Introduction
Cholera is a disease named after the bacterium that causes it, Vibrio cholerae. The first cholera outbreak in the world was in India in the year 1817, where it lasted till 1824. It later spread through trade routes to Southeast Asia, the Middle East, Europe, and Eastern Africa (WHO, 2022). Cholera remains a significant public health challenge in many developing countries of Africa and other regions of the world (Adraino, Nazir & Uwishema, 2023; Girma, 2022; Ihenachor, 2024; Shaeen, 2023; Thompson, 2020; WHO, 2024). In June 2024 alone, multiple outbreaks were recorded in 18 countries across four World Health Organisation (WHO) regions, including the Eastern Mediterranean Region, with the highest number of cases in the African, European, and Southeast Asia regions. The period also saw 166 cholera-related deaths globally. Nigeria, a sub-Saharan country in Africa, is not an exception to the devastating health challenge cholera poses (Ihenachor, 2024). Other African countries that have recorded the prevalence of cholera in the last decade include Ethiopia, Ghana and Malawi (Adraino, Nazir & Uwishema, 2023; Oluigbo, 2024). The menace of Cholera in Nigeria is evident in its reoccurrence every year, even though Dr Chikwe Ihekweazu had in 2018 stated that Nigeria should not be talking about cholera in that year (Channels TV, 2018), six years after, the country still has cholera outbreak as one of the challenges to contend with. Little wonder that cholera has been referred to as “an old enemy in the modern world” (Africa News, 2024; Oluigbo, 2024). The situation in Nigeria is that of a triple health crisis because, before the emergence of the outbreak, in June 2024, there had been Lassa fever and meningitis outbreaks.
Batta (2013) observes that after life itself, the next most important asset is health, which refers to “the state of complete physical, mental and social well-being” (p.130), which, when enjoyed, allows humans to function in other spheres of life. Diseases impede humans from realising their potential (Okon, 2015). As Musah (2019, p.74) noted, “If the health of a nation is threatened by an epidemic or plague, the deployment of national resources to curb it is given right of precedence over other national issues.” Also, Yang (2018) argues that there is a strong correlation between the level of dialogue between the government and its public and the credibility of risk information in health crises. This explains why the present cholera outbreak was declared a health emergency on June 9, 2024, in Lagos, the most populous city in Africa, after 324 alleged cases, making it the disease’s epicentre. Over the past decade, cholera has killed many.
A vast array of studies in Africa has made cholera its research focus. Many of the studies have found strong support for the need for health risk education through communication (Adeneye, 2016; Anetor & Abraham, 2020; Ogbeyi, 2017; Sow, 2022). Ogbeyi (2017) found that the majority of his respondents were not able to define cholera. All these highlight the need to increase the awareness and knowledge of the treatment, control and prevention of a disease like cholera. While communication serves as a useful tool for preventing and controlling diseases, much needs to be done to understand the type of communication that can curtail the incessant outbreak of cholera in a high-prevalence location like Nigeria.
Ndugu et al. (2021) studied the Kenyan government’s use of interpersonal communication in influencing men’s behavioural response to prostate cancer screening, using a mixed-method approach. They deployed a mixed-method survey and focus group to study men between forty years old and above. They deployed a simple random sampling. They found that the Kenyan government, at local and national levels, did not implement adequate interpersonal communication strategies to engender positive behavioural responses to the menace. They recommended that the government consider effective interpersonal communication strategies in its annual budget.
The progression in the containment efforts was hailed in the 2024 outbreak because, despite the increase in cholera cases in 2024 resulting in suspected cases rising by 220% in contrast to 2023 (The Punch Newspaper, 2024), there was a 62% reduction in suspected cases of cholera in 2024 compared to 2023. Also, the mortality rate was reduced by 71% (Punch Newspaper, 2024; WHO, 2024). All these point to the need to study the role of social and behavioural change communication in the seeming success story of containment.
Problem statement
The health status of a country and its development are intrinsically related. Despite the importance of communication in effective health promotion, in the past, it was often assumed that there was not enough communication in health enhancement endeavours (see Handebo et al., 2024; Thompson, 2020; Hailu, 2020; Ndolo & Ozoh, 2013; Ojo & Servae, 2013; Agbana & Usman, 2012; Ogbeyi, 2017; Solo-Anaeto, 2010; Okon, 2002; Okpoko & Azienge, 2014; Musah, 2019). This situation has led to scepticism about cholera eradication in third-world countries before the 2030 deadline given to the Global Task Force on Cholera Control (Charnley et al., 2023). Not many studies have delved into whether the strategies for communication of health are still inadequate in recent years, when hunger and diseases are increasing to compound people’s livelihoods, as well as the paradox of gain or harm being one of the realities of living with modern communication gadgets. Thus, Waisbord (2014) opined that efforts of behavioural change communication in health interventions often concentrate on strategies that tackle behavioural change at individual levels, not at community levels. In the same vein, Laninhun & Oyeleye observed that prior research only concentrated on how people respond to disease prevention without taking cognisance of the content of information (in the context of this paper, the focus is the strategies of communication) This gap informed the decision to embark on this study which seeks to establish the communication strategies deployed to tame the surge of the 2024 cholera outbreak in Nigeria. Musah (2019) stressed the need to identify communication strategies that are significant to individuals’ “way of life” (p.70) and how they culminate into awareness creation and ensuring compliance with healthy behaviours because, according to Fuller (2019), context is crucial to meaning-making. This study may help to gauge the extent to which Nigeria is inclined towards the attainment of Sustainable Development Goal 3, which has to do with good health and well-being (Osuagwu, 2022) and the African Union’s Agenda 2063.
This study provides preliminary evidence that social and behavioural change communication (hereafter referred to as SBCC) is gradually gaining popularity in health communication domains. This is in line with Schiavo’s (2016) observation about the need to address concerns about social, behavioural and policy change among different health stakeholders. Especially because in the context of new media, communication is more sophisticated and more equipped to change behaviour than in the past (Waisbord, 2014) because of its attribute of broad reach and the capacity to tackle negative attitudes that impede disease prevention (Mazonde & Goldstein, 2023). The new media can also address both individual and structural behaviour change (Elder et al., 2014; Higgs et al., 2014; Storey & Obregon, 2023)
Research Questions
1) Which elements of the social and behavioural change framework, including new media, were employed in public health information dissemination during the 2024 cholera outbreak in Nigeria?
2) What arrays of conventional and new media public health information dissemination channels were utilised during the 2024 cholera outbreak in Nigeria?
3) What challenges impeded the conventional and new media public health information dissemination during the 2024 cholera outbreak in Nigeria?
Communication and health
Communication is one of the strategies for tackling diseases at pandemic and epidemic levels (Nwasum & Abaneme, 2022; Ndolo & Ozoh, 2013; Paek, et al., 2010; Okoro & Nwachukwu, 2015) especially because the world has never been free of diseases; in this present day, new diseases are combining with old ones and as well as their variants to threaten humanity. This explains why, since the past decade, health communication has been accorded a special place in global scholarship.
According to Ojo & Servaes (2013), individuals’ comprehension of issues relating to health is better when placed within the ambit of a “well defined communication process and information dissemination...” (p.156). Health communication encompasses the concepts of health and communication to mean the utilisation of communication strategies to inform and influence individual and community decisions for health enhancement (Centres for Disease Control, 2011; Dutta, 2010; Okoro & Nwachukwu, 2015). Thus, the importance of effective communication includes the creation of awareness of health risks and solutions, motivating people for risk reduction, affecting or reinforcing attitudes and providing information geared towards making complex choices like choosing health plans, care providers and treatments. In addition, health communication influences policy advocacy, influences public agenda for positive health promotion and enhancement of social norms that are beneficial to healthy behaviour and quality of life (Schiavo, 2014; National Center for Health Statistics, 2012) Suffice to say that health communication is effective when it conveys factual and scientifically based messages taking cognisance of audience differences and reaches them in familiar mediums (Musah, 2019; Okpoko, 2013; Ojo & Servae, 2013).
It is noteworthy to note that not every health communication is successful (Okoro & Nwachukwu, 2015; Innocent, 2016). This underscores the importance of planning and execution in health communication as a process-driven endeavour as opposed to a haphazard one. Thus, a UNESCO document entitled “Twelve Steps in Health Communication” has identified some steps in achieving effective health communication outcomes. In what follows, the steps will be summarised:
1. Clearly define the health behaviour that is being promoted.
2. Decide the particular population to be influenced to produce age and culturally-appropriate messages.
3. Determine the new skills required for the new health behaviour.
4. Learn the target audiences’ current health knowledge, beliefs and behaviour.
5. Ascertain whether the current health behaviour being promoted has already been done previously.
6. Find out the present health information sources for the target audience.
7. Select the communication channels or media most appropriate for reaching the target audience. Mass media channels consist of radio, television, newspapers, magazines and new media. On the other hand, interpersonal channels are health professionals, community health workers, religious and community leaders, traditional health practitioners, women’s and youth organisations, school teachers, and development and development workers.
8. Mix multiple channels of communication for the target audience to receive the message on various sides. Health messages should be designed using local languages/dialects and expressions that are colloquial for easy comprehension. Messages should be brief, relevant, positive, practical, technically correct, and culturally and socially suitable.
9. Educational materials should be developed and tested.
10. Align educational programmes with other health and development services, taking cognisance of social and infrastructural deficits that can impair campaign goals. In other words, educational programmes and the availability of health facilities like hospitals, drugs and medical personnel must complement each other; to make sure what is needed is available (For instance, in this instance of a cholera outbreak, campaigns are emphasising on hand washing even when hand washing facilities are not readily available in public places).
11. Evaluate whether the new behaviour is being adhered to or implemented.
12. Repeat and adjust the messages intermittently over many years.
The outlined steps for effective health communication align with the four Cs of effective communication, which include the communicator, content, context, and channels. The applicability of these steps is not limited to urban health communication; they are particularly relevant for conveying health messages in rural areas, where the majority of the population is underserved and impoverished. Such individuals require an increasing amount of communication to adopt healthy practices. Hence, there is a need for an approach that is dialogic, promotes mutual learning, and builds consensus (Ndolo & Ozoh, 2013). In this regard, theatre (when applied in the context of SBCC) can serve as an essential tool for instilling attitudinal change and development (Adeyemi, 2019; Ezeaka, 2022).
Channels of health promotion interventions
Channels of communication refer to means, vehicles, media or forms through which information or messages are passed to people for healthy habits (Abba et al, 2021; Yar’Adua, Msughter & Usman, 2023). Some of them include newspapers, magazines, radio, television, video games, CDs, and internet facilities (Haruna & Ibrahim, 2014, Yar’Adua, Msughter & Usman, 2023) The attributes of cost and reach have always made the mass media indispensable in health behaviour change communication (Yar’Adua, Msughter & Usman, 2023). The media influence knowledge and behaviour towards health promotion in dual contexts, which include deliberative and or incidental contexts.
Radio has frequently been praised as a medium that penetrates all strata and transcends literacy barriers, suggesting it is well-suited for reaching underserved communities in rural areas (Moemeka, 2000, citing UNESCO, 1965). The formats of radio for health promotion and development include “jingles/spot announcements, drama and playlets, talks and features; short stories; question and answer sessions and speeches from community/political leaders” (Okoro & Nwachukwu, 2015, p.75 citing Moemeka, 2000).
The above steps, as prescribed by UNESCO (nd) are vital to the success of every health communication aiming at changing behaviour. However, the eight steps that pertain to media channels did not add the new media like Facebook, YouTube, X, TikTand their actors like bloggers, citizen journalists, content creators and influencers. Such serves as a potential avenues for communicating with the youths and teenagers.
Radio is an auditory medium that appeals to the ear (Ibbi & Furomfate, 2021) and has played a significant role in broadening citizens’ media access. Radio is accessible to the majority of people because it is cheap and affordable.
Television is also a powerful communication tool because of its attributes of sight, sound and motion (Anaeto & Anaeto, 2010), which is in addition to its entertainment value and demonstrative ability (Ibbi & Furomfate, 2021; Wagumba & Kamau, 2021). Community viewing centres exist in some rural areas where people gather to get informed and enlightened on health-related issues like water, sanitation, and family planning, among others. One of the strengths of television in health promotion is the ability to increase exposure and recall of messages (Ihechu, 2021). The author argues further that messages have to be carefully crafted in such a way that message reception aligns with message adoption. For instance, the hand-washing preventative campaign strategy to curb the spread of COVID-19 in Abia did not have a high adoption rate because of the use of the President of the country, whom the residents of the state did not identify with.
Studies have demonstrated that entertainment or creative arts have inherent edutainment features that are beneficial to society (Ibrahim & Alatu, 2021; Omoera, 2021; Shaka & Uchendu, 2012). Like Ojo & Servae (2013), Leeuw (2021) argues that movies like Contagion (2011) and Outbreak (1995), Laurie Garrett’s The Coming Plague (1994) were used to present facts about diseases and demand vigilance in the past.
Hence, films, which are images and motions viewed on screens or in cinemas, have the potential for reaching a large audience. According to Shaka & Uchendu (2012), films are a vital mass communication tool that transcends national and cultural boundaries owing to their global distribution. If properly harnessed, films’ health promotion attributes include highlighting country life and culture. However, Ojo & Sevae (2013) observed that despite their potential for engendering behaviour change, “only a few Nollywood (Nigerian) movies have engaged in health-related issues and awareness campaigns...” (p.159).
Newspapers are also a potent medium for health communication (Agbana & Usman, 2012; Okpoko & Azieneger, 2014). According to Nyekwere & Ajaero (2013), newspapers can set the agenda for health discourses that culminate in behaviour change. They argue that through editorials, news stories, special reports, news analysis/interpretation reports, reviews, portraits/personality profiles, features, advertisements, reviews/criticisms, newspapers increase participation through community conversations. However, Laninhun & Solomon’s (2021) study found that print materials were not apt for audiences in rural areas. Also, Mukenge (2021) found that posters were not effective in the campaign for voluntary medical male circumcision in Zimbabwe because the posters challenged the existing notion of masculine identities in the country.
The mainstream mass media in general have been accused of a shortage or inadequate coverage of diseases like cholera, HIV/AIDS, diabetes and child mortality in developing countries (see Ojo & Servae, 2013; Okon, 2014; Okon, 2011; Musah, 2019; Nyekwere & Ajaero, 2019). This inadequacy or lack of coverage is more evident in rural areas (Ata-Awaji, 2019; Ochonogor, 2019). Hence, this situation accounts for disease prevalence.
Interpersonal communication is one of the communication arsenals for maximising health interventions that border on behaviour change (Ndung’u et al., 2021). The interpersonal level refers to all dyadic relationships that occur between healthcare providers and their patients or clients (Batta, 2013), often in face-to-face contexts. When applied to health promotion endeavours, interpersonal communication allows patient-centred care and helps to ensure culturally appropriate messages, which, when not in place, often pose barriers to effective health communication (Woods et al., 2014; Ndung’u et al., 2021). Hence, for any genuine behaviour change intervention to succeed, interpersonal communication must be given its prominence.
The traditional channels of communication, although often less acknowledged in health communication, also serve as viable outlets for health information dissemination in the traditional setting. The traditional outlets of communication appeal to communities because they facilitate dialogue, learning, respect for traditional values and symbols, and ensure message credibility (Nwasum & Abaneme, 2022; Ekpe & Wilson, 2022; Asadu, 2012), as they offer the type of culture-centred approach to health communication equality that Dutta (2018) suggested. Some traditional modes of communication are town criers, talking drums, storytelling, folklore, myths and cultural artefacts. They are usually classified into instrumental, demonstrative, iconographic, visual, institutional and extramundane modes (Nwasum & Abaneme, 2022, citing Wilson 1998).
The new media can transcend the barriers of the mainstream media. They have brough huge transformation to how health information is disseminated and have proven to be effective (Chen & Wang, 2021; Wang & Tang, 2021;) They have complemented and extended capabilities and have made life more convenient and better through decentralised communication, agenda-setting effect for behaviour change, knowledge enhancement and community engagement (Adelakun et al., 2021; Anaeto & Anaeto, 2010; Ata-Awaji, 2019; Cambell et al., 2014; Dapoet & Moven, 2021; Park & Kaye, 2018). Specifically, Ata-Awaji (2019) notes that media consumption in the digital era is characterised by source plurality, leading to further discussions of issues in micro and macro categories of society. Wang & Tang (2021) demonstrated the efficacy of new media on behaviour change in their study which found that those exposed to Weechat were more likely to adopt healthy behaviours than those who did not. Even as far back as a decade ago, some rural areas had genuinely embraced their potential (Igboaka & Ha, 2010). Thus, convergence, which refers to the coming together of diverse media where print and broadcast media exist online (Campbell, Martin, & Fabos, 2017; Campbell et al., 2014), has made it possible for new media to be an enhancer of healthy living.
The new media are available to all age groups in society, with their popularity more prevalent among the younger ones as prosumers (producers and consumers) (Ayedun-Aluma, 2017), and as Chen & Pain (2021) have noted, they are complementing the mainstream media in information dissemination. Ignorance about issues in the social system is abating because of the proliferation of digital media’s accessibility, interactivity, audience duplication capability and participatory features (Dapoet & Moven, 2023; Ogaraku & Archibong, 2017; Adelakun et al., 2021; Lee & Ying, 2021), which are culminating in new engagements (Adeniran & Atofojomo,2017). Hence, Adelakun et al. (2021) argue that comments on social media posts serve as metrics on attitudes towards a particular health communication agenda. Similarly, Yang et al., (2018) study has established that new media like online health forums serve as sources of community support of “warmth and helpfulness” (p.1037) from peers and fellow patients who can identify with each other.
In the same vein, Yar’Adua, Msughter & Usman (2023) noted a significant relationship between development, social change and digital media and stressed that: “Nations around the world are harnessing the potential of digital resources and cyberspace to grow and transform their societies in all sectors.”
Despite the pervasiveness of the digital media, Ata-Awaji (2019) stress that “Issues such as erosion, malnutrition, cholera, dilapidated public structures, rape, juvenile delinquency” and other happenings are infrequently reported in rural areas and this further buttresses Dutta’s (2018) notion of communication inequalities. He attributed the situation to urbanised journalism, the lack of computer literacy and ICT tools. He suggested the need to extend internet coverage to rural areas and educate rural dwellers on the need for smartphones. In this same vein, in this regard, Yar’Adua, Msughter & Usman (2023) asserted that Nigeria has not tapped the huge resources of digital media to improve the quality of life of its citizenry.
The new media have had their fair share of criticisms. They have been accused of inducing depressive thoughts (Ogunsesan & Adeniji, 2021), perpetrating fake news and fake identities (Msughter, Mojaiye & Maradun, 2023; Madaki, 2023; Onobe & Okocha, 2023) and posing a threat to people’s lives (Fuller, 2019).
The potential of communication channels in instigating behaviour change for healthy practices notwithstanding, Ojo and Servae (2013) noted that the various approaches to health communication are not always effective when applied in isolation. Necessary behaviour change can only be achieved when the broad aspect of the environment that inhibits change is combined with strategies. This observation necessitates the application of the social and behavioural change model as discussed below to this study.
Interpersonal communication is one of the communication arsenals for maximising health interventions that border on behaviour change (Ndung’u et al., 2021; Onwunali & Lagada-Abayomi, 2021). When applied to health promotion endeavours, interpersonal communication allows patient-centred care and helps to ensure culturally appropriate messages, which, when not in place, often pose barriers to effective communication (Woods et al., 2014; Ndung’u et al., 2021). Hence, for any genuine behaviour change intervention to succeed, interpersonal communication and new media must be given prominence in health campaigns.
Knowledge of Cholera and Prevention
Prior research on cholera and communication tends to focus on knowledge, highlighting the critical role of health education in enhancing awareness and prevention of the disease, as opposed to how communication is deployed. These studies generally conclude that communication can help disseminate knowledge about cholera and preventative measures, with little concern for strategies deployed. Only a few studies recognised Social Behaviour Change Communication (SBCC) as a viable and all-encompassing approach that can address knowledge differentiations across the intersection of age, gender and socio-economic status, among others (See Adeneye et al., 2016). Still, the existing studies seem to focus on quantitative or mixed methods, therefore, ignoring comprehensive qualitative research endeavours.
Anetor and Abraham (2020) found that younger residents in Durumi had better knowledge of cholera and its preventive measures compared to older individuals, indicating a need for targeted health education for those over 50 years of age. Similarly, Ogbeyi et al. (2017) reported that only a small proportion of respondents in a Makurdi slum could correctly define cholera, emphasising the importance of community involvement in health education. Anetor (2020) further confirmed that demographic factors such as age, gender, and education significantly influenced cholera knowledge and prevention practices. Additionally, Adeneye et al. (2016) identified poor sanitation and limited access to clean water as major risk factors, underscoring the necessity for comprehensive educational programs to improve cholera awareness and control in affected communities.
Adeneye et al. (2016) were concerned with the risk factors associated with the 2010 cholera outbreak in some Nigerian states. Their survey of patients and/or their parents/guardians in Bauchi and Gombe States in North East Nigeria showed a lack of knowledge about cholera transmission routes and poor sanitation practices as risk factors for cholera outbreaks in Nigeria. The study also found gender differences in the lack of knowledge about the risk factors for cholera. In this regard, the study underscores the need for educational programmes.
Anetor & Abraham (2022) studied the residents of Durumi in FCT Abuja to establish their knowledge of cholera and its preventative measures to “get baseline information and ascertain the role of health education in curtailing cholera in the community.” Using a descriptive survey design and multistage sampling technique, they selected 360 participants comprising 171 females and 159 males. Their study showed “adequate” knowledge and awareness of cholera preventive measures. However, they found a paucity of knowledge and awareness of cholera preventive measures among respondents aged 50 years. They recommended that targeted health education should be utilised in cholera prevention.
Onwunali & Lagada-Abayomi (2021) were concerned with the communication strategies used to implement the public health campaign used in the National Immunisation Plus Days in Agege Local Government in Lagos. In addition to examining the strategies, their study sought to establish the effectiveness and challenges of the campaign. The study adopted survey and interview methods and found that the strategies deployed were effective, as the majority of the respondents voluntarily released their children for immunisation. They also found that chief among the challenges that impeded the frequency of reception of the messages was the use of a foreign language or a local language that was alien to the people and the non-usage of community and religious leaders to give information.
Adelakun et al. (2021) examined the contents of Facebook for the period of the first five months of the COVID-19 pandemic in Nigeria. The study found a second layer agenda (competition of agenda within the same issue) as agenda that borders on palliatives competed with containment, lockdown and political permutations and world leaders and their local collaborators’ frames. They suggested further studies to explore comparative analysis to explain the correlations of variables and that subsequent studies should focus on other social media platforms to analyse social media framing effects on health epidemics.
Social and Behavioural Change Communication Approach
Social and Behaviour Change Communication (SBCC) is a novel approach to communication that evolved from the Behavioural Change Communication (BCC) approach. The criticism of the BCC as an individualistic approach heralded the formulation of SBCC. Thus, it is a data and theory-driven and tailored communication approach aimed at engendering positive changes in behaviour, attitudes, knowledge, norms, beliefs, and across various strata of society (Unicef, 2024). The theory combines communication strategies from mass media, advocacy, marketing and community mobilisation to enhance individual and social change. Accordingly, Ineji (2019, p.11) explains that:
BCC metamorphosed into SBCC that uses a combination of strategies, unique techniques, participatory and interactive communication processes, employs multimedia for awareness creation, addresses social and cultural norms, and uses ecological perspectives to address issues at the individual, community and societal levels during interventions.
The recognition of the interdependence among individuals, social relations and the broader structural and environmental systems like culture, community, gender, as well as socio-political contexts, necessitated the addition of ‘S’ to BCC (Remsberg, 2017; Ineji, 2019). SBCC is an evidence-based approach designed to tackle complex behavioural issues. Its goal is to comprehend the socio-ecological context that impacts behaviour, taking cognisance of the role of multiple micro and macro factors that underlie an individual’s actions. Such factors range from family/friends, community, and broader societal structures. The theory is rooted in behaviour science and highlights the significance of engaging with the target audience to develop tailored communication strategies that resonate with their specific contexts and needs.
As a theory-driven approach, SBCC utilises existing theories to analyse situations, define problems and highlight solutions. The theories include planned reasoning, stages of change, precaution adoption process, health belief model, diffusion of innovation, participatory model, social/cognitive learning, value change theory, social network and social support theory (Ineji, 2019; Ndolo & Ozoh,2013). All those are often referred to as change theories.
Decolonising communication is a precursor to social change (Dutta, 2015). In the same vein, Ndolo & Ozoh (2013) stress the need for communication to target behaviours and practices of individuals, households, and communities in addition to conventions and social norms. Thus, the efficiency of SBCC in all contexts of social change is often explained through the social-ecological model, which identifies four levels of influence on behaviour as analysed in what follows.
First, is the Individual Level where personalised factors such as knowledge, attitudes, and skills are identified as factors for behavioural influence. Second, Family and peer networks also serve as influencing factors through close relationships and social support. The third level is the community, which constitutes contextual elements like community leadership and service provision. The last level is called the social/structural level, which embeds broader societal influences like cultural norms, policies, and economic conditions. Ineji (2019) call these models “strategies” and condenses them into three. In this context, the three major strategies often deployed in SBCC include, first, behaviour change communication which targets change at the individual level by disseminating information to dislodge beliefs, attitudes, knowledge and practices that are inimical to change. The second strategy is social mobilisation, which involves collaborations among the community, stakeholders and partners to engender a sense of ownership and participation. The last strategy, which involves influencing decision-makers and political leaders to extract acceptance, commitment and deployment of resources at the societal level, is known as advocacy.
All these levels are targeted in SBCC interventions aiming to address barriers and enhance positive outcomes. This aligns with Relly & Gonzalez de Bustamante’s (2017) position that collective actions help bring about positive social change.
Besides being a socio-ecological model/strategy, SBCC as a process uses the C-planning model, which uses five different stages in planning communication interventions. The stages include understanding the situation, focusing and designing, creating, implementing and monitoring, monitoring and evaluation and evaluation and replanning (Ineji, 2019).
Yet, Okoro and Nwachukwu (2015) argue that sometimes health awareness campaigns do not always result in the adoption of health interventions. A study has demonstrated how family planning methods promoted through broadcasting had not yielded any significant increase in adoption and another study has shown that anti-discriminatory messages on HIV/AIDS have not stemmed discriminatory practices (Omoera, 2010; Ochonogor,2005). They identified education, efficacy of the promoted intervention, culture, socioeconomic factors and message design as some intervening variables that can hinder the “acceptance, receptivity and adoption of health interventions” (Okoro and Nwachukwu, 2015, p.68).
This approach provides evidence for the nature of communication aimed at eradicating cholera in Nigeria. In this regard, the SBBC deployed in the 2024 cholera outbreak, as highlighted, may serve as a model for other outbreaks like monkeypox (a currently ravaging disease also), meningitis and Lassa fever among others. Adeneye et al. (2016) assert that efforts to increase knowledge on cholera in communities should embrace educational programmes through information, education and communication/behavioural change communication. In this context, SBCC recognises a variety of communication channels to maximise reach and impact. The channels include interpersonal communication, social media, mass media campaigns, and community engagement initiatives. The strategic mixture of these channels is important for engendering sustainable behaviour change.
SBCC interventions are evidence-based and developed through a systematic process that includes formative research to identify barriers to behaviour change and the motivations that can facilitate it. This research informs the design of comprehensive interventions tailored to the specific audience, ensuring that communication efforts are grounded in data and community insights.
Criticisms of SBCC
SBCC has been criticised for its limitations, which include the following: One, when used alone, it is inadequate for achieving social and behavioural change outcomes as it often only disseminates information, encourages policy compliance and neglects the structural and social barriers that obstruct sustainable behaviour change. Two, SBCC programmes are said to lack enough funds and staff, consequently making them function optimally during health emergencies (sbcguidance.org, n.d.). Closely related to funding and staffing is the challenge of inadequate coordination, which sometimes results in conflicting interventions and a lack of compliance (Gonah & Nomatshila, 2024). Three, the lack of recognition of the significance of technology in health information management during a pandemic is a challenge to the implementation of SBCC tactics in health. Difficulty quantifying behaviour change impact makes evaluation difficult. Fourth, is the challenge of infodemic management, which borders on combating misinformation for effective communication to thrive (Gomah & Nomatshila, 2024). Last are the obstacles to behaviour change, which range from the lack of environmental support for making behaviour easy to adopt, the lack of social proof and the lack of ownership and autonomy owing to nonparticipation (Dirkson, 2016).
According to Dirkson (2016), the challenges can be surmounted when SBBC tactics involve good feedback mechanisms and modelling behaviours through opinion leaders and testimonials. Allowing people to think about and generate solutions is another remedy.
Cholera Education Guide for Community Engagement
In May 2024, ICAP (a Colombian-based global health organisation) supported the Nigeria Center for Disease Control and Prevention (NCDC) in surveying over 16,000 respondents. The essence of the survey was to “assess knowledge, attitudes, and perceptions (KAP) of cholera among Nigerian communities. This effort, supported by The Global Fund, aimed to inform evidence-based interventions and social and behaviour change communication (SBCC) messages for cholera prevention, and ultimately catalysed the development of an important cholera education guide now utilised across the country by 500 health educators in 22 Nigerian states” (ICAP, 2024).
The Survey’s findings showed that the respondents trusted their sources of health information and also revealed open defecation as the major cause of cholera. Hence, the findings made ICAP in Nigeria, in partnership with the Risk Communications and Community Engagement (RCCE) unit of the NCDC and technical partners, develop a cholera education guide for the deployment of state and local health educators during community engagement activities. The guide contains information on cholera sources of transmission, methods of prevention and the preparation of Oral Rehydration Solution (ORS). Also, a section on information was included to address communication lapses in cholera education as evidenced in the surveys.
The guide underscores the importance of communication as one of the ICAP risk communication professionals in Nigeria noted, “We developed different communication materials such as comics, graphics, radio dramas, and radio jingles in different disease areas, including for cholera. Following the dissemination of the cholera materials online, the impact of these messages could be seen through the reach, engagement, and comments left on the posts shared.” The guide helps community educators pass on the correct health information as it serves as a quick reference material for ensuring the accuracy of messaging. Consequently, the guide is a significant milestone that shares common goals with the Global Task Force on Cholera Control and the National Cholera Plan in Nigeria (PAMI, 2024)
New Media, SBCC and Cholera in Nigeria
Even though the traditional modes of communication are still the standards in Nigeria and Africa generally, their relevance is dwindling because of the rise in internet access, phone usage, online news portals and social media messaging apps (Barry, 2023). New media are emerging as vital tools for SBCC and health communication in the continent of Africa and Nigeria is not an exception. For instance, social media influencers were used in Kenya to enhance COVID-19 prevention behaviour using quizzes, videos and memes on various digital platforms (Covid-19 Hygiene Hub, 2021). Just as edutainment tactics have been deployed through multimedia platforms to promote HIV/AIDS awareness. Still, in Nigeria, the “spread the truth, not the virus” SBCC campaign utilised various new media platforms to promote truthful information about COVID-19 and counter false information (Ochu et al., 2021). The benefits the new media holds for SBCC are inherent in their reach, engagement and cost-effectiveness when compared to the mainstream media.
It has been established in scholarship that the lack of knowledge about the causes of cholera has continued to be the bane of solutions (Eneh et al., 2024). This is because of cultural beliefs surrounding the causes of illness in third-world countries that attribute the causes of diseases to supernatural phenomena whose antidotes are prayers and all sorts of spiritual interventions (Osuagwu, 2022). In this regard, Osuagwu demonstrated how cultural ideas impeded COVID-19 message receptivity. Scholars are beginning to advocate innovative approaches that include giving primacy to reporting health through the use of technology like mobile telemedicine apps that are akin to the “one2one” app in Nigeria to facilitate effective communication between health professionals and underserved communities in rural areas (Lawal, 2023).
The new media landscape is complementing and strengthening the general media landscape. Hence, the concept of convergence that allows the conventional media to exist on digital platforms enables quick sharing of messages about health from radio, television and even newspapers on digital channels and other social messaging platforms (Insights, 2023). Also, new media devices like mobile phones have become very useful for health communication because they have democratised communication. Tam et al (2021) showed how the usage of multiple social media platforms helped the dissemination of adequate information and knowledge and also influenced safety-seeking behaviours in Vietnam during the COVID-19 pandemic (Tam et al, 2021). In the same vein, Ochu et al., (2021) investigated how the Center for Disease Control (CDC) responded to the COVI D-19 pandemic through social and behavioural change communication and found the use of new media like blogs, social media and websites to be relevant to the success of the social and behaviour change communication.
Despite the potential usage of new media in health communication, only a few studies have empirically investigated the SBCC approach in line with the new media. It is in this regard that Cheng and Wang (2021), Ochu et al., (2021), Eneh et al., (2024) suggested that subsequent studies should use both primary and secondary data to investigate the health communication which is what this study has done.
Method and procedures
Research design
This study employed a qualitative research method. Observation and focus group discussions were carried out. The qualitative method describes events and characteristics of people without amounts or measurements (Ihejirika & Omego, 2011); their data come in diverse forms like observation, interviews, documents, diaries and journal reviews (Wimmer & Dominic, 1997). Observation is a qualitative research approach involving the collection and documentation of individuals’ experiences and behaviours in a particular scenario to gain insights into their specific contexts (Bentzon, 2000). Through observation, the researcher gained an understanding of the phenomenon that needed further enquiry in the Focus Group Sessions.
Sampling procedure
Sampling procedure
A purposive sampling technique (judgemental sampling based on the researcher’s intention) was used to select 36 discussants for four focus group sessions comprising two groups each from Kogi State and Rivers State, Port Harcourt, made up of nine discussants in three sessions, except the fourth group in Kogi, which comprised eight discussants. All 36 participants gave their consent for the FGD sessions. They were allocated serial numbers for the sake of anonymity. For instance, 17 participants in Kogi numbered from 1-17, while those in Port Harcourt numbered 18-36. Each session lasted forty minutes.
Instruments of data collection
Recorded observations and interview guides were used as instruments of data collection. The researcher observed situations where the outbreak was discussed in the areas of study and took written notes. For the focus group discussions, a topic-based interview guide was used to guide the various sessions which were recorded. The recorded discussions were thematically analysed using keywords in context to code.
Population
Two Nigerian states where cholera cases were recorded during the 2024 outbreak in Nigeria were used for the study. The states are Kogi State and Rivers State (Port Harcourt). The two states were chosen for the study because they belong to different regions of North-Central and South-South, respectively. The two towns selected for the study were Igburita (Port Harcourt, Rivers State) and Aiyegunle Gbede in Kogi State.
The demographic distribution of the discussants reflected that 14 were males while 22 were females; the age of participants ranged from 16-45 and their occupations included farming, business owners, health workers and students. The tables below represent the demographic information of the participants.
Data analysis
The recorded data were transcribed thematically, analysed and coded according to keywords in context. In other words, the spoken words were converted into written words to identify and interpret trends and patterns as they occur within the larger data. The observation transcripts were woven into the section on results to corroborate or disagree with the focus group results.
Results
Research Question 1
The discussants identified the following activities, which we have identified and grouped as strategies that fall within the ambit of social and behavioural change communication.
Sensitisation and advocacy seminars to strengthen health workers’ capacity
The health workers among the discussants said they were appropriately sensitised every morning about how to handle their cholera patients and how to give health talks to other patients regarding the outbreak. A female discussant (Participant 18) in Port Harcourt said, “Usually in our clinic, we normally have health talks every Monday morning. But since this cholera outbreak, our director ensures that he updates us with news about the outbreak, which he had listened to via the radio, television or social media, especially Facebook and WhatsApp.” In Kogi State, number 14, said “In our cottage (Local Government Clinic), the Doctor in charge keeps saying we should look out for the symptoms in our patients, as some of them do not know the symptoms. A patient will say I am stooling or I have a runny stomach. Most often, they don’t know it is cholera. The knowledge I have acquired here has made it very possible for me to prepare Oral Dehydration Therapy (salt and sugar solution) for them.” The observation transcript agrees with the situation of sensitisation and advocacy in the FGD sessions because the researcher observed situations where health officials taught people how to mix ORT.
Community dialogue with relevant stakeholders
A participant in Kogi State reported that the king of the town had held frequent meetings with them where he continually briefed them about the escalation of the scourge of cholera. In his words, the traditional ruler of this town has said that the State Commissioner for Health had instructed all traditional rulers to keep talking to our people about the need to keep our environment clean. In Port Harcourt, participant 24) also reported thus, “My husband was in a meeting of traditional rulers, Local Government Chairmen, Pastors, Imams, Commissioner for Health and the Rivers State Governor yesterday. Still, because of the cholera crisis. They were told to instruct their subjects to keep their waterways clean this rainy season because floods often compound the spread of cholera.” The observation phase of the research supports this fact of community dialogue, as youths and women’s organisations were observed to be holding town hall meetings to discuss the resurgence of cholera.
Community mobilizers moving within the communities
Participants in Rivers state mentioned that they saw people moving from door to door asking if they had cases of cholera and teaching them how to prepare the ORT solution. A discussant reported, “In my neighbourhood, we noticed the presence of some people asking us whether we have people who are stooling and vomiting. In my case, I told them that I had stooled four times that morning. The visitors said If I still passed more stools before evening, I should prepare water and salt solution and drink. They taught me how to do it.” Another man in the Port Harcourt group (participant 24) noted thus, “The people who came to my house were speaking the English language, I did not answer them since my child, who normally interprets English for me, was in school. My wife and I did not grant them audiences.”
Mass media and social media campaigns
The majority of the participants in Kogi and Rivers State reported that they had been exposed to messages about cholera causes, symptoms, treatment, control and prevention in the media. Participant 35 in Port Harcourt said, “I listen to my car radio as I drive to work every day. Since the outbreak, there have been radio discussions, jingles, and news about the outbreak. That has helped me in passing information about cholera to my family members and friends through social media like Facebook Messenger and WhatsApp. Participant 32, a male discussant, corroborated, “The other day, I watched a discussion programme on television where a medical expert gave a health talk on Cholera. As he talked about how dirty hands make us susceptible to cholera, the cameraman in the studio quickly sanitised his hands because of fear, as reported by the anchor of the programme. A student participant (number 12 in Kogi) said, “I saw a humorous skit about Cholera on Facebook.” I saw some posts about cholera on Twitter (X) and also read about the outbreak on “the cable news website on my phone.” Still (Participant 34), a male in Port Harcourt, also asserted, My phone is full of short messages from the Centre for Disease Control (CDC) about the need to keep my environment clean to keep cholera at bay.”
Research Question 2
The majority of the discussants said they were aware of the outbreak as they were increasingly involved in interpersonal conversations about the outbreak in their homes, markets, churches, mosques and even hospitals. Such conversations normally ensued with families, friends, acquaintances, religious groups, traditional rulers and health workers. Participant 3 in Kogi State stated, “In this town, from when the outbreak started, our king told the town crier to announce the outbreak and to tell us how to maintain clean sanitation, like covering our pit toilets, avoiding open defecation and washing our hands regularly.” Participant 6 corroborated her statement in saying, “everybody around me in this town seems to be talking about cholera. Even on Sunday in church, our pastor mentioned it while preaching.” “In the market, one of my customers said I should wash my hands before touching the locust bean that she wanted me to give her. My customer was scared because she said she saw images of victims of cholera on Instagram and Ticktock” The situation in Kogi was also recorded in the FGD sessions in Port Harcourt where participants said they had all engaged in conversations regarding the outbreak with less than half of the discussants reporting that they had listened to radio, watched television programmes and read about it on newspapers and digital media. In the voice of Participant 24,” I heard radio jingles about Cholera on my phone, while listening to Arise morning Show (A news and entertainment breakfast show) and saw posters and leaflets on handwashing. But many of our people cannot read the newspaper messages. They are a waste of money.” This agrees with the researcher’s observation about the preponderance of communication about the disease. Conversations about Cholera were observed on every medium, with the new media platforms serving as the basis for intermedia agenda setting for awareness creation.
None of the participants mentioned film/movie as the source of awareness. The discussants underscored the utilisation of traditional, interpersonal communication arsenals and social media in awareness creation in health communication. It also highlights the importance of a multiplicity of communication channels for health promotion. All these align with the researcher’s observation, as documented before the research, about the usage of interpersonal communication, mass communication and social media to disseminate information about the outbreak.
Research Question 3
The discussant in all the FGD mentioned linguistic barriers, the lack of electricity, and non-usage of community educators who have had enough competence in the languages of the communities for community engagements and the lack of enough usage of new media platforms to amplify and showcase the other community engagement SBCC strategies. According to Participant 12 in Kogi State, “Sometimes, I did not engage in conversations about Cholera because those health officials spoke the ‘Oyibo language’ (English) that I did not comprehend at my level. Sometimes I was too busy to listen to them. Participant 15 supported her in saying, “Why are they bringing aliens to speak to us about cholera? Are our youths, women, pastors and imams not enough for information dissemination about cholera?” In Port Harcourt, Participant 19 puts it thus, I like radio and television news about cholera, but my challenge is constant power outages. Still, a participant affirms the same point as indicated below:
Discussion
This study examined SBCC in response to Nigeria’s 2024 cholera outbreak. The containment efforts drew responses from the majority of Nigerians who hailed the strategies in 2024 (e.g., Punch Newspaper, 2024; WHO, 2024). Yet, little or no research has explored the role of communication, especially the SBCC in the containment efforts of Nigeria’s Cholera outbreak in 2024. Furthermore, the challenges encountered in the use of the SBCC in those containment efforts have not been studied.
The first vital finding is that the strategies used in addressing the cholera outbreak satisfied some of the necessary conditions for the SBCC approach, similar to the prescription in the cholera education guide for community engagement on the combination of strategies in proffering solutions and engendering behaviour change. Worthy of mention is the influence of community individuals like religious leaders, village heads and peers who get exposed to health information on new media and cascade such messages to other community members to impact change in behaviour. Recognition of the possibilities of new media in behavioural change communication. The elements of SBCC found in the study were sensitisation and advocacy, community dialogue, the use of community mobilisers, use of mass media and new media, reflecting the efficacy of a multichannel approach as a driver of behaviour change. New media allow two-way communication that allows solution-driven collaboration. This agrees with Niederberger’s (2023) and Oluigbo’s (2024) position about the need to engage with the local population in tackling or mitigating diseases, especially cholera, using modern methods (new media). Also, Al-Ayoubi (2015) condemns one-way communication in disease prevention. However, the study found that some entertainment genres, which also have great change potential, were largely ignored in the strategies for combating the disease. As Ojo & Servae (2013) and Ezeaka 2022) observed, edutainment contents are also invaluable in engendering developmental initiatives (Ezeaka, 2022), thus, genres like films and drama were rarely employed.
Another finding from this study was that awareness of the Cholera outbreak was mainly spread through interpersonal conversations in homes, markets, churches, mosques and even hospitals in conjunction with social media. Such conversations account for knowledge and acceptance of preventive measures like hand washing and clean sanitation. This is consistent with previous research about the mixture of different channels of communication to engender attitudinal change. Several communication strategies which include the traditional mass media, the new media, indigenous communication media and interpersonal communication have been advocated for sustainable social behavioural change (e.g., Batta, 2013; Cheng and Wang, 2021; Ezeaka, 2022 Schiavo, 2016; Waisbord, 2014). Specifically, Cheng & Wang (2021) advocated the proper use of social media for behaviour change in health communication.
The last finding is that although the strategies used in addressing the cholera outbreak satisfied some of the necessary conditions for the SBCC approach, which is a combination of strategies in proffering solutions and engendering behaviour change, the study found language to be a major barrier to health communication about cholera. This corroborates Lanininhun & Oyeleye (2021) and Onwunali & Lagada-Abayomi (2021), who have questioned the appropriateness of language use in health communication. The finding about the survival quest as an obstacle to paying attention to health information is inherent in the way people preoccupy themselves with pursuits of means of livelihood and do not care to get health information. Little wonder that Ezeaka (2022) stressed policy advocacy as a strategy for addressing norms and structures that impede healthy behaviours. Poverty or the quest for survival is one of the structural impediments to behaviour change. The study underscores the importance of access to electricity to the deployment of new media in health communication in the third world.
Contribution to Knowledge
The study has contributed to new media and health promotion literature by empirically demonstrating the influence of new media on behavioural change in a specific disease like cholera that has been ravaging Nigeria and other emerging countries. It has been shown that new media help to authenticate health messages and people are increasingly recognising their potential for health purposes.
Study limitations
The current study is qualitative research and cannot do a comparative analysis of the communication interventions in 2023 and 2024. Future studies are needed in this area. A mixed methods design will be needed for a direct comparison.
The findings of this study are limited by the use of only two states among the 36 states in Nigeria. Also, caution needs to be applied in generalising the results of this study owing to the use of a purposive/convenient sampling method. The sample size might be seen as not being representative of the entire population of Nigeria.
The current research dwells on communication and behavioural change in individuals and communities. The other components of behaviour change in SBCC include organisational and public policy behaviour change. Future deeper comprehension of the role of SBCC in cholera eradication research should take into consideration the other components of behaviour change in organisations and public policy levels, using policy document analysis or experimental designs.
Conclusion
How to tackle the recurrence of cholera is among the plethora of human concerns in Nigeria. Nigeria’s society rose to the challenge of curbing the menace of cholera in 2024 using multiple approaches, which align with the social and behavioural communication change paradigm. This paper critically examined the communication strategies deployed within the SBCC framework in Nigeria’s Cholera outbreak in 2024. Although this paper has proven the fact of maximal adoption of the SBCC communication approach, especially the potentiality of new media in promoting healthful behaviour for curbing cholera, the non-usage of entertainment arsenals like films and community theatre was observed. Also, challenges like language, survival quest and the lack of electricity to access mass media and new media offerings often pose challenges to effective health communication.
Recommendations
One, there should be a total adoption of the tenet of the SBCC approach through a study comprising disaggregated data about gender, social status and age to help mainstream communication and help in choosing community mobilisers that the community members can identify with.
Two, this study recommends the extension of channels of communication for health behavioural change to include more usage of new media like Facebook, WhatsApp, Instagram and Twitter (X), news websites and health apps, for effective health information distribution. Also, more entertainment genres like films, skits and community theatre for health promotion.
Three, to address framing issues, health education should balance communication and not focus more on cure rather than prevention. Prevention will focus on the provision of clean water, proper sanitation and vaccination in addition to health information dissemination in local languages and the provision of a conducive environment for the effective utilisation of new media for the promotion of healthy behaviours.
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