Evaluation of RISE II Integrated Social and Behavior Change Activities in Niger: Baseline Report

"Programs that are integrated do not always separate out each component of the program, making it challenging to understand what is influencing the outcome. Measuring specific behavior change messages or combinations is critical to building successful programs and learning lessons for scale."

In Niger and Burkina Faso, Breakthrough ACTION is supporting the United States Agency for International Development (USAID)'s Resilience in the Sahel Enhanced (RISE) II project to develop integrated social and behaviour change (SBC) strategies addressing family planning (FP); maternal, newborn, and child health (MNCH); nutrition; and water, sanitation, and hygiene (WASH). The purpose of this technical report from Breakthrough RESEARCH is to provide baseline data that supports the RISE II Resilience Food Security Activity (RFSA) to understand how to tailor planned SBC approaches to address barriers to adopting targeted health behaviours in the Maradi and Zinder regions of Niger.

RFSA partners in Niger include Hamzari (led by CARE), Girma (led by Catholic Relief Services), and Wadata (led by Save the Children). These partners are implementing integrated SBC approaches to improve health outcomes at the household and community levels. RFSAs use a variety of SBC approaches, including community engagement and interpersonal communication (IPC) through peer group activities and radio. RFSAs have traditionally used group IPC activities called care groups to focus on influencing nutrition for pregnant and lactating women, infant/young child nutrition practices, and WASH-related behaviours. Under RISE II, the care groups will expand to cover other influential demographic subgroups and serve as a "hub" for interrelated community-wide activities, including male engagement and couple's communication, savings and loan groups, youth theatre, and grandparent clubs. All partners use the basic structure of care groups, which relies on cascade training from paid promoters to volunteer leaders to neighbourhood mothers to enable broad geographic coverage.

The SBC approaches are designed to reach not only individual women and men but also family and peers, community members, and influencers because social relationships within a community have a strong influence on health behaviours. The SBC activities aim to improve knowledge, intermediate outcomes (e.g., ideational determinants such as attitudes, self-efficacy, and norms), and intention to adopt healthy behaviours by taking advantage of the social structural factors that influence behavioural choices, including relationships and equitable availability of social and material resources. By shifting attitudes and behaviours of key members of the community around health behaviours, RISE II partners anticipate improved health behaviours and outcomes.

The overall evaluation design collects data through a repeated cross-sectional survey at three time points (baseline, midline, and endline. The researchers randomly selected two communes from each RFSA intervention zone ("intervention" groups) and two neighbouring communes as comparison zones ("control" groups) with similar sociodemographic characteristics, healthcare accessibility, and population density. Baseline data collection took place in April and May 2021.

Knowledge, attitudes, self-efficacy, and social and gender norms are often strong predictors of health behaviours. Thus, the questions posed in the survey were designed to explore these behavioural determinants to understand how SBC activities can be better tailored to address factors influencing health behaviours. For example, a large percentage of women thought that marrying before the age of 18 protects a female from being harassed. In addition, most women thought that a female should be married as soon as she reaches puberty and that marrying their daughters early protects them from engaging in nonmarital sexual activities, which is culturally not permissible. About half of the women in the intervention groups reported social norms associated with the acceptability of early marriage, while a statistically significant higher percentages of women in the control groups did so.

Reports from Girma indicate that men and local authorities have traditionally been the main intended audience for efforts to increase the age at marriage by organisations such as the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA). However, despite the efforts to reach men, Girma noted it is the women who may be less receptive to messages since girls are more subject to social pressure, and their mothers are traditionally the ones who bear the blame when a girl gives birth out of wedlock. Girma suggests the need to consider approaches that reach multiple audiences, as well as to address the underlying causes and social pressures that drive early marriage.

In addition to these and other findings around women's and men's attitudes, norms, and behaviours related to early marriage, the report shares findings in the areas of FP, maternal health, breastfeeding and complementary feeding, child nutrition, WASH, and child immunisation. One example of a finding from the latter section of the report: The majority of female participants in all three study groups (Hamzari, Wadata, and Girma) had heard messaging about the importance of vaccinations in the past three months, ranging from approximately 50% to 90%. Healthcare workers were the most frequent source of these messages in the Hamzari intervention group (85%) and Wadata intervention group (42%), followed by radio. In Girma, 26% of intervention group participants heard these messages at community events, followed by radio and healthcare workers.

Key findings and recommendations for different health areas are outlined in the report. Here is a sample:

• Given the study population's limited exposure to mass media (e.g., fewer than 10% of households interviewed indicated they owned a television) and low levels of education, consider more SBC approaches that are community based and IPC related. Options may include sharing radio station programmes through memory cards with listening groups, as proposed by Girma, as well as increased use of community health volunteers, as proposed by Wadata.
• Given the importance that family members (e.g., fathers) and religious leaders play in determining when both men and women are married, ensure that SBC activities are geared toward the broader community when discussing early marriage, and communicate that a girl's body is still maturing years after the onset of puberty.
• Given that men play an important role in decision making related to FP use, promote messages aimed at increasing awareness, particularly among male audiences, related to the importance of healthy timing and spacing of pregnancies and ways to achieve healthy timing and spacing through different contraceptive options.
• Communicate messages aimed at addressing behavioural determinants of maternal health, including attitudes toward the use of antenatal care (ANC) and health facilities for delivery, through radio programmes aired in the evening to strengthen support for obtaining health care during pregnancy and delivery.
• Focus on increasing knowledge about when a child should receive his/her first vaccine and the number of vaccines the child should receive, utilising commonly reported sources of information such as healthcare workers, religious leaders, or traditional barbers who shave the child's head within the first week of life.
• Leverage key influencers like healthcare staff to support/encourage mothers to continue breastfeeding and dispel misconceptions about breast milk supply.
• Seek to address the misalignment in the high levels of intermediate behavioural determinants and self-reported behaviours and the limited observed WASH behavioural practices, such as through availability of a handwashing station with soap and water as well as presence of a latrine, particularly in the Wadata survey areas.
• Convey to men the need to invest in or pay for health care, given they most often control the financial resources, which may help strengthen women's access to health care.

Over the period from 2021 through 2022 and 2023, baseline, midline, and endline waves of the survey will be used to assess the effectiveness of the RISE II integrated SBC activities for child marriage, FP, maternal health, immunisation, child nutrition, and WASH behaviours in the Maradi and Zinder regions of Niger.

In conclusion: "Results from the baseline study highlight the potential for an integrated SBC program coupled with community-led development to increase access and demand for health services and ultimately improve health-related outcomes. Results show that using multiple channels adapted to men and to women for disseminating messages, fostering partner communication, and addressing misalignment in attitudes and social norms is a promising approach to empower women, men, and communities to improve their health."