Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda

Adolescents (female and male) in and out of school described multiple issues concerning their sexual and reproductive health needs. The most important health problems expressed were HIV/STIs (all FGDs), unwanted pregnancies, sexual advances for the females from adult males and fellow male adolescents (expressed by female adolescents mostly), defilement and rape and the use of alcohol and other substances.

Most of the youths don’t have what to do - they resort to taking alcohol, opium, cigarettes and marijuana. Even girls think that it is the today’s style to put on thin trousers called ‘skin tight’. And in so doing they meet these boys who have taken opium along the roadside and they force them into sex. In every town there are places like clubs and bars where youths take alcohol. (Males out of school)

The participants in both female and male FGDs reported post abortion care services as a great need that was not catered for. In some FGDs especially those with in school adolescents, they reported knowledge of their colleagues in schools and out of school who had used traditional dangerous methods and other unsafe means to get rid of unwanted pregnancies even with knowledge of consequences associated with these means including death. Some also reported that some health workers give them medicines to take home in case they want to abort or even help with illegal abortions.

I was told that there are some girls who get some medicines from health workers. It is in form of tablets. When they swallow it, it gives them labour like pain, then they deliver and the pregnancy is terminated. (Males out of school)

Another problem I see as a young person is among the girls, they have aborted a lot. They don’t get good counselling or advice on how they can protect and take care of the pregnancies. So they end up aborting. (Males in school)

Infrastructure providing exclusive services for teenagers was reported as lacking in the majority (seventeen of the twenty) of FGDs. Some male adolescents said that it was always hard for them to collect condoms and other medicines from the general health facilities where all the adults including their parents and relatives receive care from. However, they expressed willingness to freely do so if they had a separate medical centre.

…[we need a teenage centre] for even medical check-ups, so that you know that if you are not feeling safe there is a centre where you can go for check-up and know your HIV status, or Candida [STIs] or if you are pregnant. That is better than these services which cost money where you may even be afraid and you take about 3 years without testing. (Females in school)

There was an expressed wish about the staff working in such proposed centres to be of some age range or at least trained to handle youth problems according to the adolescents’ perception.

Youth centre as you hear that word youth centre, which means even the workers must be youths. It will be easy to consult them about what happened to me and they tell me. It means there will be family planning, their use and their effects. (Males in school)

Regarding contraceptive access, the issue of condom availability and cost was highlighted as a main problem especially by the males in nine out of ten male FGDs and the females in school. Only two out of the five out-of-school female expressed the condom problem.

The problem we have pertaining condoms e.g. life guard, some are expensive especially in the shops and the cheap ones are not available. So we young people end up having sex without condoms. (Males in school)

Our results further point out some gaps related to sex education reported by a few male adolescents but that could be very important to ignore. For example within health centres, it was pointed out that in some cases health workers distribute condoms without accompanying health education on their use.

…the need for condoms, you can go to the health facility and they give them to you but there are some people who do not know how to use them. He will just put it on anyhow. It requires that there is someone who gives them out but he/she first educated you on how to use them and he tells you that “I have given you that thing, use it like this. But there are those who just have them for showing off; they tell their friends that they have them. (Males out of school)

Sexual activity was reportedly high among the adolescents and thus a need for contraceptive education and provision. Most female FGDs expressed a need to provide family planning education including the natural methods as highlighted below.

And another thing, is the need to educate them [adolescents] how to count those menstrual days in the cycle though they keep on changing say for one month you have periods on 5 ^th and the second month you experience periods on 3 ^rd . Because some of the girls use those safe days but they don’t know how to count them for example like this one has said she doesn’t know the day she goes into her MPs. But if you health educate here, say you tell her that since you started this month on 3 ^rd the next month you will experience your periods on this date. So they will know. (Females in school)

Regarding available services adolescents reported that condoms, male circumcision services and post abortion care services were the least available services in health facilities at the community level while HIV Counselling and Testing was more available.

[we need post abortion services], my cousin for example got an unwanted pregnancy and she went to one of the health workers in a clinic to abort and the health worker performed some procedures, told her to go back home and after the two to three hours to go where she wants to drop that foetus and it will come out. So she squat on a bucket and it came out but she felt a lot of pain for about 2 weeks and it was associated with a lot of bleeding. She is fine now but sometimes still experiences pain inside her stomach. [Such people] when they want to abort, should be directed the right ways of aborting so that they don’t feel that pain. (Females in school)

We assessed the health seeking behaviours of adolescents for RH needs. In all FGDs, we asked adolescents what they and other adolescents do when they have RH needs. Our findings show that some adolescents when faced with RH problems take no action. It is only later when these problems persist that they either visit a health facility. This was reported in thirteen of all FGDs. Reasons for this poor health seeking behaviour reported included cost, privacy issues and the long queues due to very few health workers serving large populations. Some adolescents in male FGDs reported “nosy” health workers who they thought asked many questions making them uncomfortable.

You cannot come and tell a health worker to give you what you want, she will ask you a lot of questions and afterwards she will not even give you what you want. You may just find yourself failing to tell her what you want because she is asking you a lot of questions. (Males in school)

Our results show that there were ‘under-the-table’ payments in health service delivery. In some cases unofficial payments were reportedly solicited which further made the services for adolescents hard to access because majority do not have money but depend on parents/guardians.

When I get a problem, I go to the health facility. You can go there early and you sit in a queue for long then someone comes with their money e.g. 3000/=, which they give to the health worker and they tell them to go and get them medication. So they are worked on before you. Also if you go for things like drawing blood for tests, the health worker first asks for money to buy gloves and sometimes these could be available yet they don’t want to use them. So the one who has given them money is the one who is given drugs and then you: you could be given only Panadol: like 3 tablets or so and then you leave. (Females out of school)

Worth noting is that some of the adolescents (when problems persisted), sought help from traditional healers or used herbs. This was reported in seven of the ten female FGDs and in two of the 10 male FGDs. In half of the FGDs, some adolescents reported that they sought advice from parents and peers when faced with such problems.

One would rather go to a traditional herbalist than a health worker …because he will think that the health worker will tell others about his sickness but a traditional healer who is far where he is not known is where he goes.(Males in school)

You tell the person who is available: if you have your mum, you tell her. If you have your aunty, you tell her. Those who have their fathers, it is difficult for them to disclose to them because many fear telling their fathers feminine problems, they prefer mothers. (Females in school)

In a few FGDs (6/20), adolescents also noted that they seek advice from more older people in the community while others who can afford go and buy medicines from drug shops or pharmacies (4/20 FGDs). Private health facilities (including clinics, pharmacies and drug shops) were the most accessible to the adolescents than public health facilities. Access in this case was beyond just the physical dimension.

When we get problems, sometimes we tell our friends. Me I have a friend who has Candida, but she told us her friends and we inquired from an older person about it, who told us about some local medicine so that is what she is using. She had been to Kasangati health centre and they told her that the drugs are not there, they just wrote a prescription and they told her to buy the drugs from a clinic yet she had no money and no parents. So sometimes you can tell friend or neighbours, they may be of help. (Females in school)

In this study, we also asked adolescents whether they went to the health facilities to seek for SRH information. In half of the FGDs, they reported to have never gone to the health facilities to seek SRH information. The reasons given were lack of information about the availability of these services at the health facilities while others feared to seek services in the same facilities with the older community members and with different sex of health workers.

Another problem is that most of the health workers here are females (they laugh). Such ladies are easy to their fellow ladies but to us boys it is not easy.(Males in school)

The problem we have found as young men, you may get into a situation. You know young people of our age; they date as girlfriend and boyfriend. So he may have no condoms and he may not go to the health facility to pick them yet they are there; he is just shy. So he may have intercourse and he gets HIV/AIDS because he has acted shy saying “how will I be seen picking them?” (Males in school)

Only in one quarter of the FGDs (5/20), adolescents reported ever seeking services at the health facilities for SRH. Among those who said yes, we investigated what their attitudes were about the services provided. In nearly all FGDs (19/20), the adolescents reported that they did not think they were a priority at the health facilities, hence found no need to go back for SRH information and services. In most FGDs (18/20) also adolescents reported that health workers were not friendly to them (at worst labelling them as rude) and barked at them. They further reported a lack of privacy at these facilities for them in seventeen of all FGDs while in nineteen of the twenty FGDs adolescents noted that where the services were not free, the cost was not affordable to them (19/20). The overall quality of SRH services at the facilities was reportedly of poor quality to most of them as reported in fifteen of twenty FGDs.

Sometimes it is difficult at the health facility. You could go with your friends and you do not want them to know what is disease [STI] is bothering you. Then as you are explaining to the health worker calmly, some of them bark at you saying “speak louder.” But you are scared of speaking loudly because your friendly will hear, you continue narrating to him in a low tone and then he screams “which disease?… syphilis?” So this leaves you too ashamed in the consultation room. The health workers are too tough; they should reduce on their toughness. (Males out of school)

Other reported attitudes were: non flexible opening and closing hours of facilities (5/20), lack of necessary drugs for STIs and other SRH problems (12/20), few health workers yet adolescents feared to open up to health workers of the opposite sex, and mistrusting of the health workers by the adolescents.

If you are from school and you have gone to the health facility and you are putting on a uniform, they may work on you vary first because they know you are a student but if you go in casual wear like on weekends, they treat you like the rest of the people. And after telling the health worker your problem, they may tell another health worker that “this one has this kind of illness, this one has this kind of illness.” You came to seek treatment from the health workers but they just discuss about you and that becomes a problem. (Females in school)

Adolescents were asked which SRH services they wanted to be provided in their communities and facilities. Most of these preferred services reflect the adolescent health needs reported in the first part of the results. In half of the FGDs, adolescents reported a need for a dedicated teenage health centre equipped with youth friendly health workers and stocked medicines. Adolescents also wanted provision of adolescent counselling services and health education. In health facilities outside of the teenage centre, adolescents want separate services to ensure privacy for them.

Now what I am saying is that we as the youth we should get a special day say like the weekend and we have counselling and guidance, it will help us. (Males in school)

We [the adolescents] need health talks because there are some problems we face when we totally have no idea on how to go about them. So we should be health educated such that we know what to do. (Females out of school)

Regarding modalities of service provision, the adolescents preferred that services be available all the time (opening and closing hours), by younger health workers and of the same sex and in places that ensure privacy. The out-of- the school male adolescent FGDs preferred services to in an outreach form in the communities, at no cost and preferably with health workers not from the same area. Those in school preferred friendly health care workers and reduction in waiting time at the health facilities.

Me I think there should be a private room for picking condoms (they laugh), so that when you go there you just get enter: the person there knows what you want and they don’t ask for money. But if you go when all the health workers work from there, when one asks you, you will be afraid of telling them what you want but if you just enter a room, the person you find there automatically knows what you have gone to pick from there. (Males out of school)

For me am 19 years but the years I have lived here, I have never seen people coming to offer youth counselling here. Yes as youths we normally get problems and we fear to visit the health facilities that health workers will harass us. We cannot tell our parents neither our friends because they will spread the information to the public, so we need youth counselling here in the community. (Males out of school)