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PMC Articles

Participation of young women in sexual and reproductive health decision-making in Malawi: Local realities versus global rhetoric

PMCID: PMC10022123

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Abstract

Despite the global prioritization of addressing adolescent girls’ and young women’s sexual and reproductive health (SRH) and participatory rights, little research has examined their lived experiences in shaping their engagement in SRH decision-making processes in the global South. Further, few studies have explored how structural and societal factors influence their agency and participation. This critical and focused ethnography, informed by postcolonial feminist and difference-centred citizenship theories, conducted in Malawi (2017–2018) elicited perspectives of youth and key informants to help address these knowledge gaps. Our findings show that the effective implementation and uptake of global discourse on participation and gender equity is hindered by inadequate consideration of girls’ and young women’s local political, cultural and social realities. Many girls and young women demonstrate passion to participate in SRH policymaking as agents of change. However, patriarchal and gerontocratic political and social structures/institutions, and gendered and adultist norms and practices limit their active and meaningful participation in SRH decision-making. In addition, donors’ roles in SRH policymaking and their prioritization of the “girl child” highlight an enduring postcolonial power over agenda-setting processes. Understanding young people’s experiences of gendered participation and scrutinizing underlying systemic forces are critical steps toward realizing young women’s SRH and participatory rights.

Full Text

Global actors have increasingly championed the participation of young people, particularly young women, in decision-making processes as a critical strategy to realizing their health and wellbeing [1]. In recent decades, substantial international, regional and national commitments have been made to ensuring young people’s “right to participate” in decisions that affect them, including Article 12 of the Convention on the Rights of the Child and Article 11 in the African Youth Charter [2, 3]. In Malawi, human rights-based, youth, and sexual and reproductive health (SRH) policies, and the creation of youth participatory structures at all levels of governance show progress in meeting these obligations [4–6]. Also, Malawi has committed to the global Sustainable Development Goals (SDGs), including Goal 5, which aims to achieve gender equality and empower all women and girls [7]. Despite these efforts, in 2018 Malawi ranked 172 out of 189 countries worldwide on measures of gender equality, encompassing reproductive health, empowerment (education, empowerment index and political participation), and female participation in the labour market [8]. Our study aims to explore this disconnect between the global rhetoric on gender equality and youth participation and young women’s lived experiences of SRH participation in Malawi.
Gender inequity and limited representation of youth in policymaking processes are ongoing challenges worldwide [9]. The participation of girls and young women is poorly documented in youth, girlhood and human rights literature [10, 11]. “Girlhood” discourses in the global South have contested the use of “empowerment” strategies as the main solutions to what are deeply rooted, systemic inequities [12]. Scholars highlight the overlap between poverty, gender and gender-based violence in limiting girls’ agency, access to SRH services and their participation in decision-making [13]. A global study with youth advocates in HIV/SRH decision-making bodies found that participation depth and quality was limited, particularly illustrating inadequate integration of voices from younger adolescents, girls and young women [14]. Moreover, to measure progress towards global objectives, such as the SDGs, empirical evidence reflecting the everyday realities of youth is lacking, particularly in the global South [15]. Notwithstanding a dearth of evidence on young women’s political participation within youth, girlhood or human rights discourses [10], recent scholarship demonstrates that young women in Latin America often engage in activism and political participation, informally outside the realms of the political sphere [16]. Recent research has examined the policies, progress, and challenges to engaging youth in SRH decision-making in Malawi. Despite established policies and participatory mechanisms for youth, there is limited understanding of the underlying structural and societal factors circumscribing young people’s meaningful engagement at all stages of the policymaking process [6]. This study aims to provide a deeper understanding of structural inequities and power relations encountered by young Malawian women through exploring how gender, age, and other categories of social difference intersect to influence their status in largely adult and male-dominated SRH decision-making spaces and processes.
We conducted a critical and focused ethnographic study [6], informed by postcolonial feminism [17] and difference-centred citizenship theory [18] to explore how young women’s complex everyday realities of participating in SRH policymaking in Malawi are shaped by underlying structural and societal forces. This aimed to challenge current SRH policymaking practices and inform the development/implementation of gendered local, youth-driven SRH policies and programs. The terms “youth” and “young people” are used interchangeably throughout this paper. Despite recognizing diversity in young people’s “gender” and “gender identity”, in this study the terms gender, gender equity and gender equality are frequently employed along binary dimensions (Table 1). We also acknowledge the heterogeneity of young people’s trajectories towards adulthood, including their lived realities and SRH needs. These vary substantially both between, and within, countries during the transition to adulthood, amidst significant physiological, cognitive, emotional and social changes [1, 19, 20].
Malawi offers a compelling context for the study of youth participation in SRH policymaking, as young people aged 10–35 years account for more than half of the country’s population and they experience a substantial burden of health and SRH issues, including high rates of unplanned pregnancy, HIV/AIDS and sexually transmitted infections (STIs), unmet need for contraception and unsafe abortion [4, 35, 36]. Further, young women are particularly vulnerable to experiencing gender-based violence, including intimate partner violence, forced or coerced sex and human trafficking [35]. In Malawi, traditional and cultural practices also shape young people’s SRH knowledge, attitudes and behaviours through initiation ceremonies, high rates of child marriage and early sexual activity [37]. Moreover, an entrenched culture of adultist beliefs and gerontocratic structures in Malawi [38] has circumscribed young people’s citizenship, participation and agency [18]. Research that analyzes these underlying forces, including gender inequality, and social, gender and adultist norms [20] is particularly relevant to gaining insights of the inequities impeding progress for youth SRH and participation [1].
Historical and contemporary colonial institutions have also firmly established gender as a social construct, contributed to the subordination of African women, and undermined young women’s status and authentic participation [39]. African feminist Oyewuni argues that the conceptualization of “woman” is deeply-rooted in and imposed by Western discourses of “biological determinism and the linkages between the body and the ‘social’” [39]. Semu [40] also argues that colonialism has undermined women’s autonomy, status and roles in Malawi through the introduction of more narrowly defined gender roles and inequitable opportunities for education. Traditional Chewa women were afforded higher status as the “root of a lineage, [where] the woman was seen as a sacred vessel of life” as their power and personhood was intimately related to their ability to bear children [41]. However, several key factors starting in the 19th century are implicated in the “erosion” of this status: i) the introduction of slavery and its continued practice until the late 19th century; ii) the reinforcement of patrilineal societies under colonialism; iii) the introduction of Christianity and its pervasive influence; and iv) the introduction of a capitalist economy and displacement of women’s roles in agricultural production [40]. Religion remains an important element of the research context in Malawi; most of the population is Christian (86.9%), while nearly 13% is Muslim [37]. Although Islam was first introduced to Malawi during the 16th century via traffic and trade opportunities from East Africa [42], Christianity was implicated in “crushing” the practices and tenets incompatible with its male dominance [41]. Colonial rule also transformed male-privileging norms that shaped women’s autonomy and status, by limiting their educational opportunities, inheritance claims, and traditional roles in food production and agriculture [40]. In particular, the large role played by Christian missionaries under colonialism in Malawi fostered enduring class and gender educational differentials by training men as pastors, teachers, clerks and tradesmen [40].
In Malawi, both patrilineal and matrilineal structures exist amongst the 12 major ethnic groups [36], yet even within matrilineal systems women’s participatory power, status and autonomy were circumscribed [40]. Despite post-independence legal reforms and human rights discourse adopted by President Kamuzu Banda which appeared to champion women and gender equity (e.g., nominating women to parliament), tangible progress for Malawian women has remained constrained [40]. These political, social, historical and economic factors have influenced the availability and type of opportunities for youth, particularly young women, to be engaged in decision-making processes [1]. However, there is limited empirical evidence on how these forces determine young people’s power and lived experiences of SRH participation, in practice [43].
A postcolonial feminist theory (PCF) and difference-centred citizenship approach (DCA) informed all stages of our research, including the development of the research questions, the methodology and study design, participant sampling, data generation, analysis and interpretation, and knowledge translation. This combined theoretical framework exposes the “gendered, racialized, and adultist” [18] assumptions and structures that shape young people’s participation in SRH policymaking in Malawi. Moreover, it emphasizes young people’s agency, a “dialectical relationship between individual sense of self and collective action”, as a critical driver of their participation to overcome sources of inequity and oppression [18].
PCF is a critical theoretical lens that aims to understand the “complex matrix” of historical, cultural, political and economic contexts contributing to inequities in power and health among non-Western populations [28]. Grounded in scholarship from postcolonial theorists, such as Mohanty [17, 29], and Black feminists, including Collins and Crenshaw [44, 45], scholars “at the margins” have challenged the inadequacies of, and expanded on, white/Western-centric feminist theory to (re)present all women’s experiences. They also aimed to produce a novel theorization at, and of, the intersection of gender, race, class and coloniality in postcolonial contexts [46]. Postcolonial feminist scholars’ integration of intersectionality conceptualizes the interlocking systems of oppression experienced by youth due to their social location (e.g., age, gender and class) and acknowledges the fluidity of these mechanisms of power under colonialism and postcolonialism [28]. Although an intersectional approach has helped us unpack and distinguish among the range of youth identities and experiences that are otherwise often homogenized, several scholars have also argued that contemporary intersectionality theory on its own is limited in its conceptualization of agency, privilege and structural power relations [47–49].
To overcome this limitation, our study utilizes a postcolonial feminist lens to understand how young people’s agency and structural forces, social, political, economic, cultural and historical contexts and asymmetrical power relations have shaped young people’s engagement in SRH policymaking in Malawi. A PCF approach views “culture” as a “fluid entity” to expand understandings of oppression to account for the ways in which “patriarchy, traditionalism and modernity” impact individuals’ everyday realities [50, 51]. Development discourse is also critiqued by Mohanty [29] for its “reductive cross-cultural comparisons”; dominant forms of knowledge from the global North colonize young women’s daily experiences and frequently homogenize the political interests of young women in the global South, silencing and subjugating them as the “Other” [17, 28]. By employing a PCF perspective, we challenge perceptions of “youth” as a universal category and young women as victims of oppressive socio-cultural structures. Young people represent “subject(s) of power” shaped by their contexts and experiences, to resist the dichotomies of “power” (e.g., “possessing power versus being powerless”) [29]. This understanding frames youth as capable, active participants with agency in decision-making, in order to provide a more inclusive understanding of systemic forces of power and inequity [17]. Moreover, we understand the concept of “youth” as a dynamic and evolving category, shaped by the plurality of historical, political and social contexts and experiences [52].
Complementing PCF, Moosa-Mitha’s [18] DCA offers a more inclusive understanding of young people’s participation and citizenship, and challenges normative, liberal citizenship models, as these discourses and their colonial roots inadequately reflect young people’s everyday social, political, cultural and historical contexts in postcolonial settings, such as Malawi [53]. “Differences” in young people’s social positions (e.g. age, gender, race, sexuality and class) vary by context and represent assets of their citizenship, rather than limitations [18]; they acknowledge young people’s citizenship rights and value their participation because of their identity as youth. It also recognizes youth as “differently-equal” through their informal, domestic or grassroots agency and participation, despite deviation from “adultist norms” [18]. This approach advocates for the pluralism of democratic values (e.g., rationality, individuality, and universality) to generate a framework articulating the “multiplicity of forms of subordination” within social and power relations due to gender, race, class, sexuality, and other power relations [54]. It also recognizes young people’s agency, expressed as collective action and participation against oppression, as a key strategy to create space and shape their lived realities [18].
Conceptualization of typologies or frameworks also has dominated literature on youth participation, with relatively limited emphasis or empirical evidence of young people’s everyday realities of SRH participation [55–59]. Considering the dearth of literature of the structural and societal determinants that shape young people’s opportunities for, and experiences of, participating in SRH decision-making [43], this research–informed by postcolonial feminist and difference-centred citizenship theories–employed a focused critical ethnographic approach to generate empirical insights of youth participation in SRH policymaking in Malawi. It represents a significant and timely research contribution, as it is the first study to explore young people’s lived experiences of participating in SRH policymaking, not only in Malawi but also, to our knowledge, within sub-Saharan Africa.
A critical ethnographic approach was used to generate data about the lived experiences of young people participating in SRH decision-making processes. Informed by postcolonial feminist and difference-centred citizenship theories and reflexive practice, critical ethnography aims to expose underlying social structures, power relations and their impact on human agency [60]. Critical ethnography evolved as a methodological approach in response to critiques of “traditional” ethnography for its ‘Othering’ and colonizing approach to knowledge generation, lack of researcher reflexivity and its inadequate consideration of power relations within social and cultural structures and groups [61]. Further, our approach was “focused” in the sense that a focused ethnography seeks to answer specific research questions in applied social research within “fragmented and specialized” areas of inquiry in order to challenge normative assumptions about youth SRH participation. It involved generating data during intensive and defined periods of fieldwork to explore our specific research interests [62]. Our focus on understanding young people’s roles within SRH decision-making illustrates that culture is ubiquitous and “unbounded” [60]. In particular, our combined critical and focused ethnographic approach aimed to explore how the culture of youth participants’ everyday realities of SRH decision-making are shaped by broad structural and societal forces, including class, patriarchy and racism, in order to address power inequities and advance social justice [50, 60].
Fieldwork was conducted in Malawi from October 2017 to May 2018, in Nkhata Bay (north), Dowa (central) and Zomba districts (south) and the capital, Lilongwe. Over 85% of the population in Malawi live in rural areas [36], where Dowa and Nkhata Bay represent largely rural regions, and both Zomba and Lilongwe are composed of rural and urban settings. We were hosted by a non-governmental organization (NGO), the Parent and Child Health Initiative (PACHI). Ethics approval was obtained from the University of Toronto Health Sciences Research Ethics Board in August 2017 and the National Health Sciences Research Committee in Malawi in October 2017. Local written approval to conduct research in Dowa, Nkhata Bay and Zomba districts also was obtained. An ethics deviation and amendment was submitted to the University of Toronto and approved in November 2017 to increase the size of focus groups from 4–5 individuals to 5–10 per group due to interest by participants. Informed, written consent (in English or Chichewa) was obtained from all study participants.
Reflexivity about our “creative presence” [63] as researchers conducting a critical ethnography in Malawi underscores the importance of exploring the “complex (and sometimes contradictory) perspectives on privilege and difference” [64]. Our positionality reflects how differences produced along multiple dimensions, such as age, gender, ethnicity, nationality (or geographic provenance) and class, inherently shaped the power dynamics with research participants, their representation and knowledge generation [65]. For example, JW’s social identity as a Canadian middle-class adult white female doctoral student and her previous work experience on a maternal and newborn health project in Malawi influenced her motivations, interests, assumptions and relationships to both the substantive and geographic areas of focus for this research. We also grappled with our positionality and the decolonial imperatives facing researchers from the global North working in in the global South. Therefore, we aimed to conduct ethical and deeply reflexive research which promotes and (re)presents young people’s lived experiences of SRH participation. Lived experiences relate to young people’s unique representation and understanding of experiences, choices and options, and their perception of knowledge; it is shaped by diverse factors including race, class, gender, sexuality, religion, and other elements that impact their everyday realities [66].
However, we recognize that youth researchers’ engagement in research stages prior to data generations (e.g., research focus, objectives and tools) and their sustained involvement post-fieldwork in analysis and knowledge translation (e.g., coding, conceptualization and theorization) was limited. One youth researcher (MK) and research assistant (SP) remain engaged in writing and producing manuscripts for publication. Power relations between JW and the Malawian research team were also critically considered, as SP acted as an interpret, translator and “cultural guide” to understanding local culture and context, and is/was an active participant throughout the research process [65].
We also critically reflect on the language employed throughout our work. For example, the terms “stigma” and “taboo” represent popular, often naturalized terms in SRH literature. Despite substantial variation in how “stigma” is defined and applied to substantive areas of inquiry, it is also critiqued for its individualistic focus, limited consideration of structural influences and connection of social labels to “undesirable” attributes to separate “us” from “them” [67]. The use of “taboo” is also inherently problematic, often defined by society and social norms to describe and control the “permitted and the prohibited, the do’s and don’ts” [68]. Although, in this study, both youth and key informant participants frequently employed these terms, we have chosen to use these terms with quotations to reflect these challenges and to critically interrogate their meaning.
Purposive sampling strategies employed maximum variation and “snowball” sampling [69, 70]. Sampling of youth aimed to capture diverse social positions (e.g., age, gender, education and geographic location), and levels of participation (e.g., community/district/national/international). We recruited 46 youth to engage in FGDs, and 30 in semi-structured interviews with an open-ended drawing exercise. Engaged youth self-identified as either currently participating in SRH policy spaces from community to international levels, or not currently participating in SRH policymaking. The latter group includes out-of-school youth or youth experiencing homelessness [6]. Youth participants were on average 21 and 22 years for FGDs/interviews, respectively. Most had completed some secondary education, and were unmarried without children (Table 2). Recruitment posters in both English/Chichewa were shared in print (e.g., at local youth centres, district youth offices, local/international NGO/CSOs working in youth/SRH/participation and university student unions), and electronically through email and social media. Youth researchers also distributed posters through their networks, including youth clubs, schools and communities. Participants were compensated for their time commitment and transportation, and provided a drink/snack.
Multiple research methods were employed to generate data, outlined in Table 3. Together these approaches informed the conceptualization and theorization of our results.
The analytic strategies we employed included: reflexive, thematic analysis [73], and document and visual analyses. We engaged in the six stages of reflexive, thematic analysis outlined by Braun and Clarke [73], as we: i) reviewed the data; ii) generated initial codes; iii) generated initial themes; iv) reviewed themes; v) defined/named themes; and vi) produced written interpretations. An initial code list was developed based on our theoretical framework, literature, and in vivo codes (e.g., key words/processes/events) and used to code data (e.g., FGDs, observations and fieldwork journal) [74]. JW coded all interview/FGD transcripts, observation fieldnotes and fieldwork journal to “organize, manage and retrieve meaningful bits of data” (Coffey & Atkinson, 1996, p. 26). All interviews/FGDs were audio-recorded with participants’ permission and transcribed, and Chichewa data was translated to English. NVivo 12 was employed to manage and support data analysis. Analytic summaries/memos documented coding; codes were developed into higher order categories and concepts, and used to generate themes in our work. Findings from FGDs and interviews are presented together due to the overlapping discussions and themes generated across these methods. Conceptual mapping was used to explore relationships and identify overarching themes within our data [75].
Analysis of SRH- and youth-focused policies and strategies was guided by our adaptation of the WHO Gender Assessment Tool [76], to evaluate the level of “youth responsiveness” (e.g., definition, framing and prioritization of youth) [6]. We also employed a critical visual methodology to analyze drawings and reflect upon the participant, researcher and drawing. Drawings were analyzed alongside participants’ descriptions to explore meanings produced, to reflect on the image and significance to their drawing and statements [72]. Mitchell and Sommer [77] underscore the “power of the visual to represent what is not easily put into words”, and how youth articulate their own experience of relative power within the study.
Despite mainstreaming or integrating gender in policies and public actions designed to achieve gender equity in the workplace/polis, significant disparities in female participation were highlighted by both youth participants and key informants. A public campaign for the Gender Equality Act (GEA) in Lilongwe paradoxically illustrated inequity by advocating for 40/60 representation, with women lacking significant leadership positions within that proportion (Fig 1). Although at the time of research the GEA had been in place only four years, many key informants already flagged concerns around its implementation and accountability. They pointed to organizations and political bodies claiming to achieve gender “parity” by recruiting women to administrative or entry-level positions but failing to ensure equitable leadership opportunities for women. Furthermore, few national youth, SRH or health policies offer data on youth participation or SRH disaggregated by sex, nor acknowledge the systemic exclusion of young women in decision-making spaces.
For example, several key informants identified the introduction of the Adolescent Girls and Young Women Strategy [78], and submission of the Termination of Pregnancy Bill to Parliament as recent examples of SRH policymaking, championed largely by bilateral donors (the United States and the United Kingdom, respectively). These donor-driven SRH policy efforts were not fully owned/endorsed by the Malawian Government and involved limited consultation of young women.
Young women are expected to occupy “private” spaces in society, and must balance their participation with competing responsibilities, including domestic labour, subsistence farming and childcare. Key informants indicated that gendered parenting practices shape young people’s trajectories and participation; boys are groomed to engage in decision-making, while girls are primed for domestic duties and considered “second-class” citizens. Several participants also outlined young women’s role in maintaining local culture, through marriage/childbearing. According to a bilateral donor, young women’s “ability to bear children and be an active member of your community” linked their responsibilities for social reproduction to their citizenship, power and participation. Social and gender norms reinforce the interpretation of young women’s SRH rights, visualized by a male youth participant (Fig 2). They described young women’s “right to conceive” involving pictures/slogans drawn on local buildings depicting having children and getting married. These are a typical form of promotions in many Malawian communities; however, these gendered and restrictive slogans may be interpreted as refashioning and naturalizing young women’s “human rights” with expectations of their social reproduction.
Various cultural practices were identified as harmful by youth participants and key informants, including initiation ceremonies (“kusasa fumbi”) or arranged marriages for pre-pubescent girls to an adult male in the community (“kutomera”). Key informants emphasized men represent the custodians of these traditional practices, with the power to stop them. They viewed these practices as forms of gender-based violence, subjugating young women and restricting their SRH participation. Although key informants cited a decline in prevalence of these customs (Rates of child marriages and early pregnancies have increased during the COVID-19 pandemic due to school closures and public health restrictions [100].), many are still widely practiced and represent formative experiences that shape young people’s SRH knowledge/behaviours. Few young women shared personal encounters with these practices, yet they were raised frequently by participants in interviews/FGDs. Nearly all youth interpreted cultural practices, particularly child marriage, as detrimental to girls’ SRH and participatory rights. Young people relayed examples of their own agency to prevent child marriage in their communities, as a male youth indicated “if a girl gets married aged 17 or below, we go as a youth club to get her out of that marriage.” Young people’s efforts were recognized by multiple key informants, with one district policymaker celebrating “the youth have really fought so hard to make sure that nobody gets married early.”
The centrality of achieving gender equality to young people’s active and meaningful SRH participation, and the urgent need for collective efforts and responsibility to foster equality was visualized by a youth (Fig 3).
International commitments to youth, SRH and gender equality were articulated through the 2015 adoption of the SDGs, and at a national level through the 2013 introduction of Malawi’s Gender Equality Act, National Youth Policy, and the 2017 constitutional amendments that raised the minimum age of marriage [5, 79, 80]. However, our research reveals a disconnect between the pervasive global and national gender equality rhetoric and young women’s lived realities of their SRH and participatory rights in Malawi. Although many participants noted the importance of gender parity within international/national SRH policy spaces (e.g., youth parliament or donor forums), our overall findings indicated that underlying discrimination continues to circumscribe the active and meaningful engagement of young women at all levels of governance, particularly within their own communities. The frequent marginalization of young women’s voices in SRH decision-making are shaped by both age and gender discrimination. As such, efforts to achieve gender equity must be grounded in and driven by the lived experiences of young women, in order to achieve significant shifts in their participation.
Participation in both SRH and overall policymaking in Malawi is highly gendered across generations, with underrepresentation of young women in youth participatory spaces and of adult women in democratic governance structures [81, 82]. Women account for just 10% of traditional leaders [82] in Malawi, and as of May 2019, only 44 elected members of Parliament (or 23%) were women [81]. This problem is of course not exclusive to Malawi: inequitable gender representation in National Parliaments remains a global challenge, with most countries (both North and South) failing to realize gender equity in elected bodies. In Canada, women comprise only 29% of elected members of parliament, versus other countries that have achieved gender parity, such as Rwanda (61.3%), Cuba (53.2%) and Bolivia (53.1%) [81]. Research on gender equity and SRH within Malawi’s dual (democratic and traditional) governance systems highlights the potential impact of greater women’s political engagement, given that female traditional leaders and members of parliament more effectively promote women’s SRH rights than do men [82]. Malawian Senior Chief Theresa Kachindamoto is an example of the importance of female leadership: she has championed both local and national legislation to increase the legal age of marriage and nullified over 1,000 unions that violate these laws [82, 83]. Failure to prioritize young women’s participation within key national policies, including the National Youth Policy, limit opportunities for capacity building and perpetuates inequities in their engagement moving forward [5].
Our results show that young women’s participation and gender equity are interrelated and interdependent. The equal, active, and meaningful SRH participation of young women is contingent on societal recognition and overcoming of gaps in gender equality. Our study extends recent scholarship that has conceptualized the relationship between social norms around gender norms and young people’s SRH [84, 85] to also consider the impact of gender inequity on their authentic engagement; whereby young people’s voices, and young women’s voices in particular, are given equal space and consideration within SRH decision-making processes. As such, SRH policy scholars argue that the continued prioritization of youth is essential to addressing gender (in)equality [86]. This research acknowledges young women’s engagement in SRH policymaking, both formal and informal, and represents the critical first step toward overcoming restrictive gender norms.
African critiques around the role and influence of foreign development donors reflects longstanding concerns of neocolonial appropriation of priority-setting and decision-making [87]. In Malawi, international donors contribute over 60% of spending on health care (2012–2015), with funding for SRH and sexually transmitted infections (including HIV/AIDS) representing nearly half (47%) of all external health expenditure [88, 89]. We show that donors’ political and ideological priorities profoundly influence the entire SRH policymaking process, which simultaneously proscribes and promotes the engagement of girls and young women. Recently proposed legislation to liberalize abortion (Termination of Pregnancy Bill) and the adopted Adolescent Girls and Young Women Strategy were identified by informants as examples of “donor-driven” SRH policy efforts.
We expose and acknowledge the patriarchal and colonial legacy of the SRH field, and especially the promotion of contraceptives: funding and implementation of SRH initiatives and policies by former colonial powers is problematic and even suspect as a form of neocolonialism [90]. Participants questioned whether donor-driven SRH policies aligned with Malawian priorities and values, highlighting conflicting neocolonial influence by donors amid local politico-cultural realities. The donor-driven nature of SRH policymaking often means that young women’s priorities for SRH information and services are eclipsed by donor ideologies and agendas that introduce global norms within the Malawian context. This illustrates the ways in which the micropolitics of young women’s everyday SRH participation are intimately connected to global economic and political processes [17]. Renewed calls to decolonize global health also must work to transform current global rhetoric and approaches within SRH [90, 91].
Notwithstanding these substantial concerns, many youth participants and key informants believed that donors’ prioritization of young women has increased their engagement in SRH decision-making processes. This finding contradicts critical literature linking the “turn to the girl” or the “girling of development” to neoliberalism; employing “empowerment” and “agency” discourses are criticized seeking to “rescue” and homogenize young women in the global South [12]. According to critics, girl-oriented development approaches frame girls as both victims of oppression and heroes with agency [12], whilst placing responsibility on girls to overcome poverty or address SRH issues using only their “voice” or “agency”, rather than making structural change through their meaningful participation. Our results also reveal that the donor-driven “girl child” discourse in Malawi has triggered young men’s hostility and a capitalist, class-based competition towards their female peers, with few men acknowledging the underlying structural forces that often restrict young women’s SRH participation. This prioritization of young women, and the neglect of young men was considered ineffective by many, and unintentionally may perpetuate discrimination, undermining youth SRH efforts in Malawi. Continued engagement of both young men and women is needed to address more holistically gender discrimination, norms, and power and health inequities.
Study participants associated increased public acceptance of SRH issues with efforts to address high rates of HIV/AIDS in Malawi over the last two decades. Despite perceived progress, SRH and young people’s participation in SRH decision-making remains controversial. Older (often male) community members consider young women promiscuous and disrespectful for “voicing out”, limiting their ability to speak openly about SRH issues. Moreover, the continued practice of traditional customs preserves patriarchal control over young women’s reproduction and bodies, and their economic and decision-making power [92].
Many youth participants and key informants shared that their religion and culture posed barriers to young women’s participation in SRH policymaking. However, postcolonial feminists argue that a focus on “culture” alone is insufficient. Challenging “essentialist interpretations” of the role of culture on young women’s lived experiences of participation must consider how it is situated within and shaped by other historical, political, economic and social forces [50]. Our research considers how other underlying influences, including patriarchy, gerontocracy and donors’ postcolonial powers, impact the opportunity and quality of young women’s SRH participation.
The historical, social and economic contexts of the lives of young women in Malawi have long shaped the ways in which patriarchal gender norms and roles are reproduced. Our study participants explained that men often act as cultural custodians or gatekeepers who control young women’s access to SRH information, services, and participation in policymaking spaces. Study participants also pointed to the tokenistic or symbolic engagement of young women in community youth clubs and district decision-making structures. This suggests that a large proportion of young women may be privy to SRH decision-making as permitted by male custodians. Recent empirical evidence from other previously colonized countries (e.g., Senegal and Kenya) also found that formal/informal opportunities for youth to participate meaningfully, often reproduced underlying discourses of gender (in)equality and patriarchy, gendered norms and constructions of citizenship [93, 94].
Young people’s intersectional social identities shape their lived experiences of participation. Older youth, males, young people living in urban areas, and those with more formal education have greater opportunities than younger, female, less educated and rural residents to participate in SRH policymaking in Malawi [6]. Although all but two of the youth participants in our study were 18 years of age or older, many shared significant experiences of age-based discrimination and marginalization prior to and during their involvement in SRH decision-making processes. Literature on engagement of young women in the United Nations Commission on the Status of Women also highlights that the intersection of age and gender reinforced their political marginalization [10]. Overlapping and systemic patriarchal and adultist norms highlight the ambiguity of the temporality of social identities and young women’s transition into adulthood; several participants associated transitioning into adulthood with young women’s marital and childbearing status. Young women are often relegated to “second-class” citizen status due to their systemic discrimination and failure to protect and realize their basic participatory and SRH rights [95]. These shortcomings highlight the importance of challenging normative perceptions of young women’s status roles in society, by generating contextualized insights of young people’s lived experiences of SRH participation. Efforts are needed to ensure the continued engagement of young women who are married or have children; their perspectives and priorities are underrepresented in current SRH decision-making processes. Further evidence is also needed to reflect younger adolescent girls’ experiences of SRH participation, as they are likely to encounter even greater hurdles to engage actively and meaningfully.
Youth engagement in SRH decision-making and gender equality represented shared priorities among both male and female youth participants. Participants emphasized a consensus that young women experienced inequitable barriers, underscoring that age, gender, race, and class interact to challenge their participation [54]. Both groups reported that young men’s perspectives were preferred in SRH policymaking, and that judgment/shame associated with participating in decision-making or accessing SRH services was reserved for young women. Both male and female youth reported that young women were uncomfortable speaking about SRH in policy spaces, particularly with older, male decision-makers.
Our findings underscore the substantial challenges to effectively democratize SRH decision-making power to poor and female Malawian youth. Multiple participants emphasized the inequitable power and socioeconomic status of young women, which threatened their capacity to participate and realize their SRH and participatory rights. Inadequate knowledge of policymaking or ability to read and write English represented critical barriers to their engagement. Creating open and authentic policy spaces, and training and mobilizing all youth to challenge this “hypocrisy” and cycle of patriarchal and gerontocratic systems is critical to addressing the inequitable participation and SRH among young women [96].
Opportunities for young women to participate and lead in SRH decision-making demonstrate both progress and potential for their engagement in Malawi. Despite encountering structural forces, young women emerged in our study as passionate community role models and agents of SRH change, motivated by their duty to support their community and country [6]. Several young female participants overcame personal and systemic barriers to pursue educational opportunities and SRH participation. Our PCF/DCA perspective emphasizes that recognition of young women’s heterogeneous experiences are critical to disrupting the systems of power that marginalize their SRH engagement [50, 97]. Through both formal (e.g., national youth parliament) and informal participation (e.g., advocacy to increase the age of marriage), young women in our study demonstrated significant capacity, knowledge of SRH issues, and agency to lay the foundation for a grassroots movement to ensure their active and meaningful involvement in SRH decision-making.
Our findings illustrate that young people are shaped by their economic, cultural, and social contexts, yet simultaneously resist dichotomies of power [29]. To many of our female youth participants, being a young woman represented an asset to their participation. This perspective confronts normative understandings of citizenship by advocating for the recognition and celebration of “difference” [54]. This was illustrated by a female youth as she resisted patriarchal attitudes and power inequities “when people see me, they think that being a woman doesn’t mean that we are inferior, that we can also bring change to the world.” The recent global/national prioritization of young women and youth participation has also created promising opportunities for their engagement in decision-making, which must continue to be leveraged to mobilize sustainable changes to existing gendered and adultist norms.
Our study finds that underlying gendered structural and systemic forces continue to challenge progress towards achieving global goals pertaining to young women’s SRH and their meaningful participation in SRH policymaking (and beyond). Many participants were interested in how youth in other countries (e.g., Canada) are engaged in SRH policymaking and these discussions highlighted the comparative progress and promising policy efforts for youth participation in Malawi, versus some countries in the global North [98]. As a result, we argue that engaging young people in SRH decision-making, particularly young women, represents a challenge that is not unique to Malawi, but a broader global health and human rights concern.
Recent global developments, including the COVID-19 pandemic, reinforce the urgency of addressing young people’s SRH and ensuring their inclusion in decision-making processes. Decades of progress and efforts targeting gender equality and SRH are at risk, as many countries in the global South, such as Malawi, struggle to ensure accessibility of contraception, skilled health providers, and YFHS amidst competing demands on the health system [99]. School closures and public health restrictions in many sub-Saharan African countries, including Malawi, already have been linked to increases in adolescent pregnancy [100]. A rapid assessment conducted by the government highlighted that teenage pregnancies increased by 11% from March to July 2020, as compared to the same time period in 2019. Key drivers identified were religious beliefs, inadequate economic and social opportunities and a desire to start childbearing [101]. In addition, research examining school enrollment pre- and post-school closures found that the highest rate of dropouts were amongst older female youths, aged 17–19 years, exacerbating existing gender inequalities in education [102]. This suggests that COVID-19 represents not only a current health threat, but is likely to have long-lasting impact on young people’s SRH and participation. Our work reinforces that addressing the systemic silencing of young women is crucial to ensure that SRH policymaking processes reflect young people’s lived realities, now more than ever.
In addition, although we aimed to be inclusive and recruit diverse youth perspectives, we acknowledge that this research and focus on youth SRH in Malawi was influenced by underlying heteronormative assumptions. In Malawi, a country that has not legalized same-sex relations, many LGBTQ communities face discrimination, violence and the threat of criminal penalty for failing to conform to heteronormative standards [103]. Adopting a postcolonial queer feminist perspective may be necessary to challenge heteronormative structures, which limit the participation of individuals who don’t fall within binary categories of sex/gender [104]. Specifically, research that is inclusive of those with diverse gender and sexual identities and orientations, yet culturally grounded (and legal), is needed to understand the SRH needs of these groups and the role of heteronormative assumptions in shaping youth participation in SRH decision-making processes in Malawi and beyond.
Significant global development discourse and national policy efforts have focused on gender equality and youth participation in SRH. However, the lived experiences of young women participating in SRH policymaking in Malawi demonstrate entrenched power structures that privilege men, adults, and individuals in higher social economic status. Understanding how gender and age together shape young people’s involvement in Malawi will help inform contextualized and tailored strategies to support the participation of young women in SRH decision-making. Young women experience gendered participation in SRH policymaking at all levels, as they are too often underrepresented and undervalued. Despite these systemic barriers young women also represent critical resources and local agents of change for youth SRH. Young women’s vital roles and contributions in SRH policymaking must be recognized through continued advocacy and education of their peers, families, communities and decision-makers. Our use of postcolonial feminism aims to inspire “solidarity across borders” [17]. The lessons from progress and challenges to engaging young women in SRH policymaking in Malawi are applicable across both the global South and North. Gender equality and youth participation represent distinct areas within global and national development processes, yet our research shows that they are clearly interdependent. The active and meaningful participation of young women in Malawi (and beyond) is not possible without collective efforts to catalyze political, societal, and cultural change to challenge systemic gender and power inequities.

Sections

"[{\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref001\", \"pgph.0001297.ref002\", \"pgph.0001297.ref003\", \"pgph.0001297.ref004\", \"pgph.0001297.ref006\", \"pgph.0001297.ref007\", \"pgph.0001297.ref008\"], \"section\": \"Introduction\", \"text\": \"Global actors have increasingly championed the participation of young people, particularly young women, in decision-making processes as a critical strategy to realizing their health and wellbeing [1]. In recent decades, substantial international, regional and national commitments have been made to ensuring young people\\u2019s \\u201cright to participate\\u201d in decisions that affect them, including Article 12 of the Convention on the Rights of the Child and Article 11 in the African Youth Charter [2, 3]. In Malawi, human rights-based, youth, and sexual and reproductive health (SRH) policies, and the creation of youth participatory structures at all levels of governance show progress in meeting these obligations [4\\u20136]. Also, Malawi has committed to the global Sustainable Development Goals (SDGs), including Goal 5, which aims to achieve gender equality and empower all women and girls [7]. Despite these efforts, in 2018 Malawi ranked 172 out of 189 countries worldwide on measures of gender equality, encompassing reproductive health, empowerment (education, empowerment index and political participation), and female participation in the labour market [8]. Our study aims to explore this disconnect between the global rhetoric on gender equality and youth participation and young women\\u2019s lived experiences of SRH participation in Malawi.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref009\", \"pgph.0001297.ref010\", \"pgph.0001297.ref011\", \"pgph.0001297.ref012\", \"pgph.0001297.ref013\", \"pgph.0001297.ref014\", \"pgph.0001297.ref015\", \"pgph.0001297.ref010\", \"pgph.0001297.ref016\", \"pgph.0001297.ref006\"], \"section\": \"Introduction\", \"text\": \"Gender inequity and limited representation of youth in policymaking processes are ongoing challenges worldwide [9]. The participation of girls and young women is poorly documented in youth, girlhood and human rights literature [10, 11]. \\u201cGirlhood\\u201d discourses in the global South have contested the use of \\u201cempowerment\\u201d strategies as the main solutions to what are deeply rooted, systemic inequities [12]. Scholars highlight the overlap between poverty, gender and gender-based violence in limiting girls\\u2019 agency, access to SRH services and their participation in decision-making [13]. A global study with youth advocates in HIV/SRH decision-making bodies found that participation depth and quality was limited, particularly illustrating inadequate integration of voices from younger adolescents, girls and young women [14]. Moreover, to measure progress towards global objectives, such as the SDGs, empirical evidence reflecting the everyday realities of youth is lacking, particularly in the global South [15]. Notwithstanding a dearth of evidence on young women\\u2019s political participation within youth, girlhood or human rights discourses [10], recent scholarship demonstrates that young women in Latin America often engage in activism and political participation, informally outside the realms of the political sphere [16]. Recent research has examined the policies, progress, and challenges to engaging youth in SRH decision-making in Malawi. Despite established policies and participatory mechanisms for youth, there is limited understanding of the underlying structural and societal factors circumscribing young people\\u2019s meaningful engagement at all stages of the policymaking process [6]. This study aims to provide a deeper understanding of structural inequities and power relations encountered by young Malawian women through exploring how gender, age, and other categories of social difference intersect to influence their status in largely adult and male-dominated SRH decision-making spaces and processes.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref006\", \"pgph.0001297.ref017\", \"pgph.0001297.ref018\", \"pgph.0001297.t001\", \"pgph.0001297.ref001\", \"pgph.0001297.ref019\", \"pgph.0001297.ref020\"], \"section\": \"Introduction\", \"text\": \"We conducted a critical and focused ethnographic study [6], informed by postcolonial feminism [17] and difference-centred citizenship theory [18] to explore how young women\\u2019s complex everyday realities of participating in SRH policymaking in Malawi are shaped by underlying structural and societal forces. This aimed to challenge current SRH policymaking practices and inform the development/implementation of gendered local, youth-driven SRH policies and programs. The terms \\u201cyouth\\u201d and \\u201cyoung people\\u201d are used interchangeably throughout this paper. Despite recognizing diversity in young people\\u2019s \\u201cgender\\u201d and \\u201cgender identity\\u201d, in this study the terms gender, gender equity and gender equality are frequently employed along binary dimensions (Table 1). We also acknowledge the heterogeneity of young people\\u2019s trajectories towards adulthood, including their lived realities and SRH needs. These vary substantially both between, and within, countries during the transition to adulthood, amidst significant physiological, cognitive, emotional and social changes [1, 19, 20].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref004\", \"pgph.0001297.ref035\", \"pgph.0001297.ref036\", \"pgph.0001297.ref035\", \"pgph.0001297.ref037\", \"pgph.0001297.ref038\", \"pgph.0001297.ref018\", \"pgph.0001297.ref020\", \"pgph.0001297.ref001\"], \"section\": \"Sociohistorical context\", \"text\": \"Malawi offers a compelling context for the study of youth participation in SRH policymaking, as young people aged 10\\u201335 years account for more than half of the country\\u2019s population and they experience a substantial burden of health and SRH issues, including high rates of unplanned pregnancy, HIV/AIDS and sexually transmitted infections (STIs), unmet need for contraception and unsafe abortion [4, 35, 36]. Further, young women are particularly vulnerable to experiencing gender-based violence, including intimate partner violence, forced or coerced sex and human trafficking [35]. In Malawi, traditional and cultural practices also shape young people\\u2019s SRH knowledge, attitudes and behaviours through initiation ceremonies, high rates of child marriage and early sexual activity [37]. Moreover, an entrenched culture of adultist beliefs and gerontocratic structures in Malawi [38] has circumscribed young people\\u2019s citizenship, participation and agency [18]. Research that analyzes these underlying forces, including gender inequality, and social, gender and adultist norms [20] is particularly relevant to gaining insights of the inequities impeding progress for youth SRH and participation [1].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref039\", \"pgph.0001297.ref039\", \"pgph.0001297.ref040\", \"pgph.0001297.ref041\", \"pgph.0001297.ref040\", \"pgph.0001297.ref037\", \"pgph.0001297.ref042\", \"pgph.0001297.ref041\", \"pgph.0001297.ref040\", \"pgph.0001297.ref040\"], \"section\": \"Sociohistorical context\", \"text\": \"Historical and contemporary colonial institutions have also firmly established gender as a social construct, contributed to the subordination of African women, and undermined young women\\u2019s status and authentic participation [39]. African feminist Oyewuni argues that the conceptualization of \\u201cwoman\\u201d is deeply-rooted in and imposed by Western discourses of \\u201cbiological determinism and the linkages between the body and the \\u2018social\\u2019\\u201d [39]. Semu [40] also argues that colonialism has undermined women\\u2019s autonomy, status and roles in Malawi through the introduction of more narrowly defined gender roles and inequitable opportunities for education. Traditional Chewa women were afforded higher status as the \\u201croot of a lineage, [where] the woman was seen as a sacred vessel of life\\u201d as their power and personhood was intimately related to their ability to bear children [41]. However, several key factors starting in the 19th century are implicated in the \\u201cerosion\\u201d of this status: i) the introduction of slavery and its continued practice until the late 19th century; ii) the reinforcement of patrilineal societies under colonialism; iii) the introduction of Christianity and its pervasive influence; and iv) the introduction of a capitalist economy and displacement of women\\u2019s roles in agricultural production [40]. Religion remains an important element of the research context in Malawi; most of the population is Christian (86.9%), while nearly 13% is Muslim [37]. Although Islam was first introduced to Malawi during the 16th century via traffic and trade opportunities from East Africa [42], Christianity was implicated in \\u201ccrushing\\u201d the practices and tenets incompatible with its male dominance [41]. Colonial rule also transformed male-privileging norms that shaped women\\u2019s autonomy and status, by limiting their educational opportunities, inheritance claims, and traditional roles in food production and agriculture [40]. In particular, the large role played by Christian missionaries under colonialism in Malawi fostered enduring class and gender educational differentials by training men as pastors, teachers, clerks and tradesmen [40].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref036\", \"pgph.0001297.ref040\", \"pgph.0001297.ref040\", \"pgph.0001297.ref001\", \"pgph.0001297.ref043\"], \"section\": \"Sociohistorical context\", \"text\": \"In Malawi, both patrilineal and matrilineal structures exist amongst the 12 major ethnic groups [36], yet even within matrilineal systems women\\u2019s participatory power, status and autonomy were circumscribed [40]. Despite post-independence legal reforms and human rights discourse adopted by President Kamuzu Banda which appeared to champion women and gender equity (e.g., nominating women to parliament), tangible progress for Malawian women has remained constrained [40]. These political, social, historical and economic factors have influenced the availability and type of opportunities for youth, particularly young women, to be engaged in decision-making processes [1]. However, there is limited empirical evidence on how these forces determine young people\\u2019s power and lived experiences of SRH participation, in practice [43].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref018\", \"pgph.0001297.ref018\"], \"section\": \"Theoretical approach\", \"text\": \"A postcolonial feminist theory (PCF) and difference-centred citizenship approach (DCA) informed all stages of our research, including the development of the research questions, the methodology and study design, participant sampling, data generation, analysis and interpretation, and knowledge translation. This combined theoretical framework exposes the \\u201cgendered, racialized, and adultist\\u201d [18] assumptions and structures that shape young people\\u2019s participation in SRH policymaking in Malawi. Moreover, it emphasizes young people\\u2019s agency, a \\u201cdialectical relationship between individual sense of self and collective action\\u201d, as a critical driver of their participation to overcome sources of inequity and oppression [18].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref028\", \"pgph.0001297.ref017\", \"pgph.0001297.ref029\", \"pgph.0001297.ref044\", \"pgph.0001297.ref045\", \"pgph.0001297.ref046\", \"pgph.0001297.ref028\", \"pgph.0001297.ref047\", \"pgph.0001297.ref049\"], \"section\": \"Theoretical approach\", \"text\": \"PCF is a critical theoretical lens that aims to understand the \\u201ccomplex matrix\\u201d of historical, cultural, political and economic contexts contributing to inequities in power and health among non-Western populations [28]. Grounded in scholarship from postcolonial theorists, such as Mohanty [17, 29], and Black feminists, including Collins and Crenshaw [44, 45], scholars \\u201cat the margins\\u201d have challenged the inadequacies of, and expanded on, white/Western-centric feminist theory to (re)present all women\\u2019s experiences. They also aimed to produce a novel theorization at, and of, the intersection of gender, race, class and coloniality in postcolonial contexts [46]. Postcolonial feminist scholars\\u2019 integration of intersectionality conceptualizes the interlocking systems of oppression experienced by youth due to their social location (e.g., age, gender and class) and acknowledges the fluidity of these mechanisms of power under colonialism and postcolonialism [28]. Although an intersectional approach has helped us unpack and distinguish among the range of youth identities and experiences that are otherwise often homogenized, several scholars have also argued that contemporary intersectionality theory on its own is limited in its conceptualization of agency, privilege and structural power relations [47\\u201349].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref050\", \"pgph.0001297.ref051\", \"pgph.0001297.ref029\", \"pgph.0001297.ref017\", \"pgph.0001297.ref028\", \"pgph.0001297.ref029\", \"pgph.0001297.ref017\", \"pgph.0001297.ref052\"], \"section\": \"Theoretical approach\", \"text\": \"To overcome this limitation, our study utilizes a postcolonial feminist lens to understand how young people\\u2019s agency and structural forces, social, political, economic, cultural and historical contexts and asymmetrical power relations have shaped young people\\u2019s engagement in SRH policymaking in Malawi. A PCF approach views \\u201cculture\\u201d as a \\u201cfluid entity\\u201d to expand understandings of oppression to account for the ways in which \\u201cpatriarchy, traditionalism and modernity\\u201d impact individuals\\u2019 everyday realities [50, 51]. Development discourse is also critiqued by Mohanty [29] for its \\u201creductive cross-cultural comparisons\\u201d; dominant forms of knowledge from the global North colonize young women\\u2019s daily experiences and frequently homogenize the political interests of young women in the global South, silencing and subjugating them as the \\u201cOther\\u201d [17, 28]. By employing a PCF perspective, we challenge perceptions of \\u201cyouth\\u201d as a universal category and young women as victims of oppressive socio-cultural structures. Young people represent \\u201csubject(s) of power\\u201d shaped by their contexts and experiences, to resist the dichotomies of \\u201cpower\\u201d (e.g., \\u201cpossessing power versus being powerless\\u201d) [29]. This understanding frames youth as capable, active participants with agency in decision-making, in order to provide a more inclusive understanding of systemic forces of power and inequity [17]. Moreover, we understand the concept of \\u201cyouth\\u201d as a dynamic and evolving category, shaped by the plurality of historical, political and social contexts and experiences [52].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref018\", \"pgph.0001297.ref053\", \"pgph.0001297.ref018\", \"pgph.0001297.ref018\", \"pgph.0001297.ref054\", \"pgph.0001297.ref018\"], \"section\": \"Theoretical approach\", \"text\": \"Complementing PCF, Moosa-Mitha\\u2019s [18] DCA offers a more inclusive understanding of young people\\u2019s participation and citizenship, and challenges normative, liberal citizenship models, as these discourses and their colonial roots inadequately reflect young people\\u2019s everyday social, political, cultural and historical contexts in postcolonial settings, such as Malawi [53]. \\u201cDifferences\\u201d in young people\\u2019s social positions (e.g. age, gender, race, sexuality and class) vary by context and represent assets of their citizenship, rather than limitations [18]; they acknowledge young people\\u2019s citizenship rights and value their participation because of their identity as youth. It also recognizes youth as \\u201cdifferently-equal\\u201d through their informal, domestic or grassroots agency and participation, despite deviation from \\u201cadultist norms\\u201d [18]. This approach advocates for the pluralism of democratic values (e.g., rationality, individuality, and universality) to generate a framework articulating the \\u201cmultiplicity of forms of subordination\\u201d within social and power relations due to gender, race, class, sexuality, and other power relations [54]. It also recognizes young people\\u2019s agency, expressed as collective action and participation against oppression, as a key strategy to create space and shape their lived realities [18].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref055\", \"pgph.0001297.ref059\", \"pgph.0001297.ref043\"], \"section\": \"Theoretical approach\", \"text\": \"Conceptualization of typologies or frameworks also has dominated literature on youth participation, with relatively limited emphasis or empirical evidence of young people\\u2019s everyday realities of SRH participation [55\\u201359]. Considering the dearth of literature of the structural and societal determinants that shape young people\\u2019s opportunities for, and experiences of, participating in SRH decision-making [43], this research\\u2013informed by postcolonial feminist and difference-centred citizenship theories\\u2013employed a focused critical ethnographic approach to generate empirical insights of youth participation in SRH policymaking in Malawi. It represents a significant and timely research contribution, as it is the first study to explore young people\\u2019s lived experiences of participating in SRH policymaking, not only in Malawi but also, to our knowledge, within sub-Saharan Africa.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref060\", \"pgph.0001297.ref061\", \"pgph.0001297.ref062\", \"pgph.0001297.ref060\", \"pgph.0001297.ref050\", \"pgph.0001297.ref060\"], \"section\": \"Methodology\", \"text\": \"A critical ethnographic approach was used to generate data about the lived experiences of young people participating in SRH decision-making processes. Informed by postcolonial feminist and difference-centred citizenship theories and reflexive practice, critical ethnography aims to expose underlying social structures, power relations and their impact on human agency [60]. Critical ethnography evolved as a methodological approach in response to critiques of \\u201ctraditional\\u201d ethnography for its \\u2018Othering\\u2019 and colonizing approach to knowledge generation, lack of researcher reflexivity and its inadequate consideration of power relations within social and cultural structures and groups [61]. Further, our approach was \\u201cfocused\\u201d in the sense that a focused ethnography seeks to answer specific research questions in applied social research within \\u201cfragmented and specialized\\u201d areas of inquiry in order to challenge normative assumptions about youth SRH participation. It involved generating data during intensive and defined periods of fieldwork to explore our specific research interests [62]. Our focus on understanding young people\\u2019s roles within SRH decision-making illustrates that culture is ubiquitous and \\u201cunbounded\\u201d [60]. In particular, our combined critical and focused ethnographic approach aimed to explore how the culture of youth participants\\u2019 everyday realities of SRH decision-making are shaped by broad structural and societal forces, including class, patriarchy and racism, in order to address power inequities and advance social justice [50, 60].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref036\"], \"section\": \"Methodology\", \"text\": \"Fieldwork was conducted in Malawi from October 2017 to May 2018, in Nkhata Bay (north), Dowa (central) and Zomba districts (south) and the capital, Lilongwe. Over 85% of the population in Malawi live in rural areas [36], where Dowa and Nkhata Bay represent largely rural regions, and both Zomba and Lilongwe are composed of rural and urban settings. We were hosted by a non-governmental organization (NGO), the Parent and Child Health Initiative (PACHI). Ethics approval was obtained from the University of Toronto Health Sciences Research Ethics Board in August 2017 and the National Health Sciences Research Committee in Malawi in October 2017. Local written approval to conduct research in Dowa, Nkhata Bay and Zomba districts also was obtained. An ethics deviation and amendment was submitted to the University of Toronto and approved in November 2017 to increase the size of focus groups from 4\\u20135 individuals to 5\\u201310 per group due to interest by participants. Informed, written consent (in English or Chichewa) was obtained from all study participants.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref063\", \"pgph.0001297.ref064\", \"pgph.0001297.ref065\", \"pgph.0001297.ref066\"], \"section\": \"Reflexivity\", \"text\": \"Reflexivity about our \\u201ccreative presence\\u201d [63] as researchers conducting a critical ethnography in Malawi underscores the importance of exploring the \\u201ccomplex (and sometimes contradictory) perspectives on privilege and difference\\u201d [64]. Our positionality reflects how differences produced along multiple dimensions, such as age, gender, ethnicity, nationality (or geographic provenance) and class, inherently shaped the power dynamics with research participants, their representation and knowledge generation [65]. For example, JW\\u2019s social identity as a Canadian middle-class adult white female doctoral student and her previous work experience on a maternal and newborn health project in Malawi influenced her motivations, interests, assumptions and relationships to both the substantive and geographic areas of focus for this research. We also grappled with our positionality and the decolonial imperatives facing researchers from the global North working in in the global South. Therefore, we aimed to conduct ethical and deeply reflexive research which promotes and (re)presents young people\\u2019s lived experiences of SRH participation. Lived experiences relate to young people\\u2019s unique representation and understanding of experiences, choices and options, and their perception of knowledge; it is shaped by diverse factors including race, class, gender, sexuality, religion, and other elements that impact their everyday realities [66].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref065\"], \"section\": \"Reflexivity\", \"text\": \"However, we recognize that youth researchers\\u2019 engagement in research stages prior to data generations (e.g., research focus, objectives and tools) and their sustained involvement post-fieldwork in analysis and knowledge translation (e.g., coding, conceptualization and theorization) was limited. One youth researcher (MK) and research assistant (SP) remain engaged in writing and producing manuscripts for publication. Power relations between JW and the Malawian research team were also critically considered, as SP acted as an interpret, translator and \\u201ccultural guide\\u201d to understanding local culture and context, and is/was an active participant throughout the research process [65].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref067\", \"pgph.0001297.ref068\"], \"section\": \"Reflexivity\", \"text\": \"We also critically reflect on the language employed throughout our work. For example, the terms \\u201cstigma\\u201d and \\u201ctaboo\\u201d represent popular, often naturalized terms in SRH literature. Despite substantial variation in how \\u201cstigma\\u201d is defined and applied to substantive areas of inquiry, it is also critiqued for its individualistic focus, limited consideration of structural influences and connection of social labels to \\u201cundesirable\\u201d attributes to separate \\u201cus\\u201d from \\u201cthem\\u201d [67]. The use of \\u201ctaboo\\u201d is also inherently problematic, often defined by society and social norms to describe and control the \\u201cpermitted and the prohibited, the do\\u2019s and don\\u2019ts\\u201d [68]. Although, in this study, both youth and key informant participants frequently employed these terms, we have chosen to use these terms with quotations to reflect these challenges and to critically interrogate their meaning.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref069\", \"pgph.0001297.ref070\", \"pgph.0001297.ref006\", \"pgph.0001297.t002\"], \"section\": \"Participant sampling and recruitment\", \"text\": \"Purposive sampling strategies employed maximum variation and \\u201csnowball\\u201d sampling [69, 70]. Sampling of youth aimed to capture diverse social positions (e.g., age, gender, education and geographic location), and levels of participation (e.g., community/district/national/international). We recruited 46 youth to engage in FGDs, and 30 in semi-structured interviews with an open-ended drawing exercise. Engaged youth self-identified as either currently participating in SRH policy spaces from community to international levels, or not currently participating in SRH policymaking. The latter group includes out-of-school youth or youth experiencing homelessness [6]. Youth participants were on average 21 and 22 years for FGDs/interviews, respectively. Most had completed some secondary education, and were unmarried without children (Table 2). Recruitment posters in both English/Chichewa were shared in print (e.g., at local youth centres, district youth offices, local/international NGO/CSOs working in youth/SRH/participation and university student unions), and electronically through email and social media. Youth researchers also distributed posters through their networks, including youth clubs, schools and communities. Participants were compensated for their time commitment and transportation, and provided a drink/snack.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.t003\"], \"section\": \"Data generation methods\", \"text\": \"Multiple research methods were employed to generate data, outlined in Table 3. Together these approaches informed the conceptualization and theorization of our results.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref073\", \"pgph.0001297.ref073\", \"pgph.0001297.ref074\", \"pgph.0001297.ref075\"], \"section\": \"Data analysis\", \"text\": \"The analytic strategies we employed included: reflexive, thematic analysis [73], and document and visual analyses. We engaged in the six stages of reflexive, thematic analysis outlined by Braun and Clarke [73], as we: i) reviewed the data; ii) generated initial codes; iii) generated initial themes; iv) reviewed themes; v) defined/named themes; and vi) produced written interpretations. An initial code list was developed based on our theoretical framework, literature, and in vivo codes (e.g., key words/processes/events) and used to code data (e.g., FGDs, observations and fieldwork journal) [74]. JW coded all interview/FGD transcripts, observation fieldnotes and fieldwork journal to \\u201corganize, manage and retrieve meaningful bits of data\\u201d (Coffey & Atkinson, 1996, p. 26). All interviews/FGDs were audio-recorded with participants\\u2019 permission and transcribed, and Chichewa data was translated to English. NVivo 12 was employed to manage and support data analysis. Analytic summaries/memos documented coding; codes were developed into higher order categories and concepts, and used to generate themes in our work. Findings from FGDs and interviews are presented together due to the overlapping discussions and themes generated across these methods. Conceptual mapping was used to explore relationships and identify overarching themes within our data [75].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref076\", \"pgph.0001297.ref006\", \"pgph.0001297.ref072\", \"pgph.0001297.ref077\"], \"section\": \"Data analysis\", \"text\": \"Analysis of SRH- and youth-focused policies and strategies was guided by our adaptation of the WHO Gender Assessment Tool [76], to evaluate the level of \\u201cyouth responsiveness\\u201d (e.g., definition, framing and prioritization of youth) [6]. We also employed a critical visual methodology to analyze drawings and reflect upon the participant, researcher and drawing. Drawings were analyzed alongside participants\\u2019 descriptions to explore meanings produced, to reflect on the image and significance to their drawing and statements [72]. Mitchell and Sommer [77] underscore the \\u201cpower of the visual to represent what is not easily put into words\\u201d, and how youth articulate their own experience of relative power within the study.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.g001\"], \"section\": \"Gender equality rhetoric\", \"text\": \"Despite mainstreaming or integrating gender in policies and public actions designed to achieve gender equity in the workplace/polis, significant disparities in female participation were highlighted by both youth participants and key informants. A public campaign for the Gender Equality Act (GEA) in Lilongwe paradoxically illustrated inequity by advocating for 40/60 representation, with women lacking significant leadership positions within that proportion (Fig 1). Although at the time of research the GEA had been in place only four years, many key informants already flagged concerns around its implementation and accountability. They pointed to organizations and political bodies claiming to achieve gender \\u201cparity\\u201d by recruiting women to administrative or entry-level positions but failing to ensure equitable leadership opportunities for women. Furthermore, few national youth, SRH or health policies offer data on youth participation or SRH disaggregated by sex, nor acknowledge the systemic exclusion of young women in decision-making spaces.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref078\"], \"section\": \"Donor influence on youth and SRH policy\", \"text\": \"For example, several key informants identified the introduction of the Adolescent Girls and Young Women Strategy [78], and submission of the Termination of Pregnancy Bill to Parliament as recent examples of SRH policymaking, championed largely by bilateral donors (the United States and the United Kingdom, respectively). These donor-driven SRH policy efforts were not fully owned/endorsed by the Malawian Government and involved limited consultation of young women.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.g002\"], \"section\": \"Patriarchal culture and norms\", \"text\": \"Young women are expected to occupy \\u201cprivate\\u201d spaces in society, and must balance their participation with competing responsibilities, including domestic labour, subsistence farming and childcare. Key informants indicated that gendered parenting practices shape young people\\u2019s trajectories and participation; boys are groomed to engage in decision-making, while girls are primed for domestic duties and considered \\u201csecond-class\\u201d citizens. Several participants also outlined young women\\u2019s role in maintaining local culture, through marriage/childbearing. According to a bilateral donor, young women\\u2019s \\u201cability to bear children and be an active member of your community\\u201d linked their responsibilities for social reproduction to their citizenship, power and participation. Social and gender norms reinforce the interpretation of young women\\u2019s SRH rights, visualized by a male youth participant (Fig 2). They described young women\\u2019s \\u201cright to conceive\\u201d involving pictures/slogans drawn on local buildings depicting having children and getting married. These are a typical form of promotions in many Malawian communities; however, these gendered and restrictive slogans may be interpreted as refashioning and naturalizing young women\\u2019s \\u201chuman rights\\u201d with expectations of their social reproduction.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref100\"], \"section\": \"Patriarchal culture and norms\", \"text\": \"Various cultural practices were identified as harmful by youth participants and key informants, including initiation ceremonies (\\u201ckusasa fumbi\\u201d) or arranged marriages for pre-pubescent girls to an adult male in the community (\\u201ckutomera\\u201d). Key informants emphasized men represent the custodians of these traditional practices, with the power to stop them. They viewed these practices as forms of gender-based violence, subjugating young women and restricting their SRH participation. Although key informants cited a decline in prevalence of these customs (Rates of child marriages and early pregnancies have increased during the COVID-19 pandemic due to school closures and public health restrictions [100].), many are still widely practiced and represent formative experiences that shape young people\\u2019s SRH knowledge/behaviours. Few young women shared personal encounters with these practices, yet they were raised frequently by participants in interviews/FGDs. Nearly all youth interpreted cultural practices, particularly child marriage, as detrimental to girls\\u2019 SRH and participatory rights. Young people relayed examples of their own agency to prevent child marriage in their communities, as a male youth indicated \\u201cif a girl gets married aged 17 or below, we go as a youth club to get her out of that marriage.\\u201d Young people\\u2019s efforts were recognized by multiple key informants, with one district policymaker celebrating \\u201cthe youth have really fought so hard to make sure that nobody gets married early.\\u201d\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.g003\"], \"section\": \"Young women as agents of change: Challenges and prospects\", \"text\": \"The centrality of achieving gender equality to young people\\u2019s active and meaningful SRH participation, and the urgent need for collective efforts and responsibility to foster equality was visualized by a youth (Fig 3).\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref005\", \"pgph.0001297.ref079\", \"pgph.0001297.ref080\"], \"section\": \"Global rhetoric and local realities\", \"text\": \"International commitments to youth, SRH and gender equality were articulated through the 2015 adoption of the SDGs, and at a national level through the 2013 introduction of Malawi\\u2019s Gender Equality Act, National Youth Policy, and the 2017 constitutional amendments that raised the minimum age of marriage [5, 79, 80]. However, our research reveals a disconnect between the pervasive global and national gender equality rhetoric and young women\\u2019s lived realities of their SRH and participatory rights in Malawi. Although many participants noted the importance of gender parity within international/national SRH policy spaces (e.g., youth parliament or donor forums), our overall findings indicated that underlying discrimination continues to circumscribe the active and meaningful engagement of young women at all levels of governance, particularly within their own communities. The frequent marginalization of young women\\u2019s voices in SRH decision-making are shaped by both age and gender discrimination. As such, efforts to achieve gender equity must be grounded in and driven by the lived experiences of young women, in order to achieve significant shifts in their participation.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref081\", \"pgph.0001297.ref082\", \"pgph.0001297.ref082\", \"pgph.0001297.ref081\", \"pgph.0001297.ref081\", \"pgph.0001297.ref082\", \"pgph.0001297.ref082\", \"pgph.0001297.ref083\", \"pgph.0001297.ref005\"], \"section\": \"Global rhetoric and local realities\", \"text\": \"Participation in both SRH and overall policymaking in Malawi is highly gendered across generations, with underrepresentation of young women in youth participatory spaces and of adult women in democratic governance structures [81, 82]. Women account for just 10% of traditional leaders [82] in Malawi, and as of May 2019, only 44 elected members of Parliament (or 23%) were women [81]. This problem is of course not exclusive to Malawi: inequitable gender representation in National Parliaments remains a global challenge, with most countries (both North and South) failing to realize gender equity in elected bodies. In Canada, women comprise only 29% of elected members of parliament, versus other countries that have achieved gender parity, such as Rwanda (61.3%), Cuba (53.2%) and Bolivia (53.1%) [81]. Research on gender equity and SRH within Malawi\\u2019s dual (democratic and traditional) governance systems highlights the potential impact of greater women\\u2019s political engagement, given that female traditional leaders and members of parliament more effectively promote women\\u2019s SRH rights than do men [82]. Malawian Senior Chief Theresa Kachindamoto is an example of the importance of female leadership: she has championed both local and national legislation to increase the legal age of marriage and nullified over 1,000 unions that violate these laws [82, 83]. Failure to prioritize young women\\u2019s participation within key national policies, including the National Youth Policy, limit opportunities for capacity building and perpetuates inequities in their engagement moving forward [5].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref084\", \"pgph.0001297.ref085\", \"pgph.0001297.ref086\"], \"section\": \"Global rhetoric and local realities\", \"text\": \"Our results show that young women\\u2019s participation and gender equity are interrelated and interdependent. The equal, active, and meaningful SRH participation of young women is contingent on societal recognition and overcoming of gaps in gender equality. Our study extends recent scholarship that has conceptualized the relationship between social norms around gender norms and young people\\u2019s SRH [84, 85] to also consider the impact of gender inequity on their authentic engagement; whereby young people\\u2019s voices, and young women\\u2019s voices in particular, are given equal space and consideration within SRH decision-making processes. As such, SRH policy scholars argue that the continued prioritization of youth is essential to addressing gender (in)equality [86]. This research acknowledges young women\\u2019s engagement in SRH policymaking, both formal and informal, and represents the critical first step toward overcoming restrictive gender norms.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref087\", \"pgph.0001297.ref088\", \"pgph.0001297.ref089\"], \"section\": \"Donors and the \\u201cgirl child\\u201d\", \"text\": \"African critiques around the role and influence of foreign development donors reflects longstanding concerns of neocolonial appropriation of priority-setting and decision-making [87]. In Malawi, international donors contribute over 60% of spending on health care (2012\\u20132015), with funding for SRH and sexually transmitted infections (including HIV/AIDS) representing nearly half (47%) of all external health expenditure [88, 89]. We show that donors\\u2019 political and ideological priorities profoundly influence the entire SRH policymaking process, which simultaneously proscribes and promotes the engagement of girls and young women. Recently proposed legislation to liberalize abortion (Termination of Pregnancy Bill) and the adopted Adolescent Girls and Young Women Strategy were identified by informants as examples of \\u201cdonor-driven\\u201d SRH policy efforts.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref090\", \"pgph.0001297.ref017\", \"pgph.0001297.ref090\", \"pgph.0001297.ref091\"], \"section\": \"Donors and the \\u201cgirl child\\u201d\", \"text\": \"We expose and acknowledge the patriarchal and colonial legacy of the SRH field, and especially the promotion of contraceptives: funding and implementation of SRH initiatives and policies by former colonial powers is problematic and even suspect as a form of neocolonialism [90]. Participants questioned whether donor-driven SRH policies aligned with Malawian priorities and values, highlighting conflicting neocolonial influence by donors amid local politico-cultural realities. The donor-driven nature of SRH policymaking often means that young women\\u2019s priorities for SRH information and services are eclipsed by donor ideologies and agendas that introduce global norms within the Malawian context. This illustrates the ways in which the micropolitics of young women\\u2019s everyday SRH participation are intimately connected to global economic and political processes [17]. Renewed calls to decolonize global health also must work to transform current global rhetoric and approaches within SRH [90, 91].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref012\", \"pgph.0001297.ref012\"], \"section\": \"Donors and the \\u201cgirl child\\u201d\", \"text\": \"Notwithstanding these substantial concerns, many youth participants and key informants believed that donors\\u2019 prioritization of young women has increased their engagement in SRH decision-making processes. This finding contradicts critical literature linking the \\u201cturn to the girl\\u201d or the \\u201cgirling of development\\u201d to neoliberalism; employing \\u201cempowerment\\u201d and \\u201cagency\\u201d discourses are criticized seeking to \\u201crescue\\u201d and homogenize young women in the global South [12]. According to critics, girl-oriented development approaches frame girls as both victims of oppression and heroes with agency [12], whilst placing responsibility on girls to overcome poverty or address SRH issues using only their \\u201cvoice\\u201d or \\u201cagency\\u201d, rather than making structural change through their meaningful participation. Our results also reveal that the donor-driven \\u201cgirl child\\u201d discourse in Malawi has triggered young men\\u2019s hostility and a capitalist, class-based competition towards their female peers, with few men acknowledging the underlying structural forces that often restrict young women\\u2019s SRH participation. This prioritization of young women, and the neglect of young men was considered ineffective by many, and unintentionally may perpetuate discrimination, undermining youth SRH efforts in Malawi. Continued engagement of both young men and women is needed to address more holistically gender discrimination, norms, and power and health inequities.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref092\"], \"section\": \"SRH within a \\u201cculture\\u201d of silence and \\u201cstigma\\u201d\", \"text\": \"Study participants associated increased public acceptance of SRH issues with efforts to address high rates of HIV/AIDS in Malawi over the last two decades. Despite perceived progress, SRH and young people\\u2019s participation in SRH decision-making remains controversial. Older (often male) community members consider young women promiscuous and disrespectful for \\u201cvoicing out\\u201d, limiting their ability to speak openly about SRH issues. Moreover, the continued practice of traditional customs preserves patriarchal control over young women\\u2019s reproduction and bodies, and their economic and decision-making power [92].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref050\"], \"section\": \"SRH within a \\u201cculture\\u201d of silence and \\u201cstigma\\u201d\", \"text\": \"Many youth participants and key informants shared that their religion and culture posed barriers to young women\\u2019s participation in SRH policymaking. However, postcolonial feminists argue that a focus on \\u201cculture\\u201d alone is insufficient. Challenging \\u201cessentialist interpretations\\u201d of the role of culture on young women\\u2019s lived experiences of participation must consider how it is situated within and shaped by other historical, political, economic and social forces [50]. Our research considers how other underlying influences, including patriarchy, gerontocracy and donors\\u2019 postcolonial powers, impact the opportunity and quality of young women\\u2019s SRH participation.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref093\", \"pgph.0001297.ref094\"], \"section\": \"Patriarchy and postcolonialism\", \"text\": \"The historical, social and economic contexts of the lives of young women in Malawi have long shaped the ways in which patriarchal gender norms and roles are reproduced. Our study participants explained that men often act as cultural custodians or gatekeepers who control young women\\u2019s access to SRH information, services, and participation in policymaking spaces. Study participants also pointed to the tokenistic or symbolic engagement of young women in community youth clubs and district decision-making structures. This suggests that a large proportion of young women may be privy to SRH decision-making as permitted by male custodians. Recent empirical evidence from other previously colonized countries (e.g., Senegal and Kenya) also found that formal/informal opportunities for youth to participate meaningfully, often reproduced underlying discourses of gender (in)equality and patriarchy, gendered norms and constructions of citizenship [93, 94].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref006\", \"pgph.0001297.ref010\", \"pgph.0001297.ref095\"], \"section\": \"Young women as \\u201csecond-class\\u201d citizens\", \"text\": \"Young people\\u2019s intersectional social identities shape their lived experiences of participation. Older youth, males, young people living in urban areas, and those with more formal education have greater opportunities than younger, female, less educated and rural residents to participate in SRH policymaking in Malawi [6]. Although all but two of the youth participants in our study were 18 years of age or older, many shared significant experiences of age-based discrimination and marginalization prior to and during their involvement in SRH decision-making processes. Literature on engagement of young women in the United Nations Commission on the Status of Women also highlights that the intersection of age and gender reinforced their political marginalization [10]. Overlapping and systemic patriarchal and adultist norms highlight the ambiguity of the temporality of social identities and young women\\u2019s transition into adulthood; several participants associated transitioning into adulthood with young women\\u2019s marital and childbearing status. Young women are often relegated to \\u201csecond-class\\u201d citizen status due to their systemic discrimination and failure to protect and realize their basic participatory and SRH rights [95]. These shortcomings highlight the importance of challenging normative perceptions of young women\\u2019s status roles in society, by generating contextualized insights of young people\\u2019s lived experiences of SRH participation. Efforts are needed to ensure the continued engagement of young women who are married or have children; their perspectives and priorities are underrepresented in current SRH decision-making processes. Further evidence is also needed to reflect younger adolescent girls\\u2019 experiences of SRH participation, as they are likely to encounter even greater hurdles to engage actively and meaningfully.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref054\"], \"section\": \"Young women as \\u201csecond-class\\u201d citizens\", \"text\": \"Youth engagement in SRH decision-making and gender equality represented shared priorities among both male and female youth participants. Participants emphasized a consensus that young women experienced inequitable barriers, underscoring that age, gender, race, and class interact to challenge their participation [54]. Both groups reported that young men\\u2019s perspectives were preferred in SRH policymaking, and that judgment/shame associated with participating in decision-making or accessing SRH services was reserved for young women. Both male and female youth reported that young women were uncomfortable speaking about SRH in policy spaces, particularly with older, male decision-makers.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref096\"], \"section\": \"Young women as \\u201csecond-class\\u201d citizens\", \"text\": \"Our findings underscore the substantial challenges to effectively democratize SRH decision-making power to poor and female Malawian youth. Multiple participants emphasized the inequitable power and socioeconomic status of young women, which threatened their capacity to participate and realize their SRH and participatory rights. Inadequate knowledge of policymaking or ability to read and write English represented critical barriers to their engagement. Creating open and authentic policy spaces, and training and mobilizing all youth to challenge this \\u201chypocrisy\\u201d and cycle of patriarchal and gerontocratic systems is critical to addressing the inequitable participation and SRH among young women [96].\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref006\", \"pgph.0001297.ref050\", \"pgph.0001297.ref097\"], \"section\": \"Young women as agents of SRH change\", \"text\": \"Opportunities for young women to participate and lead in SRH decision-making demonstrate both progress and potential for their engagement in Malawi. Despite encountering structural forces, young women emerged in our study as passionate community role models and agents of SRH change, motivated by their duty to support their community and country [6]. Several young female participants overcame personal and systemic barriers to pursue educational opportunities and SRH participation. Our PCF/DCA perspective emphasizes that recognition of young women\\u2019s heterogeneous experiences are critical to disrupting the systems of power that marginalize their SRH engagement [50, 97]. Through both formal (e.g., national youth parliament) and informal participation (e.g., advocacy to increase the age of marriage), young women in our study demonstrated significant capacity, knowledge of SRH issues, and agency to lay the foundation for a grassroots movement to ensure their active and meaningful involvement in SRH decision-making.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref029\", \"pgph.0001297.ref054\"], \"section\": \"Young women as agents of SRH change\", \"text\": \"Our findings illustrate that young people are shaped by their economic, cultural, and social contexts, yet simultaneously resist dichotomies of power [29]. To many of our female youth participants, being a young woman represented an asset to their participation. This perspective confronts normative understandings of citizenship by advocating for the recognition and celebration of \\u201cdifference\\u201d [54]. This was illustrated by a female youth as she resisted patriarchal attitudes and power inequities \\u201cwhen people see me, they think that being a woman doesn\\u2019t mean that we are inferior, that we can also bring change to the world.\\u201d The recent global/national prioritization of young women and youth participation has also created promising opportunities for their engagement in decision-making, which must continue to be leveraged to mobilize sustainable changes to existing gendered and adultist norms.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref098\"], \"section\": \"Research implications\", \"text\": \"Our study finds that underlying gendered structural and systemic forces continue to challenge progress towards achieving global goals pertaining to young women\\u2019s SRH and their meaningful participation in SRH policymaking (and beyond). Many participants were interested in how youth in other countries (e.g., Canada) are engaged in SRH policymaking and these discussions highlighted the comparative progress and promising policy efforts for youth participation in Malawi, versus some countries in the global North [98]. As a result, we argue that engaging young people in SRH decision-making, particularly young women, represents a challenge that is not unique to Malawi, but a broader global health and human rights concern.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref099\", \"pgph.0001297.ref100\", \"pgph.0001297.ref101\", \"pgph.0001297.ref102\"], \"section\": \"Research implications\", \"text\": \"Recent global developments, including the COVID-19 pandemic, reinforce the urgency of addressing young people\\u2019s SRH and ensuring their inclusion in decision-making processes. Decades of progress and efforts targeting gender equality and SRH are at risk, as many countries in the global South, such as Malawi, struggle to ensure accessibility of contraception, skilled health providers, and YFHS amidst competing demands on the health system [99]. School closures and public health restrictions in many sub-Saharan African countries, including Malawi, already have been linked to increases in adolescent pregnancy [100]. A rapid assessment conducted by the government highlighted that teenage pregnancies increased by 11% from March to July 2020, as compared to the same time period in 2019. Key drivers identified were religious beliefs, inadequate economic and social opportunities and a desire to start childbearing [101]. In addition, research examining school enrollment pre- and post-school closures found that the highest rate of dropouts were amongst older female youths, aged 17\\u201319 years, exacerbating existing gender inequalities in education [102]. This suggests that COVID-19 represents not only a current health threat, but is likely to have long-lasting impact on young people\\u2019s SRH and participation. Our work reinforces that addressing the systemic silencing of young women is crucial to ensure that SRH policymaking processes reflect young people\\u2019s lived realities, now more than ever.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref103\", \"pgph.0001297.ref104\"], \"section\": \"Study limitations\", \"text\": \"In addition, although we aimed to be inclusive and recruit diverse youth perspectives, we acknowledge that this research and focus on youth SRH in Malawi was influenced by underlying heteronormative assumptions. In Malawi, a country that has not legalized same-sex relations, many LGBTQ communities face discrimination, violence and the threat of criminal penalty for failing to conform to heteronormative standards [103]. Adopting a postcolonial queer feminist perspective may be necessary to challenge heteronormative structures, which limit the participation of individuals who don\\u2019t fall within binary categories of sex/gender [104]. Specifically, research that is inclusive of those with diverse gender and sexual identities and orientations, yet culturally grounded (and legal), is needed to understand the SRH needs of these groups and the role of heteronormative assumptions in shaping youth participation in SRH decision-making processes in Malawi and beyond.\"}, {\"pmc\": \"PMC10022123\", \"pmid\": \"\", \"reference_ids\": [\"pgph.0001297.ref017\"], \"section\": \"Conclusion\", \"text\": \"Significant global development discourse and national policy efforts have focused on gender equality and youth participation in SRH. However, the lived experiences of young women participating in SRH policymaking in Malawi demonstrate entrenched power structures that privilege men, adults, and individuals in higher social economic status. Understanding how gender and age together shape young people\\u2019s involvement in Malawi will help inform contextualized and tailored strategies to support the participation of young women in SRH decision-making. Young women experience gendered participation in SRH policymaking at all levels, as they are too often underrepresented and undervalued. Despite these systemic barriers young women also represent critical resources and local agents of change for youth SRH. Young women\\u2019s vital roles and contributions in SRH policymaking must be recognized through continued advocacy and education of their peers, families, communities and decision-makers. Our use of postcolonial feminism aims to inspire \\u201csolidarity across borders\\u201d [17]. The lessons from progress and challenges to engaging young women in SRH policymaking in Malawi are applicable across both the global South and North. Gender equality and youth participation represent distinct areas within global and national development processes, yet our research shows that they are clearly interdependent. The active and meaningful participation of young women in Malawi (and beyond) is not possible without collective efforts to catalyze political, societal, and cultural change to challenge systemic gender and power inequities.\"}]"

Metadata

"{\"Data Availability\": \"The data that support the findings of this study are not publicly available due to the ethics consent form indicating that participant data would not be shared outside of the research team. This study is based on extensive identifiable data from observations, interviews and focus group discussions. These data may contain information that could compromise the trust, confidentiality, and privacy of research participants, and thus will not be made publicly available. This research study was approved by the Research Ethics Board at the University of Toronto. If you have any questions or concerns or requests for data access, please contact the Research Oversight and Compliance Office \\u2013 Human Research Ethics Program at \", \"Submission Version\": \"1\"}"