Youth-Friendly Health Services in Malawi: Do Youth Know of and Use These Services?

Publication date: 2015

HEALTH POL ICY P R O J E C T YOUTH-FRIENDLY HEALTH SERVICES IN MALAWI DO YOUTH KNOW OF AND USE THESE SERVICES? March 2015 Introduction There are approximately 5 million young people in Malawi between the ages of 10 and 24.1 They represent a diverse generation that needs a range of sexual and reproductive health (SRH) information and services to match their lifecycle stage. In 2007, to promote high- quality SRH services for young people, the Malawi government launched the Youth-Friendly Health Services National Standards and Youth-Friendly Health Services2 (YFHS) program. From 2013–2014, the Ministry of Health Reproductive Health Directorate (MOH-RHD)—with assistance from the USAID-supported Evidence to Action project and the Centre for Social Research, University of Malawi—conducted its first comprehensive evaluation of the YFHS program to assess its scope, quality, and outcomes since the inception of the YFHS standards. It also analyzed young people’s awareness and use of YFHS, in order to determine coverage of the YFHS program and youth satisfaction with the YFHS package. The evaluation was conducted in 10 districts3 across the five health zones, with both qualitative and quantitative components. Brief Health Policy Project, Futures Group Youth-friendly health services (YFHS) are a key component of Malawi’s National Sexual and Reproductive Health Program and will help facilitate the attainment of Malawi’s FP2020 commitment to achieve a 60 percent contraceptive prevalence rate, with a focused increase among those ages 15–24 years. Managing the performance of the YFHS program is one aspect of safeguarding young people’s transition into adulthood and improving health indicators for 5 million people in Malawi. This brief, prepared by the USAID-funded Health Policy Project, summarizes the evaluation report’s findings on young people’s knowledge and use of services to help inform future planning and implementation by policymakers and stakeholders. 2 March 2015 Awareness and Use of YFHS4 Awareness of the YFHS program is low, with less than one-third of community youth survey respondents reporting to have ever heard about YFHS and only 13 percent reporting to have ever used YFHS (see Figure 1). Almost 70 percent of youth knew a place that offers health services to youth, whereas only 24 percent knew of a designated YFHS delivery point (in communities where there were no designated YFHS delivery points, this dropped to 19%). In addition, the majority of parents interviewed expressed having little knowledge of the nature of YFHS. These data suggest poor links and coordination among the service delivery points, the YFHS program, and surrounding communities. Young people who listened to the radio at least once per week were more aware of the YFHS program. However, some youth respondents perceive the YFHS program mainly in terms of the provision of contraceptive methods, especially condom distribution. In communities where the local health facilities were implementing YFHS, youth residing in that area had only a slightly higher awareness of the services, suggesting that health facilities are not adequately promoting them. Awareness and use of YFHS increased with age and was higher among males, sexually experienced youth, out-of-school youth, and those who have attained secondary education or higher education than their counterparts. This suggests that where young people are in their lifecycle plays a significant role in their knowledge and use of YFHS. Sources of Information on YFHS Understanding the common sources of information for the YFHS program can help in developing strategies to strengthen channels of communication, address misconceptions among youth, and collect user feedback on YFHS. This, in turn, would stimulate increased awareness and use of the services. Young people reported receiving information on YFHS mainly from three sources: (1) friends or peers;5 (2) sign posts or posters visible within the healthcare facilities; and (3) the radio and local media through special programs and announcements. Although youth clubs, schools, and community-based distribution agents were not top sources of information for young people, the evaluation found that each source still makes notable contributions to the provision of accurate and timely information on YFHS (see Figure 2). Knowledge of YFHS Of those who had heard of YFHS, 72 percent were able to identify one or more services offered under YFHS. The most prominent services mentioned were HIV and AIDS testing and counseling (53%), contraceptive counseling (46%), provision of contraceptives (57%), and prevention, diagnosis, and treatment of STIs (22%). Figure 1. Awareness and Use of YFHS Know a place where health services are provided to youth in their locality Have ever heard of YFHS Know where to obtain YFHS Have ever been to a YFHS delivery point 80 70 60 50 40 30 20 10 0 Community with YFHS facility Community without YFHS facility Total % o f r es po nd en ts 68 70 70 34.5 24.5 32 26 19 24 13 11 13 3 YFHS in Malawi: Do Youth Know of and Use these Services? Utilization of Services The majority (62%) of community survey respondents who ever visited a YFHS delivery point did so for the first time in the 12 months preceding the survey. The three most popular services were obtaining contraceptives, HIV testing, and general counseling (see Figure 3). Almost 60 percent of all last visits were in public health facilities; the reach of the private sector and nongovernmental organizations is limited. About 9 in 10 YFHS users reported receiving the desired services and were satisfied with the service during their last visit to a delivery point. However, fewer than half of the clients perceived the services to be of good quality. Some respondents, especially unmarried females, said they were uncomfortable accessing YFHS, as they believe it is meant for married youth. Barriers to Accessing YFHS Although Malawi’s YFHS program was initiated in 2007, only 13 percent of youth respondents had ever used the services. Access to YFHS is higher when young people are informed of the availability and benefits of the services. Likewise, when parents and communities are well informed about YFHS, they can encourage young people to seek the services. Yet, the evaluation revealed several key barriers6 to accessing YFHS, including ƒ Low self-confidence among clients and “shyness,” especially among girls ƒ Long distances to the nearest health facility ƒ The condition that youth receive HIV testing and counseling before accessing other services in some health facilities ƒ Lack of knowledge about the services and where they are delivered ƒ Lack of drugs and other medical supplies ƒ Denial of access to services by parents/church ƒ Lack of privacy and confidentiality ƒ Lack of financial resources and infrastructure ƒ Lack of youth participation in the design and implementation of the activities Addressing these barriers will be crucial to increasing coverage of YFHS among the 5 million young people in Malawi. Key Questions to Improve YFHS Poor awareness and use of YFHS is hindering overall YFHS program effectiveness. Stakeholders must leverage opportunities and appropriate strategies to increase access to age-appropriate, comprehensive sexuality education and increase awareness of all the YFHS program components among young people, in an effort to improve the YFHS program’s efficiency. Figure 2. Sources of YFHS Information 50 40 30 20 10 0 % o f r es po nd en ts Community respondents Exit interview clients 10 24 3 3 3938 13 10 3 1.5 13 10 20.5 27 19 16 7 4 1 11 3 20 0 0.2 00 0 Loc al me dia Pa mp hle ts/ Po ste rs Fri en ds /P ee rs Co mm un ity m em be rs Pa ren ts Sc ho ol so cia l g rou ps /c lub s He alt hc are de liv ery sy ste m Ra dio Co mm un ity -ba sed yo uth or ga niz ati on s Int ern et Ch urc h/ mo sq ue Sc ho ol Ot he r He alt h s urv eil lan ce as sis tan t March 2015 4 As stakeholders design interventions to strengthen the health system and improve implementation of YFHS in Malawi, several key questions should be addressed: ƒ How do we increase awareness and knowledge of the YFHS package among youth, guardians, and communities? ƒ How can traditional communication channels and the media, including peers, be used to promote and sustain an effective YFHS program? ƒ How can we address the key barriers youth experience in accessing YFHS? Notes 1. Malawi National Statistical Office. 2008. 2008 Population and Housing Census. Available at: http://www.nsomalawi.mw/2008- population-and-housing-census/107-2008-population-and- housing-census-results.html. 2. Youth-friendly health services are high-quality services that are relevant, accessible, attractive, affordable, appropriate, and acceptable to young people, as defined by Malawi’s Youth- Friendly Health Services National Standards. 3. Mzimba and Karonga (Northern Health Zone), Dowa and Kasungu (Central West Health Zone), Lilongwe and Ntcheu (Central West Health Zone), Mangochi and Phalombe (South West Health Zone), and Nsanje and Chiradzulu (South West Health Zone). 4. See chapters 6 and 7 of the Evaluation of Youth-Friendly Health Services in Malawi for more details. 5. About 40 percent of community survey respondents and 38 percent of exit interview respondents mentioned friends/peers. 6. These barriers were reported by youth in the community, health facility clients, service providers, youth coordinators, community leaders, and managers of nongovernmental organizations. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. HPP is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Contact Us Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 www.healthpolicyproject.com policyinfo@futuresgroup.com Figure 3. Services Obtained During the First and Last Visit to a YFHS Delivery Point 50 40 30 20 10 0 % o f r es po nd en ts General counseling Contraceptive counseling Obtained contraceptives HIV testing Referral to other facility STI services Antenatal care/ post-natal care Prevention of mother-to-child services Treatment of sexual abuse 30 30 18 19 40 47 36 33 1 2 5 8 2 3 0.5 1 First visit Last visit This brief is based on the Evaluation of Youth- Friendly Health Services in Malawi, available at http://www.e2aproject.org/publications-tools/ pdfs/evaluation-yfhs-malawi.pdf. 0 0

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