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Sexual health of adolescents in

northern Uganda

An exploration of sexual socialization sources influencing sexual behavior

Research Master Educational Sciences: Parenting, Education, and Child Development

University of Amsterdam, Thesis 2

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Faculty of Social and Behavioural Sciences

Graduate School of Childhood Development and Education

Sexual health of adolescents in

northern Uganda

An exploration of sexual socialization sources

influencing sexual behavior

Research Master Educational Sciences: Parenting, Education, and Child Development Thesis 2

A.L.C. (Liselotte) Dikkers, BSc (5675138) Supervisor: dr. R.G. Fukkink

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Contents Preface Research report - Abstract - Introduction - Method - Results - Discussion - Acknowledgements - Funding Acknowledgements - Conflict of Interest Statement - References

- Tables - Figures

Appendix A: Sexual motivation and impulsivity questionnaire Appendix B: Interview guide adolescent interviews

Appendix C: Interview questions teacher interviews Appendix D: Research manual

Appendix E: Handout distributed at Save the Children and other NGO’s Appendix F: Academic article

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Preface

Here I present the results of my second Research Master thesis. It concerns sexual health of adolescents in northern Uganda. Using a mixed-method approach, the gap between HIV/AIDS and (safe) sex knowledge and sexual behavior, and the influence of sexual socialization sources on this behavior was investigated. The research was designed in collaboration with Ruben Fukkink, PhD. Save the Children in the Netherlands and Save the Children in Uganda provided me the possibility to collect data in Gulu and its surroundings. During the writing process Ruben Fukkink administered me with feedback.

The results of my research are presented as a research report and as an academic article. The thesis focuses on the original research idea, with honest but disappointing results. The thesis is written without eliminating non-significant results, to describe the actual truth of the situation in Uganda, and of performing this research. I realize this thesis cannot be

published, but that was not my aim while writing it. However, the academic article is written in a publishable way, and focuses on the relevant results. Hopefully, the elaborate thesis provides the reader a sufficient impression of the Ugandan context and its consequences for this research. Moreover, this project contains a questionnaire developed by Ruben Fukkink and me (Appendix A), the interview questions (Appendix B, and C), a research manual (Appendix D), and a handout distributed at the Save the Children offices in the Netherlands and Uganda and at other NGO’s (Appendix E). The academic article (Appendix F) might be submitted to a journal (possibly Culture, Health, and Sexuality) in a later stage.

My time in Uganda was very intense and provided me with many new insights. Ruben Fukkink’s help in this thesis was highly appreciated. My experiences in conducting research in a developmental country were very informative. I will never forget this research experience and it will definitely help me in my career as a professional researcher.

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Abstract

Introduction: The aim of this research was to examine the influence of sexual socialization

sources (parents, peers, school, media, and others) on (safe) sexual behavior in northern Ugandan adolescents.

Method: Using a mixed-method approach, information about adolescents’ HIV/AIDS and

safe sex knowledge, attitudes and norms, self-efficacy, and sexual motivation and impulsivity was gathered. In this research 182 secondary school adolescents aged 12 to 18 years old (88 females, mean age = 16.48) completed standardized questionnaires, and 13 individual interviews were conducted.

Results: Adolescents’ HIV/AIDS and (safe) sex knowledge, and condom use among

adolescents who experienced sex were relatively low. Adolescents valued micro level sexual socialization sources most meaningful to their knowledge and behavior, despite the fact they learned most from media.

Discussion: Adolescents’ sources of knowledge are diverse and complex, and their

knowledge is fragmented. NGO’s and other organizations can use the results to optimize their HIV/AIDS prevention programs.

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Introduction

HIV/AIDS is one of Uganda’s main problems, with 120 thousand Ugandan children (0-14 years old) being infected, and about 23% of new HIV infections occurring in children (UNAIDS, 2010). In total, about 0.4% of boys and 2.6% of girls aged 15-19 years old are infected with HIV/AIDS (Government of Uganda, 2010). This gender difference can be explained by for example biological mechanisms, and socio-cultural reasons, such as girls practicing sex with older men (Kelly et al., 2003).

In the northern region with its Acholi people the HIV/AIDS percentage is higher than in other Ugandan regions, being 8.2% (Uganda Bureau of Statistics, 2010b). The unstable political situation in northern Uganda is one of the causes of this percentage. For example population displacement, and inconsistent infrastructure and health facilities contributed to the HIV/AIDS infections (Accorsi et al., 2005). In order to reduce the number of new HIV/AIDS infections in the northern area, non-governmental organizations (NGO), among which Save the Children in Uganda (SCiUG), implemented intervention programs in primary school and out of school children. The HIV/AIDS prevention programs are not as successful as the NGO’s admire (Orach, 2011). In the programs no information about condoms is given, as the public opinion in Uganda is that this information encourages children to have sex

(Government of Uganda, 2011; B. Orach, personal communication, May, 2012).

Focusing on both in school and out of school children is important, as many students do not finish school. Especially in rural areas children do not enter or finish school in time, and already entered adolescence or adulthood when leaving primary school. In the northern part, approximately 64% of the children drop out, indicating that many children cannot be reached by HIV/AIDS prevention programs on primary school (Bukuluki, & Byansi, 2011; Galimaka, 2008; Sabates, Akyeamponog, Westbrook, & Hunt, 2010). Secondary school enrolment in Uganda is about 22% of both male and female adolescents, but many of them

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drop out due to for instance pregnancy, marriage, or shortage of money, making the enrolment in Senior 6 around 6% (Teacher 1, personal communication, April, 2012; Uganda Bureau of Statistics, 2010b; Unicef, 2012).

Sexual knowledge and behavior

Research in Uganda has shown that adolescents have sex at an early age, with females practicing sexual intercourse earlier than males (Bankole, Biddlecom, Guiella, Singh, & Zulu, 2007; Neema, Musisi, & Kibombo, 2004). Bankole, Biddlecom et al. (2007) estimated that 7.6% of the female and 14.9% of the male adolescents between 12 and 14 year olds ever had sex. Other research indicates that no differences exist in gender experiencing sex at an earlier age (Bankole, Ahmed, Neema, Ouedraogo, & Konyani, 2007). Adolescents knowledge about HIV transmission, HIV prevention, and pregnancy prevention is only superficial (Bankole, Biddlecom et al., 2007), indicating that (sexually active) adolescents have no adequate or correct knowledge on how to protect themselves. Previous research of Bankole, Biddlecom et al. (2007) and Neema et al. (2004) is inconsistent about gender differences in knowledge in Uganda.

Specific knowledge and awareness, and behavior are not continually linked. Belgian research unfolded that adolescents’ condom use is inconsistent, and behavioral changes are necessary to prevent adolescents from HIV/AIDS infections (Berten, & Van Rossem, 2009). In South Africa research revealed the same result (James, Reddy, Taylor, & Jinabhai, 2004). Despite the fact that adolescents had correct knowledge about HIV/AIDS transmission and pregnancy, they did not practice this knowledge (James et al., 2004). Additionally, Agyei and Epema (1992) concluded that a gap between knowledge and behavior exists in Uganda as well. Reasons for not using contraception were limited access, fears about the safety, and lack of knowledge. In rural areas contraceptive use was more inconsistent than in urban areas

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(Agyei, & Epema, 1992). The existence of a gap between knowledge and behavior in Uganda is confirmed by Kayiki and Forste (2011), who concluded that awareness of ways to reduce risk of AIDS did not lead to more condom use. However, correct knowledge of condom use appeared to be related to condom use (Kayiki, & Forste, 2011). Several theories exist about the possible causes of the gap between sexual knowledge and behavior.

Sexual socialization

In developed countries it has been concluded that adolescents’ ecological system influences their sexual behavior (DiClemente, Salazar, & Crosby, 2007). Adolescents receive HIV/AIDS knowledge and attitudes from diverse sources in this ecological system

(Bronfenbrenner, 1979; DiClemente et al., 2007). Sexual socialization sources (social relationships with i.e. parents, peers, and school) affect sexual behavior by existing social norms and social connectedness. This indicates, for instance, that attitudes of parents and peers towards sexual behavior influence adolescents’ sexual behavior. Consequently, when parents or peers have permissive values towards sex, adolescents participate in sex more easily (Kirby, 2001). In order to understand adolescent sex in the Ugandan context, it is important to deconstruct and study sexual socialization sources thoroughly (Kinsman, Nyanzi, & Pool, 2000).

Bronfenbrenner (1979) developed a bio-ecological model outlining three environments surrounding a child. The micro system is closest to the child, including its own characteristics, risk factors and the characteristics of family, peers, and teacher. The meso level consists of media and features of a child’s community. The macro level includes aspects of culture, demography, and society. Factors can be ordered according to the level of proximity to the child’s everyday life, and each factor is thus considered to play a different role in relation to child’s sexual behavior. Characteristics from the micro level are expected to be more

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important to a child’s outcome, than characteristics from the meso or macro level. Thus, child features are supposed to have more influence than community features. Consequently,

socialization sources close to the child are expected to be more important for a child’s sexual behavior, than socialization sources further away, indicating that communication with parents is expected to be more important for a child’s sexual behavior, than information from

newspapers (Bronfenbrenner & Ceci, 1994; Bronfenbrenner, 1979; DiClemente et al., 2007). The bio-ecological model does not indicate that the micro level is the only influence on adolescents’ sexual behavior. Also factors from the other levels affect this behavior (DiClemente et al., 2007).

Sexual socialization in northern Uganda is diverse and unique, with many sources being available to adolescents. Bankole, Biddlecom et al. (2007) described Ugandan adolescents’ sexual socialization sources. Using this research and utilizing an ecological approach, five main sexual socialization sources can be outlined in the Ugandan context: parents, peers, schools, media, and others (among which fathers’ brothers and sisters). Each of these sources affect adolescents’ sexual knowledge, attitudes and behavior.

Parents play a role in teaching children about HIV/AIDS and sex, for instance because children regularly sleep in the same room as their parents and watch them having sex

(Kinsman et al., 2000; Twa-Twa, 1997). About half of the Ugandan female adolescents and a quarter of the Ugandan male adolescents between 12 and 14 years old receive information from their parents about HIV/AIDS or sex (Bankole, Biddlecom et al., 2007). In developed countries it has been concluded that greater parental communication is related to less sexual risk taking behavior (DiClemente, Wingood, Crosby, Cobb, Harrington, & Davies, 2001; DiClemente et al., 2007). When adolescents discuss condoms with their parents prior to their first sexual intercourse, their condom use increases (Miller, Levin, Whitaker, & Xu, 1998).

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Adolescents communicate with peers about HIV/AIDS and safe sex, having friends as an important information source. Additionally, sexual behavior of adolescents is often related to sexual behavior of their friends, indicating peer pressure (Bankole, Biddlecom et al., 2007; Kinsman et al., 2000). When peers are the primary sexual socialization source to adolescents, this leads to undesired outcomes, such as risk full sexual behavior (Somers, & Surmann, 2005).

According to one of the interviewed teachers, in both primary and secondary schools teachers and prevention programs focus on HIV/AIDS, abstinence of sex, and condom use (particularly in secondary schools) (Kinsman et al., 2000). Besides that, one of the

interviewed teachers indicated that schools organize meetings between teachers and students of the same gender, in order to inform students about developments concerning the gender. For example, female teachers advice adolescent girls about hygiene related to menstruation (Bankole, Biddlecom et al., 2007; Kayiki, & Forste, 2011; Kinsman et al., 2000; B. Orach, personal communication, May, 2012). In developed countries it has been concluded that less education from school was related to more frequent sexual behavior (Somers, & Surmann, 2005). Besides that, earlier education was not related to more frequent sexual behavior or earlier onset of sexual intercourse. Additionally, learning more and at an earlier stage at school leads to less sex (Somers, & Surmann, 2005).

Mass media is a primary source of information concerning HIV, STDs and contraceptive methods among adolescents in Uganda (Bankole, Biddlecom et al., 2007). Examples of mass media distributing information about sex or HIV/AIDS in northern Uganda are magazines (i.e. the newspaper Red Pepper), Blue Movies (pornographic movies), and signs in front of schools which are implemented by the Ugandan government or NGO’s. Mass media convicts women as sex objects, leading to undesired values and beliefs (Somers, & Surmann, 2005). Exposure to sexual content and media supporting sexual intercourse is

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related to more sexual intercourse and more risk behavior, which leads to higher STD rates (L’Engle, Brown, & Kenneavy, 2006; Wingwood, DiClemente, Harrington, Davies, Hook, & Oh, 2001). Consequently, media is an undesired source to adolescents.

Other sources, such as fathers’ brothers and sisters, religion, and neighbors affect adolescents’ knowledge and attitudes regarding HIV/AIDS and safe sex. Fathers’ brothers and sisters (called ‘Wayo’ by the Acholi) play an important role in Ugandan adolescents’ lives (B. Orach, personal communication, May, 2012). Uncles are responsible for the boys sexual education, and aunties take care of the girls. They are responsible for adolescents’ sexual knowledge and behavior, and informing them about marriage. Besides that, aunties have to find a man for their nieces, and are responsible for girls’ virginity. Due to social and

economic changes this social source has weakened, and other sources are more important for adolescents to acquire sexual knowledge than previously (Muyinda, Kengeya, Pool, & Whitworth, 2001; Muyinda, Nakuya, Pool, & Whitworth, 2003; B. Orach, personal communication, May, 2012). Besides Wayo’s, churches are an important source of sexual knowledge. According to one of the interviewed teachers, catholic churches in Uganda disapprove condoms, or only support them in married couples, while Protestant churches in this country become more positive about them.

Attitudes, norms, self-efficacy, motivation, and impulsivity

Besides sexual socialization, personal characteristics are of influence on the existence of the knowledge-behavior gap. According to the Theory of Planned Behavior (Azjen, 1991) behavior is influenced by intention (in other words ‘motivation’: the confidence one has in its own behavior). This indicates that the stronger an adolescent’s motivation to execute safe sexual behavior (from now on ‘(sexual) motivation’), the more likely this adolescent practices this safe behavior. Ssewamala, Han, Neilands, Ismayilova, and Sperber (2010) concluded that

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female adolescents have more motivation to perform safe sexual behavior than male adolescents.

Sexual motivation is dependent on three factors consistent with this theory. Attitudes towards safe sexual behavior affect sexual motivation, meaning that if adolescents recognize safe sex as positive, their motivation to perform safe sexual behavior increases. Additionally, when adolescents perceive significant others’ attitudes (sexual norms) as executing safe sexual behavior, they are more likely to execute this safe behavior (Azjen, 1991). Besides that, when adolescents’ perceived behavioral control (self-efficacy) related to safe sex is high (i.e., they recognize safe sex as uncomplicated), a higher chance of executing safe sexual behavior is apparent (Azjen, 1991; Bandura, 1982). Research in both developed countries and Africa confirms a mediating effect of self-efficacy, demonstrating that consistent knowledge-behavior relationships in health issues are bigger with high self-efficacy (Azjen, 1991; Berten, & Van Rossem, 2009; Giles, Liddell, & Bydawell, 2006; Rimal, 2000; Sayles et al., 2006).

Furthermore, the gap between knowledge and behavior can be due to impulsiveness. In developed countries it has been concluded that impulsivity can cause sexual risk taking behavior (from now on ‘(sexual) impulsivity’) (Donohew et al., 2000; Kahn, Kaplowitz, Goodman, & Emans, 2002).

Research questions

Based on the insight that socialization influences knowledge and attitudes regarding HIV/AIDS and safe sex, it is important to investigate whether sexual behavior of adolescents is dependent on sexual socialization, taking into account knowledge and attitudes related to HIV/AIDS and safe sex. To date, to our knowledge, no research examined this issue in Uganda.

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Northern Uganda is an interesting place to apply the Theory of Planned Behavior and Bronfenbrenner, due to its unique context with a high HIV/AIDS percentage, its diverse and exclusive sexual socialization sources, and the limited knowledge about adolescents’ sexual health in this area is scarce. The aim of this study is to investigate how sexual socialization affects knowledge and attitudes towards HIV/AIDS and safe sex (from now on ‘knowledge’ and ‘attitudes’) of adolescents in and around Gulu (northern Uganda), and how this influences their sexual behavior. It is investigated which social relationship of adolescents is most

important to adolescents’ knowledge and attitudes. Moreover, personal characteristics of adolescents are included in the study, as these characteristics are expected to affect the relationship between for example knowledge, attitudes, and behavior. These characteristics include sexual motivation, sexual norms, self-efficacy, sexual impulsivity, gender, and age. Based on this research it can be concluded which social relationship should have the primary focus of prevention programs related to HIV/AIDS, in order to gain the best result.

Using the bio-ecological model of Bronfenbrenner (1979) it is expected that social relationships at the micro level are more important on adolescents’ sexual lives than relationships at the meso or macro level. Consequently, parents, peers, and teachers are supposed to have more influence on children’s lives than media and cultural norms.

Moreover, it is expected that high self-efficacy, correct sexual norms, high sexual motivation, and low sexual impulsivity contribute to safe sexual behavior.

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Method

Participants

The sample consisted of 182 English speaking adolescents between 12 and 18 years of age (M = 16.48, SD = 1.35). The group included 88 females and 170 secondary school

adolescents. Almost all participants had the Ugandan nationality (N = 176), and 87 lived in an urban area. More than half of the adolescents had someone close with HIV/AIDS (52.6 %). Thirteen adolescents participated in the qualitative part of the study (M age = 16.00, SD = 1.41). Additionally, two secondary school teachers were interviewed.

Procedure

Adolescents were recruited through four secondary schools (Senior 1 to Senior 3) and five primary schools (Primary 6 and Primary 7) supported by, or in contact with SCiUG. Two schools were located in an urban area (Gulu municipality, 150.000 inhabitants; Uganda Bureau of Statistics, 2010a), and seven schools were located in rural areas (Amuru district, and Nwoya district). Both schools and adolescents provided active informed consent. Because sex and HIV/AIDS are sensitive topics, the adolescents had to sign a consent form before the start of each measurement method (Reeuwijk, 2009). It was emphasized that participation was voluntary and that it had no consequences to withdraw from the study. Parents’ consent was not asked, as the (head)teachers declared the research was an extension of their HIV/AIDS programs. According to Reeuwijk (2009), it is important to inform other teachers about the research as well. Therefore, during lunch at the participating schools, the researcher discussed the research with available teachers. No reward was given to the children, as this would encourage adolescents to participate. Based on Hart’s ladder of participation (Hart, 1992), this research included some participation, and is therefore not part of the non-participation section. A mixed methods design was used to gather information about each aspect related to

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this study. The quantitative and qualitative methods strengthened each other, and a relatively comprehensive view of adolescents’ sexual health could be reached (Creswell, Plano Clark, Gutmann, & Hanson, 2003; Morse, 2003). Qualitative information about adolescents’ sexual socialization sources was combined with quantitative data about adolescents’ sexual attitudes, norms, self-efficacy, motivation, impulsivity, and behavior. Additionally, the qualitative data helped us to increase information about adolescents’ HIV/AIDS and safe sex knowledge. More specifically, the type of mixed method design used in this study was a concurrent triangulation design, in which quantitative and qualitative data is collected simultaneously, analyzed separately, and integrated in the discussion part (Creswell et al., 2003). The priority of the research was given to the qualitative part.

The researcher implemented questionnaires in class rooms (maximum of 56 adolescents each time). Additionally, thirteen one-on-one interviews were conducted, to obtain information about sexual socialization, and to verify and support the information about adolescents’ knowledge. In primary schools, the English of adolescents was not sufficient to complete questionnaires. Therefore, these were administered in secondary schools. Interviews were conducted in both primary (four interviews) and secondary (nine interviews) schools. In this way, information about both primary and secondary school adolescents was gathered. Finally, two interviews with secondary school teachers were accomplished in order to receive additional information about sexual socialization of adolescents in the Ugandan culture, according to their opinion.

Quantitative methodology

Measures.

Sexual behavior. To obtain information about the sexual behavior of adolescents, 23

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Test for Adolescents (SKAT-A) were used. The Sexual Behavior Inventory has open and closed questions related to sexual and experiential behaviors, for example onset of sexual activity, contraceptive practices, and sexually transmitted diseases (Fullard, & Scheier, 2011). Because questions related to for example dating, homosexuality, and menstruation were either irrelevant to this study or difficult to use in the Ugandan context, a shorter version was

implemented to obtain information about adolescents’ sexual behavior. No reliability for the measurement instrument was calculated, as this was impossible due to open ended questions. Knowledge. Sexual knowledge of adolescents was assessed using the Adolescent

AIDS Knowledge Scale (AAKS). This questionnaire examines adolescents’ knowledge about HIV/AIDS. It consists of 22 items and has three answering possibilities (1 = Yes, 2 = No, 3 = Don’t know) (Zimet, 2011). One question was deleted, because it focused on homosexuality, which is a taboo topic in Uganda. A total sexual knowledge score was computed by summing individual item scores. As opposed by the AAKS guideline, answering possibility three was considered incorrect (Zimet, 2011). The AAKS had an unsatisfactory reliability with a Cronbach’s alpha of .42.

Attitudes, norms and self-efficacy. Using the Sexual Risk Behavior Beliefs and

Self-efficacy Scales (SRBBS) attitudes, HIV/AIDS and safe sex norms (from now on ‘norms’), and self-efficacy of adolescents were measured. This standardized questionnaire exists of 22 questions and consists of eight scales. Three scales cover sexual risk-taking behavior

(Attitudes about sexual intercourse (ASI), norms about sexual intercourse (NSI), and self-efficacy in refusing sex (SER)), and four scales address protective behavior (Attitudes about condom use (ACU), norms about condom use (NCU), self-efficacy in communication about condoms (SECM), and self-efficacy in using and buying condoms (SECU))1. The items related to attitudes and norms are measured on a 4-point Likert scale (ranging from 1 =

1

Originally the SRBBS includes a fifth scale related to protective behavior: ‘Barriers to condom use’ (BCU). This skill was irrelevant for this research and was not included.

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Definitely no to 5 = Definitely yes), and the items concerning self-efficacy are measured on a 3-point Likert scale (ranging from 1 = Not sure at all to 5 = Totally sure) (Basen-Engquist et al., 2011). The reliability of the attitudes, norms, and self-efficacy scales appeared to be inadequate, with Cronbach’s alpha’s of .47, .48, and .46 respectively.

Sexual motivation and impulsivity. In order to measure motivation and impulsivity

related to sexual behavior a short questionnaire was developed (Appendix A). This

questionnaire consists of 12 questions and is measured on a 5-point Likert scale (ranging from 1 = Almost always to 5 = Never). Seven questions concerned sexual motivation, and five questions were related to sexual impulsivity. The questionnaire appeared to have a

unacceptable reliability, with a Cronbach’s alpha of .37 (after deleting question seven) for sexual motivation, and .48 (after deleting question nine) for sexual impulsivity.

Despite the fact that all scale reliabilities were worrisome, the research was continued. The unreliabilities imply that the results might not represent the truth, and should therefore be interpreted with caution. Consequently, the validity of the study is low, indicating that the measurement instrument scores might not represent what they are supposed to measure (Schene et al., 2000).

Analyses.

A linear multiple regression analysis and logistic regression analyses were conducted to analyze the questionnaires. Three adolescents were removed from the sample, because they were above 18 years old. Throughout the data set several variables had more than 5% missing values. Missing Value Analysis showed that Expectation Maximization could be performed to substitute these missing values (χ 2 (2812) = 2826, p = .42). Before conducting the actual analyses independent sample t-tests and chi-square tests were performed. Several analyses

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were accomplished to assess differences between gender, age, and district in knowledge, attitudes, norms, self-efficacy, motivation, and impulsivity.

A linear multiple regression analysis was conducted to test the Theory of Planned Behavior in this research. The relationship between the dependent variable ‘motivation’ and three predictors (namely: attitudes, norms, and self-efficacy) was assessed. Based on the bio-ecological model an hierarchical analysis was accomplished. Attitudes and self-efficacy were expected to have more influence than norms. With a medium effect size and an alpha of .05 the power of this analysis was .99, indicating that the power was good.

Two standard logistic regression analyses were executed to determine the association between the dependent variables ‘sexual intercourse’ (experienced sexual intercourse or not) and ‘condom use’ (used a condom when having sexual intercourse or not), and six predictors (namely: knowledge, attitudes, norms, self-efficacy, motivation, and impulsivity). It was expected that a mediation effect existed between attitudes, norms, self-efficacy and sexual behavior, through sexual motivation. To perform the analysis related to condom use, a dichotomous variable was formed.

Assumptions were checked for each analysis. Using Green’s (1991) rules of thumb the assumption of ratio of cases to independent variables was met. Normality and

homoscedasticity were acceptable and the observations were independent. Linearity was satisfactory, except for self-efficacy in the analysis regarding sexual intercourse. Additionally, no sufficient linear relationship between knowledge, norms, and self-efficacy with its logit existed in the analysis focusing on condom use. Because transformations did not improve linearity, the variables not fulfilling the linearity assumption were removed from the equation in the specific analysis. Consequently, the final analyses did not coincide with the original research questions, meaning that the theory could not be applied exactly. However, the analyses were still relevant and could provide new insights.

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One univariate outlier was present in the variables when standardized values and a critical standardized score of ±3.29 were used. This case was not deleted, as it concerned knowledge and it is not surprising that adolescents have diverse knowledge. Subsequently, the Mahalanobis distance revealed that no multivariate outliers were apparent2. Besides that, no multicollinearity or singularity was present.

Qualitative Methodology

Measures.

Adolescent interview. From a post-structuralistic point of view it is important to

deconstruct the language of adolescents, meaning that answers of respondents should be deconstructed consistently, in order to understand how these statements are constructed. Statements are never neutral, and are always influenced by language, experiences in life, and the present subject position of the respondent. In addition, power of both interviewer and respondent should be deconstructed, as power differences are always apparent in interviews (Andermahr, Lovell, & Wolkowitz, 2000; Coward, & Ellis, 1977; Holstein, & Gubrium, 2003).

For a person, several truths can exist, which are dependent on the activated subject position. Experiences as a son or daughter might be different from experiences as a student, resulting in unequal and sometimes contradictory ideas about truth. We were interested in adolescents, and it was therefore important to activate the subject position of an adolescent prior to the interview, as the respondent’s answers would otherwise be focused on school because the interviews took place in a school context (L. Duits, personal communication, January, 2012; Spyrou, 2008). We succeeded to activate the subject position of an adolescent systematically.

2

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Moreover, it was important to decrease the power difference between the interviewer and the respondent (Archard, 2004; Eder, & Fingerson, 2003; Robinson, & Kellet, 2004). In the Ugandan culture, adults are more important than adolescents. Despite the fact the

interviewer was a young adult, the interviewer was considered by the respondents as higher in power, due to the life experiences and being a white person (Reeuwijk, 2009; Robinson, & Kellet, 2004). Therefore, it was important to provide an elaborate introduction and general starting questions to diminish the power difference, and to activate the subject position of an adolescent.

Adolescents have diverse ideas about HIV/AIDS and safe sex. It was important to understand their meanings, in other words to deconstruct adolescent’s language. Therefore, the first interview questions focused on knowledge about HIV/AIDS and (safe) sex and their explanation. More importantly, the interview focused on socialization regarding HIV/AIDS and (safe) sex. Specifically, the interview covered all possible important sexual socialization sources, namely parents, peers, school, media, and others (i.e. church). Additionally, specific sexual behaviors were mentioned, and the adolescents were asked to explain this behavior, and from whom they learned its meaning. The interview guide used for the interviews can be found in Appendix B.

Teacher interview. In the teacher interviews an elaborate introduction was provided,

in order to reduce the power difference between interviewer and respondent, and to activate the subject position of a teacher. The interview questions can be found in Appendix C. The aim of the teacher interviews was to gain information about the Ugandan culture and sexual socialization sources of adolescents in general. Consequently, all sexual socialization sources covered in the adolescent interviews were also included in the teacher interviews. Moreover, details about the information provided by these sources were covered, in order to understand

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HIV/AIDS and (safe) sex education in the Ugandan context. Only remarkable information from the teacher interviews was reported, as it was not the primary aim of the study.

Analyses.

All interviews were recorded using a voice-recorder, and transcribed verbatim in order to acquire all relevant elements (adolescent interviews consisted of 102 pages single-spaced). Content analysis as described by Huberman and Miles (1994) was used to analyze the

interviews regarding sexual socialization of adolescents. This data analysis procedure consists of three processes after data collection: data reduction, data display, and conclusion

drawing/verification. Data reduction indicates that the amount of data was reduced, by for example coding and finding themes. During data display the reduced data was organized in such a way that conclusions could be drawn. This was accomplished by putting the data in figures and tables manually, while comparing data within and between cases. Conclusion drawing and verification was executed by interpreting the data displays using several tactics, for example comparison, and noting themes (Huberman, & Miles, 1994; Miles, & Huberman, 1994). Subsequently, triangulation with the quantitative data was accomplished (reported in the discussion part).

Using three types of codes (descriptive, interpretatively, and pattern codes) the interviews were analyzed. The coding did not start blank, but used concepts outlined in theory. Coding was executed in the program MAX-QDA, leading to a reduction of data from 27 to 17 codes. These codes fitted in four themes, namely ‘Definition of sex/sexual

intercourse’, ‘Definition of HIV/AIDS’, ‘Sexual socialization sources’, and ‘Importance of sexual socialization sources’. Differences between male and female adolescents were analyzed manually. The teacher interviews were also coded using the three types of codes, and analyzed using content analysis.

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Results

More than a third of the adolescents had one or more STD’s (Table 1). The experience with sexual intercourse, sexual abuse, and pregnancy, and the reasons for (not) having sexual intercourse are outlined in this table as well. Table 2 contains condom use characteristics of the adolescents. Subsequently, descriptive statistics of the measurement instruments are displayed in Table 3.

[Insert Table 1, 2, and 3 about here]

Quantitative results

Adolescents’ knowledge was relatively low (M = 15.91, SD = 2.28). It was determined that differences between male and female adolescents exclusively existed in knowledge, and motivation, t(180) = 2.48, p < .05; t (180) = -2.59, p < .05. Male adolescents had significantly more knowledge than female adolescents, and female adolescents were significantly more motivated to perform safe sexual behavior. Besides that, older adolescents had significantly more knowledge and motivation than younger adolescents, F(1, 173) = 7.51, p < .01; F(1, 173) = 4.62, p < .05. Additionally, adolescents from the urban area had significantly more self-efficacy than adolescents from rural areas, t(180) = 3.20, p < .01.

To assess the relationships between the dependent variables and the predictors correlations were estimated (Tables 3 and 4). Due to the insignificant relationships between these variables, no mediation effect through sexual motivation could be calculated. The linear multiple regression analysis revealed that attitudes, norms, and self-efficacy did not predict sexual motivation significantly, F(3, 178) = 1.92, p = .13, indicating that the predictors as a group did not predict sexual motivation.

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[Insert Table 4 about here]

Prediction of sexual intercourse.

Using knowledge, attitudes, norms, motivation, and impulsivity the prediction of sexual intercourse remained 63.3%, similar to the intercept only model (N = 169). The full model was no significant improvement of the intercept only model, χ2(5) = 2.08, p = .84. This indicates that the predictors do not reliably distinguish between experience with sexual

intercourse or not. The influence of all predictors combined was estimated at between 1% (Cox and Snell’s R2) and 2% (Nagelkerke’s R2).

In Table 5 the regression coefficients (B), the standard errors, the Wald’s χ2 test, and the odds ratio’s with its 95% confidence intervals are displayed. None of the variables entered in the equation predicted sexual intercourse significantly. Moreover, no differences existed in gender concerning experience with sexual intercourse, χ2(1) = 1.41, p = .24. Additionally, age did not predict experience with sexual intercourse significantly, χ2(1) = 3.73, p = .05, and both the intercept only model and the full model predicted 62.0% of the cases correctly, B = .24,

SE = .13, Wald’s χ2 = 3.58, Odds ratio = 1.27 (95% CI = .99 to 1.63), Cox and Snell’s R2 = .02, Nagelkerke’s R2 = .03. Lastly, adolescents from the urban area had sexual intercourse more often than adolescents from rural areas, χ2(1) = 4.18, p < .05.

[Insert Table 5 about here]

Prediction of condom use.

The model predicting condom use of adolescents who had experienced sex, with the predictors attitudes, motivation, and impulsivity was correct in 71.7% of the times (N = 60). In comparison, the intercept only model predicted correct group membership in 70.0% of the

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times. No significant difference existed between the two models, χ2(3) = 6.81, p = .08,

meaning that the full model was no significant improvement of the intercept only model. The explained variance in sexual intercourse by all predictors combined was between 11% (Cox and Snell’s R2) and 15% (Nagelkerke’s R2). In Table 6 the regression coefficients (B) with its standard errors, the Wald’s χ2 test, and the odds ratio’s with 95% confidence intervals are displayed. Condom use was predicted by motivation significantly, meaning that adolescents with high sexual motivation were 18% more likely to use condoms. We executed an

additional analysis with sexual motivation as the only predictor in order to investigate its importance. Both this model and the constant only model predicted 70.0% of the group membership correctly. The model with sexual motivation was not significantly better than the intercept only model, χ2(1) = 2.46, p = .12, B = .12, SE = .01, Wald’s χ2 = 2.31, Odds ratio = 1.13 (95% CI = .97 to 1.31), Cox and Snell’s R2 = .04, Nagelkerke’s R2 = .06.

Furthermore, no difference existed in condom use between male and female adolescents, χ2(1) = .73, p = .39. Age significantly predicted condom use, with older

adolescents using condoms more often than younger ones. The intercept only model predicted the correct group membership 70.0% of the times, while the model including the predictors predicted it correctly 73.3% of the times. Despite the fact this difference was significant, it is negligible, χ2(1) = 5.50, p < .05, B = .52, SE = .24, Wald’s χ2 = 4.95, Odds ratio = 1.68 (95% CI = 1.06 to 2.67), Cox and Snell’s R2 = .09, Nagelkerke’s R2 = .12. Lastly, condom use was not different for adolescents from urban and rural areas, χ2(1) = .01, p = .91.

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Qualitative results

Using four themes the qualitative results of the adolescents are outlined. Remarkable information from the teacher interviews are also included. During the interviews, the

adolescents were asked to share their knowledge about sex and HIV/AIDS. They were asked to define sex and sexual intercourse, aiming to identify whether they had any knowledge about sex, and how elaborate this knowledge was. This definition is the first theme. Additionally, the adolescents were asked to define HIV/AIDS, its consequences and

prevention. The goal of this question was to determine how much they knew about this topic, resulting in the second theme. The third theme covers all sexual socialization sources, and it is described which socialization source appeared to be most important. Fourth, the importance of sexual socialization sources according to the adolescents are outlined.

Definition of sex/sexual intercourse.

In this research sex and sexual intercourse were used as synonyms of each other, as the adolescents used it as synonyms. Besides that, some adolescents did not know the meaning of sexual intercourse while they were able to define sex. In defining sex and sexual intercourse, only one adolescent used the words penis or vagina, while other adolescents were able to explain sexual intercourse to some extent, for example:

“According to my suggestion… sex is just intercourse between two people, that is a man and a woman. Yeah, sexual intercourse is the meeting between two ehm couples. Like, a man and a woman, hmm. They are having sex now.”

Several adolescents immediately focused on the dangers or bad effects of sex when defining it. One adolescent stated:

“Hmm. Because sexual intercourse is a bodily contact, with each other. People… they have to… have the contact with one another, maybe, for example, when people go overnight during the parties, and then from there they have to get the friends and then from there, people they have to be alcoholic, then after drunk, after gotten drunk, they have, they perform, they perform what peer group intend, they have to trap girls on

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their way, they have to do a lot of things, for example like… rape, then also defilement is coming out of here, yeah. That is what I know about sexual intercourse.”

Remarkably, the only two adolescents who mentioned something positive about sex, experienced sex already. One adolescent stated:

“What I know about it is that a man sleeps with a woman. What my uncle told me about sex is… He told me sex is the most gifted thing on earth, but you have to what? To wait until your time come and you are ready for it. That was what he told me, it is the most tasting thing, but you have to wait for your time.”

Knowledge about sex seemed to be unrelated to gender and whether they had sexual intercourse or not. In general, the knowledge about sex was only superficial, with adolescents being unable to define ‘meeting between a man and a woman’. Also, misconceptions about sex existed, with one adolescent indicating that sex has bad consequences without any exceptions:

“When two people have sex they are in a bed together and are having sex. When you have sex you get a disease or you get pregnant.”

Definition of HIV/AIDS.

Identifying HIV/AIDS as a virus and/or a disease was done by twelve out of thirteen adolescents. While some adolescents were able to explain HIV/AIDS elaborately and identify it as a disease without a cure, others could not come up with a consequence of the disease. Besides that, two adolescents characterized HIV/AIDS as a disease you always get when you have sex. For example:

“It’s a disease, if you ever sleep with someone you get it.”

In Figure 1 the causes of HIV/AIDS mentioned by the adolescents are outlined. Most adolescents classified sharp instruments as a cause of HIV/AIDS. Especially razorblades, needles, and blood transfusions were mentioned. Having sex was also indicated by many adolescents as a cause of HIV/AIDS. Noteworthy, one adolescent indicated having sex as a cause of HIV/AIDS, but she was unable to define sex. According to several adolescents,

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kissing and ending up in an accident can also cause HIV/AIDS, illustrated by the following examples:

“They told me, through kissing there’s a great, there’s even a great risk of getting HIV, because, like, when you have cracks in your mouth, one, and the other one also have one crack in the mouth and when you’re kissing it, the other one, the one the bloods from the one mouth and meet the other one you can get HIV.”

“Accident can occur, when you’re injured and others are injured, blood can mix up.” Lastly, one adolescent described a mother as being able to infect her child while giving birth.

[Insert Figure 1 about here]

The adolescents were also asked to outline prevention methods of HIV/AIDS. These methods are outlined in Figure 2. Abstaining and using condoms were most often mentioned by the adolescents. For example:

“I can remember some: by not having sex. Yeah. Until I am at the age of what? 18 and above. And then… I can prevent this one, by what? … by avoiding sharing sharp instruments, which has been used by, an infected person of HIV. Yeah.”

According to some adolescents condoms are only used by married people: “The use of condom that is (…) for the married people. Hmm. That is what I know. That is used for married people during sexual intercourse.”

Avoiding sharing sharp instruments, going for a blood test before having sex, and avoid going out or becoming drunk were also mentioned by several adolescents. Besides that, two adolescents indicated respecting your parents can prevent you from being infected with HIV/AIDS, just as avoiding joining peer groups. One adolescent stated:

“[He told me] I should respect my parents. Because if I what? If I respect my parents, I can never get HIV.”

Lastly, some other prevention methods were mentioned, among which avoiding sugardaddies and accidents, and asking for advice.

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[Insert Figure 2 about here]

Adolescents’ knowledge about HIV/AIDS is not continuously correct. Several misconceptions existed, such as ‘kissing can cause HIV/AIDS’, and ‘respecting your parents can prevent you from getting HIV/AIDS’. Besides that, adolescents often knew about the existence condoms, but only one adolescent was able to explain how to use it. The other adolescents did not know how to use a condom, and some adolescents did not know what a condom looks like.

Sexual socialization sources.

As outlined in Table 7, adolescents learn from many sources about HIV/AIDS and (safe) sex. Each sexual socialization source is discussed in detail, in order to investigate to what extent adolescents learn about HIV/AIDS and (safe) sex from diverse sources.

[Insert Table 7 about here]

Almost all adolescents discussed HIV/AIDS with their parents. Adolescents were especially taught that it is a dangerous disease, and that they have to stay away from it. One adolescent stated:

“Yeah, yeah. I learned from that one, that HIV can kill. So that I have to stay away from it.”

Kissing was only discussed with one adolescent, and bad touches (Ugandan term for manual sex) with none. Six parents covered sexual intercourse, but they especially focused on abstaining and being careful. No parent taught their child how to play sex, and no adolescent learned from their parents how to use a condom. This was also confirmed by the teachers,

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who indicated that parents only discuss abstaining and dangers of sex. According to the teachers, parents fear to discuss playing sex or condoms, as answering questions might become difficult. No adolescent learned anything positive about sex from their parents, for example:

“Even my mom told me that I should wait, for the time for marriage. The one that I should stick with. That is the one that I am going to do such offence with, ha-ha!”

Peers were also an important sexual socialization source to adolescents’ knowledge. Kissing and bad touches were rarely discussed, while sexual intercourse was discussed more often. However, this mainly focused on abstaining, and it was never discussed what sexual intercourse encloses, for example:

“No I think, not quite much there, because they’ll be thinking you know how to do it. And then they will not talk about that one.”

Several adolescents also heard from their peers sex is something nice. While

adolescents learn from parents to abstain, they seemed to discuss abstaining more specifically with their peers. One girl stated for example:

“She asked me: ‘why don’t you have sex, why, why don’t you want to have sex’, and I say that for me my time is not yet there… I have to wait, until when, I start with my A- level (Senior 5-6), and then I’ll go if possible, then, I think maybe, at the time when I’m going to reach in Senior 5, no one will going to pay me, then I have, even up to Senior 4, I have to stay at home, maybe for some time, I know very well. Because no one is going to pay me, yeah. And I told her that, after that one, I’ll be at home. If somebody come to our home, that for him he wants me to stay with him, then I’ll go, that is the time I’m going to have sex. Hmm. I’m going to have sex with him.”

Not every adolescent discussed HIV/AIDS or (safe) sex with peers. Some adolescents did not talk with their peers at all, while others discussed several elements. One adolescent stated he only discussed HIV/AIDS or sex with younger peers, because talking to older peers would make him a ‘spoiled guy’. These results are in contrast with the information received from the teachers. They indicated that adolescents especially learn how to play sex from peers, and also experience with bad touches with same sex peers (this is not considered homosexuality, as it is just experiencing. Homosexuality is valued as sexual abuse).

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Sex education classes on school primarily focused on HIV/AIDS and dangers related to sex. Some adolescents received lessons on reproductive health. According to several adolescents, this information was especially taught in primary school. Most adolescents had no lessons about sex, and only learned how to prevent HIV/AIDS, including a couple of adolescents learning about condoms. Also the teachers indicated that sex is only taught in biology, when discussing fertilization. Playing sex is not discussed in secondary school. According to several adolescents, the information about (safe) sex and HIV/AIDS gathered from school was more elaborate than from parents and peers. Nevertheless, adolescents received little information about sex. Some adolescents learned misconceptions from their teachers, among which kissing being a cause of HIV/AIDS and respecting your parents prevents you from HIV/AIDS. The teachers revealed that the public opinion is that informing students about bad touches or how to play sex leads to early sexual intercourse. Additionally, schools tell students a condom is a last solution, and abstaining is significantly more

important. Kissing is also not discussed in schools, as kissing was introduced by developed countries and most Ugandan people do not practice it.

Media was an important source to adolescents’ knowledge about sex. Blue Movies and stories and pictures from the Red pepper were the most important media sources. Through these sources many adolescents learned what kissing encloses. One adolescent stated:

“I just saw it from people but I didn’t practice, ha-ha. But even I saw it from someone doing ha-ha! Through the TV. Yeah I saw people, the whites. Ha-ha! Ha-ha! I saw them kissing there themselves, seriously.”

Additionally, adolescents learned how to play sex from the pornographic movies or stories, and these sources are not focused on dangers. For example:

“I started carrying out fingerscopy on her soft, silky body. “Ooh,” I moaned softly and after three minutes, she released hot magma on my hands. I couldn’t hold the

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Several radio programs broadcasted by health organizations or NGO’s teach about HIV/AIDS and the dangers of sex. Besides that, some adolescents learned from textbooks in school. The teachers indicated that the media provides the information ‘more straightforward’ and ‘more sexual’ than alternative sources. The media is therefore of significant importance to adolescents’ knowledge according to their opinion, and to many adolescents it is the only source (with peers) educating them about playing sex. In this research it appeared that media is the most important source to adolescents’ knowledge about sexual intercourse when studying their interview answers.

Other family members were also sources to some adolescents’ knowledge. Especially adolescents who lost one or two parents learned from Wayo’s or their grandparents, including misconceptions from especially the grandparents. For example:

“That, if you, have starting to have sex, when you’re very young, in future you will not produce child. Then I believe that, that one that is true. Because, I see also, I have seen from… one of my neighbor, who, when she was young, she used to have sex. And then, in future, she did not reproduce.”

The teachers also indicated grandparents’ knowledge is not always correct. They often think HIV/AIDS is a myth, and especially educate the children how to grow up as a

responsible man or lady. Wayo’s are responsible for the adolescents’ partners, and discuss the payment. Only one of the adolescents indicated this specifically, but the teachers revealed this practice is apparent with almost everyone in northern Uganda. Moreover, some adolescents discussed (safe) sex or HIV/AIDS with their elder brother or sister (the eldest one), but they only discussed it to some extent. One respondent was the elder sister, making her responsible to educate her younger brother and sisters. However, she was unable to gain knowledge, because according to her opinion her parents were ‘fearful’ about discussing sex.

When adolescents trusted their neighbors they sometimes discussed (safe) sex or HIV/AIDS with them. This focused especially on abstaining and the dangers of sex. One adolescent stated the following:

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“They have told me that I should be what? That I should be knowing the problem of sex, when you are not yet at, not yet reached the age of 18 or above. That is what I learned from them. To stay away from sex. Sex can kill. Or it can what? Make you to get HIV easily.”

Lastly, other sources were important to some adolescents’ knowledge. These sources enclosed church, health centers, and NGO’s, focusing especially on the dangers of sex and the prevention of HIV/AIDS. The health centers and NGO’s were mainly responsible for

adolescents’ knowledge about condoms, in comparison to other sources. Churches rarely talk with adolescents and only tell them to abstain.

All male and female adolescents from all districts had a big amount of sexual

socialization sources, and all situations were different. Consequently, knowledge about (safe) sex and HIV/AIDS acquired from diverse sexual socialization sources seemed to be unrelated to sexual behavior. This indicates that it did for instance not matter whether adolescents learned from their parents or peers in their experience with sex. Two adolescents indicated that sex is something you do not discuss in general, one adolescent stated:

“You know, as in, ahh… about sexual intercourse, when you are growing, you have it in the mind, there is something like sex. But eh, there are people eh, the people don’t say there’s sex. But for you personally, you know there is sex. You grow knowing that this is there.”

Importance of sexual socialization sources.

From the thirteen adolescents, eleven indicated that a source from the micro level of Bronfenbrenner’s ecological model was most important to their knowledge about (safe) sex and HIV/AIDS. Especially parents and school were important factors, according to the adolescents. The teachers expected school and peers to be most important to adolescents’ knowledge, but according to them peers’ information is often incorrect. Therefore, the teachers hoped adolescents received information from school prior to their friends’ information. However, because education in school starts in secondary school, many

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adolescents already received information from friends. Due to the public opinion it is impossible to start in primary school. Parents educate their children from puberty onwards, with girls being educated from the time they menstruate. Because most girls start

menstruating in secondary school this cannot be changed, according to the teachers.

Similarly to adolescents’ knowledge, the sexual behavior of eleven of the adolescents was influenced by sources from the micro level mostly, according to their opinion. This was equally distributed over parents, peers, and school. Consequently, the information learned from micro level sources is most important to the adolescents. In contrast to the answers, both teachers expected peers to influence adolescents’ sexual behavior the most.

The answers of the adolescents concerning importance to their knowledge is not consistent with the results. Adolescents learned primarily from the media about playing sex, as outlined in Table 7. Despite the fact adolescents declared that micro level sources are most important to them, a meso level source (namely media) appeared to provide them more information. The adolescents addressed they are not able to discuss sex with their parents. Therefore, they have to base their knowledge on media, despite the fact they would rather use their parents’, friends’, or teacher’s opinion. The influence of the desired source on the knowledge or behavior of adolescents is diverse and complex, whether they experienced sex or not.

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Discussion

The aim of this research was to examine whether the gap between knowledge and behavior is dependent on the sexual socialization source regarding HIV/AIDS and (safe) sex knowledge. The research was conducted in the unique environment of northern Uganda, with its high HIV percentage, and diverse sexual socialization sources, making it ambitious to conduct research in this area. All questionnaires had an insufficient reliability, and the validity of the questionnaires was unsatisfactory. This means that it cannot be concluded that the questionnaires measured what they were supposed to measure. Consequently, all quantitative results should be interpreted with caution, as they might not be correct. Subsequently, the explained variances were relatively low, indicating that the significant variables did not explain a significant amount of the dependent variable. The situation in northern Uganda appears to be divers and complex, and possibly the limitations of the study had a significant influence on the study. However, still some interesting results were found, which can be used in further development of HIV/AIDS prevention programs in adolescents. The results

represent the diverse and complex situation in northern Uganda clearly, and will be discussed straightforward.

The Theory of Planned Behavior could not be confirmed in this research, as attitudes, norms, and self-efficacy of adolescents was diverse and did not predict motivation

significantly. Sexual intercourse was not predicted by knowledge, attitudes, and norms, motivation, and impulsivity. Attitudes, motivation, and impulsivity did not predict condom use of adolescents who experienced sex. Adolescents appeared to have fragmented

knowledge, with many misconceptions existing in both male and female adolescents. The questionnaires revealed that differences between gender existed, with male adolescents having more knowledge. Additionally, female adolescents had more motivation to perform safe

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sexual behavior. No differences between male and female adolescents were found in having experienced sexual intercourse. Also condom use was not different between gender.

Age differences were apparent in knowledge and motivation, with older adolescents having more knowledge and more motivation than younger ones. This is unsurprising, as older adolescents have more experience with sexual education classes than others. Besides that, older adolescents used condoms more often than younger adolescents among adolescents who experienced sex. This could be expected, as older adolescents had more knowledge than younger ones. Despite the fact correct and elaborate knowledge of condoms does not imply condom use continuously, correct knowledge of condom use is a predictor of condom use.

Surprisingly, experience with sexual intercourse was not predicted by age. One would expect older adolescents to have more experience with sex, as they have more life experience. Research from Madise, Zulu, and Ciera (2007) revealed the same result. Differences between urban and rural districts existed in self-efficacy and experience with sexual intercourse, with adolescents from the urban area having more self-efficacy and more experience with sexual intercourse than adolescents from rural areas.

Due to the diverse and unique sexual socialization sources one would expect

adolescents’ sexual knowledge to be very good, as it should be pedagogically covered due to the amount of sources. However, both the quantitative and qualitative data indicated that knowledge of adolescents was limited. Especially their knowledge about sex was only fragmented, with for example knowing not having sex can prevent you from HIV, while not knowing what sex encloses. Several misconceptions existed about sexual intercourse and HIV/AIDS, such as kissing causing HIV. These misconceptions were learned from diverse sexual socialization sources, including school. Adolescents were able to identify causes of HIV/AIDS in the interviews, but this knowledge was only superficial, as they were unable to apply this to specific questions. Many adolescents were educated about HIV/AIDS and (safe)

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sex by parents, peers, and school. However, these micro level sources only mention elements, but they fail to explain them in detail. Adolescents were for instance unable to explain how to use a condom, and they were not educated what sexual intercourse encloses. These facts are learned from the media. Especially pornographic movies and pornographic stories explained adolescents how to perform kissing or sexual intercourse.

Adolescents valued micro level sources as most important to their HIV/AIDS and (safe) sex knowledge, and to their sexual behavior as well. This is in accordance with the bio-ecological model of Bronfenbrenner. In contrast, the interviews revealed that the media is the most important source for their knowledge about sex. Detailed knowledge is not generated from the sexual socialization sources from the micro level, but from pornography. These finding are not in accordance with the HIV/AIDS prevention ideas from the Ugandan government. The Uganda AIDS commission (2011) is against having media as a sexual socialization source. According to this commission, pornography encloses wrong information, and adolescents should be protected against this information.

When triangulating the quantitative data with the qualitative data, adolescents’ knowledge appears to be divers and complex. Adolescents have fragmented and limited knowledge, which is not related to sources of this knowledge. Also, adolescents’ sexual behavior is divers and inconsistent. This indicates that the gap between knowledge and behavior cannot be explained by the source of knowledge when combining the quantitative and qualitative data.

This research showed that adolescents’ sexual behavior is primarily influenced by sexual socialization sources from the micro level of Bronfenbrenner’s bio-ecological model, according to adolescents’ beliefs. However, knowledge learned from different socialization sources seems to be unrelated to sexual behavior. Having experience with sexual intercourse

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and condom use were both unrelated to their knowledge gained from the sexual socialization sources.

Because the micro level sexual socialization sources are valued most important by the adolescents and these are the desired sources based on theory, prevention programs should mainly focus on these sources. This indicates that these sources should have acceptable knowledge and should be clarified what to explain to adolescents. This also includes what sex encloses, incorporating positive sides of sex. Otherwise, adolescents might have a positive experience with sex, which is in contrast with what they were educated. This might influence their application of their knowledge and attitudes in practice, as they value positive sides of sex as something different from what they learned.

Additionally, adolescents should learn from the micro level sources that pornography is an incorrect illustration of sex. In other words, Save the Children and other NGO’s should focus parts of their HIV/AIDS prevention programs on the micro level sexual socialization sources, in order to increase the success of the programs. Parents could be targeted by

community meetings or by educating influential community leaders. Besides that, teachers at schools should be educated, in order to improve sex education classes at schools. Moreover, sexual education should start at an early age, in order to make adolescents’ knowledge sufficient before their first sexual experience. Probably, this will not increase adolescents’ engagement in sexual intercourse, as this was the conclusion in developed countries as well (Somers, & Surmann, 2005). Consequently, adolescents would learn from desired and good sources (i.e. parents and school) instead of undesired and bad sources (i.e. media) at a useful time.

This research had some limitations. For most adolescents the power disparity decreased considerably after an introduction talk in which general topics were discussed. However, despite of all attempts, it remained impossible to diminish the power difference, as

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almost all children clearly considered the young white adult researcher as higher in hierarchy. Consequently, the adolescents remained shy, and treated the researcher with respect and obedience.

In addition, it was important to activate the subject position of an adolescent.

However, the research had to be conducted in a school area, making it difficult to reach this subject position as the student subject position was activated easily. Simultaneously, in every school all students agreed to participate after a short introduction of the researcher. Despite taking informed consent as a continuous process, no adolescent ever refused to participate. This might be due to curiousness to the white person or the research, or because the children felt obliged to participate by their teacher. Ethically, it is incorrect that some children might not have participated fully voluntarily.

Moreover, travel issues increased the difficulties of visiting schools several times, making it impossible to have both qualitative and quantitative data from a significant group of children. Subsequently, due to language barriers and the adolescents having no experience with completing questionnaires, it was impossible to conduct this research in primary schools.

The present study did not offer child participation on a high step of Hart’s ladder of participation. This ladder includes eight participation steps, with the higher steps indication more participation (Hart, 1992). Because the present study encouraged adolescents to ask questions themselves and comment throughout the interview, this research included some participation. In future research it would be interesting to incorporate Ugandan adolescents in the development of the research or the execution of the research. This would decrease the power difference between adolescents and adults as adolescents’ opinions are taken seriously. Research validity improves when this hierarchy declines, and interview participants would feel more comfortable because they would have to answer to peers (Hart, 1992).

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Similar research should be conducted in primary schools, as adolescents’ sexual socialization sources in these schools might be different from secondary school adolescents. In addition, long term effects would be interesting to investigate in future research. Sexual socialization sources might have an influence on sexual behavior mediated by knowledge on a long term. Besides that, improvement of the research could be reached when it would be conducted by a Ugandan researcher. Moreover, out-of-school children should be included in the research, as they might have different sexual socialization sources because they miss school as a source.

In conclusion, this study increases our understanding of northern Ugandan adolescents regarding (safe) sex. Knowledge appears to be insufficient and fragmented, and appear to have a diverse range of sexual socialization sources. Adolescents value micro level sources as more important to their knowledge and behavior than sources further away. However, they appear to have media as the most important source at this moment. It is valuable to NGO’s to increase the knowledge of the micro level sources, in order to improve adolescents’

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Acknowledgements

Ruben G. Fukkink is thanked for his assistance, patience, and supervision during the whole research process. The author is grateful to Jacobijn Olthoff, UD, Save the Children in the Netherlands and Save the Children in Uganda for providing the possibility to accomplish this research, and Straight Talk for its help in reaching the schools. The districts, schools, teachers, and adolescents are acknowledged for participation. Henny M.W. Bos, UD, is thanked for her support in designing the research, and Suzanne C. Roodenburg, BSc, is thanked for her statistical assistance.

Conflict of Interest Statement

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