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Research on Adolescent Sexual and
Reproductive Health in Uganda


2.0. Overview

Over fifty documents were reviewed. The documents were retrieved from agencies, libraries, Medline, AIDSline, and Popline. The literature review has highlighted that despite the high knowledge on issues of sexuality, it has not been followed with the same behavioral change. Condom use and Contraception has increased especially among in school youth. There is still less access of adolescents to reproductive health services that are friendly.

There was minimal focus on.

  • Drugs and substance abuse among the youth that impacts on their sexual reproductive health
  • Life skills
  • Adolescent actual participation in planning their programs
  • Disabled youth
  • Youth in difficult circumstances (conflict areas)
  • Adolescent mothers and their children.

Geographical coverage

Most studies were done in central (Kampala, Mpigi, and Masaka), West, East and south. The north and Northeast were rarely researched.


Most of the themes emphasized knowledge, attitude, beliefs and practices in as far as HIV/AIDS/D and condom use is concerned. They emphasized factors that increase or lower the spread of HIV, strategies implemented for ASRH, advocacy for RH, etc. Needs assessment of adolescent ASRH studies were several. Few however examined the role communication channels and avenues for ASRH.

Trends, patterns and changes have not been reflected so much in the studies. ASRH studies were not operational and hence no intervention except few.


A good number of reports which were viewed are quantitative (survey), while some were done using qualitative method of data collection such as focus group discussions, in-depth interviews, key informants.

Target Groups

Mostly the adolescents, youth, young, people and few married mothers;. With key informants ,elders, parents, political leaders, medical personnel were included.

It is not clear in the studies whether the policy makers were also involved or made aware of the Studies so that the recommendation be considered where applicable.


A number of studies have been carried on adolescent sexual and reproductive health for some time. For this task, we have limited the review to those studies done from 1995 to 2000. The review was categorised along the following themes: Problems affecting adolescent, KABP on HIV/AIDS/STDS, pregnancy prevention including family planning, safer sex: condom use and abstinence. Access and utilisation of health services. Trends in vulnerability of adolescents have also been highlighted.

2.3 Problems affecting Adolescent

Sexual and reproductive health among adolescents is a major concern in Uganda where many adolescents are sexually active at an early age and premarital sex common among 15-19 years olds. Most problems faced by adolescents in Uganda are behavior related. As a result adolescents face many sexual and reproductive health problems that affect their health and development. They include STDs and HIV/AIDS, early pregnancy, early marriage and childbirth, maternal mortality, and high infant mortality rate. They are also affected by many social problems that lower their quality of life. These are Poverty, drug and alcohol abuse, and dropout of education and sexual harassment of female adolescent. To make matters worse they have little knowledge on the risk of unprotected sexual acts - thus unwanted pregnancies; STI and HIV/AIDS are the more obvious and unavoidable consequences. Studies carried out for UNICEF on the needs assessment of Adolescents in three districts of Mbale, Rukungiri and Kabale, (Kivumbi and Mpabulungi, 1999; Korukiko and Ampaire 1999; Arinaitwe and Turinde 1999) revealed that the main reproductive health problems experienced by adolescents included, early marriages, unwanted pregnancies, induced abortion and STDs. Unprotected sex, lack of health education, and sexual control due to over drinking were pointed out as the main causes of the problems.

In Mbale Kivumbi and Mpabulungi (1999) found circumcision to be important to the lives of the people in Mbale though the festivities had some negative effects on adolescent health such as rape and defilement, over drinking, poor performance in school, famine, accidents, theft and social problems. Elicit sex during the dancing periods exposed adolescents to the twin risk of unwanted pregnancy and STIs including HIV (Othieno and Neema 1995). Similarly in Eastern Uganda adolescents were found to have a number of social problems that predispose then to poor sexual and reproductive health. The social problems included drunkardness, drug use (Marijuana), poverty, unemployment and high rate of school dropout (Ayiga et al.2000).

Lack of information on health issues, fear of contracting STD (especially AIDS), lack of information on FP and the services, expensive health services, lack of recreational services, substance abuse and misuse, unprotected sex and lack of parental guidance were identified among the problems affecting adolescents (Korukiko and Ampaire (1999).

2.4 Adolescent Sexuality

The sexual behavior of adolescents has led to increasing rates of STDs, AIDS, pregnancy, abortion, and high rates of maternal and child mortality among youth in Uganda. In Uganda the initiation of sexual activity starts as early as 10-14 years of age with a mean of 15 years (Turyasingura, 1998). Most adolescents’ sexual activity is unprotected resulting in a far-reaching health, social, demographic and pregnancies, and unsafe abortions. UDHS (1995) has revealed that teenage fertility has risen in the recent 5 years with one third giving birth annually. This is a result of low contraceptive prevalence rate (7.2%). Among adolescents over 15 years old the leading cause of inpatient morbidity are associated with pregnancy and child birth which accounts for 24.5% of admission. In Mulago National Hospital 44.7% of the women who died as a result of abortions complications were adolescents (MoH, 1999). Studies have revealed that there are numerous factors influencing the sexual behavior of the youth, such as the need to experiment, peer influence, lack of guidance and poor role modeling by adults (parents and older siblings). The breakdown of traditional institutions, socialization and media influence have been blamed for the changing patterns of sexual activity (Bohmer and Kirumira, 1997; Busulwa and Neema 1999).

A study on Ugandan out-of-school adolescents regarding sexuality, economics and family issues found that those adolescents clearly lack information and opportunities compared with in-school adolescents (Bohmer and Kirumira, 1997). Out-of-school youths often experienced strong financial pressures. Lack of access to cash and employment opportunities for females resulted in risky sex. For both sexes, it means difficulty accessing condoms and contraceptives, as well as curative health services at local clinics. Adolescent behavior related to HIV/AIDS was affected by multiple factors including economics, gender dynamics, trust and communication, and social perceptions.

Lewicky and Wheeler (1996) assessed the knowledge, attitudes and practices towards sexual activity, and HIV/AIDS, as well as the media habits of adolescent boys and girls in the districts of Jinja, Kasese, Kampala, Masaka, Masindi and Luwero. The study showed that more boys (62%) than girls (38%) reported being sexually active with the mean age of female respondents at 14 years. Most of the active respondents (56%) have had more than one partner, 70% of the sexually active respondents discussed HIV/AIDS with their partners before having sex. About 54% used a condom at the last sexual encounter and. 38% did not use a condom, believing their partner was not infected. Another proportion (37%) did not know about condoms. Of those who used a condom, 87% used it to protect themselves against HIV/AIDS. About 42% of all respondents did not know where to get condoms. Thirty five percent believed the methods of choice for protection against HIV/AIDS infection was abstinence, 25% using a condom and abstinence before marriage (23%). 41% did not believe in using condoms, 52% believed condoms break, and 38% believed the AIDS virus passes through the little holes in condoms. On sources of information, 35% listed that radio as the most frequent source of HIV/SIDS, 13% newspapers, 12% medical facilities and 11% friends or teachers at school.

Trends in sexual behavior

However, Ndyanabangi et al (1998) in a survey among 15 secondary schools in Uganda's Kabarole District since 1994 to 1997 have documented steady increases in knowledge and adoption of safer sexual practices among young people. Positive changes recorded included increases in knowledge of methods used to prevent sexually transmitted diseases (STDs) and pregnancy from 55% in 1994 to 87% in 1997, ever use of condoms from 46% in 1995 to 62% in 1997, and condom use among students who were sexually active in the 3 months preceding the survey from 58% in 1994 to 85% in 1997. Sentinel surveillance data collected in the district each year since 1991 further revealed a significant decline in HIV prevalence among pregnant women 15-14 years of age. The observed declines in HIV prevalence far exceeded those that would be expected from the natural progression of the epidemic and can be interpreted as a result of positive changes in sexual practices among young people.

Similarly, Assimwe-Okiror et al 1997 showed that there was a 2 year delay in the onset of sexual intercourse among youths aged 15-24 years and 9% decrease in casual sex in the past year in male youths aged 15-24 years. Men and women reported a 40% and 30% increase in experience of condom use respectively. There was an overall 40% decline in the rates of HIV sero-prevalence among pregnant women attending antenatal clinics these declining trends of HIV can be hypothesized to correspond t a change in sexual behavior and condom use especially among youths. The observed decline in HIV sero-prevalence in young pregnant women in urban Uganda may be an encouragement to AIDS programs to pursue their prevention activities.

Kamali et al. 1997 showed that sexual behavior in the study area of Kyamulibwa had changed to some extent in response to AIDS epidemic, mainly through partner reduction and some increase in the use of condoms (that is why adult HIV prevalence was falling). Results from that study on sexual behavior in Bulayi suggest that adolescents who had developed a complacent attitude to sex that put them at risk of HIV infection

Early marriages and pregnancies

UDHS (1995 revealed that more than one third (38%) of the girls 15-19 years are married and more than 68% of 20-24 years are married. Males enter into first union at a much later age than females. Early marriages expose adolescent girls to risks of too early pregnancies that results in complications during delivery and eventual poor health. They are at higher risk of obstetric complications since their pelvis are not yet well developed , leading to obstructed labor. And other complications such as prolonged labor, still birth, postpartum hemorrhage and maternal distress. Since adolescent mothers are usually single and school drop outs there are in most cases don’t attend antenatal because they are ashamed of their pregnancies or they might not realize that they are pregnant until later (MoGCD, 1995).

Condom Use

Condom use as a barrier method against unwanted pregnancy and STIs including HIV has increased steadily among young people in Uganda (Ndyanabangi et al.1998; Assimwe-Okiror, 1997, MoH/STD 1999). A study by Ayiga et al. 2000 revealed that knowledge of condoms was high (over 80%) among adolescents in Tororo. Its use has also increased with over 60% of adolescents using condoms (Ayiga 2000). Busulwa and Neema (1999) while studying adolescent girls in Mubende found that 39.9% (162) admitted to having began sexual activity, 52.5% (85) of these had never had sex without a condom. However, 27.2% (44) of them admitted to having had a sexual partner who they knew had other ongoing sexual partners, at the time. Only one third (33.8%, 26/77) of girls who admitted to sex without a condom, had it with an assumption or belief that the partner was HIV positive.

HIV/AIDS and other STDs among adolescents

The AIDS epidemic in Uganda seriously threatens the future of the country's youth. Female adolescents are at high risk of contracting HIV/AIDS because of socio-cultural pressures, including traditional sex behavior, and because of developmental and behavioral factors, including early initiation of sexual activity (Amuyunzu-Nyamongo et al. 1999). In the country it is estimated 1.5 million Ugandans are infected with HIV while about 350,000 have already developed AIDS. The youth form nearly 50% of the total number of those infected, with a male:female ratio to HIV infection being 1:4 for teenage compared to 1:1 for adults (MoH, 1999). HIV/AIDS is among the leading causes of illness in Uganda, especially those in reproductive age group.

Studies show that knowledge on HIV/AIDS has dramatically increased, but with behavioral changes though evident have been low (Ndyanabangi et.al. 1997, Assimwe –Okiror, 1997). The level of information and knowledge about HIV/AIDS in Uganda is over 90%. Most people, including the youth and adolescents, know about HIV/AIDS, its modes of transmission and available preventive options. However, according to surveillance reports from the Aids Control Program, over 80% of new HIV infections are through sexual coitus. Konde-Lule et al (1997) in a study in Rakai district revealed that no adolescents aged 13-14 years were HIV-infected. Among those aged 15-19 years, 1.8% of men and 19.0% of women were HIV-positive. Among young women aged 15-19 years in marital/consensual union, 21.3% were HIV-positive; this rate did not differ significantly from the 29.1% prevalence in those reporting non-permanent relationships; prevalence was significantly lower in women reporting no current relationship (4.3%).

Violence against Adolescents

Violence against adolescents is not uncommon. Anecdotal information especially from the Ugandan media show that a number of adolescents have been sexually abused. For example an earlier study among secondary school youth showed that 31% of girls and 15% of boys had been forced to have sex (Bagarukayo 1993) . In another study for Hope After Rape, Neema and Kiguli (1996) revealed that sexual abuse among adolescent is common and the people who were abusing them were usually those known to the adolescents not jus mere stranger. Circumstances leading to sexual abuse included: poverty or economic dependency, indecent dressing staying with the people of opposite sex in closed places, children left by themselves and those left with other people such as houseboys. And for house girls their bosses when their wives are away for sometime, they can turn against them. In Kiboga district, about 100 cases of defilement are reported each year to the probation office since 1995.

Female genital cutting is still practiced (though it has declined) after the Reproductive Education and Community Health Project (REACH ) in Kapchorwa that has tried to devise other means to initiation into womanhood and discourage the practice of female genital cutting (FGC). A study by Kiirya and Kibombo (1999) showed that the decline started in 1992, the biggest drop rate of 60% having been recorded in 1994-1999. The decline was attributed to mobilization and sensitization of community members against the practice. The study further revealed that 82% 0f the female eligible for circumcision objected to carry out female genital cutting. Among the community members only 21% wanted the practice to be maintained, 11% wanted it modified and 68% were in favor of eradication of the practice.

Unsafe Abortion

Unsafe abortion is a major problem in Uganda contributing to about 22% of maternal deaths and many more morbidity. It is mostly done by unmarried young girls who because of economic and social reasons resort to illegal services (MoH, 1999). Due to adolescents low perception of the risks of unprotected sex, studies have shown that adolescents at risk of complications of unsafe abortion. Approximately 15% of female youth who had ever been pregnant had terminated a pregnancy (Agyei, 1992). A study done by FPAU in Mbarara in 1997 revealed that most adolescents (82%) knew of a girl who had got pregnant and 78% knew one who had an induced abortion. Induced abortions were reported mainly to be performed using local methods (36.4%) such as taking herbs, tea leaves, and drugs such as aspirin; 23% by the medical health workers

High rates of maternal mortality and morbidity have been associated with high rates of induced abortion, increased school dropout, violence and expulsion from home (Mirembe, 1993). Pupils in Kyamulibwa claimed to make frequent use of abortion to terminate unwanted pregnancies and girls had extensive knowledge of techniques; and money transactions were a major component of adolescent sexual relationships (Kamali et al 1997).

Busulwa and Neema (1999) revealed that 11.6% (47) of the female adolescents studied had ever been pregnant, only five of them had two pregnancies, with no one with history of more than 2 pregnancies in the sample. Eleven respondents had ever had an abortion; representing 6.8% of those who had began sexual activity. However, only 4 of these were induced while 7 were spontaneous. The overall abortion rate was therefore 23.4% (11/47) of all pregnancies.

Substance abuse

Though rarely investigated, substance abuse is not uncommon in Uganda; instead it is on the increase. It is common among street children and urban city secondary schools. The most commonly used is Marijuana (cannabis Sativa). There appears to be a close relationship between drug abuse and violence and HIV/AIDS. Habituation and drug addition is a problem that has multiple devastating impacts on the youth, their health and social structure (MoH, 1999). Drug abuse, violence and reckless sexual behavior have a close relationship with consequences of unwanted pregnancies STDs and HIVAIDS.

Studies commissioned by UNICEF in 1999 (Kivumbi and Mpapulungi, 1999; Korukiko and Ampaire, 1999; Arinaitwe and Turinde, 1999) showed that substance abuse is emerging as a problem among adolescent. Boys smoke cigarettes, drink local brews and there is an increasing use of opium and marijuana.

Economic needs and vulnerability

A study by Busulwa and Neema (1999) on the economic needs and vulnerability of female adolescents to HIV Infection in Mubende district revealed that pocket money or cash followed by expensive dresses were the most tempting items in the groups of adolescents. Parents seemed to look less favorably to the needs of girls who were out of schools. 70.3% of adolescents indicated that cash was the most common means of reward for sex.

On the whole 39.9% (162) of the sample admitted to having began sexual activity, 19.0% (77) had ever had sex without a condom, and 10.1% (41) had ever had a genital ulcer disease. While 39.9% (162) admitted to having began sexual activity, 52.5% (85) of these had never had sex without a condom. However, 27.2% (44) of them admitted to having had a sexual partner who they knew had other ongoing sexual partners, at the time. 45.7% (77/162) of those who were sexually active admitted to prior sex without a condom. For 41.6% (32) of these respondents unprotected sex had occurred in the preceding 6 months period at a frequency ranging from once to 10 times, and averaging 2.7 times. Only one third (33.8%, 26/77) of girls who admitted to sex without a condom, had it with an assumption or belief that the partner was HIV positive).

Difficult to reach adolescents:

Street Children/adolescents

Due to civil strife, family disintegration and AIDS pandemic, some children have taken to the street as a source of livelihood. Street children and adolescents survive through manual labour, carrying loads for business people, stealing, pick pocketing, while girls get involved in sex for survival. Defilement is common among these children. They have suffered a number of diseases such as STDs/HIV, cough and skin rash. A number of them have become pregnant, carry out abortions and sometimes abandon their children (Neema and Kiguli, 1997). A number of organizations have come in to help these street children e.g. Friends of Children Association (FOCA), Uganda Youth Development Link (UYDEL).

Children/adolescents in armed conflict

Northern Uganda and parts of western Uganda has had insurgency and civil strife for some time. Many young girls have been defiled by the warring factions (soldiers). They have been exposed to STD/HIV and early and unwanted pregnacies. Some adolescents as a result of being defiled have been forced into early and unplanned marriages (NUPSNA, 1998).


The total number of children orphaned by AIDS, mainly HIV negative children under 15 who have lost one or both parents to AIDS, is currently estimated at 7.8 million in Africa. As more countries in Africa move from HIV to an AIDS epidemic with corresponding rise in deaths, the number of orphans will continue to rise steeply (SAFAIDS Bulletin 1998). Care of orphaned children in Uganda usually falls to the extended family irrespective of whether the extended family can cope or not. Currently, in most cases, the extended family can no longer afford to absorb this additional burden as they find themselves battling to survive with the current economic hardships that everyone else in the villages faces. Orphans not accommodated into the extended family and looking after themselves and their siblings, children shuttled between relatives all face stigma and being singled out. Many have to make crucial life decisions without guidance or support from parents or elders. Poor parenting and socialization, and fragmented schooling affect these children. Further more, even those absorbed, by relatives or members of the community. frequently abuse them especially orphaned girls, while others have been turned into child slaves leading to low self-esteem and self-efficacy. The orphanhood situation has been worsened by the death of both parents thus leaving complete total orphans in the family - the child headed households (Neema et.al 2000).

Children living alone in child headed houses is not a new Phenomenon though it has become more pronounced in the recent past. Such refers to children between the age of 13-17years heading families or households. The definition CHH in this regard goes beyond families of children living alone to include those with bedridden and elderly guardians. A study by Neema et.al 2000 in Rakai revealed that adolescent girls in such households have suffered defilement, or have engaged themselves in early sexual activities for basic necessities at home. Some have got married or got pregnant at an early age.

Why adolescents have persistently practiced unsafe sex and involved in sex at an early age

The review wanted to find out despite the interventions why adolescents still have early and unprotected/unsafe sex. Data revealed that a number of adolescents are still practicing unsafe sex due to a number of factors. A study by FPAU (1997) revealed that circumstances of first sex by adolescents were varied. They included: to show love to lover (35.3%), to know how it feels (32%), forced into sex (11.2%), to be like friends (8.8%`).

Pressures of early sex

Girls are particularly vulnerable to pressures for early sex. The phenomena of "sugar daddies" is still prevalent. Older men are persistently enticing young girls into sex for favours/gifts/money. This problem has been exacerbated by the AIDS epidemic where more men are seeking adolescent girls in an attempt to avoid contact with HIV.

Financial needs

Rampant poverty among adolescents makes it difficult for them to afford some basic needs and also buying condoms in order to avoid having unprotected sex. Poverty is one of the leading problems particularly among the girls. Some of these girls who get involved in sex at an early age is because some lack financial support from their parents and guardians. Parents might not satisfy their daughters financial need which forces their daughters to go out and expose themselves to risks of unprotected sex. In other instances, some girls would even fail to attend school due to lack of what to wear and sanitary towels to use during menstruation. Search for support by girls could result into early and unwanted pregnancies and acquiring of STDs (Korukiko and Ampaire 1997). Accepting gifts from men binds some adolescents to these men and end up paying in kind through sex.

Cultural issues affecting adolescent RH

Adolescents are being exploited partly due to the culture of silence in Uganda. They lack a voice in the family and community affairs, and assertiveness when confronted with adults who may entice them into sex has made them more vulnerable. Most of the social mechanisms operate in the principle of cutting off girls’ options and opportunities right from birth. Male children compared to female are accorded higher value (Turyasingura, 1996). Uganda adolescents are living in a time of socio-cultural transition where traditional practices that formerly limited adolescents’ sexual experience are breaking down. Traditionally, in a number of ethnic groups in Uganda, an aunt discussed matters related to sexuality with adolescents females (Kirumira, 1988) and males were educated by community elders. Parents did not traditionally discuss sexual matters with their children a thing that is still prevalent today. Very few parents talk to their adolescents about sexuality. Currently adolescents are exposed to a number of information from NGOs such as Straight Talk Foundation IEC materials, yet others are relying on their peers for information (Kyaddondo 1999; Kivumbi, 1999; Arinaitwe, 1999). Some of the information is already distorted.

Lack guidance from parents

Parents also seemed not to be guiding their children with the necessary information while growing up. The breakdown of child-parent communication seemed to be seriously affecting the behaviour and morals of the young people. Lack of parental guidance is one of the possible causes for early marriages and the associated problems of having no career and bearing many children that young people could not afford to look after. The socio-cultural orientation is not favourable to enable parents talk to their children on sexual issues yet young people feel their parents are backward to advise them. There are instances where parents would even force their young daughters to get married so that they could receive dowry from the in-laws (Korukiko and Ampaire 1997). All this exposes the adolescents to unprotected and early sexual activity.

Poor/lack of negotiation skills

Many adolescents have poor or lack negotiation skills and hence are forced into having unprotected sex. Gendered sexual norms and socialization clearly shape the nature of sexual negotiation. Adolescent girls would find it more difficult to ask a partner to use a condom for protection. (Blanc et.al 1996).

Peer Pressure

Peer Pressure is a significant force making youth engage in early and unprotected sex. Adolescent engages in unprotected sex because their friends are doing it. A midterm reviews of STF (Neema et.al 2000) revealed that adolescent both in school and out of school were engaging into unprotected sex due to bad groups they associate with. Peer pressure motivates many adolescents to initiate sexual activity.

Dropping out of school early, force girls to have sex at an early age and hence early pregnancies and marriages.

Others engage in unprotected sex because of lack of access to condoms and lack of knowledge on the proper use as well as belief that condoms are unsafe.

Limited access to Adolescent Friendly Services

Limited access to adolescent friendly services and information is another problems affecting adolescents in the bid to have protected sex or postpone sex. Most services in the country are generally offered to all people, there few units with AFS. Adolescent were not accessing the services due to lack of confidentiality and rudeness among service providers, rumours about contraception use and ignorance about the existence of these services. Lack of contraception among the adolescents featured as a serious problem because it usually led to unprotected sex (Korukiko and Ampaire). Fear of embarrassment could also have caused adolescents fail to seek health care when with STDs. Lack of IEC on health issues, especially on STIs including AIDS for adolescents is another factors that exposes them to less information about protected sex and postponement of sex. Even where there is some information being given, it is usually inadequate.

Poor enforcement of defilement laws

Defilement is a crime in Uganda, but most of the cases of defilement have been either handled poorly especially by the community and families involved The penalty has been so minimal that many of the offenders have gone away with it. This also applies to early marriages below 18 years.

2.5 Access and Utilisation of Services

Most programs to change behavior have included equipping young people with accurate information, provision of recreational and health facilities, improving the management of young people's sexual health needs, and improving the socioeconomic status of the youth. Lack of access to health related information and services appear to be a common trend across all the components relating to adolescent health in Uganda (MoH, 1999).

Access to Health Services

Access to preventive and curative services including contraceptives and treatment of sexually transmitted diseases are important in ensuring reproductive health of youths. Access to RHS is the extent to which youth can obtain appropriate reproductive health services at a level of effort and cost that is both acceptable to and within the means of a large majority of youth in a given population. Access could be in terms of geographical access that includes convenient hours and location, and wide range of necessary services. Economic access involves affordability in terms of cost of the services. Psychosocial access is the perception of privacy e.g. perception that male, female, married or unmarried are welcome, feel of safety and confidentiality. Administrative access involves trained staff who have respect for young people, adequate time for interactions, and youth involvement in design and continuing feedback (.).

In Uganda studies have revealed that the current services are not oriented to offer adolescent friendly services (MOH 1999). The report further stipulates that there exists a communication gap between the adults and the adolescent associated with a breakdown of in the traditional institutions, which used to prepare adolescents for responsible adulthood. The situation has been compounded by mixed most times confusing information from electronic and other mass media. Reviewed studies have revealed that private clinics appear to be the major sources of treatment used by male and female adolescents supervised by doctors. For those who never got treatment, males reported embarrassment while females, reported cost of treatment as the main reasons Ayiga et al. 2000. A study by DISH (1998) in Jinja found gaps in services delivery, inadequate skills of health workers, and prevailing negative attitudes between health workers and adolescents.

Specific services targeting adolescent are limited to schools. These included curative services; IEC on growth and development through film shows seminars talks and the school syllabus. Recreation services in schools are mainly in form of games. IEC found in schools, health units and religious institution mainly focused on STI/AIDS, sex education, growth and development, life skills education and behavior change. These are being offered by NGOs, churches and health care providers. Posters, media talks and seminars are being used to convey health information to young people (Korukiko and Ampaire, 1999; Arinaitwe and Turinde, 1999). However, a number of young people are not benefiting (especially from health units) because of the unfriendliness of the health staff. These studies further revealed that there was existence of guidance and counseling in schools, churches, health units, community by leaders but minimal at household level. Young people were not targeted for contraception use; instead most institutions were advocating for abstinence. Substance abuse control services or programs were non-existent though it was an issue of concern.

Civil strife and armed conflict, which have led to massive movements of people and family disintegration have inhibited the ability of parents to provide the necessary care and protection to young people. Displaced and refugee girls are therefore exposed to sexual abuse through rape and defilement, which often results to genital injury/sores (Laenkholm & Cuijspers, 1997). These factors coupled with low knowledge on HIV/AIDS and limited access to health and information services tend to make young people who live on the streets especially vulnerable to HIV infection.

Unmet needs

The unmet health needs of young people were largely information on health, provision of reproductive health services, counseling, other health services and addressing the reported rampant poverty among young people. Other needs included addressing alcohol and substance abuse, good leadership and sanitation. The vulnerable adolescents who needed to be reached were those with disability, street children, the married, the out-of-school, school girls, house-girls/boys, orphans and those living in remote areas.

The main causes of the above gaps were identified as lack of adolescent participation in planning of programs that affect them, poverty among adolescents, poor leadership, corruption and breakdown in parent-child communication. Lack law enforcement, negative socio-cultural beliefs and practices and negligence among adolescents were reported as other causes. There is need to educate both parents and adolescents on the child statute so that parents do not find it difficult to counsel or discipline children thinking that it is against children’s rights. Parents also need to be encouraged to give sex education to their children.

2.5.1 Contraceptive knowledge, access and use

Adolescents are known to be poor users of contraceptives. UDHS 1995 revealed that in the age group 15-19, 7.2% were using any method compared to national average of 13.4%. While contraceptive knowledge among adolescent female and male was high, the level of actual use among sexually active adolescents was very low due to little knowledge about their use and the high cost. The compulsory payment of 300 shillings in public health facilities was considered unaffordable by adolescents (Arinaitwe and Turinde, 1999). The beliefs that contraceptives are unsafe also discourage some intending users. Barriers to practice safer sex practices including contraception were that parents do not wish their children to be exposed to contraception especially condom use. They argued that this would encourage adolescents into more sexual practices. However, adolescents expressed need for contraception (Arinaitwe and Turinde 1999). Although adolescents have high knowledge about contraception, this is not equivalent to the actual use. Fewer than 25% of the sexually active male and females actually use a method, the prevalence being highest in urban (30% males and 35% females). In the rural areas only 13% male and 5% females youth use contraceptives. The use of contraceptives, involving condoms, is highest among educated adolescents, 15-18%. At the same time, however, unmarried adolescents cannot easily obtain family planning supplies and advice.

There were no services in a number of districts specifically designed for adolescents. However, various providers in the district both government and private had a component for adolescent health services in their programs. Providers of adolescent services in the communities included drug shops, teachers, health workers, and community resource people among others. Adolescents rarely utilized government health facilities because of inaccessibility due to distance, poor reception by health workers, lack of drugs at the health units, and lack of financial support (Arinaitwe and Turinde, 1999, MoH, 1999).

The provision of AFHS in the study areas was affected by several factors such as religion, cultural beliefs and parental negligence and refusal of their children to seek care.

It was noted that training should include facts about the adolescent sexual and reproductive health (adolescent growth and development, sexuality and its consequences), the role of parents to their children, safe sex practices (condom use, masturbation), life skills, counseling, referral system and record keeping.

A study commissioned by Ministry of Health (MoH. 1998) and stakeholder’s workshop on reproductive health issues in Uganda identified the following in the area of adolescent Health and STIs:

  • Lack of national coverage by adolescent health programs;
  • To have the adolescent health policy finalized;
  • Need for co-ordinating to eliminate o duplication of training manuals by different implementing agencies;
  • Lack of screening services (e.g. pregnancy, STDs and HIV), especially in rural areas and school;
  • Commotion to sharing information among various partners and stakeholders;
  • Good practices and interventions need to be co-ordinated and replicated.

It was recommended that there should be well-articulated relevant policy guidelines developed at Ministry of Health with participation of various stakeholders to be disseminated up to grassroots on major aspect of Sexual and Reproductive Health as soon as they were developed. Also the adolescent friendly health services and other relevant Sexual and Reproductive Health interventions need to be put in place to cater for: school youths and out-of school youths.

2.6 School health education program

A school health education program in primary schools to prevent AIDS in Soroti district that emphasized improved access to information, improved peer interaction, and improved quality of performance of the existing school health education system made some impact. A cross-sectional sample of students of mean age 14 years, in their final year of primary school showed that the percentage of students who stated that they had been sexually active fell from 42.9% to 11.1% in the intervention group, while no significant change was recorded in a control group. Students in the intervention group tended to speak to peers and teachers more often about sexual matters. Overall study findings indicate that a primary school health education program which emphasizes social interaction methods can increase the level of sexual abstinence among school-going adolescents in Uganda (Shuey et al.1999).

2.7 Media

Studies have indicated that media campaigns in the 1990s have been instrumental in reducing HIV prevalence among young women. The campaign in promoting safer sex among adolescents, included abstinence, partner reduction, and condom use. They produced a rise in monogamy, condom use in risky sexual relationships, and later age of sexual debut (Keller, 1997). In 1995 the campaign by the Delivery of Improved Services for Health (DISH) Project, implemented by Pathfinder International and Johns Hopkins University, promoted HIV prevention messages through songs and soap operas, rap music contests, drama, and newsletters and posters. In surveys of 1681 adolescents condom use among them increased from 46% before the campaign to 69% afterwards. The AIDS Information Center used radio announcements to promote HIV testing, with the result of young people turning up in large numbers. The study found that if messages appear in different media simultaneously (music, television, radio, movies, and posters) the campaigns become even more effective.

The intervention was associated with substantial increases in levels of correct reproductive knowledge and practice, a dramatic postponement of first intercourse, a significant reduction in the number of teenagers having multiple sexual partners, and increases in condom use. It is recommended that adolescent reproductive health services be expanded to include the development of life coping skills, STD screening and treatment, AIDS awareness and prevention, pregnancy screening and antenatal care, psychosocial guidance, and contraceptive availability for sexually active teenagers (Njau et al 1995)


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