Qualitative Research on Breakthrough ACTION's Advocacy Core Group Model for Integrated Social Behavior Change Programming in Nigeria

"Yes, frankly, as a result of my participation in ACG, we have meetings with other youths to sensitize them on health issues because that is what we were being educated on during our ACG meetings. We ensure that we pass the message across to the youths." - youth leader, Bauchi

In northern Nigeria, traditional and religious leaders tend to be highly influential in all aspects of people's lives, including their health. In northwestern Nigeria, the United States Agency for International Development (USAID)-funded Breakthrough ACTION project has been working with religious and community leaders using an approach known as the Advocacy Core Group (ACG) model. This report describes the results of a Breakthrough RESEARCH/Nigeria assessment of the ACG model, which works through key opinion leaders and influencers to influence community-level health norms and individual behaviours, focusing on the uptake of essential reproductive, maternal, newborn, and child health services. Results are intended to inform Breakthrough ACTION/Nigeria's programme implementation, as well as to contribute to the broader social and behaviour change (SBC) implementation science literature.

ACG activities are shaped by the concept of "adalci", which is a Nigerian term for Islamic guidance on family and community principles, and programming focuses on addressing the gender norms described in this report. Using the lens of adalci, Breakthrough ACTION/Nigeria is implementing interventions with the deliberate inclusion of women, particularly female religious leaders, to disseminate information in the community and bring the needs of women to the forefront. ACG members undertake several roles and responsibilities (described in the report) through advocacy, facilitation, engagement with communities, and general support.

The study was qualitative in design and was conducted in Bauchi and Sokoto states of Nigeria from November 15-26 2021. Phase I methods included in-depth interviews (IDIs) and community conversations (CCs) that were designed using the social norms exploration (SNE) methodology. In the CCs, the "My Social Networks" tool was used to identify reference groups for community members, and the "Five whys" tool was used to elicit information on reasons for behaviours of interest. Phase II methods included IDIs and social network analysis (SNA) methodology, the practice of examining social structures using network theory and graph theory - namely, by defining networked systems in terms of their nodes and the connections, edges, or links that connect those nodes to one another.

Key findings:

• Operationally, the ACG model appears to be working as intended, per the experiences of individuals both providing and receiving programming. Selection of ACG members is tied to having experience leading existing community groups and associations. This experience was critical for the functioning of the ACG model. The study noted ACG model successes in the following areas:
  1. Engagement with the community: ACG members reported directly engaging community members through various means, including community religious events and ceremonies, household visits, and community dialogues. They also mentioned referring community members to health facilities for services. Interactions with community members using community platforms and face-to-face meetings facilitate messaging on the project's priority health behaviours and create demand in communities for maternal, newborn, and child health plus nutrition (MNCH+N), malaria, and child spacing services. Well-attended and culturally relevant community platforms are routinely used for advocacy and sharing of health promotion messages.
  2. Performance: ACG members reported perceptions of positively influencing community members on all practices related to the priority health behaviours (e.g., family planning, antenatal care (ANC), immunisation). This perception was linked most closely to perceptions of reductions in home births, increase in adoption of child spacing methods, and improvements in care-seeking for childhood illnesses.
  3. Linkages with the healthcare community: The model appears to have facilitated linkages between ACG members and healthcare workers - for example, by advocating for needed improvements in health facilities - which has helped build demand for services and advocacy for quality improvement.
  4. Reach: ACG structures involving religious leaders were described as having a wider reach relative to other traditional and community leaders. Religious leaders regularly use sermons infused with health messages and capitalise on their more elevated status in the social ecology to achieve broad support for messaging. Other ACG members have worked through narrower population sub-groups, facilitating linkages with community associations such as those for youth and women. The perception is that religious leaders who are ACG members may have a broader impact because they are able to work across all population groups.
• While it was not possible to directly demonstrate measurable changes in norms, the study revealed findings in these areas:
  1. Shifting attidues in norms supportive of limited mobility and social interactions for women: ACG members perceived that husbands/male guardians are increasingly likely to grant permission for women to seek necessary health care. ACG beneficiaries reported the same. However, this finding "does not appear to be a true shift in norms, rather a change to the timing of granting permission."
  2. Perceptions of shifts toward more shared decision-making: Traditionally, husbands are the ultimate decision makers for many health behaviours. ACGs appear to be fulfilling their responsibilities by actively discussing and encouraging shared decision-making on health matters.
  3. Work to shift norms around acceptance of early marriage/childbearing: While the data collection did not result in any information on changes to norms around early marriage, by enlisting religious leaders into their model, the ACG approach is working to shift norms promoting greater acceptance of reproductive health services, including ANC, facility deliveries, and family planning.
  4. Reduced tolerance for gender-based violence (GBV): Community norms related to GBV appear to be shifting due to modernisation and progressive beliefs. An example of this was assertion of ACG beneficiaries that incidents of GBV has reduced owing to increased education among community members. ACG members received training on creating awareness and understanding to reduce it.
  5. Efforts to tackle traditional nutritional practices and restrictions: Infants are often given holy water and denied first breast milk under the belief that colostrum, because of being perceived as dirty or polluted, has no benefit. ACG members note they encourage exclusive breastfeeding for the first six months of life, although the exact definition of "exclusive" used by ACG members is sometimes unclear. ACG members also encouraged community members to seek health care workers' opinions for complementary feeding after six months of exclusive breastfeeding, but traditional nutritional practices and restrictions are slow to change.
  6. Changes in belief in traditional practices for MNCH issues: ACG members have been encouraging and facilitating the utilisation of health services for MNCH issues, but these norms are slow to change.

Promising areas in terms of integrated SBC messaging within the ACG model include:

• Skill-building in community engagement and community liaison: ACG members described receiving supportive training from Breakthrough ACTION on how to mobilise communities, which is beneficial even beyond their roles as health advocates. They further reported that the formalised structure of the ACG programme provides a good entry to communities and serves as an important conduit by which district heads can reach those communities, again providing useful community support beyond health.
• Combination of mid- and mass media: ACG members noted that their work has been bolstered by radio broadcasters transmitting similar SBC messages, lending credibility and support to their own work, reinforcing health messaging, and reaching broader audiences. This complementarity between the ACG model and mass media SBC, a central component of the Breakthrough ACTION/Nigeria approach, could serve as a promising avenue for future SBC programming and expansion.
• ACG model setup: The structure of the ACG model, based on close liaison and social support from government leaders at all levels to mobilise and reach communities of interest, provides a source of intrinsic motivation to ACG members, despite the lack of financial remuneration. Members feel empowered to do their work given the strong social connections and support for advocacy.
• Reach of ACGs: The potential of ACGs to influence health appears strong yet can vary by geography and health topic.

Both ACG members and beneficiaries of the programme expressed a positive regard for the work and a perceived resultant improvement in health and behaviour. Challenges or pitfalls were described mainly in relation to the lack of tangible benefits that ACG members could provide to communities, as well as the perception that media may be more effective than person-to-person communication.

Recommendations include:

• Continue to support the ACG members, perhaps with some tweaks to the model such as promoting further involvement of ACG in complementary media campaigns and providing greater supportive supervision.
• Increase the reach and effectiveness of the ACG model through mass media and other channels.
• Strengthen the ability of ACG members to advocate for beneficiaries in matters of health service quality improvement.
• Explore supportive structures to maintain ACG members' high level of motivation and pro-social commitment.
• Provide additional support in the form of incentives or linkages with complementary programmes to ACG members for addressing entrenched norms that appear slower to change such as on immunisation, GBV, and nutrition.
• Proactively address potential issues of sustainability, such as by preparing local governance structures to support ACG members to continue their work through sensitisation and providing evidence of benefit.
• Compare perceptions of increased service utilisation with quantitative data on health service utilisation in areas where the ACG model is active (as well as in control areas where the ACG model does not operate) to provide additional empirical support for the effectiveness of the ACG model.