DOI: 10.5061/dryad.6q573n5w8
title: Sociocultural context and innovation scale up

description: Objectives To explore how sociocultural factors may support or impede the
 adoption of community-based distribution of injectable contraceptives in
 Nigeria. Design A qualitative study based on a grounded theory approach
 was conducted through indepth interviews and focus group discussions.
 Setting Most participants lived in Gombe State, North East Nigeria. Other
 participants were from Ibadan (South West) and Abuja (Federal capital
 territory). Participants Through seven key informant interviews, 15
 in-depth interviews and 10 focus group discussions, 102 participants were
 involved in the study. Methods This study, conducted in 2016 was part of a
 larger study on scale up of communitybased distribution of injectable
 contraceptives. Qualitative data were collected from traditional and
 religious leaders, health workers and community members. The data were
 audio recorded, transcribed and analysed using a thematic framework
 method. Results Sociocultural challenges to scale up included patriarchy
 and men’s fear of losing control over their spouses, traditional and
 religious beliefs about fertility, and myths about contraceptives and
 family planning. As a result of deep-rooted beliefs that children are
 ‘divine blessings’ and that procreation should not be regulated,
 participants described a subtle resistance to uptake of injectable
 contraceptives. Since Gombe is largely a patriarchal society, male
 involvement emerged as important to the success of meaningful innovation
 uptake. Community leaders largely described their participation in the
 scale up process as active, although they also identified scope for
 further involvement and recognition. Conclusion Scale up is more than
 setting up health sector implementing structures, training health workers
 and getting innovation supplies, but also requires preparedness which
 includes paying attention to complex contextual issues. Policy
 implementers should also see scale up as a learning process and be willing
 to move at the speed of the community.
description: <strong>Methods</strong>
 <br> 2.1 <strong>Study design and
 setting</strong><br> This cross-sectional study conducted from
 September to November 2016, was part of a larger research project which
 explored the interplay between barriers and facilitators of scale up of
 the community-based distribution of injectable contraceptives guided by
 the AIDED model in order to inform wider scale up of this innovation in
 Nigeria. The project took place in Gombe (North eastern Nigeria), one of
 36 States in Nigeria and a predominantly Muslim community. Gombe State,
 with a population of 2,353,879 people according to the 2006 population
 census, has one of the lowest contraceptive prevalence rates in the
 country (3.5% for modern methods and 4.0% for any method) and one of the
 highest maternal mortality rates (1,726/100,000). Gombe was purposively
 selected because it was the setting for the national pilot test for
 community-based distribution of injectable contraceptives in 2010. Gombe
 is divided administratively into 11 Local Government Areas (LGAs). The
 study was conducted in two LGAs – Gombe (A) and Yamaltu/Deba (B). Although
 participants were primarily based in Gombe State, one interview took place
 in another state (Ibadan in the South west) and 3 interviews in Abuja at
 national level (Federal Capital Territory). <br>
 <strong>Participants and sample</strong><br> In total,
 102 people participated in this study (see Table 1). The participants were
 selected through a purposive sampling method, where study respondents were
 recruited based on characteristics of interest, availability, and ability
 to provide relevant information about the research question: how may
 sociocultural context influence the process of introducing, translating
 and integrating health innovation? Participants included a range of
 stakeholders, including traditional and religious leaders, health workers
 as well as community members. One FGD each was conducted with different
 types of participants who were involved and could give an account based on
 their experiences of the program with the aim of exploring qualitatively
 the views, concerns from this range of key role players, not aiming to
 quantify, compare or rank frequency of views. Each of the FGDs had eight
 participants. The selected participants were therefore deemed appropriate
 role players to share their own experience and views as well as reflect on
 and summarize the views of others about the implementation of the
 community-based distribution of injectable contraceptives within their
 sociocultural context. The number of interviews and FGDs was determined by
 the principles of saturation, a point where no new information is
 emerging, and availability of resources as well as study time. The
 interviews and FGDs were conducted by the first author assisted by three
 trained research assistants. <br> This study adopted the inductive
 thematic analysis. This approach was guided by available literature as
 well as insights from the participants – codes were generated from key
 themes identified from transcripts. <strong>2.2
 Data collection</strong><br> Data were collected through seven
 key informant interviews (KIIs), 15 in-depth interviews (IDIs) and 10
 focus group discussions (FGDs). KIIS, IDIs and FGDs were conducted with
 senior stakeholders, healthcare workers and community members,
 respectively. Guides were used to conduct the interviews and focus group
 discussions (see Supplementary file 1). All guides were translated to the
 predominant local language - Hausa. The main issues covered during the
 interviews and discussions included community perceptions about
 contraceptives and specifically about the innovation (community-based
 delivery of contraceptives), their role in the scale up process, as well
 as their views regarding the sociocultural challenges and facilitators of
 the scale up process and community engagement regarding the scale up.
 Interviews and discussions were tape-recorded and later transcribed in
 full and translated where necessary. Transcription was done using a
 protocol which emphasizes verbatim transcription of recordings. Both
 transcription and translation were done by the same research associate who
 is vast in both Hausa and English languages. Back translation was
 subsequently done by another associate vast in the two languages; the back
 translations were afterwards compared with the original transcripts in
 order to ensure that the original meaning is retained.
 <br> <strong>2.3</strong> <strong>Data
 analysis</strong><br> Transcripts were analyzed iteratively
 with the aid of the NVIVO (version 10) software using the inductive
 thematic approach. Coding were done by the first and last authors
 independently at first before analysis started; these codes were then
 compared and harmonized. Emerging codes from the transcripts were added to
 pre-defined themes: community members’ perceptions regarding
 community-based distribution of injectable contraceptives, community
 members’ acceptance (or rejection) of contraceptives, and community
 engagement in the scale up process. Emerging themes were indexed and
 compared with themes from subsequent interviews until saturation was
 attained. A codebook was developed after all the data were collected; this
 was then applied to the transcripts. Although number of interviews and
 FGDs were set at the outset based on empirical guidance, however during
 analysis, it was confirmed that saturation, where no new information was
 obtained, was actually reached before the cap was reached in both
 interviews and FGDs. Analysis progressed alongside data collection. The
 SRQR reporting guidelines for qualitative studies was used in preparing
 this manuscript. <br> <strong>2.4 Ethics
 approval and consent to participate</strong><br> Ethical
 approval for this study was obtained from the University of
 Ibadan/University College Hospital Ethical Review Board (Reference No.:
 UI/EC/16/0022) as well as the Human Research Ethics Committee (Medical) of
 the University of the Witwatersrand (Reference No.: M160737). Written
 informed consent were obtained from study participants before the
 interviews and FGDs (see Supplementary file 2). Participants were also
 assured of confidentiality by ensuring that all identifiers were removed
 from the data and that only the research team has access to the
 data. <br> <strong>2.5 Patient and Public
 Involvement </strong><br> The study participants were involved
 in shaping the study particularly during the pre-test which led to the
 modification of some ambiguous questions in the guides. Also, some
 participants helped with the recruitment of other respondents through a
 snowball sampling procedure. Furthermore, findings from this study and the
 larger research project have been presented in conferences with useful
 feedback; a policy brief has been developed to be disseminated to policy
 makers.
description: The transcripts and analysis are uploaded as an NVIVO file