Challenges of Adopting Local Visual Contents in Awareness Campaigns for Control of Communicable Diseases

1 Federal University of Technology, Akure, P. M. B. 704 (c/o FUTA, Industrial Design), Nigeria. 2 Kyambogo University, Kampala, P. O. Box 1, Kyambogo, Uganda (c/o Teacher Education and Development Studies). 3 Federal Institute of Industrial Research, Oshodi, P. M. B. 21023 (c/o FIIRO, Ikeja, Lagos), Nigeria. 4 University College Leuven-Limburg, 3001 Geldenaaksebaan, Leuven (c/o UCLL, International Management), Belgium. *Author for correspondence email: ezerodjimin@gmail.com.


INTRODUCTION
Ensuring public health service delivery is an inherently moral, policy, and ethical obligation for all health professionals, practitioners, and awareness creation (AC) content designers. This is primary since infectious and non-communicable diseases are among the most significant threats to human development in developing countries (Thomas, Sage, Dillenberg, & Guillory, 2002). Various communicable diseases (CD) have over the years ravaged public health in the developing world (Neuberger, et al., 2012;WHO, 2014;Crompton, Malcolm, Cadet, Kelly, & Degennaro, 2016;Nabil, 2018;Clive, Lacreisha, & Nadine, 2019). From social and economic perspectives, CDs have for decades hampered sustainable development goals (SDGs) especially SDG 3 progress on universal access to quality primary healthcare in Africa (UN, 2015). Recent CDs outbreaks such as Lassa fever, Ebola, and the COVID-19 pandemic proved grievously challenging to contain or manage even for seemingly well-developed nations with the death toll for COVID-19 yet growing as at the time of this review (Odji, 2020;Odji, 2020b;WHO, 2020). Developing economies like the Western African nations have struggled to contain CDs such as . It is feared that if CDs like the COVID-19 pandemic persists; many nations like Nigeria might become failed or fragile states as the citizens of some countries did not believe that it was a major threat to them due to a dearth of local visual evidences (LVE) substantiating their prevalence (Odji, 2020;Odji, 2020b;Odji, 2020c). Therefore, this study reviewed the need for the adoption of LVE based public awareness creation/education with a view to helping policymakers, relevant concerned agencies and actors make more informed decisions as a prevailing CD or other forms of crises may demand, with reference to some possible challenges that may accompany the recommended strategy.

METHODS
This paper was informed by a systematic literature review, policy analysis, relevant good practice, lessons learned, and results of previous studies on awareness creation with a focus on communicable diseases in Nigeria. This review examined the probable prospects and challenges of adopting local-visual-evidence-based AC contents to provide policymakers, public health, and safety agencies accessible information services for effective decision-making options. Additional information was obtained through multiple internet searches using popular search engines with a focus on the keywords. More data were obtained from national, regional, or international agencies including news bulletins, key informants, and informal email discussions on the issue.

Negative Attitudes towards Positive Health Messages
Despite widespread AC in Africa, there were yet evidences of poor attitudinal responses to CD preventive health messages. Many locals in Nigeria for example, despite the high level of investment in awareness creation in the country, yet did not believe CDs such as COVID-19 existed or were as serious as the governments made it to look like. This negative belief system wrongly shaped their mind-sets or attitudes towards curbing of the CDs. The result was the spread of CD infections aggravated by negative behavioural tendencies like defying the standard CD prevention or control guidelines.
These negative attitudes towards positive persuasive health messages were attributed to reasons including ignorance (Odji, 2020c), false knowledge or misperception (Odji, 2020c), economic factor or financial survival pressures informed by poverty (Odji, 2020b;Qutieshat, 2020), poor persuasiveness of the adopted AC contents, statistics based policies i.e. lack of local visual evidences to substantiate CD prevalence claims (Odji, 2020b), selfishness (as individuals or groups who were not directly affected by the prevailing diseases had greater tendencies to be lax) and lack of trust in the message sponsors (i.e. governments). According to a recent study on the influence of attraction on attitudes and attitude confidence, the physical attraction of the source of a message can influence recipients' attitudes about the received message (Mello, Garcia-Marques, Briñol, Cancela, & Petty, 2020). Most of these challenges were knowledge/education-related.
Apparently, the shared characteristics of some of these challenges affirm the recommendations of previous studies for the adoption of AC as a CD preventive or control measure (Odji, 2020;Odji, 2020b;Okaka, 2018). However, for AC based preventive strategies to be effective, there is the need for active participants and agencies to seek the information required in specific localities so as to implement policies and programs that protect and promote health (Thomas et al, 2002) and other key sectors. According to the code of ethics, public health organisations and their employees should engage in collaborations and affiliations in ways that build the public's trust and the organisations' effectiveness (Thomas et al, 2002). For instance, the use of digital technology may be effective in controlling unethical social media contents like fake news (Maltby, Thornham, & Bennett, 2015) which promotes false knowledge or ignorance.

Public Access to Local Visual Evidences (LVE) and Advantages
AC has been classified into two major categories: LVE based AC and NLVE (Non-Local Visual Evidence) based AC. NLVE based AC were campaigns adopting foreign visual evidences (Ibezim-Ohaeri, 2020). LVE-based AC were campaigns adopting local visual evidences for public awareness and or education. However, this classification depended on the place of application. For example, visual evidence harvested in Kenya or Uganda and adopted in Nigeria will be classified as NLVE. If the same evidence is adopted for AC in the country/region of harvest, it will be classified as an LVE.
While economic factors topped the list of reasons given for defying CD prevention or safety guidelines in Nigeria, the lack of Local Visual Evidence (LVE) to support the claims of the prevailing CDs turned out as the most common reasons for defying CD prevention or control guidelines (Odji, 2020b). According to the study, it is impossible to practice something correctly when we lack the necessary knowledge because ignorance is a key factor in spreading infectious diseases (Odji, 2020c). However, a study of COVID-19 spread in Nigeria, revealed that many Nigerians were not ignorant of the pandemic cause, yet they defied the COVID-19 standard operating procedures (SOPs) due to lack of LVE (Odji, 2020b). This reason was also confirmed by another study (Odji, 2020) identifying 'the lack of LVEs from the relevant government agencies as a cause. Therefore, local visual evidence-based policies were necessary for alleviating the rising toll of public health threats (McCambridge, Kypri, Sheldon, Madden, & Babor, 2020).
This health education/promotion AC strategy, adoption of LVEs, was vital for obvious reasons which included: 1. Increased AC content believability 2. Optimised attention-arresting effectiveness 3. Consequently, improved message acceptability 4. Goal achievement e.g. reduced risks of CD prevalence.
AC contents are useless if attention is not given to them by the target audience (Odji, Oladumiye, & Adelabu, 2016). The effectiveness of any persuasive content begins with the volume of attention it is able to arrest which, if the persuasive content is effective enough, is supposed to influence the audience to progress to targeted action(s) (Odji et al, 2016). The increased believability of the AC contents due to the adoption of more local-visual-contents was expected to yield greater attention arresting effectiveness. Audiences tended to take less seriously what they perceived only little or no believability from. Watching a close local community member or one's own country's citizen die helplessly in agony attracts greater attention and empathy than a foreign remote image presenting similar contexts.
If LVE could improve AC contents/message believability, improve acceptability and attention arresting effectiveness, then achieving the campaign goals is most feasible. Persuasion, deliberate attempts to motivate attitudinal or behavioural adjustments (Odji, 2020d), is more relatively achievable when the public has greater access to LVE as opposed to mere statistics so that CD prevalence claims will not be mistaken for mere political, economic or social propagandas as it was evidently prevalent in Nigeria as at the time of this review.

Awareness Creation in CD Preventive, Management, or Control Strategies
In the absence of a defined cure or vaccine for some CDs, there was a need to concentrate more on preventive and control measures (Zühlke & Engel, 2013). Various preventive, management, or containment measures were put in place by disease control agencies in Nigeria and other African nations depending on the unique needs of their citizens, preparedness of their disease control agencies and the capacity of the nation to cope with an outbreak, epidemic or pandemic. Some of the measures were similar and so were summarised hereunder simple headings including but not limited to: health coordination meetings, health education/awareness creation, vector control, active periodic population or target group screening/tests, mass surveys to identification of affected areas, provision/enforcement of preventive/containment guidelines/measures, improved hygiene practices [including personal and environmental hygiene], early diagnosis and integrated management of illnesses or symptoms, support for CD victims and their families, provision of basic amenities, policy making/adjustment to cater for prevailing crisis situations and so on (Ampofo, n.d.;Zühlke et al, 2013;WHO, 2014;Odji, 2020c;WHO, 2020). Prominent on the list was AC or health education.
The critical need for effective education and awareness creation strategies places the key focus on the health educators, peer influencers, media practitioners, and AC content designers as these must be addressed to prevent or control the spread of the CDs due to lack of awareness and knowledge (WHO, 2014;Abdulrahim, Alasasfeh, Khader, & Iblan, 2019). According to the world health organisation (WHO), the supply of vaccines in Africa used to be over 99% from external sources and less than 1% internal production (Ampofo, n.d.) which leaves many African governments more with the AC options which was 100% under their controls.
However, for an awareness campaign to be effective in reaching a specific population, there was the need for it to contain contents with which members of the target population may readily relate (Odji, 2020) and the role of Indigenous Knowledge (IK) is highly prominent (Okaka, 2018). Hence, the adoption of more LVE based AC contents for optimised effective reach was recommended (Odji, 2020a;. Unfortunately, this AC type is not without its disadvantages, some of which are highlighted below: 1. A bridge of the code of rights (of patients) 2. Bridge of professional trust 3. Stigmatisation of recognisable survivors 4. Risk of public panic and so on.
Although adopting LVE-based AC contents have been justifiably recommended in previous studies because of the obvious advantages it portended for greater effectiveness in combating the prevalence of CD, it however possesses considerable ethical, legal and or moral challenges. For example, a patient has the right to privacy and confidentiality that must be assured at all stages of his/her treatment or monitoring. The patient has the right to be free from unwarranted public exposure, except in such cases as when the rights are waived by the patient him/herself, through a court order or when such is necessary for public health and safety (SAMCH, 2020). According to the guidelines of the University College Hospital, Ibadan (UCH), a patient expects that, within the confines of his/her rights as provided by the law, all communications concerning him/her shall be treated confidentially (UCH, 2019). Adoption of LVE may breach this code of medical practice. In addition, possible discrimination against CD or non-communicable disease (NCD) victims, recovered patients, next of kins, dependants, family, or friends (Hoffman, 1989;Meel, 2003;Mawar, Sahay, Pandit, & Mahajan, 2005;Clarke & Chess, 2008;Charles, 2007;Siu, 2008 Obviously, the adoption of LVE based AC campaigns has its advantages, yet, its disadvantages, if not well provided for, may outweigh them. An effective attention arresting content may yield an increase in knowledge, but the increase in knowledge may not necessarily translate into targeted action or behavioural/attitudinal adjustments (Odji, 2020).
However, the need to urgently curb the prevalence of CDs such as COVID-19 demands rather drastic approaches which may include the adoption of LVE, despite the challenges attached, with the aim of saving lives where possible. Therefore, the adoption of LVE, when and if adopted, must be done with appropriate cautions effectively taken. For example, the figures of patients or other individuals involved in a harvested visual evidence intended to be adopted for AC content creation must be properly identity-screened, as recommended for example in a previous study (Odji, 2020b), to provide for possible plausible deniability both for the patients and the content designers or design sponsors. It is required that prudent public policies should be made and implemented only after proper problem identification and construction (Reiter-Palmon & Robinson, 2009) has been carried out successfully. Public health information policies enacted in a hurry, especially during emergencies such as the COVID-19 pandemic outbreak must address the ethical rights of patients or victims and their families.
As shown in Figure 1, adoption of LVE is dependent on a liaison between realities and responsibility both on the path of the policymakers whose responsibility is to ensure the safety of public health and medical/health professionals whose responsibilities are their patients' interests and wellbeing.

A Proposed LVE Adoption Pattern
The following have been established already about the adoption of LVE: 1. LVE based AC has both advantages and disadvantages despite its established effectiveness in AC campaigns. 2. Is dependent upon ethical, professional codes of conduct and government policies. 3. Is dependent on the patient's consents and rights in relation to both professional conduct and government policies.

Figure 1: A Proposed LVE Adoption Pattern in Crisis Situations
Therefore, as shown in Figure 1, for any crisis situation, if advantages outweigh disadvantages, LVE may be adopted. However, when disadvantages outweigh the advantages, LVE adoption may be rejected. Both cases, at every stage of consideration, are dependent on ethical or professional codes of conduct and prevailing policies. The decision for eventual adoption or rejection is dependent on a liaison between professional (medical/health practices), individual (patients' rights/privileges) and government or related agencies' responsibilities or rights and the realities presented by a prevailing crisis situation.

Advantages of adoption outweighs disadvantages
Ethical, moral, professional codes of conduct and policies

RECOMMENDATIONS
The following recommendations are made for the early adoption of LVE for health AC effectiveness: • Obtain a patient's informed written consent because the rights of a patient must not be violated by anyone, any agency, professional, or the government, therefore there is the need to officially obtain the written consent directly from a patient according to the right protocol. Ethical practices to protect a patient's privacy rights must be strictly observed.
• Establish a standard reward system to compensate patients who volunteer to allow their visual or personal data to be adopted in AC contents creations. Such proposed compensations may be extended directly to CD survivors or the appropriate, rightful, or legal persons or next of kin.
• The public should be educated against promoting stigma against CD survivors, especially those involved in campaign strategies for containing communicable diseases or risks to public health and safety practice.
• Adoption of LVE based AC contents should be done only with appropriate precautions taken as recommended.
• Public awareness communication practitioners, governmental and nongovernmental organisations that are involved in the management or prevention of the epidemic, should know that participatory community engagement leads to higher awareness for behaviour change to prevent or control the spread of communicable infections and health risks to public safety.

CONCLUSION
LVE based AC contents have already been established as the preferable alternative to adopt at the community/local level for the purpose of public awareness/education in containing or preventing CD or other public safety threats. However, adopting LVE based AC contents are not without downsides. It is really difficult deciding which AC content type to adopt and the 'code of rights' or 'code of ethics', for example, should serve as guides with reference to teaching, research, and/or use of data obtained from patients (both visual and non-visual).
So far, not all public policies agree with the principles stated by professional medical associations because many professional healthcare providers may find the adoption of LVEs uncomfortable for their professional responsibilities. The public policy-makers owe it to the public to protect their health and safety as a right. The decision for or against the adoption of LVE for health AC may then be hinged on the liaison between responsibility and reality.