Youth-Friendly Health Services in Malawi: Young People's Sexual Experiences
Publication date: 2015
HEALTH POL ICY P R O J E C T YOUTH-FRIENDLY HEALTH SERVICES IN MALAWI: YOUNG PEOPLE’S SEXUAL EXPERIENCES 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.2 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 Services3 (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 the sexual behavior of young people to promote evidence-based design and implementation of youth reproductive health programs that are responsive to changing health needs. The evaluation was conducted in 10 districts4 across the five health zones, with both qualitative and quantitative components. This brief, prepared by the USAID-funded Health Policy Project, summarizes the evaluation report’s findings on young people’s sexual experiences to help inform future program planning and implementation by policymakers and stakeholders. 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 of improving health indicators for 5 million people in Malawi. 2 March 2015 Sexual Awareness and Activity Sexual awareness among early adolescents ages 10–14 years is high, with more than 76 percent of males and 66 percent of females in this age group having heard of or talked about sex. Over 12 percent of those ages 10–14, and almost 52 percent of those ages 15–19, reported to have had sex. Among sexually active young people, a higher percentage of males reported to have had sex. Regarding age differential among sexual partners, 87 percent of males reported to have had sex with younger or same-age partners; while 63 percent of females reported that their sexual partners were older than them. Contraceptive Use During First, Last, and Future Sex Fewer than half of sexually experienced young people reported the use of a contraceptive method during first sex, exposing many young people to unwanted pregnancies and sexually transmitted infections, including HIV. However, almost all young people (94%) who used a contraceptive method at first sex used the male condom. Contraceptive use increased at last sex, with preference for contraceptive methods broadening: 86 percent of males used the male condom, while among female youth, 42 percent used the male condom, and 42 percent used injectables. Youth have a strong desire to use contraceptives during future sex: 86 percent of male youth expressed a high preference for condoms, while 40 percent of females expressed preference for injectable contraceptives, 37 percent for condoms, and about another 5 percent for oral pills (see Figure 1). Reasons for not intending to use contraceptives were varied and included the desire to become pregnant, difficulty in obtaining the methods, and fear of side effects. The majority of young people mentioned public health facilities and markets/shops as sources of contraceptives for future sex. Other private sources Figure 1. Intention to Use Contraceptive Methods During Future Sex, Among Sexually Active Youth Oral contraceptives Intrauterine devices Injectables Implants Male condoms Female condoms Withdrawal Others Do not know 0 10 20 30 40 50 90 80 70 60 Male Female 1.5 4.7 0.4 0.8 8.7 40.4 1.3 11.9 85.7 36.6 0.6 1.9 0.2 0.3 0.9 2.8 0.6 0.6 % o f r es po nd en ts 3 Youth-friendly Health Services in Malawi: Young People’s Sexual Experiences and the Christian Health Association of Malawi health facilities were not mentioned as significant sources of contraceptive methods for youth. The high intention of sexually active youth to use contraception at future sex suggests an unmet need for more comprehensive counseling and services aimed at youth. The current existence of comprehensive condom programming at local levels in Malawi could be leveraged to broaden the availability of and access to a wider range of contraceptives for youth, especially long-acting reversible methods. Unmet Need for Contraception The number of unplanned and unwanted pregnancies is high among young people. Approximately 72 percent of the sexually active young women interviewed for the evaluation reported having been pregnant; and of those, only 43 percent wanted their last pregnancy, 31 percent did not want the pregnancy at all, and 9 percent wanted to wait until a later time (see Figure 2). Approximately 20 percent of adolescent girls ages 10–14 years had been pregnant, and 60 percent of girls ages 15–19 years had been pregnant. According to the World Health Organization, adolescents who become pregnant experience much higher rates of maternal mortality and morbidity, and babies born to adolescents have significantly higher rates of health issues such as preterm birth, low birth weight, and even neonatal death.5 These data indicate a need to strengthen Malawi’s SRH programming for both younger (ages 10–14) and older (ages 15–19) adolescents. The ideal family size for both male and female youth was four children, but the mean age at which they desired to have their first child was 20 years for males and 22 years for females. Forty percent of young women who had already been pregnant did not want their last pregnancy or wanted to wait, which suggests that comprehensive sexuality education and contraceptives need to be made more accessible for adolescents. 50 40 30 20 10 Wanted to be pregnant Wanted to wait Did not want to be pregnant Did not think of it 0 43.3 9.3 31 16.2% o f r es po nd en ts Figure 2. Desire for Last Pregnancy, Among Female Youth Youth-friendly Health Services in Malawi: Young People’s Sexual Experiences 4 Key Questions to Improve YFHS Informed by the data from the MOH’s 2014 YFHS evaluation, policymakers and program managers have better insight into the SRH knowledge, behavior, and service needs of Malawian youth. In using this information, YFHS program design and implementation will be better aligned and responsive to youth development and their changing health needs. This should help increase adherence to the key principles of the YFHS National Standards, further delay sexual initiation among early adolescents, and promote healthier sexual behaviors among older youth. As stakeholders design interventions to strengthen the health system and improve implementation of YFHS in Malawi, the following key questions should be addressed: How can we best address key sexual behavior determinants, rooted in gender roles and cultural norms? How comprehensive is the sexuality education currently being offered, and how widely available is it? How do we best facilitate parent and child communication about sexuality? Are younger and hard-to-reach youth adequately targeted by SRH initiatives? What is the role of nongovernmental organizations, private facilities, and public health facilities in increasing access to and availability of contraceptives, especially long-acting reversible contraceptives? 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. See chapter 3 of the Evaluation of Youth-Friendly Health Services in Malawi for more details. 3. 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. 4. 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). 5. World Health Organization. No date. “Adolescent Pregancy.” Available at: http://www.who.int/ maternal_child_adolescent/topics/maternal/ adolescent_pregnancy/en/. 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 firstname.lastname@example.org 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.
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