Equity of access to reproductive health services among youths in resource-limited suburban communities of Mandalay City, Myanmar

Myanmar is located in South-East Asia, bordered by India, Bangladesh, China, Thailand and Laos. It is listed by WHO as a low-income country with an average GDP of $821. Of the 60 million residents, 32.7% have an income under the international poverty line [20]. Mandalay City, situated in central Myanmar, is a densely populated area with relatively low cultural, racial and social heterogeneity. There are 10 resource-limited communities situated in suburban areas of the city which are enriched with hard-to-reach, informal settings and residents with a low socio-economic status. All areas of Mandalay City are covered by RH projects and the availability of RH services has been ascertained; however, it is not known whether youths living in these areas have sufficient access to those RH services. Likewise, understanding their exact RH needs in order to tailor services to those needs remains a challenge for policy makers since there has been no previous study focusing on this vulnerable group.

A community-based, cross-sectional study was conducted from May 2011 to September 2011. Male and female youths aged between 15–24 years residing in any of the 10 resource-limited, suburban communities of Mandalay City were included in the study. Those who were not available for interviews or unwilling to participate in the study were excluded. The sample size was calculated based on an estimated utilization of RH services of 50% and adjusted for a 10% rate of incomplete information. Because of perceived variation of utilization levels among the different communities and between males and females, a design effect of 2 was also employed. Thus at least 215 female and 215 male youths, or a total of 430 youths, were required to estimate the utilization level with an accuracy of 10%.

Youths, in accordance with the inclusion and exclusion criteria in each community, were selected by simple random sampling. The process of sampling was conducted using the following steps. Firstly, all 10 resource-limited communities in all townships of Mandalay City were identified and confirmed by the township medical officers (TMOs). Secondly, lists of youths living in these communities were obtained from the community leaders. Thirdly, in each community, a roughly equal number of males and females were randomly selected using a random number generator based on the sex-stratified lists of youths living in each community. Finally, the appointments between the selected youths and the interviewers were made with the facilitation of community leaders.

The interviewers went to the youths’ houses at the scheduled appointment dates and times and conducted the interviews. For those who were not available at the first appointment, a second appointment was made. Before the interviews, all youths were informed about the objectives of the study and a signed consent form was obtained from each one. Privacy, anonymity and confidentiality were maintained throughout the process of this study. Discussions among the interviewers were made on a daily basis to check the accuracy of data.

The outcome measures were overall accessibility to RH services, overall utilization of RH services and youth's unmet needs for the four RH components mentioned previously.

The accessibility in our study applied both geographical and financial considerations based on the youths’ own perception. Youths who lived within a 30-minute walk and within a one-mile distance from the nearest RH service centre from their home, and were aware that the service existed, were classified as having high geographical accessibility. For financial accessibility, we considered three aspects: travelling costs, service costs (drug fees, consultant fees) and youth’s perception of affordability. High financial accessibility was defined as a cost of travel less than 500 kyat ($0.63) and a cost of service less than 1500 kyat (US$1.9) with a perceived affordability of all costs. Youths having both high geographical and high financial accessibility were classified as having high overall accessibility and low accessibility otherwise.

Four essential components of RH services were assessed, namely SRH information services (any health education sessions/talks/classes that emphasized on SRH given in schools, clinics, or other places involving peer-based education excluding mass media), family planning services, comprehensive maternal care services (at least one antenatal care (ANC) visit, delivery by skilled birth attendance (SBA) and at least one postnatal care visit) and STI/HIV testing services.

Overall utilization of RH services was classified as the youths having sought or received at least one of the above four RH services. For SRH information and family planning, utilization must have been within the past 6 months for the youth to be classified as having utilized the service. For maternal health services and STI/HIV testing, if the youth used these services anytime in their life, they were classified as having utilized that service.

Independent variables included demographic and socioeconomic characteristics, reproductive characteristics and family characteristics. Demographic and socio-economic characteristics included age, gender, ethnicity, religion, place of residence, schooling status, level of education, occupation, personal income, knowledge of RH services and types of providers, perceived norm of peer exposure to RH services, and exposure to any mass media on SRH via resources such as books, television, radio, or the Internet (never versus ever in their life). Youths were classified as either adolescent (age 15–19) or young adult (age 20–25). Education level was classified as none, low (less than secondary), middle (secondary) or high (more than secondary). Occupations were classified into 3 categories: unemployed (dependent/housewife/jobless), waste recycler (people who wander and collect used material all over the city and sell them to the recycling factories) and other employed (shopkeeper/municipal worker/labourer). Because waste cyclers were so common, their occupation was singled out. The international poverty line of $37.5 or 30,000 kyat (800 kyat per $1) was used as the threshold for a low personal income. Knowing the available types of services and types of providers within the area was regarded as knowledge of RH services and providers. Knowledge score was calculated by asking each youth if they knew of the available types of RH services and providers in their local area, which included a total of five types of services and eight types of providers. For each known type of service or provider, a youth was given one point reflecting a maximal score of 13. If the youths responded that his/her friends or relatives utilized any type of RH services, the perceived norm of peer exposure to RH services was classified as “yes”. Reproductive characteristics included past sexual experience, marital status, and pregnancy status. Family characteristics included parental status (alive or dead) and educational level, household income and number of family members.

The percentages of accessibility to RH services, utilization of RH services, and unmet needs for the four SRH components were presented descriptively. The association between independent variables and the three main outcome measures was initially assessed by univariate analysis. Independent variables which had a p-value of less than 0.2 were included in the multivariate logistic regression analysis. Statistical significance was considered if a variable had a p-value less than 0.05 in the final model. All analysis was done using R.

The proposal was approved by the Institutional Ethics Committee of the Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand and the Ethics Committee of the Department of Medical Research (Upper Myanmar) before the study was conducted. All eligible youths were informed of their right to participate in the study using informed consent and their anonymity and confidentiality was stringently maintained throughout the study.

All sampled youths agreed to participate in the study and completed the interviews for a response rate of 100%. The demographic, socio-economic, reproductive and family characteristics of the youths are shown in Table 1. Of 444 youths interviewed, 215 were males and 229 were females. Among them, 231 (52%) were adolescents and 213 (48%) were young adults. Almost all were Buddhists and of Bamar ethnicity. Most (88%) were out of school, and very few attained a high-school level of education. Unemployment rate was considerably high (21%). One-fourth worked as waste recyclers. The personal income of the youths was very low and nearly half had an income under the international poverty line. Although there was a high prevalence of positive perceived norm of peer exposure to RH services, the youths had very little knowledge of available types of provider and RH services in their communities. Nearly one-third had never accessed any type of mass media (books/magazines, TV, radio or the Internet) for information on RH. More than half (53%) had a history of sexual exposure and less than half (44%) had ever been married. The majority (70%) of the youths, or their spouses, had never been pregnant. One-fourth of the youths had one deceased parent (mostly their fathers, who passed away before age fifty). Parental education level was mostly low. The average household income was US$ 178.

The majority of the participants said that there was at least one RH service centre within a 30-minute walk (94%) and within one mile (80%) from their home. The most common mode of transportation to the RH centre was by foot (83%). Only 5% said that the service was free of charge, 20% said that they had to pay less than $1.29, while 75% said that they had to pay more than $1.29. Based on the youth’s self perception, 69% thought that all costs (travelling and service) were not affordable.

A summary of the geographical, financial and overall accessibility and utilization levels for males and females are presented in Table 2. Most had a high level of geographical accessibility (79%) and a low level of financial accessibility (81%). Most had a low overall level of accessibility (66%). There was no difference between males and females in all three aspects of accessibility.

Table 3 shows the final model of factors associated with overall accessibility. Youths living in the south (adjusted OR (AOR) 0.29, 95% confidence interval (CI) 0.16-0.52) or south-western (AOR 0.36, 95% CI 0.15-0.84) suburbs, having one or more deceased parent (AOR 0.5, 95% CI 0.31-0.81), never being married (AOR 0.57, 95% CI 0.36-0.90) or having never been exposed to mass media (AOR 0.55, 95% CI 0.35-0.86) were less likely to have a high overall accessibility to RH services.

Of the 444 youths, 67% had ever utilized at least one type of RH service. The most utilized service was family planning (70%). Common service providers were midwives (39%) and non-governmental organizations (NGOs) (22%). Table 4 depicts the factors associated with the overall utilization of any RH services. Being a young adult, current student, working as a waste recycler, having a history of sexual exposure, ever being married, exposure to mass media, having a high knowledge of RH services and providers or having a high level of accessibility to RH services significantly increased the likelihood of utilizing those services. The difference in utilization between males and females was statistically significant (Table 2).

Table 5 shows factors associated with unmet needs for all four components of RH services. A lower unmet need for SRH information was found among young adults (AOR 0.55, 95% CI 0.34-0.91), youths who had a high accessibility to RH services (AOR 0.61, 95% CI 0.39-0.94) and a high knowledge of RH services and providers (AOR 0.78, 95% CI 0.68-0.90), while out-of-school youths were more likely to have an unmet need for SRH information (AOR 4.47, 95% CI 2.30-8.68).

Preventative factors significantly associated with unmet need for family planning were being married (AOR 0.09, 95% CI 0.01-0.97), exposure to mass media (AOR 0.21, 95% CI 0.05-0.83) and having a high knowledge of RH services and providers (AOR 0.61, 95% CI 0.41-0.89).

Youths who lived in a family having more than 5 family members had a higher likelihood of having an unmet need for maternal health services (AOR 2.60, 95% CI 1.25-5.37) while those who had a perceived norm of peer exposure to RH services had a lower likelihood (AOR 0.09, 95% CI 0.01-0.76).

Youths who lived in the south (AOR 3.16, 95% CI 1.40-7.16) or south-western (AOR 5.14, 95% CI 1.68-15.75) suburbs had a higher unmet need for STI/HIV testing services, whereas preventive factors were being a young adult (AOR 0.43, 95% CI 0.21-0.86), having a perceived norm of peer exposure to RH services (AOR 0.16, 95% CI 0.05-0.54) and having a high knowledge of RH services and providers (AOR 0.72, 95% CI 0.59-0.88).

A holistic view of the accessibility to and utilization of RH services and youth’s unmet needs towards RH services was elicited in our study. The challenges and factors hindering access to RH services among youths living in hard-to-reach, resource-limited suburban communities were also highlighted. The questions used in the questionnaire were modified from the International Demographic Health Survey and we also used a multidimensional approach for accessibility to RH services, i.e. geographical and financial aspects. In addition, all outcome measures were based on either standard definitions or actual needs of the youths. The triangulation of factors associated with outcomes identified from regression analysis was consistent with youth’s own reasons. There were some limitations in our study. First, the three main outcomes were obtained from the youth’s own perceptions and responses, and were not objectively measured or confirmed by medical reports. However, anonymity and confidentiality were stressed and the youths were encouraged to answer all questions truthfully. Second, the results cannot be generalized to all youths living outside resource-limited communities because the demographic and socio-economic characteristics of youths living outside our study area may be different. Third, even though the community leaders, with the help of municipal authorities, provided a list of all youths living in their communities, it is possible that some youths may have not been included in the lists. Lastly, the level of unmet need for STI/HIV testing services was not assessed according to the youth’s risky sexual behaviours since sexual behaviour is a culturally sensitive issue in Myanmar.