"We Help People Change Harmful Norms": Working with Key Opinion Leaders to Influence MNCH+N Behaviors in Nigeria

"It is intended that the findings from this study will contribute towards the broader SBC [social and behaviour change] implementation science literature surrounding the roles, effectiveness, successes, and challenges of leveraging religious and traditional leaders and social structures to improve social normative environments for health."

Several studies have highlighted the importance of addressing socio-cultural barriers and norms to improve the uptake of maternal, newborn, and child health and nutrition (MNCH+N) services. Studies in Nigeria and other West African countries have identified a potential role for religious leaders in improving health and shifting socio-cultural norms that influence MNCH+N behaviours. Since 2017, the United States Agency for International Development (USAID)-funded Breakthrough ACTION/Nigeria project has worked with leaders in northern Nigeria to implement the Advocacy Core Group (ACG) model, a social and behaviour change (SBC) approach aimed at influencing community norms and promoting uptake of MNCH+N behaviours. This paper draws on a study conducted by Breakthrough RESEARCH/Nigeria and explores how the ACG model operates and its potential effectiveness in influencing community-level norms and individual behaviours for MNCH+N, family planning, and malaria prevention.

As detailed in this paper and the report available at Related Summaries, below, Breakthrough ACTION/Nigeria offers capacity building and technical support to ACG members, who are religious and traditional leaders wielding influence in communities. This support is expected to empower ACG members to: dispel misunderstandings and obstacles related to MNCH+N; foster demand and promote the uptake of MNCH+N services, including family planning and malaria; advocate for resources from governments, non-governmental organisations (NGOs), and institutions; collaborate with local leaders; challenge detrimental norms; raise awareness at state and local levels through SBC communication channels to facilitate effective uptake of MNCH+N-related behaviours; and strengthen access to high-quality MNCH+N services by establishing robust connections between communities and healthcare facilities.

Conducted in Bauchi State and Sokoto State, the study was qualitative in design and included 51 in-depth interviews (IDIs) and 24 focus group discussions (FGDs) that were designed using the social norms exploration (SNE) approach. The SNE technique is a participatory, team-based approach used to uncover social norms that impact target behaviours of interest, with its findings shaping the intervention design and monitoring for results. The SNE technique was used to clarify facilitators and barriers to behaviour change in the context of the ACG model. There were two categories of participants: (i) ACG members, including religious, women, and traditional leaders who were living in the communities and were active members of the group; and (ii) programme beneficiaries, who were men and women of reproductive age (15-49 years) who were caregivers of under-2 children.

ACG members described achievements in community engagement and linkages with healthcare facilities through direct engagement with programme beneficiaries across a range of activities, such as community religious events and ceremonies, household visits, and community dialogues.

Overall, the study found the ACG model to be vital in the uptake of MNCH+N behaviours. ACG members reported perceptions of positively influencing programme beneficiaries on all practices related to priority health behaviours, as well as on demand creation for MNCH+N-related services. For example, according to participants, family planning has been reported to be very well accepted in areas where ACG members are operating, even among remote populations, and they felt more women now utilise family planning services. Conversations with programme beneficiaries corroborated this perception, using phrases such as "we have been enlightened" when discussing vignettes in key MNCH+N areas.

The study found that some norms appear to be shifting to facilitate MNCH+N-related behaviours. ACG members reportedly fostered discussion on collaborative decision-making between spouses on health matters. This strategy was linked to perceptions of shifts towards more shared decision making, notably in antenatal care (ANC) and facility-based deliveries.

However, normative barriers to improving MNCH+N outcomes included perceived religious conflicts with family planning, preference for traditional care in pregnancy, misinformation on exclusive breastfeeding (EBF), and gender-based violence resulting from women's decision-making. For example, infants are often given holy water instead of breast milk. While ACGs said they encourage EBF for the first six months of life, the precise definition of "exclusive" used was sometimes unclear. This is a gap that could affect the effectiveness of health messaging and could relate to why breastfeeding norms remain pervasive.

Furthermore, some male ACGs expressed hesitancy in engaging communities in discussions about certain health issues, such as family planning. This reluctance stems from their perception of potential discomfort, particularly when addressing these matters with female programme beneficiaries. Although the ACG programme deliberately included women religious and community leaders to disseminate information within the community, due to entrenched social norms, only a small number of women hold positions of authority within these communities.

There may also be a perception by ACG members that they do not have tangible benefits to offer communities who they are reaching on health topics. The ability to offer incentives appears to be something the members feel could strengthen their advocacy efforts.

Many ACG members complained that despite several sensitisation and awareness efforts, broader health systems challenges, such as the poor service received at facilities, negative attitude of health workers, and insufficient health workers, discourage women from accessing care.

In conclusion, the "findings indicated that the ACG model was linked to increased awareness of health issues across key priority health areas and improvements in the uptake of recommended MNCH+N behaviors. There is a need for the model to continue targeting norms that are slow to change such as those related to EBF and GBV. This could mean more capacity building for ACGs to further help drive social and behavior change. Furthermore, the prospect of ACG members holding identical normative ideas that limit MNCH+N behavior uptake necessitates interventions in value clarification and attitudinal adjustment. Increased and concerted interventions to address health system issues will further complement the efforts to drive behavior change."