Distributing material and convincing them all

Sewing a Healthy Future & Playing Safe

Project profile: This project was implemented by CARE Deutschland / CARE International (Cambodia) in partnership with Gender and Development for Cambodia (GAD/C). Sewing a Healthy Future (SHF), was first developed under the RHI Phase 1, to address low levels of SRH knowledge among young garment factory workers and to work towards increased utilization of youth-friendly health services by enhancing the capacities of Government, NGOs and the private sector. Playing Safe Project (PS) began under phase 2 of the EU/UNFPA funding in September 2003 in recognition of the need for a greater focus on young men as key agents in condom and sex negotiation.

Aware of the need for a greater focus on urban young men in Phnom Penh as key agents in SRH negotiation and decision making, PS used the social structure to encourage safe and responsible SRH practice and increase community / political support for ASRH interventions and policy. PS was implemented by CARE in partnership with GAD/C until December 2004 and began working with KYA in February 2005.

Empower young men enables to create positive social networks and address key topics including cultural stereotypes, sexual coercion, violence and gender awareness. The project also accessed young men in local hangouts during their leisure time – the time many engage in sexual activities. Activities included trainings, working with key sporting organizations to integrate SRH activities, innovative Peer based outreach in the development events at discos/nightclubs and of an evening drop-in facility where young men could socialize, listen to music, pick up IEC materials, buy condoms and access free counseling.

Strategy: CARE recognized the significant importance of contributing to the capacity of indigenous institutions to develop, implement and monitor programs. There was indeed a need to contribute to the capacity building needs of the MoSVY . CARE also realized that there was insufficient knowledge and risk awareness of SRH issues among youth: gender norms/relations and the impact of cultural/societal constraints on them remain unexamined within a SRH context; Despite high knowledge on STIs/HIV/AIDS transmission, A/Y are unable to change SRH behavior; Drug use is a growing problem among A/Y. In fact, CARE identified that this lack of knowledge was also due to an insufficient quantity /accessibility of information and services for A/Y, a lack of coherent advocacy in support for youth oriented SRH and an insufficient knowledge/understanding of A/Y culture within the Cambodian context with respect to SRH behavior (especially of men) and underlying factors leading to widespread sexual violence.

CARE tried to respond to ASRH priorities through working with local NGOs alongside the Government’s Ministries to develop the local capacity and provide in-line and formal training in SRH and project management. CARE’s strategy insisted on targeting primarily those who hold the power in sexual relationship (men) to safer SRH among both young men and their more vulnerable female partners and on developing a comprehensive life skills curriculum (especially for young men) through participatory methods to provide graduates with SRH knowledge and decision making /negotiation skills. CARE undertook operational research to examine the issues surrounding young men’s experience to understand key SRH choices within Cambodia and provide direction for future initiatives (4 reports were produced). To reach a wider group, CARE insisted on using peer approach through outreach/in-reach strategies and created non–threatening environments such as a youth friendly safe spaces where A/Y could learn/discuss on SRH and access condoms. CARE also developed a peer to peer referral system enabling youth to access services such as VCCT and STI treatment. The development of support at all levels of community through engaging gatekeepers in project activities and providing them with training and ASRH messages was also a key component of CARE’s strategy. The utilization of a co-implementation strategy (CARE+GAD/C) allowed partners to gain proficiency in the delivery of ASRH services and management.

Outputs: 1) Increased political and community support for ASRH interventions: Community members were engaged in all aspects of the project activities: 72 gatekeepers (parents, teachers and community leaders) were provided with specifically designed ASRH training; PS events (project opening party, parent/children discussions, health promotion activities, celebrations) addressed concerns about the ‘obscene’ nature of SRH interventions; PS contributed to build an official level for ASRH interventions through partnership with the MDoEYS (for SRH focused football events in schools), and with the MoSVY (for Global Fund supporting SRH activities in garment factories). ASRH support was further demonstrated through the attendance of senior government figures (Directors, member of Royal Family…) to events, and through government’s commitment to integrate HIV/AIDS education into the revised national curriculum and provide training to teachers.

2) Favorable attitudes and increased knowledge of SRH issues and awareness of risks among target group: The PS life skills curriculum provided training on SRH, STIs, HIV/AIDS issues and on gender and consent on a participatory approach giving graduates not only technical knowledge but also tools to apply it; The 544 trained peer educators disseminated IEC / BCC messages and contacted more than 98,000 A/Y (out of which 74,408 were young men) in Phnom Penh area through various project activities; A key component was the outreach van which enabled A/Y to access SRH information and advice in a non-threatening and relatively anonymous atmosphere as opposed to clinical services, and met youth when and where they choose to spend their leisure time. Peer educators demonstrated some changes in understanding gender/human rights and the concept of consent revealing that A/Y tend to make some different choices relating to SRH behavior and decision making.

3) Increased access to quality youth orientated SRH services: Access to peer educators grew over the project period with a vast majority of second round respondents able to either identify PS by name or contact them. A large number of A/Y benefited from SRH information / commodities through outreach /in-reach activities, especially through the sale of “safe” soft drinks (with condom as a gift) which inhibited impact of shame /embarrassment to access condoms; Graduates of PS life skills curriculum perceived a decrease of barriers in accessing contraception after training; PS provided free counseling in youth centers and via mobile phone (non-clinical based source of information and advise) and established a formal peer referral network that provided formalized links to 17 SRH services providers throughout Phnom Penh including NGOs, Government and private clinics and health centers. This network resulted in the training of 240 specialized referral peers and in the production of referral handbooks containing addresses and information about partner services.

4) Enhanced technical, planning and managerial capacity for local provision of youth friendly SRH services: CARE provided a combination of technical SRH and project management training to 2 local NGOs (GAD/C and KYA) over the project’s life, contributing to their ability to provide quality SRH in the future; PS built the base level skills sets of MoEYS and MoSVY staff in responding to ASRH needs; Youth was involved in the development, planning, implementation and monitoring of the activities thus ensuring youth friendly status of the project and peer educators’ contribution to the sustained provision of SRH services. The key outcome of this strategy was the establishment of a new local NGO, People Health Development (PHD) by a group of peer educators in 2005. CARE provided mentoring, technical support, proposal development and report writing skills to PHD, handed over some low cost project activities and developed a sustainability strategy to support PHD’s continued growth and function. During the project PS linked CARE staff, partner staff and volunteers with 344 SRH /technical trainings and professional development opportunities.

5) Improved understanding of critical ASRH issues in Cambodia: PS sought to identify and understand the constraints, ways and context in which young men make their decisions regarding SRH and therefore produced several research reports to provide directions for further interventions: PS produced 2 research reports to gain additional insight into the issue of bauk with findings disseminated in a workshop held in 2004 attended by representatives from government, civil society and the NGO community; At the final stage of the project PS sought to reexamine the ASRH context in Phnom Penh and the changes across time: A PER report was produced to understand critical young men SRH issues in Cambodia and to provide insight into the impact of PS, focusing on the utility of peer educators and outreach strategies as designed in the project. A second study into the impact of PS on both peer educators and the wider group was produced using the MSC technique and sought to examine “significant” impacts of the project as defined by stakeholders (Under review for publication).

Lessons learned: Gender: The project research suggested that failure by the target group to adopt safe and responsible sexual practices is an issue of attitudes rather than of knowledge. Including young women in the projects encouraged males to discuss SRH issues with them, increased understanding of the gender impact of sexual behavior and respect for women’s rights, to constrain young men in their capacity to make safe and responsible choices. By actively acknowledging the socio-cultural / gender stereotypes, PS stepped away from the typical female centered approach to SRH and sought to address issues of power and choices.

The value of the outreach van in particular as a non-clinic based source of information should be considered. Routine monitoring identified that 2000 young people have been referred to partner clinics and a total of 1476 completed referrals have been reported through the van outreach activity. Peer educators were responsible for the implementation of the van activities and the successful soft drink strategy through which condoms were provided.

Peer approach and the project impact: Structured outreach activities not only increased the cascade effect of the peer education model (compared to talk approach) but also allowed closer support of peers by project staff. These activities and health promotion events accounted for the majority of peer to peer contacts within the project and formed the core strength of interventions. However, findings from the PER study raised questions on the efficacy of peer based approach for dealing with issues of social change: despite evidence of the project impact on HIV/AIDS knowledge, access to services, condom use and drugs, there were no evidence of change in gender attitudes or understanding of human rights amongst the wider target group. Future SRH intervention addressing these concepts should focus on intensive and repeated interactions with members of the target group for additional changes.

Partnerships/linkages are important: Young people involvement allowed them to own and contribute to the development of the project activities and to strengthen the outcomes. Involvement of gatekeepers in SRH training and the MSC study demonstrated the potential within the Cambodian context for young people and gatekeepers to work together to find solutions for improving ASRH. Working with the Department of Education through the placement of liaison staff with the project was effective in facilitating a strong relationship.

Use of popular culture and sport was an effective way to attract youth to be involved in SRH activities. Playing Safe involved local celebrities and pop stars in public health promotion and special event celebrations whenever possible, recruiting them as PS ambassadors. Combining SRH with sport encouraged youth (particularly males) involvement in project activities and enabled PS to access youth in schools.

Partner Profile: Care's mission is to serve individuals and families in the poorest communities of the world. Drawing strength from global diversity, resources and experience, Care promotes innovative solutions and are advocates for global responsibility. Over the years, CARE Cambodia has shifted its focus from short-term but vital relief operations to long-term development programmes, helping poor communities improve their standard of living. In Cambodia, CARE raises awareness about HIV and AIDS among commercial sex workers by training peer educators, who teach others within their profession about the disease and how to protect themselves against infection. Under the RHIYA, Care Cambodia focused on urban young men in Phnom Penh as key agents in SRH negotiation and decision making. Through the project “Playing Safe”, Care used the social structure to encourage safe and responsible SRH practice and increase community and political support for ASRH interventions and policies.

Contact: Care Cambodia Street: 352, #52 Phnom Penh Cambodia, Tel/Fax: +855 23 215 267