Adolescent Sexual and Reproductive Health in Malawi: Results from the 2004 National Survey of Adolescents Alister Munthali, Eliya M. Zulu, Nyovani Madise, Ann M. Moore, Sidon Konyani, James Kaphuka and Dixie Maluwa-Banda Occasional Report No. 24 July 2006 Adolescent Sexual and Reproductive Health in Malawi: Results from the 2004 National Survey of Adolescents was written by Alister Munthali, the Cen- tre for Social Research, Zomba, Malawi; Eliya M. Zulu and Nyovani Madise, the African Population and Health Research Center, Nairobi, Kenya; Ann M. Moore, the Guttmacher Institute, New York, USA; Sidon Konyani, the Centre for Social Research, Zomba, Malawi, James Kaphuka, the National Statis- tical Office, Zomba, Malawi; and Dixie Maluwa- Banda, University of Malawi, Chancellor College, Zomba, Malawi. The authors thank their colleagues, Christine Oue- draogo and Georges Guiella, Institut Supérieur des Sci- ences de la Population (Burkina Faso); Stella Neema and Richard Kibombo, Makerere Institute of Social Research (Uganda); Kofi Awusabo-Asare and Akwasi Kumi-Kyereme, University of Cape Coast (Ghana); Alex Ezeh, African Population and Health Research Center (Kenya); and Pav Govindasamy, Albert Themme, Jeanne Cushing, Alfredo Aliaga, Rebecca Stallings and Shane Ryland, all from ORC Macro, for input into all facets of the survey design and coordinat- ing the pretest, sample selection, training, fielding, and data editing and cleaning; colleagues from the Nation- al Statistical Office of the Government of Malawi, namely Charles Machinjili, Commissioner for Statis- tics, Mercy Kanyuka, Deputy Commissioner for Sta- tistics, and Elliot Phiri, Assistant Commissioner, for implementing the survey and for their roles in the de- sign of survey instruments and/or data collection and processing; and Susheela Singh, Akinrinola Bankole, Ann E. Biddlecom and Humera Ahmed from the Guttmacher Institute, for helping to develop the design of the survey questionnaire, providing initial feedback on the results and contributing insights to the interpre- tations presented in this report. Data tabulation and entry assistance were provided by Suzette Audam, Humera Ahmed and Kate Patterson of the Guttmacher Institute. The authors would also like to thank all the research assistants, field editors and their supervisors for collecting the data upon which this report is based. The authors also thank Charles Chilimampunga, Director of the Centre for Social Research at Chancel- lor College, Zomba, Malawi; Chiweni Chimbwete, As- sociate at Ibis Reproductive Health; Flora Nankhuni, David E. Bell Fellow at the Harvard Center for Popu- lation and Development Studies; Roy Hauya, Director of Programs at the National AIDS Commission, Lilongwe, Malawi; and Barbara Mensch, Senior Asso- ciate at the Population Council, for their constructive comments and suggestions. The research for this report was conducted under the Guttmacher Institute’s project Protecting the Next Generation: Understanding HIV Risk Among Youth, which is supported by the Bill & Melinda Gates Foun- dation, the Rockefeller Foundation and the National In- stitute of Child Health and Human Development (Grant 5 R24 HD043610). Suggested citation: Munthali A et al., Adolescent Sexual and Reproductive Health in Malawi: Results from the 2004 National Survey of Adolescents, Occasional Report, New York: Guttmacher Institute, 2006, No. 24. To order this report, go to www.guttmacher.org. © 2006, Guttmacher Institute. ISBN: 0-939253-86-0 Acknowledgments Executive Summary . . . . . . . . . . . . . . . . . . . . . . .7 Characteristics of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . .7 Sexual Activity and Relationships . . . . . . . . . . . . . . . . . . . . . . . .7 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Pregnancy and Childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 HIV/AIDS and Other STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Profiles of Young Peoples’ Risk and Protective Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Sexual and Reproductive Health Information and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . .11 The Protecting the Next Generation Project . . . . . . . . . . . . . . .11 Malawi: Political and Historical Background . . . . . . . . . . . . . . .12 Malawi’s Economic and Population Growth . . . . . . . . . . . . . . .12 Adolescent Sexual and Reproductive Health . . . . . . . . . . . . . .13 Chapter 2: Methodology . . . . . . . . . . . . . . . . . . .15 Questionnaire Design and Content . . . . . . . . . . . . . . . . . . . . . . .15 Field Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Tables: 2.1 Interview characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 2.2 Households, interviews and response rates . . . . . . . . . . . . . . . .22 2.3 Adolescent interview characteristics . . . . . . . . . . . . . . . . . . . . . . .23 2.4 Comparison of 2003 DHS and 2004 NSA . . . . . . . . . . . . . . . . . . . .24 Chart: 2.1 Conceptual framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Chapter 3: Context of Adolescent’s Lives . . . . .27 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . .27 Family Formation and Living Arrangements . . . . . . . . . . . . . .27 Schooling Experiences and Expectations . . . . . . . . . . . . . . . .28 Time Use and Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Social Ties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Talking About Sex-Related Matters . . . . . . . . . . . . . . . . . . . . . .30 Alcohol and Drug Use, Physical Abuse . . . . . . . . . . . . . . . . . . . .31 Current Worries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Policy and Program Implications . . . . . . . . . . . . . . . . . . . . . . . .31 Tables: 3.1 Sociodemographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . .33 3.2 Union status, childbearing and living arrangements . . . . . . . . .34 3.3 Orphanhood characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 3.4 Level of schooling completed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 3.5 Reasons for leaving school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 3.6 Schooling characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 3.7 Time use and work characteristics . . . . . . . . . . . . . . . . . . . . . . . .39 3.8 Religious and social group participation . . . . . . . . . . . . . . . . . . .40 3.9 Parent and teacher monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 3.10 Characteristics of friendship networks . . . . . . . . . . . . . . . . . . . . .42 3.11 People who spoke about sex with adolescents . . . . . . . . . . . . . .43 3.12 Alcohol and drug use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 3.13 Level of worry about different issues . . . . . . . . . . . . . . . . . . . . . .45 Charts: 3.1 Frequency of contact with biological mother . . . . . . . . . . . . . . .46 3.2 Frequency of contact with biological father . . . . . . . . . . . . . . . .47 3.3 Current school attendance among those who ever attended school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 3.4. Work and school status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 3.5 Communication with parents about sex-related matters . . . .50 Chapter 4: Sexual Activity and Relationships 51 Puberty and Initiation Rites . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Sexual Activity and Awareness . . . . . . . . . . . . . . . . . . . . . . . . . .51 First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Sex Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Sex in Exchange for Money or Gifts . . . . . . . . . . . . . . . . . . . . . .55 Other Sexual Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Sexual Abuse and Coercion . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .57 Tables: 4.1 Experiences of menstruation, puberty, circumcision and initiation rites . . . . . . . . . . . . . . . . . . . . . . . . . . .58 4.2 Relationship status and sexual activity . . . . . . . . . . . . . . . . . . . .59 4.3 Reasons for never having had sexual intercourse . . . . . . . . . . .60 4.4 Sexual activity status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 4.5 Attitudes about sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 4.6 Relationship with first sex partner . . . . . . . . . . . . . . . . . . . . . . . . .63 Table of Contents 4.7 Characteristics of first sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 4.8 Number of sex partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 4.9 Characteristics of last sex partner . . . . . . . . . . . . . . . . . . . . . . . . .66 4.10 Sex in exchange for money or other items . . . . . . . . . . . . . . . . .67 4.11 Anal sex and drying the vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 4.12 Sexual abuse and coercion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Chart: 4.1 Proportion of adolescents who have had their first sexual experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 Chapter 5: Contraception . . . . . . . . . . . . . . . . . .71 Contraceptive Method Knowledge . . . . . . . . . . . . . . . . . . . . . . .71 Knowledge of the Fertile Period and of the Withdrawal Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Attitudes About the Impact of Contraception on Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 Ever Use of Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 Current Use of Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . .72 Characteristics of those Using Contraception at Last Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . . .73 Tables: 5.1 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . .74 5.2 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 5.3 Knowledge of the withdrawal method . . . . . . . . . . . . . . . . . . . . . .76 5.4 Attitude about availability of methods . . . . . . . . . . . . . . . . . . . . .77 5.5 Ever-use of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . .78 5.6 Current use of contraceptive methods . . . . . . . . . . . . . . . . . . . . .79 5.7 Contraceptive use by relationship status . . . . . . . . . . . . . . . . . .80 5.8 Characteristics of condom use at last sex . . . . . . . . . . . . . . . . . . .81 Chapter 6: Pregnancy and Childbearing . . . . . .83 Perceptions of How Pregnancy Happens . . . . . . . . . . . . . . . . .83 Pregnancy and Childbearing Experiences . . . . . . . . . . . . . . . .83 Desired Timing of Pregnancy or Birth . . . . . . . . . . . . . . . . . . . .84 Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .85 Tables: 6.1 Perceptions of how pregnancy occurs . . . . . . . . . . . . . . . . . . . . .86 6.2 Pregnancy and childbearing status . . . . . . . . . . . . . . . . . . . . . . . .87 6.3 Desired timing of next birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 6.4 Knowledge and experience of abortion . . . . . . . . . . . . . . . . . . . .89 Chapter 7: HIV/AIDS and Other STIs . . . . . . . . . .91 Knowledge About HIV/AIDS Transmission and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Personal Knowledge About and Attitudes About People with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Knowledge of STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Experience of STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .93 Tables: 7.1 Awareness of and knowledge about HIV/AIDS . . . . . . . . . . . . . . .94 7.2 Personal ties to and attitudes about persons with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 7.3 Awareness, knowledge and experience of STIs . . . . . . . . . . . . .96 Chapter 8: Profiles of Young People’s Risk and Protective Behaviors . . . . . . . . . . . . .97 Self-Perceived Risk of Contracting HIV . . . . . . . . . . . . . . . . . . .97 Profiles of Adolescent Sexual Behavior and Condom Use . .97 Condom Use at Last Intercourse . . . . . . . . . . . . . . . . . . . . . . . .98 Consistent Condom Use and Reported Problems with Recent Condom Use . . . . . . . . . . . . . . . . . . . .99 Knowledge and Attitudes About Male Condoms . . . . . . . . .100 Recent Experiences with Cutting or Piercing and Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .102 Tables: 8.1 Use of a male condom at last sex by relationship characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . .103 8.2 Reasons for nonuse of condoms at last sex . . . . . . . . . . . . . . . .104 8.3 Characteristic of sexual intercourse among males . . . . . . . . .105 8.4 Knowledge about male condoms . . . . . . . . . . . . . . . . . . . . . . . . .106 8.5 Attitudes about male condoms . . . . . . . . . . . . . . . . . . . . . . . . . . .107 8.6 Other sociocultural risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . .108 Charts: 8.1 Self-perceived risk of HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 8.2 Self-perceived risk of HIV among older females by union status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 8.3 Sexual behavior and condom use at last sex among females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 8.4 Sexual behavior and condom use at last sex among males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 8.5 Number of partners and condom use at last sex among females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 8.6 Number of partners and condom use at last sex among males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Chapter 9: Sexual and Reproductive Health Information and Services . . . . . . . . . . . . . . . . .113 Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Sex Education Experiences and Attitudes . . . . . . . . . . . . . . . .113 Information and Service Sources for Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Information and Service Sources for STIs . . . . . . . . . . . . . . . .116 Information Sources and Exposure to Mass Media Messages for HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 HIV Voluntary Counseling and Testing . . . . . . . . . . . . . . . . . . .118 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .118 Tables: 9.1 Exposure to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 9.2 Content, form and exposure to sex education . . . . . . . . . . . . . .120 9.3 Attitudes about sex education, condom and AIDS instruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 9.4 Information sources for contraceptives . . . . . . . . . . . . . . . . . . .122 9.5 Perceived barriers to obtaining contraceptives . . . . . . . . . . . .123 9.6 Known and preferred sources for contraceptives . . . . . . . . . . .124 9.7 Perceptions of government clinics or hospitals as sources for contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 9.8 Perceptions of most preferred source for contraceptives . . .126 9.9 Sources for contraceptives obtained . . . . . . . . . . . . . . . . . . . . . .127 9.10 Mass media messages about family planning . . . . . . . . . . . . . .128 9.11 Used and preferred sources of information on STIs . . . . . . . . .129 9.12 Perceived sources of information on STIs reported by adolescents who did not know any STIs . . . . . . . . . . . . . . . . .130 9.13 Perceived barriers to obtaining advice or treatment for STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 9.14 Known and preferred sources of STI treatment . . . . . . . . . . . .132 9.15 Perceptions of government clinics or hospitals as a source of STI treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133 9.16 Perceptions of preferred source of STI treatment . . . . . . . . . .134 9.17 Self-reported STI treatment behavior . . . . . . . . . . . . . . . . . . . . . .135 9.18 HIV/AIDS information sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 9.19 Mass media messages about HIV/AIDS . . . . . . . . . . . . . . . . . . . . .137 9.20 HIV testing experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 9.21 Knowledge about voluntary counseling and testing . . . . . . . .139 9.22Desire for HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Charts: 9.1 School attendance and exposure to sex education . . . . . . . . .141 9.2 Urban-rural difference in contraceptive information among females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 9.3 Urban-rural difference in contraceptive information among males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143 9.4 Used and preferred sources of information on contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 9.5 Knowledge and experience of voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Chapter 10: Conclusions . . . . . . . . . . . . . . . . . .147 Policy and Programmatic Implications . . . . . . . . . . . . . . . . . .148 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 [...]... behavior among adolescents have also been documented in the United States for surveys conducted in the same year.25 Therefore, these differences 19 Guttmacher Institute not withstanding, as a national survey on aspects of sexual and reproductive health, the 2004 MNSA provides detailed information on sexual and reproductive health of adolescents, thus complementing results from the 2004 MDHS and the trends... address the problems 17 Guttmacher Institute Table 2.1 shows the length of interview, privacy of interview and how well the interviewer thought the respondent understood the survey questions in general The duration of the interview can indicate the burden on the adolescent respondent in answering questions: The survey aimed for a 45-minute interview on average The results show that in general, males’ interviews... examine why some adolescents are at higher risk of HIV transmission and unwanted pregnancy than other adolescents; document adolescents barriers to seeking sexual and reproductive health services and information; and provide new information about what very young adolescents (aged 12–14) know and do with respect to sexual and reproductive health In 2004 a nationally representative survey of adolescents. .. to influence their protective and risk behaviors are also discussed in this chapter Characteristics of Survey Respondents A description of the basic characteristics of the adolescents interviewed in the survey provides a background for interpreting findings on sexual and reproductive health presented later in the report Table 3.1 shows that most of the adolescents were not in union; only about 7% of. .. on sexual and reproductive health that is disseminated in schools This underscores the need for interventions directed at outof-school adolescents • The high proportion of adolescents who are members of youth groups and clubs (the majority of which are faith-based groups) highlights the potential value of these networks in reaching adolescents with sexual and reproductive health and livelihood interventions... they earn income and what they do, where they work, and the degree to which they control that money is potentially helpful when thinking about the nature of programs to help adolescents meet their reproductive health needs This information can also help us understand the broader context in which adolescents make decisions regarding their sexual and reproductive health Table 3.7 shows how adolescents. .. from the 2004 MDHS and the trends over time in behaviors that the MDHS documents 20 Adolescent Sexual and Reproductive Health in Malawi TABLE 2.1 Percentage of adolescents duration of interview and others present during interview, and percentage distribution of adolescents by interview characteristics, all according to sex and age, 2004 National Survey of Adolescents Characteristic Female 12–14 (N=936)... females in the 2004 MDHS had had sex at the time of the survey; the corresponding percentage was 37% in the 2004 MNSA The 2004 MDHS shows a higher proportion of 15–19year-old females who reported having had a child (25%) than the 2004 MNSA (16%) Differences in the proportion ever having had sex and ever having had a child between the two surveys are very likely a product of the difference in proportion of. .. behaviors and their use of health information and services.5 Also in 2003, about 100 in- depth interviews* with adolescents were conducted in each country in order to understand the social context of young people’s romantic and sexual relationships and their health- seeking behavior Finally, about 60 in- depth interviews in each country were conducted in 2005 with health providers, teachers, and parents,... adolescents, a group often neglected The purpose of this report is to provide a comprehensive overview of the results of this survey on sexual and reproductive health of 12–19-year-old females and males in Malawi in 2004 Results are mainly descriptive of the knowledge, attitudes and behaviors of adolescents, with attention to differences and similarities according to gender and age Relevant policy and programmatic . for implementing the survey and for their roles in the de- sign of survey instruments and/ or data collection and processing; and Susheela Singh, Akinrinola Bankole, Ann. al., Adolescent Sexual and Reproductive Health in Malawi: Results from the 2004 National Survey of Adolescents, Occasional Report, New York: Guttmacher Institute, 2006,