Power in culture: 4 steps to unlock population health

Chinenye Ezeanolue, MD, Associate Medical Director


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Can baby showers increase HIV testing? Dr. Chinenye Ezeanolue shares the story behind her published cluster randomized trial using cultural-context dependent strategies that improved HIV testing rates in the partners of pregnant women in Nigeria. Her example of designing an intervention to work with existing culture may enhance care delivery abroad and at home. 

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I spent many evenings after long work days in discussion with my husband, Dr. Echezona Ezeanolue. Nigeria, close to both of us, has one of the highest burdens of Human Immunodeficiency Virus (HIV) in Sub-Saharan Africa (SSA). How could we make an impact?

Identify the outcome you wish to change

We looked at the four-pronged comprehensive approach to HIV prevention put forward by the United Nations (UN). Prevention of transmission from mother to child is fundamental to slowing the virus.

Our intervention would focus on HIV testing for pregnant women and their partners. To increase the number tested we looked to previous research showing that partner involvement offers a large statistical boost to uptake of antenatal services.

We would find a way to involve fathers and therefore engage both parents in care of their baby, including HIV testing and prophylaxis. In doing so our intervention, if successful, would greatly reduce the number of HIV positive children.

Identify barriers that influence your population

My husband and I put our heads together. We have a close understanding of Nigerian socio-cultural norms, and beliefs. Understanding the population you serve: their social lives, hopes, fears and challenges are important research elements to develop a protocol.

Nigeria’s specific barriers:

  1. Social expectations: One expectation is that men are hands off during a pregnancy, with their role is seen to be financial providers and there is limited interaction with health care entities. Prior to our study, male partners attending at least one antenatal visit ranged between 1.8% and 32% in SSA.1

  2. Stigma: The contradictory combination of perceived low personal risk and fear of knowing their results prevented many individuals from HIV testing. Being singled out as “going in for testing” has a great deal of stigma attached and can be a source of distrust within a relationship. Seventy percent of men knew where to get an HIV test, but a mere 10% were tested in the last year. This rate dipped lower in rural areas with less access.2

  3. Access: Many residents live far from clinics. Within Nevada, there are many rural areas and services within these areas are limited. Even in the case that a person wished to be tested and could get to the clinic, clinic hours frequently conflicted with patient work hours. Convenient times were hard to find and often there was not a convenient place to have antenatal testing and counseling.

Design an intervention addressing barriers

We had more than a few barriers to address. Fortunately, with a holistic understanding of our population, we found a bridge that could carry us across many health barriers.

Nigerians value faith and it plays a large role in their lives. A village may not have a hospital or clinic, but it will have houses for worship. The dominant religion is Christian (Catholic and Anglican) in South East Nigeria.

Making church, a second home with significant trust, the centerpiece of our intervention, addressed numerous identified challenges.


Baby showers are a celebration I learned during my many years in the United States. Baby showers, not a part of the typical Nigerian pregnancy, became an extension of church events, and our moment to put the intervention into action.

Our group, the family-centered and culturally adapted Healthy Beginning Initiative (HBI) team, spoke with respected clergy in the communities where our intervention was planned.

We educated them on the positive outcomes of testing and how parental involvement would lead to healthier babies in their congregation. Clergy were instrumental in gaining trust and lending credibility to our study among congregants.

Deploy the intervention, collect data and be flexible

Our study involved the clergy member bringing forward pregnant couples to receive a special prayer for the health of the unborn baby.

Once a month, after church those who’d gotten the blessing were given a “baby shower” with food, gifts, well-wishes and the opportunity to be brought into another room for testing to check mom (and therefore baby’s) health.

Tests included blood typing, Hepatitis B, sickle cell trait, malaria, syphilis and hemoglobin. Men enjoyed seeing their hemoglobin, as it is associated with strength.

The “baby shower” model reduced the individual stigma of testing for HIV by:

  1. Giving the test in a group setting focused on the joy of healthy babies
  2. Offering HIV testing not as the sole feature but a component piece of a battery of tests desired by the parents-to-be

Based on testing, parents could be counseled on prophylactic measures. HBI’s results were impressive, with males being tested at rates between 86.4% and 88.9%. Their participation was 12 times higher than at baseline.3

We believe the community focus and barrier addressing study informs not only about the possibility for improved infant health in Nigeria, but also a new view on study design.

Population health is crucial for public health improvement to move forward, and as the HBI study continues to make an impact in Nigeria, we are proud to have found a way to meet our patients where they are to improve health and outcomes.

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  1. Ezeanolue, E. E., Obiefune, M. C., Yang, W., Ezeanolue, C. O., Pharr, J., Osuji, A., ... & Ehiri, J. E. (2017). What do you need to get male partners of pregnant women tested for HIV in resource limited settings? The baby shower cluster randomized trial. AIDS and Behavior, 21(2), 587-596.
  2. Ibid
  3. Ibid

This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of Optum Care. The views and opinions expressed may change without notice. 

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