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This report comprehensively summarizes the FHI/AIDSCAP program in Rwanda (1993-1997). The report includes a discussion of background and context, as well as accomplishments, constraints, implementation and management issues, outcomes, and lessons learned and recommendations for each of two components.
Table of Contents I. Country Program Description C. Accomplishments and Outcomes D. Implementation and Management Issues II. Lessons Learned and Recommendations III. Refugee Intervention in Tanzania IV. Subproject Highlights IV. Subproject Highlights Rwanda Condom Social Marketing
Background and Scope of the Intervention The Rwanda Condom Social Marketing Project was launched in 1993 by Population Services International (PSI). Relying on support from a number of donors, PSI introduced its Prudence brand condom in March, 1993. In August 1993, the project received funding from AIDSCAP for condom social marketing activities through August 26, 1996. Due to civil war, the project was completely shut down from April 1994 until March 1995. The AIDSCAP funding made an impressive impact and condom sales exceeded 300,000 in April 1996 for the first time ever. In addition to the AIDSCAP funding, condoms were separately supplied during this period by PSI, the Government of Rwanda, and the German Development Bank (KfW) at no cost to USAID. The purpose of the Rwanda Condom Social Marketing Project under AIDSCAP has been to bring about a sustainable increase in condom use among high risk groups and the general population in Rwanda. To achieve this, the project aimed to:
With sales averaging 229,724 per month throughout 1996, project condoms available in all Rwanda prefectures, over 185,000 persons reached by IEC campaigns, over 122,000 promotional items distributed, and over 1,000 mass media messages aired or seen, PSI/Rwanda reached its sales and distribution and communications targets outlined in its contract with AIDSCAP. Accomplishments & Outcomes1 People Trained During the three years of the task order period, PSI was involved in a host of training and other IEC-related sessions. From the period March 1995 - August 1996, PSI trained 330 trainers and 565 military personnel in condom usage, 751 community-based sales agents in selling skills, condom use demonstration, and HIV/AIDS prevention techniques, and taught over 10,000 persons basic HIV/AIDS prevention messages. An additional 174 women participated in 29 group meetings where safer sex and sexual negotiation were discussed. Over 2,300 youth participated in similar group meetings. PSI also conducted some 44 focus groups to evaluate various communication products. Condoms Distributed Some 3,150, 647 Prudence/Prudence Plus condoms were sold at a price of 20 FRw. (US $ .07) per 4-pack from August 1993 to August 1996 at an average monthly rate of over 108,643 condoms (not including the 12 months of non-activity due to the war and its aftermath). Between August 1993 and March 1994, 583,632 condoms were sold with a monthly average of 83,376 condoms. During March 1995 - August 1996 (program re-launch phase), 2,575,328 condoms were sold with a monthly average of 151,001 condoms. The 18 month "Re-launch Phase" accounts for 81% of total condoms sold during the actual 26 month life-of-project. In the first eight months of 1996 alone, 1,837,788 condoms, or 58% of the project's total, were sold with a monthly average of 229,724 condoms. As of August, 1996, the project's Prudence Plus condoms were on sale in all eleven of the country's prefectures. PSI opened approximately 1,500 new points-of-purchase, of which 65% were boutiques/kiosks/food stores and 13% were nontraditional bar/nightclub types. Additional outlets have been established by community-based condom sales agents (approximately 344 agents as of August 1996) and by independent wholesalers working with the project. Increased accessibility of condoms has been achieved with seventy-one per cent of condoms sold being purchased from four widely-accessible outlet client categories: The greatest sales increases have been seen in clinics/health centers and community based sales partners. At the end of 1995, clinics/health centers represented only 1% of annual sales and community based sales partners represented only 5%. Special Activities Advertising -- During 1993, "rap" jingles and messages about acceptability and accessibility were produced as radio advertisements. Four radio campaigns were developed during the program "re-launch" phase. The first, "Once Again, Prudence," reintroduced the condom brand to Rwandan consumers at the war's end and the re-establishment of civilian government. The second (acceptability), "Prudence in High Demand," reinforced the impression that everyone was buying Prudence. This campaign was an emergency response to the change in the type of condoms sold. The third campaign's message was product accessibility. The fourth campaign supported the launch of Prudence Plus (with new name and packaging) and the project's new advertising slogan -- Dushishoze Maze Turambe ("Let's be Prudent in order to Have a Healthy Life"). A number of spots were developed to promote new wholesalers throughout the country. Ads were also run in Rwandan newspapers and on strategically-placed billboards. Radio Prudence Time (a weekly radio program) -- 15 minutes with varied issues. The radio program covered a multitude of safer sex topics such as women and AIDS, youth and relationships, new developments in AIDS research, community-based condom distribution, launch of Prudence Plus, Rwandan culture and AIDS, efficacy of condoms, etc. The format included interviews with ordinary Rwandans, as well as experts, mixed with music. IEC Information Booths -- The first of its kind, a strategically placed information booth on the main roundabout in Kigali offered HIV/AIDS prevention information (pamphlets, articles, handouts); condoms and soft drinks to attract clients. In addition, weekly promotional activities such as lotteries, question-and-answer sessions for targeted groups (youth, drivers, military, women, etc.) were conducted. The booth remains open in evenings for last-minute purchases. Ciné Mobile -- The ciné mobile is a mobile video unit (Landcruiser equipped with video projector, speakers, screen) which shows HIV/AIDS prevention and informational videos to targeted groups throughout in Rwanda. The project has shown videos in public, outdoor settings in nearly every Rwandan commune, in schools, at the majority of military bases, and during the 1995 World AIDS Day events. The videos were also used as a training tool, to stimulate discussion among specific target groups such as women and youth. Crowds averaged 1,500 persons during each two hour showing. Rwanda-specific videos have been produced by the PSI/Rwanda video production crew at its studio. The team also produced live, on-location interviews with government and local leaders and citizens after the video presentations. Ciné mobile events have reached over 80,000 potential condom users in 13 months of activity. Training and IEC Meetings -- Safer sex discussions and condom use demonstrations are organized throughout the country for a multitude of groups. Condom use demonstrations have been included in the PNLS-sponsored STI training, military training, business training, women's associations, youth meetings, etc. Safer sex discussions have been conducted for women's and youth groups, military groups, etc. Women's Social Marketing Program -- Marketing strategies were developed to make Prudence/Prudence Plus more appealing and accessible to women consumers. The PSI employed a women's social marketing program coordinator who identified female groups to educate and train as condom peer educators, launched "community based sales" programs in conjunction with women's associations, and sold Prudence/Prudence Plus to "women friendly" outlets such as hair salons. Sponsorship of Events -- To raise awareness and increase demand for Prudence/Prudence Plus, the project sponsored concerts, talent shows, a fashion show, market day mobilizations (education sessions held during market days, particularly in rural areas), and participated in two major business fairs. World AIDS Days -- In addition to opening the IEC Information Booth in December 1995 on the main roundabout in Kigali, activities included distribution of World AIDS Day condom samplers, sales of Prudence condoms in the project's promotional tent, a taxi motorcycle rally around Kigali, sponsorship of a concert and a special showing of the ciné-mobile for a crowd of over 5,000 in Kigali. Prudence/Prudence Plus is the best -known commercial condom brand available on the Rwandan market today. This is due to the nationwide diffusion of promotional, educational and point-of-sale materials, as well as intensive mass media advertising. During March 1995 - August 1996, more than 122,000 promotional items and educational/informational materials were distributed and 854 radio spots aired. Promotional materials included T-shirts, baseball caps, key chains, stickers, headbands, bumper stickers, plastic bags, and demonstration penises. Educational/informational materials included comic books, condom use instruction/condom sampler brochures, videos and one-page bulletins. In addition, every condom packet sold includes illustrated instructions with explanatory text on proper use and disposal of condoms. Point-of-sale materials included Prudence/Prudence Plus counter dispensers, hanging dispensers, "En Vente Ici" (on sale here) stickers, posters, and 1996 calendars. Five videos were produced, targeted at different vulnerable groups (women and youth). The videos were used in ciné mobile events and copies were made and distributed to UNICEF, NGOs, the Ministries of Youth and Women, PNLS and schools. Important Constraints The PSI/Rwanda project suffered several major constraints and many minor ones. The greatest constraints were the difficulties associated with the war including the deaths of several key staff and a protracted shortage of condoms once activities resumed in March 1995. Minor constraints consisted of insufficient vehicles (six months into the restart phase of the project, the project had only two vehicles), delay in receiving imported promotional items (the project lacked promotional items for the first six months), personnel changes of the accountant and the marketing director, delays in finding appropriate warehouse space, and difficulty in finding a complementary donor to fund expected research activities. Capacity Building PSI implemented several strategies to build its institutional capacity and enhance project sustainability, including: capacity building through training of the local staff, the institutionalization of condom sales among NGOs, enhanced promotional skills among community-based sales agents, and the establishment of a local NGO or association, affiliated with PSI able to solicit donor funds. Training was emphasized throughout the reporting period. In-house training was held on such subjects as the sales process, sales coverage, the difference between brand promotion and IEC, video filming and editing, radio production, participative research techniques, and community based sales. The Sales Manager also participated in a sales conference sponsored by PSI/Tanzania. The IEC Coordinator and the Women's Social Marketing Program Coordinator attended the 11th International Conference on AIDS in Africa, in Kampala. Additionally, information about HIV/AIDS, gender issues, communication techniques, etc. were regularly distributed to appropriate staff. In-house French and English lessons were offered to the staff. Behavioral Data The AIDSCAP task order included plans for a KABP survey and distribution and consumer intercept surveys to be conducted provided funds were obtained from "other donors". No AIDSCAP funds were budgeted to conduct this research. PSI/Rwanda aggressively sought funding for research but funding never materialized. UNFPA had agreed to fund some discrete research activities focusing on women which was to be used as the basis for a targeted women's condom promotion campaign. However, as of the end of project in August 1996, UNFPA had not yet provided the research funding. PSI made use of the findings of the KABP conducted by CARE in the Gitarama Prefecture. Several small studies were conducted by PSI. At the beginning of the restart phase, an informal pricing survey was conducted among shop keepers in the greater Kigali area. The results revealed that shop owners approved of selling Prudence for its former retail price of 20 FRw. per package of four condoms. FGDs were employed dozens of times throughout the lifetime of the project. Some of these were used to evaluate attitudes toward the packaging and served as the basis for packaging, logo and brand name changes. Focus groups were also used to evaluate various communications interventions such as radio spots, the weekly radio program, the design and name for the IEC kiosk in Kigali, Prudence Plus launch theme, and the condom sampler brochure. Lessons Learned and Recommendations
PSI Condom Social Marketing Program Summary of Achievements
Process Indicator Summary
CARE : HIV/AIDS Prevention in Gitarama Prefecture
Background and Scope of the Intervention The first phase of the HIV/AIDS Prevention Project in Gitarama commenced on September 26, 1995 and finished on November 30, 1996. Primary funding for the first phase (14 months) of an anticipated three year community-based peer education project was provided by AIDSCAP. Supplementary funding for materials and equipment was provided by the World AIDS Foundation (WAF), UNICEF, and CARE International. The overall goal of the three year intervention was to contribute to the stabilization or reduction of STI prevalence in specific population centers in the prefecture. The project's purpose was to reduce high risk sexual behavior among targeted populations in Gitarama Prefecture. This would be accomplished by the delivery of IEC messages, adapted to postwar realities, to specific target audiences by a community-based network of volunteer peer educators. During the fourteen months of the subproject, peer education activities were operational for nine months in eight randomly chosen communes of Gitarama. Accomplishments and Outcomes Training A total of 25 staff members and 353 Peer Educators were trained by CARE during the first phase of the project. At the beginning of the project, 20 staff members (including 15 Peer Education Field Supervisors, two IEC Team Members, two Peer Education Team Leaders, and one Deputy Project Manager) participated in a two-week Training of Trainers workshop conducted by an internal CARE consultant. This training focused on participatory and adult education techniques for the delivery of STI/HIV prevention messages. Each of the 15 Field Supervisors also received training in how to supervise their 20 Peer Educators on a daily, weekly and monthly basis. At the conclusion of the Training of Trainers workshop, all program staff participated in field visits to all 17 communes of the prefecture to introduce the project to local political, religious, military and health officials. These officials were requested to identify and select the Peer Educators from among their populations using criteria determined during the Training of Training workshop. The directors of the local health centers, representing the Région Sanitaire de Gitarama at the commune level, played an important role in this selection process. They were also asked to estimate, in their opinion, which were the most vulnerable target groups for STI/HIV infection within their communes. This information was used, along with demographic information collected simultaneously by a locally-hired statistician, to randomly select eight of the 17 communes in the prefecture. After the local authorities had selected their Peer Educators, CARE conducted a three-week training for all 303 Peer Educators. This training included an introduction to the most common STIs in the region and their symptoms, the transmission and prevention of STIs and HIV, and the relationship between STIs and HIV. The Peer Educators were also trained to give condom use demonstrations with a wooden penis model and how to use a condom brochure and flipchart. Finally, the Peer Educators were trained on how to conduct informal, participatory adult education sessions using the IEC materials provided by CARE. A major midyear retraining took place in July 1996 for all Peer Educators to update their knowledge regarding the relationship between STIs and HIV, to refine their skills in using the two IEC materials and to reemphasize the participatory adult education methodologies taught during the initial training. Two members from the CARE IEC team participated in the CIDC-sponsored "Materials Development workshop" held in Kigali in October 1995. This was followed by a two-week training in February 1996. This specialized training focused on formative research, focus group discussion, and the creation of a linkage between the IEC and Peer Education Teams. Peer Education Sessions Held, Target Beneficiaries Reached After completion of the initial Peer Education training, the Peer Educators began conducting their bimonthly educational sessions in March 1996. For the nine months between March and November 1996, the Peer Educators conducted 2,452 educational sessions during which 40,947 target group beneficiaries (21,408 females and 19,539 males) were educated in basic knowledge about STI/HIV transmission and prevention. Special attention was given to condom use and negotiation skills for these target groups. The five target groups included adolescent males, adolescent females, married men, married women, and women heads-of-households (a broad group which included widows, single mothers and commercial sex workers). In May 1996, CARE's IEC Team trained an additional 12 rural adolescents from a local NGO, ARBEF (l'Association Rwandaise pour le Bien-Etre Familial), in qualitative research methodologies for the design and development of a dramatic script for a package of three new IEC materials: a video, comic book and radio program. After the production of these new IEC materials, the IEC Team educated an additional 5,350 persons, mostly adolescent students, in basic STI/HIV transmission and prevention methods during informal question and answer sessions after showing CARE's new video "Hitamo Igikwiye" along with "Silent Epidemic" (an educational video on STIs translated into the local language, Kinyarwanda, by the CARE refugee project in Tanzania). The IEC Team's radio soap opera version of "Hitamo Igikwiye" reached an unknown number of listeners in Rwanda, Burundi and eastern Zaire during the two national radio broadcasts which were aired by Radio Rwanda in October and November 1996. Condoms Distributed A total of 135,061 condoms were distributed during the project's first phase. The vast majority of these -- 132,061 -- were distributed by the Peer Educators during their 2,452 peer education sessions. The remaining 6,000+ were distributed during World AIDS Day activities in Gitarama and during IEC focus group discussions. IEC Messages and Materials Developed and Distributed Four new IEC materials were developed and distributed during the project's first phase: a traditional cloth (igitenge) imprinted with the theme of World AIDS Day 1995 ("Shared Rights and Responsibilities") and a package of three interrelated educational materials: a video, comic book and radio soap opera. A total of 53 focus group discussions were conducted by the IEC Team throughout the first phase with widows, adolescent males and adolescent females to collect the necessary qualitative information to design the new IEC messages and to pre-test the new IEC material. The principal IEC message of the three interrelated materials, all of which were targeted to rural adolescents, was "You must carefully choose between abstinence before marriage, sexual intercourse with a condom, or sexual intercourse without a condom, because it is you who will have to live with the consequences". This IEC message is reflected in the title of the three materials, "Hitamo Igikwiye", which translates to "Choose Well". A fifth IEC material -- laminated flash cards as a participatory approach for widows to discuss the difference between high risk, low risk and no risk sexual behaviors -- was designed during the first phase and will be finalized and distributed at the beginning of the project's second phase with different donor funding. Two other educational materials were adapted and distributed to the Peer Educators during the project's first phase: 500 copies of a Peer Education Manual in the local language ("Agatabo k'umujyanama w'ubuzima"), and 400 copies of an updated version of a pre-war AIDS prevention flipchart. Two prewar IEC materials were used by the Peer Education Team at the beginning of the project while the IEC Team was in the process of developing its new educational materials. The first was a condom-use brochure, originally developed by the Program for Appropriate Technology in Health (PATH, USA), which was adapted and translated into Kinyarwanda by CARE International before the war. After the war, CARE International again pre-tested this condom-use brochure for cultural acceptability and relevance in both Gitarama and Kigali. The results of this postwar pretest found that both rural and urban populations still prefer this widely-used brochure to other brochures which are not as graphic. The second prewar IEC material used in the project's first phase was an AIDS flipchart. This flipchart was redesigned and reprinted at the beginning of the project prior to the initial training of the 303 Peer Educators. Each Peer Educator received specific instruction in how to use this flipchart with illiterate target group audiences. The flipchart's principal IEC message for the Peer Educators to communicate was: "HIV has no symptoms, therefore, it is impossible to tell who is infected with HIV just by looking at them. As a result, everyone should use a condom during sexual intercourse to reduce the risk of being exposed to HIV, even with regular sexual partners because they may have other partners." The comic book version of "Hitamo Igikwiye" has been so popular that CARE's office in Gitarama has been inundated with individuals -- adults as well as adolescents -- who knock on CARE's door requesting their own personal copy. CARE plans to reprint an additional 50,000 comic books during the second phase of the project in order to supply copies to all the schools and health centers in Gitarama which have requested comic books. The Ministry of Education in Kigali (MINIPRISEC) has also requested several thousand copies for distribution at the national level. Each of the 303 Peer Educators was given 50 copies of the comic book to distribute during their December peer education sessions. Of the 100 video cassettes distributed during the project's first phase, 50 were given to the PNLS to distribute to all 11 prefectures of the country for World AIDS Day 1996. An additional five video cassettes were provided to the Gitarama Health Region, and one to each of the 17 "bourgemestres" (mayors) in the prefecture. This video is now being used by the Peer Education Team to complement the bimonthly peer education sessions targeted to adolescent males and females. After viewing the video, these target group beneficiaries each receive one copy of the new comic book, to help them remember the principal IEC messages portrayed in the video. Capacity Building, Special Events CARE participated in a variety of seminars/workshops, field visits, and conferences related to STIs, HIV/AIDS, and reproductive health throughout the project's AIDSCAP-funded phase. In October 1995, CARE sent two participants to AIDSCAP's IEC Workshop in Kigali, a 10 day training which focused on formative research methodologies for the development of IEC messages for the prevention of STIs/HIV in Rwanda. In December 1995, the Project Manager participated in the 11th International Conference on AIDS in Africa, held in Kampala, Uganda. CARE collaborated with PSI/Rwanda to train all 303 of its Peer Educators, plus several Community Health Workers belonging to the Gitarama Health Region, in condom use, condom negotiation and community-based sales of condoms. Of the 303 Peer Educators who were trained, 265 agreed to become community-based sales agents of Prudence Plus condoms. In June 1996, CARE presented preliminary data from its baseline KABP survey to participants at AIDSCAP's quarterly meeting. In October 1996, CARE revisited Kampala, Uganda, this time with three representatives from the Gitarama Health Region2 including the Medical Director (MEDIRESA), to make site visits to two internationally known AIDS prevention organizations: The AIDS Support Organization (TASO) and the AIDS Information Center (AIC). The purpose of this field trip was to learn how these two local NGOs, both with more than ten years of experience in community-based HIV/AIDS prevention efforts, had come to refine and prioritize their approach to STI/HIV prevention. Important Constraints The project experienced a fair amount of staff turnover during its AIDSCAP-funded phase. The Deputy Project Manager and one of the two Team Leaders of the Peer Education Team both resigned within the first eight months of the project. Both positions were vacant for a month before suitable replacements could be hired and trained. The temporary absence of these two senior staff members definitely reduced project efficiency at both the programmatic and administrative levels. Within the Peer Education Team, which is composed of 15 Field Supervisors, five new Supervisors were hired to replace those who had either resigned or had been let go. The IEC Team also suffered from staff turnover. One researcher resigned and the other was let go. Since April 1996, however, the IEC Team has been stable with two excellent field researchers. The largest turnover, as expected, was experienced within the group of volunteer Peer Educators themselves. Of the 303 volunteers who began working with the project in February 1996, 50 Peer Educators (16.5%) had resigned by November 1996 for a wide variety of reasons: too much work; not enough time; not enough money or incentives; marriage; pregnancy; illness; other. The 50 Peer Educators were replaced and trained by CARE over the course of the project. The largest logistical constraint during the project's first phase was keeping the fleet of motorcycles in working condition for the Peer Education Team. The logistics of keeping the motorcycles properly fueled and maintain remain a challenge due to the rugged terrain, and the lack of fueling and maintenance facilities in the rural areas. In addition to the anticipated resistance from the Catholic Church to the project's distribution and demonstration of condoms, the project also experienced a certain amount of cultural resistance for women to be seen touching, purchasing or otherwise accepting condoms from the Peer Educators in public. This means that some of the Peer Educators, who have been trained to encourage their target group participants to open a sample condom and practice using it on a wooden penis model during the education sessions, have difficulty distributing as many condoms as are expected of them. However, it has been noted that some of the same women who refuse to touch or accept a free condom during a peer education session actually go out of their way to visit the home of the Peer Educator later in the week to request a free condom in private. Another sociocultural constraint is that condoms are not considered appropriate for use between married partners, due to the strong social norm of producing children within the marriage. Lessons Learned and Recommendations The major lessons learned during the project's AIDSCAP-funded first year are highlighted below:
CARE International : Peer Education in Gitarama Summary of Achievements
*includes 50 new PEs trained to replace those lost to attrition Process Indicator Summary
Endnotes
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