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Sanusi Abubakar Using Participatory Sanusi Abubakar Using Participatory Methods To Improve Health Literacy Of Mothers In Northern Nigeria: An Action Research Project Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Health and Related Research April 2019 ii For Hajia Saratu Saidu and Alhaji Abubakar Adofu; Hajia Hauwa M. Ari and Hajia Ummul-Khairi Suleiman; Dr Aisha Mukhtar, Dr Salamatu Abubakar and Hajia Zainab Abubakar; Abdurahman, Habibullah, Ihsan, Abdallah, Abba, Husna and Eaman. ii Declaration I certify that this thesis submitted for the degree of Doctor of Philosophy is the result of my own research, except where otherwise acknowledged. No portion of the work presented in this thesis has been submitted for another degree or qualification to this, or any other, university or institution. Sanusi Abubakar 3 Abstract Background: Maternal and neonatal health is an important global public health priority. Outcomes remain poor, especially in rural, peri-urban or marginalised communities. Public health interventions and conventional health promotion programmes are often challenging to implement and can fail to lead to sustainable change. Research suggests that participation influences literacy; which in turn is more likely to lead to sustainable health-related changes especially in marginalised settings, but there are challenges to implementation. Aim: To assess whether an action research approach using a mix of participatory methods can improve the health literacy of women living in peri-urban and rural areas of Northern Nigeria Methods: Three communities were recruited into the project; one as comparison and two in which women’s groups were established. The research project had three stages: designing, implementing and evaluating the complex (health promotion) intervention. A range of participatory approaches (Community-Based Participatory Research, Auto-diagnosis, Most Significant Change) were adopted. Qualitative methods including interviews, focus group discussions, storytelling, group discussions and visual methods were used during group development; and to explore mechanisms and factors that determine the development and impact of women's groups. 4 Findings: The planned transition from facilitator-led to a peer-led women's group was achieved by women's group members during the project's duration. Evaluation of the complex process of co-designing and co-implementing this complex intervention showed that peer-led participatory learning sessions with participatory visual methods were feasible and were used effectively by groups in addressing maternal and neonatal danger signs and promotion of healthy nutrition. Conclusion: Action research approach and combination of participatory methods enabled the development of women's groups with the potential to empower women with knowledge and skills for local maternal health actions. Further work is needed to understand whether groups are sustainable and can have a direct impact on maternal and neonatal morbidity and mortality over time. 5 Acknowledgements I would not have started the highly rewarding but tortuous journey of embarking on the pursuit of a PhD without the initial stimulus from the British Chevening Scholarship and the British Council/BUK MacArthur Grant; both provided initial funding for my postgraduate studies (MSc and PhD respectively) in the UK. I must thank my two-in one supervisory team. Firstly; Prof Elizabeth C Goyder, Graham Jones, Emma Everson Hock and Muhammad I Saddiq for your unflinching support, friendship and shared vision of enabling participation by the underserved. I was privileged and thankful to receive a University of Sheffield Fieldwork Data Collection Grant which was supplemented by a Bayero University Grant, and in kind support from the Department of Community Medicine, Bayero University Kano as well as my personal funds. All these funds went towards supporting the expenses for the research project. I must also thank all the people that assisted me throughout my research project, most especially my co- researchers (research team members/female facilitators - Fatima, Halima and Hauwa, including the women's group members at Tudun Kaba and Kayi, as well as community members at Tsamawa) who were very generous within their limited resources, gave their consent to participate in the research project and made personal sacrifices for maternal and neonatal health in their communities. In addition, consent for both taking and using the photographs of group members was confirmed with the groups and individuals in the respective communities. The Community Advisory Board, Kumbotso also deserves special mention for the support they gave the research project. I must also thank my other tutors and PGR colleagues in ScHARR as well as my 'remote location' buddies with whom we have undertaken this journey together. I must mention 6 Padam Simkhada, Jenny Owen and Zubairu Iliyasu. Your listening ears, encouragement and friendship helped to keep me motivated to steer the course. Finally, I want to thank my family and especially my mother for their love and fervent prayers which helped me to reach this landmark. I hope that this will make all of you proud. Sanusi Abubakar 7 Table of Contents Declaration ................................................................................................................................. 3 Acknowledgements .................................................................................................................... 6 Table of Contents ....................................................................................................................... 8 List of Tables ........................................................................................................................... 16 Conference presentations in support of this thesis ................................................................... 17 List of Abbreviations and Acronyms ....................................................................................... 18 Glossary of Some Hausa Terms ............................................................................................... 22 Chapter One: Introduction ....................................................................................................... 26 Chapter Two: Literature Review ............................................................................................. 30 2.1. Preamble ........................................................................................................................... 30 2.2. General literacy ................................................................................................................. 30 2.3. Definitions of health literacy ............................................................................................ 31 2.4. Health literacy models ...................................................................................................... 33 2.5. Measuring health literacy .................................................................................................. 34 2.6. Maternal health literacy .................................................................................................... 36 2.7. Review of health literacy research in LMICs ................................................................... 36 2.8. Critical health literacy ....................................................................................................... 38 2.9. Women's empowerment .................................................................................................... 39 2.10. Social capital ................................................................................................................... 39 2.11. Critical health literacy, women's empowerment and social capital ................................ 41 2.12. Health literacy, empowerment, participation, and participatory research approaches ... 42 2.13. Participatory research approaches ................................................................................... 44 2.14. Selected participatory research approaches - community based participatory research, participatory visual methods and participatory women's groups approach ............................. 46 2.15. Health psychology .......................................................................................................... 49 2.16. Participatory monitoring and evaluation – the most significant change (MSC) method 50 2.17. The project management cycle during the fieldwork stage - (inception/design, implementation and evaluation phases) ................................................................................... 50 2.18. Project design during the inception phase ...................................................................... 51 8 2.19. Project implementation phase ......................................................................................... 52 2.20. Contextual factors during implementation...................................................................... 52 2.21. Project implementation challenges ................................................................................. 53 2.22. Project evaluation phase ................................................................................................. 54 2.23. Research paradigms and choice of evaluation methodologies ....................................... 54 2.24. Evaluation approaches ...................................................................................................
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