The Impact of the Madagascar TOP Reseau Social Marketing Program on Sexual: Behavior and Use of Reproductive Health Services

"A study of Population Services International's (PSI) TOP Réseau network of franchised youth clinics in Madagascar demonstrates that the program contributed to removing barriers to condom use and motivated sexually experienced young people to use condoms.

The HIV prevalence rate in Madagascar was estimated at 1.7% at the end of 2003 but is expected to rise dramatically in the near future, particularly among youth. Sexually transmitted infections (STIs), which increase risk of HIV transmission, are prevalent among youth. Malagasy youth initiate sexual activity early and have low knowledge of HIV and STIs: a 1997 survey suggested that 50% of 15- to 24-year-old women had never heard of an STI, over 30% had never heard of AIDS and only 11% reported ever using a condom.

In January 2001, PSI launched a social franchise of adolescent reproductive health clinics called TOP Réseau with support from the Bill and Melinda Gates Foundation. TOP Réseau clinics supplied youth-friendly, high quality and affordable reproductive health services to young people aged 15 to 24. A complementary communication campaign promoted the franchised clinics and motivated youth to adopt safer behavior, including abstinence, correct and consistent condom use and the treatment of STIs. Mass media and interpersonal communication included peer educators, televised youth debates, mobile video unit shows and radio and television spots. All communication products were developed in the Malagasy language and tested to ensure cultural suitability. As of August 2004, the TOP Réseau network consisted of 119 trained providers working at 83 clinics in Antananarivo, Antsiranana, Taolagnaro and Toamasina.

The results emphasise the importance of developing communication campaigns to complement service delivery initiatives: in Madagascar, exposure to both communication activities and clinics together was essential for behavior change. Since increased condom use was reported only by youth who had been exposed to more than one element, future communication campaigns should target youth repeatedly with both interpersonal and mass media communication to promote behavior change. The discrepancy between the number of youth reached by communication activities and those who actually attended clinic-based programmes implies that communication is having limited effect on motivating youth to use clinic services. The fact that the analysis included both urban and rural youth while the TOP Réseau intervention targeted youth primarily in the urban area of Toamasina town, closer to the clinics, may have also contributed to this discrepancy. In light of the small number of youth who sought STI treatment at TOP Réseau clinics, future programmes should attempt to increase the perceived need for and attractiveness of clinic-based services. To better attract youth to clinics, future programmes need to determine which services are most appropriate for clinic based approaches. Results indicate that family planning services may be well-suited for this approach."

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