‘I rose up’: marginalised young women’s navigation of social protection in Uganda’s protracted crises

BackgroundMuch of the research literature about the use of family planning generalizes contraceptive use among all women, using age as a covariate. In Uganda, a country with divergent trends in modern family planning use, this study was set to explore whether or not the predictors of contraceptive use differ by age. This was assessed by using data from the 2011 Uganda Demographic and Health Survey (UDHS).MethodsWe restricted the sample from each round to fecund, non-pregnant married women age 15–34 who were sexually active within one year prior to the survey, resulting in a sample of 2,814 women. We used logistic regression with age variable used as an interaction term to model the relationship between selected independent variables and the outcome variable (modern contraception use) for each group of women.ResultsWe found that the key factors associated with use of modern contraceptives varied among young and older married women age 15–24 and 25–34 respectively. Results showed that perception on distance to health facility, listening to radio and geographical differences exhibited significant variability in contraceptive use among the young and the older women. Other key factors that were important for both age groups in explaining contraceptive use were; desire to have children after two years and education level.ConclusionsAddressing contraceptive use among old and young women in Uganda requires concerted efforts that target such women to address the socio economic barriers that exist. There is need for increased access of family planning service to the population through strengthening the use of Village Health Teams (VHTs) whose service is currently limited in coverage (MoH, 2009). Given the variation in contraceptive use between the two age groups, our findings further suggest that there is need for variability in media targeting among the young and the older women categories for improved use of modern contraceptives, for instance using alternative media strategies to reach the young women. Family planning policies should also be tailored to address the specific needs of different age groups of women with varied geographical locations.

Uganda has a rapidly urbanizing population and the world's second youngest population. Further, gender inequities contribute to young women in urban Uganda experiencing multiple unmet health and wellbeing needs. However, their perspectives are rarely included in health research or decision making and their lives rarely examined to capture community strengths. We conducted a qualitative study using Photovoice with 15 women aged 18-24 years across three urban sites within Kampala, Uganda. To capture perceptions of strengths, we prompted participants to take photos reflecting 'TOPOWA', meaning 'don't give up' in Luganda. Researchers conducted inductive thematic analysis of photos and discussion transcripts and participants contributed to theme validation. Multiple themes emerged from the narrative and visual data across all three sites. This article focuses on the theme of wellbeing and mental health, which encompasses community strengths, protective factors and resilience. Findings provide evidence for health promotion for young women in urban Kampala and similar sub-Saharan African settings through unique, contextual visual and narrative evidence. Notably, existing community strengths are highlighted as potential areas to build upon for health promotion interventions for wellbeing and mental health. Furthermore, findings shaped an ongoing cohort study of mental health trajectories for young women in Uganda.

This paper sets out to explore Ugandan young women's definitions and perceptions of sexual coercion. A qualitative study was conducted with seven young women in rural Uganda. Participants filmed videos, wrote stories, made drawings and participated in transect walks before analysing their data through formal and informal discussions. Forced sex is defined narrowly to mean only rape. Verbal forms of sexual coercion were recognised, but only after some discussion. Verbal coercion is referred to as "abusing" or "convincing". Young women are commonly pressured into consenting to have sex, despite what they really want, owing to the socio-cultural circumstances. Young women in Uganda are significantly tolerant of sexual coercion. This tolerance appears to arise from power differentials between genders, and the socio-cultural environment shaping their lives. The paper improves understanding of young women's definitions and perceptions of sexual coercion, which is essential to provide effective violence prevention programmes. It also suggests that further research is warranted in this field.

BackgroundPrevious studies were conflicting regarding the associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors and STIs. This study compared the HPV-vaccinated and non-vaccinated young women in Uganda regarding cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections 5 years after vaccine implementation.MethodsThis was a population-based comparative cross-sectional survey conducted in Uganda. The 438 participants were sexually active young women aged 15–24 years and mean age was 18.6 (SD 1.4). The majority (53.0%) were HPV-vaccinated in 2008 without assessment of sexual activity prior to HPV vaccination. Upon verbal assessment of sexual activity at the time of follow-up, data were collected using a questionnaire and laboratory testing of blood samples for syphilis and HIV infections.ResultsThere were no significant differences between the HPV-vaccinated and non-vaccinated groups regarding the prevalence of high-risk sexual behaviors, syphilis and HIV infections. Cervical cancer risk perceptions and age at sexual debut were nonetheless significantly lower among the vaccinated group compared to their non-vaccinated counterparts. However, HPV vaccination was not significantly associated to cervical cancer risk perceptions and early age at sexual debut in multivariate logistic regression analysis.ConclusionsWe found no associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections among young women in Uganda 5 years after vaccine implementation. Young girls in the study population were found to be sexually active at a young age, affirming the importance of targeting girls of younger age for HPV vaccination.

Adolescent girls and young women in Uganda face numerous public health challenges including high HIV prevalence, teenage pregnancies, poor sexual and reproductive health rights, child marriage, and violence. This evidence review explores which interventions focusing on the empowerment of adolescent girls and young women to address these challenges are suitable for Ugandan policy. We reviewed the literature to identify experimental studies and systematic reviews of interventions which improve sexual and reproductive health outcomes and/or prevent violence in adolescent girls and young women in low- and middle-income countries (LMICs). Two authors independently reviewed the studies identified through a comprehensive search strategy and assessed their quality. From this evidence base, two policy options were explored in depth considering benefits, harms, equity impacts, and costs, given the Ugandan context. The screen yielded 47 studies, of which 12 remained after applying inclusion and exclusion criteria and relevance, applicability and quality assessment. Feasible policy options included: a vertical cash-incentive approach at a national or local level to support girls' attainment of education; and a horizontal integrated community approach focusing on skills and knowledge building. A combination of both is recommended for young female empowerment in Uganda, allowing for the full range of socio-cultural and economic drivers to be targeted. Research into the link between female empowerment and sexual and reproductive health outcomes is still in early development. This review contributes to evidence on this topic and outlines an approach that is potentially suitable for adoption across similar LMICs in Africa.

Provides a comprehensive diagnostic of the effects of the COVID-19 pandemic on the human capital of young people ages 15–24, and identifies promising policy responses for governments by describing the ways in which the crisis affected youth human capital and providing estimates of the magnitude of the losses, primarily using microdata from labor force surveys for 12 countries. The pandemic led to a sharp reduction in employment and an uneven recovery globally, with some countries showing little sign of an improvement in youth employment. During the pandemic the enrollment of youth in educational institutions rose in some countries but not in others, and where increases in school enrollment did occur, they remained smaller than the corresponding declines in employment. Beyond the labor market, the pandemic led to a deterioration of other youth outcomes, including increases in teenage pregnancy, diminishment of mental health, and a decline in the development of key social-emotional skills and executive functions.

Injectable depot medroxyprogesterone acetate (DMPA) is the most common contraceptive choice among young women in Uganda, where HIV burden is high and HIV preexposure prophylaxis (PrEP) may be offered. For young women who choose to use both agents concurrently, it is unknown whether they will experience declines in bone mineral density (BMD) beyond those elicited by either product singly. From 2018 to 2022, we conducted a 2-year prospective study with women ages 16-25 years in Kampala, Uganda desiring pregnancy and HIV prevention. Women were provided condoms, injectable DMPA, and/or FTC/TDF, according to their choices and underwent annual dual X-ray absorptiometry (DXA) scans. We used tenofovir-diphosphate (TFV-DP) quantification in dried blood spots and DMPA injection dates to classify exposure. Linear regression models estimated the difference in percent BMD change from baseline to month 12 for women using FTC/TDF and DMPA versus women using neither product. Of 499 enrolled women, discontinuation and re-starting of contraception and PrEP was common. Women consistently using neither product ( n = 39) experienced BMD increases. Women with consistent use of both products during 1 year ( n = 22) experienced an average BMD loss of 1.04% at lumbar spine and hip and 1.77% at femoral neck. These losses were different relative to women who used neither agent: lumbar spine -3.35% (95% CI -5.13 to -1.56%, P = 0.001), total hip -2.24% (95% CI -3.87 to -0.60%, P = 0.009), and femoral neck -1.71% (95% CI -3.73 to 0.31%, P = 0.102). We observed a trend for women with concurrent DMPA and FTC/TDF PrEP use to have 1-3% lower BMD than unexposed women after 12 months.

Short pregnancy intervals can contribute to maternal and child morbidity and mortality. No previous research has explored factors associated with short pregnancy intervals among young women in Uganda, where adolescent pregnancy and short birth intervals are common. Data on 626 married or cohabiting women aged 15-22 with one or two previous pregnancies were drawn from the 2011 Uganda Demographic and Health Survey. Bivariate and multivariable logistic regression analyses were used to examine characteristics associated with rapid repeat pregnancy, defined in two ways: a pregnancy occurring within 24 months or 12 months of a prior pregnancy outcome. Among women, 74% and 37% had experienced a rapid repeat pregnancy within 24 months and 12 months, respectively. Rural women were more likely than urban women to have had a rapid repeat pregnancy within 24 months (odds ratio, 2.4). Women aged 15-17 and those 18 or older at first union were more likely than women younger than 15 to have had a rapid repeat pregnancy within 24 months (3.8 and 3.4); those whose partner had at least a secondary education had lower odds than others of the outcome (0.6). The odds of rapid repeat pregnancy increased with the number of months between marriage and first birth (1.05). Variables associated with rapid repeat pregnancy within 12 months included urban-rural residence, region, age at first union and marriage-to-birth interval. Efforts to reduce rapid repeat pregnancy among young women in Uganda should focus on rural areas. Strategies to reach women during antenatal care and the postpartum period after their first birth should be prioritized.

Sexual violence (SV) is a significant global public health problem. To develop effectively targeted interventions to prevent SV and allocate resources equitably requires identifying the most vulnerable groups and the magnitude of these social inequities. However, these data are currently lacking. Using the Uganda Demographic and Health Survey, we examined SV among all young women and ever-married young women. We conducted univariate and bivariate analyses to characterise the prevalence and social patterning of SV, and then utilised the World Health Organization Health Equity Assessment Toolkit (HEAT) to assess the magnitude of social inequities in SV. At the national level, 5.5% among all young women and 20.5% of ever-married young women had experienced SV. For all young women, the largest inequities in SV were based on sub-national region of residence. Among the ever-married young women, we found profound education, wealth and place-based inequities in SV, which favoured young women with higher education, in wealthier households, and within central regions of Uganda. Our findings suggest a need for regionally targeted multi-sectoral interventions that take into consideration that multiple intersecting social dimensions such as education, poverty and the safe built environment, to address young women's risk for SV.

STI-prevalence and differences in social background and sexual behavior among urban and rural young women in Uganda

BackgroundUnintended pregnancies lead to unsafe abortions, which are a leading cause of preventable maternal mortality among young women in Uganda. There is a discrepancy between the desire to prevent pregnancy and actual contraceptive use. Health care providers' perspectives on factors influencing contraceptive use and service provision to young people aged 15-24 in two rural districts in Uganda were explored.MethodsSemi-structured questionnaires were used for face- to-face interviews with 102 providers of contraceptive service at public, private not-for-profit, and private for-profit health facilities in two rural districts in Uganda. Descriptive and inferential statistics were used in the analysis of data.ResultsProviders identified service delivery, provider-focused, structural, and client-specific factors that influence contraceptive use among young people. Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, and the limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers' self-rated competence by facility type; private for-profit providers' competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children.ConclusionProvider, client, and health system factors restricted contraceptive provision and use for young people. Their contraceptive use prospects are dependent on provider behavior and health system improvements.

Young motherhood is associated with persistently high rates of fertility and adverse maternal, neonatal and social outcomes in many sub-Saharan African countries. This study examined the trends and explained the persistence of high incidence of premarital childbearing among sexually active unmarried women in Uganda. Cross-sectional data from the 2001, 2006 and 2011 Uganda Demographic and Health Surveys were used. The study revealed that across the span of the study period the prevalence of premarital childbearing remained high and stable at more than 25% in all the three surveys. Premarital childbearing is significantly predicted by age group 20–24, young age at sexual debut, female headed households, and households headed by the young women themselves, low level of education, rural residence and multiple lifetime sexual partnerships. Increasing and maintaining access to programmes that increase age at sexual debut, level of education and reduce number of lifetime sex partners are recommended.

BackgroundFemale adolescents and young women have the highest risk of curable sexually transmitted infections (STIs) globally. Data on the prevalence of STIs among young women in Uganda are limited. In this study, we investigated the time trends and correlates of STIs among adolescent girls and young women (15–24 years) in Uganda.MethodsWe estimated the percentage of women 15–24 years from three recent consecutive Uganda Demographic and Health Surveys (2006, 2011, and 2016), who reported suffering from genital sores, and or genital discharge or any other varginal complaints acquired after sexual intercourse within 12 months of the studies and examined the changes over time. A pooled multivariable logistic regression was used to examine the correlates of reporting an STI in the last 12 months preceding the study. Svyset command in Stata was used to cater for the survey sample design.ResultsThe pooled self-reported STI prevalence was 26.0%. Among these young women, 22.0, 36.3, and 23.1% reported a sexually transmitted infection in 2006, 2011, and 2016 respectively. Between 2006 and 2011, there was evidence of change (+ 14.3%, p < 0.001) in STI prevalence before a significant reduction (− 12.0%, p< 0.001) in 2016. Youths aged 20–24 years reported a higher STI prevalence (27.3%) compared to young participants (23.6%). Correlates of reporting an STI among rural and urban young women were: having multiple total lifetime partners (adjusted odds ratio (aOR 1.6, 95% CI 1.4–1.6), being sexually active in the last 4 weeks (aOR 1.3, 95% CI 1.1–1.6), and being affiliated to Muslim faith (aOR 1.3, 95% CI 1.1–1.6) or other religions (aOR 1.8, 95% CI 1.1–2.9) as compared to Christian were more likely to report an STI. Living in Northern Uganda compared to living in Kampala city was found protective against STIs (aOR 0.5, 95% CI 0.3–0.7).ConclusionThe prevalence of STIs was high among female youths, 15–24 years. This highlights the need for a comprehensive STIs screening, surveillance, and treatment programme to potentially reduce the burden of STIs in the country.

This paper aims to explore the motivations of young women in Busoga, Uganda, engaging in "Something-for-something" love (SFSL) relationships. Something-for-something love is defined as engaging in sex in exchange for money, favours, gifts and goods. This paper examines whether these relationships affect young women's ability to negotiate safe sex. Qualitative methods were used with a group of six young women including participatory video, drawing, stories and life histories. In addition, semi-structured interviews were conducted with each participant and two key informants. Data were analysed using an inductive thematic approach. Peer pressure, financial gain, school fees, basic needs and family pressure were key motivations for SFSL. Power dynamics embedded in Ugandan local culture were found to play a significant role in SFSL and family pressure is suggested to assume a greater role than previously perceived. Transaction was considered to be part of what was expected within a "natural romantic relationship". Condom use was less likely in relationships where a great amount of gifts were exchanged, as men were more likely to negotiate sex on their terms, and this often led to unprotected sex. The study contributes much-needed insight into motivations behind young women participating in SFSL. Young women involved in such relationships are portrayed along a spectrum ranging from vulnerable to empowered. The study emphasises the role parents and other kin play in influencing their children's sexual and reproductive health choices. The study highlights to policy makers that interventions aimed at improving parent-child communication are needed; as well as a more informed approach to HIV prevention, taking onboard the complexities of SFSL.

This study aims to explore the life experiences and expectations of young women of Busoga in Eastern Uganda. Using qualitative methods, a small group of young women drew, wrote stories and made videos together. The data which emerged from this exercise were analysed alongside the researcher's own observations. Basoga society's main expectation of young women is that they will work in the home. Yet, young women describe very different ideas of what they want from their lives; this includes a desire for access to a good educational experience, and different expectations for family life than cultural norms. They find, however, that there are many barriers to meeting those expectations. The study is important because it acknowledges and forefronts Ugandan young women's life expectations. Typically, development focuses on "outsider" considerations rather than "insider" views and desires. The desires of the marginalised, such as young women in Africa, are a particularly neglected subject. There is a need for continued efforts to explore and include young women's experiences and expectations countering gender inequality and as part of ongoing gender empowerment and sexual health strategies.