IVORY COAST LITERATURE REVIEW

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Cote D’Ivoire: Childspacing Information, Education and Communication Needs Assessment, Prepared by Opiah Mensah Kumah, JHU/PCS , June 1989

Introduction

Although this report is dated (1989) and focuses primarily on child spacing, it provides a comprehensive historical and socio-political overview of Cote D’Ivoire as it relates to population and family planning. Overviews of the service delivery infrastructure and resources, IEC infrastructure and resources, IEC training resources, research and evaluation resources and international donor community interests and activities are set forth in a clear and accessible format. Although progress has certainly taken place since 1989, this report represents a good starting point on which to base further knowledge. A copy of important sections of this report is included with this review. A brief overview is included here.

Immigration

International migration is an important contributor to population growth in Cote d’Ivoire. An estimated one percent of the four percent annual population growth is accounted for by immigration. Current estimates put the immigrant population at over 2 million or about 23% of the population. It is largely composed of nationals of neighboring West African states. (See Regional Background section for a more detailed description of immigration in West Africa).

Service Delivery

Ministry of Health and Population and other GOCI health delivery systems: The government health care delivery system has two basic components, a fixed site component and an outreach component. The fixed site component comprises a three-tier system with (1) a cluster of three teaching and research hospitals and seven regional hospitals at the top of the hierarchy; (2) health centers which offer both curative and preventive services and where services are ‘partitioned,’such as into maternal and child health services or maternity clinics, at the intermediate level and; (3) health delivery offered through the Rural Health Sector in rural communities.

Private Medical and Paramedical Service Providers: Some 176 private medical and 415 paramedical practitioners operated under license in Cote d’ Ivoire. Private medical and paramedical practice is strictly regulated by government as well as professional watchdog bodies.

The Association Ivoirienne pour le Bien-Etre Familial (AIBEF): AIBEF was founded in 1979 and became an affiliate of the IPPF several years later. It is well established as the prime child spacing organization in Cote d’Ivoire. Today (1989), AIBEF’s service delivery network includes two clinics in Abidjan, and three regional branches in Korogho and Boundiali in the north and Bouake in the central region.

Non-governmental Organization (NGO) Service Providers: Three types of NGO’s exist: churches, indigenous non-profit organizations and international non-profits based in Cote d’Ivoire. Indigenous non-profits include the Association Ivoirienne de Femmes, N’Daya International, and l’Association pour la Promotion de la Vie Familial which promotes natural family planning. International NGO’s which promote child spacing include the Institute of Cultural Affairs.

Pharmacies: A 1986 study indicates that 175 pharmacies and 70 drug depots in smaller towns freely sell contraceptives. About half of all pharmacies are in Abidjan but there is at least one pharmacy in each town with a population of 5,000 or more. The study estimates that 45% of the population has access to a pharmacy.

IEC Infrastructure and Resources

Radio: The radio is the most important mass medium in Cote d’Ivoire. (See Country Demographic Sheets for current estimates on the number of radios in country). A 1987 study clearly established that Ivoirians of all socio-economic classes listen to Ivoirian radio significantly more than to any other (foreign) stations. Ivoirian radio has tow broadcasting stations based in Abidjan and Bouake.

Television: The distribution of television sets shows a clear urban bias and is probably the most important medium in the urban areas in terms of influence on attitudes and behavior. Ivoirian television, like the radio, is owned and controlled by the government through the Ministry of Information. Even more so than radio, program production and dissemination is centralized in Abidjan.

The Press: The indigenous press in Cote d’Ivoire comprises two major daily newspapers, two major weeklies, and several more or less specialized magazines. The two daily papers are: Fraternite Matin (circulation: 60,000) and Ivoire Soir (50,000).

Agence Ivoirienne de Presse (AIP): The AIP plays a crucial gatekeeping role in news gathering and dissemination in Cote d’Ivoire. The agency serves as a clearinghouse for all foreign news coming into the country. The AIP edits all incoming news and distributes it to some 20 subscribers, including local media houses as well as foreign correspondents based in the country.

Cinema: The cinema is essentially an urban medium. The 49 registered cinemas cited by Ivoire Media in their rate card are located in 24 of the largest towns.

Video Cassettes: Video cassettes have become an important form of home entertainment in Abidjan and the larger cities among the middle and upper classes. So far they have not been considered by the advertising industry but it is a medium to be studied for its mass communication potential.

Outdoor Advertising Media: The outdoor advertising media is well organized and highly regulated. Two types of outdoor media may be distinguished: static billboards or posters, and mobile signs.

Advertising: Cote d’Ivoire has a modern advertising sector built around several advertising agencies, advertising production houses and media contractors. There are about a dozen full service advertising agencies, all based in Abidjan.

Traditional: Traditional Ivorian culture is rich in music and drama and although with the advent of modern communication has diminished the importance of traditional media, their use is still widespread especially in rural areas. In the past decade the Ministry of Culture and the Institut National des Arts have taken the lead in promoting traditional arts for communication purposes.

IEC Training Resources

Cote d’Ivoire has a number of higher training institutions which can offer facilities and professional resources for child spacing IEC training: (1) The University of Abidjan (2) the Ecole Nationale Superieure des Sciences Economiques Appliquees which provides training and research in population demography with the support of UNFPA (3) Institut National des Arts (4) Institut de Linguistique Appliquee which is interested in adult literacy programs and research (5) Institut National de Sante Publique.

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Ivory Coast: Diagnosing Quality of Care Through a Management Information System, Africa Operations Research and Technical Assistance Project, The Population Council, January 1993

Introduction

The Ivory Coast’s IPPF affiliate, AIBEF, has begun a service expansion program built around high-volume family planning clinics in the private sector, a limited number of multi service MCH/FP public-sector clinics, and community based distribution (CBD) activities. Quality of care issues are a priority concern in this new program. The management information system (MIS) developed by AIBEF is a fundamental building block for the rapid changing family planning program in the Ivory Coast.

The MIS relies on two data sources: a clinic consultation card that is filled out for each new acceptor and updated during each subsequent visit, and monthly service statistics reports from each clinic. In April 1992, a sample of 1,000 new acceptors was randomly drawn from the consultation cards in the 10 clinics that had begun using the new card the previous October. These clients’ experiences on the quality of care indicators were abstracted from the consultation cards and an analysis of the data was performed.

Information received

Pertinent findings from the MIS in Cote D’Ivoire indicate that:

*Twenty-seven percent of AIBEF’s clients report they have lost at least one child

*Forty-five percent report at least one miscarriage or abortion

*AIBEF clients have an average of three living children

*Ninety-eight percent of clients report that their last child is alive

*Forty-one percent of family planning clients were breast-feeding at the time of their first visit

Choice of methods

Results from the panel study indicated that there was no clear association between a client’s reproductive intentions and the contraceptive method provided, apart from women who stated that they did not desire any more children. The Ivorian family planning program is a one-method program, where approximately two-thirds of all clients receive oral contraceptives. The distribution of different types of oral contraceptives is skewed, inappropriately so for women who are breast-feeding (45% of whom received an oral contraceptive that is contraindicated for them.)

Overall, a large proportion of AIBEF clients abandon services within a short period of time. Sixty-three percent of the clients who begin using an oral contraceptive stop coming to the same clinic for services after six months. The dropout rate is mediated somewhat by the observation that among clients who fail to return for services, 39% stated that they wanted to wait only a short time before becoming pregnant again.

Strategies recommended

The recommendations offered by this report include instituting guidelines for staff concerning breast-feeding women regarding their use of contraceptives, instituting guidelines for counseling regarding side-effects of contraceptives and their treatment, and increasing CBD programs.

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Trip Report: Monitoring and Technical Assistance Visit, Cote D’Ivoire, Prepared by Opiah Mensah Kumah, JHU/PCS, August 1991.

Introduction

Preliminary results from data collection and analysis activities conducted by the University of Abidjan’s Center for Communication Training and Research (CERCOM) as part of the North Central Region Family Planning Promotion Project in Bouake were included in a trip report prepared by the Deputy Chief of the Africa Division at JHU/PCS. The trip report however does not provide the methodology for the data collected.

Findings

Women’s knowledge and use of modern family planning methods

The results indicated a relatively low awareness and utilization of modern methods among the women clients of health centers and social centers. Only 59.9% could spontaneously identify one modern method, 37% reported having used a contraceptive, and 22.2% reported current usage. The results also indicated a substantial unmet need among the women for family planning information and services. Among non-users, 57.4% have felt the need to prevent a pregnancy in the past, and 37.7% cited lack of information as their reason for non-use.

Youths’ knowledge and use of modern family planning methods and knowledge of STDs

The results showed that school going youth, in particular those aged over 17, are more knowledgeable about contraception and practiced it more than their elders. Over 72% could cite at least one modern method spontaneously, and 62% could cite at least two. Some 39% reported current use of contraceptives, compared to 22% for the older women. The youth were also highly aware of sexually transmitted diseases (STD’s), with nearly 96% citing gonorrhea and 79% citing syphilis spontaneously.

Youths’ level of sexual experience and attitudes toward pregnancy

The youth also proved to be sexually active. The vast majority have had a sexual experience (59% of those aged 14 to 17 and 91% of those aged 17 to 21), and 57% were sexually active at the time of the survey. Yet the youth remained naive about the consequences of sex. Although 28% of the girls had ever become pregnant and 20% of the boys said they had caused a pregnancy, 46% still believed they run no risk of an unwanted pregnancy. Another significant finding was the lack of responsibility/blame assigned to male partners of young women. The youth of both sexes place the responsibility largely on girls themselves (31%) or their parents (27%). Only 13% hold male partners responsible.

Women’s sources of information about family planning

For both the women and youth the most common source of information about contraception is their friends. Both groups would, however, prefer other sources. The women would prefer information from health or social workers and the radio.

Youths’ preferred sources of information

The students would prefer information from their classes, print materials, lectures and symposia, and mass media, particularly radio, video and posters.

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Sociocultural Aspects of AIDS in an Urban Peripheral Area of Abidjan (Cote d’Ivoire), S.Yelibi et al., AIDS Care, Vol.5, No.2, 1993

Introduction

This study aimed to gain a better understanding of the social dynamics-migration, urbanization, the status of women, education-related to AIDS in an urban peripheral area of Abidjan. Structured interviews were administered to 420 people, selected through cluster random sampling. Focus groups and semi-structured interviews were performed with key-informants. The results show that 26.9% of the interviewees are foreigners and 40% of all people interviewed participate in ethnic associations. Knowledge of AIDS is associated with age, gender, educational level and purchasing power. Those who are generally better informed about AIDS are: younger people; people with a higher education; and wealthier people. Men respond correctly to questions more frequently than women. French, the chosen language of the education campaigns, is not understood by 18% of the immigrants, and when considering only immigrant women, the figure increases to 38%. Particular attention should be paid to the design of health education messages and strategies for specific groups, such as non-educated people, women and immigrants. Care must also be taken to match the language used to the target population. Ethnic associations constitute an important starting point, particularly in relation to their use by immigrants, and these should be involved in educational programs.

Results

Knowledge about AIDS

-All people in the sample had heard about AIDS

-Sexual transmissionn is acknowledged by 93.8% of the interviewed people

-Concept of of seropositivity understood by only 62.6%

-Non-western explanation of AIDS transmission by witchcraft is widespread especially among adults (35-49)

-51.4% believe that AIDS can be spread by misquitoes

-40.7% believe it is possible to get AIDS "by giving blood at the hospital."

-Those who are better informed about AIDS are: younger, people with a higher education and relatively wealthier

-Men provide more correct answers than women

-Immigrants provide less correct answers than Ivorians (difference is related to immigrants lower educational level and lower levels of French language)

Perceptions of the extent of AIDS and attitudes towards it

-34% thought that AIDS is a problem only among certain groups (such as prostitutes or ‘sexual wanderers’)

-15.5% believe that AIDS can be cured

-24.3% are convinced that other diseases such as cholera, meningitis and tuberculosis are more serious than AIDS

-Women essentially relate the risk of AIDS to ‘sexual wanderers’, while men relate it to prostiutes

-50% of those interviewed blame the sick person for having AIDS while the other half blame (in decreasing numbers) God, the sexual partner, society or no one

-66.9% believe that AIDS patients should be isolated from society

AIDS and preventive behavior

-Although 7.6% of interviewees have never heard of a condom, its use in the prevention of AIDS is recognized by 75.7%

-Regarding the utilization of condoms, it must be stressed that 64.3% have never used one

-The most mentioned source of condom supply is the pharmacy (49%), partner or friends (33.1%), health centers (9.9%) and markets and supermarkets (8%)

-Younger-age groups (15-34) use condoms more than the older ones (35-49)

-Nearly all men agree that the condom reduces sexual pleasure and most women affirm that sexual intercourse is no longer natural

-Fidelity to one sexual partner as a preventive action is recognized by 75% of the interviewed people, while 17.1% of them do not believe it and 7.9% don’t know

-Women believe in fidelity less than men (66% vs 84%) because of mens’ infidelity

Participation in associations

In order to study the participation of the sample in social groups and/or associations, the following have been taken into consideration: religious groups, youth/women’s associations and ethnic associations. Regarding ethnic groups, a distinction should be made between nationals living in Abidjan who come from rural areas, and foreigners. Focus groups findings reveal that nationals use these organizations to keep in contact with their villages of origin. They meet and discuss village problems, and respond by finding solutions for them. Instead, immigrants join ethnic associations because they offer a mutually supportive environment, and provide help with finding accomodation, job, and social support. All associations have leaders that are responsible for representing their members to the commune’s administrative authorities.

-Of those interviewed, 39.5% belong to an ethnic group

-Participation in youth.womens associations and in religious groups was 17.4% and 16% respectively (religious group participation does not refer to church attendance, but to taking part in meetings, activities and educational programmes)

-women participate less than men in ethnic associations and foreigners participate in ethnic groups (40.7%) about the same as Ivorians (39%)

Discussion

Misunderstandings

The notions of transmission ‘by misquitoes’ and ‘by giving blood’ may be considered as resulting from the misunderstanding of mass information campaigns. The idea of transmission "by giving blood at the hospital" can be the consequence of misinterpreting the concept of blood transmission and, thuse,once the threshold has been crossed, andy act involving the presence of blood-including injections for blood tests-can become a reasonable fear for rejection. All messages concerning the concepts of blood transmission should be rethought and replaced.

Religious groups

It would be advisable to involve the Muslims and religious groups in the campaigns that promote public awareness, because of the capacity of religion to motivate people and to mobilize large sectors of society.

Attitudes and perceptions of the problem

The urban population’s perception of the AIDS problem is at the very heart of the societal attitude shown towards it and, in turn, the strategies to be developed in order to solve or to limit it. The results confirm the hypothesis that the risk of AIDS is not yet perceived in its full severity and magnitude. The impression is that people do not feel personally involved: the ‘logic of the scapegoat’ is the norm, while the responsibility is always with ‘the others’.

Preventive behaviours

Even though some other structural and economic factors can help to explain the small usage of condoms in Abidjan, the authors are convinced that the cultural acceptability of the condom is crucial and that this should be considered in the development of programs for the promotion of its use.The authors make the following points:

-It is not advisable to ‘over-medicalize’ this prevention method but it would be useful to give it a certain exposure

-Both women and men widely report is that condoms intervene in the intimate relationship between two human beings and create a context of mutual distrust

-Women do not believe in sexual fidelity as a preventive measure as it is out of their control

Recommendations

1. Present IEC campaigns must be improved by adjusting their content to the sociocultural context, diversifying the strategies and integrating them into the social network of the city.

2. When formulating the message content, special attention should be given to the education level of the different population strata as well as to the traditional values that are still found in the urban context.

3. Particular attention should be given to groups such as uneducated young people, women and immigrants.

4. Young people between 15-24 should be especially targeted for the prevention of sexual transmission of AIDS.

5 The ethnic associations should be involved in educational programs. Ethnic and youth associations constitute an important starting point, particularly for immigrants.

6. Illiterate young people can only be reached through innovative approaches that look to newer channels for social action. To this end, the ‘commune’ can play an important role in the development of youth associations and social services

7. Comprehensive information should also be given to the population in order to correct certain ‘misunderstandings’ or ‘misinterpretations’. The concept of transmission "by giving blood to the hospital" could dangerously increase people’s mistrust towards health personnel and endanger national campaigns promoting the voluntary donation of blood. The concept of ‘seropositivity’ or ‘carrier’ should be made clear.

8. It is necessary to diversify communciation channels according to the target groups and to integrate IEC campaigns into the existing social networks.

 

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The Perception of AIDS in the Bete and Baoule of the Ivory Coast, Andrea Caprara et al., Soc Sci. Med. Vol.36, No.9, pp.1229-1235, 1993

Introduction

The purpose of this study was to gain a better understanding of the socio-cultural aspects of transmissible diseases, in particular AIDS perception, among the two major Ivorian ethnic groups, the Bete and Baoule, in order to implement more suitable educational programs for both men, women and youth. The methods used consist of structured interviews to obtain quantitative findings on knowledge and practices, and focus groups and semi-structured interviews with key-informants for the collection of qualitative data. This is an excellent article not only in terms of the research results but also as general background reading on Cote D’Ivoire’s two largest ethnic groups as well as the distinct ways African societies have for interpreting the causes of illness. It is included along with this review.

The Bete, with a population of about 600,000 belong to the larger group Krou, while the Baoule, with a population of about 1,000,000, pertain to the Akan.

Interpretations according to traditional ways of thinking are widespread among both the Bete and Baoule. Urinating where an AIDS patient has urinated and sorcery attacks are considered possible ways of transmitting AIDS according to traditional categories of pure-impure and supernatural powers intervention. Educational level is the factor which most influences a person’s knowledge of AIDS and prevention methods through western categories. Education as well as a better knowledge of the disease appear to be associated with an attitude that favors isolating the patient. The content of health education messages on AIDS, in the rural environment, cannot be separated from the Betes or Baoules conceptions of transmissible diseases.

Findings

Awareness of AIDS and its lethality

Ninety-five percent of both ethnic groups have heard about AIDS and 52% are aware that no treatment is available. Better knowledge is linked to being male, younger, more educated and having a higher income. Among the Bete, better knowledge is related to a higher level of education, income and age. Among the Baoule, it is largely the educational level that influences knowledge. A high percentage of both populations interviewed has correct information concerning means of transmission and the lethality of AIDS although only 5.8% of both groups were able to suggest a micro-organism as the cause of the disease and those who responded correctly were highly educated.

Beliefs about AIDS transmission

Interpretations of traditional ways of thinking are widespread among the Bete and Baoule: 20% of each group believe in transmission through witchcraft, 52% through the use of public toilets. Thirty-three percent of the Bete see AIDS as a traditionally known disease called Bagoumele. This disease is perceived mainly as a sexually transmitted disease and has such symptoms as chronic diarrhea. The identification of AIDS with curable Bagoumele among the Bete is not present among the Baoule and could lead to an underestimate of the seriousness of AIDS.

Attitudes towards AIDS and caring for the AIDS patient

Sexually transmitted diseases are perceived as shameful and stigmatized by the Bete and Baoule. Several diseases require that the sick person by isolated to protect the community but at the same time the individual is considered contagious, a sinner, a victim of sorcery or a sorcerer himself. In both groups, higher education is associated with an attitude of blaming the sick person for contracting the disease and supports the need to isolate the patient. However, most people tend to think the family should take care of the sick person rather than the hospital or health center (52% vs 43%).

Perception of risk

While a majority of both groups would like to know whether they have been infected by HIV, the Bete seem to perceive themselves as being at risk more than the Baoule. Sex, age, education, income and religion do not influence this perception. A majority of younger people in both groups do not consider themselves at risk. To the question on whether they changed their behavior after learning about AIDS, 59% deny any change.

Beliefs about prevention

Misperception of possible prevention by washing after intercourse is more widely spread among the Baoule (20%). A minority believes in protection by sorcerers. Condoms are known by about 50% (66% Bete, 33% Baoule) among these only 57% of the Bete and 34% of the Baoule see them as a means of preventing AIDS. Forty-three% of the Bete and 28% of the Baoule affirm having used condoms but only 11% and 6% use condoms frequently and these are almost exclusively males. Higher education and younger age are associated with a better knowledge of condom function. Forty-five percent of the people perceive condoms as means to prevent sexually transmitted diseases and pregnancies.

When asked what behaviors should change, reduction of sexual partners is mentioned as a preventive practice (34%), fidelity to one partner (29%) and use of condoms (10%).

Sources of information

Concerning resources of information perceived as the most effective, it is interesting to note that village assemblies are mentioned by Bete men, while Bete women express preference for a more personal approach: this is probably due to their subordinate position within the assemblies. A similar gap is not seen among the Baoule.

The radio seems to be the main source of information on AIDS, followed by TV, neighbors and friends; only a small percentage of interviewees indicate other sources such as newspapers, relatives, health centers, churches or mosques and school. There are no major ethnic differences in the answers. People report listening to the radio broadcasts most frequently between 6:00-8:00 in the morning and 16:00-20:00 in the evening.

Being male, having a better education and a higher economic status are the factors associated with listening to radio broadcasts. Males and younger people are more likely to read newspapers. Television broadcasts are watched by a substantial number of interviewees, albeit irregularly. The Baoule watch television far more than the Bete (65% vs 29.9%) especially those who are younger and have higher incomes. Educational status appears not to affect television watching. Television is generally watched outside the persons own house.

Respondents’ suggestions regarding the most appropriate means for an education campaign include the village assembly (34%), radio (28%), and television (17%) while a few mention health centers (6%) and journals (5%). Limited coverage of peripheral health care and the absence of primary health operators may explain the lack of consideration expressed by the population towards health centers as sites for AIDS prevention activities. Illiteracy levels are too high to evaluate the effectiveness of written messages. Radio and TV spots are constrained by the limited availability of sets. Not many have the opportunity to listen to broadcasts and still fewer understand French-most listen to programmes only when broadcasted in local languages.

Recommendations

The organization of information dissemination and health education campaigns on AIDS in the rural environment cannot be separated from the Bete’s or Baoule’s understanding of this disease and traditionally known transmissible diseases. The percentage of answers identifying sorcery as one of the possible causes of AIDS illustrates the need to take this aspect into account when defining the content of messages.

Efforts should be concentrated on increasing younger people’s awareness of the risk of getting the disease and of the existence of healthy carriers, as well as whether and when a need for isolation really exists. Within the Bete group, considering the fair level of knowledge of condoms, educational campaigns should contain messages enhancing their acceptability and improving knowledge regarding modes of transmission through blood. Differences between AIDS and Bagoumele should be elicited. Among the Baoule, the function of condoms must be explained before implementing activities of promotion or distribution.

Further research activities should be conducted to support and monitor the educational programs with continuous feedback. Social and cultural aspects as well as knowledge and practices linked to AIDS should be investigated in urban areas and between other Ivorian ethnic groups or among selected groups in the population such as prostitutes, students, immigrants or workers that may be at increased risk. Comparison between results of these studies and HIV-seroprevalence surveys in selected areas could be useful in determining populations at risk, and in this regard, an accurate surveillance system is also high priority.

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Musical and clothing invitations to protection, Francis Deniaud, AIDS Health Promotion Exchange, No.3, 1993

Introduction

The Chaussez Capote Project for youth in the Ivory Coast has sought to reinforce their AIDS/STD prevention messages via the use of attractive auditory and visual materials. In the first part of research to determine the best way to provide present information on condom use, in-depth interviews were held with 48 young people, aged 14 to 25 years in the cities of Abidjan and Dabou. Among the questions asked were: "In your opinion, what should be done to get young African of your age to use condoms?" They responded that information on condoms should:

Findings

Strategies for AIDS prevention (increasing condom use) among youth

*be attractive and not associated with a dramatic image of AIDS;

*advise that condom use should be according to circumstance and not necessarily life-long;

*note other prevention methods besides condoms, such as temporary abstinence and fidelity;

*be portrayed visually or orally by youth for youth;

*by regularly repeated.

Sources of information on AIDS prevention among youth

A semi-quantitative study, using multiple-choice questions, was then done among 251 young people aged 15-25 years in Abidjan. The results were as follows:

*more than 80% had already discussed AIDS, STDs and prevention, mostly with their peers (friends, siblings);

*nine out of ten still wanted more advice on those themes, 50% from medical staff and 25% from the media;

*condom promotion should be associated with information on AIDS, STDs and contraception or information on general health;

*40% of young people who had already used condoms did so incorrectly;

*1/3 had experienced condom breakage during use;

*90% thought that emphasis should be given to the quality and efficacy of condoms in Africa.

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