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Trends in Knowledge Attitude and Practices of Harmful Traditional Practices in Ethiopia (1997 to 2007)

SEMINAR ON THE RIGHT TO DECIDESexual and Reproductive Rights Practices That Affect The Health Of Women And Children 9-10 December 2009 Vitoria-gasteiz (SPAIN)Prepared by Mr. Abate Gunduffa (EGLDAM) and Mr. Ezana Haddis (BLIE) Presented by Ezana Haddis (BLIE)

Presentation OutlineBackground about the Ethiopia IntroductionDiscussion of trendsThe 15 HTPDetail discussion in the major HTPsInstitutional framework and actors in the Fight Against HTPChallenges Conclusion

December 2009Presenation to Haurralde Foundation 2Background to the Nation (Ethiopia)73.9 million with only 16% urban population Covers about one million square kilometersFound in the horn of Africa b/n 3 and 15 degrees North latitude And 34 and 48 degrees East longitude Has more than 80 ethnic groupsIt is a federal country, where there are autonomous nine regional states and two city administrations

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Regions of Ethiopia 1- Addis Ababa2- Afar3- Amahara4- Benishangul Gumz 5- Dire Dawa 6- Gambella 7- Harari8- Oromiya 9- Somali10- South Nations, Nationalities and Peoples (SNNPR)11- Tigray

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Health Status and Services Indicator 2006 Data Life Expectancy at birth54Infant Mortality Rate per 1000 live birth77Maternal mortality rate per 100,000 live births870Immunization Coverage75.6 %Contraceptive usage36%Population growth rate 2.7%Primary Health Coverage77%December 2009Presenation to Haurralde Foundation 6Introduction This presentation is prepared based on two surveys the Baseline Survey (1997) and Follow-up Survey (2007)Which were conducted on the Harmful Traditional Practices in Ethiopia by NCTPE/EGLDAM December 2009Presenation to Haurralde Foundation 7Introduction: The Surveys Baseline SurveyFollow Up SurveyDate19972007ImplementerNCTPEEGLDAMManagement SupportOSSEREASCN-EFundingNORADNORADTeamFissehaYayehyiradAmareFissehaYayehyiradAmareDecember 2009Presenation to Haurralde Foundation 8Introduction: The ReportBaseline SurveyFollow Up SurveyDate19982008ImplementerNCTPEEGLDAMManagement SupportOSSEREASCN-EFundingNORADNORADTeamFissehaYayehyiradAmareFissehaYayehyiradAmareDecember 2009Presenation to Haurralde Foundation 9Introduction: Book [+Amharic adaptation]Baseline SurveyFollow Up SurveyDate20032008ImplementerNCTPEEGLDAMManagement SupportOSSEREASCN-EFundingNORADNORADTeamDehabYayehyiradAsmelashFissehaYayehyiradAmareDecember 2009Presenation to Haurralde Foundation 10Objectives of FUSMajor Objective"to examine/measure changes observed on prevalence, knowledge, attitude, intention and behavior......... towards HTP at national level and to recommend appropriate strategies in future directions".

December 2009Presenation to Haurralde Foundation 11Specific objectivesAssess change & current:Prevalence, knowledge, attitude, intention & behaviourReasons, harmful effect & victimsImpact on HIVIdentifyMajor actors in HTPActivities by different actorsAchievements so farDecember 2009Presenation to Haurralde Foundation 12..December 2009Presenation to Haurralde Foundation 13Framework for Methodological DevelopmentFollow up survey, therefore, as much as feasible same method with the baseline surveyHowever, adapted because of:Need to asses the changes over timeNew objectives interventions & organizationsApproaches:Literature/documents reviewQuestionnaire surveysFGD13Methodology Adaptation ProcessConceptualization of the follow up Framework for social change analysis [Dr Yeraswork]The nature of change in culture and traditionFactors/determinants of change and how they interactThe role of change agents (traditional leaders, FBOs, NGO, government etc) and possible assessment of their (differential) impactModels/methods of assessing changes and their applicability to HTP in EthiopiaFramework for statistical analysis [Prof Ayenew & Behayelu]Sample frame in line with the baseline studySample size to ensure quantification of prevalence change for, at least, FGM in the stronghold nationalitiesDecember 2009Presenation to Haurralde Foundation 1414Assessing Change: FrameworkCommunityHTPInstrument - Lit/Doc

-Q2 & FGD

- Q1 & FGD

December 2009Presenation to Haurralde Foundation 15 EnvironmentGovNGO/CBOEGLDAM15.EnvironmentGeography & demographyPolitical decentralization, High number of Organizations/NGOEconomy povertySocio-cultural gender, childrenEducationHealth & health servicesActors:GovernmentNGOPrivateEGLDAMChanges in: Knowledge, Attitude, Reasons, Harm, Intention, Behaviour, Practice, PrevalenceOther issues:Problems facedHTP & HIVHTP & SRHFuture interventionsDecember 2009Presenation to Haurralde Foundation 16161. Literature/Document Review Geared towards change in the last ten years and new developmentsBackgroundGeography & demographyPolitical decentralizationHigh number of NGOEconomy povertySocio-cultural gender, childrenEducationHealth & health servicesHTP (5 years because NCTPE 2003)FGMMarriage relatedChildren relatedTaboos/prohibitionsOthersDecember 2009Presenation to Haurralde Foundation 17172. Qualitative and Quantitative Methods & InstrumentsCross-sectional sample survey [Q1]Adult pop (F & M), general info on 20 HTP [Q1a, 100 households from each Kebele]Prevalence of 5 HTP [Q1b, 20 HH from each Kebele]Info from opinion makers (20 from Woreda; educated, informed)Info on 20 HTP (Q2a, mostly close-ended)Others mostly Food/Work Prohibition (Q2b, open-ended) FGD, 2 per Woreda (District):CapitalKebele/Farmers Association December 2009Presenation to Haurralde Foundation 1818Contents of Baseline & Follow Up SurveysBaselineFollow upIdentificationLegal Knowledge-Information-Occurrence/MagnitudeAttitudeFutureTrendPerpetratorsActors-December 2009Presenation to Haurralde Foundation 19Sample Population: CriteriaSame with baseline as feasibleHowever changes but no up to date dataZones (sub-regions) some new onesWoredas (districts) some merged, some new, specialKebeles (the smallest local admin) some merged, some new names etcDecember 2009Presenation to Haurralde Foundation 2020Principles for decision (in field)Cover all zones (sub-regional entities): 2 woredas (districts) per zoneUse the same woredas (district) & Kebeles (the smallest local admin) as baseline (i.e. same locality)Include Dire Dawa & zones in SomaliInclude additional ethnic groupsDecember 2009Presenation to Haurralde Foundation 2121Study PopulationBaselineFollow upEthnic groups6981Farmer Associations (rural local admin)110132Woredas (District) 112132Kebeles (Urban local admin)6772Towns2223Zones (sub-regional administrations) 5874Total pop Q1aTotal pop Q1b25,30915,71034,00019,000Total pop Q21,9302,500Total pop FGD1,2321,500December 2009Presenation to Haurralde Foundation 2222DiscussionKAPr 15 HTP 2007December 2009Presenation to Haurralde Foundation 23Comparison of knowledge towards the 15 HTP in BLS and FUSDecember 2009Presenation to Haurralde Foundation 24Knowledge: FGM by regionDecember 2009Presenation to Haurralde Foundation 25FGM, Baseline & Current Prevalence by Region

December 2009Presenation to Haurralde Foundation 2626Prevalence of FGM by Age GroupBaseline (BLS) & Follow up (FUS) SurveysDecember 2009Presenation to Haurralde Foundation 2727Important decrease in prevalence:Prevalence of FGM by Age FUS

December 2009Presenation to Haurralde Foundation 2828Map Prevalence of FGM by Region 2007

December 2009Presenation to Haurralde Foundation 2929FGM: Harmful Effects December 2009Presenation to Haurralde Foundation 30Early Marriage: Knowledge BLS & FUS by Region December 2009Presenation to Haurralde Foundation 3131Early Marriage: Attitude in BLS and FUS by RegionDecember 2009Presenation to Haurralde Foundation 32Early Marriage Prevalence: BLS & FUSDecember 2009Presenation to Haurralde Foundation 33EM: Harmful Effects in BLS & FUSEffectBLSFUSHarm to the uterus and the body in general54.341.2Problems in delivery45.742.6Loveless marriage often ending in divorce30.427.9Girl not mature enough to run a HHd26.126.5Early pregnancy17.419.1Psychological Problems13.033.8High expenses for marriage8.78.8Discontinuation of education-14.7Exposure to prostitution-10.3December 2009Presenation to Haurralde Foundation 3434December 2009Presenation to Haurralde Foundation 35

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MBA: Knowledge in BLS and FUSDecember 2009Presenation to Haurralde Foundation 4242MBA: Attitude in BLS and FUSDecember 2009Presenation to Haurralde Foundation 43MBA: Prevalence in BLS and FUSDecember 2009Presenation to Haurralde Foundation 44MBA: Harmful Effects in BLS & FUSEffects BLSFUSMistreatment of girls61.554.9Conflict/feud b/n family, community, ethnic group61.529.4Unhappy marriage42.323.5Psychological stress11.5 19.6Heavy expenses (as compensation)10.3-Dropping out of school9.017.6Rape5.15.9Exposure to HIV/AIDS-39.2December 2009Presenation to Haurralde Foundation 45UC Baseline & Current (ascending order) Prevalence by Region

December 2009Presenation to Haurralde Foundation 46Prevalence of UC by Age: Baseline & Follow up Surveys December 2009Presenation to Haurralde Foundation 4747UC: Harmful Effects in BLS and FUS EffectBaselineFollow-Up Infection/poisoning due to unclean instruments50.022.6Heavy bleeding46.937.7Speech problem/distortion 25.018.9Death17.819.8Injury (pulling of) the tongue 16.714.2Pain/excessive crying14.617.0Teneta (Passing of fluid into the trachea)10.48.5No harm (if well performed)8.30.9December 2009Presenation to Haurralde Foundation 48MTE: Prevalence in Baseline & Follow up Surveys by region (ascending order)

December 2009Presenation to Haurralde Foundation 4949Comparison of knowledge with the baseline result (descending order change)December 2009Presenation to Haurralde Foundation 50Categorization of Food Taboos to Pregnant Women, Children and the Community, in BLS and FUSProhibitionHighestLowestBLSFUSBLSFUS1.Pregnant WomenAmhara (41.2)SNNPR (35.6)Oromia (31.9)Amhara (39.7)SNNPR (25.7)Tigray (24.5)Somali (0.0)Gambella (18.2)A.A (23.2)Somali (3.3)Gambella (3.5)A.A (0) 2.ChildrenA.A (51.8) SNNPR (46.8)Oromia (43.7)A.A (44.5)Oromia (38.8SNNP (31.5)Somali (2.9)Gambella (9.5)Benishangul/Gumuz (19.4)Somali (1.7)Harari (10.5)Gambella (9.5)3.CommunityGambella(59.1Harari (55.0)Affar (44.8)Gambella (23.8)Afar (24.7)Harari (40.4)Somali (5.7)Benishangul/Gumuz (6.0)Amhara (17.1)Somali (7.5)Benishangul/Gumuz (11.1Amhara (13.6December 2009Presenation to Haurralde Foundation 5151Categorization of Work Restriction to Women, Men and the Community by RegionRestriction HighestLowestBLSFUSBLSFUS1. For WomenGambellaAmharaOromiaAmharaOromiaGambellaBenishangul/GumuzSomaliAddis AbabaBenishangul/GumuzSomaliAddis Ababa2. For MenGambellaAmharaSNNPRAmhara AADire DawaBenishangul/GumuzSomaliHarariBenishangul/GumuzSomaliAfar3. For CommunityAmharaSNNPAffarAmharaSNNPDire DawaGambellaBenishangul/GumuzAddis AbabaGambellaBenishangul/GumuzAddis AbabaDecember 2009Presenation to Haurralde Foundation 5252Link: HTP and HIV/AIDSIn the opinion of FGD participants HTPs suspected by the FGD participants to transmit HIV/AIDSHighest frequency mentioned: FGM (104) followed by Uvula cutting, milk teeth extraction, Abduction followed rape, polygamy [1] and inheritance marriage.

[1] Polygamy, even though identified as HTP in a number of regions, is more a religious rather than purely traditional practice. December 2009Presenation to Haurralde Foundation 5353HTP and Gender and Gender Based ViolenceRelationship identified by FGD participants:sexual harassment, Abduction followed by rape,undermining the status of women, early marriage, excessive work load on women, denying equal property rights to women,FGM,Polygamy, divorce with out sufficient reason, Inheritance marriage andWife beating (Hitting [DEBDEBA])December 2009Presenation to Haurralde Foundation 5454Relationship between HTP & RHMajor HTP identified by FGD include:FGM Early Marriage Abduction Polygamy Frequent pregnancy Inheritance marriage December 2009Presenation to Haurralde Foundation 5555Overall gains High level of awareness and declared support to elimination of HTPStrong legal frameworks nationally and internationallyStrong policy level (political) will/mood internationally & in countryHigh number of government and non-government organizations involved

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Institutional framework towards HTPs InternationallyUniversal Declaration of Human RightsConvention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages 1964International Convention on Economic, Social and Cultural Rights 1966International Convention on Civil and Political Rights 1966Convention on Elimination of All Forms of Discrimination against Women 1979The African Charter on Human and People Rights (1981)Convention on the Rights of the Child 1989.African Charter on the Rights and Welfare of the Child (ACRWC, 1999)Eradication of Violence Against Women and Children (1998)Protocol on the African Charter on Human and Peoples Rights on the Rights of Women in Africa (2003)

December 2009Presenation to Haurralde Foundation 6161Institutional framework towards Htp (contd) In countryFDRE Constitution (1995)Penal Law of the countryNational Policy on Women (1993)National Health Policy (1993)Health StrategyHIV/AIDS StrategyReproductive Health StrategyEducation and Training Policy (1994)

December 2009Presenation to Haurralde Foundation 62High number of GO & NGO involved Government almost allWomens AffairHealthEducationLaw EnforcementInternationalBilateralNORADUSAIDMultilateral: WHO, UNICEF..NGO National: EGLDAM. FGAEInternational: NSC, PathfinderFBO: EOCDICAC, Islamic Affairs, EECMYCBO: IdirsAssociations: Womens, YouthENMA, EMA, EPHA, ESOG..December 2009Presenation to Haurralde Foundation 6363ChallengesProgress not commensurate with effortDistribution & prevalence still high (