Presented by Yvette Ribaira at the 2015 American Public Health Association Meeting on November 3, 2015.

1. Community-Based Integrated
Health Program (CBIHP/
MAHEFA)
Using the Mentoring Approach
to Meet Family Planning Needs of
Underserved Youth in Madagascar
Presented by Yvette Ribaira, MD, MPH
APHA, Chicago, November 3, 2015

2. Presenter Disclosures
(1) The following personal financial relationships with
commercial interests relevant to this presentation existed
during the past 12 months:
Yvette Ribaira, MD, MPH
No relationships to disclose

3. Outline
1. Objective
2. Background
3. Intervention
4. Methodology
5. Key findings
6. Conclusions

4. 1. Objective
Describe the community mentoring approach
used to increase utilization of family planning
and reproductive health (FP/RH) services
among youth in Madagascar.

5. 2. Background: Madagascar
• 22,434,363 inhabitants
with 80% rural and 32%
youth (10-24 yrs)
• Total Fertility Rate: 4.8;
Rural areas: 5.2
• 46% of women 15-24 yrs
have given birth, including
26% of youth 15-19 yrs
Sources: Madagascar, INSTAT, 2014; DHS, 2008/2009

6. 5%
10%
18%
29%
34%
25% 23%
16%
0%
10%
20%
30%
40%
DHS 1992 DHS 1997 DHS
2003/04
DHS
2008/09
%
Trends in Contraceptive Prevalence
Rate and Unmet Needs, Madagascar,
1992-2008: 15-49 yrs women in union,
CPR Unmet need
8%
12%
20%
36%35%
26%
24%
15%
0%
5%
10%
15%
20%
25%
30%
35%
40%
DHS 1992 DHS 1997 DHS 2003/04 DHS 2008/09
%
30-34 age group
CPR Unmet need
3%
9%
18%
28%
31%
27%
22%
17%
0%
5%
10%
15%
20%
25%
30%
35%
DHS 1992 DHS 1997 DHS
2003/04
DHS
2008/09
%
20-24 age group
CPR Unmet need
1% 3%
11%
17%
24%
22% 20%
27%
0%
5%
10%
15%
20%
25%
30%
DHS 1992 DHS 1997 DHS 2003/04 DHS 2008/09
%
15-19 age group
CPR Unmet need
Source: Madagascar, DHS, 2008/2009

7. 2. Background: CBIHP/MAHEFA
CBIHP/MAHEFA reaches 3.4
million people in six remote
regions (279 communes, 1/5 of
national population).
Community health volunteers
(CHVs) provide integrated health
services, including FP/RH, to all
community members.

8. 2. Background: MAHEFA regions
• 64% of young women aged 15-24 have given
birth; 46% before the age of 19*.
• Formative research in 2012 revealed important
enablers to acceptability of FP (all, p<.002):**
– Recognition of the absence of disadvantages of FP
– Acknowledgement of importance of FP
– Importance of support from mother, friends,
husband.
Sources: CBIHP/MAHEFA: *Baseline, 2012; **Barriers Analysis, 2012

9. 3. Intervention
• Use findings from formative research to
design approach for community-based service
provision for youth in 24/279 communes.
• One commune per district was selected to be
a youth-focused commune.
• The youth-focused communes have higher
concentrations of youth compared to other
communes in their district.

10. 3. Intervention
• Each youth-focused commune has Youth
Peer Educators (YPE) trained to promote
FP/RH services for youth (629 YPEs)
• Each YPE is linked to a CHV mentor who
receives specialized training in provision of
FP/RH services to youth. (629 CHV youth
mentors /6,080 CHVs)

11. 3. Intervention
• In 2015, MAHEFA added the following
communications activities to its youth
approach
• Trained YPEs to distribute FP/RH messages via SMS
• Radio programs focused on issues important to youth
• A “live-chat” line for youth to call and receive advice and
referrals.

12. 4. Methodology
• Evaluated routine data on FP/RH service
provision by CHVs in 279 communes
• Reporting period: FY2013-FY2015
• Data analysis using Excel and SPSS.20 with a
statistical test (Anova test)

13. Source: USAID/Madagascar, Outcome Monitoring Survey in MAHEFA areas, April 2015
9.9%
41.3%
75.0%
0.0% 20.0% 40.0% 60.0% 80.0%
ANALALAVA
BEALANANA
SOALALA
PORT-BERGE
ANTSOHIHY
VOHEMAR
MITSINJO
AMBILOBE
ENSEMBLE
MIANDRIVAZO
ANTSIRANANAI
MANDRITSARA
MAINTIRANO
BESALAMPY
MAHABO
BEFANDRIANA NORD
NOSY-BE
ANTSIRANANA II
AMBANJA
ANTSALOVA
MORONDAVA
MANJA
BELO SUR…
AMBATOMAINTY
MORAFENOBE
14.4%
26.9%
45.4%
0.0% 20.0% 40.0% 60.0%
MANDRITSARA
BEFANDRIANA NORD
NOSY-BE
ANALALAVA
MANJA
ANTSIRANANAI
BESALAMPY
BEALANANA
VOHEMAR
SOALALA
MAINTIRANO
ANTSOHIHY
ENSEMBLE
AMBATOMAINTY
ANTSIRANANA II
ANTSALOVA
MAHABO
AMBILOBE
PORT-BERGE
MITSINJO
MIANDRIVAZO
MORAFENOBE
BELO SUR TSIRIBIHINA
MORONDAVA
AMBANJA
Average
increased
1.6 times in
2 years
5. Key findings: CPR by district 2012, 2014

14. 5. Key findings
• Significant increase in use of FP among all
clients in 24 districts: 172,892 in FY2015
compared to 24,970 FY2013
Sources: CBIHP/MAHEFA data, October 2015

15. 5. Key findings (FY2015)
• 55,636 young people received FP/RH
messages from YPEs in FY2015.
• 4,507 youth <24 years called the live chat line.
• Majority of the calls were about FP/RH,
followed closely by HIV/STIs.
• 6,627 youth were referred by YPEs to CHVs
and/or CSBs for further FP/RH services.
Source: CBIHP/MAHEFA data, October 2015

16. 5. Key findings
• Did CHV youth mentors have higher rates of
FP use among youth than non-mentors in the
same district? (22 districts*):
–5 districts: higher rates for CHV mentors.
–14 districts: equal rates between CHV
mentors and non-mentors.
–3 districts: lower rates for CHV mentors.
Sources: CBIHP/MAHEFA, quarterly reports, 2013 – 2015
*2 districts could not be analyzed due to lack of reporting by same CHVs across time

17. 6. Conclusions
• CHV services increased overall knowledge and
use of FP/RH services among youth and adults.
• YPEs are able to reach large numbers of youth
with FP/RH messages.
• Impact of specialized youth approach may not
be apparent in the context of a positive impact
from a general FP/RH intervention.
• More support needed for CHV youth mentors to
develop mentoring skills.

18. Limitations, Further research
• Timing of introduction of youth approach makes it
difficult to isolate the effect from other program
interventions.
• Need to compare mentoring approach with other
youth approaches in Madagascar to increase
access to FP/RH services (e.g., youth-friendly
centers, life skills approach).
• Need for further research on communes that
have successfully increased uptake among youth
(positive deviants).

19. Thank you
This document is made possible by the generous support
of the American people through the United States Agency
for International Development (USAID). The contents are
the responsibility of JSI Research & Training Institute, Inc.
and do not necessarily reflect the views of USAID or the
United States Government.