Healthy Business, Healthy Lives: Promoting the sexual health of
young people in rural Uganda
An exploratory, qualitative study investigating the potential for a community outreach health
initiative to create a health-enabling environment for the promotion of young people’s sexual
health in Greater Kibaale, Uganda
MSc International Development Studies – Thesis
Katy Elliott
10855718
klelliott94@gmail.com
Word Count: 24,661
Supervisor: Dr E.A.J Miedema
Second Reader: Dr W. Koster
16/08/2017
2
Abstract
There is widespread acknowledgement that the sexual health of young people is a pressing issue for consideration globally. Debates exist regarding how to design sexual health programmes to meet the needs of young people, with scholars arguing for approaches which address both risk and vulnerability to negative sexual health outcomes. This study set out to investigate how the Healthy Business, Healthy Lives initiative could achieve such aims by creating a health-enabling environment for young people in Greater Kibaale, Uganda. Healthy Business, Healthy Lives involves ‘Healthy Entrepreneurs’ providing young people with condoms and sexual health education on a mobile tablet. Knowledge about this unique initiative contributes insights regarding the design of sexual health programmes in resource poor settings.
The research was exploratory in nature and used qualitative methods. It was found that sexual activity was considered only appropriate for those over 18, thus affecting young people’s access to condoms and sexual health information. Young people also had limited discussions with parents and teachers about sex and faced a variety of access barriers to sexual health services in this context. Healthy Entrepreneurs were found to be a friend and confidant for young people and could provide practical information using the mobile tablet. The study concludes that, while some aspects of young people’s risks and vulnerabilities are addressed by Healthy Business, Healthy Lives, the Healthy Entrepreneurs could be seen to be conforming to age-based norms and moral discourses as to the appropriate moment and context for sexual relations, which – along with resource restrictions - prevented the creation of a health-enabling environment. This implies that there is considerable scope for improving the initiative to better meet the sexual health needs of young people in Greater Kibaale, by encouraging Healthy Entrepreneurs to both reflect on the information they are providing and consider the sexual agency of young people.
Key words: Sexual health promotion, risk and vulnerability, health-enabling environment, sexual and
3
Acknowledgements
First and foremost, I would like to thank the young people and Healthy Entrepreneurs who took the time to participate in the research and provided me with unique insights on which to write this thesis. I also have a large amount of gratitude for the staff at Emesco Development Foundation, who warmly hosted me in Karaguuza and ensured I had everything I needed to complete the research project. Particular thanks should be given to Nicholas, who acted as my local supervisor and was invaluable in organising the practicalities of the research.
I would like to also sincerely thank the staff working at the Healthy Business, Healthy Lives warehouse who allowed me to conduct my work at their office. I am particularly grateful to Penelope, who acted as my interpreter and helped me to navigate Greater Kibaale, which would have otherwise been impossible for a girl from England!
In the Netherlands, thank you to Renate at Simavi who helped me with the initial stages of the research by putting me in contact with those in Uganda. Without your facilitation, the research would not have been possible. Thank you to Esther who acted as my academic supervisor and was a source of invaluable support both while in Uganda and back in Amsterdam. Your help and guidance made the entire thesis process much easier. Further thanks are for Winny Koster, who agreed to be my second reader.
Finally, I’d like to thank my friends all over the world, from North America to Australia, who were always at the other end of the phone while I was in Uganda and have continued to listen to endless talk about the project for the past five months! The same is true for my family, who consistently remain a source of support throughout everything I do.
4
Table of Contents
Abstract ... 2
Acknowledgements ... 3
Table of Contents………4
List of acronyms ... 6
List of figures, maps, tables and images ... 7
1 Introduction ... 8
1.1 Young people’s SRHR ... 8
1.2 Addressing young people’s sexual health: A multi-pronged approach ... 9
1.3 Research aim ... 9
1.4 Academic and social relevance of research ... 10
1.5 Thesis overview ... 10
2 Conceptual Framework ... 11
2.1 The promotion of sexual health ... 11
2.1.1 Defining sexual health and the conditions required to achieve it ... 11
2.1.2 Promoting sexual health: addressing risk or vulnerability? ... 12
2.1.3 The creation of a health-enabling environment ... 13
2.2 Sexuality education discourses ... 14
2.3 Addressing structure and agency ... 15
2.4 Conceptual scheme ... 16
2.5 Concluding comments ... 17
3 Research Context ... 18
3.1 Uganda: An introduction ... 18
3.2 The sexual and reproductive health of young people in Uganda ... 18
3.3 Health systems in Uganda ... 19
3.4 Sex education in Uganda ... 19
3.5 Research location - Greater Kibaale ... 20
3.6 Health facilities and sexual health in Greater Kibaale ... 20
3.7 Healthy Business, Healthy Lives initiative ... 21
3.8 Concluding comments ... 22
4 Research Methodology and Design ... 23
4.1 Research questions ... 23
4.2 Sampling methods ... 23
4.3 Data collection methods ... 24
4.3.1 Content analysis of education on the mobile tablet ... 25
4.3.2 Semi-structured interviews ... 25
4.3.3 Focus group discussions and participatory methods ... 25
4.3.4 Field notes ... 26
4.4 Data analysis ... 26
4.5 Quality criteria ... 26
4.6 Ethics ... 28
4.7 Limitations of the study ... 29
4.7.1 Sampling methods and sample size ... 29
4.7.2 Use of an interpreter ... 29
4.7.3 Positionality ... 29
4.8 Concluding comments ... 30
5 Lived realities of young people in Greater Kibaale ... 31
5.1 Attitudes of adults ... 31
5.1.1 Attitudes of parents ... 31
5.1.2 Attitudes of teachers ... 32
5.2 Specific vulnerabilities of women and girls ... 33
5
5.2.2 Power within relationships ... 34
5.3 Age-based norms and secretive sex ... 35
5.3.1 Beliefs and realities regarding when young people have sex ... 35
5.3.2 Hiding indicators of sexual activity ... 36
5.4 Access to services and education ... 36
5.4.1 Services at health centres ... 36
5.4.2 Condoms ... 37
5.4.3 School-based SRHR education ... 38
5.5 Concluding comments ... 39
6 ‘We talk, we use the tablet and we have the products’ - The unique features of the HBHL
initiative ... 40
6.1 Healthy Entrepreneurs ... 40
6.1.1 Beliefs of Healthy Entrepreneurs ... 40
6.1.2 Position of Healthy Entrepreneurs ... 42
6.1.3 Strategies of Healthy Entrepreneurs ... 43
6.2 Mobile Tablet ... 44
6.1.1 Tablet encourages engagement in discussions about sexual health ... 44
6.2.2 Tablet contains practical education ... 45
6.2.3 Tablet removes language barrier ... 46
6.3 Products ... 47
6.4 Concluding comments ... 48
7 Choose to abstain: Sexual health information received by young people in Greater Kibaale
... 49
7.1 Information from the wider community ... 49
7.1.1 Focus on abstinence ... 49
7.1.2 Information about condoms ... 51
7.1.3 Information young people pass on to their friends ... 51
7.2 Information on the mobile tablet ... 52
7.3 Information passed on by Healthy Entrepreneurs ... 54
7.3.1 Healthy Entrepreneur focus on abstinence ... 54
7.3.2 Information about condoms ... 56
7.4 Concluding comments ... 57
8 Discussion and conclusion ... 58
8.1 Summary of findings per sub-question ... 58
8.2 Strong focus on abstinence and missing discourses of pleasure: Information about sexual health in Greater Kibaale heavily influenced by moral norms and values ... 59
8.3 Considering how the HBHL initiative works at multiple levels to improve the ability of young people to act upon sexual health information ... 61
8.4 Answer to the research question – ‘How does the Healthy Business, Healthy Lives initiative create a health-enabling environment for addressing the SRHR-related risks and vulnerabilities of young people in Greater Kibaale, Uganda? ... 63
8.5 Recommendations for the HBHL initiative ... 64
8.6 Suggestions for further research ... 65
9 Literature List ... 66
Appendix I: Operationalisation Table ... 75
Appendix II: Script for gaining verbal consent ... 79
Appendix III: Interview Guides ... 80
Appendix IV: Focus Group Discussion Guide ... 84
6
List of acronyms
ABC Abstain, Be Faithful, Use Condoms
CHW Community Health Worker
FGD Focus Group Discussion
GBV Gender Based Violence
GDP Gross Domestic Product
HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome
HBHL Healthy Business, Healthy Lives
HE Healthy Entrepreneur
ICPD International Conference on Population and Development
NGO Non-Governmental Organisation
PIASCY Presidential Initiative on AIDS Strategy to Youth
SRH Sexual and Reproductive Health
SRHR Sexual and Reproductive Health and Rights
STI Sexually Transmitted Infection
VHT Village Health Team
7
List of figures, maps, tables and images
Figure 1: Conceptual scheme
Figure 2: Uganda population pyramid 2016
Figure 3: Information about sexual health on the mobile tablet
Figure 4: Information about sexual health passed on by Healthy Entrepreneurs
Map 1: Location of Uganda in East Africa
Map 2: Location of Greater Kibaale in Uganda
Map 3: Sub-counties in Greater Kibaale
Table 1: Health facilities in Greater Kibaale
Table 2: Characteristics of research participants
Image 1: Healthy Business, Healthy Lives warehouse
Image 2: Education on the mobile tablet
Image 3: Message on the wall at Igayaaza Primary School
Image 4: Message on the wall at Igayaaza Primary School
Image 5: Message on the wall at Igayaaza Primary School
8
1 Introduction
Young people throughout the world, but particularly those in developing countries, are disproportionately affected by negative sexual health outcomes, including unwanted pregnancies, sexually transmitted infections (STIs) and gender-based violence (Chandra-Mouli et al. 2015; Fatusi 2016). There is acknowledgement within the international development community and academia that the sexual and reproductive health and rights (SRHR) of young people are vital to address (see: WHO 2010; Chandra-Mouli et al. 2015; Bearinger et al. 2007). However, there is a continuing prevalence of negative sexual health outcomes globally - with Sub-Saharan Africa a region of particular concern - and the best methods by which to meet young people’s unique SRHR-related needs remains a topic of debate (Chandra-Mouli et al. 2015; Fatusi 2016).
There does however exist a consensus that programmes to promote the sexual health of young people should be multi-pronged and address both risk and vulnerability to negative sexual health outcomes, which has been conceptualised by some scholars as a ‘health-enabling environment’ (Bearinger et al. 2007; Aggleton and Campbell 2000; Svanemyr et al. 2015). In light of the aforementioned continuing prevalence of negative sexual health outcomes, there is a need to determine whether existing sexual health promotion programmes are creating such an environment (Aggleton and Campbell 2000). Therefore, the purpose of this study is to consider a health-enabling environment in the context of an outreach community health programme operating in rural Uganda. The following chapter presents an overview of the rationale for the research, introducing the SRHR of young people (section 1.1) and the importance of a multi-pronged approach to sexual health promotion (section 1.2), before discussing the research aim and relevance of the study in sections 1.3 and 1.4 respectively. Finally, an overview of the research is found in section 1.5.
1.1 Young people’s SRHR
This study specifically considers young people within the age range of 10 to 19, a group which constitutes a larger proportion of the global population than ever before, especially in developing countries (Braeken and Rondinelli 2007; Bearinger et al. 2007). The dialogue on young people’s SRHR was first introduced on an international scale at the International Conference on Population and Development (ICPD) in 1994, during which there were calls for ‘meeting the educational and service needs of adolescents to enable them to deal in a positive and responsible way with their sexuality’ (United Nations 1994, quoted in Chandra-Mouli et al. 2015, p.1). The need to provide sexual and reproductive health (SRH) services and education has remained prominent in global discourses, most recently reaffirmed for the post-2015 development agenda by the World Health Organisation (WHO) at the 67th session of the World Health Assembly in 2014 (Temmerman et al. 2014). Furthermore, access to SRH services and accurate and complete information on SRHR are rights enshrined in the Convention on the Rights of the Child (Center for Reproductive Rights 2014; Rijsdijk et al. 2013). Since the ICPD, governments have progressed with implementing strategies to improve the sexual and reproductive health of their young people, however high rates of negative sexual health outcomes still
9
prevail within this group and there remain gaps which means universal access to good quality SRH services has yet to be achieved (Temmerman et al. 2014; Aninanya et al. 2015). With particular reference to Sub-Saharan Africa, AIDS is the leading cause of death among those aged 10-19 (UNAIDS 2015), while the region also has the highest rates of childbirth among young people, with 123 births per 1,000 (UNPFA 2013).1.2 Addressing young people’s sexual health: A multi-pronged approach
Young people as a group have unique needs and are affected by factors associated with the social, cultural and economic context in which they live; all of which need to be addressed when implementing a programme to promote their sexual health (Bearinger et al. 2007; Morris and Rushwan 2015). Bearinger et al. (2007) therefore discuss how such programmes should be ‘multi-pronged’, considering both individual behaviours and the social contexts and structural factors which act against safe sexual practices. Therefore, young people should be provided with the information and services required for healthy behaviour, at the same time as the underlying structures and forces which can inhibit the adoption of such healthy behaviour are addressed (Aggleton and Campbell 2000). A further conceptualisation of a multi-pronged approach considers collaboration between sectors, something the WHO (2010) states to be of great importance, as the chances of achieving a successful sexual health intervention are increased when sectors work in tandem. The health and education sectors are both included in the WHO’s (2010) framework for sexual health programmes, with health systems included because they can meet SRHR-related needs by providing a variety of services, including STI testing and treatment, counselling, abortions and post abortion care, and contraception distribution (Temmerman et al. 2014; WHO 2010). Furthermore, education which supplies people with comprehensive and objective information can contribute to a reduction in negative sexual health outcomes, because it provides the means for individuals to make well-informed, independent decisions about their sexual health (WHO 2010; Rijsdijk et al. 2013).
1.3 Research aim
This research investigates how a community outreach health initiative called Healthy Business, Healthy Lives (HBHL) can create a health-enabling environment for the sexual health of young people in rural Uganda, through the provision of SRHR-related products and education. Specifically, the research considers how the HBHL initiative can address the SRHR-related risks and vulnerabilities of young people in the research location of Greater Kibaale, through the creation of the aforementioned health-enabling environment. The study therefore aims to contribute to discussions of the sexual health of young people in rural Uganda, as well as the debate regarding how to design effective programmes to meet the SRHR-related needs of young people in resource poor settings. Furthermore, the study considers the implications of the research findings for policy and practice related to the design and implementation of the HBHL initiative in Greater Kibaale.
10
1.4 Academic and social relevance of research
The academic relevance of the research stems from the unique nature of the HBHL initiative, on which limited research has been undertaken. There are numerous aspects of this initiative which make it different to other SRHR-related services and education, firstly because of the focus on individual health workers who are chosen by the community and visit people’s homes to provide education and basic products. Secondly, the format of the initiative means it bridges a gap between the healthcare and education sectors. Finally, the aforementioned education is provided from a healthcare perspective, outside the formal education sector and on a mobile tablet. Previous studies situated in rural Uganda have considered the structural factors which influence the vulnerability of young people to negative sexual health outcomes, as well as school based sex education programmes and the presence of youth-friendly services at health centres (Bell and Aggleton 2013; Iyer and Aggleton 2014; Hampanda et al. 2014; Kipp et al. 2007). Therefore, the unique combination of aspects provides an opening from which to potentially address the knowledge gap identified by Chandra-Mouli et al. (2015), regarding the best way to design and implement effective interventions to meet the SRHR-related needs of young people. It also provides a means of further exploring the creation of a ‘health-enabling environment’, which Svanemyr et al. (2015) identify as an emerging field.
Furthermore, while there have been two previous studies conducted on the HBHL initiative, these did not specifically focus on young people, were largely quantitative in nature and were undertaken from a public health perspective. Therefore, there is a gap for in-depth qualitative analysis from a social science perspective to investigate the experiences and perspectives of young beneficiaries, which is of societal relevance as the resulting knowledge can be used to consider whether the HBHL initiative can be improved to better meet the SRHR-related needs of young people in Greater Kibaale.
1.5 Thesis overview
The following section explores the conceptual framework behind the research. After is a consideration of the Ugandan context in section 3 and the research design and methodologies in section 4. The main findings of the research are presented in the three subsequent chapters: the lived realities of young people in Greater Kibaale (section 5), an exploration of how the HBHL initiative responds to these realities (section 6) and consideration of the information young people in Greater Kibaale receive about sexual health (section 7). Finally, a discussion of the findings and conclusions of the research are presented in section 8.
11
2 Conceptual Framework
This chapter addresses the conceptual framework underpinning the research. Section 2.1 considers the promotion of sexual health, including whether risk or vulnerability to negative sexual health outcomes should be taken into account. Section 2.2 explores sexuality education discourses. A discussion of structure and agency in health promotion follows in section 2.3, before the conceptual scheme is presented in section 2.4. Concluding comments can be found in section 2.5.
2.1 The promotion of sexual health
2.1.1 Defining sexual health and the conditions required to achieve it
When considering the promotion of sexual health, it is first necessary to determine what is meant by ‘health’, before narrowing this definition to sexual health and considering the desired behaviours and conditions for an environment which promotes such a state. Debates exist regarding the best way to define health, in response to the WHO’s (1948) definition of health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity’. While this definition has been commended for acknowledging health as more than the absence of disease (Giami 2002), critics view the use of ‘complete’ as problematic, due to the absolute nature of the term and the difficulties associated with measuring complete health (Huber et al. 2011). The Ottawa Charter further expands the WHO definition by viewing health as ‘a positive concept which emphasises an individual’s social and personal resources as well as physical capacities’ (WHO 1986). According to the Charter, in order to achieve a state of health, an individual must be able to ‘identify and realise aspirations, to satisfy needs and to change or cope with the environment’ (WHO 1986). The latter more complex definition of health will be adopted within this research, due to the way in which it ties in with the discussions of risk, vulnerability, structure and agency explored later in this section.
Furthermore, the WHO defines sexual health as:
“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health 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. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (2006, p. 5)
According to Davis (2009, p.13), ‘The World Association for Sexual Health and the WHO are in agreement of the fact that sexual health is more than the absence of disease, as it also encompasses universal rights associated with autonomy, freedom of association, freedom from coercion and violence and access to knowledge and education, reproductive decision making and sexual health care’. Aggleton and Campbell (2000) support the WHO definition by asserting that sexual health is an affirmative concept which covers
12
more than the absence of STIs and unwanted pregnancy and more than activity which occurs within procreative heterosexual relationships. Sexual health also respects the variety of sexual experiences, needs and identities, covers the right of all people to be free from sexual exploitation and allows for the attainment of sexual pleasure rather than the repression of sexual desires (Aggleton and Campbell 2000). When considering programmes which promote such a state for young people, Aggleton and Campbell (1999, p. 250) suggest the inclusion of four components: access to reliable and factual information about sexual health risks, an age and culturally appropriate ‘menu’ of risk reduction options, along with the opportunity to examine values, commitments, responsibilities and personal relationships which affect motivation and behaviour, access to youth-friendly health services and the opportunity for young people and adults to discuss issues related to sex, sexuality and relationships.2.1.2 Promoting sexual health: addressing risk or vulnerability?
Scholars have considered whether sexual health promotion programmes should address risk, vulnerability, or both when attempting to improve the sexual health of individuals and communities. Such debates have mainly arisen with regard to HIV prevention (Kippax et al. 2013; Aggleton 2004), but also apply to wider sexual health programmes (Aggleton and Campbell 2000). With regards to sexual health, individual risk is defined by Bell and Aggleton (2013, p. 102) as ‘what individuals know and how they choose to act to reduce or increase their chance of acquiring an STI or becoming pregnant’. Furthermore, societal vulnerability is defined as ‘the socio-cultural, economic, political and legal factors constraining individuals’ opportunities to reduce risk’ (Bell and Aggleton 2013, p. 102). Programmes designed to specifically address risk are therefore concerned with targeting the behaviours which increase the likelihood of an individual experiencing negative sexual health outcomes, by providing the individual with the knowledge and services required for behaviour change (Kippax et al. 2013;Aggleton 2004). According to Kippax et al. (2013) and Choby and Clark (2013), such an approach views the individual as a rational neoliberal agent who will change their behaviour if they are exposed to information and services. Studies undertaken in sub-Saharan Africa have found that increased awareness of the link between AIDS mortality and risky sexual behaviour - as well as behaviour change interventions and condom distribution - can be linked to declines in HIV rates (Halperin et al. 2011; Johnson et al. 2012). Whilst these studies suggest that solely addressing risk can result in a reduction of negative sexual health outcomes, critics assert that it can be an individualistic approach which considers the behaviour of individuals as independent of the context in which it takes place (Choby and Clark 2013; Kippax et al. 2013).
In response to the above critique, programmes which address the underlying structural factors constraining an individual’s ability to reduce their risk of experiencing negative sexual health outcomes have become increasingly popular in recent times (Kippax et al. 2013). This is due to a growing awareness of the fact that sexual practice and health-seeking behaviour are socially constituted and therefore decisions made by persons are influenced by structural factors beyond the individual level (Kippax et al. 2013; Bell and Aggleton 2013; Bohmer and Kirumbira 2000). To support this position, Svanemyr et al. (2015) identify the
13
existence of social, cultural, political and economic factors which both increase young people’s vulnerability to SRHR-related risks and constitute barriers of access to SRH information and services. Such factors are split by Bell and Aggleton (2013) into proximal factors, examples of which include interpersonal relationships and lack of access to condoms, information and health services, and distal factors, including prevailing cultural norms and values and poverty. Scholars argue that vulnerability is best addressed when sexual health programmes are applicable to the socio-cultural context in which the beneficiary population is negotiating issues of sexuality, as this allows the specific social contexts and structural factors which result in unsafe sexual behaviours to be addressed (Kippax and Stephenson 2005; Bearinger et al. 2007; Bell and Aggleton 2012). The active involvement of young people in the design and implementation of sexual health programmes is cited by numerous scholars to be an effective method for ensuring the programme is applicable to their socio-cultural context, as it allows for an understanding of how young people perceive sexual health practices and the factors which lead to negative sexual health outcomes (Braeken and Rondinelli 2012;Bell and Aggleton 2012; Aggleton and Campbell 2000).2.1.3 The creation of a health-enabling environment
Following the discussion in the preceding sections, Aggleton and Campbell (1999) identify that health-related behaviours are influenced by both the rational choice of the individual based upon the information they have been given and the extent to which broader contextual factors support their behaviour. Therefore, sexual health programmes need to encourage individuals to change their behaviour at the same time as addressing the societal factors which constrict this behaviour, thus addressing both risk and vulnerability to negative sexual health outcomes (Aggleton and Campbell 2000). Therefore, Aggleton and Campbell (1999; 2000) identify a key challenge for policy as the creation of a health-enabling environment, the existence of which can assessed by considering both the quality of the information young people receive and their ability to act upon this information. The need to take into account both risk and vulnerability is supported by the WHO (2010), which stipulates that efforts to change behaviour at an individual or group level are unlikely to succeed without also addressing underlying structures and therefore advocates for interventions that address both risk and vulnerability in the context of sexual practice. Svanemyr et al. (2015) further assert that a health-enabling environment is created by addressing broad structural factors which exist at the individual level and beyond. Therefore, the authors identify the need to work at individual, relationship, community and societal levels (Svanemyr et al. 2015). On their view, working to create an enabling environment at the individual level consists of empowering young people through building their economic and social assets, and at the relationship level by fostering relationships which support positive health behaviours (Svanemyr et al. 2015). Furthermore, working at the community level involves promoting positive social norms and community support for young people to access SRH information and services, while working at the societal level involves the promotion of policies which contribute to broader societal norms supporting the SRHR of young people (Svanemyr et al 2015).
14
2.2 Sexuality education discourses
As well as addressing underlying structural factors, a further element of a health-enabling environment is the provision of quality information about sex and sexual health (Aggleton and Campbell 2000). There is a debate regarding what can be considered ‘quality’ information about sexual health, as the type and content of sexuality education is influenced by different visions, messages and missions (Braeken and Cardinal 2008). Sexuality education discourses are divided by Braeken and Cardinal (2008) into the three categories of morality, health and rights-based. Morality discourses are based upon a society’s prevailing religious and/or moral norms and values regarding sexuality (Braeken and Cardinal 2008; Miedema et al. 2011). Such discourses are underpinned by a fear that discussing sex with young people encourages them to become sexually active (de Haas et al. 2017). Messages are related to what is considered to be socially acceptable with regards to sexual behaviour and sex is often constructed as occurring within a heterosexual marriage, meaning that abstinence is heavily promoted for unmarried young people and heterosexuality is presented as the norm (Braeken and Cardinal 2008; Miedema et al. 2011). Critics assert that these discourses do not respond to the lived realities of young people, especially those who are engaging in sexual behaviour before social norms and values dictate that it is appropriate (Altinyelken and Olthoff 2014; Iyer and Aggleton 2014). Furthermore, a health approach provides technical education regarding the reproductive system and information about how to prevent unwanted pregnancies, HIV and other STIs (Braeken and Cardinall 2008). Discourses are focused around facts, for example with relation to HIV/AIDS, these facts include how the disease can be transmitted, its effects on the body and the methods by which individuals can protect themselves (Miedema et al. 2011).This is comparable to the moral approach, due to the way it often neglects both the social context in which sexual practices exist and the agency of the learner (Braeken and Cardinall 2008). Finally, a rights-based approach is focused on empowering young people to claim their sexual rights, viewing young people as active sexual agents who are negotiating their own sexualities and thus require objective information to make well-informed decisions regarding their sexual health (Braeken and Cardinal 2008; Miedema et al. 2011; de Haas et al. 2017). A rights-based approach revolves around ‘providing young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality - physically and emotionally, individually and in relationships’ (International Planned Parenthood Federation 2010, p. 6).
When considering the ‘quality’ information discussed in Aggleton and Campbell’s (2000) definition of a health-enabling environment, current thinking promotes comprehensive sexuality education as providing information of the highest quality (see: Rijsdijk et al. 2013; Iyer and Aggleton 2014). Braeken and Cardinall (2008) conceptualise comprehensive sexuality education as a combination of the three aforementioned discourses. Therefore, the information provided within this approach covers issues such as human development, personal skills, and society and culture to promote an understanding of SRHR, as well as more health-based issues to allow young people to make informed choices regarding their reproductive health (Braeken and Cardinall 2008). Furthermore, the information provided must promote values such as gender
15
equality, respect for others and freedom from discrimination and violence, foster critical thinking skills and exist in the context of the lived realities of the learners (Braeken and Cardinall 2008). These assertions are supported in the context of Uganda by Rijsdijk et al. (2013), who conducted an explorative study with the involvement of young people to identify the need for the provision of objective information on sexuality issues, the development of critical thinking skills in order to evaluate the information about sexual health received from different sources, and the need for the information provided to be appropriate to young people’s daily realities (Rijsdijk et al. 2013).2.3 Addressing structure and agency
There exist longstanding debates within health scholarship regarding the influential roles of structure and agency on health, as well as wider debates within the social sciences between supporters of structuralist approaches and advocates for action theory (Choby and Clark 2013; Rütten and Gelius 2011). With regards to health interventions, such debates link with the earlier discussion of risk and vulnerability, as they consider whether interventions should target individual behaviours, the aspects of structure which affect these behaviours, or both (Choby and Clark 2013). Scholars have raised the fact that health promotion contains both structural and agentic perspectives, firstly because the concept of health promotion critiques interventions based solely on individual lifestyles, instead emphasising the importance of the social conditions affecting individuals’ daily life conduct (Rütten and Gelius 2011). Secondly, agency is an important outcome of health promotion as it aims to increase the agentic capacities of individuals to exercise control over their own health (Rütten and Gelius 2011; Abel and Frohlich 2011). Consideration of a health-enabling environment as a method of sexual health promotion illustrates the above point, as the definition of such an environment addresses the need to consider structural factors beyond the individual level, yet it also considers agency by ‘facilitating young people’s efforts to protect and enhance their sexual health’ (Svanemyr et al. 2015; Aggleton and Campbell 1999, p. 249). Furthermore, Kippax and Stephenson (2005, p. 359) identify that ‘successful sex and relationship education promotes agency and targets sexual practice as it is socially produced’. Regarding addressing structure and agency within a health-enabling environment, important lessons can be drawn from Giddens’ (1984) theory of structuration, which highlights the mutually reinforcing nature of structure and agency and therefore the need to consider the context in which the two interact (Rütten and Gelius 2011). Within the theory of structuration, Giddens argues that human agency encompasses an awareness of the rules of social interaction, with individuals contributing to the reproduction of social structures by acting according to these rules. Therefore, structures can be viewed as ‘both the medium and the outcome of the practices which constitute social systems’ (Giddens 1984, cited in Rütten and Gelius 2011, p. 954). It is important to note here that there is a tendency to view structures as only constricting, which overlooks the fact that they can also be enabling (Giddens 1984, cited in Rütten and Gelius 2011). Despite the contribution to health promotion made by this theory, critics state that the central focus on the constant reproduction of structures via agency leads to a static view of structures, thus underplaying the potential for such structures to be changed (Rütten and Gelius 2011; Sewell 1992). Such a
16
critique illustrates the need to consider the agency of individuals to change the structures in which they are located, further supported by Abel and Frohlich (2011, p.237), who state that ‘structurally transformative agency is a critical component for the reduction of social inequalities’. Therefore, discussions of a health-enabling environment for the sexual health of young people can consider whether young people are encouraged to use their own agency to alter the structures affecting their SRHR-related risks and vulnerabilities.2.4 Conceptual scheme
The conceptual scheme developed as a result of the preceding discussion is displayed in Figure 1. The overarching component of the research is the lived realities of young people in Greater Kibaale, which influences the context in which young people are negotiating issues of sexual practice and sexual health. Situated within these lived realities is the HBHL initiative, made up of Healthy Entrepreneurs, the mobile tablet and the products. The effect of the HBHL initiative on a health-enabling environment – identified by the information provided about sexual health and the ability of young people to act upon this information – and on the risks and vulnerabilities of young people is shown. The link between a health enabling environment and SRHR-related risks and vulnerabilities is also shown.
17
2.5 Concluding comments
This chapter has clarified the theoretical considerations underpinning the research, before presenting the resulting conceptual scheme. The next chapter provides an overview of the context of the research.
18
3 Research Context
This section explores the context of the research, beginning with the national context, which includes Uganda’s socio-economic conditions (section 3.1), the sexual health of young Ugandans (section 3.2), the national health system (section 3.3) and national sex education policies (section 3.4). Following is an exploration of the specific research location (sections 3.5 and 3.6) and the context of the HBHL initiative (section 3.7). Concluding comments are found in section 3.8.
3.1 Uganda: An introduction
Uganda is located in East Africa, landlocked between the
countries of Kenya, South Sudan, Democratic Republic of Congo, Tanzania and Rwanda, as can be seen on Map 1 (Uganda Bureau of Statistics 2016). The 2014 census identified that the population size was 34.6 million people and the fertility rate was 5.8 children per woman, with an annual population growth of 3% (Uganda Bureau of Statistics 2016). In 2014, 39.3% of the population were Catholic, 32% Anglican, 13.7% Muslim and 15% other religions (Uganda Bureau of Statistics 2016). With regards to economics, 64% of Uganda’s working population participates in subsistence agriculture (Uganda Bureau of Statistics 2016). In 2016, the GDP of Uganda was $84.93 billion with a real growth rate of 4.9%, earning a categorisation by the World Bank as a low-income economy (Central Intelligence Agency 2017; World Bank 2017). Furthermore, the percentage of the population living below the poverty line was 19.7% in 2013 (World Bank 2016). Finally, Uganda has a rating of 0.49 on the Human Development Index, positioning it at 163 of the 188 countries ranked in 2016 (UNDP 2016).
3.2 The sexual and reproductive health of young people in Uganda
The 2014 national census identified that people under the age of 25 made up 68.5% of the total population, with young people aged 10-19 constituting 25.6% of this percentage (Uganda Bureau of Statistics 2016). The population pyramid shown in Figure 2 illustrates the extent of the youth bulge in Uganda for the year 2014. Regarding the sexual activity of young people, a nationally representative survey undertaken in 2004 found that among those aged between 15 and 19, nearly half of all females and males had had sex (Neema et al. 2006). It is also estimated that 5% of females and 2% of males aged between 15 and 24 are HIV positive and over one million new sexually transmitted infections are acquired within this group every day (Hampanda et al. 2014; Crossland et al. 2015). These statistics illustrate the importance of taking into account the specific needs of this large - and sexually active - group when attempting to improve the sexual health of the national population.
Map 1: Location of Uganda in East
19
3.3 Health systems in Uganda
Health systems in many African countries face issues with regards to providing the entire population with access to good quality, affordable health care (Okwaro et al. 2015). In the context of Uganda, the absolute number of health workers in 2011 was 1.8 per 1000 people, below the 2.3 per 1000 recommended by the WHO to meet the Millennium Development Goals (MOH et al. 2012). Furthermore, the geographic distribution of healthcare workers is skewed towards cities, a problem because only 13% of the population live in urban areas (MOH et al. 2012). Gaps in provision of services to rural areas extends to sexual and reproductive health, with differing levels of access to contraceptives, family planning services and maternal healthcare affecting the sexual health of people in rural areas (Yao et al. 2013; Neema et al. 2004). In 2001, the Ugandan government implemented a Village Health Team (VHT) scheme, with the aim of expanding the reach of the healthcare system to rural areas (MOH 2010; Kimbugwe et al. 2014). Such a scheme encompasses the training of people who have been selected by their community to be community health workers (CHW), who then provide outreach healthcare in the form of health promotion and preventative care to people in their community (Kimbugwe et al. 2014). CHWs are considered in many cases to constitute a vital link between the community in which they are working and the primary healthcare system, serving as the first point of contact for people in their community (Tran et al. 2014; Kimbugwe et al. 2014). CHWs adopt voluntary positions and receive no reimbursements for expenses such as travel, which previous studies have found limits the time they can spend on community health work, as they have to use much of their time to complete other income generating activities (van’t Hoff 2016).
3.4 Sex education in Uganda
Ugandan national policies concerning sexuality education ‘aim to provide all learners with life skills and age-appropriate, accurate, complete and scientifically factual information on HIV and AIDS’ (Rijsdijk et al.
20
2013, p. 410). The key governmental policy relating to school-based sex education is PIASCY, which advocates for an ‘ABC’ (abstain, be faithful, use condoms) approach to sex education (Iyer and Aggleton 2014). This approach has received international praise for its role in the reduction of HIV rates in Uganda, yet it should be noted it existed in parallel with a nation-wide effort to promote the behaviours associated with ABC to the general public from actors at all levels – from the national government to local women’s and religious groups (Murphy et al. 2006). For young people who have yet to have sex, there is a strong focus on delaying sexual debut as the best method of HIV prevention (Okware et al. 2005). Such a focus on abstinence and other individual behaviours as a way to prevent the spread of HIV has been criticised because it does not take into account the underlying social, economic and political causes of the epidemic (Murphy et al. 2006; Okware et al. 2005). In addition, Iyer and Aggleton (2014) identified the prevalence of a morally conservative approach to sex education in schools, resulting in the characterisation of sex outside of marriage as dangerous and the promotion of virginity as a way to prevent the spread of AIDS, which exist according to the conceptualisation of ‘normal’ sexual behaviour as that which occurs within a procreative, heterosexual marriage. Furthermore, recent developments in late 2016 saw the Ministry of Gender propose and pass a ban on comprehensive sexuality education in schools, with a variety of news sources reporting that the decision was based on a concern that such education was eroding national values (Rutgers 2016; Daily Monitor 2016). This has recently resulted in a lawsuit against the Ugandan government by a Ugandan based NGO, amid confusion regarding the aspects of sexual health which can and cannot be discussed (Fallon 2017).3.5 Research location - Greater Kibaale
Greater Kibaale is located approximately 200km west of the capital city of Kampala with a population of 785,000 (Uganda Bureau of Statistics 2016). Greater Kibaale is made up of three districts, consisting of Kagadi District, Kibaale District and Kakumiro District. These districts are further split into 18 sub-counties. Research took place in nine of these sub-counties, in the rural areas in which the Healthy Entrepreneurs conduct their work. The research base was the office of Emesco Development Foundation, located in the town of Karaguuza in Kibaale District.
3.6 Health facilities and sexual health in Greater Kibaale
There are a total of 55 health facilities distributed throughout Greater Kibaale, as shown in Table 1. 65% of these are government aided and 35% are run by NGOs. There is a mixture of level 2, 3 and 4 health centres which differ in the complexity of conditions they treat and the type of staff employed - level 2 facilities are run by nurses and treat common diseases such as malaria, while level 4 facilities should have the capacity to admit patients and have a doctor on site for emergency operations (Kavuma 2009). The single district hospital is located in Kagadi town.
Map 2: Location of Greater Kibaale
21
Data obtained from these health facilities illustrates that between July 2016 and February 2017, 2829 women aged between 5 and 59 presented with an STI. For men in the same age group, the number was 945 (Greater Kibaale District Health Office 2017). Additionally, between July 2016 and February 2017, 6252 young women aged 10-19 visited an antenatal clinic for the first time (Greater Kibaale District Health Office 2017).3.7 Healthy Business, Healthy Lives initiative
The HBHL initiative is an outreach community health programme implemented by the two Dutch organisations Simavi and Healthy Entrepreneurs, as well as local partner Emesco Development Foundation (Simavi 2015). The aim of the HBHL initiative is to train individuals to become Healthy Entrepreneurs, health workers who deliver outreach healthcare to their communities by selling quality medicines and livelihood products and providing health education via eHealth applications on a mobile tablet, as well as making referrals for more complex health problems (Simavi 2015). Many Healthy Entrepreneurs were previously CHWs and were therefore already engaged in delivering community outreach healthcare. Becoming a Healthy Entrepreneur is different to their previous activities, as it gives these people the opportunity to generate an income from their work. Participants are trained how to use the tablet and how to successfully run their mobile pharmacy by the organisations, and the entrepreneur must cover 25% of the costs, before paying the rest back over a period of time using their profits (Simavi 2015). There are currently 130 entrepreneurs trained in Greater Kibaale, with 32 of these having been trained most recently between November and December 2016.
The local partner Emesco Development Foundation oversees the warehouse from which the entrepreneurs replenish their stock (Simavi 2015), as seen in Image 1. With regards to sexual health, condoms are sold by the entrepreneurs and the tablets contain educational videos regarding various aspects of SRHR and counselling videos about contraceptives and family planning (Healthy Entrepreneurs n.d.). The Healthy Entrepreneurs conduct their work in their local community; some walk around the village with their tablet and products, while others have a base where they are visited by their customers.
Health Facility Government NGO Total
Hospital 1 0 1
HC IV 3 1 4
HC III 16 9 25
HC II 16 9 25
22
3.8 Concluding comments
Uganda is a low-income country, with limited resources and a large proportion of the population living in poverty. Nationwide, young people are sexually active and experiencing negative sexual health outcomes, which the health and education systems are struggling to address. The same conditions can be seen within the research location of Greater Kibaale, where the HBHL initiative exists with the aim of using innovative methods to improve the health of the population. The next chapter moves on to explore the research design and methodology which underpins the research.
Image 1: The Healthy Entrepreneurs warehouse and office located in
23
4 Research Methodology and Design
This chapter considers the research methodology and design, beginning with an exploration of the research questions in section 4.1. Then follows a discussion of the sampling strategies (section 4.2), data collection methods (section 4.3) and data analysis methods (section 4.4). After is a consideration of quality criteria (section 4.5), ethics (section 4.6) and limitations of the research design (section 4.7). Section 4.8 contains concluding comments.
4.1 Research questions
Research suggests that SRHR-related risks and vulnerabilities can be addressed via the creation of a health-enabling environment and that the existence of such an environment can be determined by reviewing the quality of information received by young people, as well as their ability to act upon this information (Aggleton and Campbell 2000). Therefore, the following research question and sub-questions were devised:
How does the Healthy Business, Healthy Lives initiative create a health-enabling environment for addressing the SRHR-related risks and vulnerabilities of young people in Greater Kibaale, Uganda?
• What are the SRHR-related risks and vulnerabilities which can be identified from the lived realities of young people in Greater Kibaale?
• How does the HBHL initiative respond to the SRHR-related risks and vulnerabilities of young people in Greater Kibaale?
• What information do young people in Greater Kibaale receive about sex and sexual health?
4.2 Sampling methods
As Greater Kibaale encompasses a large area of land, it was decided upon reaching the research location that data collection would take place in a sample of the sub-counties within the region. Random sampling was used to determine the sub-counties in which data collection would occur, with Kibaale town added due to its close proximity to the research base. The sub-counties chosen were: Mpeefu, Muhorro, Mugarama, Nyamarunda, Bwanswa, Matale, Bwamiramira and Nkooko. The locations of these sub-counties within Greater Kibaale can be seen on Map 3.
24
Once the sub-counties had been selected, a mixture of purposive and convenience sampling was used to identify the research participants. Firstly, purposive sampling was used to identify the Healthy Entrepreneurs and young people to participate in the interviews. This method is defined by Patton (1998) as sampling cases which are information rich and will be most pertinent to the questions under study and it was chosen because there were specific characteristics which needed to be met by the participants to ensure they could make a meaningful contribution to the research. Healthy Entrepreneurs needed to be active and discussing sexual health with young people, while young people needed to be beneficiaries of the Healthy Entrepreneurs’ service. Further characteristics of the research participants can be seen in Table 2. The knowledge of the local HBHL staff was used to select appropriate Healthy Entrepreneurs and young people to participate in the research for each of the selected areas.Furthermore, convenience sampling is defined by Patton (1990) as the sampling of cases which are easiest to access under given conditions, including time and resource constraints. Convenience sampling was necessary for the focus group discussions (FGDs) due to logistical issues associated with getting groups together and the high monetary and time costs associated with travelling long distances within Greater Kibaale. Therefore, four schools in Kibaale sub-county were selected as locations for the FGDs with young people who met the desired characteristics and opted to be involved in the research. Meanwhile, the single FGD with Healthy Entrepreneurs was conducted with a group who were already meeting.
4.3 Data collection methods
Data collection methods which are qualitative in nature were chosen because these represent the best way to understand the context in which young people are negotiating sexual practice, as well as providing an
Group Interviews FGDs
Male Female Male Female
Healthy Entrepreneurs 6 10 3 2 In school age 16-19 7 8 6 5 In school age 13-15 2 3 15 11 Out of school 2 1 Key Informants 4
25
opportunity to explore the perceptions and experiences of research participants (Bohmer and Kirumira 2000; Hennink et al. 2011). Furthermore, triangulation of different qualitative data collection methods was used in an attempt to reduce the bias encountered when using a single data collection method, as it allows the problem to be viewed from multiple perspectives (Thurmond 2001). The data collection methods chosen for this study consist of content analysis, in-depth interviews and FGDs. The interviews and FGDs were recorded after gaining informed consent from participants and were mainly conducted in English, with interpretation provided by Penelope from the HBHL team when necessary.4.3.1 Content analysis of education on the mobile tablet
The first step of data collection involved analysis of the educational modules on the mobile tablet. Such analysis involved creating a data-driven coding scheme based on the research interest behind the study (Flick 2014), which in this case was information about sexual health. Codes developed from the material on the tablet were also added during the process, an action permitted due to the flexible nature of content analysis (Flick 2014). Specific ‘messages’ identified during the content analysis of the mobile tablet were used to stimulate discussions during the following interviews and FGDs, allowing for an exploration of whether or not these messages were familiar to research participants.
4.3.2 Semi-structured interviews
In-depth interviews allow the researcher to obtain detailed insights into the research issues from the perspective of the study participant, as well as develop an understanding of the subjectivity of the interviewee (Hennink et al. 2011). These aims are achieved by considering what the interviewee regards as important when explaining and understanding events, patterns and forms of behaviour (Bryman 2012). Therefore, interviews were used within this study to understand the attitudes and strategies of Healthy Entrepreneurs and the perceptions of young people regarding topics including sex and their experiences of the HBHL initiative. The interviews were semi-structured in nature because discussion was based on a pre-developed interview guide, however there was flexibility for the participant to steer the discussion and talk about the issues of most importance to them (Bryman 2012). In total, 44 interviews were conducted with young people of varying ages both in and out of school, Healthy Entrepreneurs and key informants including the Greater Kibaale District Health Officer and the HBHL manager.
4.3.3 Focus group discussions and participatory methods
FGDs involve the exploration of a particular theme or topic with a small group of research participants, with the aim of understanding the views and perspectives of the people within the group (Bryman 2012; Hennink et al. 2011). This provides a useful method for understanding community perspectives, norms and values due to the fact that the understanding of social phenomena occurs via interaction and discussion with others (Bryman 2012). Therefore, FGDs were used in this research to explore the lived realities of young people in Greater Kibaale, young people’s perceptions of the HBHL service and Healthy Entrepreneurs’ views
26
regarding young people’s sexuality. During the FGDs, I also conducted further participatory data collection methods including mapping and ranking exercises. Such exercises were used to understand where young people prefer to get sexual health information and services, as well as the importance placed on different sexual health messages by both Healthy Entrepreneurs and young people. The FGDs consisted of five or six participants, as suggested by Hennink et al. (2011) as the optimum number in order to gain a diversity of perspectives whilst maintaining a meaningful discussion. Six FGDs were conducted - three with in- school boys, two with in-school girls and one with mixed gender Healthy Entrepreneurs. The participants in each FGD were of a similar age to maintain the necessary group homogeneity.4.3.4 Field notes
Throughout the data collection period I kept comprehensive field notes, consisting of observations and reflections which were relevant to the research. Such notes included details of participant body language during FGDs and interviews, interactions between people - most pertinently Healthy Entrepreneurs and their beneficiaries - observations of the social setting, descriptions of events which took place and personal reflections on the research process. These notes were used to contribute to my understanding of the overall context of the HBHL programme, something identified by Patton (1990) as a valuable part of the research process. .
4.4 Data analysis
As the research is exploratory in nature, the data analysis approach allowed for codes and themes to be derived from the data. Verbatim transcriptions of the interviews and FGDs were created while still in the field, during which I identified the key themes arising from data collection. These were then used to inform topics of discussion in succeeding periods of data collection, with the aim of having a saturation of categories at the end of the data collection period, thus indicating there is nothing new to be identified from further data collection (Boeije 2010). Following my return from the field, I undertook a more formal coding process using the qualitative analysis software Atlas.ti to ease the exercise of coding large transcripts. I began this process by breaking down the data using open coding, which involves dividing the data into segments and attaching a ‘conceptual label’ to each segment (Flick 2014). These codes derived from what was present in the data, rather than preconceived notions or ideas. After this, I made sense of the data using axial and selective coding, which involves determining the definition and content of each category, identifying dominant and less important categories and making connections between the categories (Flick 2014; Boeije 2010). During this process, data was also compared to previous studies on the subject, in order to embed the findings in current discussions and debates.
4.5 Quality criteria
Lincoln and Guba (1985) suggest five categories for assessment when determining the quality of qualitative research. Firstly, credibility is concerned with whether the research contains a credible account of reality
27
(Bryman 2012). The triangulation of data collection methods has already been identified as a means to reduce bias, thus contributing to the credibility of the research. In a further attempt to increase credibility, I was sure to build trust with research participants before conducting interviews and FGDs. This was achieved because I was accompanied by a member of HBHL staff who was well known by the local people and because I spent time building up rapport with participants before beginning an interview or FGD. Furthermore, data collection was conducted in locations which were familiar to the research participants, such as schools, homes and places of work in the hope that this would provide a comfortable environment. Despite this, I observed that some participants (especially girls) were reluctant to fully participate in the discussions. It is also likely that the answers to some questions may have been affected by my presumed affiliation with the HBHL programme because I was accompanied by one of their staff. These issues were difficult to resolve, despite efforts to ensure the participants were as comfortable as possible. I also participated in continuous discussion with the HBHL staff, during which they provided me with further details of the programme context. I could compare the content of these discussions with the observations I had made, in order to confirm my understanding of the research context.Transferability addresses whether the findings of the research can be applied to other contexts, something
which Bryman (2012) acknowledges is difficult to achieve for qualitative research. This research is specific to the context of Greater Kibaale; however there is the potential for the findings to be applied to the other locations in which the HBHL programme is implemented. In order to achieve such replicability, Geertz (1973) indicates that a ‘thick description’ is required in order to provide a baseline which researchers can then use to apply the findings to other contexts. Such a thick description entails providing a rich account of the details of a culture, something best achieved by using ethnographic methods. While not being purely ethnographic, my research drew on ethnographic methods, as I was immersed in the programme context and observed the behaviour of individuals at all opportunities during the data collection process. Furthermore, the in-depth nature of the methods used allowed for interpretation of the meanings and social structures behind the observed behaviours, which Geertz (1973) states contributes to a thick description.
Dependability entails being transparent about the choices, methods and problems encountered during the
research by keeping clear records of all phases of the research process (Bryman 2012). I have kept accurate notes of all aspects of data collection, which could be passed to a peer for auditing, during which they can establish whether the correct procedures have been followed (Bryman 2012). The existence of an audit trail means that peer auditing could be carried out should it be deemed necessary.
Confirmability is achieved when the researcher acts in good faith, and does not overtly allow their personal
values or theoretical inclinations to affect the conduct of the research (Bryman 2012). My personal values are different to the often moral views held by many with regard to the sexuality of young people in Uganda, but I was consistently aware of this position and therefore ensured that research participants could adequately express their views and that these views were accurately portrayed throughout the thesis.
28
Finally, authenticity considers the wider impact of the research and how it can be used to improve the lives of the participants (Bryman 2012). I will provide the report and a list of best practice tips to Emesco Development Foundation. It is hoped they will share the findings and tips with the Healthy Entrepreneurs, meaning these can be used to improve the service for the young people in Greater Kibaale. The provision of this list of tips to share with individuals is deliberate because I observed that it would be difficult to bring the Healthy Entrepreneurs for a training session due to the remoteness of many areas, poor roads and inability of the organisation to provide reimbursement for transport. Furthermore, the research process itself has the potential to improve the HBHL initiative for young people in Greater Kibaale, as Healthy Entrepreneurs indicated that participating in the research had made them reflect on their practices when addressing the sexual health of young people in their communities.4.6 Ethics
Ethics are vital to consider during social science research, as the researcher is required to fulfil various obligations and responsibilities to their research participants (Dowling 2000). The nature of sex as a sensitive topic in Uganda and the involvement of young people in the research further underlined the importance of addressing ethics in this particular study. Dowling (2000) divides the ethical considerations into the three categories of ‘privacy and confidentiality’ ‘informed consent’ and ‘harm’. All of these were taken into account during the research design and fully discussed with the interpreter before data collection began. Privacy and confidentiality are concerned with ensuring that research participants’ personal information does not become public knowledge (Dowling 2000). Privacy was ensured during data collection by conducting interviews and FGDs in private locations away from other people. If anyone did remain in earshot - for example teachers at schools, or the beneficiaries’ friends - they were asked to leave until the interview or FGD had finished. Furthermore, to ensure confidentiality, the recordings and subsequent transcriptions were kept secure on a password protected computer. Pseudonyms have also been used throughout the thesis to ensure that responses cannot be traced back to a specific individual. Participants were informed about issues of confidentiality and anonymity during the process of gaining verbal informed consent, which was carried out before each interview or FGD. During this process, participants were also provided with an overview of the aim of the study, what the data would be used for and the fact that participation was voluntary and they could withdraw at any time. Details of the script read to the research participants can be found inAppendix II. Gaining informed consent in this manner prevented the occurrence of a further ethical issue of deception, as all participants were fully aware of my position as a researcher (Dowling 2000). Furthermore, there is a potential in social science research for participants to be exposed to psycho-social harm associated with the questions being asked, something particularly pertinent due to the sensitive nature of sex in Uganda (Dowling 2000). Therefore, I had the contact details of an individual who could be contacted should participants require further support after taking part in data collection.
