Young people in Uganda face a range of challenges in accessing sexual and reproductive health (SRH) services. These barriers can be particularly pronounced for refugees and other vulnerable groups, and are often aggravated by gender norms and social stigma. Understanding how social norms interact with other societal structures to block or facilitate SRH access can be a critical step in supporting sexual and reproductive autonomy in Uganda and around the world.
This report highlights key findings and recommendations from a qualitative study conducted by the Guttmacher Institute, in collaboration with Makerere University School of Public Health, that explores the impact of social norms on access to SRH information and services among young people aged 15–24, in four districts in Uganda. The study relied on focus group discussions (FGDs) in both refugee and non-refugee communities and included both in-school and out-of-school participants, to help identify specific barriers and facilitators to their accessing sexual and reproductive health services.
Recurrently identified barriers included stigma around premarital sex and contraception, financial and cultural barriers at SRH clinics, and gendered inequities regarding forced and early marriage, sex education, and sexual coercion. Participants also identified a number of educational and structural interventions that would facilitate greater youth access to SRH. These included teaching health care workers to respect the privacy and autonomy of young people; strengthening youth and community education to reduce stigma and advance gender equity; and addressing the financial and logistical barriers that make accessing SRH clinics particularly difficult for young people.
This study is a component of a larger project led by Oxfam Canada called Stand Up for Sexual and Reproductive Health and Rights, which aims to address the factors affecting the sexual and reproductive health and rights (SRHR) of marginalized and vulnerable adolescents and young people in Uganda and Mozambique. The project partners in Uganda include Oxfam Uganda, Femme Forte, the Center for Health, Human Rights and Development (CEHURD) and Reproductive Health Uganda, in addition to Makerere University School of Public Health.
Background
Adolescents and young people aged 10–24 comprise one-fourth of the global population, and ensuring their physical, social, emotional and financial well-being is essential for countries’ overall development.1 Globally, nine out of 10 people in this age-group live in less developed countries.2 At least 777,000 girls younger than 15 and approximately 12 million adolescent women aged 15–19 give birth each year in low-income countries. In low- and middle-income countries, 10 million unintended pregnancies occur annually among adolescents aged 15–19. Young people are at risk of unsafe abortions due to a variety of barriers to accessing safe services, including unclear or restrictive laws, stigma and discrimination. The situation has been exacerbated considerably by the triple threat of conflict, climate change and the COVID-19 pandemic.1
In Uganda, more than 30% of the total population is aged 10–24 years, making it one of the youngest countries in the world.3 The median age at first sex is 16.4 years, and child marriage is prevalent: Nearly half (43%) of women aged 25–49 report having married by the age of 18.4 Uganda is ranked 16th globally for highest rates of child marriage, defined as marriage before the age of 18.5 Teenage pregnancy and HIV infection rates remain high: According to the most recent data available, 570 adolescent and young women (AYW) become infected with HIV every week in Uganda.3 One in four teenage girls is pregnant or has had a child, and more than half (58%) of young women aged 15–19 have experienced physical or sexual violence.6 Although there has been an increase in modern contraceptive usage among adolescents, the unmet need for family planning services remains high.7 This unmet need is a major driver of early pregnancy and unsafe abortion, as well as HIV infections and poor maternal and newborn outcomes.8
In 2013, half of adolescent pregnancies in Uganda were unintended, and 15% (57,000) ended in abortion.9 More recent data suggest that unsafe abortion and poor access to postabortion care remain significant problems.10 The most recently published Demographic and Health Survey indicates that the Eastern Region of Uganda (Busoga) has the highest number of teenage pregnancies in the country.3 There are many determinants of teenage pregnancies in the region, including inadequate knowledge on preventing pregnancy, low acceptance and use of contraceptives, parental neglect, sexual abuse, pressure to contribute to family welfare through early marriage or sexual transactions, and social norms that promote early marriage and childbearing.11 In the West Nile region, gender-based violence (GBV) was found to be prevalent among adolescents, while access to SRH services was particularly limited among adolescents, young mothers, refugees and sexual minorities.12 The population of adolescents and young people in Uganda, especially young women and marginalized groups such as refugees, faces unique challenges, including long waiting times at health facilities, lack of privacy, mistreatment and general poor quality of services.13 Such factors deter these patients from using health services, ultimately placing them at risk for negative SRH outcomes, including HIV infection, unintended pregnancy and unsafe abortion.14
A recent study of the SRHR landscape in Uganda found that the majority of adolescents and young people were sexually active.15 More than one in 10 AYW reported experiencing an STI (13%); among them, 16% did not seek treatment. Thirteen percent of AYW who had ever had sex reported that they were “not willing at all” the first time they had sex, and nearly half (48%) did not do anything to prevent pregnancy the first time they had sex. Less than a third (28%) of AYW had ever visited a health facility to receive services or information on contraception, pregnancy, abortion or STIs.
Despite the importance of these challenges, there is still little research on factors that pose barriers or facilitate access to SRH services among young people, especially from their own perspectives. Few studies have specifically explored the role of social norms in influencing access to SRH services among refugee and non-refugee adolescents and young people in Uganda.
Study Objectives
This study examines the barriers that marginalized and vulnerable adolescents and young people in Uganda face in accessing high-quality sexual and reproductive health services, as well as the factors that potentially facilitate their access to care and to sexual and reproductive health and rights. The study specifically aimed to explore social norms and their impact on access to information and services among in-school youth, out-of-school youth, and refugees aged 15–24 in four districts (Terego, Madi-Okollo, Mayuge and Namayingo).
Methods
Study setting
The study was conducted in four districts. Two districts were selected from West Nile in northern Uganda (Madi-Okollo and Terego) because they contain the Rhino Camp Refugee Settlement and the Imvepi Refugee Settlement.3 Two districts were selected from eastern Uganda (Mayuge and Namayingo). Mayuge is predominantly Basoga, and Namayingo is predominantly Samia. However, the lake shore and islands off both districts are also populated by minority ethnic groups such as the Baganda, Gisu, Japadhola and other groups from Kenya who cross into Uganda to fish.
Sampling procedures
Refugees: The refugees in northern Uganda originate mainly from Sudan and the Democratic Republic of the Congo. To engage with the refugees, the study team sought administrative clearance from the Office of the Prime Minister and country representative from the United Nations High Commissioner for Refugees. Local authorities (camp commandants) connected the study team with implementing partners that employ social workers and community health workers whose clients include young people in the refugee settlements. Representatives of the implementing partners provided guidance on the zones in the camps with greatest concentration of out-of-school adolescents, teenage pregnancies, and HIV/AIDS cases. It is from these zones that the study team selected the participants, prioritizing respondents who had a disability, had gotten pregnant before age 18, or who had experienced gender-based violence.
Non-refugees: When selecting respondents, researchers prioritized recruitment from sub-counties with more out-of-school adolescents, teenage pregnancies, and HIV/AIDS cases. The study team worked closely with local authorities, i.e., chief administrative officers, who provided access to district leaders, community health workers and village health teams. The village health teams acted as field guides, connecting the research assistants to eligible respondents.
Inclusion and exclusion criteria
| Table 1: Inclusion criteria per study component | |
| Study component | Inclusion criteria |
| Focus groups with refugee AYW 15–24 | Refugee AYW aged 15–24, either in-school or out-of-school, who were residents of at least a year in either the Rhino Refugee Settlement in Madi-Okollo or the Imvepi Refugee Settlement in Terego. Parental consent was required for the recruitment of adolescents younger than 18. |
| Focus groups with non-refugee AYW 15–24 | Non-refugee AYW aged 15–24, either in-school or out-of-school, who resided in the study sites and had lived there at least one year. Parental consent was required for the recruitment of adolescents younger than 18. |
| Focus group discussions with AYM 18–21 (refugee & non-refugee) | Adolescent and young men (AYM) aged 18–21 who resided in the study sites and had lived there at least one year. The age-group of 18–21 years was chosen because it is above the legal age of consent and these individuals have autonomy to engage in sexual intercourse without parental restrictions or permission. |
Research assistants from the study team introduced the study to each eligible individual, explained the study procedures and purpose, took eligible participants through the informed consent process, and answered any questions that arose. The study excluded respondents who did not consent (or, in the case of minors, assent) to participate, minors whose parent or guardian did not consent to their participation, and those who were feeling unwell.
Data collection
The research team at the Makerere University School of Public Health led the fieldwork. Male and female fieldworkers were selected on the basis of their experience with qualitative interviewing and their language skills. Fieldworkers underwent a weeklong training led by a joint team of researchers from the Guttmacher Institute, Makerere University School of Public Health, Oxford University and Oxfam Uganda. The training included modules on qualitative interviewing techniques; ethical considerations and informed consent practices; confidentiality; focus group discussion procedures such as recording, transcription and data storage; as well as in-depth instruction on the guide that was used for FGDs. The FGD guide included sections on community attitudes and social norms regarding SRHR-related topics; informational and service needs of adolescents and young people; young people’s experiences with premarital sex, family planning, pregnancy, abortion, STIs and sexual violence; as well as the barriers young people face from their community, parents and providers in accessing services and information in health facilities. At the end of the training, the team piloted the interview guide with a sample group based on the inclusion criteria, and changes were made based on the pilot experience.
Fieldworkers conducted a total of 24 FGDs. Sixteen FGDs were conducted with AYW grouped by age: 15–19 and 20–24. Eight FGDs were conducted with AYM aged 18–21 years. Each group had 7 or 8 participants, and informed consent was obtained prior to the discussion. Each FGD had a moderator, a notetaker and an observer. Discussions lasted 90–180 minutes.
Data management and analysis
Audio files from the qualitative interviews were transcribed verbatim by the data collectors. Supervisors then checked transcriptions for accuracy and sent them to the central research team, where they were kept in limited access folders on a cloud software platform. All transcripts were reviewed for accuracy and stripped of identifying information by a member of the research team. The research team then developed codes and codebook definitions based on the study objectives while integrating themes from the data as they emerged. The codebook was developed and agreed upon by the qualitative analysts and investigators. The transcripts were uploaded to a qualitative coding and analysis program, NVivo 14.
During data analysis, the team read and discussed the code report and then categorized codes into frameworks. Data were summarised in an analysis framework comprising references, transcript numbers and illustrative quotes. (This method has been used in a study by Bamuya et al.16) The code reports generated in Nvivo were read and discussed by the qualitative analysts and investigators who agreed on themes, organizing themes and basic codes.
Intercoder reliability was calculated using a percent agreement between coefficient indices, which is a common statistical approach in measuring codes and themes. Overall, the team had intercoder reliability of more than 90% on all nodes.
The themes featured in this report include social norms and sanctions related to premarital sex, contraceptive use, sexual violence, unintended pregnancy, and abortion, as well as stigma and discrimination in health facilities and within communities. The findings presented in this report were presented, discussed and validated during two workshops held in the study areas. The validation workshops included knowledgeable and influential stakeholders such as members of the Uganda Ministry of Health, District Health Offices in the study areas, community health workers/village health teams, several NGOs working in SRHR in refugee and non-refugee settings in Uganda, as well as in-school and out-of-school youth.
Ethical considerations
Ethical clearance was obtained from the Research and Ethics Committee of Makerere University School of Public Health (ref: SPH-2022-361:), the Uganda National Council for Science and Technology (ref: SS1673ES) and the Guttmacher Institute Institutional Review Board. Prior to conducting interviews, interviewers obtained written informed consent from all respondents. For individuals who traveled to the discussion location, transportation reimbursement was provided. To ensure confidentiality, discussions were conducted in secluded, private locations agreed on by all participants. Discussions were audio recorded on password protected devices which were accessible only to research team members. All data files were labeled with unique identifiers to increase confidentiality, and all information that could identify participants was removed from the data by the study team prior to analysis. To minimize emotional harm to participants, all fieldworkers were trained in basic counseling skills.
Results
| Table 2: Sociodemographic characteristics of participants | ||||
| Characteristics | N | % | N | % |
| Sex | Female | Male | ||
| 114 | 71 | 46 | 29 | |
| Age | ||||
| 15–19 | 68 | 60 | 24 | 52 |
| 20–24 | 46 | 40 | 22 | 48 |
| Education level | ||||
| No formal education | 1 | 1 | 1 | 2 |
| Primary | 53 | 47 | 6 | 13 |
| Secondary | 60 | 53 | 39 | 85 |
| Tertiary | 0 | 0 | 0 | 0 |
| Years out of school (n= 58 for females and 21 for males) | ||||
| 1–4 | 39 | 67 | 16 | 76 |
| 5–8 | 17 | 29 | 4 | 19 |
| 9–12 | 2 | 4 | 1 | 5 |
| Relationship status | ||||
| Single, never married | 80 | 70 | 39 | 85 |
| Single, ever married (divorced, separated) | 15 | 13 | 1 | 2 |
| Married/cohabiting | 16 | 14 | 0 | 0 |
| In a non-cohabiting serious relationship | 3 | 3 | 6 | 13 |
| Refugee status | ||||
| Refugee | 50 | 44 | 24 | 52 |
| Non-refugee | 64 | 56 | 22 | 48 |
| Income status | ||||
| No income (dependent/student) | 55 | 48 | 26 | 57 |
| No income (unemployed/not a student) | 29 | 26 | 12 | 26 |
| Some form of income | 30 | 26 | 8 | 17 |
Social norms and sanctions related to premarital sex
Participants in several focus groups noted that the community considers unmarried adolescents and young people as still being under the care of their parents or guardians. In the study areas, engaging in premarital sex is reportedly considered unacceptable behavior. The results suggest that young people who do have sex before marriage are considered by society to be out-of-control and violating religious and cultural norms; they face various challenges, including discrimination. For unmarried individuals who are found, or believed, to be engaging in sex, negative community sanctions were said to include physical beating (mostly inflicted by the caregivers or guardians) and, in some cases and especially among refugees, forced marriage. Data show that these sanctions vary by gender. For example, young men may be taken to authorities for a range of punishments including imprisonment, especially when a female partner is under the age of consent. Other punishments for young men include fines or forced departure from the community.
According to participants, there are several negative consequences for adolescent and young women who engage in premarital sex, including ostracization by the community, revoked educational opportunities and forced early marriage. It was reported that young women who engage in sex become isolated from their community and families because community members worry that they may influence other young people to do the same. There was also reporting of familial shame and fear associated with premarital sex. Young women who have premarital sex are seen as irresponsible and undeserving of respect; the community thinks they will not attain their educational goals, and they often are referred to as “prostitutes.”
Many participants reported that parents will stop paying their daughters’ school fees once they start engaging in sex because they believe that they will not be able to concentrate on their studies.
It was reported that in some cases, parents view their unmarried daughters engaging in sex as a sign of maturity and use forced marriage as an opportunity to get a bride price from the man, based on the premise that they would not allow their daughter to engage in sexual encounters without gaining something in return.
Stigma and discrimination in health facilities and communities
Participants in several FGDs mentioned that young people hesitate to go to health facilities for SRH-related services because they would be seen and judged by older people gathering outside of facilities waiting for their appointments. Participants reported that if people saw a young woman at a facility they would assume she was there for family planning, which would mean she was having sex. Due to the stigma around contraceptive use, participants mentioned that young women may even fear that they will fail to find a marital partner later in life if anyone thought or knew they were using contraception. This fear of discrimination was thought to ultimately derail some young people’s utilization of SRH services.
Adolescent and young men also expressed concerns about accessing condoms at facilities:
Even those who overcome the fear of stigma and seek services at health facilities face challenges accessing services. According to participants, young women face discrimination from health workers, as well as from health educators who visit schools. At health facilities, AYW are denied access to condoms because health workers presume they are too young for contraception. When health educators go to schools to orient students about condoms, adolescent and young women are excluded from the demonstrations.
In refugee settings in particular, participants highlighted the lack of autonomy AYW experience around their sexual and reproductive health. Young unmarried women are sometimes required by health workers to get their parents’ consent before they can access contraceptive services, though this is not required by the national guidelines. Since some parents have negative perceptions of premarital sex and believe that use of contraception will introduce their children to the sex industry and cause side effects such as infertility, unmarried young women can face serious challenges accessing services. Married young women (especially those without children) also face barriers, with some participants reporting that health workers demand their partners’ approval before providing contraceptive services—another practice that is contrary to the national guidelines. This introduces a barrier for women with partners who are unsupportive of using contraception. Participants reported that some men, especially migrant workers, may not allow their wives to use contraception because they think it would promote promiscuity. Married women, especially in refugee communities, were said to be expected by society and their families to produce children and therefore many who access contraception do so in secret without disclosing its use even to their partners.
Accessing contraception and other SRH services
Despite negative community perceptions and common fears highlighted by respondents, participants in both refugee and non-refugee settings said most young people appreciate the importance of using a contraceptive method. Young people reported accessing contraceptive information and services from multiple sources for a variety of reasons. Young people in most FGDs said they prefer to go to public health facilities for SRH-related needs because they offer free services, provide a range of services including STI testing and treatment, and offer care that young people trust. Participants also reported that some health care workers at public facilities were understanding of young people’s reasons for seeking SRH care, especially if they were students.
Participants in many FGDs said young people prioritize privacy and discretion when it comes to accessing SRH services, given the stigma associated with sex among young unmarried people, so they prefer health facilities that offer specialized services just for young people.
To address concerns about privacy and parental or partner consent requirements at health facilities, some respondents suggested making free contraceptive services more accessible through community outlets such as dispensaries and salons or via community-based health workers, such as village health teams (VHTs).
Other respondents thought that young people prefer to access contraception at private clinics because many are geographically accessible and offer more privacy than public facilities, and because health workers at these clinics do not ask as many questions. Others reported that young people use traditional methods or get condoms from friends, especially when they have limited time to seek contraception.
Consequences of unintended pregnancy
Participants discussed several physical, financial, emotional and social consequences for unmarried AYW and AYM who experience pregnancy. Many AYM in FGDs said young men generally want to use contraception to avoid unintended pregnancy, given the consequences they would face. Several participants in FGDs with AYW said that if an unmarried young woman were to become pregnant, her partner would likely run away either to avoid the responsibility of fatherhood or the punishment they would face in society. This issue came up most frequently in FGDs with non-refugee participants.
On the other hand, many refugee and non-refugee participants agreed that unmarried AYW who become pregnant are rarely supported by friends and family members, who may be unwilling to help even if the young woman’s partner has fled. In many cases, it was said that young women cope with pregnancies on their own while facing ridicule from the community and judgment from health care providers.
Abortion
Many participants suggested that unmarried AYW who become pregnant see abortion as their best option. However, given the illegality of abortion in Uganda, they may be discouraged by the community and by providers in health facilities; this appears to be especially true for refugee populations. Some refugee participants reported that if a young unmarried woman became pregnant she would be advised to carry the pregnancy to term and get married, and that health care workers would not provide abortions.
Participants observed that, in many cases, young women are afraid to tell anyone about their pregnancy or their abortion plans and have no interest in going to a health facility because they assume they will be forced to keep the pregnancy. Some cited the dangers of illegal abortion being a main source of pressure to continue unwanted pregnancies.
Others mentioned that the social pressure and stigma around abortion leads AYW to seek unsafe abortion from herbalists or untrained medical providers.
Postabortion care, which should be accessible to all in case of complications, was described as similarly difficult for young or unmarried women to access. Participants reported their perception that health care workers would require parental or partner consent even for this essential service. Consequently, AYW said that young people often feel as though they are not trusted to make decisions about their own sexual and reproductive health.
Other facility-level barriers to accessing SRH services
Inadequate supplies and staffing at public facilities
Participants reported that a lack of medicines and adequate staffing at public health care facilities also prevented adolescents from accessing high quality and timely sexual and reproductive health services. Refugee adolescents, for example, reported being limited to only one HIV test a year by public health facilities, despite self-perceived high risk of the infection. Due to drug shortages and stockouts in government health care facilities, adolescents were at times examined by providers at the public facility, but then referred to private clinics for medication they were unable to afford. Participants reported that adolescents have the most trust in the treatment provided by government health care facilities despite shortages of supplies and medicines, and lamented young people having to resort to expensive private facilities that they did not trust. Some discussions revealed that young people may experiment with traditional medicines, even though they found them to be less effective.
Many participants also mentioned that staff shortages at public facilities had led to long waiting times to be seen by a provider. The long wait times contributed to the lack of privacy at facilities, as most people had to wait outside or in groups where they could be observed by other people waiting, a further barrier for young people seeking SRH services. Others noted that even when young people do access care at public health care facilities, providers are often too busy to attend to them.
Additional barriers to care for refugees
There were several barriers to accessing SRHR-related information and services that were distinct for refugees, as well as for other communities living in more rural or remote areas. Participants discussed the downstream effects of facility staff shortages, especially in curtailing health care workers’ ability to conduct community outreach that could bring much needed services to refugees and other remote populations. Because of the lack of outreach, participants in the refugee FGDs mentioned that they had a difficult time accessing information and services.
Adolescents in refugee settings also cited language barriers as a hindrance to accessing SRH-related information and services, including treatment for sexually transmitted infections. Due to the language barrier, some refugee patients found it challenging to communicate their sexual and reproductive problems to the health care providers and reported leaving without treatment for SRH issues.
Although not a legal requirement for the provision of services, participants mentioned that in many public facilities refugees are asked to show a Uganda national identification card before receiving care. As a result, some are forced to either forego care or seek it at more expensive private clinics.
Social norms related to sexual violence
Sexual violence was, at first glance, considered by participants to be mostly unacceptable. Communities were said to be critical of sexual violence against young women due to associated health impacts, including vaginal bleeding, unwanted pregnancies, and increased risk of sexually transmitted infections. Sexual violence was also said to lead to spontaneous abortion or harm to the fetus among pregnant women. Perpetrators of sexual violence were said to be punished and at times imprisoned. However, as discussions continued, participants revealed several circumstances under which coercion or violence was considered commonplace and potentially accepted in society. Participants reported that some older people may coerce younger, poorer people to have sex in exchange for money, and that this was not considered sexual violence.
Some individuals described circumstances under which sexual violence against young women occurred. In an FGD conducted in a non-refugee setting, for example, a participant reported that women were not allowed to access bathing places for men and that when they happened to cross over into the designated male area, they were subjected to sexual abuse.
In one FGD, some participants justified rape of women who have many sexual partners, those who refuse sexual relationships, and those who are in multiple sexual relationships for money. Violence against unmarried women who are considered old enough to be married was also deemed acceptable in some instances according to some participants, as was forcing sex on married women who had delayed conceiving. Sexual violence is technically prohibited in the refugee settings due to government policies but, according to some participants, married women do not have the right to refuse sexual intercourse with their husbands and might face fines if they refuse for any reason.
Some participants reported sexual violence being perpetrated by women against men. However, due to the expectation that men should be dominant, there is stigma associated with this experience and men do not report this violence.
Due to the cultural norms of parents taking care of their daughters until they are married, participants reported that parents, especially in refugee settings, would sometimes force their children to have sex if they thought they were old enough for marriage.
Conclusion
The experiences explored in this study speak to the potentially harmful impact that social norms and attitudes can have on individual lives, including the denial of medical services or the self-denial of those services for fear of social stigma. When the social sanctions experienced by young people who engage in premarital sex are potentially life-altering (e.g., forced marriage, social ostracism), there is a need to better understand those social norms and resulting consequences. When respondents discussed the social norms surrounding premarital sex and contraceptive use among young people, young women’s desires were frequently not considered. Both AYM and AYW should feel empowered to make their own informed decisions regarding sex and contraception, and to have the information and services they need to do so safely. Many adolescents face stigma while coping with the trauma of unwanted sexual experiences, demonstrating how often social norms ignore the circumstances of sexual encounters in ways that diminish AYW’s sexual and reproductive autonomy. Another way that AYW’s agency and preferences are erased is through the frequently reported notion that marriage reduces the perceived harm of engaging in premarital sex. In this context, familial and law enforcement intervention often leads to unwanted early marriage. Even if AYWs are interested in sexual experiences or marriage, this interference and pressure can lead to unwanted unions.
With an increase in average education level among Ugandans and the minimum marriage age being raised from 17 to 19, rates of premarital sex have increased over recent decades and will likely continue to climb. Even with these cultural shifts, conservative social norms persist, demonstrating the slow rate of social change. Taking young people’s preferences about their sexual activity and contraceptive use into account may be an important step toward honoring the agency that young people have within this highly contested domain. Interventions and campaigns need to be designed to address the social norms that deter young people from obtaining and using SRH services. Additionally, designing interventions to target all stakeholders, including service providers, young people, and the community at large, is a vital undertaking.
Strengths and Limitations
Including data from discussions with a diverse sample of refugees and non-refugees, females and males, and young people in-school and out-of-school provides a broad perspective on the social norms that influence access to and utilization of sexual and reproductive health services. Our study allows young people to contribute their voices to the discourse around programs and interventions that can impact their experience of sexual and reproductive health and rights. Despite these benefits, the study also has some limitations. The study was conducted in only four districts, providing a snapshot of the situation in those areas; therefore the findings may not be generalizable to Uganda as a whole. Further, the participants were recruited through networks of community health workers, and it is likely that some of the most vulnerable populations in these areas were excluded, either because they had no interaction with the health care system or refused to participate. The study would have also benefited from including key informant interviews with service providers and health care managers, as well as with parents and community leaders, to provide a holistic understanding of social norms and their nuances related to health service access and utilization. For example, key stakeholders in our validation workshops raised the issue of “disco Matanga,” fundraising events for funerals that are typically conducted throughout the night and which sometimes involve transactional sex. This practice was said to be driving teenage pregnancies in non-refugee settings. Exploring this phenomenon could have provided further context for young people’s SRH needs. Further, the study did not include many questions specific to people with disabilities, which was identified during the validation workshops as a key vulnerable demographic in our study setting. Further research should be done to better understand their unique SRH experiences and needs.
Key Themes and Recommendations
Autonomy
- Health facilities that required AYW to bring a parent or partner in order to receive services were frequently reported as a hindrance to timely care and to reproductive autonomy, despite the practice having no basis in national health guidelines.
- To help mitigate this challenge, there is a need for health workers to respect young people’s rights to patient autonomy and informed consent, based on an accurate understanding of the laws and guidelines surrounding youth services. Providers must also be familiar with the unique needs of young people for privacy, confidentially, accessible information and non-judgmental care.
Youth education
- Participants reported that, depending on the topics, training and educational opportunities were often not available to both AYW and AYM, which suggests a need for expanded educational interventions to address gender equity concerns.
- There was an expressed desire for SRH trainings to be designed to engage both men and women. AYW’s knowledge of condoms is just as important as AYM’s understanding of menstruation, fertile windows, and other topics.
- The Sexuality Education Framework needs to be strengthened and widely implemented to raise awareness of SRHR issues in schools.
- Concurrently, increased support for young people remaining in school may be a useful strategy for ensuring more young people receive accurate and standardized SRHR-related education.
Community-based education
- Participants reported that parent–adolescent (PA) communication was limited on SRH topics. Interventions that target the PA relationship can serve to foster communication and address social norms that deter the utilization of SRH services.
- Trainings that debunk myths around contraception and premarital sex may help reduce discrimination against young people seeking SRH services.
- Establishing accessible information sources, such as a reliable, toll-free government hotline, could help diffuse SRH knowledge among young people and the greater community. When adolescents are empowered with this knowledge, they are better equipped to lead healthy, fulfilling lives.
Health facility improvements
- Participants reported an array of challenges related to the public health facility system, despite it being their preferred source of information and services. To better serve the community, public health facility resources should be prioritized by the Ministry of Health; public facilities should be fully staffed and stocked with essential SRH medicines and equipment to avoid unnecessary referrals to private facilities.
- Health facilities should support SRH access by making service fees clear to all clients before provision.
- Health worker training should familiarize workers with guidelines for contraceptive information and services, STI treatment, and postabortion care to prevent the inappropriate denial of services. Health workers should also be trained in managing contraceptive side effects and on how to accurately disseminate information to their clients.
- Health facilities should be equipped with patient rooms that provide auditory and visual privacy for all people who receive information or care.
- Health facilities should establish operating hours that extend past the school day to ensure services are accessible to students.
- All providers of SRH-related information or services should participate in values clarification trainings, to assess their own attitudes and beliefs and to address potential barriers they may have to providing care.
Financial empowerment
- In order to holistically approach SRHR, policymakers, program developers and implementors should prioritize economic empowerment for young people.
- Young people engaging in sex for money, especially young women, constitute a special high-risk group who need to be considered when crafting interventions.
- Educational programming should be developed that engages youth and fosters life and vocational skills that can lead to careers and financial gain beyond transactional sex.
- In addition to human capital development, improving health and financial literacy for all young people is a key to supporting their sexual and reproductive autonomy.
Refugee access
- Establishing reliable systems for health care workers to conduct outreach in refugee communities, especially those in the most remote areas, will ensure information and services are reaching those in need.
- Information circulation should be tailored to specific communities. In refugee settings, community leaders can help to disperse health information, and translation to local languages and dialects can ensure it is accessible to all community members.
Access for differently-abled people
- Participants in the validation workshops highlighted barriers that prevent differently-abled people from accessing SRH services. Interventions need to be designed with a focus on the unique needs of people with disabilities. Communication barriers for people with hearing and other disabilities can be addressed with interpreters and sign-language specialists. Health facilities should ensure equipment and buildings are accessible for people with physical disabilities.
