Analysis of sexual and reproductive healthcare utilisation among young people in Zimbabwe.
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Date
2020
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Abstract
Despite the development and implementation of an adolescent and youth sexual and
reproductive health (ASRH) strategic plan in 2010, Zimbabwe has the third-highest
HIV prevalence amongst sexually active teenagers in Southern Africa. The country
can potentially suffer future socioeconomic decline due to adverse health outcomes
resulting from the current risky sexual and reproductive health behaviour among its
youth and adolescents. The attainment of the United Nations’ Sustainable
Development Goals (SDGs) may be compromised owing to this predicament. The
thesis analysed the utilisation of adolescent and youth sexual and reproductive health
services and their outcomes in four essays.
The first essay investigated the socioeconomic factors that influence ASRH service
utilisation, the resultant outcomes and their distribution. The essay updated existing
literature by providing recent evidence on ASRH specific socioeconomic determinants
and their equity connotations, which has been lacking since the implementation of the
ASRH strategy in 2010. The essay applied the logistic regression and concentration
index techniques on the Zimbabwe Demographic Health survey (ZDHS) data. Findings
revealed that inequalities favouring advantaged groups widened in STI treatment, HIV
testing, STI treatment, as well as in condom and contraceptive use. Progress was
made in early childbearing, which declined among the uneducated. Another positive
development was the disproportionately higher HIV infection among females, which
declined by almost half between 2005 and 2015.
The second essay analysed the impact of the government’s ASRH strategy on the
utilisation of ASRH services. The essay’s contribution was its quantitative insight into
whether a multi-pronged approach or commitment of more resources results in better
ASRH outcomes. The difference-in-differences impact evaluation technique was
applied to ZDHS data collected in 2010 and 2015. Results indicated that service
utilisation for HIV testing and treatment of sexually transmitted infections (STIs)
increased. The ASRH strategy also reduced HIV prevalence. These impacts differed
by education status and place of residence. Results also showed that provinces that received more resources did not attain better ASRH outcomes, suggesting that future
focus should be on the quality of services.
The third essay sought to characterise the risk preferences of youth. Its contribution
lies in using prospect theory to fit youth risk-taking in the domain of sexual and
reproductive health as a departure from the normally assumed expected utility theory.
Primary data was collected from university students in Zimbabwe using a
socioeconomic questionnaire and pairwise lottery choice tasks based on hypothetical
ASRH interventions with uncertain outcomes. Prospect theory parameters were
estimated using patterns of the respondents’ choices over the lottery tasks. This is the
first study, to the researcher’s best knowledge, that estimates ASRH risk parameters
within the prospect theory framework. Bivariate techniques, ordinary least squares and
interval regression methods were used to examine socioeconomic differences in risk
preferences. Results indicated that the ASRH behaviour of youth fits within prospect
theory. Bivariate and multivariate regression analyses showed that income, prior
sexual and reproductive health knowledge, and alcoholism were associated with risk
and loss aversion.
The fourth essay investigated the long-term consequences of ASRH practices from
the female youths’ perspective as the hardest hit gender. The essay’s contribution lies
in unearthing the magnitude of lifelong effects of failure to utilise ASRH interventions
during adolescence, which is missing from Zimbabwean literature. The essay applied
propensity score matching and multivariate regression techniques on ZDHS data
collected in 2015. Findings revealed that non-utilisation of ASRH services leads to
lower educational attainment, lesser chances of career development, poverty, as well
as the contracting of STIs and HIV infections.
Overall, these findings have several implications. Firstly, health policymaking must
consider inclusive ASRH strategies that target currently excluded youths in rural areas,
uneducated and poor households, and consider their unique risk preferences. In
addition to that, future ASRH strategies should focus on service quality and increased
coverage to improve outcomes and attain SDG targets. Secondly, the nature of youths’
risk preferences entails that ASRH awareness campaigns be positively framed to
improve uptake of ASRH services. In addition to that, policymakers need to facilitate youth economic emancipation to increase economic prospects, which improves
economic reference points that are critical facilitators of risk aversion. Lastly, future
ASRH strategies need to have better coordination and monitoring since they involve
different implementers. Furthermore, the ASRH strategy needs to be integrated into
other sectors' goals that it impacts, such as education and labour.
Description
Doctoral Degree. University of KwaZulu-Natal, Durban.