"Like a Broom Tied Together": A Qualitative Exploration of Social Cohesion and Its Role in Community Capacity Strengthening to Support Integrated Health in Nigeria

"Honestly there is an agreement, we understand each other there is no difference. If anything comes up, everybody trusts and understands each other. There is nothing bigger than when you unite and work together. If we didn't accept each other, we would not have been doing things together. There is no misunderstanding or disagreement between us." - Bauchi, male ward development committee (WDC) member

Social cohesion, broadly understood as the degree of connectedness, solidarity, and trust across various community groups and between individuals, is critical for community capacity: the individual and aggregate strengths of members to overcome barriers and find or cultivate opportunities to improve community and individual well-being. Community capacity programmes strive to strengthen community engagement, mobilisation, and ownership, which can have a long-term influence on public health. This paper examines social cohesion and its role in community capacity strengthening for sustaining integrated health gains in Nigeria.

This study took place in the context of a mid-course qualitative evaluation of Breakthrough ACTION/Nigeria's community capacity strengthening (CCS) approach, which focuses on engaging ward development committees (WDC) to increase community agency, to coordinate and support the ward-level health ecosystem, and to ensure sustained community-level activities supporting behaviour change for improved health outcomes. As detailed at Related Summaries, below, the CCS intervention in Bauchi and Sokoto states included an approach in which WDC members across selected wards were trained and provided technical support to support and guide monthly micro-planning meetings, monitoring and evaluation, and data use for decision-making. The support provided allowed committee members to surmount challenges hindering the utilisation of certain maternal, neonatal, child health, and nutrition (MNCH+N) services.

The study used a qualitative design based on: (i) in-depth interviews (IDIs) conducted among WDC members, village development committee (VDC) members, community volunteers (CVs), local government area (LGA) officials, and traditional leaders; and (ii) key informant interviews (KIIs) conducted among Breakthrough ACTION/Nigeria project staff. The study was conducted in 4 wards in Bauchi and 4 in Sokoto in 2021.

The study's findings are presented in accordance with a social cohesion framework that consists of 3 separate yet interconnected levels:

1. The individual level is divided into 3 factors: (i) self-motivation, which is related to the reasons that motivate an individual to be in a group and includes topics on intimate face-to-face communication, recognition, and legitimacy; (ii) perceptions, norms, and values, which refer to the individual's perspective on the group they are a part of and their own set of beliefs (e.g., the degree of "like-dislike" and sense of community); and (iii) participation and performance, which relate to a person's motivation to act and assume responsibility in a group. This third component is influenced by initiative, individual participation, task competence, and individual behaviour.
2. The community level is divided into 3 factors: (i) the social environment, which is connected to a group's social climate and could be associated with shared norms and values, formal/informal control of the group, friendship networks, pressures for conformity and caring for group norms, or civic society; (ii) relationships and ties, which is related to social capital, trust, reciprocal loyalty and solidarity, moral support, or the value of incentives in the group; and (iii) process performance and goal attainment, which are concerned with the group's performance and its common objectives and are therefore related to common goals and moral behaviours/norms.
3. The institutional level is divided into 3 factors: (i) conflict management and decision-making, which are seen as the governance of formal institutions in society and can be linked to social disorder or conflict, as well as the reduction of inequities and exclusion; (ii) human rights, which considers the agency, access to basic needs, and freedom of the person while in a group/society; and (iii) the environment (structures, norms, and values), which refers to the formal institutions and individuals in society who are accountable for their upkeep.

Thematic content analysis findings reveal, for example:

• At the individual level, committee members leverage regular meetings to discuss ideas on a variety of health issues. These meetings are vital for resolution of challenges and provide motivation for members. Recognition and legitimacy were operationalised through the election of members into committees, which in turn gave them a sense of identity and credibility. Capacity is demonstrated, for example, by community committees' successful implementation and perceived progress in enhancing their communities' access to healthcare. Even though gender-based recruitment of committee members was intended to be fair/equitable, women's participation is mostly determined by availability and social norms.
• At the community level, WDCs leveraged the influence of social networks in the community to achieve their goals. A female CV underscored collaboration as necessary to leverage social capital: "We are all united, we have become like a broom tied together. Everyone has a role to play. When we hear any [health] challenge, we will look for this party and that other party...we CVs will not be enough, WDCs will not be enough.... [Since we] joined hands, we have been having progress." Trust was also identified as a prerequisite to the acceptance and accomplishment of social and behaviour change (SBC) programming. For example, study participants emphasised that the endorsement and cooperation of influential traditional and community leaders, along with committee members, were vital for the successful reception of community sensitisation and education efforts.
• At the institutional level, the findings revealed strong conflict management skills and high collective efficacy of committee members for programme implementation. There was high cohesion among committee members, promoting a sense of belonging and agency and facilitating SBC activities for improved health outcomes. However, WDCs and VDCs provided evidence of limited agency due to gender roles and expectations. In the Northern region of the country, gender socialisation has resulted in differing responsibilities for male and female members. A male VDC member in Bauchi remarked that "Female leaders are the ones tasked with going into women's houses, which...is not in place for a guy to walk into even if it is to enlighten women."

As noted here, the sustainability of community efforts depends in part on social cohesion, but other elements and aspects may be threatened by challenges that the community organisation members may not be able to surmount, such as challenges related to finances, logistics, and service delivery. Furthermore, insights from a Breakthrough ACTION/Nigeria staff revealed that the commitment, capability, and competence of LGA officials to offer effective supervision will significantly influence the long-term sustainability of the initiatives implemented under the CCS approach in support of community-level SBC, behavioural uptake, and overall improved health of the community.

In conclusion, the "findings demonstrate a high level of social cohesion among community organisation members which has advanced the implementation of integrated health programmes in the community....While cohesive community health committees present a good opportunity for the implementation of health programmes, there is a need for further investment in the capacity of committee members and the health facilities they support."