Demographics
The description of the social actors is shown in Table 2. A total of 45 participants were engaged across study states for the OH and MSC activities. The majority were males (35/45), and half were either technical officers (17/45) or Directors/Deputy Directors (7/45). Technical officers comprised participants such as the Information Officer, Health Education Officer, and the State disease surveillance and notification officer (SDNO). Furthermore, the majority were drawn from either SPHCDAs (19/45) or SMOHs (7/45).
Table 2: Demographics of study participants for OH and MSC
Description
|
Bauchi (n=9)
|
Ebonyi
(n=9)
|
Kebbi (n=9)
|
Nasarawa (n=9)
|
Sokoto (n=9)
|
Total (n=45)
|
Sex
|
|
|
|
|
|
|
Male
|
9
|
3
|
8
|
8
|
7
|
35
|
Female
|
_
|
6
|
1
|
1
|
2
|
10
|
Role
|
|
|
|
|
|
|
Head of MDA
|
_
|
1
|
1
|
_
|
_
|
2
|
Director/Deputy Director
|
3
|
_
|
1
|
_
|
3
|
7
|
Manager
|
2
|
1
|
3
|
1
|
_
|
7
|
Coordinator
|
_
|
2
|
1
|
2
|
2
|
7
|
Technical Officer
|
3
|
3
|
2
|
6
|
3
|
17
|
Media Personnel
|
1
|
2
|
_
|
1
|
1
|
5
|
MDAs
|
|
|
|
|
|
|
SMOH
|
_
|
2
|
3
|
2
|
_
|
7
|
SPHCDA
|
5
|
4
|
5
|
_
|
5
|
19
|
State broadcasting corporation
|
1
|
2
|
1
|
1
|
_
|
5
|
LGA
|
1
|
1
|
_
|
6
|
1
|
9
|
Others*
|
2
|
_
|
_
|
_
|
3
|
5
|
Changes documented at the three SBCC Capacity Ecosystem levels.
Individual Level
At the individual level, the success of the PSCS approach was marked by public sector stakeholders' enhanced abilities in developing health content and messages, organizing, and conducting training sessions, monitoring social and behavior change (SBC) activities, and generating demand for health services.
Development of health content and messages
The PSCS approach has provided public sector stakeholders with support in disseminating crucial health messages through mass media and fostering interactive communication with the audience. This has proven to be a valuable opportunity for effectively reaching individuals at the community level and the wider public, ensuring the successful dissemination of vital health information. Furthermore, there is evidence of improved skills among media personnel in delivering health messages. Media personnel in this study are radio/TV broadcasters as well as directors at media organizations who were also targeted as part of the PSCS approach to improve health outcomes. Specific media personnel have been given the opportunity to attend training sessions, workshops, and seminars, enabling them to enhance their skills and ultimately, program delivery. This has resulted in more engaging and impactful strategies for conveying information and motivating individuals to adopt healthier habits.
We have received support in securing slots with various media outlets, particularly radio stations. This opportunity allows us to broadcast live programs, including health talks and interactive communication programs. Through this initiative, we have been able to effectively reach people at the grassroots level in the community and the wider public.
Technical Officer, Bauchi
Before the intervention, programs were conducted randomly without a sequential approach. The lack of basic skills and proper preparation hindered effective program delivery. Working with professionals has brought joy to colleagues, who now have access to training, workshops, and seminars to improve their skills.
Media Personnel, Bauchi
Demand creation
Participants were also equipped with the necessary skills and knowledge to enhance the demand for crucial health services. This involved training on relevant health issues and the dissemination of vital prevention information, enabling them to effectively educate and raise awareness within their communities. As a result, the PSCS capacity building efforts proved beneficial in fostering a proactive approach to improving access to healthcare services.
During the training, we learned about tuberculosis, malaria, and HIV, and the importance of testing to differentiate these diseases. We also gained knowledge on preventive measures. The training covered insecticide-treated nets (ITNs) and the challenges of net usage, along with promoting proper care and monitoring in the community. Identifying net champions was emphasized. I utilized this knowledge to sensitize communities, such as in a compound meeting where community members testified about the positive impact of malaria testing and proper treatment, replacing reliance on herbal remedies. This feedback confirms the effectiveness of the message in practice.
Technical Officer, Nasarawa
Monitoring of health activities
Participants mentioned that their ability to monitor and gather data for health programs had been enhanced through capacity building efforts. A Technical Officer in Nasarawa expressed the opinion that these efforts had resulted in improved monitoring practices among public sector stakeholders, leading to better record-keeping and referrals.
Monitoring and evaluation play a crucial role in strengthening health systems, particularly in improving record-keeping. The number of referrals, treatments, and further management becomes a key indicator of progress and areas for improvement. Breakthrough ACTION has supported us by providing training at the local government and facility levels, enabling us to identify appropriate referral destinations. This support has been invaluable in assisting individuals who lack resources or knowledge to access necessary services.
Technical Officer, Nasarawa
Most significant change story at individual level
A male technical officer in Bauchi shared a story that highlighted the transformative impact of the PSCS intervention in relation to content development skills. The participant revealed that prior to the intervention, there was poor proficiency in knowledge aspects such as content creation, information management on social media, and effective online engagement. This has changed with the advent of the PSCS approach. The story underscores the significance of capacity building in promoting public health awareness and engagement.
SBC training equips stakeholders with health content development skills.
I had always struggled with developing content, but everything changed with the PSCS intervention. I was pleasantly surprised by the newfound abilities I discovered. Thanks to a recent training, I have learned valuable skills in content creation, information management on social media platforms, and effectively engaging with people online.
In Bauchi, we faced numerous challenges regarding vaccine uptake. However, with the recent capacity building, I have gained knowledge on budgeting for content creation, developing impactful content, and performing analyses. In the past, I was unfamiliar with these aspects. Additionally, I now possess the ability to craft narratives around other crucial health topics such as antenatal care, exclusive breastfeeding, and malaria. Gone are the days when I simply wrote without proficiency.
Recently, I have been receiving guidance on developing newsletters. The State Primary Healthcare Department had never published any materials documenting their activities, aside from what was handled by the M&E officer. However, we recognized that health-related issues shouldn't be the sole responsibility of the M&E officer. Therefore, we advocated for the involvement of other units. I distinctly recall an interview conducted by someone who traveled all the way from Abuja to speak with me. To prepare for this, I had to collaborate with the M&E officer to gather documented scorecards. I also had to convince the primary healthcare management to start producing our own newsletter.
Technical Officer, Bauchi State
Organization Level
Coordination of SBC activities
Support was provided to public sector stakeholders to develop tools and integrate plans with other partners, enabling them to effectively coordinate and monitor SBC activities. This collaboration also facilitated the harmonization of campaigns and demand creation for health services. Through these efforts, stakeholders were able to streamline their activities, ensuring a cohesive and unified approach to SBC interventions.
Yes, we have successfully completed the process of micro planning. In preparation for a malaria campaign scheduled for this year, we conducted a micro planning meeting last year. During the meeting, we had the opportunity to collaborate with other partners in the state. Together, we harmonized our activities and tailored certain tools to suit our specific needs. At the end of the day, we utilized the tools during the campaign. They [Breakthrough ACTION] sponsored the event and offered technical assistance.
Director, Bauchi
Likewise, several participants expressed that their training in leadership and strategic communication enabled them to acquire essential skills for coordinating and managing SBC activities, while also playing a pivotal role in developing their communication abilities.
I had the opportunity to attend the intensive two-week training on leadership and strategic communication in 2019. This training significantly enhanced my communication skills and equipped me to effectively coordinate SBC) activities. As a result, I am currently overseeing SBC activities at the local government level, ensuring accurate reporting of our initiatives. The training has empowered me to confidently serve as a communication leader, capable of delivering impactful messages on all aspects of malaria.
Program Manager, Nasarawa
Facilitation skills for cascade of knowledge
To ensure widespread dissemination of SBC knowledge, a cascade training model was employed to build capacity at the local government level. This involved training public sector stakeholders at the state level who held responsibilities in addressing various health challenges such as maternal, newborn, child health, malaria, and family planning. These stakeholders were equipped with the necessary facilitation skills to train other personnel at local level and engage in SBC activities, including the dissemination of crucial health messages during community gatherings like compound meetings. This strategy aimed to enhance the reach and impact of SBC interventions from the state level down to the local communities.
They always invite me, anytime we want to maybe enlighten the populace, we are selected to go and speak to them and even at the local government level whenever they are having their compound meetings, at times they tell us because we were trained at the state level and then we cascade the training to those at the local government level. So, there are times when they want to have any activity, they invite some of us and we go to give our own support too.
Director, Sokoto
An important product of the cascade training model was the increased provision of health services in accordance with national guidelines. Components of existing guidelines focuses on concepts such as respectful maternity care (RMC) aimed at promoting respectful, equitable, and person-centered care, while aiming to eliminate mistreatment, abuse, and disrespectful practices that may occur within maternal health settings. Participants shared that they received training on RMC which in turn translated into good relationships between health workers and community members.
I attended a training session on Respectful Maternity Care (RMC) that was much needed to address outdated practices among healthcare providers. This training positively influenced our approach to Malaria in Pregnancy (MIP) and other social behavioral change activities. It inspired us and significantly improved the bond between health workers and the community. We are now seen as friends and partners, with community members willingly participating in our activities. This positive attitudinal change has fostered a cordial and supportive relationship between health workers and the community.
Program Coordinator, Ebonyi
Participants also provided information on increased provision of malaria-related services in accordance with malaria guidelines especially on the use of sulfadoxine-pyrimethamine (SP) as intermittent preventive treatment (IPTp) during pregnancy to safeguard against malaria and minimize the associated risks and complications.
The capacity of health workers, most especially in-charges have been built on malaria in pregnancy, including the importance of administering sulfadoxine-pyrimethamine (SP). This was crucial because health workers are often rotated among different hospitals. Previously, health workers lacked knowledge about the importance of SP. However, now, all health facilities are well-informed about malaria in pregnancy, including the timing and administration of SP. We have witnessed significant improvements compared to the past, and our people have benefited from enhanced knowledge and awareness.
Director, Sokoto
Most significant change story at organization level
A program coordinator shared an impactful story that showcased the positive outcomes of capacity building efforts at the organizational level. The story emphasized the influence of Breakthrough Action/Nigeria programming, specifically in raising awareness among health personnel regarding malaria as a risk factor for miscarriage during early pregnancy, particularly the first trimester. The coordinator's participation in SBC training provided valuable knowledge that led to their recommendation for conducting malaria tests. This story highlighted how capacity building and SBC training can significantly impact decision-making and improve the quality of care provided.
SBC training promotes awareness of the effects of malaria in pregnancy.
There was a woman that I know vividly. In the past, there was a time she had a pregnancy, of which unknowingly, she had a miscarriage. That miscarriage was as a result of malaria in a pregnancy that she didn't know about. It was after she had that miscarriage and was bleeding (hemorrhaging) that she was rushed to our facility. When she came to the facility that day, I saw her…and together with the officer in-charge of the facility, advised that she be taken to the labor room to clean up the blood to examine the cause of the hemorrhage… They wanted to discharge the woman to just go home… I said, “can’t you just take her to the lab to find out if maybe, there are some other causes to this miscarriage?” They agreed [did a microscopy] and confirmed that [from the lab] … she had a lot of malaria parasite… So that made the woman to understand that it was malaria that made her lose her baby. Then going forward, when this program came on board, we happened to reach her community with the discussion of once if you took ill, rush to the hospital and to go for antenatal visits and ensure that you obtain the necessary drugs. Those drugs given to pregnant women will include SP, SP, SP [IPTp-sulfadoxine-pyrimethamine]. Now today, if I'm passing through that axis, once the woman sees me, she calls me SP, SP, SP as a nickname.
Program Coordinator, Nasarawa
System Level
At the system level, the PSCS approach focused on institutionalizing improved coordination and increased capacity for SBC design and programming. This especially focused on driving the work of the ward development committees and institutionalizing the gains of the process. Participants affirmed that Breakthrough ACTION/Nigeria supported the revitalization of committees in the covered areas, providing essential support in terms of materials and capacity building. This has led to increased capacity of community members to address health challenges in their communities.
The state has been supported to reviewing the laws and guidelines governing the WDCs. They have established regulations for the number of members in the WDC executive committee, including a percentage for female representation. Previously, there were no female members in the WDCs. With the support of Breakthrough Action Nigeria, a WDC forum has been established, holding regular meetings and its activities are monitored. Efforts are being made to track and enhance their capacity-building processes.
Program Manager, Bauchi
WDCs are leading the promotion of sustainability, particularly in addressing structural deficiencies in their domain. When WDCs are sensitized about the significance of these structures, they actively contribute based on their available resources. While the government has played its part, Breakthrough ACTION has also made contributions, either through material support or capacity building initiatives.
Technical Officer, Sokoto
Most significant change at system level
A Director shared a compelling story highlighting the impact of WDCs in promoting community ownership of the local health system. The story highlighted the significant role of WDCs in establishing health structures and how this responsibility has sparked a sense of shared accountability among communities in making health-related decisions and maintaining health structures.
WDC action inspires community shared responsibility for health decision-making.
I will give you an example, you know Akwanga local government, if you go to Akwanga local government, there is a PHC, it's one of the most beautiful primary health cares in Nasarawa state. It was built by the Officer In-Charge with the support of the WDC. This has led to a change in the community's understanding of the importance of their involvement in decision-making processes. Our communities now know the importance of being part of decision-making. So, there is that change - a very, very wide change. Previously, the Officer In-Charge had complete authority over the health facility, making decisions without considering community input. However, now it is widely recognized that the community has a role to play through the WDC. We were migrating from that ideology of “okay, I own the facility, I can decide whatever I intend to decide” and embracing a shared responsibility for health facility and its operations.
Director, Nasarawa
Challenges experienced.
Participants highlighted several challenges that hinder their application of skills acquired from the PSCS approach. These challenges include inadequate human resources for health, insufficient funding, religious and cultural barriers, limited translation of messages, lack of mobility, security concerns, negative attitudes of health workers, and inadequate intervention coverage.
A participant highlighted the significant challenge of human resource especially that there are not enough female health workers which makes service uptake difficult. Another challenge raised was the insufficient funding for the implementation of SBC activities.
When you look at human resources for health, it is very big issue because one will say “I would not allow male health worker to touch my wife”. Previously, I had that mindset [laughs]. “Why should a male doctor look at my wife, why?” To allow our girl child education is very important. There is need to come up with some innovations or something that can help us enroll our women. Also, insufficient funding poses a significant barrier to the successful implementation of our work. If there is no money the work would not go perfectly okay.
Technical Officer, Kebbi
A program manager in Kebbi expressed that religious and cultural barriers still exist and hinder the implementation of capacity built by the PSCS approach, despite notable progress, but remains optimistic about further change in the future.
Despite significant progress, there are still some challenges related to religion, tradition, and finances. While the issues surrounding religion and tradition have been greatly reduced, they persist to some extent. Additionally, financial constraints pose another obstacle. It's important to acknowledge that when dealing with people, there will always be individuals who hold different perspectives and may emphasize their own reasons for certain beliefs or actions. Although these challenges remain, there is optimism that they will diminish over time and pave the way for smoother progress in the future.
Program Manager, Kebbi
The dissemination of health messages through the media can be challenging at times due to limitations imposed by language restrictions that may not align with the target audience's needs.
The challenge we face is related to translation. Different radio stations have restrictions on the languages used for broadcasting. Some stations limit the use of English, while others restrict it to Igbo or specific dialects. This poses a problem because not everyone can understand all the languages.
Program Coordinator, Ebonyi
A technical officer in Ebonyi identified several gaps that hinder the application of knowledge and skills acquired through the PSCS approach. These include community disinterest in health messages, lack of government ownership, negative attitude of health workers, limited accessibility, and inadequate coverage. These gaps pose challenges for beneficiaries in effectively addressing health issues within communities.
People often prefer to engage in small-scale fights for small amounts of money rather than sitting down and listening to information that can help them. This leads them to rely on patent medicine vendors and self-medication, instead of being educated on how to prevent such challenges. While we hope for government assistance, it doesn't always work out that way. The issue of sustainability is still distant without government involvement. Another challenge is the attitude of health workers who may overcharge patients even when services are meant to be free. This can demoralize communities seeking interventions. Furthermore, security problems also exist in some areas and there is a lack of mobility in certain areas. This makes it difficult for health educators to reach these areas. Lastly, the program's support is limited to only a few LGAs, which poses another challenge.
Technical Officer, Ebonyi
Another participant emphasized that inadequate funding and poor mobility are significant challenges that directly impact crucial activities like monitoring of SBC activities.
One of our challenges is in the monitoring activities at the ward level, particularly in training community members. We aim for equal dissemination of health education messages. However, constraints include inaccessible roads in some communities, limited finances for frequent visits, and transportation issues. Having a designated means of mobility for health educators would greatly enhance our efficiency. Despite these challenges, we strive to do our best within the constraints we face.
Technical Officer, Bauchi