Analysis of sexual and reproductive healthcare utilisation among young people in Zimbabwe.

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.