Building sustainable and scalable peer-based programming: promising approaches from TESFA in Ethiopia

Abstract

Background Girls in Ethiopia’s Amhara region experience high rates of child marriage and are less able to negotiate sex or use family planning. Seeking to improve their lives, CARE’s TESFA programme delivered reproductive health and financial savings curricula to married girls via reflective dialogues in peer-based solidarity groups. From 2010 to 2013, 5,000 adolescent girls participated via three intervention arms: sexual and reproductive health, economic empowerment, and a combination of both. At end-line, participants reported improvements across health and empowerment outcomes. Four years post-TESFA, 88% of groups reported meeting without continued assistance from CARE. Some original participants had created new groups based on the TESFA model, and some girls not recruited for TESFA spontaneously replicated it to create their own groups. However, questions remained about what had contributed to this organic sustainment and scale-up of groups. Methods This 2018 study investigated factors affecting sustainability and scale-up of peer solidarity groups through a systematic mapping of TESFA groups across five woredas (districts) and interviews with key stakeholders. Data were collected from 39 focus groups with active and dissolved Girl Groups, Social Analysis and Action groups, and girls’ husbands and from 29 in-depth interviews with group facilitators and community health workers across three districts. Data were coded and analyzed per grounded theory principles. Results Changes in reproductive health knowledge and specific behaviours, such as contraceptive use and institutional delivery, were maintained 5 years after the intervention ended. Group connectedness, spousal support, integration of holistic community platforms, and opportunities for financial independence were found to be important for group sustainability. Observed changes in TESFA girls’ confidence to negotiate and assert their rights, hopes of improved mobility, and the promise of economic opportunity commonly inspired spontaneous replication of groups. Recommendations for future peer-based programmes include creating environments of solidarity and holistically engaging intervention communities. Conclusion By increasing knowledge of and access to reproductive health services, TESFA mitigates some of the harmful effects of child marriage. The maintenance and organic replication of groups suggest that TESFA provides a successful, scalable and sustainable tested model for reproductive health program delivery through peer-based solidarity groups.

Can Peer-based Interventions Improve Adolescent Sexual and Reproductive Health Outcomes? An Overview of Reviews

“…It has recently been employed in a pilot feasibility study that aims to “capitalize on mechanisms of social influence” [ 56 ]. Linked to this idea, a recent 10 year follow up mapping and qualitative evaluation of the ‘Toward Economic and Sexual/Reproductive Health Outcomes for Adolescent Girls’ program that used peer-based solidarity groups in Ethiopia to improve the wellbeing of married adolescent girls [ 57 ], found that this was effective and that increasing awareness of and access to services was crucial to this success.…”

A systematic review of school-based student peer-led oral health interventions to promote the oral health of school children

“…The recent Commissioning Better Oral Health for Children and Young People recommends the investigation of community/peer-led programmes which facilitate improvements in oral health [ 33 ]. Other studies have encouraged community involvement whilst tackling cultural barriers, ensuring access to those often ‘hard to reach’ and engaging intervention communities to build sustainable and scalable peer-led programmes [ 16 , 34 ].…”

A systematic review of school-based student peer-led oral health interventions to promote the oral health of schoolchildren

“…The recent Commissioning Better Oral Health for Children and Young People recommends the investigation of community/peer-led programmes which facilitate improvements in oral health (31). Other studies have encouraged community involvement whilst tackling cultural barriers, ensuring access to those often 'hard to reach' and engaging intervention communities to build sustainable and scalable peer-led programmes (15,32).…”