Sexual and Reproductive Health and Rights-
related needs and challenges of
young displaced people
In Bidibidi Refugee Settlement,
Yumbe District, Uganda.
University of Amsterdam
MSc International Development Studies (IDS) 2017-2018
Graduate School of Social Sciences
Faculty of Social and Behavioral Sciences
Master’s Thesis – 14 January 2018
Sexual and Reproductive Health and Rights-related needs and challenges of
young displaced people in Bidibidi Refugee Settlement, Yumbe District,
Uganda.
Anne Boleyn Niwetwesiga (niwetwesigaanne@gmail.com) Student number: 11169125
Supervisor: Dr. Esther Mediema - lecturer University of Amsterdam Second reader: Datzberger Simone - lecturer University of Amsterdam
i
Dedication
My father – Late Rev. Godfrey Mazaariro
Dad, on your death bed few weeks towards my bachelors’ graduation you said, “My daughter, I am not sure if I will be able to go with you for graduation, but in case I am already gone [dead], your mum will go with you”. Dad, I graduated and promised never to give up. I dedicate my effort to you dad.
ii Acknowledgement
Many people have helped and supported me to make this thesis a reality. Dr. Esther Mediema – I am so thankful for your encouraging comments and suggestions that kept me on track whenever I would almost give up.
My sincere gratitude goes to young people in Bidibidi Refugee Settlement who honestly participated in workshops and focus group discussions. I also thank the staff of various NGOs who spared their valuable time to give me information for my study.
I acknowledge the authorities of Bidibidi Refugee Settlement for allowing me conduct my research study from the settlement. I thank my local supervisor, gatekeepers and friends for their guidance and company during the period of my study.
I thank my mom and dad (RIP) who gave me a firm educational background as a stepping stone for my further studies. Mom, I thank you for always encouraging me and being proud of me. I also thank my siblings and relatives who have always referred to me as a ‘hardworking woman’ – you have encouraged me to even work harder.
I finally thank my husband who has been there for me during the sleepless nights, he has been my editor and proofreader. My children, I have no better expression than saying “I love you”.
iii Abstract
Young people are among the most vulnerable population to sexual violence, exploitation and HIV/AIDS infections in emergency situations. Sexual and reproductive health and rights (SRHR)-related services are helpful in reducing sexual violence-(SRHR)-related risks and HIV/AIDS infections. However, provision of SRHR services to young people is often overlooked in humanitarian emergencies. The existing body of research on young people and SRHR barely engages with young people living in refugee camps. This research study therefore primarily analyzes SRHR-related needs and challenges of young displaced people in Bidibidi Refugee Settlement in Uganda and how service provision responds to these needs and challenges. Data collection was done through interviews, focus group discussions, observation, document review, field notes and workshops. The findings of this research study are expected to fill the gaps in literature in the field of SRHR-related issues of young people in refugee camps. Additionally, engaging directly with young people provides data that can support efforts of policy-makers and humanitarian organizations in designing, delivery and evaluation of SRHR-related programmes and packages for young people in humanitarian settings. The main findings of the study indicate that young displaced people are provided with SRHR-related services but insufficient knowledge and information on SRHR-related issues they have, causes inefficient utilization of the facilities and services in presence. Traditional and cultural norms are a challenge to young people especially girls and young women to realize their SRHR and hinder service provision. SRHR service provision encounters challenges of unfavorable humanitarian conditions. Finally this research calls for further study on SRHR-related issues of very young displaced people (10-14) years.
Key words: SRHR, SRHR-related needs, young displaced people, SRHR service provision, and Bidibidi Refugee Settlement.
iv Table of contents
Dedication………...i
Acknowledgement………..………...ii
Abstract………...iii
List of boxes/tables ………...….vii
List of figures………..………..…vii
List of acronyms ………...ix
Chapter one: Introduction ……….……….1
1.1 Research question (s) ……..………..3
1.2 Research Location and background ……….…....3
1.2.1 SRHR background in Uganda………..…...6
1.2.2 SRHR background in South Sudan………...8
1.3 Thesis overview………9
Chapter two: Theoretical framework………...…..10
2.1. Young Displaced People……….………....10
2.1.1 Young people……….10
2.1.2 State of displacement……….……….………...11
2.2. Sexual and Reproductive Health and Rights (SRHR) and SRHR-related needs and challenges….…………..………..12
2.3. Youth SRHR-friendly services………..………...16
2.4. Conceptual framework………...20
Chapter three: Research methodology………...……….…………...22
3.1 Sampling strategies……….………22
3.2 Sample size………..23
3.3. Data collection methods….………...………..23
3.3.1. Focus Group Discussions (FGDs)……….…………..23
v 3.3.3. Observation……….………25 3.3.4. Workshops……….………...27 3.3.5. Field notes ………..……….………29 3.3.6. Documentary review ……….………..………...29 3.4. Ethical consideration………...29
3.5. Unit of analysis and sample ………31
3.6. Limitations………31
3.7. Data analysis……….……….31
3.8. Methodological reflection………...………33
Chapter four: SRHR-related needs and challenges of young displaced people………....34
4.1. Knowledge and information on SRHR……….………..34
4.2. SRHR-related services provided in relation to needs and challenges of young displaced people………..………37
4.2.1 Family planning services ………..………..37
4.2.2 Screening, testing, counselling and treatment of STIs and HIV/AIDS…………40
4.2.3 Condom distribution for safer sex……….………..……….42
4.2.4 Training, sensitization and awareness creation on SRHR- related issues…..44
4.3. Marriage and SRHR………..……….45
4.3.1. Early marriages and early pregnancies………46
4.4. Sex and Sexual relationships among young people……….………...48
4.5. Misconceptions among young displaced people on contraceptives and condom use...51
4.6. Young displaced people’s recommendations ……….………51
4.7. Concluding remarks ………..………54
Chapter five: SRHR-related services provision …….………..………55
5.1. SRHR-related Service providers………..………..55
5.2. SRHR-related services provided to young displaced people……….56
5.3. Perception of service providers on SRHR-related needs of young displaced people….…61 5.4. Concluding remarks ………..………62
vi
Chapter six: Discussion of the findings and conclusion………..………...63
6.1. Introduction……….………..63
6.2. SRHR-related needs and challenges of young displaced people……….……..63
6.3. SRHR services provision……….….66
6.4. Conclusion……….…....70
6.5. Reflection on operationalization of concepts………..70
6.6. Recommendation for policy makers………..………...71
6.7. Suggestions and recommendations for future research………..72
References……….…………...74
vii List of tables/boxes
Table I: WHO (2014) working definition of SRHR….………..………..….13
Table II: Recommended SRHR services by ……….………..…………..17
Table III: SRHR-related services offered to young displaced people in Bidibidi Refugee Settlement……….……….57
Table IV: Post-abortion cases among young people (10-24 years) registered at Yumbe Referral hospital March- June 2017………..…………62
List of figures Figure 1: Description of study location……….………...4
Figure 2: Signposts indicating aid landscape in Bidibidi………...6
Figure 3: Conceptual framework...………..………..21
Figure 4: Workshop drawings………..………..28
Figure 5: Signpost of Koro health center showing services provided………..…………....32
Figure 6: Example of health facilities’ structures……….………....41
Figure 7: Condom dispenser………..………….43
Figure 8: Demonstration of a masturbatory technique………..………...50
Figure 9: Talking environment………..……….53
Figure 10: Distribution of health facilities in zones in Bidibidi Refugee Settlement…..……..……59
viii Acronyms
AIDS: Acquired Immunodeficiency Syndrome ART: Antiretroviral Treatment
ARV: Antiretroviral
CBMs: Community Based Mobilizers
CRC: Convention on the Rights of the Child CSE: Comprehensive Sexuality Education FGDs: Focus Group Discussions
HIV: Human Immunodeficiency Virus ISPs: Information Support Points
LGBTI: Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex NGOs: Non-Governmental Organizations
OPM: Office of the Prime Minister
PIASCY: Presidential Initiative on AIDS Strategy for Communication to Youth PEP: Post Exposure Prophylaxis
RWC: Refugee Welfare Committee SDGs: Sustainable Development Goals SGBV: Sexual and Gender Based Violence SRH: Sexual and Reproductive Health
SRHR: Sexual and Reproductive Health and Rights STIs: Sexually Transmitted Infections
ix UBOS: Uganda Bureau of Statistics
VHTs: Village Health Teams WHO: World Health Organization
UNESCO: United Nations Educational, Scientific and Cultural Organization UNFAO: United Nations Food Agriculture Organization
UNFPA: United Nations Population Fund
UNHCR: United Nations High Commissioner for Refugees UNICEF: United Nations Children’s Fund
1
Chapter one: Introduction
The 1994 International Conference on Population and Development (ICPD) and the resulting Programme of Action, (UNFPA, 1994) gave a platform through which issues relating to sex, sexuality and sexual health were openly debated as a central point of discussion (Parker, 1997). The conference is also considered a landmark event for Adolescent Sexual and Reproductive Health in that, young people’s Sexual and Reproductive Health needs and Rights (SRHR) were acknowledged (Chandra-Mouli et al, 2015).
A commitment to address young people’s challenges including sexual and reproductive health was shown by United Nations in World Programme for Youth in 1995 (World Programme of Action for Youth, 2010). These international commitments led to continental dedication in addressing sexual and reproductive health issues at a closer level. For instance, a special session of African Union conference of Ministers of Health and delegates from 48 African countries was held in Maputo, Mozambique in September 2006. The outcome was The Maputo Plan of Action (Maputo PoA) for the operationalization of the continental Policy Framework for SRHR. The Maputo Plan of Action is Africa’s policy framework for providing universal access to comprehensive sexuality and reproductive health services (African Union Commission, 2006).
Subsequently, in October 2013, 52 African nations adopted the Addis-Ababa Declaration in order to ratify the Maputo Plan of Action on SRHR, the Continental Policy Framework on SRHR, and the Abuja Actions towards the Elimination of HIV and AIDS, Tuberculosis, and Malaria in Africa by 2030. A central aim of the Addis Ababa declaration was to achieve universal access to Sexual and Reproductive Health (SRH) services by providing a comprehensive package of services. According to the agreement established, such a package should be non-discriminatory and pay particular attention to the needs of adolescents, youth, older persons, persons with disabilities and indigenous people, especially in remote areas and in humanitarian settings (UNFPA, 2013).
Young people account for a large percentage of those in emergencies globally and they are among the most vulnerable to HIV infections, exploitation, and sexual violence (UNFPA 2016b). Girls in particular are among the most vulnerable -- many having unplanned pregnancies, for example. SRHR-related services and information are helpful in risks of transmission of diseases and unintended pregnancies among young people (UNFPA, 2016a). However, although displaced populations usually
2 receive emergency humanitarian aid, SRHR and HIV/AIDS-related issues are often neglected (IPPF 2005: 1). SRH needs are usually overlooked and young people are extremely vulnerable yet they hardly get access to basic information and services (UNFPA, 2016b).
The aim of this research study is to fill the gaps in the literature with regard to the SRHR-related needs of vulnerable young people living in refugee settlements. While there exists a considerable body of research on young people and SRHR (Tanton et al, 2015; Njoroge et al, 2010; Germain, Dixon-Mueller & Sen, 2009; Glasier et al, 2006), there is very little that engages with young displaced persons living in refugee settlements. The little existing literature that focuses on displaced people (McGinn et al., 2004) pays scant attention to young people, and crucially, does not address young displaced persons’ particular vulnerabilities. Given literature suggests that boys and girls begin to demonstrate sexual feelings and behaviours at a young age (Kågesten et al., 2016), it is essential they get SRHR-related knowledge and skills, and have access to youth-friendly services that will guide and help them enjoy and manage their SRH life appropriately.
The IPPF (2005: 1) indicates that one of the challenges of humanitarian organizations working in emergencies is lack of a clearly stipulated SRHR and HIV/AIDS package for such populations. The inadequacy could be attributed to little or no clear information about their needs especially those of young people. Engaging directly with young people provides data that can inform the work of organizations and institutions active on the ground. Therefore, the findings from this study are expected to support efforts of policy-makers and humanitarian organizations in the design, delivery and evaluation of SRHR-related programmes and packages for young people in humanitarian settings. Additionally, the findings from the research are expected to contribute to attaining Sustainable Development Goals (SDGs). As various authors have argued, protecting and promoting young people’s SRHR is crucial to successful achievement of the SDGs- particularly the goals related to health (Goal 3), education (Goal 4) and gender equality (Goal 5) (Woog & Kågesten, 2017; Rebecca, 2015). The central aim of this study was to identify the SRHR-related needs and challenges of young displaced people living in refugee settlements, and establish how service providers were currently meeting these needs. The study was carried out in Bidibidi Refugee Settlement, Yumbe District-Uganda, one of the refugee settlements that host the largest number of population from South Sudan.
3
1.1
Research question
The central research question of my study is:
“What are the Sexual and Reproductive Health and Rights-related needs and challenges of young displaced persons in Bidibidi Refugee Settlement in Uganda, and how are service providers responding to these needs?”
To ease answering the main question, the following sub-questions were put in place:
1. What are the SRHR-related needs and challenges of young displaced persons in the Bidibidi Refugee Settlement?
2. How do SRHR service providers perceive SRHR-related needs and challenges of young displaced persons in the Bidibidi Refugee Settlement?
3. How does SRHR-related service provision to young displaced persons in the Bidibidi Refugee Settlement relate to Tomasevski’s 4A framework?
I use Tomasevski’s (2001) 4A framework to relate to SRHR-related service provision to young displaced people in the Bidibidi Refugee Settlement and thereby establish whether the framework is transferable to other fields, in this case health, and SRHR in particular.
1.2. Research location and background
The location of my study was the Bidibidi Refugee Settlement in Uganda. Uganda is Eastern Africa’s landlocked country, bordered by Tanzania in the south, Democratic Republic of Congo in the west, South Sudan in the north, Rwanda in the south-west and Kenya in the east. Uganda is said to be a ‘home away from home’ for refugees considering a favorable refugee policy that allows refugees to get pieces of land, carry out businesses, access education and health care, as well as having free movement (Uganda Refugee Act, 2006). December 2017 demographics indicate that Uganda currently hosts 1,398,991 refugees and asylum seekers (D1). The above figure is distributed in 30 refugee settlements located in 12 hosting districts. Out of the total refugee population in Uganda, there are approximately 1,053,276 South Sudanese, 231,504 Congolese from the DRC, 40,313 Burundians, 36,909 Somalis, 15,260 Rwandese, and 21,729 from other countries (D1).
4
Figure 1. Description of study location
Source: UNHCR (2017); D1
Bidibidi Refugee Settlement is located in Yumbe District of Northern Uganda (see figure 1). The settlement was established in July 2016 to contain the overwhelming number of refugees that were fleeing the country for safety and protection following an outbreak of fighting in South Sudan’s capital city-Juba (I1). Out of 1,398,991 displaced people hosted in Uganda, approximately 987, 601 are in Northern Uganda distributed in different settlements in Arua, Yumbe, Moyo and Adjumani districts (DI). The Red Cross Society-Uganda (2017) indicates that 86% of the total refugees’ population in the country are women and children under 18. According to the Office of the Prime Minister (2016),
5 critical areas for intervention in refugee settlements included addressing sexual and gender-based violence, protection of children and provision of social services (including health and education). Bidibidi is said to be the largest single refugee settlement (The Guardian, 2017), or one of the largest in the world with an estimate population of 287,087 by December 2017 (D1). Having almost tripled the 100,000 planned potential capacity, new entrants were no longer received in the settlement, apart from those on family reunion. They were being directed to Imvepi and Palorinya settlements in Arua and Moyo Districts respectively that opened later to accommodate the excess population. The settlement is comprised of five zones, and each zone is divided into villages referred to as ‘blocks’, up to between eight and fourteen blocks each zone. Refugee communities have social structures and elect their leaders and representatives. Each block has its own administrative office to make easier access of services by the inhabitants. The constituent units in refugee settlement are headed by village chairpersons referred to as Refugee Welfare Committees (RWC) (I11; I14; I15). One of the tasks of the RWC is to mediate in the conflicts and solve problems with in the villages in his/her constituency (OPM, 2016). Each individual household in the settlement is given a 30x30 meters plot of land on which they erect shelter and put some kitchen gardens (I11; I14; I15).
Humanitarian work in the settlement is provided by a number of United Nations (UN) Agencies, international and national Non-Governmental Organizations (NGOs) supporting the Office of the Prime Minister of Uganda (OPM). UN Agencies working/funding partners in Yumbe include UNHCR, UNWFP, UNFPA, UNFAO and UNICEF. Implementing organizations include; Action Africa Help International (AAHI), Danish Church Aid (DCA), International Rescue Committee (IRC), Norwegian Refugee Council (NRC), Real Medicine Foundation (RMF), Transcultural Psychosocial Organization (TPO), World Vision International (WVI), Windle Trust Uganda (WTU), Uganda Red Cross Society (URCS), and Yumbe District Local Government. In addition, over 15 other organizations work as operating partners under the supervision of implementing partners listed above (D2; D3). Implementing partners are agencies that get direct funding from UNHCR and also seek additional funding from other donors to implement activities (D3).
A diversity of humanitarian aid was rendered to displaced people in Bidibidi refugee settlement. Different organizations involved in provision of different services such as education, health, Water, Sanitation and Hygiene (WASH), protection, and environmental issues. Through observation,
6 although Bidibidi refugee settlement was established on humanitarian crisis, it has created development in the surrounding areas- particularly Yumbe District. New hotels and accommodation businesses sprung up so as to cater for the large number of people working in various NGOs. On my arrival in Yumbe Town (the nearest town to Bidibidi), a ‘street’ of NGOs’ sign posts and presence of NGOs’ official vehicles that roamed in and around the town revealed to me the diversity of humanitarian aid offered in Bidibidi Refugee Settlement (figure 2).
Figure 2. Signposts indicating aid landscape in Bidibidi
Source: Anne (fieldwork photos, July 2017).
1.2.1. SRHR background in Uganda
In December 2013, health and education ministers and representatives from 20 countries in Eastern and Southern Africa (ESA) including Uganda affirmed a commitment to scale up sexuality education and SRH services for adolescents and young people. Agreement was reached that culturally-sensitive and age-appropriate sexuality education was effective and that – Comprehensive Sexuality Education (CSE) was to be integrated into school curricula (UNESCO, UNFPA & UNAIDS, 2016). However, in Uganda efforts by the Ministry of Education to integrate CSE in school curriculum met with stiff resistance from parents and other stakeholders. The resistance was on the grounds that CSE contradicts Ugandan cultural norms, morals and virtues, and has inappropriate approaches in guiding children at a tender age. Lobby groups blamed CSE initiatives for the widespread of immoral practices such as premarital sex, abortions and homosexuality (Uganda ScieGirl Science Journalist in East Africa, 2016) and as containing messages that undermine the teachings and core values of the church (Uganda Joint Christian Committee, 2016).
7 Despite the resistance to integrate CSE into the school curricula, Uganda provides sexual education in schools. Some issues related to sexuality and marriage are taught through some subjects on the curriculum specifically Christian Religious Education, Islamic Religious Studies and Biology as part of the Uganda Certificate of Education (Muhanguzi & Ninsiima, 2011).
Talking about AIDS had been a taboo in most African countries including Uganda. Consequently, the president of Uganda – Museveni made a commitment to talk about AIDS himself. Accordingly, in 2004 he started a program called Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY). PIASCY was then implemented in (public) primary and secondary schools in Uganda to educate the youth about HIV/AIDS, sex and protection strategies. PIASCY program used ABC framework with an idea that individuals should abstain, but if abstinence failed, they should be faithful to one partner. Alternatively, failure to abstain or being faithful they should use condoms to protect themselves from AIDS (Buonocore, 2005). Although PIASCY emphasized abstinence, young people continued to show interest and involvement in sexual relationships (Råssjö & Kiwanuka, 2010; Bankole et al., 2007). However, many parents and teachers are uncomfortable to adequately address the needs and challenges of young people even when risks of HIV/AIDS within sexual relationships in Uganda have been noted. Conversation on sexual issues between young people and adults in Uganda is not common (Mutonyi, et al., 2010; Rujumba & Kwiringira, 2010), therefore a private matter between a girl and her aunt on her wedding night (Sommer, 2010; Muyinda et al., 2001).
Emphasis on abstinence has resulted into young people getting involved in secret relationships which consequently lead to early pregnancies among girls. The fact that abortion in Uganda is illegal according to the law (Uganda constitution, 1995: article 22), early pregnancies lead to school drop-outs and early marriages. Section 141, 142, 143 and 212 of the Uganda Penal Code Act provide for offences relating to abortion, whereas section 224 provides a defense against prosecution for an offence relating to abortion (see appendix ii). In line with section 224, African Women’s Protocol affirms women’s rights to abortion when pregnancy results from a sexual assault, incest, rape or when a pregnant woman’s life is in imminent danger (Article 14 (2c). With regard to illegality of abortion, a research carried out on knowledge and perceptions of Ugandan opinion-leaders on unsafe abortion by Moore, Kibombo & Baril (2013) revealed that, current restrictions on abortion push women to depend on hidden services of unreliable quality in unsafe environments, and incur long-term health effects such as infertility. According to Moore and colleagues, legalization of abortion on
8 the other hand reduces death rates among girls and women, reduces punishment or stigma towards women having abortions including abortion-related violence, and school girls are able to continue with their education.
On February 2014, the Government of the Republic of Uganda enacted the Anti-Homosexuality Act that consequently affected provision of SRHR-related services. The Anti-Homosexuality Act was meant to restrain open promotion of homosexuality especially among children and other vulnerable groups (The Republic of Uganda, 2014). The Act was also to protect the traditional family by prohibiting any form of sexual relations between people of the same sex (Eighth Parliament of Uganda, 2013). As a result of Anti-Homosexual bill, several projects in Kampala which provided condoms and HIV testing closed, for example, The AIDS Support Organization (TASO) – Uganda’s biggest organization dealing with HIV/AIDS – had its “Moonlight Clinics” program which offered HIV testing and educational services to LGBT persons closed (Human Rights Watch, 2014). Also, the United States Government withheld part of financial aid to Uganda which culminated into suspension of funds related to antiretroviral drugs and HIV testing kits (Croome, 2014).
1.2.2. SRHR background in South Sudan
The Reproductive Health Policy (2013: 12) indicates that South Sudan has some of the worst reproductive health status indicators in the world. The report indicates high prevalence of Sexual and Gender-Based Violence, yet there was absence of effective legislation to address such issues. The report also shows that rape was still very common but hardly reported, and domestic violence in pregnancy was a significant cause of abortion and maternal morbidity and mortality. Early marriage and pregnancy among young women was high — one out of three girls at the age of 19 was already married and produced a child. Use of contraceptives was indicated a practice only to the urban dwellers and well-educated women. Consequences of inadequate family planning services were indicated to affect one out of five women of child-bearing age, and 87% delivered their children from homes.
The above indicated low levels of contraceptives use and family planning practices are associated with social norms established among most South Sudan societies. Women are expected to produce as many children as possible (Kane et al. 2017) to replace people who died during civil wars, and could to wage national struggle to liberate their nation if they grew up (Macklin, 2004).
9
1.3. Thesis overview
The thesis comprises of six chapters. Chapter one introduces the problem under study and gives the justification of the importance of the problem. The chapter also brings out the academic and societal relevance of the study. Furthermore, the chapter states the main research question, and outlines the sub-questions that guided me in data collection. Finally, a description of the study location and SRHR context and background are given.
Chapter two details the theoretical framework by considering three central concepts, that is, young displaced people, Sexual and Reproductive Health and Rights (SRHR), and youth- friendly SRHR services. The first part describes characteristics of young people in general and the situation of being displaced. The second part discusses what SRHR are in relation to the general human rights. The last part of the concepts looks at qualities of youth friendly SRHR-related services. The chapter finalizes with a conceptual scheme in relation to the theoretical framework.
Chapter three presents the methodology of the research. It describes the sampling strategy that I employed, the methods used to collect data, the method used to analyze data, limitations experienced and how they were mitigated, and the research ethics that were respected in the process of data collection.
Chapter 4 and 5 present the findings. In chapter four, young people’s accounts concerning their sexual and reproductive needs and challenges are detailed, while chapter five describes the services that are provided to meet the needs and challenges of young displaced people under study and the manner in which they are delivered.
Chapter 6 gives the discussion of the findings in relation to existing literature, and a summary of answers to the research question is given. Then the chapter presents recommendations for policy makers, and finally gives suggestions for future research considering shortfalls in the thesis findings and the available literature.
10
Chapter two: Theoretical Framework
This chapter presents theoretical overview of three concepts that guide the flow of the study. The first one is the concept of displaced persons with a particular focus on young people and their state of displacement. Secondly, an elaborate description of SRH rights and needs is provided. Finally, the chapter discusses the notion of ‘youth-friendly’ SRHR services.
2.1. Young displaced people
2.1.1.
Young peopleThe UN define adolescence as the period between 10-19 years (UNFPA, 2017b), whilst the category of ‘youth includes those between the ages of 15-24 years (UN World Programme For Action For Youth, 1995). A pragmatic approach was developed to merge the two definitions and came up with 10-24 years to refer to young people. This encompasses the three five-year sub-divisions of 10-14, 15-19, and 20-24 years.
For the purposes of my study, I used the pragmatic approach definition of 10-24 years to refer to young people. It is important to note that for stylistic reasons, this thesis also uses the terms adolescents and youth to refer to young people.
As the Youth Health and Rights Coalition (YHRC) (2011) indicates, young people are valuable assets due to their continuous social, economic, political, and cultural contributions not only to their lives, but also to their families, communities, and countries. It is argued in the YHCR (2011) that young people have particular challenges and distinct needs, compared to those of adults and therefore program approaches should prioritize and accommodate age-related needs, challenges, and access barriers. Although governments, private sectors, local and international NGOS provide reproductive health services, most are not designed to take into account the special needs of young people. Young people go through transitional stages of development in which they experience physical, psychological, and social changes. Young adolescence stage is when puberty and sexual maturation begin to manifest (Pierce & Hardy, 2012; Downing & Bellis, 2009) and at this point, girls and boys start experiencing body changes (UNESCO, 2014). Wegelin-Schuringa et al (2014) argue that the changes vary between individuals, and differ between males and females. They further argue that
11 development stages young people go through are shaped by social and cultural environment in which they live, for instance the prevailing norms and values and beliefs.
During early adolescent period, some boys and girls begin to demonstrate sexual feelings and behaviours and to a certain level they also encounter unwanted or pressurized sexual experiences (Kågesten et al., 2016). It is documented that with improved health and nutrition, the onset of puberty takes place earlier in most developed countries (Gluckman & Hanson, 2006; Pinyerd & Zipf, 2005) and such quick maturity of young people, makes their first sexual debut happen often earlier (Helmer, et al., 2015). However, due to the taboo on talking about sexual matters in many cultures, young people lack sufficient access to information and to make informed choices on relationships.
2.1.2.
State of DisplacementDisplacement refers to a social change brought by forced movement of people from their local environment and occupational activities. The major cause of displacement is armed conflict, but other factors like natural disasters, famine, development and economic changes may also account for displacement (UNESCO, 2017).
The concept of ‘refugees’ emerged through a Post-Second World War United Nations (UN) Convention 1951 and protocol 1967 relating to status of refugees. Article 1 of this Convention defines a ‘refugee’ as an individual:
“owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it” (p. 14).
Research shows that loss of social structures, changes in power relationships, idleness, substance abuse and separation of family units during emergencies can lead to new vulnerabilities and increased risks for young people (Ritsema, 2004; Krause, Jones, & Purdin, 2000). The breakdown of social structures can create barriers to access existing services and can greatly affect the ability of young people to practice safe reproductive health behaviors. As reported in the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010), the new environment can be violent, stressful and unhealthy for young people. Young people (especially women) are highly
12 vulnerable to sexual coercion, exploitation, humiliation and torture (The Refugee Council, 2009; Correa et al., 2008). Women may engage in high risk or transactional sex for survival, and the risks become greater among women and children arriving to a refugee setting without a male company (Larsson 2013). The risks are faced during flight from home, when crossing borders, applying for and processing refugee status, and in settlements, with the latter forming the particular focus on the current study (Nyanzi, 2012). Potential perpetrators include armed people in conflict bandits, border guards, and pirates (The Refugee Council, 2009), as well as fellow refugees, family members and friends, members of the host communities and humanitarian officials (Larsson, 2013; Nyanzi, 2012). Sexual violence is most often committed by men against women ⁄ girls, although an increasing evidence of men committing sexual violence against other men ⁄ boys has also been noted (Horwood, 2007, 56). Baaz (2009) states that the situation of women in Peru defines rape as torture, affecting women of all ages and social classes in detention after being separated from their men. Rape is used as a weapon of war and terrorism, inflicting fear and humiliation by security forces to bring down opposition group in the conflict (Beijing Declaration and Platform for Action, 1995; Human Rights Watch, 1992: 16; Bunster-Burotto, 1986: 302–303). For instance, rape of a wife or daughter is intended to punish her absent husband, father or relative, often to pressure him to surrender to the authorities during efforts to capture the opponents (Vulnerable Women’s Project 2009).
Studies show that sexual violence in general is used to generate revenue through trafficking, sexual slavery, enforced prostitution and extortion of ransoms from desperate families. Women and girls are themselves treated as the “wages of war” in some circumstances, being gifted as form of in-kind compensation or payment to fighters (The UN Report on conflict-related sexual violence, 2017: 5-6).
2.2. Sexual and Reproductive Health and Rights (SRHR) and SRHR-related needs
As the Programme of Action adopted at the ICPD stipulates:“All human beings are born free and equal in dignity and rights. Everyone is entitled to all the rights and freedoms set forth in the Universal Declaration of Human Rights, without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Everyone has the right to life, liberty and security of person’’ ‘Principle 1’ (ICPD 1994: 8), including all migrants ‘principle 2’ (ICPD 1994: 15).
13 In line with the explicit recognition of young displaced people’s fundamental human rights in the ICPD action programme, Correa, Petchesky, and Parker (2008) embrace the notion that human rights are already recognized by the United Nations and its various agencies. Therefore, young displaced persons are entitled to SRHR as stipulated in Article 34 of the UN Convention on the Rights of the Child (CRC, 1989) that guarantees protection from all forms of sexual exploitation and abuse. The World Health Organization (WHO) (2014) reportedly developed a working definition of Sexual and Reproductive Health and Rights as elaborated in box 1 below:
SRHR is a right of all persons to;
Seek, receive, and impart information related to sexuality. Receive sexuality education.
Have respect for bodily integrity. Choose their partner.
Decide to be sexually active or not. Have consensual sexual relations. Have consensual marriage.
Decide whether or not, and when, to have children. Pursue a satisfying, safe, and pleasurable sexual life. Have freedom from coercion, discrimination and violence.
Obtain standardized sexual health and access sexual and reproductive health services. Table I. WHO (2014) working definition of SRHR.
The main discussion among activists and scholars at present is that other than UN and other multilateral bodies, there is no formal recognition of sexual rights as human rights at a global level. With regard to the above argument, Hunt (2004:15) notes that there is need for incorporation and recognition of sexual rights as human rights in fundamental human rights principles and norms. Jolly & Cornwall (2006) argue that recognition of SRHR as human rights perhaps creates a remedy to the continuous rise of HIV infection and the sexual and reproductive ill-health of women, men and trans-gender people.
The concepts sexual health and sexual rights are used and work interchangeably. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (Durojaye & Murungi, (2014). Although Jolly (2005) notes that the focus of sexual rights on a historical view has been the right to be free from coercion around sexuality, the focus started shifting to view sexual rights as a fundamental element of human rights which encompass the positive rights to
14 experience pleasurable sexuality (Petchesky, 2005; Klugman, 2000). Similarly, Correa (2002) recommends that sexual rights should be about freedom and pleasure as well as public health. However, sexual rights have been misunderstood by some people due to misinterpretation of the concepts involved. Tensions between lesbians
and heterosexual feminist activists were identified by the Mexican activist and scholar, Gloria Careaga, who is also a member of the Mexican Delegation to the Beijing Fourth World Conference on Women, as she was quoted by Girard (2007) arguing: (see the box).
In line with the above argument, marginalization of sexual rights as human rights in state policies in Africa manifests when the rights of LGBTQI (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex) collide with cultural beliefs. For instance, Nyeck (2014) states that apart from South Africa, African States are not protecting the rights of their LGBTQI citizens. Instead homosexual behavior is criminalized regardless of the age of consenting partners. In Uganda for instance, there was special alliance between the state and evangelical churches that led to the introduction of an anti-homosexual bill in the parliament in 2009 (Nyeck, 2014: 75).
Paul Hunt, a UN special Rapporteur on the Rights of Health (2004) argues that sexuality is a characteristic of all human beings. However, according to some scholars the concepts sexual rights and sexual health have not been well defined, and have turned into a controversial subject that has often sparked off debate across the world. Echoing the controversy, Durojaye & Murungi (2014) argue that sexual rights as compared to reproductive health and rights are a recently evolved set of rights under international law. Additionally, countries in which religion and culture are so much valued in people’s lives, SRHR-related issues are seen as promotion of traditionally held perception of reproduction and heterosexuality. To properly define sexual health and rights concept, Miller (2000) commends that sexual health and rights discussions should be accommodative to include different groups of people and issues, such as homosexuality, heterosexuality, reproductive and non-reproductive sexual activities.
“Most heterosexual women’s health activists thought sexual rights was about lesbian, gay, bisexual and transgender rights, while lesbians
thought it was about women’s rights about sexuality. Lesbians felt that the responsibility of
defending sexual rights was left to them.’’ Girard (2007: 323)
15 Correa (2002) contends that ‘sexual freedom and liberation’ agenda has shifted to sexual risk. She attributes this shift to conventional public health and population concerns regarding family planning and the HIV and AIDS pandemic. Correa (2002) further argues that sexual rights concept seem to be related to negative connotations by emphasizing victimization, including gender-based violence and rape, as well as sexual and reproductive health problems.
The World Health Organization (WHO, 2006) developed a working definition of sexual health which comprehensively describes sexual health as:
A state of physical, emotional, mental and social well-being in relation to sexuality. Not merely the absence of disease, dysfunction or infirmity.
Requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences.
Free of coercion, discrimination and violence.
Similarly to WHO (2014), Save the Children (2014) advocates for an SRH rights-based approach, by suggesting four separate though related elements:
The consideration that sexual and reproductive rights are entitlement to everyone, unexceptional of young people.
Programs should aim at targeting more than just health outcomes.
SRH information and education content be widened to include rights-related issues and individual rights and responsibilities in relationships and
Consideration of mechanisms to stimulate critical thinking and participation among individuals.
To define sexual health, the term sexuality has to be broadly understood. Tamale (2017; 2003) asserts that sexuality comprehensively cuts across every aspect of human life and in different dimensions as sexual knowledge, beliefs, values, attitudes and behaviors, sexual orientation as well as personal and interpersonal sexual relations. Similarly, Correa, Petchesky & Parker (2008) argue that sex goes beyond knowing about bodies and desires to issues related with economies, systems of governance, cultural and religious norms, kinship structures, and power dynamics.
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2.3. Youth Sexual and Reproductive Health and Rights-friendly services
Correa, Petchesky & Parker (2008) recommend that SRH services should be delivered in a rights-based approach in order to be effective. A rights-based approach focuses on the attainment of rights within local cultural and power dynamics, emphasizing social inclusion, equality, and empowerment (Braeken & Cardinal, 2008), and ensures and upholds non-discrimination and respect among people (Ahlberg & Kulane 2011; 313). Correa et al, (2008) argue that ‘people who receive SRHR services should not be treated as ‘consumers or users’ of those services or as subjects of marketing research for testing the clients’ preferences over the products and carrying out evaluations of the usability of the products. In agreement with the above argument, Paiva (2003: 199) asserts that in provision of SRHR services, a client should be treated a ‘citizen with rights’ that encourages her ‘to feel that she has ‘the right to have rights and to create rights’.
Friendliness of youth services is one of the crucial issues to be considered by service providers in planning and implementing SRHR related services for young displaced persons. Tomaševski (2001) in her 4A framework recommends that an effective strategy in provision of friendly services is one that considers availability, accessibility, acceptability and adaptability of the services. Services should be of high-quality that can provide access to full information, give clients the opportunity to make informed choices, and respect the dignity of the clients (Guttmacher Institute, 2015). In consonant with Tomaševski’s 4A framework, WHO (2012) suggests equity, appropriateness, and effectiveness of services, whilst the Young People Today (YPT) (2013: 34) advocates safe and affordable services. Most scholars who have identified qualities and characteristics of youth friendly services seem to be in support of Tomaševski’s 4A framework in one way or the other. Ambresin et al., (2013: 678) proposed eight domains of characteristics which have similarity to the 4A framework. They argue that youth friendly services should consider accessibility of health care, staff attitude, communication, medical competency, guideline-driven care, age-appropriate environment, involvement in health care, and health outcomes. Similarly, Wegelin-Schuringa et al (2014) recommend consideration of provider characteristics which include selection criteria, attitudes, skills and knowledge. Other crucial concerns are environmental design, clinic hours, educational activities and materials, administrative procedures and service fees.
17 Privacy and confidentiality are fundamental aspects of youth friendly services (Wegelin-Schuringa et al, 2014; Tylee et al., 2007). Delivery of SRHR related services take different forms world-wide. SRHR services should be located in reach by public transport (Wegelin-Schuringa et al., 2014) or affordable type of transport (Ahlberg & Kulane, 2011). The location should be convenient to youth such as where they live, go to school, relax from or work. The facility could be part of hospital, a reproductive health clinic, school-based clinic, youth centers or private clinics (Wegelin-Schuringa et al, 2014).
Various scholars, ministries and NGOs appear to comply with and supplement each other as far as friendly SRHR-related services are concerned. For instance, a wide range of different youth-friendly SRHR-related services but with similar characteristics have been recommended as in table II below: Recommended SRHR services UNFPA (2017) holistic, youth-friendly health-care package of services
Universal access to accurate sexual and reproductive health information Range of safe and affordable contraceptive methods
Sensitive counselling
Quality obstetric and antenatal care for all pregnant women and girls, Prevention and management of sexually transmitted infections, including
HIV Wegelin-Schuringa et al (2014) Youth SRHR-related services.
Reproductive health information and education – counselling on reproductive health, on contraceptives so as to make informed choice taking into account the nature of the sexual relationships and behavior in which the individuals are engaged.
Information, education and counselling as well as treatment of STIs and HIV/AIDS
Information and education on sexual abuse and violence. Post abuse and violence care and treatment.
Support for healthy sexual development
Provision of referral services where services are not provided in the available clinic
Abortion related services: where it is legal - safe abortion services, where it is illegal – post-abortion care and treatment.
Antenatal, pre-natal and post-natal services
Provision of contraceptives including emergency contraceptives. Sexuality education
18 UNHCR (2002) Basic Reproductive Health Needs and Rights
Information on sexuality and reproductive health Access to family planning services
Access to comprehensive antenatal Safe delivery and postpartum services
Confidentiality, privacy and respect when seeking and receiving services Prevention of unsafe abortion and access to post-abortion care
Access to quality STI prevention and services
Freedom and protection from sexual and other gender-based abuses and access to appropriate services
IPPF (1996) comprehensive sexual and reproductive health (SRH) services
Contraceptive information and services
Maternity care (antenatal and postnatal care, and delivery care) Prevention and appropriate treatment of infertility
Safe abortion and post-abortion care.
Prevention, care, and treatment of sexually transmitted infections, HIV/AIDS, reproductive tract infections, and reproductive cancers.
Information, education, and counseling.
Prevention and surveillance of violence against women (VAW) Care for survivors of violence
Actions to eliminate harmful traditional practices such as female genital mutilation (FGM) and early and forced marriage.
Table II: Recommended youth-friendly SRHR services (UNFPA, 2017; Wegelin-Schuringa et al., 2014;UNHCR, 2002; IPPF, 1996)
According to the Youth Health and Rights Coalition (YHRC) (2011), efforts to establish programs intended for specifically young people are still limited. YHRC, (2011) indicates that many existing large scale sexual, reproductive, and maternal health programs tend to ignore the unique needs of young people. The programs often fail to shape approaches that can effectively deliver information and services to a large population of both married and unmarried young people. In developing countries young people experience structural, socio-cultural and legal barriers in obtaining sexual and reproductive health information and services. SRHR barriers include lack of awareness and insufficient knowledge about SRHR, low self-efficacy towards (safe) sexual behaviors, socio-cultural norms towards gender issues (Rijsdijk, 2013), un-affordable services, lack of guaranteed confidentiality and privacy, and restricting laws on adolescents about receiving the required information (Chandra-Mouli et al., 2014; Kirby, Obasi, & Laris, 2006).
Not far from the above, Belmonte et al, (2000) identify four categories of barriers to adolescents’ use of reproductive health services: physical barriers which encompass both physical distance to the
19 facility and terms of awareness about the existence of such services. Economic barriers relating to high costs of services in comparison to affordability of young people to pay. Administrative barriers that cover policies related to SRHR services of young people as well as staff trained in such services, and availability and active distribution of equipment and supplies. Psychosocial barriers go with negative feelings about young people’s own sexuality, where the fears to be judged negatively by family and peers creates a sense of anxiety, shame and guilty within them. Due to lack of confidentiality, young people end up not using health services.
Wegelin-Schuringa and colleagues (2014) recommended some strategies that can mitigate the barriers mentioned by Belmonte et al, (2000) above. First, the environment or design of the facility should be attractive and welcoming with provision of separate waiting rooms for youth, separate counselling and examination space that provides privacy. Second, there should be standards and guidelines to guide service providers and assurance of safety, confidentiality and privacy be publicly displayed. Third, free or affordable services be provided. Fourth, selection criteria of staff should consider gender, age, experience in working with young people, positive attitude to youth sexuality and understanding of youth rights to SRHR services. Fifth, youth be involved in planning, implementation, monitoring and evaluation of SRHR programs and services of young people.
Heslop et al (in Parkes 2015) argue that planning and implementing of SRHR services of young people could be shaped by identification of different gender characteristics because young men and women have different needs which should be attended to differently. Social norms and gender inequality surrounding most societies influence the expression of sexuality and sexual behavior. For instance, Weaver et al (2005) argue that many young women have low levels of power or control in their sexual relationships, whereas young men on the other hand, may feel pressure from their peers to act according to male sexual stereotypes and engage in controlling or harmful behaviors.
Important to note is that, in order to improve SRHR for young people, certain strategies have to be put in place. Chandra-Mouli, Lane, & Wong (2015) suggest provision of youth centers that are friendly, safe and non-judgmental where SRH information and services alongside other social services can be provided. The above scholars also argue that peer education is a social, cost effective and more efficient approach to reach marginalized or vulnerable young people than an adult-led approach. In support of the above argument, Norton & Mutonyi, (2007) stress that participation of
20 young people in peer education develops their leadership skills and provides ways to raise gender issues. More so, establishment of a peer education program using participatory approaches helps make programs more youth‐friendly and empowers young people to create change in society (Isikwenu, Omokiti, & Nurudeen, 2010).
Other scholars assert that, comprehensive rights-based sex education (CRSE) plays a major role in promoting SRHR for young people, by ensuring that they receive the necessary information and education to take their own well-informed decisions on sexuality and sexual behavior (Kirby, 2007; Kirby, Obasi, & Laris, 2006; Gallant & Maticka-Tyndale, 2004). A rights-based approach to comprehensive sex education equips young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality – physically and emotionally (IPPF) 2010).
2.4. Conceptual framework
The purpose of the conceptual scheme is to present the relationship among different concepts that I used in my research. The concepts are young displaced persons, sexual and reproductive health and rights–related needs, and youth SRHR friendly services. The concept builds on the theoretical background in line with my main research question and research study in general. The conceptual scheme illustrates how young displaced persons –like other people, have sexual and reproductive health and rights-related needs and challenges. The SRHR-related needs and challenges of young displaced persons can be met through provision of SRHR services. SRHR services can be understood to be youth friendly if they are accessible, available, acceptable and adaptable in nature. Service providers of youth friendly services include those who facilitate funding programs and facilities, as well as those who plan and implement programs. They include the host government, United Nations (UN) agencies, and International and national Non-Government organizations (NGOs). Another category of service providers involved in the study was composed of health care workers, counselors and other related staff who work under the supervision of the above mentioned service providers.
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Figure 3. Conceptual Framework
The circle represents Bidibidi refugee settlement where young displaced people live. The black arrow reflects that young displaced people have SRHR-related needs and challenges that are met by provision of youth friendly services SRHR- services as indicated by orange arrows. Lemon green arrows show characteristics of youth friendly services – availability, accessibility, acceptability and adaptability (Tomasevski 2001) delivered to young people through service providers, that is, the host government, UN agencies, and International and national NGOs as reflected with blue arrows.
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Chapter three: Research methodology
This chapter presents the methodology and methods employed during research study. The first section describes the sampling strategies that I used to identify research participants. The second section looks at the sample size of participants that were involved in the study. The third section elaborates the methods I used to correct data. Fourth is description of ethical guidelines that I followed during data collection. The fifth part shows unit of analysis and sample. The next section explains the limitations of the study and how they were mitigated. This is followed by strategies I used to analyze the data, and finally is methodological reflection.
3.1. Sampling strategies
The circumstances and conditions surrounding the location of study (the Bidibidi Refugee settlement) determined the sampling strategies that were used. Purposive sampling was employed to specifically identify participants that were relevant to the research questions (Bryman 2016: 408). Purposively, I selected one of the organizations that was involved in providing services in the settlement and identified its Director as my local supervisor. I identified this organization because it was providing services in the field related to my topic of study, that is - SRHR. This stage marked the beginning of a process in which I applied snowball sampling strategy to recruit a small group of people relevant to the research question. The sampled participants suggested other possible participants with similar characteristics and attributes for the study, (Bryman, 2016; Berg, 2001).
Using the snowball strategy I also gained access to the Regional Office of Prime Minister (OPM) and identified other relevant organizations that were working in the field of SRHR in the settlement. The OPM also suggested to me that United Nations High Commissioner for Refugees (UNHCR) was in best position to answer some of my questions, therefore, I had to include UNHCR among the key informants. Directors/managers of organizations active in the field of SRHR in turn helped me to identify appropriate participants from among their staff that were working in fields related to my area of study – SRHR – and who were willing to participate. Representatives of young displaced persons were also identified through the use of snowballing method. The field officers representing individual selected organizations identified local leaders and youth counselors. Local leaders and counselors also proposed other names of young displaced people that would participate in the study.
23 In selecting young people who participated in focus group discussions, I used two youth counselors as gatekeepers because they understood well the young people under study.
3.2. Sample size
The total sample was composed of 109 participants: comprising of 22 who took part in interviews, 49 in focus group discussions and 38 in workshops. 22 interviewees, included one OPM representative, two local government officials, ten staff from implementing and operating organizations, three local leaders, two school representatives, two youth councilors and two young displaced persons. Of 109 participants, 53 were men and 56 were women. Originally I had planned a total sample of 95 participants: 80 young displaced people and 15 key informants. The additional number resulted from strong willingness of young displaced people to participate in the study that culminated into inclusion of extra participants in the study. Also, it was deemed necessary to have an increased number of unstructured interviews with field officers who were always on the ground interacting with young people. I used mixed gender focus group discussions so as to gauge gender diversity during their discussions. I also considered homogeneity when I used mixed gender because the participants knew each other well, they were from the same villages, same age group and friends. Some studied in the same school and class, and the discussions took place during school time, within school premises.
3.3. Data collection methods
The methods of data collection were determined by the prevailing circumstances such as the type of information needed, the category of participants and the available resources such as money and time. I applied triangulation of methods of data collection, data sources and theories so as to internalize the phenomenon under study (Bryman 2016). The study was primarily qualitative and thus I used interviews, focus-group discussions, workshops, documentary review, observations and field notes. 3.3.1. Focus Group Discussions (FGDs)
I employed focus group discussions method because they are time and money saving, and effective in eliciting a wide variety of different views on a topic that is very important and significant to participants (Bryman, 2016). I conducted FGDs with five separate groups of young displaced persons, with a minimum of six and maximum of twelve participants. One of the five groups comprised only
24 young married females. This group was organized in an effort to create a safe setting for young women so as to discuss issues that seemed to apply to married young people.
At the start of every FGD, there would be self-introduction using naming exercise as an ice-breaker. Naming exercise involves self-introduction and introducing a closest friend who has already introduced himself/herself. E.g., my name is Anne, I am 18 years old, and I am in class five. My friend is Peter, he is 21 years old, comes from South Sudan….etc.
I then would show appreciation to the participants for their presence. Research goals and purpose of using FGDs and the necessity to record the discussion would be clearly explained to the participants. Participation procedures such as allowing one person to speak at a time and assuring the participants that there was no wrong answer would be done. I would then request the participants to fill in forms providing basic demographic information specifically age, sex, marital status, country of origin, and level of education. All focus group discussions were audio-recorded. I would first request for permission to audio-record the discussions and would commence the recording after being granted permission. I personally facilitated all the FGDs. Each session would end with thanking the participants for their participation (Peek and Fothergill, 2009). In the topic guide were open-guided questions on the general knowledge young displaced people had on SRHR- related issues, the perceived SRHR-related needs and challenges, and kinds and nature of SRHR services young people acknowledged having been provided to meet their needs and challenges.
With the help of local leaders, youth counselors and managers of involved organizations, I identified participants for FGDs. While conducting the FGDs, I kept in mind the limitation of this method put by Bryman, (2016) that is, the potential difficulties in data analysis, organizational challenges and time consuming recording and transcribing. I tackled the latter challenge transcribing audio-recording as soon as possible after the FGD before losing track of what transpired in the discussion.
Through use of FGDs, I gathered data on SRHR related needs and challenges of young displaced persons, how they would wish to have their needs met, and their perceptions on SRHR services provided in the settlement. Generally, the technique was not challenging to conduct as majority of the participants could speak and understand English.
25 3.3.2. Interviews
MacDonald and Headlamp (2011) argue that interviews are crucial to exploring the beliefs, values, understandings, feelings, experiences, attitudes and/or perceptions of individuals about an issue. Building on this argument, I employed in-depth semi-structured and unstructured interviews as one of data collection methods. Semi-structured interviews were conducted on key informants who included OPM representative, local government officials, staff from implementing and operating organizations, local leaders and school representatives. On the other hand, unstructured interviews were used on youth counselors and young displaced people. Semi-structured interviews were helpful due to their flexibility (Bryman, 2016; MacDonald and Headlam, 2011) and the manner they followed key themes rather than specific questions gave me room to respond to the participants as new themes and issues would develop (MacDonald and Headlam, 2011). Unstructured interviews on the other hand with the use of an interview guide, helped me to allow participants to discuss any point that came their way (Rayburn & Guittar 2013), and some points would generate new ideas to engage with in the subsequent interviews.
I personally interviewed all respondents because they could speak and understand English. I used interviews to correct data on general refugee status in Uganda and their views as to the situation in Bidibidi refugee settlement in particular, getting demographic data where necessary. Interviews were also used to get data on the types of services provided to young displaced persons in relation to their needs and the perception of service providers on young people’s SRHR-related needs.
3.3.3. Observation Participant Observation
DeWalt and DeWalt (2002) refer to participant observation as a data-collecting technique where the researcher becomes involved with the community of people she/he is studying in their natural environment and over a lengthy period of time. In a similar vein, Rabinow and Sullivan (1987) argue that, through studying the people in their own space and time, the researcher gains a close and intimate familiarity with them and their practices. I thus used participant observation to gain more in-depth understanding of the quality of SRHR service provision for young displaced people in the refugee settlement. I attended one workshop for registration of Persons with Specific Needs (PSNs) on 13 July 2017 and realized that SRHR-related issues were brought up by a UNHCR official though
