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Social influences on young people’s sexual health in Uganda
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London, UK, and
Stephen Bell Peter Aggleton National Centre in HIV Social Research, University of New South Wales, Sydney, Australia
Received 23 January 2012 Revised 7 June 2012 Accepted 27 July 2012
Abstract Purpose – The purpose of this paper is to examine the influence of social context on young people’s sexual lives and sexual health, and to highlight the need for HIV prevention and sexual health programmes which better take into account these contextual influences. Design/methodology/approach – The paper draws on findings from a multi-method, qualitative study involving young people aged between 11-24 years, conducted in three rural areas in Uganda. Data were collected by means of 52 single-sex focus group discussions, 117 in-depth interviews, and further participatory research with 23 of these young men and women. Contextual information was gathered through interviews with parents (17), teachers (7), religious leaders (7), local clan leaders (6), community-based NGO/CBO workers (12) and local government staff (33). Findings – Local beliefs about age and gender suggest that intimate relationships and sexual behaviour among young people are forbidden, or at least should be hidden. Social norms produced and reproduced both by adults and young people themselves increase the likelihood of secretive, unprotected sexual relations, and inhibit young people’s ability to seek sexual health-related support and advice. Originality/value – An understanding of these contextual influences has important implications for improving the design of HIV prevention and sexual health programming in rural communities in Uganda. Keywords Sexual health, HIV, Prevention, Young people, Uganda, Africa, Empowerment, Rural regions, Youth Paper type Research paper
Health Education Vol. 113 No. 2, 2013 pp. 102-114 r Emerald Group Publishing Limited 0965-4283 DOI 10.1108/09654281311298795
Introduction Two key messages drive the widely endorsed joint United Nations Programme on AIDS (UNAIDS) 2011-2015 strategy, getting to zero (UNAIDS, 2010). The first is the need to intensify HIV prevention by implementing more comprehensive forms of sexuality education, encouraging public discussion about sexuality, changing the social, cultural, economic and political context and by addressing social, sexual and gender factors that create HIV-related vulnerabilities. The second is young people’s role in leading and owning what has been called a socially transformative approach to HIV prevention. The UNAIDS strategy states that “it is critical that we empower and facilitate young people as change agents in activating their communities to redress harmful social norms governing sexuality, gender roles and other behaviour” (UNAIDS, 2010, pp. 34-5). Two broad sets of factors have been identified as contributing to detrimental sexual health outcomes such as STIs, HIV infection and unintended pregnancy – individual risk and societal vulnerability (Mane and Aggleton, 2001). Individual risk is characterised by what individuals know and how they choose to act to reduce or increase their chance of acquiring an STI or becoming pregnant, whereas societal
vulnerability stems from socio-cultural, economic, political and legal factors constraining individuals’ opportunities to reduce risk (Melendez and Tolman, 2006, p. 29). In recent years, there has been a shift from attempting to understand risk behaviour as primarily determined by individual-level attributes, towards a greater recognition of the importance of social influences (Aggleton, 2004; Ingham, 2006). The influence of contextual factors on young people’s sexual health is well documented (e.g. Bhana et al., 2010; Bhana and Pattman, 2011; Campbell et al., 2005; Masvawure, 2010; Parker, 2009; Samuelson, 2006). This includes the powerful impact of proximal factors (e.g. interpersonal relationships, and lack of access to condoms, information and sexual health services) and distal factors (e.g. cultural beliefs, poverty) on young people’s lives (Eaton et al., 2003; Kaufman et al., 2004; Rivers and Aggleton, 1999). Improving the sexual health of young people requires actions to target a range of social, cultural and economic influences enabling and supporting health protective behaviour among young people and other community members (Collumbien et al., 2006, p. 156). Against this background, the research described in this paper sought to explore the risks and vulnerabilities confronting young people in rural areas of Uganda. It analyses social and cultural aspects of rural Ugandan society influencing how young people should or should not behave. It cautions against too strong a focus on the individual, using recent research on age- and gender-based social influences as a lens through which to analyse the broader consequences of young people’s relationships, and the influence of social context on sexual practices and outcomes (see also Ingham, 2006). Without this focus, HIV prevention and sexual health programming may be limited, creating further problems for young people. Work which explores young people’s sexual health practices might usefully pay greater attention to what Aggleton et al. (2006, p. 4) have called the systematic “structuring of vulnerability” to HIV and sexual health risk. The sociological concepts of “doing gender” (Melendez and Tolman, 2006, p. 33) and “performing age” (Laz, 1998) offer insight into how this takes place, describing the ways in which people produce, live through and reproduce gender and age relations in society. With respect to gender relations, for example, Melendez and Tolman (2006, p. 33) have argued that: [y] by engaging in the process of behaving in, thinking about, or even feeling in the prescribed ways that [a] society ascribes to males and females, each person actively enacts gender – over and over and over again. This process makes it virtually impossible to ‘see’ the production of gender until one is aware of this process. Thus gender relations, as well as gendered individuals, are constantly created, maintained and reproduced in everyday life.
A similar process operates with respect to age-related expectations, with young people and adults being intimately involved both in the production and reproduction of agerelated norms and behaviours. Engaging with these ideas, we seek to identify more clearly than hitherto some of the consequences – both intended and unintended – of these different processes. Methods This paper draws on findings from a multi-method study undertaken in Uganda. Work examined aspects of everyday life for young people in three cultural groups (Basoga, Bagisu and Baganda) in three rural areas – Iganga, Mbale and Mpigi – with a focus on HIV and sexual health. The aim of the research was to better understand what empowerment means in relation to young people and their sexual health, from both
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conceptual and practical programme perspectives. Choice of the three cultural groups and rural settings was based on the partner NGO programmes which were also under study. In this paper, which is one of several detailing findings from the study (see also Bell, 2012; Bell and Aggleton, 2012a, b), we focus in particular on the social and cultural influences affecting the sexual health of young people, aged 11-24 years. The research approach was rooted in a number of ethnographic principles (Hammersley and Atkinson, 1995). It aimed to be “emic” rather than “etic”, exploring how participants constructed and interpreted behaviours in the light of their social realities and meaning systems. It also aimed to be context-sensitive and reflexive, whereby the researcher tried to remain self-critically aware, questioning his own behaviour, attitudes, values and beliefs in the light of the influence these may have on the research. Various data collection methods were utilised including participant observation, key informant interviewing and participatory techniques. Following pilot work to develop the methods used, in-depth qualitative and ethnographic enquiry was conducted with respondents participating in three HIV prevention and sexual health programmes. This included 52 single-sex focus group discussions and 117 in-depth interviews with young men and women aged between 11 and 24 years, in and out of school. Focus groups, comprising between 5 and 12 participants and lasting between 45 and 90 minutes, were carried out with young people in each of the three research areas: with young men in (19 focus groups) and out (eight focus groups) of school, and with young women in (19 focus groups) and out (six focus groups) of school. The choice of focus group participants was dependent on the focus of local NGO interventions, whereby one of the programmes only worked with students, and the other two worked with young people in and out of school. Focus groups with young people out of school were organised by friendship group, and focus groups in school were conducted in class-based groupings (first two years of secondary school; final two years of primary school at the start of the study). Focus group discussions elicited information about respondents’ experiences of being a young person in the local area, and their perceptions of social differences (e.g. between young and old, male and female, rich and poor) and associated local power relations. Focus groups were undertaken in English where possible, and in local language with translation support. Interviews were conducted with young men aged between 12 and 18 (38 interviews) in school, young men aged 15-24 (19 interviews) out of school, young women aged 12-17 (38 interviews) in school and young women aged 13-22 (22 interviews) out of school, 11 of whom were young mothers. Topics explored during the interviews included family and home life, social networks, young people’s roles and responsibilities, income generating opportunities, emotional well-being, relationships and sex and future aspirations. The large sample size of 117 interviews (41 in Mbale, 35 in Mpigi and 41 in Iganga) was necessary as data saturation needed to be achieved with young people of different ages, in and out of school, across a range of topics. Interviews were undertaken in English where possible, and in local language with translation support. Purposive sampling was used to select young people from the focus groups for interviews to meet the broader research objectives of better understanding empowerment processes affecting young people’s sexual health. For this reason, young people were chosen to reflect a broad range of life experience in relation to: reported sexual behaviour (e.g. sexual experience, and involvement in a boyfriendgirlfriend relationship); levels of confidence and self-esteem (e.g. open and willing to talk, or shy and embarrassed when talking in groups); financial independence
(e.g. opportunity to earn own money); types of family livelihood (e.g. subsistence farming or salaried jobs); and parental support (e.g. small family, polygamous families, single parents or orphaned). Contextual information was also gathered in each fieldwork site through interviews with parents (17), teachers (seven), religious leaders (seven), local clan leaders (six), community-based NGO/CBO workers (12) and local government staff (33). After an initial period of analysis, further participatory research (including semi-structured thematic conversations, life history interviews and participatory exercises) took place with 23 of the 117 young people previously interviewed. Together, these methods produced several rich data sets, including transcripts, field diary notes and pictures/diagrams from participatory exercises. These were subjected to a rigorous grounded and systematic analysis by the first author following Crang’s (1997) system of thematic “open” and “axial” coding. Open coding involves reading through the data to increase familiarity and to record “theoretical memos” (Crang, 1997, p. 186) as analytical reminders for generating ideas and making links between different data. Axial coding describes the process of linking or organising open codes into themes and sub-themes, and providing evidence to support thematic findings. No data analysis software was used. Findings, interpretations and inferences were cross-checked against one another through processes of “triangulation” to maximise validity (Hammersley and Atkinson, 1995). Ethical review of the study took place at the institution from where the study was conducted (Royal Holloway, University of London). Ethical principles including voluntary participation, informed consent, confidentiality, maintaining anonymity through the use of pseudonyms and the ability to opt out of the study at any stage were adhered to throughout the study. Informed consent was gained from young people themselves, as well as from parents for those respondents aged under 18 years. Findings Research participants and context Of the 117 young people interviewed, 48 per cent of girls (29) and 68 per cent of boys (39) reported having been involved in relationships with members of the opposite sex; 44 per cent of girls (26) and 53 per cent of boys (30) reported having experienced sexual intercourse. Girls (25 per cent) and boys (40 per cent) in school were less likely to have had sex than girls (79 per cent) and boys (77 per cent) out of school. Intimate relationships between people of similar age were the norm. Three-quarters of participants came from rural homesteads dependent on subsistence agriculture for survival. A third of these were from female-headed households. The remaining 25 per cent came from families where parents were able to derive an income from agricultural and informal sector work as well as formal wage-based employment. Whilst district-level HIV prevalence data were unavailable at the time of study, anecdotal evidence suggested that each fieldwork area had been heavily affected by HIV. None of the young people interviewed claimed to be HIV-positive, but three in ten (31 per cent) had lost one or more birth or step parents to AIDS-related illness by the end of fieldwork. Research participants had access to a third-level health centre in each fieldwork site (with outpatient services, maternity and general wards and a laboratory, serving 20,000 people), as well as an additional second-level health centre in one fieldwork area (outpatient services only, serving 5,000 people).
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Local norms, beliefs and cultural expectations Sex as an adult privilege. Discussion with the large majority of young people, parents and community members indicated that having a boyfriend or girlfriend was seen as unacceptable, whether or not the relationship was sexual (see also Harrison, 2008). Whilst friendships between boys and girls were positively perceived, parents warned that these could lead to love and “promiscuity” if allowed to go too far. Parents and young people agreed that it was better to have boyfriend-girlfriend relationships after leaving school: Sex is not allowed until marriage. The influence of modernity leads to moral decadence. Now it is a big problem. Children below 15 are getting pregnant. Formerly, it was not allowed until they were married. We have so many rebels now (Patrick, local Christian leader). It is not good to love girls. We must wait until we have finished education. [y] I am not making a relationship of love with girls as it can make disunity with parents. I have never had love with girls, and I will not play [sex] until the future, when I have completed my education and got employment and I am married (Taibu, male, student, 16).
Sex was portrayed as being an “adult” privilege. The easiest way for young people to violate adult standards of good behaviour was to be sexually active openly at a young age. If young people did become sexually active, this had to happen in secret from all adults and most peers to avoid gossip and relationships becoming public knowledge. The gendering of sexuality In fieldwork contexts, young people saw “behaving well” as central to daily existence. Whilst boys referred to avoiding verbal or physical abuse, stealing, smoking, quarrelling and drinking alcohol, girls made greater reference to sexual behaviours. Specific behaviours to avoid included falling in love, talking with members of the opposite sex and wearing clothing which showed too much flesh. These were associated with promiscuity and girls were supposed to act with self-restraint and discipline (see also Harrison, 2008; Keys et al., 2006): Good behaviours are like greeting people. As we are sitting here, if you pass without waving they will talk badly of me and say that I don’t greet. Also not quarrelling or drinking. [y] If you don’t behave well you are a ‘muyaye’ [Lumpen]. You are bad. They will say you don’t behave well. In the case of any problem they will say I don’t behave well in the community and they will refuse to help me ( Joseph, male, out of school, 17). You should be well behaved. You should respect your parents. You should read your books all the time. And not shouting or making noise in class. [y] You don’t behave badly, like gossiping about people. You do not play with boys. And you do not wear the mini-skirt [y]. If you do, the parents can leave you to be on your own and the world will be hard for you. At school you are caned. In the community people just leave you alone when you get a problem, no one will help you (Mastula, female, student, 13).
Discussion about reputation revealed that girls were likely to be judged more negatively than boys with regard to sexual conduct. A girl should remain in control of her sexuality, while boys were allowed to try their luck without being judged (see also Dowsett et al., 1998; Keys et al., 2006): It is a bad thing for girls to have a child before marriage. An embarrassment to the family. Traditionally, the girl was not allowed to come back to the house and not allowed to eat with her father, unless the father excused her. For boys it is not an embarrassment. What happens is the other family comes for a fine, or asks the boy to marry the girl. But it is not an embarrassment ( Juma, father).
For boys, vulnerabilities arise from contradictory messages that discourage and yet permit them to have sex. Girls on the other hand have to negotiate sexual pressures from boys alongside wider expectations to maintain a good reputation. Relationships with elders The importance of “respect” was often mentioned by young people when describing their relationships with parents and elders. It was considered disrespectful, for example, for young people to argue with, answer back, disobey or question elders’ judgements. Young people were expected to remain dependent on their parents until marriage, at which point they became adults, responsible for themselves and their own families (see also Boehm, 2006, p. 153): Young people are respected as an adult after having got married, but if they are not married, people don’t respect you. There will be no contribution in meetings. They will have no respect even if they are clever. Marriage leads to adulthood. Even if you have a degree you are not respected. You are underrated (Patrick, Christian leader).
Parents thought that young people could not and should not make decisions, as they are perceived as too young to do so appropriately. Independent decision making was condoned only if it conformed to parental expectations. These pressures have implications for HIV prevention and sexual health. First, respecting elders may discourage young people from seeking advice, particularly if the issues involved are sensitive. Second, because reputation is dependent on behaving well, young people’s sexual relationships take place in private. Finally, silence limits young people’s capacity to participate fully in their communities, discuss sexual health needs and seek health services. Preparation for adulthood Despite age setting limits of young people’s behaviour, there are transitional markers which encourage young people to prepare for the future. For example, the onset of puberty signals that girls are becoming ready for marriage: It is when the girl grows to 14 or 15 years, and has menstruation periods. After the girl experiences that, she is free to marry. After having periods she is now believed to be mature. [y] If the girl is not in school, we as parents look for a husband, according to how she behaves. If we see interactions with boys, then we marry them off to avoid [premarital] pregnancy. Education has now come, so you allow for studies, but when the girl reaches marriage, she decides ( Juma, father).
Rites of passage also mark the transition to adulthood. Girls approaching the onset of menstruation and puberty talked about “visiting the bush” or “pulling”, referring to the practice of elongating the labia minora (Larsen, 2010; Perez and Namulondo, 2011). Reasons given for this practice, which is taught by their aunts or ssengas, include preparing young women for marriage, and satisfying future husbands’ sexual tastes and needs (Seeley et al., 1991). Boys in Mbale, eastern Uganda, discussed their circumcision ceremony, and the conflicting messages given to young people during this celebration. Traditionally among the Bagisu people, becoming circumcised marks a boy’s transition to manhood, the gaining of adult privileges (including marriage, sexual relationships and respect), as well as growing confidence and self-esteem (see also Heald, 1998; Khamalwa, 2004). During circumcision celebrations, young men are encouraged to act like adults, and younger boys imitate these behaviours irrespective of what is normally considered
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appropriate. This poses problems for young women who sing and dance to help prepare for the circumcision ceremony. Whilst many girls enjoyed participating, interviewees highlighted the fear of unwanted touching, sex, rape, pregnancy and forced early marriage: Circumcision has made many people problems. If girls go there they want to dance. They are raped by boys before accepting. Some boys and girls stop studying. The boys may carry you and take you to their homes, and you fear that the parents will say that I did not sleep at home and they will beat you. So you end up marrying him like that (Zaina, female, student, 14).
By attending and participating in traditional customs, boys and girls gain confidence and self-respect. Visiting the bush offers girls the chance to develop solidarity through interaction with peers and their ssenga. Boys circumcised in the same year are referred to as “brothers” and can traditionally call on each other for support. Domestic roles and responsibilities An important part of growing up in the communities studied involves learning roles and responsibilities at home. After the age of 14, domestic roles become more clear-cut: boys are sent to shops to buy food and look after grazing animals, while girls spend a greater proportion of time in the home. This division of labour restricts young women’s movements and impacts on their ability to move freely in the community: I employ restrictions on my daughters. For example, not leaving home when it’s late. Girls must remain at home to cook but boys can go fetch water and fetch things from the shops (Agnes, mother).
Restrictions on the use of space and time also affects girls’ ability to achieve what might be described as “relational empowerment” (Rowlands, 1997) through association with people with whom they can share personal worries, seek sexual health advice or generate independent income. This increases the likelihood of their seeking a boyfriend as a livelihood strategy. Opportunities for girls and boys to meet are also restricted. As a result sexual experiences become opportunistic, rushed and hidden, with limited opportunity for support before, during or after the event: Did you see? There [at the road side]. There was a boy and girl lying together in the dark. Most young people here are without houses. Parents are strict. These people, they must solve their affairs [have relationships] in private, like here in the banana plantations where it is so dark and they cannot be seen. There it is usually safe to discuss and play sex (Alex, student, 14).
Constraints and possibilities Moving beyond adult-centric community health work and services. Local health centre staff in Iganga talked positively about their success in reaching young people in and out of school. Their programme involved regular school visits and Saturday clinics for young people to educate about HIV, contraception and gender equality in decision making, and to provide condoms and family planning free of charge. However, there were contradictions between these claims of success and young people’s own experiences. Reflecting comments from young people more generally, one 14-year-old school girl in Iganga explained that she remembered being told about condoms and family planning options on these visits, but said young people were informed that these were only suitable for older or married people: I stopped listening properly as I didn’t think it applied to my life as condoms are for over 18s and the other types are for married people. They do the same lesson every time so I haven’t learnt anything new since the first time (Florence, female, student, 14).
And a young man recalled: The nurses said that it is okay to use family planning and condoms when you reach the stage where you need them. Not now. I am 16 only. But when I reach the stage. Like at 18 or 21. It is ever okay then. They say that I am not old enough now and that I should never be using them until I am old enough (Rogers, male, student, 16).
Health centre staff working in clinics in each research area also described a number of challenges, including the fact that few of them really focused on young people and their needs: There are services that the youth use, but in reality they’re not specifically for youth. Many of them are called youth-friendly by the government, but nothing is actually different about them than from what adults receive. But youth-friendly programmes and staff are needed (Godfrey, doctor, health centre III).
Beyond this, services offered were often seen by young people as inappropriate in terms of timing and location. The Saturday morning health centre clinic in Iganga, for example, clashed with young people’s domestic responsibilities, especially those of girls who had less opportunity to attend due to their home-based duties. Young people also had concerns about whether they could trust local adult health workers, for fear of confidentiality being broken and reputations being damaged: For outreach work, we can’t use local health workers as young people won’t open up. They have to be from outside, especially with the girls. It is better if these outreaches have nurses and doctors who come from further away, such as Jinja, as people fear them less, and know there won’t be consequences of their parents or other relatives/community members finding out (Godfrey, doctor, health centre III).
Staff attitudes also inhibited young people’s attendance at health centres. Health centre staff were seen as overbearing, telling young people what they think rather than encouraging and facilitating dialogue. They also tended to lecture young people about abstinence and the need to refrain from sexual relationships (see also Warenius et al., 2006): Some young couples come in together, and tell the doctor what they want. Many health workers will give them a lecture about abstaining and discourage them from having sex, but not address their individual needs. This is a big problem as young people don’t take this advice. They just leave without help, or without protection, and don’t stop having sex (Godfrey, doctor, health centre III).
Limited dialogue with parents about sexuality. Both parents and young people indicated that there was limited communication about sex and sexual health in the home. This has been widely documented, including problems communicating with parents (Amuyunzu-Myamongo et al., 2005; Seeley et al., 1991) and extended family members (Muyinda et al., 2004). Despite recognising the importance of HIV prevention, parents stated, “Ah, we don’t know anything about those things” and “For us elders, we don’t hear about those problems”. Gender norms made it hard for mothers to discuss sex and relationships issues with both their sons and their daughters: I take the trouble of talking to my own children, but not too directly. I make sure I use stories and examples from other areas where youth have died from AIDS to make them have not too much interest in playing sex. [y] Basing on our culture, despite that I am an HIV facilitator in our community, I am not open enough. Culturally I cannot be so open with my children. With some youth I can tell them how it is openly, but with my children I cannot (Aisha, mother).
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Parents’ insecurities about levels of knowledge impacted on their willingness, confidence and ability to teach their children. All the parents interviewed said it was important for young people to protect themselves against HIV. But 36 out of 39 of them also said they needed to learn more about sexual health to be able to educate their children, friends and family members. Limited dialogue with teachers about sexuality. In each of the eight schools involved in the study a senior male teacher and a senior female teacher were reportedly available to provide young people with advice, but worries about discipline prevented students from approaching them: We hear those things from teachers. [y] The senior woman teacher was teaching me about puberty, and saying that you can have children if you play sex. But I was just nodding and wanted to go. If I was telling her about my boyfriend, I would have been beaten. They are telling the parents about those things. You cannot talk to a teacher like that (Brenda, female, out of school, 16).
Teachers recognised that they were jointly responsible with parents for talking to young people about their health, but said they required better training in how to give this guidance effectively. They explained that they rarely discussed the emotional aspects of HIV and AIDS, and found it difficult to talk to students about sexual issues beyond the biology: Teachers feel very difficult about teaching sex, as the community views them as parents, and parents are not allowed to talk about sex. [y] Such talk is obscene [y] Sex is meant to be private. We cannot even mention private parts by name. It is unacceptable. Even the word ‘penis’ is too obscene. Instead we talk of animals, or allude to it (Hussein, headmaster, rural secondary school).
Young people reproduce social influences. It is perhaps not unexpected that young people incorporate into their own repertoires the age and gender expectations to which they are exposed. One example of this can be seen in the attitudes some young people held towards contraception: Family planning and condoms are examples of contraception. They are acceptable if you reach that stage when you are able. Like at 18 years (Daniel, male, student, 16). Religious beliefs impact very much. It only allows abstaining, and people respect religion more than anything else. I am not generally against condoms and family planning, but for me I won’t use them as I respect religion more than anything else ( Justine, female, out of school, 15).
Young people also explained that boys should be responsible for deciding whether to use condoms, for arranging when and where to meet, and for deciding whether or not a girl should have an abortion. Girls reported having little influence over these decisions, and tended to acquiesce to what was suggested: When I conceived, the boyfriend said we should abort. I accepted but after two weeks he returned back saying we should not abort and he committed to looking after the baby. [y] I was not happy, I wanted to abort and go back to school and I feared the parents. I didn’t abort because the boy was responsible for paying the abortion so it was his decision (Fidha, female, out of school, 18).
Young people’s secretive sex. As indicated earlier, the most significant systematic impact of these social influences on young people’s sexual lives was the prevalence of
secretive, opportunistic sexual experiences amongst young people (Bell, 2012; Harrison, 2008):
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We are making the relationship confidential so the parents of the girl don’t find out about it. I can meet her on the way and I will give her the programme [arrangements] so that the parents are not aware of it (Yasin, male, out of school, 22).
Hiding sexual activities and relationships from adults was a strategy by which to accommodate such practices within the confines of dominant social expectations, along the principle of “out of sight, out of mind”. Through secret meetings, young people avoided the negative consequences of relationships becoming public knowledge in a restrictive social context. These included parental punishment, school drop-out, fines and imprisonment for defilement and increased poverty during early parenthood or single motherhood. Issues such as sex as an adult privilege and the view that young people should not have sexual relations until marriage are important when trying to better understand young people’s sexual health vulnerabilities. These ideas encourage young people to initiate and maintain relationships in secret, restricting their ability to express themselves sexually and deal with problems that arise during a relationship. The absence of good quality health services locally further compounds the problem. Conclusions and implications Throughout this paper we have highlighted how social influences, especially age and gender roles and expectations, impact upon young people’s sexual health in rural areas of Uganda. The findings reveal the existence of few opportunities for young people to talk openly about sexual matters. Within the contexts studied, there are strong constraints on their ability to build relationships with peers, partners, parents, teachers and clinic-based and community health workers. As a result, sexual relations tend to take place without support, advice and dialogue, increasing the likelihood of negative health outcomes. This paper also illustrates the systematic nature of vulnerabilities that arise from restrictive factors within the local social context. Through their efforts to conform to gender and age norms, parents, teachers, extended family members and community health workers, together with young people themselves, reproduce the very ideologies, practices and relations that make young people vulnerable in the first place. These findings have important implications for HIV prevention and sexual health programming. In settings such as those described in this paper, young women and young men are likely to engage in sexual activities, whether or not adults find this acceptable. However, if programme and service assumptions are not aligned with the realities of young people’s lives, young people are unlikely to be reached by or engage with them and secretive sex will remain the norm. The findings illustrate clearly the influence of social and cultural contexts on young people’s vulnerability to sexual ill-health, and the need for sexual health and HIV prevention work to consider how programme design and implementation might encourage changes to longstanding social beliefs. Understanding of, and action to transform, the broader social context is therefore fundamental to successful programme development. Whilst findings relate to young people in rural Uganda, reference to other studies with similar findings in other African countries (see Samuelson, 2006; Harrison, 2008) would suggest that issues raised in this study have relevance to other settings as well.
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From a research perspective, more work is required to identify the strategies used within NGO programmes and by young people themselves, to challenge and rebalance power relations between young people and adults. It is also important to understand better the tensions that can arise when these actions occur. From a programme perspective, it is important to continue to work with young people to build individual knowledge and life skills, but also reflective dialogue about sexuality and health more broadly. Tackling the relational and contextual influences affecting risk and vulnerability involves creating environments that are more facilitative of young people’s sexual health (Campbell et al., 2009; Campbell and Cornish, 2010). Achieving this goal requires work with adults as well as with young people to acknowledge that change may be required in community attitudes and to understand what impact this change may have on society more generally. Dialogue and engagement with adults about their own sexual and reproductive health may have an important role to play as part of a larger process building bridges across age and gender divides. References Aggleton, P. (2004), “Sexuality, HIV prevention, vulnerability and risk”, Journal of Psychology and Human Sexuality, Vol. 16 No. 1, pp. 1-11. Aggleton, P., Ball, A. and Mane, P. (2006), “Introduction”, in Aggleton, P., Ball, A. and Mane, P. (Eds), Sex, Drugs and Young People, Routledge, London, pp. 1-9. Amuyunzu-Myamongo, M., Biddlecom, A.E., Ouedraogo, C. and Woog, V. (2005), “Qualitative evidence on adolescents’ views of sexual and reproductive health in Sub-Saharan Africa”, Occasional Report No. 16, available at: www.guttmacher.org/pubs/2005/03/01/or16.pdf (accessed 16 November 2012). Bell, S.A. (2012), “Young people and sexual agency in rural Uganda”, Culture, Health and Sexuality, Vol. 14 No. 3, pp. 283-96. Bell, S.A. and Aggleton, P. (2012a), “Time to invest in a ‘counterpublic health’ approach: promoting sexual health among sexually active young people in rural Uganda”, Children’s Geographies, Vol. 10 No. 4, pp. 385-97. Bell, S.A. and Aggleton, P. (2012b), “Integrating ethnographic principles in NGO monitoring and impact evaluation”, Journal of International Development, Vol. 24 No. 6, pp. 795-807. Bhana, D. and Pattman, R. (2011), “Girls want money, boys want virgins: the materiality of love amongst South African township youth in the context of HIV and AIDS”, Culture, Health & Sexuality, Vol. 13 No. 8, pp. 961-72. Bhana, D., Morrell, R., Shefer, T. and Ngabaza, S. (2010), “South African teachers’ responses to teenage pregnancy and teenage mothers in schools”, Culture, Health and Sexuality, Vol. 12 No. 8, pp. 871-83. Boehm, C. (2006), “Industrial labour, marital strategy and changing livelihood trajectories among young women in Lesotho”, in Christiansen, C., Utas, M. and Vigh H.E. (Eds), Navigating Youth Generating Adulthood, Nordiska Afrikainstitutet, Uppsala, pp. 153-82. Campbell, C. and Cornish, F. (2010), “How can community health programmes build enabling environments for transformative communication?: experiences from India and South Africa”, HCD Working Papers No. 1, London School of Economics and Political Science, London. Campbell, C., Foulis, C., Maimane, S. and Sibiya, Z. (2005), “The impact of social environments on the effectiveness of youth HIV prevention: a South African case study”, AIDS Care, Vol. 17 No. 4, pp. 471-8. Campbell, C., Gibbs, A., Maimane, S., Nair, Y. and Sibiya, Z. (2009), “Youth participation in the fight against AIDS in South Africa: from policy to practice”, Journal of Youth Studies, Vol. 12 No. 1, pp. 93-109.
Collumbien, M., Douthwaite, M. and Jana, L. (2006), “Using evaluation to improve sexual health of young people”, in Ingham, R. and Aggleton, P. (Eds), Promoting Young People’s Sexual Health. International Perspectives, Routledge, London, pp. 155-73. Crang, M. (1997), “Analysing qualitative materials”, in Flowerdew, R. and Martin, D. (Eds), Methods in Human Geography, Longman, Harlow, pp. 183-96. Dowsett, G., Aggleton, P., Abega, S.C., Jenkins, C., Marshall, T.M., Rungunga, A., Schifter, J., Tan, M.L. and Tarr, C.M. (1998), “Changing gender relations among young people: the global challenge for HIV/AIDS prevention”, Critical Public Health, Vol. 8 No. 4, pp. 291-310. Eaton, L., Flisher, A.J. and Aaro, L.E. (2003), “Unsafe sexual behaviour in South African youth”, Social Science and Medicine, Vol. 56 No. 1, pp. 149-65. Hammersley, M. and Atkinson, P. (1995), Ethnography: Principles in Practice, Routledge, London. Harrison, A. (2008), “Hidden love: sexual ideologies and relationship ideals among rural South African adolescents in the context of HIV/AIDS”, Culture, Health and Sexuality, Vol. 10 No. 2, pp. 175-89. Heald, S. (1998), Controlling Anger: The Anthropology of Gisu Violence, James Currey, Oxford. Ingham, R. (2006), “The importance of context in understanding and seeking to promote sexual health”, in Ingham, R. and Aggleton, P. (Eds), Promoting Young People’s Sexual Health. International Perspectives, Routledge, London, pp. 41-60. Kaufman, C.E., Clark, S., Manzini, N. and May, J. (2004), “Communities, opportunities, and adolescents’ sexual behaviour in KwaZulu-Natal, South Africa”, Studies in Family Planning, Vol. 34 No. 2, pp. 261-74. Keys, D., Rosenthal, D. and Pitts, M. (2006), “Young people, sexual practice and meanings”, in Aggleton, P., Ball, A. and Mane, P. (Eds), Sex, Drugs and Young People. International Perspectives, Routledge, London, pp. 65-83. Khamalwa, W. (2004), Identity, Power and Culture: Imbalu: Initiation Among the Bamasaba in Uganda, African Studies Series Bayreuth, Bayreuth African Studies, available at: www.openisbn.com/isbn/3927510815/ Larsen, J. (2010), “The social vagina: labia elongation and social capital among women in Rwanda”, Culture, Health and Sexuality, Vol. 12 No. 7, pp. 813-26. Laz, C. (1998), “Act your age”, Sociological Forum, Vol. 13 No. 1, pp. 85-113. Mane, P. and Aggleton, P. (2001), “Gender and HIV/AIDS: what do men have to do with it?”, Current Sociology, Vol. 49 No. 6, pp. 23-37. Masvawure, T. (2010), “‘I just need to be flashy on campus’: female students and transactional sex at a university in Zimbabwe”, Culture, Health & Sexuality, Vol. 12 No. 8, pp. 857-70. Melendez, R.M. and Tolman, D.L. (2006), “Gender, vulnerability and young people”, in Aggleton, P., Ball, A. and Mane, P. (Eds), Sex, Drugs and Young People. International Perspectives, Routledge, London, pp. 29-47. Muyinda, H., Nakuya, J., Whitworth, J.A.G. and Pool, R. (2004), “Community sex education among adolescents in rural Uganda: utilizing indigenous institutions”, AIDS Care, Vol. 16 No. 1, pp. 69-79. Parker, R. (2009), “Sexuality, culture and society: shifting paradigms in sexuality research”, Culture, Health and Sexuality, Vol. 11 No. 3, pp. 251-66. Perez, G.M. and Namulondo, H. (2011), “Elongation of labia minora in Uganda: including Baganda men in a risk reduction education programme”, Culture, Health and Sexuality, Vol. 13 No. 1, pp. 45-57. Rivers, K. and Aggleton, P. (1999), Men and the HIV Epidemic, UNDP, New York, NY. Rowlands, J. (1997), Questioning Empowerment: Working with Women in Honduras, Oxfam Publications, Oxford.
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Samuelson, H. (2006), “Love, lifestyles and the risk of AIDS: the moral worlds of young people in Bobo-Dioulasso, Burkina Faso”, Culture, Health and Sexuality, Vol. 8 No. 3, pp. 211-24. Seeley, J., Wagner, U., Mulemwa, J., Kengeya-Kayondo, J. and Mulder, D. (1991), “The development of a community-based HIV/AIDS counselling service in a rural area in Uganda”, AIDS Care, Vol. 3 No. 2, pp. 207-17. UNAIDS (2010), Getting to Zero. 2011-2015 Strategy, UNAIDS, Geneva. Warenius, L., Nissen, E., Chishimba, P., Musandu, J., Ong’any, A. and Faxelid, E. (2006), “Nurse-midwives’ attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia”, Reproductive Health Matters, Vol. 14 No. 27, pp. 119-28. About the authors Stephen Bell is an Independent Consultant (Social Development and Monitoring and Evaluation), and a former ESRC Postdoctoral Research Fellow in the School of Education and Social Work at the University of Sussex. His interests lie in young people’s sexual health, the role of NGOs and CBOs in HIV prevention and sexual health programming, and international development more broadly. Stephen Bell is the corresponding author and can be contacted at:
[email protected] Peter Aggleton is Professor in Education and Health in the National Centre in HIV Social Research at the University of New South Wales in Sydney.
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