Assessment of Adolescent Girls and Young Women’s Contraceptive Knowledge in East Central - Timeline 1

June 2016

TABLE OF CONTENTS

Table of Contents ...... i List of Tables ...... ii List of Figures ...... ii Acknowledgement ...... 1

Executive Summary ...... Error! Bookmark not defined. 1.1 Background ...... Error! Bookmark not defined. 1.2 Why the baseline assessment? ...... Error! Bookmark not defined. 2. Methodology ...... Error! Bookmark not defined. 2.1 Data Management ...... 8

3. Key findings ...... 9 3.1 Introduction to the Presentation of findings: ...... Error! Bookmark not defined. 3.2 BACKGROUND CHARACTERISTICS ...... Error! Bookmark not defined. 3.2.1 General Social Demographics ...... 9 3.2.2 Wealth related demographics ...... Error! Bookmark not defined. 3.2.3 Proxy of wealthy status ...... Error! Bookmark not defined.

3.3 CONTRACEPTIVE KNOWLEDGE AND CHOICES ...... 14 3.3.1 Awareness of modern contraceptives and methods ...... Error! Bookmark not defined. 3.3.2 Knowledge about use of modern contraceptives and methods ...... Error! Bookmark not defined. 3.4. Seeking advice on contraceptives ...... Error! Bookmark not defined.

3.5. LIKELIHOOD AND ABILITY TO USE CONTRACEPTIVES ...... Error! Bookmark not defined. 3.5.1. Current use of contraceptives in the target districts ...... Error! Bookmark not defined. 3.5.2 Intent to use selected modern contraceptives ...... Error! Bookmark not defined. 3.5.2. a. Intent to seek contraceptives in the next 6 months...... Error! Bookmark not defined. 3.5.2. b. Intent to use contraceptives in the next 6 months ...... Error! Bookmark not defined. 3.5.2. c: Intention to delay sex debut in the next 6 months ...... Error! Bookmark not defined.

3.5.3 Ability to delay sex debut ...... 9 3.5.4 Norms and attitudes ...... Error! Bookmark not defined. 3.5.4a Ability to act ...... Error! Bookmark not defined. 3.5.4b Need of skill on contraceptives ...... Error! Bookmark not defined. 3.6 ATTITUDE TOWARDS CONTRACEPTIVE USE ...... 13 3.7 RIGHTS TO CONTRACEPTIVE KNOWLEDGE ...... Error! Bookmark not defined. 3.8 EXPOSURE TO INFORMATION ON HEALTH ...... Error! Bookmark not defined. 3.8.1 Current exposure to messages on HIV prevention and contraceptives ...... Error! Bookmark not defined.

4. IMPLICATIONS FOR SBCC INTERVENTIONS ...... Error! Bookmark not defined. 5. Study limitation: ...... 20 References ...... 21 Annex 1: Data weighing procedure ...... 22

i | P a g e

LIST OF TABLES

Table 1: Sampled intervention Sub Counties...... 6 Table 2: Control sub counties for the assessment ...... 6 Table 3: Distribution of sampled VDT units per Sub County ...... 7 Table 4: Marital status by Age group and religion ...... 10 Table 5: Status of AGYW on pregnancy and number of children ...... 11 Table 6: Education attainment by District ...... 11 Table 7: Residential locations of AGYW ...... 12 Table 8: Main pre-occupation by age group ...... 13 Table 9: Awareness about contraceptives methods by Age group and district ...... 1 Table 10: Proportion of AGYW with knowledge on how to use selected modern contraceptives ...... 2 Table 11: Proportion of AGYW seeking advice on contraceptives by age and residence ...... 3 Table 13: Main Reason for seeking advice by age category and residence ...... 5 Table 17: Ability to use contraceptives by marital status and residential status ...... 10 Table 18: Skills on Contraceptives and where to obtain contraceptives ...... 11

LIST OF FIGURES

Figure 1: Flow of sampling of respondents ...... 8

ii | P a g e

List of Acronyms

AGYW: Adolescent Girls and Young Women

CHC: Communication for Healthy Communities

COP: Chief of Party

DFID: Department for International Development

FP: Family Planning

IUCD: Intrauterine Device

SBCC: Social Behavioral Change Communication

SSA: Sub-Saharan Africa

UDHS: Uganda Demographic Health Survey

UNFPA: Uganda Family Planning Association

USAID: United States Agency for International Development

VDT: Venue Day Time

WHO: World Health Organization

iii | P a g e

Authors

Richard Batamwita, Justus Atwijukire, Leonard Bufumbo, Paul Odeke, Andrew Kabala, Davinah Nabirye and

Anne Fiedler

Recommendations

Richard B. Justus, A. Leonard, B. Paul, O. et al: (2016). Assessment of adolescent girls and young women’s contraceptive knowledge in East central Uganda. Communication for Healthy Communities (CHC) program.

Acknowledgment

This adolescent girls and young women (AGYW) assessment was made possible with financial support from United Kingdom’s Department for International Development (DFID) through USAID to Communication for Healthy Communities (CHC).

We acknowledge the significant contribution of Ministry of Health, Health Promotion and Education Division, specifically Dr. Paul Kagwa; Assistant Commissioner for the support given to the CHC team during the planning and execution of the assessment. We also acknowledge the support and efforts of District Health Officers in the districts where the assessment was conducted.

Finally, CHC would like to acknowledge the invaluable role of all respondents and research assistants.

The views and opinions of authors expressed herein do not necessarily state or reflect those of the U.S. Government or the USAID, and shall not be used for advertising or product endorsement purposes.

1 | P a g e

Executive Summary

Through the United States Agency for International Development’s (USAID) partnership with the United Kingdom Department for International Development (DFID), USAID Uganda/CHC (Communication for Healthy Communities) program plans to design and implement an intensive health communication campaign for adolescent girls and young women. The campaign, uses a 360 degree “surround sound” communication design to target adolescent girls (15- 19 years) and young women (20-24), specifically those out of school. The campaign aims to empower adolescent girls and boys as well as young women with relevant Family Planning (FP) and reproductive health information; and referral to services to enable them make informed contraceptive choices for a better future.

The campaign is premised on the right to a better future for adolescent girls and young women in Uganda that will not be realized if adolescent girls and young women (AGYW) are not aware of, or are denied access to reproductive health information, services and product choices. The campaign will also seek to enable parents with information and skills on the various contraceptive and reproductive health choices for young women, thereby creating an environment where AGYW are, without discrimination, able to access the reproductive health information necessary to make informed decisions and choices.

The project is located in the east central region of Uganda, selected for the high level of vulnerability of AGYWs and teenage pregnancy rates (30%), compared to other Uganda regions such as the south-west with only 15%.

The intervention will additionally create an environment, where AGYW in rural areas realize their right to quality reproductive health services including information about contraceptives to help make informed choices, to prevent unwanted pregnancies and sexually transmitted diseases. A baseline assessment was conducted between October and November 2015. The specific assessment objectives were: to determine the awareness levels and comprehensive knowledge about modern contraceptive choices; and to explore the current level of exposure to USAID/CHC’s OBULAMU integrated health communication platform messages The results reported in this report are for Timeline 1.

The study design adopted a time-space-sampling technique. Potential respondents were intercepted at venues using a Venue Day Time (VDT) unit sample frame. The VDT sample approach provides a probability-based sample determination. Before any data collection, preliminary information was gathered with key informants to construct a complete VDT unit sample frame in each assessment site. Data collection and analysis methods were only quantitative.

Overall, 1245 AGYW were sampled. Of these, 448 (36%) were aged15-19 years while, 797 (64%) were 20- 24 years. Thirty-nine percent of the15-19 years and 70% of the 20-24 years indicated they were married at the time of the assessment. Overall, 66% lived in rural areas.

2 | P a g e

In total, 181(15%) of the respondents were pregnant at the time of study. The proportion of pregnant respondents was equal for both age groups (15%). Eight hundred forty-one (68%), already had a child. More specifically, 23% of respondents aged 15-19 years and 77% aged 20-24 years had children.

Contraceptive awareness was high at 965(78%), but highest at 20-24 years, 680 (85%). Short term contraceptives were more known than long term and permanent methods. The results show that Pills were the most known method at 74%, followed by DEPO (62%), male condoms (47%), and IUD at 47%. Spermicide, lactation Amenorrhea and vasectomy were the least known, each at 1%.

Knowledge on contraceptive methods and how to use the known method differed with a wide margin. Knowledge on how a method is used was low, for example, only 45% and 26% knew how pills, and the Intra Uterine Device are used.

Information seeking about contraceptives was low, at 35%. Those who had sought, information on contraceptives in the previous six months, revealed the main sources as; VHTs/Health workers (46%), followed by same sex peers (22%), and peer educators (19%). The least sources of advice on contraception for AGYW included: husbands (7%), aunties (Ssengas) (3%), and different sex peers (4%).

The reasons for seeking knowledge on contraceptives varied and included: birth spacing 158 (36%), pregnancy prevention 150(34%), menstruation 32 (7%), sexual health 19(4%), and relationship issues 14 (3%).

Almost all respondents approved of contraceptive use. The proportion of those who approved increased with education levels ranging from 63% for primary education leavers to 90% among those with senior six or higher education. and districts had the least approval levels towards contraceptive use at 46% and 38% respectively. Both districts are not intervention districts covered by the project but served as control districts.

The proportion of those likely to use contraceptives was high at 83%. Of those that intended to use contraceptives, 54% were “very much” confident to use contraceptives. The level of confidence was highest among the married and those living in urban areas.

At the time of the assessment, 19,320 AGYW between 15-24 years were using contraceptives. Among the users, majority (8,506) were using injectables while 7,791 used male condoms. A total of 7,420 AGYW had visited health facilities to get family planning services for the first time1. The limitation with these numbers of the AGYW seeking services is that it is hard to compare with districts population of AGYW because of lack of complete denominator information, but nevertheless, the numbers provide insight t seeking family planning services.

The findings suggest four major optional interventions for the AGYW: 1. Child spacing or child limiting for those that are already married and already have a child; 2. Delaying sexual debut for those that are not yet sexually active; 3.

1HMIS data October 2015 3 | P a g e

Pregnant AGYW to benefit from the general population pregnancy interventions under the OBULAMU campaign; 4. There is need to provide more knowledge on how contraceptive methods work to stimulate motivation and use; 5. Lastly, for the AGYW who are not yet pregnant, interventions should cause a shift from knowledge to action by; focusing on motivation and emotional triggers to transform or enhance ability to prevent teenage pregnancy, through delayed sexual debut or condom use, while addressing fears and misconceptions.

4 | P a g e

1.1 Background

Uganda’s current population is estimated at 35 million and is projected to increase rapidly if the current demographic determining factors such as infant mortality rate decrease.(1). Although major population determinants such as total fertility rate and contraceptive prevalence stand at 6.2%and 30% respectively, these rates are comparatively high. Uganda has a young population, with 52% children below 15years and 59% below 18 years. By age 18, most teenagers will have given birth. The proportion of births by age 18 stands at 33%.(2)

Ugandan girls are more likely to have children early and become engaged in risky behavior because of the low exposure to health information, low education and employment indicators(3). Uganda is one of the 15 countries in sub Saharan Africa with a high prevalence of pregnancy among girls less than 18 years of age(4). The Uganda contraceptive prevalence rate of 30% is still below the national target of 40%(5).A negligible proportion (14%) of girls aged 15-19 use a contraceptive method.(6).In addition, at 6.2% Uganda has one of the highest fertility rates in the world. The East Central region of Uganda, in particular, has the highest proportion of young women who begin child bearing at a young age (30.6%)(6).

1.2 Why the baseline assessment Before campaign implementation, CHC, in collaboration with the Government of Uganda and Implementing Partners (IPs), planned a baseline assessment on knowledge of contraceptive choices; motivation and attitudes; skills and norms. The purpose of the assessment was to inform the design of campaign interventions and to provide a baseline status upon which improvements or changes arising from the health communication program could be based.

2. Methodology

The assessment was executed using a time-space-sampling methodology. Potential participants were intercepted at venues using a Venue-Day-Time (VDT) unit sample frame. The VDT sample approach provides a probability-based sample determination. Sequentially, preliminary information was gathered with key informants to construct a VDT unit sample frame in each assessment site. The survey analysis domains were based on the socio-ecological model (7). Forty percent of sub-counties for the intervention were sampled (Table 1).

5 | P a g e

Table 1: Sampled intervention Sub Counties

District Mayuge (n=5) (n=4) Kamuli (n=4) Namutumba Luuka (n=3) (n=3) Sub counties Mayuge Nakalama Nabwigulu Ivukula Luuka T/C Mpungwe Nambaale Namwendwa Kibale Bulongo Jagusi Nawandala Butansi Matanga Waibuga Buwaaya Bulamagi Balawoli Bukatube

In addition to the intervention sub counties, the survey also adopted the use of control sub counties, which were selected based on proximity to intervention districts or within an intervention district, and not receiving planned AGYW interventions. A ratio of 4:1 between intervention and control districts was considered. (details in table 2).

Table 2: Control sub counties for the assessment

District Control sub county Muterere Namayiingo Banda Kaliro Namugongo Kamuli Bugulumbya Iganga Busembatia

Fifty percent of VDT units were sampled, with each sub county allocated VDT units as shown in Table 3. A VDT unit sample frame universe depicting a diversity of venues and greater likelihood of inclusion of potential respondents was developed per district. This served as the first level of determining the respondents- type I enumeration.

6 | P a g e

Table 3: Distribution of sampled VDT units per Sub County

Interventi Number ofIntervention Sampled Venue Sampled on district S/counties S/counties S/counties universe venues

Mayuge 13 13 5 21 10 Namutu 7 7 3 28 15 mba Iganga 16 10 4 13 7 Kamuli 13 10 4 169 84 Luuka 7 7 3 32 16

Control district Number ofControl Venue Sampled S/counties S/ counties universe venues Namayingo 9 1 29 14 Bugiri 11 1 35 18 Iganga 16 1 4 2 Kamuli 13 1 26 13 Kaliro 6 1 19 9

Each sampled VDT unit was visited for a data collection event. The second level of selection of respondents (type II enumeration) was during data collection. Research assistants (RAs) that conducted the interceptor role, counted and verified numbers of adolescent girls and young women (AGYW) attending a given venue. Those found eligible were screened, and consented or assent obtained before data collection. A local leader was available at each sampling event to respond to any unfriendly reception to the research team from the community. In total, 1245 respondents consented to participate in the study (Figure 1). The completion rate was 93%, and the response rate 82%.

7 | P a g e

Figure 1: Flow of sampling of respondents

375 identified and verified Venue Day Time Units from venues at level I enumeration

188 VDT Units sampled

4276 potential participants visited VDT Unit (Esstimated)

1417 screened for eligibility

1302 eligible for the first time

457 were aged between 15- 19 years 785 were aged between 20-24 years

1245 n

2.1Data Management

Data was collected by trained research assistants who resided in the study localities and knew the local dialects. Data was collected using Open Data Kit (ODK) mobile data collection and there after uploaded onto a server.

At the preliminary level, analysis was based on frequency distributions with proportions that were mainly disaggregated across the age categories and districts. Further analysis is anticipated to compare results across the intervention and control districts. In the presentation of findings, proportions were compared with the current literature on sexual and reproductive among AGYW with Sub-Saharan Africa (SSA) and Uganda in particular.

8 | P a g e

3. Key findings

3.1 Introduction to the presentation of findings

This section is structured around five main sub sections of the AGYW assessment; a) background characteristics; b) contraceptive knowledge levels; intention towards contraceptives; c) knowledge on how the contraceptive methods are used; d) attitudes and norms, as well as, e) exposure to health communication messages. This approach is aligned to the Social Behavioral Change Communication (SBCC) framework adopted by CHC. The SBCC framework informed the assessment question formulation. The key variables for assessment include; exposure, access, attitudes of adolescent girls and young women regarding knowledge of contraceptive choices. Under each section, key findings are highlighted to provide an overview of the section.

3.2. Background characteristics

Key background data about sampled respondents • The study sampled 1245 out of school AGYW aged (15-19) and (20-24) years in eight districts of East Central Uganda. • Forty percent never completed primary school level. The highest proportions of those who never completed primary level were in Namayingo (65%) and Bugiri (51%). • Overall, 66% lived in rural places • Forty-one percent were not married • Fifteen percent were pregnant at the time of interview. • Sixty-six percent the AGYW had a child; 15% among (15-19) and 51% among the (20-24) years. • Forty-one percent of those who were not married had children.

Data was collected from specific background variables including; completed education level, marital status, age, main occupation, and residence. These variables were necessary as they are often reported as key determinants of reproductive health and therefore critical in understanding the nature, quality and level of access to reproductive health choices in the respective districts. (6)

9 | P a g e

3.2.1. Social demographic characteristics

The study reached 1245 respondents; out of school adolescent girls (15-19 years), and young women aged (20-24) years in eight districts of East Central Uganda. Table 4 summarizes the profile of respondents in regard to selected respondent socio-demographic characteristics.

Table 4: Marital status by age group and religion

Religion Not Married Not Married Married Married Total Total Total 15-19 20-24 15-19 20-24 %(n) years years years years Catholic 50 48 98 34 110 144 242(19) Muslim 86 63 149 64 154 218 367(29) Pentecostal 44 27 71 19 49 68 139(11) Protestant 83 86 169 54 219 273 442(36) Seventh Day 3 8 11 1 13 14 25(2) Adventist Other 9 7 16 1 13 14 30(2) Total 275(54) 239(46) 514(41) 173(24) 558(76) 731(59) N=1245

Table 4, shows that overall,731(59%) were married. For AGYW aged 15-19 years, 173 (24%) were married while 558 (76%) were married in the age group 20-24 years. The high numbers of AGYW in marriage relationships could be explained by the lack of economic choices as well as limited opportunities for further education or gainful employment. Based on the marital situation of the majority of AGWY, the most appropriate form of family planning is adoption of child spacing methods as a choice.

The results above also indicated that among the 731 AGYW that were married,349 (48%), 131(18%) married traditionally while 248 (34%) were religiously married. had the highest traditional marriages, 94(84%). Often traditional marriages are associated with early marriage practices. This practice could be changed through the use of IPC with positive deviant homes and families.

The number of self-reported pregnancies at the time of the survey were 181 (15%) with no variations between the two age groups. A small proportion 35 (3%) were unsure of their pregnancy status. Of those pregnant, 36 (20%) were not married.

10 | P a g e

Table 5: Status of AGYW on pregnancy and number of children

Not Married %(n) Married %(n) Total(N)

Option 15-19years 20-24years Total(n) 15-19years 20-24years Total(n) Not 90(247) 93(221) 468 70(120) 79(439) 559 82 (1027) Pregnant Unsure 2(5) 1(3) 8 5(9) 3(18) 27 3 (35) Pregnant 8(21) 6(15) 36 25(44) 18(101) 145 15 (181) Number of children None 73 (201) 42 (101) 302 33 (56) 8(46) 102 32.4 (404 ) One 24 (65) 34 (82) 147 47 (81) 30 (165) 246 31.6(393) Two 3(9) 16 (38) 47 14 (25) 35(195) 220 21.4 (267) Three and - 8 (18) 18 6 (11) 27 (152) 163 14.6 (181) above Total 54(275) 46(239) 514 24(173) 76(558) 731 1245

According to table 5, two thirds (67.6%) of the respondents had at least one biological child. Generally, there is a big difference in the number of children for those who were married and the non-married. For instance, for ages 15-19 years, the percentage with at least a child amongst the married was 117(67%) compared to 74(27%) for the unmarried These results mean that delaying marriage is an important aspect in delaying teenage pregnancy.

Table 6: AGYW Education attainment by District

No Completed Completed Senior Respondents Schooling (n) Primary Senior Six and Above %(n) %(n) Four %(n) %(n) Bugiri (51) 30 (37) 22 (10) 6 (2) 1 59 Iganga (21)13 (52) 31 (25) 15 (2) 1 61 Kaliro (31) 17 (50) 27 (19) 10 (0) 54 Kamuli (36) 209 (45) 262 (16) 91 (2)14 576 Luuka (37) 54 (37) 54 (21) 30 (5) 8 146 Mayuge (47) 46 (38) 37 (14) 14 (1) 1 98 Namayingo (65) 60 (30) 28 (3) 3 (1) 1 92 Namutumba (44) 70 (40) 63 (14) 23 (3) 4 159 Total (n=1245) (40) 499 (42) 524 (15) 192 (2) 30 1245 Age Group 15-19years 50 (224) (44 )195 (6) 27 (7) 2 448

11 | P a g e

20-24years 35 (275) (41)329 (21) 165 (4) 28 797

Table 6 indicates that 524(42%) AGYW completed primary education (completion means they sat primary seven leaving examinations), while 499(40%) did not attend or complete primary education. The highest proportion of those who never completed primary level education were found in Namayingo (65%) and Bugiri (51%) districts.

The proportion of those that completed senior four was relatively high among the AGYW aged between 20-24 years, 165 (21%), compared to 21 (6%) among those aged 15-19years. In addition, the proportion of those who never completed primary or attended school at all was higher among those aged 15-19 years, 224 (50%), compared to 275 (35%) for the age group 20-24 years. The difference in education attainment, among the groups, means that without interventions, those in age group 15-19 years will in the near future have more children, based on statistics that links lower the education with higher the fertility rates.

Table 7: Residential locations of AGYW

15-19years %(n) 20-24years %(n) Total(N) District Rural Urban Total(n) Rural Urban Total(n) Bugiri 68(15) 32(7) 22 76(28) 24(9) 37 59 Iganga 68(21) 32(10) 31 70(21) 30(9) 30 61 Kaliro 85(28) 15(5) 33 76(16) 24(5) 21 54 Kamuli 68(131) 32(62) 193 66(254) 34(129) 383 576 Luuka 70(31) 30(13) 44 48(49) 52(53) 102 146 Mayuge 58(21) 42(15) 36 45(28) 55(34) 62 98 Namayingo 65(30) 35(16) 46 87(40) 13(6) 46 92 Namutumba 65(28) 35(15) 43 69(80) 31(36) 116 159 Total 68(305) 32(143) 448 65(516) 35(281) 797 1245

The results in table 7 indicate that overall, 305 (68%) of the AGYW aged between 15-19 years lived in rural places, very similar to the age group 20-24 years, with 516 (65%) living in rural areas. The high proportion of AGYW residing in rural areas has implications on the communication channels needed to reach these groups. Radio, interpersonal communication, and respected community champions could be viable options.

Additionally, the majority of respondents 1152(93%) indicated that they stay with other people in the household. Among these, 473 (41%) were staying with partners or husbands, 210 (18%) lived with parents, and 109 (9%) stay with parent’s siblings.

The respondents were asked about their relationship with the household head; 396 (34%) were wives, 248 (22%) were daughters, and 395 (34%) reported other relationships with the household head. The residential status and the relations with the household head and others imply that decision making and support for adopting contraceptive choices will, to some extent, be determined or influenced by those persons the AGWY live with. Therefore, planned interventions must target, peers, family members and the community at large to gain approval.

12 | P a g e

3.2.2 Wealth related demographics

One of the outstanding factors that lead girls into pregnancy is the economic status, as a cause and consequence (6).The relationship between economic inequalities and pregnancy in adolescent health are well described in literature of teenage pregnancy causes(9). This assessment explores the type of economic occupation for AGYW. Table 8 indicates the main occupation of the respondents.

Table 8: Main occupation by age group

Main Occupation 15-19years %(n) 20-24years %(n) Total(n)%(n) Brewing Alcohol 20(1) 80(4) (0.4)5 Dobby 100(1) 0 (0.1)1 Food Vending 36(47) 64(82) (10.4)129 Hawking 6(1) 94(15) (1.3)16 Housewife 43(54) 57(72) (10.1)126 Maid 78(7) 22(2) (0.7)9 Other 39(83) 61(132) (17.3)215 Peasant Farmer 34(175) 66(334) (40.9)509 Salon 43(46) 57(62) (8.7)108 Shop Attendant 24(22) 76(71) (7.5)93 Tailoring 32(11) 68(23) (10.1)34 Total 448 797 1245

Table 8, indicates that the majority 509 (41%) AGYW were economically engaged in subsistence farming, 129 (10%) vended foodstuff, 93(7%) were shop attendants, 108(9%) worked in hair salons, and 34(3%) were tailors. Generally, 126 (10%) indicated that they were housewives, and were not engaged in any economic activity. These figures highlight the economic vulnerability of the AGYW. Economic empowerment is a key factor in decision making contraceptive choices.

The 2011, UDHS, showed that 34% of adolescents who got pregnant while teenagers were from poorest families compared 16% from wealthy households. Other reports have indicated that the youth constitute 80% of the Uganda unemployed population. The AGYW form a big component of the youth in Uganda. The Uganda Social Development Investment Plan of 2015-2016, puts youth at 57% (6.5 million) of the population, yet only 19% of these are employed. Unemployment is linked to failure of the economy to generate jobs to absorb the youth, and is also driven by a high population growth rate of 3.2%. The report notes that high unemployment rates, have made youth turn to anti- social activities. In Uganda, the International Youth Foundation Project, (10) made recommendations for employment creation with emphasis on youth led-enterprise development.

13 | P a g e

3.2.3 Proxy of wealthy status

Majority of the respondents 810 (65%) indicated that they had not paid for entertainment in the last one week preceding the study, 580 (47%) had not paid for smart looks, but 417 (33%) had paid once for smart looks in the last week to the study.

Implications: The respondent’s socio-demographic characteristics described above, point to a relatively vulnerable AGYW population which compromises their access to contraceptive choices. From contemporary literature, low levels of education are a determinant of: early marital engagements, teenage pregnancies, early child births and poor adoption of reproductive health choices. These factors combined contribute to high risk factors leading to generalized poor health outcomes among adolescent girls and young women in East Central Uganda. This is also supported by literature in other underserved areas of Pakistan (8).

3.3 Contraceptive knowledge and choices Key Findings • Contraceptive awareness was generally high, 64% for 15-19 years and 85% for 20-24 years. • There was a difference in proportions of those who were aware of a contraceptive choice, and those who knew how the method works. • The married were more aware about contraceptive choices, at 83%, compared to un-married at 69%. • The most known contraceptive choice across eight districts was pills at 74%, followed by; Depo-Provera at 62%, IUD and Male condom at 47% each. • Only 25% of the AGYW had sought advice about contraceptives in the past six months preceding the survey. • Majority sought advice on contraceptives from Health Workers/VHTs (46%), followed by; same sex peers (22%) and peer educators (15%) • The main reasons for seeking advice on contraceptives were birth spacing (36%) and pregnancy prevention (34%). • Fifty-four percent of the AGYW between 15-19 years who indicated that they would seek advice about contraceptives in the next 6 months mentioned pregnancy prevention as their main reason.

The conceptualization of the assessment domains about AGYW was based on the socio-ecological model as earlier mentioned. It is generally well known that health related changes are likely to happen if the target community has relevant health knowledge, intention and ability to act to overcome the risk factors, while adopting protective factors. The sub sections below present details about this framework of analysis.

3.3.1 Awareness of modern contraceptives and methods In this assessment, awareness and knowledge are distinct. To assess awareness about available contraceptive choices among AGYW; a list of available modern contraceptives and methods were generated and AGYW were asked to mention all the methods that they were aware of.

The results in Table 9, shows that awareness about contraceptives is generally high among the age group 20-24 at 680 (85%) compared to 285 (64%) among the 15-19 years. Similarly, the married were more aware about contraceptive choices, 609(83%), compared to un-married at 356(69%). Since both the married and unmarried are to some extent affected either by using or not using a particular contraceptive, it is recommended to increase awareness for both groups. The most mentioned contraceptive method across the eight districts was pills 714(74%), followed by Depo-Provera at 596 (62%).

14 | P a g e

Table 9: Awareness about contraceptives methods by age group and district

ligation

Spermicides Awareness about about Awareness contraceptives (n) Tuba Vasectomy IUD Implants Pills Condoms Male Condoms Female LAM Calendar Standard Withdrawal Depo Other Total District Yes (%)

15-19 years (n=448) 285 64 3 35 31 66 47 5 2 3 4 54 14 448 Bugiri 14 64 21 7 57 50 43 29 22 Iganga 14 45 21 14 64 64 7 14 29 21 29 31

Kaliro 14 42 14 21 36 57 14 7 14 64 33 Kamuli 117 61 3 40 35 76 40 5 1 3 2 3 64 7 193 Luuka 35 80 3 31 29 66 51 3 63 6 44 Mayuge 27 75 4 37 41 70 19 7 4 41 19 36

Namayingo 35 76 23 31 43 66 9 6 3 63 46 Namutumba 29 67 14 55 34 72 62 7 48 24 43 20-24 years (n=680) 680 85 9 2 52 50 77 47 9 2 1 6 5 65 13 797

Bugiri 32 86 6 50 38 72 34 3 56 38 37 Iganga 25 83 12 12 28 44 56 80 24 8 16 24 40 28 30 Kaliro 19 90 21 5 47 58 47 47 21 16 16 5 63 21 Kamuli 309 81 8 2 53 51 82 40 9 3 1 5 3 71 1 383

Luuka 99 97 5 51 45 85 52 2 2 2 4 80 14 102 Mayuge 56 90 16 5 73 70 82 23 2 2 2 11 7 45 7 62

1 | P a g e

ligation

Spermicides Awareness about about Awareness contraceptives (n) Tuba Vasectomy IUD Implants Pills Condoms Male Condoms Female LAM Calendar Standard Withdrawal Depo Other Total District Yes (%)

Namayingo 40 87 3 48 45 78 53 20 3 10 5 85 46 Namutumba 100 86 9 10 51 45 66 72 15 1 3 2 57 116 Total (n=965) 965 78 7 1 47 44 74 47 8 1 1 5 4 62 13 1245

2 | P a g e

Awareness about contraceptive choices (injections, pills, male condoms, implants, Intra Uterine Contraceptive Device (IUCD) and Withdraw), significantly varies across the seven districts. Over all, had the least awareness levels among AGYW 15-19 years at 42%, compared to at 80%. Among the 20-24 year olds, awareness levels were 81% for and 97% for Luuka. Awareness about Lactation Amenorrhea, female sterilization, did not vary much across the eight districts. The findings about the most frequently known methods of contraceptives is similar to another study in Kenya that focused on opportunities for social behavior communication (11).

Both this study and others show that awareness of at least one contraceptive method of is high. In this study, overall awareness was 78% for all respondents, slightly lower than the UDHS. According to the UDHS 2011, awareness of modern FP/ Contraceptives is high with 98% women and 100% men aware of at least one family planning method. Awareness of only one method is insufficient as the there are multiple choices of modern FP methods. Awareness of multiple choices is most desired, because it provides a chance for an individual to made a decision on desired method, out of the several that are available.

3.3.2 Knowledge on use of modern contraceptives and methods

To draw clear conclusions, the study assessed knowledge levels of how specific contraceptives methods are used. The results show that knowledge about how particular modern contraceptives method are used was lower compared to awareness. Knowledge on how specific methods are used, gives an insight about the potential for use of the selected contraceptive (table 10).

Out of the 74% of respondents who reported that they are aware of pills (table 9), only 45% (table 10), reported to know how the method (pills) are used. This trend was also observed with other methods including implants, vasectomy, tubal-ligation, IUCD and male and female condoms.

The results are similar to what is reported in the UDHS 2011. According to the UDHS 2011, despite the high levels of knowledge about modern contraceptives, their use remains low in Uganda. The UDHS 2011 states that the modern contraceptive prevalence stands at 26%, and the unmet need for modern contraceptives standing at 34%.

Promotion of awareness, improving knowledge on how the available contraceptive choices work is critical in motivating the adolescents and young women to shift to action. Increased knowledge will deter negative attitudes and improve the potential for uptake of available modern contraceptives which are considered effective. CHC interventions must therefore focus on increasing knowledge levels about modern contraception.

1 | P a g e

Table 10: Proportion of AGYW with knowledge on use of selected modern contraceptives

Tubal- Vasectomy IUD Implant Pills Male Female DEPO Spermicide ligation condom condom 15-19years 22 22 40 46 71 57 54 0 Bugiri 3 1 8 7 6 Iganga 3 2 9 9 1 3 Kaliro 2 3 5 8 2 Kamuli 3 47 41 89 47 6 75 1 Luuka 1 11 10 23 18 22 Mayuge 1 10 11 19 5 11 Namayingo 8 11 15 23 3 22 Namutumba 4 16 10 21 18 2 14 20-24years 32 36 31 48 45 67 44 71 36 Bugiri 2 16 12 23 11 18 Iganga 3 3 7 11 14 20 6 10 Kaliro 4 1 9 11 9 9 4 1 Kamuli 25 7 163 157 252 125 28 219 9 Luuka 5 50 45 84 51 2 79 Mayuge 9 3 41 39 46 13 1 25 1 Namayingo 1 19 18 31 21 8 34 Namutumba 10 51 45 66 72 15 57 1 Grand Total 31 43 29 46 45 68 46 67 33

3.4 Seeking advice on contraceptives

Negative attitudes and taboo about sex within the community prevent many AGYW from seeking information on contraceptives. The study sought to establish AGYW information seeking behaviors on contraceptives, and the common sources of advice.

Findings indicate that 25% of the respondents had sought advice on contraceptives in the six months preceding the survey (Refer Table 11). Further analysis indicated that married respondents were more likely to seek advice, (42 %), compared to the unmarried, (25%). There were no major differences in information seeking behavior between respondents in urban and rural areas across the two age groups, except for the married in the 15- 19 years’ category in which rural respondents (34%) sought advice more than their urban counterparts (24%). In most FP programs, seeking advice is based on a number of factors, but knowledge, supportive environment from family are key. The project should address factors to strengthen a supportive environment.

2 | P a g e

3.4.1 Source of advice on contraceptives

The study established that respondents sought advice from health workers/VHTs (46%), same sex peers (22%), and peer educators (15%). The least sources of advice were Ssengas (3%), different sex peer (4%), and husbands (7%). This data suggests that the respondents have more trust in health workers and same sex peers. The use of health workers with their expertise in providing health related knowledge remains critical in determining a successful contraceptive uptake campaign.

Table 11: Proportion of AGYW seeking advice on contraceptives by age and residence

Did you seek Source of Advice advice on Contraceptives in the last 6 months? No Yes Mother H/worker/ Sister Same Different Ssenga Peer Husband Other sex sex peer educator % % VHT peer Not Married 75 25 12 40 18 22 3 5 15 2 514

15-19years 84 16 18 27 24 31 4 7 13 275 Rural 84 16 17 17 31 38 3 14 181 Urban 83 17 19 44 13 19 13 13 13 94

20-24years 64 36 9 48 14 17 2 5 16 2 239 Rural 65 35 6 45 14 24 4 6 16 146 Urban 62 38 14 51 14 9 0 3 17 6 93 Married 58 42 7 49 7 22 4 3 21 9 731 15-19years 69 31 15 37 9 17 2 6 26 7 173

Rural 66 34 12 40 12 14 2 7 26 10 124 Urban 76 24 25 25 25 25 49 20-24years 55 45 6 51 6 23 4 2 19 10 558 Rural 55 45 7 52 7 26 3 1 20 8 370 Urban 54 46 3 51 6 17 7 3 18 11 188 Total 65 35 9 46 10 22 4 3 19 7 1245

Further analysis indicated that that the most preferred source of advice is older people 108(80%), (table 12). This can be attributed to their perceived knowledge and experience on sexuality, and family planning in particular. This finding suggest the use of a mixture of champions: relatively older individuals and peers.

3 | P a g e

Table 12: AGYW preference in seeking advice on contraceptives by marital status and age group

About Same Age % Mixture % Older % Younger % Total (n) Not Married %(n) 10(13) 6(8) 82(108) 2(2) 131

15-19years 11 4 82 2 45 Rural 10 86 3 29 Urban 13 13 75 16 20-24years 9 7 83 1 86

Rural 6 6 86 2 51 Urban 14 9 77 35 Married %(n) 7(22) 11(35) 79(242) 2(7) 306 15-19years 6 7 87 54

Rural 2 10 88 42 Urban 17 83 12 20-24years 8 12 77 3 252 Rural 7 11 80 2 165 Urban 8 15 72 5 87 Total (n=437) 8(35) 10(43) 80(350) 2(9) 437

3.4.2 Main reasons for seeking advice

The results in table 13 show that the main reasons for seeking advice on contraceptive choices in the next six months is to space births,158 (36%), and to prevent a pregnancy,150 (34%). For birth spacing, married adolescents,138(45%), plan to seek advice compared to their unmarried counterparts, 20(15%).

More than half (54%), of the respondents aged15-19 years who indicated that they would seek advice about contraceptives in the next 6 months gave pregnancy prevention as their main reason. Other reasons mentioned across the different age groups included menstruation (7%), sexual health (4%), and relationship issues (3%).

Much as birth spacing and pregnancy prevention stand out as the major reasons for seeking advice or intention to seek advice on contraception, promotion of contraceptives should consider sensitizing the target audience about all the available options. This will improve knowledge, impact on demand for services or adoption of favorable behaviors given the multiple contraceptive choices. Additionally, CHC should promote a wide range of modern contraceptive methods to cater for the varying needs of the specific age groups.

4 | P a g e

Table 12: Main Reason for seeking advice by age category and residence

Birth Menstruation % Other % Pregnancy Relationship Sexual Total Spacing % Prevention % Issues % Health (n) % Not Married 15(20) 8(11) 15(20) 54(71) 5(7) 2(2) 131 %(n)

15-19years 9 7 16 62 4 2 45 Rural 7 7 17 62 7 29 Urban 13 6 13 63 6 16 20-24years 19 9 15 50 6 1 86

Rural 22 12 12 45 8 2 51 Urban 14 6 20 57 3 35 Married %(n) 45(138) 7(21) 14(44) 26(79) 2(7) 6(17) 306 15-19years 39 4 11 37 4 6 54

Rural 40 5 12 38 2 2 42 Urban 33 8 33 8 17 12 20-24years 46 8 15 23 2 6 252

Rural 44 8 13 24 3 7 165 Urban 51 6 18 22 3 87 Total (n=437) 36(158) 7(32) 15(64) 34(150) 3(14) 4(19) 437

5 | P a g e

3.5 Likelihood and ability to use contraceptives

Key Findings based on respondents • Fifty-seven percent are likely to seek advice on contraceptives in the next 6 months • Fifty-six percent are likely to use contraceptives in the next six months. • Respondents in age category of 20-24 years, regardless of marital status were more likely to use contraceptives in the next six months than those aged 15-19 years • The proportions of those who have intention of delaying sex debut were relatively low at 27% • Sixty-three percent of those who were not sexually active needed skills to delay sex debut • The proportion of those likely to use contraceptives was high at 83%. • Fifty-four percent of those that intended to use contraceptives were “very much” confident to use contraceptives. • The level of confidence was higher among the married and those living in urban areas than unmarried and rural based AGYW.

Knowledge is a precursor to the likelihood for action and ability to act. Besides examining knowledge, the assessment sought to understand the likelihood and ability to use contraceptives. The subsequent sub sections provide specific details about the likelihood to act or seek contraceptives, based on a range of predetermined service options for modern family planning contraceptives.

3.5.1 Current use of contraceptives in the target districts In order to establish the current level of contraceptive use in the target districts, secondary data from DHIS2 was reviewed. The data indicated that 19,320 AGYW between 15-24 years were using contraceptives. Among the users, the majority (8,506), were using injectable, while 7,791 used the male condom.

Seven thousand four hundred twenty (7,420) AGYW had visited health facilities to get family planning services for the first time.

Data in table 14 indicate that Namayingo and Kaliro had the least number of AGYW using contraceptives. This is also reflected by low levels awareness and knowledge on the use of contraceptives; and low percentages of AGYW (24%) in the district who knew their rights to contraceptive knowledge, use and approval. However, the data is not comparable with other districts since the data collected is based on numbers only. Using the current number as baseline and at end line, the same data sources and variables will be extracted to compare any possible changes.

6 | P a g e

Table 14: Number of AGYW using contraceptive prior to the assessment Total FP FP Oral: Female Injecta Male Oral: Lo- Oral : Other District Users (All first IUDs Natural Microg Condom bles Condom Feminal Ovrette Methods Methods) visit ynon Bugiri 3647 2335 114 20 1197 2196 43 57 20 Iganga 1752 990 3 462 952 143 134 58 Kaliro 1062 175 2 1 359 671 22 7 Kamuli 3981 1491 150 28 2157 1032 198 58 320 13 25 Luuka 1892 920 0 11 881 964 0 1 33 0 2 Mayuge 3004 1019 145 14 1229 1333 47 112 1 123 Namayin go 957 399 86 26 539 271 26 0 4 0 5 Namutu mba 3025 91 26 1192 1181 91 64 187 284 Total 19320 7420 500 588 8506 7791 427 123 854 14 517 Data Source: HMIS data October 2015

3.5.2 Intent to use selected modern contraceptives

Intent to use contraceptive methods was categorized into three analytical components; seeking, using contraceptives and delaying sex debut. For the sex debut component, we only focused on unmarried adolescents.

3.5.2 (A) Intent to seek contraceptives in the next 6 months

To measure intention to seek contraceptives, including advice, in the next 6 months, an odd number scale of three levels (likely, somewhat likely and unlikely) was used.

Table 15 indicates that those likely to seek advice on contraceptives within the next 6 months (57%), was almost double those who were unlikely, (26%). The married were more likely to seek advice than the unmarried, 63% and 49% respectively. The proportion of those unlikely to seek advice (26%) was quite high and justifies a behavioral based intervention, initially to increase knowledge and create demand for contraceptives.

3.5.2(B) Intent to use contraceptives in the next 6 months

Similar for intent to seek contraceptives, in the next 6 months, an odd number scale of three levels (likely, somewhat likely and unlikely) was used to measure intent to use contraceptives. Slightly more than half (56%), were likely to use contraceptives in the next six months. AGYW in the age group 20-24 years, regardless of their marital status, were more likely to use contraceptives in the next six months than those aged 15-19 years.

As indicated in Table 15, there were no major differences between those who were likely to seek contraceptives and those likely to use them in the next six months. Whereas 57% of the respondents were likely to seek contraceptives, 56% reported that they were likely to use contraceptives in the next six months. Generally, intent to use was highest among those aged 20-24 years, 64% for the married and 59% for the unmarried. Twenty-eight percent (28%) indicated that they were unlikely to use contraceptives in the next six months. These statistics portray a need for demand creation and change in attitudes towards adoption of contraceptives among the AGYW in the region. The

7 | P a g e

low figures justify the need for innovative approaches to share knowledge, and challenge negative attitudes against contraceptive use.

Table 15: Proportion of AGYW with intent to seek, use contraceptives and delay sex debut in the next six months

Likely To Seek Likely To Use Contraceptives Delay Sex Debut Contraceptives

% % %

% % %

% % %

% % % %

nlikely nlikely nlikely ikely ikely ikely Total (n) Total Don’ t Know L Likely Somewhat U Don’ t Know L Likely Somewhat U Sex Had Already Debut Don’ t Know L Likely Somewhat U Not Married 8 49 12 31 8 49 11 33 49 5 27 8 11 514 15-19years 15 40 10 35 13 39 9 39 40 8 33 8 11 275 Rural 17 39 10 34 15 38 9 37 40 8 35 4 12 181 Urban 11 43 10 37 9 41 7 43 41 6 29 14 10 94 20-24years 1 60 13 26 1 59 13 27 59 3 20 8 11 239 Rural 1 58 13 27 1 55 14 29 53 3 22 12 10 146 Urban 1 62 14 23 1 66 10 24 67 2 16 1 14 93 Married 4 63 11 22 3 62 11 24 100 731 15-19years 5 57 12 26 5 54 13 28 100 Na Na Na Na 173 Rural 5 58 11 26 4 52 15 29 100 Na Na Na Na 124 Urban 4 55 14 27 6 59 10 24 100 Na Na Na Na 49 20-24years 4 65 10 21 3 64 10 23 100 Na Na Na Na 558 Rural 4 65 10 22 2 64 11 24 100 Na Na Na Na 370 Urban 4 65 10 20 4 66 10 20 10 Na Na Na Na 188 Total (n=1245) 6 57 11 26 5 56 11 28 100 1245

3.5.2 (C) Intent to delay sexual debut in the next 6 months

At a conceptual level, the goal is to help females who have not had their sexual debut to delay, and for those who have already had sex to seek and take up contraceptive methods, either to prevent pregnancy or space child bearing. Tables 15 and 16, illustrate details about intention related to delaying sexual debut and the confidence in doing it.

The proportion of respondents who intend to delay sexual debut were relatively low (table 15). The study established that 252 (49%) of the unmarried were already sexually active; 27% reported that they were likely, 8% somewhat likely while 11% were unlikely to delay sexual debut in the next six months. Among the 15-19 year olds, those intending to delay sexual debut were 33% compared to 20% among those aged 20-24 years. Those unlikely to delay

8 | P a g e were the same (11%) among both age groups. AGYW living in rural areas were more likely to delay sexual debut than their urban counterparts.

3.5.3 Ability to delay sexual debut

The ability and confidence levels to delay sexual debut was assessed on the proportion of the AGYW who needed skills and their reported confidence in delaying sexual debut. The confidence levels were rated on an ordinal scale of; likely, somewhat likely, unlikely and don’t know as shown in table16. Unlike results in table 15 where 27 percent (139/514) of the participants indicated that they were likely to delay sexual debut, the results displayed in table 16 indicate that 63 percent (165/262) percent of the participants who were not sexually active needed skills to delay sexual debut while 37 percent (97/262) did not. Additionally, only 138 (27%) were confident they would delay sexual debut while 57 (11%) were unlikely to do so.

Table 16: Confidence and ability to delay sex debut

Require additional Confidence to delay sex debut skills to delay sex

debut Yes % No % Sexually Likely Somewhat Unlikely Don’t Active Likely know Age group 63 37 49 27 8 11 5 15-19 Years 66 34 40 33 8 11 8 20-24 Years 60 40 59 20 8 11 3 Residence 63 37 49 27 8 11 5 Urban 61 39 54 23 85 12 4 Rural 64 36 46 29 8 11 6 Total 63 37 49 27 8 11 5 N=262 Note: This table considered only respondents who were not married at the time of the interview

3.5.4 Norms and attitudes

Norms of the respondents were explored at an individual level focusing on approval of health behaviors. The assessment explored if the respondents generally approve, disapprove, or feel neutral towards contraceptive use. (see details in sub sections).

9 | P a g e

3.5.4 (A) Ability to act

Ability to act was assessed on the intention to use contraceptives by the AGYW and their level of confidence to use the contraceptives. Table 17 shows a high proportion, 83%(1035) of respondents likely to use contraceptives. Generally, the married were more likely to use contraceptives than the unmarried. There were no major differences on intention to use contraceptives between AGYW in urban and rural areas across different age groups.

The level of confidence varied from age group, marital status and residential status. The results show that overall 557(54%) of those that intended to use contraceptives were “very much” confident to use. The level of confidence was higher among the married and those living in urban areas than unmarried and rural based respondents.

Table 13: Intention and Ability to use contraceptives by marital status and residential status

Intend to Use Level of Confidence contraceptive No % Yes% Don’t Little Moderate Not At Very Total Total Know All Much (N) “yes” (n) Not Married 22 78 5 15 26 3 51 514 399 15-19years 33 67 7 21 26 5 42 275 183 Rural 35 65 6 20 23 6 45 181 117 Urban 30 70 8 23 30 5 35 94 66 20-24years 10 90 4 5 14 1 32 239 216 Rural 12 88 5 9 26 2 57 146 129 Urban 6 94 1 10 26 1 61 93 87 Married 13 87 4 11 26 3 56 731 636 15-19years 16 84 5 14 28 4 49 173 146 Rural 17 83 7 14 30 4 46 124 103 Urban 12 88 2 14 23 5 56 49 43 20-24years 12 88 4 10 26 3 58 558 490 Rural 15 85 5 9 27 3 55 370 316 Urban 7 93 1 11 24 2 63 188 174 Total 17 83 4 12 26 3 54 1245 1035

3.5.4 (B) Need of skill on contraceptive use

Respondents were asked if they needed skills on contraceptive use and whether they knew where to obtain the skills. The results in table 17 indicate that 1106(89%) needed skills on contraceptive use, but only 1033(83%) knew where to get the skills. Among those who indicated that they knew where to get the skills, the majority 816 (79%) mentioned a government health center, while 434 (42%) indicated a government hospital. Only 283(27%) indicated private hospital or health facility.

10 | P a g e

Based on the observations around behavioral intentions and the ability to act, several conclusions can be drawn. Firstly, the proportion of AGYW who are likely delay sex debut is very small, specifically among the unmarried and those who have not had sex. Additionally, most of the respondents indicated the need for skills either to build confidence or to negotiate safer sex options. These observations call for intensified counseling to delay sexual debut and tailored sensitizations to promote skills on contraceptive use. Much as the majority approve the use of contraceptives, those with confidence to act are few, indicating that interventions to build individual confidence are necessary.

Table 148: Skills on Contraceptives and where to obtain contraceptives

%

%

%

% %

% %

%

%

% %

%

sector

%

% % %

%

/VHT “yes”

harmacy (n) (N) Skills Need Additional Contraceptives Where To Obtain Govt Hospital Center Govt Health Clinic Family Planning Outreach CHW public Other Private Hospital Private Clinic P Shop Drug Nurse Midwife Private Doctor Outreach Clinic Center /PeeCornerYouth Peer Educator Ngo worker Private Medical Other yes yes Total Tota l Not 83 75 41 77 9 3 2 1 9 29 10 20 2 3 1 1 1 Married % 384 514 15- 77 63 34 76 6 3 2 7 25 6 19 2 3 1 19years 173 275 Rural 78 62 25 81 5 3 1 6 26 8 21 2 3 112 181 Urban 73 65 51 66 8 5 3 8 23 3 16 3 5 2 61 94 20- 91 88 46 77 12 2 1 2 10 33 13 20 1 2 1 1 24years 211 239

Rural 90 88 43 81 14 2 2 4 11 33 14 19 1 2 2 1 2 129 146 Urban 94 88 51 72 9 1 10 34 11 21 1 2 0 82 93 Married 93 89 43 80 10 3 4 1 10 26 7 15 1 3 1 1 3 % 649 731 15- 90 83 39 81 8 2 1 3 24 6 14 1 4 3 19years 143 173 Rural 87 84 38 84 7 2 1 4 21 6 12 1 4 4 104 124 Urban 96 80 41 74 10 3 31 5 21 5 3 39 49 20- 94 91 44 80 11 4 5 1 11 27 8 15 1 3 1 1 1 2 24years 506 558 Rural 94 91 39 84 11 4 5 1 12 29 7 15 1 2 1 1 1 2 338 370 Urban 34 33 54 73 12 4 4 2 11 23 10 15 1 5 1 1 2 2 168 188

11 | P a g e

Total(n=1 89 83 42 79 10 3 1 9 27 8 17 1 3 1 1 2 033 1033 1245 District Bugiri 86 80 45 66 4 21 13 4 2 47 59 Iganga 74 79 33 98 8 10 4 6 4 33 13 13 4 4 2 4 48 61

Kaliro 3 3 18 94 18 6 6 38 18 32 9 6 3 34 54 Kamuli 92 83 54 72 16 4 4 1 10 24 6 12 4 1 1 1 477 576 Luuka 90 89 34 87 5 8 16 9 28 2 1 1 1 130 146 Mayuge 87 87 20 85 5 5 1 11 21 15 24 1 5 1 1 1 85 98 Namaying 79 85 49 67 1 3 22 38 8 32 5 1 17 o 78 92 Namutum 96 84 25 93 5 1 3 1 7 44 6 9 1 2 1 1 ba 134 159 Total 89 83 42 79 10 3 3 1 9 27 8 17 1 3 1 1 2 1033 1245

12 | P a g e

3.6 Attitude towards contraceptive use

Key findings

• Sixty-nine percent of the respondents approve the use of contraceptives • The proportion who approve the use of contraception increases with education • Kaliro and Namayingo districts had the least approval levels towards contraceptive use, 46% and 38% respectively.

The respondents were asked if they approve, disapprove, or feel free or neutral towards contraceptive use (Table 19). In total, 860(69%)approved, 84(7%) disapproved, 235(19%)were neutral, while 66(5%) did not know.

Within the age groups, the proportion of respondents who approve contraceptive use among those aged 20-24 years was high at 615(77%), compared to 245(55%) for ages15-19 years. The results also indicate that 310 (60%) of the unmarried AGYW and 550 (75%) of the married approved using contraceptives.

The approval of contraception use increases with education. Sixty-three percent of AGYW with no education approved the use of contraceptives compared to 74% and 90% among those who completed senior four and senior six and above respectively.

District specific data indicate that Kaliro and Namayingo districts had the least approval levels at 46 percent and 38 percent respectively. The highest numbers of AGYW who disapprove of the use of contraceptives were observed in Kaliro district with 13%.

In terms of place of residence, there were no major differences among those who approved or disapproved the use of contraceptives. For example, 574 (70%) in rural and 286 (67%) in urban approved the use of contraceptives.

13 | P a g e

Table 19: Attitudes towards contraceptive use by age group and district

Approve Disapprove %(n) Don’t Know Neutral %(n) Total (n) %(n) %(n) Marital Status 69 (860) 7 (84) 5 (66) 19 (235) 1245 Not Married 60(310) 10(50) 10(50) 20(104) 514 Married 75(550) 5(34) 2(16) 18(131) 731 Age group 69 (860) 7 (84) 5 (66) 19(235) 1245 15-19 years 55(245) 10 (46) 12 (53) 23(104) 448 20-24years 77 (615) 5%(38) 2 (13) 16 (131) 797 Place of residence 75(550) 5(34) 2(16) 18(131) 731 Rural 70(574) 6.3 (52) 5.7 (47) 18 (148) 821 Urban 67 (286) 8 (32) 4 (19) 21 (87) 424 Education No education 63 (314) 5 (25) 9(44) 23 (115) 499 Primary level 72 (377) 8 (42) 4 (21) 16 (84) 524 Senior Four 74 (142) 8 (15) 2 (4) 17 (33) 192 90 (27) 3 (1) 0 7 (2) 30 District Bugiri 78 (46) 0 (0) 7 (4) 15 (9) 59 Iganga 67 (41) 10 (6) 5 (3) 18 (11) 61 Kaliro 46 (25) 13 (7) 24 (13) 17 (9) 54 kamuli 74 (426) 9(52) 3 (17) 14 (81) 576 Luuka 66 (96) 2 (3) 5 (7) 27 (39) 146 Mayuge 78 (76) 6 (6) 2 (2) 14 (14) 98 Namayingo 38 (35) 9 (8) 11 (17) 42 (39) 92 Namutumba 72(114) 3 (5) 5(8) 20 (32) 159 Total 69(860) 7(84) 5%(66) 19%(235) 1245

14 | P a g e

3.7 Rights to contraceptive knowledge

Key findings

• Slightly more than half (54%) of the respondents indicated that they knew their rights to contraceptive knowledge and use • Knowledge on contraceptive rights was slightly higher in urban areas across the different age groups, and with marital status. • Kaliro district had the least number (24%) of respondents who knew their rights to contraceptive knowledge and use while had the highest scores on knowledge rights about contraceptives at 64%.

Uganda has a liberal FP policy, which stresses that all sexually active men and women have access to contraceptives without consent from partners or parents. The respondents were asked if they knew about their rights to contraceptive knowledge and use (table 20).

The results in table 20 indicate that overall slightly more than half (54%) of the respondents indicated that they knew their rights to contraceptive knowledge and use. Knowledge on contraceptive rights was slightly higher in urban areas across the different age groups, and with marital status.

Knowledge on the right to contraceptives was high among the married AGYW at 424(58%) compared to the un- married at 247(48%). Generally, the proportion of respondents who knew their rights to contraceptives was higher in urban areas across different age groups and marital status, than in rural areas.

Within the participating districts, knowledge on rights to contraceptive use ranged from 64% to 24%. Kaliro district scored least with 24% while Bugiri district had the highest scores at 64%.

15 | P a g e

Table 20: Rights to contraceptives by marital status, age group and residence

Do you know your rights to contraceptive Total knowledge and use %(n) No Yes Not Married 52(267) 48(247) 514 15-19years 59(162) 41(113) 275 Rural 63(114) 37(67) 181 Urban 51(48) 49(46) 94 20-24years 44(105) 56(134) 239 Rural 45(65) 55(81) 146 Urban 43(40) 57(53) 93 Married 42(307) 58(424) 731 15-19years 45(77) 55(96) 173 Rural 49(61) 51(63) 124 Urban 33(16) 67(33) 49 20-24years 41(230) 59(328) 558 Rural 43(159) 57(211) 370 Urban 38(71) 62(117) 188 Total 46(574) 54(671) 1245

3.8 Exposure to information on health

Key findings

• The majority (62%) of the respondents heard messages about HIV/AIDs on radio, 59% from health centres, and 25% from community outreaches. • CHC intervention districts (Iganga, Kamuli, Namutumba, Luuka and Mayuge) have more people exposed to messages compared to the control districts (Bugiri, Namayingo). • Respondents in Namutumba, Luuka and Kamuli districts had the highest levels of exposure to health topics/messages at 25%, 22% and 20% respectively.

The study investigated exposure to health topics such as HIV/AIDS prevention, condom use, partner reduction, HIV testing, and HIV treatment among others.

The exposure was rated over the last six months prior to the study. The questions related to having heard a massage on selected health topics from various sources which included:1=Radio; 2=TV; 3=Health center; 4=Posters, billboards, leaflets, 5=Outreach, mobile counseling, medical camp; 6: Home visits by VHT, champions; 7=Social

16 | P a g e media, SMS; 8=Video halls/dens; 9=Community Events, church, burials; 10=Ssengas; No=11; 12=Don’t know 13=Declined

3.8.1 Current exposure to messages on HIV prevention and contraceptives

CHC is implementing the OBULAMU Campaign across the country including the east central region. The assessment partly explored the extent of exposure among AGYW to this campaign. The assessment used both unprompted and prompted questions regarding exposure to the OBULAMU campaign. Exposure is defined here as having seen or heard of a health related topic such as HIV prevention and or contraceptive use in the last six months. Generally, 90% have heard or seen a health related topic in the last 6 months. Specifically, 5% saw/heard once, 30% heard/saw two to three times, and 55% heard/saw five and more times.

Table 21 indicates that the majority (62%) of the respondents heard messages about HIV/AIDs on radio, 59% from health centres, and 25% from mobile outreach. The least mentioned sources of information were social media and Ssengas at 1%.

There is also a general observation that the CHC intervention districts (Iganga, Kamuli, Namutumba, Luuka and Mayuge) have more people exposed to the messages compared to the control districts (Bugiri, Namayingo). Much as Kaliro is a control district, the proportion on exposure was quite high (85%).

Exposure to health messages through community shows was highest in the intervention districts: Namutumba (25%), Luuka (22%) and Kamuli (20%).

17 | P a g e

Table 21: Exposure to HIV/AIDS and contraceptive messages by source, age group and district

% %

%

%

% %

% %

% %

eclined adio sengas

R TV Centre Health Billboards Posters Leaflets Mobile Outreach Medical Counseling camp VHT By Visit Home ,SMS media Social Dens hall Video Event Community Burials Church S no Don’ Know t D Total(N) 15-19years 61 6 51 6 23 8 1 18 2 11 1 448 Bugiri 41 9 9 9 41 22 Iganga 77 3 71 10 19 3 16 6 31 Kaliro 88 6 76 36 45 21 3 6 3 6 33 Kamuli 52 10 44 1 22 7 1 23 1 16 1 1 193 Luuka 91 2 39 7 14 25 5 44 Mayuge 56 3 42 3 11 3 3 6 3 6 36 Namayingo 57 70 7 35 24 9 7 4 2 46

Namutumba 53 6 2 23 7 23 5 2 2 2 43 20-24years 62 8 63 5 27 9 1 18 1 7 1 797 Bugiri 38 3 41 5 22 22 11 37 Iganga 90 17 67 10 20 10 3 3 30 Kaliro 81 5 81 29 48 10 14 21 Kamuli 57 6 60 5 31 11 1 19 1 10 1 383 Luuka 83 24 66 6 24 3 5 1 21 3 2 1 102 Mayuge 56 5 45 6 6 8 10 3 62 Namayingo 54 80 4 46 26 4 2 46

Namutumba 62 3 78 1 2 4 26 5 1 116 Total 62 7 59 5 25 9 1 18 1 8 1 1245 (N=1245)

18 | P a g e

4. Implications for SBCC interventions

As mentioned above, the socio-ecological model was used to focus these results for possible utilization by the program intervention. Data were analyzed for the core principles of knowledge, motivation, ability to act, and norms. Below are outstanding implications and suggested interventions.

Knowledge

a. Most AGYW in the sample have low education levels (primary and below), hence the need to design simple easy to understand messages, preferably illustrative. Awareness about available modern contraceptive methods is high, but knowledge on how the contraceptive methods work is low, a factor which could be limiting their use. Health communication interventions should primarily focus on increasing knowledge levels on how the different contraceptive methods to optimize use by AGYW.

Motivation

a. Benefits of births spacing and delayed conception should be emphasized, in addition to addressing fears and misconceptions. This suggestion is supported by findings from participatory action research with the same target population (June 2015). Additionally, the AGYW, should know about contraceptive choices and be supported in making decisions about these choices.

Ability to act

a. Most of the respondents expressed ability and intent to act, and admitted to knowing where to go for services. Communication interventions with motivational actions are needed to shift the intent and ability to services uptake. b. A large proportion of the respondents in all age groups were already married or had a child. Health communication interventions should promote options for child spacing as well as limiting the number of children. c. Respondents who had intention to use contraceptives were lower than those who intended to seek advice on contraceptive use. Health communication interventions should focus on a call to uptake. d. The respondents who expressed the ability to delay sexual debut were few, less than 30%. Communication should aim at empowering the girls with skills to negotiate condom use, sexual decisions and healthy relationships with the opposite sex. e. Seeking advice on contraception is low. Though, the reasons for this were not expressed, communication needs to identify and empower the trusted sources (peers, friends and relatives) to provide information to the AGYW.

Norms

a. Results indicate that while the majority of the respondents approved the use of contraceptives, uptake is low. Communication interventions should inform about the availability of contraceptive choices, address fears, and neither options nor choices.

19 | P a g e

5. Study limitations

The study was limited to knowledge of contraceptives choices, sampled out of school AGYW. Understanding issues that put AGYW at risk of pregnancy would require a qualitative component. This was not done because the interest of the program was to provide services within the domain of contraceptive choices for AGYW. Despite this limitation, the study strength lay in the use of a robust methodology of adopting control and treatment study arms and benefited from other existing literature and HMIS records and internal peer review mechanisms at CHC.

20 | P a g e

REFERENCES

1. Statistics UBo. National Population and Housing Census 2014 Provisional Results. 2014 Revised Edition ed2014. 2. Uganda U. Republic of Uganda.Harnessing The Demographic Dividend:Summary. In: Development MoFaE, editor. 2014. 3. Bandiera OB, N.; Burgess, R.; Goldstein, M.; Gulesci, S.; Rasul, I.; Sulaiman, M. Empowering adolescent girls in Uganda. World Bank. Contract No.: 4. 4. UNFPA. Adolescent pregnancy, a review of the evidence. New York: 2013. 5. Health Mo. Annual Health Sector Performance Report, Financial Year 2013/2014,. 2014. 6. Inc. UBoSUaII. Uganda Demographic and Health Survey 2011. , Uganda: UBOS and Calverton, Maryland: ICF International Inc2012. 7. McKee N, Erma Manoncourt, Chin Saik Yoon, and Rachel Carnegie, . Involving people, evolving behavior. The Unicef Experience New York: UNICEF; 2000. 8. Syed Khurram Azmat MA, Muhammad Ishaque, Ghulam Mustafa, Waqas Hameed Omar Farooq Khan, Ghazunfer Abbas, Marleen Temmerman and Erik Munroe. Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: results of a cross-sectional baseline survey Bio medical Central. 2015:12-25. 9. WHO. WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries. 2011. 10. Foundation IY. A cross-section Situation Analysis of Youth in Uganda: Navigating Challenges, Charting Hope. 2011. 11. Alaii J. Fears, Misconceptions and Side Effects of Modern Contraceptives in Kenya: . In: G. Nanda aAN, editor. Opportunities for Social and Behaviral Change Communication Washington, DC:: FHI 360/C-Change; 2012.

21 | P a g e

ANNEX 1: DATA WEIGHING PROCEDURE

Weighting:

A simplified approach was used based on enumeration counts (Number of AGYW counted at each venue/venue) of each sampling event which produced probability weights (p weights). This was achieved by using the enumeration count of each venue/event as the basis for the weight. In many cases, the number of participants at each event is different to warrant weighting.

In brief, the weighting produced estimates that reflect the ratio of the number of persons enrolled to the number of eligible persons at each recruitment venue/event. If the same ratio is conserved across all recruitment events, then the sample is self-weighted or no adjustment would be needed.

To show how we weighted, the following table illustrates the details of the study, the enumeration counts for each venue/event and the total number of interviews completed at each of those venues/events. Column 2 shows the total number of potential AGYW enumerated at each venue/event, column 4 is the proportion that each venue/event represents of the total enumeration count for the entire study (for event 2 that would be 160/366 = 0.437158), column 3 is the total number of interviews completed at each event and column 5 is the proportion of the total number of completed interviews that each venue/event represents (for event 2 that is 31/87 = 0.437158). Finally, column 6 shows the calculated p weight for each event (for event 2 0.437158/0.356322 = 1.226864). This p weight would then be applied to each interview completed during that event.

Venue/Event enum_count int_count p_enum p_int p_weight BUMUTBPSSA24 28 7 0.076503 0.08046 0.95082 BUMUTLPBSU47 160 31 0.437158 0.356322 1.226864 BUMUTMTCSA46 120 21 0.327869 0.241379 1.358314 IGBUSBMAFR26 41 15 0.112022 0.172414 0.649727 IGNAKNHCTH91 17 13 0.046448 0.149425 0.310845

366 87 1 1 4.496569

The following implementation was used in stata to declare the survey variables for a weighted analysis: svyset venue [pweight=p_weight], strata(agegroup) vce(linearized) singleunit(missing)

pweight: p_weight

VCE: linearized

Single unit: missing

Strata 1: agegroup

SU 1: venue

FPC 1:

22 | P a g e