Lessons Learned Community Education Component of the PPP Program by Plan Nederland

Part of the knowledge strengthening component of the MDG5 Meshwork Public Private Partnerships Programme for the improvement of Maternal Health in Sierra Leone

Lessons Learned Community Education Component of the PPP Program Franz F. Wong (PhD) April 2013

Lessons Learned: Community Education Component of the PPP

The author acknowledges the Medical Research Centre (MRC) for their partnership in the Public Partnership Programme as well as the Ministry of Foreign Affairs of the Netherlands and Cordaid for their support.

Disclaimer The views expressed and the information contained herein are not necessarily those of or endorsed by the Dutch Ministry of Foreign Affairs, Cordaid Memisa or MRC, and are the sole responsibility of the author.

Reference: Wong F. 2013, Lessons Learned: Community Education Component of the PPP, Royal Tropical Institute, Amsterdam, The Netherlands

Contact information Royal Tropical Institute (KIT) Development, Policy and Practice Mauritskade 631092 AD Amsterdam The Netherlands www.kit.nl Tel: + 31 20 5688494

Lessons Learned: Community Education Component of the PPP

Table of Contents Acknowledgements .................................................................................................................... 5 Introduction ................................................................................................................................ 6 Achievements as Reported by Participants ................................................................................ 7 Appeal to the Community ...................................................................................................... 7 Awareness Raising and Behaviour Change ........................................................................... 8 Lessons Learned about External Interventions such as IGD .................................................... 10 Internalizing the External ..................................................................................................... 10 Sustainability/Dependence ................................................................................................... 14 Planning, Design and Communication ................................................................................. 15 Dominant Ways of Knowing................................................................................................ 19 Conclusions .............................................................................................................................. 21 Recommendations .................................................................................................................... 22 References ................................................................................................................................ 24

Lessons Learned: Community Education Component of the PPP

Acknowledgements A big thank you needs to go to all participants, facilitators and managers of the programme. In particular the Medical Research Centre (MRC) who initiated the community education component together with other stakeholders in Sierra Leone and the Royal Tropical Institute. MRC managed the logistics, the formative research that informed the programme and the tools for the review of this pilot programme. Alpha Mohammed Jalloh needs to be thanked for managing the research component and logistics in the field and Heidi Jalloh-Vos for the overall management of the programme, the contribution to the design of the research and her constructive comments on the drafts of this lessons learned report. Korrie de Koning is thanked for the initiation and oversight of the programme, the design of the research instruments for the review of the pilot programme (KIT) as well as she and Kathy Herschderfer for their useful comments on the report. Aminata Koroma was lead facilitator for this programme contributing her expertise in facilitating generational dialogue based on her earlier experiences facilitating this methodology with a focus on FGM for AMNET in collaboration with GIZ trainers.

Lessons Learned: Community Education Component of the PPP

Introduction The Public Private Partnership (PPP) program aimed to improve maternal and newborn health in Sierra Leone. The knowledge system strengthening part of the PPP program was implemented by KIT (Royal Tropical Institute), TNO, MRC (Medical Research Centre) and University of Sierra Leone (USL) in close collaboration with Ministry of Health and Sanitation (MOHS). A 2011 rapid assessment pointed to a number of barriers to timely access and referral to antenatal and delivery care including dominant socio-gender norms related to sexual and reproductive health including teenage pregnancy (Herschderfer et al., 2011). The Community Education Component of the PPP program concerned the uncovering and transformation of such norms that are detrimental to womenâ&#x20AC;&#x2122;s health, particularly maternal health, through the implementation of community education using a Generation Dialogue (GD) approach1. The specific aim was to strengthen the capacity of community-based change agents and other influencers to facilitate critical reflection of dominant gender and social norms, beliefs and practices related to womenâ&#x20AC;&#x2122;s and maternal health and teenage pregnancy. The overall aim was to positively transform norms in support of improved maternal health. From September to December 2013, MRC and KIT undertook an IGD process in four communities in the Niawa Lenga Chiefdom of Bo district of Sierra Leone: Sahn, Nengbema, Ngogbebu and Korbu. A team of four facilitators from MRC and WAVES, supported by a lead facilitator from AmNet2, worked with four groups, each of which had 40 community members (10 young females, 10 older females, 10 young males, 10 older males), through seven IGD sessions custom-designed to focus on maternal health and teenage pregnancy. In each location, a Community Coordinator acted as a liaison between the community and assisted the facilitators with mobilizing participants and organizing refreshments. This report summarizes lessons learned from the employment of IGD. It is based on an analysis of focus group discussions conducted with participants after completing the IGD process as well as interviews with the facilitators and community coordinators.3 It comprises of three main sections. The first provides an overview the results of the IGD process as perceived by participants. The aim is provide a context for the second and main section of this report, lessons learned. The report ends with a conclusion and recommendations.

The methodology was based on and adapted from a set of manuals on the Generation Dialogue approach that communication expert Anna von Roenne developed for GIZ (GIZ, forthcoming 2013). 2 WAVES (Women Against Violence and Exploitation in Society) is a womenâ&#x20AC;&#x2122;s rights NGO, based in Bo, Sierra Leone, that promotes the rights of women and girls and raise their consciousness to be able to stand up for themselves. AmNet (Advocacy Movement Network ) is an human rights organization, based in Freetown, Sierra Leone, that was established to bring positive changes through advocacy, capacity building, empowerment and gender equity. AmNet has substantial experience with using IGD in Sierra Leone and provided the lead facilitator who trained and supported the facilitators and provided overall coordination and supervision. Four facilitators, two women and two men, from WAVES and MRC respectively, were chosen from a cohort that was trained in IGD by CEC; they were selected for their complementary experiences with and knowledge of maternal health and gender issues as well as their facilitation skills. 3 In total, 16 FGDs were conducted with 124 IGD participants: 30 younger women, 34 older women, 29 younger men and 34 older men. In addition, semi-structured interviewers were conducted with all four community coordinators (3 men and 1 woman) and five facilitators (2 men and 3 women). This exercise was one of a number conducted in the communities including scanning and baseline data collection activities. Lessons Learned: Community Education Component of the PPP

The analysis and conclusions in the report include a number of limitations.  The data was collected immediately after the end of the IGD process so there is likely a “halo” effect on what participants report as achievements. Moreover, the CEC is one of a number of initiatives conducted under the PPP program which aimed to improve maternal health, while also other programs are ongoing with similar aims. The methodology used does not allow for assessing attribution given these factors and, therefore, does not attempt identify CEC results beyond what participants claim.  Focus group discussions and interviews were conducted in Mende and Krio. Recordings of these were translated into English and transcripts were analysed by the author who was not present at the interviews and does not speak Mende or Krio. In cases where English colloquialism were unclear, these were verified for meaning and the original Mende and Krio transcripts reviewed as needed.

Achievements as Reported by Participants Appeal to the Community Participants spoke of a number of aspects of the initiative that appealed to them. One concerned the main theme “Let’s Talk” and the idea of promoting dialogue between family members including wives being able to talk to husbands, learning how to speak between elders and youth, parents and children. This concerned showing respect for elders as well as appreciating the younger generation and an overall appreciation for comparing the past and present and for what both have to offer. In particular, participants appreciated discussions concerning spousal relations such as women and men being more caring for each other, especially men taking more care when wives are pregnant and not abandoning them, the importance of monogamy and the need to delay marriage and stop early marriage, especially to promote girls education and maternal health. In particular, a main reason for practicing monogamy and family planning was that it helps to address poverty. Parenting and improved spousal relations were especially appealing as participants realized this can have a positive impact on their children’s, especially girls’, education, their taking responsibility and avoiding what were seen as harmful activities such as attending discos and watching pornography. Improved spousal relations was also related to improved maternal health. Better communication was linked to men taking more interest and care when women are pregnant which was seen as contributing to better maternal health from accessing ante natal and other health seeking behaviours. Participants said that they appreciated the focus on maternal health and how women should not die during pregnancy and child birth. They liked realizing the need to change practices, particularly from the ones practiced in the past. Talking about family planning and reducing the size of families was especially appealing. Relatedly, the focus on teenage pregnancy and the need for educating girls about teenage pregnancy, regulating schedules of discos and passing laws about boys, who impregnate girls, having to leave schools were cited as issues participants liked. As discussed in the next section, the focus on laws, while a seemingly common approach to social control, was problematic.

Lessons Learned: Community Education Component of the PPP

Awareness Raising and Behaviour Change What participants say stayed with them from their participation indicates some perceived shifts in thinking and behavior, which in many cases parallels what appealed to participants. The need to talk and communicate is a major theme for learning. This concerned talking across generations and within the community to teach people who are led astray, such as girls who get pregnant and drop out of school, and to stop following the old ways, particularly concerning maternal health practices. For example, these comments of what people claimed they learned are typical of the participants more generally. M: You too, is there anything that stayed with you? R: “Yes, is about those things of the past, we have to eradicate them. M: Why do you want it to be eradicated”. R: “Because in those when our wives get pregnant they mix concoction and gave it to them to drink. We have seen that it not good so we must eradicate it”. (FGD, Older man) They taught us how to talk to other people, and we compared the old generation to the young generation, what were the good and bad things they did, and also pregnant women should not be abandoned by their husbands for another woman. Then we should stop giving birth to plenty children, we should space them and a man should not married more than one wife it is not good for the family so that is what I like. (FGD, Young woman) Better communication also concerned children and parents communicating more openly and respectfully, particularly about teenage pregnancy and family planning, especially with girls. It particularly was referred to in relation to couples living in peace, having mutual respect and listening to each other, stop having so many children, bringing up children properly to stop teenage pregnancy and monogamy. Concerning the role of husbands, both women and men learned of the need for husbands to take care when their wives are pregnant, such as talking with her, supporting her and taking her to the clinic as well as showing overall more respect and assuming a greater role in the family. Two women report that they learned that men should consult with their wives more, “this programme has taught us that the men needs to consult his wife first before he makes any decision” (FGD, Young woman), though as describes below, this was not accepted by at least one male participant. For wives, women stated that they learned about having fewer children, the

importance of monogamy and living in peace as well as talking to and obeying their husbands. For example, as on older woman states in response to the question of what stayed with her from the IGD process, It is the same thing this woman said about peace between us and our husbands. You have to obey what your husband tells you so that you will be in peace and even if you bear children for him he will take good care of them, but if you are not in good relationship, and any of your child gets pregnant and wants to deliver, but there is a problem he will not even look at you. So there should be respect between the two of you. (FGD) In the case of according to a young woman, both men consulting with women and women being obedient were part of the promises:

Lessons Learned: Community Education Component of the PPP

We promised that men alone will no longer take decision alone. He should consult with the wife first and they both agree before they make any decision. We the women also promised the we will be obedient to our husbands so that there will be unity in the home. The men also promised that they will stop treating their wives bad, the will take good care of their wives, they will take her to the hospital when she is pregnant, and we also promised that girls will not get pregnant at an early age. Participants report change in how they communicate. Parents said they are not talking to children harshly and learned to speak with children and listen. Children reported that they listened to their elders more and learned how to communicate with them in a respectful way which seemed to overall allow for more and better communication. One youth reported that he is now listening to his family and has decided to return to school (FGD, Young man). Within the community, participants claim they are communicating better. They are taking a calmer approach, able to defuse tensions and potential conflicts and not allowing people to quarrel. They engage in more constructive communications by being more respectful. They realize they can and are teaching others. Participants claim they have more knowledge about maternal health such as the causes of maternal death and how practices of the old days are dangerous and how today there are clinics so people do not have to go to the bush to give birth. There is a common understanding of the need for pregnant women to take care and to be taken care of. They should be reporting pregnancy to the nurse and going to the clinic for check-ups and medicines. Women and men alike learned of family planning methods and were corrected in their misunderstandings from the past. The following example was echoed by a majority of respondents: Like before there was no hospital, so they drank herb water when they are pregnant. But now we go to hospital when we are pregnant, they give us drugs which we drink to allow the baby grows. Before the women did not have access to hospital, they drink herbs. (FGD, Young woman) For the most part, family planning was understood in terms of modern contraceptives (condoms, injections) and for which one needed advice from a health practitioner. There was one example when family planning was associated with abstinence: “Eh thank you Sir, the session that I liked best was when they sensitized us about this unprotected sex, or when you have not reached the stage to have sex (mami en daddy bisnes). That is the part I liked best and they advised us to refrain from sex until we reach the stage when we can do it peacefully” (FGD, Young man). Participants report change in maternal health seeking behaviours. They are going to the clinic, men are supporting pregnant women both at home, such as needing better food, and to go to the clinic. In particular, participants – young, older, women and men – state they better understand the need to prevent teenage pregnancy, both in term of health hazards to young women as well as the implications for a girls’ future in terms of her education and future in general. There is an acknowledgement of the responsibility of adults for their children (particularly the need for fathers as well as mothers to monitor and bring up their children) and the causes of teenage pregnancy (family disunity, dances and pornography). There is strong support for imposing penalties, as a deterrent, on boys who impregnate girls, which was often discussed as something they will do. In at least one case, this was manifested as a new law that the chief and IGD participants initiated (FGD, older man). In addition, one woman said that she won’t send her daughters to the Bondo society at such a young age, as Lessons Learned: Community Education Component of the PPP

she had in the past when she “was so small” (FGD, Older woman). Others reported taking more care at home and being more attentive of their children so they do not get caught up in activities that are understood as conducive to teenage pregnancy. Claims of teenage pregnancy reducing, however, are not credible such as the community coordinator’s observation. M: What changes do you think have taken place about this teenage pregnancy? R: “In the past we can see children less than 18 years of age coming to the hospital with their parents for checkups, when they check her it turns out to be pregnancy. But when we have started this training it has taken time now without seen such things”. M: Why did that change take place? R: “Because within this seven week of this training, it has started to reduce. Initially, the children were wayward but now they are beginning to calm down”.

Lessons Learned about External Interventions such as IGD The nature of the CEC is that it is an externally driven initiative, despite being based on participatory principles of drawing on community knowledge, facilitating reflection and engendering community ownership and initiative. Measures were taken to inculcate a community ownership, such as having community coordinators and following procedures to promote community buy-in (such as consulting with chiefs and other community decision makers). The implementation of this adaptation of the intergenerational dialogue used Sierra Leonean male and female trained facilitators4. The male facilitators were well known to the community as implementers of a NGO programme. Still, the initiative was seen as externally driven (IGD sponsors were sometimes referred to as “white men”5) in part from what community members are used to and what probably needs to happen in underserved and remote areas: external assistance is needed. This external-internal dynamic, however, poses a number of challenges. Internalizing the External Harrison (1997) speaks of the “hybridization of externally induced values” as a process of what happens at an individual level to ideas that are introduced: people interpret them within their own value-base and through their current world view. One such view is patriarchy where, for example, concerns for teenage pregnancy were sometimes seen as a problem of girls. As one respondent expresses her concern “what worry me are the girls who go to those dance with short skirts” (FGD, Older woman). Similarly, two young men (FGD, Young men) see girls as being responsible for teenage pregnancy, which is echoed by a number of others, mainly men. R1: “I said if a parent has a girl child let him control her, instead of leaving her to the streets. If there is a disco dance on film show tell your child to stay away from there or let her go in and sleep. Control her so that she will obey you and listen to you.”

Facilitators were trained for 5 days and supported on the job by the lead facilitator who attended and debriefed all sessions except 1. 5 It is unclear from where this term originated: what is does indicate is that at least some of the participants perceived the programme as being initiated from outside. Lessons Learned: Community Education Component of the PPP

R3: “ … I like all the sessions, but the one which said we should talk to our girl child about sex, did not go down well with us. If you start to talk about sex the girls will start to have sex. This is why teenage pregnancy is rampart now.” This is not to say that girls do not play a role in becoming pregnant and some participants certainly recognized that boys have a role as well. But in many cases, it was girls who are said to be needing to take responsibility and needing to be educated about contraceptives. One respondent suggests that this idea may have come from the CEC. As an older woman says “Yes, when this programme came, we meet and they told us we the women our faults that girls get pregnant. But we said we are not responsible because it is the responsibility of the husband to also look after the child, but they have left everything in our hands.” (FGD) Similarly, a number of participants want to stop pornography being shown because of how it badly influences women, without mentioning men. As a younger woman says (FGD) R: “Well what I want to say is that the film which they play, especially the blues film should not be allowed to be played” M: What do you call blues film? R: “It is responsible for the waywardness of the girls” Likewise, ideas about mutual respect among couples and listening to each other are often interpreted, by young and older women and men, as women obeying their husbands. As a young man says “If you want to take this programme elsewhere call all the town people to learn, there will be no problem, everybody will take control or obey his or her husband” (FGD). In one case, the idea promoted in the IGD session of the need for men to listen their wives was not liked. Similarly, taking wives to the clinic is interpreted as a way to keep wives in check and, in this case, to ensure she did go to the clinic. As an older man says They also told us that you have to follow your wife to the hospital to make sure that she attends clinic, because some of them they will tell you they want to go to the hospital, when you give them the money they will not go there. That is why when she returns from the clinic; ask her to give you the card for you to verify whether she really went to clinic. (FGD) Such cases are not examples of people not learning new ideas, but rather of how they integrated then with other ideas. For example, many understood the issue of maternal mortality and the need for good maternal health practices. But when understood from a lens of dominant gender division of labour, it is understood as women’s responsibility. As the community coordinator says, which both reinforced women’s need to follow men’s order and the fault of girls for getting pregnant, M: During the whole programme, what actually stayed with you? R: “What actually stayed with is the respect that should exist between the man and the woman”. M: And what is it? R: “For instance of a man tell his wife to do things to bring the children up she must comply. That is one thing that stayed in my mind. Apart from that, how to take care of our girl children, we must carefully look after our children so that they cannot not to get pregnant”. Lessons Learned: Community Education Component of the PPP

M: So why did that aspect stay with you? R: “Because if we did not listen to that there will be many deaths and I don’t want many deaths. When a child gets pregnant at an early age it will be difficult for her to deliver, she might lose her life. .so that is what I don’t like to be in a community”. In some cases, coordinators seem to have also have this idea as something they learned (“For instance of a man tell his wife to do things to bring the children up she must comply. That is one thing that stayed in my mind”, Community Coordinator), which is of concern as the message of women obeying their husbands may have been promoted by them. While greater communication between husbands and wives is welcome, as is the notion that men should be consulting with women, this sometimes reinforced men’s position and authority. For example, greater support for women during pregnancy was translated as men giving women money (“If you and your husband are in peace, he will give you money to go to the hospital. That is good for me” FGD, Older woman) not necessarily greater equity in decision making. A number of women also saw their role in better spousal relations as having sex with their husbands, during and after pregnancy, as a way of preventing him from having sex with others (“When you deliver after months, you start to have sex with your man so that he will not go out to other women, the woman will not go to the big house to sleep again, but sleep close to the man”. FGD, Older woman). There is a general understanding having sex with their pregnant or breastfeeding wives is alright and is necessary (“The man needs to have sex with her” FGD, Young woman) and even considered as a form of support. As an older man says, “when a woman is pregnant the husband should continue to have sex and romance her, that you should not snub her” (FGD). Similarly, while overall maternal health is understood as both a responsibility for women and men, it is sometimes still seen as an issue only for women. A number of participants said that their pledges of sharing what they learned meant that they would go to the clinic to educate women, hence possibly reinforcing the idea that maternal health is only the purview of women. For example an older woman says of their pledges “We agreed that on the day of clinic, we will go there as there will be many pregnant women and mothers. So we will talk to them, teach them about what we have learnt, we made all those promises” (FGD). On the other hand, sometimes, women are left out of the picture where the concern is about others but not necessarily girls as a focus. As this participant states, teenage pregnancy is a problem for the boy and her family, likely in terms of financial responsibility, but does not mention the girl or her well-being. M: Why did (teenage pregnancy) stay with you? R: “Because when you get pregnant while attending school may be the boy will not be able to responsible. So your parents will be responsible, and that is a problem” (FGD, Younger woman) Other socio norms were also drawn upon and integrated into people’s new understanding of needing to take action against teenage pregnancy. One concerns the use of by-laws to regulate and discourage teenage pregnancy. Fining boys and men if they impregnate girls is one of the most common community pledges as is removal of the responsible boy from school until the mother gives birth and the child can walk. Besides the issues of the efficacy of such laws as a deterrent (at least one respondent has little faith in such measures) and the fairness (one respondent feels that missing school only means further impoverishment of the boy), there is an issue of how empowering such measures are: they are more regressive than opportunity Lessons Learned: Community Education Component of the PPP

seeking. Moreover, this is another example of how ideas introduced by the IGD are understood from the perspective of dominant social relations and norms. The challenge for future initiative is how mitigating measures can be more consistent with ideas of gender equality: why can’t pregnant girls and young mothers as well as young father continue go to school except for the time she gives birth? Another norm that was reproduced is the need to respect elders within the context of the need to listen to youth and promote inter-generational dialogue. While there is overall support for these practices, sometimes underlying them is resistance and disagreement. In one case, while the community passed a decision to stop discos, at least one female disagrees with this. For her, they are one of the few opportunities in the community for recreation and she supports, as an alternative, shifting the time to earlier in the day and parents taking more responsibility. R: “No I did not agree, because dance is not what is responsible for pregnancy” M: So you want dance to restored? R: “Yes, because dance is not what is responsible for pregnancy. You will not stop a school going child not to go for dance. All you the parent have to do is to control your child not to go for dance at night” … M: why did you not agree? R: “Because you need to give chance to the child to enjoy. If you go to the dance at night and when you get tired, return home” (FGD, Younger woman) This is not surprising: intergenerational differences of recreation are common. Rather perhaps what these examples point to is that underlying ideas of greater communication and mutual respect are social hierarchies of gender and age that need to be attended to. How does IGD promote mutual respect and mutual listening where youth are encouraged to take responsibility and make decisions accordingly? There are some cases where participants seem to have got the wrong idea as older beliefs are integrated with newer ones. One concern an understanding that communities are being encouraged to abandon culture and tradition M: Can you throw light on why people should not just abolish culture like that so that I can understand you properly? R: “Like what my brother has just said, I just want to declare. When you talk about old time culture, during Christmas they celebrate by playing with mask devils, they dance around the town. But now, when you attempt those things our people shout at us, they said we must stop that. I am trying to say that we must not condemn culture. If you did not practice you culture, even if they call you to do anything you cannot be able to do it. So that is why culture is so important to us. I will talk more as the programme continues”. (FGD, Young man) In another related example, not only did a participant understand that they have to abandon older ways, but that they are in fact, when it came to family planning, effective. M: Which one was that? R: “When they told us that we must discard those olden days things; for instance the Shegbureh (musical instrument associated with the Bondo or Sande secret Societies in Sierra Leone), Bembe (fishing net), Kaar (a fishing net), leaves and all sort of things we brought it forward”. Lessons Learned: Community Education Component of the PPP

M: The one that is dealing with life path? R: “They asked us about the functions of all of them and we explained to them. For instance, in those days when a woman gets pregnant we do not go to the hospital we grained the leaves, mixed it into concoction and give it to her, we call it ‘Cololay’ (let the pregnancy grow), we also stuffed cowry shell with leaves and tie it round the waist of the baby believing that even if the woman gets sexual intercourse she cannot get pregnant, and that is true because it used to work. That was an interesting part in that session”. (FGD, Older man) What these above examples demonstrate is the complex process of changing beliefs, values and norms: it is not a matter of switching from one to another such as replacing a defective part. It is a process of hybridization of ideas that previously exist with those that are introduced. What this calls for is a methodology that is attentive to such processes which have implications for facilitation, monitoring and on-going support. Sustainability/Dependence With any external intervention, sustainability and creating dependence are always a concern. The CEC took measures to build local ownership by using participatory methods and strengthening community capacities to act. Still, a number of responses from participants suggest that community members depend on external sources for carrying the initiative forward. Part of the problem is what people are used to, which is a reasonable assumption; if they have received resources from external source before, they will expect them in future. This perspective of seeing external organisations as sources of support is also understandable given the levels of impoverishment. Still, the complication is that MRC, as the external agent introducing CEC, is also seen as a provider of other support, which is echoed by a number of people. One group (FGD, Older woman) wanted a well, another wanted help with stopping teenage pregnancy (FGD, older women) who also wanted the facilitators to write a proposal for a women’s project. This is in part to support one of their pledges (“We agreed that we should have a small project for women in this community”) but also to counter community accusations that IGD participants are only interested in the food provided during the sessions (discussed later). “What that woman is saying is true, we want project that will bring development. People have been laughing at us that we only go for that training because of food. So we want them to be ashamed of us, that is why we need a project”. Clearly the CEC is seen as external intervention, as an older woman comments indicate: We had 8 sessions, and after that we asked them if there is going to be any token, but the facilitator did say that the white man that brought this programme only provided food, not money. They even asked us if teacher or student who is suppose to pay the other, but we said the student should pay the teacher (they all laugh) so that is it” There is some evidence that the externality of the programme was exacerbated or perceived as such by facilitators. As a Young man states “Ya, those who came to train us at the end of the day, they told us that the Whiteman who owns the programme will one day pay a visit. So they advised us to embrace the programme” (FGD, Young man). A number of participants mention the need for additional support, for example medicines from MRC (“What we talked about was that MRC should help our Nurse with some medicines for this hospital”, FGD, older woman), communication materials to help them raise awareness of others such as pictures used in the sessions) and with monitoring. Lessons Learned: Community Education Component of the PPP

R2: “You should check on us every week to know if we are teaching the people”. M: They should every week? R2: “Not every week now, but after every two weeks”. M: what about you, what do you want to see different from what we did here? (long pause, and low tone) R3: “They should come here every week to monitor us”. M: Is that all you want us to do for this programme to go elsewhere? R3: “yes every week, so that we will not forget what we learnt”. M: What about you, do you want any change to happen? R4: “They should visit us frequently so that they will know when we gather that we have been teaching other people, and we are interested in the programme”. (FGD, Young women) While the last example is possibly illustrative of interest in following up from the IGD process, it also shows a reliance on external agents and, possibly, a confusion of the relationship between the community with MRC and KIT, as the comment of a young man illustrates (FGD). He sees his role as working on behalf of the organisations. M: Is there anything that you can suggest for us to do differently? R: “Just like my brother said anything you are doing, needs incentive. For this programme to hold, you need to see to our strains. You cannot keep us all day long without giving us anything to complement our effort. Is not the food that matters, we eat a lot. If you make us happy we are ready to work with you. I am talking for the Young Generation, so that is my take. Thank you Sir”.

Planning, Design and Communication The last quote is indicative of another major issue raised by participants in all communities: wanting to be provided an incentive to participate in the group and continue the work. This interest arose from a number of perspectives. First concerns the food provided during the meetings. While appreciated, this caused a number of problems. One is the communities’ perception of the provision of food and the rationale for the sessions. A number of participants mention how they were referred to as the “eating group” as this seemed to be the only reason they met, to eat. However, in some cases, when the community saw what the group had accomplished, after the community presentations at the end, community members were more understanding. M: who else has something to say? R: “What really changed my thinking was when they came with this programme to teach us, but people tell us we are going there for food “ M: They provoke you? R: “They provoke us that we only go there for food, so when we came and we acted the play and presented all what we learnt, they believed us, but if not for that they would not have believed us”. (FGD, older woman) Second is the difficult position that eating during the meetings put participants in when they returned home empty handed but well fed, as two participants explain: If you attend the workshop and return home with nothing, your wife will be expecting you have money so that you will buy some pepper, Maggie or salt, and you tell her

Lessons Learned: Community Education Component of the PPP

they did not give you any money, she will quarrel with you because she will be expecting you to have some money. (FGD, Young man) Yes like what my sister (Name) has said, I am very happy for what she said. You have seen that there are not enough people here because people provoke us, but in as much as we have accepted to undergo the training, we did our best, but you need to give us some incentive in other to hold our peace. In fact I don’t even know when I return if my husband will not quarrel with me when I go empty handed (FGD, Young woman) Similarly, provision of “soap money” is seen as a way of sharing the benefits of the project. An older man’s comment (FGD) is echoed by a number of others. “Before go and eat leaving our wives and children behind, we to be having it in cash so that when we return home we can share with our wives and children.” For others, it is seen as a way of compensating for their time, at least according to one facilitator, that would otherwise been spending farming if not participating in the project. R: The bone of contention was that they are eating while their family, wives and children are starving and hungry, where do I get money to feed them when I did not go to the farm. So we engage their entire day and cannot go to their farms. So we need to change that, but feeding is not the only thing to give them, we also need to give them some money to take home…(FGD) R: Well, it is not a bribe to me; we were embarrassed in every community that we went. They asked us, now that we have eaten what should we take to our children in other to eat for that day so that was very embarrassing for us”. M: So that was the expectations of the people? R: “Yes! That was the first expectation of the people. They even asked us; M: So that was the expectations of the people? R: “Yes! That was the first expectation of the people. They even asked us; now that you have trained us, which benefit do we stand to gain?” but we told them that their pregnant wives will not die again, their girl child will not get pregnant at teenage. But said that is not the benefit they want, they want money. They have seen in other programmes when they train people, they give them money. Third, it appears that the lack of cash incentive is one reason for people dropping out6, as a young man states: “Our people said promised that the best thing to do is, when they came and realized that there was no financial gain they withdrew from the programme. Most of our brothers are not here because there is no financial benefit in the programme” (FGD). This is also true for participants in one of the communities, as one states “So we gave our names, but people went there only two times and withdrew because they thought it was a waste of time as the rice in the farms were ready for harvest, but we said we want to see the benefit behind this training, and we still waiting to see the benefit” (FGD, Young woman). While not necessarily a condition for working, at least one coordinator feels that they should receive payment for their work. Fourth, giving cash is seen as an incentive that many participants and coordinators feel they need to follow-up from the sessions and share the information they received. A young man’s comments are repeated by a number of others

Several participants mentioned drop-outs but this contradicts claims that there was almost 100% attendance. It may be a case that dropping-out was related to attending the FGDs. Lessons Learned: Community Education Component of the PPP

M: Is there anything else that you would like us to do different in the other villages? R: “Yes, the thing which we would like you to do for us is that we like you to give us some financial support. If you do that we will be happy to do the work perfectly but if we are not getting it will dampen our spirit. So we are pleading that you give us the support”. (FGD, Young man) Moreover, providing financial incentive is seen as a key to successfully expanding the programme elsewhere. A young man’s comments is echoed in almost all FGD in all communities: According to my own experience, we who have gone through the training we have seen that it is a benefit for us. The only thing I am saying is that if we want to take this programme to another village, you must ensure that you provide incentives, when some people know that there is no financial gain behind it, I swear to my God, they will not take it seriously. Otherwise we have employ some plan to bring them on board. (FGD) Fifth, while a few claim they told that they would be paid or had expectations from what community members expected, which in itself created some complications, a major justification for being paid is that they understand that they are expected to pass on what they learned or, as described by a number of participants, to teach others which, in some cases as mentioned before, which is understood to be done on behalf of MRC. This was not the intent and, despite interviewers attempts to clarify that their question about recommendations for future activities was hypothetical, participants generally only understood the question in the context of a planned activity. For some, they feel that did not gain anything, which is sometimes contradicted by saying that they gained knowledge. But still, “gaining” seems to be understood in material terms. M: What is in your mind, that you would like to be changed or that can be different from what you have done here? R: “The only thing about this programme is that we have been informed that White people are going to come to visit us but you are our black brothers now that you are here, what we want to say is this, that it is not easy for a stupid man to convince a clever man, i.e. there has to be an incentive. We have been on this for over seven and we have not gained anything. So we need to have something encourage us. We would like that to be included in the programme”. (FGD, Older man) In this case, while a number of participants mention that they would have liked to have received certificates, the rationale for this seems unclear. Some linked the idea of receiving certificates as a way to legitimize their role of teaching others and is sometimes linked to receiving payment in order to be more effective. As a younger woman states, “Like we have gone through this programme and have decided to change for the better, we will continue to change and do more. But we need certificates, as for us Mende even if you learn something and you have paper they will not respect you, so we need certificates” (FGD). Not all participants feel that their passing on knowledge, however, is conditional upon receiving financial incentive. Some state that they are happy to continue working, regardless of receiving payment but would appreciate it. A older man’s comment is echoed by others. “I believe, we did not get any financial benefit from this training but what have gained in terms of good training that would benefit our homes is good.” (FGD). Similarly, a younger woman states Lessons Learned: Community Education Component of the PPP

The only thing they should do for us is that they should give some money to buy soap, because people are talking a lot about us who are on this programme, that we are only wasting our time but we still have faith in this programme as it has taught us a lot especially those teenage pregnancy cases. Some girls get pregnant while going to school but now we can prevent that by joining them on family planning, so she will continue her education very well.

Another planning issue is scheduling in terms of the amount of time participants spent in the IGD sessions, as mentioned above, as well as when they were conducted, particularly in regards to the time and year which was the dry season7. For example, a younger man states “Well what you should do, you cannot just come and take somebody and say let go out there, he too has a schedule. Like me, this is a dry season, I need to go and brush my Cocoa farm, we need to go and brush our palm oil farm. So if you have come to take us away, you have to give us transport or soap money so that at the end of the day we can be happy, then we can be able to convince others to follow us. So that is my own idea about that”. In the case of a young woman, the timing of the sessions made it prohibitive for people to participate. “So we gave our names, but people went there only two times and withdrew because they thought it was a waste of time as the rice in the farms were ready for harvest” (FGD). Related to scheduling, there are examples of the need to be more aware and sensitive of participants own schedules, for not doing so only reinforces the dominant role of the external agent and the recipient role of community participation. For example, “What I want to say is that you have to be time conscious, when coming; you should inform people on time. You couldn’t have met us in town, we all have to go to the bush. Next time when coming you have to inform us earlier”. (FGD, Older man) “Also in that 7th week, they told us they will be leaving but some other people will come after them after three months, so it was surprising to us to receive a letter tell us that you are going to be here today. But we did not disappoint you because we are serious about it”. (FGD, Older man)

Related to planning is the issue of onerous data collection and application of questionnaires8. As one facilitator notes “One of the things that were not detailed to me were the questionnaires attached to the IGD session. Those questionnaires gave us a hell lot of problem. Especially when we wanted to administer them, it took us a hell lot of time for them to answer those questions. So we need to focus more on the IGD sessions and set aside time for questionnaires, but if we combine the questionnaire to IGD sessions it wastes a lot of time”.

This differs from the lead facilitator who felt that the timing of the IGD was appropriate as it fit into the agriculture calendar. 8 The CEC undertook various community assessments in order to initially establish key issues concerned with maternal health and teenage pregnancy as well as a baseline of knowledge and understanding about these. Lessons Learned: Community Education Component of the PPP

Indeed, there seemed to have been numerous data collection activities that may be been better planned and streamlined. Dominant Ways of Knowing The IGD process predominantly assumes a learner-centred approach where facilitators are meant to encourage communication and reflection. Otherwise, knowledge and experience are supposed to come from participants, which is exchanged among participants as a basis for mutual and individual learning. This approach is based on an understanding of a particular way of knowing or epistemology, and of knowledge: knowledge does not come from the outside or from external agents. It is generated by the person, who has knowledge, where the facilitator’s role is to help the person reflect upon his/her experiences and generate new knowledge in part from being exposed to new and different ideas. This approach stands in contrast to how many people usually learn and the main approach to building knowledge: it comes from the outside that learners are filled with the assumption they do not have previous knowledge and/or that it is irrelevant or wrong. Interviews with participants, and coordinators in particular, however, reveal a different understanding of the approach used in IGD. For the most part, they understand their role is to teach others by passing on what they learned. This is particularly evident when participants in the FGD consistently are confused about the question about what should be changed if the project were to be taken to another town. All FGD participants understood that they were being asked to take the learnings elsewhere. M: “Is there no other way we can do things in another town different from the way you were taught here?” R: “Like we were forty in number when this programme started, but if they add fifteen to that number, we will be able to go to other towns and teach them what we have learnt about living in peace with our husband, taking good care of the children, encourage them to pay attention to education. Again we will talk to them on teenage pregnancy, and pregnant women going to the hospital. We will talk to them in other to follow in our footsteps, so that they will stop doing the bad things” (FGD, Older woman) Their role is seen as change agents but how they were to support change is perhaps unclear. Ideally, they would have facilitated discussion and reflection just as they had had done during the IGD. This approach was, however, made somewhat confusing as there is an element of conveying knowledge in the IGD process (such as in Session 5 when participants learned about maternal health and teenage pregnancy), which is a change in approach. Also, given the dominant teaching approach, that of teacher – as expert – filling students with knowledge, this is not surprising and also explains why some participants feel that a financial incentive is appropriate as are certificates: “If you take this programme to another town and you have a certificate to show them, they will mock at you and tell you words that will not go down well with you. That is why we want the certificates” (FGD, Older woman). In one case, resource persons

were not seen as credible; for example, when they had many children, the message of family planning was seen as hypocritical. As a young man states Well they came and thought us the area I didn’t like much was the advice that we should not give birth to many children, whiles most of them have given birth to their own children, they have 4 or 5 children but when they came they limited us to only 2 or 3 children. To me, that aspect is not fine because I have not given birth to my own children yet. (FGD)

Lessons Learned: Community Education Component of the PPP

The point is not that resource persons have to necessarily be models of behavior, but how participants are prepared to engage with their and othersâ&#x20AC;&#x2122; experiences, which is a skill that facilitators and coordinators need. Perhaps greater emphasis on facilitation and reflection of knowledge is required, although for people more familiar with rote and hierarchical ways of learning and knowing, this can be difficult.

Lessons Learned: Community Education Component of the PPP

Conclusions Overall, the topic, design and approach of the IGD seems to have had a positive effect of participants’ perceptions, according to participants, coordinators and facilitators alike. Participants claim changes in beliefs and behaviours concerning maternal health and teenage pregnancy. They claim they have more knowledge about maternal health such as the causes of maternal death and how practices of the old days are dangerous. The mixed-age and -gender compositions of community groups seems to have contributed to better communications, mutual understanding and learning across generations and genders. The opportunity to engage in a learning process should not be under-estimated, particularly given the socio-historical context of post-conflict rural Sierra Leone. Still, with any learning process, learners are not empty vessels (Freire, 1993) to be filled with knowledge. There is a process of internalizing the external (Long, 1992), which has proven to be a critical stage in transforming dominant socio-gender norms and beliefs. In particular, participants’ explanations of what they learned underscore the inter-relationship between gender norms and social rules that reproduce and maintain socio-gender relations. As a result, tackling of gender norms also concerns addressing dominant social relations, whether among old and young and those with authority and those without whether concerning chiefs or heads of households, that tend to be hierarchical. It also concerns taking into account dominant ways social order is maintained and assessing in what ways these maybe amicable to social change or can be subverted. Similarly, facilitators, coordinators and learners come with their own assumptions about what is knowledge, how it is generated and how one learns. For example, while the IGD sessions were not described as “training workshops”, that they were about learning meant that they were associated as such, in particular, and with formal teaching more generally. For example, when the IGD is understood as a “workshop”, expectations normally associated with such events, such as payments, certificates, teaching others, arise. This is understandable, given learning processes participants are likely familiar with and the interpretive processes, described above, that occur throughout the chain of actors – facilitators, coordinators, participants. This explains to some degree the discrepancy between what was intended and what was understood. It is difficult to say how some of unintended ideas arose: from facilitators? Coordinators? Participants? It is likely a combination and influence of all three.

Lessons Learned: Community Education Component of the PPP

Recommendations The above analysis, however, suggests a number of recommendations for future use of IGD to address beliefs and behaviours concerning maternal health and teenage pregnancy. 1. Content, Methodology and Facilitation a. Both content and approach should be more oriented to gender as a social relation not just gender as a social construction of roles. Such an emphasis will hopefully allow for an understanding of the relative value given to men and women by society and how this is both reinforced, challenged or negotiated based on relations of power. This will also require that facilitators as well as coordinators not only understand maternal health and teenage pregnancy from this perspective but that group analysis is facilitated from this viewpoint. b. As suggested by the lead facilitator, more in-depth training and mentoring of facilitators would help them not only be able to engage participants in reflective practice more but also in better understanding gender as a social relation and its relationship to maternal health and teenage pregnancy. In particular, facilitation of IGD, as well as other participatory processes, requires a rather high level of skill between getting across a particular idea without imposing the idea. It also requires a high level of self-awareness and reflection on part of the facilitators: they too are socialized and gendered persons with their own biases and agendas, whether explicit or implicit. They often hold and are perceived to hold positions of “authority”. As needed, work is needed with facilitators to uncover and better understand their own beliefs and social position, particularly as “outsiders”, often working from an international development context, holding higher positions within social hierarchy. This is especially relevant when facilitators are associated, whether intentionally or not, as/with a “donor” that generates assumptions and expectations from both the community and from the facilitators themselves. c. That participants drew upon pre-existing conceptions of change (to enforce and regulate) and strategies for change (fines and penalties) is understandable, despite some acknowledging that they are not always enforced. Efforts need to be made to understand the thinking behind these strategies (used just as threat?) , their conduciveness to support social transformation and promoting gender equality and how IGD processes can facilitate reflection of how change happens. For example, while pledges are supposed to be initiated by participants who then request community members’ support, it appears that in some cases, chiefs took part if not led this process. The problem is that they did not participate in the IGD processes which were very much concerned with empowering community members to take responsibility. That chiefs participated in decision making in the end undermines the aim of community and women’s empowerment. In future, perhaps chiefs need to participate more substantially in cases where they did not attend any or all the sessions. If this is not feasible or welcome, they should be integrated as part of the process so that they can support the wider aim of community empowerment, as possible. 2. Community Coordinators We probably underestimated the role community coordinators would assume or be expected to assume given community dynamics. They were supposed to be primarily concerned with logistics, a role they seemed to have undertaken well. At the same time, they were seen as resource persons, either by themselves and/or IGD Lessons Learned: Community Education Component of the PPP

participants, and the interface between the CEC and the communities. While their role could be limited to logistics, given dominant associations with learning, understandings of learning events, whether called “workshops” or not as well as the assumed social status associated with such a position, it is reasonable to expect there will be slippage in understanding of their remit. In this case, they need to be better prepared, which is related to how they are selected. a. Train group of coordinators and select best from pool b. Build knowledge and beliefs on gender and social norms, social relations of gender and facilitation skills with specific training for them c. Be more clear of role of community coordinators and support them accordingly. They should be in a position to engage community members d. Have two from each community, one man and one woman, so they can work together and support each other 3. IGD Processes a. As process of awareness raising, reflection and moblisation, the IGD process appears effective at promoting people to analysis their situation and take action. Perhaps where more attention is needed is in the thinking of actions. This phase is left to the participants but perhaps greater facilitation is needed to encourage participants to think through what they are committing to, why and what alternative plans can be made. The phase should be extended so as to provide greater reflection and facilitation concerning community commitments b. The provision of knowledge does not always translate into changed practice and beliefs. This was the impetus for the CEC, which came late in the PPP. In future, the knowledge-practice-beliefs relationships should be part of the original design and better integrated so they are mutually reinforcing. c. The IGD process already is quite demanding for community members and facilitators alike, but greater attention to empowering women and men to counter dominant gender norms may be of benefit. Such a session would fit well after the medical intervention to encourage reflection on how to act upon knowledge. According to the lead facilitator, the groups started with knowledge about SRH. The question is why people could or would not act upon this knowledge previously. The IGD partially has addressed this question but greater emphasis on the acting upon knowledge is likely needed. d. IGD processes need to take into local schedules and timetables in order to not overly burden participants. Still, and despite the recommended shortening of the process (see CEC Facilitators Guide, March 2013), the process does require a time commitment by participants. The provision of food was seen as one way to compensate participants’ contributions which, as described above, was also problematic as was the issue of not providing payments. A discussion of expectation upfront in the process may help manage expectations and allow for participants to make a fully-informed decision of whether they want or can participate. It appears from participants’ recollections that some were appointed to participate by chiefs and other community decision makers, which suggests that for some, their participation was not fully voluntary. Voluntary and informed participation needs to be ensured in future.

Lessons Learned: Community Education Component of the PPP

References Freire, P. (1993) Pedagogy of the oppressed, New York, Continuum Books. Harrison, E. (1997) Fish, Feminists and the FAO: Translating 'Gender' through Different Institutions in the Development Process. IN GOETZ, A.-M. (Ed.) Getting Institutions Right for Women in Development. New York, Zed Books. Herschderfer, K, de Koning, K. Mâ&#x20AC;&#x2122;balu Sam, E. Walker, P. Jalloh-Vos, H. and Detmar, S. (2011). Barriers and Promising Interventions for Improving Maternal and Newborn Health in Sierra Leone. Amsterdam, KIT Publishers. Koning de K., Jalloh-Vos H, A., Kok M., Jalloh A.M., Herschderfer K, 2013, Realities of teenage pregnancy. Amsterdam, KIT Publishers. Long, N. (1992) Introduction. IN LONG, N. & LONG, A. (Eds.) Battlefields of Knowledge: The interlocking of theory and practice in social research and development. London, Routledge.

Lessons Learned: Community Education Component of the PPP