The Socioeconomic and Sexual Health Status of Young People Living in Urban Slum Areas of Kampala, Uganda

Abstract

Slum dweller youth in Kampala, Uganda, face social economic exclusion and a plethora of health risks, and their needs are poorly understood. The aim of the current study was to analyze their needs and to suggest contextual evidence-based solutions to improve their well-being sustainably. We conducted a qualitative study involving 10 focus group discussions (FGDs; N = 113) and 20 key informant (KII) interviews. Emerging themes and sub-themes were identified, defined, reviewed, and organized and narrated following the structuration theoretical framework, which enabled the examination of the inherent capacity of slum dweller youth to make choices independently and the recurrent rules and resources that influence or limit the choices and opportunities available to them. The findings suggest that the slum dweller youth’s ability to reach and fulfil their potential remains constrained by a confluence of individual and societal-level factors. The individual factors were poor quality of and dissatisfaction with life, and poor sexual and reproductive health practices. The societal-level factors were poor sexual and reproductive health services, and an extremely weak labor market. The needs of slum dweller youth in Kampala, Uganda, remain unaddressed, and leaving such a large population economically unproductive and dissatisfied with life is a recipe for political instability and insecurity. Interventions to address their needs need to adopt a whole-community approach in order to engage and empower all parts of the slum community and strengthen community structures that improve livelihoods and harness the opportunities that engender income fortification and socio-civic transformation for the youth.

Background

Despite international global development agendas, such as the Millennium Development Goals (MDGs) and recently the Sustainable Development Goals (SDGs) to address poverty, youth remain disproportionally affected by poverty in low- and middle-income countries. In most low-income countries, youth experience deprivation, socioeconomic exclusion, and poor sexual reproductive health, and their needs are poorly understood. It is well acknowledged that, when given the required skills and presented with adequate opportunities, young people can live healthy lives and be a positive force for development. Yet, they remain negatively affected by limited economic opportunities and poor sexual health which remain key challenges among the youth population in most low- and middle-income countries such as Uganda. This study examined the social economic and sexual health status of the urban youth in the slums of Kampala, Uganda.

SDG 8 acknowledges the challenges associated with growing global unemployment rates and has set specific targets related to improving access to financial services and benefits, increasing labor productivity, and reducing unemployment rates, especially among young people [1–3]. Low-income countries have been experiencing rapid urbanization accompanied by a significant annual slum population growth [4]. For the purpose of this study, a slum is a group of low economic standing households in squalor conditions with inadequate tenure security, living space, and social services [5]. Slums are commonly located on the fringes of urban areas and linked to the surrounding non-slum communities by social economic factors such as the supply of cheap labor.

Slums are associated with overcrowding and poor living conditions, deprivation, limited economic opportunities, reduced social mobility, and unhealthy behaviors, including drug use, gambling, and sexual risks [6]. The United Nations estimates that 718 million people globally are slum dwellers, of these, 189 million are from Sub-Saharan Africa [7]. Slum population is projected to grow especially in poor countries due to rapid urban population growth and limited opportunities [8]. The growth is driven by the absence of economic opportunities in rural areas that compel young people enter the cities in search of work.

In the cities, these young people relocate mainly in the slum areas where they live dissatisfied with their conditions and engage in health risks for survival. Available evidence suggests that material deprivation increases sexual and reproductive health risks among youth in urban slums including exposure to HIV/AIDs and other sexually transmitted infections, unplanned pregnancy [9–11]. Youth in slums are two times more likely to undertake sexual risks than their counterparts outside slums [9]. Sexual risks such as HIV/AIDS, early pregnancies, and obstetric fistula curtail youth’s ability to optimize their full potential and constrain them to the life of poverty and ill-health [11]. It has been documented that recognizing adolescents and young people as a priority is one of the prerequisites to achieving bold international goals such as the millennium and sustainable development goals [12, 13], yet adolescent sexual and reproductive health remains a challenge and is poorly addressed by these international development agendas [14].

Youth conceptualize their dissatisfaction in terms of exclusion from social and economic opportunities, and use whatever means including violence to address their exclusion [15]. This mind frame makes them vulnerable to manipulation by agents of self-interests for political or financial gain [15, 16]. For example, a study among incarcerated youth north of Southeastern Brazil noted that most offenders were from slum areas deprived of education and economic opportunities [17]. The deprivation pushed the youth to gain access to money through illegal ways like drug trafficking and violence which resulted into their incarceration. Expressing dissatisfaction with life can easily turn into large-scale security threats. In Egypt, Tunisia, and Syria, exclusion form social economic advancement and political participation galvanized the youth dissatisfaction into collective uprising that challenged government’s legitimation with devastating consequences [18–20]. Nonetheless, the slum youth can be mobilized into productivity because of their eagerness to overcome exclusion and deprivation. Their desperation enables them to seize whatever opportunity that emerges. For example, a report by the Brookings Institution suggested that simple initiatives such as clean waste-to-energy technology dependent on low cost solid waste generated economic opportunities for over 400 youth of Kariobangi slum of Nairobi [21].

Youth accounts for one out of every six people worldwide, estimated between 1.2 billion aged 15–24 years or 1.8 billion aged 10–24 years [22]. However, the largest youth populations are concentrated in low-income countries. For example, the Ugandan age structure of the population suggests the country has one of the youngest and most rapidly growing populations in the world. Almost half of its population (48.3%) is below 15 years (vs. a world average of 26% and a Sub-Saharan Africa’s average of 43%). A further 21.1% comprises youth between 15 and 24 years old, while only 30.6% of the population is aged 25 years or older [23].

Ugandan youth experience high unemployment rates—among the highest in Africa [24]. Evidence suggests the country experiences high rural to urban migration and unemployment, and its urban population has been growing exponentially; for example, between 2002 and 2014, the annual urban population growth rate was 6.8% [25]. Urban life and its perceived opportunities have drawn many youths in rural areas to the city of Kampala where 60% of the population live in slums [25]. The city of Kampala has 57 slum communities spread across five divisions, i.e., Kampala Central, Kawempe, Nakawa, Lubaga, and Makindye [26, 27]. Worth noting is that the slums in Uganda are a product of the first urban development plans of 1912 and 1919 which racialized residential areas between the European settlers and the Asian middle class and confined the natives to spaces underserved with social services [28, 29]. It is some of these low socioeconomic areas alongside new ones that continue to shelter the poor and low-skilled migrant youths. More than 67% of Kampala’s population is made up of unemployed or under-employed youths, some of whom resort to crime, gambling, drug abuse, and other social problems [24, 30].

Despite Uganda’s impressive poverty reduction efforts from 31.1 to 19.7% between 2006 and 2013, trend analyses suggest that the economy has been growing at a slower rate in the last 5 years, which constitutes a significant constraint to job creation [31]. If well harnessed, the youthful population in Uganda could provide good development dividends for the country. However, there are many barriers to youth participation in economic development. The main sources of income among the youth in urban areas are informal businesses, casual employment in factories, and the hospitality industry, such as hotels and restaurants, but the majority remain unemployed and without an income [27]. The Ugandan government has established schemes such as youth loans, the national job-matching database to match youths with job opportunities as well as employment service bureaux to prepare youth for employment and entrepreneurial opportunities [32]. Other government initiatives to promote youth financial inclusion and productivity are bona bagagawale (“prosperity for all”), operation wealth creation, entandikwa (venture capital), and the savings and credit cooperative societies (SACCOS) [33, 34]. Nonetheless, youth unemployment remains rampant, especially in slum areas. Factors that contribute to the youth’s poor economic and civic engagement in slum areas of Kampala are poorly understood.

Therefore, the aim of this study was to analyze the social economic and sexual health status of the slum-based youth and to suggest contextual evidence-based solutions to improve their well-being. The findings will contribute to and strengthen policy dialogue to accelerate interventions that improve the quality of life for youths in urban slum areas and their participation in the socioeconomic development discourse.

Study Setting

The study was conducted in Kampala city, in the subdivisions of Makindye and Nakawa divisions. Kampala has five divisions of Kampala Central, Kawempe, Nakawa, Lubaga, and Makindye [26, 27] The study areas of Makindye and Nakawa which are further subdivided into 24 zones and host almost 46% of Kampala City’s population of 1,723,300 [35]. Both Nakawa and Makindye divisions are ethnically diverse with migrants from rural parts of Uganda with the Baganda ethnic group being the largest in both divisions [36]^.

Methodological Approaches

Theoretical Framework

The study was informed by the structuration theory, which enables the examination of both agency (e.g., the capacity of humans to take action independently and to make their own choices) and social structure (i.e., patterned arrangements, such as rules and resources that are recurrent and which influence or limit the choices and opportunities available) and their interplay [37]. The structuration theory allowed the conceptualization of the knowledgeability of young people in slum areas (i.e., knowledgeable young people with the capacity to transform their environments) and its relationship to young people’s agency and action. It also allowed a better understanding of the degree of institutional structures upon which young people draw and the supportive environment, social structure, and human interactions in the wider community to which they have access.

In doing so, structuration theory allowed the research team to draw attention to social factors, such as the exercise of power and sanction and their effect on young people’s participation at both macro (the structure) and micro (agency) level. Structuration theory is premised on the assumption that reflective actors are transformative elements of the social process, capable of reflecting on actions and identities, as well as putting their intentions into effect [38]. The potential role of structuration theory and its robustness in informing the research are reflected in its ability to allow the research team to comprehend the experiences of young people further. This is done by analyzing the structural forces that form part of young people’s experiences, which is needed to inform policy, including an interaction of macro and micro processes of individual actions and social forms. Such knowledge is essential for a holistic design and delivery of services for young people in urban slum areas.

Operational Definitions, Design, and Participant Recruitment

Although the United Nations defines youth as persons aged 15–24 years [39], the Ugandan law prescribes that youth are aged 13–30 years and to be nominated for the youth Member of Parliament seat, one must be in the 21–30 years age bracket [40]. Therefore, given the geographic focus of the study, youth aged between 13 and 30 years, caregivers of youth with intellectual disability, and teachers and community leaders were included in the study to gain broad understanding of issues that affect them. Using a qualitative research design, a thorough mapping of community structures was carried out in all the 24 zones of Makindye and Nakawa divisions of Kampala, Uganda. A list of government, community, and social service structures assisting youth was compiled concomitant with the structuration theory. Three criteria were employed in the selection of participants: (1) geographical (according to their slum of residence), (2) rural-urban migration status, and (3) met the Ugandan definition of “youth.”

Consistent with the structuration theory’s concepts of agency, social structure, and their interplay, it was important to understand and conceptualize the duality of structure in the implementation of the project (the relationship the agency has with community structures) [41]. That is, to better understand and engage with influential people in slum areas and how they interact with community structures, participants were recruited using purposeful sampling through existing community structures. These included youth’s groups, churches and mosques, mechanic and wielding apprentices, sports betting and gambling venues, and youth service providers [42]. In order to interpret the ongoing relatively formal social interactions between youth and their communities at large, a steering committee was established to oversee the implementation of the project. It comprised 14 people: four community representatives, two government officials from the study areas, and eight representatives from World Vision International, Uganda Youth Network, Feed the Children, Uganda, and the research team. All participation in the study was by written consent and parents, and caregivers gave consent for intellectually challenged youth participation. The study was approved by the Monash University Human Research Ethics Committee (approval no. CF16/1001-2016000532).

Data Collection

Data were collected using a combination of interviews with key informants (KII) and focus group discussions (FGDs) and altogether the study included 10 FGDs (N = 113) and 20 individual interviews (Table 1). The combination of KII and FGDs allowed for the systematic analysis and a broad and deep understanding of issues affecting youth in Kampala and divergent results were interpreted through the lens of the acculturation theory [43, 44].

Table 1.

Demographic characteristics of focus group discussion participants

FGD no.	Stakeholder (target)	Number of people per FGD	Age range (years)	Median age of participants (years)	Gender make-up	Villages covered
1	Young people in sports betting	12.0	18–25	20.5	25% F and 75% M	Makindye
2	Church/mosque leaders	8.0	14–25	22.0	75% F and25% M	Makindye
3	Citizen voice and action/women’s group	16.0	16–24	19.0	50% F and 50% M	Nakawa
4	Secondary school students	17.0	10–17	13.0	52.9% F and 47.1% M	Nakawa
5	Young people in metal fabricators and welding	8.0	18–24	20.0	100% M	Makindye
6	Young people trading in market places	13.0	15–25	21.0	30.8% F and 69.2% M	Makindye
7	Young people: mechanic workshop	8	16–25	22	100% M	Nakawa
8	Young people: market place/traders	7	13–25	22	42.3% F and 57.1% M	Nakawa
9	Children with disability and caregivers*	10.0	5–15**	30.5***	66.7% F and 33.3% M	Nakawa
10	Caregivers/teachers	14.0	25–50	37.0	71.4% F and 28.6% M	Nakawa

*Children with disability (N = 5) and their care givers (N = 5), **age range of children, ***median age of care givers (range 24–33 years)

Slum areas in Kampala are geographically dispersed; therefore, one-on-one interviews were identified as the most suited method for collecting data from geographically dispersed populations and when the topic being discussed is highly sensitive or highly personal such as socioeconomic and sexual health status of young people living in urban slum areas [44]. This approach to data collection allowed participants’ privacy to share their experiences and the flexibility to venture into and discuss salient matters. Individual interviews were conducted with representatives from the public sector and social service structures as well as other community stakeholders, namely retailers and faith organizations, representatives of youth serving organizations, officers of the local governments charged with community-based services, community activist and human right advocates, the Uganda Police Force, community social and health services, and World Vision staff.

One-on-one interviews were complemented by FGDs by bringing together data from different sources to develop a comprehensive understanding of youth in slum areas. FGDs are particularly useful when researchers are concerned with exploring multiple topics, and such a data collection method stimulates discussions through snowball of ideas and spontaneity while also providing a platform for verification, clarity, synergy, and differences in participants’ responses [45, 46]. Each FGD had a minimum of seven and a maximum of 14 participants. Mixed genders were the preferred option for FGDs because heterogeneous FGDs are well known to be more effective than homogenous FGD [47], as the former allows for the collection of rich data that capture and emphasize similar and varying gender experiences. The advantages of mixed gender FGDs include stimulating more diversity in the answers to FGD questions in order to explore a wider range of issues and create an opportunity to gather different but complimentary insights as well as to maximize FGD attendance (given youth in slums areas are disenfranchised) [45–47].

Prior to data collection, interviewers explained the study objectives and acquired consent of participation. Interviewers also explained that participants could withdraw their participation at any time during the interview. The FGD schedule and interview guide were informed by existing literature on youth studies and were reviewed, expanded, and aligned with the aim of the study by the steering committee. Both the FGD schedule and the interview guide comprised of open ended and probing questions to stimulate perspectives on youth needs and contextual solutions. All interviews and FGDs were conducted in English by trained bilingual workers. A total of 12 experienced bilingual workers were trained over 2 days plus an extra half day of practice prior to the data collection. The training covered interview techniques, note-taking, confidentiality, FGD dynamics, and probing. Each interview lasted 30 minutes while each FGD lasted 90 minutes. In addition to note-taking, the interviews and FGDs were audio-recorded. The audio files and field notes were then reviewed by the steering committee (many of whom spoke English and Luganda which are widely spoken in Kampala) to establish data saturation and the credibility of the responses via member checking. Audio files were transcribed verbatim prior to data analysis.

Data Analysis

Data were analyzed using six steps, as recommended by Braun and Clarke’s six-step approach [48]. The steps comprised familiarization with the data by reading and re-reading transcripts and field notes, generating initial codes and inserting codes into the transcripts, searching for themes and grouping codes into potential themes, reviewing the themes and creating a thematic “map,” defining and naming themes and subthemes, and narrating the themes and sub-themes with a selection of participant voices as illustrative exemplars for each theme. Preliminary thematic analysis was undertaken by AMNR and JKK, followed by an independent review of the process by the study steering committee. These processes ensured the trustworthiness (e.g., credibility, transferability, dependability, and confirmability) of the findings [49–51].

Results

We found the youth’s ability to reach and fulfil their potential remains constrained by multiple factors and these include:

Limited Economic Opportunities

One of the major issues to emerge from the findings was limited economic opportunities manifested through poor quality of and dissatisfaction with life. Participants noted that most of the youths in the slum areas of Kampala were involved in anti-social activities due to unemployment. Anti-social activities included crimes such as stealing, abusing drugs and alcohol, and gambling. In turn, youth involvement in these anti-social activities reduces their chances of getting employed. Participants noted for example:

Personal lifestyle is critical. Without a job we resort to anti-social activities. We are all seen as drug users, alcoholic, and disorderly. If an employer has seen a young person in a gambling or betting house, he might not give him a job for fear that the young person may be a thug and untrustworthy … In the eye of the employer we are all the same. (FGD with Citizen Voice and Action)

For the most part, the youths indicated their urgent desire for financial security and therefore talked about becoming rich and wealthy in order to escape poverty and to provide for their families. However, such desire relies heavily on financial support from government, especially seeding funds and capital to start businesses. Due to their limited education, the youths are not able to secure jobs. They also lack the necessary skills and knowledge to run businesses successfully, which reduces their likelihood of getting a loan from government or financial institutions. Consequently, young people in the slum areas of Kampala use multiple modalities of interpretive schemes to build enough capital to start a business and to survive, including addiction to everyday gambling in an effort to multiply whatever small amount of money they have. When they lose their money to gambling, they resort to borrowing money from their friends with the agreement that it would be paid back with interest, as well as selling their valuables. The participating young people emphasized that addressing the issue of gambling may not be in the government’s best interest because the government receives revenue from gambling institutions through taxation and other fees. As participants explained:

When we are in debt we ask friends to lend us money. When that option is exhausted, we sell what we have … I sold off my pair of shoes and got more money for betting. You can request a friend who has a boda boda [a bicycle or motorcycle taxi] to lend you for at least one hour and you make money for betting. (FGD with youth group)

If am working somewhere or staying at home and I am given some money to buy things, I deduct some money and save it for betting. (FGD with women’s group)

I think that the media has made criminal activity acceptable in our community where they publicly state that stealing is the only way of getting money. I heard somebody on radio the other day that he never thought that one could get money without stealing. I don’t know if he was joking but that’s what he meant … but what I think he was legitimising theft. (FGD with religious leaders)

So you find for instance if you get to the streets of Kampala you see a number of mad people. Most of them have become drug addicts so you see that a very big problem in terms of the wellbeing of the youth. (KII with a government official)

Many respondents from the FGDs rated their quality of life as 0 out of 10. This was mainly due to not having enough money to meet their daily needs, not being able to gain meaningful employment, and the amount of time they spent gambling. Gambling remains a source of continuous stress as youth remain unsure of the outcomes of their gambling, hence a setback affecting their ability to make ends meet. The youths expressed a desire to make enough money to live comfortably, which implied that many were willing to engage in criminal behavior to do so and to bribe potential employers as well as employment brokers in order to gain employment. When they gained employment, young people were sexually exploited, especially girls who were underpaid or not paid at all for the work they did. As a result of employers not paying their young employees, the youth become frustrated and stop working and some turn back to anti-social and criminal behaviors due to idleness. This pattern is exacerbated by employers’ mistrust of young people, perceiving young people as thugs when in some instances they are not. Differentials within the realm of social capital were also described with regard to one’s socioeconomic status. For instance, young people who were rich were more likely to find employment while those who were poor were actively excluded from the job market, and young people with disabilities were the most neglected in the communities. People with disabilities were not aware of the services available to them and experienced discrimination in seeking employment, as indicated in the examples below:

Labour exploitation is a serious issue in our community. Young people do not have a voice. We are paid less than what we deserve for the jobs we do … A rich man may hire a youth, when he realises that the boy is desperate and cannot meet his basic needs; the rich man will not pay the boy. When the boy asks for his wages, the rich will say. “I give you food to eat.” (FGD with youth group, Secondary School students)

Young people are exploited at work. We sometimes go unpaid for a long period. In addition, most of our jobs involve handling breakable materials. In case of damages or breakages of the materials, our salaries will be withheld to pay for damaged goods. (FGD with Citizen Voice and Action)

[F]irst of all, the opportunities are very few. Secondly, they [young people] are exploited. They are given very little salary. Thirdly, there are some who are not paid at all. Basically, the pay is very little; it can’t sustain them, to pay rent, buying food and meeting medical costs in case they fall sick. (A KII with service providers)

Some people, when you work, they pay the first time, second and the third time. But next time, this person will say that I don’t have money. Even you may say that this person is broke. But he used to pay me. So you may keep working. And if you ask for the salary, this person will say that I don’t have money. Sometimes they take advantage that you are still young, you are new to work. So they take advantage. (FGD with religious leaders)

Unemployment was identified as the biggest challenge. Young people lack employment skills, which force them to start their own small businesses which do not require large amounts of capital. Young people noted that a lack of training and experience was the most important problem in terms of youth employment, and that they lacked the necessary skills and experience to be competitive in the job market. For gainful employment, especially in the formal sector, acquiring employment training is required to enhance their employability. Therefore, most youths were not able to secure employment because of the lack of qualification and experience.

One of the biggest challenges young people face is a requirement for experience. In many cases young people do not have the qualification and work experience to be competitive. If we had a very good arrangement of having young people go through internships, it will improve their plight. (KII public servant)

Young people noted that, before they get a job, employers would investigate their background and origins before making a decision on whether to hire him or her. The investigations included young people’s socioeconomic status, their peer groups, behavior within their community and family background, including where they were from.

Youth from Makindye tend to be discriminated against, if you hold an ID [identity document] from Makindye, you are taken as a thug or a prostitute. Girls from Makindye are expected to be easy-going, to accept everything the employers have to say, to give sexual favours. This is against our faith as Muslims. (FGD with youth mechanics)

The name Katwe is associated with fake products. This comes a long way back from our great grandparents. Katwe is a place of vocational practice, making of local items like saucepans, beds, fabricated metal doors, etc. so if a product does not perform well, people ask if it’s from Katwe. If you are from there, it is hard to get a job. You are seen as fake and incompetent. (FGD with religious leader)

Tribalism was identified as one of the main factors that affect young people’s ability to secure employment. For instance, employment gatekeepers make decisions about potential employees based on ethnic or linguistic markers. One of the respondents told a story about attending an employment site and a receptionist who spoke Runyakore (a language spoken in Western Uganda) started communicating with him in her language. While the respondent could understand her, he could not respond as he was not fluent in Runyakore. The next day when he went to follow up on his application, he found it in the bin. The receptionist had not forwarded the application to the human resource office.

The ability to speak the employer’s language or mother tongue is important. This is also tribalism. One time I went to ask for a job. To the employer I looked like a Munyankore so they greeted me in Runyankore, but am not one and could not answer, and because of this I was not called back. (FGD with youth participants, market places)

Compared to other divisions, Makindye has many companies operating there, but getting a job requires a youth to have connections within the company. One will be asked, whose child are you? (FGD participant, mechanic workshop)

Other social structures identified by young people that affect their ability to gain employment included the importance of having a relationship with the employer or any sort of connection as a stepping stone and the need to bribe to get a job. However, bribery did not guarantee employment. For instance, some who bribed prospective employers were told to wait while their application was being processed. They undertook unpaid training or probation, only to hear that someone else had been given the job. Some employers also make decisions about who to employ based on one’s physical appearance, especially for women. Study participants suggested that this was with the intention to exploit women sexually. Participants reported that, to secure employment, female applicants on probation were asked to dress provocatively to attract customers, in that they become an “appetizer” for clients. The practice of objectification of women as appetiser was common and affected the image of women in society, especially those in the workforce.

In some places, like supermarkets, they want girls to dress up in miniskirts, commonly known as ‘appetisers’ for customers, yet as Muslims, our faith forbids us to dress that way. (FGD with youth participants, disability)

We have the skills, but to get to the person in charge of recruitment, you need personal connections and to bribe someone. For example for a Boda Boda job, you will part with 50,000UGX. However, we don’t have that money. If I have 5,000 UGX (about USD1.35), I will place a bet at the gambling house with the hope that I will raise more money to bribe the recruiting agency or person. (FGD CVA)

Paradoxically, not all employers wanted to hire women who were very attractive or “appetizing” as some employers assumed that such women were engaged in sex work. Males were also judged on their appearance. Specifically, employers were unlikely to hire men if they were shabbily dressed or dressed as if they were thugs.

The general appearance is important. Unfortunately, young people’s dress code does not resonate with what employers are after even though they have the required skills. They do not know how to present themselves professionally. For example, one day my friend and I applied for a PC mechanic’s job but the boy who had dreadlocks was denied access to the site and the job. Another friend of mine went somewhere to ask for a job. The moment they looked at him and the way he was dressed he was sent away immediately. (FGD, fabricators & welding)

Sexual and Reproductive Health

A number of issues related to sexual and reproductive health needs and rights arose from the study. The study found that young people in the study area did not want to talk about sexuality. Importantly, they had limited knowledge, awareness, and skills to negotiate safe sex practices. The main sources of information about sexual education were school teachers, parents, and family members. Interestingly, health professionals, friends, the internet, parents’ support groups, and TV/radio were not major sources of information about sexual education. Young people indicated that aunts and uncles were a source of sexual education within the family. It was, however, not clear to which extent aunts and uncles taught children about safe sex as most young people in slum areas left their relatives behind in rural areas. When asked to comment on the sexual education they received from relatives, the main response was:

[T]raditionally, uncles teach boys and aunties teach girls. They teach the girls bedroom manners, how to look after their husbands in bed. Boys learn how a man is supposed to behave in the bedroom. (FGD with care givers)

Participants noted that a lack of sexual education makes young people go astray. They go out to experience what sex is without thinking of the consequences and without any understanding of the Ugandan legislation that governs age of consent. In addition, the issue of sexual rights remains a new concept that does not resonate with young people, which is a significant driver of the high burden of unwanted pregnancies in the slum community. The lack of sexual education provides a window of opportunity for sexual exploitation. Participants also noted that young people have children at a very young age  and therefore do not have the capacity to pass on lessons of safe sex behaviors to their children, leading to the intergenerational effect of early pregnancy. Sexual education is also not given to the children because the parents are too busy working away from home in order to make a living. As such, parents are unable to engage in children’s day-to-day care and activities. Some of them had their children when they were very young. That is why sexual matters are a big issue in the community and parents have limited information to pass on to their children.

How can someone involved in sexual transactions at early age be able to provide their children adequate sex education? Where are their parents? Busy with work and have no time to provide sexual education to their children. That is why we have serious issues with early pregnancies among our youth. (KII with service provider)

I have seen most people using money to take advantage, the girls are generally weak. You find like a young girl of senior one or senior two [first two years of secondary education] when given 50,000 UGX [about USD13.75] has no capacity to bargain that you use a condom … The majority are having sex with someone who is 10 years older than them. With current HIV trend suggesting that HIV is in the married people who are 30 or older, the issue is not just unwanted pregnancy but also the associated increased risk of HIV. (KII with public servant)

Our study found that there is peer pressure for young people to have sex at a very early age. Most young people unanimously indicated that it is normal and common practice to have first sexual intercourse at between 7 and 10 years. However, participants noted that girls are sexually more active than boys at a younger age. One girl indicated, “I know of girls whose sexual debut was at seven years of age.” Peer pressure among young people to have sex at early age is too much to bear for many participants. Any young person who has not had sex by 15 year is subjected to ridicules, called names like “unadventurous,” “ignorant,” and “abnormal,” “expired”. Participants noted:

If you have not had sex by 15 years, you are expired. If at 15 years a child is still a virgin, children will laugh at him/her. A virgin boy or girl at 15 years would be considered not to be functioning normally. We think that if one does not engage in sex at our age, when they are older they will have backache problem. (FGD with youth in sports betting venues)

I have a granddaughter. She was told by her peers that if she doesn’t have sex she will get a curse. She was scared and told me about it. I tried to educate about sexual and reproductive health. So, our children need sex education, let us not wait for teachers to tell them, parents, let’s do our part. (FDG with community leaders)

If you have not had sex by 15 years, there is a feeling that there is something not well with you. That’s why they go into that early, they want to try out things because like you interact with colleagues and they want to try it out. Otherwise they feel like they are not man enough, especially for men, they are not man enough; they want to try out and prove that am really a normal person. (FGD CVA)

There was an indication of girls engaging in sexual behaviors with older men, predominantly for assistance, which led to sexual exploitation, abuse, and coercion. For instance, FGD participants indicated that some girls engaged in sexual intercourse because they were promised employment. Others who had difficulty finding work took up sex work to make enough money for their basic needs or to make enough money to survive. Sexual exploitation also occurred among boys. Some male youths were sexually involved with older women (called “sugar mummies”) as these women had enough money to support them. Further, young men were unable to support the costs associated with having a girlfriend closer to their age.

Young people are involved in sex with older women called “sugar mummies” who have much money. Older women like young people because they have sexual strength … Young girls of our age won’t take care of us, while older women will take care of us. If a sugar mummy comes and gives you 100,000 Ugandan shillings [about USD27.5] a day, anybody can’t refuse to go with her … However, what a sweet mama does is to turn you into her baby and you don’t have to work, she give you everything and you are like a picture or photograph to her. But after some time she begins maltreating you or devaluing you like asking you, “Wash my underwears”. That is the situation. (FGD with youth, traders)

When young people were asked how they would know whether or not someone who is 15 has had sexual experience, they responded, “By appearance and the way they look,” “through rumours,” “the way they walk,” or “by teasing them and see how they react.” However, not all young people shared this view. Few of them indicated that they will respect someone who has not had sex by 15 years, especially those belonging to a church group. They noted:

Virgin? Yes, in fact I would admire him. I would wish to be like him. I will respect them according to where you are from such as if you are with religious people, you will be respected. However, in the market place, at school or university, they can mock you if you are virgin. You will be mocked, called an amateur, referred to as one who has no experience. (FGD with women’s group)

Interestingly, this view was corroborated by data from KII participants, except a few of them who tended to suggest that first sexual intercourse occurs between 12 and 15 years. It is important to note that most KII participants were predominantly public servants who could not afford to portray a situation where underage sex is prevalent, as it would reflect negatively on government. Nevertheless, KIIs and FGD participants agreed that young people were being exposed to sex at early age due to poor housing conditions. They saw their parents having sex as all are living in the same room or very close quarters. In order to mimic their parents’ behaviors, some young people  engage in a “mummy–daddy” game. In this game, young people emulate the movements and actions of coitus. Some end up having sex without realizing that this is what they are doing. Participants noted:

Because of inappropriate accommodation – in slum areas, a one room is shared by a man, his wife and children. When the parents are having sex at night, the children see and hear them. Before long, the children also want to try out what mummy and daddy do. (FGD with community leaders)

Children play the daddy–mummy game, they act out a play where some are children, other parents. They cook food, even make a bed and try to do what mummy and daddy do in their bed. (KII with service provider)

This is because, in slum areas, our accommodation is very poor. We parents share one room with the children. The children sleep on a double- or triple-decker and much as a curtain separates our beds. They can see our bed from the height of their bed. (FGD with CVA)

[L]ike when you are bored and you want to play, you say … let us build our house. A small ka-house [a tiny house]. When you don’t want other to know, you tell others that you are children and this is father and I am the mother. So, you get like one hundred shillings [USD 0.02754], and tell them to go and buy cassava and mum cooks, and then you do bad things. (FGD with youth, sports betting venues)

Participants highlighted myths about family planning methods and unwanted teen pregnancy. They believed that using barriers (e.g., condoms) or other family planning methods will prevent them from having children in future. So, they have sex without any protection. As a result, unwanted teen pregnancy and sexually transmitted infections (STIs) were identified as big issues within the community as most of young people do not use protection and they end up getting pregnant or contracting STIs.

Unwanted pregnancy is a big problem. At this centre we get like 15–20 young a month that are pregnant, I mean below 19 years, and 13 out of 15 are unwanted. Only two can say yeah am ready for it. Not old enough to have been exposed to adequate sex education. (KII with service provider)

[I]t is common in this area for young people to be involved in commercial sex and get unwanted pregnancy. The main reason being that most men don’t want to use condoms with young people. In the end they find themselves pregnant. These girls tend to be children of young mothers who have not been exposed to sex education. It will be the same for their offspring. (FGD with community leaders)

Discussion

Our study sought to assess contextual urban youth’s needs and present evidence-based solutions to the poor quality of and dissatisfaction with life. Uganda is overwhelmingly a youthful country, and such a level of dissatisfaction among the largest proportion of the population could be a reflection of systematic exclusion from participation and productivity. The Ugandan government has undertaken a plethora of interventions geared towards financial inclusion and participation of the youth [32]. However, the low literacy level and limited entrepreneurial skills impede the success of such interventions. In addition, the interventions have been encumbered by many other limitations, such as corruption and manipulation by politicians to achieve their ends. For the interventions to achieve their intended objectives requires them to be de-politicized. This could be achieved by transferring the strategic oversight of interventions from political offices to technical civil service and tightening performance monitoring with checks and balances. Such a move would further promote transparency and accountability of the interventions.

The youth’s dissatisfaction with life manifests in different ways, such as anti-social behavior like crime and drug abuse, which are threats to the larger population. Organized criminal gangs involved in violent crime are reported to be on the increase [52–54]. Reports suggest Kampala slum areas are a haven for violent youth gangs who rob, rape, and kill their victims [52, 55]. Additionally, our data suggest that young people experience abuse such as deprivation of basic necessities and physical, sexual, and psychological abuse by family members. When the abuse becomes unbearable, young people run away from home to gain a sense of freedom, which in itself is a risk to their well-being. These young people often end up homeless and experience further abuse from a wider community. This is consistent with other studies, which identified various categories of perpetrators of abuse and violence against street children and homeless youth [6, 56, 57].

Media reports suggest violence against young people by their carers is a common and a deep-rooted practice that sometimes results in physical impairment or death and aggravates dissatisfaction [58–60]. Such a situation requires sustainable policy interventions nuanced within the customary and social milieu. For example, like the gachacha courts established to promote reconciliation post genocide in Rwanda, kitewuliza is an old and disappeared community juridical system that emphasized reconciliation in Central Uganda and akiriket elder’s arbitration councils in North Eastern Uganda [61–65]. Customary structures are necessary because they are inherent among the communities and because retributive justice interventions have failed to sustainably address violence against young people. There are cultural barriers to compliance with retributive justice especially when the perpetrator is a close family member. Such barriers are poor access and a negative perception of the formal justice system, fear of the effect of retributive punishment, such as imprisonment, loss of livelihood, and support for the family [6, 61]. These impediments undermine deterrent interventions such as law enforcement against perpetrators. Some of the traditional jurisprudence approaches combine restoration, retributive, distributive, and procedural justice and are usually guaranteed by the entire community for sustainable outcomes while preventing potential re-occurrence [53]. Moreover, the best regulation is when communities regulate themselves rather than formal justice based on fear of retribution. Therefore, culturally nuanced approaches could be more effective in addressing youth problems.

We found low participation of young people in the labor market, and whenever they participated, they were exploited. A lack of employment has led to youth in slum areas exploring other avenues to survive, such as migrating abroad for work. Vulnerable youths, especially those in slum areas, have been lured to countries, particularly the Middle East and as far as China and Malaysia with promises of low skills jobs [66]. In the Middle East, Ugandan youths get trapped into domestic slavery and experience a plethora of abuse, including forced labor, corporal punishment, confinement in houses, violence, and sexual abuse [67, 68]. In China, Thailand, and Malaysia, most trafficked Ugandan youth end up in forced prostitution [66, 69, 70].

This migration to foreign countries is synonymous with human trafficking and requires interventions that directly address the youth dissatisfaction with their status quo. Human trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery (p. 488) [71]. Curbing the growing trafficking industry require a multi-pronged approach. This requires addressing the push factors before the youth get entangled, and streamlining the coordination of external employment to strengthen vetting of employment agencies, institute and standardize overseas workers identification procedures, track and support youth who travel for work, and establish bilateral facilities of supplying manual labor force with recipient governments. The Ugandan government established a statutory external employment unit in 2005 responsible to management of Ugandan workers overseas [72]. However, weak capacity, insufficient funding, and corruption constrain the unit from streamlining the industry plagued by dubious employment agencies [73].

Politicians have exploited the wave of dissatisfaction to mobilize youths for defiance campaigns, which paralyzed urban areas, especially Kampala city. Defiance campaigns involve walking to urban central districts to protest against the government. The protests usually turn violent and destroy businesses while crippling the economy [74]. A recent study found that Ugandan youths are politically active but vulnerable to political bribery and manipulation [24]. The youth rating themselves 0 on a score of 10 is a reflection of their state of hopelessness that makes them vulnerable to manipulation as well as high-risk behavior, such as crime and prostitution, for survival. It is this kind of hopelessness that led a young person to self-immolation in Tunisia, which marked the start of the Arab Spring, which toppled governments and led to civil wars in North Africa and the Middle East [75]. However, dissatisfaction and desperation can be deconstructed into hope and youth engagement by addressing the push factors for rural-urban migration such as the improvement of rural social services and economic opportunities. Ugandan news have frequently profiled anecdotal initiatives like smart farming involving small pieces of land and limited capital yet provide high returns than formal employment [76–79]. The government could seize the opportunity to promote such interventions as an alternative path to formal employment. Besides, Ugandans are known for embracing miniature economic structures of signification [80].

Our study found a combination of early pregnancy, early sexual debut, and insufficient sexual education reflected key determinants of poor quality of life among the youths. These findings are similar to those reported in developing countries by the World Health Organization [81]. Insufficient reproductive health education has implications on the national fight against HIV/AIDS. Uganda effectively reversed HIV/AIDS trends from a staggering prevalence of 18% in 1992 to as low as 6.4% in 2005 [82]. Evidence suggests that prevalence of the disease is on the increase and youths feature high in the increase [82]. If not addressed, the national AIDS burden, especially treatment, could cost the country up to 21% of the gross domestic product (GDP) between 2015 and 2050 [83]. Furthermore, the intergenerational burden of early pregnancy perpetuates poor health and poverty, as young children become mothers before their bodies are physically ready. This leads to various health complications with significant financial implications on national health as well as the girls’ quality of life. For example, Uganda is among the few countries where obstetric fistula is still prevalent [84]. This condition is predominantly prevalent among young poor mothers whose birth canals tear during childbirth leaving their reproductive organs permanently damaged, unable to control the passing of urine and faeces. The World Health Organization reports that childbirth complications are one of the leading causes of death among girls aged between 15 and 19 [81]. Early pregnancy also has negative implications on the socioeconomic status of the girls. When girls get pregnant, they drop out of school to become mothers before attaining sufficient education and skills to propel them into gainful employment.

We found poor housing conditions were a determinant of early sexual debut. Poor housing conditions made adult privacy difficult. For example, parents have sex in spaces they share with children when the latter pretend to be asleep or are sleeping. In some instances, the parents’ bed is separated from the rest of the family by a cloth curtain through which young people follow their parents’ sexual activity when they are not fully asleep at night. This exposure accelerates the young people's desire to try out early sex without realizing the consequences. Their experiences demystify sex. They try out what they have seen and heard, and expose themselves to risks associated with early sex. This finding is consistent with earlier studies, which identified early sexual debut as one of the key HIV risk factors among young Ugandans [85, 86]. Interventions to address sexual health are likely to be more effective if interwoven within the broader issues of decent living conditions and social economic participation. This approach would facilitate the construct of slum hood not only as poor squalid conditions but as a representative of the quality of life, health, and social and economic conditions of the dwellers.

Limitations

The application and extension of our findings to other contexts should be handled with caution because we used purposeful sampling to achieve diversity in the study sample. In addition, our study was based in the low socioeconomic slum areas of Kampala. However, it should be noted that generalizability of findings is not the main concern of qualitative research [87].

Conclusion

We assessed the needs of urban youths in the low socioeconomic areas of Kampala. We found youths have basic needs that remain unaddressed. Interventions that seek to address the needs are too few to match the large and growing youthful population. Such a large population remaining unproductive and dissatisfied with life is a recipe for future trouble and cloud incubate insecurity. This has implications, especially on the national economy, and could aggravate impoverishment, poor quality of life, and well-being. Uganda is a poor country that cannot afford an effective social welfare programme but can accelerate investments and policies targeting youth needs within the constraints of the economy.

Abbreviations

AIDS

acquired immune-deficiency syndrome

CVA

citizen’s voice and action

FGD

focus group discussion

GDP

gross domestic product

HIV

human immune-deficiency syndrome

KII

key informants interview

MDG

Millennium Development Goals

PC

Personal computer

SDGs

Sustainable Development Goals

SACCOS

savings and credit cooperative societies

STI

sexually transmitted infections

UNICEF

United Nations International Children’s Emergency Fund

USD

United States dollar

Authors’ Contributions

JKK and AMNR conceptualized the study. AMNR, BMN, and RE collected the data. AMNR performed the statistical analysis. JKK and AMNR interpreted the findings, and JKK drafted the manuscript. GK reviewed and edited the manuscript to enhance its intellectual content. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Ethics Approval and Consent to Participate

The study was approved by the Monash University Human Research Ethics Committee (approval no. CF16/1001-2016000532).