Behavioral Sentinel Surveillance Survey in Nigeria

"There has been recent and growing interest in and implementation of integrated, multi-component SBC [social and behaviour change] programming....Yet there have been few systematic evaluations of integrated SBC programs and limited robust evidence on the effectiveness of integrated SBC programs in improving target health and development outcomes..."

This technical report presents results of a baseline Behavioral Sentinel Surveillance (BSS) survey conducted by Breakthrough RESEARCH in Nigeria in September and October 2019. Its purpose is to inform Breakthrough ACTION/Nigeria implementation and scale-up by assessing the effectiveness of integrated social and behaviour change (SBC) approaches that promote a wide range of healthy family behaviours and outcomes across the Breakthrough ACTION/Nigeria project life cycle. The BSS focused on pregnant women and women within the 1,000-day window of opportunity, and it is closely tied to the primary Breakthrough ACTION/Nigeria objective of improving key behaviours and ideations related to maternal, newborn, and child health plus nutrition (MNCH+N), malaria, and family planning among this group in order to improve the lives and well-being of Nigerian women and families.

The partnership of Breakthrough ACTION/Nigeria and Breakthrough RESEARCH/Nigeria presents an opportunity to identify whether or not integrated SBC programming is more effective than vertical programming in promoting select healthy family behaviours. That is, beginning with this BSS, baseline, midline, and endline surveys will assess the effectiveness of Breakthrough ACTION integrated SBC activities for MNCH+N, malaria, and family planning in Kebbi and Sokoto in comparison to Breakthrough ACTION's exclusively malaria-focused activities in Zamfara state.

The BSS included 6,034 households, with 4,022 (67%) in Kebbi/Sokoto and 2,012 (33%) in Zamfara. There were 3,026 currently pregnant women 15 to 49 years old, including 2,023 (67%) in Kebbi/Sokoto and 1,003 (33%) in Zamfara. There were 3,040 women 15 to 49 years old with a child under 2 years, or observations of last-born children in the past two years, including 1,971 (65%) in Kebbi/Sokoto and 1,069 (35%) in Zamfara. BSS survey questions were administered face-to-face by trained interviewers who entered responses into a secured handheld device (tablet).

Ideational factors are central to Breakthrough ACTION's SBC programming and include knowledge, beliefs, values, risk perceptions, self-efficacy, social norms, perceived social support from key influencers, and spousal communication, among others. The more positive ideational factors held by a person about a given behaviour, the more likely they are to engage in that behaviour. Thus, the BSS questionnaire was informed by Kincaid's Theory of Strategic Communication and Behavior Change (see below). In this model, ideations consist of three main domains: cognitive, emotional, and social. Because these components of ideation are regarded as intermediate outcome variables impacting intention and behaviour, the Kincaid model represents a causal chain of the determinants of behaviour, where change is interdependent, simultaneous, and interactive.

Key findings and recommendations from the BSS include:

• Albishirin Ku! ("Glad Tidings" in Hausa) - Awareness of Breakthrough ACTION/Nigeria's Albishirin Ku! radio programming, which leverages the power of storytelling to deliver good health messages, is apparent even at this baseline period. However, Albishirin Ku! radio programme awareness in Kebbi and Sokoto is significantly lower among respondents in the economically poorest households (12%) than in the wealthiest households (42%), which is likely due to lower radio ownership. Going forward, Breakthrough ACTION/Nigeria should ensure that ongoing SBC outreach efforts (e.g., household visits or community events) are reaching this population.
• Family planning - Non-pregnant respondents reported low modern contraceptive use, with higher use in Zamfara (15%) than in Kebbi (9%) and Sokoto (12%). The most common reasons non-pregnant respondents stated for not currently using contraception were fatalism ("It's up to God") (25%), currently breastfeeding (23%), partner opposition (21%), and respondent opposition (18%). In line with this result, 52% of respondents said they do not personally approve of using contraception for birth spacing, indicating a hurdle to Breakthrough ACTION/Nigeria SBC messaging for changing family planning practices. In addition, one in five respondents believed that people in their community would call them bad names or avoid their company if others knew they were using contraception for birth spacing, which further highlights the importance of addressing social norms in family planning. About half of the respondents agreed that religious leaders should speak publicly about using modern contraceptives, which underscores an important pillar of Breakthrough ACTION/Nigeria programming. Furthermore, common contraceptive myths also persist across study areas, suggesting that SBC programming needs to actively work to dispel specific myths going forward to help promote behaviour change. Only about half of respondents across study areas were confident in their ability to convince their partner to use modern contraception for spacing births. These findings further underscore the need for SBC activities to engage couples in decision-making about birth spacing and to support women's agency in health decision-making to help raise contraceptive use rates.
• Malaria - Overall, ownership of long-lasting insecticide nets (LLINs) was high, and there was high overall awareness about the importance of LLINs in malaria prevention. The results suggest that SBC programming to raise awareness about malaria prevention measures is not needed, but improving access, acceptability, and efficacy to use LLINs as directed may be a useful programmatic focus. Data also underscore the need for SBC messaging to reinforce the importance of intermittent preventive treatment for malaria during pregnancy (IPTp) as a key component of essential antenatal care services. Building knowledge of malaria risks and specific health consequences for the fetus may be a driver toward greater adoption of prevention behaviours. The most important reasons for choosing the treatment location for paediatric fever care were trust (36%), nearby location (33%), and effective treatment (28%). Other findings suggest that while respondents know the recommendation and have stated intentions to act, such knowledge and intentions may still not translate to behavioural action.
• MNCH+N
  • Antenatal care (ANC): There is low ANC attendance across Breakthrough ACTION programme areas. The most common reasons for not attending ANC were lack of perceived need (42%), spousal opposition (25%), fatalism ("It's up to God") (20%), and perceptions that ANC is not the norm (13%). This finding suggests lack of information, poor risk perceptions, and lack of awareness about the benefits of ANC to a mother and her newborn. In addition, 67% of respondents said their spouses influence their decision to go to ANC four or more times, which suggests that capturing husband ideations may be important to inform future spousal communications interventions. There are also common ANC myths that persist among respondents; in response, for example, SBC messaging could be designed to improve awareness of the benefits of ANC even for healthy pregnancies.
  • Facility delivery: Facility delivery was an uncommon practice in Kebbi/Sokoto (14%) and Zamfara (16%) among respondents during their last pregnancy. When respondents were asked who influences the decision to have a facility delivery, partner/spouse (57%) was the most common response, making spousal opposition another critical barrier to service utilisation. About half (55%) were confident they could start a conversation with their husband about facility delivery, and a similar proportion (51%) intended to deliver their next child at a health facility. These positive intentions around facility-based delivery represent an opportunity for SBC programmes to support women with interventions to make it easier for them to act in accordance with their beliefs and intentions.
  • Breastfeeding: Nearly all respondents (96%) reported ever breastfeeding their last-born child under 2 years, with 23% of respondents agreeing that mother's breastmilk after birth (colostrum) is bad - suggesting an area for future SBC messaging. Forty-one percent of respondents believed that most other women in their communities gave breastmilk exclusively to their infants, indicating an opportunity to support mothers with their breastfeeding intentions, such as increasing family or social supports.
  • Vaccination: There was very low vaccination coverage, with only 4% and 8% of children aged 12 to 23 months in Kebbi/Sokoto and Zamfara, respectively, who were fully vaccinated. Across study areas, 73% of respondents reported that their spouses influence their decision about child vaccinations, making spousal opposition an important barrier to vaccine uptake. Also, 26% of respondents agreed that vaccines contain dangerous chemicals that could harm a child's health, and few knew when a child should first be vaccinated and the number of vaccinations children should receive by their first birthdays. Taken together, results suggest relatively low vaccine knowledge, common perceptions of frequent vaccine stockouts at health facilities, spousal opposition to vaccine uptake, and the persistence of vaccine myths across the study area.
  • Acute respiratory infections: The most common reasons for choosing the source of care across study areas were nearby location (40%), provider trust (36%), family/friend recommendation (30%), and effective treatment (27%), which underscores the importance to women of convenient, trusted, and high-quality healthcare providers in their communities. Overall, the results point to the need to shift care-seeking from pharmacies to formal medical sources and to improve overall pneumonia knowledge.
  • Diarrhoea: Few children with diarrhoea were given both oral rehydration solutions (ORS) and zinc. The results point to the need to shift care-seeking from pharmacies to formal medical sources in the study areas.

Going forward, in-depth analyses of the BSS baseline dataset will provide further evidence about the relative importance of different ideations on behavioural outcomes across health areas. Breakthrough RESEARCH will also examine the differences among doers and non-doers of promoted behaviours and take a deeper dive into the role of spousal communication, and other key topic areas, in the uptake of promoted behaviours by Breakthrough ACTION/Nigeria.