HIV/AIDS through Health Service Extension
Program in Meskan District, SNNPR, Ethiopia
By- Dereje Mamo (B. Sc)
Advisors: - Dr. Fessahaye Alemseged (MD, MPHE)
Dr Yunis Mussema (MD, MPHE)
Evaluation Research Thesis submitted to the Department of Health Planning and Health Services Management, Jimma University as partial fulfillment of the requirements for the Degree of Master of Science in Health Monitoring and Evaluation
February 2008
Jimma, Ethiopia
Abstract
Background: HIV/AIDS is the major public health problem in Ethiopia. Behavioral
intervention is one of the most effective strategies to prevent and control the spread HIV/AIDS. The government has designed different approaches for HIV/AIDS prevention, particularly undertaking of IEC/BCC package. IEC/BCC through the Health service extension program was found to be a cross cutting approach for prevention of HIV/AIDS.
However, there is limitation in information on program evaluation. In agreement with all stakeholders, this evaluative study was conducted to assess and determine to whether the program is carried out accordingly or not and to identify strengths and weaknesses of the program to enable stakeholders make informed decision for its improvement.
Evaluation Objectives: The objective of this evaluation study was to assess process of
IEC/BCC intervention on HIV/AIDS through health service extension program in Meskan District, Guragie zone, SNNPR, Ethiopia.
Methods: Qualitative and supportive quantitative house hold survey was conducted
from August to September 2007 to address the main evaluation question. For qualitative part a case study research method was conducted using in-depth interview, document review and observation check list and analyzed by using thematic and content analysis. While cross-sectional study was employed for quantitative part. Stratified random sampling technique was used to select study subjects. Data were collected using Standard pre-tested closed ended questionnaire and analyzed using Epi-info version 3.3.2.
Results: Of the total respondents 376 (90.8%) reported that they had heard of HIV/AIDS
and Source of information were mass media (radio/TV), health workers, Edir/different community gathering and teacher/school. 184(48.9%) of the respondent heard from multiple resource including HEWs. Of the total respondents, 73.1% and 42.1% knows at least two routes of HIV/AIDS transmission and methods of prevention respectively. The main communication channel used for education where health talks or lecturing. Of the total respondent Only 21 (5.6%) of the respondent had provided with IEC/BCC materials.
supply and distribution at health facility and house hold level, lack of participatory approach during education. Moreover, all health facilities lack IEC/BCC intervention implementation guideline. Information dissemination using the HEW to the target group of WCBA was Adequate in achieving its objective. Communication channel and method used by seven health extension workers to communicate about HIV/AIDS with WCBA were 40.8% and was inadequate. Regarding IEC/BCC materials supply, distribution and utilization at health facility and house hold level was found (50%) fair and 32%
(inadequate) respectively. The presence of plan on IEC/BCC intervention, standard
recording book, standard reporting format and supportive supervision logbook was 50% and was fair.
Conclusion and recommendation: In general, it was concluded the achievements of
the overall implementations on IEC/BCC intervention on HIV/AIDS were 56.9% (fair) level performance. On the other hand the program needs improvement on communication channel selection, IEC/BCC materials and implementation guideline supply and utilization. Detail recommendation was generated for district health office, health facilities and health extension workers in general.
Acknowledgement
I would like to express my appreciation and sincere thanks to my advisors Dr. Fessahaye Alemseged and Dr. Yunis Mussema of Department of Epidemiology and Biostatistics, Jimma University for their critical review, guidance and support.
My appreciation also goes to Dr. Fisseha Yitbarek and Mr. Lelisa Sena of Jimma University; Ms. Beverly Stauffer and Prof. Carl Kendall of Tulane University and Prof. Elizabeth dos Santos of Oswald Cruz Foundation for their valuable advice and comments.
In addition, I would like to acknowledge the financial and logistic support of Tulane University, Addis Ababa office and SNNPR Health Bureau/HAPCS/ .
Finally, my sincere thanks go to my family specially my wife and kid for their encouragement and support during this study.
Acronyms
AIDS Acquired Human Immunodeficiency Syndrome
ART Anti Retroviral Therapy
BCC Behavioral Change Communication
BSS Behavioral Surveillance Survey
CCE_CC Community Capacity Enhancement through Community Conversation
CHP Community Health Promoters
CNHDE Center for National Health Development in Ethiopia CSA Central Statistical Authority
GZHD Guragie Zone Health Department
HAPCO HIV/AIDS Prevention and Control Office
HEW Health Extension Worker
HSDP Health Sector Development Program
HESP Health Service Extension Program
HIV Human Immune Virus
IEC Information Education Communication
MOH Ministry of Health
NGO Non Governmental Organization
PHC Primary Health Care
PLWHAS People Living with HIV/AIDS
PMTCT Prevention of Mother to Child Transmission
SNNPRHB South Nations and Nationalities People’s Region Health Bureau
SPM Strategic Planning and Management
STI Sexually Transmitted Infection
UNAIDS United Nations Program on HIV/AIDS UNICEF United Nations Children Fund
VCT Voluntary Counseling and Testing
Table of Contents
Contents page Abstract...i Acknowledgement...iii Acronyms...iv Table of Contents...v Tables...vi Figures...vi 1. Background...1 2. Problem statement...93. The need for evaluation...11
4. Stakeholder description /consultation...12
5. Objectives of evaluation...16
6. Evaluation Method...17
7. Results...32
7.1 Quantitative study result...32
7.2 Qualitative study result...38
7.3 Result of Matrix of judgment analysis...46
8. Discussion...47
9. Limitation of the evaluation...50
4. Conclusion...51
11. Recommendation...53
12. Meta evaluation...55
13. Reference...56
Tables
Page Table 1Stakeholder analysis...14 Table 2: Socio Demographic Characteristics of Respondents in Meskan District, SNNPR, September, 2007...32 Table 3: Awareness of respondents on HIV/AIDS, its transmission routes and prevention methods in Meskan District, SNNPR, September, 2007...33 Table 4: Percentage of respondents who knew at least two routes of
transmission and prevention methods in Meskan district, SNNPR, September, 2007...34 Table 5: Respondent source of information on HIV/AIDS, its transmission routes and prevention method in Meskan district, SNNPR, September, 2007...34 Table 6 : Awareness on HIV voluntary counseling and testing and source of information among women in child bearing age in Meskan District, SNNPR, September 2007...35 Table 7 Awareness on HIV/AIDS prevention and control service among women of child bearing age, in Meskan District, SNNPR, September, 2007...37
Figures
Page Figure 1 Logical model of IEC/BCC on HIV/AIDS service...7 Figure 2: conceptual frame work of evaluation IEC/BCC intervention on
prevention and control of HIV/AIDS...19 Figure 3: Map of Guragie zone...17 Figure 4: IEC/BCC materials on HIV/AIDS distribution for women in child bearing age in Meskan District, SNNPR, and September, 2007...36
1. Background
1.1 Overview of HIV/AIDS prevention and control Program 1.1.1 Burden of HIV/AIDS
Acquired Immune Deficiency Syndrome (AIDS) has killed more than 25 million people, making it one of the most destructive epidemics in recorded history. Despite improved access to antiretroviral treatment and care in many regions of the world, the AIDS epidemic claimed 2.8 million [2.4–3.3 million] lives in 2006; more than half a million were children. The total number of people living with the Human Immunodeficiency Virus (HIV) reached its highest level: an estimated 38.6 million [33.4–46.0 million]. An estimated 4.1 million [3.4–6.2 million] people were newly infected with the virus in 2006, world wide (UNAIDS/WHO, 2006).
Sub-Saharan African Countries are affected the most. Africa accounts for only one tenth of the world's population, but nine out of ten new cases of HIV infection and 83% of all AIDS deaths are in Africa. The burden of disease is especially great in Southern and Eastern Africa of which Ethiopia is a part (FAO, 2006).
Ethiopia national HIV prevalence rate is low (an estimated 3.5%) compared with many other south Africa countries Botswana 38.8% Zimbabwe 33.7% South Africa 20.1 %( MOH/HAPCO, 2005). However the recent DHS report estimates the prevalence at 1.4% and attributes the discrepancy to higher prevalence at sentinel sites. The number of PLWHA is estimated at about 1.3 million in 2005, the third highest in the world (CSA, 2005). The epidemic especially affected urban areas. Incidentally, a large part of the AIDS burden is shifting to rural communities where more people are now being infected with HIV than in urban areas (MOH/HAPCO, 2006)
In a country where AIDS caused an estimated 30% of all adult deaths in 2003, fewer than 10% of people in need of antiretroviral therapy were receiving it by mid-2005 (MOH/HAPCO, 2006; UNAIDS/WHO, 2005). Limited resources for
prevention and call for a comprehensive evaluation of current activities.
The HIV prevalence in SNNPR varies across population groups and areas. The prevalence was 3.5% for females and 2.7% for males; 10.19% for urban and 1.54% for rural areas in 2005. The figures clearly indicate that women are disproportionately affected. Despite low prevalence in rural areas, the number of PLWHA is greater in the rural areas, which make up 80% of the population (SNNPR HB, 2006, MOH/HAPCO, 2005). Moreover, the prevalence at rural Guragie (Attat hospital) based on ANC sentinel site report of 2005 showed 3.5%.
1.1.2 HIV/AIDS prevention and control program intervention strategies
In response to the HIV/AIDS related problem, SNNPR has adopted the national HIV/AIDS policy and organized a council with secretariat to implement HIV/AIDS prevention and control interventions in multi- sectoral approaches. Six strategic issues have been identified in the strategic plan these are: capacity building; community mobilization and involvement; integration with health programs; leadership and mainstreaming; coordination and networking; and targeted response (SNNPR HB, 2005). IEC/BCC is the priority intervention areas in the region related to HIV/AIDS prevention and control intervention.
Achieving the MDG goal of halting and reversing the HIV/AIDS epidemic cannot be materialized without responsive and targeted IEC/BCC interventions. Improvement of communication capacity, training health service providers and the production and distribution of IEC/BCC materials are also of main concern.
The current direction of the RHB is to strengthen Community mobilization through Community capacity enhancement using community conversation /CCE_CC/ involving Health Extension Workers /HEWs/ and Community Health Promoters /CHPs/. Taking into account the political and financial commitment for
HB, 2005).
1.1.3 Health Service Extension Program Description
The Health Service Extension Program (HSEP) is an innovative health service delivery program that aims at universal coverage of primary health care. The program gives priority to the prevention and control of communicable diseases with active community participation and a goal of providing equitable access to health services. The program is based on expanding physical health infrastructure and developing a cadre of Health Extension Workers (HEWs) who will provide basic preventive and curative health services in every rural community (Center for national health development in Ethiopia [CNHDE], 2006).
HSEP is implemented in two modalities. These are an outreach program centered on rapid vocational training of health extension workers and construction and equipping of health posts since 2004. The health extension workers are assigned to health posts to provide mainly IEC/BCC on major areas of health problems like HIV/AIDS, TB and malaria. They are also expected to provide some technical services such as immunization and family planning (CNHDE, 2006).
The government decided to accelerate the implementation of the HSEP in order to cover the whole country by 2009. So far, 17,653 HEWs have been trained and deployed in 8,826 villages, and a total of 30,000 HEWs will be trained by 2009. Currently, 34 training centers in seven regions are training HEW workers (MOH, 2007).
The health service extension program is designed in 16 major packages focusing mainly on four major components: Family Health Care Packages, Environmental
(Malaria, HIV/AIDS, and TB) Prevention and Control Packages, and IEC/BCC packages (MOH, 2005).
A community promotion program is centered on community promoters (1 for 10 households or 60 inhabitants), who are working under the supervision/guidance of the health extension worker. It aims on the provision of key health messages and actions to health promoters and then through them to their families and their neighbors to bring behavioral change (SNNPRHB, 2005).
Records indicated that the SNNPR potential health service coverage was raised from 28% in 1993 to 48% in 2005/06. However, over half of the population is still without access to basic healthcare services. This is further compounded by low quality of services, which has resulted in low utilization of existing health care services. For instance, annual health report of RHB for 2005/06 has indicated that health service utilization is 0.2vist/capita when compared with W.H.O. Standard is 2visits/person/year (SNNPRHB, 2005).
In order to address the prevailing gaps in healthcare service delivery to the public at large, the health services extension program was started as pilot program in 24 kebeles of 6 District in six zones in 2003. Following a pilot study the region has trained 4465 health extension workers in 6 technical and vocational training centers in first, second and third batches and deployed in 2232 kebeles. At the same time, over 24,245 community health promoters’ /CHPs/ were trained and assigned to support the HEWs (SNNPR HB, 2007).
program
In 1993 the transitional government of Ethiopia revised the health policy and started introduction of health sector developments program (HSDP) emphasizing on household centered approach through Health Service Extension Program (HSEP). Health service extension program is an innovative approach designed to enable the delivery of packages of primary health care services at household and community levels with the active involvement of beneficiary communities. HSEP is a strategy in translating the national health policy, focusing on disease prevention and health promotion. This program is considered one of the most important institutional frameworks for achieving the Millennium Development Goals (Hailu, 2005).
HSDP II and I planned to develop regional community and facility based IEC/BCC strategy, institutionalization of IEC/BCC activities, and responsive and targeted IEC/BCC interventions around priority health sector problems. Continuous tracking of healthy life style and behavior, knowledge, attitude, and practice and then the designing of responsive IEC/BCC interventions were the major plans of HSDP II & I. Since the region enjoys more than 50 % of the nation’s ethnic diversity, having its own audio-visual center was justified since HSDP I (SNNPR HB, 2005).
More remarkable results were achieved during HSDP II through community mobilization and empowerment. In order to exert a concerted effort to prevent and control the epidemic, the government issued HIV/AIDS policy, organized council with secretariat, and a multi-sectoral implementation approach at all levels. As part of this effort, the new HSEP has been instrumental to address institutional service delivery gaps that existed at the community level (MOH, 2004).
other sexually transmitted diseases were prepared for the health extension worker to expand the effort in all areas of the country, raise the awareness of the rural population on HIV/AIDS and bring about behavioral change (MOH, 2004). .
More innovative approaches of IEC such as community health promotion initiatives, high level advocacy and political leadership at all levels, community conversation and dialogue were adopted to enhance community capacity and involvement in the matters affecting their health. This has resulted in high service utilization and owning of health programs to the extent it would be a global experience (SNNPR HB, 2005).
1.2 Logic Model
The intended out comes and all the necessary inputs of the health service extension program are described here with the following logical model. The Logic model includes program elements, infrastructure, inputs, activities, outputs, processes, out come and impact, and shows the linkage between elements (CDC of USA, 1999).
Outcome
Input Activities Output Impact
Policy Training materials Financial resource IEC/BCC materials (Leaflet, Posters, brochures, Flipchart) Trained Health extension workers Registration book Reporting formats Implementation guidelines, manuals Awareness creation through HEWs Distributing IEC/BCC materials Recording& reporting of HIV/AIDS activities Conducting anti AIDS campaign
Provision of implementation
guideline & manuals to HEWs
Training of HEWs & IEC/BCC co. on CCE_CC
Conducting individual and group HIV
education
Number mothers who get HIV information through HEWs Number and type of IEC/BCC materials distributed
Number of complete and timely reporting Number of HEWs guide line & manuals
distributed
Number of HEWs & IEC/BCC CO. trained in HIV/AIDS CCE_CC Number of mothers who did get aware of HIV/AIDS Decreased risk behaviors to HIV/AIDS Increased Utilization of VCT, PMTCT and ART services Knowledge of mothers on HIV prevention Decrease HIV incidence and prevalence Decrease morbidity & mortality due to HIV/AIDS
1.3 Program Objective of IEC/BCC General objective of the program
To enhance HIV/AIDS prevention and control program through IEC/BCC intervention on HIV/AIDS.
Specific objectives of the program
1. To increase awareness of WCBA on HIV/AIDS coverage to 100% by the year 2006/7
2. To cover 50% of WCBA on HIV/AIDS prevention and control information through health extension workers (HEW) by the year 2006/07
3. To increase awareness of WCBA on HIV/AIDS transmission routes and prevention methods to 80% by the year 2006/7
4. To cover 50% of WCBA on HIV/AIDS information session with two ways communication channel by the year 2006/07.
5. To provide 50% of WCBA and 100% health facilities with IEC/BCC materials by the year 2006/07
6. To conduct one annual anti AIDS campaign at all kebeles of the health facility catchments area by the year 2006/07
7. To train all IEC/BCC coordinators and HEW on CCE by the year 2006/07 8. To provide all Health facilities with health service extension program
(HSEP) and IEC/BCC implementation guide line by year 2006/07
9. To strengthen HIMS in all health facilities in support of IEC/BCC intervention on HIV/AIDS
2. Problem statement
Different stakeholders including MOH have conducted different IEC/BCC interventions. However, behavioral change was not yet attained in a level that reduces transmission and reverses the epidemic. Although, almost all people have heard about HIV/AIDS, low proportion comprehends the transmission routes and prevention methods of HIV/AIDS. According to BSS 2002, in SNNPR, not more than 40% of respondents knew transmission routes and prevention methods of HIV (MOH/HAPCO, 2002).
Study conducted by A. Degene et al. 2005 on determinants of behavioral change in HIV/AIDS and IEC/BCC approach for rural Ethiopia, showed that 82.7 % of women had heard about HIV/AIDS and less than 35% of women obtained information from two or more sources (A. Degene et al., 2005)
About 90 percent of women and 97percent of men have heard of HIV/AIDS (DHS, 2005). However, a relatively lower percentage of women and men believe that there is a way to avoid HIV infection. There were also substantial differences in knowledge of HIV/AIDS by place of residence. People living in rural areas of the country are less likely to have knowledge of HIV/AIDS with the difference much more obvious among women than men (CSA, 2005).
Even though continuous attempt was made to create awareness among community, there is little attitudinal and behavioral change towards prevention and control of HIV/AIDS. This is because of absence of standardization, lack of measuring the effect of IEC/BCC session for continuous monitoring of IEC/BCC success and deficiency in production of locally suited teaching materials that fit diverse ethnic and socio-cultural contexts in the region. In addition to this, there was not adequate IEC targeting materials to most vulnerable groups like women, school youth, out of school youth, adolescents, street children, farmers, pastoral communities, and the urban poor (SNNPR HB, 2005).
The low level of community awareness, low level of health service coverage and utilization, lack of regular and adequate in-service training associated with limited incentives further complicate the problem (GZHD, 2006). The low health service coverage in the region calls for an innovative program like the HSEP to deliver an effective and relevant IEC/BCC. Incidentally, this program is considered one of the most important institutional frameworks for achieving the Millennium Development Goals in the health sector (Hailu, 2005). However, there are limitation studies documenting a process evaluation of the implementation process.
This study, thus, sets out to fill this gap in knowledge by evaluating the process of IEC/BCC on HIV/AIDS through the Health Service Extension Program with emphasis on women of childbearing age in rural Areas.
3. The need for evaluation
National, regional as well as local stakeholders have been engaged in comprehensive intervention activities. The government has found that IEC/BCC Package is an important and appropriate approach for the prevention of HIV/AIDS. IEC/BCC is also one of the main components of the Health Services Extension Program (HSEP).
IEC/BCC intervention on HIV/AIDS is the component of health services extension program (HSEP) and a new approach used as one of the best ways to tackle HIV/AIDS. The government allocates large amount of money and time for the program. However, the status of IEC/BCC intervention on HIV/AIDS is not well known. The program owner/RHB/ and other stakeholders, all emphasize the need for process evaluation in order to inform implementation and attain the set objectives.
4. Stakeholder description /consultation
A stakeholder is anyone who has a stake on the program. Stakeholders are individuals, groups, or organizations that tended to have vested interests on how well a program functions (Rossi, Lipsey M & Freeman 2004).
Stakeholders for the evaluation program are primary and secondary. Primary stakeholders are those directly involved or affected by the program; whereas secondary stakeholders are indirectly involved or affected by the program (Sandra M., 1998)
4.1 Key stakeholders and their role
Key stakeholders
The key stakeholders are: SNNP Regional Health Bureau, SNNP Regional HIV/AIDS Prevention and Control Office (HAPCO), Jimma University, Zonal and District Health Office, Community representatives, NGO’S involved in HSEP, UNICEF and ESHE, health facilities and Health Extension workers.
4.2 Process for stakeholder participation
Stakeholder participation analysis was done at the outset to develop an understanding of the power relationships, influence, and interests of the various people involved in this activity and to determine who should participate, how, and when.
The analysis was conducted through preliminary discussions with regional health bureau officials and other stakeholders on the need for evaluation. A consensus was reached to continue planning for the evaluation and key stakeholders on the program were identified.
4.3 Communication with stakeholders
Communication with stakeholders was given due attention to ensure their participation in the program evaluation. During evaluability assessment, frequent face-to- face communications were conducted with the District health office and health facilities involved.
Telephone was also used to share information with the District health office and zonal health department. Guragie zone health department and Meskan District health office have provided base line information, which was useful in designing this study. Moreover, the parameters of judgment for evaluation were developed with the full participation and agreement of the District IEC/BCC unit and other stakeholders.
Dissemination of final evaluation report to District, zonal health department and RHB will be done through presentations, meetings and provision of the study report.
4.4 Utilization of evaluation findings stakeholders’ perspective
Program evaluation should be an integral part of the health program planning, implementation, review, and change cycle. In addition, the systematic collection of information about the activities, characteristics, and outcomes of programs help make judgments about the program, improve program effectiveness, and/or inform decisions about future programming (Patton, 1997).
This evaluation aims to identify strengths, gaps, and barriers of the program implementation. Stakeholders such as RHB, District health office, HAPCO, ZHD, and involved health posts plan to utilize the evaluation findings to take corrective measures; strengthen/develop /revise/ strategies. Stakeholders also aim to utilize the findings to plan for over all program improvement and experience sharing UNICEF, in particular, has plans to use this data to inform its plans for capacity building, and program support in the area.
The role of stakeholders in the program evaluation is expressed in the table below.
Table 1Stakeholder analysis
Stakeholder Category Role in program Participatio n or Role in evaluation Utilization of finding SNNPR health bureau Program coordinato r and implement er Coordinating the program Training & assigning of HEWs to District Resource allocation Supply of IEC/BCC materials Supportive supervision & monitoring Information provider
For future planning and decision makings District Health Office (Meskan) Program coordinato r and implement er Leading HSE program Training of HEWs on IEC/BCC Assign trained HEWs to kebeles Follow up & supervise HEWs Receive & distribute IEC/BCC materials Implementation of IEC/BCC Receive and compile HEWs report
Send the complied report to RHB Provision of data and facilitation of data collection. Provide support in the entire process of the evaluation as requested.
For future planning To identify gaps in the process of implementation and designing strategies to fill the gaps To use the finding and
recommendation of the evaluation for improving the program
To use the finding as evidence in working with partners Health Facilities Program implement er Facilitating distribution of IEC/BCC materials Health education Community mobilization Provision of data
For future planning to improve
implementation of the program
Stakeholder Category Role in program Participatio n or Role in evaluation Utilization of finding UNICEF/ESH E Collaborat or Donation of budget and supply to RHB Consultancy for RHB on IEC/BCC program Participating during planning, and discussion of evaluation process by providing information Collaboration with stakeholders during implementation of findings To improve sustainability of the progress thorough ensuring community ownership Jimma University Collaborat or Support in policy, strategy and national action plan formulation Funding of the evaluatio n Letter of support for evaluation Share experiences from study results
Health extension workers Program implement er Preparing IEC/BCC plan Educating community at house hold, health facility and other places Request and distribute IEC/BCC materials Preparing and submitting of monthly report Providing data Participating during in-depth interview Cooperate in document review
For future planning to improve implementation of the program Community Beneficiar y Utilization of the program products Participation in all aspects of program implementation Provision of data To improve utilization and participation in the program
5.
Objectives of evaluation
5.1 The evaluation questions
1. Did the target population receive HIV/AIDS information?
2. Did the health extension workers contribute to raising awareness among women of childbearing age as planned?
3. Have the health extension workers been using two-way communication teaching techniques during education?
4. Have HIV/AIDS IEC/BCC materials been supplied, distributed and utilized as planned? If yes, how? If no why?
5. Did HEWs and IEC/BCC coordinators participate in CCE_CC training? 6. Did HEWs and IEC/BCC coordinators provided with IEC/BCC & HSEP
implementation guideline?
7. Did the health facilities generate data for monitoring of IEC/BCC intervention on HIV/AIDS?
5.2 General objectives
To assess implementation of IEC/BCC intervention on HIV/AIDS in Meskan district, Guragie zone, SNNPR.
5.3 Specific objectives
1) To assess awareness of HIV/AIDS transmission and prevention among women in child bearing age.
2) To assess the source of HIV/AIDS information in the study population and measure the contribution of HEWs.
3) To evaluate the appropriateness of methods for creating awareness to the target community
4) To review HIV/AIDS IEC/BCC materials supply, distribution and utilization in the study area.
5) To assess training conducted on CCE_CC for HEWs and IEC/BCC coordinators.
6) To identify the availability of HSEP and IEC/BCC implementation guide line.
7) To review the management (recording & reporting) of IEC/BCC intervention data among health facilities.
6.
Evaluation Method
6.1 Study Design
This study utilizes a case study research method with triangulation of qualitative and quantitative methods. The qualitative part includes purposely-selected health facilities, HEWs and IEC/BCC coordinators. It was conducted using in-depth interview, document review and observation check list. While cross-sectional study was employed for quantitative part and simple random sampling technique was used to select study units in WCBA. Triangulation was used to reach at a comprehensive and detailed understanding of the intervention and its context as well as ascertain validity and generalizability.
6.2 Study Areas and Period
The study was conducted in Meskan District of Guragie zone, SNNPR from August 25 to September 10, 2007.
6.1.2 Study Area
Meskan District is one of the 13 Districts of Guragie zone located 150 Km south of Addis Ababa. It has 2 urban and 40 rural kebeles. Twenty five (62.5%) of the rural kebeles have HEWS. The population is currently estimated at 206,995, 23% of which is comprised of women of childbearing age (CSA, 2004, GZHD, 2006).
The District has 2 hospitals, 4 health centers, and 25 health posts with potential health service coverage of 79% (GZHD, 2006).
6.3 Logical model of the evaluation
Logical framework method was used because this method enables the way to review progress and take corrective actions for program improvement. The logical framework method involves engaging stakeholders to clarify objectives and design activities of a program. It helps to identify expected causal links (input, process, output, outcome, and impact) including coverage and reach across beneficiaries. Performance indicators at each stage will be determined and factors, which affect achievement of objectives, could be identified (World Bank, 2004).
Figure 3: conceptual frame work of evaluation IEC/BCC intervention on prevention and control of HIV/AIDS
Feed back
NOTE: 1) availability and 2) compliance to IEC/BCC guide lines are dimensions of getting access to IEC/BCC service on HIV/AIDS prevention and control
MOH HAPCO RHB ZHD WHO Awareness creation among mothers and community Get access to IEC/BCC service on HIV/AIDS prevention and control 1) Availability IEC/BCC materials Trained HEWs 2) Compliance to the national guideline -implementation guide line distribution National HIV/AIDS policy
6.4 Focus, approach and purposes of the evaluation Focus
The focus of Evaluation was process evaluation because the health service extension program is on going. Its key elements are, thus, assessing whether inputs, activities and out puts met set standards or not. Process evaluation supplements the monitoring of inputs and outputs and characterized by an explanatory dimension, enabling the understanding of how the organizational context may affect the program (CDC, 1999).
Approach
This is a formative evaluation conducted to assess ongoing IEC/BCC interventions on HIV/AIDS with emphasis on the health service extension program. As such, it aims to assess how well the program is implemented and determine ways to improve program delivery.
Purpose
To identify the strength and limitations of the program in the area so as to provide stakeholders with relevant information that could be used for improving the program.
6. 5 Dimension of Evaluation
The evaluation dimensions deemed relevant to this intervention were compliance to the national guideline, compliance to Annual plan, coverage and availability of IEC/BCC materials and trained HEWs.
6.5 Targets and Source Population Target population
The target population for the quantitative study is the total number of women in child bearing age (15-49 years) which is about 4217 found in the seven rural kebeles of Meskan District with health extension workers of two and more service years. Study subjects for the qualitative study were all of seven health extension workers of two and more service years, all of six IEC/BCC coordinators and 13 health facilities (two hospitals, 4 health centers and 7 health posts) in Meskan District of Guragie zone.
Source population and Inclusion criteria:
Source population was 13 health facilities, 6 IEC/BCC coordinators of health facility, 7 health extension workers, IEC/BCC document of 13 health facilities and 422 mothers in childbearing age (15-49 years). Pertaining to inclusion criteria, all HEWs having two and more service years in Meskan district was included in this study. This is because they fulfill the HSEP requirements of two HEWs in one health post and expecting that they implement full package of the service. As a result only seven kebeles found to fulfill the criteria and included in the study. This study focused on Women in childbearing age as the HSEP program design mainly targets them and protecting women will have the dual benefit of preventing HIV transmission to children. Moreover it helps to know how effectively HEWs are using IEC/BCC intervention with target group.
6.6 Sampling technique and sample size
A total of 422 WCBA were selected using simple random sampling technique from the seven target kebeles using computer generated random numbers. A list of all women in childbearing age in seven selected kebeles was found from Butajera rural health project. At household level primarily mothers and in their absence elder daughter in the child bearing age was included in the study. Moreover the study subjects were the residents of the selected kebele at least for two years.
Purposive sampling technique is one of the most common sampling technique and preferred method of sampling for many qualitative designs (FHI, 2006). Both hospitals and all four health centers in the district as well as seven health posts purposely selected and included for document review. For the in-depth interview, six IEC/BCC coordinators and seven health extension workers were included. Of the six IEC/BCC coordinators two came from the two hospitals, one from each health centers and seven HEWs from the seven health posts. The same health extension workers were involved in the structured observation of health education sessions.
Sample size
The sample size is determined by using single proportion cross-sectional survey formula: n=Z2 (p) (1-p)/d2
Z value at 5%level of significance = 1.96
The proportion (p) of awareness level of among women (DHS, 2005) = 90% Margin of error = 0.03
Calculated Sample size = 384
By considering 10% none response rate, the final sample size for the study will be 422 women in child bearing age in seven rural kebeles of Meskan District. The total sample size was distributed to the selected seven kebeles proportional to their population size. So that, the number of women in child bearing age selected for the study was 125 for Jolle, 63 for Yemerewacho, 57 for Dobenagola, 56 for Sosteamba, 48 for Sheseramecmena, 42 for weja, and 32 for Dobenabati.
6.7 Indicators and source of data
A. Indicators of IEC/BCC materials distribution
IEC/BCC materials supply and utilization by health facilities IEC/BCC materials supplied to women
Source of data
Health post document review Survey of women
B. Indicators of raising awareness
HEWs who had HIV education schedule for the current month
HEWs that had individual and group HIV daily education session using household visit
Source of data
HEW interviews, Women, Health facilities document review and observation of posted or used IEC/BCC materials and work schedules.
C. Indicators of mobilizing society
Topics discussed and teaching methods used
IEC /BCC materials utilization during education session
Information provided to Women on HIV/AIDS prevention and control services (VCT, condom distribution, PMTCT, ART) utilization.
Sources of data Women interview
D. Indicators of strengthening HMIS Documentation and reporting
Source of data
6.8 Data collection Instrument development
1. Interviewer administered structured questionnaire
A standard closed-ended questionnaire, adopted from family health international, was used for the quantitative study (annex I & II). It is prepared in English and translated to Amharic, widely spoken Language by the community, by language experts and translated back to English by another translator (FHI, 2003).
2. Observation checklist
Standard observation checklist is prepared to assess Women HEWs interaction during sessions as well as posted IEC/BCC materials, and other methods used for awareness creation (annex III).
3. In-depth interview guide
Unstructured in-depth interview guide was used as a tool for qualitative data collection for health extension workers and IEC/BCC coordinators (annex IV). Health extension workers were interviewed regarding training on IEC/BCC intervention on HIV/AIDS prevention and control, IEC/BCC material supply and distribution at health post, method of conducting health education on HIV/AIDS, recording books/reporting formats and implementation guidelines. Whereas, IEC/BCC coordinators were interviewed on health post supervision/monitoring, challenges and issues/ideas for changing or improving IEC/BCC intervention on HIV/AIDS prevention and control.
4. Document review format
Document review was used to confirm whether the HEWs had a written plan or not; to compare HEW records and reports with registration book and reporting formats and to assess implementation guidelines and teaching materials for conducting HIV/AIDS prevention education at health facility level (annex V).
6.9 Data collection
1. Qualitative data collection
The investigator conducted in-depth interviews. In-depth interview data from 13 health facility experts (6 IEC/BCC coordinators and 7 health extension workers) was collected using a series of guides containing suggested questions for each key evaluation areas. The investigator and supervisors did observation during group or individual health education sessions and on utilization of IEC/BCC materials at health facility or individual level. The investigator and supervisors also reviewed documents of 13 health facilities. The reviews were conducted to collect data on plan/performance report, teaching materials supply and distribution; supportive supervision feed back and method of awareness creation on HIV/AIDS prevention and control. In addition to this, registration books were reviewed for recording and reporting format
2. Quantitative data collection
Originally it was planned to interview 422 WCBA but only 414 were interviewed giving a response rate of 98.10 %. During visit if women are not available during the first visit, the interviewer continued to the next women and made repeated visit of missing women and if still not available for the day the next house at the right side was included.
6.10 Data Analysis
Analysis for in-depth interview, document review and observation of IEC/BCC session were compared with pre identified common themes and interpreted and summarized for each section. It was organized manually and the result was presented in narrative form.
Data obtained from respondents was checked, cleaned and coded and ready for analysis. The quantitative data was entered and verified using Epi-info version 3.3.2 for analysis and the result was presented using tables and graphs.
.
6.11 Data Quality management
Pre-testing: Closed- ended questionnaire was pre-tested by collecting data equivalent to 5% of the sample size in kebeles out side the study area. The questionnaire was pre-coded and questions that were difficult to respond were rephrased before actual data collection.
Training: Data collectors and supervisors were selected in collaboration with the District health office. Data collectors were health education officers and supervisors were senior public health officers from neighboring district. Both data collectors and supervisors were trained for two days on study instrument, interview techniques, and sampling technique by using training guide (Annex VI). Supervisors were also trained on techniques of reviewing data quality and random observation of data collection.
Supervision: principal investigator with the assistance of supervisors did a daily supervision and follow up. Data collectors submitted the completed questionnaires every day to supervisors and were checked for completeness with principal investigator.
Data management: Each afternoon, field note of Qualitative data was recorded as fair notes in English by principal investigator. These notes was transcribed or entered directly into MS Word.
Every day at the field, quantitative survey data was checked for completeness and consistency by supervisors. In order to get high quality data and to give an assistance for data collectors when need arises, principal investigator and supervisors was assigned for each site. Two supervisors (senior public health officers) were monitoring the data collection process
6.12 Interpretation of matrix analysis and evaluation dimension
The most appropriate and feasible data collection method has been chosen for each of the questions identified in the evaluation plan. As this is a process evaluation, the analysis and judgment depended on how the activities and outputs compare with what was planned, or whether they met targets, standards or guidelines.
Basis for Judgment of evaluation
The judgment of evaluation was based on parameters and weights given for each dimension in percent. The evaluation dimension availability and compliance to the guideline was sub divided in to specific objectives and weight value was given. For each specific objective indicator was developed. Weights were given for indicators based on their degree of importance. Evaluation parameters & judgment criteria were drafted and scaled as inadequate, fair, adequate and successful.
6.14 Ethical Consideration
Ethical approval was secured from the ethical clearance committee of Jimma University as well as the SNNPR Health Bureau. The health facilities and kebele administrations in which the study was conducted were notified in writing before hand. The study subjects were asked to give their written consent by giving adequate explanation about the purpose, significance, potential harm & benefit of the study. Health education on transmission and prevention of HIV/AIDS was also given at the end. Omitting the name and administrating individually could also assure confidentiality.
6.15 Evaluation dissemination plan
A copy of the final report will be given to Meskan District health office, Guragie zone health department, SNNPR health bureau and Jimma University. The study will also be submitted for publication in a peer-reviewed journal.
6.16 Operational Definition
Approprariate teaching materials: refers to teaching materials used for IEC session local suited and accepted by MOH standard
Availability: means the availability of IEC/BCC material such as leaflet, posters for health education and other resources like condoms.
Awareness: refers t the level of health information on HIV reached to target population women in childbearing age.
CCE_CC: community capacity enhancement is one such approach, which utilizes community conversations as a space for understanding, sharing, and healing and informed community decision – making.
Compliance to annual plan: means annual plan of the district to conduct HIV/ADIS prevention and control services
workers performance in line with the guideline that has been prepared to provide HIV/AIDS behavioral intervention
Coverage: means Health Extension workers performance in line with the plan to cover WCBA on HIV/AIDS information.
“Dado”: A group of adult women get together on monthly basis with small ceremony to chat at their major problems. All members turn by turn prepare the ceremony.
Health Extension Package - It is package of services that include provision of immunization, prevention control and treatment of malaria, prevention of HIV/AIDS/STDS, Tuberculosis, provision of oral contraceptives, deliveries, follow up of high risk pregnant mothers, first aid, sanitation services and increased health awareness through IEC/BCC.
Health Extension workers: females that are one year trained civil servant public health workers who serve 5000 inhabitants in one kebeles.
Health Service Extension Program: is community based health care delivery system that creates universal access to primary health care services by all house hold and communities and aims at improved family and community health status through increased involvement in health programs and utilization of health care services.
Kebele– The smallest administrative unit of the government that comprises around 5,000 peoples and measures have been started to equip with one health post and two female Health Extension Workers to deliver promotion, preventive, and limited curative health services
Awareness about routes of HIV/AIDS transmission: subjects were considered having knowledge if they identified at least two major routes of HIV transmission, namely, unprotected sex and sharing of infected sharp instruments.
having knowledge if they identified at least two major methods of HIV prevention, namely, ABC rule and not using sharing of infected sharp instruments in common.
“Lika”: a group of adult men get together on monthly basis to discuss their problems.
7. Results
7.1 Quantitative study result
7.1.1 Socio Demographic Characteristics
Among 422 sampled subjects, 414 had responded to the questionnaire giving of 98.10% response rate. Most of the respondents, 342 (82.6%) were married and 64(15.5%) were single, the remaining 8(1.93%) were divorced and widowed. The mean age of the respondent was found to be 28.2 years with standard deviation of 8.6. The majority of the respondents 291 (70.3%) couldn’t read and write. Muslim and Orthodox Christian were the dominant religions in the study area with 205 (49.5%) and 201 (48.6%) respectively. Pertaining to the respondents occupation 340 (82.1%) were housewives, 40(9.7%) students and 25(6%) unemployed. Guragie was the main 340(82.1%) ethnic group followed by Silite 36(8.7%). The mean family size of households was 5.9 with standard deviation of 2.0(Table2).
1 Marital Status of respondent Married 342 82.61 Unmarried/single/ 64 15.46 Divorced 5 1.21 Widowed 3 0.72 Total 414 100.00 2 Age 15-24 135 32.61 25-34 169 40.62 35-44 85 20.53 45-49 25 6.04 Total 414 100.00 3 Educational status
Unable to read and write 291 70.29
Read and write 26 6.28
Grade 1-4 38 9.18
Grade 5-8 52 12.56
Grade 9-12 & College and above 7 1.69
Total 414 100.00 4 Occupation House wife 340 82.13 Student 40 9.66 Unemployed 25 6.04 Others 9 2.17 Total 414 100.00 5 Ethnicity Guragie 340 82.13 Silite 36 8.70 Mareko 15 3.62 Amhara 14 3.38 Oromo 9 2.17 Total 414 100.00 6 Religion Muslim 205 49.52 Orthodox 201 48.35 Protestant 8 1.93 Total 414 100.00
7.1.2 Awareness of women on methods of HIV/AIDS transmission and prevention
least two routes of transmission, 84(22.3%) single route and 17(4.5%) did not know transmission routes. Regarding the prevention methods the majority of respondents 168(44.7%) knew single method, 126(33.5%) two or more methods and 82(21.8%) did not know any prevention methods (Table 3).
Table 3: Awareness of respondents on HIV/AIDS, its transmission routes and prevention methods in Meskan District, SNNPR, September, 2007
Table 4: Percentage of respondents who knew at least two routes of transmission and prevention methods in Meskan district, SNNPR, September 2007
Variable Knew single transmissionroute /prevention method
transmission route/prevention
methods Don’t know Total
Transmission 84(22.30%) 275(73.10%) 17(4.50%) 376(100.00%)
Prevention 168(44.70%) 126(33.50%) 82(21.80%) 376(100.00%)
7.1.3 Source of information on HIV/AIDS
A total of 376 (90.8%) respondents had heard about HIV/AIDS from different source of information. 69(18.35%) of the total respondents reported both radio and Edir as their main Source of information, followed by 67(17.82%) both radio and health extension workers. A total of 184(48.90%) study subjects indicated that health extension workers as their source of information. Of these, 32(8.35%) had heard only from HEW, the remaining 152(40.40%) had heard from a combined source of HEW and others.
Table 5: Respondent source of information on HIV/AIDS, its transmission routes and prevention method in Meskan district, SNNPR, September, 2007
Sr.n
o Source of information Number %
1 Radio 42 11.17 2 Edir/different gathering 44 11.7 3 Health extension workers/HEW/ 32 8.51 4 Teachers/schools 23 6.12
5 Radio and Edir 69 18.35
6 Radio and HEW 67 17.82
7 Radio, Edir and HEW 40 10.64
8
Radio, Edir, Teacher and
HEW 31 8.24
9 Edir and Teacher/Schools 14 3.72
10 Teachers/school and HEW 12 3.19
11 Edir and HEW 2 0.53
Total 376 100
respondents reported taking VCT, 57(15.2%) by looking at him/her, 25(6.6%) Debilitated person and 48 (12.8%) mentioned that they had no knowledge.
Source of information for VCT service were:-HEWs 139 (62.1%), different community gathering 30 (13.4 %), radio/TV (mass media), 28 (12.5%), and teacher or school 27 (12.1 %).
Table 6: Awareness on HIV voluntary counseling and testing and source of information among women in child bearing age in Meskan District, SNNPR, September 2007
Sr.n o
Variables Number %
1 Can one know having HIV/AIDS or not By taking VCT 244 64.9 By looking at him/her 57 15.2 Don’t know 48 12.8 Debilitated person 25 6.6 Others 2 0.5 Total 376 100.0
2 Source of information about VCT service
Health facility /Kebele health
workers (HEWs) 139 57.0
Different community gathering 40 16.4
Radio/TV (mass media) 38 15.6
Teachers 27 11.1
Total 244 100.0
As presented in figure four among respondents who were asked whether they had received IEC/BCC materials on HIV/AIDS 355 (94.4%) said they did not receive any materials.
Figure 4: Proportion of respondents who received IEC/BCC materials on HIV/AIDS in Meskan District, SNNPR, September 2007
From respondents who get IEC/BCC material 13 (61.9 %) received leaflet and for the rest of types of materials see figure five.
Figure 5 Distribution of IEC/BCC materials on HIV/AIDS by type in Meskan District, SNNPR, September 2007
7.1.6 Awareness of women on HIV/AIDS prevention and control service availability
A total of 216(57.4%) study subjects were aware of locally available services HIV/AIDS. Of this 122(56.5%) were aware of condom distribution, 55(25.5%) ART, 27(12.5%) VCT, 10(4.6%) care and support and 2(0.9%) PMTCT services On the other hand the remaining 160(42.6%) were not aware of any HIV/AIDS prevention and control services.
Table 7 Awareness on HIV/AIDS prevention and control service among women of child bearing age, in Meskan District, SNNPR, September, 2007
Sr.no Variables Number %
1 Heard of HIV/AIDS service
Yes 216 57.4 No 160 42.6 Total 376 100.0 2 Type of service Condom distribution 122 56.5 ART 55 25.5 VCT 27 12.5
Care and Support 10 4.6
PMTCT 2 0.9
7.2 Qualitative study result
In depth interviews were conducted for selected IEC/BCC coordinators and HEW with a total of 6 coordinators and 7 HEWs. The IEC coordinators were selected from two hospitals and 4-health center of Meskan district. All the HEWs were selected from 7 kebeles of Meskan district. Of the total coordinators five of them were nurses (different category) and one environmental health in their professions.
7.2.1 In-depth interview with IEC/BCC coordinators of health facilities A. Knowledge on IEC/BCC
In-depth interviews were conducted to assess the knowledge of the coordinators on IEC/BCC concept. Five of the respondents could not clearly explained what IEC /BCC stands for and the strategies to implement the IEC /BCC program in relation to HIV/AIDS prevention and control. Only one of the interviewee has explained the concept
“IEC/BCC is empowering the community in prevention and control of communicable disease as well as health promotion among the community through health education using peer groups, community volunteers and community capacity enhancement through community conversation”.
B. Role of IEC/BCC on HIV/AIDS prevention and control
All of the interviewees knew that IEC/BCC has great role in the prevention of HIV/AIDS. They indicated that IEC/BCC contributes a lot by increasing the awareness of the community to know and utilize services available in the prevention and control of HIV/AIDS.
One of the interviewee from the health center said that, “we use community health promoters and school clubs to reach the wider community with HIV/AIDS focused health messages.”
communicate with the community on HIV/AIDS transmission and prevention /control methods. In addition it increases the community awareness to support those living with HIV virus.”
C. Health extension workers training package and supervision
When asked with what objective the HEWs were trained, all the interviewees knew that they were trained in technical and vocational school on 16 HSE packages for a year and take practical attachment course at different health facilities and community. They also mentioned upon completion of their courses they would be deployed to work in rural kebeles at health post level and reported their performance to the health centers. And they also noted that IEC/BCC intervention is the cross cutting issue. Regarding the supervision those from the health centers knew that all health center departments' staffs to provide them with on job training to improve the quality of service they are providing have supervised the health extension workers. On the other hand all interviewees from hospital, had responded that they had no knowledge on type of training and supervision of HEWs. They also indicated they had no work relation ship with HEW as they are working in hospital.
D. Duties expected from HEW on IEC/BCC
Two experts working at Hospitals explained that they had no HEW under their supervision and were unable to answer questions related to annual plan (daily, monthly and annual) and communication with CHPs. Four respondents reported that HEW had good work relationship with CHPs but they did not come across with any HEW with annual plan and scheduled activity plan, which focused on IEC/BCC intervention.
but it is to indicate that the intervention is not going as it is put in the implementation guideline.”
E. Training on IEC/BCC Intervention
All the interviewees reported that they were not trained in participatory community conversation enhancement.
F. Availability of IEC/BCC materials and guidelines
All reported that there is no IEC/BCC and HSEP guideline at the health facility. Besides they mentioned that there was in adequate and interrupted supply of IEC/BCC materials at facility level. They also commented that they didn’t participate in the development of IEC/BCC material.
G. Conducting Supervision/ monitoring
Almost all interviewee agreed the necessity of supervision and monitoring. In this case they had been asked the availability of appropriate reporting format, registers and procedures on IEC/BCC intervention in general and HIV/AIDS related in particular. Those from the health centers mentioned they had an experience to discuss with the HEW on IEC/BCC intervention though not in organized and prepared procedure. They monitor the performance of the IEC/BCC intervention by using routine monthly reports from HEWs but not regular and believed it was not adequate.
H. Challenges faced while coordinating IEC/BCC Intervention on HIV/AIDS According to some of interviewees the under listed were some of the challenges in implementing IEC/BCC intervention:
Inadequate supply of IEC/BCC materials Lack of training on IEC/BCC intervention
Cultural and religious barriers from the side of the community
I. What has to be done to improve IEC/BCC Intervention on HIV/AIDS? The following were solution forwarded by the interviewees to tackle the challenges:
IEC/BCC materials should be provided in adequate amount
Health centers should strengthen supportive supervision and monitoring Training on IEC/BCC
7.2.2 In-depth interview of health extension workers A. Knowledge on IEC/BCC
All HEWs correctly mentioned what IEC/BCC stands for and the strategies used in implementing the activities in relation to HIV/AIDS prevention and control. One respondent focused on how to conduct the IEC /BCC intervention. More over, the other two noted that it is a cross cutting issue in health service extension package implementation. They also explained how they use local gatherings like Edir, Kebele meetings, coffee and funeral ceremony, traditional events like “Lika” and “dado” to cascade the message at household level.
B. The role of IEC/BCC in HIV/AIDS prevention and control
All of the respondents explained that the role of IEC/BCC as Important strategies for prevention and control of HIV/ADIS. Moreover, four of the participants mentioned IEC/BCC would contribute to bring behavioral change. However, two of the respondents explained IEC/BCC helps to increase awareness and utilization of HIV/AIDS prevention and control services.
C. Supply and distribution of HIV/AIDS IEC/BCC materials
All of the respondents had reported that they had received some IEC /BCC materials which focused on HIV/AIDS prevention and control. They also noted that poster and leaflets were the common type of IEC /BCC materials they had been supplied. On the other hand they complained that the quantity of the
specific.
D. Training on IEC/BCC Intervention
All the interviewees reported that they had been given participatory community conversation enhancement training for one week with in last two months. According to the respondents the content of the training was focused on HIV/AIDS prevention and control. They also said it had helped them in conducting participatory communication method instead of simple and ineffective health talk.
E. Availability of IEC/BCC and HSEP Implementation guide line
All interviewees responded that IEC/BCC and HSEP implementation guidelines were not available at the health facilities. The reason mentioned for this was that the woreda health office didn’t provide the guideline.
F. IEC/BCC intervention messages reaching target population
Six of respondents explained that IEC/BCC messages were addressing the major target group of population through CCE_CC; volunteer and peer group involvement, youth group, home to home visiting, school clubs, Edir, church and safety net place on weekly base .In addition they indicated that they were conducting anti AIDS campaign once a year as planned. However, one interviewee explained they had not reached target population due to different assignment. Seven of the respondents reported WCBA were their target.
G. Communication channels used
Regarding communication channel four reported they did not widely used printed IEC materials, video show, local song, and drama. However, seven of the interviewees used lecturing/health talk/, anti AIDS campaign, small group discussion and house to house as a communication channel for HIV/AIDS
show, song and printed materials were used during IEC/BCC session.
H. Involvement of audience in message development
Seven participants reported that they had received all finished printed materials and there were no chance to involve the audience in message development of printed materials. However, five responded that participatory approach would give them a chance to know whether the audience clearly understand the message and get feed back from the audience for future use.
I. Recording & reporting of IEC/BCC intervention on HIV/AIDS
All the respondents reported that they had monthly reporting format, which includes IEC/BCC intervention. On the IEC/BCC part only the topic, number of session and the number of participant were reported. The reporting format had no place to identify the target group. Two third of the respondents reported that they did not use permanent registration book for daily recording of IEC/BCC interventions and use simple note book.
Document reviews were made in seven health posts, four health centers and two hospitals. Accordingly, except one health post and two health centers, all visited health facilities had 2006/2007 annual plan of IEC/BCC intervention on HIV/AIDS. While all visited health facilities had annual performance report of the fiscal year 2006/2007.
In general one or more type of printed IEC/BCC materials on HIV/ AIDS prevention and control were available at all health facilities. Poster was the main IEC material distributed and followed by leaflets. All health centers and hospitals had registered the distribution of IEC/BCC materials. Except one health post IEC material distribution was not registered. In general there were at least one or more type of IEC material posted in all health facilities, which focused on prevention and control of HIV/AIDS. No health facilities were found which had IEC/BCC intervention implementation guideline manual, despite the fact that all health facilities need to have and use it. Two of the health facilities had permanent registration book to record IEC/BCC intervention. From those few facilities which had the registration book, there were health facilities not using it. Though all health facilities were checked for supervisors’ feedback on IEC/BCC intervention, no health facility was found with supportive supervision logbook.
Concerning IEC/BCC material supply and utilization at health facility level: brochure was supplied and utilized at one health post and one health center; flip chart was supplied and utilized at one health post and one health center; posters was supplied and utilized at two hospitals; three health centers and four health posts and leaflet was supplied and utilized at two hospitals, three health centers and one health post. On the other hand, distribution of IEC/BCC materials to the households was not registered except in one health post, two hospitals and three health centers, which registered, leaflet distribution. Besides, one health post and
