Exploring the Relationship Between National Health Education Policy Implementation Fidelity and Primary Health Outcomes in Nigeria: A Cross-State Comparative Study

Policy implementation fidelity is a critical determinant of whether national health education policies translate into meaningful primary health outcomes, yet the relationship between fidelity and outcomes remains underexplored in the Nigerian policy science literature. This study examined the relationship between national health education policy implementation fidelity and primary health outcomes across Nigerian states through a cross-state comparative study. A mixed methods comparative design was employed, incorporating a validated Policy Implementation Fidelity Assessment Tool administered to 240 state-level health education officials and programme coordinators from 12 purposively selected states representing all six geopolitical zones. Implementation fidelity scores were correlated with state-level primary health outcome indicators sourced from the 2023 National Health Management Information System database and Nigeria Demographic and Health Survey supplementary data. Qualitative interviews with 30 policy implementers and 6 state-level case studies provided explanatory depth. Pearson's correlation and regression analysis were applied to quantitative data. Results showed a significant positive relationship between implementation fidelity scores and composite primary health outcome indices (r 0.67, p less than 0.01), including immunisation coverage, antenatal care utilisation, and child malnutrition rates. Political commitment, health educator workforce deployment, and monitoring system strength were the fidelity dimensions most strongly associated with outcomes. The study recommends development of a National Health Education Policy Fidelity Monitoring System. Keywords: policy implementation fidelity, health education policy, primary health outcomes, Nigeria, comparative study