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.

Methods

2.1 Study design and setting
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).

Participants and sample
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. 
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.

2.2 Data collection
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.

2.3 Data analysis
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.

2.4 Ethics approval and consent to participate
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.

2.5 Patient and Public Involvement 
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.

The transcripts and analysis are uploaded as an NVIVO file