A mother can want the best for her child, trust a health worker and still be unable to make the final decision about whether that child receives medicine.
That finding from a sentiment study across 11 northern Nigerian states offers an important lesson for policymakers working to improve child survival, that reaching caregivers is not always the same as reaching decision-makers.
The finding is contained in Earning Public Confidence and Household Trust in the Reduction of Child Mortality in Northern Nigeria, a white paper examining what it will take to translate the promise of proven child-survival interventions into sustained participation at household level.
The SARMAAN/REACH programme provides approved dosage in the mass administration of azithromycin to children aged one to 59 months across 11 northern states. Evidence from the MORDOR trial found that the intervention reduced all-cause child mortality by 13.5% in high-mortality settings.
The opportunity is significant, but getting a proven intervention to children requires more than making the medicine available. It requires households to trust the programme enough to participate.
The sentiments study found an overall Emotional Sentiment Index (ESI) score of 48 out of 100 across the exposed states; meaning that caregivers are participating in the programme but their confidence of understanding of the programme is fragile.
. The index measures caregiver confidence and readiness to participate in and advocate for the programme.
The state-level picture varies considerably. Kano recorded an ESI of 73, while Yobe and Kaduna recorded 36 and 28 respectively. The white paper describes these findings as baselines, rather than permanent judgments and that distinction is important as trust can change, and governments have an opportunity to influence how it changes.
There is another finding policymakers should pay particular attention to. Only 16% of mothers surveyed said they had sole authority over whether their child receives the medicine. In 51% of households, the decision is made jointly, while in 33%, the husband has sole authority.
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This means a programme can successfully reach a mother and still fail to secure household participation.
It also changes how health communication should be designed. If the people receiving information are not always the people making the final decision, communication cannot stop with mothers. Fathers, male elders and other household decision-makers need to be part of the conversation, particularly in communities where they hold significant influence.
There is an encouraging tension in the findings. Across the states, 96% of caregivers said they intend to participate in SARMAAN again.
The white paper recommends that states establish year-round relationships with trusted community messengers, including frontline health workers, religious leaders and women’s networks, rather than activating them only when medicines are being distributed. It also recommends building the capacity to identify and respond to emerging concerns before they become entrenched.
Nigeria has seen the value of this approach before. When distrust disrupted polio vaccination across three northern states in 2003, structured investment in credible community messengers contributed to a dramatic reduction in new cases, from 384 to 21 in a single year.
The lesson is not that communication can substitute for functioning health systems. It cannot. Financing, health workers, supply chains and service delivery remain fundamental. But trust is part of that infrastructure. Without it, even effective interventions can struggle to reach the children they were designed to protect.
For policymakers, the actions are practical. We need a budget for trust-building, maintain credible community networks between programme rounds, engage household decision-makers, establish mechanisms to track and respond to concerns, and make child survival a visible public accountability priority.
These investments can also extend beyond programmes like SARMAAN/REACH to ensure that stronger relationships between citizens, communities and health systems can support future health interventions as well.
Nigeria’s child-survival challenge remains enormous, but the findings point to encouraging insights that some of the barriers to participation are identifiable, measurable and actionable. The question now is whether policymakers will use that knowledge.