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Background: Malawi has one of the highest adolescent pregnancy rates worldwide; at 141 births/1000 girls it is 3-fold higher than the global average. Adolescent pregnancy contributes to poor maternal and neonatal outcomes, school dropout, and poverty. In preparation for an information, education, and communication (IEC) intervention to reduce unintended pregnancy among adolescent girls, formative research was conducted to understand how and what sexual and reproductive health (SRH) information is shared with girls in southern, rural Malawi, and perceptions of such information among key informants. Methods: Forty semi-structured interviews were conducted with three participant groups: adolescent girls (n = 18), mothers/female guardians (M/FGs) of adolescent girls (n = 12), and leaders of initiation rites (n = 10). Interviews were conducted in 15 villages. Data were analyzed and coded using Dedoose 7.5. Results: Participants widely acknowledged both the health risks and the general social unacceptability of early childbearing, yet adolescent pregnancy is common in the region. Respondents also acknowledged the importance of female school completion and the norm that pregnancy usually marks the end of a girl’s education. Unprotected transactional sex was reported to be common and driven by poverty. Initiation rites were described as prevalent and often encourage girls to practice sex at puberty. Contraceptives, and even condoms, were reportedly discouraged for adolescents due to concerns about inappropriateness for nulliparous and young girls and misconceptions about side effects. Adolescent respondents also noted barriers to accessing condoms and contraceptives. M/FGs were described as gatekeepers to SRH information and services, and many parents reported delaying SRH discussions until after sexual debut due to concerns about encouraging sexual activity. Adolescent and M/FG participants expressed a desire for role models or “outside experts” to provide SRH education and to promote an alternate vision to adolescent motherhood. Conclusion: To improve SRH outcomes for adolescent girls, it is critical to engage key stakeholders and create an enabling environment so that girls can effectively act on the IEC they receive. Initiation counselors remain entrenched information sources; efforts to provide them with training on accurate SRH messaging could leverage an existing channel. Engaging parents, especially mothers, is crucial to encourage earlier SRH education and to gain their acceptance of adolescent access to SRH services. Also important is mobilizing the broader community of influencers in support of girls’ SRH and vision for a healthier future. Sensitization messages focusing on the health, educational and economic benefits of preventing early pregnancy may overcome misconceptions about and barriers to contraceptive use. Finally, fostering girls’ aspirations for school completion and jobs and other income generating opportunities via role models can encourage an alternative to adolescent motherhood. Ultimately, poverty and gender inequity reduction is critical for long-lasting impact on the SRH of adolescent girls in the region.
We conducted 40 key informant interviews in 15 villages in Mulanje. A GAIA coordinator assisted the research team in choosing the villages, based on geographic and religious diversity, as well as accessibility. We recruited three types of interview participants: We recruited adolescents up to age 18, as this is the legal age of marriage. In addition, while we set out to include younger adolescents down to age 10, a higher proportion of girls in this age group declined to participate. As a result, the older adolescent sub-group had twice (n = 12) as many participants as the early adolescent (ages 10–14) sub-group (n = 6). We included twelve M/FG participants; another five declined due to scheduling conflicts. Of the 10 initiation counselors interviewed, four identified as religious counselors, one as a traditional counselor, and five as both religious and traditional. They all reported beginning as traditional counselors. No counselors or older adolescent girls refused to participate. The interviews in each participant category were conducted until informational saturation was reached [21]. Three semi-structured interview topic guides were adapted from tools developed and validated by the World Health Organization, [22] and translated into Chichewa, the predominant local language. Areas explored included: pubertal changes and menses; sexual expectations and behavior; early pregnancy and childbirth; contraception and condom use; as well as sources of SRH information including initiation ceremonies. We also asked about the value of education for girls. The interview guides included open-ended questions in each of these areas, making no assumptions about knowledge levels, attitudes or beliefs. For each area, we commenced with asking girls what they knew about that topic. For example, “I’m interested in what you know about growing up and bodily changes,” followed by questions regarding from whom and where they learned the information (e.g., parents, school, media, peers), and about their preferred information sources. Village chiefs provided lists of households with adolescent girls, generally 15–20 households per village. Going door-to-door, we recruited girls and M/FGs based on who was home at the time of our visit, aiming for geographic and demographic diversity. Village chiefs and GAIA coordinators provided lists of traditional and religious counselors who were visited at home in similar fashion. The principal investigator (KN) along with a team of eight local interviewers — mostly females, ranging in age from 22 to 30 — conducted face-to-face interviews in Chichewa in April 2016. They were trained to establish rapport, make the key informants feel as comfortable as possible, and remind them that they could ask questions or opt out at any time. Individual interviews lasted approximately 45 to 60 min, with some going longer to accommodate participant responses. All interviews were audio-recorded, transcribed, translated into English, and coded using Dedoose 7.5. Clusters of coded data were reviewed alone and in relation to the overall data set. An inductive approach was used to identify overarching themes and sub-themes. Verbal informed consent/assent was obtained from each participant. The study protocol was approved by the University of Washington (Human Subjects Application #50229) and the Malawi National Health Sciences Research Committee (Protocol/Approval #16/3/1546).
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