In total, we conducted 12 FGDs and 17 KIIs. The study participants described different roles that are performed by community leaders in protecting adolescents from HIV infection and improve SRH and rights. Notably, the roles included advisory, regulating cultural practices and beliefs, advocacy and protection over domestic violence.
Advisory role on health life for adolescents
We found that the majority of community leaders advises adolescents on abstinence to avoid contracting HIV. One of the key informant said: “I always talk with adolescents on the risk of HIV and how they can prevent it, I mostly put much emphasis on the need for them to abstain from premarital sex because in doing so they cannot contract HIV.” (Key informant 12). Community leaders also reported that there are some adolescents who cannot resist from sexual intercourse. Such adolescents are advised to use condoms. One of the key informants reported that: “Some of the adolescents cannot stand the temptation of having sexual intercourse due to modern technologies as most of these youth have modern cell phones they use to browse pornographic videos (zithunzi zolaula) as such I strongly encourage them to use condoms when they are in that situation.” (Key informant 13).
However, some community leaders expressed different views on advising adolescents to use condoms. A participant reported that: “I don’t discuss issues concerning condom use with adolescents because it’s like I am encouraging them to commit adultery.” (Key informant 6). Another participant said, “It’s against our belief to encourage adolescents to use condoms whenever they have a desire to have sexual intercourse.” (FGD 5, respondent No 7)
The community leaders indicated that they advise adolescents on the importance of HIV testing and counseling. They reported that knowing the HIV status can help the adolescents to make decisions that could prevent the spread of HIV. One of the participant reported that, “I advise adolescents to go and have HIV test at the health centre to ascertain their HIV status.” (Key informant 3).
The community leaders indicated that they also encourage those living with HIV to continue taking their Anti-retroviral drugs “It is our role to ensure that those adolescents living with the HIV are living positively and stay health, so we encourage them to continue taking their drugs daily and whenever they are not feeling well, we encourage them to seek medical attention.” (FGD 12, respondent number 1).
Encouragement role on safe behaviour towards prevention of HIV and SRH
The community leaders explained that they encourage adolescent boys on medical male circumcision instead of going for tradition circumcision. Traditional male circumcision is conducted by the untrained local initiation counsellors in most of the rural areas of Malawi. This was mostly disclosed by the community leaders affiliated to the religious denominations. One of the religious leaders reported that: “Our religion demands that male children should be circumcised and in the past we used to send them to ndagala (Initiation camps) where they were being circumcised by the ngalibas (local initiation counsellors). Due to the HIV, we are now sending our children to the health facilities where they are circumcised first before enrolling them into initiation camps.” (Key informant 13).
The majority of female community leaders reported that they have the responsibility to encourage adolescent girls to go and access cancer screening service at the health facilities when they have reached an adulthood age. A female community leader reported that: “Whenever adolescents have gathered at one place, I always have an opportunity to discuss and encourage them to go and have cancer screening at the health facility when they are old enough as I believe in early preparation (mmera npoyamba).” (Key informant 4). This claim was affirmed by another community leader who reported that: “I advocate for safe motherhood issues within this area and most of the times, when I chat with adolescents, I also inform them on the dangers of cervical cancer” (FGD 6, respondent 1).
Some of the community leaders reported to encourage adolescents on contraceptive use. This was reported by the majority of the community leaders in both FGDs and KIIs. One of the community leaders in a FGD reported that: “I sometimes advise adolescents to consider taking contraceptives especially girls whenever they feel that they cannot convince their boyfriends to use condoms so that they can avoid early pregnancies.” (FGD 4, respondent 6). Likewise, in KII interviews another community leader supported this by saying: “I know there are some adolescent girls who do not take our advice seriously and don’t like the issue of condom use, so I always ask them to go to the health facilities and get contraceptives to avoid pregnancy.” (Key informant 11).
There were also mixed feelings among the community leaders about advising adolescents on contraceptive use. Some community leaders reported that they do not advise adolescents to use contraceptives such as pills, injections, intra-uterine devices and Norplant as that might encourage them to practice unprotected sex and be exposed to STIs including HIV. A respondent said: “I do not advise adolescents to use pills or injections because it may look like I am encouraging them to practice unsafe sexual intercourse.” (A female respondent, FGD 10).
Several community leaders reported to encourage the adolescents on their education. However, long distances to schools was mentioned as a challenge faced by many adolescents. This was highlighted in FGDs and KIIs. In acknowledgement of this claim, one respondent in FGD said: “As leaders we took time to encourage adolescents to concentrate on their education if they are to become reliable leaders in the future.” (FGD 5, respondent 6). This was also reported in KIIs as another key informant said: “Whenever I have called for a meeting with my subjects I remind them on the need to encourage adolescents on education, however, the long distance to schools and lack of hostels makes it difficult to monitor the behavior of adolescents as some take advantage of that to indulge in bad habits including sexual intercourse.” (Key informant 8).
The role of regulating and restricting harmful cultural practices and beliefs that fuel HIV and deterred SRH rights
The community leaders also indicated that they have a role in determining what should be practiced or not within their communities by restricting harmful cultural practices that fuel spread of HIV. The majority of the community leaders reported that they condemns harmful cultural practice of cleansing (kusasa fumbi). A community leader reported that: “I personally restrict anakungwi and ngalibas (initiation councsellors) never to tell any adolescent that once out of initiation camp should have sexual intercourse to cleanse themselves. If anyone disobeys this order I do ban such person from practicing in my area apart from fining him/her.” (A male respondent, KIIs 1). This was also highlighted in the FGDs and one of the respondents said: “Much as we are supposed to safeguard our culture but we also have responsibility to ensure that we stop all harmful cultural practices and beliefs that increases the spread of HIV because things are changing. During our days we had curable diseases (meaning other STIs) but now we have AIDS that cannot be cured, so I always discuss with my subject to restrict some harmful cultural practices that promote spread of HIV in their respective villages.” (FGD 2, respondent 11).
The role of formulating and advocating for bye-laws that guide adolescent SRH
The community leaders indicated that they perform many roles on adolescent SRH in their respective areas. They perform these roles to prepare and safeguard adolescents from problems that come with early pregnancies. The community leaders reported to have a role in formulating bye-laws to guide adolescents SRH within their areas. They advocate for these bye-laws to be discussed at the district level during full council meetings. One of the key informants reported that: “We formulate bye-laws like ensuring that no adolescent is married before reaching an adulthood age which we present during council meetings at DCs office” (Key informant, number 16). In agreement to this, another traditional leader reported that: “In my area, I have informed all my subjects to ensure that no adolescent fails to attend school because of early marriage or employment, if anyone found doing that can be punished by paying MK10, 000.00 and everyone is fully aware of this.” (Key informant number 3).
The role of dealing with sexual abuse
The community leaders also reported that they have a role in dealing with domestic violence including sexual abuse. They perform this role by either bringing the perpetrators and punish them under the local laws or reporting them to police. A female community leader reported that: “When I receive a report that an adolescent has been sexually abused, I make sure that the culprit is brought to book and punished. Sometimes I report such cases to police if the issue is beyond us like rape cases” (Key informant no 16). In agreement to this, another community leader reported that: “I have been sending some issues to the police for their intervention, I remember one of the cases was to do with an adolescent who was impregnated by her step father, however, there are some issues we discuss here and if punishable under local laws then we normally do so, otherwise we don’t just refer each and every issue to police.” (A male community leader, FGD 5).
The Role of Promoting Youth Friendly Reproductive Health Services (YFRHS)
Majority of the community leaders were not sure of the YFRHS available at their nearby health facilities hence they are unable to inform adolescents on that. One of the community leaders reported that; “To be honest with you I don’t know anything about the YFRHS.” (Key informant 2). However, some of the community leaders indicated that they are aware of the YFRHS at their health facilities. A community leader said, “I have heard of the YFRHS at our health facility but I don’t know exactly what type of services are provided to these adolescents, so I don’t advise them anything on that.” (FGD 6, respondent 2)
The community leaders also mentioned that they faced some challenges as they perform their duties when advising adolescents. They indicated that lack of parental support, inadequate knowledge on SRH issues and adolescent’s rudeness were among some of the challenges. One of the community leaders reported that, “Some adolescents are rude and they cannot listen to you when advising them which discourages some of us.”
How do the roles influence health seeking behaviour among adolescents.
We further explored the influence of the roles of the community leaders on adolescent’s health seeking behaviour. The community leaders reported that the advice they give to the adolescents are giving positive outcomes. They reported that many of the adolescents are able to access health services when the need arises. One respondent in FGD reported that: “There is positive response from the adolescents nowadays, I have seen some of them going to the health facility for HIV test unlike how things were before.”(FGD 2, respondent 9).
The community leaders also reported an improvement on SRH as adolescents are able to access services including the contraceptives. A study participant reported that: “I have seen some adolescents especially boys coming to me complaining about shortage of condoms at the health facility. To me this is the sign of positive results of our discussions with them, its encouragement on our part.” (KII No 14). Another participant reported that: “I have seen many girls getting contraceptives especially injection which is an indication that they are taking our advice seriously.” (FGD 10, respondent 7)
Ways of improving adolescents SRH rights from local perspective
The community leaders mentioned various ways of improving adolescents SRH rights in their communities. The ways mentioned include trainings, community awareness and use of leaflets and addition of SRH rights on education curriculum.
Training the community leaders on SRH rights
The majority of the community leaders mentioned the need to train them on the adolescents SRH and Rights to improve their knowledge. A community leader said, “If I can be trained on the adolescents SRH and rights then I will be able to advocate for that as I will have enough knowledge about the rights. Sometimes I fail to answer basic questions concerning the rights as a leader but if trained I can easily answer some of the questions.”(Key informant 13). A village Head said, “Hahaha ok I can say that let those who have information whether from government or NGOs come and train us, may be from there we will have enough information about the importance of the SRH rights.” (FGD 10 participant 1).
Intensifying community awareness and advocating for the SRH rights through Village Action Groups (VAGs)
Some of the community leaders mentioned the need for intensifying community awareness. This will enable many of the community leaders to access messages and have knowledge onthe SRH rights. Some of the community leaders mentioned of the VAGs as vehicles for strengthening adolescent SRH and rights within their communities. A participant reported that: “Let the NGOs take a leading role through community awareness. This will assist some of us to be conversant with adolescent SRH rights.” (FGD 18, respondent No 11). Another participant reported that; “In our communities we have what we call community actions groups (meaning VAGs) who are championing various projects, these people can also be used to promote adolescents SRH and rights if properly trained.” (FGD 9, respondent 5).
The Use of printed leaflets
Some of the community leaders suggested on the use of the print out leaflets as a way of promoting adolescents SRH and rights within their communities. The printed leaflets in both languages, Chichewa and English, should be displayed in common places like community grounds, health facilities and school notice boards. One of the community leaders said; “I can read and write and if I can get a printed leaflet concerning adolescents SRH and rights I can easily read, especially one in our local language “Chichewa.” (A female respondent No 2, FGD 4). A female key informant said; “Although I didn’t go very far with school but at least “a yekha ndimatomuziwa” (meaning she can manage to read some basic printed materials) but I don’t have chance of having these print-outs about adolescents SRH and rights.” (Key informant 2).
Inclusion of the SRH rights into education curriculum
Some of the community leaders were of the opinion that SRH and rights should be included in the education curriculum. They suggested that this will assist the adolescents to know these rights early and how they can exercise them responsibly. A community leader reported that: “The SRH and rights should be taught in our schools so that adolescents can have clear understanding and exercise them with some responsibilities.”(Key informant 11). Another community leader reported that: “I think it is right time now that SRH and rights for adolescents should be taught in our schools for early preparation of our children.” (FGD 4, respondent 12).