“Safe sex advice is good - but so difficult to follow”. Views and experiences of the youth in a health centre in Kampala

Abstract

Background

Young people in Uganda are advised by the Ministry of Health and other authorities to abstain from sex in order to avoid the human immunodeficiency virus (HIV), other sexually transmitted diseases (STD) and early pregnancies. If they cannot abstain they should use condoms and they should stay faithful to their partner.

Objective

To find out how young people perceive this advice and if they find it possible and realistic to follow.

Method

In May and June 2000 twenty informants were selected by purposeful sampling and were interviewed in English. Given items were discussed. The interviews were recorded on tape, transcribed, extracted and sorted into categories in a qualitative research method.

Results

Most of the interviewed youth claimed that the advice is good and helpful but there are many obstacles. The results showed that information given in schools about condom use and safer sex behaviour is not always adequate. However, despite lack of clear health education messages, the risk of being HIV positive is of major concern to many youth. In addition, the expected lack of support if the test is positive is a common reason for abstaining from HIV testing.

Conclusions

More discussions in society are needed to create consensus on safe sex messages presented to young people. HIV infection is a major concern but many young people abstain from testing, as they expect to receive inadequate support.

Introduction

Adolescents in Uganda are at high risk of acquiring HIV and other STDs. In the 1995 Uganda Demographic and Health Survey, 72% of young females indicated that they had experienced intercourse by age 18 and median age of first intercourse was 16.5 years. ¹ Thirty percent of female adolescents reported having had sexual intercourse by the age of 15. Due to biological and other factors adolescents are regarded as being more susceptible to STDs. ² In Rakai, a rural district in southwestern Uganda, the incidence and prevalence of HIV-1 infection was investigated in a population-based study undertaken in 1990. ³ Among those aged 15–19 years, 1.8% of men and 19.0% of women were HIV-positive. During the 2 years of follow up the incidence of HIV-1 infection remained at a substantial level: 1.1 seroconversions per 100 person-years (PY) of observation among men age 15–19 and 3.9 per 100 PY of observation among 15–19 year old women, despite reported behavioural change. A study in Mbale, Uganda, where focus group discussions were held with 17–18 year old youth showed that knowledge of safe-sex behaviour and reported behaviour have little in common. ⁴ Among the married adolescent women in the Rakai study the spouse was on average eight years older than the woman was. This age differential might explain the difference in infection rate between adolescent men and women. For both men and women, rates of HIV infection were higher among residents in trading centres as opposed to more rural areas and also higher with higher level of education ^3,5. This implies that the STD/HIV situation among adolescents in an urban area like Kampala could be even worse.

There is consensus in many countries among decision-makers and non-government organisations (NGOs) that prevention of the spread of HIV and other STDs is necessary. In Uganda three major life skill “rules” are often presented: 1. Abstain from sex! (until marriage) ². If you can't, use condoms! ³. Stick to one partner! (for life). These messages are spread by the Ministry of Health and different NGOs through advertisements, radio and TV programs and others.

Condom use is a controversial issue in Uganda and elsewhere. Some church leaders and others are advising strongly against the use of condoms while the government has a more positive attitude.

Is it possible for young people in Kampala to follow the recommendations on abstinence, condom use and faithfulness? How are the recommendations perceived and what are the experiences among the young people who come to a youth clinic for health care and counselling? Is there a discrepancy between knowledge about reproductive health risk factors and actual behaviour? The objective of this study was to find out how young people in a Kampala suburb perceive recommendations about safe sex behaviour.

Material

The research was performed in Kiswa Clinic, which is located in a Kampala suburb. It is a health centre run by Kampala City Council (KCC). Since 1999 the clinic has been offering health services, free of charge, for young people at a separate youth clinic. Most of the visitors to the youth clinic present with problems related to reproductive health. HIV testing with pre- and post-testing counselling is also available at the clinic at a cost of US $2/test. Sixty percent of the visitors are females and 40% are males. Approximately 50% of the visitors have migrated to Kampala from other parts of Uganda and therefore have different languages as a mother tongue. The majority of youth clinic visitors are literate in English.

Twenty visitors to Kiswa Health Centre, 6 men and 14 women, were informed about the study and asked if they wanted to participate or not. The youngest participant was 16 years and the oldest 23. Mean age among the women was 19,5 years and among the men 18,0 years. They could all understand and express themselves in English.

Method

In research approaches using quantitative methods, it can be difficult or impossible to find answers to “why” and “how” questions. A qualitative research method was chosen for this study in preference to quantitative methods, as in-depth, open-ended interviewing styles can elicit personal meaning and explanations in a more detailed way than quantitative methods, and with small numbers can prove an important way of exploring new subject areas where the hypotheses are not initially explicit. ⁶

Sample size in qualitative research most often consists of between 4 and 40 informants. ⁷

In this study we had 20 informants. The number of informants needed for the study was not decided on beforehand. New participants were recruited as long as there were more aspects of young people's reproductive health and sexually related health issues that we wanted to know more about. As described by Malterud ⁸ a specific number of informants cannot be decided. It all depends on the amount of information contributed by each informant and the subject for the interviews.

It was explained to the informants that they could chose to abstain from participating but still get the service or information they had come for. A semi structured interview method as described by Malterud was used. ⁸ In this method the interview situation should ideally be like a conversation where some themes are discussed in all interviews but not necessarily limited to these questions. The sequence of questions can also vary. A tape recorder is used and everything that is said during the interview is transcribed verbatim. This text mass is screened for quotations “with meaning” These are extracted and sorted into categories or themes.

The participants in this study were selected through purposeful sampling with the ambition to get information from people with different social background, representing different experiences like being orphan, teenage mother, student, out of school unemployed and others. They were recruited among young people who came to the Kiswa Youth clinic for different reasons. Some of them presented with health problems, some came for family planning advice and some had been told about the study by one of the peer communicators connected to the clinic. One interview that was held in Luganda through an interpreter was omitted. The information obtained through that interview was very poor, probably because of the sensitive character of the questions.

The principle investigator (E-B R) has been working with the youth clinic in Kiswa since its inception in 1999. In those cases where the informant had come for treatment or examination at the clinic this was done before the interview by the local staff, not by the interviewer. Sometimes health advice was given by the interviewer after finishing the interview. All participants had given verbal informed consent to be interviewed and were informed that a tape recorder was to be used. The time for each interview varied from 15 to 45 minutes. All the interviews were held in English in a private room at Kiswa Clinic.

The purpose of the interviews was explained to the participants and they were encouraged to feel free to share their views with the interviewer. It was also explained that we were interested in their opinions and experiences, not to get the “right” answers.

The three strategies to avoid STDs and unwanted pregnancy: abstaining from sex, condom use and reducing number of sexual partners were presented to the informants as an introduction: “In health education young people are usually advised to abstain from sex (or to use condoms, to stay with one partner). What is your opinion about this advice?” In most of the interviews the issue of HIV testing was also discussed. The interviewer did a transcription soon after each interview. The written material was analysed and interpreted to determine themes. Discussions of similar recurrent and important themes were drawn together and compared and their relationship to other statements within the data material was examined. Statements relevant to the research questions were analysed and the findings are presented in this paper. The tapes and transcripts are kept by the authors.

The study was approved by the Research Secretariat, President's Office, Kampala, the Uganda National Council for Science and Technology as a general permit for research within Kampala District into the area of STD, using the PCR method in Uganda, and the Ethics Committee, Uppsala University, Sweden.

Results

Social characteristics of the informants

Five of the 6 young men were still in school while 8 of the 14 women had dropped out of school. In one case (20 year old woman with 3 children) the level of education was never asked for. All the other informants had at least 7 years of education.

Four men and 5 of the women came to the clinic without any health problems, just to participate in the study. Four boys were living with both parents. Two boys were living with their mother. Two of the women had children and were cohabiting with the father of the children. One woman had lost her child due to pneumonia and was now divorced, living with her grandmother. Another woman with 2 children had also left her husband and was living with her sister. Five girls were staying with their mothers. One was staying with her sister and one was at campus, Makerere University. Two of the young men had never had sexual intercourse. Only one of the other men had a steady partner. All the women had some sexual experience. Ten of them had a boyfriend or husband while 4 did not have a regular partner.

Abstaining from sex

Many young people find the advice to abstain from sex till marriage good and helpful and they intend to abstain but there are many obstacles.

Culturally it is not accepted to have sex before marriage but cultural values have less influence on people today. This was explained by a 20 year old man: “Me, I'm a Muganda. In our culture boys are not supposed to have sex before marriage. Likewise also to girls. Now since such (cultural values) has died out people just go for it.”

The religious background can sometimes influence sexual behaviour. One boy explains what has helped him to abstain from sex: “But maybe because of the religious background I have, I'm fearing God. That is why I have abstained.”

On the other hand, when it comes to other people he is not so sure that religious beliefs have any influence: “You can't tell people that now there is God, what, what. That one is going to ask you: Where is he? You see? So by going to school they tend to do what - think they are bright, asking questions, what, what. So I think the guidance you should have got from religion dies out. So one does whatever he wants. Because he thinks there is no God. No one is going to judge me.”

For some, especially those who are not yet sexually active, a suggested strategy to help abstain from sex is to keep yourself busy: “Because if you are busy you really know what you are doing and have things to do. Then I think, slowly, gradually, the idea of not being able to abstain will be shut out of your mind. Eventually this person will be having no more big interest in sex. That's what I think.” (18-year-old boy) “Me I aim at - I want to do something like work, to be getting somewhere, to keep myself busy. Not to keep myself in this business of loving boys and men around. No, I hate. I just want to work and keep myself busy, get my money. That's all.” (20-year-old woman)

Some of the men were directly asked if they thought that masturbation could be used as a way to avoid sexual risk taking. The cultural acceptance seems to be low. In school, if the topic on masturbation is brought up, it is discouraged. “Because they say it is the wrong way. It is a misuse of sex. Not in God's line yes of the usefulness of sex.”

For another young man masturbation was something he had heard about but thought about as “weird” and “not proper“.

Curiosity and the urge to have sex were mentioned by some of the boys as the reason why it is so difficult to abstain: “Sometimes it is very difficult, seriously speaking. You know, youth like us, we have that kind of spirit of adventure. What is it all about? We would like to know. What is it all about? These kind of things. It is very good to abstain, but it is not easy, frankly.”

The way the subject of abstaining is brought up by counsellors and health workers is also important: “Because it is something natural, something that can actually drive you to feel: I should at least have sex. And so you can't come abruptly and just tell me that: You boy - you should abstain from sex. I will not understand. So at least I should know, sex is good, all right. It is something that is natural. You can not avoid it, you can just control it.”

Some of the informants claim that there is a difference between boys and girls in this aspect, that the urge to have sex is stronger for boys while girls have sex for other reasons.

One girl explained how falling in love can cause people to forget about being careful and to give in to the demands of the boyfriend. Losing the boyfriend unless you have sex with him can also be a reason: “Now, if you really love that someone and you refuse having sex with him he will start doubting you and you feel if you really want to stay with that person…” Both boys and girls mentioned that girls sometimes have sex for economic reasons. Only one girl said that this was her reason for not abstaining from sex: “It is very difficult. You know some men… I am very poor. Then a man has a lot of money…”

Condom use

All of these young people were well informed about condoms and how to use them. The women had a slightly more positive attitude towards condom use. Everybody seemed to know that “going live”, as they call having sex without a condom, is to take a big risk. All of the informants seemed to be aware of the necessity of using condoms or otherwise abstaining from sex. As one woman expressed her view: “Auntie, when you don't use condoms you might find yourself catching the virus.”

Some of the men expressed that they did not trust condoms completely and that the fact that condoms are not 100% safe is worrying: “To me I don't think whether it is good, because most health workers claim they are 99% safe. So I wonder this 1% what it is. I don't think they are safe at all. Taking a 99% safety- it isn't necessary.” (18-year-old boy who had not had sex yet)

A negative attitude to condom use in the community is also reflected in some answers: “Sometime back still in school, I was in senior 2, we had a seminar about condoms. They told us condoms have pores. Is that true?” “It's good (condom use) but there are some men that don't want to use… They go to the hospital there. They use to tell them that condoms bring cancer to their private parts.”

One woman claimed that men sometimes were unwilling to use condoms, especially in more permanent relationships: “I asked him we continue using them. He said no, I want you now to become as a wife.”

To refuse having sex without a condom can be taken as a sign of distrust: “Well for example, some boys may say that now, if you don't want to have unprotected sex with me it means you don't love me, like that. And they say that if you have sex with a condom it is not nice. They tend to have that feeling.”

To stay with only one partner

The informants were asked if the advice to stay with only one partner is realistic. Most of them were of the opinion that having only one partner is something very good, but how to find this person who you can trust is a problem. By studying a person for some time, his behaviour and character can help you to know if that person is trustworthy: “When you live together you know the moves for that person. That is when you can tell he is what - faithful to you.”

“You can know for example when you get married, like that. When he comes home in time he's not a bad character. For example if he drinks, comes back maybe too late, like that. … That makes you worried.”

But for some of these girls getting married was not part of their plans: “I think getting married is not that necessary. Because when you get married a lot of boys tends to deceive at times. If you get married to someone the man starts deceiving you. They are not faithful, like that. So you get heart broken.”

Even the boys seemed to doubt that marriage would be a solution: “Like now you know in Africa, for us here we study. Right from the time you join the nursery you are not enjoying yourself, you get suffering, you complete and at last you get a simple job somewhere. Then you get to handle money and you feel excited and if you have already trapped yourself somewhere with a wife - You can't divorce her. The only way to do what- is to cheat her when she doesn't know. That's how some people…”

One 20 year old man explained that although he was not married himself it was his experience that good examples on faithfulness was hard to find among adults: “So if you make a survey of 10 families you can only get 2 people who are faithful to each other”

It is common for young people who intend to spend their lives together to go for HIV test together. It seems to be a modern way of showing that you are serious about the relationship: “Then when I was in senior 6 vacation he introduced me to his parents… After he introduced me he told me we go for HIV test. So we went to some clinic. That was in 1998… We found out that we were all fine. So from that time he told me, now we leave the other - condoms. So now we make just live sex and I last met him in March.”

HIV testing

There were mixed feelings about HIV testing. This 18 year old girl is reasoning just like Ugandan health authorities want people to do: “If you know that now you are negative you can try to control yourself. Then, even if you know you are positive you will know how you will control that disease not to give it to other people.”

While others, like this 16 year old boy, thought that knowing that you are HIV positive could only be destructive: “No, for us people it is no good (to know your HIV status) because if I know, now I have HIV, I will ever be thinking: What can I do? So now when I stay here I don't know. I'm free. I have hope. But now (if I have the test) - I'm not well settled as I was before. That's why most people don't concentrate on blood testing.” Some of the youth had been tested and could refer to their own experience: “I was so scared. In fact we were around 6 people there, waiting for the results. Then a man came and took us, me and my boyfriend, to a private room. He started to ask us: Now if I tell you that the result has come out and you are positive - what shall we do? I got so scared! I thought: now it's me! I have it!. I was almost running out of that room. They got hold of me at the door. I got so scared. But finally the result came and it was ok.”

People from the blood bank had convinced this 19-year-old boy to have his blood tested for HIV when they visited the health centre. They offered HIV testing free of charge for blood donors. The boy had had unprotected sex some time back and was really scared that he might have the infection. Knowing his HIV status has helped him to change his behaviour: “I am confident. Since that time I was tested I never had sex with anyone. I have very many girl friends. We just talk, go to church and that. …. I know that I'm not on the other side. At least now I can say no. And I know to say no.”

For others it was something they intended to do although they feared the result: “If they tell me I've got the virus, how will I move from there at all. That's the only reason (for hesitating).” Some of them wanted to finish school before they could go for testing.

Discussion

Methodology

It should be noted that the sample employed in this study do not represent the young population of visitors to Kiswa Youth Clinic, as the informants were purposively selected to include both girls and boys and to cover the age range 15–24 years. Thus it is not a random sample. The reason for interviewing more women than men (14 women versus 6 men) was that it was difficult to obtain information from the girls. This gender difference is probably due to cultural habits. Most Ugandan girls are not as outspoken as the boys usually are. The fact that there was a kind of patient-doctor relationship between informant and interviewer can influence the way people choose to answer questions. If this influence is positive, so that the informant feels more confident in giving truthful answers or negative, giving the answers that he/she think is expected, is difficult to know for sure. Some people might hesitate to express their true feelings due to respect for the doctor. The principle investigator (E-B R) is familiar with the young people in the area and the kind of problems often presented by them. Many young people come to the clinic because they fear STDs, especially syphilis. It is less common that they express their fear of HIV/AIDS.

Patients and health workers have told the author that it is quite common to give and receive gifts and money in exchange for sex. This is not considered as commercial sex. The problems with unemployment, difficulties to get money for school fees and others are also well known to the authors. Although most of the interviewed people were first time visitors this pre-knowledge about social problems can influence the interpretation of the findings. Still the experience from previous contacts where many of the themes that came up during the interviews are recognised can be helpful. It can help to identify findings that are unexpected and also to recognise thoughts and beliefs that are common. The fact that the investigator has come from a different culture probably made it easier for some of the youth to feel free to explain their views. They would not assume that everything was clear and well known to the investigator, especially cultural values and habits. Even though the sample is rather small, the interviewed youth correspond quite well to the common visitor to the youth clinic when it comes to age, gender and education. ⁹ We still lack information from the very young and especially those who do not speak English or with short formal school education. This group has up till now not been seen frequently at the clinic. This is something that needs attention.

Main findings

There is a discrepancy between knowledge and reported behaviour. This was confirmed in this study as well as in other research reports. A study in Mbale, Uganda, where focus group interviews were held with 17–18 years old youth showed that knowledge of safe-sex behaviour and reported behaviour have little in common. ³ The reason for this is complex. Although the majority of the interviewed young people in our study find the advice to abstain from sex up until marriage and to stay with only one partner good and helpful, they find it difficult to live up to. According to the youth in this study good examples among adults seem to be lacking. Very few of the interviewed young people mentioned any positive aspects of sexual life. Is this something that has been neglected in sex and family life education? In the United States an intervention aimed to postpone the onset of sexual intercourse through promotion of abstinence-only messages did not show any significant change in adolescents' values and attitudes about premarital sexual activity. ¹⁰ Even if attitudes can be changed the impact on sexual behaviour is difficult to show. An abstinence-based small-group intervention in New York schools led by trained social workers did not have any impact on the initiation of sexual intercourse among females. ¹¹ Other intervention programs report more positive results.

In Namibia a randomised trial of a face-to-face intervention program showed reduced HIV risk behavior at least among sexually inexperienced youth. ¹² The habit of exchanging of money or gifts for sexual favours seems to exist in East Africa as in many other countries. This has been well described by Nyanzi et al ¹³ in Uganda and by Tengia-Kessy in Tanzania ¹⁴. For some girls this is the only opportunity to earn some money but the issue is probably much more complex than that. It has also been shown that women involved in non-professional, commercial sex are at even higher risk to contract HIV/STD. ¹⁵ The use of condoms seems to be controversial to some of the youth. Of course the difficulties and shortcomings with condom use have to be discussed with the youth but this can be done without discouraging the use of condoms. In a study by Bagarukayo (1994) in Soroti district, teachers were mentioned as the most common source of information. ¹⁶ In the same study it was revealed that many teachers were of the opinion that pupils should not be told about condoms. Also, in the study presented here, we find that information obtained from school is not always helpful in promoting safer sexual behaviour.

Not many young people come to the clinic to discuss the possibility of being HIV positive. It is much more common that they present with the suspicion that they have syphilis or some other curable disease. In this study, where their thoughts about HIV and HIV testing were asked for, we found that the risk of having HIV infection is of major concern to a majority of young people. To many the big worry they had was how to go on with life after knowing that you are HIV positive. Counselling and support is needed, not only immediately after the HIV test result is out, but for a long time, through all the stages of crisis.

Implications

There seems to be a lack of consensus in the society on what messages to bring to the youth. Conflicting information and the spread of bad rumours about condoms should be avoided. A single strong message from health workers and teachers would help to dispel the myths and give young. People confidence in the advice they are getting. Communication and negotiation skills should be emphasised when life skills training is planned in schools. As many of the interviewees fear that they would be neglected after a positive HIV test result, pre and post HIV testing counselling should be improved and extended to cover the period when the individual goes through crisis. This could be achieved through post test clubs like the ones at the Aids Information Center in Kampala.