Impact of universal home visits on child health in Bauchi State, Nigeria: a stepped wedge cluster randomised controlled trial

The Equity Impact of Universal Home Visits to Pregnant Women and Their Spouses in Bauchi State, Nigeria: Secondary Analysis From a Cluster Randomised Controlled Trial

BACKGROUND

Socio-economically disadvantaged women have poor maternal health outcomes. Maternal health interventions often fail to reach those who need them most and may exacerbate inequalities. In Bauchi State, Nigeria, a recent cluster randomised controlled trial (CRCT) showed an impressive impact on maternal health outcomes of universal home visits to pregnant women and their spouses. The home visitors shared evidence about local risk factors actionable by households themselves and the program included specific efforts to ensure all households in the intervention areas received visits.

PURPOSE

To examine equity of the intervention implementation and its pro-equity impact.

RESEARCH DESIGN AND STUDY SAMPLE

The overall study was a CRCT in a stepped wedge design, examining outcomes among 15,912 pregnant women.

ANALYSIS

We examined coverage of the home visits (three or more visits) and their impact on maternal health outcomes according to equity factors at community, household, and individual levels.

RESULTS

Disadvantaged pregnant women (living in rural communities, from the poorest households, and without education) were as likely as those less disadvantaged to receive three or more visits. Improvements in maternal knowledge of danger signs and spousal communication, and reductions in heavy work, pregnancy complications, and post-natal sepsis were significantly greater among disadvantaged women according to the same equity factors.

CONCLUSIONS

The universal home visits had equitable coverage, reaching all pregnant women, including those who do not access facility-based services, and had an important pro-equity impact on maternal health.

Promoting gender equity in a home visits programme: a qualitative study in Northern Nigeria

BACKGROUND

Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women's decision-making autonomy impede women's access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme.

METHODS

The research team explored participants' views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings.

RESULTS

All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women's maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses' permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme.

CONCLUSION

The home visits programme, as implemented, contributed to gender equity.

Added value of video edutainment on android handsets in home visits to improve maternal and child health in Bauchi State, Nigeria: Secondary analysis from a cluster randomised controlled trial

Objective

A trial of evidence-based health promotion home visits to pregnant women and their spouses in northern Nigeria found significant improvements in maternal and child health outcomes. This study tested the added value for these outcomes of including video edutainment in the visits.

Methods

In total, 19,718 households in three randomly allocated intervention wards (administrative areas) received home visits including short videos on android handsets to spark discussion about local risk factors for maternal and child health; 16,751 households in three control wards received visits with only verbal discussion about risk factors. We compared outcomes between wards with and without videos in the visits, calculating the odds ratio (OR) and 95% confidence interval (95%CI) of differences, in bivariate and then multivariate analysis adjusting for socio-economic differences between the video and non-video wards.

Results

Pregnant women from video wards were more likely than those from non-video wards to have discussed pregnancy and childbirth often with their husbands (OR 2.22, 95%CI 1.07-4.59). Male spouses in video wards were more likely to know to give more fluids and continued feeding to a child with diarrhoea (OR 1.61, 95%CI 1.21-2.13). For most outcomes there was no significant difference between video and non-video wards. The home visitors who shared videos considered they helped pregnant women and their spouses to appreciate the information about risk factors.

Conclusion

The lack of added value of the videos in the context of a research study may reflect the intensive training of home visitors and the effective evidence-based discussions included in all the visits. Further research could rollout routine home visits with and without videos and test the impact of video edutainment added to home visits carried out in a routine service context.

Community Groups Co-Design Evidence-Based Docudramas to Communicate About Child Spacing in Bauchi State, Nigeria: A Qualitative Descriptive Study

In Bauchi State, northern Nigeria, communities recognise short birth interval (kunika in the Hausa language) as harmful, but family planning is a sensitive topic. This paper describes the development of a culturally safe way to communicate about kunika in a conservative Muslim setting. The objective was to co-design culturally safe communication material, based on local knowledge about short birth interval, to share with women and men in households.Six community co-design groups of women and six of men (total 96 participants) reviewed summaries of their previously created maps of perceived local causes of kunika, categorised as frequent sex, family dynamics and non-use of contraception. They advised how these causes could be discussed effectively and acceptably with women and their husbands in households and suggested storylines for three short video docudramas about the prevention of kunika. The research team created the docudramas with a local producer and fieldworkers piloted their use in households.The design groups advised that communication materials should focus on child spacing rather than on limitation of family size. Even sensitive issues could be covered. People would not change their sexual behaviour but could be advised to use contraceptives to prevent kunika. The groups approved the final videos and six focus groups of visited women and men reported they were acceptable and helpful. Community co-design of communication about kunika was feasible and led to videos about a sensitive topic that were acceptable to ordinary men and women in communities in Bauchi.

"To give life is a journey through the unknown": an ethnographic account of childbirth experiences and practices in Southern Benin

In Benin maternal mortality remains high at 397 deaths per 100,000 live births, despite 80% of births being attended by skilled birth attendants in health facilities. To identify childbirth practices that potentially contribute to this trend, an ethnographic study was conducted on the use of biomedical and alternative health services along the continuum of maternal care in Allada, Benin. Data collection techniques included in-depth interviews (N = 83), informal interviews (N = 86), observations (N = 32) and group discussions (N = 3). Informants included biomedical, spiritual and alternative care providers and community members with a variety of socioeconomic and religious profiles. In Southern Benin alternative and spiritual care, inspired by the Vodoun, Christian or Muslim religions, is commonly used in addition to biomedical care. As childbirth is perceived as a "risky journey to the unknown", these care modalities aim to protect the mother and child from malevolent spirits, facilitate the birth and limit postpartum complications using herbal decoctions and spiritual rites and rituals. These practices are based on mystical interpretations of childbirth that result in the need for additional care during facility-based childbirth. Because such complementary care is not foreseen in health facilities, facility-based childbirth is initiated only at an advanced stage of labour or at the onset of a perceived immediate life-threatening complication for the mother or baby. Programmes and policies to reduce maternal mortality in Benin must seek synergies with alternative providers and practices and consider the complementary and integrated use of alternative and spiritual care practices that are not harmful.

Universal home visits improve male knowledge and attitudes about maternal and child health in Bauchi State, Nigeria: Secondary outcome analysis of a stepped wedge cluster randomised controlled trial

Background

Methods

Results

Conclusion

Trial registration

Participatory health research under COVID-19 restrictions in Bauchi State, Nigeria: Feasibility of cellular teleconferencing for virtual discussions with community groups in a low-resource setting

INTRODUCTION

During the COVID-19 pandemic, researchers have used Internet-based applications to conduct virtual group meetings, but this is not feasible in low-resource settings. In a community health research project in Bauchi State, Nigeria, COVID-19 restrictions precluded planned face-to-face meetings with community groups. We tested the feasibility of using cellular teleconferencing for these meetings.

METHODS

In an initial exercise, we used cellular teleconferencing to conduct six male and six female community focus group discussions. Informed by this experience, we conducted cellular teleconferences with 10 male and 10 female groups of community leaders, in different communities, to discuss progress with previously formulated action plans. Ahead of each teleconference call, a call coordinator contacted individual participants to seek consent and confirm availability. The coordinator connected the facilitator, the reporter, and the participants on each conference call, and audio-recorded the call. Each call lasted less than 1 h. Field notes and debriefing meetings with field teams supported the assessment of feasibility of the teleconference meetings.

RESULTS

Cellular teleconferencing was feasible and inexpensive. Using multiple handsets at the base allowed more participants in a call. Guidelines for facilitators and participants developed after the initial meetings were helpful, as were reminder calls ahead of the meeting. Connecting women participants was challenging. Facilitators needed extra practice to support group interactions without eye contact and body language signals.

CONCLUSIONS

With careful preparation and training, cellular teleconferencing can be a feasible and inexpensive method of conducting group discussions in a low-resource setting.

"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

BACKGROUND

Universal home visits to pregnant women and their spouses in Bauchi State, northern Nigeria, 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 includes Conscious knowledge, Attitudes, Subjective norms, intention to Change, Agency to change, Discussion of options, and Action to change. Previous quantitative analysis confirmed the impact of the visits on maternal and child outcomes. To explore the mechanisms of the quantitative improvements, we analysed participants' narratives of changes in their lives they attributed to the visits.

METHODS

Local researchers collected stories of change from 23 women and 21 men in households who had received home visits, from eight male and eight female home visitors, and from four government officers attached to the home visits program. We used a deductive thematic analysis based on the CASCADA results chain to analyze stories from women and men in households, and an inductive thematic approach to analyze stories from home visitors and government officials.

RESULTS

The stories from the visited women and men illustrated all steps in the CASCADA results chain. Almost all stories described increases in knowledge. Stories also described marked changes in attitudes and positive deviations from harmful subjective norms. 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. Men, as well as women, described significant changes. The home visitors' stories described increases in knowledge, increased self-confidence and status in the community, and, among women, financial empowerment.

CONCLUSIONS

The narratives of change gave insights into likely mechanisms of impact of the home visits, at least in the Bauchi setting. The compatibility of our 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.