or approach that is targeted at behaviour change need to understand that communication forbehaviour change is a process, and not just an ephemeral event that needs to be strategically approached because individuals differ in levels of motivation or readiness to change. More so, it is important for us to note thatin a bid to achieve lasting and sustainable behaviour change through health communication, the maximum participation of the target people in the entire process is a very crucial factor. That is, the communication approach needs to be anchored on the principle of participation. Involvement of key community stakeholders, who usually constitute individuals that are able to influence other members of the community to adopt a particular behaviour or course of action, could go a long way in facilitating the emergence of and subsequent sustenance of the desired behaviour change. This is very important because the peoples‟ agency, which is the major motivating factor for behavior change need to be appreciated and considered in health communication processes for the purpose of engendering sustainable behaviour change.


In other words, the local people who are usually the target beneficiaries of health interventions need to be involved in the entire process of such interventions. This is important because behaviour change communication concern trusting the people enough and believing that with the necessary motivation and support, they will adjust to the required behaviour that is friendly to their collective well-being (Chambers, 2005:167).


Premised on the foregoing therefore, a retrospective view of communication for development approaches in the third world from the modernization era till the late 1970s reveals that the initial communication approaches and strategies used in third world development drive were mostly top-down in nature which had little or no place in the cultural matrix of the local people. This is because the communication approaches were more concerned with disseminating information, than ensuring concrete and sustainable behaviour change. Consequently, they failed to engender sustainable development. Since then, international development agencies, NGOs and national governments have continued to emphasize the need for development communication to reflect local yearnings and aspiration of the people.


There is still more to be done in order to bridge some gaps traceable in development communication approaches used in the third world countries. For example, research has shown that many communication approaches used in development interventions in Africa are still more concerned with information dissemination than engendering sustainable behaviour change. As a result, they usually fail to make the desired impact among the local people. Corroborating this assertion, Nwadigwe (2012:17)


argues that “many communication projects fail to make the intended impact as the target audiences remain apathetic despite the health information being disseminated”. The implication of this statement is a disconnect between the local people‟s social realities and the communication approaches which most experts deploy in health interventions. Therefore, there is an urgent need for a careful review of communication approaches and strategies used in communicating health in Nigeria. Perhaps this could be the solution to age long diseases that have continued to ravage communities in the country.


Various studies have also shown that there is a relationship between several dangerous diseases that have continued to be responsible for the deaths of many people in Nigeria (despite the huge monetary allocation being channeled to the health sector) and some of the people‟s behaviours, cultural and social practices. One of such diseases is viral hepatitis which is the focus of this study.


It is important to note here that the persistent problem of viral hepatitis disease in Nigeria cannot be blamed solely on failure of communication. This is because hepatitis communication can do little or nothing concerning problems such as staggering infrastructure, epileptic health policies and corruption in the health sector. This by extension points to the limitation of health communication itself. Yet, the deployment of effective communication can play a significant role in mitigating the problem of increasing prevalence rate of viral hepatitis infection, albeit by helping in providing timely, adequate and convincing information to people yet to be infected. This assertion is corroborated by Schiavo (2007:26), who argues that:


Health communication cannot replace the lack of local infrastructure (such as the absence of appropriate health services or hospitals) or capability (such as an inadequate number of health care providers in relation to the size of the population being attended). It cannot compensate for inadequate medical solutions to treat, diagnose, or prevent any disease. But it can help advocate for change and create a receptive environment to support the development of new health services…to encourage change and improve health outcomes.


Therefore, effective use of communication would not only educate the people about the most common social practices and behaviours that aid the spread of the disease in order to engender behaviour change, but can also ensure that such change is sustained. Sustainability of behaviour change among the general public is an important stepping stone to winning the war against viral hepatitis in Nigeria. What then is viral hepatitis, and how much damage has the disease done to mankind so far?


The Online Medical News Today reveals that the word hepatitis comes from the ancient Greek word „hepar‟ (root word hepat) meaning “liver”, and in Latin, it means inflammation. In essence, hepatitis means injury to the liver with inflammation of the liver cells. Viral hepatitis may however occur in acute or chronic forms. The most common causes of viral hepatitis are the five unrelated hepatotropic viruses: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D and Hepatitis E. Nevertheless, Hepatitis B and C are the most chronic and the leading cause of death among the five viruses. According to the Global Burden of Disease estimates, hepatitis B and C together caused 1.4 Million deaths in 2010, including deaths from acute infection, liver cancer and cirrhosis.


To put these figures in the context of other major infectious diseases, it is estimated that Malaria caused 660000 deaths in 2010, while Tuberculosis and HIV had 1.4 and 1.7 Million deaths respectively in 2011. This is a stunning indication of the endemic nature of viral hepatitis disease as a global health problem from which no country, rich or poor is spared. (World Malaria Report, 2012, Global Tuberculosis Report, 2012, UNAIDS Report on the global AIDS epidemic, 2012, Lozano, et‟al 2012).

Even though viral hepatitis has been in existence for a long period of time, it is only in 2010 that the disease attracted global attention as an endemic health threat when the World Health Assembly adopted resolution WHA 63.18 in recognition of viral hepatitis as a global health problem. The resolution emphasized the need for governments and populations to take action to prevent, diagnose and treat viral hepatitis, and tasked World Health Organization (WHO) to develop and implement a comprehensive global strategy to support these efforts. WHO‟s strategy was developed to address the following:


  • Awareness-raising, Partnership and Resource Mobilization


  • Evidence-based policy and Data for Action


  • Prevention of Transmission


  • Screening, care and Treatment


The 2010 resolution by World Health Assembly furthermore designated 28 July as World Hepatitis Day, envisioning this as an opportunity for Member States to promote awareness on viral hepatitis. The first official World Hepatitis Day was in 2011. The World Health Organization (WHO) encourages governments, international organizations, non-governmental organizations (NGOs) and civil society groups around the world to observe World Hepatitis Day with activities that call attention to the disease burden imposed by viral hepatitis, and to the prevention and control measures that need to be implemented. However, the extent to which WHO‟s aims can be achieved is largely dependent on the level of attention given to the disease by national governments, NGOs, Civil Society Groups and other related organizations across the world (WHO,2012).


Various researchers have revealed that the African continent is one of the regions of the world with an alarming number of people infected by viral hepatitis:


The African Region is estimated to have some of the highest prevalence rates for hepatitis A globally, with over 90% of children in sub-Saharan Africa exposed to the infection at the age of 10 years. The prevalence of hepatitis E in the Region varies from less than 2% in several countries to greater than 20% in Central Africa, while that of hepatitis B is estimated at 8% in West Africa and 5% to 7% in Central, Eastern and Southern Africa. (Aggarwal, 2010, Ott, et‟al 2012, Moh‟d, et‟al,2013, Jacobsen and Wiersma, 2010).


In Nigeria, the global outcry against the astronomical increase in viral hepatitis


infection rates has not been met with corresponding efforts to tackle the menace, especially


in relation to designing effective communication frameworks that will bring about concrete


and sustainable behaviour change. Studies reveal that over  one million Nigerians  are


estimated to be infected with Hepatitis B virus, making Nigeria one of the countries with


highest  incidence  of  HBV  in  the  world.  This  assertion  is  corroborated  by  Olusegun


(2010:02)who reveals that:


Unlike in the United States where the incidence of acute Hepatitis B Virus (HBV) infection is declining, due to the availability of hepatitis B vaccines, Nigeria and Africa as a whole is yet to record significant decline in the incidence of viral hepatitis. About 400,000 new acute HBV infections still occur each year. Of those new infections, about 10,000 infants acquire the infection during birth from their HBV-positive mothers. The implication of this is that, viral hepatitis is a serious health challenge confronting the nation which requires maximum attention. Yet, at the moment, there is no designated governmental unit or department in Nigeria that is solely committed to coordinating and, or  carrying  out  viral  hepatitis-related  activities.  What  the  government  has  is  a  viral hepatitis  prevention  and  control  programme  that  includes  activities  targeting  specific population: health care workers (including health-care waste handlers). Consequently, the average prevalence of hepatitis B virus (HBV) in Nigeria is estimated at 13.7% with higher prevalence in rural areas than urban areas. HBV is more common and spreads more easily than HIV, which has an average prevalence rate of 4.5% (Emechebe, 2009, Ott, et‟al, 2012, Moh‟d et‟al 2013).


There are many transmission routes for the disease depending on the type of the virus. However, transmission routes that have contributed greatly to the spread of hepatitis over the years include exposure to infected blood via blood transfusion, unsafe injection practices, including the use of unsterile needles and syringe, eating contaminated food and drinking unclean water, indiscriminate sharing of items like toothbrush and towel, unprotected sex and contact with body fluids of the infected persons, mother to child through breastfeeding and pre-chewing of food before feeding the child among others.


In view of the above, any effective onslaught against viral hepatitis must be targeted at changing these harmful practices. People must be made to know how these practices encourage the spread of the disease. There is a need to arouse people‟s awareness about the existence of the disease, its nature and the concomitant dangers associated with it before any meaningful behaviour change can occur.


More so, there seems to be a dearth of information on viral hepatitis despite efforts of the government and other concerned NGOs in combating the disease. Corroborating this assertion, Dr Funmi Lesi, a Consultant Gastroenterologist at Lagos University Teaching Hospital (LUTH) reveals that “HBV is a silent killer in our environment; unfortunately the people‟s knowledge of the virus is very faint” (Thisday, 2014). This underscores the imperative of a re-examination of the communication approaches and strategies being deployed by NGOs and other related government ministries or departments that deal with hepatitis disease in order to seek more creative ways of strengthening them for greater efficiency. When this is done, winning the war against viral hepatitis will be a reality. To carry out this task therefore, this study focuses on the communication approaches used by one of the organizations at the frontline of fight against viral and non-viral hepatitis in Nigeria known as Viral Hepatitis Association of Nigeria (VHAN).


Viral Hepatitis Association of Nigeria (VHAN) is a preventive and early detective consultancy medical association charged with the responsibility of advocacy and creation of awareness on viral and non-viral Hepatitis. The Association was inaugurated in Jos, Plateau State on October 31st, 2003. As an organization that was founded to promote public interest, it was formally incorporated as an organization on the 17th September, 2009 with the Corporate Affairs Commission.


The mission of the organization is to ensure a Hepatitis free nation/ Nigeria through the provision of value adding strategies for prevention of viral hepatitis infection. This is done through research, advocacy, encouraging governmental policies, seminars, and provision of products for all at risk of the disease and provision of strategic care for those infected. The vision of the organization is to see a Nigeria free of Viral and non-Viral Hepatitis infection.


The association has a list of strategic approaches it deploys in a bid to achieve its mission and vision that include: Researches, Advocacy, Professional Seminars, Public Lectures, Conferences (National, International, and Regional), Training workshops, and Publication. Much of the researches, awareness creation, screening, programmes and products administration on all the organization‟s beneficiaries are carried out by its medical professionals and consultants (Viral Hepatitis Association of Nigeria: Work Overview, 2014).

Enlightenment campaigns are one of the major activities of the organization nationwide. It is through this medium that VHAN gets to interact with people with the aim of creating awareness of viral hepatitis as a dangerous disease, educating them about the modes of transmission and how it can be prevented. In Kaduna, the organization carries out its campaigns to public places and institutions such as car parks, banks, schools and churches. This study therefore, did a critical study of VHAN communication approaches, that is, how the organization deploys them in creating awareness on viral hepatitis. The study has also dwelt more on the potency of these approaches not in creating awareness only, but how they have been able to engender sustainable behaviour change among the organization‟s target audience.


Among several interventions of VHAN, this study focuses on ECWA Goodnews School Narayi HighCost, Kaduna South LGA, Kaduna State. The school is one of the many education arms of the Evangelical Church Winning All (ECWA) that seeks to raise a Christ-conscious generation through effective teaching, discipline and the promotion of the fear of God among children. The school‟s mission is to nurture and train children in the fear of the Lord and instill discipline through learning. Located in the heart of Narayi HighCost, the school is housed in the compound of one of the biggest ECWA church in Kaduna metropolis: ECWA Goodnews Church, Narayi HighCost, Kaduna.


Established in 1994, ECWA Goodnews School Narayi HighCosthas both junior (JSS1-3) and senior (SS1-3) secondary sections. The school has carved a niche for itself as a beehive of academic and moral excellence as far as secondary school education in concerned in Kaduna State. Consequently, it has over the years become a regular port of call for many government and non-governmental organizations (NGOs) who seek to interact with students in special intervention programmes. More so, the school has a long standing relationship with VHAN that is why the researcher deemed it fit to engage both its students and the teachers in this study in order to examine the efficacy of the organization‟s communication approaches among its target audience. The school‟s population cuts across both adults and children which made it a more suitable ground to carry out a study of this nature because everyone is vulnerable to viral hepatitis.


Another category of people which VHAN interacts with are those who have been infected by viral hepatitis. These people usually visit the organization for treatment and counselling on how to manage the disease. The population of these patients cut across those living within Kaduna metropolis and those from other local communities within Kaduna State. Therefore, they also form part of the study population. The organization also conducts research worldwide to improve policies, programmes and products in the area of viral and non-viral hepatitis.


The current National President of VHAN reports that, “with over ten years of operational experience, we have been able to create awareness against viral hepatitis to more than three million Nigerians. As at today, we are number one ranking as providers of services concerning Viral Hepatitis…” (Olusegun, 2010). This testimony calls for a critical reflection on the issue of viral hepatitis, especially against the backdrop of the current astronomical increase in the number of people being infected daily by viral hepatitis infection in Nigeria. Could it be that the people are aware of the existence of the disease, yet not aware of how to prevent it? Or could it be that the people are not yet fully aware of some of the harmful social practices that aid the transmission of the disease? These are some of the knotty issues that the study has set out to untie.


1.2 Statement of the Research Problem


There has been a persistent increase in the number of people getting infected by viral hepatitis worldwide. An estimated 400 million persons worldwide have been infected with Hepatitis B virus and more than 350 Million have chronic life-long and life threatening infections. Also, 1.5 million deaths have been recorded each year as a result of viral hepatitis according to the most recent statistics released by the World Health Organization to mark this year‟s World Hepatitis Day (28/7/2016). Emechebe et‟al, (2009) reported that Hepatitis B virus carriage rate in Nigeria ranges from 9-39%, and a carrier rate above 7% in a population is classified hyper endemic.


Although various campaigns have been embarked upon by many Non-Governmental Organizations (NGOs) to create awareness on the disease, these campaigns have largely been ineffective. This is evident in the fact that the prevalence rate of people getting infected by viral hepatitis keeps on increasing by the day. This grim situation is worsened by the existence of some social practices that are common in most African societies which include among others, poor attitude to health care issues, pre-chewing of food by mothers before feeding a child, over reliance on traditional herbs instead of proper medical test, sharing of items like toothbrush, razors, nail clippers and towel, eating contaminated food and drinking unclean water, and transfusion of infected blood to patients in the hospital.


Worse still, there seem to be a dearth of public awareness about these social practices that aid the spread of the disease in rural and urban communities. Many people may have heard about viral hepatitis disease, but they are not armed with the working knowledge of the dangers that are associated with the disease. There are also communities whose knowledge level of viral hepatitis is very low due to paucity of information about the disease.


The poor access to information on viral hepatitis, especially on the harmful social practices that aid the spread of the disease is owing to several variables, among which include the ineffective communication strategies deployed by most government and non-governmental organizations (NGOs) which do not take a holistic view of the cultural, traditional and social variables that encourage the spread of the disease.


Therefore, there is a need to re-strategize the communication approaches being used in order to make people to avoid such negative social practices. In order to achieve this, key community stake holders need to be involved in the entire communication process because it is when the people actively participate in the process that the success and sustainability of the intervention could be highly guaranteed.


This study therefore, seeks to investigate the communication approaches used by Viral Hepatitis Association of Nigeria (VHAN) with a view to determining their implications for behaviour change.



1.3 Aim of the Study


Given that viral hepatitis is a deadly disease that has continued to claim more than a million lives worldwide every year, the ultimate aim of this study is tostrengthen the viral hepatitis communication approaches used for interventions in order to realize a lasting behaviour change among the people in Nigerian communities.



1.4 Objectives of the Study


The research is set to achieve the following objectives:


  1. To investigate the role played by VHAN in enhancing people‟s awareness and knowledge of viral hepatitis.


  1. To critically examine VHAN‟s communication approaches deployed in Viral Hepatitis interventions and their implications for behaviour change.


  • To determine factors militating against communication for change on hepatitis issue.


  1. To suggest ways through which viral hepatitis disease can be effectively communicated among the local communities in Kaduna, and by extension Nigeria.



1.5 Research Questions



The study seeks to address the following questions:


  1. How much do people know about viral hepatitis as a result of their engagement with VHAN?


  1. How is hepatitis being communicated by VHAN and what are the implications of the communication approaches used for behaviour change among community members?


  • What are the factors militating against effective communication of viral hepatitis?


  1. What measures can be taken to strengthen existing communication approaches, thereby making hepatitis intervention more effective and sustainable?


1.6 Significance of the Study


The study seeks not only to increase people‟s awareness and knowledge on the existence of the viral hepatitis, but also to point out some of the social, traditional and cultural practices that encourage the spread of the disease. This is anchored on the belief that if the war against viral hepatitis must succeed, these harmful social practices and behaviours must be changed.


This study is also significant because it explores the potency of communication approaches employed by VHAN in improving knowledge on viral hepatitis and creating more awareness on social practices that encourage the spread of the disease. More so, it analyzes the strengths and weaknesses of these communication approaches and also suggests ways through which they can be strengthened for greater efficiency, especially in engendering sustainable behaviour change among the organization‟s target audience.


The alternative measures on how to consolidate the existing communication approaches of the organization suggested in study can also serve as communication templates for other government ministries and related NGOs concerned with engendering sustainable behaviour change among their target audience.


The research also contributes to the advancement of knowledge in academia and it is also hoped that policy makers and other concerned institutions will have access to the findings of this study and apply it to improve the campaign against viral hepatitis in Nigeria.



1.7 Scope of the Study


Although the campaign against viral hepatitis is a cause being championed by various NGOs across the country, the researcher focused on the mode of operation of Viral

Hepatitis Association of Nigeria (VHAN), Kaduna Chapter. The choice of Kaduna was necessitated by the findings of several research which indicate high rate of viral hepatitis infection in the state.


One of such studies was conducted in 2010 at the Department of Haematology/ Immunology, Ahmadu Bello University Teaching Hospital (ABUTH) Zaria, involving randomly selected blood donors (voluntary and commercial) between the age of 15 to 60 years, who patronize the hospital to donate blood to patients as relatives or otherwise. The findings of that study indicate a hyper prevalence rate of viral hepatitis, with the highest prevalence among men (86.6%) as against women with the prevalence rate of only 13.3%. (Alhassan, S. et‟al, 2010).The implication of this is that, if this negative trend is not given due attention, the vision of achieving a Hepatitis-free nation will remain elusive.


In its bid to combat viral hepatitis in Kaduna State, VHAN carries out enlightenment campaigns in public places and institutions such as car parks, banks and schools. The organization also extends its activities to rural communities within Kaduna State. However, most of the organization‟s activities are restricted within Kaduna metropolis. In these places, they usually engage people in discussion about the disease with the aim of creating awareness among the general public.


Among the institutions covered by VHAN within Kaduna metropolis, the researcher restricted himself to ECWA Goodnews School Narayi HighCost, Kaduna in order to carry out a more comprehensive study of the approaches used by the organization in the case study school where some members of staff and students of the schools were engaged on the subject matter. The researcher also engaged the patients from communities within and outside Kaduna metropolis who are currently receiving treatment in the organization.


Focus group discussions were used to elicit vital information from the patients, staff and students‟ groups. More so, only senior students (SS1-3) were engaged. This study is mainly concerned with the communication approaches used by the organization under study.


In other words, the study explored how enlightenment campaigns are carried out by the organization in the case study school, and how they have helped in enhancing staff and students‟ knowledge on viral hepatitis. The effectiveness of counseling method, which is the main communication approach used by the organization on its patients was investigated to ascertain whether it has helped in influencing their attitudes and behaviours towards hepatitis related issues among them or not. The issue of audience participation which is very crucial in health communication was also explored in this study.



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