Evaluation of the RISE II Integrated Social and Behavior Change Approach in Niger: A Contribution Analysis

"Male engagement activities and income-generating opportunities for women were highlighted as crucial elements contributing to positive health behaviors and women's empowerment."

Niger faces a myriad of health challenges, and development efforts are complicated by persistent poverty, high population growth rates, and climate change. Integrated social and behaviour change (SBC) addresses health outcomes through collective action and approaches (e.g., community engagement, interpersonal communication) at the limited points of entry individuals have with the health system (in the community and/or at a facility). The United States Agency for International Development (USAID) supported the Resilience in the Sahel Enhanced (RISE) II project to reach chronically vulnerable populations through integrated SBC programming that was designed to improve priority behaviours and health outcomes in family planning (FP); maternal, newborn, and child health (MNCH); nutrition; and water, sanitation, and hygiene (WASH). This paper shares the results of a mixed-methods study to evaluate the effectiveness of RISE II in the Maradi and Zinder regions of Niger from 2019-2023. It focuses its findings on the effectiveness of programming on 4 health outcomes: FP use, maternal health, nutrition, and WASH behaviours.

RISE II was implemented through Resilience Food Security Activity (RFSA) partners, which in Niger included Hamzari (led by Care), Girma (led by Catholic Relief Services), and Wadata (led by Save the Children). Based on a theory of change that is guided by the socio-ecological model, RFSAs used a variety of SBC approaches to address factors influencing health outcomes at the individual, interpersonal, and community levels. In brief:
 

• At the individual level, volunteer leaders identified pregnant women and children up to six months of age in the village and trained facilitators conducted monthly community based peer group meetings ("Care groups") and conducted home visits to share messages that encouraged these women to visit health centres for prenatal consultations before childbirth, to opt for skilled birth attendants, to adopt optimal lactating practices following birth and to improve hygiene practices through the use of locally made, low cost handwashing stations that motivate handwashing at critical moments. The groups relied on cascade training from paid promoters to volunteer leaders to neighbourhood mothers to enable broad geographic coverage.
• At the interpersonal level, similar community-based peer groups were organised for men. Through the Husbands' Schools model, men educated their peers on issues relating to sexual and reproductive health (SRH) and child nutrition. Through both Care groups and Husbands' Schools, RFSAs encouraged intra-couple dialogue as a lever of behaviour change to promote joint decision making for health behaviours, particularly related to contraceptive use and maternal health care.
• At the community level, RFSAs worked with community leaders and through radio programmes to reinforce health messages. Radio programs developed by RFSAs served as a platform where members in the community debated social issues and addressed social norms such as early pregnancy among young married adolescents. In addition to the primary SBC strategies, RFSAs supported community group activities to enable income generation.

The researchers conducted a mixed-methods triangulation study drawing from a pre-post quasi-experimental survey and qualitative in-depth interviews with programme participants. The baseline quantitative survey started in April and concluded in early May 2021, with a final sample of N = 2,708. The endline survey was conducted in February 2023 and concluded in March 2023, with a final endline sample of N = 2,727. Qualitative interviews were conducted in June 2022. The researchers applied contribution analysis, a theory-based plausibility analysis, to assess contributions of the intervention.

In brief, the study found that RISE II in Niger contributed to improved behavioural determinants. There was not a statistically observable effect of the intervention on the four health outcomes. However, across two of the four outcomes, the researchers found that women who were exposed to RISE II messages were significantly more likely to have improved health outcomes. They found an increased odds of using modern contraception (adjusted odds ratio (AOR) = 1.7, p < 0.001) and an increased odds of having a handwashing station (AOR = 1.4, p<0.01). For women participating in a RFSA-sponsored women's group, there was an increased odds of using modern contraception (AOR) = 1.4, p < 0.05) but a negative association with households having a handwashing station (AOR) = 0.6, p < 0.001).

Furthermore, the researchers observed statistically significant positive associations with knowledge and perceived norms for all health behaviours except for exclusive breastfeeding. They observed statistically significant positive associations with self-efficacy for all health behaviours except handwashing. They observed negative associations for attitudes and self-efficacy for the handwashing behaviour. A plausible explanation for the decline in the handwashing measure may be because the baseline study occurred one year after the onset of COVID-19, when many organisations were stressing the importance of hygiene-related behaviours. It is conceivable that declines in this outcome were due to waning programmatic emphasis on hygiene behaviour over time.

Qualitative examples of findings from each socioecological level include:
 

• Individual level: Across all health messages, women were significantly more likely to have heard or seen a health message in the intervention group. Some women were resistant to engage with the volunteers on health messages because they felt they should receive something in exchange, but this resistance was resolved through dialogue.
• Interpersonal level: Findings from the qualitative data explored exposure to the SBC approach among family and peers and how this exposure contributed to improved knowledge and attitudes about health behaviours among programme participants. Respondents reflected on the RFSA-sponsored community activities and how the programme engaged husbands and wives. This approach helped to facilitate communication between couples and even the broader family to identify solutions to household problems.
• Community level: Radio programmes served as a channel to share health messages. However, fewer than one-third of women interviewed listened to the radio at least once a week at baseline. While access to radios was limited, several programme participants reflected on hearing health messages transmitted through radio programmes.

Notably, the study found that male engagement activities under RISE II contributed to increased dialogue among families about health behaviours and helped foster a supportive environment for women to practice health behaviours. Consistent with previous studies, these findings suggest that emphasis on male engagement programming has the potential to provide direct and indirect benefits to women's health by improving partner communication. However, increases in male partner out-migration were negatively associated with health outcomes.

As part of this research, the study team generated a contribution story for the integrated SBC activities implemented under RISE II in Niger. Here are some highlights:
 

• The programme worked primarily at the community level by engaging directly through community-based groups with women and members of their family to provide information and support that would contribute to improved knowledge, perceived norms, and self-efficacy - enabling them to adopt healthy behaviours.
• Strengthened male involvement in household responsibilities contributed to an improved home environment where women felt supported. Income-generating activities contributed to financial autonomy for women to access services.
• Evidence supports the conclusion that higher levels of knowledge, attitudes, perceived norms, and self-efficacy observed in the intervention area at endline, coupled with statistically significant associations with the behavioural determinants and health outcomes, suggest that progress has been made, as described in the theory of change.
• Given there were only two years between the baseline and endline, continuing activities with sustained implementation of the integrated SBC approach at scale may result in a statistically significant change in health outcomes, particularly with continued emphasis on income-generating activities, which may serve as a protective factor, given the continued increase in male partners moving away in search of financial resources.

In conclusion: "While the RISE II program demonstrated positive impacts on behavioral determinants, adaptation and sustained implementation at scale are required to ensure program effectiveness considering the contextual challenges in Niger."