Together will Change Mozambique,

Transcription

1 Together will Change Mozambique,

2 An Inspiring Journey by Patricia Poppe Maria Elena Figueroa

3 First Things First: Formative Research identifies windows of opportunities

4 RELATIONSHIP PARADIGM FOR COUPLES Men set the rules within the family and women obey Breadwinner of the house Take care of the house and children DESIRED ATTRIBUTES ASPIRATIONAL Men and women favor views of more equitable roles Greater understanding More dialogue (HIV, condom) Peace in the family Lasting relationship Reduce the workload at home Appreciation for women Disagree with DV and encourage dialogue Greater understanding: Be a brother More dialogue Respect for her opinions Sharing leisure time and activities Consider the workload in the house He appreciates/values me, it makes me feel strong RUPTURES & OPPORTUNITIES for change THREATS to the emerging paradigm Men admire men who are faithful = smart, honest, an example to their kids Men and women s views on subordination = strains family relationships, brings conflicts, dissatisfaction Women are looking for spaces to compare and discuss their marital life Peers and neighbors reinforce traditional norms Relatives and rite of passage counselors are gatekeepers of inequitable norms Alcohol consumption favors unprotected sex Mutual lack of trust between couples Domestic Violence

5 More socially acceptable Categories of MCP -- ANDAR FORA, social acceptability and risk perception(*) Walking out with a FRIEND and protecting oneself Walking out with a FRIEND Walking with an AMANTE Walking out with AMANTE & protecting oneself BEING ALL OVER THE PLACE Walking with a TEEN AGER and protecting oneself Walking with a TEEN AGER and not protecting oneself Walking with a TEEN AGER Greater perceived HIV risk Holman, Emily. 2007

6 What emerged from the study? Gender inequitable norms are starting to be questioned by both men and women in small circles Evidence of disagreements re: traditional and ideal gender and sexual role Women and men realize that there is high risk of HIV associated with MCP different modalities and practices. Also, MCP behavior brings conflicts not only to the couple but to the extended family

7 What emerged from the study? There is an increasing social disapproval for MCP behaviors in particular those associated with having stable lovers (casa 2) and intense (espalhado) extramarital sex. It drains household resources, affect children and family well-being. Men and women aspire to engage in a lasting relationship where dialogue, harmony and understanding prevails. Fear to act differently due to criticism from peers and relatives Women and men recognize the existence of women s rights and refer to the Family Law

8 Theoretical Foundation: BREAKING THE SPIRAL OF SILENCE From Silent Majority to Champions of Change People tend to remain silent when they feel that their views are in the minority. Elizabeth Noelle Neuman People have a fear of isolation and know what behaviors will increase their likelihood of being isolated.

9 Social & Behavior Change Communication Pathways for HIV Prevention & Treatment Strategic Communication Approaches Intermediate Social and Behavior Change Results Sustainable Health Outcomes SERVICES & PREVENTION Promote HIV/AIDS services Increase debate on ART adherence Build interpersonal communication skills among HIV/AIDS providers Develop tools and IEC materials for providers and clients SOCIAL AND BEHAVIORAL NORMS Model behavior change via mass media (TV, radio) and video groups -equitable gender norms -concurrent partners Media Advocacy Public debate with Leaders CAPACITY STRENGTHENING Consolidate BCC Coordination & Leadership at the National & provincial levels Train partners in BCC Systems Strengthening Norms Services Increase access to ART, PMTCT & CT information Strengthen provider s skills to increase ART adherence Use communications tools to increase ART adherence Promote HIV services and health seeking behaviors Media partnership Gender Norms examined Preventive Behaviors Modeled Risk perception increased Committed leaders to HIV/AIDS preventive behaviors Community support to PLWHA & referrals to clinics increased Stigma reduced Collective efficacy to change increased BCC National & provincial leadership MCP Campaigned coordinated and implemented Increase Use of HIV Services Reduced Stigma Reduced HIV Transmission

10 PROGRAM INTERVENTIONS NORMATIVE, GENDER AND BEHAVIORAL CHANGES Tchova Tchova Historias de Vida Radio Magazine: Champions in the airwaves HIV/AIDS Advocacy among Leaders Mocambique em Accao: TTHV hit BIG PRIVATE MEDIA MCP multi-media campaign: Andar Fora e Maningue Arriscado Tsha Tsha drama series in prime time Journalist Networks increase HIV/AIDS media coverage STRENGTHENING HIV/AIDS SERVICES TO INCREASE ART ADHERENCE Provider s skills to increase ART Adherence Job Aids for HIV providers (PMTCT, ART, Pediatric AIDS) Set of ART adherence for clients LEADERSHIP TO COORDINATE AND HARMONIZE HIV/AIDS PREVENTION COMMUNICATION STRATEGIES Leadership & Coordination of national HIV/AIDS prevention SBCC

11 Tchova Tchova Historias de Vida Normative & Behavioral objectives Increase equitable gender values and improve communication & interaction between men and women Increase risk perception related to MCP Reduce number of concurrent partners Increase collective efficacy to lead change Increase commitment among community leaders to HIV/AIDS preventive behavior Reduce HIV/AIDS stigma

12 Components Tchova Tchova Historias de Vida Gender and HIV profiles Facilitator s and Reference Guides Field implementation model 15 Champion s stories mini posters: early adopters Cue-to-Action cards: Lembranças de TTHV TTHV Advocacy keeping the group together and expanding beyond the workshop TT Radio Magazine- Champion in the Airwaves Program and Outcome Monitoring Impact evaluation

13 Gender & HIV/AIDS Profiles Themes covered Gender Based Violence Traditions against women: inheritance rights Blaming women for bringing HIV home Sexual networks (MCP) Discordant & positive couple ART adherence Adult Child Dialogue & SexEdu at home Working together = Session #11

14 Operational model Strong operational model guided by: Established targets (PEPFAR) CBOs as true partners - full time job Trained and mentored teams Three-cycles planned simultaneously per team Adult education methodologies Mentoring & supervision tools Video technology: laptops Program and Outcome Monitoring system

15 Implementation model Sofala Province Provincial Coordination: 1 Monitoring Officer: 1 District level supervisors: 6 CBO Partners: 5 Total Teams: 28 pairs BEIRA Luz na Comunidade 6 TEAMS DONDO KULUPIRA 4 TEAMS BUZI Luz na Comunidade 5 TEAMS CHEMBA PRO VIDA 4 TEAMS MARROMEU AJULSID 5 TEAMS NHAMATANDA AMAC 4 TEAMS

16 Mentoring & Supervision Weekly meetings to strengthen facilitation skills, collect monitoring data & troubleshooting: On-the-job training Reporting on and documenting emerging Champions of Change

17 Champions of Change Facilitators were trained to identify Champions of Change among TTHV participants. They agreed to share their stories to inspire others through radio interviews, champion s stories posters and pictures of their new lives. Trickle Up Approach Men ignores his brother opinion and supports his wife s decision to work outside the home

18 52 Stories of Champions Documented Respect and Trust for his wife makes the husband support her desire for continuing education Men gain awareness of his alcohol abuse and achieve harmony at home

19 52 Stories of Champions Documented Religious leader fosters new roles for women at his church A couple decides to stop domestic violence and rebuild their lives

20 Keeping the momentum Cue-to-action Visual Cards Freire s Stimulating Themes : voices from within (from monitoring data) Lembrancas capture participants testimonies after each session and devolve them as a reminder of what they value to pursue change

21 TTHV Advocacy Post - TTHV Initiatives Achieving Social Cohesion Agreed on and hold weekly meetings to continue TTHV group discussions Selected 2 TTHV participants as their leaders to coordinate discussions Established community green houses, open new wells Advocating TTHV Conducted home visits among non TTHV participants Provided counseling to couples affected by GBV Organized discussion groups among non-tthv participants Spoke out in religious gatherings

22 TTHV Model CATALYST TCHOVA TCHOVA HISTORIAS DE VIDA COMMUNITY DIALOGUE COLLECTIVE ACTION COLLECTIVE ACTION TT LOCAL COMMITTEES LEADERS DIALOGUE CHAMPIONS OF CHANGE ADVOCACY & SUSTAINED CHANGE

23 TTHV in numbers (18 months operation) INPUT 19 NGOs & CBOs 344 community facilitators 17 mentoring teams INPUT 1,134 workshops 267 villages 17 districts OUTPUT 32,679 participant 54 champions of change

24 Results Per Province

25 What is Next? PACT: Active Prevention & Communication for All

26 Intensify Normative Change by Expanding & Connecting Social Networks HIV Leadership and skills within TT groups to keep influencing others and maintaining change-- endogenous force change from within. Connecting TT groups across communities and linking up to Districts- horizontal diffusion & bounded normative influence. Achieving political legitimacy and visibility through the media - from minority to majority, setting the agenda to catalyze desire to change.

27 PACTO s Ecological model ONE COMMUNITY COMMUNITY NETWORK DISTRICT FORUM CATALYST TCHOVA TCHOVA HISTORIAS DE VIDA COMMUNITY DIALOGUE LEADERS DIALOGUE COLLECTIVE ACTION CHAMPIONS OF CHANGE TT COLLECTIVE ACTION 2 TT TT TT LOCAL 1 3 COMMITTEES TT 4 TT 5 DISTRICT 1 DISTRICT 2 DISTRICT 3 ADVOCACY & SUSTAINED CHANGE

28 Monitoring & Evaluation Program Monitoring Implementation of TTHV Sessions Broadcasting of Radio Series Outcome Monitoring Reactions to TTHV Sessions Listeners feedback to radio series Media tracking (print) Evaluation Effect of TTHV on program outcomes Exposure to TTHV Sessions and radio

29 Need for thorough monitoring Sensitive issues Open group discussions on gender and sexuality Local traditions (normative environment) Decentralized program implementation Local NGO s, CBO s and facilitators Local radio stations Prompt program feedback On program progress On response to TTHV sessions

30 M&E Timeline and tools Program Monitoring * TTHV monitoring forms (4) * Monitoring system (flow charts) * Structured field visits by M&E staff * Journalists training feedback form Outcome Monitoring * TTHV evaluation interviews (2) * FGD with participants * Couples follow-up interviews * Text messages (radio) * Media tracking (print ) Evaluation * Survey based on individual interview on July 2010 (with input from outcome monitoring)

31 Program Monitoring: Flow chart for M&E in province

32 Outcome Monitoring TTHV evaluation interviews Provided quantitative assessment of changes and tested attitudinal statements Focus group discussions w/tthv participants Identified reactions to TTHV and components most valued by participants Explored in more depth gender relations and sexual norms as well as perceived changes Couples follow up interviews Allowed to compare initial effect on couples

33 Outcome Monitoring: Perceptions of TTHV Sparked admiration and high regard Gave prestige and status Provided a sense of belonging and brotherhood identity Encouraged family harmony (violence, alcohol) Viewed as the new doctrine (ritos and church) with strong learnings for a better life Increased community cohesion (harmony ) 17 FGD, n= 72 men and 70 women in Zambezia and Sofala

34 Outcome Monitoring: Deconstructing Gender and Sexual norms Building Blocks Image of wife as an instrument Multiple meanings of faithfulness Love and commitment (vs condom) Health and sickness (symptoms) Men need sexual pleasure, women don t 17 FGD, n= 72 men and 70 women in Zambezia and Sofala

35 Quincot & Figueroa, TT model. Community dialogue on gender and HIV prevention. Qualitative evaluation study. JHU.CCP

36 Arias & Figueroa, TT model. Community dialogue on gender and HIV prevention. Qualitative evaluation study. JHU.CCP

37 Valuing of women Outcome Monitoring: Key reported changes Recognition of property rights of widows & their children Changing roles of men & women Men helping with machamba (agric work) Recognizing women s rights to work & study Better understanding of HIV/AIDS More inclusion of PLHV Better relations & understanding with neighbors

38 Outcome Monitoring: Remaining Challenges Faithfulness as protection against HIV Multiple meanings, differences by gender Condom use Need to change positioning & meaning of condoms Asymptomatic nature of HIV Sex remains a taboo Difficult for parents to provide sex ed to their children Avoiding violence to educate children Short life expectancy makes the prevention message less credible/motivating (alcohol, MCP)

39 TTHV Evaluation Post-only survey with nonequivalent control group 462 TTHV participants (men and women) from Zambezia & Sofala 453 men & women who had not participated in TTHV but accepted to participate Field work conducted by Ernst & Young Mozambique during July 19-29, 2010

40 TTHV evaluation: Sample differences Characteristic Intervention % 1 Control % 1 Age 36.1*** (mean) 33.1 (mean) Number of children 3.9*** (mean) 3.3 (mean) SES/poverty (days w/o food, others) 2.0*** (mean) 1.8 (mean) SES/# of durables at home 3.0** (mean) 3.3 (mean) Marital status - Married - In union 35.5*** Listens to the radio everyday 49.0* 42.6 Watches TV everyday 14.0* 16.0 * difference between groups statistically significant at (p<.05); ** (p<.01); *** (p<.001) 1 Figures are percentages unless specified otherwise

41 TTHV evaluation: High attendance to TTHV sessions 64% of participants reported attending all 9 sessions Other 35% attended a median of 5 sessions About 80% attended at least 5 of the nine sessions

42 Level of participation in TTHV sessions. Intervention group. Mozambique 2010 Percentage Attended all 9 sessions Attended 9 sessions -men Attended 9 sessions - women Spouse participated Spouse in same group* Source: Mozambique Tchova Tchova Evaluation Survey, Total intervention sample=462 respondents.

43 TTHV evaluation: Spontaneous recall of topics Diverse recall of topics discussed in sessions 47% of respondents recalled sexual networks as a topic 40% of respondents recalled sexual violence in the house, alcohol, and condom use as topics discussed High level of image and story recall from TTHV videos 70% recalled each of the 5 images shown and their stories Men had significantly higher recall of images related to topics specifically aimed at men

44 TTHV evaluation: High recall of image Profiles and stories Photo shown Percentage Total Women Men Image 1: (what women/men can do) * 96.0* Image 2: (traditions, dead husbands goods) Image 3: (domestic violence, alcohol abuse) * 81.8* Image 4: (TARV) Image 5: (sexual network) All 5 images recalled None of the images recalled % of respondents provided spontaneous valid answers related to the image shown

45 TTHV evaluation: media exposure 82% of all respondents had heard of TT in general 63% of control group (non TTHV participants) had heard of TT

46 Frequency of listening to TT radio. Intervention and control groups. Mozambique 2010 Percentage 80 TTHV intervention Control or more times a week At least once a week Less than once a week Source: Mozambique Tchova Tchova Evaluation Survey. (n=652) Differences between intervention and control group are statistically significant (p<.001)

47 Gender equity TTHV Evaluation BEHAVIORAL OUTCOMES 12 statements used to measure gender equity attitudes; 8 used to create gender equity variable Assessed shared household tasks from 11 tasks HIV partner communication Discussed HIV in last 3 months Spontaneous report on HIV issues discussed HIV risk perception Correct answers to question about ways to prevent HIV (spontaneous response)

48 HIV stigma TTHV Evaluation BEHAVIORAL OUTCOMES 7 statements used to create a stigma attitude variable Multiple and concurrent partners

49 TTHV Evaluation GENDER ATTITUDES Control group: No TTHV participants Intervention group: TTHV participants Density attgender8rev Density attgender8rev Average attitude score=3.1* Average attitude score=3.6 Attitude score adjusted by sociodemographic characteristics, media consumption, participation in community activities, and exposure to other HIV programs (* p<.001)

50 TTHV Evaluation GENDER ROLES Greater differences for traditionally gender differentiated tasks

51 Average household tasks shared by level of gender attitudes. Mozambique Bottom quartile 2nd quartile 3rd quartile Higher quartile Level of Gender Equitable Attitudes Adjusted by sociodemographic variables, media consumption and other potential confounders. Source: Mozambique Tchova Tchova Evaluation Survey. (n=915) Differences not statistically significant.

52 TTHV Evaluation HIV PARTNER COMMUNICATION 80% of respondents reported talking with partner about HIV/sexual behavior in last 3 months 88% among intervention group 72% among control group HIV topics discussed among partners Intervention group respondents talked about significantly more HIV topics than did controls 3 topics vs 2 (after adjusting for potential confounders p<.001) Controls exposed to TT radio also talked about significantly more HIV topics than controls that were not exposed to TT radio

53 TTHV Evaluation HIV PARTNER COMMUNICATION Graph 4.4 Partner communication on HIV and exposure to Tchova Tchova program. Mozambique 2010 Percent that talked to partner 100 % All sample Intervention Control Control exposed to radio 60 Control unexposed to radio Source: Mozambique Tchova Tchova Evaluation Survey. (total sample n=915. control sample n=453). Differences statistically significant (p<.001) Graph 4.5 HIV topics discussed by partners in TTHV intervention and control groups. Mozambique TTHV intervention * * Control * * * 14 0 HIV risk (generic) HIV prev (generic) Condom use Andar fora Being faithful MCP HIV tesing Source: Mozambique Tchova Tchova Evaluation Survey. (n=732 respondents that talked to their partners) * indicates differences statistically significant (p<.05)

54 TTHV Evaluation HIV RISK Intervention group respondents significantly more likely to correctly identify ways to prevent HIV infection What can people do to prevent getting infected with HIV? (spontaneous responses) Percentage* Intervention Abstain from sex Use condom Have sex with only one partner Be faithful to your one partner Avoid sex with prostitutes Avoid having more than one partner Reduce the number of partners Avoid having sex with someone that has other partners Bring new blade to healer (curandeiro) 24.2 (ns) 20.7 Demand new syringe (seringa) in health services 13.4 (ns) 13.5 Average number of correct answers Maximum number of positive answers provided 10 7 * All differences between groups are statistically significant (p<.01), except where (ns) is indicated. (ns) Difference between groups is not statistically significant. Control

55 TTHV Evaluation MCP Percent of respondents with multiple sexual partners. Intervention and control groups. Mozambique % All sample TTHV intervention Control Source: Mozambique Tchova Tchova Evaluation Survey. (n=915) Differences between intervention and control group are statistically significant (p<.001) 3+ times as many controls as intervention respondents reported having more than 1 sexual partner

56 THANKS for coming! OBRIGADA pela participação...!