The evaluation of the reproductive health programme in Ambohimahamasina: A summary

An evaluation of the community reproductive health and family planning training programme, between April and October 2002, was carried out in collaboration with the project “Malagasy Green Healthy Communities” (MGHC), and the consultant Mr. Haja Andrianjafy. The survey part of the evaluation was conducted between the 19th and the 29th May 2003, and consisted of semi-structured individual interviews with villagers and with key informers such as school directors, health workers, the Fokontany presidents and teachers, a group interview with secondary school pupils as well as a participatory workshop which regrouped a mix of people in order to analyse their different perspectives on the programme. The eleven villages surveyed were chosen according to their distance from the centre of the commune, and the eight participants in each village were chosen using a quota system.

Overview of results:

Positive points:

All the villages (71) of the commune were touched by the training programme.
Increased awareness concerning the problems posed by STIs (sexually transmitted infections) / HIV/AIDS.
Recognition of the need for family planning.
Contribution to the increase in family planning users in the commune.
Decrease in teenage pregnancy and increased understanding of the risks associated with abortion.
Increase in the number of childbirths at the health centre.
Increased knowledge on reproductive health.
Natural family planning methods, including exclusive breast-feeding, were the subject of great interest and were at times successfully adopted.
The trained traditional birth attendants (TBAs) are key resource people for the implementation of safe motherhood.
Increase in condom use (although still minimal).

Negative points:

Villagers’ poor education levels result in a low capacity to assimilate new ideas (there is a clear correlation between education levels and the uptake of ideas from trainings)
Women and men being trained at the same time may, for some villages, have lowered the effectiveness of trainings.
Reluctance to use condoms continues.
Taboos related to the discussion of sex.
The programme reached less men and adolescents than was hoped.
The distance of some villages from the health centre lowers their attendance of it.

Details of results:

Concerning villagers’ understanding of the different subjects covered during trainings:

Subject	% of participants having understood well
Reproductive system / fertilisation	63
Natural family planning (following the menstrual	25
The risks associated with STI / AIDS	80
The treatment of STI	90
Contraceptive methods	59
Prenatal consultation	92
Nutrition during pregnancy	69
Necessity of spacing childbirth	83
Exclusive breast-feeding during the first 6 months	73

Poor education levels were found to be a particularly great limiting factor to villagers’ understanding of natural family planning methods

Themes cited as most interesting participants were the following:

Family planning in general (37 mentions)
Natural family planning methods and exclusive breast-feeding (17 mentions)
STI/AIDS (15 mentions)
Reproductive health (9 mentions)
Safe motherhood (4 mentions)
Condom use (2 mentions)

The main reasons for the attraction of family planning, and natural methods in particular, were (in order of importance); the wish to space childbirth, economic reasons (increase in productivity), and the wish to limit family size (often from women’s own experience of motherhood). Despite the great interest aroused in the subject, natural family planning methods were found to have been poorly understood by 16 of 52 villagers interviewed. Even those who understood the explanation well at the time of the training claim to have forgotten, and request that the trainings repeat periodically.

Condom use was the main theme rejected by villagers, 50% claim to be unconvinced. Roughly 19% of participants declare to be unconvinced by modern family planning methods, principally the pill and injectables, for fear of side effects (generally due to rumours), and the difficulty of their use (notably the problem of remembering to take the pill). Even so, the number of contraceptive users at the health centre in Ambohimahamasina increased from 102 (May 2002) to 170 (April 2003). This relates to a rate of family planning use of 4.3 %.

Audiovisual aids were found to be effective; roughly 80% of those who received brochures on the themes covered during training claimed to have understood them well. Also, there were on average an additional three people that read these training aids. The video sessions held in certain villages were well received but could have a greater impact if they were held more regularly and during times of large social events such as on market day or festivals.

The number of people claiming to have changed their perception or behaviour since the trainings:

Type of behaviour change	Percentage of villagers interviewed
Reproductive health	40.40
Natural family planning	46.20
Condoms	7.70
Other family planning methods	11.50
Consultation STI	5.80
Pre and post-natal consultations	19.20
Nutritional surveillance	21.20
Exclusive breast-feeding	17.30

The main reasons cited for not attending trainings were:

Work / farming (15 mentions)
Lack of interest (13 mentions)
Taboo / unease concerning sex (9 mentions)
Absence from village (9 mentions)

In sum, Feedback’s project was an overall success, if only in terms of exposing villagers to new ideas, which is a precondition for all types of development. However, one-off trainings in each village are unlikely to have an enormous long-term change on people’s behaviour.

Recommendations:

Reinforce villagers capacity of understanding (adult literacy, …):

Since it has been identified that education levels constitute a limiting factor for the uptake and application of new ideas, it is advisable that future interventions include a literacy programme

Train key resource people at the village level

Considering that all projects will come to an end one day, it is necessary for future interventions to train community members capable to continue awareness raising and who can serve as resource people in their communities. This is especially the case for youngsters, who were least affected by the trainings.

Train and motivate the health committees

At the start, Feedback planned to carry out trainings in collaboration with traditional birth attendants (TBAs) and health committees, but this met with varied success. One reason was perhaps the lack of motivation of these committees, since their motivation often lies in material terms.

Distribute more audio-visual supports such as calendars with family planning messages

Audio-visual also has the advantage of taking away the barrier between educated and non-educated villagers. Video sessions should be held more often and in as many different villages as possible.

Improve the supply of condoms to the health centre

The insufficiency of condom stocks at the health centre, as well as the irregularity of provisions, is a problem in the area. Stocks should be kept stable and sufficient, and the health centre should be assisted in completing its tasks. However, it is necessary not only to improve supplies in health centres, but also to increase the number of distribution points in the commune in order to increase accessibility

Strengthen awareness raising on AIDS so as to increase the rate of condom use, especially amongst young men.

It was noted that young men were less affected by the training programme than other population groups, despite them being in most need of training, especially concerning STI / AIDS and condom use. Also, the secondary school teachers hope to receive training on reproductive health and family planning so as to improve their lessons.