Unfpa Country Support Team

UNFPA COUNTRY SUPPORT TEAM

Office for the South Pacific

DISCUSSION PAPER NO. 17

Prospects for Demographic Behavioural Change

in Vanuatu:

The Results of a KAP Survey

by

William J House

Adviser on Population Policies & Development Strategies

UNFPA/CST, Suva

The views and opinions contained in this Report

have not been officially cleared and thus do not

necessarily represent the position of the

United Nations Population Fund

December 1998

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Executive Summary

Information on the nature and determinants of demographic behaviour in Vanuatu is extremely limited. A Knowledge, Attitude and Practice (KAP) Survey was conducted in urban and rural areas of Vanuatu in June 1995 with support from the South Pacific Alliance for Family Health (SPAFH), the South Pacific Commission (SPC) and the Statistics Office of the Government of Vanuatu.

Our analysis of the survey reveals that 71% of women and 65% of men know of at least one contraceptive method. Male knowledge exceeds female knowledge for those methods which are strictly male i.e. condom, male sterilization and withdrawal, as well as for the Billings method. The pill, condoms and female sterilization were the most widely known methods; “inefficient” methods - withdrawal, abstinence and traditional methods - were among the least known.

As expected, knowledge of family planning rises with age and education. The relatively low level of knowledge for younger age groups should be disturbing to the authorities given their concern with the increasing incidence of teenage pregnancy and the threat from HIV/AIDS. Of those aged 15-24 69% of currently married women and only 53% of single women are aware of family planning. The corresponding data for currently married and single men were 60% and 55%. Evidently, large numbers of young persons are ignorant of the benefits to be derived from contraception and family planning, which must impede progress in promoting delayed pregnancy and child spacing as methods of improving the health of mothers and children.

The current contraceptive prevalence rate is estimated to be 31% for all methods but only 21% for modern methods. Almost one half of female users of modern methods are dependent on the contraceptive pill. While better educated women are more likely to know of the concept of family planning, they are no more likely than less educated women to have adopted the practice. In contrast to female respondents, the rate of male current use at 35% (half of which are using condoms) rises consistently across education levels.

There are still wide gaps across the country in the knowledge and use of contraceptive methods. While awareness of family planning is far from universal, it is very much higher than the actual practice of family planning. Past engagement of health workers and radio programmes to spread the message has been very effective. More extensive use of these mechanisms seems justified, particularly in light of the relatively low rate of use of modern methods of contraception. Major emphasis must be given to closing the gap between awareness of family planning and recognition of the benefits to be derived by individual families from actually practising family planning, particularly modern, effective methods of contraception. Such an approach would assist in closing the extremely large unmet need for limiting future childbearing at 30% of currently married women. While this analysis was unable to estimate the level of unmet need for child spacing, evidence from other countries would suggest this far exceeds the size of the unmet need for limiting future births, which is already quite extensive in Vanuatu.

The perceived dispersion in access to service facilities across the country is wide, as is the kind of services offered in the clinics. More in-depth assessment of these perceptions is warranted, as would be an evaluation of the actual disparity in services offered across the regions.

The generally pronatalist, high fertility and non-contracepting environment prevalent in Vanuatu is characteristic of many other less developed countries at its stage of development. Thus, it would be surprising if individual behavioural factors were to be important in explaining demographic behaviour. For example, women’s education attainments do not assist in explaining inter-personal differences in achieved fertility or the use of contraceptives. That more education seems to induce a decline in desired family size (mean of 3.85) offers some hope for an eventual change in demographic behaviour. The same is true of our finding that women in non-agricultural wage employment achieve lower fertility and are more likely to use contraception. As Vanuatu creates more opportunities for female education and non-traditional economic opportunities, demographic behavioural changes will be more likely.

Vanuatu has commenced an exercise in designing a comprehensive population and development policy and some of the results of the KAP survey reported here may be of direct interest to the drafters of the policy. Evidently, enlargement of the extent of knowledge of family planning and its benefits to the individual family and its members throughout all corners of Vanuatu is a pre-requisite for future demographic behavioural change. Measures to raise the overall status of women to a level where they can identify the incompatibility between their own fertility and both the share of economic responsibility they bear for raising children and the ever greater costs of feeding and educating them should receive priority in such a policy statement. Only then will those with the requisite knowledge and awareness be induced to adopt methods to plan and control their fertility.

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Table of Contents

Prospects for Demographic Behavioural Change......

Executive Summary

I.Introduction......

Overview......

Family Planning Policy......

II.An Expanded Knowledge Base On Demographic Behaviour......

The 1995 Vanuatu Family Planning or KAP Survey......

III.The Vanuatu KAP Survey Analysis......

Demographic Behaviour: Some Theoretic Underpinnings......

The Survey Results......

Current Use of Family Planning......

Ever Use of Family Planning......

Perceptions of Service Facilities......

IV.Estimating The Unmet Need for Family Planning......

Conceptualising the Level of Unmet Need for Family Planning......

Socio-Economic Characteristics of Women with Unmet Need......

V.The Determinants of Demographic Behaviour......

Other Factors......

Multivariate Analysis of Demographic Behaviour......

Fertility Behaviour......

Desired Family Size......

Knowledge and Use of Contraception......

Unmet Need for Family Planning......

VI.Conclusions......

References

Appendices……………………………………………………………………….

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I.Introduction[*]

Overview

The Republic of Vanuatu, formerly known as the New Hebrides, has a population of over 170,000, which is concentrated on the three major islands. The capital of Port Vila has a population of about 24,000 and Luganville, the only other major town has a population of about 8,000. Villages tend to be scattered around the coastal zones of the archipelago and have poor infrastructure and limited communication links to the urban centres. The Melanesian people speak around 100 dialects with Bislama, English, and French used as official languages, the latter reflecting the influence of the pre-Independence Anglo-French Condominium government.

The rural population has avoided the severe poverty experienced in many low income countries but access to education beyond basic schooling is extremely restricted, workforce skills are very underdeveloped and primary health care receives too little attention in rural areas. The dualistic structure of the economy is reflected in a highly skewed income distribution; ni-Vanuatu people constitute 97 per cent of the population but receive only 70 percent of measured GDP, meaning that their incomes are only 7 percent of the expatriates’ average.

In keeping with its status as a least developed country Vanuatu ranks 124th of 175 countries in the UNDP 1997 Human Development Index (UNDP, 1997). The HDI combines a weighted mean of life expectancy at birth, adult literacy and purchasing power per capita. According to the 1997 UNDP report, Vanuatu has a life expectancy of 65.9 years, a 64% rate of adult literacy and US$2,276 in purchasing power per capita. This compares for example, with nearby Australia which ranks 14th on the HDI, with life expectancy of 78.1 years, 99% adult literacy and purchasing power per capita of US$19,285. Neighbouring Papua New Guinea lies below Vanuatu in 128th place with life expectancy of 56.4 years, adult literacy of 71% and purchasing power of US$2,821.

Vanuatu’s demographic dynamics reflect its underdeveloped status in that fertility is relatively high, mortality and life expectancy have improved but do not warrant complacency, population growth has declined but still, at the current rate, population size will double in 23 years, and the rate of urbanisation exceeds overall population growth by a factor of almost three.

From the 1989 Census it is estimated that the total fertility rate fell during the 1979-89 intercensal years, from 6.5 to 5.3, with that of rural women being higher than urban women, while rural childbearing continues into the 40 plus years (Republic of Vanuatu, 1991). Over the same period the infant mortality rate declined from 94 to 45 per thousand live births while the crude death rate fell from 12 to 9 per thousand population and the annual rate of population growth fell from 3.4% to 2.8%. Women’s educational attainment is negatively related to fertility, which is line with the findings of global research. The use of modern contraceptives is becoming more common, but they are thought to be more widely used by urban rather than rural women. It is believed that the latter rely more on traditional methods to reduce fertility, such as the use of the lif (leaf) and extended periods of abstinence after a birth. However, reporting and record keeping are poor and past estimates of the national rate of contraceptive prevalence must be viewed with some skepticism.

Family Planning services have been provided through the Department of Health since before Independence. During the early 1980s it was an active service providing family planning (FP) to around 4,000 users. Then, in 1983, due to concerns regarding the use of the long acting contraceptive Depo-Provera, the practice of FP fell into disrepute and the number of users fell dramatically. Consequently the programme was inactive during the mid-1980s. However, late in the decade, community interest in family planning increased in recognition of the strong health-related arguments for using family planning. In order to reach the objectives of the FP programme, an estimate of the contraceptive prevalence rate is essential, but it has been very difficult to establish because of gross inaccuracies in the data collected, since they reflect the number of FP visits and not the number of users. Therefore, the contraceptive prevalence rate for women of childbearing age (CBA) has been inaccurate and unreliable.

Conventional wisdom has it that many women consider four children an ideal number, and since the current fertility rate is higher, this suggests that there may be an unmet demand for family planning. However, in most communities traditional methods of birth control have fallen into disuse, and modern methods of family planning are not yet widely used. Although modern methods are available through health care channels, service statistics from the Department of Health suggest that few women are using them. Since close to 15% of the population are Catholic, the Church’s official attitude to family planning may have a negative impact on the uptake of modern methods, both for Catholics and, via rumor-mongering, for non-Catholics. One rural survey indicated that modern family planning methods (most commonly sterilization) were used primarily by women who already had over four children. This suggests that these methods are used to limit family size, perhaps after the “ideal” size is reached, rather than to space births. The reasons given for the limited use of modern family planning methods include a lack of knowledge of these methods and a fear of side effects, inadequate counselling, and reluctance by women to approach male nurses on these sensitive matters. Cultural views of the role of women in bearing children, and misconceptions about family planning, may also be important factors. The Department of Health has acknowledged that unambiguous messages on family planning methods are not yet widely available, that sometimes they are restricted to certain age groups of married women, that the choice of methods offered may be inadequate and that men are not sufficiently involved in family planning. Currently, activities are underway to broaden the scope of family planning services to encompass more reproductive health concerns following the International Conference on Population and Development (ICPD) and its Programme of Action of 1994. The suggested improvements include better training of service providers in the use of family planning methods and the development of counselling skills, and increased community education on family planning. Education initiatives need to involve men, women and adolescents.

As is the case in much of Melanesia, men play the prominent role in traditional society in Vanuatu. As a result women still suffer from limited opportunities to participate in the economy and decision-making generally. They are largely excluded from government extension programmes in the productive sectors and are hardly represented in the higher levels of government. Women account for only about a third of paid employment and 30% of the public service, mostly in low status occupations. In education, the overall female enrolment rate is 36% compared with 42% for males, with the disadvantage concentrated in secondary and post-secondary education. For ages 6-14, in 1989 the male and female enrolment rates were close to 70% but, for those aged 15-19, the male rate was close to 26% while the female rate was around 18% (Republic of Vanuatu, 1991). In addition, women have poor access to family planning, with only about 25 % of the relevant age group believed to be using some modern form of family planning method, according to service statistics. However, this paper throws much more reliable evidence on the nature and level of contraceptive prevalence in the country, as reported later. Maternal and child care facilities are also rudimentary.

This paper concentrates on an in-depth analysis of the data collected in a recent 1995 Vanuatu Family Planning or KAP (Knowledge, Attitudes and Practice) survey undertaken in the country. The analysis identifies some of the socio-economic determinants of demographic behaviour, including knowledge and use of family planning, the unmet need for family planning, desired family size and children ever born. The paper also explores male and female perceptions of the family planning programme and its facilities in Vanuatu. It is expected that the results of this analysis will prove useful to population policy-makers and planners who are attempting to respond to the demographic challenge by improving access to quality reproductive health and family planning services in a cost-efficient manner.

Family Planning Policy

While Maternal and Child Health/Family Planning (MCH/FP) is one of the eight elements under the umbrella of the Primary Health Care (PHC) approach, the Ministry of Health has also published a National Family Planning Policy Statement and Guidelines (Vanuatu, NFPP, 1993) to provide official support to the family planning programme. Thebasic premise of the Vanuatu NFPP is:

"For the good health and prosperity of the people of Vanuatu, it is a basic right of all individuals and couples within community norms, to be able to freely and responsibly decide on when to have children and how many to have. To allow individuals and couples to exercise their choice in the timing, spacing and number of their children, then they must be provided with family planning services, the information on how to plan their families and the means to do so" (National Family Planning Policy Statement, 1993)

The overall goal of the FP programme is proclaimed as:

"Family planning services, including family planning education, shall be provided in Vanuatu to benefit the health and welfare of individuals, families and communities and to promote the socio-economic development of the country".

The statement identifies the need to raise awareness and involve political and community leaders in family planning issues. It notes that women and men of reproductive age, including teenagers, need to be provided with adequate information, education and counselling to make informed choices and that they will have access to the family planning method of their choice. How do these noble intentions fare in practice?

As noted earlier, estimates of the rate of contraceptive prevalence remain imprecise and scepticism is warranted. However, current national estimates of the Ministry of Health on family planning acceptance suggest that about 25% of women of childbearing age (15-49 years) use modern contraception ("pills, condoms, the intrauterine device or sterilisation”). Moreover, the contraceptive prevalence rate in rural areas is thought to be significantly lower than in urban areas; and births occurring within 2-3 years of the previous birth are greater in rural areas. This is due, at least partially, to the lack of family health education, the generally pro-natalist environment, and the consequent lack of effective demand for contraceptive services. However, major problems in service provision also contribute to low contraceptive use. More and better community education on family planning is believed to be fostering a growing interest in contraceptive use and generating a demand for services which needs to be fulfilled.

In addition to difficulties common to most programme activities in Vanuatu (e.g. logistical problems in a widespread archipelago), two specific challenges confront the Family Health/Planning programme: reaching two important target groups, men and young people, and bridging the gap between ideal cultural and religious moral values and the reality of a changing society where teenage pregnancy and sexually transmitted diseases are no longer uncommon. Strategies to overcome these are being addressed by rural health workers familiar with the problems and able to identify appropriate and practical solutions.