Sexual Activity of the Youth Population in Malawi: The Emerging Health Care Scenario

Abstract

The sexual behaviour of youths in Malawi is believed to play an important role in the spread of sexually transmitted infections (STIs). Relevant data from the Malawi Demographic and Health Survey 2010 and a sample of 16,217 youths aged 15–24 have been studied and subjected to bivariate and logistic regression analysis. The results show that married youths were not interested in using condoms (94.2%, p < 0.05) and that those who were living together were 69 times (OR = 1.69, 95% CI, 1.26–2.26) more likely to be involved in early sexual activity than those who were not living together. It is argued that the results should help other researchers, policy makers and planners to create strategies to encourage these youths make use of contraception.

Keywords

Condom use early sexual debut reproductive tract infections (RTIs)sexual partners sexually transmitted infections (STIs)Malawi youth population

Introduction

The impact of sexually transmitted infections has been deeply felt in the sub-Saharan region of Africa, and there is an urgent need for preventive measures in order to curb their spread. The effect has been particularly prevalent among youths, a result of their irresponsible sexual behaviour. Research has shown that exposure to unsafe sexual relations is closely related to demographic, socio-economic and cultural factors. The increasing prevalence of these infections and their rapid spread suggest the need for urgent attention in most sub-Saharan countries and thus a need for continuous research into methods of minimizing their spread and the resulting negative social and economic effects. The devastating socio-economic impact and its increasing prevalence have therefore stimulated a shift of research priorities from a biomedical to a societal context of sexual behaviours and STIs (Chimbiri, 2007; Dawn, 2011; Mah and Halperin, 2010). It has been observed in countries such as Uganda that the introduction of a preventive approach, which includes risk avoidance, partner fidelity and protected sex, may help in reducing the incidence of sexually transmitted infections (Tarkang, 2009). Abstinence (refraining from sex until marriage) and delaying the age of coital debut (first sexual intercourse) are risk-avoidance measures that could help reduce the pandemic. The lack of both abstinence and delaying sexual debut have forced researchers and policy makers to continue to study related problems (Limaye et al., 2012). It has been found, for example, that the majority of young people aged 15–24 and almost 3 million youths below 15 years of age are living with STIs in sub-Saharan Africa. Swaziland, a small, landlocked country that lies between the republic of South Africa and Mozambique, has been severely affected, with 17% of males and 31% of females between15 and 24 years of age in 2001 being infected. The majority of youths remain uninformed about sexuality and STIs, and those who have heard of STIs still do not know how they are spread and do not believe they are at risk (Aaron, 2004). The sexual behaviour of youths during most relationships has been seen to be related to a number of different variables. This present research therefore targeted the 15–24 age group and, to understand the pattern of sexual behaviour among young people, we identify indicators such as early age of sexual debut, condom use at last sexual encounter, multiple sexual partnerships and knowledge and awareness of sexually transmitted diseases (STDs) and preventive measures.

Malawi has a low life expectancy, a high infant mortality rate and a high prevalence of STDs, including HIV/AIDS, with an estimated 11.9% of the population living with the disease in 2007 and approximately 68,000 deaths a year from STIs including HIV/AIDS (Ankomah et al. 2011). The rate of infection has resulted in an estimated 5.8% of the farm labour force dying of the disease. Malawi is therefore a country on the African continent that has been devastated by STIs such as HIV/AIDS. Considering the mode of transmission of this epidemic and the fact that antiretroviral therapy for the treatment of STDs such as HIV/AIDS is severely limited, youths therefore need to manage their sexual habits. Every day in Malawi, people are infected with HIV, and a good number die because of this virus and related diseases (Morris et al., 2007). STDs, including HIV/AIDS, have been actively monitored in Malawi, not for the purpose of assessing the magnitude and spread of the virus but rather for planning and designing appropriate, important and relevant intervention strategies. It has been estimated that 90% of STD cases are spread through heterosexual contact and that about 13% of STI cases and 25% of national cases occur among the young people between 15 and 24 years of age, probably because of low rates of the use of contraceptives such as condoms (Tarkang, 2009). Irrespective of the major incidence and prevalence rates of this virus, it is clear that STDs pose many challenges to the general level of health of the Malawi people. Given the youthfulness of Malawi’s population – almost half of the population is under the age of 15 and 64% are under the age of 24 – it is therefore imperative that researchers turn their focus to this critical problem in order to help reduce the spread of these infections.

Data and methods

Data

This research uses data obtained from the Malawi Demographic and Health Study (MDHS) 2010. The MDHS 2010 used three types of questionnaires, aimed specifically at households, women and men. A nationally representative sample of more than 27,000 households and all eligible women aged 15–49 and all eligible men aged 15–54 were interviewed: 16,217 youths aged 15–24 years participated in the survey, of which 72.3% were aged 15–19 and 27.7% were aged 20–24 years; in the households 72.8% were headed by males and 27.2% by females.

Method

The logistic regression technique was used for some background variables that were chosen from the DHS 2010. We used three dependent variables: condom use at last sexual encounter; early age at sexual debut; and the number of sexual partners an individual had during their sexually-active life. It is necessary to understand that several factors determine youth sexual behaviour in the study, but our main concern was with factors that reflected some consistency and quality in our data. These variables were used to evaluate the level of significance between each independent variable on dependent variables. In this case, the dependent variables were dichotomous: if ‘yes’, coded as 1 and if ‘no’, coded as 0. That is, one of two outcomes was possible: either they did not use condoms (0 = no) or they used condoms (1 = yes). The independent variables were made up of two groups: one dichotomous and the other categorical. The dichotomous group comprised place of residence, age group and gender of the head of household. The categorical variables included regions, religion, educational attainment, current marital status, ethnicity, wealth and employment.

Results

As shown in Table 1, most (91%) of the respondents did not use condoms during their last sexual encounter and 93.2% were between the ages of 20 and 24 (p < –0.098). Highly educated individuals did not use condoms (68.4%). Most of the households were headed by men, and the majority of them did not support use of condoms (92.6%, p < 0.05). Married youths were also not interested in using condoms (94.2%, p < 0.05), followed by those living together (94.1%), and 92.6% used them on a seasonal basis. More than 94% of those who did not use condoms were from the Chewa ethnic group. Condom use during the last sexual encounter was reported as low because most of the people did not want to use condoms. For those with higher education, 40.8% were involved in an early sexual debut, perhaps reflecting their need to spend more time in school. Females were involved in early sexual debuts more often(66.5%) than males (61.2%), with a majority of them being able read whole sentences (66.2%, p < 0.05) and not being married (94.6%), followed by those who were divorced (61.0%, p < 0.05). Those who were engaged most in early sexual activity were from the Tonga ethnic group (76.2%), followed by those from Lomwe (73%), with most of them being from the richer class (64.9%), followed by those categorized as richest (64.7%). This therefore implies that early sexual debut is at a higher rate in Malawi, and this exposes the youths in the country to a higher risk of contracting STIs.

Table 1.

Summary data on the proportion of youths that use condoms, or not; early sexual debut; and number of sexual partners.

Variables	Condom use		P- values	Early sexual debut		P-values	Sexual partner		p-values
	Did not use condom	Use condom		Before 18 years	At or after 18		One sexual partner (85.9%)	More than one sexual partner (14.1%)
	(91%)	(9%)		(62.6%)	(37.4%)		One sexual partner (85.9%)	More than one sexual partner (14.1%)
Age group			0.098			0.000			0.097
15 – 19	92.4	7.6		63.3	36.7		86.0	14.0
20 – 24	93.2	6.8		35.4	64.6		87.0	13.0
Gender of head of household			0.000			0.000			0.000
Male	92.6	7.4		61.2	38.8		88.7	11.3
Female	83.9	16.1		66.5	33.5		77.6	22.4
Place of residence			0.000			0.000			0.000
Urban	85.6	14.4		65.6	34.4		82.5	17.5
Rural	91.7	8.3		62.2	37.8		86.3	13.7
Region			0.000			0.000			0.000
Northern	86.8	13.2		63.2	36.8		88.1	11.9
Central	93.3	6.7		55.1	44.9		91.1	8.9
Southern	90.9	9.1		67.8	32.2		81.4	18.6
Religion			0.000			0.000			0.000
Catholic	89.9	10.1		62.7	37.3		87.9	12.1
CCAP	88.4	11.6		60.4	39.6		88.0	12.0
Anglican	90.6	9.4		61.8	38.2		84.6	15.4
Seventh-day adventist	90.0	10.0		63.8	36.2		86.7	13.3
Muslim	93.4	6.6		69.5	30.5		78.7	21.3
No religion	93.5	6.5		44.5	55.5		86.8	13.2
Educational attainment			0.000			0.000			0.000
No education	95.4	4.6		49.3	50.7		84.2	15.8
Incomplete primary	91.9	8.1		65.0	35.0		86.1	13.9
Complete primary	90.8	9.2		67.4	32.6		87.9	12.1
Incomplete secondary	84.4	15.6		70.2	29.8		86.9	13.1
Complete secondary	83.6	16.4		53.2	46.8		84.1	15.9
Higher	68.4	31.6		40.8	59.2		79.4	20.6
Literacy			0.000			0.000			0.607
Cannot read at all	94.5	5.5		56.6	44.0		85.6	14.4
Read part of sentence	90.5	9.5		62.6	37.4		86.7	13.3
Read whole sentence	88.8	11.2		66.2	33.8		85.8	14.2
Blind/visually impaired	89.5	10.5		54.8	45.2		89.7	10.3
Wealth			0.000			0.000			0.989
Poorer	92.9	7.1		59.2	40.8		85.7	14.3
Poorest	92.8	7.2		61.6	38.4		85.9	14.1
Middle	92.3	7.7		62.6	37.4		86.1	13.9
Richer	90.8	9.2		64.9	35.1		85.7	14.3
Richest	85.5	14.5		64.7	35.3		85.8	14.2
Current marital status			0.000			0.000			0.000
Never married	54.4	45.6		94.6	5.4		88.8	11.2
Married	94.2	5.8		54.3	45.7		88.5	11.5
Living together	94.1	5.9		51.8	48.2		88.0	12.0
Widowed	64.6	35.4		53.8	46.2		74.9	25.1
Divorced	75.8	24.2		61.0	39.0		68.8	31.3
Not living together	84.4	15.6		59.9	40.1		71.4	28.6
Employment			0.000			0.000			0.000
All year	89.3	10.7		59.6	40.4		82.1	17.9
Seasonal	92.6	7.4		59.5	40.5		87.0	13.0
Occasional	89.5	10.5		64.0	33.0		85.8	14.2
Ethnicity			0.000			0.000			0.000
Chewa	93.9	6.1		55.5	44.5		91.0	9.0
Tumbuka	87.2	12.8		57.5	42.5		90.0	10.0
Lomwe	89.7	10.3		73.0	27.0		77.7	22.3
Tonga	87.5	12.5		76.2	23.8		77.7	22.3
Yao	91.7	8.3		69.2	30.8		77.7	22.3
Sena	93.3	6.7		60.7	39.3		92.7	7.3
Nkhonde	85.7	14.3		57.0	43.0		92.6	7.4
Ngoni	89.6	10.4		61.9	38.1		87.0	13.0
Mang’anja	92.6	7.4		63.2	36.8		84.7	15.3
Lambya	85.0	15.0		67.1	32.9		94.3	5.7
Ndali	87.3	12.7		64.4	35.6		87.6	12.4
Nyanja	90.0	10.0		66.0	34.0		76.6	23.4
Other	88.4	11.6		63.4	36.6		87.0	13.0
Condom use						0.04			0.00
No	–	–		90.6	91.4		92.3	89.3
Yes	–	–		9.4	8.6		7.7	10.7

Source: MDHS 2010, weighted cases.

The prevalence of respondents having more than one sexual partner was higher if they were aged 15–19 (14%) and residing in the Southern region (18.2%, p < 0.05), with a majority of them from the urban areas (17.5%, p < 0.05), indicating some association between the variables. The females (22.4%) were more involved than the males (11.3%, p < 0.05).Those with higher education had more sexual partners (20.6%), followed by those with complete secondary education (15.9%). The prevalence of having more than one sexual partner were greater among the Muslims (21.3%) than in any other religious group (p < 0.05), especially those who were divorced (31.3%), with the majority of them employed all year (17.9%, p<0.05). Those from the Nyanja ethnic group (23.4%) were more involved in multiple sexual partnerships than those of any other ethnic background. Moreover, condom use also influenced early sexual debut. The prevalence of condom use was high (9.4%, p < 0.05) among those engaged in early sexual debut (i.e. before 18 years), and among those with more than one sexual partner (10.7%). However, the prevalence of not using condoms was high (90.6%) among those engaged in early sexual debut, and higher (92.3%, p < 0.05) among those with one sexual partner.

Table 2 presents a summary of the proportion of youths currently using condoms. The data show that while the majority of respondents believed that having one sexual partner can help reduce the risk of getting STIs, 90.9% of them did not use condoms. Those who said condoms should be used at all times during sex to avoid risk of contracting an STI (90.5%) did not use a condom during their last sexual encounter. Others who said having one sexual partner would help reduce the risk of STIs (90.8%) did not use a condom during their last sexual encounter. Of those who believed that STIs cannot be contracted from a mosquito bite, 67.3% were not using condoms, and 92.3% of those who accepted that STIs could not be contracted by sharing food with an infected person did not use condoms: thus these variables were not significant (p > 0.05). Most of the respondents had never contracted any STI (91.2%), nor did they have any genital sores (83.8%) or genital discharge (91.2%) and they did not use condoms during their last encounter. These were all significant (p < 0.05). The results show that 91% of respondents who had a radio did not use condoms during their last sexual encounter; meanwhile 91.7% who did not have a television did not use condoms. Having a television was statistically significant (p < 0.05), thus suggesting that young people who are more exposed television engage in sexual activity early.

Table 2.

Factors associated with sexual behaviour of youths and current use of condom at last sexual intercourse.

Background characteristics	Did not use condom at last intercourse (91%)	Did use condom at last intercourse (9%)	Total	P – values
Background characteristics	Did not use condom at last intercourse (91%)	Did use condom at last intercourse (9%)	(100%)	P – values
Ever been tested STI				0.025
No	92.0	8.0	100.0
Yes	90.7	9.3	100.0
Ever heard of STI				0.320
No	94.7	5.3	100.0
Yes	91.0	9.0	100.0
Reduce risk of getting STI by not having sex at all				0.946
No	91.0	9.0	100.0
Yes	90.9	9.1	100.0
Avoid STI; use condom all the time				0.003
No	92.0	8.0	100.0
Yes	90.5	9.5	100.0
Reduce risk of getting STI, having one sex partner				0.037
No	92.2	7.8	100.0
Yes	90.8	9.2	100.0
STI contracted from mosquitoes				0.085
No	90.6	9.4	100.0
Yes	91.5	8.5	100.0
STI contracted by sharing food with infected persons				0.076
No	90.8	9.2	100.0
Yes	92.3	7.7	100.0
Had STI in last 12 months				0.000
No	91.2	8.8	100.0
Yes	80.7	19.3	100.0
Had genital sore in last 12 months				0.000
No	91.2	8.8	100.0
Yes	88.3	11.7	100.0
Had genital discharge in last 12 months				0.000
No	91.2	8.8	100.0
Yes	86.8	13.2	100.0
Listening to radio				0.723
No	91.2	8.8	100.0
Yes	91.0	9.0	100.0
Watching television				0.000
No	91.7	8.3	100.0
Yes	86.4	13.6	100.0

Source: MDHS 2010, weighted cases

Logistic regression

Table 3, model 1 shows that never-married respondents were 60 times (OR = 1.60, 95% CI, 0.85–3.01) more likely to use condoms than their counterparts who were not living together. Those who were married were 67 percent (OR = 0.33, 95% CI, 0.22–0.50) less likely to use condoms during their last sexual encounter than those who were not living together. The data also show that those with no education were 72 percent (OR = 0.28, 95% CI, 0.12–0.65) less likely to use condoms than those with higher educational attainment. Those with partial primary education were 54 times less likely to use condoms during their last sexual encounter than those with higher education. Further, the data indicate that respondents who were younger (15–19 years) were about 27% (OR = 1.27, 95% CI, 1.00–1.61) more likely to use condoms compared to their counterparts age 20 to 24 years.

Table 3.

Regression results (Odd ratio) for condom use, early sexual debut and number of sexual partners.

Variables	Model 1. Condom use (N = 5742)			Model 2.Early sexual debut (N = 6742)			Model 3. Number of sexual partners (N = 6742)
	Exp(B)	95% C.I. for EXP(B)		Exp(B)	95% C.I. for EXP(B)		Exp(B)	95% C.I. for EXP(B)
	Exp(B)	Lower	Upper	Exp(B)	Lower	Upper	Exp(B)	Lower	Upper
Region
Southern^®	1.00			1.00			1.00
Northern	1.91	1.19	3.08	0.88	0.68	1.151	0.73	0.52	1.03
Central	1.06	0.78	1.45	1.53	1.32	1.784	0.75	0.63	0.90
Sex of household head
Female^®	1.00			1.00			1.00
Male	0.80	0.60	1.05	0.98	0.84	1.135	0.67	0.57	0.79
Place of residence
Rural^®	1.00			1.00			1.00
Urban	1.12	0.82	1.55	0.97	0.81	1.16	0.89	0.71	1.13
Age group
2 –24^®	1.00			1.00			1.00
15–19	1.27	1.00	1.61	0.28	0.25	0.32	1.02	0.88	1.17
Religion
No religion^®	1.00			1.00			1.00
Catholic	0.90	0.31	2.55	0.65	0.42	1.02	0.32	0.21	0.51
CCAP	0.98	0.34	2.79	0.72	0.46	1.13	0.35	0.12	0.42
Anglican	1.06	0.34	3.26	0.61	0.37	1.00	0.38	0.23	0.63
Seventh-day adventist	0.86	0.29	2.51	0.71	0.45	1.12	0.35	0.22	0.56
Muslim	0.91	0.30	2.72	0.40	0.25	0.65	0.55	0.34	0.88
Educational attainment
Higher^®	1.00			1.00			1.00
No education	0.28	0.12	0.65	1.01	0.61	1.67	4.38	1.82	10.51
Incompleteprimary	0.46	0.22	0.99	0.76	0.46	1.23	3.04	1.28	7.20
Complete primary	0.51	0.22	1.14	0.91	0.54	1.50	2.29	0.94	5.55
Incomplete secondary	0.62	0.29	1.32	0.68	0.41	1.11	1.39	0.57	3.36
Complete secondary	0.71	0.32	1.57	1.11	0.66	1.85	1.59	0.64	3.94
Marital status
Not living together ^®	1.00			1.00			1.00
Never married	1.60	0.85	3.01	0.49	0.31	0.77	0.64	0.50	0.83
Married	0.33	0.22	0.50	1.43	1.13	1.82	1.01	0.74	1.38
Living together	0.27	0.15	0.47	1.69	1.26	2.26	0.68	0.49	0.96
Widowed	3.11	1.76	5.48	1.41	1.03	1.91	0.85	0.63	1.15
Divorced	1.30	0.79	2.14	1.07	0.79	1.43	1.20	0.42	1.14
Wealth index
Richest^®	1.00			1.00			1.00
Poorer	0.94	0.65	1.37	1.16	0.95	1.41	1.46	1.15	1.86
Poorest	0.91	0.64	1.30	1.09	0.91	1.32	1.46	1.16	1.85
Middle	0.97	0.70	1.35	1.07	0.90	1.28	1.27	1.01	1.61
Richer	0.85	0.62	1.17	1.18	1.00	1.41	1.31	1.04	1.62
Ethnicity
Other^®	1.00			1.00			1.00
Chewa	0.56	0.27	1.17	1.32	0.88	1.97	1.06	0.65	1.73
Tumbuka	0.83	0.41	1.64	2.07	1.39	3.08	1.05	0.63	1.74
Lomwe	1.01	0.48	2.14	0.75	0.50	1.14	1.72	1.05	2.81
Tonga	0.53	0.22	1.28	0.59	0.36	0.97	1.42	0.79	2.56
Yao	0.61	0.26	1.41	1.16	0.74	1.79	1.25	0.74	2.09
Sena	0.83	0.31	2.18	1.25	0.77	2.04	0.65	0.35	1.20
Nkhonde	0.98	0.41	2.33	2.18	1.28	3.74	0.78	0.36	1.67
Ngoni	0.85	0.41	1.78	1.02	0.68	1.53	1.04	0.64	1.71
Mang’anja	0.66	0.25	1.71	1.00	0.61	1.63	1.29	0.72	2.29
Lambya	1.47	0.52	4.12	1.31	0.62	2.76	0.54	0.15	1.94
Ndali	0.79	0.23	2.73	1.48	0.71	3.08	0.93	0.34	2.52
Nyanja	0.61	0.19	1.96	1.10	0.61	1.98	2.18	1.14	4.18
Employment
Occasional^®	1.00			1.00			1.00
All year	0.93	0.67	1.28	1.18	0.99	1.41	1.16	0.94	1.44
Seasonal	0.84	0.61	1.15	1.19	1.01	1.40	1.05	0.86	1.29

Note; ^®Reference category, weighted cases.

Those from the central region were 6% (OR = 1.06, 95% CI, 0.78, 1.45) more likely to use condoms than those from the Southern region. Ethnicity was not significant with condom use (p > 0.05). The results show that those from the Chewa ethnic group were 44 times (OR = 0.56, 95% CI, 0.27–1.17) less likely to use condoms compared to those of the other ethnic groups. Those from the Lomwe group were 1 time (OR= 1.01, 95% CI, 0.48–2.14) more likely to use condoms than those of other ethnic groups.

Model 2

Shows that never married respondents were 51 times (OR = 0.49, 95% CI, 0.31–0.77) less likely to engage in early sexual debut compared to their counterparts who were not living together. Those who were living together were 69 times (OR = 1.69, 95% CI, 1.26–2.26) more likely to be involved in early sexual activity compared to those who were not living together. The variable age group was significant because it gave a p < 0.05, and the results indicate that respondents aged 15–19 were about 72% (OR = 0.28, 95% CI, 0.25–0.32) less likely to engage in an early sexual debut than those aged 20–24. Those who were employed seasonally were 19% (OR = 1.19, 95% CI, 1.01–1.40) more likely to be involved in early sexual activity compared to those employed occasionally. In terms of religious background, there was some significance noticed as the p-value was less than 0.05. Ethnicity was statistically significant with early age of first sexual debut (p < 0.05), and the results show that those from the Chewa ethnic group were 32 times (OR = 1.32, 95% CI, 0.88–1.97) more likely to engage in an early sexual debut compared to those of the other ethnic groups.

Model 3: number of sexual partners

There was some significant interaction between sexual behaviour indicators and the variable current marital status (p<0.05), and the results show that never-married respondents were 36 times (OR = 0.64, 95% CI, 0.50–0.83) less likely to have more than one sexual partner than those who were not living together. Those from the central region were 25% (OR = 0.75, 95% CI, 0.63, 0.90) less likely to have more than one sexual partner than those from the Southern region. Those from the northern region were 27 times (OR = 0.73, 95% CI, 0.52 1.03) less likely to be involved with more sexual partners than their counter parts in the Southern region (p<0.05). The results indicate that males were 33 times less likely to have more sexual partners than their female counterparts. In terms of religious background, there was some significance noticed as the p-value was less than 0.05. The variable wealth results show that poorer respondents were 46 times more likely to have more than one sexual partner than the richest category. The results show that those from the Chewa ethnic group were 6% (OR = 1.06, 95% CI, 0.65–1.73) more likely to have more than one sexual partner compared to those from the other ethnic groups.

Discussion

There is a reluctance in youths in Malawi to talk with parents and children, partners, and peers about sexual activities and sexual relationships, a result of lack of confidence and necessary skills in dealing with such matters (Boniface, 2010). Most of the citizens of Malawi are aware of STIs, their modes of transmission and their effect on health, but very few make use of contraceptives. This has been attributed separately to the fact that partners trust each other, the mistaken belief that a condom can get stuck in a woman’s vagina, the idea that sexual performance is disrupted when one uses a condom, and the lack of available condoms. Men sometimes claim that they are ‘too large’ for a condom, using this as an excuse for not using one: in fact, a condom can expand to a size larger than a hand (Aaron, 2004).

The rate of condom use is generally low among Malawian youths; for those aged 15–24, 16.1% of the women reported using condoms, and 7.4% of men reported using a condom the last time they had sex. Thus, this situation extends even to higher-risk sexual encounters such as non-marital sexual activities and even with non-cohabiting partners (Limaye et al., 2012).

Furthermore, there is a high rate of early sexual debut among Malawi youths, leading to a high rate of STIs as a result of changing sexual behaviour, creating more opportunities for infection to occur. Never-married respondents were less likely to engage in an early sexual debut than their counterparts not living together. Moreover, those who never went to school were more likely to engage in an early sexual debut than those with higher education. This is probably due to the fact that they spent much of their time roaming around the community, an as a consequence they get involved in risky behaviours such as sex. Moreover, they spent more time viewing of locally produced movies, peer pressure, and involvement in transactional sex, whereby girls exchange sex for gifts, cash or other favours (Ankomah et al., 2011). For instance, 60% of girls and 53% of boys had experienced their sexual debut by the age of 18 (Limaye et al., 2012). According to the data, among youths aged 15–19 years, 61.2% of males and 66.5% of females were involved in an early sexual debut, with a majority of them (65.6%) residing in urban areas rather than in rural areas (62.2%). This could be as a result of exposure in urban areas to information regarding sexual activities or watching movies that contain sexual acts. Education has also been regarded as an important factor with regard to early sexual debut. From the data it can be seen that the more educated an individual is, the less likely that individual will be engaged in an early sexual debut. Moreover, those who were not married (94.6%) were more likely to engage in an early sexual debut (we can speculate that this is because they were not under control of husbands or in-laws).

The research has shown that in attempting to identify problems regarding the spread of STIs, much attention needs to be paid to the role of concurrent sexual partnerships or having more than one sexual partner (Ankomah et al., 2011). It is necessary to understand that concurrent partnerships lead to greater risk of STI transmission than the same number of sequential, multiple sexual partnerships because having concurrent sexual partners in a dense sexual network increases the risk of STI, thus allowing any virus to spread rapidly (McCabe, 2009). Those who engage in multiple sexual relationships have done so probably because of dissatisfaction with their partners sexually or otherwise, in addition to lack of communication and romance among partners and a lack of skills in lovemaking: a desire for variety in partners and sexual practices might cause one partner to take part in multiple sexual partnerships. A study by Shelton (2009) points out that people get involved in multiple sexual partnerships because they want to have ‘insurance’ in case they lose their main sexual partner, and that some do so in order to find the right life partner. Moreover, in partnerships where fidelity was lacking, some became involved with multiple sexual partners to take revenge on their partners for the partner’s infidelity. In Malawi, couples have adopted a specific communication strategy, to discourage any outside relationships and thus reduce or eliminate the need to accuse their partners of having outside relationships.

From a general perspective, there is a lack of awareness of problems associated with STIs and their complications; there is also competition for resources to deal with other important health problems outside of the impact of STIs, and this creates more opportunities for the spread of the infections. Furthermore, the reluctance of public health policymakers to deal with diseases that are associated with sexual behaviour has also contributed to the continued existence of this pandemic (Wafa, 2008). It is therefore necessary to understand that women are more vulnerable than men to infections that are STD-related, and their complications such as infertility and inflammatory diseases. From a biological perspective, women are more susceptible to most STDs than men, probably because of the greater mucosal surface that is exposed in females to pathogens during sexual intercourse (Brown, 2000).

Conclusion

Despite the high level of awareness of sexually transmitted infections among the youths of Malawi, efforts need to be made to emphasise the safety, convenience and importance of using contraceptives. This would help reduce misunderstanding among youths about contraceptive use. Thus, health care service providers should educate young people on the effects of STIs and on the importance of contraceptives in preventing the spread of these infection. The necessary education on STDs should be introduced to encourage premarital screening and thus help reduce the risk of spreading infections. However, sexual relationship education needs to be made a statutory component of personal, social and health education in schools and efforts need to be made in order to incorporate it into school curriculums. This will help educate youths to avoid engaging in early sexual relationships and will also help educate them about the consequences of having more than one sexual partner.

Efforts also need to be made to educate the general public about the safety and convenience of modern, long-term and reversible methods of contraception, as an alternative to sterilization. This would help reduce both the rate of STI transmission and unwanted and unplanned pregnancies. Effort is also needed to create awareness and continuing knowledge among health care professionals of long-term methods of contraception. Health educators need to adopt an integrated approach, to create knowledge and awareness in coping with the spread of STDs among young people. We would argue that there is a need for further, in-depth qualitative investigations.

Footnotes

Acknowledgements

Authors would like to thank Macro International for providing Malawian Demographic and Health Survey 2010 data.

Consent

Consent of participants was not necessary because the study used secondary data from the Malawi Demographic and Health Survey (MDHS) 2010 (E-mail: info@measuredhs.com, Internet: ). All data were anonymised to prevent individuals being identified.

Funding

There were no sources of funding for the study, for the authors or for the manuscript preparation.

Author biographies

W. Chialepeh Ningpuanyeh is a doctoral research fellow in the Department of Statistics and Population Studies, University of the Western Cape, Cape Town South Africa.

A. Sathiya Susuman has an MA, MPhil in Population Studies and a PhD in Demography. He has specialized in the social science research area of demographic analysis and reproductive health. His specific research area is fertility, mortality, gender, reproductive health and public health. He has published several articles in reputed journals.

References

Aaron

. 2004. Patterns of sexual behaviour among secondary school students in Swaziland, Southern Africa. Culture, Health and Sexuality, Taylor & Francis Ltd. vol. 6 no. 4.

Ankomah

Mamman-Daura

Omoregie

Anyanti

(2011) Reasons for delaying or engaging in early sexual initiation among adolescent in Nigeria. Adolescent Health, Medicine and Therapeutics 2: 75–84.

Boniface

(2010) Empowering young sex workers for safer sex in Dowa and Lilongwe Districts of Malawi. Malawi Medical Journal 22(1):10–11.

Brown

(2000) Adolescent sexuality at the dawn of the 21st century. Adolescent Medicine 11(1): 19–34.

Chimbiri

(2007) The condom is an ‘intruder’ in marriage: Evidence from rural Malawi. Social Science and Medicine 64(5): 1102–1115.

Dawn

(2011) How to respond to men’s excuses for not wanting to wear a condom. Available at: http://contraception.about.com/od/talkingaboutbirthcontrol/ht/responses.httm (accessed 15/05/2013).

Limaye

Rimal

Mkandawire

Roberts

Dothi

Brown

(2012) Talking about Sex in Malawi; toward a better understanding of interpersonal communication for HIV prevention, Journal of Public Health Research 1(2): 117–125.

McCabe

(2009) Private sector pharmaceutical supply and distribution chains: Ghana, Mali and Malawi, Health System Outcome (HSO) Report. Available at: http://apps.who.int/medicinedocs/documents/s17508en/s17508en.pdf (accessed 04 February 2012).

Mah

Halperin

(2010) Concurrent Sexual partnership and the Sexually transmitted diseases epidemics in Africa: Evidence to move forward. AIDS and Behaviour 14(1): 11–16.

10.

Measure DHS 2010; accessed http://www.dhsprogam.com/data/available-datasets.cfm

11.

Morris

Goodreau

Moody

(2007) Sexual networks, concurrency and STD/HIV. In: Holmes

. (eds.) Sexually Transmitted Diseases, 4th edition, New York, NY: McGraw-Hill.

12.

Shelton

(2009) Why multiple sexual partners? The Lancet 374(9687): 367–369.

13.

Tarkang

(2009) Knowledge, attitudes and perceptions regarding HIV/AIDS and sexual behaviours among seniour secondary school learners in Kumba, Cameroon. PhD Thesis, University of South Africa. Available at: http://uir.unisa.ac.za/bitstream/handle/10500/3899/dissertation_tarkang_e.pdf?sequence=1 (accessed 06 August 2014).

14.

Wafa

(2008) Awareness of sexually transmitted diseases among adolescent in Saudi Arabia. Journal of King Abdulaziz University: Medical Sciences 15(1): 77–90.