Summary

Over 90% of the population in the Anosy region of Madagascar live in extreme poverty, with severe lack of access to and investment in health services. Women are particularly disadvantaged - the region suffers some of the highest levels of maternal and child mortality in the country, with around 20% of deaths in women aged 15-24 related to pregnancy or birth. Local doctors estimate that 40% of women in the urban centre of Fort Dauphin are living with a STI, while the number of people in town testing positive for HIV has increased by 64% over the last 4 years. In a recent survey conducted in Fort Dauphin by Azafady 37% of women interviewed reported having an unplanned pregnancy, 29% reported a first pregnancy by the age of 18, and over 50% reported receiving no information about HIV, STIs and family planning at school.

Project Teza was a 12 month maternal HIV prevention project that ran in the urban commune of Fort Dauphin from September 2010 until September 2011. The project aimed to prevent HIV/STI transmission while promoting maternal and child health through a peer educator training programme with 6 women's associations and an antenatal programme which identified eligible women from 6 of the poorest districts in Fort Dauphin.

Principal activities

Peer educator training programme
The peer educator training programme was set up to work with members of 6 women's associations in the poorest districts of Fort Dauphin (Amparihy, Ampotatra, Ambinanikely, Amboanato, Tanamaboa, Esokaka).

The programme involved 2 hour training sessions held in the community every two weeks covering a range of topics including: HIV and STIs and their interrelationships with other health issues, menstruation, family planning, pregnancy, condom use, unplanned pregnancy and the link with child malnutrition, types of sexual relationships, negotiating sexual relationships and life choices, water and sanitation, the role and identity of women in Madagascar, the role of peer educators and women's associations in providing health education and social support, facilitating sessions and conducting health related demonstrations and sessions in schools and the community.

Additional workshops were also organised on the topics of self-esteem and volunteering, team building and trust, lambahoany design, nutrition (including sessions on baby feeding and the use of Moringa Oleifera), entrepreneurialism and creativity (including making jewellery, clothes, bunting, cakes, juice and hot gloves), costume, decoration and poster design, singing and dance classes (with 22 sessions held in preparation for mass mobilisations and the end of year celebration), CV writing and interview practice.

HIV sessions were also held in 9 classes in the CEG and Lycee for World AIDS Day, reaching 700 students, and a condom poster design competition received 250 entries. A traditional Malagasy music video about the importance of condom use for preventing unwanted pregnancies, HIV and STIs was produced in collaboration with the 6 women's associations. This process included: auditioning, screenplay and storyboard writing, dance practice, costume design and filming. Over the course of the project mass mobilisations were also held in celebration of World AIDS Day, International Women's Day, Independence Day and World Water Day.

Antenatal programme
The antenatal programme involved the organisation of four 5-week courses with a total of 45 women recruited through the women's associations in the 6 targeted districts. The courses used film projections, role plays, games, music, practical demonstrations and IEC materials to stimulate discussion of a range of topics including malnutrition, water and sanitation, malaria, TB, HIV and STIs, family planning, vaccinations, giving birth and breast feeding. A new range of IEC materials were especially developed for the topics of malnutrition, STIs, malaria, diarrhoea and rehydration drinks. As part of each course the women were also offered doctor's consultations and a follow-up doctor's visit 4 weeks after completion of the course.

Project impact

The impact of Teza's peer educator training programme was monitored throughout the year using questionnaires. Knowledge of HIV increased from 25% to 80% of women able to name the 3 modes of transmission. Knowledge of HIV prevention increased by 25% with 90% of the women now able to name 2 prevention methods and 98% can advise where to have an HIV test in town. Despite malaria being identified by the women at the beginning of the course as one of the most common local illnesses only 58% knew the source was mosquitoes – after training this increased to 91% of the women who understand how malaria is contracted. Following several sessions linking malnutrition in children with unplanned pregnancies, 87% of the women were able to name 3 signs of malnutrition which can aid the identification of malnourished children for feedings sessions led by the women's associations in the community.

The impact of the peer educator training programme on women's perception of their social status in the community and the home and their confidence to discuss health issues in these spaces was also measured. The singing and dancing classes aimed to strengthen the women's social support networks and confidence to act as peer educators in mass mobilisations and facilitating activities in the community. By the end of the year women's self-ratings on a social status ladder increased by 37% in the home and 34% in the community. This increase in confidence is also reflected in the frequency that the women admitted to discussing HIV and malaria in their homes and their community, increasing by 37%-66% and resulting in 98%-100% of the women now feeling confident to openly discuss these health issues. Another indicator of empowerment was revealed in the end of year test when the participants were asked “when should a woman have a baby?” The ‘safidy’ song (‘choice’ song) that Teza had made up for International Women's Day focused on family planning and the active role of women in the decision-making process. As a result 82% of the women answered this question “when she chooses to”. Overall 100% (54) of the women who participated in the Teza peer educator training programme passed the test and said they would recommend the course to a friend or undertake further training if it was offered. Impressively 78% of the women scored over 80% in the test which included questions about HIV, malaria, family planning, menstruation cycles, child malnutrition, the role of peer educators, and a situation role play on advice-giving.

Further information

For more details about this project you can check out Ailie Tam's Vodafone World of Difference blog.