Poverty, gender and reproductive justice. A qualitative study among adolescent girls in Western Uganda.

Low socio-economic status has been consistently identified as a primary risk factor for sexual and reproductive health violations affecting young women. This study shows how poverty interacts with gender power relations to impact upon adolescent girls' sexual and reproductive lives in Western Uganda. Qualitative research with 147 participants was undertaken. This comprised 59 in-depth interviews and 11 focus group discussions with groups of 12-14 year-old young women, teachers and parents. Data were analysed manually using open and axial coding, and conclusions were generated inductively. Findings reveal that young women are restricted in exercising their sexual and reproductive rights not only by poverty and unequal gender relations, but also by corruption and poor service provision. In contrast to interventions using liberal rights-based approaches, we advocate the use of a 'marketplace of options' since access to sexual and reproductive health services is very limited for poor girls and not evenly distributed. Moreover, while poverty and unequal gender relations render girls vulnerable to sexual coercion and violence, the criminal justice system is often weak, leaving victims powerless. Investment in appropriate resources and inclusive and affordable access to justice is essential to advance young women's sexual and reproductive health.

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda.

BACKGROUND: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. METHODS: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. RESULTS: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. CONCLUSION: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. TRIAL REGISTRATION: NCT03669913 , registered retrospectively on September 13th, 2018.

Process evaluation of a comprehensive sexuality education intervention in primary schools in South Western Uganda.

BACKGROUND: We present findings of a process evaluation of a Comprehensive Sexuality Education (CSE) program for young adolescents in 15 schools in South-Western Uganda. METHODS: Using the Medical Research Council (UK) framework for process evaluation and the European Expert Group guidance on evaluation of sexuality education programs, we conducted a mixed methods study comprised of a review of relevant implementation documents, qualitative interviews(16), and focus group discussions(4) distributed among 50 participants including pupils, teachers, student educators and parents. RESULTS: Delivery of the anticipated 11 CSE lessons occurred in all target schools with moderate to high pupil attendance, however the duration of sessions was often shorter than planned. Facilitating factors for implementation included establishment of a community advisory board, use of multiple interactive delivery methods and high acceptance of the program by key stakeholders. Socio-cultural norms, geographical access, time constraints and school related factors were barriers. CONCLUSIONS: It was feasible to implement a contextually adapted CSE program for young adolescents in schools successfully with overall high acceptance by key stakeholders. Proper coordination of school activities with the program, ensuring linkages of the school based CSE program with community support systems for adolescent SRH and addressing socio-cultural impedances could be beneficial.

Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior.

BACKGROUND: In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda. METHODS: A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages). RESULTS: A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection. CONCLUSION: Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

Adolescents' Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms.

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense-i.e., body image, self-esteem, and gender equitable norms-and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10-14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7-28) and median 22 (IQR: 19, 24, possible range: 5-25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11-44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended.

"Girls Have More Challenges; They Need to Be Locked Up": A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda.

Unequal power and gender norms expose adolescent girls to higher risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores the social construction of gender norms from early childhood, and how it influences adolescents' agency. Contrary to the mainstream theory of agency, which focuses on the ability to make informed choices, adolescents' agency appears constrained by context-specific obstacles. This study adopted qualitative research approaches involving 132 participants. Of these, 44 were in-depth interviews and 11 were focus group discussions, parcelled out into separate groups of adolescents (12-14 years), teachers, and parents (n = 88), in Western Uganda. Data were analysed manually using open and axial codes, and conclusions were inductive. Results show that gender norms are established early in life, and have a very substantial impact on the agency of young adolescents. There were stereotypical gender norms depicting boys as sexually active and girls as restrained; girls' movements were restricted; their sexual agency constrained; and prevention of pregnancy was perceived as a girl's responsibility. Programs targeting behavioural change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents.