The negotiation and management of sexual and reproductive health behaviour in marital relationships in rural south-western Uganda Ailie Tam 2019 Submitted for the qualification of Doctor of Philosophy in International Development University of East Anglia School of International Development This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that use of any information derived there from must be in accordance with current UK Copyright Law. In addition, any quotation or extract must include full attribution i Contents List of tables, maps and photographs .................................................................................... v Abstract ................................................................................................................................... vii Chapter 1 – Introduction ...................................................................................................... 10 1.1 HIV/AIDS in Uganda ..................................................................................................... 12 1.2 Rates of fertility and family planning ............................................................................ 15 1.3 The sexual and reproductive health needs of married individuals ................................. 18 1.4 Research aims and questions .......................................................................................... 20 1.5 Thesis outline ................................................................................................................. 21 1.6 Study location and population ........................................................................................ 22 Chapter 2 – Theoretical framework ..................................................................................... 24 2.1 The social determinants of health................................................................................... 26 2.2 Structure-agency............................................................................................................. 27 2.3 The institution of gender ................................................................................................ 30 2.4 Marriage ......................................................................................................................... 32 2.5 Risk environment ........................................................................................................... 35 2.6 Summary ........................................................................................................................ 38 Chapter 3 – Methodology ...................................................................................................... 40 3.1 Overview of research design .......................................................................................... 40 3.2 Epistemology underpinning a mixed social science methodology ................................ 41 3.3 Study site – HIV prevalence........................................................................................... 44 3.4 Village selection ............................................................................................................. 45 3.5 Sampling and data collection ......................................................................................... 49 3.5.1 Pre-test and pilot interviews and focus group ......................................................... 50 3.5.2 Life-story respondent sampling and interviews ....................................................... 50 3.5.2 Focus group sampling and discussions .................................................................... 56 3.5.3 Key informant sampling and interviews .................................................................. 57 3.6 Data analysis .................................................................................................................. 58 3.7 Strengths and limitations of the data .............................................................................. 61 3.8 Ethical considerations .................................................................................................... 62 3.9 Researcher reflexivity .................................................................................................... 64 Chapter 4 – Marriage and types of marital relationship ................................................... 67 4.1. Typology of marital relationship ................................................................................... 68 4.1.1 Life-story respondents ............................................................................................. 70 4.1.2 Patterns of marriage by sex and age ........................................................................ 71 4.1.3 Polygamous and extra-marital relationships ............................................................ 72 ii 4.2 Informal marriage ........................................................................................................... 74 4.3 Customary marriage ....................................................................................................... 79 4.4 Religious marriage ......................................................................................................... 83 4.5 Summary ........................................................................................................................ 89 Chapter 5 –Female roles, duties and practices relating to marriage ................................ 93 5.1 Linda’s story ................................................................................................................... 95 5.2. Girlhood ........................................................................................................................ 98 5.2.1 Preparing girls for marriage ..................................................................................... 98 5.2.2 Domestic work and discontinuing education ......................................................... 100 5.2.3 ‘Playing sex’, transactional sex and sexual coercion ............................................ 100 5.2.4 Rape and culture of sexual violence ...................................................................... 104 5.3 Wifehood ...................................................................................................................... 105 5.3.1 The duties of being a ‘good’ wife .......................................................................... 106 5.3.2 Showing love, cooperation and being submissive ................................................. 109 5.3.3 Hygiene practices and sexually satisfying a spouse .............................................. 110 5.4 Motherhood .................................................................................................................. 113 5.4.1 Demonstrating fertility capabilities ....................................................................... 113 5.4.2 Being a ‘good’ mother ........................................................................................... 115 5.5 Summary ...................................................................................................................... 117 Chapter 6 – Manhood and the values of masculinity ....................................................... 121 6.1 Michael’s Story ............................................................................................................ 122 6.2 Attracting and retaining sexual partners....................................................................... 126 6.3 Work, mobility and spaces of sexual mixing ............................................................... 129 6.4 Authority, control and violence .................................................................................... 133 6.5 Virility and fathering children ...................................................................................... 136 6.6 Summary ...................................................................................................................... 139 Chapter 7 – Fertility and family planning ......................................................................... 142 7.1 High fertility in this setting .......................................................................................... 145 7.2 Infant deaths and reproductive mishaps ....................................................................... 146 7.3 Fertility preferences and discussing family planning with a spouse ............................ 147 7.3.1 Female views on fertility preferences .................................................................... 148 7.3.2 Male views of family planning .............................................................................. 149 7.3.3 Discussing family planning in marriage ................................................................ 150 7.4 Aisha’s story ................................................................................................................. 151 7.5 Family planning approaches over the life-course ........................................................ 152 7.5.1 God’s family planning ........................................................................................... 155 7.5.2 Abstinence ............................................................................................................. 157 iii 7.5.3 The Safe Days Approach ......................................................................................