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Youth reproductive health services in Bulawayo, Zimbabwe
Health & Place 8 (2002) 273–283
Youth reproductive health services in Bulawayo, Zimbabwe Alethea Mashamba, Elsbeth Robson* School of Earth Sciences and Geography, Keele University, Keele, Staffordshire ST5 5BG, UK Accepted 1 November 2001
Abstract This study examines young people’s access to reproductive healthcare services via an urban youth advisory centre in Bulawayo, Zimbabwe. The aim is to explain why teenagers do not always use existing health services. Data from exit questionnaires with users and focus groups with non-users are analysed to evaluate service accessibility. Analysis suggests that even where clinics are spatially accessible, barriers to access include temporal factors, lack of factual knowledge and stigmatisation. The paper concludes that spatial accessibility is not the only factor necessary to ensure equal access to health services. Recommendations are made towards tackling young people’s unmet needs for reproductive healthcare services. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Youth; Reproductive health; Health services; Bulawayo; Zimbabwe
Introduction Young people are the future everywhere. Globally, there are 1.04 billion young people aged 15–24 years, 87% of whom live in developing countries and form an estimated 18% of the global population (UNFPA, 2000a). Almost 50% of Zimbabwe’s 11.3 million population is under 18 years (UNICEF, 2000). Youth1 are increasingly being recognised as a marginalised social group, both in terms of their access to health care and their relative neglect by policy makers (Mann and Tarantola, 1996) and academics, including geographers (Matthews and Limb, 1999; Holloway and Valentine, 2000; Matthews and Tucker, 2000; Matthews et al., 1998). In particular, aspects of the health geographies of young people have been subjected to limited investigation, with few exceptions like Hayes’ work on the impact of childhood experiences on health through the life course (Hayes, 1999). Overcoming health inequalities, including those faced by young people, is an issue of *Corresponding author. Tel.: +44-1782-584339; fax: +441782-715261. E-mail address: [email protected] (E. Robson). 1 Youth and adolescents are used synonymously in this paper to refer to young people of 10–24 years of age.
global concern to geographers (Kearns, 1997), healthcare providers and others. Health geography needs to take into account young people as both potential and actual recipients (as well as informal providers) of health care. This paper focuses on evaluating efforts to meet young people’s reproductive health needs. Poor reproductive health including high rates of early pregnancy and STD infection among adolescents are matters of concern for parents, teachers, youth workers, medical practitioners, and young people themselves who may face early parenthood, morbidity, criminality and even mortality. Effective delivery of health services to youthful populations can reduce risky behaviour, ameliorate its negative impacts and ensure good reproductive health.2 This paper is rooted in the premise embraced by the World Health Organisation (2000) and UNFPA (2000b) that reproductive health is a basic human right. Reproductive health embraces not just an absence of disease or infirmity, but a state of complete physical, mental and social well-being in all matters related to the
2
At the recent UN African Summit on HIV/AIDS, a key objective outlined was empowering young people to protect themselves.
1353-8292/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 1 3 5 3 - 8 2 9 2 ( 0 2 ) 0 0 0 0 7 - 2
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Zimbabwe continues to be a country (like much of Southern Africa and the developing world) with high reproductive ill-health indices among its youth and adolescents. As young people become sexually active, their access to reproductive health services is vital. Young women suffer greater reproductive ill health than young men. Arguably, this is largely because of the female biological capacity of pregnancy and childbearing, but growing up in patriarchal societies, a heavy weight of social disadvantage falls on girls and young women. Young people in Zimbabwe often become sexually active in adolescence. One study suggests 18.8 years is the median age of first sexual intercourse (UNAIDS/ WHO, 2000), while in another study, 46.4% boys, but only 2.7% girls in secondary school (mean age 17.4 years) reported having had sexual intercourse (Wilson et al., 1989). We should be cautious of unquestioning acceptance of quantitative survey results because severe
under-reporting of sexual activity by girls is not unusual. Not least it reflects culturally prevalent negative attitudes towards female premarital sex (Gelfand, 1979). Early sexual activity has many consequences for adolescents’ reproductive health and healthcare needs. The adolescent fertility rates in Zimbabwe are high with births to mothers under 20 years old accounting for 14.5% all births (UNDP, 1999, p. 227). Overall 20% women aged 15–19 years are mothers, or expecting their first child (Government of Zimbabwe, 1994). Figures are higher in the rural (22%) than the urban (15%) areas and among girls with only primary school education (28%) compared to girls who have been to secondary school (13%) (op. cit.). We can safely assume that the actual rate of adolescent fertility is even higher as births and pregnancies among 10–14 year olds go largely unreported due to assumed sexual inactivity, the stigmas surrounding youth pregnancy and the criminal status of abortion. Adolescent childbearing is associated with various health and social concerns. Adolescent mothers are more likely than older mothers to experience health problems, have larger families and less formal schooling. Ninety percent of girls who become pregnant while in school subsequently dropout (Boohene et al., 1991). Children of young mothers have increased risks of illness and mortality. Adolescents reported that 40% of their births were wanted later and 70% births overall were unwanted (Government of Zimbabwe, 1994). A Harare study of recently delivered mothers found women aged 19 years and below more likely to report their pregnancy as unplanned. Unplanned pregnancy was also found to be particularly associated with mothers who were single, unemployed, had low income, and/or living with their parents. It is known that unplanned pregnancies have higher risks of maternal morbidity and mortality (Mbviso et al., 1997b). Especially among young women, unwanted pregnancies often lead to attempted abortions, often with particularly severe consequences. Abortion in Zimbabwe is illegal, hence making it a ‘backstreet’ operation with high risks of complications. Rates of attempted abortion contribute to the high maternal mortality rates in the country.4 As abortion remains a criminal offence in Zimbabwe, young women can be jailed for inducing abortion and for other related consequences of unwanted pregnancy including infanticide and so-called ‘baby-dumping’. Consequently, there is gross underreporting of abortion-related ‘crimes’ in Zimbabwe. Family planning use among young women in Zimbabwe is low, leaving a substantial unmet need for contraception. It is illegal in Zimbabwe to provide family planning supplies to young people below 16
3 Of course, participation itself is not a new strategy for development and empowerment (e.g. Friere, 1972).
4 Current maternal mortality rate for Zimbabwe is 280 per 100,000 live births (World Bank, 2000a, p. 243).
reproductive system, its functions and processes. Reproductive good health includes having a safe and satisfying sex life, the capability to have children and the freedom to decide if, when and how often to do so. Furthermore, women and men of all ages have the right to information and access to safe, effective, affordable and acceptable methods of fertility regulation of their choice. Women have the right to health care for safe pregnancy and childbirth. Reproductive health care contributes to good reproductive health and well-being by preventing and ameliorating problems of reproductive health. While there are very commendable programmes for the under-5’s and attention paid to maternity services for women, the reproductive health needs of young people are often neglected by healthcare professionals and policy makers alike. Where targeted services do exist they often suffer from adultist bias, being designed by adults with little consultation with young people. Participation by children and young people is slowly being recognised as essential for effective development strategies (Johnson et al., 1998).3 Youth reproductive health is a key issue within the varied health geography of Southern Africa, and elsewhere. This case study contributes to tackling health inequalities by exploring the factors contributing to low utilisation of reproductive health services by young people, thus providing useful policy-informing research in regard to healthcare access.
ContextFthe unmet needs of youth reproductive health care in Zimbabwe
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years, unless parental consent is given, or they are married. Only about three out of ten married 15–19 year olds use contraception (mostly the pill), compared with 50% or more older women (20–39 years) (Government of Zimbabwe, 1994). As many as one-fifth of the married adolescent women 15–19 years old (compared to only 13% among 20–34 year olds) have ‘unmet need’ for family planning (op. cit.). They want to limit or space their births, but are not using contraception. Just 6.4% of 15–19 year olds and 27.7% of 20–24 year olds have ever used a condom (UNAIDS/WHO, 2000), even though knowledge levels about family planning methods among Zimbabwean adolescents is generally high and a wide range of contraceptives are available through health institutions, pharmacies and the market. Southern Africa has been hard hit by the HIV/AIDS pandemic. Infection rates are highest among 20–39 year olds who comprise 57% of reported AIDS cases in Zimbabwe (UNAIDS/WHO, 2000). Nearly half (47%) of male Harare factory workers who became HIV positive during a 2-year study were 18–24 years old (Ray et al., 1998, p. 1433). Among 15–19 year olds, infection rates for young women are six times greater than that for their male counterparts (Munodawafa and Gwede, 1996). This is due to the ‘sugar daddy’ phenomenon (Kalipeni, 2000, p. 977). As so-called ‘sugar daddies’ older men, fearing risks of infection from older women, seek younger women, especially virgins and often school girls, as (extra-marital) sexual partners and to whom they often give gifts and favours. High infection rates of all STDs, including HIV, and unwanted pregnancy among young people are attributable to vulnerability to risky sexual behaviour. For example, in a survey of Zimbabwean secondary school pupils, 37.8% male students reported sexual intercourse with two or more partners and 15.8% reported having had sexual intercourse with a prostitute (Wilson et al., 1989, p. 959). Risky sexual behaviour is exacerbated by ignorance (although knowledge about HIV/AIDS is generally high in the country, especially among urban youngsters (Wilson et al., 1989; Munodawafa and Gwede, 1996)), lack of condom availability and unwillingness to use condomsFboys complain of diminished pleasure and girls fear being labelled promiscuous. Rape5 and violent sex also contribute to high infection rates among young people in Zimbabwe. In recent years, the harsh economic times of structural adjustment have meant high rates of school dropout and unemployment leading to more prostitution, street children and ‘sugar daddies’ with consequent unfavourable reproductive health consequences for young people (Bourdillon, 2000; Gwaunza et al., 1994).
Risks of reproductive ill health among adolescents in Zimbabwe, as elsewhere are exacerbated by lack of relevant factual knowledge and self-empowerment (Campbell and Mbizvo, 1994). In some societies and cultures within Zimbabwe, sexual matters are not discussed between parents and children. Thus, many young people today rely on misinformation by their peers in relation to sexual matters. The traditional sex education provision (by aunts for girls and village elders for boys) is breaking down with urbanisation and rapid modernisation. The media are also blamed for encouraging early and risky sexual behaviour among young people. Preventing pregnancy and STD infection, postponing childbearing, accessing contraception, safe abortion and knowledge are clearly among the priority reproductive health needs of young women and men in Zimbabwe. The picture for Zimbabwe is similar for poor urban youth across the whole Southern African region (e.g. Ndubani and Hojer, 2001). Good youth reproductive health care is needed to decelerate the AIDS epidemic by preventing new HIV infections (Foster, 1998), as well as reduce high rates of STD infection, pregnancy, abortions, ‘baby-dumping’ and infanticide. At least until relatively recently, Zimbabwe has had an impressive health service for sub-Saharan Africa. Recent economic instability has led to the country’s formal state-provided healthcare system undergoing major ‘reform’ associated with economic structural adjustment policies (Bassett et al., 1997; Bijlmakers et al., 1996). Despite widespread reference to the erosion of Zimbabwe’s healthcare system (Kalipeni, 2000, p. 978), it still has many commendable aspects (Loewenson et al., 1991). For example, it has one of the highest infant immunisation rates in the region (Kalipeni, 2000). Adolescent reproductive health is identified by the Zimbabwe Government and recent UN proclamations as a priority health issue. However, given the poor reproductive health indices for young people, it would appear that despite the existence of specific tailor-made youth reproductive health centres, these are either under-utilised and/or inadequate. A potential explanation for this is that youth reproductive health services are located mostly in urban centres, and do not serve rural areas where the majority of the (young) population of Zimbabwe live.6 Furthermore, within urban centres, the youth reproductive health services are inappropriately located for the majority of urban youth who live in low-income townships (highdensity areas).
5 Zimbabwe recorded 3100 rapes in 1994 (UNDP, 1999, p. 223).
6 Only 35% of the population of Zimbabwe is urban (World Bank, 2000b).
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The study This study highlights an aspect of health service provision in Southern Africa by examining access to reproductive health services among young people (10–24 years) in Bulawayo, Zimbabwe (Fig. 1). A central aim is to explain why teenagers may opt not to use clinic services, even where they are spatially accessible. This study questions how accessible and effective are urban youth advisory centres with regard to meeting adolescents’ reproductive health needs. After the capital Harare, Bulawayo forms the second largest urban centre in Zimbabwe with a youthful population: 33% of its population aged 10–24 years (CSO, 1994, p. 186). The case study focuses on the services provided by the Bulawayo Youth Advisory Centre (BYAC). At the time of this research, it was the only provider of reproductive health services in Bulawayo, particularly family planning, specifically to young people. The BYAC is run by the Zimbabwe National
Family Planning Council with significant support from USAID, other donors and interested parties. The centre is staffed with four full-time local black Zimbabwean staff: a nurse, a clerk/receptionist and two youth advisors.
Data collection methods The primary data collection was carried out over a 3week period in July 1997 at the BYAC (Fig. 1). The data collection methods include exit questionnaires with users and focus groups with non-users of the clinic services. The interviews and focus group discussions were conducted by the first named authorFa black Zimbabwean woman, experienced community nurse midwife and mother of teenagers. She was assisted by two local research assistantsFblack male Zimbabwean youths (aged 18 and 19 years) with O-level qualifications. All three researchers grew up in Bulawayo and speak fluent
Fig. 1. Location of study.
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Fig. 2. Attendance by age at the Youth Advisory Centre 1995–1997. The drop in attendances of both adults and young people during August and September 1996 was due to the nurse being on leave. Source: Monthly return forms, ZNFPC service statistics.
Ndebele, Shona and English. Prior to data collection, the assistants were briefed about the research and given some orientation and training on how to interview, probe and listen. Exit interviews were completed with a total of 30 young peopleFabout a third (30%) of the clients aged 10–24 years. Systematic sampling was used. Every third client within this age group was approached after they had been seen at the centre. Before interviewing, the research aims were explained to each participant, their confidentiality assured and verbal agreement to participate in the research obtained. The focus groups were conducted in the Lobengula, Mzilikazi and Mpopoma townships of Bulawayo (Fig. 1) with mixed groups of young men and women in three age bands. Participants were recruited through municipal-run youth clubs that offer vocational courses, skills training and recreational activities to the townships’ young people (mostly 14–24 year olds) whether in or out of school. A focus group with 10–14 year olds was organised at Lobengula youth club. Thirteen 15–19 year olds (a mix of young men and women) participated in a focus group at Mzilikazi art and craft centre and 20–24 year olds participated in a focus group at Inyathi youth club in Mpopoma township. The discussions mainly in English (at times mixed with Shona and Ndebele) were audio-taped and later transcribed. The focus group discussions focussed on elucidating: (i) the factors that hinder young people from accessing and using the BYAC; (ii) the aspects of young people’s behaviour that impact their reproductive health and (iii) the young people’s perceptions of the problems they face related to reproductive health and how best to solve them.
Data analysis In this central part of the paper, the collected data are analysed to evaluate the accessibility of youth advisory services in terms of meeting the reproductive health needs of urban youth.
Characteristics of users of the Bulawayo Youth Advisory Centre This section deals with who is using/not using the centre to examine how effectively the centre reaches young people. The BYAC until 1992 was a family planning centre providing contraception, counselling and STD treatment mainly to adults. In 1992, under ZNFPC policy changes, it was re-designated to serve youth only, and today there are clear notices stating that only youth are attended at the centre. However, adults over 24 years are still being seen there. Attendance records for 1995–1997 (Fig. 2) show that attendance by young people steadily increased during the 2-year period, with corresponding simultaneous decline in utilisation by adults. Thus, despite its present designation as a youth advisory centre, the BYAC is in fact still providing services to a significant number of adults older than its designated clientele of under 24 year olds. There are several reasons for adults who are older than 24 years continuing to be a proportion of clients at the BYAC. Firstly, the location: the nearest alternative family planning clinic is over 2 km distant on the other side of Bulawayo (ZNFPC in Fig. 1) in a location not
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served by buses or emergency taxis;7 hence some adult users from the townships have no alternative easy access to reproductive health services in the city centre, although there are other family planning clinics in the townships. The central location of BYAC (Fig. 1) next to a busy market, bus terminus and several beer halls means it is convenient for local sex workers to use the services of the centre, especially to collect free condoms. It would clearly be unethical to deny services to those who need them, thus the staff at BYAC continue to serve a small number of other people, many of whom are commercial sex workers. This creates problems of access for young people who are wary of stigmatisation by association. During the 1997 survey period, the BYAC provided reproductive health services to 129 clients, most of whom (78%) were aged 10–24 years, making young people the vast majority of BYAC users. This section examines the characteristics of the youth (under 24 years) who attended the centre during the survey period (Table 1). The survey results indicate that most of the youth users of the services provided are young women (83%) of childbearing age. All the respondents were at least 15 years old and over a quarter (27%) already had at least one child. Less than one in 20 (17%) of the young respondents were male. Altogether, the majority of respondents were unmarried (77%) and yet to have children (73%). Roughly a third of the youth were unemployed or out of school (33%), but over a quarter were in work (27%), while even more were in education (39%). The survey reveals an interesting spatial feature of attendance patterns. Despite the residential area adjacent to the centre being low-density town houses (formerly a designated white area, now occupied by urban elites) of Bulawayo, all the clients interviewed were overwhelmingly black (94%) or of mixed race (6%), and mostly (80%) living in high-density areas. No white or Asian young people were recorded as attending the centre although it is open to all regardless of ethnicity.8 Accessing youth reproductive health services Just over half of those attending the BYAC came by bus or emergency taxi (57%) and the remainder on foot (43%) (Table 2), which is not surprising given the centre’s central location close to the city’s major bus terminus. The most frequently cited reason for visiting the centre was to obtain contraceptives and family planning advice. Only male condoms are free and contraceptives cannot legally be given to anyone under 7 Emergency taxis are small minibuses licensed to provide essential transport to the public in Zimbabwe. 8 Over 97% of Zimbabwe’s population is black African (CSO, 1994, p. 19).
Table 1 Characteristics of the respondents Characteristics of the respondents
%
n
Age (years)
20–24 15–19 10–14
73 27 0
22 8 0
Gender
Male Female
17 83
5 25
Ethnicity
Shona Ndebele Mixed race White Asian
47 47 6 0 0
14 14 2 0 0
Education/employment status
In primary school In secondary school In tertiary institution Employed Unemployed Out of school
3 13 23 27 23 10
1 4 7 8 7 3
Residential location
High-density suburb (township) Low-density suburb
80
24
20
6
Marital status
Single Married
77 23
23 7
Parenthood status
No children One child Two children
73 23 4
22 7 1
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997.
16 years. Forms of emergency contraception (i.e. the morning after pill) are not prescribed or even known about by staff at the centre.9 As abortion is illegal in Zimbabwe, young women with unwanted pregnancies are offered counselling and referred for antenatal care elsewhere. Twenty percent of the young people questioned came for free information relating to sexual and reproductive health that the BYAC provides with posters, video screenings, lectures, pamphlets and its small library. Using the counselling service was the reason cited by 17% of youngsters coming to the BYAC, while just 10% were accessing the limited clinical services available (e.g. pregnancy testing, Pap tests). While nearly a quarter of those questioned heard about the centre through school, the majority (80%) was aware of BYAC from the media and just 3 from their parents. 9
A similar lack of awareness of the morning-after pill among reproductive health personnel in Bulawayo is reported by Rutgers and Verjuyk (1998).
A. Mashamba, E. Robson / Health & Place 8 (2002) 273–283 Table 2 Respondents’ use of the Youth Advisory Centre Respondents’ use of the Youth Advisory Centre
%
n
Reason for visiting the centrea
70
21
20
6
17 7 3
5 2 1
Source of information about the existence of the centreb
Mode of travel to the centre
Family planning/ contraceptive services Sexual/reproductive health information Counselling services Pregnancy testing Pap test Media (radio, newspapers, magazines, pamphlets) School Parents Nurse Youth club Beer hall
80
24
23 10 3 3 3
7 3 1 1 1
Bus/emergency taxi On foot
57 43
17 13
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997. a Some young people had more than one reason for attending the centre. b Some young people had heard about the centre from more than one source.
Among the non-users of the BYAC who were questioned in focus group discussions with township youth, the 10–14 year olds did not know about BYAC at all, although they did know about ‘the association that teaches about family planning’, i.e. the ZNFPC which runs the BYAC. The 15–19 year old group initially claimed not to know about the BYAC and the services offered there. However, after probing and reassurances, they admitted that they had heard of the centre, that it treats people with STDs and shows video films on AIDS, family planning and STDs; but were ignorant of the full range of services it has to offer them. The oldest group (20–24 year olds) were more willing to admit awareness of the BYAC, but also did not know about the full range of services it offers. Thus, it seems that knowledge of the existence of BYAC increases with age among the Bulawayo youth but even the oldest young people have incomplete knowledge of what it offers, even if they have greater confidence and self-assurance to admit being aware of the centre. Barriers to access No users interviewed were under 15 years. Like the youngest (10–14 years) non-user focus group, most youngsters under 15 years of age are still pre-pubescent
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and (presumably) do not need reproductive health services. But like the older focus group participants, the 10–14 year olds shared the view that some adolescents become sexually active as young as 10–12 years and they knew that some of their contemporaries had left school because of pregnancy. We can surmise that a few youngsters, albeit a small minority, under the age of 15 could benefit from accessing the services of BYAC. Reasons that under-15’s do not access the centre could include awareness of the legal prohibition on issuing contraceptives to youngsters under 16, fear, ignorance, stigma and embarrassment. Cultural taboos also play a part. For example, the 10–14 year old focus group participants were reluctant to discuss issues of sexuality, claiming that family planing was okwabadala (Ndebele: ‘for adults’) and so they could not talk about it. Among the 15–19 year old non-users, a significant barrier to accessing the BYAC services appears to be stigma attached to being seen at the centre. One boy said ‘‘ywe are not having those problems (i.e. STDs) that is why we do not go there’’. The girls supported this saying ‘‘y(we) won’t feel free about being seen (there) by friends’’. Similarly, the 20–24 year olds were concerned not to be seen at the BYAC as they associate it with STDs. These comments illustrate the peer pressure that influences young people not to use the centre. Attitudes towards contraception, namely its association with loose sexual morals, may also be a barrier to young people accessing the contraceptive and family planning services available. Among the 15–19 year olds, comments reflecting such attitudes were made, for example, ‘‘yif girls carry condoms, they are in business (prostitution)’’ and ‘‘yif a girl carries condoms it means she thinks about nothing but sex’’.
Levels of satisfaction Examining the level of satisfaction with reproductive health services received by users suggests possible barriers to non-users. On the whole, the users reported high levels of satisfaction (Table 3), but a few points of dissatisfaction included inconvenient opening hours and a threatening/unwelcoming atmosphere to the centre. Only two clients interviewed said that they were so unsatisfied that they would not come back, or recommend the centre to friends. They gave the following reasons for their dissatisfaction: abruptness of the nurse, fear of being seen by friends attending the centre ‘‘ywho would think that I have a sexually transmitted disease’’, and preference for talking to and being attended to by a peer. As many as a third of the users questioned said that they would prefer to be advised by a peer rather than the existing adult staff (Table 3).
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Table 3 Satisfaction with the Youth Advisory Centre services Satisfaction with the Youth Advisory Centre services
%
n
Opening times
Convenient Inconvenient
93 28 7 2
Atmosphere of the centre
Welcoming/ non-threatening Unsatisfactory
93 28 7
2
Waiting times
Satisfactory
100 30
Satisfaction with services received
Satisfied Dissatisfied
93 28 7 2
Preferred advisor/ service provider
Female health worker Peer No preference
47 14 30 9 23 7
Suggestions for improvement
Younger counsellors Better attitude of nurses Provide services in high-density suburbs School visits by staff Daily opening Make building & reception area more welcoming Better written pamphlets More HIV education
17 13
5 4
10 10 7
3 3 2
7 7 3
2 2 1
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997.
Suggested service improvements A range of improvements to the BYAC services were suggested by the users interviewed (Table 3). The most frequent suggestions were for younger counsellors and more friendly, open and accepting attitudes of the nursing staff. Other suggestions for improvement include provision of services and/or outreach visits by BYAC staff in the township and schools,10 daily opening times convenient for those at school or working and making the BYAC a more welcoming place. The non-users of BYAC consulted in the focus groups also made several suggestions for improving youth reproductive health services. The 15–19 year olds at Mzilikazi art and craft centre firstly suggested extending the programmes to parents, as well as to young people so that they know how to start talking and discussing 10 Others (e.g. Mbviso et al., 1997a), including government bodies (Government of Zimbabwe and UNICEF, 1993; NACP et al., 1997), have called for and are promoting better schoolbased reproductive health education programmes in Zimbabwe.
with their children from an early age. Second, they were in favour of teaching young people to promote health education messages to each other without misinformation and to be more open in discussing issues of sexuality and sexual health with one another. When asked to suggest improvements for reproductive health services, the first reaction of the older (20–24 year olds) focus group participants at Inyathi Youth Club was ‘‘Why think about sex when you wake up hungry’’. This comment raises a serious issue. For many young people, reproductive health issues pale beside more serious concerns of poverty, unemployment and lack of opportunities for income earning in the severely under-developed areas where they live. However, in further discussion, the 20–24 year olds suggested a youth consultation forum would be helpful so that they could discuss how to solve the many problems they face, not only issues of sexuality and reproductive health problems.
Conclusions The central location of the BYAC in Bulawayo means that although it is accessed by low-income township black youth, (especially girls), more than half have to use public transport to get there. Its situation close to the market and not far from the bus terminus make access to the BYAC relatively convenient for its targeted users. Fewer male than female users is not surprising as girls generally have more reproductive health problems associated with child-bearing capacity. Indeed, this finding is encouraging as there are renewed calls for special efforts to protect girls and young women exposed to the risk of HIV/AIDS (Matlin and Spence, 2000). A dominance of black users reflects the ethnic makeup of the general population and also that White and Asian minorities are likely to be in higher-income groups able to access private healthcare services. However, although the BYAC is spatially accessible to many, it may not be temporally accessible because opening hours coincide with times when young people are in school. Analysis of the youth’s responses suggests that other access barriers include ignorance of the BYAC and services it offers, peer pressure, problems of stigmatisation and negative associations with STDs, prostitution, loose sexual morals, ignorance and cultural taboos in discussing matters of sexuality; making young people reluctant to visit. Thus, being close to the beer halls and the haunts of sex workers is a part of BYAC’s complex interaction with other places and something that clearly has an important role in influencing young people’s access to the centre. Other aspects of the BYAC itself as a place which form barriers to young people’s use of the facilities include the adult-only staff, unwelcoming atmosphere, waiting times and poor attitudes of the
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staff and opening hours that coincide with young people being in school. The analysis shows that the mere provision of healthcare services, in this case a youth reproductive health advisory service, does not always ensure client utilisation and satisfaction. Efforts need to be made to overcome the barriers identified that prevent young people from using the services available. From the data analysed above, it can be concluded that spatial accessibility is not the only factor to be overcome in ensuring equal access to health services. Place matters, but distance is not the only factor in determining access, utilisation and satisfaction. This study confirms that health geographers must look beyond space and location in identifying and explaining inequalities in healthcare access. These conclusions have broader implications for those striving to overcome the neglect of young people in research and policy making and striving to reduce their exclusion from accessing reproductive healthcare services. Our conclusions can be translated into a series of recommendations for policy (see below). Such findings also demonstrate the as-yetlargely unexplored potential for including geographers in the scope of multi-disciplinary planning of youth services.
Policy recommendations From the findings of this limited study (particularly, the suggestions given by the young participants), some general policy recommendations can be made. These recommendations suggest more effective ways of ensuring better access to reproductive health care by young people in Bulawayo, but may have wider applicability. As an outcome of this study, the authors recommend: *
*
*
*
Youth reproductive health services be located within residential areas (especially high-density townships) to prevent travel time and cost preventing access. The times of service provision be accessible to youths in full-time education or employment. For example, by including evening /weekend service provision or even 24 hour services attached to places frequented by youth such as internet caf!es. Regular ‘youth-friendliness training’ for adult service providers to reduce/avoid adultist bias. The involvement of young people as peer educators, counsellors, etc. to increase youths’ ownership of service provision. Parental involvement to dispel suspicion and ignorance about youth reproductive health service provision and to encourage informed discussion of sexuality/sexual health within the home environment.
*
*
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Purpose-built facilities for provision of youth reproductive health services,11 as preferential to conversion from existing facilities to prevent the previous purpose and users deterring youth. Provision of youth reproductive health services within multi-purpose environments (e.g. youth centres) providing recreation, leisure activities, entertainment and skills training in order to respond to the wider needs of young people within which their reproductive health needs are embedded.
As demonstrated in the recommendations above, a multi-pronged approach is needed to overcome barriers preventing young people’s utilisation and satisfaction in accessing existing reproductive health services. Service provision needs to be targeted spatially to where young people live and at times when they are not in school/work. Such provision needs to be acceptable to, and tailored specifically for, young people; recognising that they are individuals (albeit embedded in families) with reproductive health needs that intertwine with other aspects of their identity and situation. As such, this echoes recent calls by the UN and others for multi-sectoral strategies to improve healthFparticularly, in the context of the HIV/AIDS pandemic. The recommendations made above may be generalisable to provision of specialist youth health services not only in Zimbabwe, but also for the Southern African region, the developing and even the developed world. It is our hope that in a small way this study, despite its inherent limitations,12 may improve young people’s access to reproductive health care in Zimbabwe and beyond. The urban focus of this study should be complemented by future research on rural youth’s access to reproductive health care, not in the least because rural young people suffer greater reproductive ill health (especially adolescent pregnancy) than their urban counterparts and barriers to access (spatial and otherwise) are even more challenging. Acknowledgements This paper is a successful collaboration demonstrating the potential for geographers and health workers to work together. The paper summarises dissertation research completed in partial fulfilment of the requirements for a Masters in Business Administration (Health, Population and Nutrition) by Alethea Mashamba. This dissertation covered access issues more broadly, 11
ZNFPC policy aims for one purpose-built youth facility in each major town. In 1997, these already existed in Harare, Mutare and Masvingo. 12 Time and resource limitations restricted the research to a single case study, using a relatively small sample.
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following Maxwell (1984). Alethea Mashamba acknowledges research guidance received from Ruth Hope and Frank Paulin; financial support from the Canon Collins Foundation for Southern Africa and the Commonwealth Secretariat; the co-operation of ZNFPC and the helpfulness of staff at the ZNFPC centre in Bulawayo in carrying out the field research. Andy Lawrence is thanked for providing excellent cartography. The comments of the editors of this special issue and two anonymous referees helped polish this paper. Both authors gratefully acknowledge the young people who shared their views and feelings.
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Kalipeni, E., 2000. Health and disease in Southern Africa: a comparative and vulnerability perspective. Social Science and Medicine 50, 965–983. Kearns, R., 1997. Narrative and metaphor in health geographies. Progress in Human Geography 21, 269–277. Loewenson, R., Sanders, D., Davies, R., 1991. Challenges to equity in health and health care: a Zimbabwean case study. Social Science and Medicine 32, 1079–1088. Mann, J.M., Tarantola, D.J.M. (Eds.), 1996. AIDS in the World, Vol. II. Oxford University Press, New York. Matlin, S., Spence, N., 2000. The Gender Aspects of the HIV/ AIDS Pandemic. UN Division for the Advancement of Women [available at http://www.un.org/womenwatch/daw/ csw/hivaids/matlinspence.html]. Matthews, H., Limb, M., 1999. Defining an agenda for the geography of children: review and prospect. Progress in Human Geography 23, 61–90. Matthews, H., Tucker, F., 2000. Consulting children. Journal of Geography in Higher Education 24, 299–310. Matthews, H., Limb, M., Taylor, M., 1998. The geography of children: some ethical and methodological considerations for project and dissertation work. Journal of Geography in Higher Education 22, 311–324. Maxwell, R.J., 1984. Quality assessment in health. British Medical Journal 288, 1470–1472. Mbviso, M.J., Kasule, J., Gupta, V., Rusakaniko, S., Kinoti, S.N., Mapanju-Shumbushu, W., Sebina-Zziwa, A.J., Mwateba, R., Padayachy, J., 1997a. Effects of a randomized health education intervention on aspects of reproductive health knowledge and reported behaviour among adolescents in Zimbabwe. Social Science and Medicine 44, 573–577. Mbviso, M.T., Bonduelle, M.M.J., Chadzuka, S., Lindmark, G., Nystrom, L., 1997b. Unplanned pregnancies in Harare: what are the social and sexual determinants? Social Science and Medicine 45, 937–942. Munodawafa, D., Gwede, C., 1996. Patterns of HIV/AIDS in Zimbabwe: implications for health education. AIDS Education and Prevention 8, 1–10. Ndubani, P., Hojer, B., 2001. Sexual behaviour and sexually transmitted diseases among young men in Zambia. Health Policy & Planning 16, 107–112. NACP (National AIDS Coordination Programme) and Ministry of Health and Child Welfare, 1997. HIV/AIDS in Zimbabwe: Background, Projections, Impact and Interventions. Government of Zimbabwe, Harare. Ray, S., Latif, A., Machekano, R., Katzenstein, D., 1998. Sexual behaviour and risk assessment of HIV seroconvertors among urban male factory workers in Zimbabwe. Social Science and Medicine 47, 1431–1443. Rutgers, R.A.K., Verjuyk, D.A.A., 1998. Please help, our condom tore last night. A report on visits of fake clients, pretending to be in need of emergency contraception, to health facilities in Bulawayo, Zimbabwe. South African Medical Journal 88, 143–145. UNAIDS/WHO, 2000. Zimbabwe epidemiological fact sheet on HIV/AIDS and sexually transmitted infections [accessed 27/11/2000] internet site: http://www.unaids.org/hivaidsinfo/statistics/june00/fact sheets/pdfs/zimbabwe.pdf. UNDP, 1999. Human Development Report. Oxford University Press, New York.
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Youth reproductive health services in Bulawayo, Zimbabwe Alethea Mashamba, Elsbeth Robson* School of Earth Sciences and Geography, Keele University, Keele, Staffordshire ST5 5BG, UK Accepted 1 November 2001
Abstract This study examines young people’s access to reproductive healthcare services via an urban youth advisory centre in Bulawayo, Zimbabwe. The aim is to explain why teenagers do not always use existing health services. Data from exit questionnaires with users and focus groups with non-users are analysed to evaluate service accessibility. Analysis suggests that even where clinics are spatially accessible, barriers to access include temporal factors, lack of factual knowledge and stigmatisation. The paper concludes that spatial accessibility is not the only factor necessary to ensure equal access to health services. Recommendations are made towards tackling young people’s unmet needs for reproductive healthcare services. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Youth; Reproductive health; Health services; Bulawayo; Zimbabwe
Introduction Young people are the future everywhere. Globally, there are 1.04 billion young people aged 15–24 years, 87% of whom live in developing countries and form an estimated 18% of the global population (UNFPA, 2000a). Almost 50% of Zimbabwe’s 11.3 million population is under 18 years (UNICEF, 2000). Youth1 are increasingly being recognised as a marginalised social group, both in terms of their access to health care and their relative neglect by policy makers (Mann and Tarantola, 1996) and academics, including geographers (Matthews and Limb, 1999; Holloway and Valentine, 2000; Matthews and Tucker, 2000; Matthews et al., 1998). In particular, aspects of the health geographies of young people have been subjected to limited investigation, with few exceptions like Hayes’ work on the impact of childhood experiences on health through the life course (Hayes, 1999). Overcoming health inequalities, including those faced by young people, is an issue of *Corresponding author. Tel.: +44-1782-584339; fax: +441782-715261. E-mail address: [email protected] (E. Robson). 1 Youth and adolescents are used synonymously in this paper to refer to young people of 10–24 years of age.
global concern to geographers (Kearns, 1997), healthcare providers and others. Health geography needs to take into account young people as both potential and actual recipients (as well as informal providers) of health care. This paper focuses on evaluating efforts to meet young people’s reproductive health needs. Poor reproductive health including high rates of early pregnancy and STD infection among adolescents are matters of concern for parents, teachers, youth workers, medical practitioners, and young people themselves who may face early parenthood, morbidity, criminality and even mortality. Effective delivery of health services to youthful populations can reduce risky behaviour, ameliorate its negative impacts and ensure good reproductive health.2 This paper is rooted in the premise embraced by the World Health Organisation (2000) and UNFPA (2000b) that reproductive health is a basic human right. Reproductive health embraces not just an absence of disease or infirmity, but a state of complete physical, mental and social well-being in all matters related to the
2
At the recent UN African Summit on HIV/AIDS, a key objective outlined was empowering young people to protect themselves.
1353-8292/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 1 3 5 3 - 8 2 9 2 ( 0 2 ) 0 0 0 0 7 - 2
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Zimbabwe continues to be a country (like much of Southern Africa and the developing world) with high reproductive ill-health indices among its youth and adolescents. As young people become sexually active, their access to reproductive health services is vital. Young women suffer greater reproductive ill health than young men. Arguably, this is largely because of the female biological capacity of pregnancy and childbearing, but growing up in patriarchal societies, a heavy weight of social disadvantage falls on girls and young women. Young people in Zimbabwe often become sexually active in adolescence. One study suggests 18.8 years is the median age of first sexual intercourse (UNAIDS/ WHO, 2000), while in another study, 46.4% boys, but only 2.7% girls in secondary school (mean age 17.4 years) reported having had sexual intercourse (Wilson et al., 1989). We should be cautious of unquestioning acceptance of quantitative survey results because severe
under-reporting of sexual activity by girls is not unusual. Not least it reflects culturally prevalent negative attitudes towards female premarital sex (Gelfand, 1979). Early sexual activity has many consequences for adolescents’ reproductive health and healthcare needs. The adolescent fertility rates in Zimbabwe are high with births to mothers under 20 years old accounting for 14.5% all births (UNDP, 1999, p. 227). Overall 20% women aged 15–19 years are mothers, or expecting their first child (Government of Zimbabwe, 1994). Figures are higher in the rural (22%) than the urban (15%) areas and among girls with only primary school education (28%) compared to girls who have been to secondary school (13%) (op. cit.). We can safely assume that the actual rate of adolescent fertility is even higher as births and pregnancies among 10–14 year olds go largely unreported due to assumed sexual inactivity, the stigmas surrounding youth pregnancy and the criminal status of abortion. Adolescent childbearing is associated with various health and social concerns. Adolescent mothers are more likely than older mothers to experience health problems, have larger families and less formal schooling. Ninety percent of girls who become pregnant while in school subsequently dropout (Boohene et al., 1991). Children of young mothers have increased risks of illness and mortality. Adolescents reported that 40% of their births were wanted later and 70% births overall were unwanted (Government of Zimbabwe, 1994). A Harare study of recently delivered mothers found women aged 19 years and below more likely to report their pregnancy as unplanned. Unplanned pregnancy was also found to be particularly associated with mothers who were single, unemployed, had low income, and/or living with their parents. It is known that unplanned pregnancies have higher risks of maternal morbidity and mortality (Mbviso et al., 1997b). Especially among young women, unwanted pregnancies often lead to attempted abortions, often with particularly severe consequences. Abortion in Zimbabwe is illegal, hence making it a ‘backstreet’ operation with high risks of complications. Rates of attempted abortion contribute to the high maternal mortality rates in the country.4 As abortion remains a criminal offence in Zimbabwe, young women can be jailed for inducing abortion and for other related consequences of unwanted pregnancy including infanticide and so-called ‘baby-dumping’. Consequently, there is gross underreporting of abortion-related ‘crimes’ in Zimbabwe. Family planning use among young women in Zimbabwe is low, leaving a substantial unmet need for contraception. It is illegal in Zimbabwe to provide family planning supplies to young people below 16
3 Of course, participation itself is not a new strategy for development and empowerment (e.g. Friere, 1972).
4 Current maternal mortality rate for Zimbabwe is 280 per 100,000 live births (World Bank, 2000a, p. 243).
reproductive system, its functions and processes. Reproductive good health includes having a safe and satisfying sex life, the capability to have children and the freedom to decide if, when and how often to do so. Furthermore, women and men of all ages have the right to information and access to safe, effective, affordable and acceptable methods of fertility regulation of their choice. Women have the right to health care for safe pregnancy and childbirth. Reproductive health care contributes to good reproductive health and well-being by preventing and ameliorating problems of reproductive health. While there are very commendable programmes for the under-5’s and attention paid to maternity services for women, the reproductive health needs of young people are often neglected by healthcare professionals and policy makers alike. Where targeted services do exist they often suffer from adultist bias, being designed by adults with little consultation with young people. Participation by children and young people is slowly being recognised as essential for effective development strategies (Johnson et al., 1998).3 Youth reproductive health is a key issue within the varied health geography of Southern Africa, and elsewhere. This case study contributes to tackling health inequalities by exploring the factors contributing to low utilisation of reproductive health services by young people, thus providing useful policy-informing research in regard to healthcare access.
ContextFthe unmet needs of youth reproductive health care in Zimbabwe
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years, unless parental consent is given, or they are married. Only about three out of ten married 15–19 year olds use contraception (mostly the pill), compared with 50% or more older women (20–39 years) (Government of Zimbabwe, 1994). As many as one-fifth of the married adolescent women 15–19 years old (compared to only 13% among 20–34 year olds) have ‘unmet need’ for family planning (op. cit.). They want to limit or space their births, but are not using contraception. Just 6.4% of 15–19 year olds and 27.7% of 20–24 year olds have ever used a condom (UNAIDS/WHO, 2000), even though knowledge levels about family planning methods among Zimbabwean adolescents is generally high and a wide range of contraceptives are available through health institutions, pharmacies and the market. Southern Africa has been hard hit by the HIV/AIDS pandemic. Infection rates are highest among 20–39 year olds who comprise 57% of reported AIDS cases in Zimbabwe (UNAIDS/WHO, 2000). Nearly half (47%) of male Harare factory workers who became HIV positive during a 2-year study were 18–24 years old (Ray et al., 1998, p. 1433). Among 15–19 year olds, infection rates for young women are six times greater than that for their male counterparts (Munodawafa and Gwede, 1996). This is due to the ‘sugar daddy’ phenomenon (Kalipeni, 2000, p. 977). As so-called ‘sugar daddies’ older men, fearing risks of infection from older women, seek younger women, especially virgins and often school girls, as (extra-marital) sexual partners and to whom they often give gifts and favours. High infection rates of all STDs, including HIV, and unwanted pregnancy among young people are attributable to vulnerability to risky sexual behaviour. For example, in a survey of Zimbabwean secondary school pupils, 37.8% male students reported sexual intercourse with two or more partners and 15.8% reported having had sexual intercourse with a prostitute (Wilson et al., 1989, p. 959). Risky sexual behaviour is exacerbated by ignorance (although knowledge about HIV/AIDS is generally high in the country, especially among urban youngsters (Wilson et al., 1989; Munodawafa and Gwede, 1996)), lack of condom availability and unwillingness to use condomsFboys complain of diminished pleasure and girls fear being labelled promiscuous. Rape5 and violent sex also contribute to high infection rates among young people in Zimbabwe. In recent years, the harsh economic times of structural adjustment have meant high rates of school dropout and unemployment leading to more prostitution, street children and ‘sugar daddies’ with consequent unfavourable reproductive health consequences for young people (Bourdillon, 2000; Gwaunza et al., 1994).
Risks of reproductive ill health among adolescents in Zimbabwe, as elsewhere are exacerbated by lack of relevant factual knowledge and self-empowerment (Campbell and Mbizvo, 1994). In some societies and cultures within Zimbabwe, sexual matters are not discussed between parents and children. Thus, many young people today rely on misinformation by their peers in relation to sexual matters. The traditional sex education provision (by aunts for girls and village elders for boys) is breaking down with urbanisation and rapid modernisation. The media are also blamed for encouraging early and risky sexual behaviour among young people. Preventing pregnancy and STD infection, postponing childbearing, accessing contraception, safe abortion and knowledge are clearly among the priority reproductive health needs of young women and men in Zimbabwe. The picture for Zimbabwe is similar for poor urban youth across the whole Southern African region (e.g. Ndubani and Hojer, 2001). Good youth reproductive health care is needed to decelerate the AIDS epidemic by preventing new HIV infections (Foster, 1998), as well as reduce high rates of STD infection, pregnancy, abortions, ‘baby-dumping’ and infanticide. At least until relatively recently, Zimbabwe has had an impressive health service for sub-Saharan Africa. Recent economic instability has led to the country’s formal state-provided healthcare system undergoing major ‘reform’ associated with economic structural adjustment policies (Bassett et al., 1997; Bijlmakers et al., 1996). Despite widespread reference to the erosion of Zimbabwe’s healthcare system (Kalipeni, 2000, p. 978), it still has many commendable aspects (Loewenson et al., 1991). For example, it has one of the highest infant immunisation rates in the region (Kalipeni, 2000). Adolescent reproductive health is identified by the Zimbabwe Government and recent UN proclamations as a priority health issue. However, given the poor reproductive health indices for young people, it would appear that despite the existence of specific tailor-made youth reproductive health centres, these are either under-utilised and/or inadequate. A potential explanation for this is that youth reproductive health services are located mostly in urban centres, and do not serve rural areas where the majority of the (young) population of Zimbabwe live.6 Furthermore, within urban centres, the youth reproductive health services are inappropriately located for the majority of urban youth who live in low-income townships (highdensity areas).
5 Zimbabwe recorded 3100 rapes in 1994 (UNDP, 1999, p. 223).
6 Only 35% of the population of Zimbabwe is urban (World Bank, 2000b).
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The study This study highlights an aspect of health service provision in Southern Africa by examining access to reproductive health services among young people (10–24 years) in Bulawayo, Zimbabwe (Fig. 1). A central aim is to explain why teenagers may opt not to use clinic services, even where they are spatially accessible. This study questions how accessible and effective are urban youth advisory centres with regard to meeting adolescents’ reproductive health needs. After the capital Harare, Bulawayo forms the second largest urban centre in Zimbabwe with a youthful population: 33% of its population aged 10–24 years (CSO, 1994, p. 186). The case study focuses on the services provided by the Bulawayo Youth Advisory Centre (BYAC). At the time of this research, it was the only provider of reproductive health services in Bulawayo, particularly family planning, specifically to young people. The BYAC is run by the Zimbabwe National
Family Planning Council with significant support from USAID, other donors and interested parties. The centre is staffed with four full-time local black Zimbabwean staff: a nurse, a clerk/receptionist and two youth advisors.
Data collection methods The primary data collection was carried out over a 3week period in July 1997 at the BYAC (Fig. 1). The data collection methods include exit questionnaires with users and focus groups with non-users of the clinic services. The interviews and focus group discussions were conducted by the first named authorFa black Zimbabwean woman, experienced community nurse midwife and mother of teenagers. She was assisted by two local research assistantsFblack male Zimbabwean youths (aged 18 and 19 years) with O-level qualifications. All three researchers grew up in Bulawayo and speak fluent
Fig. 1. Location of study.
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Fig. 2. Attendance by age at the Youth Advisory Centre 1995–1997. The drop in attendances of both adults and young people during August and September 1996 was due to the nurse being on leave. Source: Monthly return forms, ZNFPC service statistics.
Ndebele, Shona and English. Prior to data collection, the assistants were briefed about the research and given some orientation and training on how to interview, probe and listen. Exit interviews were completed with a total of 30 young peopleFabout a third (30%) of the clients aged 10–24 years. Systematic sampling was used. Every third client within this age group was approached after they had been seen at the centre. Before interviewing, the research aims were explained to each participant, their confidentiality assured and verbal agreement to participate in the research obtained. The focus groups were conducted in the Lobengula, Mzilikazi and Mpopoma townships of Bulawayo (Fig. 1) with mixed groups of young men and women in three age bands. Participants were recruited through municipal-run youth clubs that offer vocational courses, skills training and recreational activities to the townships’ young people (mostly 14–24 year olds) whether in or out of school. A focus group with 10–14 year olds was organised at Lobengula youth club. Thirteen 15–19 year olds (a mix of young men and women) participated in a focus group at Mzilikazi art and craft centre and 20–24 year olds participated in a focus group at Inyathi youth club in Mpopoma township. The discussions mainly in English (at times mixed with Shona and Ndebele) were audio-taped and later transcribed. The focus group discussions focussed on elucidating: (i) the factors that hinder young people from accessing and using the BYAC; (ii) the aspects of young people’s behaviour that impact their reproductive health and (iii) the young people’s perceptions of the problems they face related to reproductive health and how best to solve them.
Data analysis In this central part of the paper, the collected data are analysed to evaluate the accessibility of youth advisory services in terms of meeting the reproductive health needs of urban youth.
Characteristics of users of the Bulawayo Youth Advisory Centre This section deals with who is using/not using the centre to examine how effectively the centre reaches young people. The BYAC until 1992 was a family planning centre providing contraception, counselling and STD treatment mainly to adults. In 1992, under ZNFPC policy changes, it was re-designated to serve youth only, and today there are clear notices stating that only youth are attended at the centre. However, adults over 24 years are still being seen there. Attendance records for 1995–1997 (Fig. 2) show that attendance by young people steadily increased during the 2-year period, with corresponding simultaneous decline in utilisation by adults. Thus, despite its present designation as a youth advisory centre, the BYAC is in fact still providing services to a significant number of adults older than its designated clientele of under 24 year olds. There are several reasons for adults who are older than 24 years continuing to be a proportion of clients at the BYAC. Firstly, the location: the nearest alternative family planning clinic is over 2 km distant on the other side of Bulawayo (ZNFPC in Fig. 1) in a location not
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served by buses or emergency taxis;7 hence some adult users from the townships have no alternative easy access to reproductive health services in the city centre, although there are other family planning clinics in the townships. The central location of BYAC (Fig. 1) next to a busy market, bus terminus and several beer halls means it is convenient for local sex workers to use the services of the centre, especially to collect free condoms. It would clearly be unethical to deny services to those who need them, thus the staff at BYAC continue to serve a small number of other people, many of whom are commercial sex workers. This creates problems of access for young people who are wary of stigmatisation by association. During the 1997 survey period, the BYAC provided reproductive health services to 129 clients, most of whom (78%) were aged 10–24 years, making young people the vast majority of BYAC users. This section examines the characteristics of the youth (under 24 years) who attended the centre during the survey period (Table 1). The survey results indicate that most of the youth users of the services provided are young women (83%) of childbearing age. All the respondents were at least 15 years old and over a quarter (27%) already had at least one child. Less than one in 20 (17%) of the young respondents were male. Altogether, the majority of respondents were unmarried (77%) and yet to have children (73%). Roughly a third of the youth were unemployed or out of school (33%), but over a quarter were in work (27%), while even more were in education (39%). The survey reveals an interesting spatial feature of attendance patterns. Despite the residential area adjacent to the centre being low-density town houses (formerly a designated white area, now occupied by urban elites) of Bulawayo, all the clients interviewed were overwhelmingly black (94%) or of mixed race (6%), and mostly (80%) living in high-density areas. No white or Asian young people were recorded as attending the centre although it is open to all regardless of ethnicity.8 Accessing youth reproductive health services Just over half of those attending the BYAC came by bus or emergency taxi (57%) and the remainder on foot (43%) (Table 2), which is not surprising given the centre’s central location close to the city’s major bus terminus. The most frequently cited reason for visiting the centre was to obtain contraceptives and family planning advice. Only male condoms are free and contraceptives cannot legally be given to anyone under 7 Emergency taxis are small minibuses licensed to provide essential transport to the public in Zimbabwe. 8 Over 97% of Zimbabwe’s population is black African (CSO, 1994, p. 19).
Table 1 Characteristics of the respondents Characteristics of the respondents
%
n
Age (years)
20–24 15–19 10–14
73 27 0
22 8 0
Gender
Male Female
17 83
5 25
Ethnicity
Shona Ndebele Mixed race White Asian
47 47 6 0 0
14 14 2 0 0
Education/employment status
In primary school In secondary school In tertiary institution Employed Unemployed Out of school
3 13 23 27 23 10
1 4 7 8 7 3
Residential location
High-density suburb (township) Low-density suburb
80
24
20
6
Marital status
Single Married
77 23
23 7
Parenthood status
No children One child Two children
73 23 4
22 7 1
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997.
16 years. Forms of emergency contraception (i.e. the morning after pill) are not prescribed or even known about by staff at the centre.9 As abortion is illegal in Zimbabwe, young women with unwanted pregnancies are offered counselling and referred for antenatal care elsewhere. Twenty percent of the young people questioned came for free information relating to sexual and reproductive health that the BYAC provides with posters, video screenings, lectures, pamphlets and its small library. Using the counselling service was the reason cited by 17% of youngsters coming to the BYAC, while just 10% were accessing the limited clinical services available (e.g. pregnancy testing, Pap tests). While nearly a quarter of those questioned heard about the centre through school, the majority (80%) was aware of BYAC from the media and just 3 from their parents. 9
A similar lack of awareness of the morning-after pill among reproductive health personnel in Bulawayo is reported by Rutgers and Verjuyk (1998).
A. Mashamba, E. Robson / Health & Place 8 (2002) 273–283 Table 2 Respondents’ use of the Youth Advisory Centre Respondents’ use of the Youth Advisory Centre
%
n
Reason for visiting the centrea
70
21
20
6
17 7 3
5 2 1
Source of information about the existence of the centreb
Mode of travel to the centre
Family planning/ contraceptive services Sexual/reproductive health information Counselling services Pregnancy testing Pap test Media (radio, newspapers, magazines, pamphlets) School Parents Nurse Youth club Beer hall
80
24
23 10 3 3 3
7 3 1 1 1
Bus/emergency taxi On foot
57 43
17 13
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997. a Some young people had more than one reason for attending the centre. b Some young people had heard about the centre from more than one source.
Among the non-users of the BYAC who were questioned in focus group discussions with township youth, the 10–14 year olds did not know about BYAC at all, although they did know about ‘the association that teaches about family planning’, i.e. the ZNFPC which runs the BYAC. The 15–19 year old group initially claimed not to know about the BYAC and the services offered there. However, after probing and reassurances, they admitted that they had heard of the centre, that it treats people with STDs and shows video films on AIDS, family planning and STDs; but were ignorant of the full range of services it has to offer them. The oldest group (20–24 year olds) were more willing to admit awareness of the BYAC, but also did not know about the full range of services it offers. Thus, it seems that knowledge of the existence of BYAC increases with age among the Bulawayo youth but even the oldest young people have incomplete knowledge of what it offers, even if they have greater confidence and self-assurance to admit being aware of the centre. Barriers to access No users interviewed were under 15 years. Like the youngest (10–14 years) non-user focus group, most youngsters under 15 years of age are still pre-pubescent
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and (presumably) do not need reproductive health services. But like the older focus group participants, the 10–14 year olds shared the view that some adolescents become sexually active as young as 10–12 years and they knew that some of their contemporaries had left school because of pregnancy. We can surmise that a few youngsters, albeit a small minority, under the age of 15 could benefit from accessing the services of BYAC. Reasons that under-15’s do not access the centre could include awareness of the legal prohibition on issuing contraceptives to youngsters under 16, fear, ignorance, stigma and embarrassment. Cultural taboos also play a part. For example, the 10–14 year old focus group participants were reluctant to discuss issues of sexuality, claiming that family planing was okwabadala (Ndebele: ‘for adults’) and so they could not talk about it. Among the 15–19 year old non-users, a significant barrier to accessing the BYAC services appears to be stigma attached to being seen at the centre. One boy said ‘‘ywe are not having those problems (i.e. STDs) that is why we do not go there’’. The girls supported this saying ‘‘y(we) won’t feel free about being seen (there) by friends’’. Similarly, the 20–24 year olds were concerned not to be seen at the BYAC as they associate it with STDs. These comments illustrate the peer pressure that influences young people not to use the centre. Attitudes towards contraception, namely its association with loose sexual morals, may also be a barrier to young people accessing the contraceptive and family planning services available. Among the 15–19 year olds, comments reflecting such attitudes were made, for example, ‘‘yif girls carry condoms, they are in business (prostitution)’’ and ‘‘yif a girl carries condoms it means she thinks about nothing but sex’’.
Levels of satisfaction Examining the level of satisfaction with reproductive health services received by users suggests possible barriers to non-users. On the whole, the users reported high levels of satisfaction (Table 3), but a few points of dissatisfaction included inconvenient opening hours and a threatening/unwelcoming atmosphere to the centre. Only two clients interviewed said that they were so unsatisfied that they would not come back, or recommend the centre to friends. They gave the following reasons for their dissatisfaction: abruptness of the nurse, fear of being seen by friends attending the centre ‘‘ywho would think that I have a sexually transmitted disease’’, and preference for talking to and being attended to by a peer. As many as a third of the users questioned said that they would prefer to be advised by a peer rather than the existing adult staff (Table 3).
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Table 3 Satisfaction with the Youth Advisory Centre services Satisfaction with the Youth Advisory Centre services
%
n
Opening times
Convenient Inconvenient
93 28 7 2
Atmosphere of the centre
Welcoming/ non-threatening Unsatisfactory
93 28 7
2
Waiting times
Satisfactory
100 30
Satisfaction with services received
Satisfied Dissatisfied
93 28 7 2
Preferred advisor/ service provider
Female health worker Peer No preference
47 14 30 9 23 7
Suggestions for improvement
Younger counsellors Better attitude of nurses Provide services in high-density suburbs School visits by staff Daily opening Make building & reception area more welcoming Better written pamphlets More HIV education
17 13
5 4
10 10 7
3 3 2
7 7 3
2 2 1
Source: Fieldwork questionnaire completed with 30 users of BYAC, July 1997.
Suggested service improvements A range of improvements to the BYAC services were suggested by the users interviewed (Table 3). The most frequent suggestions were for younger counsellors and more friendly, open and accepting attitudes of the nursing staff. Other suggestions for improvement include provision of services and/or outreach visits by BYAC staff in the township and schools,10 daily opening times convenient for those at school or working and making the BYAC a more welcoming place. The non-users of BYAC consulted in the focus groups also made several suggestions for improving youth reproductive health services. The 15–19 year olds at Mzilikazi art and craft centre firstly suggested extending the programmes to parents, as well as to young people so that they know how to start talking and discussing 10 Others (e.g. Mbviso et al., 1997a), including government bodies (Government of Zimbabwe and UNICEF, 1993; NACP et al., 1997), have called for and are promoting better schoolbased reproductive health education programmes in Zimbabwe.
with their children from an early age. Second, they were in favour of teaching young people to promote health education messages to each other without misinformation and to be more open in discussing issues of sexuality and sexual health with one another. When asked to suggest improvements for reproductive health services, the first reaction of the older (20–24 year olds) focus group participants at Inyathi Youth Club was ‘‘Why think about sex when you wake up hungry’’. This comment raises a serious issue. For many young people, reproductive health issues pale beside more serious concerns of poverty, unemployment and lack of opportunities for income earning in the severely under-developed areas where they live. However, in further discussion, the 20–24 year olds suggested a youth consultation forum would be helpful so that they could discuss how to solve the many problems they face, not only issues of sexuality and reproductive health problems.
Conclusions The central location of the BYAC in Bulawayo means that although it is accessed by low-income township black youth, (especially girls), more than half have to use public transport to get there. Its situation close to the market and not far from the bus terminus make access to the BYAC relatively convenient for its targeted users. Fewer male than female users is not surprising as girls generally have more reproductive health problems associated with child-bearing capacity. Indeed, this finding is encouraging as there are renewed calls for special efforts to protect girls and young women exposed to the risk of HIV/AIDS (Matlin and Spence, 2000). A dominance of black users reflects the ethnic makeup of the general population and also that White and Asian minorities are likely to be in higher-income groups able to access private healthcare services. However, although the BYAC is spatially accessible to many, it may not be temporally accessible because opening hours coincide with times when young people are in school. Analysis of the youth’s responses suggests that other access barriers include ignorance of the BYAC and services it offers, peer pressure, problems of stigmatisation and negative associations with STDs, prostitution, loose sexual morals, ignorance and cultural taboos in discussing matters of sexuality; making young people reluctant to visit. Thus, being close to the beer halls and the haunts of sex workers is a part of BYAC’s complex interaction with other places and something that clearly has an important role in influencing young people’s access to the centre. Other aspects of the BYAC itself as a place which form barriers to young people’s use of the facilities include the adult-only staff, unwelcoming atmosphere, waiting times and poor attitudes of the
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staff and opening hours that coincide with young people being in school. The analysis shows that the mere provision of healthcare services, in this case a youth reproductive health advisory service, does not always ensure client utilisation and satisfaction. Efforts need to be made to overcome the barriers identified that prevent young people from using the services available. From the data analysed above, it can be concluded that spatial accessibility is not the only factor to be overcome in ensuring equal access to health services. Place matters, but distance is not the only factor in determining access, utilisation and satisfaction. This study confirms that health geographers must look beyond space and location in identifying and explaining inequalities in healthcare access. These conclusions have broader implications for those striving to overcome the neglect of young people in research and policy making and striving to reduce their exclusion from accessing reproductive healthcare services. Our conclusions can be translated into a series of recommendations for policy (see below). Such findings also demonstrate the as-yetlargely unexplored potential for including geographers in the scope of multi-disciplinary planning of youth services.
Policy recommendations From the findings of this limited study (particularly, the suggestions given by the young participants), some general policy recommendations can be made. These recommendations suggest more effective ways of ensuring better access to reproductive health care by young people in Bulawayo, but may have wider applicability. As an outcome of this study, the authors recommend: *
*
*
*
Youth reproductive health services be located within residential areas (especially high-density townships) to prevent travel time and cost preventing access. The times of service provision be accessible to youths in full-time education or employment. For example, by including evening /weekend service provision or even 24 hour services attached to places frequented by youth such as internet caf!es. Regular ‘youth-friendliness training’ for adult service providers to reduce/avoid adultist bias. The involvement of young people as peer educators, counsellors, etc. to increase youths’ ownership of service provision. Parental involvement to dispel suspicion and ignorance about youth reproductive health service provision and to encourage informed discussion of sexuality/sexual health within the home environment.
*
*
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Purpose-built facilities for provision of youth reproductive health services,11 as preferential to conversion from existing facilities to prevent the previous purpose and users deterring youth. Provision of youth reproductive health services within multi-purpose environments (e.g. youth centres) providing recreation, leisure activities, entertainment and skills training in order to respond to the wider needs of young people within which their reproductive health needs are embedded.
As demonstrated in the recommendations above, a multi-pronged approach is needed to overcome barriers preventing young people’s utilisation and satisfaction in accessing existing reproductive health services. Service provision needs to be targeted spatially to where young people live and at times when they are not in school/work. Such provision needs to be acceptable to, and tailored specifically for, young people; recognising that they are individuals (albeit embedded in families) with reproductive health needs that intertwine with other aspects of their identity and situation. As such, this echoes recent calls by the UN and others for multi-sectoral strategies to improve healthFparticularly, in the context of the HIV/AIDS pandemic. The recommendations made above may be generalisable to provision of specialist youth health services not only in Zimbabwe, but also for the Southern African region, the developing and even the developed world. It is our hope that in a small way this study, despite its inherent limitations,12 may improve young people’s access to reproductive health care in Zimbabwe and beyond. The urban focus of this study should be complemented by future research on rural youth’s access to reproductive health care, not in the least because rural young people suffer greater reproductive ill health (especially adolescent pregnancy) than their urban counterparts and barriers to access (spatial and otherwise) are even more challenging. Acknowledgements This paper is a successful collaboration demonstrating the potential for geographers and health workers to work together. The paper summarises dissertation research completed in partial fulfilment of the requirements for a Masters in Business Administration (Health, Population and Nutrition) by Alethea Mashamba. This dissertation covered access issues more broadly, 11
ZNFPC policy aims for one purpose-built youth facility in each major town. In 1997, these already existed in Harare, Mutare and Masvingo. 12 Time and resource limitations restricted the research to a single case study, using a relatively small sample.
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following Maxwell (1984). Alethea Mashamba acknowledges research guidance received from Ruth Hope and Frank Paulin; financial support from the Canon Collins Foundation for Southern Africa and the Commonwealth Secretariat; the co-operation of ZNFPC and the helpfulness of staff at the ZNFPC centre in Bulawayo in carrying out the field research. Andy Lawrence is thanked for providing excellent cartography. The comments of the editors of this special issue and two anonymous referees helped polish this paper. Both authors gratefully acknowledge the young people who shared their views and feelings.
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