Setting
Bauchi State in North-Eastern Nigeria has a population of around five million, extrapolating from the 2006 census. The population is predominately Muslim with Hausa ethnicity. Some 63% of women in Bauchi have no education, compared with 35% nationally. Polygyny and large family size are common. In Bauchi, the fertility rate is 7.2 children per woman [17].
The maternal mortality ratio in Nigeria is among the highest in the World, with 1047 maternal deaths per 100,000 live births in 2020 [18]. The Maternal Mortality Ratio is even higher in the Northeastern region [19]. Women in Bauchi have poor access to maternal healthcare services. Only 20% give birth in a health facility, and only 46% of women receive antenatal care from a trained health worker [17]. Less than 20% participate independently or jointly in household decisions. Over 50% of ever-married women have experienced emotional, physical, or sexual violence committed by their current or most recent husband or partner [17].
Home visits intervention
Between 2015 and 2020, we conducted a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in eight wards (smallest administrative area) of Toro Local Government Area (LGA), Bauchi State, North-Eastern Nigeria [20].
Women home visitors visited all pregnant women every two months during their pregnancies and again after delivery, and men home visitors visited their husbands. Having women and men home visitors interact separately with the pregnant women and their male spouses followed faith-based cultural norms in Bauchi and was endorsed by religious leadership. The research team engaged with Muslim and Christian religious leaders and traditional leaders in each community, and these leaders supported the home visits programme.
The women’s home visitors visited every pregnant woman every two months during the pregnancy, and the men’s home visitors separately visited the male spouses of the pregnant women every two months. The women visitors visited every woman who gave birth within two months of the birth and again when the child was 12–18 months old.
The women and men visitors shared evidence about actionable risk factors for maternal and early child health from a recent survey in Bauchi State [21], separately from pregnant women and their spouses. The home visits significantly improved maternal and child health outcomes and male knowledge and attitudes [22,23,24]. Narratives of change helped to explore the experience of participants and possible mechanisms for the impact of the home visits [25].
The home visits programme deliberately aimed to increase men’s engagement in promoting maternal and child health. The risk factors for maternal health discussed in the home visits with pregnant women and their spouses included strongly gendered issues: women continuing heavy work during pregnancy, domestic violence, lack of spousal communication, and lack of knowledge (including among men) of danger signs during pregnancy and childbirth [13]. The men’s home visitors made specific arrangements to interact with the spouses of pregnant women; this often meant visiting in the evenings or at weekends when the men were home.
The programme recruited local women and men as home visitors, allowing them to earn an income and increase their social status. Women, in particular, reported earning an income as an important positive change in their lives from their involvement in the programme [26].
To support the sustainability of the home visits after the trial, the government agencies collaborating with the home visits programme at State, LGA and ward levels nominated women and men officers to work with the programme, including training to manage and monitor the home visits.
Focus group discussions and individual interviews
This qualitative study is based on focus group discussions and key informant interviews. The research team designed focus group discussions and individual interview guides (Appendix 1). The research team included female and male researchers from a Bauchi non-governmental organisation (NGO), representatives from the Bauchi State Primary Health Care Development Agency (BSPHCDA), and male and female international researchers with over ten years of experience in community-based research in Bauchi. Six people facilitated the focus groups and/or conducted key informant interviews: three men and three women. All but one were from Bauchi and affiliated with the local organisation implementing the home visits programme. Their qualifications ranged from a higher national diploma to a medical doctor. All had training and several years of experience facilitating Focus Group Discussions (FGD) and conducting KI key informant interviews. All of them were engaged in implementing the home visits programme and believed in its aims of improving maternal and child health by supporting households in taking action to reduce risk factors. They had no relationship with the participants before the study other than through their engagement in the home visits programme.
A technical working group from the research team drafted the instruments, and the project steering committee approved them. The team refined the guides using an iterative process. After each interview/focus group discussion, the team met to discuss how it went and refine questions to increase clarity if necessary. The guides covered how the visits addressed gender equity, perceptions of the programme, data monitoring about equitable coverage of the programme, capacity-building, challenges and opportunities in home visit implementation, and strengths and weaknesses of the programme. In this paper, we focus specifically on views about the gender equity aspects of the home visits programme.
Focus group discussions and individual interviews took place in August and September 2020.
The team used a purposive sampling strategy to recruit stakeholder participants [27]. The stakeholder groups were women and men from the households who received the home visits, community leaders involved in facilitating the programme in their communities, home visitors, supervisors of home visitors, and senior government officers.
The team liaised with the Toro Local Government Authority (LGA) coordinators and the ward focal persons to select stakeholders for the community focus groups. First, they selected three communities, one each from an urban, rural, and remote group of communities in the six wards. For each community, the team asked the ward focal person to invite women and their spouses who had received home visits during the project and were available and willing to spare time to participate. The focus group discussions took place in private and quiet spaces, often classrooms in primary schools.
Table 1 shows details of the focus groups and the number of participants in each group. Fourteen focus group discussions occurred in eight urban, six rural, and four rural-remote communities. They included ten gender and age-segregated groups of women (four) and men (six) from households that had received home visits, two groups of community leaders (male and female), and two groups of home visitors (male and female). The mean age was 49.3 years across the three older male groups, while the mean age across the three younger male groups was 27.7 years. The mean age was 39.7 years for the older women groups and 21.8 years for the younger women groups.
Two further focus groups covered supervisors from Toro LGA and the State level. Most of the supervisors at the LGA level were ward focal points (part-time government workers at this local level), while most of those at the State level were from the BSPHCDA.
Local facilitators (female and male) conducted the focus group discussions in the Hausa language. They are well-trained in qualitative research, have worked with the team on several projects, and understand the home visits programme well. A trained reporter took detailed notes during each meeting and sat with the facilitator after the meeting to produce a report in English. Facilitators did not audio-record the focus groups. Detailed notes by well-trained field workers are an effective approach to reporting focus group discussions [28].
The local skilled research team conducted nine interviews with senior government officers associated with the home visits programme. The interview guide covered government health priorities, the government’s role in designing and implementing the home visits programme, perceived equity in program coverage, data monitoring to support equity, capacity building, and gender equity. They telephoned to invite the officers to participate, and the interviews usually took place in their offices. The discussions were in English, and the interviewers took detailed notes and prepared a report after each interview.
One additional focus group included members of the local research team who implemented and managed the home visits programme. The discussion focused on their experience implementing the programme and their views on its perceived impact on gender equity. The first author (LB), external to the project, facilitated the discussion.
Only the researchers and the participants were present during the focus group discussions and the key informant interviews. The team encountered no participant refusals to join these discussions and interviews. We did not return the transcripts to the participants. Data saturation was achieved from the focus group discussions and key informant interviews. The interviews and focus groups ranged from one to two hours.
Analysis of focus group and interview reports and strategies for trustworthiness
The first author (a female of North African descent, external to the home visits project) and one female team member from Bauchi (HM), both experienced in qualitative research, conducted a deductive thematic analysis of the focus group and individual interview reports, following the steps proposed by Braun and Clarke [29]. They read all the texts, identified and clustered themes related to gender outcomes, and organized them into categories and subcategories to look for meanings and patterns.
In this paper, we understand gender as a multidimensional concept. It refers to “the characteristics of women, men, girls, and boys that are socially constructed. This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other” [30]. We adapted a gender analysis framework [31], which captures gender dimensions and has been widely used in mainstream health [2, 32,33,34,35]. We used this framework to explore how the home visits programme affected gender norms and dynamics. It included the following items: (i) division of labour, (ii) access to resources, (iii) decision-making, and (iv) values (social norms, ideologies, beliefs). In this paper, values were not analysed as an independent category but throughout the other categories. The framework positions gender as power relations negotiated about resource access, division of labour, social norms and decision-making [2] (Table 2). Appendix 2 describes the coding trees used to conduct the thematic analysis for each participant group (Appendix 2: coding trees).
In addition to these dimensions from the gender analysis framework, we explored in the focus group and interview reports views about lack of spousal communication, heavy work in pregnancy and gender violence during pregnancy. These factors were identified as actionable factors associated with maternal morbidity in a survey in Bauchi conducted before the co-design and implementation of the home visits programme [21].
Several strategies increased trustworthiness [36]. We used validated methods for data collection (individual interviews, focus group discussions) and analysis (deductive thematic analysis). We triangulated findings by data sources (community members, community leaders, home visitors, supervisors, and senior government officers). We did not do a member-checking exercise with the participants; however, we discussed the findings with government officers in Bauchi.
To increase transferability, we describe the stakeholders and the study context. The researchers examined their biases, assumptions, beliefs, and suppositions that might affect their interpretation of findings to increase conformability. Some local research team members were involved in the home visit programmes. The team explained to the participants that the study’s objective is to understand their views on the home visit programmes and improve them if necessary. In reporting the study, we followed the 32-item COREQ checklist for reporting qualitative research (appendix 3).
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