Community-based distribution of injectable contraceptives in Nigeria: Does the innovation delivery fit stakeholders' preferences?

doi:10.21203/rs.3.rs-1617898/v1

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Research Article

Community-based distribution of injectable contraceptives in Nigeria: Does the innovation delivery fit stakeholders' preferences?

https://doi.org/10.21203/rs.3.rs-1617898/v1

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Background

This study explored the fit between the design and delivery of community-based distribution of injectable contraceptive innovation and stakeholders' preferences. Furthermore, it assessed whether and how program implementers engaged potential user groups and community members in the design of innovation delivery.

Methods

This qualitative study was part of a more extensive cross-sectional study on the scale up of the community-based distribution of injectable contraceptives in Gombe, Northeast Nigeria. The authors conducted fifteen in-depth interviews (IDIs), seven key informant interviews (KIIs), and ten focus group discussions (FGDs) between September and November 2016 to obtain data from health workers, religious and traditional leaders, and community members, including users of injectable contraceptives. Additionally, the transcripts were analyzed using thematic analysis for important topics about delivery design and stakeholder preference.

Results

Although the innovation was community-based, only a narrow fit was identified between the innovation's design and stakeholders' preferences. However, by continuously engaging with stakeholders, even after the implementation, the delivery of the innovation was modified to consider cultural, religious, and programmatic factors, thereby improving the 'fit.' Modifications included the use of markets as mobile posts to distribute the injectables and to provide healthcare for women, dissemination outreach at women's gatherings, and distribution of contraceptives from community health extension workers' homes. Other modifications involved recruiting young female community volunteers as peer educators, partnering with patent medicine vendors, and social marketing using mobile phones to improve compliance. In addition, community participation through community-based organizations and community gatekeepers took place from the outset, across the planning stages to scale up.

Conclusion

Most of the modifications to the delivery of this innovation resulted from sociocultural, religious, and programmatic considerations. Therefore, innovation delivery should be context-relevant and cost-effective. Also, there might be a need to combine strategies for synergy and integrate community-based distribution with existing programs and infrastructures.

Innovation delivery

Scale up

Community-based distribution of injectable contraceptives

Sociocultural context

Social marketing

Innovation refers to ways of doing something differently. It may involve the creation of new products, teams, roles, or markets; or the rejigging or modification of processes, ideas, or systems [1–3]. Innovations have the potential to influence not just immediate or present users but also the networks in which these users are embedded [1, 4]. Integrating and involving all stakeholders, including potential users, in the innovation delivery galvanizes the process and improves the chances of successful diffusion and implementation [1, 5]. Understanding potential users' expectations, perceptions, and attitudes towards the innovation are essential when planning innovation scale up as these drive public perceptions and shape acceptability. However, these may not necessarily be in sync or 'fitted' with expert opinions and submissions [5–7].

Delivery denotes a product or service presentation to make it attractive to stakeholders, potential clients, or users [1]. According to Kühne and colleagues [1], delivery does not change the core characteristics of innovation but provides additional desired benefits, such as community-based injectable contraceptives, flexibility, and confidentiality. Thus, delivery is not a substitute for innovation quality and safety [1]. However, it determines whether and how the innovation is scaled up.

Scaling up, making health innovations available over a broader geographical coverage and more people, is essential to achieving universal health coverage (UHC) [8, 9]. However, the inability to adapt health innovation delivery to stakeholders' preferences, including potential users, is one of the main reasons why the scale up of innovations fails [10]. The failure is because the innovation's delivery can influence the preferences of potential consumers of the invention.

There is abundant research evidence that community-allied health professionals, including community health workers and outreach workers, can safely administer the injectable contraceptive Depo-Provera in the community with negligible risk to the users [11–13]. This innovation is safe and effective in demonstrated projects in many African countries, including Ethiopia, Malawi, Kenya, Rwanda, and Uganda [14, 15]. Contraception prevalence rates have increased in countries where it has been introduced [16]. In addition, there is a long history of community-based distribution programs (going back at least six decades) for improving access to health services and commodities in rural and under-served areas, particularly in developing countries [16].

Community-based distribution of injectable contraceptives (CBDIC) was officially adopted as an innovation in Nigeria after its successful pilot in two Local Government Areas (LGAs) of Gombe State in 2010 [17, 18]. CBDIC was put in place to respond to the country's generally low contraceptive prevalence rate (16.0% for any method and 11.1% for modern methods) [19]. In addition, Nigeria has a high fertility rate (5.5 births per woman) with a high maternal mortality ratio – 576/per 100,000 live births [19, 20]. The CBDIC innovation entails community health workers providing injectable contraceptives to women at home or in other settings outside the health facility. In Gombe, more than four-fifths of community health professionals are women, as are all health workers involved in the CBD of injectable contraceptives. After the initial pilot, the scale up of this innovation started in 2014, led by a national non-governmental organization (NGO) and supported by international donor agencies [17]. The ongoing scale up began in Gombe State, in all LGAs, then moved to 10 states in the country. This was followed by a five-year development plan by the federal government. Contraceptive forecasting and national quantification was done in 2017. Since 2018, there has been full nationwide implementation of the CBD of injectable contraceptives. The lessons learned from the pilot were used in the modification of the innovation delivery during scale up.

The AIDED model [10] – the conceptual framework adopted for this study – provides a valuable lens for understanding the scale up process. AIDED is an acronym for the model's five non-linear and interrelated components of scale up: Assess, Innovate, Develop, Engage and Devolve. 'Innovate' entails aligning the innovation delivery to user preference to optimize receptivity, while 'Develop' means gaining social support for the idea and addressing issues or objections. According to Bradley et al., a good understanding of potential users' preferences is essential for successful innovation diffusion. In addition, this understanding will assist health managers in packaging the CBDIC innovation in context-specific and responsive ways [10].

However, there is no evidence of how well the CBDIC innovation package met consumer expectations and preferences during and after the pilot. This study, therefore, explored the fit between the design and packaging of the CBDIC innovation and stakeholders' preferences; and assessed user groups and community engagement during design and delivery.

Study design and setting

This qualitative study was part of a more extensive cross-sectional study on the scale up of the community-based distribution of injectable contraceptives in Gombe, Northeast Nigeria [21–23]. Gombe State is divided into 11 administrative units (Local Government Areas) and has about 2.4 million people [24]. Also, some of the interviews were in Abuja, Nigeria's Federal Capital Territory, and Ibadan, the country's southwest region. The study was conducted between September and November 2016 to obtain data from health workers, religious and traditional leaders, and community members, including users of injectable contraceptives. CBD injectable contraceptives have been available on a national scale since 2018. In addition, the depot subcutaneous medroxyprogesterone acetate, DMPA-SC (Sayana Press®) with self-injection, was added to the country's contraceptive mix.

There were fifteen in-depth interviews (IDIs), seven key informant interviews (KIIs), and ten focus group discussions (FGDs) with eight persons each to obtain data from health workers, religious and traditional leaders, and community members. Details about the study sites, methods of data collection and participants’ description have been published elsewhere [23]. Participant selection was purposive based on their capacity to offer needed information and previous experience with injectable contraceptive provision and distribution. The number of interviews and discussions was determined using the saturation principle, implying that the participants have no new information [25]. Overall, a total of 102 people participated in the study.

Data collection and analysis

The first author (lecturer and public health physician with about ten years of qualitative research experience) and three research assistants (community health extension workers with ordinary national diplomas, two females and one male, with an average of 8 years of qualitative research experience) conducted the interviews. A guide was used in conducting the interviews and discussions. The interview guide covered issues about innovation preferences, factors affecting accessibility and uptake, and qualities that make the innovation enjoyable to stakeholders, including community members. Most interviews and FGDs were conducted in English, while a few interviews were conducted in the Hausa language and later translated to English. The duration of the interviews and discussions ranged from 40 minutes to one hour. All interviews and discussions were audio-recorded and transcribed.

Transcripts were forwarded to interested participants to validate that they were accurate expressions of their opinions and solicit feedback on the study's findings. During the interviews, notes were collected to complement the recordings. Furthermore, two researchers coded independently and then compared and merged their codes to verify intercoder reliability [26]. Throughout the inquiry, new themes were added to previously found themes.

Inductive thematic analysis was used in this study. This approach was driven by available literature and participant insights—key themes found from transcripts were used to construct codes. Transcripts were analyzed using the NVIVO-10 software [27, 28]. Information from the different qualitative methods is also compared. This publication was prepared using the Standards for Reporting Qualitative Research reporting guidelines for qualitative studies [29] (Supplementary Material 1).

This report summarizes the findings of a qualitative study on the fit between innovation delivery and stakeholder preferences, and community involvement in design and packaging. In addition, the respondents described several innovation modifications following the initial pilot, including the change to the service delivery models and alignment of innovation delivery to stakeholders' preferences and needs.

Addressing sociocultural issues and stigma through fixed posts and community gatherings for innovation delivery

In the initial design of the CBDIC, community health workers should go house to house to administer injectable contraceptives to women of the reproductive age group. Though this remained the primary CBD modality, however, due to several factors, including lack of support from spouses and significant others (particularly mothers and mothers-in-law), the health workers had to modify delivery channels to preserve the confidentiality of women. One respondent declared: "…Since we're in the North, our men will not allow their wives to go out…" (FP coordinator SMoH, female)

"There are two groups of health workers – some are linked to public facilities while some are linked to partners (like DKTp). It was a mix of different modalities depending on the partners' preference" (NGO Program manager, male)

Also, due to cultural and religious factors, particularly in northern Nigeria, some young unmarried women find it challenging to request contraceptives from health workers in facilities because of their marital status. Some of the modifications designed in response to this practical challenge include using the markets as fixed posts for distributing non-prescriptive contraceptives (including injectable contraceptives) so that no woman feels stigmatized. Sometimes, the health workers also designed outreach activities for social gatherings where contraceptive services are extended to women "…especially naming ceremony, weddings and women political gatherings…" (FP coordinator SMoH, female). Another respondent sums it up this way:

In Northern Nigeria, because of the peculiar culture and norms, the majority of young women are still left behind (so to say) because older interventions are very focused on middle-aged, elderly women who are more vocal in the community. But what happens with time is that younger women who want access to this method sort of shy away, because of the peculiarity of their culture and the fact that they don't want to be labeled … a lot of unwanted pregnancies will have happened because they (young women) cannot come out to say 'I want some help'. (NGO Program manager, male)

Furthermore, because women were lost to follow up when they were referred to health facilities either for proper assessment before initiation of contraceptive or as a result of a health complaint, a modification was made to the process to have women assessed by health workers (CHEWs) in mobile posts located in the markets. Thereby, they were offered health advice and care without needing to leave their businesses or risk stigmatization if health workers visited their homes.

Sending people to the facility for referrals was quite a challenge because a lot of women who are referred are lost in the process. We are still having a lot of losses to follow-up …So what we have done now is to firstly, ensure that we have points within those markets where CHEWs can come in like the health clinics or a formal post within the market or a local shop that the CHEW comes in to pay a regular visit so that she can have a one on one conversion that the woman who does not want to come to the facility can come to on market days to see them. (NGO Program manager, male)

Maintaining confidentiality and promoting convenience

Furthermore, women occasionally meet CHEWs in their homes, sometimes at night, to preserve confidentiality since the communities are closely knit.

As long as she (CHEW) is in the community and lives in that community, the woman will patronize her since it's a two-way service; she either goes to them or they come to her… (FP coordinator SMoH, female).

The position above was corroborated by a reproductive age-group woman when she narrated her experience:

In the maternity, they gave me a paper and said if I had any health worker close to me (in the community), she could give me the (contraceptive) injection without me coming to the maternity all the time. So, this my friend does help out, and if there is any challenge, I go back to her for explanations (Current user of injectable contraceptive).

One additional modification was to keep the innovation discrete and almost 'hidden' or secret for users:

We found that women find it convenient because of the balance of power within homes and families, particularly in the North. Women usually have difficulty with the uptake of interventions like this that are good for their health, but the injectables are something you can take without necessarily anybody knowing that you are taking it. The issue of taking permission from spouses to be able to take it will not be an issue for this woman, so they don't need to leave their houses to go to the facility to access the service, so it was quite acceptable. After a while, that became a practice that the women knew where the community health extension worker lived, and so because they (CHEWs) were with them, they could go to their homes and get the service. (NGO Program manager, female)

We found that women preferred to meet them (CHEWs) in their homes; being that it was a Northern setting – if you go to see a CHEW, you can go to see her for any reason, and going at night usually, there was no problem with that but going to the facility where people can know you got an injection or not we do find that women prefer to see them in their homes… So, they don't want the CHEWs to come to their house so that people around will not know what is happening. (NGO Program manager, female)

Engagement of community volunteers and patent medicine vendors

Likewise, young women were recruited as community volunteers and trained by the coordinating NGO to enable a form of 'peer-to-peer influence,' thereby earning the confidence of the young women through 'age-specific contraceptive messaging.' In addition to the original design of community-based distribution, patent medicine vendors, and popular low cadre dispensers of over-the-counter medicines within the community, were also recruited and trained to distribute the injectable contraceptives. Although retention was challenging (particularly when incentives waned), some of the community volunteers stayed on in the program:

We are looking at three to four interventions: in the market, which is anybody's friend; we are looking at a patent medicine vendor who is the first point of call of care; looking at community volunteers who can go into people's homes. We were initially thinking of training more mature women who could talk to them, but at that point of intervention, it became apparent that we needed to look at some younger people to take them into our training because of peer-to-peer influence; I mean age-specific contraceptive messaging will be able to help younger people to be able to accept methods. Some, of course, of our training, we had to expand the age range of people that will need to be trained. (NGO Program manager, male)

The program performed well because the volunteers were the sole source of contraceptives in hard-to-reach communities. It was not easy retaining the volunteers once incentives were over; volunteering became challenging. Volunteering in Nigeria is still largely incentives-based. Incentives are sometimes given for transportation and feeding, and sometimes, incentives are financial. (NGO Program manager, male)

Due to the sensitive cultural and religious environment in Northern Nigeria, practically all health professionals selected for the community-based distribution were women.

Because of the religious and cultural sensitivity, having women CHEWs that will go to homes was very important. In this case, most of them were women, close to 100% were women, yes, most of them were women. It makes it more acceptable. It is more acceptable if it's a woman. In the North, it was difficult for a man to be visiting homes and meet with women; it would not be acceptable. So, it's easier when you roll this out with women. (NGO Program manager, female)

Some of these modifications do not only fit well into stakeholders' preferences but also the human resource for health realities, especially in northern Nigeria. For instance, in "…most parts of the North, CHEWs man most of our primary health centers and as such, they may not have enough time to work in the community…" (FP coordinator FMoH, male).

Use of mobile telephony in social marketing

Furthermore, social marketing collaboration with an international firm used mobile phone technology to establish a reminder system to guarantee women took their contraceptive injections. Reminders are sent to women a week ahead and the day before. Then, she gets a congratulatory message whether the woman gets the injection at the facility or through the community-based approach.

Then also the fact that we are working with DKT, another international agency. They are into social marketing for contraceptives, but, they have a unique platform, a technology platform that mobile technology that gives messages to women so that the first time they are enrolled, they send a code, the provider sends a code using the woman's number, she gets a text message that she has taken that method that day. So that subsequently, when she's due for the three months injection, she gets a text message a week before that time, she gets it a day before- a reminder, and if she gets the injection either in the facility or in the community, then she gets a congratulatory message on the day she takes her injection. That way, you are sure there's a constant reminder. (NGO Program manager, male)

Box 1 below summarises the modifications made to the packaging of the CBDIC innovation.

Box 1

Modifications to the delivery of the CBDIC innovation

Stakeholders' participation in the design and delivery process

Qualitative research methods were adopted during the design and delivery of the innovation to assess stakeholders' preferences in distributing community-based injectable contraceptives. In addition, a baseline assessment was carried out by stakeholders in the scale up process. This baseline assessment helped the program managers factor in the users' preferences and contextual realities into the innovation delivery and implementation. In addition, community gatekeepers were consulted to determine what community members prefer concerning CBDIC.

Baseline assessment was conducted by the NGO, the other staff at the state level partnered together (FP coordinator SMoH, female)

During the development of the scale up plan through FGDs, key informant interviews, we found out some of the preferences of the women, and mostly we found that younger girls knew much less about family planning and those older women had wrong misconceptions about family planning, so we built that into the scale up plan to address the issues. (NGO Program manager, female)

We went through the gatekeepers (community and religious leaders) who let us realize that community distribution will be a thing that they desire. (FP coordinator FMoH, male)

According to Prata and colleagues [16], community-based distribution of contraceptives (CBD) helps developing countries, particularly in hard-to-reach areas. Our study revealed some modifications to the original design of the community-based distribution of injectable contraceptive approaches to align the innovation delivery to users' preferences. Similar to other studies [16], our findings highlight the use of various mobile and fixed posts for contraceptive provision in a discrete manner, age-specific messaging, and one-on-one and group education meetings as part of a responsive CBD model. However, in our study, the model of CBD evolved as a result of, and in response to, contextual factors – mainly cultural and religious reasons, as Nigeria is generally a patriarchal and religious society [30]. Other studies show that common reasons for modifications to classical CBD include ensuring efficiency in service delivery, particularly when community needs surpass a program's capacity to deliver [31, 32]. In addition, when the community's preference was not initially understood or when there is a lack of support from local organizations and political leadership, modification to CBD delivery in injectable contraceptives might be imperative when the family planning market is saturated [16, 33]. This lack of support may manifest as inadequate funding or insufficient infrastructure for health workers [34].

Our study highlights that CBD does not exist in isolation but can only work in the local context - within the community's health infrastructures, particularly when initiating contraceptive use and treating adverse effects of contraceptives. However, studies [30–32] caution that the integration of CBD programs with existing health infrastructures might become impractical as the community's needs for contraceptives increase. This integration may necessitate bringing in more voluntary health workers focused on CBD.

Community volunteers were a significant part of the health workforce for the diffusion of the innovation in this study. There is, however, a divergent opinion in the literature about the desirability of volunteer health workers versus paid health workers in a program like CBDIC [16, 35], with some suggesting that it might be more challenging to hold volunteer health workers accountable for their actions [16]. However, Alam and colleagues [36] believe that community volunteers remain a great asset, particularly in many developing countries' inadequate human resources for health. Our study similarly shows that volunteers are essential for shoring up the human resource for health deficiency in northern Nigeria.

In addition, the volunteers in this study acted as peer influencers through their interactions with potential innovation users. Peer influence may encourage behavior change and can contribute to improved health status [37–41] for many health conditions, including breast cancer [42], cardiovascular diseases [43], diabetes [44], HIV [44], and reproductive health issues [45]. Peer influence is a potentially helpful measure to influence behavioral change in developing countries [46]. However, some research has shown ambivalent results about the effect of peer influence on behavioral health change [42, 47]. As seen in this study, engaging young women to interact with their peers can improve the uptake of community-based injectable contraceptives.

Furthermore, findings from this study show value in establishing a partnership with proprietary patent medicine vendors (PPMVs) to distribute injectable contraceptives. PPMVs, individuals who sell orthodox medicines in retail without formal pharmaceutical training [48, 49], are found everywhere in Nigeria [48, 50], and they are generally perceived to be more accessible and to provide quicker, more confidential, and cheaper services [50]. PPMVs in Nigeria and other developing countries have been reported to be engaged in the distribution of health commodities like emergency contraceptives [50], oral contraceptive pills [49], condoms, intrauterine devices [51], insecticide-treated nets [52], the treatment of sexually transmitted infections [53] and provision of health education [53]. Although PPMVs can play a pivotal role in distributing reproductive health products [53], a study in Southwest Nigeria revealed that their knowledge about reproductive health issues and products and drug dosing and treatment might be small [50]. Moreover, PPMVs comply poorly with the Federal Ministry of Health's guidelines on contraceptive dispensing [51].

Additionally, Ujuju and colleagues [49] reported, in a study done in four Nigerian states, that the quality of advice given by PPMVs fell short of the standards for safety. A systematic review by Beyeler and colleagues validated these findings [48]. Therefore, it has been suggested that PPMVs be formally integrated into Nigeria's sexual and reproductive management system [54], and their training is regularly updated [55], with continual supervision and monitoring, to improve safe access to reproductive health products like injectable contraceptives.

This study used mobile technology (phones) as a social marketing tool to ensure compliance. Social marketing is a high-impact and effective tool to maintain contraceptive knowledge and usage in sub-Saharan Africa [56, 57]. For example, Liu and colleagues [58], while detailing the role of the private sector in introducing injectable contraceptives in southwest Nigeria via social marketing, described how a combination of supply and demand-side measures were used to promote the innovation. These measures include the availability of quality products, behavior change campaigns, partnering with health worker associations, health worker training, and using traditional and online media [58].

Furthermore, our findings highlight that innovation delivery may not be successful without adequate community engagement [59]. The importance of community participation for the uptake and sustainability of health programs has been demonstrated in the literature [59, 60]. The role of community and religious leaders in understanding the community preferences and gaining acceptance for health innovation, particularly in developing countries, cannot be over-emphasized [59, 61]. Without this understanding, the objective of innovation delivery, particularly improved health access, might not be achieved [62].

Some limitations of this study should be stated. Since delivery of health innovations is contextual and the country is very diverse, innovation delivery that worked in northern Nigeria, where this study was primarily carried out, may not be practical or necessary in other country regions. Efforts to scale up health innovations should be tailored according to contextual realities at a local level. Nevertheless, this study provides valuable insights into innovation delivery and its possible influence on health innovations' diffusion and uptake, such as the community-based distribution of injectable contraceptives.

We demonstrate several modifications to the delivery of the community-based distribution of injectable contraceptive innovation. Most of the changes resulted from sociocultural, religious, and programmatic considerations. These include using fixed posts to offer injectable contraceptives to potential users, recruitment of young women as community volunteers to provide peer-to-peer contraceptive messaging, partnership with patent medicine vendors, and social marketing. Innovation delivery should be contextual and cost-effective. Also, there might be a need to combine strategies for synergy and to integrate community-based distribution with existing programs and infrastructures. All these should be done with full community participation to achieve maximal success.

AIDED Assess, Innovate, Develop, Engage and Devolve

CBD Community-based distribution

CBDIC Community-based distribution of injectable contraceptives

CHEWs Community health extension workers

CPR Contraceptive prevalence rates

DMPA-SC Depot subcutaneous medroxyprogesterone acetate

FGD Focus groups discussions

FP Family planning

IDI In-depth interviews

KII Key informant interviews

LGA Local Government Area

LMICs Low- and middle-income countries

MoH Ministry of Health

NGO Non-governmental organisation

UHC Universal health coverage

Ethical approval

Ethical approval for this study was obtained from the University of Ibadan/University College Hospital Ethical Review Board (Ref. No.: UI/EC/16/0022) and the Human Research Ethics Committee (Medical) of the University of Witwatersrand (Ref. No.: M160737). Also, written informed consent was obtained from all participants in this study.

Acknowledgments

Drs. Edward Oladele, Mariya Saleh Wole Adefalu, and Hadiza Kamofu were instrumental in gaining access to key informants during the data gathering process. We'd like to thank everyone who took part in this study. We are grateful to Dr. Busola Adebayo, Jimi Latunji, and Wunmi Senjobi for their assistance in revising the paper.

Funding

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100113), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z) and Deutscher Akademischer Austauschdienst (DAAD). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS) 's Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the authors.

Availability of data and materials

The data used and analyzed in this study are available from Dr. Oluwaseun Akinyemi on request.

Authors' contributions

The study was conceived and designed by OOA and MK. OOA collected the data. The manuscript was written and commented on by OOA, BH and MK. The final version of the manuscript was read and approved by OOA, BH and MK.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Kühne B, Vanhonacker F, Gellynck X, Verbeke W. Innovation in traditional food products in Europe: Do sector innovation activities match consumers’ acceptance? Food quality and preference. 2010;21(6):629-38.
Lundvall B-Å. National systems of innovation: Toward a theory of innovation and interactive learning: Anthem press; 2010.
Oboirien K, Harris B, Goudge J, Eyles J. Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system. BMC health services research. 2018;18(1):600.
Pittaway L, Robertson M, Munir K, Denyer D, Neely A. Networking and innovation: a systematic review of the evidence. International journal of management reviews. 2004;5(3‐4):137-68.
Gellynck X, Kühne B. Innovation and collaboration in traditional food chain networks. Journal on Chain and Network Science. 2008;8(2):121-9.
Linnemann AR, Benner M, Verkerk R, van Boekel MA. Consumer-driven food product development. Trends in Food Science & Technology. 2006;17(4):184-90.
Verbeke W, Frewer LJ, Scholderer J, De Brabander HF. Why consumers behave as they do with respect to food safety and risk information. Analytica chimica acta. 2007;586(1-2):2-7.
Mangham LJ, Hanson K. Scaling up in international health: what are the key issues? Health policy and planning. 2010;25(2):85-96.
Subramanian S, Naimoli J, Matsubayashi T, Peters DH. Do we have the right models for scaling up health services to achieve the Millennium Development Goals? BMC health services research. 2011;11(1):336.
Bradley EH, Curry LA, Taylor LA, Pallas SW, Talbert-Slagle K, Yuan C, et al. A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study. BMJ open. 2012;2(4):e000987.
Bradley E, Curry L, Pérez-Escamilla R, Berg D, Bledsoe S, Ciccone D. Dissemination, diffusion and scale up of family health innovations in low-income countries. Yale Global Health Leadership Institute. 2011.
Malarcher S, Meirik O, Lebetkin E, Shah I, Spieler J, Stanback J. Provision of DMPA by community health workers: what the evidence shows. Contraception. 2011;83(6):495-503.
Stanback J, Spieler J, Shah I, Finger WR. Community-based health workers can safely and effectively administer injectable contraceptives: conclusions from a technical consultation. Contraception. 2010;81(3):181-4.
Prata N, Gessessew A, Cartwright A, Fraser A. Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents. Bulletin of the World Health Organization. 2011;89:556-64.
USAID, Family Health International. Community-Based Access to Injectable Contraception Educational Tour Guidance Package.
Prata N, Vahidnia F, Potts M, Dries-Daffner I. Revisiting community-based distribution programs: are they still needed? Contraception. 2005;72(6):402-7.
Family Health International. The Effectiveness of Community-Based Access to Injectable Contraceptives in Nigeria. 2010.
Association for Reproductive and Family Health. Increasing access to contraceptives in Nigeria through task-shifting to Community Health Extension Workers (CHEWs) Abuja: Association for Reproductive and Family Health. 2015.
Macro I, Commission NP. Nigeria demographic and health survey 2013. 2014.
National Population Commission, ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria. 2014.
Akinyemi O, Harris B, Kawonga M. Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria. BMC health services research. 2019;19(1):1-11.
Akinyemi O, Harris B, Kawonga M. Innovation diffusion: how homogenous networks influence the uptake of community-based injectable contraceptives. BMC Public Health. 2019;19(1):1520.
Akinyemi OO, Harris B, Kawonga M. ‘Our culture prohibits some things’: qualitative inquiry into how sociocultural context influences the scale-up of community-based injectable contraceptives in Nigeria. BMJ open. 2020;10(7):e035311.
National Population Commission. Population and housing census of the Federal Republic of Nigeria. Priority tables. 2006;1.
Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. 2018;52(4):1893-907.
MacPhail C, Khoza N, Abler L, Ranganathan MJQr. Process guidelines for establishing intercoder reliability in qualitative studies. 2016;16(2):198-212.
Hutchison AJ, Johnston LH, Breckon JD. Using QSR‐NVivo to facilitate the development of a grounded theory project: an account of a worked example. International Journal of Social Research Methodology. 2010;13(4):283-302.
Temple B, Edwards R. Interpreters/translators and cross-language research: Reflexivity and border crossings. International journal of qualitative methods. 2002;1(2):1-12.
O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DAJAm. Standards for reporting qualitative research: a synthesis of recommendations. 2014;89(9):1245-51.
Titilayo A, Palamuleni ME, Olaoye-Oyesola JO, Owoeye OM. Religious perceptions and attitudes of men towards discontinuation of female genital cutting in Nigeria: evidence from the 2013 Nigeria Demographic and Health Survey. African journal of reproductive health. 2018;22(1):20-8.
Katz KR, West CG, Doumbia F, Kane F. Increasing access to family planning services in rural Mali through community-based distribution. International Family Planning Perspectives. 1998:104-10.
Soares H, Prata N, Mitchell B. NGOs providing low cost, high quality family planning and reproductive health services. Case study, FEMAP-MEXICO. University of California, Berkeley: Bay Area International Group Monograph Series. 2002;1(3-3):1.3-.2002.
Phillips JF, Greene WL, Jackson EF. Lessons from community-based distribution of family planning in Africa: Citeseer; 1999.
Shiffman J, Smith SJTl. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. 2007;370(9595):1370-9.
Janowitz B, Chege J, Thompson A, Rutenberg N, Homan R. Community-based distribution in Tanzania: costs and impacts of alternative strategies to improve worker performance. International Family Planning Perspectives. 2000:158-95.
Alam K, Tasneem S, Oliveras E. Performance of female volunteer community health workers in Dhaka urban slums. Social science & medicine. 2012;75(3):511-5.
Yuan CT, Pronovost PJ, Marsteller JA. Harnessing the power of peer influence to improve quality. American Journal of Medical Quality. 2018;33(5):549-51.
Wang C, Hipp JR, Butts CT, Jose R, Lakon CM. Peer influence, peer selection and adolescent alcohol use: a simulation study using a dynamic network model of friendship ties and alcohol use. Prevention science. 2017;18(4):382-93.
Andrews JL, Foulkes L, Blakemore S-J. Peer influence in adolescence: Public-health implications for COVID-19. Trends in Cognitive Sciences. 2020.
Ali MM, Amialchuk A, Dwyer DS. Social network effects in contraceptive behavior among adolescents. Journal of Developmental & Behavioral Pediatrics. 2011;32(8):563-71.
Peҫi B. Peer influence and adolescent sexual behavior trajectories: Links to sexual initation. European Journal of Multidisciplinary Studies. 2017;2(3):96-105.
Hu J, Wang X, Guo S, Chen F, Wu Y-y, Ji F-j, et al. Peer support interventions for breast cancer patients: a systematic review. Breast Cancer Research and Treatment. 2019;174(2):325-41.
Gómez-Pardo E, Fernández-Alvira JM, Vilanova M, Haro D, Martínez R, Carvajal I, et al. A comprehensive lifestyle peer group–based intervention on cardiovascular risk factors: The Randomized Controlled Fifty-Fifty Program. Journal of the American College of Cardiology. 2016;67(5):476-85.
Fisher EB, Boothroyd RI, Elstad EA, Hays L, Henes A, Maslow GR, et al. Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews. Clinical diabetes and endocrinology. 2017;3(1):4.
Villa-Torres L, Svanemyr J. Ensuring youth's right to participation and promotion of youth leadership in the development of sexual and reproductive health policies and programs. Journal of Adolescent Health. 2015;56(1):S51-S7.
Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet. 2016;387(10036):2423-78.
Toija AS, Kettunen TH, Leidenius MHK, Vainiola THK, Roine RPA. Effectiveness of peer support on health-related quality of life in recently diagnosed breast cancer patients: a randomized controlled trial. Supportive Care in Cancer. 2019;27(1):123-30.
Beyeler N, Liu J, Sieverding M. A systematic review of the role of proprietary and patent medicine vendors in healthcare provision in Nigeria. PLoS One. 2015;10(1):e0117165.
Ujuju C, Adebayo SB, Anyanti J, Oluigbo O, Muhammad F, Ankomah A. An assessment of the quality of advice provided by patent medicine vendors to users of oral contraceptive pills in urban Nigeria. Journal of multidisciplinary healthcare. 2014;7:163.
Fayemi MM, Oduola OL, Ogbuji QC, Osinowo KA, Oyewo AE, Osiberu OM. The knowledge of emergency contraception and dispensing practices of Patent Medicine Vendors in South West Nigeria. Journal of public health policy. 2010;31(3):281-94.
Ajayi OO, Ajuwon AJ. Contraceptive knowledge and compliance with guidelines for providing contraceptive services by patent medicine vendors in Ibadan North Local Government Area, Nigeria. African Journal of Biomedical Research. 2015;18(2):123-33.
Oguonu T, Okafor H, Obu HA. Caregivers's knowledge, attitude and practice on childhood malaria and treatment in urban and rural communities in Enugu, south-east Nigeria. Public health. 2005;119(5):409-14.
Okonkwo A, Okonkwo U. Patent medicine vendors, community pharmacists and STI management in Abuja, Nigeria. African health sciences. 2010;10(3).
Okonkwo A, Okonkwo UJAhs. Patent medicine vendors, community pharmacists and STI management in Abuja, Nigeria. 2010;10(3).
Ujuju C, Adebayo SB, Anyanti J, Oluigbo O, Muhammad F, Ankomah AJJoMH. An assessment of the quality of advice provided by patent medicine vendors to users of oral contraceptive pills in urban Nigeria. 2014;7:163.
Dalglish SL, Vandermark J, Rossier C, Kemou A, Neighbor H. Using marketing science to understand contraceptive demand in high‐fertility Niger. Studies in family planning. 2018;49(4):367-83.
Chattopadhyay I, Townsend J, RamaRao S. Utilizing social marketing and social franchising models to expand access to the progesterone contraceptive vaginal ring. 2015.
Liu J, Schatzkin E, Omoluabi E, Fajemisin M, Onuoha C, Erinfolami T, et al. Introducing the subcutaneous depot medroxyprogesterone acetate injectable contraceptive via social marketing: lessons learned from Nigeria's private sector. Contraception. 2018;98(5):438-48.
Iyanda OF, Akinyemi OO. Our chairman is very efficient: community participation in the delivery of primary health care in Ibadan, Southwest Nigeria. The Pan African medical journal. 2017;27.
Magawa R. Primary health care implementation: A brief review. Public Health Discussion Paper Consultancy Africa Intelligence. 2012;16.
Arulogun OS, Adewole IF, Adesina AO, Olayinka-Alli L. Community gate keepers' awareness and perception of prevention of mother-to-child transmission of HIV services in Ibadan, Nigeria. African Journal of Reproductive Health. 2007;11(1):67-75.
Odugleh-Kolev A, Parrish-Sprowl J. Universal health coverage and community engagement. Bulletin of the World Health Organization. 2018;96(9):660.

No competing interests reported.

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Supplementary Material 1 Standards for Reporting Qualitative Research reporting guidelines for qualitative studies

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Community-based distribution of injectable contraceptives in Nigeria: Does the innovation delivery fit stakeholders' preferences?

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Abstract

Introduction

Methods

Study design and setting

Data collection and analysis

Results

Addressing sociocultural issues and stigma through fixed posts and community gatherings for innovation delivery

Maintaining confidentiality and promoting convenience

Engagement of community volunteers and patent medicine vendors

Use of mobile telephony in social marketing

Stakeholders' participation in the design and delivery process

Discussion

Conclusion

Abbreviations

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References

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