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close this bookReproductive Health and Communication at the Grassroots - Experiences from Africa and Asia - Proceedings, 1997, Ethiopian Red Cross society training institute, Addis Ababa, Ethiopia (IIRR, 1997, 292 p.)
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Open this folder and view contentsConference resolutions
Open this folder and view contentsAnnexes

(introduction...)

Proceedings of the Conference on Reproductive Health and Communication at the Grassroots:
Experiences from Africa and Asia May 12-16, 1997
Ethiopian Red Cross Society Training Institute Addis Ababa, Ethiopia

FGAE
Family Guidance Association of Ethiopia
P.O. Box 5716, Addis Ababa, Ethiopia
Tel: 251-1-518909 or 514111

IIRR
International Institute of Rural Reconstruction
World Headquarters, Silang, Cavite, Philippines
Tel: 63-46-414 2417

Africa Regional Office, P.O. Box 66873, Nairobi, Kenya
Tel: 254-02-442610

Acknowledgement

The conference and production of this publication were supported by the following organizations.

DANIDA ROYAL DANISH MINISTRY OF FOREIGN AFFAIRS

DGIS

Lutheran World Relief

Christian Aid


FGAE

The Family Guidance Association of Ethiopia is a national non-governmental and non-profit organization founded in 1966. It is an affiliate member of the IPPF, the leading international family planning movement organization. It pioneered the family planning movement in Ethiopia, emphasizing the health rationale. FGAE gives training in family planning, provides family planning services and promotes use of contraceptives, family planning caters for adolescent sexual and reproductive health, and is involved in institutional and management capacity-building.


IIRR

The International Institute of Rural Reconstruction is a non-profit, non-governmental organization that aims to improve the quality of lives of the rural poor in developing countries through rural reconstruction: a sustainable, integrated, people-centered development strategy generated through practical field experiences. Based in the Philippines, IIRR has regional offices in Africa (Nairobi), Latin America (Quito) and Asia (Silang, the Philippines). IIRR's Africa office is committed to strengthening the institutional capacity of partner organizations through knowledge generation, acquisition and sharing.

IIRR publications are not copyrighted. The Institute encourages the translation, adaptation and copying of materials for non-commercial use, provided an acknowledgement to IIRR is included

Correct citation

FGAE and IIRR. 1998. Reproductive Health and Communication at the Grassroots: Experiences from Africa and Asia. Family Guidance Association of Ethiopia, Addis Ababa, Ethiopia, International Institute of Rural Reconstruction, Silang, Cavite, Philippines and International Institute of Rural Reconstruction - Africa Regional Office, Nairobi, Kenya.

Printed in Kenya (1998)
ISBN 0-942717-88-0

(introduction...)

(* Speech delivered by a participant-representative during the closing ceremony of the conference)

Weaving conversations and techniques across the African and Asian cultures

We have been weaving conversations and techniques across the Asian and African cultures over the past week in order to resolve very urgent problems and needs in our various communities and countries.

We have seen what has worked and what else we need to improve and how.

Personally, I have been tremendously enriched by this Conference. Nobody has ever given me an opportunity to co-author any publication in my entire 15 years of hard work in development for Africa. And for this reason, I feel especially honored by the organizers of this Conference - FGAE and IIRR. I am sure that you share with me the sentiment of our special honour and privilege for having been chosen as both contributors and benefactors of this unique conference.

We have worked very hard in pinpointing what has worked and what has not; when, why and how. In particular, we have pinpointed the critical communication strategies in redressing program needs in the area of HIV/AIDS, Family Planning and Adolescents' reproductive health. Amongst them is the special need to pay great attention to the various cultural, religious, political and socio-economic contexts in selecting and applying the various communication strategies.

I believe that we have each been enriched by the great sharing, in-depth analysis and reflections that have taken place in this Conference. We have reasoned together. We have acquired newer insights and additional skills.

Let us now go back to our various programs and communities and implement what we have learnt. Let us go back and find our various symbols of: reflection, rootedness, solidarity, protection and peace. Let us go back and find those "camel riders" that we spoke about. Let us go back and find our wise women and men who are still connected or not connected and may be there is still some little root of sacredness left in our communities. And if we could allow the wind to blow, may be those little roots may germinate and grow and fertilize our various communities.

I believe that we have found new visions and directions in our Conference Resolution. Let us go back with renewed hope to implement our new found visions.

I thank you all.

Mary Okumu
Conference Participant

Conference objectives

· Document, exchange and analyze experiences generated through the development and application at grassroots level of different indigenous communication strategies related to reproductive health.

· Critically assess the effectiveness of the different approaches, identify the main success factors and possible areas for impact enhancement.

· Explore ways for further consolidation and wider dissemination of experiences generated through the strategies presented.

· Produce a resource material: an illustrated compilation and analysis of successful indigenous strategies based on lessons learned.


Figure

Preparation

The conference framework was defined with the specific areas of concern. Organizations with field projects to address the concerns were then identified and invited to write their case studies. The papers were then screened for relevance to the conference concerns. Among those that were turned down were clinical and laboratory research projects on reproductive health.

The mechanics of the conference had round table sessions for the case presentation and subsequent discussion. The plenary session was for the discussion of the round table outputs. This design represented three levels of abstraction: first level - case study presentation; second level - discussion and enrichment of the case with inputs from the other participants' experiences and the third level - plenary discussion, the contribution from the other round table groups. It was made clear that the case study was meant to trigger the discussion and analysis of the communication strategy based on the participants' experiences and should not be the center of the discussion (see guidelines: abstraction guide for case presentation, round table sessions and plenary). The affirmation or negation of the results should be based on actual experiences and not on theory. This entails hard work for the participants and would not follow the conventional conference design, where participants get bored listening to a series of presentations.

The case study writers/presentors were briefed on the design of the conference.

Conference proper

Day 1

The opening ceremony had the Minister of Health of Ethiopia for the keynote address while the Head of Population provided the implications of this conference to the government's population efforts.

A technical briefing was given on the "WHY, WHAT and HOW" of the conference (with separate paper-discussion on page 35). The first afternoon had simultaneous roundtable session on five papers on AIDS.

Day 2

The second morning was the roundtable sessions for six cases on HIV/AIDS/STD and the plenary session. The summary of the outputs and discussion of the two round table session on the first theme, HIV/AIDS/STD, was presented. It highlighted the abstraction guide format, this time in simpler categories of FOR WHOM (the audience characteristics); FOR WHAT (expected behavioral results) and WHAT (reproductive health messages); HOW (communication media used); issues and concerns and areas for enhancement. This was related to the generic communication framework of SENDER (who), MESSAGE (what), CHANNEL (how), RECEIVER (to whom), EFFECT (for what) and FEEDBACK.

The second theme, family planning, was started in the afternoon with six case studies for the round table sessions and part of the plenary session.

Day 3

The morning continued the plenary session for the remaining two round table session outputs presented, followed by the discussion. Given the heavy schedule and the expected midweek slump, the participants took the afternoon off for a quick tour of the city. The evening was for a two-hour cultural show featuring Ethiopian songs and dances.

Day 4

Instead of the roundtable session, the four cases on the Agricultural Approach to Family Planning was presented in plenary. By afternoon, the broader concern - Reproductive Health Concerns, the third theme, was tackled in the fifth round table session with seven case studies. Four outputs were discussed in the plenary.

A sample of a case study in its final lay-out form was distributed to the participants earlier during the day to motivate them for an early submission of the case revisions. The material production from its original state to its final form was shared for guidance of the case writers. The document flow had been used since the first day of the conference as a parallel, behind the scene process.

Day 5

The plenary had the last two reports and the discussion. An added feature was the video show on female genital mutilation from Ethiopia and Uganda. A summary of the third theme was presented. The participants were afterwards divided by gender to identify the next steps and the resolutions. The two genders met in plenary to identify similarities and differences of the two outputs. A task force of volunteers from both groups worked on a consolidation for the Conference Resolution.

The closing ceremony had the Minister of Woman's Affairs of Ethiopia as the keynote speaker and a representative of the participants giving the response.

Post-production

Pre-conference activities

After the conference, the materials were compiled and edited to come up with a proceedings-resource book. This is intended for use of field practitioners dealing with reproductive health concerns.


1 Development of the conference theme.


2 Conceptualization of the conference output.


3 Development of the basic structure, format and content of the output.


4 Identification and invitation of resource persons.


5 Submission of case papers.


6 Categorization of the conference papers according to theme.

Conference activities


7 Presentation of individual case papers in a workshop group categorized into themes.


8 Revision of case papers based on input of the workshop group (including editing, illustration and desktop work).


9 Abstraction within the workshop group.


10 Preparation of summary and abstractions.

Post-conference activities


11 Presentation summary and abstractions in a plenary


12 Preparation of camera-ready materials.


13 Printing of the conference output.


14 Distribution of the printed conference output.


15 Evaluation.

Materials production process


Materials production process

Conference schedule

Day 1

9:00 - 9:15

: Welcome Statement by Ato Teka Feyera, Executive Director of FGAE

9:15 - 9:30

: Conference Theme by Dr. Isaac Bekalo, Director of IIRR Africa Regional Office

9:30 - 9:45

: Opening Remark by Dr. Neguissie Tefera, Head of Population Office

9:45 -10:00

: Opening Address by His Excellency, Dr. Adem Ibrahim, Minister of Health

10:00 -11:00

: Coffee and Tea Break

11:00 -12:30

: Conference Orientation: Administrative and Technical

12:30-2:00

: Lunch

2:00 - 3:30

Round Table Session 1: AIDS (5 cases)


· Communicating Messages on HIV/AIDS to Rural Groups Experiences of the MYRADA-PLAN AIDS Community Awareness Program by Smita Ramanathan and Vidya Ramachandran


· Peer Education for Sustained HIV/AIDS Awareness by Ma. Charito Alcoreza and Bernardo Mondragon


· Participatory Method for Community Mobilization Against HIV/ AIDS by Dolina A. Odera


· HIV/AIDS Prevention The Safer Sex Campaign for the Youth in Uganda by Anne B. Gamurorwa, Cheryl L. Lettenmaier and Nan Lewicky


· Assessment of Peer Counselling among University Students by Samson O. Ogwalo

3:30-4:00

: Tea Break

4:00-5:30

: Plenary 1

Day 2

8:30-10:30

: Plenary 1 (Continuation)

10:30- 11:00

: Tea Break

11:00 - 1:00

: Round Table Session 2: AIDS (6 cases)


· Small Group Education to Prevent HIV/AIDS The Case in Addis Ababa by Negussie Yitbarek, Roma Hein and Lilian T. Wambua


· Problem-based Communication Approach for 100% Condom Use among Sex Workers by Tussnai Kantayaporn


· Communication Strategies to Control STDs/HIV/AIDS The Case of Commercial Sex Workers in Addis Ababa by Almaz Haile-Selassie


· Participatory Action Research: An Approach to Rural HIV/AID Education by Phoebe V. Maata


· Communication Media to Prevent HIV/AIDS The Case of Out-of-School Youth in Addis Ababa by Teshome B. Wanta


· Communicating with Young People on HIV/AIDS/STDs The Youth Centre Approach by Akwasi A. Boakye-Yiadom

1:00-2:00

: Lunch

2:00-3:30

: Plenary 2

3:30-4:00

: Tea Break

Day 3

8:00-8:30

: Plenary 2

8:30 - 10:30

: Round Table Session 3: Family Planning (6 cases)


· Family Planning Campaign The Case in Masaka District, Uganda by Jennifer R. Sengendo and Deus Yiga


· Communication Strategies for Grassroots People in Burkina The Cases of Griottes, Naba, Dolotis and Camel Riders by Yacouba Yaro and Julien Tougouri


· Integrated Maternal Health and Family Planning Project The Case of the Christian Health Association of Kenya by Sellah A. Nakhisa


· Use of Drama to Promote Family Planning The Uasin Gishu Experience by Peter N. Kagwe


· Communication Pattern to Promote Rights to Reproductive Health by Zohra Andi Baso


· Family Planning Communication at the Grassroots The Case of Yirgalem Family Planning Projec by Amare Bedada Desta

10:30-11:00

: Tea Break

11:00-1:00

: Plenary 3

1:00-2:00

: Lunch

2:00 - 5:00

: Round Table Session 3: Family Planning

Day 4

8:30 -10:30

: Plenary Presentation and Discussion 4: Family Planning (4 cases)


· Agricultural Approach to Family Planning The Uganda Experience by Elizabeth K. Bamutire


· Agricultural Approach to Family Planning The Talebpur Experience by Shaikh Halim


· Agricultural Approach to Family Planning and Reproductive Health The Case of the Family Guidance Association of Ethiopia by Tilaye Tesfaye


· Agricultural Approach to Family Planning The Cross -cultural Adaptation by Estrella P. Gonzaga

10:30-11:00

: Tea Break

11:00 -1:00

: Round Table Session 5: Reproductive Health (7 cases)


· Reproductive Health and Communication within an Extension Programme by Alemu Bogalech


· Family Life and Adolescent Reproductive Health Project The Egerton University Experience by Wakube A. Wataka


· Addressing Sexuality and Health Needs through Partnership The Kenya Experience by Mary Y. Okumu


· Participatory Community Diagnosis on Reproductive Health The Case of Adolescents and Community Members in Mwanza, Tanzania by Edua Matasha and L. Wambua


· Education Strategies to Eradicate Female Genital Mutilation The Case of High School Students in Ethiopia by Amare Dejene


· Pregnancy Prevention The Case of the Surma of Southwestern Ethiopia by Mirgissa Kaba


· Communicating Health Issues with Women by Pallavi Patel and the CHETNA Team

1:00-2:00

: Lunch

2:00-4:00

: Plenary 5

4:00-4:15

: Tea Break

Day 5

Activities

Video Showing on Female Genital Mutilation
Plenary 6
Formulation of conference resolution
Closing Remarks by Woz. Tadelech Haile Michael, Minister of Women Affairs of Ethiopia
Closing Remarks by Mary Y. Okumu, conference participant

Conference participants

Bangladesh

Shaikh A. Halim
Executive Director
Village Education Resource Center
Anandapur, Savar
Dhaka, Bangladesh
or
G.P.O. Box 2281
Dhaka, Bangladesh
Tel. nos.: (880-06226) 412 or 779
Fax no.: (880-2) 813095 (attn: VERC)
Email: verc@bangla.net

Burkina Faso

Yacouba Yaro
Researcher/Demographer
Unit of Training and Research in Demography (UERD)
02 BP 5472, Ouagadougon 02
Burkina Faso
Tel. nos.: (226) 362115/3621860
Fax no.: (226) 362138
Email: yaroy@uerd.uerd.bf

Ethiopia

Bogalech Alemu
Head
Women's Affairs Department
Ministry of Agriculture
P.O. Box 62347
Addis Ababa, Ethiopia
Tel. no.: (251-1) 518040
Fax no.: (251-1) 512984

Yetnayet Asfaw
Director
Education, Health and Children's
Affair Department
Good Shepherd Family Care Service
P.O. Box 8046
Addis Ababa, Ethiopia
Tel. no.: (251-1) 550958
Fax no.: (251-1) 552300

Amare Dejene
Head
Epidemiology/Biology Department
Ethiopian Health and Nutrition
Research Institute
P.O. Box 1242
Addis Ababa, Ethiopia
Tel. no.: (251-1) 751522

Araya Demissie
Director of Programmes
Family Guidance Association of Ethiopia
P.O. Box 5716
Addis Ababa, Ethiopia
Tel. nos.: (251-1) 512193/514111
Fax no.: (251-1) 512192

Amare Bedada Desta
Regional Manager
Southern Branch Office
Family Guidance Association
of Ethiopia
P.O. Box 606
Awassa, Sidamo
Ethiopia
Tel. no.: (251-1) 200249

Burka Felema
Personnel Administrator and
Health Assistant
Kind Heart's Child and
Development Organization
P.O. Box 3726
Addis Ababa, Ethiopia
Tel. no.: (251-1) 610968

Roma Hein
Project Officer
United Nations Children's Fund
(UNICEF)
P.O. Box 1169 Addis Ababa, Ethiopia
Tel. no.: (251-1) 515155
Fax no.: (251-1) 511628

Samuel Heramo
FP CBD Project Area Manager
Ethiopian Evangelical Church
Mekane Yesus
South Central Synod-Hossana
P.O. Box 5, Tell 334
Hossana Ethiopia
Tel. no.: 55-37-22/55-31-74

Mirgissa Kaba
Coordinator
Community-Based Training Program
Jimma Institute of Health Sciences
P.O. Box 564
Jimma, Ethiopia
Tel. nos.: (251-7) 111256/111432
Fax nos.: (251-7) 111450/110575
Email: jihs@telecom.net.et

Bossena Kasa
Coordinator
Society for Women Against AIDS
in Africa-Ethiopia
Teklu Desta Building
Near National Theatre
Office Room No. 59
Addis Ababa, Ethiopia
or
P.O. Box 3829
Addis Ababa, Ethiopia
Tel. no.: (251-1) 444075

Danile Kassa
Addis Ababa Red Cross Anti- AIDS
Society Member
Red Cross
Tekel Haymanote
Red Cross and Anti-AIDS Club
Addis Ababa, Ethiopia
Tel. nos.: (251-1) 133424

Asres Kebede
Coordinator
National POP/IEC
The National Office of Population
P.O. Box 2619
Addis Ababa, Ethiopia
Fax no.: (251-1) 554066

Solomon Kumbi
Head, Department of OB-GY
Gondar College of Medical Sciences
P.O. Box 196
Gondar, Ethiopia
Tel. nos.: (251-8) 110174/110243
Fax no.: (251-8) 111479
Email: gcms@eth.healthnet.org

Assefu Lemlem
RH/FP Coordinator
National Office of Population
P.O. Box 4457
Addis Ababa, Ethiopia
Tel. no.: (251-1) 184367

Mary Yuanita Okumu
Regional Representative for the Horn
OXFAM-America
P.O. Box 2333
Addis Ababa, Ethiopia
Tel. no.: (251-1) 512439
Fax no.: (251-1) 510211

Almaz Haile-Selassie
Manager for Social Development
African Creative Consultancy Network
(AFCON)
P.O. Box 15912
Addis Ababa, Ethiopia
Tel. nos.: (251-1) 510856

Bouwe-Jan Smeding
Consultant
Health/Family Planning
SNV/Netherlands Development
Organization
P.O. Box 40675
Ababa, Ethiopia
Tel. no.: (251-1) 654386
Fax no.: (251-1) 654388

Senait Alemu Tassew
Nurse-Midwife Tutor
Addis Ababa Midwifery School
c/o St. Paulos Nursing School
P.O. Box 870
Addis Ababa, Ethiopia
Tel. nos.: (251-1) 755041/131685
Fax no.: (251-1)511628

Tilaye Tesfaye
Head
Information, Education and
Communications Department (IEC)
Family Guidance Association of Ethiopia
P.O. Box 5716
Addis Ababa, Ethiopia
Tel. no.: (251-1) 514111
Fax no.: (251-1) 512192

Teshome Bongassie Wanta
AIDS/CBD Programme Officer
Marie Stopes International-Ethiopia
P.O. Box 5775
Addis Ababa, Ethiopia
Tel. no.: (251-1) 516642
Fax no.: (251-1) 512368

Negussie Yitbarek
Project Coordinator
Adolescent Sexual Reproductive
Health Project
Region 14, Zone 1, Woreda 6
P.O. Box 31539
Addis Ababa, Ethiopia
Tel. no.: (251-1) 133290

Eritrea

Daniel Redie
Acting Head IEC
Planned Parenthood Association
of Eritrea (PPAE)
P.O. Box 226
Asmara, Eritrea
Tel. nos.: (291-1) 127333/115331
Fax no.: (291-1) 120194

Ghana

Akwasi A. Boakye-Yiadom
Area Manager
Planned Parenthood Association of Ghana
P.O. Box 3672
Kumasi, Ashanti, Ghana
Telefax no.: (233-51)25004

India

Pallavi Patel
Dy. Director (WHDRC)
Centre for Health Education Training
and Nutrition Awareness (CHETNA)
Lilavati Lalbhai's Bungalow
Civil Camp Road, Shahibag
Ahmedabad 380004, Gujarat
India

Tel. nos.: (+91-79)

7866695/7868856


7865636

Fax no.: (+91-79) 7866513
Email: indu.capoor@lwahm.nandanet.com

Smita Ramanathan
Documentation Officer
MYRADA/PLAN-AIDS Community
Awareness Project
Bus Stand Road, Gokak 591 307
District: Belgaum, Karnataka
India
Tel. nos.: (91-8332) 26001/86416
Fax no.: (91-8332) 86724

Indonesia

Zohra Andi Baso
Director
South Sulawesi Consumer Organization
Jl. Sunu Kompleks UNHAS
Samping Gedung Tamarunanga
Ujung Pandang 90211
Indonesia
Tel. nos.: (62-411) 445573/445574
Fax no.: (62-411)854518

Kenya

Joyce Agalo
A/V (Media) Librarian
Library Department
MOI University
P.O. Box 3900
Eldoret, Kenya
Tel. no.: (254-321) 43720 ext. 225
Fax nos.: (254-321) 43275/43047

Peter Njoroge Kagwe
Project Manager
C.P.K. Diocese of Eldoret
CBD/Family Planning Project
P.O. Box 3404
Eldoret, Kenya
Tel. no.: (254-321)62469
Fax no.: (254-321)62472

Mary C. Ndethiu
Assistant Programme Officer
Family Planning Association of Kenya
P.O. Box 768
Meru, Kenya
Tel. no.: (254-164) 20280

Dollina Awuor Odera
Project Coordinator
Centres for Disease Control-Kenya
Medical Research Institute
(CDC/KEMRI)
P.O. Box 1454 or 1578 Kisumu, Kenya
Tel. no.: (254-35) 22902
Fax no.: (254-35) 22981
Email: kisian.cgnet.com

Sam Ogwalo
Chairman, USACA
c/o Dean of Students
University of Nairobi
P.O. Box 30197
Nairobi, Kenya
Tel. no.: (254-2) 334244

Anne Elizabeth A. Owiti
Director
Kibera Community Self-Help
Programme-Kenya
P.O. Box 49531
Nairobi, Kenya
Tel. no.: (254-2) 5 71081

Jason K. Ole Parantai
Programme Coordinator
Maasai Aids Awareness Programme
P.O. Box 510
Kajiado, Kenya
Tel. nos.: (254-2) 221713/332444

Nakhisa Sellah
Agricultural Health Services Director
Christian Health Association of Kenya
P.O. Box 30690
Nairobi, Kenya
Tel. nos.: (254-2)441920/445160
Fax no.: (254-2) 440306

Moses Sika
Program Director
Lutheran World Relief
East and Southern Africa Region
P.O. Box 66220
Nairobi, Kenya
Tel. nos.: (254-2) 447611/441643
Fax no.: (254-2) 445866
Email: lwr-earo@africa online.co.ke

Lilian Tendo Wambua
Coordinator
Adolescent Reproductive Health Project
African Medical and Research
Foundation (AMREF)
P.O. Box 30125
Nairobi, Kenya
Tel. nos.: (254-2) 602187/501301
Fax no.: (254-2)506112

Wakube A. Wataka
Project Director
Health Centre Project
Egerton University
P.O. Box 536
Njoro, Kenya
Tel. nos.: (254-37) 61040
Fax no.: (254-37)61442

Malawi

Inget Kaponya
Assistant Development Officer
Evangelical Lutheran Development
Programme
Evangelical Lutheran Church-Malawi
P.O. Box 650
Lilongwe, Malawi
Tel. no.: (265)632297
Fax no.:(265) 6323870

Philippines

Charito F. Alcoreza
Program Officer
Philippine HIV/AIDS NGO Support
Program (PHANSuP)
2nd Floor, Brickville Building
#28 N. Domingo Street
New Manila, Quezon City
Philippines 1112
Tel. no.: (63-2) 4154381
Fax no.: (63-2) 4154381

Estrella P. Gonzaga
Health Specialist
Community Health, Reproductive
Health and Nutrition (CHRHN)
International Institute of
Rural Reconstruction (IIRR)
Y.C. James Yen Center
Silang 4118, Cavite
Philippines
Tel. nos.: (63-2) 4142417 to 19
Fax no.: (63-2) 4142420

Phoebe V. Maata
Associate Health Specialist
Community Health, Reproductive
Health and Nutrition (CHRHN)
International Institute of
Rural Reconstruction (IIRR)
Y.C. James Yen Center
Silang 4118, Cavite
Philippines
Tel. nos.: (63-2) 4142417 to 19
Fax no.: (63-2) 4142420

South Africa

Kate Stratten
IEC Officer
Planned Parenthood Association of
South Africa (PPASA)
P.O. Box 1008
Melville 2109, Johannesburg
South Africa
Tel. no.: (27-11)4824601
Fax no.: (27-11)4824602
Email: ppasa@wn.apc.org

Tanzania

Edna Matasha
Project Manager
Adolescent Sexual and
Reproductive Health
African Medical and
Research Foundation
P.O. Box 1482
Mwanza, Tanzania
Tel. no.: (255-68) 500220
Fax no.: (255-68) 500742
Email: amref@tan.2healthnet.org

Thailand

Tussnai Kantayaporn
Associate Program Officer
Program for Appropriate Technology in Health
37 Petchburi 15
Petchburi Road
Bangkok 10400, Thailand
Tel. nos.: (66-2) 6537563 to 5
Fax no.: (66-2) 6537568
Email: pathbkk@mozart.inet.co.th

Uganda

Elizabeth K. Bamutire
IECI Programme Officer
Family Planning Association of Uganda
Plot 2, Kabego Road, Kamyoka
P.O. Box 10746
Kampala, Uganda
Tel. no.: (256-41)540658
Fax no.:(256-41) 54065 7

Anne B. Gamurorwa
IEC Coordinator
USAID/DISH Project
Plot 20, Kawalya Kaggwa Close
P.O. Box 3495
Kampala, Uganda
Tel. nos.: (256-41) 344075/235613
235614
Fax no-: (256-41)250124

Jennifer Sengendo
IEC Coordinator
Delivery of Improved Services for
Health (DISH)
Plot 20, Kawalya Kaggwa
P.O. Box 3495
Kampala, Uganda
Tel. nos.: (256-41) 344075/235613/
235614
Fax no.: (256-41)250124

United States of America

Jane K. Boorstein
Trustee
International Institute of
Rural Reconstruction (IIRR)
535 Park Avenue
New York, NY 10021
U.S.A.
Tel. no.: (1-212) 7516265
Fax no.: (1-212) 7553755
Email: jkb535@aol.com

Welcome statement

Ato Teka Feyera
Executive Director
Family Guidance Association of Ethiopia

On behalf of the conference organizing committee and on my own behalf, I have the privilege and honor to welcome you all to this important conference on Reproductive Health and Communication at the Grassroots: Experiences from Africa and Asia organized jointly by the Family Guidance Association of Ethiopia and the International Institute of Rural Reconstruction. May I specially welcome Dr. Adem Ibrahim, Minister of Health of the Government of the Federal Democratic Republic of Ethiopia who has taken a day off from his busy schedule to be amongst us to officially open this conference. I also extend a warm welcome to colleagues from Africa and Asia and the representatives of various government institutions and the NGO community in Ethiopia.

This conference has come at a time when Ethiopia is in the midst of implementing policies and programs that have a direct and indirect relation to the theme that this conference will be deliberating upon. And these policies and programs are, among others, the National Health, Population, Women and Education Policies and Programs which are aimed at raising the level of welfare and quality of life of the population. Hence, both the theme and the timing of the conference are pertinent and timely as reproductive health and family planning services are increasingly being viewed and implemented as integral components of sustainable development interventions. And in this connection, it is gratifying to note that the Family Guidance Association of Ethiopia is very happy in associating itself with its long-time partner, the International Institute of Rural Reconstruction, in jointly organizing this important conference.

A word or two about the Family Guidance Association of Ethiopia would explain better the reasons for our happiness for co-organizing this conference with the International Institute of Rural Reconstruction.

Since its establishment in 1966, the Association has played a pioneering role in the introduction and promotion of family planning services in the country. It, however, had been operating in the past in the midst of oppositions to its programs and activities from pro naturalist regimes and traditionalists. Thanks to the efforts of its dedicated volunteers and staff, the association has braved oppositions and had made valuable contributions in promoting family planning programs through persistent and appropriate information, education and communication programs as well as training of personnel in family planning. It has also played an important role in the introduction of various contraceptive methods an in their distribution in government and non-government health institutions. Furthermore, in the years when it was operating without any policy guidelines from the government, it had advocated in various ways and different occasions about the need for a population policy in the country.

Now that the National Health as well as Population Policies are in place and an enabling environment has been created, the Association is expanding its family planning and reproductive health programs to reach the hitherto unreached sections and segments of the population.

Presently, the Association has seven branch associations and offices, 10 clinics, over 40 outreach sites and over 200 Community-Based Distribution outlets throughout the country.

Hence, although we believe that we have a lot of accumulated experience in our three decades of operation in the area of family planning and reproductive health, which we will be happy to share with you, we also feel that there is yet a lot to learn from the experiences of our African and Asian colleagues. And it is this opportunity that we would also like to seize and take advantage of in co-organizing and participating in this conference.

Finally, I extend once again my warm welcome to all of you who have made it to this conference and wish you all the best in your deliberations and a pleasant stay here in Addis Ababa.

Conference theme

Isaac Bekalo
Regional Director for Africa
International Institute of Rural Reconstruction

My task this morning is to answer two sets of questions, namely the why and the what of this conference. In other words, the rationale and objectives and expected outcomes.

Why reproductive health and communication

The concept of Reproductive Health is a holistic concept. It is "a state of physical, mental and social well-being..." in all matters relating to Reproductive system, function and processes. It embraces the rights of both sex-male and female-to make reproductive health decisions free from any forms of discrimination, coersion and violence whose ultimately aim is improved quality of life.

Reproductive Health is an integral component of development interventions, aimed at improving environment protection, unemployment, malnutrition and ultimately, alleviating poverty.

The expected outputs

The conference participants will:

· Gain valuable cross-cultural insight into dynamics of Reproductive Health and Communication models.

· Have better understanding of critical factors deterring impact and effectiveness of communication approaches in different settings.

· Propose action plan for future consolidation and wider dissemination of selected strategies.

· Produce a resource manual for popular distribution.

Why in Ethiopia?

· A country in Africa with the third largest population size.

· It is a country that has been isolated by a totalitarian rule for almost two decades and denied the right to learn and share.

· A country that is in the midst of implementing a comprehensive Population Policy.

In summary, this conference aims to:

· Promote South-South sharing of experiences.

· Document and analyze experiences of different grassroots communication strategies.

· Critically assess the effectiveness of the different approaches and identify successful strategies and areas for improvement.

· Explore ways of further consolidation and wider dissemination of experiences.

· Produce a resource manual.

Finally, I like to thank

His excellency for giving importance to this conference; to FGAE management/staff for being our host and compatible partner.

Thanks also to our sponsor; Lutheran World Relief (LWR), DGIS (Dutch Government), DANIDA (Royal Danish Ministry of Foreign Affairs) and Christian AID for funding this conference.

Opening remarks

Dr. Neguissie Tefera
Head, Population Office
Federal Democratic Republic of Ethiopia

It gives me a great honor to speak to you on this important experience-sharing conference on Reproductive Health and Communication at the Grassroots: Experiences from Africa and Asia. Before I go further, I would like to express my heartfelt appreciation both to the Family Guidance Association of Ethiopia and the International Institute of Rural Reconstruction for organizing this important and very timely conference which. I sincerely believe, would be instrumental in giving us additional insights and vision to explore and develop practical and sound strategies in Reproductive Health and Communication

This conference is an opportunity for us to share some of the highlights of Ethiopian experience on the status of Reproductive Health and Communication strategy used to reach different target audiences.

During the last four decades, Ethiopia has registered one of the highest population growth rates in the world, due to very high levels of fertility which were only partially offset by high levels of mortality. Today, it is estimated that the annual rate of growth of the population is 3% per annum. This rapid population growth contributed to food insecurity, slow economic development and environmental degradation, among other problems. But, at that time, there were significant barriers to implementing the needed large-scale population program. Previous governments chose to overlook the linkage between rapid population growth and the economic and social problems of the country.

The reproductive health and family planning needs of the country, however, were enormous. In 1990, the total fertility rate was over seven children per woman; infant mortality was 140 per 1,000 live births and maternal mortality was perhaps 1,400 women dying per 100,000 live births. Rapid population growth was placing great demands on natural resources and the economy. Migration and urbanization, sexually-transmitted diseases and HIV/AIDS and adolescent reproductive health problems were emerging issues of concern. The health infrastructure, shattered by war and neglect, reached less than half of the population.

The change in government which took place in 1991 also changed the climate and context in which health and population issues are viewed. The new economic policy recognized the formulation and implementation of a population policy as an integral part of macro-economic planning, and as necessary to ensure a balance between rates of population and economic growth. In April 1993, the first National Population Policy was announced by the Government. These are linked together in the overall goal of improving the lives of children, women and men in Ethiopia within the context of the new political climate.

The objective of the Population Policy is to maximize the welfare of the country by:

· harmonizing its rate of population growth with its resource capacity; and by
· improving the health of individuals, families and communities.

Specific objectives of these policies include:

· reducing the total fertility rate;
· increasing the contraceptive prevalence rate; and
· reducing maternal, infant and child morbidity and mortality rates.

To assist the implementation of the objectives of the National Population Policy in general and reproductive health in particular, one of the major areas of population program activities which is given priority attention is information, education and communication.

As you are well aware, today, there is a growing realization in the internal community that a major shortcoming of any development efforts of the past three decades has been the absence of close communication between all those policymakers, professional planners and the population experts involved in development programs.

Experience has shown that a well-designed and well-managed communication activities can contribute significantly to creating awareness and interest, increasing knowledge and understanding and changing attitudes and even behavior within a reasonable period of time.

The advancement of modern communication media and its great impact to our society has led to predictions that the mass media will completely reshape day-to-day life in the future.

It is becoming increasingly clear that socio-economic development, including reproductive health programs, require an effective communication system. A comprehensive and coherent policy of socio-economic development should, therefore, make provision for the development of communication strategy and set the means whereby communication can contribute to efforts to achieve the aims and objectives of overall development.

Today, in most developing countries, the mass media, group media and interpersonal communication are considered the most powerful channels used to educate, inform and encourage the people to build a nation in which spiritual richness and material comfort can exist in equilibrium. Therefore, a major criterion by which the general public evaluates any communication output is the extent of its influence on society, or, in other words, its educational value.

The success and effective implementation of any kind of development program, whether in population, health or agriculture, requires information and communication support. Today, the importance of using effective information and communication as an integral part of national development in general and reproductive health in particular is beginning to take root in most developing countries, including Ethiopia.

To achieve the objectives of the National Population Policy and to mobilize public understanding and support at all levels among community and religious leaders, professionals, social organizations and the individuals at the grassroots level, it is then becoming crucial to develop effective communication strategy. The major goal of population communication activity is to enable learners to acquire the knowledge, skills attitudes and values necessary to make informed decisions about population events and issues which affect the present and future quality of life for themselves, their families, communities, societies and nationals. People need to be convinced, know how it works and how it will benefit them.

In our situation, in order to effectively reach various target audiences through communication activities, the National Population Policy envisages a structure whereby relevant program implementation partners at all levels (central/regional) play a role in implementing the population IEC under the coordination of the National Office of Population.

Members of implementing partners at the central level include the Ministry of Health, Ministry of Education, Ministry of Information and Culture, Ministry of Labor and Social Affairs, Ministry of Agriculture and Women's Affairs Sectors. Moving down from the central level, there are regional and zonal offices of population and various sectoral bureaus which facilitate the implementation of IEC and advocacy activities.

The population IEC and advocacy objectives and activities focus on increasing knowledge, understanding and commitment by policymakers, community leaders, families, couples, interest groups at all levels through planned advocacy and POP/IEC;

· changing attitudes, beliefs, values, behavior or norms about population issues;
· increasing knowledge of men and women of reproductive age on family planning methods and their intention to practice family planning through specific information and education.

To meet the above-mentioned objectives, some of the activities found to be essential were: a wider and more systematic use of multi-media channels to facilitate the use of POP/IEC and advocacy in expediting attitudinal change related to family size and reproductive health.

The dissemination of population-related information through community organizations, interest groups, NGOs, adult education classes, agricultural extension workers, community level development practitioners and other work establishments has been fruitful.

The incorporation of population and family life education topics as integral parts of formal education curricula at all levels of learning (elementary, secondary, college) and strengthening the capacity of program implementing partners through POP/IEC training and technical support are necessary to produce and disseminate IEC and advocacy programs to target audiences.

The mass media has been engaged in disseminating population information and population messages and materials have been incorporated into the national and regional print, radio and television distribution and broadcasting systems. Population IEC messages have also been disseminated to a large segment of the population through drama groups, musical and song groups in support of the reproductive health family planning interventions in the country.

Population and family life education has been initiated in about 17 high schools on pilot basis which is now completed. Population and family life education will continue at full swing in all high schools starting next year. Related to this is the effort made by mass media education to produce and broadcast target specific - population family life education programs regularly. The higher education main department in the Ministry of Education has also been able to integrate population and family life education into the curricula of higher schools of learning namely Agricultural and Teacher Training Colleges.

The results that have been obtained in reproductive health communication in general is indeed encouraging. Unlike the days of the past, population issues are being discussed in the offices, schools and in the streets in our country. Surprisingly, enough community-based distribution workers have now started distribution of contraceptives in church compounds, a phenomenon which nationals and non-nationals could not think about only three years ago.

All efforts are being made to involve non-government organizations in the implementation process. NGOs are represented in the national and regional population councils. The National Population Policy has clearly put the role NGOs can play in the implementation of the policy.

It is the combined effort of government and non-government organizations, including UN agencies, that had been responsible for increasing demand of family planning services.

For more concrete and elaborate action with regard to sensitization and awareness creation, it is planned to develop comprehensive IEC strategy. To be used as input in the IEC strategy development, researches on capacity building have been undertaken and are now in the final stage of IEC strategy development. We do understand that IEC strategy development takes a long time as observed from the experiences of other countries and yet concerted efforts were made to formulate a comprehensive IEC strategy in a relatively shorter period of time.

In conclusion, I would like to express my sincere belief that this experience sharing forum is a step forward in gathering real and fresh insight into issues of reproductive health and communication programs. The next challenge would be to translate your field-based findings, discussions and recommendations into strategies and practical program activities. I would also like to express my heartfelt gratitude to those resource persons who have made great efforts to share with us their rich experience and knowledge in the area of their expertise.

I wish all of you tremendous success in your discussion.

Thank you.

Opening address

Dr. Adem Ibrahim
Minister of Health
Federal Democratic Republic of Ethiopia

It gives me a great pleasure to open this important Conference on Reproductive Health and Communication at the Grassroots: African and Asian Experiences.

Reproductive Health has been recognised by countries and governments all over the world as one of the essential elements of human welfare and development since over 180 countries endorsed this new vision at the International Conference on Population and Development (ICPD) held in Cairo in September 1994. At that Conference, Reproductive Health has been defined as "a state of complete physical, mental and social well-being and not merely the absence of diseases or infirmity in all matters relating to the reproductive system and to its function and processes''.

This definition recognizes the capability of people to reproduce and the freedom to decide if, when and how often to do so. It also recognizes the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice for regulation of fertility which are not against the law, and the right of access to health care services that will enable women to go safely through pregnancy and child birth. In short, focus on reproductive health will enable countries to address both health and population issues with an emphasis on women's health needs.

It has been clearly demonstrated at the ICPD that widespread poverty and social and gender inequalities have significant influences on, and are, in turn, influenced by demographic factors such as population growth, structure and distribution. This means that the solutions to reproductive health and population problems cannot be concerned outside of the overall development framework. They have to be integrated with a sustainable development strategy aimed at eradicating poverty, promoting social justice and improving the quality of life of the people.

Here in Ethiopia, we have realized the need for an integrated and sustainable development and have taken the necessary steps towards its achievement. The government of the Federal Democratic Republic of Ethiopia has adopted population, health and other social and economic policies and programmes with the hope of ensuring integrated and sustainable development.

The goal of our Population Policy is the harmonization of the rate of the population growth and the capacity of the country for the development and rational utilization of natural resources so that the level of the welfare of the population is maximized over time. Our health policy emphasizes disease prevention and health promotion within a decentralized and equitably-distributed health service structure. Our five-year rural-based development programme aims at improving the standard of living of our people through the achievement of food self sufficiency, expanding educational opportunities and increasing the health service coverage.

Policy initiatives, plans and programmes are not ends in themselves. What matters most in the successful translation of these plans and programmes into concrete and tangible outcome that manifests itself through positive changes in people's lives. No plan, however impressive it may look on paper, will bring the desired changes unless the people at the grassroots level are involved in its design and implementation. Meaningful grassroots involvement can be only achieved if we are able to identify and employ effective and appropriate communication strategies that are sensitive to the indigenous culture and have relevance to people's life experience.

For these reasons, I consider the theme of this conference which is "Reproductive Health and Communication at the Grassroots" extremely relevant and timely. Your effort to document, analyze and share experiences of successful communication strategies in reproductive health from Asia and Africa is highly commendable. I am quite sure that the developing nations of these two great continents have valuable experiences in reproductive health and communication strategies which they could share for the benefit of their people. I believe that this conference will provide an appropriate forum for sharing such experiences. I also believe that international organizations should work hand in hand with local governments and indigenous NGOs in promoting reproductive health and sustainable development.

Finally, I would like express my appreciation to the organizers of this Conference, namely, the International Institute of Rural Reconstruction and the Family Guidance Association of Ethiopia for choosing an appropriate and timely theme for the Conference as well as for their great effort in arranging the conference to take place here in Addis Ababa. I would also like to wish the participants who have come from Asia and Africa that your stay in Addis Ababa will be enjoyable. I wish you all success in your deliberations.

I now declare that the Conference is officially opened.

Thank you.

Technical briefing. The why, what and how of the conference on reproductive health and communication at the grassroots

Estrella P. Gonzaga
Associate Senior Health Specialist
International Institute of Rural Reconstruction

Why (Transparency 1)

This conference is primarily designed to provide opportunity for REFLECTION. Practitioners from different background and people of different economic, political and social heritage are gathered here. We are here to look at the first stage - that of ACTION. We will be travelling a common road, gathering insights and lessons along the way, hopefully leading to better ACTION when we leave this conference. ACT REFLECT-ACT is the LIFEWORK cycle of field practitioners. Friere's framework provides us the context for the process to be adopted at the conference.


Transparency 1

What (Transparency 2)

We will examine the successes and pitfalls and opportunities for replicability related to reproductive health and communications at the grassroots.

Transparency 2

What

Reproductive health and communications

Examine the

· successes and pitfalls
· replicability

More specifically, after this SOUTH- SOUTH exchange, the two sponsoring organizations - Family Guidance Association of Ethiopia and the International Institute of Rural Reconstruction - expect that the conference participants will be "not better technicians but re-oriented personalities with new values, new outlooks, new loyalties, equipped with new practical techniques for effective work with villagers". " When we return to our own countries, we must be capable of generating a new movement that will become a real force in the evolution and shaping of our own rural and urban Societies. " (Transparency 3)

Transparency 3

After the south-south exchange, FGAE and IIRR view:

Not better technician

BUT Re-oriented personalities with:


· new values


· new outlooks


· new loyalties


· new practical techniques


for effective work with villagers

When we return to our own countries, we must be capable of generating a new movement that will become a real force in the evolution and shaping of our own rural/urban societies

HOW (Transparency 4)

"History is the mirror of the future ", an often quoted Chinese adage by IIRR's founder, Dr. Y. C. James Yen, captures the spirit of the reflection - the "HOW" of this conference. The difficulty of field practitioners in documenting the lessons and insights in a form that is easily passed on is widely recognized. Available literature may not adequately reflect the current state of reproductive health work and communications as these are in the "brain mine" of the field practitioners themselves. The structure of this conference will address this concern. For the next five days, the grassroots - or a better term since we do not eat grass - the millet, maize, teff and rice roots will speak. The sharing of lifework of participants will go through a "distillation" in the form of case studies, round table sessions and plenary sessions and finally a "codification" into a resource book . An abstraction guide has been developed following the conference framework.

How


Millet/maize/teff and rice roots speak

Sharing

·Case studies

·Abstraction guide

·Round table sessions

Þ Resource book

·Plenary sessions


Distillation

Codification

"Distillation" involves the systematic study and analysis of experiences. This entails critical search and examination, discernment of shortcomings and ways of infusing greater vitality into programs. (IIRR BLUE BOOK) (Transparency 5)

Transparency 5

How


Distillation
Systematically studied and analyzed experiencies


· critical search and examination
· discern its shortcomings
· discern ways and means of infusing greater vitality into program

The spirit of distillation is to listen and speak from the heart. To listen from the heart means "to have an open mind, neither closed nor empty" and "have the humility to learn and to unlearn." (Transparency 6)

Transparency 6

Spirit of distillation
(Listen and speak from the heart

· Listen
· Open mind

Humility to unlearn


To speak from the heart means three considerations: 1) to "sift the chaff from the grain, keep the grain and with a breath of kindness, blow the chaff away" ; 2) "not to point an accusing finger, for the thumb points to a factor that only God knows, the pointing finger relates to the accused, but the three remaining fingers point to the accuser (factors that we ourselves have contributed to the situation) - (Y. C. James Yen); and 3) imagery of our two hands - the fingers representing our strengths and the webs our weaknesses. Distillation should be based on our strengths. When we produce a "CLAP", both hands can not firmly grasp anything in between . But it is not the SOUND that we are after but the "SPACE", the strengths of one field experience to meet the weaknesses of another. Have the fingers intertwined for a 'CLASP" to produce a hollow in our hand for a "SPACE" to hold our learnings in this conference. (Transparency 7)

Transparency 7

Spirit of distillation
(Listen and speack from the heart)



· SIFT chaff from grain

- Keep the grain
- Breath of kindness, blow the chaff


· NOT an accusing finger


only God knows

1


related to acused

1



related to acuser

3


·Not sound (clap)

But

space (clasp)

In any learning encounter, there is exchange of TALENT, TREASURE and TIME. Of these three, TIME is the only non renewable resource. For our presentors and participants, let us be good stewards of time, if not, others will lose the opportunity to share. (Transparency 8)

Transparency 8

Presentors - Participants

Good stewards


Not a renewable resource

"Codification" is to document lessons and insights based on actual field-based experiences. It produces "unpedantic literature of intellectual quality and practical value" " Too often, lessons of successes as well as failures are lost. (Transparency 9)

Transparency 9

How

Codification
Codifying actual experiencies (field-based).


· unpedantic literature of intellectual quality and practical value
· too often: lessons of successes as well as failures are lost

For Whom - for What (Transparency 10)

We are here to seek ways to change the existing bitter conditions of our people who have lost their dignity and have become beasts of burden. We recognize that they have their inherent strength and potentials that we then build on for them to decide and take action. From beasts of burden, they, the people, regain their dignity and become masters of their destiny. It is expected that the resource book which will be the final output of this conference will be of use to field practitioners. The authorship will belong to the conference participants, with the Family Guidance Association of Ethiopia and the International Institute of Rural Reconstruction as the secretariat. There is no copyright to the book, however the FGAE and IIRR would appreciate acknowledgement in any use of the material and would appreciate feedback on strengths and weaknesses, usefulness and unintended consequences. This will further enhance the knowledge base generated by this conference.

Transparency 10

For whom- for what
· Bitter conditions Ü Change Þ People
· Strenght (potential) Ü Build Þ Masters of their destiny

Ý

People
Field practioners' use
___________________________________
Authorship: Conference participants
Secretariat: FGAE


IIRR

Copyright: None

This conference is a collective learning opportunity for field experts. Similarities and differences across cultures are distilled, in search of the " Soul of the Race". For, as the IIRR founder, Dr. Y. C. James Yen would fondly remind us, we are "Under heaven - one family". (Transparency 11)

Transparency 11

Collective learning

(Field experts)

Across cultures:

Similarities


Differences

In search of the "Soul of the Race"


Communicating messages on HIV-AIDS to rural groups

Experiences of the MYRADA-PLAN AIDS Community Awareness Project

Smita Ramanathan and Vidya Ramachandran

"Why are you talking about AIDS when we have so many other problems?"

This was an oft-heard query when the MYRIAD-PLAN AIDS Community Awareness Project (AIDSCAP) was launched. The project hoped to create awareness on the prevention and control of human immunodeficiency virus/acquired immune deficiency syndrome (HIV-AIDS) transmission and other sexually-transmitted diseases (STDs) in the rural areas of Belgaum district in the southern Indian State of Karnataka. Indeed, in rural India, with its diverse problems, AIDS might seem a distant concern. But the fact remains that HIV is spreading rapidly throughout the country and no community, rich or poor, rural or urban, can consider itself immune. Conveying the message of disease prevention is therefore an important task.


Figure


Figure

In July 1994, MYRADA, a voluntary organization working in the field of rural development, launched the MYRADA-PLAN AIDSCAP Project in partnership with PLAN International, an international support organization. Based in Gokak, Belgaum District of Karnataka State, India, the project targeted approximately one million beneficiaries in 492 villages of four administrative subdivisions (talukas): Gokak, Chikkodi, Hukkeri and Raibag during its first phase of operation (July 1994 to August 1996).

Community where project was implemented

Majority of the people in the community have received no formal education. Most of them depend on agriculture for their livelihood. Cotton and sugarcane are among the major crops grown that draw migrant labor. A busy intercity highway that connects two major Indian metropolises passes through the area which also has a history of the "devadasi" system. The devadasis are young girls dedicated to the service of gods. The element of sexual services to the king who is often considered as "God on earth" formed a part to the tradition. However, this tradition gradually deteriorated into a community-sanctioned way for poor families to let their young girls enter the sex trade.

Reproductive health concept introduced

For this project on AIDS awareness, there was no particular sector of the population targeted as this would only further isolate sex workers who were already marginalized. A baseline survey conducted to assess levels of awareness about AIDS and STDs revealed that less than 30% of the population had ever heard of AIDS. Fewer persons were aware of the methods of transmission and prevention. Several misconceptions about the disease existed in the minds of most people. Accordingly, the project set for itself the following goals:

· Creating awareness in the 15-49 age group about the modes of transmission and methods of prevention of HIV and STDs.

· Upgrading the skills of medical practitioners in the syndromic approach to STD management and encouraging people to seek timely treatment for STDs.

· Promoting condom use through education and social marketing.

· Training healthcare providers and other community workers to respond with sensitivity and understanding to concerns regarding HIV-AIDS and guiding them to seek professional assistance from appropriate sources when required.

In dealing with a largely non-literate and rural-based population, the project staff had to be imaginative, creative and skilled to improve, innovate and ensure that:

· the media chosen for information dissemination had maximum reach; and

· the messages were communicated in ways that would have maximum impact on the probability of their assimilation and retention by the local communities.

Communication media used

A multi-media approach was adopted, the key components of which were:

· wall paintings;
· street theater;
· folk music performances;
· information rallies;
· combination of media events during fairs and other village functions; video shows;
· widespread dissemination of published materials such as calendars, posters, handbills, information booklets and pamphlets;
· training of peer educators who could function as local resource persons and could continue after the completion of the project period;
· establishment of community AIDS information centers managed by village youth; and
· high school and college-based HIV-AIDS education program.


Figure

None of the chosen media forms were new to the program. What made the MYRADA-PLAN Program unique were:

· targeted exclusively at rural audiences;
· used in quick and appropriate combinations;
· intensity with which the awareness programs were carried out;
· size and stratified nature of the population were targeted;
· enthusiastic support sought from and given by the government and other local institutions; and · overwhelming response from the rural people (who were allowed to talk freely about "personal" matters.

Two media approaches are highlighted in this paper. The street theater and the peer educators' program were chosen not only because they were named by the people as having the maximum influence on the process of information dissemination but also because they made use of locally- available resources and skills that can be easily adapted for use in a variety of situations by almost any country in the world.

Street theater

Theater is a popular and immensely versatile medium of communication that can both entertain and educate. When taken to the streets, it can be a powerful means of communication as it carries the message almost to the people's doorstep. It is an informal means of communication and reaches out to a large number of people.

The project used this medium in the following manner:

First, a search was initiated for local young men and women who would be willing to perform in the villages on a regular basis. The project ended with two teams, one with 15 men and the other with 13 women. For cultural reasons, the men and women were not mixed but kept as two separate teams.

The teams were trained and given assistance in drafting appropriate scripts. Theater professionals were hired to provide this input. The scripts addressed HIV-AIDS problems and also other issues like alcoholism, literacy, the devadasi system, and the like. Jokes, parodies and songs were also used with no demeaning reference to "prostitutes" or "devadasis". The focus was to "care for your own health" and not on moralizing the issue.

For a while, inhibitions prevailed on how to talk about sex or demonstrate condom use and other "sensitive" issues. But it was discovered that the public was more open and receptive than expected: fairly explicit dramatizations were received with laughter and acceptance.

When the teams and scripts were ready, the logistics and field work processes were worked out. Because the project was implemented in four talukas (administrative subdivisions), each team was assigned two talukas to be toured intensively for one year. A vehicle was hired for each team for the entire period. Schedules of performances for each were drawn up once in two weeks and given to each teams. The teams would then leave to make the rounds while the vehicles were installed with loudspeakers. The team would begin by making an announcement of the program and the venue for the play, which would generally be in the evenings in the public open spaces. In larger villages, more than one performance would be held in different locations.

On an average, each team would perform two to three times per day. At three performances per day for 21 days in a month, the two teams conducted 126 performances per month. For 18 months, most of the villages were visited more than once, usually for repeat performances to reinforce the message.

The teams received a monthly honoraria. And street theater became a regular source of employment to the team members for the next 18 months of the project. Because the team members could not return home each night, the project sought the cooperation of the local village leaders in the Panchayath (village governing body) and the local government authorities which provided team members with a place to stay. Utensils were provided to each team by the project and the members cooked their own meals.

The sequencing of events in each village was another issue. The project followed the typical street theater format: the loudspeaker announcements, followed by songs, dances and jokes to attract the audience. Then, the actual play was performed and theater team members distributed handbills and pamphlets. The question-and-answer session with the audience was also encouraged. The actors would also demonstrate condom use in the course of the play.


A street conducted in one of the villages

Sometimes, on-the-spot modifications would be made which would then be discussed by both teams with the project staff. In one area with a large population of sex workers, the play initially showed two men visiting a brothel and eventually getting AIDS. The women said, "So you think we are responsible for spreading AIDS?" Because this was not the intended message, the scene was later re-drafted.

Because the project staff were not with the theater team most of the time, a monitoring register was collectively designed and handed over to the teams to maintain. This included a record of each performance to be stamped and signed by a Panchayath before the team leaves the village.

The street play proved to have the maximum reach in terms of numbers. For 18 months, the teams performed 2,254 times which were watched by over 1.1 million people. In an evaluation, 68% of the respondents cited the street play as their main source of information on HIV-AIDS and were also effective in targeting women. It was interesting to note that when a play was performed in a village for the first time, the men gathered around while the women watched from the fringes or from within their homes. But when the village was revisited for a second performance, women came out to watch.

Peer educators' training

The project targeted to train 1,000 peer educators who would also educate others in their villages. This was necessary to create a cadre of workers who could continue to communicate HIV-AIDS awareness messages beyond the project.

Most peer educators trained by the project were members of the youth and women's groups. To organize training sessions, project staff approached leaders of these groups or village elders to mobilize people. Training sessions were usually held at the village for the convenience of the trainees. In some cases, trainings were conducted in one village for participants from three or four surrounding villages. In such cases, trainees were paid travel fare. At all training sessions, trainees were provided food.

Initially, the project trained men and women in mixed groups. However, the women were shy and reluctant to participate. Thus, separate sessions were organized later. Contents of the sessions also underwent changes to suit trainee needs. Earlier sessions covered only AIDS and STDs but at such sessions many people would ask questions on pregnancy and menstruation. As a result, the content evolved to include the larger context of reproductive health that also provided a forum where people could voice their concerns on sex and sexuality. Condom demonstration was an integral part of every session.

Before, it was thought that all who underwent training would automatically become peer educators. At the planning stage, it was also assumed that one training program would be enough for the trainees to understand and assimilate the contents and communicate them to others. This was an incorrect assumption. Questions were asked which the project staff themselves would find difficult to answer, let alone a one-time trained peer educator. So the program was modified.

The staff met regularly each month for "Technical Update Meetings" at which new information was shared and community concerns were brought up. As mentioned, community concerns were not limited to HIV-AIDS but also on sex and sexuality and personally-experienced problems. While these were no longer part of the project, project staff had to address these concerns to move on to discussions on HIV-AIDS. Furthermore, the community perceived the project staff as "experts" and acceptance by the community depended to a large extent on how confidently they could address such concerns. So, "Questions from the Community" became a regular part of staff meetings.


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The peer educators themselves were identified after a series of trainings for identified community members. The first session lasted one whole day and then followed by two refresher training sessions at an interval of 15 - 30 days. Peer educators were selected from those who attended all the three sessions based on their level of interest. They were given a bag with a set of posters, stickers, booklets, etc. They were also given postcards to inform the project of any activity in their village and often they would conduct AIDS education program in these activities. The project made a conscious effort to train more women as peer educators.

An evaluation was conducted at the end of the first phase to determine the level of awareness of the different sectors: men and women with no formal education, college educated men and women, government staff and others. One category chosen for evaluation was the peer educators. The respondents were administered open-ended questionnaire that did not draw many correct responses. When administered with the multiple choice questionnaire, 100% of the peer educators interviewed gave all-correct responses on how HIV is transmitted while 95% gave correct responses on how HIV transmission could be prevented.

Expected behavioral results

The behavioral result that was expected from the above communication campaigns was an increased awareness about HIV/AIDS/STDs which would, in turn, lead to change in sexual behavior. The project specifically hoped to increase the demand for condoms and also encourage a health-care seeking behavior especially with regards to STDs.

Major findings

The communication media used in the project were both effective. However, it was not always possible to convey the entire message through street plays. People have short attention. This might result to incomplete messages going to some people if they do not watch the entire play. But in an evaluation of street plays it was discovered that different people notice different aspects of the play thus it was recommended that the scripts and dialogues be constantly revised to sustain audience interest. It was also necessary to evolve new strategies because repeated performances waned the interest of the audience and also the actors.

A major strength of the street play is that, it is informal and can thus reach out to a wide audience - both literate and illiterate.

In terms of peer educators' training, it was difficult to cover a large number of people through trainings as organizing and mobilizing people require considerable time and effort. It was important to maintain constant contact with the peer educators to monitor their work and to supply them with materials. In this project, however, this was not always possible because project areas were vast and the number of staff was limited.

The peer educators' training was part of the project's efforts to ensure sustainability. The project trained 5,463 women and 6,502 men. Of these, 832 were selected as peer educators. Like the street play, the training sessions were effective because they reached the non-literate. It scored over the street play, however, because people were trained and given thorough and complete information. It was also possible during these sessions to clear a lot of misconceptions about sex and sexuality in general and HIV/AIDS in particular.

Conclusions and recommendations

When the project was implemented, one of the major hurdles in communicating was the feeling of most people that AIDS was not their concern. Perhaps this feeling could never be completely erased. What is possible, however, is to sensitize people and make them aware. Awareness levels have certainly gone up as indicated by surveys at the end of the first phase. Surveys also indicated an increased demand for condoms.

Many people are now consulting the project with their problems that are considered "private". Persons with HIV/AIDS have also begun approaching the project. There is clearly a need to provide counselling and referral services to address the needs of persons with HIV/AIDS.

Now, in its second phase, the project is attempting to provide these services and ensure that they continue to be available even after the project ends.

Peer educators trained during the first phase have been motivated to set up resource centers in their villages that offer information and guidance to anyone in the village who seeks information. One hundred such community resource centers have been established in the last six months. Doctors in the area are trained to offer counselling and referral services to clients with HIV-AIDS or STDs. It is hoped that the task of communication will be taken on by the community itself once the project withdraws from the area.

Peer education for sustained HIV/AIDS awareness

Charito F. Alcoreza and Bernardo Mondragon

HIGALA Association, Inc., where this case was taken, is one of the Philippine HIV/AIDS NGO Support Program (PHANSuP)-supported non-government organization (NGO). It is based in Davao City, Philippines.

PHANSuP is a non-government linking organization that extends financial and technical assistance to NGOs, community-based organizations and people's organizations in developing and enhancing their respective HIV/AIDS and other reproductive health programs.

HIGALA's one-year project entitled Integrated Health Education Towards HIV/AIDS Prevention Among Students in Eight Public Schools of Davao City ends in June 1997. It targeted in-school youth of Davao City (13-16 years old).


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Community where project was implemented

Health organizations claim that many clients of hospitality women (commercial sex workers) are high school students. It has been revealed that pre-marital sex and homosexual activities prevail in most schools, including involvement in free sex locally called the bontog phenomenon.

In Davao, public school students come from low-income class who experience harsh conditions brought about by extreme poverty. They are confronted with problems and issues that are not adequately addressed by their parents nor mentors. Their need for belongingness and affection is never satisfied but instead, they experience violence in their own homes. These conditions lead many students to practice risky behaviors that expose them to greater vulnerability of contracting HIV/AIDS. They cope by turning to drugs and to their barkadas (peers) who pass on non-conforming values and provide wrong information.

In the Philippines, about 40% of recorded HIV Ab + from 1984 to February 1997 are within the 13 to 29 years age bracket. This shows that a significant portion of the population at high risk are the youth.

Reproductive health concept introduced

HIGALA's activities focused on sustained awareness on HIV/AIDS to prevent the spread of HIV disease among in-school students. The NGO emphasized on the sexual vulnerability of adolescents in contracting HIV/AIDS and on any kind of sexually-transmitted disease (STD).

Communication media used

The communication strategies of HIGALA were three-fold: training of peer educators, advocacy and information, education and communication (IEC) materials development. HIGALA's awareness program on HIV/AIDS was anchored at training peer educators and advocacy work to gain support from school administrators.


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These were also aimed to create a caring and loving school atmosphere for the students. Series of peer educators' trainings were conducted to provide pre-selected peer educators with knowledge and skill. Modules included principles and roles of peer educators, STD/HIV/ AIDS, sexuality, reproductive health, basic communication skills, global facts on youth, adolescent development and a practicum. At the end I of the trainings, the "peers" were expected to display proper attitudes of an educator.

The HIGALA experience demonstrated peer education in different forms. It was customized to give recognition to the individuality of the students and the schools. Approaches used were big and small group discussions (symposia, classroom lectures, informal small group discussions) and in other cases, one-to-one approach. These communication strategies provided the students with a venue to express themselves, ask questions and interact with each other.

To supplement these activities, IEC materials such as brochures, posters, bags, jingles and bookmarks were developed by the youth. Poster designs were selected through poster making contests while bags, bookmarks and brochures were designed participatorily and pre-tested by the youth themselves. These were developed scientifically and were audience-centered. A special session was even conducted on appropriateness. These IEC materials helped a lot in the continuous awareness-raising activities because of its motivational nature. Appreciation was high because the youth themselves were the developers of these materials. Through these communication strategies, the peers understood in simple terms the concepts that were introduced such as modes of HIV transmission, methods of prevention and most especially, their vulnerabilities.

They were also involved in the celebration of the World AIDS Day and International Candlelight Memorial. The students went on parade, had a program and engaged in activities that made the community aware of HIV/AIDS.

Expected behavioral results

The immediate result expected from the efforts is the increased level of awareness on STDs/HIV/AIDS. The risky sexual behaviors had been modified into practice of safer sex. There should be a delay of sexual relationships that put them into risky situations. The students should avoid activities that are directly or indirectly related to contracting the disease such as use of alcohol and drugs.

The long-term behavioral result expected was sustained behavior change and this was left to the individuals to do. Behavior change takes a long time and the process could even be painful on the individual. The peer can only provide support.

Major findings

Choice of peer education in this context was based on the fact that the barkada is a very strong peer power influence. The peer belongs to the same age group, understands the same language and spends more time with them where they exchange a lot of information and possibly misinformation. Hence, the peer was identified to be the best provider of correct information.

Through the use of various communication media, it was easier for the peer educators to convey their messages. The classroom lectures required the students to listen. The informal group discussions strengthened the peer relationships which became the natural monitor of the behavior of the peers. The symposia covered a mass of individuals at one given time.

Though it seems that the communication package is complete (approach, strategy, content, speaker, visuals), limitations were still inevitable either on the strategy itself or on the delivery of the message. During symposia, the audience was too big and there was less time for everybody to participate and sometimes no participation at all. Symposia did not assure quality of learning. For peer educators, one-to-one communication was difficult, especially when the peers were substance users or had psychological and emotional problems. Establishing trust was not always easy and opening up regarding sexual relationship was a taboo. On the other hand, peer educators had helped in referring rare cases like incest relationships and sex orgies.

One difficulty that HIGALA experienced was the lack of support from the school administrators and teachers that affected the interest of the students to learn about HIV prevention. Among the eight public schools targeted, only four schools were supportive of the activity. This was the reason why other forms of communication strategies were used to fit to the school situation such as one-to-one and informal group discussions.

Conclusions and recommendations

Peer education should be customized. IEC materials must be developed for continuous awareness. And peer education could be further developed into peer counselling.

The peer educators may sell the IEC materials they had developed upon reproduction and use the income to reproduce other materials for cyclical selling. This income-generating activity would be double-edged such that constant visibility of these materials would help sustain HIV/AIDS awareness, keep the issue alive, and keep people reminded and active, and at the same time, raise money. HIGALA should bring along samples of IEC materials to conferences or exchanges.

Song analysis (of the jingles they composed) could be an interesting springboard for discussion.

Advocacy work with the school administration should be strengthened in a project like this. It would also be better if coordination with the Department of Education, Culture and Sports (DECS) is undertaken. At this point, HIGALA needs to innovate methods in handling sessions for small groups. Small group discussion is one of the most-highly recommended approaches in HIV/AIDS work especially with the youth who have so many stories to tell and questions to ask.

A drop-in center should be established to provide services like recreation, education counselling, consultation and referrals in a homely atmosphere to make the youth relaxed and comfortable. Other activities recommended are exchanges or exposure of peer educators, training for peer counselling, youth camp and organized youth groups such as clubs. The youth must participate from planning, implementation and evaluation. And parents must be educated, involved and be part in the action towards sustained HIV/AIDS awareness.


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HIGALA should get into the culture of the government institutions in the Philippines like the public schools to get support. Establishing linkage with higher authorities other than the school administrator (district or provincial superintendents) should be explored The aim is to seek for memorandum circulars including HIV/AIDS prevention in the high school curriculum or credits should be given to the students who attend special seminars on HIV/AIDS. The topic could also be integrated in the sex education module Moreover, HIGALA should work out for the official recognition of the peer educators in school to give them credits for their efforts.

The ultimate goal is to prevent the spread of HIV/AIDS. However, this could only be attained when individuals change risky behaviors and sustain it. This takes time. This is why awareness interventions must also be sustained to increase level of awareness from zero to low to high which will hopefully lead to behavior modification and sustained behavior change.

Peer education can only effect so much. Peer educators can only do so much. Micro and macro school and community systems must support the "peers" in order to have a synergistic approach to HIV/AIDS prevention.

Participatory method for community mobilization against HIV/AIDS

Dollina A. Odera

In 1993, villagers in 15 malaria study villages in Asembo Bay area of Siaya district (population of 22,000) asked the Centre for Disease Control and Prevention that coordinates the activities with Kenya Medical Research Institute (CDC/KEMRI) to provide access to Human Immunodeficiency Virus (HIV) - antibody testing. Motivation for this request was not immediately clear but subsequent meetings established that the needs of these villages in relation to HIV and AIDS went beyond a simple request for access to HIV testing. Recognizing important research possibilities, CDC/KEMRI decided to investigate further. Few successful models of rural counselling and testing in Africa existed at the time, but there was none in Kenya From the beginning, it was clear that there were important cultural considerations to be considered when selecting a methodology. Further more, studies by the Medical Research Center in Uganda showed difficulties in setting up rural access to HIV counselling and testing without the villagers themselves participating in decision-making and planning. A participatory methodology was therefore sought that would involve the villagers and which would be sensitive to their culture.


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The principal aim of the project was to develop and pilot a participatory methodology that would allow villagers to make informed decisions regarding access to HIV counselling and testing and to start a process of village mobilization. Starting initially with prevention, it was hoped that this process would eventually include support for those affected by AIDS (food security, resources for widows and orphans, etc.), if access to HIV counselling and testing was provided.

Reproductive health concepts introduced

· HIV/AIDS - Awareness creation, voluntary counselling and testing
· Behavioral change from risky cultural sex practices and exposure
· Safe sex practices - condom use and education on sexuality

Communication media used

A literature review of participatory methods was carried out and over 40 different projects in Kenya and Uganda were visited. Various non-government organizations (NGOs) spared time to help structure the new methodology and a three-day workshop was held at which trainers from different backgrounds were invited to discuss specific participatory tools and activities.

A field guide book was developed in the local language and provided for use by the project team, village leaders and project volunteers. Many participatory tools were also developed for community members to participate effectively. The tools included mapping; disease ranking; migration calendar; semi-structured homestead interviews; three pile attitude sort (explores perceptions on knowledge attitudes, beliefs and practices); Odindo's activity (cultural practices that promote sex); family story (HIV transmission); rocks and carts (HIV prevention); and ranking solutions. To single out, one of the tools used for mobilization was the Participatory Education Theatre (PET).

The PET was a group of nine young men and women who performed skits related to HIV/AIDS. The PET applied participatory techniques, allowing the audience to probe, reflect on and respond to issues of their concern. The primary concern was the development of conceptual thinking through an understanding of the interconnected nature of social problems. The PET approach grappled with the dialectical nature of human interaction, posing questions and problems, rather than supplying answers and solutions.

Expected behavioral results

The PET aimed to contribute towards change in the target communities' (the audience) perception of the world and themselves as individuals within it. By doing so, awareness was raised and the community was allowed to examine their attitudes towards unresolved dilemmas and contradictions in the skit that reflected their lives. It was not yet clear to what extent behavioral change could be effected through any short-term period. However, clues for change were generated through feedback from designed checklist on the entire activities of the project.


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Major findings

As the second year of the project is nearing completion, several preliminary conclusions can be drawn:

· There is high level of knowledge about HIV/AIDS in these rural communities; traditional beliefs about chira are increasingly challenged by the burden of HIV/ AIDS in this population.

· There is a high rate of HIV seropositivity (21% overall) among village residents who opt for HIV testing.

· A survey carried out on peer checklist and evaluation on the condom sales reveals that condoms are being used more, particularly by younger men.

· Confidentiality of HIV test results can be maintained in this setting. The project uses the coding system for clients rather than names. The community also bestows a lot of confidence on the counsellors whom they choose to be their confidant, a virtue that counsellors respect, too.

· Because it has become widely known that confidentiality can be maintained, HIV counseling and testing has become established in this rural area; decentralization of counseling activities from the AIC to home-based counseling has improved demands for these services.

· Participatory Rural Rapid Appraisal (PRRA) has wide acceptability as a method to assist villagers identify and analyze problems specific to them and to implement interventions based on this information. This has the potential to have a positive impact on control of the HIV epidemic in rural communities with limited resources.

· Village residents can be trained to conduct all major aspects of the project. There are plans to use some community members as trainers/facilitators on PRRA in new areas when it is requested.

· The PET is a very effective and well-accepted methodology to provide information about HIV/AIDS, to allow for open discussion of culturally-sensitive topics related to HIV transmission and persons living with HIV/AIDS.


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Conclusions and recommendations

The project has become well-known in this part of Siaya District and there have been several requests to expand these activities into a larger area. Although the project staff has developed expertise in a number of important areas related to HIV/AIDS prevention and community mobilization, expansion into a larger area will depend on local initiative and directives and is not likely to have similar acceptability if directed by persons outside the target communities. There is a need to provide similar prevention efforts to other communities. The project staff has committed themselves to providing training opportunities to others who would like to learn from their experiences in HIV/AIDS prevention. The participatory approach has proven to be the best with techniques being adaptable to any community.

There is a growing need to develop a program to provide training and support for families engaged in home-based care for persons with AIDS.

Inexpensive HIV rapid tests have the potential to augment efforts to develop sustainable and cost-effective HIV testing programs in rural communities.

HIV/AIDS Prevention. The safer sex campaign for the youth in Uganda

Anne B. Gamurorwa, Cheryl L. Lettenmaier and Nan Lewicky

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a serious problem in Uganda. According to sentinel site surveillance of antenatal clients, 10-15% of the population are HIV positive.


Figure


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The Safer Sex Campaign is implemented through the Delivery of Improved Services for Health (DISH) Project, a USAID-funded project that works in 10 districts in Uganda. It is a reproductive health project that aims to improve the quality of reproductive health services, behavior, knowledge and attitudes in the areas of family planning, HIV/AIDS and sexually-transmitted diseases (STDs) prevention and treatment and maternal and child health. The project has sub-projects on training for nurses, midwives, doctors and medical assistants; information, education and communication (IEC); logistics and management information systems; health finance; and community health workers. The IEC component of the project is implemented at the district level by the District Health Educators, with technical assistance from IEC coordinators based in Kampala. Technical support is provided by the Johns Hopkins University Center for Communication Programs.

In 1994, when DISH project started in Uganda, youths aged 15-19 years had the highest risk of becoming infected among the age groups. This prompted a review of research, focus groups and in-depth interviews with youth to determine some of the factors contributing to this. It was found out from the study that many youth did not believe that they could avoid infection. They held very fatalistic attitudes, even though they knew that abstinence and monogamy could prevent HIV infection.

Few young people accepted condoms as an effective or acceptable way of avoiding infection with HIV. Despite these attitudes, many of the young people admitted to being sexually-active. Most had more than one sexual partner and almost no one had ever discussed how to prevent HIV infection with their partners. Most young men experienced a lot of pressure from their peers and parents to prove their manhood early during adolescence. Many believed that abstinence could harm them physically and could affect their ability to perform sexually in the future.

Based on these findings, a group of health educators from 10 districts of Uganda met with DISH project communication staff and professionals from similar organizations in early 1996 to design a message and media strategy for youth on HIV prevention. The group decided to focus primarily on unmarried men 15-19 years old in 10 project districts and secondarily to their potential sexual partners, 12-19 years old unmarried women. These women reasoned that the men usually initiated sexual advances and that the men also had more control over condom use.

Reproductive health concept introduced

The objective of the campaign was to increase the number of people who practice safer sex - that is, to abstain from sex until marriage or to use condoms every time they have sex.

All campaign activities and materials carried a message of hope for young people, that they CAN avoid HIV infection by practicing safer sex. The main messages were:

· Resist peer pressure. Make your own decisions about how you will protect yourselves from HIV infection.

· Abstinence will not hurt you. Abstain from sex until you find one life-long partner who will remain faithful to you.

· Use condoms every time you have sex. Condoms are effective barriers to the HIV virus. They have been tested and approved for use by the Ministry of Health.

Communication media used

The campaign used a combination of mass media and local activities in some of the districts.

Mass media

Mass media included print materials, radio programs and spots, music contest (Hits for Hope) and quizzes. The DISH project contracted an advertising agency to produce posters, newsletters, radio jingles and spots, and a half-hour weekly radio program in English and the vernacular called Straight Talk. The weekly Straight Talk radio programs and the Straight Talk newsletters used the two most widely spoken local languages, Luganda and Runyankole. The program is still ongoing.

Campaign slogan

Safer Sex or Aids: the choice is in your hands


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Hits for Hope Music Contest

In 1995, the project worked with the 10 district health educators to organize two Hits for Hope music contests. The district health educators distributed posters and entry forms intensively to youth groups and the local council chairperson throughout the 10 districts. Music groups were invited to submit original lyrics that carried the campaign messages in any language. The district health educators and the DISH IEC staff reviewed the lyrics. Music groups who had submitted lyrics that properly carried the campaign messages were invited to perform their songs during district auditions. Youth adjudicators listened to each performance and selected the three or four songs they liked best to be performed at outdoor district concerts. Each audition was a health education opportunity. The auditions were widely publicized and were attended by audiences of up to 200-300 youth, each receiving a campaign newsletter, Straight Talk.


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The finalists from each district performed during 10 outdoor concerts in the seven districts. The audience and a panel of youth adjudicators selected the best song in each district.

After the first Hits for Hope contest in May and June 1995, the project invited a panel of professional music producers, disc jockeys and artists to listen to the winning performances on videotape. The panel selected one national winner that was recorded professionally and released on the nation's three radio stations in July 1996. The song Ray of Hope became a hit, reaching number three on the Coca Cola Hot Seven Top Songs.

In September 1996, the Hits for Hope music cassette was released for sale throughout Uganda. The cassette contains eight songs from the two contests, including Ray of Hope. Many of the songs have been played often on the national radio stations. In addition, the winning music groups toured the 10 districts in September and October 1996, with the Group Africa Road Show. About 7,000 copies of the music cassette have been sold to date.


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Local events in support of the mass media campaign

In addition, the district health educators organized district level events in four of the 10 districts. The events included Safer Sex or AIDS bicycle rallies, drama contests in schools, drama tours with discussions, a rap music contest in one district and video shows with discussions. The district activities took place between December 1995 and June 1996. About 40,000 youths attended these district events.

Drama competitions and tours

The organization of these competitions and tours varied from district to district. In some, there were inter-school drama competitions in English. The winning school toured other schools in the district and played at national events. Other districts organized community drama troupes who were given prepared script with campaign messages. These toured the districts staging drama in community village halls for mostly the rural out-of-school audience. Runyankole and Luganda dialects were used.

Video shows

These were for both in- and out-of-school youths. They were shown in community village halls and in schools, using videos with the campaign messages of hope. The video entitled More Time was translated into two local dialects, Runyankole and Luganda to be able to reach the out-of- school youths. The video shows attracted large audiences and they were most popular in the areas without television sets. There was a pre-recorded videotape containing campaign messages in form of spots. This was played at the beginning or end of the main film to trigger interest and discussions about safer sex and behavior change.

Bicycle rallies

This is a popular sport for young men, especially the intended audience. The rallies drew crowd averaging 8,000, half of whom were the intended audience. These rallies were opportunities for HIV/AIDS/STDs campaign. The messages were communicated through songs, dramas, T-shirts, banners and posters at check points and at the flag-off and finishing points. Most rallies were participated in by 60-70 youths.


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Major findings

The project conducted baseline and follow-up surveys in 1,500 in- and out-of-school youths in seven of the project districts to evaluate the effectiveness of these interventions. The baseline survey took place in August 1995; the follow-up survey was conducted in October 1996. Findings showed that the campaign was very successful in reach and impact.

· Youth participation in the campaigns was very high.

· More than 90% of the youth surveyed had been exposed to at least one of the campaign media; on average, respondents had been exposed to five or six of the media.

· More than three-fourths of the respondents stated that the campaign messages had influenced them to change their sexual behavior in some way.

· The majority claimed to have decided to abstain from sex and a large proportion began using condoms.

· The proportion of respondents who were sexually active remained stable at around 50%.

Radio was most effective but more so in areas with local activities.

Experience with the Safer Sex or AIDS Campaign showed that radio is an important medium for safer sex messages. As many as 80% of the survey respondents heard one of the radio spots of the jingle and two-thirds had heard one of the Straight Talk radio programs.

Aside from its wide reach, radio was most effective at influencing changes in behavior in districts with organized local events. During these events, local personalities spoke to youths in their own languages and contexts. In addition, youths in the districts with local events were more likely to have read one of the Straight Talk publications because these events offered excellent opportunities for distribution.

The local campaign events were particularly useful in mobilizing local support for safer sex behavior. Perhaps for the first time, the youth saw their local leaders, teachers, headmaster and fellow youth speaking publicly in favor of condom use. This had a powerful impact because there had never been such a campaign in any of these districts before.

The factors that contributed to the success of the campaign were:

· active involvement of the intended audience in research and implementation;
· well-defined and consistent campaign theme and messages;
· support, advocacy and active participation of local leaders at the grassroots level;
· strong and effective publicity campaign using posters, radio and interpersonal communication;
· support and active participation of DISH and the Ministry of Health and Uganda's positive policy;
· hiring of advertising agency to produce and implement mass media campaigns;
· thorough distribution of campaign materials to the intended audience at the grassroots level;
· networking with other organizations and professionals to form Action Committees at district levels to make the campaign activities happen; and
· process-led and research-based campaign.

Weaknesses of media selection

In using state-run radio, there was no control over prime air time and it was difficult to control the attitude of radio producers and presenters to keep the audience interested.

Though policy is positive in Uganda, there is no clear policy or action about negative media on safer sex and condoms. Messages on the other radio programs, mostly the private radio stations, may undo the campaign messages.

Conclusions and recommendations

There is a need to reinforce and sustain behavior change so that those who adopted healthy sexual behaviors will not fall back onto the old behavior. This can be done through another campaign at a later date. Also, there is a need to target the community in general and the youth in particular so that they take over ownership and responsibility of the campaign.

There is also a need for additional research to find out if patterns of sexual behavior have changed over time.

Assessment of peer counselling among university students

Samson O. Ogwalo

".... Being a youth is in itself a risk factor. "

Mr. Sleeuwagen, Belgium Embassy, speaking at the 1995 International Students Conference on AIDS (ISCA) in Nairobi. Kenya


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Notwithstanding the concerted efforts being piled by various organizations towards the reversal of the toll of sexually-transmitted diseases/human immunodeficiency virus/acquired immune deficiency syndrome (STDs/HIV/AIDS), the youth, especially in Africa, continue to squarely bear the brunt of the AIDS pandemic. The endurance is manifested in the alarming statistical data from the research on the youth sexual activities, attitudes and the implication of the same. The Kenya national AIDS/STD control programmes' HIV/ AIDS statistics (1995) shows the highest infection rates as occurring in the age groups 15-24 and about 2/3 of the infected are in the institutions of higher learning.

A Knowledge, Attitudes and Practices (KAP) survey conducted by the family planning private sector (1993) indicated that there was a discrepancy between what they know and what they practice. And that (university) students are sexually active or exhibit high-risk behavior.

University Students AIDS Control Association (USACA), a non-profit organization founded in 1993 and run by volunteer students, seeks to respond to the STD/AIDS scourge within the University of Nairobi community (although now spread to other universities in Kenya), meeting an overall objective of creating AIDS awareness by enhancing a sustainable behavior change among students.

After two years of operation (1995), USACA organized the first International Students Conference on AIDS (ISCA '95) in Nairobi, Kenya that brought together over 300 students from Rwanda, Uganda, Tanzania, Zaire, South Africa and Kenya.

On the same year, USACA selected 30 members and trained them as peer counsellors on reproductive health a project founded by the family planning private sector. The training of 30 peer counsellors was initially a project of another students association but later became an independent organization that undertook peer counselling and AIDS awareness alongside USACA. In 1996, the peer counselling project conducted a KAP survey to assess the impact of these concerted efforts and the findings are also discussed in this paper.

This case highlights how peer counselling as a strategy has impacted in creating AIDS and STD awareness in the University of Nairobi. It also examines counselling among students from the point of view of a case study alongside its parent organization, USACA.

Reproductive health concept introduced

The overall objective of the project was to enhance positive and sustainable behavior change among students. This had to be made possible through creating awareness on HIV/AIDS/STDs and popularizing contraceptive use.

Communication media used

The project targeted both male and female university students aged between 19-25 years. The students are based in the university in the city of Nairobi. The students have mixed economic status because they come from diverse backgrounds - from the poorest to the most elitist. Although some students may have rural backgrounds, they are based in the city.

The communication media used were peer education/counselling, focus group discussions (FGD); talk shows and video shows.

Peer education/counselling involved sharing of information and experiences on HIV/ AIDS/STDs and family planning among students by a trained facilitator. The trained facilitator/counsellor gave the audience information in a descriptive way, presented options on safe sexual practices, AIDS manifestations, preventive/coping mechanisms and even family planning (FP) vis-a-vis contraception.

Peer counselling within the University of Nairobi campuses reached an average of 400 students monthly through a multi-media strategy. Counselling was done at very personal. one-to-one level, through focus group discussions (FGDs), video shows, distribution of literature or combination of the various media forms. Forms of interpersonal communication wore original. They followed no deliberate and obvious formula. The counsellors ware not restricted to a particular approach. They could meet the students (counsellees) in any appropriate place and start a discussion depending on the prevailing circumstances. They (counsellors) could also talk to friends or friends of friends. In essence, each counsellor was free to devise his/her own approach to fit the clients' idiosyncratic differences. The distribution of condoms was done by counsellors based on the demand of the students, either after a talk show or interpersonal discussions.

The FGD was conducted with two to three facilitators assigned per group of 12-15 persons or more. The number of facilitators per group was a precaution against lack of clarity of knowledge about concepts. The topics of discussion emerged out of introductory remarks by the facilitator.


Figure

Talk shows wore organized with professionals as speakers. Questions asked by students were usually a reflection of their religious convictions, level of awareness or a current controversy, i.e. Dr. Obel's "Pearl Omega", an alleged cure for AIDS. (Dr. Arthur Obel is a lecturer and Senior Researcher in the Department of Microbiology, Medical School, University of Nairobi. In 1996, he claimed to have discovered 'Pearl Omega' which can cure AIDS.) Apart from putting in place all the arrangements for talk shows, peer educators sat at the platform with the speaker and responded to questions that were addressed to them. Questions that pertained to the reproductive health problems and services within the University, e.g., where to get what help, wore always answered by the counsellors during the show.

Whereas the FGD lasted one to one and a half hours, the talk shows went on for as long as three hours depending on flexibility of format, length of the speeches, students' response in terms of questions and sometimes on the availability of time in terms of students' schedule. The talk shows and FGDs tock place over the weekends and mostly in the evenings.

Video shows on AIDS/STDs ware arranged on a fortnight basis in the student halls of residence. An average of 20-30 students attended at the beginning of the semester but towards the end, only about 20-25 attended. Due to the monotony of the AIDS documentary videotapes, the counsellors only showed them as preludes to other "thrilling" shows not on AIDS or STDs. This strategy held the students because they could not walk out of the showrooms before watching a thriller which, sometimes, they have paid for.


Figure

Distribution of pamphlets, brochures and newsletters were normally done during talk shows, seminars and video shows.

Major findings

The realization of the gap between the expanding pandemic and the students' response to the same, formed the basis of the conception of peer counselling on reproductive health among university students. The hypothesis hereof was that interpersonal communication among students of same peer is enhanced by 'sameness' and equality of age. socio-economic and intellectual status.

Opinion reviews carried out informally showed that students are reluctant to watch AIDS shows all the time because as D.H. Kiiru of Literature Department, U.O.N. says, this could be a painful reminder to some students of some past careless sexual behaviors and probable consequences. The most common video documentary was Raphael Tuju's Silent Epidemic.

The students reached by the media were undergraduates whose ages ranged from 19-25 years. There was, however, a remarkably recurrent low turnout by female students. The ratio of male to female was 5:1 even when the functions were held in the halls of residence of female students. Even the women's participation in creating awareness had been very low over the years.

The impact of the peer education was assessed here based on the results of the KAP survey. It should be noted that peer counselling message was often supplemented by information received through the mass media, USACA's efforts and other means.

The data was collected from seven universities of Nairobi campuses between May-June 1996 by volunteer students through administered questionnaires. The data collectors randomly sampled 20% of the students in their halls of residence and the respondents returned filled in questionnaires either to the halls' custodian offices or awaiting collection by enumerators.

Of the 600 respondents, 77.7% were males while 22.2% were females, with ages between 21-24 in almost equal distribution. In terms of civil status, 94% of the respondents were single, 3% married but living apart, and 1.8% living together with spouses, while 1% married but divorced/separated.

The most widely known contraceptive among the students were: condoms (83%), pills (77%) and IUDs (61.65%). Injectables, norplant and vaginal foams were cited in a few instances. About 52.5% claimed to have used contraceptives before while 46.7% had not. However, only 33.2% affirmed current use. Methods used were condoms (27.7%), vaginal foams (4.5%), pills (1%), injectables (0.7%), IUDs (5%) and norplant (0.2%).

Students generally prefer condoms that were bought to them than those that were freely distributed. Freely-given condoms give an impression that condoms were of low class. Assessment of enhanced awareness may not necessarily be reflected by the increased number of condoms distributed. Mere distribution may not necessarily indicate use.

For those who had never used contraceptives before, 10.2% never had sex, 5.5% pointed lack of trust and religious convictions while 5.8% and 1.8%) were not married or used natural family planning methods, respectively. The students who confirmed non-use of contraceptives gave various reasons: they are virgins and they do not trust contraceptives. Others said they are married and trusted their spouses so they do not have reasons to use contraceptives (especially condoms).

On effectiveness of contraceptives on pregnancy prevention when properly used, 63.3% affirmed, 19.8% pointed non-effectiveness, 8.5% did not know.

When asked if people should be introduced to contraceptives, 30.2% disapproved and 66% affirmed. About 21.8% suggested age of introduction to be 18-20, 18.2% and 17.8% proposed 15-17 and 12-14 respectively. About 6% proposed 9-11 years.

Most (85.3%) of the respondents reported never had contracted STD while 13%) had. Vulnerability to HIV was affirmed by majority (78.5%).

Interpersonal communication had been observed to have greater impact when there was a discussion between people of different sexes, e.g., male-female or vice-versa. The explanation attached to this was that females felt free to talk to males openly but not so with their female counterparts due to fear of gossip and compromised confidentiality. On the other hand, males found it easier to talk to females and felt much challenged that females knew more than they did. Condom demonstration, when done by a female, was found more challenging and the message went through more clearly.


Figure

Weaknesses of the media

The weakness of the strategy was on the unmet financial expectations of the peer counsellors. The counsellors expected financial rewards after the training because they were given sitting allowances during the training workshops. The other weakness was the acceptability of peer counsellors, especially if the counsellor was of lower academic standing compared to the counsellee, e.g., second year counselling fourth year.

The project faced serious financial constraints because the assistance the counsellors got from the family planning private sector was basically in kind. The university administration was not supportive either. To enhance sustainability, the project started a shop from which funds for incidental expenses could be generated.

Conclusions and recommendations

From the survey, it was apparent that the sexual activities of the university students were not quite different from the out-of-school youth. Compared to the earlier 1993 survey by FPPS, the disparities existing were not so alarming. This could largely be attributed to the reproductive health counselling done.

It is clear from the survey that there are still some students who do not know and/or are not sure whether only condoms are effective in STD/AIDS prevention. This should form the core of future awareness and enlightenment campaigns.

Reproductive health education should form part and parcel of university curriculum so as to take care of those who prefer to take information from teachers as indicated by the survey.

There is a need to involve the university authorities right from the beginning of the project. Financial and material resources should be availed by the university and relevant organizations to support the operations of the reproductive health awareness groups.

The clubs and associations undertaking reproductive health information should have a joint front so that there is coordination of activities and avoid duplication.

There should be a networking strategy for all the partners in the reproductive health education. Research should be done to establish the reasons for reluctance of women to either receive or participate in awareness campaigns.

References

Cross Roads: FPPS Quarterly Newsletter. November 1995.

Daily Nation Newspaper. STD Control Vital in Battle Against AIDS. July 12, 1996.

Muniae. 1996. Community-based Reproductive Health and Family Planning Survey.

Odingo, G. and D. Ochieng. 1996. UNEPEC KAP Survey Report.

Otieno, I. and S. O. Ogwalo. 1995. ISCA '95 Conference Report. Nairobi, Kenya.

Small group education to prevent HIV/AIDS. The case in Addis Ababa

Negussie Yitbarek, Roma Hein and Lilian T. Wambua

The project on Adolescent Sexual Reproductive Health focusing on sexually-transmitted diseases/human immunodeficiency virus/ acquired immune deficiency syndrome (STDs/HIV/AIDS) and unwanted pregnancies in Addis Ababa is a collaborative effort of the African Medical Research Foundation (AMREF), United Nations Children's Fund (UNICEF) and the 14 Regional Health Bureaus in Woreda 6, Zone 1 of Addis Ababa. The project targeted the youth, 10-24 years, both in and out of schools from the poorest communities of Addis Ababa. An initial qualitative survey, focus group discussions and key informant interviews, followed by a quantitative survey were conducted to identify youth issues related to their sexuality and reproductive health.


Figure

The survey revealed that adolescents are ill-informed of the physical, mental and psychological changes occurring at puberty. One of the striking misconceptions of adolescents was that one should have sexual intercourse to ascertain maturity. Awareness of STDs/HIV/AIDS was high but not translated into safer sexual practices. Their sex urge was a more powerful driving force than the risks of contracting STDs/HIV/AIDS. This can be summed up in the statement given by a male adolescent - "In our age, we indulge in sexual acts to satisfy our bodily needs only. We do not think about what follows, what problems we will face after committing such acts. "

Sources of information on sexual and reproductive health were videos, pornographic materials and peers. Parents commented that they felt inadequate to discuss sexual matters with their children. The youth demanded health education and information to enable them to manage their sexuality.

Reproductive health concept introduced

The survey revealed that the adolescents needed correct information, education and counselling for responsible sexual behavior and effective prevention of STDs/HIV/ AIDS and unplanned pregnancies.

Communication medium used

Adolescents include both children and adults. However, they fit into neither of the two in society. Service providers have a problem providing friendly services to adolescents. As a result, adolescents feel neglected and rejected. What is needed is a place where adolescents will be accepted and understood, where they will be listened to and be treated as a unique group, "adolescents".

A Youth Center was initiated, primarily for youth aged 10-24 years, both in and out of school. This was done through the involvement of the Regional and Zonal Health Bureau and the local administration. A steering committee comprising of community leaders, parents, youth representatives, religious leaders, members of the Zonal Health Department and project delegates was formed. The youths were encouraged to form clubs. Group leaders were identified, trained and encouraged to lead group discussions and establish or strengthen anti-AIDS clubs in their schools.


Figure

Amharic is the common language used and understood by all youth attending the Center. Activities at the Youth Center included video film shows, provision of print media (e.g., leaflets, magazines, booklets, posters and newspapers), focus group discussions, counselling/question and answer sessions which were facilitated by skilled youth educators, social workers and a health educator. Recreational activities included chess, table tennis and soccer. Competitions on poems, games and knowledge of HIV/AIDS/STDs were held on special days like the World AIDS Day (December 1).


Figure


Figure

Major findings

The Youth Center started with 14 youth groups, each group having 20-30 members in June 1996. There had been a steady increase in the number of groups and there were currently 64. Both girls and boys were equally represented in the groups.

The choice of the communication medium depended on the target audience. Video films were shown at the Center from Monday through Saturday. The youths were free to come to the Center any day, any time but there were set time for group discussions. Depending on the video, the discussions that followed took the form of questions and answers, person to person or person to small group. It was found that the person to person communication was most effective.


Figure

Improved and correct knowledge of HIV/AIDS among the youth was manifested when the youth won the prize for correctly answering questions on HIV/AIDS.


Figure

The youths were able to develop positive attitudes towards HIV/AIDS. Previously, only a few was willing to come to the center for fear of rejection and stigmatization due to HIV/AIDS. Those who dared to enter the Youth Center were able to win over their peers. They are now highly motivated and are producing songs and dramas to educate their peers.

The youth had become open and keen to know more about HIV/AIDS and sexual and reproductive health and other matters relating to self improvement and acquiring skills to earn their livelihood. The youth appreciated the Center and had become responsible members of the center.

Besides education, the youth needed to be equipped with skills that would enable them to meet life socially as well as economically. They would need training in livelihood skills.

Efforts are, therefore, underway to include vocational and life planning skills training at the Center.

Conclusions and recommendations

The problem of HIV/AIDS is becoming more complicated and interwoven with other socio-economic issues in many countries of the world, including Ethiopia. The pandemic is spreading fast in both urban and rural settings.

The Ethiopian Netherlands AIDS Research Project (ENARP) estimated that out of every 100 young adults, more than five are infected each year in Addis Ababa. According to the Ministry of Health-Ethiopia, the least infected are in the age group 5-14. This is the age group when children are not yet or are just beginning to become sexually active. This is the age group that offers the best hope for prevention of HIV/AIDS. Efforts should be made for all concerned (international bodies, non-government organizations and the government) to make a concerted effort to get the young adolescents in HIV/ AIDS prevention programs. This should include not only information giving but also skills training that would enable the youth to meet the psychological and economic demands of society. This should not be a one-time effort as the youths need to acquire sustainable positive behaviors. Furthermore, adolescent programs should be promoted as the adolescents need guidance in their reproductive health behaviors.

In view of the above, the following recommendations are made:

1. Organizations working in the field of Adolescent Sexual Reproductive Health focusing on the prevention of STDs/HIV/AIDS should be encouraged.

2. Networking among agencies (government, non-government and international) working in this field be established for the sharing of information and experiences.

3. Youth-friendly centers and services be established and/or accommodated to address the reproductive health needs of adolescents.

4. Parents and community leaders should be informed and encouraged to participate in adolescent reproductive health programs.

5. Community-based adolescent programs should be linked to in-school youth programs.

6. Increase in knowledge does not necessarily spell out positive behavioral changes. Information giving and sharing would have to be further followed up through training and retraining sessions on life planning skills involving not only the youth but also the elders in the community.

It is hoped that the community would take over the challenge and run the Center in the future.

Problem-based communication approach for 100% condom use among sex workers

Tussnai Kantayaporn

Brothels proliferated in Thailand during the Ayuddaya period (1537-1782), catering to high class citizens serviced mostly by female slaves. The service continued commercializing even after the abolition of slaves in 1905. The sex-service has extended to China town and to sex tea-houses as well. It was the establishment of US army bases in Thailand during the Indo-China war that initiated more patterns of sex-service like the ago-go bar, night-club and massage parlor.

The sex-industry became an international business because of the tourism policy. The other contributing factor is Thailand's industrialization and modernization that promoted the consumerism among the Thais. This has further increased the sex-service demand that required more women to apply to the industry. Presently, the sex-industry of Thailand is provided not only by the That women, but also by women from Myanmar, Cambodia, the South of China and the former states of USSR who have been trafficked from their countries.

The paper focuses on the project "AIDS prevention in 109 brothels" implemented by Chiengmai Provincial Health Office and other government health service centers, with technical assistance from Program for Appropriate Technology in Health (PATH). The project was implemented in 1990-1992.


Figure

Community where project was implemented

Chiengmai is well-known for both Thai and foreign tourists. There are various types of sex-services provided by the northern girls from rural families. In general, the northern girls have become commercial sex workers (CSWs) to combat poverty, whether they are definitely or relatively poor. Because the local norm forces them to generate wealth for the family, they perceive sex-service as the only way to earn quick income and pay back gratitude to their parents. At the same time, they suffer from the social stigma which makes them prone to ignore any information on AIDS.

Women, aged 14-23, join brothels in Chiengmai City because the job generates more income than work at any other province in the region. Most of them are still single and have experience in local brothel(s). They reach the city with their relatives, friends, parents or middlemen and start sex-service with debt advanced for their families. During the first three to six months, they work without income at the brothels. The human immunodeficiency virus (HIV) prevalence rate among CSWs in Chiengmai was higher than any other cities in the region at 41.0% (Ministry of Public Health, Epidermiological Surveillance Report, July 1990).

Reproductive health concept introduced

The AIDS prevention policy, at that time, focused on "the easy-to-control group" such as CSWs. The project aimed to promote 100% condom use among CSWs in Chiengmai to control the spread of HIV and overcome obstacles, misinformation, beliefs and by assisting them to plan for a safer life.

The emphasized message was that people with HIV may not necessarily have symptoms that can be observed. Thus, they could be infected by a customer who looks normal. This replaced the earlier message which portrayed AIDS at the symptomatic stage. The incorrect beliefs and habits to prevent HIV were also clarified. Using condom for every sexual intercourse was encouraged by raising their risk perception about HIV infection.

Expected behavioral result

The communication media aimed to raise CSWs' awareness on the risk of sex without condom. It also tried to modify misinformation and beliefs about condom. Using condom in every sexual intercourse was the expected result of this project.

Communication media used

The audience research was performed in the first year of the project to understand why sexually-transmitted diseases (STDs) infection rate was not reduced among the CSWs. This implied that the former disease-based communication had not been effective to bring behavioral change on 100% condom use.

Focus group discussion

The results of qualitative study by focus group discussion revealed that almost CSWs know about AIDS. But the AIDS campaign blamed CSWs as transmitter of the disease. This social stigma barred them from seeking more information on AIDS.

The study also found that even though CSWs attempted to use condom with their customers, they were not 100% successful. They had to accede to the customers' demands because they lacked bargaining power. Many of them even experienced violence because they wanted to use condom. In many circumstances, they decided not to use condom especially when they experience pain or allergy. Some customers spent time to reach orgasm with condom thus, CSWs themselves had to take it off to finish the service. Many CSWs decided to provide service without condom because the customers did not show symptoms of AIDS as shown in the general AIDS campaign posters.

Many CSWs did not use condom with their regular customers with the incorrect belief that these had sex only with them. They also washed their vagina with soda or washing drug after having sex, believing that it was an alternative way to be protected from HIV.

The communication message, tone and material were designed according to the desired results. The disease approach was transformed into behavioral modification, aimed to change their beliefs and to provide methods to handle difficult customers. To strengthen the practice of using condom, the cooperation of brothel owners was sought.

The study with the CSW "superstars" was performed to find ways to solve the time-consuming orgasms. Various methods to prompt customers reaching orgasm such as noise, excitement or body movement were introduced. Using the water-based lubricant correctly was also proposed to lessen the pain when using a condom during the intercourse.

The outreach education: An interpersonal communication

Outreach education at 109 brothels in Chiengmai city was the main channel to transfer the message targeting CSWs. Education session at "their place" and "their time" made them feel comfortable to raise questions. The session started with a risk perception game which demonstrated chances of getting infected with HIV. This game aimed to urge condom use in every intercourse. The session was followed by a discussion to correct misinformation, beliefs and habits related to prevention. The education ended with encouragement to protect themselves from HIV.


Figure

Support from brothel owners

The condom use was strengthened by coordinating with brothel owners. The discussion session with brothel managers was organized to let them protect CSWs from physical violence. The sticker stating, "This Brothel Welcomes Customers with Condom "-was provided to all brothels in Chiengmai City.

Education materials

Materials relevant to the CSWs' lifestyle were produced:

1. A big handbook, "Just Want to Let You Know" which was modified from a flip chart format so that it could be read and shared during their free time.

2. A cassette tape, "Just Want to Let You Know" with popular songs was produced responding to CSWs' habit. This tape included woman disk jockey (DJ) gently telling CSWs, as an elder to younger sisters, to protect themselves from AIDS.

3. The wooden man with a jumping penis was also used to make the risk perception game exciting. This model was locally made and easy to find in Chiengmai.


Figure

Major findings

The overall message for HIV prevention was designed in the context of "save yourself today for your future life". All CSWs have a dream, as other women, to leave the sex-industry and to be a good wife and mother of a warm family. The desire of CSWs to set up their personal plan and leave the work without contracting HIV motivated them to use condom. The self-protection with "how to" message was thus perceived by CSWs as more encouraging to attain their hope for a good future.

This problem-based communication strategy was appropriate to increase CSWs' awareness on their risk of HIV infection without condom. CSWs also raised many questions during outreach education and gave feedback. At the end of the session, they felt more confident to deal with difficult customers. The project also got a good cooperation from brothel owners that they were able to display the posters with the "Use Condom" message at their front doors.

One of the weaknesses of this project was that it lacked strong communication strategy to promote condom use among male customers. Although condom had been promoted in public, it had not directly reached the brothel's male customers. The baseline survey could hardly identify the male customers as from Chiengmai City or tourists. The other weakness was that some outreach educators had inadequate skill to facilitate the game, discussion and activities in the outreach sessions.

The condom use practice was assessed by an anonymous technique or "secret shopping" to overcome a limitation of one-to-one interview. In general, CSWs always replied "yes" to condom use questions whether it was true or not to please the interviewer. The anonymous or "secret shopping" method obtained the desired practice by sending research assistants pretending to be male customers to sample brothels. Conversations during service was noted and summarized later into three bargaining stages: condom purpose; condom encouragement; and reward for service without condom.

The study revealed that all CSWs liked to use condom. When the customers rejected condom use, all of them were encouraged by the CSWs to use condom. However, at the third stage, 2% of sample CSWs accepted more money for service without condom. Compared with the baseline survey, it succeeded in improving the CSWs' use of condom from 45% to 85% and to 92% in the final round.

Different opinions had been raised on this method. Was it an effective way to assess condom use? Was it ethical? Each evaluation method had its own strength and weakness appropriate to the culture. The method was consistent with self-reported data conducted in parallel which showed an increase from 82.7% to 85% and to 95.9%.

The two-year communication program reduced STD infection rate among CSWs. It also increased their awareness on HIV/AIDS to decide to use condom with every customer. However, the project was not able to be 100% successful because the CSWs had inadequate skill and bargaining power to handle all difficult customers.

Conclusions and recommendations

The high turn-over of CSWs in Chiengmai City was the major obstacle for project sustainability. Therefore, more communication strategies towards male customers are needed for the project to reach the target - 100% condom use in brothels. Even though it was hard to identify CSWs' customers, efforts should be emphasized on sexually-active male groups disclosed by CSWs, such as soldiers, laborers and/or tourists. This includes the policy and political commitment towards the prostitution issue in the country.

Finally, the negative attitude of policymakers and health communicators towards CSWs needs to be modified. An appropriate plan and communication medium should be established to better prevent and control HIV/AIDS.

Communication strategies to control STDs/HIV/AIDS. The case of commercial sex workers in Addis Ababa

Almaz Haile-Selassie

Some studies have indicated that human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a major cause of death for women between the age of 15-40 years. Socio-economic conditions and harmful traditional practices like female genital mutilation, rape and abduction make women more vulnerable to HIV/AIDS and sexually-transmitted diseases (STDs).

The problem of sex work in developing countries is mainly an economic problem. It is a question of survival. One of the high-risk behavior groups is the commercial sex workers (CSWs) as they have sex with multiple partners. They and their partners/clients are both at risk.

A study conducted among 2617 CSWs in Addis Ababa in 1989 revealed that the mean age of the women was 31.2 years and the prevalence rate of HIV was 24.7%.


Figure

The Society for Women and AIDS in Ethiopia (SWAAE) was founded in 1990 and was recognized as an NGO in 1993. The main objective of SWAAE is to create awareness among women against HIV/ AIDS and STDs through systematic training and re-training of women from different target groups. SWAAE started its activity by giving priority to the rehabilitation programme of the CSWs.

Reproductive health concepts introduced

Most of the CSWs are prone to unsafe sex practices. They are in reproductive age and pose a danger to themselves and to their partners.

SWAAE developed the following intervention scheme:

1. Awareness creation and knowledge sharing among selected CSWs against HIV/AIDS and STDs.

2. Promotion of condom use among this group.

3. Decrease of STDs/HIV transmission among CSWs and their partners.

4. Creating employment opportunities through income- generating activities.

5. Sensitizing CSWs against harmful traditional practices like female genital mutilation, harmful delivery practices, unspaced pregnancies and unsafe abortion which accelerate the spread of HIV.

6. Selection of the best communicators among the CSWs and train them as agents (animators) to change the risk behavior of their peer group.

7. Giving assistance to dependents (children) of CSWs, particularly to those who are infected with HIV/AIDS.

8. Provide counselling services for CSWs to abandon commercial sex work and engage in productive work.

Communication media used

Commercial sex workers are often jobless, unskilled, with low education and most of them come from poor and broken homes. They are stigmatized and looked down by the society. These women lack self-esteem and confidence.

An intervention scheme was carried by SWAAE in 1993 for 60 female CSWs selected from five kebeles of Wereda 5 (Arada area) which is a central place in Addis Ababa. The CSWs were between 20-35 years old. The women were very poor and had children and other dependents. A training center (premise) was acquired from the Arada Clinic.

With funding from the United Nations Workers' Wives Association and a technical support from the AIDS Control Department, different kinds of intervention programmes were carried out in the Center. These were as follows:

1. Training on information and education. SWAAE mobilized health and social workers and sociologists to give systematic and planned information on the prevention and control of STDs/HIV/AIDS. The media used for bringing attitudinal change were:

· publications, leaflets and brochures with pictures produced by AIDS Control Department;

· posters, charts and pictures;

· video films on AIDS, "The faces of AIDS in Kenya, " "AIDS life at stake ", "Female Genital Mutilation "in Uganda and Ethiopia;

· drama, panel discussions, questions and answers related to the spread of HIV, the gravity of the disease and its side effects on human life; and

· focus group discussions and role plays were also used in the participatory approach.

2. Sensitization programme against harmful traditional practices in the reduction of beliefs and misbeliefs that breed superstition about AIDS, e.g., one cannot have AIDS infection by drinking Araki (local alcohol) or eat hot pepper with their meals.

SWAAE used print materials like leaflets, brochures, posters, film shows, drama, questions and answers and focus group discussions during sensitization programme.


Sensitization program through drama, music and quiz against HIV/AIDS/STDs for about 5.000 people.

3. Skills training on sewing and handicraft, i.e., embroidery, basketry, knitting and shama (a local material) were given to the women. They were encouraged to sell their goods to the members of SWAAE. Sewing machines were purchased and given to the trainees to generate income. Through this, women were encouraged to abandon commercial sex work and engage in productive work.


CSWs engaged in income-generating activities.

4. Peer group education. Among the CSWs, the best communicators who completed primary education were selected and these women went to their peer group on a house-to-house basis. They created awareness among women in the drinking bars and distributed and demonstrated the use of condoms to other CSWs.


Promotion of safer sex behavior. IEC package and condom distribution in bars in Arada 's districts of Addis Ababa by animators (CSWs).

The expected behavioral results were practise of safe sex and increased awareness on the prevention and control of STDs/HIV/AIDS.

Major findings

The most effective communication media used for the training programme of CSWs were:

1. Film show followed by discussion

The films used for this information, education and communication (IEC) package were very touching. The discussion was lively until the end of the session.

2. Drama

SWAAE invited professional actors to stage a drama on the importance of having one partner only. This was presented to the CSWs and other women several times in a big hall. The drama used simple local language. It was entertaining and at the same time educational. The public enjoyed, there were comments and questions after the drama shows.

The most effective teaching method was to ask volunteers from the audience/group and participate in the "question and answer programme" (quiz) regarding STDs and their hazardous effects on human life. Different questions were constructed on the modes of transmission of the diseases like blood-letting, harmful traditional practices like tonsillectomy, scarification, tribal mark, female circumcision and unsafe abortion. The volunteers were told to respond to the questions raised by the moderators who were health workers. Those who got the best score were rewarded with T-shirts and umbrellas donated by the Population Service International (PSI).


Awareness creation against blood letting and other harmful traditional practices (HTPS). Blood letting, like circumcision, may contribute to the spread of HIV/AIDS.

Strengths of the media forms used

The positive aspect was that few women had an opportunity to be employed as animators. They went to each household and disseminated information on the prevention and control of HIV/AIDS to their peer groups, sensitized and distributed condom to about 10,000 women working in drinking bars.

Weaknesses of the media forms used

The print materials were not effective as the women were not interested to read the publication and also their educational background was low. The film show was very interesting to them but the language was in English which the CSWs could not understand.

The selected target group, 60 commercial sex workers, had repetitive training and retraining in the prevention and control of STDs/HIV/AIDS by health and social workers. SWAAE also tried to empower them economically to support themselves and their children.

This programme had been discontinued because of lack of funds. These women might be forced to go back to sex work.

Conclusions and recommendations

The situation and trend of HIV infection in African countries like Ethiopia is alarming. The pandemic is spreading fast in urban areas and particularly among women who are working in drinking bars. They are the victims and the possible transmitters of STDs and HIV. More attention should be made in dealing with this target group. Government and non-government organizations must mobilize their efforts in increasing knowledge among the CSWs to bring positive behavioral changes. Besides IEC package, skills training and income-generating activities should be included in the rehabilitation programme.

Participatory action research: An approach to rural HIV/AIDS education

Phoebe V. Maata

The International Institute of Rural Reconstruction (IIRR) is a non-profit, non-government organization (NGO) that believes that people have the potential powers to change and build societies. Opportunities are what they need to release these powers.

IIRR's involvement in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) education in the rural areas in the Philippines in 1994 was a pioneering task. During that time HIV/AIDS education was focused on the so-called "high-risk" group.

The relevance of HIV/AIDS education in rural areas was even uncertain at that time, especially that no one has been tested positive in the villages.


Figure

The experience in this case study would summarize IIRR's collaborative experiences with two partners - PAMANA Health Committee (PHC), a Federated people's organization and Philippine Rural Reconstruction Movement (PRRM), an NGO. In both experiences, IIRR was the facilitator. The methods of work anchored on capability-building such that it was a conscious effort to optimize the highest level of participation possible from the partners in each phase of the project management cycle.

The PHC Project was implemented in Cavite, a province adjacent to Manila. It covered five villages in the first year and expanded to seven villages in the following year. In terms of ecosystem, the villages were mainly in the upland and lowland with one peri-urban community. With PRRM, the one-year project covered 27 villages in three provinces cutting across three ecosystems - upland (indigenous group), lowland and coastal. Age of target group ranged from 11-65, both male and female (and some self-professed gays). Married and unmarried people were given equal attention. They were farmers, fisherfolks, laborers, students, housewives and a few commercial sex workers (CSWs).

The objectives of the project were to raise the level of people's awareness about HIV/AIDS and motivate them to change risk behaviors.

Reproductive health concept introduced

HIV/AIDS: Basic knowledge (what, how, risk factors, prevention, related issues, e.g. discrimination) and proper attitude towards People With HIV/AIDS (PWHAs).

General: sexuality (knowledge of one's body; keeping husband "inside the mosquito net") and fertility








Infants aged 0-11 months

Pre-school children aged 1-6 yrs. Old

School children aged 7-14 yrs. Old

Workforce of those aged 15-49 yrs. Old

The elderly or those aged 50 yrs. + above

Natural endowment:

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

1. Fertility





Starts to describe using local terms

Start to describe using local terms

Ends (45 + above) menopause


Continuing


2. Sexuality





Starts to experience

Starts to experience

Urge not consistent intense during during ovulation

Urge always felt

Urge wanes

Urge intensifies

Source of information





Reading materials

From friends





Problems related to 1 and 2


















- Early unplanned pregnancies
- Vises, drugs
- Rape/incest
- Many children
- Extra marital experiences
- Infertility



- Extra marital relationship > paid and unpaid

Causes:

1. Social - alcoholism, temptation, lack of recreational opportunities, no unity cooperation and "first love"


2. Economic - poverty


3. Cultural - second baptism

Communication media used

Methods employed were mainly trainings and interpersonal communication (focus group discussions and individual talk). Other methods which supported these were World AIDS Day (WAD) campaigns, village meetings and networking. All of these methods were adapted but the content and process of carrying out these methods were original.

Major findings

PAR is an operations research process:

1. where the villagers participate from identification of the research question to data analysis;

2. which is carried out in a partnership mode between the outsider (NGO) and the insiders (villagers). The former facilitates and the latter are the principal researchers;

3. where results are used as basis for action to benefit villagers; and

4. where villages control - keep, access, utilize - information.


Figure

PAR in HIV/AIDS education was used in proposal generation, planning (situational analysis), monitoring and evaluation of the project. Training of field implementors, Health Committees and project staff, was a critical step in the process. The conventional training design for basic HIV/AIDS was modified to include situational analysis, human sexuality, PAR and basic development communication. As a result of the formal training, risk behaviors were initially identified. This was validated and enriched during the data gathering in the villages. After the formal training the field implementors organized a Core Group in each village using the people's criteria - e.g., should compose of men and women, who were married and not, and who were trusted among their peers. Individual interview was the chosen data gathering method because of the perceived "private" and sensitivity of the topics particularly the risk behaviors. To get valid results, they decided that respondents should be interviewed by interviewers of the same sex. The facilitator was asked not to participate in the data gathering. A short Interview Guide was devised by the group. The Guide generally covered basic knowledge on HIV/AIDS, risk practices and explored attitudes towards PHWAs and communication source and preferred methods. Information was collated and analyzed. The results were translated into messages and methods of communicating these messages were planned and carried out.

PAR is an educational process in itself. The core group was able to apply scientific knowledge to practical concerns and also clarify attitude towards the cause. This promoted a deeper understanding which built their capability as educators in their communities. They themselves appreciated more equal vulnerability with stereotyped "high risk" groups. At the community level, immediate measurement was shown in higher post test results (FGD) and towards the end of one year HIV/AIDS was discussed openly and active information seeking was observed.

The concept and method were:

· people-centered - started from what people knew, needed and preferred, thus appropriate and acceptable; and

· people-controlled and not dependent on outside facilitators (decentralized).


Figure

Strengths of PAR

1. It is low-cost, replicable and maybe sustainable.
2. It builds people's capability and credibility towards their own people, the government and other NGOs.
3. People with risk behaviors are identified but confidentiality is maintained.
4. Sensitive issues are discussed in a non-threatening environment.
5. It reinforces the problem-solving process and becomes a way of life.

Weaknesses of PAR

1. PAR is input- and labor-intensive (for staff) in the initial phase.
2. The coverage is limited and the rate is low.
3. Continuity is highly dependent on trained people.
4. PAR needs intensive technical monitoring, especially in the first few months.

Conclusions and recommendations

1. Strengths overpower weaknesses.

2. Policy implications:

· funding process to be supportive of people's initiatives;
· technical support for communicators; and
· integration.

3. Need for simple but scientifically-sound study for impact assessment.

4. PAR needs to address these issues and concerns:

· initial resistance expected;
· source of continuous technical support;
· integration of content with other health and development needs;
· funding to support riceroots initiatives;
· mass production of materials vis-a-vis local production: and
· follow-up, supervision and re-training.

5. PAR is a stepping stone towards a genuine "people's research". Outsiders (development workers) should learn how to enable people to do this.

Communication media to prevent HIV/AIDS. The case of out-of-school youth in Addis Ababa

Teshome B. Wanta

The majority of AIDS cases are in developing countries where resources for prevention and management are scarce or minimal. This situation is also true in Ethiopia and the effects are not confined to urban areas but remote localities as well. The main mode of transmission in this country is through sex and it has been reported that more than 1.7 million people are infected by human immunodeficiency virus (HIV).

The alarming rate of spread of HIV among the urban and rural Ethiopian communities forced Marie Stopes International - Ethiopia (MSIE) to take up the AIDS initiative within its catchment area. MSIE is a United Kingdom-based non-profit and non-government organization (NGO). It is working in the field of family planning and reproductive health care. It has a network of projects operating in 26 countries in Europe, Africa Central and South America. It started its European programme in late 1990s. In addition to its clinic-based reproductive health care programmes, MSIE also runs community-based services/community-based distribution (CBS/CBD) programmes for low-income and displaced population in a catchment area of 25 kebeles (administrative units) in three woredas (districts) of Addis Ababa that enabled the organization to know the community in that area.


Figure

The target population was 10,907 (4,934 males and 5,973 female) whose ages were between 10-24 years and who are out-of-school. Studies show that most of the youth in this age group are sexually active with irregular and multiple partners. According to the Ministry of Health report, 56.6% of all sexually-transmitted disease (STD) cases and about 40% of acquired immune deficiency syndrome (AIDS) in Ethiopia are from this age group. The youth in this age group, being out-of-school and with no jobs, are the most difficult group to be reached by conventional methods. Hence, a specially designed programme is required to address their problems.

Reproductive health concept introduced

· Transmission, fatality and prevention of HIV infection
· Transmission (including "ping-pong" phenomena), prevention and treatment of STDs
· Advantages of using condom
· Safe sexual behavior
· Accessibility of condoms

Communication media used

Prior to the implementation of the different activities envisaged to bring about the desired behavior change, the expected outcome of the project, a baseline KABP study on a sample of the target population was conducted.

The objective of the project was to bring about desirable behavior change towards healthy and responsible sex practices among the sexually-active youth, i.e. reducing the number of sexual partners, proper use of condom for all sexual encounters and getting appropriate and timely treatment for STD. To achieve these desired results, the media forms used were peer education, production and distribution of printed materials, video shows, stage dramas, establishment of Youth Centres and interpersonal communication, i.e., counselling and group discussion. All the messages and media were planned and assessed in close consultation with the Youth AIDS Communicators (YACs).

Peer education

A total of 75 YACs were chosen and trained. Three representatives were chosen to represent each kebele (division). Criteria for selection were:

· resident of the kebele;
· completed 12 grade at least;
· accepted by the youth;
· unemployed;
· willing to accept responsibility; and
· has communication skills.

The YACs were paid about $8.00 - $9.00 per month and deployed to:

· conduct house-to-house registration of the out-of-school youth;
· organize youth in peer groups of 10-12 members per group;
· coordinate communication among youth peer groups;
· disseminate information about condom and facilitate free distribution to the peer group members;
· establish an effective and continuous communication among the youth about the availability of free condoms and treatment of STDs; and
· refer cases and contacts.


Figure

Drama

As part of the information, education and communication (IEC) strategy, and the enter-educate programme, a drama entitled "Frash Meda" (an arena of mattresses) was produced in collaboration with Aflegnaw, a nationally reknowned drama club. The drama portrayed that as soldiers die in the battlefield so also would people die in mattresses because of AIDS. Initially, it was staged weekly at the City Hall of Addis Ababa for eight months. Then, it was moved out to the different regions - Tigray, Amara and Oromiya. Currently it is staged in Southern Ethiopia Regional government.


Figure

At the beginning, MSIE paid Aflegnaw to develop the drama. MSIE also shouldered the financial cost for expenses incurred for staging the drama, e.g., tax, costumes, advertisement and rent of City Hall. A minimum entrance ticket of Birr 7 was collected from the general public for the show. The targeted youth had a pass which allowed them to watch the shows for free. The amount collected was used to pay the government tax, actors' fees and the running costs, e.g., rental and advertisement.

Youth Centres

The Youth Centres served as a forum for Behavioral Change Communication (BCC) and a venue for income generating activities such as selling of tea, coffee, snacks and indoor games (there was a minimum fee per hour for use of the facilities).


Figure

Two Youth Centres (YC) were established and managed by the peer educators - 39 in one YC, nine in the other.

Counselling

One-on-one counselling was also done in the Youth Centres. During these sessions, print materials and condoms were given and referrals were made as needed.

Major findings

Although no formal evaluation has not yet been undertaken, constant review meetings, focus group discussions (FGDs) and a rough general assessment were done.

Results of the baseline KABP study revealed the following:

· 78% (894) of the total study population identified at least two acceptable ways of preventing HIV infection: avoiding unsafe sexual activity and transfusion of untested blood;

· 29.8% (266) of the males and 21.4% (191) of the females used condom for every sexual activity;

· 36.2% (323) of the males and 12.4% (110) of females reported that they had three to five sexual partners;

· 81% (894) of the total study population had sexual relations between 15-19 years and that 7% had their first sexual intercourse before the age of 14; and

· 40% of the study population had history of STDs.

Peer education

As a result of the establishment of peer education as an operational mechanism, the following were accomplished by the YACs.

· Through the house-to-house visit, target youths were identified. Of the 150,000 total population in the area, 10,907 (4,934 males and 5,973 females) were targeted.

· The target population were organized into 839 peer groups mostly based on age and gender with a total membership of 9,093 (5,301 males and 3,792 females). A total of 1,480 peer group discussions on HIV/AIDS/STD were conducted.

· Thousands of Amharic leaflets, booklets, posters and Personal Risk Assessment Calendar (with English version) were produced and distributed to the target youth.

· About 32 video shows were conducted and there were 8,576 youth attendants (5,346 males, 3,230 females). An Amharic video film entitled Mengedegnawa Mushera (Itinerant Bride), was developed and made available not only to the targeted youth but to the entire Ethiopian nation through the Ethiopian television due to a pressing request. It is therefore difficult to estimate the watchers outside of the targeted youth.


Figure

Type of information material

Quantity distributed

Basic facts about HIV/AIDS

2,000

General information on AIDS

30,000

AIDS and other STDs

30,000

Youth on HIV/AIDS

30,000

Poster: Use condom - Don't Spread AIDS

3,000

Poster: 1 promise to remain faithful to my partner

3,000

Personal risk assessment calendar

20,000

Drama

After the production of Frash Meda, representatives of the target youth, health professionals, artists and officials of government and non-government organizations attended the drama's inauguration. During the show, an evaluation questionnaire was distributed to 540 attendants. The feedback were:

· The messages were entertaining, educational and easily understandable.

· It provided useful information not only to the out-of-school youth but also to the different groups of the society.

· Drama is the best IEC for HIV/AIDS/STDs prevention and control. It was highly recommended to be staged to the general public.


Figure

Pursuant with these recommendations, the drama is still being staged. According to the assessment made on the play, it is benefiting all ages of the Ethiopian society. Letters from students, government and non-government officials in the different regions have continued to pour in expressing their appreciation of the drama and recommending that this opportunity be extended to other regions. Apart from this, the drama inspired the targeted youth to develop their own drama shows, poetry and sports competition.

Counselling

Through linkages with the Population Service International and the Ministry of Health, 234,368 condoms were distributed - 35,855 sold and 198,513 free.

About 312 (243 males and 69 females) youths with STDs were referred to health institutions and were administered free treatment.

Weaknesses of the media forms

1. Project funding had been terminated and there were difficulties in maintaining the project's operations to continually respond to demands, e.g. new batches of out-of-school youth, monthly fees of YACs.

2. Fast turn-over of peer educators and training of replacements. Many peer educators have left and with their skills and experience it was easier for them to be employed in government as policemen or office workers.

3. Payment for peer educators. When the target group learned that the peer educators were paid, they wanted to be paid as well. As a response, free condoms were given as incentives.

4. The preferred and most acceptable communication media - video, drama and sports competitions - are expensive and not sustainable.

5. For the staff, it was a tedious and sometimes discouraging work to deal with desperate and aggressive youth who had basically problems of employment and did not have much alternatives.

Lessons learned

1. Community-based programmes were helpful in learning about the community problems and also in trying to solve them by means of participatory methods - youth educating youth.

2. The most effective and acceptable way to teach youth about reproductive health was through enter-educate (entertain and educate) programmes like drama, video shows, debates, poetry and sports competitions.

3. Creating income-generating activities helped the youth solve some of their financial problems and encouraged them to think positively and participate in preventive activities.

4. Peer education was useful in discussing sensitive issues. Gender-related issues were also found to be better discussed by people of the same sex and age.

Conclusions and recommendations

Reproductive health of the youth needs to be addressed properly and promptly because they make up a large portion of the community in developing countries like Ethiopia. The youths are predisposed to a number of undesirable situations. Unless their reproductive health needs are adequately met, the whole society will be affected in one way or the other. Therefore, the following recommendations could be made.

1. Individuals, families, parents, communities and governments must give due importance to the reproductive issues of the youth like:

· integration of sex education in the school curriculum starting at the primary level; and

· clear policy to support reproductive health programme interventions, e.g., abortion, protection of people living with HIV/AIDS.

2. Projects should be done in other places to give the youth due attention and help them meet their needs.

3. To get the attention of the youth, enter-educate (entertaining and educating) approach should be used.

4. Donor communities need to give continued support to countries and organizations that have registered good records in the past and also to those who have the determination to carry out the programme in the future.

Communicating with young people on HIV/AIDS/STDS. The youth centre project approach

Akwasi A. Boakye-Yiadom

The Youth Centre Project was designed by the Ashanti Region Branch of the Planned Parenthood Association of Ghana, a member of the International Planned Parenthood Federation. The project is based in Kumasi and the main beneficiaries are the out-of-school youths who are between 9-25 years. These beneficiaries are poor, with most working as truck pushers, dog chain sellers, local restaurant attendants and street hawkers. The greater majority are immigrants and school drop-outs from rural communities forced by social and economic circumstances to earn their living in the street. Most of them have little or no formal education.


Figure

Since its inception in February 1992, the project has gone through three different phases and has been supported by the World Health Organization (WHO), German Agency for Technical Cooperation (GTZ), Institute of Tropical Hygiene and Public Health (ITHOG), and the University of Heidelberg, Germany under its Support of Innovative Approaches in Family Planning (SIAFP).

The project seeks to improve knowledge on Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), manage sexually-transmitted diseases (STDs) as co-factors of HIV transmission and distribute condoms through the youth centre in the project community.

Reproductive health concept introduced

The project started as a vertical HIV/AIDS initiative in 1992 and as the level of HIV/AIDS awareness became quite high during implementation, this was overshadowed by a corresponding high level of misconceptions about AIDS and people with AIDS. Nearly 50% of the youth surveyed did not know that a person with the AIDS virus could look healthy

The evaluation of the first phase of the project in 1994 revealed the increase in the number of STD cases among the target group and the management of STDs became a crucial aspect during its continuation. In view of this, the following issues became the main concern of the project.

· Correcting misconceptions among the target group about AIDS and people with AIDS.

· Establishing a youth-friendly clinic in the youth centre to help in the management of STDs.

· Distributing condoms through informal channels such as lotto kiosks to make it more accessible to users.

· Expanding and improving peer education.

Communication media used

At the inception of the project, the communication media used were mass media and outreach activities. These were successful at raising awareness of the disease, building confidence of the target group and preparing them to assume full control of the project.

Because the knowledge level about the disease was low, other communication media were needed to inspire behavior change among the target group, majority of whom earn their livelihood in the street.

Among the major communication media used were:

· songs/jingles;
· print materials;
· peer education/counselling;
· street theatre/drama;
· establishment of a youth clinic at the youth centre managed by a sessional doctor; and
· condom distribution by peer educators.

The multi-media approach used by the project provided significant results. However, two of them, street theatre and interpersonal counselling sessions with the doctor at the youth centre made the strongest appeal to the youth.

Street theatre/drama

Drama has a long history in Ghana with what is termed the "Concert Party." Concert party stars who appear on television are very popular in Ghana. The use of cultural parables, Jokes and symbols to portray a concept is a very acceptable way of communicating ideas and information. Using drama to provide knowledge on sensitive sexual/reproductive health issues is very convenient. Sexuality issues have been private and hardly discussed in public especially with the breakdown of puberty rites in traditional societies. Drama was, therefore, an appropriate medium to reach the target group without undue stress on the culture.


Street theatre

The drama performances were performed by 15 peer promoters who wrote their own scripts with the help of a drama consultant. The themes for the plays were generated through participatory group discussions they had with their other peers. The performances were done in the street and videotaped for other outreach programmes.

Because the peer promoters did casual jobs to earn a living, the performances were done weekly without any fee. Most of the street performances were interactive. There were live on-going discourses between performers and audience who often sat or stood around the actors to provide an interactive input into the plays. This established a dialogue between actors and audience during the actual performance, especially in-between scenes.

Also, sensitive issues raised in the performance were at times discussed at the end where the actors were joined by the youth counsellor and drama consultant to answer questions from the audience.

Counselling at youth centre


Counselling at youth centre

The project trained 45 peer promoters to assist in counselling, both at the youth centre and also during their daily activities in the street. However, because of the daily demands on their lives. 15 dropped out and of the 30 who remained, half was used for street theatre.

The peer promoters on the street were provided with bags for storage of condoms and dummy penis models for condom use demonstrations. Group counselling sessions were held especially with organized out-of-school youth on apprenticeship at their work places.

The peer promoters kept records on sales of condom, number of youth counselled, number of youth contacted on the street and requests for lectures and filmshows. These activities were monitored by a youth counsellor who assisted at the youth centre.

Referrals were made to the youth centre where the sessional doctor and youth counsellor organized participatory group discussions and individual counselling sessions.


Figure

An evaluation conducted at the end of the first phase of the project brought to the fore an incidence of 12% of STD cases among the target group between 18-25 years. At the youth centre, the doctor combined preventive HIV counselling with STD management where all STD cases were referred to a medical laboratory for investigation. Treatment was free but the cost of laboratory tests and drugs was subsidized by the project and, in some cases, discounts were provided by the medical laboratory proprietor.

The services provided at the youth centre increased the daily attendance as the youth dropped in to play games, meet their peers and collect condoms for sale on a 40% commission basis.

Expected behavioral results

The result expected from the use of the above communication media was to reduce risk behavior. Most of the target group who used condoms generally obtained them from chemical shops. It was expected that there would be an increase in the demand and use of condoms because of its accessibility through street performances.

The project also expected the target group to cultivate the habit of seeking for proper medical care through the free STD management services provided at the youth centre.

Major findings

The major lesson learned was that the youth can initiate very innovative ways of reaching themselves and peers if helped to plan, implement and evaluate their own project. By their own initiative, establishment of a youth clinic and distribution of condoms were expanded to include non-traditional outlets like lotto kioks, fitting shops and hairdressing saloons to ensure accessibility.

The use of street theatre was found to be a very effective means of demystifying condoms and discussions on sexual and reproductive health issues. It also had wide reach and information was provided at relatively low cost per head. Through these media, the target group gradually came to identify themselves with the project and became confident in using the youth clinic. Before, they felt reluctant to visit health facilities for treatment of STDs. This was mainly due to the judgmental attitude of some health workers towards the youth who reported STD cases. As a result, they preferred self-medication or consult quack doctors.

The peer counselling sessions also showed young people examples of peers who were able to take care of their own reproductive health. This made some of the target group confident in their own skills in protecting themselves.

It was found out that even though the youth centre provided free treatment, not all the youth who reported STD cases could afford to pay the subsidized cost of laboratory test and drugs. Some youth could also not afford transportation cost to the youth centre to benefit from the services and facilities provided.

Street theatre is an expensive medium in terms of providing costume. It is also time consuming (regarding rehearsals). External factors are difficult to control (the group and environment, specially during rainy days).

In spite of these, the target group patronized the use of these communication media. Sale of condoms went up and the incidence of STDs dropped from 12% to 8%.

Conclusions and recommendations

The project is in its third phase and it is now trying to consolidate the gains already made. In disseminating the benefits, drama performances were recorded on video and shown to other youth not in the immediate project community.

The experiences from the youth centre project approach show that in order to have an effective intervention for the youth, avenues must be sought to listen to them and get them involved in all areas of the project. In attempts to seek health care from the public sector, young people have experienced being treated by staff with judgmental attitudes. Thus, they go to private sectors instead. Strategies need to be devised to overcome the biases against adolescent reproductive health services and making it more youth-friendly.

It is also recommended that additional studies be carried out to explore the possibility of the use of folk media for reproductive health programmes.

The use of single medium of communication cannot bring about the desired improvement in the reproductive health behavior of young people. There should be an interplay of media to support the ones which have been tried and proved successful, e.g., street theatre.

Plenary summary. Papers on HIV/AIDS/STDs

Where are We now? (Transparency 1)

Looking at the contemporary timeline starting from the 1950s to the year 2000, we are in 1997, three years to the turn of the century. Specifically for this conference, we are on the second day of our reflection process.

The reflection, as we had clarified at the outset of this forum, involves both distillation and codification of content, i.e., reproductive health and process - communication at the rice/maize roots.


Transparency 1

Focusing first on HIV/AIDS/STD, the distillation looked into the basic questions of (1) Who says, tells, shows? (2) What? (3) How? (4) To whom? (5) For what? and (6) How will who know whom really does for what? (Transparency 2)

Transparency 2


What worked?

Why did not work?

(streng)

(Weaknesses)

Why?

Why not?

If!...

If!...

The corresponding elements in the communication process are sender (S), message (M), channel (C), receiver (R), effect (E) and feedback (F), where their relationship in the context of the previous basic questions are graphically shown in the figure below. In reviewing this process, we had other questions: What worked (the strengths)? Why did these work?; and What did not work (the weaknesses)? Why did these not work ? For both views, we summed up the round table and plenary sessions into nuggets of learnings with "If we were to do the tasks all over again, this time we would do better...". (Transparency 3)

Transparency 3


What worked?

Why did not work?

(streng)

(Weaknesses)

Why?

Why not?

If!...

If!...

The generic distillation process not only for this topic but for the whole conference can be graphically shown in this figure: (Transparency 4)

Transparency 4

Generic distillation of the communication for reproductive health


Feedback (F)

How will who know ®

Whom really does

® For what

What worked?


Why did not work?

(streng)


(Weaknesses)

Why?


Why not?

If!...


If!...

Results (Transparency 5)

Overall, the experiences shared in the roundtable sessions, case presentations and those of the other participants have shown that communicating about HIV/AIDS/STD in Africa and Asia in different ecosystems -upland, lowland, coastal of rural and urban settings - involved both young boys and girls and grown-up men and women (to whom). The process had men and women discussing with men and women. In India and among the Moslems of Ghana, there was a segregation of gender, men shared with men and women with women (how).


Transparency 5

While messages have reached the single and married of both gender, for the former, it was only with the in-school youth. To the out-of-school (to whom), the messages (what) on HIV/AIDS/STD and planned parenthood were meant for a range of actions (for what) at the very least - awareness; next level skill building in the use of condom; provision of mutual support and how to protect oneself and others; then behavior modelling and ultimately reduced HIV infection of the defined population groups. The channels (how) taken were mass media - radio; drama including the puppet shows and street plays; peer education and interpersonal communication. (Transparency 6)

Materials were in print such as newsletter and songs. Unique channels were the sports camps and "letters in basket" (India); and optimizing the traditional women gatherings (India).

Transparency 6


What:

· HIV


· STD


·Planned parenthood

How:

· mass media: radio


· drama: puppet shows, streetplays


· peer education


· interpersonal


· materials (newsletters) songs,


· Unique: "letters in basket (India)



sports, champs



Traditional Women Gathering (India)

Communicating with the young (Transparency 7)

On specific population groups, out of school youth, mostly urban, were difficult to reach. This presents itself as an unresolved area in this conference. Another sector is the casual workers in the youth center, a peri-urban setting. The messages of safer sex, HIV AIDS/STD and teenage pregnancy were communicated to these groups disaggregated by age, using a combination of the mass media and interpersonal approach and of materials addressing this range - awareness, the use of condom, safe(r) sex to ultimately effect a decline in incidence of STD. The interactive discussions of both roundtable and plenary have yielded the following areas for future work, the ifs of this conference.

For the out-of-school youth, these are linkages to an integrated service delivery for the girls/women; decrease the school drop-out rate of youth; and maternal and child health care for the married youth. At the policy level, the issues addressed were the rights of out-of-school youth; replication of significant projects/ strategies; networking among and within organized sectors and concerned individuals and the formulation of a comprehensive program addressing the specific needs of this sector. The strategies should consider these points - confidentiality; building on the life skills of decision making and negotiation and more importantly, their own involvement - youth involvement.

Transparency 7


IF



· Linkage

*Unresolved

· confidentiality

­ integrated service delivery

· replication

· life skills - decision making



- negotiating

¯ drop-out rate

· networking


· MCH, for married

· comphrehensive

· youth involvement

· policy: Rights of OSY



Street plays and radio dramas (Transparency 8)

The strengths of street plays and of radio dramas in their one-way and two-way "interactive" forms were that there was fun, people replicate what they see and that both easily address sensitive issues. However, the message can be lost in the entertainment. Misconceptions can arise with incomplete messages received. There is the need to sustain interest not only of the audience but also of the actor, who would then change the script. Other weaknesses were the timing; and the cost given the turnover of actors and the need to follow-up.

Other significant learnings

Indigenous flavor of the messages can easily be captured with songs. The young have their "own language" were they learn about HIV/AIDS/STD. Peer education, an interpersonal communication form, raises these issues regarding the staff (peer educators) - limited number, need for trained staff and that of incentives, because they are mainly volunteers.

Transparency 8

· Streetplays/Radio dramas


S

W

· Fun but

· message can be lost in entertainment.

· People replicate what they see

· incomplete message misconception

· Easy to adress sensitive issues

· need to sustain interest


actor

audience


change script


· timing

one-way

· costly - turnover of actors

* dramas

"interactive"

· need follow-up

two-way


· "indigenous flavor" - songs


· young have "own language"


Peer education/Interpersonal communication


· incentives?


· limited number


· trained staff


Issues/concerns (Transparency 9)

Issues and concerns centered on the following: inaccuracy of messages; limited information on adolescents (India); the return of young girls to school after the birth of babies; "awareness" may not change behavior; when to start sex education (starting at secondary school is too late); and the need to recognize the "other audience" when we deal with the young. The group ranges from those comprising the closest environment to those providing the macro environment. At local level, these are the parents (their education and counselling); the schools, the churches and the local politicians. At the national level, the educational, religious and political systems have to be addressed. For religion, there is a need to find fundamental beliefs as basis for HIV/AIDS and sex education. From the two other systems - political and educational, there is a need for policies to protect the young.

Transparency 9

Issues/concerns:
- inaccuracy of mrssages
- limited information on adolescents (India)
- return of young girls to school after birth of babies
- " awareness may not change behaviour"
- " when to start sex education"? secondary school (too late)
- Other "Audience"
When we deal with young

- Religion - find fundamental beliefs as basis for HIV/sexuality message
- Political/Education: Policies

Communicating with commercial sex workers (Transparency 10)

To whom

A hierarchy exists among the commercial sex workers.- the low, medium and the high class. The social stratification became evident in campaigns where the free supply of condoms was stopped: those from the low class stopped their use while those from the high class bought condoms to continue the practice.

For what

The communication process was focused on:

· behavior change, specifically on safe sex indicated by a decline in incidence of STD such as no STD for six months;
· how to negotiate;
· use of condoms, where a high proportion was registered 70 - 98%.

What

The messages were on AIDS, STD and female genital mutilation.

How

The channels of communication were the question- answer format of video shows; drama; role plays; peer education and interpersonal communication - mainly house to house visitation. Local wisdom took the form of having the "superstar commercial sex workers" to teach others on how to handle the difficult customers.

Issues/concerns

Projects dealing with this population group raised these concerns: the indicators used in monitoring STD, where government and private sectors are involved; ethics behind the use of anonymous researchers (researchers who present themselves as customers); and the formulation of strategies directed to the male customers. Moreover, there is the need to have educational posters in bars and brothels while CSWs themselves will assert by negotiation.

Services for the CSWs have been developed that integrated education and condom supply into Maternal and Child health with an income-generating component. The latter component failed for there was no market.

Transparency 10

Commercial sex workers

To whom:





low

medium

high class

w/o free condoms

*stopped


*bought condoms

For what:

Behaviour


changes


- safe sex

D STD=none for 6 months (70-98%)


- how to negotiate

¯


- use of condoms


What: include FGM and AIDS

How:

video/questions, answer


drama/roleplay


peer education


interpersonal communication


- house to house


local wisdom: "Super CSW"


Difficult customers

Issues and concerns


· indicators - STD - gov't/private


· monitoring


· ethics - anonymous researchers?


· male customers?


· posters in bars/brothels! Yes with negotiation



Education/condom

Service: MCH±IGP®tailed - no market

Overall (Transparency 11)

Reviewing the HIV/AIDS projects, the receivers, a mixed, heterogenous general population, were mainly the "not sick". The experiences shared in this conference were limited to knowing how to communicate with two sectors; first, the "sick", particularly on the message of "where to go for what help" and second, the care providers, the training they have to undergo.

Homosexuals

In Asia, particularly the Philippines, homosexuals are accepted and organized. They have their parades, solidarity nights and interpersonal communications. This was not a significant group in the African experiences.

Transparency 11

Mixed General Population

To whom:

Not sick project most project

w/sick + care

What:


­


= where to go for what help

training

Homosexulas



Asia:

Africa:


(Phil.) accepted (organized)

not significant


What:



How: parades, solidarity nights, IPCs



Overall communication process (Transparency 12)

From the conference experiences, it became evident that there were two communication processes in sequence. The first receivers are the group of animators, actors of role plays and of street theatres and- peer educators beset by problems of high turn-over, provision of incentives, and of continuous upgrading of competencies. The ultimate receivers are the general population and specific sectors - boys, men, girls and women, commercial sex workers.

Transparency 12



"Animators"

"General population"


"Actors" -

"Specific"


"Peer educators"





- boys

- men


® high turn-over

- girls

- women

Concerns

® incentives

- CSWs



® continous upgrading



How do we make it happen (program)? (Transparency 13)

In the context of the three program management phases, planning, implementation/ monitoring and evaluation to initiate and sustain the communication process of HIV/ AIDS/STD, the PRRA of Kenya contributed to the understanding of the planning phase. The participatory action research (PAR) of the Philippines was the example of management by a people's organization for an entire project cycle. Entry points to communication can range from normal sexuality to concerns other than HIV such as water sanitation and basic needs. Identified as benefits of the projects were people's ownership, empowerment and immediate feedback.

Issues

At programmatic level, several issues were identified. The initiators were outsiders and if there were "villagers", these were the choice of local politicians, therefore their allies. Outsiders were observed to have "poor attitude" defined as "having ready-made solutions in mind". Follow- up of interventions was seen as a need including upgrading on technical areas. There exists the danger of unwittingly " stigmatizing" the receivers of the HIV/AIDS/STD messages in the way the programs are formulated. To illustrate, these should be designed not just for "truck drivers but rather a program for all male customers. This would include others at risk group such as the military personnel.

Transparency 13

How do we make it happen? (Program)


Planning ® Implementation/Monitoring ® Evaluation

Benefits:





· Qwnership

· PRRA (Kenya)




· Empowerment

· PAR




· Immediate Feedback

· Entry points

- Normal sesuality other than HIV




- Water sanitation




- Basic needs



Issues:

· Initiators are outsiders


· Choice of "villagers" by local politicians (allies).


· poor attitude of outsiders - "Have ready solutions in mind".


· need follow-up (+technical)


· "Stigmatize"


- not design for "truck drivers" but program for "male customers" military

Culture (Transparency 14)

The participants' statement "It all boils down to culture" sums up the role that culture plays in communicating at the rice/maize roots. Culture makes itself evident with "local wisdom", "local language" and "local experts" - the actors of street plays and the "Superstars of the CSWs".

Overall issues

In the round table and plenary sessions, there were three repeated concerns. One is that mass media is costly but so are the peer education approaches and the street plays. Second, there exists a difference between communicating in a rural and in an urban setting. This difference, through in terms of content (message) and of channel (media), was not clearly spelled out in the conference. Finally, the question of sustainability was raised as follows: Is there a defined phase-over? Where will the funds come from?

Transparency 14

Culture

It all boils down to culture!



· local wisdom



· local language



· local experts - actors

- "superstar"

Issues

Rural vs urban = difference

Mass media: costly

What is the difference - content


- peer education

- media


- streetplays


Sustainability


- Phase-over?


Family planning campaign. The case in Masaka District, Uganda

Jennifer R. Sengendo and Deus Yiga

Family planning is not yet widely accepted in rural Uganda. According to the 1995 Demographic and Health Survey, only 8% of married women of reproductive age used modern family planning methods. In Kampala, the contraceptive prevalence rate was 25%. Even though modern family planning methods were not in wide use, Uganda had one of the highest unmet needs for family planning with 31% of women wanting to end childbearing and 36% prefering to wait two or more years. Total fertility averaged 6.8 births, a tradition of early chilbearing that had led to both young population and high fertility. About 60% of Uganda women had their first babies before they reach the age of 20.

The reasons for non-use are not fully understood among those women who did not want to become pregnant, about 20% stated that they did not use modern family planning methods because they feared health problems, side effects, lack of information on the location of services or did not get support from their husbands.


Figure

The "Plan Today, Enjoy Tomorrow Family Planning" Campaign was implemented in 10 districts of Uganda through the Delivery of Improved Services for Health (DISH) Project, a USAID-funded project. The DISH aimed to improve the quality of reproductive health services, behavior, knowledge and attitudes of the people in the areas of family planning, human immunodeficiency virus (HIV) /acquired immune deficiency syndrome (AIDS) prevention, sexually-transmitted diseases (STDs) prevention and treatment and maternal and child health.

The project included training of nurses, midwives, doctors and medical assistants; information, education and communication (IEC); logistics and management information systems; health finance; and community health workers sub-projects.

The IEC component of the project was carried out at the district level by the district health educators, with technical assistance from IEC coordinators based in Kampala. The Johns Hopkins University Center for Communication Program provided the technical support.

Reproductive health concept introduced

The IEC campaigns focused on the advantages of family planning methods and the availability of family planning services.

Communication media used

The project hired a consultant to review the existing literature on family planning and the staff conducted focus groups and in-depth interviews with male and female users and non-users of family planning methods to determine some of the factors contributing to non-use and use of contraceptives. Most of the non-users did not know anyone using contraceptives methods. They had many fears and associated family planning with ill health and promiscuity. On the other hand, family planning users, as a whole, were very good spokespeople for family planning. They related stories of improved financial situations, more time for their family and for small business development and all were healthy and happy.

Given these findings, a group of health educators from the 10 districts of Uganda met with DISH Project Communication staff in a workshop early 1995, to design the message and media strategy for family planning campaign for rural men and women. The group decided to focus primarily on married women 18-35 years old who did not use modern family planning methods and did not wish to have another pregnancy immediately. The secondary audience were the husbands of these women.

Campaigns were designed to correct misconceptions about methods and to direct women to family planning services. All campaign activities and materials carried the promise that if couples use the modern family planning methods, they would have more peace of mind. The campaign slogan was "Plan Today, Enjoy Tomorrow." The main campaign messages were:

· The modern family planning methods are safe. They are approved for use by the Ministry of Health and are used by thousands of Ugandan women without any problems.

· Modern family planning methods allow couples to have children when they choose to . This gives couples more time to care for their children, to work and to relax.

· Modern family planning users are happy with their decisions to use modern methods. They are healthy, happy and recommend the methods to others.

· Family planning services are available from any health worker or health facility with the yellow family planning flower.


Figure

Between February and August, 1996, Masaka District organized the Plan Today, Enjoy Tomorrow Family Planning Campaign. The campaign used a multi-media approach combining print materials, radio programs, jingle and spots, and locally organized events such as market day fairs, drama tours, arrow signboards labeling family planning facilities and video shows with discussions. The DISH Project hired an advertising agency to produce posters, newsletters, leaflets, radio jingles and spots, billboards, clinic signboards and a half-hour weekly radio programme in English and the vernacular called "Choices'. Carried out in three languages: two vernacular and English, "Choices" and the "Health Matters" newsletters are still ongoing activities.

The Masaka District Health Educator worked together with representatives of local non-government organization (NGO) to organize district level events, which had an estimated attendance of 10,000 women. The local activities reinforced the mass media campaign.

The district also put up logo and arrow signboards on the major roads showing the location of facilities offering family planning services. A parallel activity was the continuing training of new service providers.

What made "Plan Today, Enjoy Tomorrow" campaign unique are the following features:

· Active involvement of the target audience in research and implementation.
· Well-defined and consistent campaign theme and specific messages.
· Strong publicity campaign using posters, radio and interpersonal communication.
· Support and active participation from DISH and the Ministry of Health.
· Formation of District Action Committees (DAC). to be in charge of the campaign made the district to feel ownership of the campaign.
· Thorough distribution of campaign materials to the target audience at grassroots level.
· Community participation.

The Market Day Fair in Masaka district

Masaka district is the fourth largest district in Uganda with population of 800,000.

Majority of the people in the community depend on agriculture with coffee, banana, beans and maize as its major crops. Luganda is the most widely-spoken language. Literacy rate among women is still low, mortality rate is high and contraceptive use is still low.

In rural areas, outdoor markets are very popular. These markets operate on specific days of the week. Market days are usually busy with many activities going on, attracting over 10,000 persons for each site.

The district organized five fairs during established market days to promote the campaign locally. To ensure that family planning fair attracted people's attention, a big banner with the campaign slogan "Plan Today, Enjoy Tomorrow" was hanged in a place where the fair was organized. Four stalls were put up, one stall for information giving, second for counseling, third for drama and video shows and fourth stall was for selling condom and pill plan. A drama troupe performed a family planning drama and nurses and midwives answered questions from the audience.

While the drama was going on, the nurses and midwives tended a small curtained-off stall where women and men could receive individual counselling and some family planning methods. After the drama presentation, a video on the modern methods was shown. The district invited sales people from Pilplan pills and Protector condoms to set up booths at the fair and give information about their products. In addition, several hundred copies of the campaign leaflets and newsletters were distributed during each fair.


Figure

Common questions and concerns asked by men were on condom:

" Can condom break during intercourse?"

"How can I convince my wife to use condom? How do I start the discussion?"

"If a man uses a condom, is his penis going to shrink as time goes?"

Women asked questions and had concerns related to infertility:

"If one takes pills for longer time, does she become infertile"?

"I fear to take pills and injection because both methods burn a woman's eggs and one can become infertile".

"Do foaming tablets affect a partner's manhood in any way?"

"I heared there is a diaphragm method, how does it work?"

Expected behaviors from the campaign:

· Increase in contraceptive prevalence rate in the campaign areas.
· Increase in number of new clients in the health facilities.
· Women are able to avail of family planning services.
· Women are able to discuss family planning issues and concerns with their husbands.

Major findings

Although no formal evaluation had been conducted, a review of records from selected health facilities in Masaka district showed a slight increase in the number of new clients. A market research survey conducted in November 1996 found that 50% of women had read the campaign newsletter; 80% had heard the family planning radio spots; and 73% could recognize the family planning logo. The market day fairs each attracted between 200 and 500 women who received information, individual counselling, referrals, and "enter-education" on the campaign's family planning messages. Many new clients were recruited during each fair and cartons of pills and condoms were sold.

The "Health Matter" newsletters distributed in vernacular were not only widely collected by women in their homes, but family planning practitioners integrated the distribution and review into their established methods discussion for new clients.

Radio programs in the vernacular were well accepted by the people, as seen by the written correspondence received by the producers and even the use of radio drama personalities into the local slang language heard on the street. Those programs which were aired in the late evenings had high listenership.

Finally, as seen in Masaka district, local campaign events were a successful way to strengthen the existing mass media materials. The one-on-one communication conducted at the market day fairs and drama presentations proved effective for the sensitive topic of family planning issues. The fairs were a friendly venue for family planning users to share their experiences with the other women. Such events also gave the women an opportunity to speak directly with medical authorities whose opinions they respected and whom they trusted. Equally important, they acted as additional stimulus to encourage other women to visit the facilities where family planning services are available.

Strengths of the market day fairs

1. Market days gave an opportunity to reach the primary audience (women 18-35 years) who were often thought to be busy and isolated in their homes and the secondary audience, i.e., the husbands.

2. Family planning messages reached homes which health educators could not ordinarily reach.

3. The audience was ready made, thus, less time and money were spent to mobilize the target audience. The cost per person was low while the audience reached 500 per market day.

4. There was immediate feedback from the audience and issues were clarified immediately.

5. The friendly, relaxed market environment gave the women opportunity to discuss or talk with men about reproductive health issues and family planning in particular.

Weaknesses of the market day fairs

1. Keeping the interests of the audience for more than one hour was difficult, because people come to market days to do many things.

2. Because market fairs are outdoor events, the success of the event was controlled very much by the weather.

3. For counselling, it was difficult to focus mainly on the primary and the secondary audience, the women and men respectively, as there were others, such as adolescents who dropped in.

4. The stall set-up of the market fairs made it difficult for women to get the services they required such as insertion of intra-uterine devices and injections. Referrals to family planning facilities were made.

5. After the fairs, it was difficult to follow-up the clients. There were no monitoring forms.

Lessons learned

1. There is a need to use more than one communication medium.

2. Clients are more free to ask questions in a familiar and friendly environment that is different from a "clinical" setting. They are more likely to accept family planning services.

3. Apart from the stalls, the friendly approach of the staff contribute to the "familiar" and informal setting.

4. The involvement of the district level at the start of the project and in the design of campaigns contributed to the successful implementation.

Conclusions and recommendations

The market fairs provide a good platform for a multi-media approach to reach the -primary audience, the women. There is a need to have 12 to 15 staff to support such campaigns. To be more effective, a variety of activities should be carried out so as not to keep the audience bored. This entails detailed planning. More impact may be achieved by conducting the fairs twice in the same site and by covering the rest of the 20 markets in the district.

A monitoring system has to be set-up to determine the effectivity of the market fairs.

Communication strategies for grassroots people in Burkina. The cases of Griottes, Naba, Dolotières and Camel Riders

Yacouba Yaro and Julien Tougouri

Burkina Faso, a landlocked country in the Sahel region of Africa, has an area of 274,000 square kilometers. Ninety percent of its population lives on agriculture, despite low and irregular rainfall. Natural resources are limited. Burkina Faso is divided into 45 provinces, 322 departments, 33 urban councils and 8,100 villages.

The population of Burkina Faso is composed of 60 ethnic groups, the largest of which are the Mossis (48%), followed by MandDioulas (12%), Fulanis (11%), Gurmantchnd Gurunsi (7%). In 1996, the population of Burkina Faso was estimated at 10.6 million. The average annual growth rate of the population has been about 2.6% between 1985 and 1996. About 49% of the population is under the age 15 and women account for 51.2% .


Figure

Reproductive health concept introduced

Family planning and the prevention of sexually- transmitted diseases (STDs) are the base of reproductive health. It is geared towards development of family planning and modern contraceptive methods. Besides family planing and prevention of STDs, reproductive health consists of mother and child health (MCH) and prevention of Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS).

According to the National Health Policy (NHP) and National Population Policy (NPP), family planning is " birth spacing to improve mother and child health" . The NHP promotes that family planning is not the " limitation of children," even though for many people, particularly in rural communities, family planning means limiting the number of children per couple. Surveys conducted in rural communities to evaluate the knowledge on family planning generated varied responses:

· Practicing family planning has the aim of making the wives sterile.

· Family planning is another strategy of urban people to lessen rural communities.

· People in rural communities accuse urban people of destabilizing or trying to destroy their society by using pills and other modern contraceptive methods.

Amidst these misconceptions, the NHP and NPP emphasized on family planning as a fertility issue, mother and child health, teen pregnancies and STDs/HIV/AIDS rates are serious, as indicated in the following examples:

· Fertility rate is still one of the highest in Africa at about 7.2. But there is a difference between urban women (4.7 children per woman) and rural women (7.3 children per woman).

· The average age of first delivery is 17.8 years and the median age is 19.1 years, meaning that 50% of women gave birth before the age of twenty.

· In 1993, the maternal mortality rate was 566 deaths for 100,000 live births and this rate varies from region to region and could be as high as 1,616 deaths per 100,000 live births in provinces in the north of the country.

The inaccessibility of some contraceptive methods, coupled with inadequate information on reproductive health explain the risks posed by early sexual activity. This is in addition to limited access to services and counseling in the field of sexual health and family planning. This situation leads to an increase in the incidence of sexually transmitted diseases, early pregnancies among adolescents and clandestine abortions.

In reality, reproductive health problems concern the rural population more than the urban population. Rural people most often reject contraceptive methods as they feel it leads to immoral behavior and can even be the cause of prostitution.

However, the main factor that explains the lack of knowledge and the limited practice of family planning and modern contraceptive methods is the communication channel used to deliver the message to the rural communities. Most of the time, the methods and channels are typically urban-oriented: radio, magazines or newspapers written in French. Even though radio is a popular medium, more than 45% of households still do not own a unit. When people listen to the radio, they select the programs that interest them and programs about modern contraceptive methods and family planning are not necessarily a priority.

With magazines and newspapers, less than 10% of the rural population is literate in either French or in their own language that creates a major obstacle. In addition, magazines and newspapers are often too expensive for the rural population.

The described project focused on new communication strategies for rural communities advocating acceptance of family planning and practise of safe sex through the promotion of condoms. The strategies were based on traditional means of communication, giving value to traditional channels of communication.

Objectives of the project

To increase the use of modern contraceptive methods and to increase the level of practice of family planning, new strategies were developed and tested in rural settings. The main characteristic of these new strategies is that they were based on traditional means of communication.

The communication strategies were based on the socio-cultural characteristics of each community. To implement the projects, sociological surveys were done to target communities or groups of people, to specify the type of communication medium most appropriate for them. The surveys were initiated by "Projet marketing social des condoms "(PROMACO), with the support of the National Committee for the Prevention of AIDS (NCLS) and the Population Program for the Prevention of Aids (PPLS).

PROMACO used the results of the surveys to focus at the rural communities, to develop strategies which could lead to changes in attitudes and behavior of the rural population against STDs and indirectly to practise family planning. The PROMACO strategies started in 1994 and were based on traditional means of communication such as griottes (traditional storytellers), naba (traditional chiefs), dolotis (women who brew millet beer) and camel riders (men who traditionally deliver news in nomad's community). The mode of communication was chosen according to the specification of each community.

Communication media used

Griottes or sung messages for life

Since 1994, an experiment has been executed with the Mandioula grassroots trough the griottes. In Mandioula culture where the majority are Moslems, words sung by a griottes are considered the truth and must be respected and practiced. To announce messages or to deliver news, everybody passed by the channel of griottes. In the past, the griottes played the role of actual medium such as radio or television. The griottes acted as popular advisers of people in delivering peace messages through their sung messages. Griottes were called as well for various ceremonies in the society (births, deaths, weddings). Griottes, like traditional counsellers, were accepted by the people. The community was most willing to accept the message.


Figure

This explains why PROMACO selected 218 griottes who were trained in their own language in information, education and communication (IEC) strategies. The training consisted among others, the following topics:

· What are sexually-transmitted diseases (STD) and AIDS?
· How are these diseases transmitted?
· How do you avoid contracting STD and AIDS?
· What are the symptoms of STDs?


Figure

The griottes were empowered to cover 35,000 households. From door to door, they promoted prevention of STDs and AIDS and the necessity to prevent STD/HIV/AIDS through three ways: faithfulness, abstinence or condoms. Most of the time, the griottes insisted on the necessity for everybody to accept condoms, the only way to prevent STDs and AIDS. One weakness was the time consumed in the house to house.

At the beginning, people were shocked to see griottes demonstrating the use of condom with wooden penises. Today, nobody is offended because condoms are recognized in the community as a tool against AIDS.

Traditional chiefs: Leader's influence against STDs and AIDS

The second experiment started in 1995 with the traditional chiefs. The choice of this medium for IEC was because of the fact that all the social and cultural organizations of the Mossi, half of which are Moslems, the other are of the African traditional religion are under their control. This target group was trained as the griottes. There were about 200 traditional chiefs involved in the struggle against STDs/HIV/AIDS. The traditional chiefs acted throughout districts and village committees. They gathered the people at whom they delivered the message within the community because nabas are not allowed to go from gate to gate .


Figure

Like the griottes, the traditional chiefs had influence on the community. The chief was respected as the highest being. For PROMACO, it was useful to involve these leaders in the project because they could really change the attitudes of their communities if they advocate for family planning and modern contraceptive methods. However, the people's respect carried with it a certain degree of fear such that the discussions these leaders conducted had often a serious tone.

Although there was no evaluation yet to appreciate the consequence of the involvement of traditional chiefs in the new strategies of communication for family planning and against STDs/HIV/AIDS, PROMACO noticed that people in this region were willing to receive condoms. It was difficult to determine the extent of their coverage as the leaders had the discussions in their own homes.

Dolotis' stand: "traditional beer yes, but safe sexual knowledge first!"

The third project was implemented in the Mossis and Gurunsi region. The communication media used by PROMACO was through the dolotis, the brewers of traditional beer. About 103 dolotis had been chosen to promote condom use. Dolotis were chosen because in this region, people often meet at the dolotis' stand (traditional bar) to drink and talk with friends. The dolotis stand was the main place for relaxation and leisure in this rural area.


Figure

During the qualitative study, the researchers noticed that the best way to reach the consumers of dolo (traditional millet beer) in convincing them to prevent AIDS and STDs, should be through the dolotis. Unlike the previous experiments, the target public of dolotis were mainly the dolo consumers, who were most often men (18 years and above).

The dolotis' stand became a safe and discreet place for dolo consumers to get condoms without feeling guilty or ashamed. However, there was no assurance if the drunken men used the condoms.

Camel riders: messengers of peace and welfare in Sahel region

Since 1995, the fourth project had been executed with the camel riders in the northern part of Burkina Faso. The northern region was occupied by Fulanis who were most of the time, nomads. This part of Burkina is a desert area where camels are well adapted to travel. This animal can resist desert calamities and it is less expensive than a car. About 110 camel riders were chosen. To reach the nomad's communities, the camel riders preached in Fulani language, from area to area.


Figure

At all times, the camel riders wire considered as the messengers of peace and welfare in the society. Like the griottes, the camel riders were well listened by the population. Their message was: the best way to enjoy life and to preserve yourself is the use of a condom.

Camel riders were most often Moslems as 96% of the people in this region belong to the Islam religion. This explained why camel riders could give appropriate responses to people who thought that condoms were inducing opposite attitudes according to the Koran precepts and the community manners.

It was also important to note that in the Fulanis community, sex is a taboo. People were ashamed to talk about it, even the adults. In this part of the country, STDs and AIDS were spreading widely, most probably as a result of shame about sex.

To reach the largest number of the population, the camel riders were organized in four caravans. They should deliver the message to 74 villages. In each village, they met the people. Through this setting, the camel riders gave the message and demonstrated the use of condoms. To be recognized, the camel riders were dressed like nomads in purple color and on their tulbans, they put the locally-used condom.

Today, almost all the Fulani communities had received one caravan of camel riders and it was easier to talk about sex than before. Because the strategy involved travel from one place to another, follow-up of the clients was a major weakness.

Expected behavioral results

The behavioral results expected from the use of traditional channels of communication was awareness about family planning and HIV/AIDS/STDs which would have a change in the sexual attitude and behavior of rural communities. PROMACO expected the increase of condom use. For Ministry of Health, the expectation was the decrease in incidence of HIV/AIDS/STDs.

Major findings

After three years of testing the traditional communication strategies in the rural areas, some findings are as follows:

· The knowledge and the practice of family planning and the prevention of AIDS and STDs increased significantly in the target communities. Today, a greater part of the population could indicate the importance of family planning, the usefulness of condom and the symptoms of STDs/HIV/AIDS.

· The use of traditional channels of communication was an experiment which should be encouraged and experimented in some other regions because it was easy to implement and it was not expensive.

· Today, almost all the targeted communities had received the message of family planning and prevention of STDS/HIV/AIDS.

· The communication strategies were sustainable because they were executed by the members of the communities.

· Monitoring of the clients was a major gap in these four traditional channels.

Conclusion and recommendations

Traditional media forms are more adapted on the context of many countries of Africa. Those strategies are easy to implement and they are not expensive. But to test these kind of strategies, some criteria should be respected.

First, in using traditional channels of communication, it is important to consider the gender issues. The media forms should be accepted and appreciated by the community; men and women.

Second, prior to the experiment, it is important to do some qualitative research to find out the traditional media forms mostly used in the community. Furthermore, it is necessary to know whether the traditional channels of communication are still used by the community and less expensive than the modern media forms like radio, theater and the like.

Finally, the spokespersons chosen must be from the target community to whom the message is addressed.

If these criteria are respected, the new communication strategies could be a very effective and efficient way to reach a great number of community members.

Despite the limitations of the traditional media forms, PROMACO still wishes to replicate this kind of project all over the country.

Integrated maternal health and family planning project. The Case of the Christian Health Association of Kenya

Sellah A. Nakhisa

The Christian Health Association of Kenya (CHAK) is a loose affiliation of church-sponsored health units that include 17 hospitals, 38 health centres and over 200 dispensaries. The over 24 different Protestant denominations are spread all over the country. The health units are oftentimes found in the remote areas where majority of the population live without any other health facility around them.


Figure

Before 1982, most CHAK member health units gave priority to curative rather than preventive health services. In 1982, results of a demographic health survey revealed that Kenya population growth rate was at 4.1%, with a fertility rate of 8.1%. Meanwhile, contraceptive prevalance was as low as 7%. Rumors and myths on modern contraceptive methods were found to be a hindering factor. After the first Population Conference in Kenya, the government directed that all health organizations in the country, whether government or non-government, must provide family planning services alongside other health services. This was prompted by the realization that population growth rate was soaring up steadily, mitigating economic growth rate.

Family Planning Project for CHAK began in 1985 with five health units. Now, it has over 24 health institutions spread out in the Republic of Kenya. Majority of these are in Western Kenya where church health institutions are concentrated.

The purpose of the family planning project was to augment government's efforts in reducing population growth rate. Specific goals set were:

· creating awareness on the importance of family planning to the communities patronizing health institutions first and foremost;

· training of nurses in provision of maternal child health and family planning services;

· making available all family planning contraceptive methods to clinics at all times;

· keeping of maternal child health and family planning (MCH/FP) clinics open from 8:00 a. m. to 5:00 p. m. from Monday to Friday as per government policy in all church project health institutions;

· training doctors in surgical contraception;

· formation of local health FP committees for community participation; and

· intersectoral collaboration with Ministry of Education and local leaders at the grassroots, including church.

For the first five years, the project was funded by FPPS and AVSC. From 1989 up to present, the USAID and AVSC are funding the project.

Reproductive health concept introduced

Family planning messages about the benefits of family planning in relation to basic human needs, e.g., food, education, love, shelter, clothing, land, health, security and employment were the main content area of all the media forms used.

Communication medium used

After studying government relevant documents, folk media was chosen as the medium for information dissemination.

Folk media

This approach was carried out in all the project sites. Each site had 10-15 troupes chosen from the health unit's cathment area. The community members regardless of age, sex, religion or economic status composed the audience.

Step 1 (duration: two months)

The Family Planning Local Health Committee (FPLHC) identified community groups for folk media, e.g., women, church, youth and schools (both primary and secondary). Following this selection, an official communication was sent to the District Education Officers who granted permission to use school children to inform and educate the community about the importance of reproductive health services and child welfare. The selection of the troupe leaders was done after brief discussions with the head teachers and group leaders informing them what the folk media entails. The selected troupe leaders underwent a five-day training in folk media while the committee members underwent a three-day leadership training course. After the training, the troupe leaders went back to their villages and schools. They selected their troupes accordingly and began the training of troupes in folk media performance, e.g., songs, traditional dance, poetry, story telling and drama.

Step 2 (duration: one month) Dress rehearsal and editing

During this period, the consultant and project director went around all sites to watch the performances. This visit encouraged both teachers and children to do even better. After each performance, a feedback was given which assisted the troupes to make the necessary modifications in preparation for the public performance.

Step 3 (duration: two months) Public performance at the district level

This one-day folk media public performance was graced by an important dignitary in the community, e.g., local member of parliament or district commissioner of provincial medical officer of health. Their presence helped the community understand the importance the government gives to the family planning services. The performance was done on a Saturday after schools have finished the end term examinations. The FPLHC put up a focal place where all the troupes within that catchment area came together. To capture a large audience, the event was announced through school children, posters, invitation cards, chief barazas and churches. Project funds facilitated transport of troupes. Lunch was provided for the troupes, troupe leaders, committee members and hospital management teams. This one-day performance helped reach thousands of people in one day. Folk media as an information, education and communication (IEC) approach is commendable.


Figure

Expected behavioral result was the increase in contraceptive prevalence among the child-bearing age group 15-49 years.

Major findings

During the first three years of the project, the performance improved. New people accepted family planning. From 1,200 clients per year, it soared to 2,589 after the introduction of folk media. This trend was for all family planning methods. Participating schools reported reduction in student pregnancy.

In terms of continuity, radio and videotapes made out of the folk media public performances are now being used by the health institutions. Introduction of community-based distributors and community health workers has assisted continuation of IEC in the community.

The communication strategy was appropriate to the concept introduced because it reached large numbers of audience, regardless of sex, age, religion, affiliation, political, social and economic status. This is important because family planning practices benefit all members of the society, in relation to education, shelter, food, jobs, health and the like.


Figure

In terms of limitations, some of the people in the crowd may have been interested in the entertainment nature of the medium much more than the message. There was no room for questions or clarifications. Also, this approach was costly in terms of time and resources.

It was learned from the project that people are hungry for the right information. The large numbers who turned up for family planning services in the clinics indicated that information helped people make right decisions. However, not all who attended the performances turned up for the services. This means that some just came to be entertained.

The high number of clients who came for family planning services in the clinics following the folk media public performance indicated acceptability of the concept in relation to the medium. In another development, it was reported that the number of girls dropping out of school due to pregnancy had reduced by as much as 80 to 100% in the schools who participated in folk media performances.

The public performances helped remove the stigma of family planning practice that caused clients to shy away due to fear of ridicule by the society. Now family planning has become the talk of the day in rural and urban areas and most people are happy to be associated with family planning.

Lessons learned

Lessons learned are in the area of preparedness. There is a need to be equipped with enough staff and facilities to ensure that the newly-created motivation for family planning services does not become a disappointment to clients due to unpreparedness.

The strengths of the strategy are as follows.

1. People got educated with or without their knowledge as they were entertained through watching different performances, e.g., traditional dance, singing, poetry, drama and story telling.

2. All the schools in the area wanted to participate as some of the participating teachers got promoted.

3. Huge numbers of people were reached within one day.

4. The family planning messages echoed by the children to their parents convinced the parents to act immediately.

5. Unlike the lecture, the public performance had good mixture that made audience to remain alert throughout the performance period.

The weaknesses of the strategy, on the other hand, are the following.

1. The process which was too long required a lot patience.

2. The project was costly in terms of transportation, food for the participants and publicity.

3. Continuity was poor because of school children movement.

4. Without government support, it might not be easy to make use of school children.

Issues and concerns

Sustainability of the troupes required built-in plans from the start of the project implementation.

Conclusions and recommendations

1. The IEC strategy should be made part and parcel of all community programs. The choice of the media should be researched properly to come up with the right approach, audience, message and timing that would not contradict beliefs and cultures of the audience.

2. Make use of all the available data and people to determine the cause of the problem prior to selecting the media. Client interviews are important to help determine individual views which are useful in selecting the media.

3. Involve community in all matters pertaining to them. Community involvement is the milestone for stepping into the community and this approach is crucial to the success of this project.

4. Involvement of children in giving IEC on reproductive health and child care messages is like killing two birds with one stone: they educated their parents and as they become adults, they will not need another folk media to help them utilize family planning services.

5. Government policy helped penetrate school system without resistance.

6. Having observed the drama depicting high death rate from HIV/AIDS, the audience would take the message seriously.

Use of drama to promote family planning. The Uasin Gishu Experience

Peter N. Kagwe

Uasin Gishu is one of the districts of the Rift Valley Province of Kenya. It is an agricultural district producing mainly maize and wheat. Most farms are at least 2 acres or more in size.

The district has a population of 445,000 in 1989 with a growth rate of 3.8%. According to the Kenya demographic survey (1989), about 61.5 % of married women in the district need family planning. In the district, 10.1% of the women of reproductive age use contraceptives.


Figure

Based on these information, the Diocese of Eldoret came up with a community based family planning project, a three year program funded by the Pathfinder International. The program started in November 1994.

The project covers most divisions of Uasin Gishu District. It has three zonal offices located at the division levels of the district namely:

· Northern Zone Offices situated in Ziwa Machine;
· Central Zone Offices situated in Eldoret - Elgon View; and
· Southern Zone Offices situated in Kesses.

Currently, the project has 120 trained Community Based Distributors (CBDs).

The main objective of the project is to increase awareness, knowledge and usage of family planning services in Uasin Gishu District through community based health care and CBDs. To attain these objectives, activities undertaken were:

· family planning (modern methods), sexually-transmitted diseases (STDs)/human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) education through the CBDs;

· supply of contraceptives through CBDs;

· counselling of clients; and

· referrals to relevant health facilities.

Reproductive health concept introduced

Family planning in Uasin Gishu District is essential given that the total fertility rate is well above 7.0 children per woman. It is therefore necessary to make people aware and understand the need for family planning by letting them know the benefits of family planning. The project informed them of the problems and risks involved in non-use of family planning.

The program disseminated information on the various methods of family planning and how these work. People were also informed on where to avail of the materials and at what cost.

Communication media used

The rural population of Uasin Gishu District is mostly semi-illiterate and disseminating messages on family planning to the people has to be made in most acceptable and understandable mode. The project introduced the use of drama to create awareness among the community on the important issues of family planning.

The project used lectures, counselling, videos, print materials, dramas and folksongs to disseminate information on family planning. But this case paper highlights the use of drama in passing messages and creating awareness.

Drama

The drama programs were usually presented to the audiences in the farming communities in the rural highlands; both men and women with majority having an average income and mostly Christians.

The drama programs were short, not taking more than 10 minutes. It was performed by the CBDs who used the local resources for demonstration.

The script, in the local language, was first memorized by the actors. This was presented to general audiences during public meetings, church gatherings, women group meetings and also during public celebrations.

Following is a sample of what was acted by the CBDs.

Drama on family planning

Script
Scene one

Father (John) and Mother (Esther) both discussing on development of the family. This is the family that has only three children.

While talking, their last born child arrives from school dressed smartly in school uniform. Greets the parents and shows them how she performed well in school examination. She looks very happy and prepared to join secondary school.

As they were rejoicing because of their daughter's success, their second born arrives from university of Nairobi. He looks healthy and happy, greets the parents and explains to them how he has been doing in the University.

Parents congratulate them for doing well.

The first born arrives. Dressed well in smart clothes. Looks happy. She completed university two years ago and currently working at Nairobi. She has brought a lot of presents for her parents.

As they were talking and drinking softdrinks, the elderly parents arrive. They looked tired and exhausted after having travelled a long distance to visit their children.

The father of the family, his wife and children greet the old people and converse together. John asks his father how his brothers are doing. His father told him that the elder son who is a brother to John has his son jailed because of stealing. His sister is sick after giving birth to her 12th child. Other children are not going to school because of lack of school fees and uniforms.

Immediately, the old man completed describing how his sons and their children are doing, the old woman (mother to John) asks why she was not able to see a small baby. Esther (John's wife) tries to explain to her that the few children they have are enough for them. Both old parents looked annoyed.

John starts to explain the importance of a small family. He tells them that he has succeeded educating his children because they are few. He describes the success he has in the family as a whole. Also states that a large family brings problems. Cited his brother as an example. The son was jailed after having broken into the hotel and stole food. Children are not going to school and they are ever starving because the family is big.

Scene two

A neighboring pregnant woman has just arrived from where she had gone for "kibarua" (manual paid labor). The husband had run away because he could not manage to feed the family. Here she comes to John's family for assistance. She wants to be given maize flour to cook porridge for the children's lunch. She carries her baby on the back. The baby cries because of hunger. The woman asks for any food to give to her baby. Instead, she was given milk. She thanks Esther and begins to go. After walking a few steps away she turns back and asks for more milk.

Both John's parents looked at the lady with curiosity.

Immediately that woman leaves, John's father thanks John and his wife for having planned their family well.

John's daughter who works in Nairobi went to the kitchen with her mother. They started discussing about what they can give to the old parents. The agreed that the blankets which she bought can be given to them and adds a thousand shilling (US$20) to each.

They now come to the sitting room. Esther starts to tell the family that their daughter has a present for them. Their daughter now starts to award both of them with what she has.

The old parents start to show how happy they are. They dance with joy inspite of their old age. Thanked all the members of John's family for the progress they have made.

They now ask permission to go back. They are escorted by John and his family.


Figure

Major findings

From the presentation of the drama, the project found out the following:

· Many people have approached the CBDs immediately after the drama presentation asking about the various methods of family planning available. They also sought clarification about the family planning issues raised in the play. The community members requested for appointments with the CBDs.

· The people recognized the problems associated with unplanned families.

· The audience found the drama presentations appropriate and very touching because they portrayed what actually happens in their daily lives. Because they were able to identify with the play and problems they were individually facing, they were able to accept the concept of family planning and adopted a method.

· The community requested for more and repeat performances of the drama presentations.

· When the play was presented in institutions like the village polytechnic school, the play was adopted by the students and was presented to other audiences, i.e., parents/ teachers' meetings.


Figure

Strengths

· The presentations enabled the CBDs to create awareness easily on family planning without having difficulties in approaching the issue.

· Drama presentations offered a good and appropriate entry point to the otherwise conservative community, especially on discussions of family planning.

Weaknesses

· When the audience is mixed, it was difficult for would-be clients to come up and express their needs.

Lessons learned

· It is important to use locally-available resources for demonstration, e.g., in Uasin Gishu, the maize cob was used to demonstrate the penis in condom use.

· The drama presentations should also highlight other related issues like nutrition, immunization, safe motherhood good hygiene.

· The size of the audience for drama presentations varies with the season and the type of production activity going on (i.e, planting, ploughing, harvesting and festival season).

Conclusions and recommendations

1. Drama presentations and plays should be used as much as possible in the promotion of family planning and also in creating awareness on HIV/AIDS.

2. Use of locally-available and acceptable resources and materials should be used in the plays/drama presentations.

3. The drama should always be relevant to the community's need and the people should be able to identify themselves to the particular need/issue being presented.

4. Specific plays should be shown to specific audiences, e.g., different drama presentation for the youth, women of reproductive age, men and other groups.

5. Because the size of the audience varies according to seasons, it is important that the drama presentation should be well-timed to attract the desired number of audience. Ill-timed plays lead to low turn-outs.

6. The CBDs may, in the future, perform the shows for a fee for sustainability purposes.

In all, the project hopes to continue using drama presentations to promote family planning services and to create awareness on HIV/AIDS. It is the project's plan that the plays will be taped and be played back to audience at various forums.

Communication pattern to promote rights to reproductive health

Zohra Andi Baso

South Sulawesi Consumer Organization (YLK-SS) is a non-government organization located in Ujupandang, South Sulawesi, Indonesia.

Its thrust is on consumer protection and advocacy while the main activities are on research and environmental issues to increase consumer welfare; strategic rules and laws of consumer protection; surveys of business activities; monitoring the impact of the environment and consumer protection; documentation and publication of consumer and environment issues; consultation and advocacy work by giving trainings and information to the consumer groups or local institutions.


Figure

On the reproductive health program, YLK-SS, in cooperation with the Ford Foundation, launched the program Advocacy on Reproductive Health Service. The main activities of this program are on research, publications, trainings and seminars and mass media advocacy. This program was carried out in three districts in South Sulawesi. In November 1995, research was started in Toraja, Pangkep and Ujung Pandang. The focus of the research on reproductive health was specific on clients' rights to family planning.

Reproductive health concept introduced

The concept promoted was the consideration that the right to reproductive health is important. Everyone has a right to information on reproductive health, particularly women who carry the bigger responsibility in the reproduction.

Issues related to family planning were also addressed. Many women still lack information on contraceptive methods, where to find and how to use them. Women are also reluctant to try something that they know little about. And most women worry about the side effects of contraception that are usually unfounded.

Communication media used

Considering the problems in the community, one of the ways used to raise awareness of the clients was the use of communication to inform people of the various reproductive health issues.

Mass media

The communication strategies used to deal with reproductive health issues consisted of two main patterns; mass media and face-to-face communication. For mass media, brochures, radio broadcasts and newspapers were used. Face-to-face communication was used in seminars and trainings.


Figure

For brochures, two versions were made. The content of the first focused on the method, use and side effects of contraceptives. The second version dealt with the rights of the contraceptive users. The target of these brochures were contraceptive users (both male and female), girls and adult women and also the promoters of family planning who come to visit the clients in the field. Brochures were also sent to government, non government organizations (NGOs), universities and contact persons in Toraja, Pangkep, Ujung Pandang and to the participants in trainings.

For radio broadcasts, two local radio stations were tapped to air programs twice a month that discussed information and issues on reproductive health and family planning. During broadcasts, the audience was given the chance to ask questions or give comments on the topic discussed.

The information contained in newspapers was written in a special column of consumer issues that also included reproductive health issues. The information reached the middle class and urbanized audiences. Two local newspapers cooperated with this program.

Face-to-face communication was used to give in-depth and comprehensive information to the consumers and promoters of family planning programs. This was particularly used in seminars and trainings to address the issues of gender, reproductive health and consumer rights. These trainings were conducted to raise the awareness and motivation of consumers and promoters of family planning clients' rights for information dissemination.

Peer educators' training

The project targeted to train 140 peer educators who would also educate others in their village (rural and urban). This was necessary to create a cadre of "family planning providers" who could communicate information on reproductive health-clients' rights awareness beyond the project.

Most peer educators trained by the project were women and men. The age range was 17-45 years and with mixed economic status. Contents of the sessions were about reproductive health, women's health, consumer rights, clients' rights, family planning -contraceptive methods and case studies.

Seminars were given twice a year. Participants included representatives from government, universities and NGOs.

Expected behavioral results

The project specifically hoped to increase the understanding of reproductive health and clients' right of government people so that they would contribute to increase service of family planning - clients' rights.

Major findings

By using mass media and face to face communication, the major findings were:

1. Media forms like brochures, radio broadcasts and newspapers can effectively reach a wide audience encompassing all levels of age, gender, economic status and community setting (rural or urban area).

2. Face-to-face communication used in seminars enabled in-depth discussions to enrich the information and knowledge of the audience to deal with reproductive health issues. In-depth information motivated the efficient delivery and spread of information to others.

The communication media forms used in the program were all effective. Many people can read the message from the newspaper and listen from the radio. However, it is not always possible to convey the entire message through street plays.

In terms of peer educators' trainings and seminars, it was difficult to cover a large number of people through training, organizing and mobilizing people because it would require considerable time and effort. The audience was very limited (about 30) and conducting such was expensive.

Conclusions and recommendations

Mass media is the most suitable form to be used in a heterogenous audience. However, audience behavior cannot be easily measured. For face-to-face communication, the audience can get more comprehensive information but the audience can be very limited. Therefore, the two patterns of communication should be used simultaneously.

Family planning communication at the grassroots. The case of Yirgalem Family Planning Project

Amare Bedada Desta

The Family and Fertility Survey conducted by the Central Statistics Authority (CSA) in 1990 revealed that the contraceptive prevalence rate in Ethiopia is extremely low. In the rural areas, it was only 2.6% and 63% of those interviewed had some knowledge on family planning methods. The gap between knowledge and practice needed serious consideration.


Figure

In the early 1990s, Ethiopia's smallest administrative unit (minimum of 3,000 people) benefited from the Expanded Programme for Immunization (EPI). The Ministry of Health (MOH) clinics provided outreach EPI services to the Peasant Associations on a monthly basis. However, family planning services were not integrated with the vaccination programmes.

This situation encouraged the Family Guidance Association of Ethiopia (FGAE) to complement the MOH programmes by integrating family planning services. Hence, the Yirgalem Family Planning Project was initiated in 1992 and was funded by Population Concern/United Kingdom.

The project was implemented in the Dale district of the Sidimo Administrative Zone, Southern Ethiopia. Out of the 76 peasant associations of the district, the project covered 20 associations with 85,700 people. This was approximately 27% of the total population of the district. Almost all (98%) of the people belonged to the Sidimo ethnic group and the majority followed the Protestant Church.

The project targeted all married couples in the reproductive age group (15-49). Besides these primary targets, the project focused on district government officials, Peasant Association Chairpersons, religious leaders, community leaders and health workers as secondary targets.

Reproductive health concept introduced

The project introduced child spacing as the main family planning concept. Using contraceptives to space pregnancies was then a new concept to the peasants and precautions were taken so that this may not be misinterpreted. The early activities of the project concentrated on creating a social climate conducive for acceptance of childspacing.

Communication media used

As the beneficiaries of the project were peasants who do not have access to the mass media, the project used interpersonal communication as the main medium to disseminate the concept. This was supported by project- developed print materials like posters, flip charts and imported films.

Steps in information dissemination

Formation of steering committees

The project conducted series of seminars that involved government officials, religious and community leaders and health workers. These were done to create a clear understanding of the objectives of the project and also to win their support during the implementation of the project in the rural areas.

These seminars were followed by the formation of steering committees at different levels: district steering committee; Peasant Association steering committee; and a committee of health workers.

Chaired by the district administration, the district level steering committee had, for its members, government officials.

The Peasant Association level steering committee consisted of the chairperson of the Peasant Association, a religious leader, a respected member of the Peasant Association and the family planning promoters. The group conducted monthly meetings. There was an overall steering committee for all the peasant associations covered by the project that met quarterly.

The committee of health professionals was composed of the district health manager, head of the Yirgalem Health Center and the staff from the five clinics. The formation of this committee was intended to strengthen the family planning activities of the health institutions. This was also done to prepare the MOH clinics to take over the activities when the project phases out.

Sponsored by the project, each of these committees met separately every quarter in the town of Yirgalem. Sometimes, one representative from the peasant association gets invited to the district level committee. These discussions focused on progress of the project activities and problems encountered, if any, with corresponding resolutions. Apart from the meetings, the members participated in the information, education and communication (IEC) campaigns.

Formation and maintenance of project field implementors

The family planning awareness creation activities were carried out mainly by the family planning educator and the peasant promoters. The family planning educator employed by the project was selected on the basis of knowledge of the local language and culture and work experience in the rural setting.

The promoters were selected from the Peasant Associations in which the project was implemented. About 46 promoters were selected on the basis of residence in the Peasant Association, knowledge of the local language and acceptance by the people. The promoters were first trained for 10 days in family planning communication and were provided with series of refresher trainings ranging from two to four days, once or twice a year. They were also called to monthly review meetings which were basically experience exchange sessions among the promoters.

The peasant promoters provided free services and were given only food and transportation allowance during review meeting days. But when the project started charging a small amount for its family planning services, the promoters as distributors, were allowed to retain 60% of the collections from the sales of condom and pills.

To supplement the interpersonal communication methods, the project produced posters and flip charts. These were based on local analogies. The poster showed spaced and crowded 'Enset' plants to show the benefits of spacing. 'Enset' is the staple food of the area and practically every peasant has at least 20-30 of these around his hut. This analogy showed the peasants that 'Enset' plants have better yields just like birth spacing will yield healthy children. The captions were written in the local language and also in Amharic.


Figure

The project also used audio tapes and 16 mm films. However, the films were imported and the people did not understand the language. The messages were translated as the films were shown.

Expected behavioral results

The project aimed at increased knowledge of family planning from 32.8% to 75% and contraceptive use from 4.1% (baseline survey) to 18% among married couples within five years time.

The quarterly meetings with the different steering committees were held to create smooth working conditions in the community.

Major findings

The face-to-face communication (discussions) with district authorities, health workers and religious leaders created a favorable situation to the project activities. As a result, the project was able to hold its promotional activities at the EPI sites, at the local church gatherings and at the community work places. The communication media used at each of these places had their own strong and weak points.

The EPI Sites

In the EPI sites, the main targets were mothers. In addition to raising awareness, this was used as an entry point for the family planning services of the project. The public address system fixed on the project car enabled the project staff to call more mothers for the EPI programmes. Even mothers who lived in the farthest corners of the Peasant Association heard the announcements from the car's megaphone.

As a result, the EPI programme attendees increased tremendously. This became an important place for family planning information and counselling for both the peasant promoters and the family planning educators.


Figure

The major shortcoming of this approach was that it targeted only the mothers. Therefore, those informed and counselled were mothers only and their husbands were not included.

After listening to the family planning talks and discussions, the mothers readily agreed to use the contraceptive pills or injectables. However, some dropped out from the family planning service after their children completed the immunization schedules. This tended to increase the drop-out rate.

The other problem the project faced in the EPI sites was that using the loudspeakers from the project cars "spoiled" the mothers. They waited in their homes until they hear the calls through megaphones. Sometimes, when the car is not useable, the promoters had to go to all the villages in the project area to inform the mothers that the team has already arrived. This sometimes overburdened the promoters.

House to house follow-up

House to house was introduced as a follow-up mechanism to trace defaulters, early in the family planning activities. But this mechanism, in some cases, created problems particularly in families where the woman used the pill without the consent of the husband. The promoter's arrival was an indicator that his wife had used family planning method without his consent.

Therefore, home visits were dropped as a follow-up mechanism. Instead, it was used as a regular IEC strategy. Home visits were made to all the households, not only to those using contraceptives. And it proved to be an appropriate IEC strategy for the rural areas. Many husbands who used to refuse to let their wives use family planning methods were easily convinced when the discussion was held at their homes.

The limitation with promoting family planning through home visits was that the promoters can make only a few visits per week. This did not allow large coverage.

The Local Church Gatherings

The participation of church leaders in the steering committees of the project made it possible for the project to disseminate family planning information, show films and distribute leaflets and booklets during church meetings.

This mechanism helped reduce religious opposition, decrease male resistance to the wives' use of contraceptives and to reach the rural youth.


Figure

The weakness of this approach, however, is that it required an experienced family planning educator or promoter who is conversant with the church ceremonies, songs and prayers. They had to be true believers for they should be able to relate the benefits of family planning in the context of practicing Christian living. The following are examples of their messages:

Promoter to a Christian woman:

" IF you have a sick baby, can you come to sing and pray? If you have five to six children who are sick, you would not have time to hear the word of God and pray together with your friends. If you are not able to come to church, you will be further and further away from God. God has given us ways to be able to space our children so we can take care of them and make them healthy. You and your children can go together to hear God's word and be good Christians."

Promoter to a Christian man:

" If your wife gives birth every year, you start to go to another woman, maybe another man's wife. Should a Christian do that? Then you do something against God, you forget your family and have unchristian ways. You may start to blame God because you have many problems, not having enough money to feed your children, and to buy medicines when they are sick. God has given ways for you to space the birth of your children. You have more time and more things to care for your wife and for your children. You start to thank God instead of blaming Him. "

The films shown in the churches to support the messages were of great help. These not only provided entertainment for the rural people but also encouraged learning

Communal Work Places

Peasants help each other in many occasions such as during harvesting or building houses. These have also been used as natural fora for family planning motivation. These offered a good venue for debates and discussions among men without the women around. As a peer education strategy, this needs to be further studied and explored.

Project achievement

Though the final evaluation is due to be carried out in June 1997, the mid-term evaluation conducted in 1996 showed the progress made. The comparison between the baseline data and the mid-term evaluation shows that the percentage of knowledge on family planning methods rose from 32.8% to 77.7% among the women. The contraceptive knowledge of the men in the rural areas increased from 45.6% at the beginning of the project to 78.3% at the time of the mid-term evaluation.

The current use of contraceptives rose from 4.1% at the start of the project to 13.7%. Many of the contraceptives were used to space pregnancies.

Lessons learned

The most important lesson learned is working together with the people and for the people. To reach the people, design an appropriate communication strategy. The right strategy will create a working relationship with politicians and religious leaders - the two gatekeepers to the ordinary people. "Vulgar words" have to be avoided in motivating couples for family planning to maintain church support of these motivational discusssions. These fora, which were identified as natural areas for discussion with individuals and couples, were useful to reach men and women.

Conclusion and recommendations

Even though the final evaluation has not yet been done, the Yirgalem Project has been successful in some important aspects. One was that it has demonstrated how a project that incorporates intensive family planning communication with services can be accepted in the rural areas. The use of communal work places of men has to be further explored as a peer education strategy.

Now, the project activity has been handed over to the community-based distribution agents and the MOH clinics. The distribution agents distribute pills and condoms while the clinics provide the injectables. An issue of concern is sustaining the active communication work and the involvement of the people in the different steering committees. Otherwise, the objective of integrating and making family planning information and services available had been achieved.

Agricultural approach to family planning. The Uganda Experience

Elizabeth K. Bamutire

Agricultural Approach to Family Planning (AAFP) is a breakthrough in family planning and contraceptive technology communication in the rural community. It is an innovative approach of designing communication, training materials and visual aids that are employed to accelerate learning and acceptance of family planning practices in rural areas.


Figure

The AAFP Project was implemented by Family Planning Association of Uganda (FPAU) from July 1992 to December 1996, in collaboration with Family Guidance Association of Ethiopia (FGAE), with funding support from Lutheran World Relief (LWR). The International Institute of Rural Reconstruction (IIRR) provided the technical backstopping required to equip the FPAU staff to effectively communicate family planning concepts to the rural people.

The project was specifically designed to address the problems of family planning field practitioners who found it difficult to simplify ideas and concepts that are of academic and Western orientation and totally unfamiliar and contradicting to local traditions and customs.

The project addressed the communication problem of rural farmers who had no access to media and cannot conceptualise the functions of modern family planning devises and terminologies. Because the approach uses simple agricultural concepts that are familiar to farmers, it catches their imagination easily.

The target audience were young school girls, women aged 20-40 years old and men. They were selected because of the uniqueness of their problems and the high incidence of adolescent pregnancies.

Reproductive health concept introduced

The agricultural analogies centered on the why, what and how (modern methods) of family planning.


Figure


Figure

Communication media used

The medium used in the AAFP was basically print. This was combined with one-on-one communication, group talks and home visits.


Figure

Agricultural parallels were elicited from the people through a workshop. The workshop focused on family planning messages and practical analogies that depict the why and how of family planning. This involved having a knowledge of family planning and later being able to formulate simple but scientifically accurate messages which are comparable and could be understood by the rural people. The analogies were also compared to their experiences. The artists worked hand in hand with participants and the messages were translated into illustrations. These were pretested and refined for translation in three local languages in Uganda. The posters produced were distributed to all key players in reproductive health and especially to community workers and satisfied users to be used as teaching materials.

Expected behavioral results were understanding of family planning concepts and eventually increasing contraceptive use.

Major findings

The posters on AAFP have been in use for approximately a year now. Although an evaluation has not been done yet, there are indicators of success for this approach. The villagers were able to grasp the concept and they understood effectively. The CBDs registered an increase in the number of referrals at FPAU clinic in their areas. A number of field health workers asked for posters to be reprinted even those from other areas which are not covered by the project. Because of the familiarity with the approach, the community was able to draw other analogies similar to the already developed ones, i.e., plunging a piece of wood in the middle of a banana shoot as an analogy for the IUD.


Figure


Figure


Figure


Figure

The strengths of AAFP are the following.

1. The community could identify itself with the posters because the ideas originated from them.

2. The approach was very useful and precise as it was built on the experiences of the people.

3. The language was acceptable to the community.

a) Local examples were used which the people were familiar with and therefore were easily understable to them.

b) Specific rural terms were identified and it was directly related to the rural environment.

c) The messages were appealing rather than intimidating.

d) A comparative family planning information was given that promoted the opportunity to make an informed choice.

e) The field workers and family planning providers were given an easier way of communicating family planning messages to the people.

f) Uganda has diversified languages but the approach allowed a common understanding of family planning concepts within some tribes.

The interpersonal communication (i.e., CBD home visits with use of charts) was slow though very effective in addressing individual concerns. Field workers, as mentioned earlier, were unfamiliar with some of these analogies and so they needed orientation in the use of this approach before providing health education to the community.

The approach used field staff and it had suffered greatly from high staff turn over due to poor remuneration. This meant that the project lacked continuity of staff who were originally oriented in this approach.

Lessons learned

· Effective communication needs the involvement of the community.

· Effective communication should start with what people know and build on their experiences.

· AAFP could be a breakthrough in communicating sensitive issues and could improve the relationship of educators with the community

Conclusion and recommendation

AAFP should be promoted and efforts be made to initiate an impact evaluation for the effective documentation of the approach. Furthermore, the field staff should be re-oriented about the approach from time to time.

Agricultural approach to family planning. The Talebpur Experience

Shaikh A. Halim

The Village Education Resource Center (VERC) in Dhaka, Bangladesh was founded in 1977 as a project of Save the Children, USA with assistance from the United Nations Children's Fund (UNICEF). Its objective is to help people help themselves in their effort to combat poverty. The center assists and works with other government and non-government organizations (NGOs) having similar objectives.


Figure

VERC has its support service programs like communication and training methods and materials development, designing and modifying low cost but appropriate technologies and implementing projects to help the poor, especially the women.

The center forms groups, encourages savings, provides education and training and small credit support to create employment and to generate income. VERC also provides health education and services for better maternal and child health care and family planning and educates women and children. These activities help uplift the prevailing socio-economic status of the poor.

The Agricultural Approach to Family Planning (AAFP) is an effective communication strategy developed by the International Institute of Rural Reconstruction (IIRR). The AAFP uses common life examples as analogies to help people understand new ideas related to reproductive health practices. In 1989, VERC worked with IIRR to develop some communication and motivational materials on health and family planning for the villagers. IIRR worked with VERC trainers and field workers in developing materials (pictorial flash cards) that gave an opportunity to share ideas with government organizations like the Directorate of Family Planning, the Bangladesh Rural Development Board and other NGOs.

Community where project was implemented

In 1990/91 -1992/93, VERC implemented a project called Women's Entrepreneurship Development and Family Planning in Talebpur union of Singair thana of Manikgonj district. The project was funded by Asian Center for Population and Community Development (ACPCD) under a Global Partnership. Its main objective was to motivate women to continue using family planning methods and to engage them in economic activities through their own savings, supplemented by VERC credit fund.

Most of the project beneficiaries were poor who earn less than the national per capita income of US$200 in 1989/90. The area is typical rural plain land criss-crossed by rivers and canals. Agriculture is the main source of livelihood of the majority of the people. They grow paddy, jute, sugarcane and vegetables; raise cattle, poultry birds and cultivate fish. Most of them are illiterate. The women are left far behind as it is a male-dominated society where women are kept at home to look after the children, cook and do household chores. Women are restricted from outside work and maintain Purdah (veils). Muslims dominate the community with a small Hindu group. The prevailing belief is that family planning in itself is immoral. There also exist religious beliefs, social traditions and superstitions that form the conventional wisdom in the society.

Reproductive health concept introduced

The project imparted knowledge and techniques of contraception to space birth and limit family size and to control or prevent related diseases. It also addressed social customs, beliefs, norms and values related to family planning. It included topics on male-female anatomy, infertility, methods of family planning, ovulation, fertilization, germination and related topics like sexually trasmitted diseases (STDs). During trainings or group meetings, topics came up either from the trainees/workers or from the villagers (participants) and/or the resource persons. The Acquired Immune Deficiency Syndrome (AIDS) as a diseases was not much known and discussed at that time. Although it came up as a new threat on which people need to learn more for precaution.

The social aspects, like the importance of family planning in maternal and child health MCH care (more time for work, good health, good care of children, more social and economic activities), bad effects of early marriage, pregnancy and early age pregnancy and the positive view of women were also raised.

Aside from family planning, the project also addressed the issue on who determines the sex of an unborn child as this frequently came up during the discussion of the human reproductive system. Majority in the project area believed that women were responsible for the sex of the baby. In a society where male children are generally preferred, this type of misconception irrationally held the women responsible for sex determination and infertility. As a result, they faced family hatred, even torture and divorce or were forced to share the sufferings of injustices by living with their husbands' other wives.

The project beneficiaries were couples aged 15 to 49, mostly from poor farming families. Though women were the direct participants, VERC trained couples to properly understand the responsibilities regarding the project activities and the reproductive health behavior and identify areas of cooperation. Separate sessions were held on reproductive system as the women were shy with the presence of their elderly male relatives or in-laws.

Communication media used

Various media forms were used by VERC workers and some were combined as required. In most cases, flash cards were used to impart messages on health and family planning, specially in trainings and meetings. In most cases, these were integrated with other programs in the field that included income generation, institution building, general awareness creation, training on family planning methods and maternal and child health care that included breast feeding. Short films or taped dramas were also used in training sessions. Other materials used for discussion were flash cards on women's status and women's work and articles in magazines and newspapers were discussed by field workers. Villagers were also advised to follow radio programs relevant to the said activities. Folk media forms were applied effectively or as the situation demanded for it.


Figure

As a process, the women were organized into socio-economic groups and were provided with knowledge of literacy and numeracy. VERC also provided necessary training on family planning to the couples. New ideas came up in the development of materials and some of which were tested and used in different training sessions. Their experiences were also published in VERC Bengali and English newsletters intended to develop field workers. Some readers made comments and querries on the concepts, approaches and use of materials.

Group discussions and plenary sessions were held to review lessons and identify issues on reproductive systems, including the use of contraceptives. During these sessions, 16 multi-colored flash cards (11" x 14") depicting issues related to over population were shown to the participants that took 10 to 12 minutes. Another 30 minutes were spent to discuss the common attitudes and beliefs of the people on various issues related to reproductive health practices and family planning methods. The pictures on common analogies to family planning concepts were shown to the participants and the facilitators tried to link up the discussion to family planning methods from the common life examples. This discussion took another 40 minutes that totalled 100 to 120 minutes in a session to include warm-up and wrap-up time. It required 16-18 sessions over the project period which was two years. On many occasions, people cited their own examples and raised many critical issues.

On the belief on who determines the sex of an unborn child, it was only through repeated education and communication campaign that such misconception might be changed. Government controlled radio/television stations aired programs (dramas plays, discussions) with a view to change the existing social attitudes and beliefs The field workers m VERC projects strived to relate their own message with those of the government and other media campaigns.

Examples of media materials that used agricultural analogies

A flash card shows a farm with many but sickly chicken and a farm with fewer but healthy chicken. Similarly, a family with fewer children will definitely have better chance of having healthy and intelligent children (importance of small family size).


Figure

Two flash cards depict inputs and care required by plants and children, respectively for their growth. This was very effectively used by the MCH workers who helped the Trained Birth Attendants to work with village women for the mother and child health care. This was used along other materials for preaching health care, immunization, family planning and nutritional messages for the mother and child (importance of health care and inputs needed).


Figure


Figure

An audiotaped drama describes awareness on family planning. Among other things, it describes through drama that birth spacing is required for the health of the mother. It gave example that many plants are spaced and kept in limited number so that soil could give enough nutrients for their growth. This was also used with other materials and the drama was followed by discussion (awareness on family planning and birth spacing through agricultural approach).


Figure

A flash card shows two pictures: a hut built with immature bamboos (can break down easily) and a hut built with matured bamboos (is strong and can last long). This shows the demerit of early marriage that is harmful for health and fatal for the young mothers. There is a practice that goats are only allowed to mate when they become mature as the kids may not survive (bad effects of early marriage).


Figure

A flash card with a few pictures shows that a farmer sowing paddy seeds (x) harvests paddy and sowing jute seeds (y) harvests jute. Similarly, a male can contribute 'X' chromosome or 'Y' chromosome to fertilize an egg contribued by a female. The female egg always contains chromosome 'X' only. If the egg is fertilized by 'X', it produces a female child and if it is fertilized by 'Y', it produces a male child. Like a farmer providing paddy or jute seeds, it is only the male, not the female, who can provide 'X' or 'Y' chromosome to determine the sex of the child to be born. As the germination of seeds depends on other factors, the fertilization of the ovum also depends on other factors (stimulates discussion clarifying misconceptions and changing attitude).


Figure

Several other analogies were brought out which may not be directly agricultural or related to health and family planning but they were taken from common life experiences and were related to various development issues:

Gender: The male and female of some bird species share work to build the nest or hatch eggs and feed the chicks. In the same way in our society, male and female could share load in all aspects. Both husbands and wives could work inside and outside home and take part in decision-making process.

Environmental sanitation: Cats, after defecation, hide their excreta with soil but dogs do not care. One should follow the better example.

Disease transmission: A water pot coated with indigo powder spread the color everywhere when touched by someone. In the same way, germs from the dirty hands of a person, after defecation, can spread all over causing diseases (role play can show this situation clearly).

Expected behavioral results

It was expected from the project that the people will have the following behavior changes.

· Appreciate the problems due to overpopulation in family and society.
· Understand the importance of family planning for the mothers and children.
· Understand demerits of frequent pregnancy and pregnancy at early age.
· Understand different methods of family planning and forget any misconceptions related to reproductive health.
· Understand that women are not responsible for determination of sex of the unborn child.
· Be aware that both male and female children can contribute equally to the family and society, if groomed properly.
· Increased and continued practice of family planning by the eligible couples under the project.

Major findings

The flash cards as a communication medium for the workers was easy to use in meetings and training sessions. The messages could be easily related through flashcards than broadcasted or telecasted in radio and television or published in daily newspapers. The workers chose colored flash cards because participants were mostly illiterate and colored pictures attracted them most and depicted common life experiences. Some pictures had to be clarified or needed some corrections/replacements for clearer understanding. However, oftentimes flash cards were lost or mixed up so it needed special attention. The materials could be bound flexibly and be numbered for easy identification. Arranging occasional video shows was also effective in some sessions.

Flash cards that showed farmers sowing paddy seeds and harvesting rice and another farmers sowing jute seeds and getting only jute crops were developed with participants' suggestions. All these were done to change the conventional belief that women were solely responsible for infertility or for bearing only female children.

New series of flash cards on new subjects needed to be developed and printed after proper selection of subjects based on needs assessments. Folk media could effectively be applied to pass on message on reproductive health attracting people's attention.

The project could effectively use the Agricultural Approach to Family Planning in health and other developmental sectors, change the attitudes of couples and successfully increase contraceptive prevalence rate from 56% during baseline survey to 80% at present. The project is now run in concerted effort with other projects and field workers are paid from the beneficiaries' service charges against credit fund given by the government.

The experience suggests that field workers need special training and regular review. It could be time-consuming but highly rewarding.

Conclusions and recommendations

Effective communication strategies using locally-developed materials are necessary to share and exchange views on reproductive health, gender issues and development, HIV-AIDS, sexually transmitted diseases and other topics. Applied communication approaches to integrate reproductive health concepts with various components of development activities need to be shared. The project focused only on family planning and support should be given to design and print new materials based on the present needs of the people. Innovative communication techniques at the grassroots level need to be developed to relate and integrate various types of media campaigns. Further study is required to develop effective communication techniques on the basis of the prevailing situation and experiences gathered.

Agricultural approach to family planning and reproductive health. The case of the Family Guidance Association of Ethiopia

Tilaye Tesfaye

The. Family Guidance Association of Ethiopia (FGAE) is a non-profit, non-government, organization (NGO) on family planning (FP). FGAE was established in 1966 and has been the leading NGO in the country in the promotion and provision of family planning services over the past 30 years. It has made great strides in the dissemination of family planning information and education to the public, both in urban and rural areas.


Figure

In most of the cases, the channel of communication used to disseminate FP messages has been interpersonal (face-to-face) communication. To strengthen the verbal communication, teaching support materials, both print and electronic media, have been produced and distributed from time to time.

In spite of the effort exerted in disseminating FP messages for many years, the 1990 Family and Fertility Survey conducted by the Central Strategical Authority of the Ethiopian government revealed that contraceptive prevalence rate (CPR) was only 4%. The current estimate from FP service statistics of the Ministry of Health indicates that CPR has reached 7-8%. However, given the number or size of the Ethiopian women in their reproductive age, the CPR is not encouraging. It is by far below average compared to East African countries.

As cited by the International Institute of Rural Reconstruction (IIRR), the United Nations Asia Population Studies, Series No. 1967 mentions that family planning, like most other aspects of development, is partly dependent on communication. Contraception is a technique and therefore has to be learned before it can be used. For many couples, contraception requires a change in behavior. Such a change tends to grow out of new information, new opportunities and new awareness of what others think and do.

Therefore, increase in contraceptive use or increase in CPR requires a lot of things to come together to bring about change in behavior. The language to be used, the type of message to be communicated, sensitivity to culture, relevance, clarity, acceptance and simplicity of visual materials are crucial points in FP communication.

However, improper use of explicit language to explain various contraceptive methods and their mechanism of action could create rumors and misconceptions that could impede the use of contraceptives. Thus, a strategy should be designed to deal with rumors and misconceptions and increase FP use by eligible individuals or couples.

Strategy to promote FP and increase CPR

Experiences gained from the IIRR showed that agricultural analogy to FP could contribute to increased contraceptive prevalence rate. This could be evidenced by the initial registered results of increased acceptance to FP concepts in Cavite, Philippines.

To replicate the experiences in the Philippines in Ethiopia, FGAE and IIRR jointly launched a project in 1993. FGAE, being the implementor, produced information, education and communication (IEC) materials analogous to agricultural life, where the overwhelming majority of the Ethiopian population depend. The project was funded by the Lutheran World Relief (LWR).

Project activities

Workshops

A training of trainers (TOT) was held for relevant FGAE staff members and others from government (Ministries of Health and Agriculture) organizations and non-government organizations. A farmer representing Farmers' Association and an artist took part in the TOT workshop.

Production of poster in three languages

Later on, FGAE designed and conducted three workshops, one in each site representing Amhara, Oromia and Tigrai regions for selected farmers. Amharic, Oromifa and Tigrigna are the three major languages spoken in Ethiopia. At each workshop, participants shared their wisdom related to the FP concept. Then, the artist translated their wisdom into visuals. Posters were developed in each of the three languages. Out of the total posters produced, only 450 posters, representing each language were distributed to the three respective areas. All posters were posted at appropriate places for many people to see. Coffee shops, grinding mills, health institutions, individual households were some of the places.

In about two years, after the posters had been posted, FGAE assessed the outcome of the posters.

Assessment of the posters using questionnaires

The posters depicted the consequences of unplanned births and benefits of family planning. These also showed different FP methods and their mechanism of action. About 300 questionnaires were designed in the Amharic language. The type of questions depended on the type of the poster. However, the questions, more or less about had similar nature.

The 100 questionnaires were distributed to each of the three major language-speaking communities where the posters were posted for the past two years. Interviewers who could speak each language were given orientation on how to conduct the interviews by translating each questions into the appropriate language.

Prior to the conduct of interviews, respondents living in the three areas (where the posters were posted) had been informed about the purpose of poster assessment. Their consent to give interviews was sought. Those who showed positive gestures were interviewed. The interviews were conducted at clinics, residential areas, public gatherings, i.e., where people gathered to do community work. Respondents from Tigrigna - and Amharic - speaking communities were shown five different posters each for their assessment. Oromifa speaking respondents were shown four different types of posters.

The questionnaires were collated, consolidated and analyzed.

Major findings

Of the 300 respondents (in the three different language-speaking communities), 299 responded to the questions. There had been 139 (46%) literate (i.e, those who can read and write) and 160 (54%) illiterate.

Table 1. Literate vs illiterate by type of language

Language

Literate

Illiterate

Tigrigna

36 (26)

64 (40)

Oromifa

60 (43)

39 (24)

Amharic

43(31)

57(36)

Total

139(100)

160(100)

The table shows that among the literate group, respondents from Oromifa - speaking community constituted the highest percentage (43%), followed by Amharic - speaking community (31%). Among the illiterate group, the highest number (40%) was from Tigrigna - speaking community. This, however, does not necessarily reflect the level/rate of illiteracy in that community. It is hardly possible to find current data on national literacy rate to compare each community.

Variables

Among many variables designed in the questionnaire, there were only five variables found important and pertinent to the purpose of this case study.

A. Interest/attraction in seeing the various posters in three different language-speaking communities

Table 2. Attraction

Tigrigna %

% Literate n=36

Illiterate n=64

Those who have seen the posters before

41

28

Those who have not seen the posters before %

59

72

Oromifa

Literate % n = 60

Illiterate n = 39

Those who have seen the posters before

57

62

Those who have not seen the posters before

43

38

Amharic

% Literate n = 43

%Illiterate n = 57

Those who have seen the posters before

22

3.5

Those who have not seen the posters before

78

96.5

On average, 40% of literate and 31% of illiterate respondents have reported having seen the different posters. Among the three communities, Oromifa - speaking people (more than 60%) seem more attracted to see the posters than the other two major language - speaking communities. There is no ground to explain the difference.


Figure

B. Visual literacy/ability to give details in all of the posters

Table 3. Visual literacy (Interpretation of details)

Tigrigna

Fully n %

Partly n %

None n %

Total

Literate

89

49.4

75

41.6

16

9

180

Illiterate

88

27.5

174

54.4

58

18.1

320








500

Oromifa

Fully n %

Partly n %

None n %

Total

Literate

148

61.7

90

37. 5

2

0.8

240

Illiterate

121

77.6

35

22.4

-

-

156








396

Amharic

Fully n %

Partly n %

None n %

Total

Literate

63

29.3

129

60.0

23

10.7

215

Illiterate

33

11.6

192

67.4

60

21

285








500

About 300 responses in all the communities (89 Tigrigna, 148 Oromifa, 63 Amharic), show that the details of the posters had been fully interpreted by the respondents in the literate group.

In the Tigrigna - speaking community, nearly half of the literates could fully interpret while more than half of the illiterates could partly interpret the posters.

Unlike the Oromifa where majority of the literates and of the illiterates could fully interpret, in the Amharic - speaking community, the majority among the two groups could only partly interpret. In other words, the majority of both groups could not properly interpret.


Figure

C. Ability of males and females to interpret posters

Table 4. Interpretation

Oromifa

Fully n %

Partly n %

None n %

Total

Male

111

41

68

54

-

-

179

Female

158

59

58

46

1

-

217

Total

269


126


1


396

Amharic

Fully n %

Partly n %

None n %

Total

Male

54

56

177

55

45

54

276

Female

42

44

144

45

38

46

224

Total

96


321


83


500

The table shows that between males and females who were able to fully interpret the details of the posters, females demonstrated better skill than males.

Majority of both men and women in Oromifa-speaking community fully interpreted the posters correctly.

D. Ability of the artist to visualize ideas

Table 5. Representation

Tigrigna

Literate n %

Illiterate n %

Total

Those who have accepted representation

56

31.1

66

20.6


Those who have not accepted representation

124

68.9

254

79.4



180


320


500

Oromifa

Literate n%

Illiterate n %

Total

Those who have accepted representation

77

32.1

37

23.7


Those who have not accepted representation

163

67.9

119

76.3



240


156


396

Amharic

Literate n %

Illiterate n %

Total

Those who have accepted representation

93

43.3

32

11.2


Those who have not accepted representation

122

56.7

253

88.8



215


285


500

Respondents' opinion about whether ideas were visualized and analogies were symbolized was sought

On average, 35.5 % of the literates and 18.5% of the illiterates had accepted the representation of the symbols/pictures. The acceptance rate is far below 50 percent in both the literate and illiterate groups.

Among the reasons given by the respondents for not accepting the representation were that some of the clothes worn by women were neat and clean which do not exist in that particular community or the kind of clothes are not familiar to their communities.


Figure

The low acceptance rate of the representation could be indicative of some kind of problem somewhere. It may be either the artists did not properly translated the opinion of the workshop participants (farmers) into visuals or it may be because of not including the ideas/views of respondents who participated in the pre-testing of the posters.

E. Correlation of analogy

Respondents were required to correlate the agricultural analogy to family planning concept regardless of their level of literacy. The posters were shown to each respondent and each was to tell the relationship of the pictures in the posters. The table below reveals the result

Table 6. Correlation

Tigrigna

Literate n%

Illiterate n%

Total

Those who had correlated the analogy

104

57.8

99

30.9


Those who were unable to correlate the analogy

76

42.2

221

69.1



180


320


500

Oromifa

Literate n%

Illiterate n%

Total

Those who had correlated the analogy

143

59.6

100

64


Those who were unable to correlate the analogy

97

40.4

56

36



240


156


396

Amharic

Literate n %

Illiterate n %

Total

Those who had correlated the analogy

26

12.1

2

.7


Those who were unable to correlate the analogy

189

87.9

283

99.3



215


285


500

During the poster assessment exercises, captions in the posters were covered so that respondents would be given opportunity to use their own imagination and correlate the concept of FP with that of agricultural concepts/analogies. The captions on the posters were covered because those who could read should not take advantage of their skill against the responses of those who could not read and distort the result of the case study.

On average, 43% of the literates in the three language group (58% Tigrigna, 60% Oromifa and 12% Amharic) were able to correlate the analogy/concepts before they were shown captions in the posters. Among the illiterates, 32% (31% Tigrigna, 64% Oromifa and 7% Amharic) were able to correlate the analogy.

On the other hand, about 57% of the literates (42% Tigrigna, 40% Oromifa and 88% Amharic) could not correlate the analogy before they were made to read the caption in the posters.

Except for the Oromifa, majority of the illiterates could not correlate the analogy. Comparing literates and illiterates in each language group, majority could correlate in the Oromifa, majority could not in Amharic.

F. Ability to correlate after caption reading

Literates who said they could read and write were given second chance to see the posters, again this time with captions uncovered.

The table below shows the ability of literates to correlate analogies after reading captions in the posters.

Table 7. Correlation Male - Female

Tigrigna

Male n %

Female n %

Total

Those able to correlate before reading

97

46.2

106

36.6

203

Those who were not able to correlate before reading

113

53.8

184

63.4

297


210


290


500

Tigrigna

Male n %

Female n %

Total

Those able to correlate after reading

73

76.8

60

70.6

133

Those who were not able to correlate after reading

22

23.2

25

29.4

47


95


85


180

Oromifa

Male n %

Female n %

Total

Those able to correlate before reading

113

61.7

138

64.8

251

Those who were not able to correlate before reading

70

38.3

75

35.2

145


183


213


396

Oromifa

Male n %

Female n %

Total

Those able to correlate after reading

64

55.7

53

43.8

117

Those who were not able to correlate after reading

51

44.3

68

56.2

119


115


121


236

Amharic

Male n %

Female n %

Total

Those able to correlate before reading

13

4.7

15

6.7

28

Those who were not able to correlate before reading

262

95.3

210

93.3

472


275


225


500

Amharic

Male %

Female %

Total

Those able to correlate after reading

89

68.5

47

55.3

136

Those who were not able to correlate after reading

41

31.5

38

44.7

79


130


85


215

The table shows that more women (259) than men (233) were able to correlate the analogies before reading the captions in all communities. However, more men (226) showed better ability than women (160) to correlate the analogies after having read the captions in the posters.

In the Amharic - speaking community, both males and females showed a little ability to correlate the analogies before reading the caption. However, a large number of males and females demonstrated better correlation ability after reading the captions.

These figures show that captions in posters play an important role for correlation.


Figure

Conclusion and recommendations

Illiterate respondents are more than literate respondents. Even though the ability of illiterates to correlate analogies seemed lower compared to the literate groups, they may do better with clear and simple pictures.

The findings showed that literate respondents were more interested or attracted to see posters.

Substantial number of both literates and illiterates did not accept the representation of the analogies in relation to their communities. This, therefore, may indicate that, the artist had not translated their views correctly or posters may not clearly transfer messages or lacked clarity and simplicity.

The literates who were not able to correlate analogies before reading captions of the posters were able to correlate properly after reading the captions. Thus, the assessment result reveals that captions can play important role in making viewers of posters better understand messages in the poster.

The results of the assessment had not indicated the impact the analogy posters made on increasing CPR.

Posters should be pre-tested and repeatedly refined so as to bring about the designed effect and to fit into changing situation that may take place.

Posters should be used as teaching materials along with interpersonal communication.

Posters should also be community-specific. This means that, for example, in a community where the same language is spoken, people may not necessarily have the same religion, way of dressing and lifestyle. There could be differences from one district to another and this should be addressed in each specified community.

Agricultural approach to family planning. The Cross-cultural Adaptation

Estrella P. Gonzaga

The Agricultural Approach to Family Planning (AAFP), is a communication strategy of the International Institute of Rural Reconstruction (IIRR) that came from the grassroots - in particular a village woman-farmer. Dr. Juan M. Flavier, former IIRR President and now a Philippine senator, pioneered the concept with Philippine rural villagers where an elderly woman, "unsure and hesitant" said "... I do not know, but when you were explaining the whole family planning process, what kept coming into my mind were agricultural situations. You mentioned ovary, ovum, uterus and frankly, they do not sound real to me, but I can understand them in terms of string beans whose seeds are extruded out and grow on fertile fields. I do not know'.


Figure

From a 60-year old peasant woman's comparison of the ovulation process to that of the maturation of bean pods where one seed is released at a time, the AAFP began in the late sixties. More examples were added for birth spacing, infertility, pills, intra-uterine device (IUD) and condom. By 1975, other agricultural analogies were evolved and adapted for other village settings, this time, among fisherfolks and sugarworkers in the central parts of the Philippines. More than a decade later, the question was "can the AAFP be adapted to various cultural settings of the Third World countries?".

To whom

From 1988 to 1990, a collaborative cross-cultural study was conducted. The strategy was shared with six countries. Two countries were in Africa (Ghana Rural Reconstruction Movement/Planned Parenthood Association of Ghana and the Family Planning Association of Kenya). Four countries represented Asia (Village Education Resource Center in Bangladesh; Indian Rural Reconstruction Movement/Rajasthan Rural Reconstruction Society in India; Yayasan Indonesia Sehatera in Indonesia; and Asian Institute for Health Development/Northern Thailand Hilltribes Family Planning Center). The Ministries of Health field staff were involved in Ghana and Indonesia because these were existing partner groups of the two non-government organizations. These countries represented the major religions; Islam, Christianity, Buddhism and the Animists in both upland and lowland ecosystems. The details are shown in the table below.

Continent/Country

Ecosystem

Religion

Africa

Ghana

Lowland

Christians, Moslem, Animists


Kenya

Lowland, Upland

Christians

Asia

Bangladesh

Lowland

Moslems


India

Lowland and Upland

Hindi, few Moslems


Indonesia

Lowland and Upland

Moslems, Christians


Thailand

Upland - Yao hill tribes

Buddhists

The study was conducted with those in the 15-45 age group, married, in both men and women, but the latter represented the majority. In Ghana and Bangladesh, it was tried with men alone. Both literates and illiterate were reached. The poor was actively sought, such as the harijans in India and the hill tribes - the Yao in Thailand.

What

Agricultural analogies were shared for three content areas of family planning - why, what and how which had two topics - anatomy and physiology of reproductive system and the artificial methods of contraception (pills, IUD and condom).

The villagers themselves, in the early years of AAFP development, identified these areas to be the minimum and critical areas of knowledge for them to be able to decide.

How and for what

Information dissemination was undertaken using material in the form of charts and posters conducted through the interpersonal approach at two levels; individual counselling and focus group discussions. These were designed to increase the awareness of villagers on family planning.


Figure

Process

The process used in selecting the medium was a two-level training. First, it was with the organization's trainers, involving health staff of Ghana, Thailand, Indonesia and Kenya and non-health staff of Bangladesh and India. Second, a sharing process was conducted by the trainers with their promoters. The latter, mostly volunteer local residents, were generally of limited education, except for Ghana which had nurses.

The strength of the process came from the involvement of the field staff in the validation and identification of the agricultural analogies. A Ghanaian family planning staff appreciated her participation and commented "First time, I had a chance of developing the family planning messages and posters on our own Ghanaian culture. Normally, these are sent to us and are alien to our culture."

The weakness of the process was the turn-over of staff who underwent the process hindering development of other media forms beside the posters and charts like streetplays and songs.

The concept - agricultural approach

In the context of communication elements - sender, message, channel, receiver and effect, agricultural approach is unique on the message (which is scientifically-sound technical information) and the channel. While the conventional channel uses technical terms, the agricultural approach has analogies - plants, animals, beliefs and household materials. In contrast to the heavy lectures of the conventional, the agricultural approach rests on the active and continuous discussions.

The steps for the adaptation of the agricultural approach to different cultural settings were derived from the collaborative project experience. At organization's level, there were five steps:

1. Identification of specific messages.
2. Making sure these are scientifically correct.
3. Comparing familiar things in the village - plants, animals and house articles.
4. Making sure comparisons are scientifically-correct.
5. Drawing of pictures.

The strategy made use of local sayings and proverbs whenever possible. The materials were then brought to the community.

1. The concept was presented to the different categories of receivers, either individually or as a separate and homogenous group, according to gender, age, literacy and civil status. The presentation to a mixed type of audience was the second stage.

2. The audience was then asked: What do you see? What do you like? What do you dislike? What changes can be made to improve the picture?

3. The audience was asked what the pictures should mean?

4. The pictures were changed participatorily.

5. They were reminded that comparisons may

- not be 100% the same
- be useful only for one village and not for others

6. The audience was asked for new ways to disseminate the same messages.

Appropriateness of the medium to the concept

Strength

The trainers and promoters found the analogies to be technically-appropriate and that the understanding was enhanced with the use of local proverbs known as mashairi (Kenya and Ghana).

Weaknesses

1. Inadequate technical capacity of the staff to respond to villagers' queries.


As an example, the villagers commented on the Ghanaian poster. "if the palm wine can overflow from this pot, will this not happen with the semen in the condom"


Figure

Clearly, the access to technical information of field staff, particularly in difficult and remote areas, has to be ensured.

Another example can unwittingly trigger a negative unintentional message like the locked-out male goat poster from Kenya that promoted polygamy. The male goat poster reflected an "unconcerned husband" pose.


Figure

2. Inaccurate representation of some concepts.

This second weakness was exemplified by the unrealistic and/or unfamiliar scenes like a baby carried at the back of a Ghanaian man. A significant complaint among the illiterates was the presence of text which they found to only clutter the pictures.


Figure

Acceptability of the concept to the medium

Trainers and promoters across the different cultural settings agreed that the materials were easy to use and facilitated their motivational work. They expressed satisfaction and enjoyment in the highly-participative sessions with the villagers. The outright display of the male contraceptive device, a culturally offensive teaching method, was obviated by the analogies. These provided an acceptable cultural cover for the discussion of a "taboo".

Promoters recalled that in their previous sessions where they showed the condom, the villagers bowed their heads or looked at other things in embarrassment. With the AAFP, the promoters, however, found that more time was needed for explanations, given the numerous questions the pictures would raise. Villagers asked for new materials to avoid the boredom of seeing the same sets over and over again.

Effect on the villagers

Despite the limitations, the AAFP increased people's interest. This was shown in the quality of their response; lively with more questions, side talks, jokes, laughter and clapping of hands. When both men and women are present, they had their own spirited discussion which, oftentimes, lead to "blaming each other" but would generally have an amicable resolution at the end. In India, the villagers even demonstrated to the promoters how to teach fellow villagers using the charts. This "reverse role technique" was a concrete indicator of the message being internalized.

The pictures comparing persons with animals generated a mixed response. Villagers in India asked: "Are you trying to make fun of us by comparing with animals". However, in Kenya and Ghana, villagers commented that "If the animals can care and plan for their young, why not us?" and contributed new animal comparisons.


Figure

Research

There were no pre- and post- test nor field studies to show impact of the communication approach. The hierarchy of indicators was recognized at the outset and that the design of the project could only measure the output levels and not the impact. The choice of the indicators depended upon the capacity of the partner organizations in terms of the field staff facilitation capacity, the type of services provided, e.g., clinical family planning, other health services and the monitoring and evaluation schemes in place and the research capability. In Indonesia, an attempt was able to measure impact; 116 new acceptors were documented for an isolated mountain village.

Increase in acceptance rates is but a proxy indicator of the AAFP as an empowering process for people. Participation, through an informed decision-making process by the people, should effect control of the technology and enjoyment of the benefits. Dr. Flavier described this as ".,. if farming couples are to decide in true freedom, they must be fully educated through non-formal means. This way, voluntary but effective family planning, becomes a reality."

Lessons learned

The nearly two decades of experiences have affirmed the value of a rural reconstruction principle for field staff in rice and maize roots communication. "Start with what they (people) know and build on what they have. "Graphically, it can be shown as follows:


Figure

Six features of the approach have evolved; four features to operationalize the first part of the principle (A) and two features for the second part (B).

Start with what they know

Dr. Flavier, during the developmental stage of the approach, identified the first features. The first was "a neighborhood group of 7 -10 individuals, both men and women. The members of the group knew each other and therefore, could discuss without inhibitions. If family planning is personal and private, then it could be realistically discussed among acquaintances."

The second was the "method of eliciting agricultural parallels from the people themselves." The agricultural situations and the comparisons to the family were shared to evoke new farmer/villager originated parallelisms.

"The scope of subject matter" - the WHY, WHAT and HOW of family planning was the third. This recognized the limitation of the conventional scope of teaching with too many content areas often "beyond the practical needs of the farmers". People, the end-users, have as much right to determine what and how much subject matter to cover.

The fourth feature which became evident in an earlier collaborative Philippines project of IIRR was the ideological orientation and the values of the trainers and field staff, ",.. that there is no better teacher for the farmer than the farmer himself with IIRR as a "mere catalyst in the education of the farmer. "The humility to learn from the farmer was manifested as the capacity "to listen".

The new analogies generated by the villagers were used as rough gauge. India's two projects with its well-defined community structures - neighborhood group network (NGN) of 20 families and promoters with good facilitating skills and development values had a total of 33 new analogies. Thailand did not have any new examples despite the small defined geographical area - Yao tribal village of 50 families. The Yao promoters who were relatively new in community development work had not been trained on village facilitation techniques. The promoters of both countries did not have any professional health training background. For the type of trainers who were also their direct field supervisors, India had community development staff while Thailand even had the distinct advantage of having health professionals as family planning staff.

A family planning staff in Ghana, while trained in the AAFP approach at the start of the project, did not ask for the new analogies because "it did not occur to me". She had been used to receive centrally-designed family planning posters.

Thus, for Thailand and Ghana, the inadequate facilitation skills of family planning promoters spelled the difference in identifying new set of agricultural comparisons.

Build on what they have

On the second part of the principle rests the last two features that would ensure a sustained process of collecting culturally- sensitive materials.

The fifth entails the mastery of the subject matter - that of scientific validation of the generated analogies. Among the collaborating organizations, Bangladesh was the only one with its own production unit such that the AAFP posters had undergone five revisions. The trainers, however, expressed their severe limitation in technically validating the new analogies. They explicitly demanded for more technical information because they had no professional health background. Even among health professionals, those working in isolated mountain villages such as some government health staff of Indonesia, aired similar concerns. Clearly, the role of a health professional with a well-grounded knowledge base to backstop the validation process is crucial to the sustenance of use of these analogies. One limitation which Dr. Flavier has cautioned practitioners in the AAFP use is that there is no 100% correspondence of the analogies and the technical content. In the earlier part of development of the analogies, the roles of agriculturists and social scientists - sociologists and anthropologists, were also critical.

The sixth feature relates to the accuracy of representation. It was noted that revisions of the posters were directed to the inaccurate representations of the rural scenes brought about by the urban bias. The city-based illustrator, even if they come from the village, have already forgotten their rural roots. Maglalang's (1976) description for a scriptwriter could very well apply to an illustrator.

" The majority of professional scriptwriters are products of urban areas. Even if their roots are rural, they have lived in the cities for too long to remember the characteristics of their rural origins. The scriptwriter must, therefore, be oriented or re-oriented into the sociology and the economics of village life."

What next

The collection of agricultural analogies from the collaborative project which also included the permanent methods (bilateral tubal ligation and vasectomy), was then revalidated back to the Philippine setting. This was done when the Department of Health (DOH) requested IIRR to develop family planning charts for rural villagers and for a new setting - the urban dwellers. Apart from the different geographical settings, there were new content areas in the HOW part - the natural methods.

A second wave to the cross-cultural adaptation started in 1993 in Uganda and Ethiopia rural settings (the cases presented here in the conference). The same approach had been used to a then relatively new emerging threat - HIV/ AIDS in Ethiopia initiated by the IIRR Regional Director for Africa, Dr. Isaac Bekalo.

The AAFP is rooted on "... one unchanging premise, a recognition of the ultimate wisdom of the people" The idea originated from them - a Philippine woman farmer.

Participation of the people does not end in the identification of the agricultural parallels. It is a two-way continuous process as they validate the mode of presentations to be accurate representations of their everyday realities and as they articulate new analogies. This provides the dynamic corrective element to the approach.

The challenge remains at village level - for a system of collection and enrichment by villagers themselves for culture-specific analogies to be initiated and maintained. For the sustenance of the process, the adaptation of the AAFP with an organization's communication schemes necessitates the recognition of the six features discussed that anchor on teaching the unfamiliar with the familiar. Furthermore, for a sound basis of its institutionalization, there should be measures to objectively determine the desired effect, e.g., increase in acceptance rates or shift to more effective methods. These rates should not be viewed primarily as field staff targets but should serve as quantitative indicators of the villager's use of their inherent capacities to improve their life conditions. This can be done through the inherent strength and desire to be the masters of their own lives and destiny. This will only be possible if they are provided with opportunities.

The Agricultural Approach to Family Planning contributes to this process - the release of people's powers.

References

Flavier, J. 1976. The Evolution of the Agricultural Approach. Introduction to Agricultural Approach to Family Planning. Manila, Philippines.

IIRR. 1991. The Agricultural Approach to Health and Family Planning. Cross Cultural Adaptation. Hewlett Foundation. Terminal Report.

Maglalang, D. 1976. Agricultural Approach to Family Planning. Communication Foundation for Asia. Manila, Philippines.

Plenary summary. Papers on Family Planning

To whom (Transparency 1)

Family planning messages were directed to men and women of 15 to 45 age groups and religious affiliations - Christianity, Islam, Hinduism and Buddhism.

Transparency 1


How

Traditional + "New-FP"

Modern + Traditional - media

· market day fairs (Uganda) room + car/music (Ethiopia)

· EPI sites (Ethiopia)

· Punshops Betel nut (India)

· School children (Kenia) (folk media songs, dances, dramas)

· Griottes Camel riders "Naba" Women brewers Magicians

· CBD (Kenya) (folk dramas)

· TBAs

· Mobile clinics (Ghana) for scattered settlements


Posters - using AAFP everyday scenes

Radio + newsletters combined use more effective

For what

These messages were for increasing awareness related to access to services, use of family planning methods, and of clients' rights (Indonesia). Ultimately, increase in contraceptive prevalence should be achieved.

What

The content dealt on the benefits, natural and traditional methods and the services offered in family planning.

How (Transparency 2)

Two patterns emerged. The first had the traditional forms where the new element was the introduction of the family planning message. These are exemplified by the market day fairs of Uganda, use of rooms and car with music where people traditionally gather in Ethiopia, the punshops for betel nut chewers of India and the "griottes, camel riders, naba, women brewers and magicians" to promote the use of condom in Burkina Faso, and for most countries, the traditional birth attendants. In the second pattern, the modern forms use the traditional media such as the EPI sites for Ethiopia, the school children (Kenya) with folk media songs, dances and dramas; community based delivery (Kenya) using folk dramas; mobile clinics of Ghana for the scattered settlements and posters/ charts using everyday scenes - the Agricultural Approach to Family Planning (AAFP).

The combined use of radio and newsletters was found to be more effective in reaching the intended audience/ receivers.

The first pattern - inclusion of family planning into traditional forms had for its strengths the presence of a "ready made" audience, less costs, and relied on trusted, respected persons. Noted weaknesses were the need for training, dependence on weather, and the staff had to wait for long periods for the clients to drop in. This made the new strategy more expensive.

Incorporating the traditional forms with that of the modern had weaknesses particular to the approach. For AAFP, there was a need for representation of the villagers, scientific validation, continuous adaptation, and that not all concepts have analogies. In the case of folk dramas, the timing had to consider the seasonal activities of people. Moreover, one had to contend with the turnover of actors (school children); costs of transport, meals and material production. Using the EPI sites for these folk dramas can lead into information overload. In general, posters were costly and radio had a wider range of audience but provided limited feedback.

Issues/concerns

Traditional birth attendants can be alienated from the villagers as they undergo training and start to charge fees. Where they used to provide care on a one to one ratio, after training, they accept more clients nearly on a one to ten ratio. In India, the tea's home was severely congested as it was converted into a delivery center. A second major concern was the difficulty to track the effect (impact) of the traditional channel (media used), e.g., market fairs, griottes. Kenya, however, showed an increase in statistics.

Involvement of the people, the community, religious and political leaders is crucial to these strategies. Consultation during planning with subsequent endorsement had to be ensured for Kenyan school troops. Religious and political leaders were made members of the steering committee, making them co-decision makers in Ethiopia.

Transparency 2

Traditional + Modern


S: Ready-made audience

W: Needs training

Costs ¯

Dependent on weather

Trusted, respected persons

Staff long waiting period (new strategy)



¯



(expensive)

Modern + Traditional


W:

· Representation of villagers

W

· Timing of dramas (seasonal activities of people)

need

· Continuous adaptation


· Turnover of actors, school children


· Not all concepts have analogies


· Costs - transpo/meals/prodn material


· Scientific validation


· Info overload (EPI)

· Posters - costly


· Radio - wider audience/limited feedback


Concerns:

· TBA - alienation with training = fees charges



- 1:1 care ® 1:10 (India)


congested


home - delivery center

· Difficulty to track effect/impact of channel (media used) traditional

e.g., market fair griottes


except: Kenya-Statistics ­/Ethiopia Comm media

People/Community/Religion- political leaders


- Consultation (planning)/Endorsement: Kenya school troops


- Religious and political leaders ®Steering committee


(co-decision makers): Ethiopia)

General issues/concerns (Transparency 3)

The meaning of "sustainability" in communication takes on different views. South Africa has observed that it has been costly. However, one has to be clear and make sure that the message is given to the specific target audience on and for a specific time. This is not the same as program sustainability. For Ethiopia, this means message is passed on from time to time to a continuous generation of "new young people". Adaptation is part of sustainability.

The non-government organization (NGO) has to phase over to government or to the community. Religious and political leaders have been enlisted as members of the steering committees to ensure sustainability of support. Of serious concerns are the tracking of impact and to include in the kind of methods promoted, particularly the traditional ones, like the prolonged breast feeding, use of herbs and the natural methods like those for Catholics is the "billings method". Promotion of a gender-fair approach requires that men are targeted to exemplified by the type of poster illustrations and the messages. Timing is right information at the right time. And finally at the village level, a system of collection and validation of culturally-sensitive materials for the AAFP needs to be explored.

Transparency 3

Issues/concerns

Meaning of "sustainability"

South Africa: so far, costly but any communication media should be ongoing



not same as program sustainability

Ethiopia:

· message pass on from time to time


· continous generation of new young people"


· adaptation - part of suistainability

NGO phase over to GO or community (Ethiopia) - sustainability of support of steering committee - Religious/political

Tracking impact?

Methods promoted

· Traditional - prolonged breastfeeding, herbs

· Natural - alternatives for Catholics - Billings

Gender fair approach - target men also

posters


illustrations


messages

Timing - righ information at right time

System of collection/validation: AA culturally sensitive materials - village level

Reproductive health and communication within an extension programme

Alemu Bogalech

The Ministry of Agriculture has been disseminating reproductive health information to the grassroots community in all parts of rural Ethiopia. When the country's national population policy was adopted in 1993, the Ministry of Agriculture became one of the primary institutions chosen to implement programs on reproductive health. The major goal of the policy was the harmonization of population growth with the socio-economic development, natural resource conservation and agricultural development. The integration of population and family life education into the agricultural extension programme became necessary because Ethiopia faced rapid population growth, high fertility rate, high infant mortality, high maternal mortality and other reproductive health-related problems, including an increasing incidence of human immunodeficiency virus /acquired immune deficiency syndrome (HIV/AIDS), diverse gender-related problems, rapid degradation of the environment, unwise use of natural resources, low agricultural productivity and low standard of living of the rural sector of the population.


Figure

Considering that majority of the Ethiopian population lives in the rural areas where agriculture is the major economic activity, the integration of reproductive health information and communication into the agriculture extension programme allowed the rural population to be aware of reproductive health and family planning issues.

Community where project was implemented

The programme was implemented nationwide, targeting adults in the rural areas and in the urban areas on a limited scale.

Target audience

The audience of the programme comprised the adult members of farm households, both male and female aged 15 years and above; economic status is mixed; occupation is agriculture and the religion is Orthodox and Moslem.

Key areas of reproductive health issues were:

· the importance of reproductive health and availability of services;
· sex and sexuality and responsible sexual behavior;
· sexual behavior and psycho-social problem of adolescent in Ethiopia;
· causes and modes of transmission and prevention of HIV/AIDS and sexually-transmitted diseases (STDs);
· gender and reproductive health; and
· responsible parenthood.

These were integrated into the farm household development programme which attempted to address basic family needs such as housing, nutrition, food production, maternal and environmental protection and reproductive health information.

Communication media used

The Women's Affairs Department of the Ministry implemented the reproductive health programme. Thus, the empowerment and development of women through the satisfaction of their reproductive health needs had received much emphasis in the sector.

Members of the farming communities, both male and female, received reproductive health information through home economics and development agents.

There were sets of reproductive health communication programmes in the Ministry.

1. Training on reproductive health was integrated into the pre-service training programme of the agriculture training institutes such as Agarfa, Ardaita, Bekoji, etc.

2. The second one was the integration of the reproductive health training and information activities into the on-going routine activities of home and development agents already on the job.

3. The third one was the dissemination of reproductive health information to the farm households through reproductive health information and communication institutionalized by integrating population and reproductive health courses. This allowed for a more sustainable and continued information and communication delivery system. This has reached the rural population, with the support of the United Nations Family Planning Association (UNFPA), the National Office of the Population (NOP) and the Ethiopian Family Guidance Association (FGAE), both at national and regional levels. Personnel received periodic training and experiences sharing within the country and abroad. This had strengthened the capacity of reproductive health personnel in the sector.

Training of male and female farmers included:

· mass media campaigns through the national farmers' radio programme;
· peer education through training contact farmers and follower farmers;
· interpersonal communication during home visits; and
· use of instructional materials such as videofilms, flip charts, manuals, audio cassettes and posters.

In support of the reproductive health course for the pre- and in-service trainings, different types of instructional materials like manuals, flipcharts, audio cassettes and video films were developed and disseminated for use at grassroots extension programme.

A training of trainers (TOT) to build the capacity of regional, zonal and woreda level trainers and programme implementors was conducted at all levels. Monitoring indicators were developed to measure the impact of the reproductive health information, education and communication (IEC) activities at grassroots level.

To integrate reproductive health information and communication efforts with service delivery, a pilot project was carried out.

During the monthly training of agriculture development agents at woreda level, reproductive health information was integrated with other agricultural information such as forestry, livestock, fishery, crop, horticulture and the like. The periodic training of development and home agents allowed to update their knowledge and skills in this area. FGAE provided the technical guidance for reproductive health concerns.


Figure

There was also a home visit programme implemented by the home agents where they personally went from house to house to discuss with farm households reproductive health issues. They also observed the actual family conditions and provided advisory support. This had been found to be most effective because there was interpersonal communication between the household (particularly women) and the agents. It gave the agents an opportunity to observe the needs, conditions, problems and status of the visited household and provided the desired information and referral to the available reproductive health service.

With peer education, it was easy for individuals to accept messages "if friends and not strangers tell them. " The weaknesses though were the instructional materials, being centrally designed and limited in terms of cultural relevance and situation-specific. The home and development agents provided services limited to agriculture. For reproductive health concerns, they gave their clients referrals to health facilities.


Figure

For the three sets of programmes, the communication methods used were interpersonal communication, use of the national farmers' radio programme (on primetime radio of the Ministry of Agriculture), use of teaching aids, peer education through contact farmers, counselling and discussions.

Institutional framework

The over-all constraint was the political restructuring towards a federal system. To date, a national extension package is being developed for home science in agriculture. Gender and reproductive health are among the five major units in the package. Based on the packages, each region will develop its own detailed programme strategy focusing on targets based on its specific needs and conditions.

Over the last years, a close network was established among institutions implementing reproductive health programmes such as the FGAE, Ministry of Health, Family Health Department, NOP and all the other national population policy-implementing agencies. This network reflects the country's population policy which clearly states the need for mutual support among the government ministries and non-government organizations.

A national task force for the implementation and follow-up of reproductive health in the agriculture sector was established, involving all rural women affairs team leaders in the regions and at the head office. At national level, technical support through the provision of training development and distribution of educational and information materials was given priority attention. Follow-up and monitoring of activities and policy support were carried out.

On the other hand, the Regional Rural Women's Affairs Tau am in the agriculture bureau took the responsibility of implementing reproductive health information and communication activities at grassroots level. The regional population and women's affairs offices also provided continued support to strengthen the impact of reproductive health activities in the agriculture sector.

Areas for enhancement

Programs on reproductive health can be further institutionalized within the extension system of the government by enhancing the following areas:

· stronger collaboration of the information, communication and education activities with that of services;
· development of culture-specific materials;
· upgrading the communication skills of the extension agents;
· stronger monitoring and evaluation system;
· promoting a network with reproductive health groups or organizations; and
· advocating and sensitizing policy makers to integrate family planning with agricultural production.

Expected behavioral results

The expected behavioral results are as follows:

· To recognize the relationship between population growth, environment, resource utilization, agricultural development and quality of life.

· To identify the major reproductive health-related problems and participate in intervention measures to address the problems.

· To explain basic demographic concept in relation to agricultural productivity in Ethiopia.

· To understand the factors influencing human reproduction and develop responsible behavior towards reproductive health, family planning and human sexuality.

· To identify adolescent reproductive health problems and participate actively to address them.

· To encourage parents living in the rural parts of Ethiopia to establish a small family norm in their lifestyles and enhance women's participation in economic activities (agriculture).

The specific outcomes from the different media forms used were as follows:

Mass media campaign

Created awareness on issues related to reproductive health among farmers.

Peer education

Improved learning resulting to practice of family planning and improved attitudinal change.

Interpersonal communication

Concrete advise and information given to women specific to their needs. Reproductive health information was integrated with credit scheme and other productive activities.

Instructional materials

Both printed and electronic forms enhanced the teaching and learning process that led to improved knowledge, practice of planned family life and the development of positive attitude.

Major findings

The process used in the choice of medium of reproductive health information was made through home and development agents who received pre-service and in-service trainings periodically on communication methods and maternal health concepts.

Home visits and periodic training allowed for better understanding of the maternal health concepts. Absence of maternal health service in some rural sectors was a barrier to the practice of learned concepts.

There was limited culturally-relevant training materials and regions were not strengthened to develop and use culture-specific media forms and thus, instructional materials were developed centrally in most cases.

Conclusions and recommendations

Reproductive health information delivery should be integrated with economic activities. Farmers receiving extension services, trainings, credit and technological support and women groups organized around some income-generating activities should also receive reproductive health information. This would help bring about a more profound impact from reproductive health information and communication activities in the sector.

Family life and adolescent reproductive health project. The Egerton University Experience

Wakube A. Wataka

The Egerton University, elevated from a middle level Agricultural Diploma College in the late 1980s, lies in the expansive Rift Valley, about 200 km northwest of Nairobi. It has a student population of 8,000, of which 2,000 are women.

The project was conceived as a result of the increasing concern of the University about the alarming rate of female students' dropping out due to unplanned or unwanted pregnancy. Also, an unknown number was suspected to be illegally terminating their pregnancies.


Students at graduation - many can now benefit from reproductive health sessions.

The University approached the Population Council of Kenya with a proposal. The latter, in turn, identified Pathfinder International as a donor to a Family Life and Adolescent Reproductive Health Project for the University targeting its student community.

Launched in January 1990, the Egerton University Health Centre Project aimed at addressing the issue of unwanted and/or unplanned pregnancies, the consequences of which include negative effects of early child bearing on the physiological and psychological development of the students, interrupted education, reduced future earning potential that will ultimately rob the country of its important human resource.

Baseline surveys indicated that by age 21 years, 70% of the unmarried students are sexually active. It was estimated that of these, 45% are at risk of unwanted pregnancies.

On the aspect of human sexuality, the students appeared uninformed but not inexperienced. Through there is little exposure to sex education in Kenyan secondary schools, students at the University obtained their knowledge of sexuality and contraception from other sources such as friends (peers), publications and the media.

Based on the assessment, students knew a lot but this information was erroneous and lacking in specifics. Most were unable to identify correctly the fertile period in the menstrual cycle. Many sexually-active students alleged to be using natural family planning method but they could not properly state the "safe period" which put many at the risk of pregnancy Many students were able to name the "personal protective strategies" that could be used to lessen the chances of contracting sexually transmitted diseases (STDs) and HIV/AIDS but few confessed to using these strategies.

The University is based in a rural setting but the students were drawn from both rural and urban background. They came from varied geographical regions, both highlands and lowlands as well as coastal regions. The students' backgrounds also varied from settled families practicing mixed farming to predominantly arid areas where pastoralism and nomadism are still prevalent.

The majority were in the age group of 19-25 years, except for a few "mature" entry students who joined the university after working early in life. From urban-rich to poor-rural backgrounds, the students' family income range from very high to minimal.

While most of them pay their way through University on government-guaranteed loans, all respondents were full-time students, the majority of whom reside in student halls on campus. They were drawn from diverse religious backgrounds. The majority professed Christianity but very few practice it.

Reproductive health concept introduced

The project addressed issues related to adolescent reproductive health, namely, knowledge and practice of modern contraceptive methods, prevention of unwanted or unplanned pregnancies among female students and prevention of sexually transmitted diseases and Human Immunodeficiency Virus (HIV) infection among the students.

Communication media used

Campaigns

Campaigns were held twice a semester from 2:00 p.m. of Fridays to 8:00 p.m. of Saturdays.

The students' peer educators were encouraged to be as original and as creative as possible in designing and implementing these activities.

Also invited to these gatherings were groups with drama presentations relevant to adolescent reproductive health. Presentations from notable personalities as well as persons with AIDS (PWAs) were often included.


Figure

Peer education

A resource manual for training of peer educators was developed by the project with technical assistance from a curriculum specialist. Prospective peer educators were selected from the student body after advertising about the availability of positions.

During the school holiday, the selected students underwent an intensive two-week training to which they were exposed to information related to adolescent reproductive health and family life education. After a period of intensive practice, they underwent another one-week training on counselling skills.


Peer educators preparing for an IEC event


Peer counselling workshop

Thereafter, they students (peers) were updated on special topics of interest, usually on weekends. This process of selecting and maintaining 40 peer counsellors was cyclical. Peer education of fellow students was made an ongoing project activity.

Interpersonal communication

The interpersonal communication process was made ongoing using two forms. One-to-one counselling was an integral part of this programme. The peers were encouraged to attend to not more than five students per week in order to have adequate time with their "clients" and to avoid over-committing themselves. They were to maintain an anonymous record of their activities for supervisory, monitoring and evaluation purposes.


A poster used to encourage students to avail of peer counselling services.

Focus group discussions and group counselling sessions were facilitated weekly by the peer counsellors.

Materials development

The project produced pamphlets, newsletters, magazine and colorful T-shirts with catchy messages designed and developed by the students. These were, therefore, original materials and the process was also ongoing depending on availability of funds.

Expected behavioral results

The expected behavior results were as follows:

1. Reduced unwanted and unplanned pregnancies among female students indicated by or observed as:

· a decrease in cases of attempted or incomplete abortions at the student health services clinic;

· reduced number of students seeking antenatal and maternity care at the university health services;

· decreased drop-out or discontinuation rate among female students on modem methods of contraception as seen at the university family planning clinic; and

· reduced number of female students applying for maternity leave (dean of students office).

2. Reduced high risk behavior especially among male students, observed as:

· increased availment of condoms presumably as a result of increased use;

· decreased cases of sexually transmitted disease treated at the university health clinic over time; and

· increased number of students wanting to be checked for sexually transmitted diseases and even for HIV screening specially the students worried of their past sexual indiscretion ("worried well").

3. Properly informed students on issues of reproductive health because these affect the young people become effective agents of change in society by virtue of their status.


Figure

Major findings

Strength of the media form

Early involvement of peer counsellors and other students ensured acceptability of the communication media by same students who were to implement it.

Weakness of the media form

The programme required highly-motivated students with strong sense of commitment and reliability.

Lesson learned

Early involvement of target group in design and implementation of peer education program was essential to its success.

Appropriate communication medium to concept introduced

Strengths

1. Peer education and counselling were appropriate in communicating adolescent reproductive health issues to young people.

2. The peer counsellors, educators and other students who were given accurate information on reproductive health could become powerful agents of change in the future.

3. Peer educators and counsellors were always available for the students and they did not require appointments to be assisted, i.e, no bureaucracy or red tape.


Peer educator presenting to fellow students

4. The activities were tailored to suit the "lifestyle" of the students on campus, especially in terms of time and venues.

5. Messages presented to students by fellow students (peer educators) were often in language easily understandable to the students (slang).

6. The communication medium enabled the program activities to be student-driven.

7. There had been good institutional support because the project was able to utilize existing university systems for its financial management and transport needs.

Weaknesses

1. The project required highly motivated, committed and responsible students with above average moral conduct who should be willing to give selfless service to others.

2. Selection of peer-educators/counsellors could be problematic. There was no fool proof method of screening prospective peer counsellors/educators.

3. Often the reasons of the student for joining the program could be in direct conflict with the aims and objectives of the program, e.g. joining for prestige, monetary gain or to win popularity as a step to student politics.

4. Poor selection of peer counsellors could result in high rate of burn-out and drop-outs.

5. The project required a much higher number of peer educators/ counsellors to adequately cover the student population than what available resources could sustain.

6. Considerable investment in training of the peer counsellors was necessary.

7. Religious and political climate was not always conducive to programs on adolescent reproductive health.

Lessons learned

1. Peer education and counselling were an effective way of reaching young people on issues related to adolescent reproductive health.

2. Where donor funding is available for launching or starting the program, sustainability issues should be addressed at the outset.

3. To enhance contraceptive use among young people, youth-friendly clinics should be set up with special attention to staff attitude.

4. Parents, religious organizations, political and opinion leaders in the community should be well sensitized on the issues of adolescent programs. To ensure better success, they should, as far as possible be involved in the design and implementation of the program.

Acceptability of concept in relation to medium of communication

Strength

Peer counsellors/educators were readily accepted by the target group for they were able to easily identify with their fellow students.


Gender-sensitive peer counselling logo

Weaknesses

1. Peer counsellors/educators were too few in relation to the target population.

2. It was difficult to ensure uniformity of practice (output) by the peer educators.

3. Peer educators/counsellors could be easily or prematurely be burn-out if selection was not vigorous.

4. Student union leadership was threatened by peer counsellors and their work.

5. There was sometimes an attempt by the university administration to use peer counsellors as spies on other students.

Issues and concerns

1. How to address issues of sustainability to avoid donor dependency.

2. Supervision of peer counsellors could be difficult and even problematic. The project had 10 staff who acted as supervisors at a ratio of one to two to three peer counsellors.

3. Conflicting political pronouncements on adolescent reproductive health issues in contrast to knowing government policy.

Conclusion and recommendations

The use of peer educators was an effective strategy for imparting information and knowledge to a university student community. Indeed, it is likely to be equally effective with appropriate adaptation to any other group of youths. For impact enhancement, the following have to be considered:

1. Improved condom distribution to reach more students, e.g., through depot holders, condom dispensers, campus canteens and shops.

2. Improved student contraceptive user rate through opening of student-friendly clinics with special attention to:

· site of clinic;
· general environment;
· staff attitude; and
· opening hours to suit campus life.

3. A program to address the issue of female students' sexual harassment should be incorporated.

4. A program to involve parents should be included to reduce suspicion and win their support.

5. Continued advocacy is required to influence prevailing policies.

Addressing sexuality and health needs through partnership. The Kenya Experience

Mary Y. Okumu

Changing patterns of socio-economic, political, demographic and cultural arrangements and the ongoing globalization processes continue to have tremendous negative impact and consequences on the African and Kenyan societies at many levels. Among the most affected key areas is human life; health, specifically reproductive health.

Throughout the world today, reproductive health affects all human beings at all developmental stages and throughout their life span regardless of age, race, class, religion, history and geo-political realities. Reproductive health offers human beings a medium to express love, intimacy and pleasure


"...Can we have a normal boy and girl relationship without sex?..." "...What can I do about my father who had sex with me?"

It is also the means to propagate humanity In Kenya and Africa, however, reproductive health is ".,. one of the least understood and appreciated areas of human relations and sometimes become the leading cause of morbidity and mortality.

In Africa, there still remains inadequate research, unclear policies on which to prime interventions, inadequate services and lack of political will and framework for finding ways to move forward. A compounding factor is the erosion of African values embedded in some of its positive cultures and structures. Socialization of female and male adolescents on sexuality was developed through the values and extended family systems, which, no longer exist in Kenya. These have been replaced by other values and systems from the outside. Because of all these factors, Africa and Kenya find themselves at the crossroads on the issue of reproductive health, especially for adolescents. Not only is there sharp disagreements within key sectors, there is great confusion about what can and should be done in this area affected by the fear of an external agenda being pushed by the process of globalization.

As a result, there are great disparities and inconsistencies in the quality and quantity of the services extended specially to adolescents. Meanwhile, sexuality and reproduction continue to contribute highly to morbidity and mortality, specially among women.

Because of this, the African Medical and Research Foundation (AMREF) defined and implemented a participatory operations research study in Kenya to:

· fill the critical information gaps on female adolescents' knowledge, attitude and practice (KAP) on reproductive health; and
· to develop and implement appropriate programs.

This case paper focuses on the second part of the project (interventions, strategies and outcomes) which was based on the key findings from the research study conducted in the first part of the project.

Key findings from the Participatory Operations Research (POR)

1. There was high rate of sexuality among in-school adolescent girls (47% sexually-initiated girls). About 35% of the sexually-active girls had first sexual intercourse at age 9 or in primary school. There was 7% pregnancy rate of the sexually-active and 44% unsafe abortion rate of those who became pregnant. In Kenya, induced illegal abortions account for 84% of all septic abortions and induced septic abortions account for 20% of maternal deaths. The school drop-out rate of the girls who became pregnant was 81%.

2. About 90% of the sexually - active girls had unprotected sex with an average of 13 different sex partners. Sexually-active female adolescents suffer abortion, high rate of school drop-out and sexually-transmitted diseases (STDs) compared to adult females. Multiple sex partners are associated with greater rate of STDs.

3. About 7% rate of incest prevails.

4. There exist different perceptions and needs in female adolescents' sexuality and reproductive health.

5. Adolescents experiment with lesbianism.

6. There was outcry and determination of female adolescents, concerned teachers and parents to find responsive solutions to this massive problem.

The Intervention Process

The process began with identifying the key issues from other stakeholders' perspectives through a series of consultations.

The religious domain maintained that research such as the AMREF's female adolescents' sexuality survey was intrusive into the privacy of the respondents and violated their integrity, legal and moral rights. Some of the study questions were perceived to be vulgar and viewed sex as a mere physical experience ignoring the spiritual dimension.

The parents, family and the society have the obligation to educate the youth and adults the truth about sexuality and issues of reproduction. According to this perspective, "it is immoral to engage in sexual intercourse before marriage. Therefore, the outcomes of such sexual activity as pregnancy out of wedlock is immoral and inexcusable. Young people should, therefore, abstain from sexual activity except in marriage... "

Abortion means murder and is immoral. If a young girl gets pregnant, she should deliver and give up the child for adoption if she cannot care for it. Teaching sex education in schools and providing services such as condoms in schools are immoral acts as these will increase the immorality in youths. Youths should be taught and encouraged to abstain from sexual activity until after marriage.

The government which represents public policy maintained that the school is not the place for sex education and that the public should not interfere with issues pertaining to reproductive health services. It is the government's central responsibility. The government of Kenya made it clear that it had the capability of addressing these issues and the public, especially the NGOs, should not interfere.

The legal domain's perspective is that everyone has the right to make informed choices and should exercise the freedom enshrined in the constitution of Kenya without prejudice. The legal sector holds accountable the public systems to inform the people of their rights.

The family institution is sharply divided (about 50/50) on whether or not sex education and reproductive health services should be availed to students.

The medical professionals' perspective is that adolescents should be equally given appropriate medical services, including reproductive health services. Many medical providers in Kenya advocate for the legalization of abortion. This, however, remains highly contentious.

The community level people, as a collective, want clear and practical solutions to the problems of adolescent sexuality and reproduction. They know that it is a big problem that is eating up their communities. They are very clear of what they want: not the politics or great theories while their young children are dying or becoming incapacitated. They want practical solutions but still divided on religious and cultural grounds about reproductive health issues in relation to adolescents.


Figure

Female adolescents are divided on the issue of sexuality and reproductive health. Some view sexuality as beneficial and that adults interfere with it; that adults withhold critical information about sexuality from adolescents, and, therefore, cannot be trusted to tell the truth about sexuality.

However, a similar number views adult intervention on adolescents' sexuality as vital. Although they did not agree on the scope of reproductive health services, female adolescents wanted counselling to be immediately available to them.

The Social Environment before the media intervention

From both the technical findings of the research and from the perceptions and beliefs of the stakeholders, there was a problem. Opposing views and controversies had started in raging public debate on what should be done. Each stakeholder advanced and maintained its position. The moral and spiritual domain held its ground; so did the policy domain. The two seemed to be on one camp and their position was that providing sex education, contraceptives and abortion services to adolescents in Kenya was out of the question. This was outrightly immoral and an externally-generated idea.

The legal/rights wing and some medical and social service practitioners and advocacy NGOs, some parents and some adolescents wanted services. And these composed the other camp.

Communication media used

The findings of the research had not been disseminated - but to preempt its dissemination and any possible interventions thereof, the propaganda against services have started in public media. Although negative, this pre-emptive move facilitated the development of four key communication strategies which later became the cornerstones of subsequent reproductive health programs for adolescents in Kenya. These were as follows:

· individual and group consultations with key stakeholders;
· peer training and counselling;
· broadcast media; and
· print media.

Clearly, a forum to reconcile the various perceptions was needed. Thirty NGOs closely affiliated with, or specifically working on adolescents' issues, came together and formed one umbrella in 1993. This umbrella, known as the Kenya Association for the Promotion of Adolescents' Health (KAPAH), became the forum for reflection, analysis, dialogue and advocacy on matters of adolescent sexuality and health. KAPAH established the need to define the issues in sexuality, negotiated their meanings with each stakeholder and harnessed useful dialogue that would result in improved status and well-being of adolescents while focusing squarely on the issues of sexuality and reproductive health. This remained a contentions area among the various stakeholders.

Two communication strategies were applied.

1. Identification and training a newspaper journalist who would acquire and use gender sensitive ears in reporting issues of adolescents. This training included how to report accurate and consistent messages issues of adolescence without propaganda or sensationalizing the issues.


Figure

2. Identification, acknowledgement and addressing the key stakeholders' underlying values, fears and concerns in relation to adolescents' sexuality. A long process of consultation to identify and bring together the key stakeholders was embarked on between 1993 and 1994. This was done at interpersonal and small focus group discussion levels. It was discovered that each category of stakeholder had a different understanding and concern. From the individual and group discussions, the following assumptions were established.


Figure

The religious leaders value adolescents as an important sector and they know the difficulty of growing in today's society: being single parents or having inadequate basic essentials and guidance. The religious group fears that giving the youth condoms and other contraceptives is not helping them but indicates diminishing morality (whose custody belongs to the religious institutions). They feel that little regard is given to religion or spirituality, a manifestation of failure of the religious institution. This is not acceptable and they wanted a societal affirmation of the critical role of the religious sector. They oppose the blanket recommendations that NGOs make concerning reproduction, especially for adolescents.

On the other hand, the government policymakers fear of losing power, autonomy, respect and control. Traditionally, the government had been the official and only mechanism of providing social services to its population. It had been and should be responsible for quality control and accountability to its citizens. Allowing NGOs and individuals whose credentials, motives and long-term commitments were unclear was, therefore, of serious concern to the policymakers. Secondly, government officials also feel that some NGOs do not show them any respect so they react negatively towards NGO initiatives.

Teachers and parents do not know how to ably provide guidance to adolescents on issues of sexuality because they were not trained to do so. The subject matter, in addition to being very difficult, is "embarrassing" within the Kenyan society. At the same time, due to incidences of incest in the 1992 study, there was concern by some adolescents about trusting their fathers and other relatives and some teachers on matters of their sexuality.

Given the values, the genuine fears and concerns expressed by the various stakeholders, clarifications were made and stakeholders were persuaded to come together, share their various values and concerns to reach a shared understanding. To do this, a second level repackaging of the technical data was required. This was done by the Center for the Study of Adolescents (CSA). The data was simplified, both in mathematical and linguistic terms. Ordinary language and format were used. The categories of data were also extrapolated and put into fact sheets for the various categories of stakeholders. The data was made appropriate to their language, culture, format and values.

Key messages for each stakeholder

For the religious leaders, the findings that 63% of the respondents (6,516 out of 10,344) had not engaged in sexual intercourse was highlighted. The message was for them to focus on this group by intensifying sex education and counselling services. The other message was that adolescents were looking for their assistance in issues of sexuality.

To the policymakers, the messages included the following:

· That 50% of Kenya's population of 25 million was under 20 years old and that the country could lose up to 50,000 adolescents per year due to unguided sexuality: teenage pregnancy, illegal abortion, sexually transmitted disease (STD)/human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and school drop-outs which pushed girls to prostitution or drugs.

· That 137 girls out of every 3,414 had sex by the age of 10. This means that sexual intercourse begins in the middle of primary school level for sexually-active girls and this is dangerous to the country.

· That 7% of the sexually-active girls became pregnant and either secured illegal abortion or dropped out of school. The districts most affected were highlighted to the policymakers.

For service providers, the findings that 33% (3,414 out of 10,344) girls were sexually active, did not use any protection, had up to 13 sex partners and resorted to abortion illegally, constituted the messages.

For parents and teachers, the messages were that female adolescents were unguided on issues of their sexuality and were looking for help from their parents and teachers who are in a position to help. Training opportunities were availed for this category. At such trainings, specific and detailed aspects of the relevant data and issues concerning this subject were openly discussed.

To parents and the society at large, additional messages were 50% of female adolescents who engage in sexual activity, did it because they got presents and money; and that some of their sex partners were twice their age.

For the adolescents, they were not further consulted except during the design of the intervention programs. Using the data, the girls were given a translation in simple terms of what they said in their interviews. The intervention programs/messages to the adolescents were basically answering some of the burning questions they raised in the anonymous basketbox and during the focus group discussions. Some of which are as follows:

"Can we have normal boy and girl relationship without sex?"
"What do I do with my father who regularly has sex with me?"
"What are the safe days?"
"Where do we get information/ service on reproductive health?"

In addition to answering these questions during the focus group discussions, special peer counselling sessions were held in subsequent services for in-school adolescent females. Part of the education to the girls was the implications of having sex at an early age; with multiple partners and without protection. The sex education focused on prevention and referral services for those who already needed special services. The reproductive health concepts and messages to adolescents varied based on each audience- but overall, the concepts were the following:

· That sexuality in adolescence is a normal part of growing up and is not something to be hushed over.

· That sexuality, like other normal aspects of human growth, need to be ably and responsibly managed.

· That implications of early and improper management of sexuality in adolescence is taught to adolescents.

· That the adolescents should prevent, rather than cure, the untoward outcomes of inadequately-managed sexuality. The sacredness of sex and one's body is discussed.

· That there should be accurate information dissemination on sexuality to adolescents.

· That emphasis of the intervention programs is to increase adolescents' knowledge about reproductive health and sexuality, especially how these affect the adolescents; mould their attitude and positively change their behavior.

Major findings

When repackaged, simplified and placed in the right context, the research findings found significant meaning. The conveyed messages touched the core of the various stakeholders and moved them to action. They began coming together to negotiate and find solutions.

Each stakeholder, when approached with due respect, had genuine interest, commitment and technical or personal skills to respond and improve the welfare of adolescents. However, before these resources could be adequately mobilized and tapped, clarification of perceptions, issues, values, principles, concepts and definitions of sexuality, reproduction, health, freedom of choice and associations had to be done first.

On adolescent sexuality

Thus, adolescent sexuality was agreed upon to include personal hygiene; human anatomy and how it works (normally and abnormally); the difference in females and males; what it means to be an adolescent; what the stages of adolescence mean in the human growth and development process; how to manage one's growth; where to get what kind of information on reproductive health; when to seek medical and social services; how to responsibly manage one's sexuality; nutrition; parenthood - what it is and what it means; how to grow up to be a responsible citizen/student; gender roles and responsibilities; useful and harmful cultural values and how to uphold/eliminate them; kinship/bonding; and health/infectious diseases from sexual intercourse - STD/HIV/ AIDS and the like.

Outcomes of Collaboration

The general outcomes of the collaboration between NGOs and key stakeholders included:

· An advocacy instrument and NGO collaboration mechanism (KAPAH) on adolescent reproductive health was established. This had given special focus on legitimacy and new impetus.

· There was greater clarity of purpose in both advocacy and service programs. There was functional and applied definition of adolescent sexuality.

· There was greater distinction between and appreciation of myth and reality in relation to adolescent sexuality and health needs. It was no longer taboo to discuss sex-related matters in public.

The specific outcomes were as follows:

· Pregnant teenage girls could return and complete their education after delivering their baby.

· Education on sexuality/reproduction had been included in the primary school curriculum and is being effectively taught.

· Around 15 counselling centers for adolescents had been established and are functioning adequately.

· Health services are now specially provided to adolescents. There is room for all stakeholders and each is contributing to their key interest areas.

· Adolescents are core participants in the adolescent reproduction and other welfare interventions. They are currently producing and managing an educational views exchange program on national television, radio and print media in Kenya.

· There is greater collaboration between the government, NGOs and religious sector. This is resulting in consistency and clarity on the issues of adolescent reproductive health and well-being.

· More resources have been mobilized for the welfare of adolescents.

Lessons learned

· There were assumptions by the research and the NGOs that concepts such as sexuality were commonly known and shared when in fact this was not so; Therefore, in carrying research and intervention programs on such issues, abstract/ technical terms must be defined and explained in relevant local language and cultures.

· Mass media was only appropriate in increasing awareness and in mobilizing responses on sexuality issues in Kenya. Interpersonal and focus group discussion worked out better in the data collection phase.

· Anonymous boxes gave more information than the self-administered or focus group discussions.

· Data presentation and messages must target different stakeholders/ audiences for optimum impact.

· When all stakeholders' perspectives were accorded respect, they became more supportive of programs.

There was misconception by key stakeholders that sexuality meant only abortion and sex for · adolescents but when appropriately expanded to include other areas such as prevention - diseases and health, it became an acceptable topic of dialogue.

Challenges

The major challenges after the research were as follows:

· To bring together diverse and often opposing views and reach a shared set of views and values about adolescents' sexuality.

· To establish a mechanism for linking, learning and effectively responding to the needs as defined by the research findings.

· To define and enlist each stakeholders' special role in adolescents' sexuality in Kenya.

Conclusions and recommendations

Concepts such as sexuality, love, culture and reproduction are complex and abstract in the Kenyan context and can not be adequately dealt with unless, and until a common sharing of fears, concerns, values, principles and understanding by the stakeholders is done. Such an understanding will necessarily be reached based on a negotiated agreement. It has to consider differing needs, fears and concerns of the various stakeholders.

These fears and concerns are genuine and must be responded to.


Figure

One way of responding is by acknowledging that they exist and need both a political and professional will to address them.

The second need is in defining these concepts, using local core values where, stakeholders are able to recognize the meaning. When the meaning of sexuality was expanded, negotiated and commonly shared, it found new meaning and application which became interesting and important to all stakeholders. The concept of sexuality was expanded to include normal growth and development, personal hygiene, health, social relations and expected social roles in the various development stages. It was discovered that all the stakeholders wanted more information and assistance in finding the correct media and strategies to address the issues in adolescent sexuality. However, they did not know this, nor did they know where and how to get help. Through consultation, reflection, validation and negotiation, a correct balance was found and quality programs are now being implemented.

The POR greatly contributed to the discourse and programming. It provided comprehensive, technically and culturally sound and undisputable data. It is recommended, therefore, that all advocacy work for the promotion of adolescents' reproductive health must be backed up by undisputable and respected scientific data. This gives greater validity and legitimacy to subsequent advocacy programs.

The choice of media forms must be relevant and specific to the message and target audience.

Today, issues of adolescent sexuality are openly discussed in Kenya as a result of clear, concise and concerted efforts - further giving meaning to the phrase, "in diversity (or unity?), there is strength".

Participatory community diagnosis on reproductive health. The case of Adolescents and Community Members in Mwanza, Tanzania

Edna Matasha and L. Wambua

In Mwanza, Tanzania, over 50% of the population experienced sex by age 15 or as early as age 10-11. Median age for marriage in females was 17.

Previous survey conducted in 1990 in Mwanza region had shown that human immunodeficiency virus (HIV) prevalence and incidence in adolescents and youth were high, particularly among women. The HIV prevalence among young women was 41% and 8.2% in men (both of age 15-24 years).

The baseline survey conducted in rural villages of Mwanza revealed HIV prevalence of 4.1% in women (15-24 years), 1.8% in young men of the same age. But this was based only on small numbers of seroconventions.

Sentinel data of ANC mothers in Mwanza region indicated that around 15% of clinic attendees are HIV positive.

Young female adolescents are both biological and psycho-socially more vulnerable to sexually-transmitted diseases (STDs) and oftenly STDs in this group are undiagnosed and untreated.


Figure

Reproductive health concept introduced

A topic guide to assess knowledge, attitude and practice of the partner groups was developed and used to facilitate all discussions based on the projects' themes as follows:

· behavior-legal issues related to Adolescent Sexual and Reproductive Health (ASRH);
· importance of STDs/HIV and acquired immune deficiency syndrome (AIDS) problem;
· adolescent sexuality;
· importance of teenage pregnancy; and
· complications associated with teenage pregnancy and its prevention

Two more themes were also included:

· puberty changes; and
· channels of information and communication to young people with regard to ASRH messages.

Communication media used

The project used a variety of communication channels to mobilize the target audience. Examples of media forms used were:

- common social mapping;
- focus group discussion;
- village meetings and campaigns with different target audience;
- in-depth interviews;
- peer health educators involved in development and administration of questionnaire;
- steering committees to mobilize the target audience;
- target-oriented project planning sessions;
- video shows;
- distribution of printed materials on STDs/HIV/AIDS; and
- self-administered questionnaires.

This paper will focus on the focus group discussion (FGD) as a communication medium to explore sexual and reproductive health needs and problems. Preparations of the community took four weeks and discussions took seven to ten days for each community. Giving six weeks for the four communities, the whole process, including data analysis, took six months.

Focus Group Discussions and Data Collection Mechanism

The first set of qualitative survey was conducted between July-October 1995 by two female health behavior officers and one male education officer. This was reviewed in July and August 1996. Together with a social scientist, the team worked in close collaboration with district officials, particularly the District AIDS Control Coordinators (DACCs) and the District Education Officers (DEOs).

The initial sessions conducted in July-October 1995 totaled 46. These involved 450 participants and categorized as follows: primary and secondary school adolescents, 16 sessions (170 participants); primary and secondary school teachers, 11 sessions (99); out-of-school youths, 5 sessions (57); parents of adolescents, 6 sessions (54); community leaders, 4 sessions (38); and health workers, 4 sessions (32).

The following activities were also conducted.

· Target-Oriented Planning Procedure (TOPP) Workshop was conducted among partner groups prior to intervention to set priorities in a participatory approach.

· Two communities were identified as Intervention (I) areas and the other two as Comparison (C) areas.

· Rapid assessment of the project.

· Sketch maps of the identified areas were drawn at a radius of 5-8 km from the town center.

· The maps included an inventory of institutions and collaborative agents relevant to the project.

The participants' age range was 12-24 among in-school adolescents and 20-24 years among out-of-school youth. The adults were aged above 25.

The reviewed set involved 120 participants in 20 sessions and 21 individual interviews. Participants in FGDs were categorized by age and sexual homogeneity: younger adolescents 10-14 years; primary school pupils (boys and girls); older adolescents above 14 years; secondary school students (boys and girls); school drop-outs (boys and girls, preferably with children); school leavers; and parents of adolescent females and males.


Figure

Individual interviews

This focused on key informants with specific influence, information and had adequate knowledge on ASRH matters. People involved were male and female parents of adolescents, teachers, legal custodians, religious leaders, teenage parents and health workers (biomedical and traditional).

Interviews emphasized on sexuality (age of first contact, experience, exploits and partners). It also took up rape, incest and prostitution while others focused on pregnancy, abortion, STDs/HIV/AIDS.

The individual discussions were based on each participants' views regarding youth sexual behavior, provision of SRH services and establishing of interventions in response to adolescents' sexual and reproductive health needs.

Data analysis

The information was collected in Kishwahili and it was discussed, verified and translated in English by the survey team. The information was later categorized thematically.

Major Findings from the Study

Puberty and Pubertal Changes

Based on the survey, adolescents 10-14 of age consider themselves young people (vijana), not children.

Boys reported that wet dreams and the capability to ejaculate are signs of maturity and could make a girl pregnant. Others termed it as "graduation" or transition from childhood to manhood (kubalehe). Also, wet dreams are pleasurable and can create an urge to look for sexual partner.

For girls, maturity is marked by menstruation (kuvunja ungo) and that she is capable of becoming pregnant when she has sex with a boy/man.

But, nobody talked about this stage until it is reached.

Differences during childhood and at puberty were categorized in two major changes: physical and behavioral. Others referred to adolescent stage as "foolish" and a stage with many changes. Some of these changes are mentioned below:

Physical

The boy develops muscles and changes voice.

The girl undergoes breast enlargement and widening of pelvic area.

Both experience growth of pubic hair.

Both have strength that enables them to do heavier work.

Behavioral

Lack of respect for community members.

Sexual interest in the opposite sex.


Figure

Self-esteem and identification, especially in boys, increased mental ability and let them start thinking about education and other issues.

Smoking and drinking alcohol led some adolescents to drop out from school. Also, social and economic factors effected adolescents.

Adolescent Sexuality

Early sexual activities among adolescents were evident and raised concern especially among the older people.

Out-of-school boys (10-14 years) denied having girlfriends. In-school adolescents admitted having girlfriends but were conservative in their explanations. The out-of-school youths were more explicit in discussion and admitted having multiple partners. They earned money from casual labor which they used to seduce school girls. These girls accept small gifts or money when they engage in sexual activities.

Age of first intercourse

The age at first intercourse varied. But most of the participants said that girls started earlier than boys. Average age for girls was 12 years and boys 15 years, but some started as early as 9 -10 years. Child abuse by parents pushed girls to engage in sex.

Peer influence contributed to early sexual encounters. Adult men believed to search for school girls. But these girls believe that these men have AIDS and could not be urged to use condoms.

Domestic environment like overcrowding and the "Sukuma" culture (separating girls at monarch) were blamed for young people's sexual debut. Places like guest houses, bushes, classrooms and dark corners were mentioned as venues of sexual activities. However, these places were noted not to be conducive for negotiating protective measures.

Consequences of adolescent sexuality

Adolescents were concerned that: the girl can bleed, can have difficulty in walking and if she is still a virgin, can cry due to injury or pain.

The adults were worried about unwanted pregnancies, abortions and STDs, particularly HIV/AIDS which affect both their children and the parents.

Pregnancy

Participants, especially the adults, were affected by pre-marital pregnancy. The phenomena had harsh social and economic implications on the girls because they were from home, regarded as a prostitute and neglected by their male partners.

Unwanted pregnancies meant marital changes and reduced bride wealth to the parents. More worries were noted among in-school female adolescents who would be dropped out from school.

The result of teenage pregnancy was either to give birth that meant dropping out of school or abortion.

Abortion

Self-induced abortions were reported to be common using hazardous substances or techniques that led to complications associated with abortion (e.g., swallowing a large dose of chloroquine/tetracycline tablets, use of cassava stalks to dilate the cervix, paramedical person, etc.).

Abortion happens in communities although it is well recognized by the participants to be illegal in Tanzania. Therefore, nobody admitted having been involved in such a procedure.

It was also indicated that abortion was mostly influenced by peers, sexual partners and mothers. The places where abortions took place were private hospitals, traditional healers and mostly, self induction.

The complications pointed out were death, infertility, heavy bleeding and infections. The measures taken to minimize unwanted pregnancies were condoms, natural methods, oral pills, injection, loops and intra-uterine devices. The traditional methods used were taking of ash solution or two aspirin tablets before and after sexual intercourse, concentrated cup of tea shortly after having sex, tie-wrapped medicine (hirizi) or sticks around the waist and use of other concoctions like juice of cassava leaves and blue solution.

But pregnancy prevention was low and inappropriate among the youths.

Sexuality transmitted diseases (classical)

The adolescents described STD as "diseases acquired through love making" whereas the adults referred to them as "diseases of sinners" or promiscuous or unfaithful people who have sex out of marriage.

The young people were direct and brief but the adults tended to blame and label the victims.

The respondents mentioned a wide range of STDs: AIDS; gonorrhoea; rashes; syphilis; kaswende, bilharzia; whooping cough (kisonono); chanchroid (pangusa), measles; swollen inguinal glands; miningitis; swollen breast; abdominal pains; and kabambaru.

Respondents believed the modes of transmission of STDs were as follows:

· sexual contact with an infected person;
· sharing skin piercing instruments, clothes, especially underpants and towels;
· blood transfusion;
· mothering an unborn child; and
· sharing toilets, bath tubs, soaps and brushes, especially in urban settings.

The STD treatment was availed from both private and government hospitals and traditional healers. But young people complained that these were not youth-friendly services. Treatments were also available from pharmacies, drugs shops and stores.

Adults were more aware of STD services rather than adolescents. The complications of STDs mentioned were death, ill health, mental illness, abortions, infertility, pain, cancer and divorces.

HIV/AIDS

Not most of the respondents agreed that HIV/ AIDS is a STD and justified it to be mainly acquired through sexual intercourse.

AIDS was not considered purely an STD because it has other routes of transmission like transfer from mother to child and sharing of skin-piercing instruments.

Both adults and young people shared misconceptions on transmission routes like kissing, insect bites and condoms. The out-of-school youths were less aware of transmission dynamics.


Figure

Young people were blamed for not being careful in avoiding HIV transmission as they use a slogan "kufa kulala", meaning dying is sleeping.

In discussing the physical appearance of a person infected with HIV, most of them knew that it was impossible to identify such a person unless they develop full blown AIDS. But young people could not indicate clearly the period between HIV infection and AIDS symptoms.

Prevention of HIV/AIDS and other STDs

The participants were finally asked on preventive measures and majority mentioned: moral conduct (religious regulations); use of condoms; abstinence; faithfulness to one sexual partner; HIV testing before marriage; avoidance of blood transfusion and avoidance of skin-piercing objects.

Other points

General concerns raised were lack of access to medical and contraceptive care; intimidating service accorded to adults; poor accessibility to condoms and non-affordability of STD treatment, especially at non-government avenues.

Masturbation created a further point of discussion among secondary school boys and this really needs reconsideration of addressing the concept.

The sources of information, education and communication on ASRH among respondent were the peers, parents, teachers and religious leader.

Peers were identified as the main source of information on ASRH issues. They shared experiences on physical changes, sexual exploits and acts as go-between. It was obvious that there was a sense of trust and confidence among themselves which indicated a need for peer interventions.

Parents were another source of information. Sexuality issues are culturally like a taboo all over the country this is also true in Sukuma. Due to the AIDS epidemic, parents had a felt-need to ignore cultural barriers and improve communication among their children regarding SRH issues.

Teachers were considered by the youth as appropriate channels for SRH messages. The youth, however, observed shyness among the teachers and that they should be improved on that.

Religious leaders were another source of information. A wide range of religious leaders were involved in discussions; Moslems, Catholics and Protestants.

It was noted that all study areas had organized religion youth groups, where they provided seminars and emphasized on assertiveness and sexual abstinence skills until after marriage. They were more concerned with spiritual well - being while biomedical personnel dealt mainly with the physical aspect of the people.

One magistrate concluded that religion could be of help to many youth as there is no religion in the world that allows rape, incest and prostitution. Others also prohibit smoking and alcohol consumption.

Impacts of media

When the participants were asked to comment the media: radio, television, film and print, both young people and adults seemed scared of some Western (foreign) video films which influenced young people. It showed substance abuse, termination from school and joining bad peer groups.

Newsletters like Straight Talk available in secondary schools could help the majority. Younger adolescents from class IV onwards suggested to have related materials relevant to them.


Figure

However, a general consensus was to establish constructive educational films, e.g., on HIV/AIDS. for young people. Also, print media could be of great importance in modifying young people's moral and sexual behaviors.

Others: behavioral and legal issues related to ASRH

Rape appeared to be common although legal action was not taken for many of the cases as observed in all study sites. The girls or women were always blamed for it and normally they did not report the offense because of social stigma. Group rape was also reported.

Penalty for rape is life imprisonment although the rapist gets a sentence between 14 days - 20 years.

The magistrate observed the need for more strict punishment for rape, incest, prostitution and abduction.

Incest was defined by giving a few examples, like "the uncle of one participant had sex with his daughter when his wife was away for further studies, and eventually had a child with the daughter. The girl's mother left but she was convinced by relatives to go back". This was recognized as a criminal offense with five years imprisonment. However, males who offended girls below 12 years were liable for lifetime imprisonment.

Prostitution was observed in each community, although it was illegal in Tanzania. The exact punished was not known.

Conclusions and recommendations

This study highlighted the need for young people to be prepared and be assisted in coping with changes that occur during puberty and adolescence.

Low socio-economic status was identified as the major pre-disposing factor to early sexuality.

Although there was an observed good knowledge about STDs/HIV and AIDS, further education is needed to address the community at large.

Parents have the primary responsibility for their children but schools, peers, religions groups, health workers, community, government and mass media have a big role to play in SRH matters.

Early sexual debut, low availability and accessibility to birth control services mean a high rate of unintended pregnancies with a range of adverse outcomes.

As a strength, the Focus Group Discussion strategy was a very useful tool for assessing feelings and moods of the partner groups regarding adolescents' sexuality and health-related issues.

References

Bagurakayo H., D. Shuey and B. Babshangire. 1992. The Impact of Sex Education Program on Sexual Practices of Pupils in Primary Schools of Kabale, Africa Medical and Research Foundation, Kampala-Uganda.

Balmer, D.H. 1994. The Phenomena of Adolescense: An Ethnographic Inquiry NARESA Mongraph No. 4, Nairobi, Kenya.

Dawson S., L. Maderson and V. L. Tallo. 1992. The Focus Group Discussion Manual. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Disease.

Helitzer-Allen D., M. Makhambera, and A.N. Wangel. 1994. Obtaining Sensitive Information: The Need for More than Focus Groups. Reproductive Health Matters No. 3.

Education strategies to eradicate female genital mutilation. The case of High School Students in Ethiopia

Amare Dejene

Various traditional practices are being practised in all administrative regions in Ethiopia. Persistence of beliefs and traditions has its positive elements. For example, breast feeding is one of these practices that should be retained. On the other hand, practices such as female genital mutilation (FGM), ovulectomy, tattooing, early marriage, etc., are hazardous and have to be get rid.


Figure

Inter-African Committee (IAC) was established at regional level to fight harmful traditional practices that affect the health of women and children. At present, National Committees are established in most African countries. Among these is the National Committee on Traditional Practices in Ethiopia (NCTPE) that concerns itself with the health of women and children in Ethiopia.

The main objectives of NCTPE are as follows:

· To discourage and, in the long run, eliminate harmful traditional practices such as FGM, tooth extraction and others that are of serious effect to the health and well-being of society, especially those affecting the health of women and children.

· To promote and encourage traditional practices that have positive effects on the health of women and children.

To achieve these objectives, the NCTPE conducts different sensitization programmes and produces educational materials. The Research and Evaluation sub-committee of NCTPE collects and provides the organization with the necessary information to better plan and implement its activities. But among the different harmful traditional practices (HTPs), the focus is on FGM because this is widely practiced throughout Africa, including Ethiopia and it has severe, immediate and long-term complications.

The most practical method to change human behavior is sensitization and education. From the literature, there is still no experimental study conducted to see the effect of the different information, education and communication (IEC) methods in changing the attitude of the population against FGM in Ethiopia. The purpose of the present study was therefore to determine the extent to which education can change attitudes towards FGM. It also aimed at determining a relative of each educational intervention used in Ethiopia. The result of this study helped identify methodologies that were effective in changing attitudes towards FGM during the sensitization programme by NCTPE.

Reproductive health concept introduced

Female genital mutilation and early marriage have direct effect on the reproductive health. The long-term complication of FGM is mainly reflected during delivery of the mothers. There are three main types of FGM, including sunna and clitoridectomy (cutting the clitoris), excission (cutting the clitoris and labia minora) and infibulation (cutting the clitoris, labia minora and majora and stitching together using torn or other material). Any form of FGM involves curing part of the female genital organ. This leaves a scar that does not allow the organ to stretch as needed during delivery and exposes mothers to prolonged labor. To solve such problems, episiotomy is sometimes done on the women who deliver in the hospitals. For others who have no chance to visit health facilities, vaginal tear and vasco vaginal fistula can occur among female genital mutilated mothers.

Contributing factors for these traditional practices in Africa include poverty, ignorance (lack of basic education and information about modern lifestyles) and lack of access of women to schools and low status of women's participation in gainful employment outside the home.

Communication media used

Mechanism for information dissemination

Previous studies showed that perceptions and attitudes towards HTPs heavily depend on religion, culture and ethnic background. For this study, high school students in Addis Ababa and in the rural areas were chosen because students can relatively be approached easily. Success in changing attitudes of students will have a multiplying effect as they can influence their parents and friends. Furthermore, students in Addis Ababa and the surrounding rural areas represent the major ethnic groups and religions in the country and information obtained will give some indication of the perception of a good cross-section of the population.

High school students in grades 9, 10 and 11 formed the study subjects. The study involved 11 high school students: five from Addis Ababa and six from the rural areas. A total of 2,100 students were selected as study subjects. Out of the 11 high schools, two served as controls: one from the urban and another one from the rural areas. A pre- intervention assessment was made using a questionnaire to pre-test before the intervention. The questionnaire mainly helped collect information on the background characteristics of the study subjects, including their knowledge and attitude about FGM. For the experimental group (nine high schools) lecture, lecture and video show, lecture and drama show and lecture plus posters were the different intervention or educational strategies employed during the study. After the intervention, the same questionnaire was used as a post test to determine the knowledge and attitude gained from the different educational strategies. The information collected before (pre-test) and after (post-test) the intervention was analyzed.


Figure

To compare the effects of the intervention and to make a comparison between the different educational strategies, changes in the knowledge and attitudes were considered during the analysis. Some of the questions asked to know the knowledge and attitude towards FGM included: 1) Is FGM a harmful traditional practice (knowledge); and 2) Do you support the eradiation of FGM (attitude)? From these questions, the four possible changes that can be observed to evaluate the effect of the intervention included:

Yes to Yes, Yes to No, No to Yes and No to No. Using a two by two table, it will appear like this:

Post test

Yes

No




Yes

t

s


Pre-test

No

r

u

t

Yes to yes and no to no answers were ignored in the test of significance, because they gave no indication in favor of the intervention. Only the cells no to yes (r) (in favor of the intervention) and yes to no (s) pairs were considered.

Major findings

Table 1-3 presents both qualitative and quantitative changes observed due to the intervention. Table 1 presents the knowledge gained among the study subjects on its complication, reasons and attitude which is statistically significant, indicating a positive effect of the intervention among the experimental group. However, the change among the control group is not significant.

Table 1. Changes in response and % r on the knowledge and attitude for different questions on female genital mutilation among experimental and control group

Variable or question

Experimental

Control


r/r+s

%r

chisq

r/r+s

%r

chisq

Is FGM a HTP

320/371

86

193

22/53

42

1.00

Complication

417/483

86

253

43/79

54

0.50

Reason

665/734

91

482

33/63

52

0.06

Eradicate

136/156

87


13/30

42


Table 2 compares the change observed among multi media versus single media. This result demonstrates that multi media is superior in all aspects of the comparisons.

Table 2. Changes in response and % r on the knowledge and attitudes for different questions on female genital mutilation among multi and single media

Variable or question

Multi

Single


r/r+s

%r

chisq

r/r+s

%r

chisq

Is FGM a HTP

255/311

82

126

103/140

42

1.00

Complication

360/403

89

247

130/180

54

0.50

Reason

505/552

91

378

180/235

52

0.06

Eradicate

116/138

84

63

78/113

69

16

Table 3 shows the comparison made between the three multi educational strategies in urban and rural areas. From this table, lecture plus video appears to be superior in the urban area followed by drama and lecture. In the rural community, poster plus lecture ranks first followed by drama and lecture.

Table 3. Mean difference in the change of knowledge and attitude both by area and educational methods

Area

Changes

Lecture +Drama

Lecture + Poster

Lecture + Video

Urban

Knowledge

2.3

2.2

2.6


Attitude

0.4

0.4

0.5


Both

2.7

2.4

3.1

Rural

Knowledge

1.7

2.2

1.7


Attitude

0.7

0.6

0.2


Both

2.4

2.8

1.9

Conclusions and recommendations

Findings from this study indicates that sensitizing the school community against FGM has an effect in changing their knowledge and attitude. The multi-media approach was found superior compared to the single media.

Based on the result and the enthusiasm and interest shown by the students and teachers, it is recommended to organize similar sensitization programme to senior secondary school students as much as possible. The paramount need for organizing training information campaign (TIC) or sensitization programme in schools is evident in view of the large and rapidly growing student body. As it is true in any other segment of the Ethiopian societies, it is believed that majority of these students and teachers have been victims of one or another type of traditional practice, be it minor or severe. The number of students who boycott schooling due to early marriage and pregnancy is significant. This, combined with FGM during infancy, pose problems including great risk of prematurity, still birth, low birth weight and delivery complications.

The study recommends to conduct many sensitization programme as much as possible in all secondary schools in the country.

Action taken by NCTPE after the study

Conducting a short sensitization programme was found very effective at the end of this study. Different educational materials like posters, video films, songs and drama shows were produced by NCTPE for trainings and information campaign against FGM for different influential target groups. The NCTPE conducted mass sensitization programme in most of the high schools in Addis Ababa. During this program, a comprehensive lecture on FGM and a film show were given to educate the school community against HTPs. A similar programme had also been conducted at high schools found in different regions of the country. The response, the feedback and the interest generated from the school community were promising.

A plan is underway to cover all high schools by giving sensitization programme against FGM. A child to child programme for junior secondary schools has also been started. And this will continue in the coming five to ten year's plan of action of NCTPE.

Pregnancy prevention. The case of the Surma of Southwestern Ethiopia

Mirgissa Kaba

"The eloquent Surma - a little known pastoral people cling to traditions in the desolate reaches of Ethiopia."

Steady increase in population size is one of the major problems that worries the world. The problem is specially severe in developing countries where the rate of population growth is relatively higher. At the moment, diverse efforts are exerted from different sectors, government and non-government institutions alike, to challenge the increase in population size.


Figure

The motto of checking population growth is justified by the imbalances between growing population size and the already depleting resources. This has great implication on the advancement of family planning as a service. The basic objective of family planning thus is to reduce the growing population size by preventing unwanted births, to regulate intervals between pregnancies and to determine the number of children in the family (World Bank, 1990). This idea, however, was strongly criticized by women advocates for it undermines the right of women (Hardon, 1992).

At the moment, there are extensive differences in response to family planning devices across the world due to cultural and policy variations. Response to modern contraceptive devices is very low specifically in developing countries due, among others, to the following reasons: widely prevailing traditional practices, lack of relevant information and inaccessibility to modern contraceptive techniques. These have played an important role in adversely influencing the successful dissemination of modern contraceptive techniques. However, this does not mean that people do not practice birth control. The use of natural contraceptive methods such as medicinal plants, abstinence, withdrawal and breast feeding are customarily and widely used among different culture groups.

Ancient texts in the Idian Atharveda (2500 BC) and the Chinese Sheng Nung (1122 BC) mention names of plants which possess anti-fertility property and therefore used as contraceptives.

In Ethiopia, there is a continuous attempt to familiarize the concept of family planning and contraceptive technologies since the mid 1960s. Such an effort, however, seems to be limited to urban centers where only less than 15% of the population resides. The majority who live in rural areas are far from information on modern contraceptive technologies. Yet, people have established wisdom for the maintenance of customs that are related to marriage, sexual intercourse and childbirth whose indirect implication on family planning may be considered.

The case to be presented here is a study on the Surma ethnic group who lives in the Maji zone of the Ethio-Sudanese border, South Western Ethiopia. The study was financially supported by the Family Guidance Association of Ethiopia (FGAE) and technical assistance from the Ethiopian Traditional Medicine Department. The Jimma Institute of Health Sciences was involved in the study by allowing its staff to take part.

The Surma as an ethnic group

The Surma country is one of the remote areas in Ethiopia. The Surma had been in Ethio-Sudanese border region for centuries, subsisting on agro-pastoralism, hunting and gathering on precarious environment with insecure rainfall (averaging 480 mm). Contact with the wider society is very much limited. On average, they have to travel seven hours to come to Maji, the nearest town. Government centers are in Tum and Maji which are mainly populated by "Northerners". The Surma is thus least accessible to the world and majority of Ethiopians.

Economic and social status of the Surma

The economic base of the Surma is Sweden cultivation where they produce mainly sorghum and maize. They also cultivate cabbage, beans, sweet potatoes and peppers. Besides, they generate their livelihood from hunting, gathering roots, leaves and seeds of trees and rearing cattle. The number of livestock one owns marks the wealth status of that person. As a means of livelihood, they pierce the neck of a cattle and draw blood which they mix with milk. As markers of wealth, cattle is used as bride price among the Surma. Someone who has many livestock can marry as many wives as he wishes.

The fact that they are semi-nomads and are always in quest of grazing land puts them in confronting position with their neighbors. They clash over resources which often cause serious damage.

The data collection

A two-week field trip was made to Maji province in 1990 to find out family planning practices among the Surma ethnic group where pre-marital sex is a common exercise. Specifically, the objective was to understand the Surma's birth control cosmology and resources available at their disposal.

Among the Surmas, there are rites women and men undergo to prove their capability for marriage. For the woman, it is the lip incision wherein her lower lip is cut as large and as wide as possible using clay disc. This is a mark of her beauty and would indicate preparedness for social responsibility because the process requires endurance to pain. For the male, they have to win the Donga (stick fight) to prove that they are able to protect the tribe.

The traditions of the Surma seem to have attracted the interest of many tourists from many parts of the world. Unhappy with frequent move into and out of their territory, the Surma suspiciously looks upon tourists or visitors whom they consider as alien elements to their own ethnic group and culture. As a result, they are not willing to talk freely to people whom they consider "outsiders". When "outsiders" do not pay, they have developed a mechanism for ignoring them and it is called "Silence Strike".

So, in order to collect relevant information about their life, one has to break this strike. To this end, chloroquine drug (the area is endemic for malaria), blades and pins (they value them much) were carried to the Surma country with the intention to motivate them to talk and obtain realistic data. After the interview and discussion, each participant was given these items. Chloroquine was given out by a nurse who joined the team from Maji Health Center. An interpreter from Dizy ethnic group also assisted in the data collection process.

Major findings

Marriage and sexual practices

Marriage among the Surma is the function of willingness and interest of both parties. Specifically, women have an exclusive right on their sexuality. No one obliges her if she is not interested. Parents do not have much influence with regard to mate selection. The causal relation that starts at early childhood often continues and may culminate into marriage.

If a man decides to marry a girlfriend with whom he had sexual relations already, he gives her a bead which she wears on her arm. Beads among the Surma are symbol of decision to marry a girl to whom the bead is given. The bead, if she accepts and wears, marks that she is betrothed. When she gives birth to a son, the mother puts the bead on the waist of her baby. When he grows up, the son puts the bead on his arm until he decides to marry someone and gives it out to her as a sign of his decision. In cases where more than one son is born, the mother is supposed to buy beads from the market. This has been going on for centuries now.

Among the Surma, both men and women undergo a series of rituals before marriage. The women beautify themselves by piercing and incising their lips and ears. Furthermore, she starts to limit the number of her boyfriends. Men, on the other hand, start to build their body and prepare themselves for a ritual fight. To this effect, he isolates himself from the living quarters and stays with the cattle.

Often, clashes over women occur as related to beads. If someone else loves the girl who already wears a bead on her arm, marking that she is betrothed, he cuts it out of her arm. When the man learn this, this instigates the formal fighting game called Donga.

The elderly members of the community fix a time for fighting. On the fixed date, the two competing parties fight with stick encircled by people and the girl (would be wife) as spectators. Often, the fighting is said to risk life although the elders can stop the game based on the intensity of attack. The winner is offered greetings and a small wooden container by any virgin girl and the would-be wife gives him a kiss and a local dance. If he fails and the girl still wants him for marriage, he will be given another chance for which he has to prepare himself again.


Donga game over a girl For marriage

After proving his capability to marry, as marked by winning the Donga game, the would-be husband sends a minimum of two respected elders of the community to talk to the parents of his prospective wife. If the daughter is willing, her parents will agree. However, he is supposed to pay 15-20 heads of cattle as bride price.

Family planning practices among the Surma

After birth, the Surma mother is expected to rear and nourish her baby carefully and very well. Children are breast fed only until the age of six months. Feeding continues until the age of two with additional food prepared from maize and sorghum. The Surma wife will not have sexual activity until the baby can stand on his feet and walk around. During much of this time, the husband stays out of the house and joins a group of men herding cattle. When the baby begins walking, the wife will send a message to her husband inviting him to come home. She prepares porridge and inserts a wooden splinter symbolizing that she is ready for sexual intercourse. The husband shows this to the group so that he is not teased.

If the wife calls her husband home before the child is able to stand on its feet, her husband and community will accuse her of being emotional and is humiliated, i.e., talked about in public. And if the child happens to get sick or becomes sickly, she is blamed. Women who takes very good care of their children are highly praised and blessed.


Woman invites husband For sex when a new born is capable to walk. This is a strong spacing strategy.

Children as assets

Among the Surma, children are considered assets of the family. After marriage, the Surmas like to bear as many children as possible. They do not discriminate between sexes of newborns. Giving birth to male and female is equally valued. Sons are valued for their help in the continuous fighting between the Surma and their neighbors while daughters can fetch the family with wealth from bride price. So, both sons and daughters are equally desired. If a woman fails to rear the child very well, she loses social respect and will often be disregarded. As a consequence, IMR among the Surmas is said to be very low. Grief is more intense when infants die than pregnant women, elderly or adults.

Premarital sex and the taboo of pregnancy

Premarital sex is a common practice among the Surma. Both male and female members of the community are allowed to enjoy their own sexual life while young. Specially, daughters are said to have greater opportunity for marriage if she has dated and has gone out with many male partners. And mothers are happy to see their daughters having many partners as it signifies being liked.

But despite exposure to and practice of free sex, pregnancy and giving birth out of wedlock is considered a taboo. If a girl becomes pregnant out of wedlock, she is humiliated and forbidden to wear the lip plate. However, the one who impregnated her is forced to marry her and give cattle to her parents. The baby borne out of wedlock will be considered as her brother or sister. The man who impregnated her would either run away or stay but suffers the threat of being killed by the girl's family.

Mechanisms of birth control

From discussion with provincial administrators and 'outsiders' residing in Maji and Turn towns, the Surma's herbal medicine is widely known. Due to such extensive information, the expectation was that abortificients for prevention of pregnancy would easily be obtained. However, from the preliminary study it came out that "they do not use any plant material" to prevent pregnancy before marriage. This is, however, inconclusive as it needs a good deal of time to properly undertake a participatory study among the Surma to determine it. Similarly, termination of pregnancy still needs to be validated.

From the study, it was found out that the Surma woman starts to learn when to get pregnant from her childhood. Every Surma woman respondent know when it is safe to have sex and when it is not. Although sex is free and is a mutual decision of both parties, it could be done only at specified times of the month. This is the responsibility of women to follow and control.


Mother counselling her daughter on sexual activities

The exclusively acceptable birth control. methods practised by the Surma before marriage was the so-called "rhythm" technique. From the information gathered, it was found out that they are very much meticulous about the rhythm method.

The Surma highly respects appointments and promises. Knots and beads are religiously used as reminders. When they take appointments, they always make knots on a thread/ rope or use beads hung around their waists. Each knot or bead would represent one day. Every day, they keep on untying the knots or removing one bead. When all the knots have been untied or beads removed completely, this marks the day of the appointment.

The Surma women use similar mechanisms to prevent pregnancy before marriage. On the first day of her menstruation she makes five knots on the thread/rope, hangs this around her waist and unties one knot everyday. If her menstruation does not stop on the fifth day, she waits until it goes. After her menstruation stops, she adds 10 more knots, untying one knot everyday. When the knots are untied completely, she can start to enjoy sex until the menstruation comes again. On the other hand, if she happens to get pregnant in spite of this, it was gathered from outsiders that she is said to use herbal abortificient which they are not happy to tell. They are also said to use astrological methods - counting stars, looking at the position of the stars and their numbers - to determine the right time to have sex. This, however, needs to be further substantiated.


Untying 15 knots from the onset of menstruation to avoid pre-marital pregnancy

Communication media used

For the Surmas, girls wearing beads on their waists, knots on the rope, lip and ear incision all communicate specific messages. These media forms are part of the accepted norms and practices but they have similar or even greater effect than written or visual media. The intense and continuous counselling of daughters by mothers is also a strong medium to teach daughters when to have sex, what to do to avoid pregnancy and ways of managing their sexuality and fertility.

These media forms are acceptable and more importantly, used as part of their lives. And these entail minimum cost which the people can afford.

Conclusion and recommendation

Regulating birth control may not necessarily mean planning family size. Yet, the concept of sexuality and rules and regulations pertaining to and governing it vary from culture to culture. As indicated, the concept of birth spacing and pregnancy prevention prior to marriage existed in the Surma culture since time immemorial. This may not be the present (modern) concept of family planning but his has important implications in the overall attempts related to family planning.

Majority of the people in the rural areas do not know and/or use modern family planning methods nor are they concerned with family planning as such. They, however, like the Surmas, may have mechanisms for birth spacing through abstinence and breastfeeding, prevention of pregnancy and rearing of children which are part of "family planning". Therefore, it is recommended to seek ways to undertand local wisdom and techniques related to family planning and integrate this with the modern concepts of family planning.

The Surma's definition of family planning is comprehensive and proven effective as it covers: prevention of pre-marital pregnancy using rythm and birth spacing for adequate care of the child. In terms of decision-making, i.e. when to have sex, when not to and with whom, the women have exclusive right, power and responsibility. This should be encouraged. However, studies should be conducted to ensure that indigenous methods, knowledge on how to make modern family planning methods accessible in the context of the intricacies of Surma reproductive culture and value for children be best be integrated.

References

Abink, J. 1992. Settling the Surma: Notes on Ethiopian Relief Experiment, Human Organization. 51(2)

Beckwith, C. and A. Fischer. 1991. The Eloquent Surma, National Geographic Magazine. 179(2). Washington DC.

Bertrand, J. T. undated. Report on Factors Affecting the Use of Traditional versus Modern Family Planning methods in Bas, Zaire.

Hardon, A. 1992. The Needs of Women versus the Interest of Family Planning Personnel, Policy Makers and Researchers: Conflicting Views on Safety and Acceptability of Contraceptive, Social Science and Medicine. 35(6).

IPPF. 1998. Review of Population and Development. 15(3).

Sofowora, A. 1982. Medicinal plants and Traditional Medicine in Africa. John Wiley & Sons, Ltd,

Communicating health issues with women

Pallavi T. Patel and the CHETNA Team

CHETNA means "awareness" in several Indian languages. But the Centre for Health Education and Nutrition Awareness which is also referred to as CHETNA is a project initiated in 1980 to improve the impact of supplementary nutrition feeding programme for women and children in Gujarat, India. CHETNA's mission is to assist in the empowerment of the disadvantaged women and children to gain control over their own and that of their families' and communities' health.

Development and dissemination of information, education, and communication (IEC) materials on health and development issues was one of the main activities of CHETNA. Innovative methods, e.g., qualitative research methods to collect community-based information, were used to conduct extensive field testing prior to developing health education materials, e.g., flip charts, learning kits, manuals. CHETNA's education materials are popular, particularly among the semi-literate and non literate people. They have become tools to assist women to reflect on their social, political and cultural status and have encouraged them to take action to improve the quality of their lives.


Figure

Building the capacity of government and non-government organizations (GOs and NGOs) through workshops, trainings and information sharing, networking and advocacy was another important activity of CHETNA.

This case paper describes and analyzes CHETNA's experiences of how the traditional gathering of women was used as a communication media to create awareness about their own body, provide diagnostic treatment for their gynecological illnesses and the development process of the print media. The audience composed of rural and urban poor women from the lowlands.

Reviewing human history in India, it has been observed that women have died young in child birth or because of ill health, often as the victims of abuse, torture, violence, neglect and other acts of social discrimination. Even in today's "modern" and scientific world, the situation still prevails due to the dominance of a complex, socio-cultural web, which has conditioned women not to complain but to cope silently with their multi-faceted health problems.

A woman as a child is usually discriminated against and/or overprotected. Robbed of her golden years as a young woman, in the anxiety of early marriage, she bears the burden of becoming a mother even before she completes adolescence. The adult personality of an Indian woman is moulded out of society's manipulation of cultural norms and leads to chronic feeling of low self-esteem. Women are rarely equipped with the courage and confidence to voice any of their problems, including health. By clinging to the hope of their precious adulthood they enter into old age without understanding that by then it is too late for health problems to be treated.

In working with women, CHETNA team members came across many statements that exposed the complexity of women's health problems and their ability to seek treatment.

"What illness? We do not have any illness. I am not suffering from any illness". (40 year old woman with four children with severe white vaginal discharges from Panchmahals District, Gujarat.)

"My husband does not listen to my complaints. He says that I do not have any disease as I can walk, eat and work too." (30 year old woman suffering from RTI - Gujarat).

"I know fully well the danger of my wife's death during childbirth but I do not want to donate my blood. I take full responsibility." (Young man signed the above written statement at Udaipur hospital, Rajathan.)

"Let me die, but do not take the blood of my husband or son. They will become weak." (Woman patient at Udaipur hospital, Rajasthan.)

On the other hand, the more advantaged groups who enjoy various privileges and powers in society tend to make generalized statement such as: "women are ignorant, " "they do not understand, " "women do not talk about their health problems". This is because there is lack of understanding about the reality and complexity of women's health problems. Such assumptions and myths further entangle the socio-cultural webs that trap women in a spiral of worsening health.

Reproductive health concept introduced

· Overcome the beliefs and superstitions related to gynecological illnesses, pregnancy and menstruation.

· Sensitize women on socio-cultural and religious factors affecting their health.

· Sex education for adolescent boys and girls.

Communication media used

With a mission to contribute to developing new models of women's well-being, CHETNA team members (mainly women) spent the past decade in search for better understanding of women's health by using innovative health education approaches and creative health education materials. The field efforts have generated a great deal of common positive understanding on women's health issues, which has helped the organization to evolve a guiding principle in its work with women: listen to women -their perspective and their knowledge about their own health problems.

Preliminary meetings were held at community level to develop rapport with women. Focus group discussions were then organized to collect information on the women's perspectives and knowledge on their health concerns. Their initial response was to enumerate common symptoms like fever, headache, body ache, weakness which affect their routine household work. But when specific questions on reproductive illnesses were asked, they would mention specific conditions. These were usually leucorrhoea; problems related to menstruation-profused bleeding, prolonged menstruation, oligomenorrhea; prolapse of the uterus; sexually transmitted diseases (STDs), mainly syphilis and gonorrhoea; and urinary tract infection.

Health Mela-Fair

CHETNA's experiences indicate that due to cultural constraints, women do not avail of medical treatment but when approached as a group in an enabling environment, they would openly share their reproductive health problems very confidently.

Mela-Fair is a traditional event that takes place at least once or twice a year during certain period (depending on religious celebration or after harvest). The fair is put up in an open space and built with colorful cloths. Different stalls are set up for selling traditional handicrafts, jewelry and household items. Apart from these, there are also stalls for eating and fun games. Villagers - men, women and children - actively participate. The fair is usually organized for two to five days and activities start early in the morning and continue until late night.

CHETNA replicated this set up for education, diagnostic and treatment of gynecological illnesses of women. A similar environment was created by building a tent. Various stalls for fun and educational activities were organized. There was a large open space for dancing and conduct of traditional games like "lemon and spoon" and the "know your body" rope exhibition. A space for health and gynecological check up was also allocated.

Adult women between the age of 20-60 years participated actively in the Mela-Fair. Adolescent girls were particularly active in exhibitions, group discussions, general health check up and hemoglobin estimation. The duration of the Mela-Fair varied from one to three days depending upon the educational needs of the women.


Activity Flow at the Health Mela-Fair

Prior to the fair, the CHETNA team members went to the community level to announce the date of the fair and motivate women to attend. Women were also interviewed for their health history and those with STDs were referred to the nearby hospital. They were invited to participate in the fair but without letting them expect of treatment.

On the day of the fair, women were welcomed with flowers and got registered. After that, they went through an exhibition of "know your body" and "gynecological diseases". Information on the human body was shared through a special exhibition of posters and models. Small groups of women were guided through the exhibition by a facilitator who explained the details and answered questions.

After the exhibition, they went through a general health check up which included a hemoglobin estimation. This was followed by group discussions where simple messages on health and nutrition were given. Results of their general medical check up and hemoglobin estimate were also used to sensitize them about their health status. Various media forms like role plays, songs, print materials were used. Group discussions also helped lessen their anxiety and fear of the gynecological check up.

After the group discussions, women with gynecological problems were guided for a special checkup. While waiting for their turn, a film with general health messages was shown. A team of women remained present to provide them information on the check up and moral support if required. All women with STDs were referred to the nearby hospital. A child care facility (creche) was available where mothers could bring their small children while they had their check up.

In the evening, different stalls of games were arranged which provided them an opportunity to enjoy their evenings together with fun. They danced and sang together. They applied henna on each other's hands which is the women's expression of happiness and love

A similar fair was successfully tried out for adolescent girls and boys between the age of 12-17 years. The duration of the camp varied from one to three days. It was organized mainly to give them exposure to family life education which included discussion on menstruation, care during menstruation, sexuality, sex determination and child birth.

These experiences were documented and shared with many NGOs and GOs. It had been adopted and replicated by many NGOs in Gujarat and Rajasthan. CHETNA had provided them support to organize these fairs.

Strengths of the Health Mela-Fair

This approach has proved extremely useful to break social barriers and attract women to learn about their body and encouraged them to go through a gynecological check-up, something which they are usually afraid of.

Limitations of the Mela-Fair

1. It involved lots of time and human resources before and during the Mela-Fair/camp.
2. Immediate follow up was difficult because of time and financial constraints.
3. Treatment of STDs was not appropriate for this set-up.

Lessons Learned on the Mela-Fair

1. After the fair, women did not go for follow check-up at the nearby hospitals due to lack of female doctors and lack of friendly and supportive environment.

2. It is important to have a dedicated team of workers who could elecit trust and rapport with women so that they could openly discuss the health issues and voluntarily go for a gynecological check up.

3. In a group, women were easy to approach and the experience generated lots of experiential information related to women's health.

Areas for Enhancement (Mela-Fair)

This approach can be further adopted by involving men to educate them on prevention and treatment of RTIs and to be able to address the problems of STD.

Innovative health education materials

The health education materials produced were need-based, field-tested and mass produced in the national Gujerati language. The development of print materials went through five major steps before it was produced:

1. Understand educational needs of community, especially of women.
2. Develop educational messages and media forms.
3. Check the validity of technical information from medical professionals.
4. Field test for illustration and language.
5. Try out developed educational material by organizing educational sessions at community level.

The process of developing print media took about eight months to one year. These were widely disseminated in India but NGOs were encouraged to adapt the messages according to their own culture.

Educational Aprons

Women in the villages have many beliefs and misconceptions about the digestive and reproductive system. For example, they believe that if a pregnant woman eats much, the fetus in womb would get crushed due to weight of food. Similarly, there is a widespread belief that menstruation is nothing but removal of dirt and sin from body. Thus, in many communities of India, women are not allowed to participate in religious ceremonies when they have their menstrual period.

A set of two aprons was used to clarify this. One apron showed the digestive system and the other apron showed the female reproductive system and the process of menstruation. The educator wore the apron while explaining the location and function of the two systems.

These aprons were used for educated and illiterate adolescent girls, adult women and traditional birth attendants regardless of age. CHETNA has used these aprons in its training programmes for the last eight years and is now mass produced.

Strengths

1. It conveyed the message and the great demand for these aprons shows strength of its utility.
2. It is cheap and easy to use.
3. It can be easily replaced.


Figure

"Let Us Know More About Our Health and Body": a booklet

India implements literacy programme in each state to improve the literacy level of the country. This efforts are being made to incorporate health messages. CHETNA has developed a set of two booklets "Let Us Know More About Our Own Body and Health.

This set of booklets was developed after trying out an educational module with 5,000 adolescent girls and women of Gujarat State to teach them about their health. Information includes anemia, being a major health concern of women in India, menstruation, conception and sex determination. After a successful trial of this module, it now adopted for functional literacy programme especially for illiterates.

The set is composed of two materials: an educator's manual and a learner's booklet. The educator's manual has detailed lesson plans with technical information on each of the listed topics. Details on the various educational methods are also included. The learner's booklet is an aid for review of the topics. To make the review process interesting, activities like colour the drawing, fill in the blanks and make your own window chart were incorporated.


Figure

For numerical learning, a monthly date chart was provided wherein they would note their menstruation dates. Writing and spelling exercises let them label the parts of the reproductive system. They were also asked to repeatedly write or list words related to the body.

Strengths of the booklets "Let Us Know More About Our Health and Body"

1. It was useful when used during regular literacy or any informal adult education classes.
2. The learners' exercise book actively involved them in the learning process.

Limitation of the booklets

The teacher needs to have a good communication skills.

Useful Life Education for Adolescents

CHETNA has observed that adolescents are an important group who need exposure about their own body and some crucial educational intervention on useful life information. In India, this group stays away from scientific information as educational materials are not available and there are hardly any effort to develop need-based materials.

Both adolescent boys and girls, married and unmarried, participated in the needs assessment process. Some of the questions posed by adolescents during the needs assessment discussions were:

"It is true that girls who have well developed breasts are immoral?"

"Is it true that a man is able to find out whether his wife had sex before marriage due to broken hymen? Is there any surgery to repair it?"

"It is true that if a boy touches a girl on her breast or kisses her, she will become pregnant?"

To provide them scientific knowledge in a socio-cultural context, CHETNA developed and field tested health education materials on topics of conception and teenage pregnancy, sex determination, gender sensitization and abortion. The information was given in the form of stories.

At the beginning, it was thought that the adolescents would like to receive the information on topics using animal stories. So the first set of materials was developed accordingly. But during the pre-testing, the adolescents expressed that the issues were so similar to their experiences that they would like stories with human characters. A new set of materials with human beings as characters was developed and field tested.

The illustrations used the style of rural adolescents. The boys and girls were asked to draw illustrations and these were used to develop the illustrations used in this print material. Seeing their work made them extremely proud of themselves.

At the end of each story, questions were posed to create a balanced understanding between scientific information and their perception of issues related to the socio-cultural environment. To orient the educator on the issues, a short note from gender and holistic perspective was given.

This set of materials was used with CHETNA's Child Birth Picture Book to give technical information on topics.


Raja-Rani. Life useful materials for Adolescent Pregnancy during Adolescent


Sumati. Life useful materials for Adolescent Sex Determination.


Sushila. Life useful materials for Adolescent Abortion.


Sumati-Parvati. Life useful materials for Adolescent Gender Discrimination

Strengths of Useful Life Education for Adolescents

1. It was one of the first efforts to develop health education materials in print form for adolescents in a local language.

2. The text and illustration of the story were easy to understand

3. It could be used to teach social and technical information related to the issue.

4. It could be used both by boys and girls.

Limitation of Useful Life Education for Adolescents

The educator needs to have proper perspective on the issues of adolescence.

Conclusions and recommendations

In developing innovative health educational approaches and print media to raise women's awareness about their health, CHETNA would like to recommend the following:

1. Use the traditional media. It has been proven useful to attract women to learn about their own body and can also be effectively used for gynecological illnesses. Such approaches can be replicated easily with less financial involvement.

2. The material should give specific messages and must be developed in the gender context. Innovative or traditional media forms on women and adolescents should focus on social, cultural, religious and political aspects influencing them.

3. The materials should always address the need of women and not the NGO funders.

4. Women and adolescents need to be involved in the materials development stage from the needs assessment to the evaluation of the material. This can be done by listening to them. Appropriate, acceptable and relevant materials can be made only if women are given a chance to participate actively in the learning process.

Plenary summary. Papers on Reproductive Health

A closer look into the reproductive health experiences for a 20/20 vision has revealed that distinctions are being made - a division of rural vis-a-vis urban, men vis-a-vis women, young vv old, small society vv. large society, government organizations vv non government organizations. (Transparency 1)


Transparency 1

Health and other sectors (Transparency 2)

One critical relationship is that of health and agriculture. This was seen in the previous theme discussions. The Agricultural Approach to Family Planning is a contribution of the agricultural sector to the development of messages and channels relevant to the farming groups. A government organization, the Ministry of Agriculture in Ethiopia, designed a communication program on reproductive health for its extension program. It took a broader perspective for its desired effect (for what) - a quality of life derived from two sectors - economic, through gardening and income-generating projects and reproductive health. The communication media used were radio (prime time); peer education; interpersonal communication and print materials which were centrally-designed and produced but were not culturally-sensitive. The radio was used to increase the awareness while all the other media forms were used to effect a change in attitude and behavior. Key actors in the design were the home and development agents whose basic professional discipline was agriculture and were give additional competencies on reproductive health. Training was a deliberate strategy starting from pre-service in college, i.e., curriculum has been modified to the in-service training with its basic courses and regular updates. This was an excellent example where communication in one sectoral area (health) had been well-integrated into the service delivery of another sector (agriculture). But what about the reverse process - agriculture into health? The program, as a model, had effected a shift from an institution base to a community base.


Transparency 2

Areas for intervention (Transparency 3)

In Tanzania and Kenya, the educational system was a focal point of the intervention -targeting both the out-of-school youth through the "old/existing groups" and the in-school-youth through the changes within the curriculum and the extra curricular activities. For the former, it was to sustain awareness on female genital mutilation as part of the curriculum. Teachers were trained but this activity was government-restricted. The extra-curricular part was through the youth clubs, using drama and simplified materials and peer educators. The youth slang was recognized. Youth-friendly clinics were established. Club formation was encouraged for "new groups".

Management of the intervention involved project staff and steering committees composed of the community, teachers, students and out-of school youth themselves.

Considered threats to the intervention were:

1. adults themselves to the adolescents in the form of sexual harassment from teachers, relatives, etc., and of use of adolescents for "cleansing rites";

2. turn-over of educators where prevailing ratio is 1:200 and retraining is expensive; and

3. perceived donor-driven pressures.


Transparency 3

Small vv large Society (Transparency 4)

In contemporary times, the "small society" is characterized by having rites of passage with options to choose the best; practice natural methods of spacing - rhythm, (the man goes back to the wife when the child can walk, i.e., go to the father with a bowl); marriage is of mutual agreement - punctuated by an exclamation point; and expected to have as much children. Consequently, infant mortality rates in this small society are low. In contrast, the "larger society" has sexuality expressed as pre-marital sex and fertility becomes a serious concern. For both of these conditions, increase access to condom and its use is promoted, unwittingly leading to promiscuity. Marriage, as a matter of mutual agreement, can better be represented by an exclamation point and a question mark. How both small and larger society value children are expressed differently, i.e., in small society this means having as much children while in a larger society, less children. Yet, infant mortality rates are high.

Comparing the two societies for threats, we found that in the small society, women are the decision makers while men are the decision-makers in the larger societies. People in small society value handed down knowledge from generation to generation; in larger societies, question mark. People in small society know their bodies and the function, using beads and knots to track their reproductive cycles. The large society is just starting to do this.

Definitely, research is needed in both societies. For the small society, it is a matter of looking into how culture accommodates modernity where culture is an "interwoven fabric of life". For the large society, it is looking into how modernity accommodates culture.


Transparency 4

Culturally-sensitive harmful practice: FGM (Transparency 5)

In studying one intervention in terms of the problem, strategy and results, the project described the problem in terms of knowledge, attitude and practice. Consequently, a multimedia strategy was designed for Grades 7-9 (highs-school), rural and urban students. Increase in knowledge and attitude was observed with the use of lectures combined with drama, posters and videos. Another intervention was directed to the parents themselves as in Kenya.


Transparency 5

For this type of practice, the target group encompasses a wide range beyond the youth and ensure not only to reach women but more importantly the men as well. Political and religious leaders have to be enlisted. Enlisting religious leaders would provide the spiritual context of the health practice, i.e., in Sudan, no basis was found for female genital mutilation in both the Q'uran and the Bible. The service providers should be another target group - the circumcisers themselves and the traditional birth attendants. Awareness can further be enhanced by film showing (e.g., on female genital mutilation and female pain during delivery); use of schools and the development of agricultural analogies. A critical consideration is that the media should respect the audience (to illustrate, the showing of female parts on the screen when an imam is present).

Strategy

Strategy formulation in FGM has to consider the societal pressure for the promotion of the practice, e.g., pressure on parents. Misconceptions can arise. There are two considerations: first, there has to be sensitivity to the content- making it as part of maternal health and to the choice of media- such that there is indiscriminate genitalia exposure. Second, the expected result is not to stop but modify . For example, conducting a ceremony without actual FGM ("ceremonial nip"). However, husbands can check through this may even be more shameful to the woman. TBAs can even correct the nip and still have the full blown rite.

GO and NGO (Transparency 6)

The government organization that needs to sustain intervention has also been described as a biting dog while the non government organization whose existence is recognized as "not for eternity" is viewed as a barking dog given its advocacy slant. An issue that keeps emerging in the discussions is the system that is expected to develop, to make these two organizations enhance the existence of each other (complementarity) vis-a-vis that of a parallel system. The experiences have shown that the GO has tapped the resources of the NGO, e.g., supplies as in India, Bangladesh, South Africa, Kenya, Uganda and Ethiopia. A reverse process was noted where the staff of NGO are trained by the GO.

On the willingness to collaborate of either organization, the government may or may not be willing. The latter was seen in Indonesia on the clients' rights issue.

For target setting, the government sees the true picture but NGO makes its stand clear, i.e., not to tamper data when the targets are not reached.

Transparency 6


Willingness to collaborate


® GO may not®Indonesia on clients' rights


® Target - setting:

GO sees true picture


NGO - not temper data that targets are not reached

For what (effect) and what (message) (Transparency 7)

A quality of life for boys, men, girls and women is the ultimate goal for which life building skills are provided in the economic and reproductive health areas. Reproductive health covers both sexuality and fertility (family planning, cultural practices, e.g., female genital mutilation) concerns along biomedical and psycho-social aspects, i.e., family and the individual adolescent/ adult life.

How

The experiences have been distilled as a three-pronged intervention - that of (1) communication, the conference subject matter; (2) services and (3) the "program". For the latter, community support and policy advocacy were critical.


Transparency 7

How do we make it happen (communication program) (Transparency 8)

From a programmatic view point with its three phases of planning, implementation and evaluation, community participation in all the three phases was promoted to achieve empowerment, ownership and the enjoyment of benefits. The importance of being research-based was highlighted for planning phase. These are seen in the PRRA in Kenya and the participatory community diagnosis in Tanzania which had questionnaire survey combined with focus group discussions. One caution on the focus group discussion technique is on the translation from the local language to English as oftentimes meanings are lost. The participatory action research (PAR) in the Philippines had the community involved from the planning to the evaluation. Impact assessment was done for the PRRA and for PAR. The process and outputs could be used by conference participants back in their field practice.

The purely anthropological way of studying/learning reproductive health was questioned for there were no clear links to pursue action on the results.

A study on the adolescent female, using survey questions and focus group discussion, was operation research-based. Action was deliberately built in while planning the research, rather than as an after thought.


Transparency 8

Where were learnings derived and action took place? These were at the home, school and the community. In the school, peer pressure, known for its negative effects, was transformed into its positive meaning through education. Interventions, particularly at the nuclear family level, have shown that communication has to be initiated and maintained not only between the same gender (i.e., father-son, mother-daughter) but across gender (i.e., father-daughter and mother-son). This may, though, serve as a challenge. As a father (conference participant) lamented, "it's easier said than done! How can I tell my daughter about condoms? I do not want to lose my child! (Transparency 9)

Apart from the nuclear family, there is the role of the extended family - the aunts and uncles - who can be significant communicators in reproductive health in traditional societies (older generation).

Transparency 9


Father® son

Mother®daughter

Father® daughter

Mother®son


Institutional framework (Transparency 10)

To sustain the process, five sectors emerged that provide critical relationships apart from the adolescents themselves and the peer pressure they exert on one another. One level are parents and teachers though adolescents often do not tell the truth to parents and to teachers (their immediate environment) and are primarily concerned with their well-being. A second level are the religious leaders who provide the moral guidance; the technical sector (both the doctors and the social scientists) who need to assure quality control to the design and conduct of interventions for the adolescents. Finally, the government which wields "power" to create and nurture a warm, compassionate environment.

Adolescents can form advocacy groups to ensure their needs are met. Mass media, peer groups not only among adolescents, but also among parents and teachers, training of teachers, integration into curriculum, counselling by churches/ religious/ spiritual leaders on "love without intercourse" were actions that have been tried. In all of these interventions, two considerations have emerged - first the need for "shared understanding" among these various actors and second the need for a collaborative mechanism in its informal form as the forum for dialogues where adolescent health is tackled.

Moreover, one has to answer the question " What data is given to whom". Research generated often effect just a continuing debate among these stakeholders. Also, media choice depended on the type of stakeholder. Both of these realizations highlighted the need of a "decision-linked research".


Transparency 10

With the roundtable and plenary session acting as our spectacles for why and how we approach reproductive health, we have found out the possibility of being 'cross-eyed' but more often, teary-eyed. We do need to look, but more importantly, we need to act to stop or to change factors and events to ensure the reproductive well being of our people. After all, harnessing the human resource is at the center for the sustenance of the next generation. (Transparency 11)


Transparency 11

Closing address

WRO. Tadelech Haile Michael
Minister of Women Affairs
Federal Democratic Republic of Ethiopia

It gives me a great pleasure to be among you at the end of your successful conference on Reproductive Health and Communication at the Grassroots: African and Asian Experiences.

Although more than 180 countries have endorsed reproductive health as a new vision essential for human welfare and development, it has not been easy to translate this vision into action. I like to congratulate/the conference participants and organizers for taking this global vision forward and translating it into action.

Poverty, by its very nature, is inter-locking problems of ill-health that cannot be addressed in isolation to those of illiteracy or livelihood. Poverty, social and gender inequalities influence population growth and its structure. Your focus on reproductive health will undoubtedly enable countries and communicties to address both health and population issues with an emphasis on women's health needs.

This conference is significant in many ways.

First, this took place when Ethiopia is in its early phase of implementing its first and most comprehensive and integrated population policy. This conference serves as a motivation.

Second, it has translated into action the often talked South-South exchange and information sharing.

Third, it is brought various development actors (government, NGOs and grassroots practicioners) to work together for common goal which primarily affect women. And I am pleased to note that the majority of the conference participants are women. Your effort to explore alternative and non-traditional media forms to communicate such sensitive issues and integration of indigenous knowledge systems is very creative. I am particularly pleased that this conference has dealt with different approaches for effective communication at the grass root level regarding reproductive health. I believe that the success or failure of our development effort rests on how effectively we communicate with the masses at the grassroots who hold the key to our development endeavour.

Fourth, I am informed the this conference is unique in that it has provided all of you with a framework to document, analyze and abstract successful grassroots experience from Asia and Africa which will be published and shared widely.

Fifth, the organizers, the Family Guidance Association of Ethiopia (FGAE) and the International Institute of Rural Reconstruction (IIRR), have successfully demonstrated the ability of working together for a common goal. Development efforts can not be sustained without mutual collaboration between local, regional and international organization working hand - in hand to solve common problems. I commend the exemplary partnership between FGAE and IIRR.

I am confident that the valuable experience and knowledge that you have exchanged in this conference will be used for the enhancement of the well-being of the poor and in particular to empower women in your respective communities and nations. This conference can alternatively be named as "Conference on Empowerment Through Information".

Finally, I like to thank the two organization - The Family Guidance Association of Ethiopia and the International Institute of Rural Reconstruction for organizing this important conference and choosing Ethiopia as a venue. I also like to thank all of you, conference participants from various countries, for choosing to come to this conference and I hope you have enjoyed your stay here in Addis Ababa. I wish you a safe trip to your countries and destinations.

I now declare that the conference is officially closed. Thank you.

Conference resolution

May 16, 1997

In resolving matter related to reproductive health, in particular STDs/HIV-AIDS and family planning and acknowledging the impact of communication strategies presented in this conference, we, the South-South Peoples recommend that participatory community diagnosis be used as an entry point in addressing these issues.

Use participatory action research (PAR) to develop appropriate communication strategies with clear and simple messages to ensure effectiveness and sustainability, keeping in mind cultural sensitivities, community values, priorities and needs. Indigenous and traditional means of communication should be enhanced. The communities should be involved at all stages of the communication process. Impact assessment should be documented for further use.

Further recognizing that specially-sensitive issues like female genital mutilation, violence against women and adolescent reproductive health, be more specifically addressed and focus should move from awareness raising to attitude and behavior change.

Realizing that most messages have been focused on women, future communication strategies should give special attention to men.

Advocate for eradication of harmful traditional practices such as female genital mutilation and enhancement of helpful traditional practices.

Recognizing that networking between GOs and NGOs is essential - for policy change and service integration - advocacy, sharing of experiences and mobilization should be encouraged and affected.

We, the South-South Peoples, therefore, commit ourselves to achieving these goals in our various capacities.

Conference resolution (women)

May 16, 1997

In resolving matters related to reproductive health, in particular STDs/HIV-AIDS, FP and acknowledging the impact of community strategies presented in this conference, we the South-South Women (SSW) recommend that participatory community diagnosis be used as an entry point in addressing these issues.

Bearing in mind cultural sensitivities, community values, priorities and needs, for communication strategies to be effective and sustainable in addressing these issues, identification, planning, implementation and monitoring and evaluation of communication strategies should be research-based.

Further recognizing that specially sensitive issues like FGM, violence against women, etc, be more specifically addressed, focus should move from awareness raising to adoption of preventive practices.

Recognizing that collaboration between GOs and NGOs is essential (for policy change, service integration) advocacy and mobilization should be effected.

Realizing that most messages have been focused on women, future communication strategies should give special attention to men.

We, South-South Women, therefore commit ourselves to achieving these goals in our various capacities.

Conference resolution (men)

May 16, 1997

HIV/AIDS/STDs

Communication messages should be developed by GOs, NGOs, CBDs and all the relevant agencies, preferably in close collaboration for consistency and effectiveness.

Messages on HIV/AIDS/STD should be suitable to the receiver-clear, specific and simple. Appropriate traditional and modern media channels should be utilized.

Messages should be focused more on attitude and behaviour change. It must be suitable and culturally-sensitive based on research.

Development of messages should involve the target audience. There is a need to explore and use other innovative and creative forms of community.

Emphasis should be given to sharing of information and experiences through networking. Impact assessment should be carried out and documented and the results utilised in future. Use of PWA should be voluntarily utilised for information giving.

Family planning and other reproductive health

Family planning (FP) messages and information should be integrated (service delivery and IEC). FP communication medium should involve all relevant channels using integrated approach.

Issue of sustainability should be addressed at all levels of message and medium identification. Relevant traditional medium of communication should be enhanced and, where possible, incorporated in the conventional medium.

All relevant agencies should come out strongly and advocate for relevant and effective communication medium and strategies aimed at eradication of harmful traditional practices, in particular, FGM and enhancement of beneficial traditional practices.

Targeting of messages and information should be for both sexes.

Guidelines for structured case presentations

This guideline is not meant to limit creativity or flexibility. Variations in the format necessitated by the nature of the case are allowed.

Title

The title should be in capital letters and centered on the page.

Author

The author's name should appear as last name followed by first name and then, middle initial. (For example: Labayen, Lorna S.). Names of multiple authors should be separated by semi-colons.

Introduction

The introduction should include the background information from which the case was taken. It should provide the name of the organization, the name of the project, where the project was implemented, the major beneficiaries and other relevant information. The introduction section should not exceed one page.

Reproductive health concept introduced

Case papers should focus on reproductive health concepts. The concept could be on reproductive system, family planning, AIDS initiatives or related topics.

Communication media used

Describe the communication medium used in introducing or popularizing the reproductive health concept earlier discussed. The communication medium could be radio, comics, puppets, posters, drama, etc. or a combination of media. This section should also discuss the characteristics (age, gender, economic status, etc.) of the audience and the expected behavioral results based on the reproductive health concept introduced. Describe also the methods used and the duration of the information dissemination.

Major findings

Describe the process used in choosing the communication medium, the appropriateness of the communication medium used to the reproductive health concept introduced or popularized and the acceptability of the concept to the audience in relation to the medium. State also the strengths and weaknesses of the chosen medium and synthesize the issues and concerns from the case presented.

Conclusions and recommendations

Based on the major findings, report conclusions supported by evidence as well as policy significance. Give equal emphasis to the positive and negative findings. Recommend changes or modifications which would improve the communication approach. Indicate also whether additional study is required.

Discussion guide (round table session)

A. WHO

1. Anchor Facilitator* - moderates discussions
2. Case presentor* - presents case study in Round Table Sessions (RTS)
3. Abstractor and assistant* - writes group findings during RTS
4. Participants

* Selected by organizers

B. WHEN

Time Allocation: Case Presentation

20 min.

Clarifications

10 min.

Discussion using RTS Guide (simultaneous with abstraction)

80 min.

Validation of outputs

10 min.

C. HOW

1. Case Presentation

1.1. Content: follow case study format
1.2. Process


a) Case Presentation

20 min.

Introduction to Concept

2 min.

Communication Strategy

5 min.

Findings

10 min.

Conclusions/Recommendations

3 min.


b) Clarification

10 min.

1.3. Output

Paper can be revised as a result of the clarification and/or discussion if there were points stressed which are not found in the original paper but were part of the actual experience.

2. Discussion

2.1. The Case Study is intended to trigger participants' analysis and/or consolidation of their own experiences related to the topic. It is not meant to be the main focus of the discussion.

2.2. Participants can affirm or negate the experience based on their own field experiences.

2.3. Similarities and differences across cultures need to be identified.

2.4 At the end of the Round Table Session, the abstractor presents the outputs to the group for approval.

3. Abstraction (For abstractors)

3.1. Fill up 2 guides: 1 for presentation and 1 for discussion. Present verbatim as much as possible.

3.2. Identify organization as source of information during discussion.

3.3. Use tape recorders to fill in but not be totally dependent on it.

3.4. Outputs will be written in transparencies and presented to the group for validation at the end of RTS.

Discussion guide (plenary session)

Who

1. Moderator* - moderates discussions
2. Abstractor and assistant* - writes group findings during RTS
3. Rapporteur - presents RTS results (one per group)
4. Participants

Selected by organizers

How

A. Process

1. Reproduction of group outputs: 5-10 min./RTS Groups
2. Clarification: 5 min./RTS Group
3. Discussion using abstraction guide: 40 min (simultaneous with abstraction)
4. Validation of outputs: 5-10 min.

B. Discussion (after all the reports)

Group rules:

1. Participants can affirm or negate the experience based on their own field experiences.
2. Similarities and differences across cultures need to be identified.
3. Group output cannot be modified.
4. At the end of the plenary session, the abstractor presents the outputs to the group for approval.

C. Abstraction (for abstractors)

1. Fill up Abstraction Guide for Plenary. Be verbatim as much as possible.
2. Identify organization as source of information during discussion.
3. Use tape recorders to fill in but not be totally dependent on it.
4. Outputs will be written in transparencies and presented to the group for validation at the end of the plenary.

Discussion

1. The case study is intended to trigger participants' analysis and/or consolidation of their own experiences related to the topic. It is not meant to be the main focus of the discussion.
2. Participants can affirm or negate the experience based on their own field experiences.
3. Similarities and differences across cultures need to be identified.
4. At the end of the Round Table Session, the abstractor presents the outputs to the group for approval

Abstraction (For abstractors)

1. Fill up 2 guides: 1 for presentation and 1 for discussion. Present verbatim as much as possible.
2. Identify organization as source of information during discussion.
3. Use tape recorders to fill in but not be totally dependent on it.
4. Outputs will be written in transparencies and presented to the group for validation at the end of RTS.

Abstraction guide (case presentation)

Audience characteristics

A. __Rural

__Urban


__ Upland

__ Lowland

__ Coastal

B. Age:______

Gender: _____Female ______ Male

If mixed with majority_____(age)______(gender)

C. Economic Status:

_____Better off

_____Average

____Poor


_____Poorest

_____Mixed


D. Occupation (specify): ___________________________________________________________
E. Religion (specify): ______________________________________________________________

Reproductive health concept

____HIV/STD (specify): ____________________________________________________________
____Family Planning (specify): ______________________________________________________
____Specific issues/concerns (specify):_______________________________________________

Communication medium

A. Methods

Methods

Original

Adapted

Duration

Mass media, campaigns




Street plays, dramas




Peer educators' training




Interpersonal (FGDs, counselling, etc.)




Material (print, cassette)




B. Expected behavioral results

C. Findings

Areas

Strengths

Weaknesses

Lessons learned

1. Process used in choice of medium




2. Appropriateness of communication to concept introduced




3. Acceptability of concept in relation to medium




Issues and concerns:

D. Areas for impact enhancement

Abstraction guide (RTS discussion/plenary)

Audience characteristics

A. ____Rural

____Urban


______Upland

____Lowland

____Coastal

B. Age and gender

0-6 years

7-14 years

15-19 years

20-35 years

36-49 years

50 years and above

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male













C. Economic Status:

__Better off

__Average

__Poor


__ Poorest

__ Mixed


D. Occupation (specify): ______________________________________________
E. Religion (specify): _________________________________________________

Reproductive health concept

____HIV/STD (specify):________________________________________________
____Family Planning (specify): __________________________________________
____Specific issues/concerns (specify):___________________________________

Communication medium

A. Methods


0-6 years

7-14 years

15-19 years

20-35 years

36-49 years

50 years and above


Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Mass media, campaigns













Street plays, dramas













Peer educators' training













Interpersonal (FGDs, counselling, etc.)













Material (print, cassette)













For each method used, indicate if original (*) or adapted (0) in the appropriate cell. Use color codes to distinguish sharing from Asia and Africa.

B. Expected behavioral results

Methods

Expected behavioral results

Mass media, campaigns


Street plays/drama


Peer educators' training


Interpersonal (FGDs, counselling etc.)


Material (print, cassette)


C. Findings

Areas

Strengths

Weaknesses

Lessons learned

1. Process used in choice of medium




2. Appropriateness of communication to concept introduced




3. Acceptability of concept in relation to medium




Issues and concerns:

D. Areas for impact enhancement

Ways for consolidation and wider dissemination (For plenary only)

Conference secretariat and production staff

Steering committee

FGAE
Araya Demissie
Teka Feyera
Tilaye Tesfaye

IIRR
Isaac Bekalo
Almaz Haile-Sellasie
Mulunesh Woldemariam

Workshop staff

Support staff

FGAE
Meswaet Belachew
Teka Feyera
Bekele Hundie
Senait Kassa
Getnet Kenoshie

IIRR

Angelita Poblete-Algo
Wondwossen Girma
Adam Ketema
Nora Mwaura
Menna Selamu
Estedar Tefera
Mulunesh Woldemariam

Technical coordinators

Isaac Bekalo
Julian F. Gonsalves
Estrella P. Gonzaga
Lorna S. Labayen
Phoebe V. Maata

Materials production coordinator

Angelita Poblete-Algo

Artists

Wondwosen Gebretnsae
Tadesse Redasso

Post production staff

Editor

Joy R. Rivaca-Caminade

Artist

Ricardo E. Cantada

Desktop publishing staff

Angelita Poblete-Algo
Evangeline C. Montoya
Librado L. Ramos

Conference organizational management chart


Conference Organizational Management Chart

Duties and responsibilities

A. Transport (Mulunesh Woldemariam)

B. Accommodation (Almaz Haile-Selassie)

C. Documentation (Isaac Bekalo)

D. Media (Tilaye Tesfaye)

E. Conference hall/ facilities (Mulunesh Woldemariam)

F. Recreation (Almaz Haile-Sellasie)

· Responsible for transporting staff members, participants

· Responsible for any inquiry regarding room facilities

· Registration

· Publicity before the conference date

· Arrangements of seats, caption

· Responsible for opening and closing refreshment

· Receiving and seeing off delegates

· Food facilities, lunch, coffee break

· Case presentation and typed, duplicated, papers distributed

· Media coverage on the opening session

· Overhead and video

· Music band, cultural show on Wednesday and Friday

· Purchasing office supplies, etc.

· Medical facilities for participants

· Programmes

· Media coverage on each days' activities

· Chart, etc..

· Tour organization

· Reconfirmation/ ticketing


· Artwork

· Final deliberation

· Recording ·


· Other duties


· Secretarial services


· Technical facilities of the conference