"I Had to Change My Attitude": Narratives of Most Significant Change Explore the Experience of Universal Home Visits to Pregnant Women and Their Spouses in Bauchi State, Nigeria

"I started discussing and sharing ideas with my wife regarding the issues of her pregnancy and childbirth. My life has changed as a result of this project, and especially my ability to speak with my wife and other family members." (man, 47 years old, with 14 children, from a rural community)

Maternal mortality in Nigeria remains among the highest in the world. Systematic reviews of studies in low- and middle-income countries have concluded that male involvement is associated with increased use of maternal care services. A cluster randomised controlled trial (RCT) in Bauchi State, Nigeria, aimed to measure the impact of universal home visits to pregnant women and their spouses on maternal and infant outcomes and on male knowledge and attitudes. To explore the mechanisms of the quantitative improvements, the researchers analysed participants' narratives of changes in their lives they attributed to the visits. This paper shares that analysis.

In brief, the universal home visits to pregnant women and their spouses in Toro local government area (LGA) discussed local evidence about maternal and child health risks actionable by households. The expected results chain for improved health behaviours resulting from the visits was based on the CASCADA model, which a version of the Theory of Planned Behaviour. CASCADA is an acronym for a partial order of intermediate outcomes between knowledge and action: Conscious knowledge, Attitudes, Subjective norms, intention to Change, Agency to change, Discussion of options, and Action to change. Previous quantitative analysis (available at Related Summaries, below) revealed significant impacts of the home visits intervention: reduced complications of pregnancy and delivery and improved targeted risk factors; improvements in child health outcomes; and improved male knowledge and behaviour.

Local researchers collected 64 stories of change from: 23 women and 21 men in households who had received home visits, and from 8 male and 8 female home visitors and 4 government officers attached to the home visits programme. The researchers used a deductive thematic analysis based on the CASCADA results chain to analyse stories from women and men in households and an inductive thematic approach to analyse stories from home visitors and government officials.

The stories from the visited women and men illustrated all steps in the CASCADA results chain. Men, as well as women, described significant changes. Almost all stories described increases in knowledge; storytellers specifically reported increases in knowledge about the factors related to maternal and child health that were covered in the visits. Stories also described marked changes in attitudes and positive deviations from harmful subjective norms. For instance, many of the storytellers described previous unhelpful attitudes in themselves or their spouses, especially about childhood immunisation and heavy work during pregnancy. They attributed changes in these attitudes to the discussions with the home visitors.

Furthermore, most stories recounted a change in behaviour attributed to the home visits, and many went on to mention a beneficial outcome of the behaviour change (e.g., "This knowledge led me to stop her from engaging in any form of heavy work. I finally received the benefit of this knowledge when my wife delivered successfully without any complications or problems." - man, 30 years old, with 10 children, from a rural community). According to the health belief model, this demonstration that their actions worked may mean they are more likely to continue taking the action in future.

The home visitors described marked changes in their lives that they attributed to their work in the programme, including increases in knowledge, increased self-confidence, and status in the community, and, among women, financial empowerment. For example, for many male home visitors, the most important change in their lives was that their participation in the programme increased their social recognition within their communities.

The 4 government officers (3 men and 1 woman) who told stories talked about how the programme had impacted their work. One described improved experiential understanding of communities' needs as a result of involvement with the programme. Another described the benefit of receiving timely quantitative data from household level, which helped him plan effectively.

The researchers stress that the findings reflect the programme's core belief that simply giving people information about health risks is often not effective in changing health behaviours. They contend that the changes in behaviour described in the stories reflects the knowledge translation approach used in the home visits: not to tell people what to do but, rather, to present them with evidence in a form that helps them to make decisions and act on them. Socialising evidence for participatory action (SEPA) presents stakeholders with local evidence about actionable factors associated with an outcome, packaged to support decision-making. Thus, the home visitors did not dictate what actions the households should take but rather showed what could happen with different courses of action; each household decided on actions that worked for their context.

One effect of the repeated home visits to share and discuss evidence could have been to improve health literacy. There is evidence that health literacy is related to health outcomes.

Per the researchers, the narratives of change gave insights into likely mechanisms of impact of the home visits, at least in the Bauchi setting. The compatibility of the findings with the CASCADA results chain supports the use of this model in designing and analysing similar interventions in other settings. The indication that the home visits changed male engagement has broader relevance and contributes to the ongoing debate about how to increase male involvement in reproductive health.

In conclusion: "Taken together with the quantitative evidence of impact of the home visits on maternal and child health outcomes..., the narratives of change described here reinforce the idea that home visits to share evidence with pregnant women and their spouses can empower households to take action to improve their own situation. The Bauchi State Primary Health Care Development Agency has already committed to extending such home visits throughout the State, as funding permits."