German HIV Practice Collection Health, Education and Social Protection Division

‘Aunties’ for sexual and

reproductive health:
How unwed young mothers become advocates,
teachers and counsellors in Cameroon
 Table of Contents

Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The German HIV Practice Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Cameroon and its sexual and reproductive health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Profile of Cameroon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Sexual and reproductive health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Aunties’ Programme in seven steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Step 1: situation analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Step 2: mobilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Step 3: training and tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Step 4: building local Aunties’ associations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Step 5: community, school and individual interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Step 6: spreading the word through the media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Step 7: on-going management and monitoring and evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . 19
Achievements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
More than 140 associations with trained Aunties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
National Network of Aunties’ Associations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Impacts on trained Aunties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Impacts on other young people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Impacts on families and communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Low and sustainable costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
To improve recruitment methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
To drive home messages so they change behaviour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
To reach out to males. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
To improve monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Lessons learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
German HIV Peer Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Acronyms and Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Contacts and credits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Acknowledgements
We would like to give special thanks to the thousands of unwed young mothers recruited and trained as
Aunties, to their parents and to the government, education and health authorities in their villages,
urban neighbourhoods, municipal districts and provinces. We also give special thanks to our partners at
the national level in Cameroon.They include the Ministry for Women’s Empowerment and the Family –
with special mention of Catherine Bakang-Mbog, Victorine Ngalle and Mrs. Ebayah and the Cameroon
Association for Social Marketing – with special mention of Theresa Tapsobga and Hendricks Bile.

Flavien Ndonko and Andreas Stadler conceived and developed the Aunties Programme within the
Germano-Cameroon Health and AIDS Programme. Ursula Schoch, of InWEnt, and Regina Görgen, of
Evaplan, developed the training course on counselling of adolescents and Regina Görgen also docu-
mented the Aunties’ Programme up to April 2006. The GTZ supraregional project Sexual and Repro-
ductive Health has supported the development and the documentation of this approach from its
beginnings up to this publication. Stuart Adams was the writer of this publication, Anna von Roenne
was the managing editor and Flavien Ndonko was the principal reviewer.

2
The German HIV Practice Collection

The German HIV Practice Collection is edited PRG members believe that collabor-
by the German HIV Peer Review Group (PRG), ative knowledge management means
an initiative launched in September 2004 by ‘getting the right people, at the right
AIDS experts working in German and interna- moment, to discuss the right thing’ The peer
tional development cooperation.The aim of review, discussion and dissemination of
this group is to collaboratively manage knowl- innovative approaches developed in different
edge about good practice and lessons learnt in regions of the world accords with GTZ’s
German contributions to AIDS responses in understanding of capacity development:
developing countries.
• It is organised as a transparent and mutual
Based on a set of jointly defined criteria for learning process among AIDS experts of
‘good practice’ (see text box), PRG members German, international and partner organis-
assess different ways of responding to AIDS ations.
that have been submitted to them for peer • It provides planners and practitioners with
review. Approaches that meet the majority of a range of practical, evidence-based program-
the criteria will be documented, published and ming models.
widely disseminated as part of this Practice • It focuses on the results of the reviewed
Collection. While some of the documented approaches, looking at their achievements,
practices cannot fully meet, as yet, the criteria challenges and lessons learnt.
for ‘good practice” (i.e. several external evalu-
ations and multiple replications in different PRG membership is open to AIDS experts
countries), all of them represent examples and development cooperation planners and
of ‘promising practice’ that may inform and practitioners with an interest in German con-
inspire other actors in the complex and tributions to the AIDS response in developing
dynamic fields of HIV prevention, AIDS treat- countries. For more information, contact the
ment, impact mitigation, support and care. Secretary of the Peer Review Group at
at aidsprg@gtz de or go to
http://hiv prg googlepages com/home

Selection Criteria
• Effectiveness
• Transferability
• Participatory and empowering approach
• Gender awareness
• Quality of monitoring and evaluation
• Innovation
• Comparative cost-effectiveness
• Sustainability

3
 Summary

In 2000, a study by the Germano-Cam- In 2005, a general assembly of repre-

eroon Health and AIDS Programme found sentatives from Cameroon’s local Aunties’
that girls in Cameroon have followed world- associations formed the National Network
wide trends towards sex before marriage and of Aunties’ Associations (RENATA) and it
multiple sexual partners.This puts them at has mounted campaigns to end the gender
high risk of getting pregnant, being removed inequality and sexual abuse and exploita-
from school, forced into early marriage, tion that put the country’s girls at high risk
harmed by unsafe abortion, and acquiring of early and unwanted pregnancy and its
sexually transmitted infections including HIV. consequences and of sexually transmitted
infections including HIV. In 2006, it launched
In Cameroon, a girl’s Auntie used to be her a campaign that has exposed the previously
most trusted confidante, teacher and counsel- hidden and extremely painful and harm-
lor on sexual matters. In 2001, GTZ launched ful practice of mutilating or “ironing” the
the Aunties’ Programme which borrows from breasts of pubescent girls in order to make
this tradition. Since then, the Programme has them less attractive to boys and men.
recruited more than 6000 unwed young moth-
ers who got pregnant while still in their teens This publication describes the Aunties’
and has given them basic training in sexual and Programme and its achievements in detail
reproductive health. So trained, they become and concludes that the Aunties’ approach is
known as “Aunties” and form local Aunties’ transferable to other countries with traditions
association, through which they support each and contemporary situations not unlike those
other and also perform many of the functions found in Cameroon. This approach is a good
Aunties used to perform but not just within example of capacity development in that it en-
their own families. Instead, they reach out into ables young women at risk of marginalization
their immediate vicinities and wider com- to connect and support each other, locally and
munities and focus, in particular, on providing nationwide, and to shape their own futures.
adolescents with sex education in schools
and personal counselling outside of schools. It has the potential to make significant
contributions toward four of the eight in-
By early 2007, Cameroon’s trained Aunt- ter-related Millennium Development Goals:
ies had formed more than 140 local Aunt- gender equality and empowerment of women,
ies’ associations. Almost 500 Aunties were reduction in child mortality, improvement
experienced and skilled at providing sex of maternal health, and reduced infection
education in the schools of their villages or and harm by HIV and other diseases.
neighbourhoods and, working in pairs, they
had the potential of reaching from 38,000 to
48,000 students per year. In a joint effort,
GTZ and InWEnt had trained more than 700
Aunties for counselling and they had the
potential of counselling more than 10,500
adolescents per year. Heavily dependent on
volunteerism, the Aunties’ Programme is low
cost and sustainable. It has gone from strength
to strength in Cameroon and there is mount-
ing evidence that it is changing the behaviour
and improving the health and well-being of
thousands of trained Aunties and tens of
4
thousands of other young Cameroonians.
Introduction

In Cameroon, a girl used to call her aunt by the In 2000, the Germano-Cameroon Health
diminutive “Auntie” or in French, “Tantine”, as and AIDS Programme coordinated by GTZ did
a sign of affection for her most trusted confi- a study finding that risky sexual behaviour and
dante, teacher and counsellor in matters that pregnancies before marriage were common
were too personal and embarrassing to be throughout Cameroon. In 2001, it launched
discussed with any other adult. Her Auntie the Aunties’ Programme which invites unwed
taught her how to relate to boys and men, how young mothers to take three days of basic
to remain chaste until she got married and training in sexual and reproductive health
how, if she got pregnant before then, she and to join local associations linked linked
would be condemned and rejected by her own through a national network. Thus qualified
family and everyone else. as “Aunties,” many are given additional tools
for sex education in schools or additional
Urbanization, modern transportation and training for counselling of adolescents.
communications, globalization of youth cul-
ture, poverty, and disparities between rich and
poor have undermined such traditions. Girls
in Cameroon have followed worldwide trends
toward sex before marriage and multiple
sexual partners – sometimes driven by need
for food, shelter or clothing.This means they
are at high risk of getting pregnant, being re-
moved from school, forced into early marriage,
harmed by unsafe abortion, and acquiring
sexually transmitted infections including HIV.

Today, aunts often live far from their

nieces and, even if they live nearby, they
seldom serve as their nieces’ most trusted
confidantes, teachers and counsellors in sexual
matters. However, some traditions remain.
One is the embarrassment girls feel when Members of the Mamfe Aunties Association

discussing sex, especially with their parents

and other adults. Another is the practice of The Aunties Programme fits within a
condemning and rejecting “bad” girls who broader Ministry of Health programme, sup-
have become pregnant outside of marriage. ported by German development cooperation,
to improve the sexual and reproductive health
of young people and that broader programme
is, in turn, part of a comprehensive pro-
gramme to strengthen Cameroon’s health
care system. By providing peer education
and counselling, the Programme addresses
the problem of providing age-appropriate sex
education in a conservative environment.
Often headmasters and parents take the initia-
tive and invite the Programme into second-
ary schools to help diminish the incidence
of teen-age pregnancy and sometimes the
5
result is no such pregancies after two years.
 The objectives of the Aunties’ Programme • Counter stigmatization and discrimination.
are to: Giving unwed young mothers useful roles in
their communities increases the respect
• Establish self-help groups that reach out to others have for them.The education they
others. provide has a similar effect, as people come
Through the basic training and then through to accept that sex before marriage and
the social support provided by their local multiple sexual partners are not unique to
associations, unwed young mothers learn to unwed young mothers. Until young people
build each other’s self-confidence and are provided with the information, skills and
motivate each other to take care of their own supplies they need to avoid unwanted sex
sexual and reproductive health.They also and negotiate safe sex, it is just luck that
gather the courage to be open and honest determines who becomes pregnant or
about their own situations, share their infected with a sexually transmitted disease
personal experiences and reach out to such as HIV.
others.
This publication puts the Aunties’ Programme
• Provide Auntie-equivalents trained to address in context and then describes it and what it
today’s issues. has achieved so far.
Unwed young mothers meet needs once met
by traditional Aunties. They are non-judge-
mental advocates, teachers and counsellors
for sexual and reproductive health who
speak from their own experience at coping
with the realities all young people face in
today’s Cameroon.

• Promote education and reduce poverty.

Their local associations and national network
encourage unwed young mothers to return
to school or take advantage of opportunities
for vocational training, better employment or
small-scale business development. In addi-
tion, participation in their associations’
activities provides some with supplementary
income and medical expenses.

6
Cameroon and its sexual and
reproductive health

Profile of Cameroon Sexual and reproductive health

Cameroon has a population of 16.3 million In 2004, a Demographic and Health Survey
people. In 2004, its Gross Domestic Product (DHS) covered 10,462 households throughout
(GDP) per capita was US$ 2,174 but 50.6% of Cameroon and found:
its population survived on less than US$ 2 per
day and 17.1% on less than US$ 1 per day. An • Child-bearing begins early. By the time they
estimated 34% of its population had no reach 20, 29% of women are pregnant or
sustainable access to an improved source of have already given birth to at least one child.
water, 51% had no sustainable access to Women give birth to an average of 5.0
improved sanitation and 25% was undernour- children but averages vary from 3.2 among
ished. Its literacy rate for women 15 years and the richest and most educated to 6.5 among
older was 59.8%, compared to 77.0% for men. the poorest and least educated.
Its average annual income for women working
outside of the agricultural sector was • The median age of marriage for women is
US$1,435, compared to US$2,921 for men 17.6 – compared to a median age of 25.2 for
(UNDP, 2006). men – and 30% of married women are in
polygamous unions.
The World Health Report 2006 says that,
in 2003, Cameroon’s annual expenditure on • 59% of rural women and 71% of women from
health care was equal to US$64 per capita or the poorest households give birth at home
4.2% of GDP. Only 28.9% of that amount came without the assistance of a trained professional.
from government, the rest from private sourc-
es, and out-of-pocket spending by individuals • 53% of women have experienced physical
and families in need of health care accounted violence since the age of 15 and, of those,
for 98.3% of the money from private sources. 45% have experienced physical violence
Poverty, poor living conditions and low ex- within the past 12 months.The most fre-
penditure on health care mean that Cameroon, quent perpetrators are their male partners.
like most developing countries, has much
higher rates of death and disability from most • 90% of women know about contraception but
kinds of disease and injury than do industrial- only 26% of married women use it and only
ized countries. As a result, average life expect- 13% use modern methods.
ancy at birth is 51 for females and 50 for males
but average healthy life expectancy is only 41.8 • Within the past 12 months, 29% of women
for females and 41.1 for males (WHO, 2006). and 62% of men from 15 to 49 years old have
had high risk sex (i.e., sex with a non-marital,
non-cohabiting partner) and 8% of women
and 40% of men have had sex with more than
one partner. Only 41% of women and 55% of
men used a condom during their last high
risk sexual experience.

• HIV prevalence is 5.5% among all adults from

15 to 49 years old but 6.8% among women
and 4.1% among men.The gender gap is
growing, with 4.8% of young women from 15
to 24 years old being HIV-positive compared
7
to 1.4% of young men. (Institut National de la
Statistique and ORC Macro, 2005).
 In summary, women are poorer than men, have Auntie distributing flyers against breast-ironing
lower levels of education, are less well-in-
formed about sexual and reproductive health The vulnerability of women is com-
and are less likely to do what is necessary to pounded by biological factors. When engaged
protect themselves from harm by unwanted in heterosexual activity with an HIV-positive
pregnancy and by HIV and other sexually partner, a woman is from two to four times
transmitted disease.They tend to be consider- more likely to become infected than a man
ably younger than their male partners and male and a younger woman is at higher risk than
violence and coercion increase their vulner- an older one. One reason is that sexually
ability. transmitted infections (e.g. gonorrhoea and
syphilis) are more likely to be asymptomatic
In many countries, female genital mutila- in women, so women are less likely to seek
tion is a common way of trying to reduce treatment and are left highly susceptible
the vulnerability of girls and young women to added infection by HIV (UN, 2004).
by reducing their interest in sex and their
sexual appeal to boys and men. In Cameroon,
a comparatively low 1.2% of all women
have been circumcised but the percentages
run up to 12.5% among women from cer-
tain ethnic groups in predominantly Islamic
regions. A recent GTZ survey revealed that
breast ironing is a far more common way of
trying to reduce sexual activity (see box).

Pubescent girls mutilated by breast ironing “for their own protection”

In early 2006, the Germano-Cameroon Health and AIDS Programme did a country-wide sur-
vey of 5,700 girls and women from 10 to 82 years old to determine the extent of a practice
that girls and women rarely talk about, especially to boys and men (Ndonko F and Ngo’o G,
2006). The survey found that 24% had had their breasts ironed when they reached puberty.
This extremely painful procedure involves binding the breasts with heated towels or other
material and then pounding, rolling and massaging them flat with stones, wooden pestles,
coconut shells and other instruments.
Breast ironing is done by the girls’ mothers, grandmothers, older sisters or other female
relatives. It is meant to protect them from sexual attention but many with ironed breasts
become pregnant anyway and are forced to leave school and get married, undergo unsafe
abortion or give birth outside of marriage. Besides being extremely painful and traumatic,
breast ironing leaves permanent tissue damage and deformity. While the long-term conse-
quences have yet to be studied, they may include infections, cysts, cancer and the need for
breast removal or other surgical procedures.
Dr Flavien Ndonko, an anthropologist with the Germano-Cameroon Health and AIDS
Programme, says that the taboo on talk about sex is at root of the problem. “Parents and
other adults need to learn to talk to children and adolescents about sexual and reproductive
health, the need to protect themselves from harm and the need to respect the rights of
everyone else to go unharmed, too. The Aunties are helping to facilitate this learning.”

8
The Aunties’ Programme in seven steps

The Germano-Cameroon Health and AIDS In three provinces - North-West, Littoral and
Programme officially launched the Aunties’ South-West - 12 interviewers with training in
Programme in 2001 but did the situation social science and public health administered
analysis on which it is based the previous year. the questionnaire to 4,500 unwed young
It was the first of what can be described as people between 12 and 25 years old and
seven steps.These steps should be seen, facilitated focus group discussions with 136
however, as a flight of stairs where there is con- of them in groups of no more than eight
tinuing work on the maintenance and improve- people each.The main findings were:
ment of each step, so the whole structure
provides ever stronger support for efforts to • One-third of the unwed females and two-
promote the rights and improve the sexual and thirds of the unwed males had had two or
reproductive health of young people. more sexual partners within the past year.

Step 1: situation analysis • Half of those did not use condoms during
sexual intercourse.
Much of the evidence for a situation analysis
can be gathered from existing sources, includ- • 21% of the unwed females had already had at
ing reports produced by ministries of health least one unwanted pregnancy and, of that
and national statistics in partnership with inter- group, 36% had had at least one induced
national organizations. In Cameroon, reports abortion and it was often unsafe (not per-
on Demographic and Health Surveys in 1991, formed by a qualified professional).
1998 and 2004 and a Multiple Indicator Cluster
Survey in 2000 have provided evidence used to The situation analysis is not just a one-time or
develop and strengthen the Aunties’ Pro- periodic activity. Instead, it keeps track of the
gramme. current situation, including the availability of
sexual and reproductive health services.
In addition, the Germano-Cameroon
Health and AIDS Programme conducted its
own baseline survey in 2000 to provide more
evidence specific to unwed young people.

Find tool 1: A questionnaire and a guide for focus

group discussions for a situation analysis in the
internet toolbox for his approach at
http://hiv.prg.googlepages.com/toolboxaunties

9
 Step 2: mobilisation bers approach potential recruits for interviews,
guided by questionnaires which they fill out
Local authorities during the interviews. Once the census gets go-
Before the Aunties’ Programme begins mobiliz- ing, it snowballs as one after another young
ing unwed young mothers in any locality, it unwed mother approaches her peers and
seeks the permission and support of local explains the Programme’s intentions and
authorities.These always include the tradition- methods of operation.
al, elected or appointed leaders of the locality,
be it an urban neighbourhood, town or village. During the first few days of the census,
They usually include the mayor of the city or the team makes arrangements for a place,
municipal district and sometimes include the date and time for the initial training ses-
head of the provincial government. In addition, sion. Doing this early on means they can
they include health officials such as the city or tell most recruits what the arrangements
municipal district medical health officer and are during their recruitment interviews.The
the head of any health centre or hospital that team does its best to set the date no more
serves the locality. than three weeks after all the interviews are
done, so everything the recruits learn during
This ensures there will be no misunder- the interviews is still fresh in their minds.
standing of the Programme’s intentions and
methods and that local authorities understand During their interviews, potential recruits
that unwed mothers and everyone else will are told that their participation is voluntary,
be asked to volunteer their time and other that there is no pay involved (unless their
resources.The only financial resources the interviews reveal they may need small per
Programme brings to localities are dedicated diems and reimbursements for expenses)
to supporting the poorest unwed young and the training is not geared toward pre-
mothers with small per diems for participat- paring them for jobs.They are usually given
ing in training and other activities and with pamphlets or fliers and these provide ba-
expenses to cover babysitting and medicines. sic information on sexual and reproduc-
tive health and the Aunties Programme.
Seeking the permission and support
of local authorities also ensures that they
will assist with such matters as arranging
for the free use of public meeting places
and, in the case of health officials, with sup-
port for training and other activities.

Unwed young mothers

People will often not readily admit they are
unwed mothers or have ones in their families,
so recruitment of members for Aunties’
associations must be handled sensitively. It
begins with a local census done by “snowball-
ing.”An experienced social worker or social
scientist heads a small team (often including
unwed young mothers from Aunties’ associa-
tions in other communities) and team mem-
School children reading Aunties‘ information leaflet
10
Parents One of the key methods is personal
During the census-taking, many parents of testimony, preferably by unwed young moth-
unwed young mothers are at first astonished ers from other localities where Aunties’
that anyone from so far away is interested in associations are already established. In addi-
interviewing their “bad girls” but most become tion, trainees are invited to share their own
very cooperative and ready to help their experiences. In sections covering HIV and
daughters and other unwed young mothers in AIDS, people living with HIV and AIDS are
their communities. invited to talk.The dual purpose is, first, to
provide concrete examples and, second, to
Once Aunties’ associations are established, show trainees how to speak from their own
they meet with parents’ associations to raise experiences when advocating, teaching or
other parents’ awareness of the Aunties’ objec- counselling for sexual and reproductive health.
tives and gain their support.Though initially
suspicious of “bad girls” who might want to A variety of printed material is also used.
approach and influence their own children, For example, the Programme’s own hand-out
parents are usually relieved to learn that leaflet on virginity and HIV is distributed. So
Aunties’ associations will provide them with re- is material produced by other organizations,
sources and allies in efforts to promote sexual with technical support from the Germano-
and reproductive health among their children. Cameroon Health and AIDS Programme.The
concluding session covers formation of a local
Step 3: training and tools Aunties’ association and, for it, three docu-
ments with examples of a constitution, an
Basic training electoral code and internal rules are handed
All unwed young mothers interviewed during out. (For more on these, see Step 4.) Depend-
a local census are invited to participate in basic ing on how well this session goes, it may be
training. It provides knowledge and skills possible to elect officers and establish the
pertaining to sexual and reproductive health local Aunties’ association then and there, but
and introduces the idea of establishing a local the trainees may prefer time to digest what
Aunties’ association. Experience has shown they have learned before taking those steps.
that three days are essential if all topics are to
Find tool 2: Detailed modules for the 3-day basic
be covered adequately. It has also shown that training for Aunties in the internet toolbox for his
there will be insufficient opportunities for approach at
individual participation if more than 40 people http://hiv.prg.googlepages.com/toolboxaunties
participate in a training course. If there are
At the beginning of the
more than 40 unwed young mothers ready for project, Aunties attending
training in a locality, they are divided into training were using their
babies as desks.
separate groups. Since then, nannies are
hired to take care of
babies during training
The Ministry of Health and Ministry for sessions.
Women’s Empowerment and the Family pro-
vide the senior trainers, while unwed young
mothers who have been through training
make up the balance of training teams. A
committee made up of the Programme’s staff,
senior trainers and unwed-young-mother-
trainers meets regularly to review content,
methods and results and make adjustments.
11
 Contents of the basic training course

In March 2007, the Aunties’ Programme completed a review and update of the basic training
curriculum. The main effect was to give more opportunities for participation by the trainees
through presentations, sharing experiences, brainstorming, working in groups, and discussion
and debate. The following summarizes the twelve sessions that make up a three-day course.

1. Introduction 7. Hygiene and nutrition

Registration of trainees Hygiene of mother and child
Introductions all around Different classes of food
Outline and discussion of the course ahead Advantages of breast milk and weaning
Practical cases
2. Local situation and role for Aunties
Number of early and unwanted pregnancies 8. STIs including HIV
Testimony of an unwed young mother Definitions, local and national statistics
Causes and consequences (brainstorming) Symptoms and consequences
Role Aunties can play Modes of transmission
Testimony of an experienced Auntie Special vulnerability of women
Sharing experiences Prevention
Personal testimony and Q&A
3. Puberty
Bodies and reproductive organs 9. Aunties
Trainee explanation of how these change Role
Trainee explanation of the implications Qualities of a good Auntie
Discussion by other trainees What to do when a partner
Synthesis and summary by trainer tries to force a girl
Sensitization and role play What to do when a partner
refuses condom (debate)
4. Early and unwanted pregnancy
Definitions 10. Communication
Groups using problem trees Definition
2 groups on direct causes Role play on conveying message re
2 groups on indirect causes condom use
4 groups on consequences for Factors in success and failure
girl, partner, family, community
Medical implications 11. Course evaluation
Session-by-session analysis
5. Abortion Views of selected participants
Definition and types Production and distribution of synthesis
Local practices, hospital alternatives
Ways abortion can be avoided 12. Forming a local Aunties’ association
(brainstorming) Discussion of sample constitution,
Rape and authorized abortion electoral code, internal rules
Reading of message from GTZ
6. Abstinence and contraception Election of executive committee
Definitions and methods Reporting procedures
Pros and cons of each method
Condom demonstration
Shared experiences (using and not using)
Focus on personal responsibility for health

12
Tools for sex education in schools Aunties ask teachers to fill out monitor-
Before 2006, roughly one in fifteen Aunties ing forms after each presentation, provid-
took an additional training course where they ing their observations and giving their sig-
learned to reach out to school students with natures. In addition to providing valuable
short presentations on different aspects of feedback, these forms provide evidence of
sexual and reproductive health and HIV and to consent by headmasters and teachers and
add emotional impact by giving personal also of the content of presentations, in case
testimony about their own experiences. By there are any complaints from parents or
2006, the Aunties’ Programme had developed other community members afterwards.
simple tools that enabled the most active
Aunties to do all of the things they had
previously learned to do in the course, without
actually taking the course.

Equipped with their tools, Aunties arrange

for half-day introductory meetings in which
medical doctors participate.These meetings
inform headmasters and teachers about the
Aunties’ objectives and how they have been
trained, discuss the sexual and reproduc-
tive health issues faced by young people,
propose a programme of school presenta-
tions covering various topics, and seek per-
mission and support for the programme.

Aunties learn to gear their presentations to

different age groups and confine each presen-
tation to a particular topic, while promising to
return for additional presentations on other
topics. For students in their late childhood or
early adolescence, for example, the first topic
might be puberty and an Auntie’s personal tes-
timony during her presentation might tell the
students how she felt, what she knew and did
not know and what the consequences were.

Auntie conducting a session at school.

13
 Training for counselling of adolescents By 2004, it was apparent that most Aunties
Once an Aunties’ association is established and felt uncomfortable offering advice on such
the Aunties become known, adolescents and personal matters and that even those who
adults begin to approach them with sexual and felt comfortable lacked counselling skills.
reproductive health problems.Typical prob- The Germano-Cameroon Health and AIDS
lems include: poor communications with Programme and InWEnt asked Evaplan to
parents; conflict with parents; pain or irregu- develop a course for training Aunties in the
larities with menstruation; fear of pregnancy; counselling of adolescents. (Subsequently, the
confirmed pregnancy and what to do about it; Ministry for the Promotion of Women and the
rape; incest; sexual harassment by teachers or Family used the same course material to train
other authorities; contraception (available women for counselling in women’s centres.)
methods, how to obtain and use condoms,
negotiating the use with partners); health and Now, Aunties’ associations are asked to
hygiene of infants; how to get birth certificates; choose five to eight of their members who
getting fathers to recognize their children and would make good counsellors and roughly one
accept responsibility. in eight Aunties has taken special training in
counselling of adolescents.The first part of the
Boyfriend
training looks at typical problems, their causes
refuses to use and ways to address them.The second part
condom:
provides communication and counselling skills,
including active listening, showing empathy
Insist on condom and offering guidance. The training course
lasts for five days and, unlike the basic train-
He refuses He agrees ing course, is delivered to groups of trainees
from a number of different places. It usually
Be careful, insist on takes place far from the villages or neigh-
use of condom at all
times bourhoods where most of the trainees live.

Propose STI and Provide knowledge

HIV tests in clinic about STIs and HIV
or hospital and how to avoid Find tool 3: Detailed modules for the 5-day
infection counselling training for Aunties in the internet
toolbox for his approach at
He refuses He agrees Follow up to be sure http://hiv.prg.googlepages.com/toolboxaunties
knowledge is retained
and being applied

Has had STI and

NO HIV tests If he grows tired of
SEX condoms and starts
to refuse

- +
Support him Yes (use condom for
safety and to avoid
pregnancy)

Be careful,
insist on use of
condom at all Provide advice
times on risky sexual
behaviour

Aunties role play a counselling session between an Auntie and a

Flow chart meant to help Aunties who advise teenaged mother
14 their peers.
Step 4: building local Aunties’ • Who qualifies as an Auntie (i.e., as an associa-
associations tion member); when do they cease to qualify
(e.g., when they get married or when they
In 2003, 160 Aunties (five from each local reach a certain age?)
association) took part in a three-day workshop
where they developed guidelines that are now • How to handle non-participation or infre-
provided in three documents with examples of a quent participation of members in meetings
constitution, an electoral code and internal rules. and other events

Find tool 4: Examples of an electoral code, internal • How to nominate and elect officers, qualifica-
rules and a constitution for an Aunties‘ association tion of officers (e.g., are some not qualified
and for a network of Associations in the internet because they do not participate enough, are
toolbox for his approach at
http://hiv.prg.googlepages.com/toolboxaunties
now married, are too old?), terms of office,
scheduling of elections.
These documents encourage them to fol-
low democratic and transparent procedures in
building and running their associations.
With democracy in mind, each local asso-
ciation is encouraged to provide its mem-
bers with space and time to study and
discuss the examples and then revise and
adapt them for their own purposes.They
are encouraged to give careful considera-
tion to these matters while they so do:

15
 Step 5: community, school and School interventions
individual interventions Interventions in any particular school typically
consist of a series of short presentations,
Once a local Aunties’ association is established covering different topics and given on different
and its members are trained and well known, days spread out over a school term or year.The
the Aunties’ are able to advocate, teach and personal testimony of the Aunties who give
counsel for sexual and reproductive health in these presentations is key to their success. It
the community and its schools and among establishes trust and rapport and gives emo-
individuals. tional impact to messages, so they are truly
heard and taken to heart. Students are often
Community interventions deaf to the words of older adults who try to
Each Auntie is encouraged to begin in her own talk to them about sexual and reproductive
family, talking to her sisters and other young health because they believe older adults
female relatives and helping them avoid falling cannot empathize with their feelings of sexual
into the same traps she fell into. She should attraction, desire and love but, instead, disap-
then reach out to young females in her own prove of such feelings and prefer to moralize.
immediate neighbourhood and in any church, The Aunties, by contrast, are around their own
sports, youth or other groups she may belong age and have already done the very things
to. older adults most fear girls and young women
might do.
Aunties share their experiences making these
interventions when they attend regular To give such testimony is not easy for most
association meetings.They also maintain open Aunties. Many are too shy to stand in front of a
lines of communication with the Aunties’ group of students and share personal experi-
Programme staff so they have somewhere to ences they would find hard to share even with
turn with questions they cannot answer or their closest friends. Only about one in 15 is
problems they cannot solve among themselves. willing and well suited to give such testimony
They are never left to fend entirely for them- and these are the ones provided with the tools
selves because the nature of their interventions for sex education in schools described earlier.
means there may be hostile reactions from See the boxes on Suzie’s and Nadége’s testi-
some individuals (e.g., boys who object to mony for typical content of the testimony
anyone trying to influence their girlfriends) given in school presentations.
and there may be need for an appeasement
mission by Programme staff.

16
 Suzie’s testimony
“When I was pregnant I did not know right away because my cycle was not
regular. I could see it this month but could not see it for another two months. I
wasn’t worried because I thought it was the same problem. So I just did as
usual until, after five months, I knew that I was pregnant. But before I knew it
myself, it was already a rumour everywhere. When I passed a group of my
friends in school, they started talking about me. Before that, we always played
together, strolled and came back into class together. Now, they left me alone.
I felt so lonely during break. When I heard our mothers talking about it, I real-
ised there was something in me. Before that, they had already informed my
grandmother. She started talking to me in parables but I could not understand.
Then when my elder brother knew he called me into the room and asked me.
It was very difficult for me to say yes. So I said no. I always said no.”

Nadège’s testimony
“There was a nearby neighbour who gave me private lessons. He was like a child
of my own house but when I went there for private lessons he made sexual ad-
vances. I was so naïve, I did not know anything. He forced me to have intercourse
with him. When I noticed that my menses were not coming, I wanted to tell some-
one but he asked me to hold off. I said if my parents notice, how will they react?
Later on, he started buying drugs for me to take. I took the drugs but nothing
changed. No abortion took place. At four months, I said I could no longer keep it
but it was too late. I was feeling weak but I was afraid to go to the hospital and, with naivety, I kept it.
It was at eight months when my parents noticed that I was pregnant.
“It was my uncle who was sponsoring me in school, though I did not know it. He arrived one night
and saw me making fire. He called for me. I answered and he punched me everywhere, beating me
until I lost my front tooth. I ran and slept away from the house that night. I was afraid to go home.
I endured it until my aunt bought a few things for the baby. I delivered under hard labour. I tore and
I was in a coma for two days. The baby weighed five kilograms.
“I had to stop school. I could not continue, so I obtained no certificate. All that was expected from
me was lost. I still haven’t gone back to school.
“After having my baby, I continued suffering because, with all that my parents had done for me,
they said they could not continue to take care of me and my child. One day, they droved me from
home and threw wood ash* on me at a crossroads … I did not even know the place.”
* In Nadège’s ethnic group, to throw wood ash on someone is to condemn them and cast them out.
Nadège was 17 years old and in the Third Form at school when she gave birth.

17
 Individual interventions Skilled Aunties backed-up by well-established
With training and experience at counselling, Aunties’ associations and reinforced by the
Aunties become recognized as “experts” Aunties’ Programme staff can be powerful
anyone in their communities can turn to with forces for the good in their communities,
sexual and reproductive health and related giving young people somewhere they can go
problems. In cases of pregnancy, both the girls for protection and letting others know that
and the boys who got them pregnant often exploitive or abusive behaviour may no longer
seek out Aunties for advice, especially if they be hidden from view and tolerated. Aunties’
are experiencing conflict in their homes due to associations are now learning that this is so
the pregnancy. Both girls and boys also seek and developing more systematic methods for
them out in cases of incest, rape and other keeping records, following up, monitoring and
forms of abuse and violence that are often kept reporting of cases.
secret in families and communities.

Personal counselling: a typical case involving a girl and her boyfriend

Aunties are encouraged to fill out reporting sheets after each counselling session, including each
follow-up session. The following example is taken from sheets completed by one Auntie in 2004:
Beatrice, an 18-year-old student, explains that her boyfriend wants to have sex with her and use a
condom. She has refused, saying that she is clean. She complains that maybe her boyfriend does
not love her and thinks she is a prostitute, if he has so little confidence in her. She worries that a
condom will reduce her sexual pleasure, could make her ill and might even make her barren.
The Auntie corrects Beatrice’s misconceptions about condoms, explains their advantages and
advises her to agree to her boyfriend’s request and always use condoms. She also asks Beatrice
to bring her boyfriend so they can talk things through together. In a follow-up session with Beatrice
and her boyfriend, he explains that he really loves Beatrice. He wants to use condoms, not be-
cause he doesn’t have confidence in her but because he does not want her to have an unwanted
pregnancy. He is a student, too, and does not want to father a child yet.
The Auntie tells them more about the advantages of using condoms, the importance of using them
for each and every time they have sex and the importance of checking to make sure the condom
is not past its expiry date. She also tells them about other methods of contraception they can use,
if Beatrice really does not want to use a condom, but tells them they should use other methods
only after they both have been tested for HIV and other sexually transmitted infections and only
if the tests come out negative. If either of them tests positive, then they should always use
condoms.
At the end of the session with her boyfriend, Beatrice agrees to using condoms from now on.

18
Step 6: spreading the word through the This all means that a certain amount of
media ongoing technical support from the Aunt-
ies’ Programme staff is essential but that the
A newspaper feature on an Aunties’ association, amount can be gradually reduced. During the
a radio interview with an Auntie or the per- first year after a new Aunties’ association is
sonal testimony of an Auntie on television – all established, Programme staff meet with the
of these are good ways of informing the association once every trimester to review
general public about the realities facing young progress, discuss problems and find solutions.
people in the Cameroon of today and about During the second year, they meet with the
things that can be done to prevent unwanted association once during each semester. After
pregnancy and infection by HIV and other that, they meet once per year.Throughout the
sexually transmitted diseases.The media also year, Programme staff is available for consulta-
provide opportunities to shed light on largely tions by telephone and these are becoming
hidden problems such as incest, rape, clandes- ever easier with the spread of mobile phones.
tine and life-threatening abortion, female When serious problems arise, previously
circumcision, and breast ironing. unscheduled meetings can be arranged.

Step 7: on-going management and monito- Relations among association members

ring and evaluation Relations among members, including the need
for teamwork and conflict resolution, are
Before they form Aunties’ associations, most discussed at all regular meetings between
unwed young mothers have never belonged to Aunties’ associations and Aunties’ Programme
formal organizations with constitutions and staff.Typical agenda items include “power
other rules and regulations.This means that the games” among members, absenteeism, other
associations are highly vulnerable to members failures to perform by the elected officers, and
making mistakes, having misunderstandings misunderstandings regarding the roles of
and getting into conflict. Most unwed young elected officers and the regulations governing
mothers also lack experience at setting goals, their behaviour. Such problems are particularly
developing plans of action, implementing frequent and acute during the first year but
those plans and monitoring and evaluating the they serve the purpose of helping members
results. understand the importance of upcoming
elections and the nomination of the best
candidates for officer positions.

Resolving a conflict concerning mobile phones

All associations are given a mobile phone and a monthly budget allowing them to communicate
regularly with staff at the Programme office. In some associations, these phones proved to be
sources of conflict. They were a novelty and rare luxury and there was resentment and jealousy
when some members were seen to be getting more than their fair share of time using the phones.
Phones given to some associations disappeared and there were suspicions and accusations all
around. An annual general assembly of representatives from all Aunties’ associations agreed to
make presidents of local associations ultimately responsible for loss or damage of phones and to
penalize them with 50% of the cost for replacement or repair of phones.

19
 Planning, implementation and monitoring and Inputs
evaluation ✖ Numbers of educational materials, con-
Building capacity to plan, implement and doms,“morning after” pills and so on that
monitor and evaluate programmes is the other were distributed during the year
main topic of discussion at all regular meetings
between Auntie’s associations and Aunties’ Process
Programme staff. Associations are encouraged ✖ Numbers of girls and young women given
to develop simple goals, plans of action and basic training, tools for school interven-
monitoring and evaluation procedures. tions and training for personal counselling
✖ Numbers of interventions in the commu-
At the end of the first year of an associa- nity and its schools and among individuals
tion’s operations, Programme staff facilitates
participatory evaluations using the simple Outputs
SWOT (Strengths, Weaknesses, Opportunities ✖ Any before and after numbers that may be
and Threats) method for assessing past per- available, e.g., the number of school girls
formance and challenges ahead. For subse- who became pregnant in the year before
quent years, associations are urge to identify and the year after they attended presenta-
a simple set of indicators for monitoring tions by an Aunties’ association.
progress on implementation of their plans of
action. A typical set of core indicators includes:

20
Achievements

More than 140 associations with trained National Network of Aunties’

Aunties Associations

By 2003, two years after GTZ launched the In August 2005, the Réseau National des
Aunties’ Programme, there were 23 local Associations de Tantines (RENATA) or National
Aunties’ associations and they were having Network of Aunties’ Associations was launched
such positive impacts that GTZ decided to at a general assembly of representatives from
accelerate the recruitment and training of new all local Aunties’ associations. RENATA has a
Aunties and the establishment of new associa- website (www.tantines.org), publishes English
tions. By June 2007, there were 141 local and French versions of a newsletter and
Aunties’ associations spread across eight of spearheads nation-wide campaigns to promote
Cameroon’s ten provinces and plans were the sexual and reproductive health of young
afoot to establish associations in the two people.These campaigns appeal to political
remaining provinces before the end of 2007. authorities and the general public to put an
end to the gender inequality and sexual abuse
Almost 60% of all unwed young mothers and exploitation of girls that puts them at high
who are identified and interviewed during the risk of early and unwanted pregnancy and of
recruitment process actually follow up and infection by HIV and other sexually transmit-
take the basic training and join local Aunt- ted disease. Since early 2006, RENATA has been
ies’ associations.The table below shows the leading a national campaign against breast
numbers who took basic training during the ironing.
first six years of the Programme, the numbers
who went on to take additional training for sex
education in schools before it was replaced by
a simple set of tools for the most active Aunties,
and the numbers who went on to take addi-
tional training for counselling of adolescents.

Numbers of unwed young mothers

provided with training, 2001-07
Year Basic for school for
training programmes counselling

2001 77 43
2002 213 55
2003 2213 94
2004 481 43 211
2005 1251 42 212
2006 1637 0 279

total 5872 277 702

21
 Impacts on trained Aunties • 43% said they attended meetings of their
Aunties’ associations regularly, 28% irregularly
A recent survey of trained Aunties and 29% never.
In late 2006, the Aunties’ Programme conduct-
ed a survey covering 802 trained Aunties in the • 30% had taken additional training for sex edu-
eight provinces that have local Aunties’ associa- cation in schools or personal counselling.
tions (Ndonko F, 2007). Interviewers gave
interviewees blank questionnaires, which
asked for no information that might identify
them, and asked them to fill these out and seal
them in unmarked envelopes. (The interview-
ers filled out the questionnaires if the inter-
viewees could not read or write.) The results
showed that the 802 Aunties had the following
characteristics:

• They ranged in age from 15 to 35 and had a

median age of 22; 16% were 15-19 years old;
56% were 20-24; 23% were 25-29 and 4%
were 30-35. (The Programme aims to recruit
unwed mothers who become pregnant in
their teens but they are often older than that
when they are recruited and, of course, they
continue to grow older as they remain
members of Aunties’ associations. Local
associations usually have rules that restrict
older members from holding executive
positions and that may also require them
withdraw from membership when they reach
a certain age.)

• 52% had one child, 46% had from 2 to 6

children, 2% had lost their children, and the
average was 1.6 children per Auntie.

• 6% had no schooling, 35% some primary Auntie Madeleine Songo, elected by her association to
attend a workshop in Germany
education, 58% some secondary education
and 1% some tertiary education.

• 25% were unemployed, 18% students, 17%

agricultural workers, 12% commercial
workers, 9% clothing makers, 8% hair dress-
ers, 2% employees or operators of telephone
call boxes, 9% other.

22
Impacts on their behaviour and sexual and the question and the answers did not
reproductive health make this sufficiently clear.)
The survey found the following patterns and
trends in behaviour and sexual and reproduc- ✖ Of those who acquired an STI, 8% bought
tive health among the 802 trained Aunties medicine from street vendors (who often
interviewed: sell counterfeit or fake drugs), 9% in a
pharmacy and 69% in a hospital while 11%
Condom and other contraceptive use self-medicated or did something else and
✖ Before training as Aunties, 26% always used the remaining 11% did nothing.
condoms. Since training condom use is
27% among those who attend Aunties’ HIV testing
association meetings sporadically, 47% ✖ Before training as Aunties, 39% had been
among those who attend regularly, and tested for HIV. Since training, 48% have
50% among those who have taken addi- been tested. (A similar survey conducted
tional training for counselling of adoles- in 2004 found that only 39% had been
cents. tested after training as Aunties.)

✖ During their last sex, 52% used condoms; ✖ In early 2007 – after the survey – the
36% always use them, 49% often do and Aunties’ Programme began offering
15% never do. voluntary and confidential HIV counselling
and testing to Aunties who attend training
✖ The proportion always using condoms courses for counselling of adolescents.This
varies from a low of 10% in one province new offer was spurred, in part, by the
to a high of 57% in another. (Efforts are promise that antiretroviral therapy would
underway to strengthen training and soon be offered for free to those who need
Aunties’ associations in provinces where it. Before this promise, it was difficult to
low percentages always use condoms.) motivate people to go for counselling and
testing. Reasons that counselling and
✖ 8% have taken a “morning-after” pill after testing are not provided in conjunction
unprotected sex, in order to prevent with basic training include that it takes
pregnancy. place where the trainees live.These
locations lack facilities and personnel able
Sexually transmitted infections (STIs) to provide counselling and testing and
✖ Since training as Aunties, 13% have ac- they also raise the Aunties’ anxieties about
quired an STI. (This is a considerable breaches of confidentiality.The fact that
improvement since 2004, when a similar training courses for counselling usually
survey found that 26% had acquired an STI take place far from where the trainees live
since training as Aunties.) makes it easier to assure Aunties that
confidentiality is guaranteed. So far, from
✖ Of those who sometimes or never use 87% to 92% of trainees have accepted the
condoms, 15% have acquired an STI. Of offer of HIV counselling and testing and
those who always use condoms, 8% have from 95% to 100% have returned to get
acquired an STI. (The latter result probably their results after tests. Of the first 164
means they started systematic use of Aunties tested, 10% were found to be HIV-
condoms after acquiring an STI, though positive.

23
 Socio-economic impacts Numbers of Aunties who received
The survey of 802 Aunties found that: honorariums, fees, free medicines

• Since training as Aunties, 19% have returned

to school. Of those who were less than 20 2004 2005 2006
when they quit school due to pregnancy, 36%
Honorariums
have returned to school.
and fees:

• 63% have taken other action to improve their � 100 207 212 283
economic prospects, such as working in � 200 to � 500 23 30 50
agriculture, serving an apprenticeship,
� 1.000 or more 7 7 9
entering a business or taking a part-time job.
Free medicines:
On average, unwed young mothers are among � 5 to � 20 20 212 283
the poorest of the poor in Cameroon.They
� 20 to � 100 0 4 10
have an estimated average annual income of
less than the equivalent of 500 to cover the more than � 1.000 0 0 1
annual cost of living for themselves and their Payments for
45 96 206
children. baby-sitting

While the Auntie’s Programme calls for

volunteerism, it provides honorariums to sup-
port some of the poorest while they partici-
pate in training or other activities associated
with their duties as Aunties. It may also pay
fees to those who are skilled and experi-
enced at sex education in schools or personal
counselling if they are asked to do more than
might normally be expected of a volunteer. In
addition, it provides some of the poorest with
free medicines and free-baby sitting while
they are participating in training or other
activities. It makes payments directly to the
baby-sitters, who are usually trained Aunties.

The Programme estimates that, over the

past three years, roughly 14% of all trained
Aunties earned additional income from
fees or honorariums for training and other
activities or received free medicines.

24
The benefits of being Aunties, in their own words These are just three of many recorded reports
The survey of 802 Aunties found that 75% were where Aunties talk about the benefits they
very satisfied with the training they had have derived, personally, from being Aunties:
received, while 23% were moderately satisfied
and 2% were not at all satisfied. Asked about
their duties as trained Aunties, 64% said they
were very satisfied, while 30% said they were “When I got pregnant I lost all
hope. I didn’t go to school for
moderately satisfied and 6% said they were not
two years. Then I registered in
at all satisfied. evening courses just to waste
time. After I trained to become
Unwed young women who have children an Auntie, I understood that all
generally find themselves in miserable situa- was not lost. I switched to take
tions. If they are not condemned and cast out courses full time during the day
and prepare for exams.”
entirely, they find themselves dependent on (Myriam Anaël Njeulong) Auntie Myriam
their parents and other relatives, who treat and her son

them and their children as unwelcome bur-

dens and who constantly remind them that
they have failed in their responsibilities and let
everyone down. When unwed young moth- Before I was only looking for
goods, clothes, no other plans
ers return to their families as trained Aunties, in mind. Now I want to study
their newly learned ability to speak about and be someone.”
their own mistakes and talk frankly about (Marie Noelle)
the kinds of behaviour that have got them
into trouble gain them respect and trust and
Auntie Marie Noelle, one of the 1% of all
other family members turn to them to talk Aunties now studying at university.
about their own troubles.There is consider-
able anecdotal evidence that, as they become
more accepted by other family members,
their children also become more accepted. After I was on television my
family and the neighbours went
crazy. Everybody wanted to talk
to me, to listen to me.”
(Madeleine Songo)

Auntie Madeleine Songo

25
 Impacts on other young people While there is no systematic monitoring and
evaluation to measure the impacts of school
Through sex education in schools and counsel- presentations, anecdotal evidence indicates
ling of adolescents, Aunties help girls and that there are significant declines in the
young women avoid unwanted sex, resist the incidence of new pregnancy among female
advances of boys they find tempting and take students after they and their male classmates
appropriate precautions when they decide to have been exposed to a series of Aunties’
have sexual relations.They provide similar presentations. In one community’s schools, 30
assistance to boys and young men but, in their girls dropped out due to pregnancy the year
case, Aunties are perhaps most effective at before Aunties made presentations and no girls
helping them understand things from the dropped out due to pregnancy the year after.
perspectives of their female partners or
potential partners. (The Aunties’ Programme In 2005, a study focused on six Aunties’
focuses mainly on empowering girls and young associations and the volunteer work of 30
women but creates an environment for Aunties trained for counselling adolescents. On
positive behaviour change by boys and men.) average, each of them had counselled 13
individuals over the 10 months immediately
Aunties make their school presentations following their training. Assuming that Aunties
in pairs and it is roughly estimated that a pair trained for personal counselling cover an
of Aunties covers an average of 160 to 200 stu- average of 15 individuals each per year, the 702
dents per year. By the end of 2006, there were Aunties trained by the end of 2006 could
477 Aunties trained to make presentations provide personal counselling to a total of more
and a potential of covering from 38,000 to than 10,500 people per year.
48,000 students per year.The reports teachers
fill out during or after presentations provide The study found that 53% of all individuals
ample evidence that they think students who asked for personal counselling were
respond enthusiastically to most presentations concerned either about how to avoid pregnan-
and the presentations have strong and last- cy or how to deal with it when it occurred.
ing impacts on the students’ behaviour. Here Another 16% came to the Aunties with men-
are two examples, taken from actual reports, strual problems, while 11% were concerned
of typical observations made by teachers: about difficulties in communicating with their
parents and 8% were concerned about rape.
‘The lecture on ‘early and unwanted pregnancies’ to the Form The Aunties’ advice often focused on the
One students was well presented. It was heavily attended by benefits of using condoms and how to use
the students, who paid close attention and demonstrated
that they understood the subject matter. This could be easily
them properly. Some girls were given “morn-
seen from the questions they asked and the good answers ing-after” pills and others received support in
they received. The lecture itself plus the attitude of the stu- bringing their pregnancy to early and safe
dents proved that many such lectures are necessary.’ termination, usually with the cooperation of
the boy or man involved. In a few instances,
‘The lecture on ‘Early and unwanted pregnancies’ at this time the entire association had supported girls in
of the year is a welcome relief, as students are preparing to getting safe abortions and even in laying
go on Christmas vacation. It will help the students resist the
sexual temptations and pressures that are often associated
charges against rapists.
with the season’s celebrations. I wish to encourage the Aunt-
ies in their social work to help change our community. Good
luck. God bless the Aunties’ Association.’

26
Impacts on families and communities Low and sustainable costs

Trained Aunties and their local associations and The Germano-Cameroon Health and AIDS Pro-
national network are breaking the taboo on gramme estimates that the cost of providing
talking openly about sex in Cameroon. In so basic training to Aunties varies from the equiva-
doing, they are making it possible for families lents of € 2 to € 20, depending on the travel,
and communities to face up to realities that accommodation and other costs that may be
have too often been kept hidden in the past. incurred by trainers and trainees.The cost of
One such reality is the kind of gender inequal- providing training for counselling of adoles-
ity that enables boys and men to go unexposed cents varies from the equivalent of € 168 to €
and unpunished for the sexual exploitation and 248.The costs are kept low by the voluntary
abuse of girls and women, while the girls and nature of the Aunties’ Programme and the fact
women they exploit and abuse often pay that it asks national ministries, local authorities
extremely high prices that may include and other partners to make donations in kind,
unwanted pregnancy, forced marriage, removal including donations of venues for meetings
from school, harm from unsafe abortion, being and training courses and donations of profes-
left on their own to support children they can sional staff to serve as senior trainers.
ill afford to support, or being condemned and
cast out by their families, friends and communi- The slow, careful step-by-step process of
ties. Another reality is the worldwide youth building a whole network of local Aunties’
culture that exposes young people everywhere associations has been the key to its cost-ef-
to the risks of early sexual initiation, sex before ficiency and sustainability.There is now a
marriage and multiple sexual partners. large cadre of trained, experienced and highly
skilled Aunties who can do much of the train-
The result is families and communities ing of new recruits and of Aunties who wish
that are more open, tolerant, empathetic and to take additional training. At the same time,
compassionate.They take steps to protect the demonstrated success of the whole Pro-
their young people from harm and to provide gramme has made partners ever more willing
them with safe and nurturing environments in to be generous in their in-kind donations.
which they can explore their sexual feelings
while learning safe sexual behaviour. In this
emerging new environment it is becoming
more possible to put a stop to forced incest,
rape and female circumcision.The Aunties’
campaign against breast ironing is a particu-
larly notable achievement. It brought to the
light of day an abhorrent practice that was
very common but deeply secret and, in so do-
ing, it promises to put a stop to that practice.
It demonstrates the potential of the Aunties’
self-help-and-empowerment approach to
insist on government action to recognize and
protect the rights of young people, including
their right to sexual and reproductive health.

27
 Challenges

To improve recruitment methods tors of the gender discrimination and sexual

exploitation and abuse that imperil the sexual
On average, around 60% of all unwed young and reproductive health of girls and young
mothers interviewed during the recruitment women. How to reach males with appropriate
process show up for basic training but, from messages and change their attitudes and
location to location, the percentages vary from behaviour is an ongoing challenge.
30% to 80%. Sometimes rumours precede the
arrival of the recruitment team, creating To speed up social change
misconceptions about the whole Aunties’
Programme and hostile opposition from Intended mainly to address the problem
religious leaders and others. Experience has of unwanted teenage pregnancy, the Aunt-
shown, however, that success at recruitment ies’ Programme has empowered marginalized
depends largely on the quality of the recruit- young women and given them the capacity
ment team. Members of the team should be to address many other problems for example,
skilled and empathetic interviewers and sexual harassment, intimidation and rape by
communicators, ready to listen and answer security forces and other males in positions
questions and able to explain and generate of authority and by male medical personnel. It
enthusiasm for the Aunties’ Programme. has also gained the enthusiastic support of key
Improving recruitment is an on-going chal- government ministries.The Aunties’ Programme
lenge but one being met by the growing cadre has the potential to be a powerful tool for so-
of trained, experienced and highly skilled cial change, including the full recognition and
Aunties who participate in recruitment teams. enforcement of the equal rights of girls and
women to health, education and employment
To drive home messages so they change and to non-discrimination in the workforce and
behaviour elsewhere in society. Realizing that potential
will require high levels of commitment and
Another on-going challenge is to drive home collaboration by many sectors of government,
messages so that people hear them clearly, take civil society and private business and industry.
them to heart and act upon them by, for
example, using condoms consistently when
engaging in risky sex.This challenge is being
To improve monitoring and
met by on-going monitoring and evaluation evaluation
and efforts to improve the training of Aunties The Germano-Cameroon Health and AIDS
and strengthen their local associations and Programme has been consistent in trying incor-
national network. porate monitoring and evaluation into the
Auntie’s Programme. However, there is consid-
To reach out to males erable room for improvement.The systematic
use of before-and-after questionnaires would
For a number of reasons (e.g., the tendency of be one way of measuring the extent to which
young males to dominate and be disruptive in information is absorbed and behaviour is
groups and the fact that the consequences of changed as a result of training provided to
pregnancy outside of marriage are generally Aunties’ and the sex education and personal
less serious for males than for females), the counselling they provide to others.The after
practice of recruiting young fathers and questionnaires might be applied some months
training them as “Uncles” was dropped from after, in order to measure retention of learning
the Aunties’ Programme in 2004. However, it and lasting changes in behaviour.
remains true that males are the main perpetra-
28
Lessons learned

Keep it simple for the fact that recruits will grow older during
The first objective of the Aunties’ Programme is their three or four years as Aunties. Experience
to provide unwed young mothers with the in Cameroon has shown, however, that there is
knowledge, skills and social support they need a real danger that older mothers will use their
to take care of their own sexual and reproduc- greater experience and self-confidence to
tive health and otherwise look out for their control a local Aunties’ association and cause
own interests and that of their children.The younger mothers to withdraw. In addition,
second objective is to empower other young older mothers are not perceived as peers by
people with knowledge and skills to take care teenagers and so lose the advantage younger
of their own sexual and reproductive health. mothers have when providing sex education
That’s it.There should be no other objectives. or personal counselling to teenagers.
Giving into the temptation to add on more will
threaten the voluntary nature of the Aunties’ Stay focused on the immediate vicinity
Programme, burdening the Aunties with too Initially, trained Aunties were encouraged to
many responsibilities and requiring that they reach out to communities far from their own
be given more training and supervision and be and were given travel allowances to do so. It
paid for all the time required of them.That will soon became apparent that they preferred to
call for levels of technical and financial support travel rather than stay near home.This not only
that will be difficult to achieve and impossible deprived their own communities of their
to sustain. services but it called for burdensome account-
ing procedures and it increased costs substan-
Think short-term tially and threatened the sustainability of
Unwed young mothers are not young for long. Aunties’ associations. Now the strong prefer-
The Aunties’ Programme can provide them ence is that Aunties provide services within
with the training, skills and support they need walking distance of their own homes or, at
to carry them through a short period of their most, within distances they can reach by
lives until they are ready to move on.Their arranging for free lifts.
position as Aunties is voluntary, part-time and
temporary and should be expected to last for Emphasize empathy, not moralizing
three or four years at most. GTZ provides Initially, some trained Aunties misunderstood
technical support to any one local Aunties’s that the intention was to advocate abstinence
association for three or four years at most, too. as an option and not the only acceptable
After that, the association should be self- option. Some were observed shouting at
supporting and GTZ’s limited resources go teenagers to stop if they saw them flirting.The
toward helping other associations get launched training should make it clear that one of the
and well-established. things Aunties have to offer is that they have
made their own mistakes and other young
Give first priority to teenagers people will be most inclined to listen to them
Unwed teenage mothers are the main target if they tell their own stories and open the
group and other teenagers are the second doors for the other young people to tell their
target group. While the programme should be stories too. Aunties should explain the risks
flexible and allow for the recruitment and involved in certain behaviour and the options
training of unwed young mothers who got for avoiding those risks but should understand
pregnant when they are teenagers but are now that scolding and moralizing are the very
somewhat older, it should give first priority to things that stop young people from listening to
teenagers.The programme should also allow older people or confiding in them.

29
 Provide strong support at the beginning As well as providing trained Aunties with
After basic training, new Aunties should be opportunities for further training and experi-
accompanied by staff or more experienced ence at making presentations in schools and
Aunties. At first, giving personal testimony and doing personal counselling, the Programme
other aspects of their work can prove a real provides some of them with opportunities to
challenge and expose them to personal participate as members of recruitment teams
comments and criticisms which may be and training teams.There are now small cadres
difficult for them to accept and digest.They of Aunties who have become highly skilled at
need back-up support and coaching until they doing the interviews involved in recruitment
acquire the confidence and skills to proceed and at helping to provide basic training and
on their own. After additional training for additional training for counselling of adoles-
counselling, Aunties should again be accompa- cents.
nied by staff or other Aunties already experi-
enced at counselling.This will ensure that they Though the emphasis is on volunteerism, the
learn to apply the communications and other experience in Cameroon has shown that small
skills covered by their training. financial rewards can also provide significant
motivation. Most Aunties are very poor and the
equivalent of one Euro is more than half of
Diminish support gradually but provide reliable their normal daily income. It can be especially
lines of communication important to ensure that they do not lose
As newly trained Aunties acquire confidence opportunities to earn income if they partici-
and skills, they should be accompanied less pate in training or in activities associated with
and less until they can work on their own. their roles as Aunties.
However, Aunties and their local associations
need to be assured of ready access to support
and advice from programme headquarters and
this is made increasingly possible with mobile
phones and computers. Crises and emergen-
cies are not uncommon and these may occa-
sionally call for site visits by programme staff.

Provide new experiences and motivation

Aunties work as volunteers, without pay, and
the training they get is not an obvious path to a
career. Without immediate or future financial
rewards, Aunties need other kinds of motiva-
tion and these can come from new and
stimulating experiences such as periodic
refresher courses, participation in radio or
television shows or visits to Aunties’ associa-
tions in other communities. Opportunities for
personal growth and acquiring skills at human
relations and communications can also provide
motivation.

30
German HIV Peer Review

The German HIV Peer Review Group has set

out a number of criteria (see p. 3) at least some
of which must be met to qualify approaches
developed in the context of German develop-
ment cooperation for publication in its HIV
Practice Collection. The Aunties’ Programme in
Cameroon meets most of these criteria.
Specifically, it is innovative, cost-effective,
sustainable, participatory, empowering, and
well-documented and it demonstrates gender
awareness. There is room for improvement in
its monitoring and evaluation methods but they
produce sufficient evidence to show that it is
effective and successful in reaching toward its
objectives.

It is also transferable, not just from locality to

locality with Cameroon but also to other
countries, many of which have traditions and
contemporary situations not very unlike those
found in Cameroon. It is an approach that
could be initiated by a government ministry, a
multilateral or bilateral agency or a non-
governmental organization and then reinforced
through partnerships. It has the potential to
make significant contributions toward achieve-
ment of the eight inter-related Millennium
Development Goals. It reaches toward four of
those goals in particular: gender equality and
empowerment of women, reduction in child
mortality, improvement of maternal health, and
reduced infection and harm by HIV and other
disease.

Aunties from different associations singing at a meeting.

31
 Tools
The following tools and materials were developed in the course of this project
and can be downloaded at

http://hiv.prg.googlepages.com/toolboxaunties

• Tool set 1: A questionnaire for a situation analyis and a guide

for focus group discussions on same
• Tool set 2: Detailed modules for the 3-day basic training for Aunties
• Tool set 3: Detailed modules for the 5-day training for counselling
• Tool set 4: E
 xamples of an electoral code, internal rules and a constitution
for an Aunties‘ association and a network of associations

32
Bibliography

Institut National de la Statistique and ORC

Macro (2005). Enquête démographique et de
santé Cameroun 2004, Juin.Yaoundé and
Calverton, Institut National de la Statistique
and ORC Macro.

Ndonko F (2005). Empowerment of Aunties

on sexual and reproductive health: How to
realize the Millennium objectives of develop-
ment in the community. Yaoundé, Programme
Germano-Camerounais de Santé/SIDA.

Ndonko F (2007). Etude de suivi des Tantines

au Cameroun.Yaoundé, Programme Germano-
Camerounais de Santé/SIDA.

Ndonko F (2007). Synthèse des activités du 1er

semester 1007.Yaoundé, Programme Germano-
Camerounais de Santé/SIDA.

Ndonko F and Ngo’o G (2006). Etude sur le

modelage des seins au Cameroun.Yaoundé,
Programme Germano-Camerounais de Santé/
SIDA.

UN (2004). World Youth Report 2003:The

global situation of young people. New York,
United Nations.

UNDP (2006). Human Development Report

2006. New York, United Nations Development
Programme.

World Health Organization (2006). World

Health Report 2006. Geneva, World Health
Organization.

33
 Acronyms and Abbreviations

AIDS Acquired Immune Deficiency Syndrome

BMZ Germany’s Federal Ministry for Economic Cooperation and Development

DHS Demographic and Health Survey

GDP Gross Domestic Product

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit

HBC Home Based Care

HIV Human Immune Deficiency Virus

InWEnt Internationale Weiterbildung und Entwicklung GmbH

NGO Non Government Organisation

RENATA National Network of Aunties’ Associations

STI Sexually Transmitted Infection

SWOT Strengths, Weaknesses, Opportunities and Threats

UN United Nations

UNAIDS United Nations Programme on HIV/AIDS

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

VCT Voluntary Counselling and Testing

WHO World Health Organisation

34
Contacts and credits

Published by Contributing consultant

The German HIV Peer Review Group Regina Görgen (evaplan Ltd.)
Project ‘Strengthening the German
contribution to the global AIDS response’ Writer
Stuart Adams
Responsible: Dr. Thomas Kirsch-Woik
Deutsche Gesellschaft für Photographs
Technische Zusammenarbeit (GTZ) GmbH Flavien N’donko, Regina Görgen,
Dag-Hammerskjöld-Weg 1-5 Patrick Grippe, Véronique de Viguerie
65760 Eschborn / Germany
E [email protected] Contact at the GTZ HIV Peer Review Group
I http://hiv.prg.googlepages.com/home E [email protected]
I http://hiv.prg.googlepages.com/home
Contact at GTZ
Health, Education and Social Protection Division Design and Production
Supraregional Project ‘Population Dynamics, Metzgerdruck, 74847 Obrigheim/Germany
Sexual and Reproductive Health and Rights’
E [email protected] Eschborn, first edition: July 2007, this edition:
I www.gtz.de/srh December 2007

Contact at InWEnt -
Internationale Weiterbildung
und Entwicklung gGmbH
Capacity Building International, Germany
Ursula Schoch
Friedrich-Ebert-Allee 40
53113 Bonn, Germany
I www.inwent.org

Contact Person in the Federal Ministry for

Economic Cooperation and Development (BMZ)
Fr. Martina Metz, Section 311
E [email protected]

Author and responsible GTZ expert:

Flavien N’donko
E [email protected]

35
 The Deutsche Gesellschaft für Technische
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owned corporation for international cooperation
with worldwide operations GTZ‘s aim is to
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