BACKGROUND PAPER
DEVELOPING NATIONAL STANDARDS FOR ADOLESCENT/YOUTH FRIENDLY HEALTH SERVICES IN MALDIVES
DRAFT
REVISED APRIL 2013
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TABLE OF CONTENTS
LIST OF ACRONYMS AND ABBREVIATIONS......
LIST OF FIGURES......
LIST OF TABLES......
1. BACKGROUND......
1.1. Aim of the Background Paper
2. EPIDEMIOLOGY......
2.1. Health Problems and Outcomes
2.2. Health related risk behaviours in adolescents and youth......
2.3. Socio-economic determinants influencing behaviours and outcomes......
3. ANALYSIS OF EXISTING POLICIES AND STRATEGIES......
3.1. National Youth Policy 1984......
3.2. The Health Master Plan 1996-2005......
3.3. Health Master Plan 2006-2015......
3.4. National Youth Health Strategy 2011-2015 (Final Draft)......
3.5. DRAFT National Strategic Plan for the Prevention and Control of HIV/AIDS 2012- 2016
3.6. Behaviour Change Communication Strategy for HIV prevention in the Maldives – The Global Fund Supported Programme in the Maldives, 2009
3.7. Population Policy of the Maldives, 2004......
3.8. UNDAF 2011-2015 Action Plan......
3.9. National Reproductive Health Strategy 2008-2010 (Final Draft)......
4. CURRENT SITUATION REGARDING THE PROVISION AND USE OF HEALTH SERVICES TO ADOLESCENTS AND YOUTH
4.1. Services Provided to Adolescents and Youth
4.2. Barriers to Provision of Health Services and Utilisation by Adolescents/Youth
4.3. Help and Health Care seeking Behaviour and Practices of Adolescents and Youth
5. EXPERIENCES IN THE COUNTRY IN APPLYING QUALITY IMPROVEMENT AND COVERAGE EXPANSION PRINCIPLES AND PRACTICES IN PUBLIC HEALTH
5.1. Assessment Report: Impact of Youth Health Café’ and Adolescent Health Clinic/IGMH Maldives (Draft, 2009)
5.2. Assessment Report Maldives: Adolescent Reproductive Health Project, 2005..
6. CONCLUSION...... 41
REFERENCES...... 42
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LIST OF ACRONYMS AND ABBREVIATIONS
AHCAdolescent Health Clinic
AIDSAcquired Immunodeficiency Syndrome
ASRHAdolescent Sexual and Reproductive Health
BBSBiological and Behavioural Survey
BCCBehaviour change communication
FGD Focus group discussion
FPFamily planning
FSWFemale sex worker
GSHSGlobal School-based Student Health Survey
HIVHuman Immunodeficiency Virus
HPAHealth Protection Agency
IDUInjecting drug user
IECInformation, education and communication
IGMHIndhira Gandhi Memorial Hospital
ILOInternational Labour Organization
LSELife skills education
MDHSMaldives demographic and health survey
MDHSMaldives Demographic and Health Survey
MFDAMaldives Food and Drug Authority
MLRMedico-legal record
MoEMinistry of Education
MoHMinistry of Health
MSMMen who have sex with men
NDANational Drug Agency
NGONon-governmental organization
RHReproductive health
RHCReproductive Health Clinic
RSARapid situation assessment
SHE Society for Health Education
SRHSexual and reproductive health
STDSexually transmitted diseases
STISexually transmitted infections
UNUnited Nations
UNAIDSJoint United Nations Programme on HIV/AIDS
UNDPUnited Nations Development Programme
UNFPA United Nations Population Fund
UNICEFUnited Nations Children’s Fund
UNODCUnited Nations Office on Drugs and Crime
UNOPSUnited Nations Office for Project Services
VCTVoluntary counselling and testing
WHOWorld Health Organization
YHCYouth Health Café
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LIST OF FIGURES
Figure 1.1 Population pyramid of Maldives, Census 2006……………………………8
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LIST OF TABLES
Table 1.1 Population of selected age groups by sex……...... 7
Table 1.2 Basic demographic indicators of Maldives in selected years……………….8
Table 3.3.1 Targets for child and adolescent health, Health Master Plan 2006-2015...19
Table 3.9.1 Objectives, strategies and interventions outlined under thematic area 5 of the RH Strategy 2008-2010…………………………………………………………...27
Table 3.9.2 The logical framework for monitoring and evaluation of the plan outlined under thematic area 5 of the RH Strategy 2008-2010……………………………...…28
Table 4.1.1 Overview of agencies involved in adolescent and youth health and their focus and activity areas………………………………………………………...... 29-31
Table 5.1.1 Key assessment findings and recommendations for YHC……………….36
Table 5.1.2 Key assessment findings and recommendations for AHC, IGMH……....37
Table 5.1.3 Key assessment findings and recommendations for AHC, IGMH……....38
1. BACKGROUND
Adolescence and youth are critical periods of young people’s development where an individual undergoes major physical and psychological changes and transit from the dependence of childhood to adulthood’s independence while gaining awareness of interdependence within a community. Adolescence is a period of opportunity to prepare for a healthy productive adulthood, as well as a period of risk where occurrence of health problems and initiation of risky behaviours could have adverse effects on an individual’s future potential and wellbeing. For statistical consistency, the UN defines adolescents as 10-19 year olds, youth as 15-24 year olds, and young people as 10-24 year olds, although youth is a more fluid category that changes with cultural contexts of individual countries. In Maldives, the youth age group is officially considered to be 18-34 years, although 15-24 years is typically considered as youth in research and literature specific to Maldives (MPND, 2008). This paper uses the UN definitions of adolescent, youth and young people to maintain consistency unless specified otherwise.
According to the Population and Housing Census of the Maldives 2006, 37.4% of the population was young people aged 10-24 years, constituting 51.1% females and 48.9% males (MPND, 2008). Table 1.1 shows the percentage representation of selected age groups within the Maldivian population. As evident from the 2006 population pyramid of Maldives shown in Figure 1.1, the country represents a largely young population. Basic demographic indicators of Maldives in selected years are summarised in Table 1.2.
Source: MPND, 2008
Figure 1.1. Population pyramid of Maldives, Census 2006
Source: MPND, 2008
Source:MoHF, 2009;MPND, 2008
1.1. Aim of the Background Paper
- To establish the basis for the provision of health services to adolescents/youth within the framework of relevant national programmes and strategies (i.e. Child and Adolescent Health, Youth and/or Reproductive Health, Mental Health policies/strategies).
- To develop a good understanding of the current situation regarding the provision of health services to adolescents, and their utilization by adolescents.
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2. EPIDEMIOLOGY
2.1. Health Problems and Outcomes
2.1.1. Sexual and Reproductive Health (SRH)
The average age of marriage in the Maldives during the mid 1990s was 16 years and consequently a vast majority of adolescents became young parents (Health Master Plan, 1996-2005). Notable educational and economic developments in the Maldives had significantly affected the fertility dynamics among young people in recent decades. In addition, the minimum age of marriage in the Maldives was set to 18 years by law through the passage of the Family Act in 2000, prior to which, children as young as 13 got married as an accepted practice (UNFPA Maldives, 2011). According to the 2009 Maldives Demographic and Health Survey (MDHS), the median age at first marriage in the Maldives is 19 years (MoHF and ICF Macro, 2010).
Despite this increase in the median age of marriage, institutionalised SRH services and commodity supplies continue tobe available exclusively to married couples. The underlying assumption here is that sexual intimacy does not or should not occur until marriage, which is consistent with socially held views, underpinned by long held religious beliefs. Nevertheless, there is ample evidence to show that this situation is inconsistent with the social realities of youth sexual behaviour (UNFPA Maldives, 2011). The 2004 RH Survey reported that youth focus group discussion (FGD) participants expressed that “Maldivian youth is generally sexually active before marriage” (MoH and UNFPA, 2004). Survey findings about unmarried youth revealed that “two thirds of those who had had sex said their first sexual intercourse was before the age of 18 years”, indicating premarital sexual initiation (MoH and UNFPA, 2004). According to the 2007 study on Women’s Health and Life Experiences (WHLE), the majority of 18-21 year olds (92%), reported their first sexual experience as “wanted” or voluntary as did 85 percent of 15-17 year olds. Although coercion and force feature strongly in these findings, especially among children below the age of 15, the prevalence of consensual sexual behaviour among these young people is notable (Ministry of Gender and Family et.al., 2007).The 2009 GSHS found that 17.8% of boys and 16.1% of girls studying in grades 8 to 10 were physically forced to have sexual intercourse, with more prevalence in the Atolls than Male’ (CDC and WHO, 2009).
The Biological and Behavioural Survey (BBS) conducted in 2008 also provided alarming evidence of youth sexual risk behaviour involving significant numbers of young female sex workers. A key finding of the report is the prevalence of “unprotected sex with multiple partners” among the high-risk groups, which includes adolescents in the 15-17 age group and older youth (DPH and GFATM, 2008).These findings also highlight the multiple issues connected to high risk, unsafe and unprotected sexual behaviours and practices, which undoubtedly contribute to the public health burden of the country. Issues stemming from the prevalence of sexual behaviour among unmarried youth include a complex mix of health, social and legal consequences, primarily connected to the occurrence of pregnancy outside marriage.
2.1.2. Early Pregnancy and Unsafe Abortion
Pregnancy during adolescence is a major health concern due to its association with increased morbidity and mortality among both mother and child. In addition, it could have adverse societal consequences such as limitations in educational attainment and potential for employment. The RH Baseline survey conducted in 1999 andthe RH survey of 2004 provide ample evidence that pregnancy outside of marriage occurs in the Maldives (MoH and UNFPA, 1999; MoH and UNFPA, 2004). Statistics from the Family Protection Unit (FPU) at IGMH shows that pregnancy outside marriage was the third most common issue among patients who were attended to by the FPU, of which 68% consisted of young women between the ages of 15-24 (IGMH and UNFPA, 2010).
As evident from medico-legal records (MLR) at IGMH, in 2010 alone, 41 cases of unmarried pregnancies were identified, of which 32 were among adolescents and youth between the ages 15-24 (UNFPA Maldives, 2011).
Case studies conducted for the study on reproductive health knowledge and behaviour of young unmarried women in Maldives (UNFPA Maldives, 2011) also confirms the occurrence and prevalence of adolescent and youth pregnancy outside of marriage to be a growing issue of concern. Additionally the study draws attention to the domestic socio-cultural context, i.e., the social and legal implications connected to unmarried pregnancies, which creates an intricate link to unsafe abortions.
A qualitative study conducted by the International Planned Parenthood Federation (IPPF) in 2008 found that abortion is more common among unmarried youth than it is among married couples in Maldives (IPPF, 2008). The study also reported a disturbing perception held by participants that abortion is “a risk free procedure” which is a “safe alternative to contraception” (IPPF, 2008). There is evidence suggesting that Maldivians frequently seek abortion services in neighbouring countries such as Sri Lanka and India, often in facilities that operate outside of the legal system of the respective country (IPPF, 2008; UNFPA Maldives, 2011). In addition, incidences have been documented of injection-induced abortions by non-medical personnel in unsafe conditions in the capital city Male’ (UNFPA Maldives, 2011).
2.1.3. Substance Use
At present, illicit drug use in Maldives is extensive among youth. The National Drug Use Survey of the Maldives, 2011/2012 (UNODC, 2013) revealed that 73% and 49% of the current drug users in Male’ and the Atolls respectively are aged between 15-24 years. The onset of drug use was found to be during adolescent years, while the majority of the respondents who had ever used drugs belonged to the age group of 15-19 years (UNODC, 2013). The study estimated that the prevalence of drug use for Malé and Atolls were 6.64% and 2.02% respectively, and found that an overwhelming majority of drug users were males (UNODC, 2013). The recently published female recovering addicts need assessment survey (Journey, 2013) conducted by the NGO Journey found that out of the 44 female respondents, the age of first drug use was 10 to 14 years for 18%, between 15-19 years for 39%, and 20-24 years for 34%. The 2009 GSHS found that the prevalence of current alcohol use among students (i.e., drinking at least one drink containing alcohol on one or more of the past 30 days) to be 6.7% with 65.8% of those who ever drank alcohol to have had their first drink before the age of 14 years (CDC and WHO, 2009). This study found the prevalence of lifetime drug use among students to be 3.7% with a significant difference between boys (7.5%) and girls (3.2%), with 67.6% trying drugs at age 13 or younger (CDC and WHO, 2009).
The Rapid Situation Assessment of Drug Abuse in Maldives (RSA) revealed that 98% of respondents were smokers. Almost half (48%) had initiated smoking between the age of 10-14 years and 42% between 15-19 years, while 5% of those who smoked started before they were 10 years old (Narcotics Control Board, 2003). In all, 95% of drug-using respondents had started smoking by the age of 20 years. Fun (66%) and fashion (9%) were cited as the most common reasons for initiation of smoking. The Global Youth Tobacco Survey conducted in 2003 in Maldives showed that current prevalence of tobacco use, in any form, among school going adolescents (13-15 years) to be 13% (CDC and WHO, 2003). The survey also revealed that a large proportion of adolescents have easy accessibility to cigarettes and half of them live in homes where others smoke, making them more vulnerable to smoking.
2.1.4. Mental Health
Mental health has been an under addressed area in the Maldives. It is evident from literature that following the 2004 Indian Ocean Tsunami, the Government of Maldives initiated prioritization and development of mental health and psychosocial support services with intentions to formulate strategic plans and legislations focusing on mental health (Ibrahim and Hameed, 2006; WHO SEARO, n.d.).The recently ratified Public Health Act addresses lifestyle diseases, although the inclusion criteria are yet to be defined in regulations that are to be developed in line with the Act. Lifestyle diseases can include mental health problems, and if included, the Act provides the capacity to create awareness on the issue, implement services for early detection and develop care and services that can assist in limiting progression of such conditions, among other health promoting strategies (Act number 7/2012).
The 2009 GSHS which addresses mental health found that 15.8% felt lonely most of the time or always, 14.8% could not sleep at night due to worries of which 56.5% were bullied, an alarming 22.2% made plans on how to attempt suicide with 19.9% of students seriously considered attempting suicide, while only 26.8% of students were taught in any of their classes in school about stress management (CDC and WHO, 2009). Issues relating to mental health have been discussed as determinants or consequences of various other public health issues. The RSA of drug abuse showed that 18% of drug users reported their primary reason for drug use to be stemming from psychological problems (Narcotics Control Board, 2003).The RSA of gangs in Male’ published in 2012 reported that bullying at school is among the factors that contribute towards youth to eventually join gangs citing revenge and the feeling of powerfulness in doing so (The Asia Foundation, 2012). The 2009 GSHS found that 41.2% of boys and 34.2% of girls were bullied at school during the 30 days preceding the survey (CDC and WHO, 2009).
A survey carried out in 2004 by the MoH, which uses the Self Reporting Questionnaire (SRQ)developed by WHO, estimates prevalence of psychoses at 1%, neuroses as22.3% and epilepsy as 6.1%. This survey used the Self Reporting Questionnaire (SRQ)developed by WHO (WHO SEARO, n.d). The Health Master Plan 2006-2015 addresses only neurotic disorders and epilepsy as mental health issues. However, the National Youth Health Strategy 2011-2015 regards improving mental health of youth as a main activity area and places focus on a broad range of mental health issues such as suicidal tendencies, coping and aggression.
2.1.5. Nutrition
Although extensive data is available on the nutritional status of children under 5 years across the Maldives, there is limited data available on nutrition of young people. The MDHS 2009 analysed nutrition data of women and found that 8.4% of those aged 15-19, and 8% of those aged 20-29 in the sample were short statured (below 145cm) (MoHF and ICF Macro, 2010). Additionally, it found that within the age group 15-19, 23.7% were thin while 23.5% were overweight or obese, while these nutritional outcomes for the 20-29 age category were 13.4% and 32.4% respectively (MoHF and ICF Macro, 2010). The Micronutrient Survey, which included women of reproductive age (15-49 years), found that 15.4% of women were anaemic, 38.4% were iron deficient, 26.8% were zinc deficient, 44% were Vitamin A deficient, and 26.8% were iodine deficient (UNICEF Maldives and MoHF, 2007). Growing public health issues relating to nutrition include the excessive use of energy drinks, fast food and sedentary lifestyle, not only among adults and young people, but also among children. The 2009 GSHS found that unhealthy dietary behaviours were prevalent among school goers, which include not having breakfast (53.5% nationally) and frequent consumption of fast food (CDC and WHO, 2009).
2.1.6. Violence, trauma and injuries
The 2009 GSHS found that 47.6% of boys and 29.2% of girls were physically attacked in the 12 months prior to the survey, while 49% of boys and 37.1% of girls were seriously injured one or more times within the same period (CDC and WHO, 2009). Of these, 8.5% of injuries that occurred among boys and 3.7% of those among girls happened while riding a bicycle or scooter (CDC and WHO, 2009).
Gang violence in the Maldives is becoming increasingly commonplace and the nature of violence more brutal as new types of drugs and weapons are being utilised. As revealed in the National Values Survey (NVS),a widespread breakdown in family structures has begun to lead young people towards finding new ways of belonging in an effort to replace the security and structure of a family (The Asia Foundation, 2011). Young people often turn to drugs to get away from their family problems, which contribute to their ending up in gangs. A common feeling among gang members is that the gang is ‘like a family’ and they say that members in the gang take care of each other, share each other’s problems and are there through the good times and the bad times, thus playing a role in their lives similar to that of family members (The Asia Foundation, 2012). A number of members belonging to gangs mentioned that they join gangs to get revenge for being bullied at school. When these kids grow up they often join gangs to overcome feelings of powerlessness and inferiority that began at school. Additionally, a number of gang members interviewed revealed that they joined gangs after their parents divorced or after the death of a parent.