When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria.

BACKGROUND: We sought to encourage health care providers to adhere to national malaria case management guidelines. This requires them to conduct malaria parasite tests for every patient presenting with a fever and provide malaria treatment only to those who test positive for malaria. Our goal was to make it easier for providers to follow guidelines by addressing drivers of nonadherence uncovered through facility observations and interviews with staff and clients. IMPLEMENTATION AND MONITORING: The case management interventions were piloted in 12 public health facilities in Akwa Ibom, Kebbi, and Nasarawa states in Nigeria between October and December 2019. Participating facilities included 1 hospital and 3 primary health centers in each state. Relevant changes included the following: (1) providers at each facility participated in facilitated discussions to correct misconceptions about the reliability of malaria test kits; (2) testing procedures were integrated into existing triage systems; (3) treatment algorithms were integrated into medical record forms; (4) providers were issued pictorial brochures outlining danger signs to share with clients, together with instructions for when to seek further care; and (5) a process was created for facilities to monitor their own adherence to guidelines. LESSONS LEARNED: The lessons learned include: (1) disentangling the drivers of behavior allows for more targeted solutions, (2) solutions that streamline processes for overburdened providers allow them to redirect their attention and efforts where they can be most impactful, and (3) changing staff perceptions of workplace norms can support a holistic and sustained approach to behavior change.

Socioeconomic inequality in exclusive breastfeeding behavior and ideation factors for social behavioral change in three north-western Nigerian states: a cross-sectional study.

BACKGROUND: Socioeconomic inequalities could mitigate the impact of social and behavior change (SBC) interventions aimed at improving positive ideation towards the practice of exclusive breastfeeding. This study explores the empirical evidence of inequalities in the practice of exclusive breastfeeding (EBF) and associated ideational dimensions and domains of the theory of Strategic Communication and Behavior Change in three north-western Nigeria states. METHODS: We used cross-sectional data from 3007 randomly selected women with under-two-year-old children; the convenient regression method was applied to estimate the concentration indexes (CIxs) of exclusive breastfeeding behavior, ranked by household wealth index. Inequality was decomposed to associated ideational factors and sociodemographic determinants. Avoidable inequalities and the proportion of linear redistribution to achieve zero inequality were estimated. RESULTS: Women from wealthier households were more likely to practice exclusive breastfeeding CIx = 0.1236, p-value = 0.00). Attendance of at least four antenatal clinic visits (ANC 4+) was the most significant contributor to the inequality, contributing CIx = 0.0307 (p-value = 0.00) to the estimated inequality in exclusive breastfeeding practice. The elasticity of exclusive breastfeeding behavior with respect to partners influencing decision to breastfeed and ANC4+, were 0.1484 (p-value = 0.00) and 0.0825 (p-value = 0.00) respectively. Inequality in the regular attendance at community meetings (CIx = 0.1887, p-value =0.00); ANC 4+) (CIx = 0.3722, p-value = 0.00); and maternal age (CIx = 0.0161, p-value = 0.00) were pro-rich. A 10.7% redistribution of exclusive breastfeeding behavior from the wealthier half to the poorer half of the population could eliminate the inequality (line of zero inequality). Inequalities were mainly in the cognitive and social norms dimension and were all pro-poor. CONCLUSION: Socioeconomic inequalities exist in exclusive breastfeeding behaviors and in associated ideation factors in the three states but are mostly avoidable. A 10.7% redistribution from wealthier to the poorer half of the population will achieve elimination. Messaging for SBC communication interventions to improve breastfeeding practices could be more effective by targeting the mitigation of these inequalities.