Breakthrough RESEARCH Nigeria: Catalysing Social and Behaviour …

Breakthrough RESEARCH is the U.S. Agency for International Development’s (USAID) global flagship social and behavioural change (SBC) research and evaluation project. Implemented in Nigeria since 2019, Breakthrough RESEARCH Nigeria has significantly contributed to shaping the implementation and adaptation of USAID-funded SBC interventions in the country.

On April 27, 2023, USAID celebrated the successful completion of its five-year SBC research and evaluation activity — Breakthrough RESEARCH Nigeria — with a day devoted to the final dissemination of results, best practices and lessons learned from studies that explored factors that influence the adoption and practice of health behaviours, which can help inform national and state level health policies and interventions that seek to increase demand for health services.

Breakthrough RESEARCH is a consortium led by the Population Council in partnership with Tulane University, Avenir Health, ideas42, Population Reference Bureau, and Institute for Reproductive Health at Georgetown University.

Breakthrough RESEARCH Nigeria implemented a suite of research and evaluation studies using quantitative and qualitative methodologies to respond to SBC questions on programme effectiveness and cost-effectiveness. The studies addressed a range of priority health behaviours being promoted by a USAID-funded SBC programme, Breakthrough ACTION Nigeria, such as antenatal care (ANC) attendance, use of child spacing methods, use of insecticide-treated nets, and infant breastfeeding in Kebbi, Sokoto, and Zamfara States. Besides generating evidence, Breakthrough RESEARCH promoted the use of evidence in iterating SBC programmes.

Image credit: Nigeria Health Watch

“We’re all committed to establishing an evidence base for what works. We’re also committed to making sure that the research we do does not become archived”, Prof. Paul Hutchinson, Technical Lead, Breakthrough RESEARCH Nigeria, Tulane University, New Orleans, said.

Sara Werth, USAID/Nigeria Deputy Mission Director, re-affirmed this position in her opening remarks. “We are proud that the Breakthrough Research activity generated valuable insights that will continue to influence USAID and government social behaviour change programmes and investments in health.”

The close-out event had in attendance the Minister of Health, represented by the Director of Health Promotion Division, Mrs Ladi Bako; the USAID Deputy Mission Director, Sara Werth; the Commissioner, Sokoto State Ministry of Health, Alhaji Muhammad Lema Abubakar; the Permanent Secretary, Zamfara State Ministry of Health, Mallam Aliyu Maikiyo; the Permanent Secretary, Kebbi State Ministry of Health, Dr Shehu Koko; and USAID’s Director of Health Population and Nutrition (HPN) office, Dr Paul McDermott.

Remarks by Sara Werth, USAID Nigeria Deputy Mission Director at the Breakthrough Research dissemination event in Abuja. Photo credit: Breakthrough RESEARCH Nigeria

As no robust research can be done without partnering with academia, representatives from the University of Abuja, the University of Ilorin, and Bingham University, which Breakthrough RESEARCH Nigeria collaborated with, were also present.

Breakthrough RESEARCH Nigeria’s work provides programmatic evidence of the impact, visibility, and cost-effectiveness of SBC interventions in Nigeria. It promotes the use of this evidence by priority audiences, including Breakthrough ACTION Nigeria and other implementing partners. The outcomes of their work include the following:

Generated high-quality evidence that informed Breakthrough ACTION Nigeria programming, which was the primary purpose of setting up Breakthrough RESEARCH Nigeria. This evidence for SBC design and programming is relevant for other stakeholders’ funding or implementation within the SBC domain.

USAID is currently using this evidence to inform the next programming for health, population, and nutrition in Nigeria.

Initiated the process of institutionalising and localising evidence generation for SBC by engaging three universities — the Universities of Abuja and Ilorin and Bingham University. By establishing the local capacity for SBC evidence generation, Breakthrough RESEARCH is contributing to a sustainable system for SBC evidence generation in Nigeria.

Two approaches to SBC programming were explored: vertical and integrated. The vertical approach focuses on a malaria-only intervention, while the integrated approach combined different health topics such as maternal, neonatal and child health (MNCH), malaria and nutrition in one approach.

Integrated and vertical SBC programming appeared beneficial in shifting multiple behaviours affected by shared norms and attitudes, such as care-seeking behaviours for sick children. However, the performance of integrated SBC over vertical programming is relative, based on the indicators considered or the context.

An evaluation of this magnitude has yet to be attempted, mainly because such evaluations face unique challenges, e.g., external factors beyond SBC programming can influence health behaviours. Also, researchers can’t always control who received an SBC intervention.

The cost-effectiveness analysis compared the integrated SBC approach addressing multiple health areas in Kebbi and Sokoto States to a malaria-only approach in Zamfara State. The study examined whether the additional cost required for an integrated SBC approach is a cost-effective investment.

The overall results indicated that relative to malaria-only SBC, the additional investments for integrated SBC are highly cost-effective based on national and regional thresholds. The impact of the programming was measured by the Behavioural Sentinel Surveillance study, which found lives saved in the integrated SBC states relative to the malaria-only SBC state. The primary drivers of the positive results in the integrated states are the increased use of antibiotics for respiratory infections and oral rehydration solution (ORS), and zinc for diarrhoea versus the decrease in use in the malaria-only state. These results, combined with data on the programme’s cost in each state, were used to assess cost-effectiveness.

Image credit: Nigeria Health Watch

According to Dr Dele Abegunde, Chief of Party, Breakthrough RESEARCH Nigeria, one would expect that the integrated SBC would be more cost-effective than the vertical SBC; however, this may be an assumption from experience in the field. “The whole of Breakthrough RESEARCH Nigeria work since 2019 is to provide the evidence around this assumption. Our research results, albeit equivocal, showed that in some areas, the integrated is more cost-effective than the vertical, and there are a few areas where the flip was seen where it showed that the vertical SBC might be more effective.”

Dr Abegunde also added that after examining the mitigating circumstances that clouded the study since 2019, such as the impact of COVID-19 and insecurity, “we judged that there is indeed evidence to show that the integrated SBC is more cost-effective according to our assumption. Although this evidence is not as strong as we would expect, we can conclude that we need to do additional tailored research to be able to clearly state without any scientific doubt that the integrated SBC is more cost-effective.”

During a discussion session at the dissemination event, Prof Hutchinson stated that this costing component of the study, led by Breakthrough RESEARCH consortium partner, Avenir Health, is one of the first to examine the cost-effectiveness of integrated SBC and therefore has important implications for SBC programmes implemented around the world.

Breakthrough RESEARCH Nigeria assessed two approaches implemented by Breakthrough ACTION Nigeria in integrated SBC programming using qualitative assessment:

Advocacy Core Group (ACG) model for integrated SBC programming in Nigeria– This study aimed to examine the operation and potential effectiveness of the ACG model, which works through key opinion leaders and influencers to influence community-level health norms and individual behaviours. The focus was on the uptake of essential reproductive and MNCH services.

Results showed that the potential to influence health behaviours appear strong but can vary by geography and health topic. Analyses of information flows in Sokoto State showed that respondents were influenced by religious or traditional leaders for ANC, immunisations, and child spacing, with traditional leaders appearing to be more influential than religious leaders.

Community capacity strengthening model for integrated SBC programming — This approach focused on engaging existing community leaders and structures, such as ward development committees, to increase community self-efficacy, coordinate and support the health ecosystem in general, and ensure sustained community-level activities supporting behaviour change and positive social norms for improved health outcomes.

The findings revealed a significant increase in awareness and knowledge regarding key health issues across various target health areas, including family planning, MNCH, malaria, immunisation, ANC, and nutrition, because of Breakthrough ACTION Nigeria’s sensitisation messages such as Albishirin Ku (Glad Tidings). This has led to the reported adoption of healthier behaviours and informed decision-making. Religious and cultural norms in some communities with limited education or exposure were barriers to adopting healthier behaviours such as child immunisation or spacing.

Significant progress has already been made towards achieving the project’s goals as high-level officials from the focus State Ministries of Health echoed their commitment to implementing the research findings to improve the healthcare delivery systems in their respective states.

For more information on Breakthrough RESEARCH Nigeria’s body of work, please visit this webpage.