Indonesian Survey Looks at Adolescent Reproductive Health

Writers: Sulistinah Irawati Achmad
Sidney B. Westley
In Indonesia, the transition from a traditional to a modern society has raised concerns about changes in family life and values-in particular about the effects of modernization on young people. As in other Asian countries, the number of adolescents and young adults is growing rapidly. Between 1970 and 2000, the 15-24-year-old age group will increase from 21 to 43 million, or from 18 to 21 percent of Indonesia's total population.

Such a "youth bulge" is an issue for pollcymakers responsible for education, health, and employment programs. As the largest generation in history becomes sexually active, young people's attitudes and behavior are also of special concern to policymakers responsible for slowing down population growth and halting the spread of HIV/AIDS.

A recent survey provides new information about young lndonesians in this period of rapid social change. The survey asked young men and women in four of Indonesia's most populous provinces about work, education, marriage, and family life and explored their knowledge and attitudes about sexuality, fertility, and HIV/AIDS and other sexually transmitted infections (STIs). This issue of Asia-Pacific Population & Policy summarizes some of the survey findings.
ABOUT THE SURVEY
The Baseline Survey of Young Adult Reproductive Welfare in Indonesia (Demographic Institute 1999) interviewed 4,106 men and 3,978 women, age 15 to 24, in three provinces of Java-West, Central, and East Java-plus Lampung Province in southern Sumatra. This was the largest youth survey of its kind ever conducted in Indonesia.

The University of Indonesia's Demographic Institute (Lembaga Demografi) conducted the survey from September through December 1998 under the auspices of the National Family Planning Coordinating Board (BKKBN). The East-West Center provided technical support, and Focus on Young Adults/Pathfinder International, the United States Agency for International Development (USAID), and the World Bank provided funding.

Because metropolitan Jakarta and the three provincial capitols (Bandung, Semarang, and Surabaya) were excluded from the survey, the 20 districts that were sampled are generally more rural and less economically developed than the Java-Lampung area as a whole. Family planning acceptance and overall health status are also relatively low. Indeed, the survey was designed to provide baseline information for BKKBN / World Bank projects to improve family planning, education, and health programs in these districts.
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MARRIAGE, SCHOOLING, AND EMPLOYMENT
All across Asia, young people are marrying later than they did in the past Indonesia is no exception. According to the 1997 Demographic and Health Survey (Central Bureau of Statistics et al. 1998), 23 percent of Indonesian women who were 45-49 years old in 1997 married at age 15 or younger. By contrast, only 3 percent of women who were 15-19 years old in 1997 married at such an early age.

The timing of marriage appears to be a complex issue for the respondents in the 1998 youth survey. They believe, on average, that men should marry at age 25 and women at 20, but many-particularly women-marry when they are much younger. Within the full sample, 42 percent of the women and 8 percent of the men are currently married or have been married. Among those married, about one-fourth (26 percent) of the men and three-fourths (75 percent) of the women married at age 17 or younger.

More than half (52 percent) of the young people who are married feel that they married too young. Many express regret that they did not stay in school longer or spend more time working and saving money. Many also regret that they did not have more time to enjoy being single or to take care of their parents and other family members. Virtually every unmarried person plans to marry in the future. Yet very few [5 percent} feel that marrying and raising a family is their most important goal in life. Most (73 percent) place the highest value on pursuing knowledge and learning employable skills, while nearly one-fourth (22 percent) give top priority to working and earning money.

Nearly all of the respondents attended primary school, but only 26 percent were still in school at the time of the survey. Among unmarried respondents women are somewhat more likely than men to be in school (Table 1).

Marital status is closely linked to schooling, with virtually no ever-married respondents-men or women-still in school. This strong inverse relationship between marriage and schooling suggests that greater educational attainment and a higher average age at marriage are likely to go hand in hand.

Most of the young men surveyed are employed [Table 1). Almost all are selfemployed or are working in private or family-owned businesses. Substantial proportions of young women, both single and married, are also employed outside the home.


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FERTILITY AND FAMILY PLANNING
Most young people who marry become parents at an early age. Ninety percent of married women already have at least one child. On average, these mothers were 18.5 years old when their first child was born.

Many young couples would probably have preferred to wait longer before becoming parents. Most young people (69 percent) say that they do not want to have children right away after marriage. They would prefer, on average, to wait two years or more after marrying before the birth of their first child. They also say that couples should space their children about four years apart. In fact, however, Indonesian mothers who were 20-24 years old in 1997 spaced their children, on average, only 2.7 years apart [Central Bureau of Statistics et al. 1998).

Despite these preferences for delaying and spacing births, only half of young women who are curiently married are using any type of contraception. This wide discrepancy between intention and practice suggests that young couples have an urgent need for better family planning services.

Survey results also suggest a need for better reproductive health care. Eight percent of women who have ever been pregnant report having had a miscarriage, and this at an average age of only 17.7 years. Fewer than half of these women sought treatment from a doctor, hospital, or health center. Most went to traditional healers or midwives, practitioners who are generally not trained or equipped to treat this type of medical emergency.
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KNOWLEDGE AND ATTITUDES
Most of the young adults covered in this survey have heard of family planning, but knowledge of specific contraceptive methods varies considerably. Young men and women who are married or have been married do necessarily know more about contraceptive methods than do young people who are single (Table 2). In general, women are better informed about contraceptive methods than are men.

The survey reveals a number of misconceptions about fertility and family planning. More than half of all respondents do not believe that a woman can become pregnant from just one act of sexual intercourse. Such knowledge gaps suggest an important role for improved reproductive health education.

Most young adults have heard of HIV/AIDS, but few have heard of any other sexually transmitted infection (Table 2). Very few have a understanding of how HIV/AIDS is transmitted. One-fourth do not realize that it is possible, to contract HIV/AIDS from someone who appears healthy, and nearly one-half believe that HIV/AIDS is curable.

Overall, only one-half [51 percent) of young adults know what a condom is (see Table 2). Among those who know about condoms, more than one-half say that condoms are too expensive to use regularly, and more than one-fourth say that the use of condoms violates their religious beliefs. Less than 10 percent of ever-married respondents have actually used a condom (single men and women were not asked).

Most of the young adults covered by the survey express attitudes about sexual behavior. Nearly all disapprove of sexual activity before or outside of marriage-either for women or for men. Yet responses to other questions suggest that attitudes may not be totally restrictive. For example, 12 percent approve of premarital sex if the couple plans to marry.

Almost no single men or women admit to being sexually themselves, but nearly one-third claim to know of others whom they believe are engaged in premarital sex. Again there is an association between premarital sex and marriage: although overall proportions are low, ever-married men and women are much more likely to report having had premarital sex than are men and women who are single.


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SOURCES OF INFORMATION
Friends, boyfriends, girifriends, and spouses are the most common sources of information about family planning and reproductive health [Table 3). Few young people discuss such topics with their parents, and less than one-third have learned about family planning and reproductive health at school. Survey results also indicate that very few young people (less than 5 percent) receive in- formation or counseling from providers when they seek family planning or health-care services or when they register to marry. Not surprisingly, 85 percent want to learn more about these topics.

Nearly all the young people covered in the survey listen to radio and watch television at least once a week. Yet fewer than one-third have seen messages on family planning on television, and fewer than one-fifth have heard family planning messages on the radio.

More than half have seen a message about HIV/AIDS on television, and nearly one-third have heard an HIV/AIDS message on the radio, but less than one in ten has seen or heard a message about any other sexually transmitted infection. Significant numbers learned about condom use from television (42 percent) or radio (28 percent).
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EFFECTS OF THE CURRENT ECONOMIC CRISIS
Many young people report that the current economic crisis is having a direct effect on their lives. Economic problems seem particularly severe in urban areas and among respondents with low levels of education. Most respondents say that their households are spending less on food or other consumer items such as soap and detergent. Nearly half report that they are earning less, and al- most as many report problems with their education. About 7 percent of those previously enrolled appear to have left school as a result of the crisis.

Ten percent of single respondents say that the economic crisis has delayed their marriage plans. A similar proportion of ever-married women report that the crisis has affected their family-planning decisions, but numbers of respondents are too small to show a clear pattern.

There is a significant decline in the use of the private sector for health care. Before the economic crisis, 40 percent of young people obtained health care from private doctors, but this proportion had shrunk to 15 percent by 1998. Because of financial constraints, young people are using the less-expensive government services or are purchasing medications from phaimacies and treating themselves. Young women are turning to pharmacies and midwives rather than to private doctors to obtain contraceptives. It is too soon to tell what effect this shift may have, if any, on fertility patterns.
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POLICY IMPLICATIONS
These survey results point out several areas where young people's lives are not matching their aspirations. Some of the gaps between ideals and realities could be reduced by well-designed reproductive-health programs and other government policies that affect youth.

The clear link between marriage and school leaving suggests the need for an information campaign to encourage adolescents to finish school and to delay marriage. For those who marry young, current programs could be expanded and new ones introduced to help married people continue their education and job training, including special programs for young women who are pregnant or have children.

Once young people marry, they tend to have children more quickly than they say they would prefer. This discrepancy between fertility preferences and reality points to an urgent need to improve family planning services for young couples, both to postpone childbearing and to increase the spacing between births.

Gaps in knowledge about family planning and reproductive health indicate a need for better family life education in classrooms, beginning at the primary level when most Indonesians are still in school. Because young men and women tend to discuss sexual issues with their friends, programs that provide information through youth organizations might be particularly effective. Family planning and health workers also need to do a better job in providing young men and women with appropriate information and counseling, and television and radio could be used more effectively to communicate information about family planning and reproductive health.

In efforts to improve young people's knowledge and use of family planning and reproductive health services, the role of the family should not be overlooked. Nearly all young people live with their parents-even married couples tend to live vrith the wife's or the husband's parents-yet few report that they discuss reproductive health issues with their mothers and even fewer with their fathers. Community programs might play a useful role in helping parents discuss these sensitive issues with their children.

One last policy issue concerns the current economic crisis. The survey shows that young people are switching from private doctors to less-expensive healthcare providers, and many are treating illnesses with herbs and other traditional medicines. In this difficult time, reproductive health programs need to make special efforts to ensure that young people get the services that they need.
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FURTHER READING
Demographic Institute, Faculty of Economics, University of Indonesia. 1999. Baseline Survey of Young Adult Reproductive Welfaie in Indonesia, 1988/1999. Six volumes. Jakarta; Demographic Institute.

Central Bureau of Statistic, State Ministry of Population/National Family Planning Coordinating Board, Ministry of Health, and Demographic and Health Surveys/Macro International Inc. 1998. Indonesia Demographic and Health Survey 1997. Jakarta: Central Bureau of Statistics.