Breakthrough ACTION-Nigeria 2018-2024: Celebrating Successes, Consolidating Learning and Transitioning for Sustainability

"Breakthrough ACTION-Nigeria has implemented SBC activities using both time-tested approaches such as community engagement and mass media campaigns, and innovative approaches such as human-centered design and behavioral science."

This book provides an overview of Breakthrough ACTION-Nigeria's social and behaviour change (SBC) activities and approaches that were used to improve the practice of priority health behaviours in the areas of malaria; maternal newborn and child health, including nutrition (MNCH+N); family planning/reproductive health (FP/RH); tuberculosis (TB); and COVID-19 and global health security (GHS) priority zoonotic diseases at the national and sub-national levels. It is intended to serve as a guide to professionals working on SBC interventions.

As explained in the book, "Breakthrough ACTION-Nigeria was the United States Agency for International Development's (USAID) flagship SBC project in Nigeria from 2018 – 2024 under the prime implementation of the Johns Hopkins Center for Communication Programs (CCP) with sub-partners Save the Children US, Viamo, ThinkPlace, ideas42 and the Nigeria Centre for Communication and Social Impact (CCSI). At a total investment of more than $100 million dollars over seven years, Breakthrough ACTION-Nigeria was the largest Social and Behavior Change (SBC) buy-in ever funded by USAID. The project worked closely with a wide spectrum of Federal and State Ministries of Health programs, departments, and agencies, USAID Implementing Partners, and other key stakeholders to co-create SBC materials, implement SBC activities and improve SBC capacity and coordination."

The book begins by outlining Breakthrough ACTION-Nigeria's theory of change and its integrated and multi-channel approaches to health communication. Its theory of change model was adapted from the socioecological model, a multi-level approach used to understand the socio-cultural and environmental determinants and the relationships and structural factors that affect behaviour. The theory of change recognises the centrality of communities, households, and the service delivery system to effect desired changes; thus, SBC interventions were implemented at each of these different levels. Gender issues were cross-cutting across all the levels and were mainstreamed into all the interventions.

Breakthrough ACTION-Nigeria employed four integrated SBC best practices to improve message comprehension, reduce message fatigue, and maximise health impact across multiple health behaviours. It created synergistic effects through mutually reinforcing, multi-channel interventions at the community level and on mass media, mobile, social media, and digital. The four integrated SBC best practices were:  

1. A focus on gateway behaviours known to influence adoption of other health behaviours. These were: antenatal care, facility delivery, immunisation, FP, use of insecticide-treated nets (ITNs), exclusive breastfeeding, and infant and young child feeding (IYCF).
2. A life stage approach that segments priority health behaviours by the life stage of the audiences: early pregnancy (first 6 months); late pregnancy, birth, and the first weeks after birth; couples with infants and children under 5 years; and all couples of reproductive age.
3. The use of an umbrella theme and platforms that tied the different health topics into an overarching, unified identity connecting all communication platforms. These included, for example, the health campaigns Albishirin Ku! (see Related Summaries, below) and Jide ka I ji, which both revolved around a radio drama.
4. The use of cycling overlay, which is an approach that layers health-specific messages concurrently on top of the messaging on the integrated platforms to increase intensity on selected topics at key points in time (e.g., seasonal malaria messages) or place (e.g., localities that have a high prevalence of TB) or both (e.g., lassa fever messages).

Overall, the report highlights the following key learnings and approaches that contributed to the success of the programme:

• Learning, adaptation, and innovation: Breakthrough ACTION-Nigeria monitored and evaluated its processes, outputs, and outcomes, and it continuously shared insights and learnings with all those involved in project implementation, from project staff to government representatives and community members. Frequent evidence-based reflection and analysis sparked innovations and adaptations to address evolving health needs and challenges more effectively. Creativity and calculated risk-taking were encouraged.
• Evidence-based and audience-centred approaches: The project embraced an evidence-based, human-centred design approach to address health behaviour challenges. The process began with a discovery phase that involved reviewing existing research, looking at approaches that succeeded in the past, and engaging in deep empathetic conversations with community members, service providers, and other stakeholders to gain insights on health challenges and to co-design solutions. As stated in the book, this process yielded innovative, contextually appropriate, and community-owned interventions that measurably increased the uptake of priority health behaviours.
• Addressing underlying health determinants: Breakthrough ACTION-Nigeria focused on affecting ideational factors strongly associated with each priority health behaviour. Ideational factors are cognitive, emotional, and social determinants that influence the way people behave. Results from the secondary analysis of Breakthrough-RESEARCH's Behavioral Surveillance Survey data showed that the integrated SBC community and mass media interventions increased positive determinants of health and thereby increased healthy behaviours across a wide array of health areas.
• Community health worker referral system: The programme implemented a large-scale community health worker intervention that engaged over 16 million community members and made 2.2 million referrals for health services, of which over 1.2 million were completed. This, according to the book, contributed an average of 18% to the uptake of all the priority health services provided in the focal areas.
• Empowered local communities: The project worked with community members, resource persons, and leaders who are trusted and know their communities best to design and lead truly impactful and sustainable community-led approaches for normative change, which included the generation of their own resources. These approaches included women's empowerment groups, SBC-advocacy core groups, and ward development committee community capacity-strengthening initiatives. Many of these approaches are continuing without project support.
• "Learning-by-doing" collaboration to build SBC capacity: Throughout implementation, the project built strong partnerships and collaborated with Government of Nigeria partners at the national, state, and local levels to co-design and co-implement SBC solutions that are aligned with government priorities. Using this learning-by-doing approach and traditional trainings, SBC practitioners at community, local government area (LGA), state, and national levels gained knowledge in theory and practical and relevant experience to design and implement evidence-based and audience-centred SBC.
• Private sector engagement: The project's partnership with Airtel Telecommunications and 140 media houses resulted in increased levels of private sector engagement and support for SBC initiatives in Nigeria, for a total contribution of more than US$4,000,000 over the life of the project.

The majority of the chapters in the book are dedicated to outlining the key learnings and approaches, as well as outputs and results, as they related to work done to address the different health areas and their specific activities, explaining in more detail how the above-mentioned key approaches were applied. Each section also includes personal success stories to further highlight the impact of the programme. The chapters and subchapters are:

Reproductive, Maternal Newborn and Child Health, Malaria and Nutrition

• Community Volunteers and Referrals for Services
• Mass Media, Mobile Phones and Digital
• SBC and Advocacy Support to ITN Campaigns

Special Initiatives Addressing Social Determinants

• Community Capacity Strengthening
• Women's Empowerment Groups
• SBC Advocacy Core Groups - Religious and Traditional Leaders

Tuberculosis

Risk Communication and Community Engagement

Cross-Cutting Initiatives

• Gender
• Provider Behavior Change
• Public Sector Capacity
• Private Sector Engagement

Research, Monitoring, Evaluation and Learning

The most notable programme results, as highlighted in the report, showed that:

1. Breakthrough ACTION-Nigeria interventions resulted in positive effects on many health determinants and behaviours, including:
   • RMNCH, nutrition and malaria behaviours;
   • TB case-finding; and
   • COVID-19 vaccination uptake.
2. Community volunteer referrals contributed to the uptake of priority health services in focal primary health care facilities.
3. Breakthrough ACTION-Nigeria interventions were found to be highly cost-effective in terms of disability-adjusted life years (DALYs) averted.
4. The programme increased SBC capacity at the national and sub-national levels.
5. Overall, the programme had a positive impact on people's lives.