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Rumors and Word of Mouth in Developing Countries

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

Eye Care in Kenya

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

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

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

There are several vital interventions that can help to reduce the number of patients who refuse free surgeries.  Within the general population, knowledge about eye illness and treatment should be improved.  The cataract surgeries that are performed should be of the highest quality to ensure successful outcomes, thereby building a good reputation in the village for eye surgeries.  Additionally, social assistance for the elderly should be improved.  Blind people are often considered to be a burden by their families, and do not want to inconvenience loved ones by asking for the surgery, therefore letting themselves go fully blind.  Patients who have been operated on should help provide this support and endorse the successful surgery to their peers.(4)

Polio Eradication in Nigeria

While the goal of completely eradicating polio from the world is within reach, it has not yet been achieved.  This is a very challenging goal to complete since a new pocket of infection can result from a single child who has not been vaccinated.  Countries must be extremely diligent about ensuring that every single person is vaccinated.  The breakdown in Nigeria’s motivation to vaccinate against polio has transformed into a classic example of how eradication campaigns can go wrong.  As Dr. Stephen L. Cochi, senior advisor in the Centers for Disease Control and Prevention’s immunization program, states, “Nigeria is clearly far and away the greatest risk to the eradication effort.  They’re just missing lots and lots of kids.”(5)

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

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

Some Nigerians were also under the impression that the polio vaccine contained estrogen, which was highly scandalous because “estrogen” was interpreted as being synonymous with “birth control.”  Other people circulated false rumors about the harm of the vaccine just in time for political campaigns. (9)  Although official hostility toward the vaccine has ended in Nigeria, resistance efforts and many obstacles still exist.  The rumors created a harmful lasting impact, and reigniting the campaign for eradication has proven to be a difficult struggle.

Neonatal Tetanus in Cameroon

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

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

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

Family Planning in Uganda

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

In order to correct these misconceptions and encourage family planning in Uganda, a standard method of family planning implementation must be established, community health workers must be better trained, counseling services should be offered to patients, satisfied users should disseminate success stories, and educational programs should be improved and scaled up.  

Conclusion

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

Potentially harmful rumors regarding critical medicines and treatments are not unique to developing countries, but are widespread, even in North America.  Many misconceptions exist regarding birth control methods, and some people perceive such methods to be an attempt at genocide.  Personal anecdotes that are spread through word of mouth can be misconstrued and distorted, yet many individuals still use them as the basis for their medical judgments.

Footnotes