Culture and behaviour in mass health interventions: lessons from the global polio eradication initiative

Success in the Polio Eradication Initiative now hinges on a very few endemic countries. Maximising household vaccination in these places is key. Evidence suggests that while vaccinator performance generally, and physical access related to security, create blockages in the vaccination supply-side, unwillingness to be vaccinated by small groups of households and communities constitutes the principal demand-side barrier. The question is why. Culture has been treated as a dominant factor determining resistance to vaccination in the global programme. Resistance, often occurring in areas with substantial Muslim population, has been associated with fear and rumour fuelled by ignorance, and religious objection - problematically merged in a religio-cultural interpretation of resistance as a kind of Islamic obscurantism. Yet attitudes to the polio programme appear to vary substantially within small geographic areas. Rather than being a matter of common belief, public orientation appears to be shaped by a combination of religio-cultural and more localised socio-economic and political factors - in particular, the potentially aggressive nature of mass vaccination, and the perceived under-supply of other development goods. Interpreting resistance to vaccination as essentially religio-cultural marginalises an understanding of resistance as the rational and strategic response by households and communities to systematic conditions of inequity and exclusion.