Religious Leaders Championing Social and Behavior Change for Improved Maternal and Child Health: The Breakthrough ACTION-Nigeria Experience

"Traditional and religious leaders are highly influential in all aspects of peoples' lives in Nigeria, particularly in northern Nigeria, and have an important role in improving their communities' health."

This document describes Breakthrough ACTION-Nigeria's approach to advocacy among religious and traditional leaders using the Social and Behavior Change Advocacy Core Group (SBC-ACG) model. It looks at how the SBC-ACGs are structured and how they function, and it highlights challenges and lessons learned. The document is designed to serve as a guide for organisations and projects planning to engage and work with religious and traditional leaders to implement health and other development programmes. The approach may be especially useful for programmes seeking to shift social and gender norms.

As explained in the document, "The SBC-ACG model adapts the Johns Hopkins Center for Communication Programs (CCP)'s Advocacy Core Group (ACG) approach, first introduced under the Nigerian Urban Reproductive Health Initiative (2009 - 2020) and refined by The Challenge Initiative and Health Communication Capacity Collaborative projects. While these projects applied the model to influence laws, policies, and resource mobilization for reproductive health, Breakthrough ACTION-Nigeria enlists community and religious leaders to identify and address social and gender norms impacting health behaviour and share positive health messages among their constituents in what it named the SBC-ACG model."

Breakthrough ACTION-Nigeria has been working with religious and community leaders through the SBC-ACG model since 2018. The model has been implemented in five States to positively influence social and gender norms and behaviour associated with reproductive, maternal, neonatal, child health, nutrition (RMNCH+N) and malaria. The project has focused primarily on five norms that limit the practice of priority health behaviours: 
 

• Restricted mobility and social interactions for women;
• Women's agency in household and health decision-making;
• Child and early/forced marriage;
• Intimate partner violence (IPV); and
• Female genital mutilation/cutting (FGM/C).

Following the background introduction, the document describes the SBC-ACG structure, composition, and functions. They comprise religious and traditional leaders, health professionals, government stakeholders, civil society organisation (CSO)/community-based organisation (CBO) representatives, women's groups, media personnel, and other community opinion leaders and have clear terms of reference for the SBC-ACGs and group structures at different levels. Members have different responsibilities, but overall, the responsibility of the SBC-ACG is to: 
 

• Work to address barriers, untruths, and misconceptions concerning RMNCH+N interventions.
• Support demand creation for RMNCH+N interventions, including childbirth spacing.
• Engage with community, traditional, key opinion, and influential leaders in the local government areas (LGAs) and communities.
• Facilitate discussions aimed at reducing barriers and increasing access to RMNCH+N interventions.
• Support efforts to ensure that messages created for demand are culturally appropriate and acceptable.
• Facilitate the dissemination of correct information on RMNCH+N interventions, including childbirth spacing, through mass media.
• Support efforts to ensure special groups, including women, youth, married adolescents, disabled people, internally displaced persons, and refugees, have access to correct information on RMNCH+N interventions.
• Advocate for resources and support among government, communities, non-governmental organisations, relevant institutions, and other stakeholders.
• Advocate with the government and implementing partners on establishing and providing accessible and quality RMNCH+N services.
• Contribute to developing and implementing RMNCH+N and childbirth spacing programmes in the states.

The document describes the process Breakthrough ACTION-Nigeria followed to form and support state- and LGA-level SBC-ACGs. Holding effective initial consultations, leveraging religious viewpoints, prioritising relationship building, employing culturally sensitive communication, fostering openness to learning, unifying messaging approaches, and implementing strategic work plans through religious leaders' active participation are vital elements.

A key component of SBC-ACGs are the "Speak Out" approaches to disseminate RMNCH+N and malaria information and influence gender norms and health behaviour. There are six primary modes described in the document: modelling, sermons, mass media, mentoring, referrals, and annual symposiums. The synergy of these approaches is essential; while modelling, mentoring, and referrals establish a direct and personal connection, mass media, sermons, and symposiums maximise reach. When all carry the same message, they reinforce one another, having an additive influence on behaviour.

The document also outlines the impact and challenges experienced by the programme, as well as the solution developed to overcome the challenges. Key findings from a qualitative assessment conducted in 2021 showed, for example, that there has been increased awareness of health issues because of the SBC-ACG activities. In addition, SBC-ACG members reported reductions in home births, increased adoption of childbirth spacing methods, and improved care-seeking for childhood illnesses (see Related Summaries below for more information on the impact of this model). Challenges mentioned in the report include, for example, ensuring representation of all religious groups and denominations in the SBC-ACGs, considering the multitude of options and the overwhelming interest from people to join. The project resolved this challenge by identifying the most influential and health-supportive sects, ensuring broad representation, sticking to its planned numbers, and focusing on leaders committed to health and development. Another challenge from the SBC-ACG's point of view was that it took time to get communities to act on their messaging. They experienced strong pushback when introducing some new health behaviour such as COVID-19 vaccination. The project addressed this issue by using varied SBC approaches - e.g., trustbuilding sessions with community members, religious leaders publicly getting COVID-19 vaccination, and continuous dialogue.

Finally, lessons learned from implementing the SBC-ACGs programme are highlighted. In brief, some of the most important are: 
 

• Build and nurture trusting relationships from the beginning to foster a sense of commitment and active involvement among religious and traditional leaders.
• Bring together stakeholders and interest groups from various backgrounds to form SBC-ACGs that own and share consistent messaging.
• Provide guiding documents, terms of reference, and ongoing capacity-building opportunities for SBC-ACGs to help members successfully assume their roles as health advocates.
• Create SBC-ACGs to continue beyond the life of the project.
• Establish a robust monitoring, evaluation, and feedback mechanism.
• Link desired normative and behaviour change to existing cultural beliefs, concepts, and language.

Breakthrough Action has also published "Transformative Stories of Religious and Traditional Leaders Inspiring Healthy Communities" [2024], which shares the impact of Breakthrough ACTION's work with religious and traditional leaders in Nigeria through personal stories.