1Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access Improving health outcomes by strengthening public sector capacity in social and behaviour change programming in Nigeria: a qualitative study Adetayo Adetunji ,1,2 Bright Addo,3 Dele Abegunde,1 Amanda Kalamar,4 Nrupa Jani Tulsiani,4 Pooja Sripad,4 Foyeke Oyedokun- Adegbabo,5 Augustine Ankomah6,7 To cite: Adetunji A, Addo B, Abegunde D, et al. Improving health outcomes by strengthening public sector capacity in social and behaviour change programming in Nigeria: a qualitative study. BMJ Open 2025;15:e089214. doi:10.1136/ bmjopen-2024-089214 ► Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi. org/10.1136/bmjopen-2024- 089214). Received 24 May 2024 Accepted 02 January 2025 For numbered affiliations see end of article. Correspondence to Mr Adetayo Adetunji; adetunjidiran@ gmail. com Original research © Author(s) (or their employer(s)) 2025. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ Group. ABSTRACT Objective This paper examines the outcomes of the public sector capacity strengthening (PSCS) approach and how they contribute to the promotion of maternal, newborn, and child health, and nutrition (MNCH+N), family planning (FP) and malaria prevention- related outcomes. Design The qualitative study implemented from July to August of 2022 used the outcome harvesting methodology and key informant interviews to elicit information including most significant change (MSC) stories to evaluate project outcomes over 5 years (2017–2022). Setting The study was conducted in Sokoto, Kebbi, Nasarawa, Bauchi and Ebonyi states of Nigeria. Participants The study focused on public sector stakeholders who were exposed to the PSCS intervention and were selected from government agencies. Nine study participants were engaged per state, bringing the total number of participants to 45. Data were analysed thematically and elicited MSC stories were analysed for content. Results The PSCS approach empowered stakeholders at the individual level to disseminate MNCH+N, FP and malaria prevention messages, monitor health and social and behaviour (SBC) activities and increase the demand for health services. At the organisational level, the approach facilitated coordination of SBC activities, enabled training cascades and promoted adherence to health service guidelines. At the system level, it strengthened ward development committees to address health challenges. Challenges hindering stakeholders’ application of PSCS- acquired skills include inadequate workforce, negative attitudes of health workers, funding constraints, cultural barriers, lack of government ownership and limited accessibility. Conclusions This study shows that the PSCS approach is an effective model to scale up capacity for SBC in MNCH+N, FP and malaria prevention programmes. In response to documented supply- side challenges impeding the application of gained knowledge and skill, we recommend inclusive health worker recruitment, sensitisation programmes for health workers, government ownership, improved security, healthcare infrastructure and transportation systems. INTRODUCTION Social and behaviour change (SBC) inter- ventions are effective in improving and maintaining health outcomes with related approaches leveraged to successfully promote the adoption of health behaviours.1 2 These interventions act in tandem with structural and system- related health interventions to promote comprehensive and long- term health gains.3 Effective SBC approaches employed to influence health behaviours have included interpersonal communication, media util- isation and community mobilisation.3 SBC strategies help address gender and societal norms, fostering informed decision- making and creating a supportive environment.4 The need to strengthen health promotion and SBC capacity in the global south has been STRENGTHS AND LIMITATIONS OF THIS STUDY ⇒ The outcome harvesting (OH) methodology situ- ated in a qualitative research context allowed for the evaluation of a complex social and behavioural intervention by helping to attribute outcomes to pro- gramme activities through participant feedback. ⇒ Combining the OH methodology with the most sig- nificant change technique allowed for triangulation that further improved study findings. ⇒ While our methodological approach proved to be useful, outcomes captured through OH are sus- ceptible to recall bias and may rely on participants’ awareness of the outcomes. ⇒ The generalisation of study findings is limited due to the predominant use of qualitative methods in this study. P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ http://orcid.org/0000-0001-7201-4899 https://doi.org/10.1136/bmjopen-2024-089214 https://doi.org/10.1136/bmjopen-2024-089214 https://doi.org/10.1136/bmjopen-2024-089214 http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-2024-089214&domain=pdf&date_stamp=2025-01-18 http://bmjopen.bmj.com/ 2 Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access well documented5 6 with an increasing acknowledgement of the need for capacity strengthening. This recogni- tion has prompted governments and non- governmental organisations to explore collaborative efforts aimed at addressing capacity gaps for SBC.7–9 The advantages of SBC make it essential to develop the capacities of crit- ical actors to apply the strategy. Furthermore, capacity building aids the sustainability of SBC programming, encompassing planning, implementation, monitoring and evaluation of activities.10 Capacity building has been described as an investment in the long- term effectiveness and sustainability of beneficia- ries’ efforts.11 Within the health system context, capacity focuses on improving skills, knowledge, resources and existing infrastructure to effectively address challenges or issues.12 The process is dynamic, requiring flexibility and strong relationships with numerous actors. Capacity building for SBC involves training, mentorship, coaching, applied learning, policy reinforcement, process improve- ment and the integration of SBC into regular health plan- ning and strategy.13 Large- scale behaviour change interventions have been documented in literature especially those that focus on increasing the capacity of change actors. For example, in Madagascar, the US Agency for International Develop- ment (USAID)/Santénet2 programme employed innova- tive activities to strengthen the community health system and achieve tangible outcomes in maternal and child health, nutrition and malaria control. The programme increased the capacity of community health workers to raise awareness and mobilise the community.14 Another intervention was the Alive and Thrive intervention that was implemented in Bangladesh from 2010 to 2014. This intervention focused on scaling up infant and young child feeding interventions and included the training of community volunteers and health workers. This training was reinforced through supportive supervision, monthly meetings and quarterly refresher training.15 16 Capacity building for public sector stakeholders plays a crucial role in enhancing health service delivery with the development of skills widely recognised as indispens- able for the successful implementation of projects.17 The public sector fills a unique role as its individuals possess the capacity to drive and sustain systems- level changes.13 The public sector capacity-strengthening approach Breakthrough ACTION/Nigeria, an 8- year project funded by USAID, implemented a comprehensive inte- grated SBC intervention with a dedicated component focused on public sector capacity strengthening (PSCS) to increase the capacity of public sector stakeholders in SBC programming to improve MNCH+N outcomes. The PSCS approach encompasses a systematic assessment, design and implementation of tailored and strategic capacity strengthening for SBC that acknowledges the involvement of the public sector across the individual, organisational and system levels. These levels are known as the SBC communication (SBCC) capacity ecosystem levels, and they are further described in the next para- graph. The PSCS approach leverages the SBCC capacity ecosystem framework developed by USAID’s Health Communication Capacity Collaborative (HC3) Project.18 The framework recognises the interconnected nature of capacity strengthening and emphasises the need for multiple interventions for meaningful change. The SBCC capacity ecosystem involves individuals, organisations and resources working across different levels and sectors to create an enabling environment for effective behaviour change. The focus of Breakthrough ACTION at the three ecosystem levels is described as follows: 1. At the individual level, the focus is on enhancing the SBC skills of both programme and government staff through a variety of on- the- job training, self- directed learning and experiential learning approaches with outcomes being increased skills to develop health mes- sages and content and generate demand for and mon- itor health services. 2. At the organisational level, the focus is on strength- ening organisational connections and coordination, as well as developing processes to facilitate outcome- oriented coordination. Key outcomes include im- proved skills in coordination and facilitation of SBC activities. 3. At the systems level, the emphasis is on reinvigorating existing platforms that could be leveraged for SBC such as SBCC technical working groups, Advocacy Communication, Social Mobilisation subcommittees and SBC- Advocacy Core Groups and ward develop- ment committees (WDCs) to create a dynamic and active coordinating body. Specific outcomes envi- sioned include coordinated and harmonised SBCC messaging; alignment of SBC activities; strengthening of the WDCs including domestication of related poli- cies, reinvigoration and strengthening the capacity of committees. Breakthrough RESEARCH, the sister project of Break- through ACTION, plays a crucial role in providing evidence for the PSCS approach, among other initia- tives. This paper, which is an outcome of a Breakthrough RESEARCH evaluation effort, examines the PSCS approach and how PSCS in SBC programming contribute to the promotion of Maternal, Newborn and Child Health plus Nutrition (MNCH+N), Family Planning (FP) and Malaria prevention outcomes. METHODS Study design This qualitative study used outcome harvesting (OH) to gather information on changes in SBC capacity influ- enced by the PSCS approach from public sector stake- holders in five Nigerian states: Sokoto, Kebbi, Nasarawa, Bauchi and Ebonyi. The data collection for this study spanned 3 weeks from July to August of 2022. The eval- uation covered the first 5 years of the PSCS intervention from 2017 to 2021. We used key informant interviews P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 3Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access (KII) to explore participants’ accounts of their involve- ment in capacity- strengthening activities and validate the information garnered from the OH process. The OH technique is a participatory evaluation method- ology that focuses on collecting and interpreting evidence of outcomes or changes resulting from a programme or intervention. For this study, we applied the six principles as set out by Wilson- Grau nd Britt19 as described in table 1. More information on this study’s application of the OH technique has been described elsewhere.20 Most significant change (MSC) stories were also collected as part of the KII process. The use of MSC stories allows for an inclusive evaluation approach during which project stakeholders are engaged to determine attribut- able changes.21 22 Our MSC approach followed a modified process outlined in the study of Akeju et al23 with steps including (1) raising the interest of stakeholder groups about the use of the MSC; (2) defining the domains of change following the SBCC capacity ecosystem levels of individual, organisation and system; (3) defining the time frame for analysing stories; (4) collecting ‘significant change’ stories from stakeholders using a developed MSC guide; (5) discussing all stories and voting for the most significant stories and why they were selected and (6) and providing feedback on the results of the selection process to participants. Study area Study states were purposively selected to correspond with the implementation states for the Breakthrough ACTION/Nigeria PSCS approach. The states represent four of the six geopolitical zones in Nigeria. Specifically, Sokoto and Kebbi states are located in the North- western geopolitical zone, Bauchi in the Northeast, Nasarawa in the North- central and Ebonyi in the South- eastern zone of the country. Study population The study focused on public sector stakeholders who were exposed to the PSCS intervention and drawn from government agencies. Six study participants were engaged per state for the KIIs as part of the OH process and an additional three were engaged to provide MSC stories in addition to the interviews bringing the total number of participants to 45. The six KII participants were selected based on their active involvement in the intervention and their level of understanding. Addition- ally, three participants per state contributed two MSC stories each, totalling 30 stories. These participants were engaged throughout the intervention, making them well suited to provide insights on programme- attributable changes. The research team determined that nine partic- ipants per state would ensure data saturation, based on a preliminary document review and the study’s method- ology. Practical considerations, including consultations with Breakthrough ACTION Nigeria staff, resource avail- ability, time constraints and logistical challenges, also influenced the sample size determination. Participants selection Participants for the study were identified and recruited by actively engaging with the Breakthrough ACTION/ Nigeria project. This collaborative effort enabled the acquisition of an extensive list of potential social actors that met the following selection criteria: 1. Working in an institution (public sector) where the SBC PSCS project activities are being implemented and in one of the five states where the study is taking place. 2. Exposed to BA- N SBC PSCS project activities. 3. Provides consent to participate. The selection was random from the provided list and took into consideration the exposure to the PSCS inter- vention and their availability to participate due to their demanding roles. Table 1 The OH process adapted from Wilson- Grau and Britt19 1 Design outcome harvest. We defined the purpose of the OH approach and determined the scope of the evaluation. In addition, we identified the different stakeholders involved as well as tools for data collection and reporting. 2 Review documentation and draft outcome descriptions. We reviewed a series of project documents for the Breakthrough ACTION programme such as annual reports and documentation on the PSCS intervention. From the exercise, we identified and drafted descriptions which are significant changes or results that have occurred because of a programme or intervention and what the intervention did to contribute to them. 3 Engage with informants in formulating outcome descriptions. Using KIIs and MSCs, we engaged study participants who are also stakeholders in this study to review the outcome descriptions based on the document review, and to identify and formulate additional outcomes. 4 Substantiate. We triangulated the information received from stakeholders with existing outcome descriptions and then reviewed the outcomes and selected those to be verified to increase the accuracy and credibility of the findings. 5 Analyse and interpret. We identified patterns and common themes and then categorise outcomes based on their significance and relevance to the evaluation. 6 Support use of findings. We shared the resulting information with the harvest users and developed knowledge products. KIIs, key informant interviews; MSCs, most significant changes; OH, outcome harvesting. P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 4 Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access Data collection The study used KIIs to gather data from 45 participants and the objective was to validate the outcomes previ- ously documented during step 2 of the OH process and explore potential new outcomes. 15 of these participants provided MSC stories reflecting on their experiences with the PSCS approach. The guide was piloted and it helped elicit information on capacity- strengthening activities and validated documented outcomes with each session typically lasting between 30 and 60 min. The MSC compo- nent of the guide included broad questions to elicit infor- mation about what was ‘considered as the MSC that has occurred since the introduction of the PSCS approach’. Data management and analysis After the completion of data collection, audio files were transcribed and carefully reviewed for accuracy. The transcripts were securely stored on password- protected computers. For data management and analysis, NVivo software (released in March 2022) was used. We classi- fied verified outcomes by the SBCC capacity ecosystem levels.24 To ensure that we attributed the documented outcomes to the appropriate level, we outlined pertinent outcomes per level as follows. 1. Individual: Describes outcomes that encompass im- proved abilities in the development of health messages and content, demand creation for health services and monitoring of health activities. 2. Organisation: Depicts outcomes related to increased coordination and facilitation skills for SBC activities further resulting in cascading of knowledge and imple- mentation of health services in accordance with exist- ing guidelines. 3. System: Refers outcomes focused on strengthening WDCs as a platform for further SBC activities. We used a deductive approach25 while following the thematic analysis steps outlined by Braun and Clarke26 to analyse qualitative data for the OH process. Four researchers conducted an initial review of selected tran- scripts for familiarisation. Immediate codes were gener- ated and used to develop a coding framework. The framework was reviewed, and discrepancies were addressed by the research team. Transcripts were then coded using the established framework to ensure consistency. All 45 transcripts were divided into 4 sets, with 3 sets containing 11 transcripts each and 1 set containing 12. Two coders were assigned to each set, with each coder independently coding all transcripts within their assigned set, ensuring double coding across all transcripts. This approach involved a total of eight coders and allowed for compar- ison of coding results and assessment of consistency. As part of the coding process, regular peer debriefing was held to review coding, discuss challenges and update the codebook. In addition, the research team kept a detailed documentation of coding decisions. Coding comparisons were done in NVivo to visually inspect discrepancies. Discrepancies were resolved through consensus- building and codes were subsequently organised into themes. These initial themes were thoroughly reviewed and defined, reaching a consensus agreement to establish the final themes for analysis. A total of 30 MSC stories were elicited through the inter- views out of which 7 (3 at the individual level and 2 each at the system and organisational levels) were validated to be the most significant stories that demonstrated changes attributable to the PSCS intervention after two rounds of review. During the first round of review, 6 stories that were completely out of scope were discarded leaving 24 stories. In the second round of review, 17 stories that met the scope but were not attributable to the PSCS inter- vention were also discarded leaving 7 stories validated as most significant. The process of validation was conducted by a five- member team that graded stories based on PSCS exposure, focus and attributable change, ranging from poor (1) to excellent (5). Each story comprised storyteller information, titles and SBC levels/domains of change that the research team identified. This paper presents one story per ecosystem level. Although this paper is part of a larger study, the focus of our results is on the findings from step 3 of the OH process gathered through our engagement with public sector stakeholders. Reflexivity Throughout the study, the research team implemented a range of reflexivity techniques to ensure credibility and integrity. Regular team meetings were held to discuss and document biases that could influence data collection, anal- ysis or interpretation. Similarly, the team’s backgrounds in public health, monitoring and evaluation, and social research brought both strengths and potential biases to the study. Although these offered invaluable knowledge, there was a chance that they would reinforce presump- tions about the effectiveness of the programme or the importance of health outcomes. These assumptions were documented and constantly discussed to ensure that the analysis remained objective. Team meetings allowed for the critical examination of assumptions and the poten- tial impact on the study. We also maintained a reflex- ivity journal, a shared document where individual team members recorded reflections on how their perspective of the research objectives and elicited data might shape analysis. Additionally, finalised results were cross- referenced with multiple data sources, including interview data, available project documents and defined outcomes from step 2 of the OH process. From the first steps of partici- pant selection to data interpretation, the entire research process was documented to monitor the decision- making process and consider how any biases were addressed at every turn. Ethical considerations The study obtained ethical approvals from the National Health Research Ethics Committee in Nigeria and the Ethical Review Boards at the state level. The study team P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 5Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access observed all the key research ethic principles by ensuring privacy and providing clear information during the informed consent process including a clear explanation of voluntariness, benefits and possible risks. RESULTS Demographics The description of the social actors is shown in table 2. A total of 45 participants were engaged across study states for the OH and MSC activities. The majority were males (35/45), and half were either technical officers (17/45) or directors/deputy directors (7/45). Technical officers comprised participants such as the information officer, health education officer and the state disease surveillance and notification officer. Furthermore, the majority were drawn from either State Primary Health Care Develop- ment Agencies (SPHCDAs) (19/45) or State Ministries of Health (SMOHs) (7/45). Changes documented at the three SBCC capacity ecosystem levels This section is organised into three main headings corresponding to the three ecosystem levels: individual, organisation and system. Each main heading includes subheadings that represent emergent codes. Individual level At the individual level, the success of the PSCS approach was marked by public sector stakeholders’ enhanced abilities in developing health content and messages, organising and conducting training sessions, monitoring SBC activities and generating demand for MNCH+N, FP and malaria prevention services. Development of health content and messages The PSCS approach has provided public sector stake- holders with support in disseminating crucial health messages through mass media and fostering interactive communication with the audience. This has proven to be a valuable opportunity for effectively reaching indi- viduals at the community level and the wider public. Furthermore, there is evidence of improved skills among media personnel in delivering MNCH+N, FP and malaria prevention messages. They have been given the opportu- nity to attend training sessions, workshops and seminars, enabling them to enhance their skills and programme delivery. This has resulted in more engaging and impactful strategies for conveying information and motivating indi- viduals to adopt healthier habits. We have received support in securing slots with var- ious media outlets, particularly radio stations. This opportunity allows us to broadcast live programs, including health talks and interactive communica- tion programs. Through this initiative, we have been able to effectively reach people at the grassroots lev- el in the community and the wider public. Technical Officer Demand creation Participants were also equipped with the necessary skills and knowledge to enhance the demand for crucial health services. This involved training on relevant health issues and the dissemination of vital prevention information, enabling them to effectively educate and raise awareness within their communities. As a result, the PSCS capacity- building efforts proved beneficial in fostering a proactive approach to improving access to healthcare services. During the training, we learned about tuberculosis, malaria, and HIV, and the importance of testing to differentiate these diseases. We also gained knowl- edge on preventive measures, insecticide- treated nets, and the challenges of net usage, along with promot- ing proper care and monitoring in the community. Identifying net champions was emphasized. I utilized this knowledge to sensitize communities about the positive impact of malaria testing and proper treat- ment. Technical Officer Monitoring of health activities Participants mentioned that their ability to monitor and gather data for MNCH+N, FP and malaria preven- tion programmes had been enhanced through capacity- building efforts. A technical officer in Nasarawa expressed the opinion that these efforts had resulted in improved monitoring practices among public sector stakeholders, leading to better record- keeping and referrals. Table 2 Demographics of study participants for OH and MSC Description Total (n=45) Sex Male 35 Female 10 Role Head of Ministry/Department/Agency 2 Director/Deputy Director 7 Manager 7 Coordinator 7 Technical officer 17 Media personnel 5 Ministries/Departments/Agencies State Ministry of Health 7 State Primary Health Care Development Agency 19 State broadcasting corporation 5 Local Government Area 9 Others 5 MSC, most significant change; OH, outcome harvesting. P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 6 Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access Monitoring and evaluation play a crucial role in strengthening health systems, particularly in im- proving record- keeping. The number of referrals, treatments, and further management becomes a key indicator of progress and areas for improvement. Breakthrough ACTION has supported us by pro- viding training at the local government and facility levels, enabling us to identify appropriate referral destinations. This support has been invaluable in as- sisting individuals who lack resources or knowledge to access necessary services. Technical Officer MSC story at individual level A male technical officer shared a story that highlighted the transformative impact of the PSCS intervention in relation to content development skills. The partic- ipant revealed that prior to the intervention, there was poor proficiency in knowledge aspects such as content creation, information management on social media and effective online engagement. This has changed with the advent of the PSCS approach. The story underscores the significance of capacity building in promoting public health awareness and engagement. SBC training equips stakeholders with health content development skills I had always struggled with developing content, but everything changed with the PSCS intervention. I was pleasantly surprised by my newfound abilities. Thanks to a recent training, I have learned valuable skills in content creation, information management on social media platforms, and effectively engaging with people online. In this state, we faced numerous challenges regarding vaccine uptake. However, with the recent capacity building, I have gained knowledge on budgeting for content creation, developing impactful content, and performing analyses. Additionally, I now possess the ability to craft narratives around other crucial health topics such as antenatal care, exclusive breastfeeding, and malaria. Gone are the days when I simply wrote without proficiency. Recently, I have been receiving guidance on devel- oping newsletters. The State Primary Healthcare Department had never published any materials documenting their activities, aside from what was handled by the M&E officer. However, we recog- nized that health- related issues shouldn't be the sole responsibility of the M&E officer. Therefore, we advocated for the involvement of other units. I distinctly recall an interview conducted by someone who travelled from Abuja to speak with me. To prepare for this, I collaborated with the M&E officer to develop scorecards. I also convinced the primary healthcare management to start producing our newsletter. Technical Officer Organisation level Coordination of SBC activities Support was provided to public sector stakeholders to develop tools and integrate plans with other partners, enabling them to effectively coordinate and monitor SBC activities. This collaboration also facilitated the harmon- isation of campaigns and demand creation for health services. Through these efforts, stakeholders were able to streamline their activities, ensuring a cohesive and unified approach to SBC interventions. Yes, we have successfully completed the process of micro- planning. In preparation for a malaria cam- paign scheduled for this year, we conducted a micro- planning meeting last year. During the meeting, we had the opportunity to collaborate with other part- ners in the state. Together, we harmonized our ac- tivities and tailored certain tools to suit our specific needs. At the end of the day, we utilized the tools during the campaign. They [Breakthrough ACTION] sponsored the event and offered technical assistance. Director Likewise, several participants expressed that their training in leadership and strategic communication enabled them to acquire essential skills for coordinating and managing SBC activities while also playing a pivotal role in developing their communication abilities. I had the opportunity to attend the intensive two week training on leadership and strategic communication in 2019. This training significantly enhanced my communication skills and equipped me to effectively coordinate SBC activities. As a result, I am current- ly overseeing SBC activities at the local government level, ensuring accurate reporting of our initiatives. Program Manager Facilitation skills for knowledge cascade To ensure knowledge dissemination, a cascade training model was employed to build capacity at the local govern- ment level. This involved training public sector stake- holders at the state level who held responsibilities in addressing various health challenges such as MNCH+N and FP. These stakeholders were equipped with the neces- sary facilitation skills to train other personnel at the local level and engage in SBC activities, including the dissem- ination of crucial health messages during community gatherings like compound meetings. They always invite me, anytime we want to maybe en- lighten the populace, we are selected to go and speak to them and even at the local government level when- ever they are having their compound meetings, at times they tell us because we were trained at the state level and then we cascade the training to those at the local government level. So, there are times when they want to have any activity, they invite some of us and we go to give our support too. Director P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 7Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access An important product of the cascade training model was the increased provision of health services in accord- ance with national guidelines. Components of existing guidelines focus on concepts such as respectful maternity care (RMC) aimed at promoting respectful, equitable and person- centred care while aiming to eliminate mistreat- ment, abuse and disrespectful practices that may occur within maternal health settings. Participants shared that they received RMC training which in turn translated into good relationships between health workers and commu- nity members. I attended a training session on RMC that was much needed to address outdated practices among health- care providers. This training positively influenced our approach to Malaria in Pregnancy and other social behavioural change activities. It inspired us and sig- nificantly improved the bond between health workers and the community. We are now seen as friends and partners, with community members willingly partici- pating in our activities. Program Coordinator Participants also provided information on increased provision of malaria- related services in accordance with malaria guidelines especially on the use of sulfadoxine- pyrimethamine as intermittent preventive treatment during pregnancy to safeguard against malaria and mini- mise the associated risks and complications. The capacity of health workers has been built on malaria in pregnancy, including the importance of administering sulfadoxine- pyrimethamine (SP). Previously, health workers lacked knowledge about the importance of SP. However, now, all health facili- ties are well- informed about malaria in pregnancy, in- cluding the timing and administration of SP. We have witnessed significant improvements compared to the past, and our people have benefited from enhanced knowledge and awareness. Director MSC story at organisation level A programme coordinator shared an impactful story that showcased the positive outcomes of capacity- building efforts at the organisational level. The story empha- sised the influence of Breakthrough Action/Nigeria programming, specifically in raising awareness among health personnel regarding malaria as a risk factor for miscarriage during early pregnancy, particularly the first trimester. The coordinator’s participation in SBC training provided valuable knowledge that led to their recommen- dation for conducting malaria tests. This story highlighted how capacity building and SBC training can significantly impact decision- making and improve the quality of care provided. SBC training promotes awareness of the effects of ma- laria in pregnancy There was a woman that I know who had a preg- nancy in the past and subsequently a miscarriage. That miscarriage was because of malaria in a preg- nancy that she didn't know about. It was after she had that miscarriage that she was rushed to our facility. When she came to the facility that day, I saw her…and together with the officer in- charge, advised that she be taken to the labour room to clean up the blood to examine the cause of the haemorrhage… They wanted to discharge the woman to just go home… I said, “can’t you just take her to the lab to find out if maybe, there are some other causes to this miscar- riage?” They did a microscopy and confirmed that she had malaria parasites… So that made the woman to understand that it was malaria that made her lose her baby. When this initiative started, we reached out to her community to educate them on the necessity of going to the hospital as soon as they became ill, attending antenatal checkups, and receiving essen- tial drugs. Those drugs given to pregnant women will include SP [IPTp- sulfadoxine- pyrimethamine]. Today, if I'm passing through that axis, once the woman sees me, she calls me SP as a nickname. Program Coordinator System level At the system level, the PSCS approach focused on institu- tionalising improved coordination and increased capacity for SBC design and programming. This especially focused on driving the work of the WDCs and institutionalising the gains of the process. Participants affirmed that Break- through ACTION/Nigeria supported the revitalisation of committees in the covered areas by providing essen- tial support in terms of resources, capacity building, supportive supervision to facilitate strategic planning sections, cocreation of accountability mechanisms to reinforce coordination skills and their capacity for SBC message design and programming. This has led to an increased capacity of community members to address health challenges in their communities. WDCs are leading the promotion of sustainability, particularly in addressing structural deficiencies in their domain. When WDCs are sensitized about the significance of these structures, they actively contrib- ute based on their available resources. While the gov- ernment has played its part, Breakthrough ACTION has also made contributions, either through materi- al support or capacity- building initiatives. Technical Officer MSC at system level A technical officer shared a compelling story highlighting the impact of WDCs in promoting community ownership of the local health system. The story highlighted the significant role of WDCs in establishing health structures and how this responsibility has sparked a sense of shared accountability among communities in making health- related decisions and maintaining health structures. P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 8 Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access WDC action inspires community shared responsibili- ty for health decision- making I will give you an example, you know this local government, if you go to the local government, there is a PHC, it’s one of the most beautiful primary health cares in the state. It was built by the Officer In- Charge with the support of the WDC. This has led to a change in the community’s understanding of the importance of their involvement in decision- making processes. Our communities now know the impor- tance of being part of decision- making. So, there is that change - a very, very wide change. Previously, the Officer In- Charge had complete authority over the health facility, making decisions without considering community input. However, now it is widely recog- nized that the community has a role to play through the WDC. We were migrating from that ideology of “okay, I own the facility, I can decide whatever I intend to decide” and embracing a shared responsi- bility for health facility and its operations. Technical Officer Challenges experienced Participants highlighted several challenges that hinder their application of skills acquired from the PSCS approach. These challenges include inadequate human resources for health, insufficient funding, religious and cultural barriers, limited translation of messages, lack of mobility, security concerns, negative attitudes of health workers and inadequate intervention coverage. These challenges limited application of SBC skills in diverse ways. For instance, inadequate human resources for health translates to fewer individuals can consistently apply SBC skills and conduct necessary outreach which in turn limits scope of the programme. Similarly, insufficient funding restricts the resources needed for implemen- tation of activities across levels and programme sustain- ability. Religion and cultural barriers limit application of skills as these beliefs could conflict with promoted health behaviours which in turn limits receipt of SBC messages. A participant highlighted the significant challenge of human resource especially that there are not enough female health workers which makes service uptake difficult. Another challenge raised was the insufficient funding for the implementation of SBC activities. When you look at human resources for health, it is very big issue because one will say “I would not al- low male health worker to touch my wife”. Also, in- sufficient funding poses a significant barrier to the successful implementation of our work. If there is no money the work would not go perfectly okay. Technical Officer A programme manager expressed that religious and cultural barriers still exist and hinder the implementation of capacity built by the PSCS approach, despite notable progress, but remains optimistic about further change in the future. Despite significant progress, there are still some chal- lenges related to religion, tradition, and finances. While the issues surrounding religion and tradition have been greatly reduced, they persist to some ex- tent. Although these challenges remain, there is op- timism that they will diminish over time and pave the way for smoother progress in the future. Program Manager DISCUSSION The PSCS approach brought about substantial improve- ments in knowledge and skills at the individual, organi- sation and system levels. At the individual level, there was increased skill in the development of health messages and content with public sector stakeholders receiving support in disseminating crucial health messages through mass media and fostering interactive communication with the audience. This outcome was achieved through training sessions that included active methods such as role- playing, group discussions and scenario- based exercises, as well as on- the- job mentorship. This led to improved self- efficacy and increased development and dissemination of health messaging. This in turn led to increased demand for MNCH+N, FP and malaria prevention services. This outcome is similar to the approach used by the Ingobyi project in Rwanda where there was a collabora- tion with public sector stakeholders to design tailored SBC messages and materials which has in turn helped to increase the timely uptake of antenatal care services, as well as health- seeking behaviour, by addressing myths, misinformation and negative perceptions of health services.27 Similarly, other studies have documented the importance of dissemination of SBC messages through mass media such as radio programmes in changing health behaviours.28 The successful dissemination of health messages and subsequent uptake of health behaviours is because of the ownership of the programme by public sector stakeholders who had their capacity built as a result of the PSCS approach. Our study revealed that the PSCS approach led to increased ability of public sector stakeholders to monitor and gather data leading to better record- keeping, refer- rals and access to essential health services. This was facil- itated through the receipt of hands- on training in data collection, analysis and reporting, which empowered them to track key health indicators and programme outcomes. Capacity building also included data review sessions that helped highlight gaps and reinforced learn- ings. This resulted in an increased capacity to track the effectiveness of health activities and make evidence- based decisions for adaptive management. Monitoring is important in understanding programmatic trends that could be used to adjust implementation over time and it also plays a crucial role in showcasing progress.29 30 At the organisation level, the PSCS approach improved stakeholder capabilities to coordinate and facilitate SBC P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 9Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access activities, effectively harmonising SBC activities and generating increased demand for MNCH+N services. The achievement of effective coordination at this level meant that different stakeholders participated in SBC activities, which in turn made it possible to navigate complicated social systems, and pool resources, knowledge and efforts, which produced sustainable results. This was facilitated by collaborative planning sessions and strategic align- ment of intervention efforts that reduced fragmentation and ensured that programme activities were aligned with community needs. An important outcome of the PSCS approach was the increased facilitation skills of public sector stakeholders which has allowed them to help cascade knowledge to the Local Government Area (LGA) level. This was achieved through a series of hands- on training- of- trainer sessions and supportive supervision activities that specifically sought to improve skills related to communication, inter- personal and engagement skills, contextualisation of training content and presentation. This in turn resulted in increased knowledge at the LGA level, improved engage- ment with communities and improved service delivery Health programmes including those aimed at MNCH+N, FP and malaria prevention have generally leveraged the cascade training model to ensure that knowledge is trans- lated to lower levels.31–33 It has been crucial in reaching a large volume of target audience leading to an increase in MNCH knowledge and skills.34 In our study, we found that these trainings allowed the target audience of health workers to facilitate key meetings as well as provide RMC and adhere to national malaria management guidelines. Similarly, the approach allowed for the contextualisation of interventions as well as an efficient use of resources. At the system level, the PSCS approach focused efforts on strengthening WDCs through the support for the domestication of relevant policies at the state level and the provision of capacity building for WDCs. This was achieved through the provision of technical support in terms of resources, capacity building, continuous supportive supervision to facilitate strategic planning sections and cocreation of accountability mechanisms to reinforce coordination skills and their capacity for SBC message design and programming. This translated to community ownership of programme activities and subse- quently increased service uptake. This development further highlights the importance of the WDCs in the Nigerian health system and how they ensure community members’ complete ownership of primary health matters such as health promotion, community mobilisation and maternal and newborn child health services. However, these committees are often inef- fective, owing to inadequate capacity for health informa- tion dissemination among other roles.35–37 The capacity building provided to address this gap through the PSCS approach is consistent with the findings of other health programmes. An example was a health programme that provided capacity building for WDCs in the training, mentoring, coaching and supportive supervision which resulted in increased involvement of WDCs in primary healthcare management and improved resource mobili- sation for health.38 These are also in line with a study by Ntoimo et al, which demonstrated that training received by WDCs enabled them to provide information on maternal and child health, leading to increased uptake of services.39 Challenges that deter public sector stakeholders from applying knowledge and skills gained through the PSCS approach include health supply- side challenges such as insufficient health workforce, particularly female health workers and negative attitudes of health workers. These are pervasive health system challenges that continue to exist in Nigeria and in the northern region where our study was implemented. A study on human resources for health in the northern states of Jigawa, Katsina and Zamfara also documented the scarcity of suitable health workers partic- ularly female health workers which dissuades uptake of services owing to the preference for female health workers due to cultural norms.40 Other studies have also revealed unfriendly attitudes of health workers as a key factor that impedes the utilisation of MNCH services.41 These atti- tudes include a lack of empathy, judgemental behaviour, impatience, rudeness and neglect, among others. These could be because of health worker burn- out, low job satis- faction and stressful working conditions. These factors hinder stakeholders’ efforts by eroding trust and making it difficult for communities to adopt new behaviours. Solu- tions to these challenges include inclusive recruitment of health workers, especially women, implementation of retention strategies like better pay, career development and improved work environments as well as the promo- tion of patient- centred care. Other challenges documented include lack of funding, lack of government ownership, cultural barriers and limited accessibility. The lack of adequate funding has consistently been identified as a significant obstacle to the success of MNCH+N, FP and malaria preven- tion programmes, leading to other challenges.42 This is not surprising, considering that these interventions primarily rely on donor funding, meaning limited financial resources and consequently restricted imple- mentation. To address this challenge, it would be bene- ficial to emphasise the importance of political will and government ownership. Our findings indicate that these crucial elements were absent from the equation, further exacerbating the funding- related challenges. Despite the successes achieved by the Breakthrough ACTION/Nigeria programme in mitigating cultural barriers, addressing these challenges remains a crucial task for stakeholders. This is primarily due to the complex nature of cultural norms, which often require substantial time and effort to rectify. Consequently, it is important to recognise that comprehensive positive outcomes may not materi- alise immediately, as transforming deeply entrenched norms requires a sustained and patient approach. We found that limited accessibility is promoted by insecu- rity and limited geographical access. Northern Nigeria P ro tected b y co p yrig h t, in clu d in g fo r u ses related to text an d d ata m in in g , A I train in g , an d sim ilar tech n o lo g ies. . b y g u est o n F eb ru ary 5, 2025 h ttp ://b m jo p en .b m j.co m / D o w n lo ad ed fro m 20 Jan u ary 2025. 10.1136/b m jo p en -2024-089214 o n B M J O p en : first p u b lish ed as http://bmjopen.bmj.com/ 10 Adetunji A, et al. BMJ Open 2025;15:e089214. doi:10.1136/bmjopen-2024-089214 Open access is fraught with insecurity which has limited coverage of health programmes.43 44 Also, limited geographical access has been documented as a key barrier to health service uptake.45 46 The solutions required to address limited accessibility could be beyond the scope of donor- driven interventions and might need strong governmental intervention. Limitations: We found the use of the OH method- ology to be innovative as it allowed for the seamless eval- uation of the complex Breakthrough ACTION Nigeria intervention. While our approach proved to be useful and important for addressing our questions, we noted a few limitations that warrant consideration. Outcomes captured through OH are susceptible to recall bias and may rely on participants’ awareness of the outcomes. Also, perspectives and interpretations of data are subjective. To address these concerns, we implemented a rigorous trian- gulation of findings and a reflexivity process, ensuring that only verified outcomes were documented. Conclusion Our findings demonstrated improvements in individual capacity for demand generation for health services and monitoring. At the organisation level, public sector stakeholders showed enhanced abilities in coordi- nating and facilitating SBC activities and system- level changes including increased support and effectiveness of WDCs. However, challenges were identified, such as inadequate health workforce, negative attitudes among health workers, funding limitations, lack of government ownership, cultural barriers and limited accessibility. Addressing these issues necessitates inclusive recruitment and retention strategies, fostering empathy and patient- centred care, implementing sensitisation programmes, promoting government ownership, enhancing security conditions and strengthening healthcare infrastructure and transportation systems. Author affiliations 1Population Council, Abuja, Nigeria 2Department of International Health and Sustainable Development, Tulane University Celia Scott Weatherhead School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA 3Department of Sociology and Social Work, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 4Population Council, Washington, District of Columbia, USA 5USAID, Abuja, Nigeria 6Population Council, Accra, Ghana 7Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana Acknowledgements The authors would like to express their gratitude to the US Agency for International Development and Breakthrough ACTION Nigeria for their support in conducting this study. Special thanks are extended to all the study participants across the five study states, as well as the research assistants who diligently collected the data. The authors are also thankful to the state agencies that graciously participated in this study. Contributors AdA, BA and NJT designed the study, AuA contributed to the design and led data collection, AdA and BA led the analysis, BA, AK, PS and FO- A contributed to the analysis process, AdA developed the initial manuscript, all authors contributed to writing and review of the paper. AdA is the guarantor of this paper. Funding This work was supported by Breakthrough RESEARCH (Cooperative Agreement AID- OAA- A- 17- 00018), made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the Breakthrough RESEARCH project and the Population Council and do not necessarily reflect the views of USAID or the United States Government. Disclaimer The contents are the responsibility of the Breakthrough RESEARCH project and the Population Council and do not necessarily reflect the views of USAID or the United States Government. Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Patient consent for publication Not applicable. Ethics approval This study involves human participants and was approved by the National Health Research Ethics Committee (Approval number: NHREC/01/01/2007- 2/06/2022), Sokoto (Approval number: SKHREC/039/2022), Bauchi (Approval number: NREC/03/11/19B/2021/52), Nasarawa (Approval number: 18/06/2017), Ebonyi (Approval number: EBSHREC/26/07//2022 – 25/07/2023) and Kebbi (Approval number: 107: 029/2022) State Ethical Review Boards. Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available on reasonable request. Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. ORCID iD Adetayo Adetunji http://orcid.org/0000-0001-7201-4899 REFERENCES 1 Babalola S, Adedokun ST, McCartney- Melstad A, et al. Factors associated with caregivers’ consistency of use of bed nets in Nigeria: a multilevel multinomial analysis of survey data. Malar J 2018;17:280. 2 Awantang G, Babalola S, Koenker H, et al. 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