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Understanding the reproductive health education needs of adolescent girls in Uganda

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Title:
Understanding the reproductive health education needs of adolescent girls in Uganda
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Song, Eunmi ( author )
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English
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1 online resource (109 pages) : illustrations ;

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Sustainable Development Practice field practicum final report, M.D.P
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theses ( marcgt )
non-fiction ( marcgt )

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Abstract:
Adolescent pregnancy and motherhood have remained major social concerns in Uganda. The purpose of this field practicum is to identify priority unmet needs, barriers, and constraints with regard to reproductive health education for adolescent girls and young women in Uganda, and to determine the best ways to meet those needs. A needs assessment and situational analysis were conducted with Shanti Uganda, which is a non-governmental organization located in Kasana Town in the Luweero District of Uganda. They are working towards reducing adolescent pregnancy by providing a reproductive health education program. Participatory and qualitative methods were used to collect data including semi-structured interviews with 31 main stakeholders and 9 girls, surveys with 55 young women aged 14 to 26, and direct observations. Data about accessible health facilities and services for girls were collected from secondary official data sources. The evaluation of the Teen Girls Workshop provided by Shanti Uganda was also used to provide supporting evidence of the results of the needs assessment. The findings of the interviews and the surveys revealed that even though the main source of information for adolescents is school, the lack of sex education and limited educational resources are still crucial obstacles in getting proper reproductive health information. There are also cultural and traditional restraints preventing girls from getting this information either in home or even in school. These barriers constrain girls from making a right decision for their health. The majority of research respondents agreed that school is the best place to educate adolescents. Also, many girls replied they are in favor in getting reproductive health services and education from health workers. It is concluded that Shanti's proposed services focusing on a school cooperative program and ( ,,,, )
Abstract:
youth-friendly spaces for girls can improve accessibility of education and ensure that the girls attend more. If Shanti develops a cooperative program with schools, they can reach more adolescent girls and their teen girls program can be implemented over a long-time period. Moreover, education and services can be provided by Shanti's health workers in youth-friendly spaces, which is a powerful way of passing knowledge to youth, allowing active participation of both service provider and youth participants.
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Includes bibliographical references.
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The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.
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by Eunmi Song.

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University of Florida
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Copyright Eunmi Song. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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1 GRANT OF PERMISSIONS In reference to the following title(s): [ E u n m i S o n g ]. [ Understanding the Reproductive Health Education Needs of Adolescent Girls in Uganda ]. Gainesville, FL: University of Florida [ 0 4 / 1 2 / 2 0 1 7 ]. I, ___ E u n m i S o n g ______________, as copyright holder or licensee with the authority to grant copyright permissions for the aforementioned title(s), hereby authorize the University of Florida, acting on behalf of the Board of Trustees of the Univers ity of Florida, to digitize, distribute, and archive the title(s) for nonprofit, educational purposes via the Internet or successive technologies. This is a non exclusive grant of permissions for on line and off line use for an indefinite term. Off line u ses shall be consistent either, for educational uses, with the terms of U.S. copyright legislation's "fair use" provisions or, by the University of Florida, with the maintenance and preservation of an archival copy. Digitization allows the University of Fl orida to generate image and text based versions as appropriate and to provide and enhance access using search software. This grant of permissions prohibits use of the digitized versions for commercial use or profit. _____________________________________ Signature of Copyright Holder ___ E u n m i S o n g ___________________ Printed or Typed Name of Copyright Holder ___ 0 4 / 1 2 / 2 0 1 7 ________ Date of Signature Attention: Digital Services / Digital Library Center Smathers Libraries University of Florida P.O. Box 117 003 Gainesville, FL32611 7003 P: 352.273.2900 DLC@uflib.ufl.edu



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UNDERSTANDING THE REPRODUCTIVE HEALTH EDUCATION NEEDS OF ADOLESCENT GIRLS IN UGANDA By EUNMI SONG MASTER OF SUSTAINABLE DEVELOMENT PRACTICE FIELD PRACTICUM FINAL REPORT UNIVERSITY OF FLORIDA 2017 Eunmi Song

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ACKNOWLEDG MENTS Special thanks to my committee members, Dr. Sarah Lindley McKune and Dr. David Diehl. Also I would like to thank Dr. Glenn Galloway, Mr. Andrew Noss and the following for their continuous support. Latin American and African Studies MDP Cohorts, Sha nti Uganda AAUW Jean and David, Korean Baptist Church Family and F riends and T hank Y ou God.

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TABLE OF CONTENTS p age ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 2 LIST OF TABLES ................................ ................................ ................................ ........................... 5 LIST OF FIGURES ................................ ................................ ................................ ......................... 6 LIST OF ABBREVIATIONS ................................ ................................ ................................ .......... 7 INTRODUCTION ................................ ................................ ................................ ......................... 10 BACKGROUND AND CONTEXT ................................ ................................ .............................. 13 Background ................................ ................................ ................................ ............................. 13 Reproductive Health and Adolescent Pregnancy in Uganda ................................ .................. 14 Consequences of Adolescent Pregnanc y ................................ ................................ ................ 15 Underlying Issues of Adolescent Pregnancy ................................ ................................ .......... 17 The Shanti Uganda Society ................................ ................................ ................................ .... 19 OBJECTIVES AND THE FRAMEWOR K OF THE FIELD PRACTICUM ............................... 21 EVALUATION OF THE TEEN GIRLS WORKSHOP ................................ ............................... 25 Evaluation Survey for Teen Girls Workshop ................................ ................................ ......... 25 Design ................................ ................................ ................................ .............................. 25 Implementation ................................ ................................ ................................ ................ 27 Analysis of Evaluation Survey of Teen Girl Workshop ................................ ......................... 28 Characteristics of The Participants ................................ ................................ .................. 28 Age of girls: ................................ ................................ ................................ .............. 28 Participant villages: ................................ ................................ ................................ .. 29 Current education level: ................................ ................................ ........................... 29 Knowledge Test ................................ ................................ ................................ ............... 30 Self assessment of knowledge level ................................ ................................ ................ 3 1 Self Assessment of Attitude ................................ ................................ ............................ 34 Self assessment of Skill ................................ ................................ ................................ ... 35 Feedback from Participants on The Teen Girls Workshop ................................ ............. 36 Feedback from Shanti Staff ................................ ................................ ............................. 38 Key Lessons from The Evalua tion Survey ................................ ................................ ...... 39 NEEDS ASSESSMENT ................................ ................................ ................................ ................ 42 Needs Assessment Methods ................................ ................................ ................................ ... 42 Semi structured Interviews ................................ ................................ .............................. 43 Design ................................ ................................ ................................ ....................... 43

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Implementation ................................ ................................ ................................ ......... 44 Needs Assessment Survey for Young Women in General in The Community .............. 46 Design ................................ ................................ ................................ ....................... 46 Implementation ................................ ................................ ................................ ................ 48 Direct Observation and Secondary Da ta Collection ................................ ........................ 49 Results And Analysis ................................ ................................ ................................ .............. 51 Analysis of the Survey Data ................................ ................................ ............................ 51 Demographic information ................................ ................................ ........................ 51 Main source of information ................................ ................................ ...................... 52 Preference for accessing reproductive health services and information .................. 53 Barriers to access reproductive health education ................................ ..................... 55 Infor mation and services that young women need ................................ ................... 57 Analysis of the Semi structured Interview Data ................................ ............................. 58 Main source of information ................................ ................................ ...................... 59 Importance of school ................................ ................................ ................................ 59 Barriers to access reproductive health education ................................ ..................... 60 Incomplete knowledge on reproductive health ................................ ........................ 61 Importance of youth friendly services ................................ ................................ ..... 63 CHALLENGES AND LIMITATIONS OF THE STUDY ................................ ............................ 66 DISCUSSION AN D RECOMMENDATIONS ................................ ................................ ............. 68 Right place and right time: School Cooperative Program ................................ ...................... 68 Youth Friendly Services in Safe Spaces ................................ ................................ ................. 69 Involving Diverse Human Resources ................................ ................................ ..................... 70 Appropriate Terms a nd Words for Reproductive Health Education ................................ ...... 71 Improving Planning, Organizing and Promotion ................................ ................................ .... 72 CONCLUSION ................................ ................................ ................................ .............................. 74 REFERENCES ................................ ................................ ................................ .............................. 76 APPENDIX ................................ ................................ ................................ ................................ .... 79 Appendix 1. Needs Assessment Instrument: Interview Questions ................................ ......... 79 Appendix 2 Needs Assessment Survey ................................ ................................ .................. 82 Appendix 3 Evaluation Instrument: Interview Questions: Staff and instructor of the teen girls workshop ................................ ................................ ................................ ..................... 90 Appendix 5. Teen Girls Workshop Budget ................................ ................................ ............ 96 Appendix 6. Activity with Interns Tee n Girls Workshop additional curriculum ................ 98

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LIST OF T ABLES Table page Table 1. Number and percentage of clients by age group, (Data from Shanti Uganda, 2016) ...... 20 Table 2. Evaluation survey structure ................................ ................................ ............................. 26 Table 3. Villages of the teen girls participants. N=32 ................................ ................................ ... 29 Table 4. Results of self assess ment of the knowledge levels for teen girl participants. ................ 32 Table 5. Results of self assessment of attitude for teen girls participants. ................................ .... 35 Table 6. Results of self assessment of skill for teen girls participants. ................................ ......... 35 Table 7. Example of Semi stru ctured interview questions ................................ ............................ 44 Table 8. Main stakeholders who participated in the semi structured interviews ........................... 46 Table 9. Needs assessment survey questions structure ................................ ................................ .. 47 Table 10. Participants of the needs assessment survey ................................ ................................ .. 49 Table 11. Schools of the young women respondents of the survey. N=55 ................................ .... 52 Table 12. Villages of the young women respondents o f the survey. N=55 ................................ ... 52 Table 13. Reprodu ctive health services fee in health facilities in Luweero District (UGX: Uganda Shilling), 2016 ................................ ................................ ................................ ...... 62 Table 14. Example of Teen Girls Workshop schedule table ................................ ......................... 73

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LIST OF FIGURES Figure page Figure 1. Uganda Map, Luweero District ................................ ................................ ...................... 14 Figure 2. Framework of the field practicum ................................ ................................ .................. 22 Figure 3. Conceptual Map: Causes and Effects with Underlying Factors for Adolescent ................................ ................................ ............... 24 Figure 4. Ages of Teen Girls Participants on the Workshop. N=32 ................................ .............. 28 Figure 5. Education levels of the teen girls participants. N=32 ................................ ..................... 29 Figure 6. Results of the reproductive health knowledge te st. ................................ ........................ 31 Figure 7. Results of self assessment of knowledge levels for teen girl participants. .................... 34 ................................ ...... 36 Figure 9. Most common b arriers to access reproductive health education (Workshop Participants). N=32 ................................ ................................ ................................ ............ 37 Figure 10. Preference with respect to whom to dis cuss about reproductive health issues. N=32 ................................ ................................ ................................ ................................ .. 38 Figure 11. Ages of the young women respondents of the survey. N=55 ................................ ....... 52 Figure 12. Main source of information regarding reproductive health. N=55 ............................... 53 Figure 13. Preference of people with which to discuss about reproductive health issues. N=55 ................................ ................................ ................................ ................................ .. 54 Figure 14. Location/people that should provide reproductive health services. N=55 ................... 55 Figure 15. Most common barriers to access reproductive health education (Needs Assessment). N=55 ................................ ................................ ................................ ............ 56 Figure 16. Persons that young ............................ 57

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LIST OF ABBREVIATIONS IUD Intrauterine device AIDS Acquired immune deficiency syndrome HIV Human immunodeficiency virus infection STDs Sexually transmitted diseases UBOS Uganda Bureau of Statistics UDHS Uganda Demographic and Health Survey UNICEF The U nited Nations Children's Fund UNFPA The United Nations Population Fund NGO Non governmental organization MDP Master of sustainable development practice MSU RHU Reproductive Health Uganda SRHR Sexual and reproductive health and rights

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ABSTRACT UNDERSTANDING THE REPRODUCTIVE HEALTH EDUCATION NEEDS OF ADOLESCENT GIRLS IN UGANDA By Eunmi Song 12 2017 Chair: Name Sarah Lindley McKune Committee Member Dr. David Diehl Adolescent pregnancy and motherhood have remained major so cial concerns in Uganda. The purpose of this field practicum is to identify priority unmet needs, barriers, and constraints with regard to reproductive health education for adolescent girls and young women in Uganda, and to determine the best ways to meet those needs. A needs assessment and situational analysis were conducted with Shanti Uganda, which is a non governmental organization located in Kasana Town in the Luweero District of Uganda. They are working towards reducing adolescent pregnancy by providi ng a reproductive health education program. Participatory and qualitative methods were used to collect data including semi structured interviews with 31 main stakeholders and 9 girls, surveys with 55 young women aged 14 to 26, and direct observations. Data about accessible health facilities and services for girls were collected from secondary official data sources. The evaluation of the Teen Girls Workshop provided by Shanti Uganda was also used to provide supporting evidence of the results of the needs assessment. The findings of the interviews and the surveys revealed that even though the main source of information for adolescents is school, the lack of sex education and limited educational resources are still crucial obstacles in getting proper repr oductive health information. There are

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also cultural and traditional restraints preventing girls from getting this information either in home or even in school. These barriers constrain girls from making a right decision for their health. The majority of r esearch respondents agreed that school is the best place to educate adolescents. Also, many girls replied they are in favor in getting reproductive health services and education from health workers. It is concluded that on a school cooperative program and youth friendly spaces for girls can improve accessibility of education and ensure that the girls attend more. If Shanti develops a cooperative program with schools, they can reach more adolescent girls and their teen gi rls program can be implemented over a long time period. Moreover, education and services can be provided f riendly spaces, which is a powerful way of passing knowledge to youth, allowing active participation of both servi ce provider and youth participants.

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CHAPTER 1 INTRODUCTION I undertook my field practicum for 10 weeks with Shanti Uganda, which is a non governmental organization located in Kasana Town in the Luweero District of Uganda. The organization is working t o improve maternal and infant health, to provide safe woman centered care, and to support the well being of birthing mothers and women living with HIV/AIDS. They are also working towards reducing adolescent pregnancy and keeping young girls in school by pr oviding reproductive health education and services. My research aimed at identifying priority unmet needs, barriers, and constraints with regard to reproductive health education for adolescent girls and young women, and to determine the best ways to meet t hose needs. I conducted a needs assessment and situational analysis with Shanti Uganda looking at the most important health and reproductive health education needs of teen girls in the Luweero district. Participatory and qualitative methods were used to co llect data including semi structured interviews, surveys, and direct observations. Data about accessible health facilities and services for girls were collected from secondary official data sources as well. I carried out semi structured interviews with 31 main stakeholders and 9 girls. The stakeholders included school teachers, health workers, NGO staff, community leaders and official workers. I also conducted a survey which is a reproductive health needs assessment f ocused on young women who live in the L uweero district. Fifty five young women aged 14 to 26 participated in the needs assessment survey. The other important source of data was the evaluation of the Teen Girls Workshop provided by Shanti Uganda. The organization regularly provides girls with a place to gather and learn about reproductive health. When I was doing my field practicum, the Teen Girls Workshop was held during the school holidays. Shanti Uganda asked me to evaluate their program, the

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method of which had not been organized during my p reparation for the practicum. Therefore, I prepared the questionnaires in Uganda and conducted the evaluation survey for participants in the Teen Girls Workshop. Though the evaluation was not planned during the preparation period, the results of the evalua tion have important implications on the needs assessment. Specifically, the findings reflected vital information about the girls attending the workshops and which particular content needed to be changed to improve the education program. Thus, the findings are integrated in the discussion section of this report, providing supporting evidence of the results of resource in developing novel, appropriate ideas for future actions of Shanti Uganda. Thus, the health education program. The remainder of this document is laid out a s follows. In the Background and Context sectio as the reproductive health status of adolescent girls is presented. It also covers some consequences and underlying issues of adolescent pregnancy and the Shanti U intervention to address these issues. Original objectives of the field practicum are covered in Objectives and the Framework of the Field Practicum. Findings of the practicum are divided into two sections Chapter 4 : Evaluation of Teen Girls Worksh op and Chapter 5 : Needs Assessment Chapter 4 includes the methods and results of the evaluation of the teen girls program. It provides information on how the reproductive health program works in Uganda, giving supporting facts on the effects of the worksh op and important feedback from the teen girls to improve services for teens. Chapter 5 : Needs Assessment is the main section of this report and covers methods of the needs assessment, and crucial findings of the interviews and surveys. It

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shows what the ma in source of reproductive health information is for adolescents, what the barriers and restrictions to accessing the reproductive health services are, and what information and services young women need. Findings from both Chapter 4 and Chapter 5 are then i ntegrated to make recommendations regarding what improvements could be made for future programs and reproductive health services by Shanti in Uganda and general. This research was reviewed and approved by the local REC in Uganda as well as University of Fl orida: TASO Research Ethnics Committee in Uganda, Institutional Review Board University of Florida in U.S.

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CHAPTER 2 BACKGROUND AND CONTEXT Background The Republic of Uganda is located in East Africa on the equator. Uganda has an area of about 241,000 km 2. More than 60 percent of the country is agricultural land and grasslands (UBOS, 2015, p.2). Lakes and swamp areas constitute 17% of the country. Total population is estimated to be about 34.9 million with an average annual growth rate of 3 percent and children under aged 18 years old account for 56% of the population (UBOS, 2015, p.14). Uganda is one of the world's least developed countries (Bureau of African Affairs, 200 8 ). Luweero is in the c entral region of Uganda (Figure 1) There are several town councils and villages within the district. Kasana is a medium sized town in Luweero with internet cafes, several churches, mosques, schools, convenience shops, a bank, a post office, a public hospital and several small food markets. eero District was the center of a bloody civil war waged between government forces and the National Resistance Army. The Bush W ar continued for 5 long years. Both sides suffered severe casualties involving killings, rape and the use of innocent civilians a s shields (Library of Congress Country Studies, 1992). According to Shanti Uganda, a non governmental organization located in the Luweero District, at present, girls in rural Kasana town in Luweero District are some of the most marginalized girls in the re gion, since many have lost their parents and live under the care of a grandmother, or female relatives (The Santi Uganda, 2016).

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Figure 1. Uganda Map, Luweero District Reproductive Health and Adolescent Pregnancy in Uganda Adolescent pregnancy and moth erhood have remained major health and social concerns in Uganda ( UBOS, 2012 p.67). For many women, pregnancy is planned and desired, but for adolescents it is often unintended. T he National Adolescent Health Policy in Uganda defines the as young people between 10 and 19 years old (Amin et al., 2013, p.78). The government of Uganda considers women between the ages of 15 and 19 who have given birth or UBOS 2012 p.67). The 2011 Uganda Demographic Health Survey (UDHS) indicates that one out of four females (24 percent) ages 15 to 19 years old are either pregnant with their first child or have had a live birth already ( UBOS, 2012 p.67 ). According to the 201 1 UDHS statistics, the median age of first childbirth among females who are now ages 20 49 is 18.9 years old. The UDHS

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report findings also indicate that the proportion of adolescent pregnancy has been declining over time, from 43 percent in 1995, to 31 pe rcent in 2001, to 25 percent in 2006, and finally, to 24 percent in 2011 ( UBOS, 2012 p.67). Despite this encouraging decline, rates of adolescent pregnancy in Uganda are still comparatively high in sub Saharan African countries ( Garenne & Zwang 2008, p.6 5 ; UBOS, 2012 p.67 ). background and adolescent pregnancy. The UDHS survey notes that girls from poor households and/or with no education have higher pregnancy rates than those from wealthier households and/or with higher educational status. For example, evidence ( UBOS, 2012 p.67) shows that rates of child bearing are higher among less educated girls ages 15 19 (45 percent of women with no education versus 16 percent of women wi th secondary education), and among poor girls (34 percent in the lowest wealth households versus 16 percent in the highest wealth households). Additionally, rural teenage girls start motherhood earlier compared to their urban counterparts (24 percent versu s 21 percent, respectively) ( UBOS, 2012 p.67). From these figures, the trends illustrate that women from marginalized backgrounds like those found in rural places, without education, and/or in the poorest wealth quintile are statistically more likely to h ave their first child earlier than women in more privileged conditions. Consequences of Adolescent Pregnancy being, as well as her children, as recognized globally and nationally (UNICEF, 2015, p.17; Edilberto & Mengjia, 2013, p.18). It exposes girls to various challenges that impact directly their health and welfare in a serious fashion. As has been indicated, adolescent pregnancy is associated with vulnerabilities of girls, and

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and psychological health, educational opportunities and social wellbeing (Leerlooijer et al., 2013, p.2; UNICEF, 2015, p.17). Researchers indicate that very young adolescents in sub Sahar an Africa have a greater risk of death during childbirth and complications, such as obstetric fistula, compared to older women ( Edilberto & Mengjia 2013, p.23; Patton et al., 2009, p.884 ) and are more likely to have childbirth related complications ( Gibbs et al., 2012. p.262). Moreover, sexual intercourse at a young age poses greater risks and is associated with multiple health problems including sexually transmitted infections (STIs) and HIV (World Health Organization, 2009, p.31). Unplanned adolescent p regnancy is a leading cause of abortions. stated that one of the major reasons for having an abortion was the fear that their lives would be interrupted due to pregnancy in their school age years. ( Nobelius 2014 p.635 ). Data on abo rtions shows that about 3.2 million abortions conducted for girls aged 15 to 19 in less developed countries annually are carried out in an unsafe fashion (Shah and Ahman, 2012, p.170). A girl may face stress or depression if she is not prepared for pregna ncy, especially when she becomes pregnant by force ( Edilberto & Mengjia, 2013, p.24). Holub that adolescent mothers experience high emotional distress during and after pregnancy brought on by difficult maternal adjustment (2007, p.15 report (2015, p.20) indicates that pre marital pregnancy remains shameful and stigmatized in many cultures in Uganda because it is associated with embarrassment and a disgrace to the family. N umerous researchers provide evidence that unmarried pregnant adolescents face a lot of stigmas, low self esteem, stress, depression, anxiety, rejection by their families, partners and community members as well as limited social support (Atuyambe et al., 2005. p.305; Gibbs et al., 2012. p.261).

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Pr egnancy and childbirth often result in the cessation or delay of education (Lloyd and Mensch, 2006. p.7). Many adolescents who are pregnant may have to drop out school and face a decreased chance to return either because of individual circumstances, such a s financial difficulties, child care and child marriage, or social stigma and pressures from family or community (Levandowski et al., 2012, p.168). Furthermore, most schools do not allow pregnant girls to attend school ( Williamson, 2013 p.v). Current poli cy of Uganda prohibits pregnant girls from attending school; consequently, laws and social forces pressure girls to terminate their education ( UBOS, 2012 p.67). When girls drop out of school it negatively affects the economy of both the girl and the over all society ( Edilberto & Mengjia, 2013, p.26). According to a World Bank study, there are huge opportunity costs associated with pregnant students dropping out of school when measured 2011, p.11). UNFPA (2013, p.26) states that because teenage mothers may not stay in school, they are less empowered socially and economically to get a job or to pursue other income opportunities. These consequences can lead to negative economic consequence s in the broader society. Underlying Issues of Adolescent Pregnancy Unintended adolescent pregnancy is interlinked with numerous causes and multi factorial drivers. These include child marriage, gender inequality, national poverty, sexual violence, less access to health services, lack of education and so on ( Williamson 2013 ). Adolescent pregnancy does not relate only to a single determinant but is the consequence of a multi layered set of risk factors from individual to national levels that taken togethe r often lead to adverse consequences. First, many girls are expected to get married at a young age, especially in developing countries. In some cultures, girls or their families see marriage as their only option or destiny

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( UNFPA, 2013, p.35), and many po or communities view having a baby as a protective and economic strategy for their survival (Amin et al., 2013, p.107). Even though the Uganda Constitution sets 18 years old as the legal minimum age for marriage (The Uganda Constitution, 1995, article 31), a UNFPA report (201 3 p.23) indicates that prevalence of child marriage in Uganda is high, estimated at 46 percent. Also, gender inequality forces many girls to be exposed to unwanted pregnancy. Even when girls know about contraception, many of them cannot use it because of rejection by male partners (Presler study (2012, p.43) shows that when a male partner is older than a female, the power differential in the relationship makes it much more difficult for her to insist on safe sex with contraception. pregnancy by forced sex or violence from their intimate partner (Kothari et al, 2012, p.43). In the ir paper, Krug et al (2002: p.149) insist that many young women reported that their first sexual activity was not intended and the experience was forced. Some of the most substantial causes of unplanned adolescent pregnancy is the lack of understanding o f contraceptive methods and lack of access to reproductive health services and education. Inaccurate information regarding sexuality, reproduction and contraception leave many girls with little awareness of what constitutes a healthy and safe life and asso ciated rights as women (Baltag and Chandra in Uganda revealed that about one in two girls and one in three boys did not know that they should use condoms only once. Neema et al (2004, p.29) s tate that in Uganda, sexual and reproductive health education for adolescents is still inadequate and the d accordingly many t eenagers have limited access to contraceptive methods as well.

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The UDHS data found that overall o nly 30% of all Ugandan women used any form of contraception, while only 14% of married teenage women and 7% of girls aged 15 19 years used some method of contraception ( UBOS, 2012 p.78). Limited access to contraceptive methods reflects an under investmen capital development, especially education and health (UNFPA, 2013, p.34). These factors are education especially for girls and the prevalence of d iverse obstacles constraining girls from attending or staying in school (UNFPA, 2013, p.29). Furthermore, limited education child protection services, and other opportunities leave many adolescent girls with little awareness of their rights as women (UNIC EF, 2015, p.14) The Shanti Uganda Society The Shanti Uganda is a non governmental organization working to improve maternal and infant health. The Shanti Uganda is located in Nsaasi Village, Kasana Luweero Dist rict 1) The Shanti Uganda Maternity and Learning Centre is located in Nsaasi Village, a 30 minute walk from Kasana Town. Agriculture is the major economic activity of the district. More than 85 percent of the district population has been estimated to be engaged in agriculture (Uganda Travel Guide, 2016). The Shanti Uganda began with a vision to heal the communities by uniting traditional birthing practices with modern best practices and prov iding conscious birth training for the communities impacted by war, poverty and HIV/AIDS. They give priority to maternal and infant health by creating sustainable pathways for mothers to be educated and empowered throughout the birth process, and for babie s to be given a safer and healthier start to life. They also work

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towards reducing adolescent pregnancy, and keeping young girls in school by providing reproductive health education and services. Table 2 1 shows the numbers and percentage of clients who vi sited Shanti by month and age group. Though most clients are 20 to 24 years old (49~57%), 28% of all clients of Shanti are under 19 years old. Table 1. Number and percentage of clients by age group, (Data from Shanti Uganda, 2016 ) Month Age March, 2016 A pril, 2016 May, 2016 10 19 25 (21%) 26 (21%) 26 (28%) 20 24 60 (49%) 62 (50%) 80 (57%) Over 24 37 (30%) 36 (29%) 35 (25%) Total 122 (100%) 124 (100%) 141 (100%) t hree times a year during a school break (May, August, and December). Normally, the Teen Girls Workshop is held for a week within the village such as schools, churches or community centers. Most participants are teenage girls some younger between the ag es of 10 to 18 years old. Workshops provide young women the skills, education, peer support, role models, leadership opportunities, and life skills needed to live empowered healthy lives. Each teen girl gets the opportunity to make her own reusable menstru al pad and learn about nutrition, reproductive health, HIV/AIDS, STIs, female role models and healthy relationships. This education combines prevention and empowerment, and allows them to make healthy decisions, which contributes to a reduction in early pr egnancy.

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CHAPTER 3 OBJECTIVES AND THE FRAMEWORK OF THE FIELD PRACTICUM The general objective of the field practicum is to contribute to the improvement of the specific objectives are 1) identi fy main sources of reproductive health information and services for adolescent girls ; 2) identify priority unmet needs, barriers, and constraints with regard to reproductive health services for adolescent girls ; 3) determine the best ways to meet the unmet needs identified during the field practicum ; and 4 ) provide preliminary r ecommendations for an improved intervention at the host organization (Figure 2 ). Although site specific information and needs of the target population a re important inputs for the d evelopment of appropriate interventions, this type of information has not been appropriately compiled, analyzed, and put to use in many rural areas. My research involved compiling, analyzing, and interpreting important information on key aspects of the soc iocultural, environmental, and economic context of adolescent girls, focusing specifically on the Luweero area In this regard, the needs assessment provides an important service to the host organization. Shanti Uganda is in the process of updating their c urriculum of reproductive health education program for adolescents. Accordingly, the information will be very helpful and timely for the development of content for the new curriculum. In addition to the overall needs assessment, my work also includes an ev aluation of an existing Shanti Uganda reproductive health education program for teen girls. Based on findings from the evaluation of this health education program (as part of monitoring and evaluation of the program), I also make recommendations for possib le improvements, with the hope of contributing to the effectiveness of the program to affect reproductive health in a positive way.

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The Framework of the field practicum (Fi g ure 2 ) shows the general workflow of my research. My research seeks to identify pr iority needs, barriers, and constraints currently unmet with regard to reproductive health services for adolescent girls, and to determine promising measures to meet those needs. I also include recommendations for the Shanti Uganda with aim of helping them Monitoring and Evaluation tools. Figure 2 Framework of the field practicum Figure 3 shows the conceptual map of adolescent pregnancy. The map shows how different pathways encom passing a range of underlying factors lead to adolescent pregnancies the context of Uganda, whereas negative physical and social effects are based on findings reported in the literature from general and global sources. The left column identifies underlying drivers, while the right column identifies negative outcomes that this development project aims

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to address and/or change. T he boxes in between are pathways, linking the underlying causes to the negative outcome. Those highlighted in blue are areas where Shanti Uganda has established interventions. Specifically, the organization is working to address the lack of reproductive health education and the lack of oth er social opportunities within the communities. Their interventions give adolescent girls the necessary skills, education, peer support, and role models to strengthen their ability to make healthy decisions (The Shanti Uganda, 2016). The box indicated in o range illustrates the focus of my field practicum; specifically, to carry out a needs assessment of reproductive health education. This study will contribute to: 1) an increased understanding of the very complex processes and challenges leading to adolesce nt pregnancy, and 2) the development of evidence based strategies to reduce barriers, overcome obstacles, and reduce adolescent pregnancy. Studying these complex connections and interactions will help identify and increase understanding of the fundamental and cultural dynamics affecting the reproductive health program and its implementation.

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Figure 3 Reproductive health in Uganda

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CHAPTER 4 EVALUATION OF THE TEEN GIRLS WO RKSHOP reduce teen pregnancy and STI/HIV transmission, improve teen health, and empower teen girls. The intermediate outcomes are a strengthened capacity to steadily work towards goal s despite challenges; desired behaviors include increased abstinence and/or consistent use of birth control and condoms. The short term outcomes of the workshop are 1) increased access to teen health education and support, 2) enhanced awareness of the impo rtance of women and their power and abilities, 3) improved knowledge of pregnancy and STI prevention, and 4) enhanced coping and self care skills. The objective of the Evaluation of the Teen Girls Workshop is to provide information to the participants on h ow the reproductive health program works in Uganda, giving supporting facts on the effects of the workshop and to get important feedback from the teen girls to improve services for teens. Evaluation Survey for Teen Girls Workshop Design Shanti Uganda pr ovided me with their existing evaluation tool (pre/post survey) for the Teen Girls Workshop, but I modified it by adding questions to acquire more comprehensive The updated surve y was prepared before the workshop to improve the quality of the evaluation. The upgraded initial questionnaire was designed to ask a range of questions regarding the background of the girls and pre existing knowledge on the topics that would be covered du ring the week. The post questionnaire was designed to determine whether the girls had learned the content covered; how

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their knowledge, attitudes, and skills regarding reproductive health had changed; and what improvements could be made for future workshop s. The purpose of the evaluation was to answer the questions of whether and by how much the workshop achieved its intended short term, intermediate and long term outcomes. An outcome evaluation was conducted to determine the impact of the Teen Girls Works hop. Because measuring the long term outcomes regarding sexual behaviors would have been impossible with the limited time and resources available, I posed four evaluation questions addressing short term outcomes. E ach evaluation question included outcomes that the program hopes to influence through the reproductive health education program. The first evaluation questions (EQ1) address ed one of the short term outcomes of the program which is to increase knowledge about sexual development, pregnancy, menstru ation, STIs and methods of contraception ( Table 2 ) EQ2 deal t and trust in health worker s providing health services. EQ3 was about self efficacy to use/make sanitary products (pads), to be a leader and a good role model in future, to participate in activities that promote healthy living and to obtain proper reproductive health information and services in their communities. Addi tional feed questions. Table 2. Evaluation survey structure EQ1 To what extent does the program increase knowledge of health and reproductive health for girls? EQ2 To what extent does the program impr ove positive attitude importance of sex education, using contraception and counseling with a health worker? EQ3 To what extent does the program increase self efficacy to use sanitary products, to be a good role model, to participate healthy activities and to obtain/access reproductive health information?

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Implementation The Teen Girls Workshop was held in Shanti Birth House from June 1 3 2016. The evaluation w as designed to compare responses obtained before and after the workshop, however, since the workshop lasted only three days, time was too short to conduct pre questionnaires. In addition, workshop attendance was greater than anticipated on the first day, i ncluding young girls under 10 years of age. Due to these unforeseen difficulties, only post questionnaires were administrated on the last day of the workshop, undermining our intention to obtain comparative responses. Nonetheless, the post workshop evaluat ion was invaluable, providing important information on the overall characteristics of participating girls in Luweero and the results of the workshop. 32 girls responded to the questions on the last day of the Teen EQ4 To what extent are the participants satisfied by the workshop? Indicators Instruments EQ1 Knowledge Knowledge of sexual development and reproductive health Knowledge of causes of pregnancy Knowledge of STIs/HIV Knowledge of methods contraception Knowledge regarding healthy relationships Knowledge of staying healthy (physical activities, food) 3 questions related to topics covered during workshops (open ended ) 7 knowledge test questions 14 self assessment knowledge level questions EQ2 Attitude Attitude toward sex education Attitude toward using contraception Attitude toward reproductive health workers 8 attitude questions EQ3 Self efficacy Self efficacy to use sanitary products Ability to be a good role model and a good leader Self efficacy to participate in healthy activities Self efficacy to obtain/access in reproductive health informatio n 5 self efficacy questions EQ4 Satisfaction Participation satisfaction (request for additional suggestions) 11 feed back questions

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Girls Workshop. This survey generated info rmation on the effect of workshops and the opinions of teen girls regarding the workshops. Analysis of Evaluation Survey of Teen Girl W orksho p T he workshops had been held previously in different villages each time and with range of partic ipants from diver se backgrounds. The results of survey generated vital information about the girls attending the workshops. Also, t he data collected at that time from the questionnaire show ed how the workshops achieved desired outcomes and where the workshops fell short. T he intention is that the results will be used to improve future workshops by modifying the curriculum and enhancing administrative aspects. Characteristics o f The Participants Age of girls: The workshop was predominantly attended by teenage girls betwee n the ages of 14 15 years (53%), as well as older teens. T wo participants were over the age of 20 (one: 20 and the other: 22 years old) B oth attend ed secondary school (seniors) (F igure 4 ) Figure 4 Ages of Teen Girls Participants on the Workshop. N=3 2 10 7 6 4 3 0 2 0 5 10 15 14 years 15 years 16 years 17 years 18 years 19 years Over 20 years Ages of Teen Girls Participants Number of responses

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Participant v illage s : Of the participants, 22 (73%) were residents of either Bukuma or Nsassi villages, which are the closest villages to the workshop site, Shanti Uganda. Three (10%) girls were from Nsozibirye and two girls (7%) were from Kikubajinja village. Kasana, Kigombe, and Mabanda village each had one participant (Table 3) Table 3. Villages of the teen girls participants. N=32 Village Bukuma Kasana Kigombe Kikubajinja Mabanda Nsaasi Nsozibirye Number 10 1 1 2 1 12 3 Percentage 33% 3.3% 3.3% 7% 3.3% 40% 10% Current education level: Of the participants, the largest percentage of girls came from Secondary 1, 2 and 3 (17% each level), followed by Primary 5, 6 and secondary 4 (13%) indicating how evenly distributed the ages were. The majority o f girls were in Secondary school (64%). This group saw no girls a bove Secondary 4 or less than P rimary 5. As seen by the bar graph in F igure 5 education levels were very evenly distributed. Figure 5 Education levels of the teen girls parti cipants. N=32 4 3 4 5 5 5 4 0 1 2 3 4 5 6 P5 P6 P7 S1 S2 S3 S4 Current Education Level Number of responses

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Knowledge Test Seven questions were included in the knowledge test. There were either multiple correct answers or a single correct answer to each question. Part icipants were allowed to check all ere divided into three categories: correct, partly correct and incorrect. For example, if the girl checks only one answer even though there were two correct answers t o the question, she was graded partly correct on that question. The questions are found in the annexes. Over 6 0% of the participants answered correctly the question regarding physical changes during puberty and 79% of them kne w the cause of pregnancy (Figure 6 ) 93% of pa rticipants understood methods for preventing AIDS (Q7). However, 82% of p articipants had partial knowledge regarding m enstruation (Q2) and 93% also had incomplete knowledge on methods for preventing pregnancy (Q4). Only 32% had a comprehensive understanding of how HIV is transmitted, while 52% of them had a partial understandin g. 61% of girls answered the question regarding the Symptom s of AIDS virus (Q6) incorrectly. The average score of the total knowledge test was 3.21 out of 7.

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Figure 6 Re sults of the reproductive health knowledge t est. Self assessment of knowledge l e vel The knowledge level part includes 14 questions with a 5 level Likert scale. There were no right or wrong answer s so participants were able to indicate what they know about each topic. Table 4 and Figure 7 knowledge across a variety of subjects ( question s 8 to 21). The chart and percentages (Table 4 and Figure 7 ) do not include cases where data were missing. Most of the participants replied that they know a lot or know a good amount about menstruation (Q8:68 %) and puberty changes (Q9:82 %). However, the percentages of participants who know a lot or a good amount about how to prevent unwanted pregnancy and STDs including HI V (sex ually transmitted diseases) were relatively low (Q10:4 1%, Q11:39 %). There were mark ed difference s in level of knowledge concerning family planning methods. Sixty three percent of participants replied that they know a good amount or a lot about condoms (Q15), while only a small percentage kne w about impl ants and IUDs (13% 64% 14% 79% 7% 36% 39% 93% 14% 82% 7% 93% 57% 22% 4% 14% 7% 61% 7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Q1.Physical changes of puberty Q2.Menstrual periods Q3. Causes of pregnancy Q4. Methods of preventing pregnancy Q5. HIV Q6. Symptom of AIDS Q7. Causes of AIDS Reproductive Health Knowledge Test Correct Partly correct Wrong

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and 15% respecti vely). Over half of participants replied they do not know anything about implants and IUD metho Implant:65%, IUD:52 %). Knowledge about injection s and birth control pill s was less than condoms ( Injection: 30% Pill: 33% and Condom: 63% ) They also noted that they know well where to get help if they have been abused, sexually assaulted or are in an unhealthy relationship ( both Q19 and Q20: 70%). However, 58 % of participants noted that they know v ery little or do not know about maintaining healthy relationships with boys (Q18). 75% of them reported that they know several ways to make feel good and stay healthy (Q17), and 72% answered that they know well about eating healthy foods for proper nutriti on (Q21) Overall, the average score of the self assessment knowledge level about changes that happen during puberty. i.e. pubic hair growth, body smells, breast development etc. lthy foods for proper nut rition (4.2) The next with 4.1 On the other confidence in their general knowledge regarding methods of preventing pregnancy scored between 1.7 to 3. Thus overall, the confidence in knowledge of contraceptive methods among participants was relatively low with the exception of co ndom use ( Table 4 and Figure 7 ) Table 4. Results of self assessment of the knowledge levels for teen girl participants. Knowledge Level 5 I know a lot 4 I know a good amount 3 I know some 2 I know very little 1 I know nothing Average Score 8. I k now about your menstruation (i.e. missing periods, pain during this time, sanitation). 61% 7% 14% 7% 11% 4

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9. I know regarding changes that happen during puberty. (i.e. pubic hair growth, body smells, breast development etc.) 67% 15% 4% 7% 7% 4.2 10. I know how to prevent unwanted pregnancy. 26% 15% 22% 15% 22% 3 11. I know about preventing STDs including HIV. 27% 12% 42% 4% 15% 3.3 I know about the following family planning methods 12. Injection 23% 7% 4% 31% 35% 2.5 13. Implant 9% 4% 4% 18% 65% 1.7 14. IUD 11% 4% 22% 11% 52% 2.1 15. Condom 46% 17% 17% 8% 12% 3.7 16. Pill 21% 1 2% 17% 21% 29% 2.7 17. I know several ways to make me feeling good and stay healthy (yoga, exercises, songs and dances). 54% 21% 14% 7% 4% 4.1 18.I know about maintaining healthy relationships with boys. 21% 8% 13% 8% 50% 2.4 19. I know where to seek help and the steps to take if I have been abused or raped. 57% 13% 22% 4% 4% 4.1 20. I know where to get help if I am in an unhealthy relationship and cannot get out 48% 22% 8% 11% 11% 3.8 21. I know about eating healthy foods for proper nutrition. 64% 8 % 16% 8% 4% 4.2

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Figure 7 Results of self assessment of knowledge levels for teen girl participants. Self Assessment o f Attitude When asked questions regarding their attitude with respect to wome and Q24, most participants agreed that women have an imp ortant role in the world (90 %) and they are important as a woman (81 %) (Table 5) In item 23, 53 Half of participants agreed that sex education is important in Uganda. More than half of the participants (Q26: 6 7%) agreed that two people having sex should use some form of birth control if they are no t ready to have a child. 70% of them had the perception that if they have sex without contraception, they would probably get pregnant (Q27). One in two of the participants agreed that if they becom e pregnant now, it will become a lot harde r for them to live their dreams, while about 47% of the girls disagreed with this (Q28). More than half (59 % ) of the participants would trust that the ir information is treated confidentially by a health care worker. 61% 67% 26% 27% 23% 9% 11% 46% 21% 54% 21% 57% 48% 64% 7% 15% 15% 12% 7% 4% 4% 17% 12% 21% 8% 13% 22% 8% 14% 4% 22% 42% 4% 4% 22% 17% 17% 14% 13% 22% 8% 16% 7% 7% 15% 4% 31% 18% 11% 8% 21% 7% 8% 4% 11% 8% 11% 7% 22% 15% 35% 65% 52% 12% 29% 4% 50% 4% 11% 4% Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18 Q19 Q20 Q21 SELF ASSESSMENT OF KNOWLEDGE LEVEL I know a lot I know a good amount I know some I know very little I know nothing

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Table 5. Results of self assessment of attitude for teen girls participants. Attitude 5 Strongly Agree 4 Agree 3 Neither 2 Disagree 1 Strongly Disagree Average Score 22. Wo men have an important role in the world. 73 % 17 % 0 % 7 % 3 % 4.5 23. Girls are less valuable than boys. 18 % 11 % 18 % 21 % 32 % 2.6 24. I am very important as a woman. 70 % 11 % 7.5 % 7.5 % 4 % 4.3 25. I think sex education for students in Uganda is important. 36 % 14 % 7 % 21.5 % 21.5 % 3.2 26. Two people having sex should use some form of birth control if they 52 % 15 % 15 % 7 % 11 % 3.8 27. If I have sex without contraception (family planning), I would probably get pregnant. 44 % 26 % 11.5 % 11. 5 % 7 % 3.8 28. If I become pregnant now, it is a lot harder to live my dreams. 46.5 % 7 % 0 % 21.5 % 25 % 3.2 29. If I need to talk with a health care worker about reproductive health issues (pregnancy, sexuality, HIV/AIDS, family planning etc.), I would trust that this information is treated confidentially. 44 % 15 % 4 % 22 % 15 % 3.5 Self assessment of S kill The majority of participants (83 %) replied that they can use/make sanitary products (pads) correct ly (Q30) (Table 6). After the workshop, 85 % of the partic ipants replied that they participate in activitie s which can make them healthy. 6 5% of participants replied they can obtain reproductive health information in their community and 59 % of them said it is not difficult to access reproductive health service s i n their community, while a qu arter of participants still had difficulty accessing reproductive information and services (Q33, Q34) Table 6. Results of self assessment of skill for teen girls participants. Skill 5 Strongly Agree 4 Agree 3 Neither 2 Disagree 1 Strongly Disagree Average Score

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30. I can use/make sanitary products (pads) correctly. 55% 28% 3.5% 10% 3.5% 4.2 31. I can be a good leader and a good role model in the future 48% 34.5% 3.5% 3.5% 10.5% 4 32. I participate in activiti es that make me feel good and stay healthy (yoga, exercises, songs and dances). 58% 27% 15% 0% 0% 4.4 33. If I need reproductive health information, I am able to obtain the information in my community. 29% 36% 7% 14% 14% 3.5 34. It is difficult to access /obtain reproductive health care services in my community. 19% 7% 15% 37% 22% 2.6 Feedback f rom Participants o n The Teen Girls Workshop Eighty eight percent of partici irls pr ogram was helpful for them and 72 % of them replied they would like to recommend the program to their friends or someone else (Figure 8 ) Almost half of them agreed that a week long workshop wa s enough to cover all the topics while 37 % of them disagreed with this. In Q37, the optional answers for t he preference of length of workshop duration was were 3 days, one or two weeks, and a month. Figure 8 Responses to question s 88% 72% 56% 4% 4% 7% 8% 24% 37% is helpful for me. Q36. I would like to recommend friends and other girls in the community. Q37. One-week workshop is enough time to cover all the topics Feedback from Participants on the Teen Girls Workshop Agree(Agree & Strongly Agree) Neither Disagree(Disagree & Strongly Disagree)

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When asked to note the obstacles faced when assessing reproductive health education, 41 % percent of the participants replied that they did not know where to get reproductive health education (Figure 9 ) More than 30% of participants answered that reproductive health education was not available anywhere nearby. Some participants answered that their parents did not want them to know abo ut reproductive health (30%), while others thought that reproductive health education was expensive (30%). A quarter of participants said they were too embarrassed or shy to go anywhere to get reproductive health education. Figure 9 Most common barriers to access reproductive health education (Workshop Participants) N=32 After the workshops, the survey asked the girls to choose the person with whom they would prefer to discuss pregnancy, HIV/AIDS, abstinence and the family planning that was covered during the workshops. There was no significant difference between the people whom the teen girl participants prefer to discuss reproductive health (Figure 10 ) Eight of the 32 responses (25%) noted that they prefer to discuss with Shanti Staff. 22% of participants answered that it is their parents or health workers with whom they prefer to talk with about reproductive health issues. 8 10 8 7 13 2 1 RHE was expensive RHE was not available anywhere near by My parents didn't want me to know about it I did not know where to get RHE I was morally wrong to know about RH in my age It is against my religion to know RH in my age Q.39 In the past, what obstacles have you faced when accessing reproductive health education before? Circle up to 3 Number of responses

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Figure 10 Preference with respect to whom to discuss about reproductive health is sues N=32 When asked about the highlight of the workshops, the responses varied. 13% of girls said that the highlight of their week was learning about healthy relationships, and leaning more about body changes and their roles. Other girls mentioned pad making, care for the reproductive health system and making cake as the highlight. Most girls had no further suggestions regarding new activities or sessions Shanti could run or did not answer this question. Two girls would like more food and transportatio n support. Furthermore, some participants would like to have an allowance and more workshop materials. Feedback f rom Shanti Staff After the teen workshop, I interviewed the interns, staff and the main instructor who were involved in the teen workshop for their feedback. It was very helpful to understand their challenges and needs in teaching girls and managing the sessions. All staff and interns m entioned that the workshop needed to be better organized. This was the most important area for improvement. Wh en Shanti changed the location from previously planned (churches or schools) to Shanti Uganda just before workshop initiation some items on the sc hedule were altered or skipped. Also some staff did not know when they should carry out their sessions or ho w to help. 22 13 13 19 22 0 25 0 5 10 15 20 25 30 Your parents Other family member School teacher Friends Health worker (clinic, hospical) Religious leader Shanti Staff With whom do you prefer to discuss these topics (pregnancy, HIV/AIDS, abstinence and family planning)? Percentage of responses

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Thus, it is necessary that the main instructors and other staff meet before starting the workshop and plan the exact time schedule. Some staff said that time management was one of the challenges. There was not en ough time to share ideas or ente r into sufficient detail on certain topics. Some topics were hurried over for lack of time Also there were not enough opportunities for the girls to ask questions. Rather than having question and answer periods throughout the discussions and days, there was only one period on the last day before graduation. Shanti staff distributed paper to each where they could jot down their questions anonymously. Then, they collected the paper s and a midwife answered their questions. Even though it was short workshop, the staff were able to address some points which girls did not understand well. With better time management, however, girls would feel free to ask more questions and would become actively involved in the discussions with others. For example, other Shanti s taff who were not directly involved in the teen girl workshop are willing to help the workshop. But there was no specific and organized schedule that they can participate in. Additional opinions and recommendations : 1. A sk a group of mothers to contribute foo d for lunch each day 2. Guest speaker (invite a community leader or woman who can be a good role model) 3. Introduce p ad making with a sewing machine ( there was not enough time to finish pad making, so us e a s e wing machine if possible) 4. Sustainable fundraising (more materials such as pen cils, pens, papers, board, marker s are always needed. Sustainable funding for the teen workshop is necessary Key Lessons from The Evaluation Survey Most girls answered that they were satisfied with the workshops, found it to be helpful and would like to recommend the workshops to others. O pinion s regarding duration of workshops varied. Some girls prefer one week, but other girls would like two weeks or even a

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month. As the workshop was carried out for 3 days and it was shorter t han previous worksh ops, some girls might feel it was not enough time to cover all the content areas to an adequate degree. Some of the concepts were covered hast ily, without enough time to truly grasp the concepts so some girls did not fully understand som e concepts and information such as how to track their period dates. Therefore, it needs to make sure the workshop is carried out over a full week or even longer period. After the workshop, one out of four (25%) girls replied that they would prefer to disc uss reproductive health issues with Shanti staff. This time, the workshop was held in Shanti Birth House so the girls could meet with staff working in Shanti and see the facility during the workshop. It implies that the girls might feel more comfortable a nd free to access reproductive health services after workshops. Also, the workshops gave the girls the opportunity to build trust in the Shanti staff, allowing them to share concerns and personal issues in confidentiality. Thus, conducting the workshops at the Shanti Birth House is beneficial. The questionnaire also shed light on the knowledge, attitude and skills of the girl s on the topics that were covered. The first section of the post questionnaire asked the girls about the knowledge they had acquired d uring the week. After the workshops, the majority of the girls had very good comprehension of the topics covered and took away key lessons with regards to role models, nutrition, puberty, the cause of pregnancy and methods for preventing AIDS. On the other hand, many girls only partly understood the topics of menstruation and methods for preventing pregnancy. Moreover, over half of the girls had misunderstandings about the symptoms of AIDS. There was still a lack of knowledge on healthy relationships and re garding different contraceptive methods, with the exception of condom use. During the next workshops,

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it would be advisable to invest additional time on core topics like STDs, contraceptive methods and menstruation. Regarding attitudes, the response s sho w ed that many girls still d id not thi nk that pregnancy itself hinders their future or they feel they can overcome issues created by pregnancy 5 9 % of girls answered that they would trust that their reproductive health information is treated confidentially b y a health care worker, while 37 % of girls still do not have this trust. So, more youth friendly services and environmental supports are needed for building up trust and providing better education for girls. Participants also showed a good level of self e fficacy on using sanitary products (pads) correctly, participating in healthy activities and eating healthy food. After the workshop, more than half of them noted that they can access reproductive health services and information in the community. These res ults may indicate that the workshops provide an opportunity for the girls to better access reproductive health service s in the community Another key lesson from the questionnaire was the barriers the girls faced in accessing reproductive health education. The obstacles faced by most girls were that they did not know where to get reproductive health education. Also some girls replied that it is due to a lack of services. Discomfort with p arents and feelings of embarrassment were further obstacles to accessi ng reproductive health education. Gaining an understanding o f these obstacles was important as a first step for finding a way to overcome them. Shanti may serve to improve accessibility of reproductive health education and ensur e greater attendance.

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CHAPTER 5 NEEDS ASSESSMENT Needs Assessment Methods In order to better understand the barriers and constraints limiting reproductive health service for young women in Uganda, participatory and qualitative research methods were us ed to collect data to examine the issues from many different angles. These included individual semi structured interviews with important stakeholders in the community to assess their needs for reproductive health education and services, surveys with young women, and direct observations in Luweero District, central Uganda. Information about accessibility to health care facilities and reproductive health services for girls was collected through direct field visits and secondary data sources. The reproductive health education needs assessment targeted young women, in general, who live in Luweero district. It was necessary to include a survey of young women instead of a focus group discussion with teen girls, which I had originally planned to do in my field prac ticum. During the first attempt to conduct a focus group discussion, adolescent girls felt shy and did not express their opinions openly about reproductive health issues, even in small discussion groups, so I decided to change the method to individual surv eys. Research methods and design respected the communication rules that exist within the society. For example, I followed a culturally appropriate dress code. Clothing that reveals the upper thighs, midriff, or cleavage would not have been acceptable, nor would tight fitting clothing such as leggings or yoga tights. When representing Shanti Uganda, I dressed by Ugandan standards of modesty and professionalism.

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Semi structured Interviews Design oductive health education, it cultural context, particularly social norms about sexuality and reproductive health education. Therefore, before conducting interviews, I reviewed the existing literature on reproductive health education, on reproductive health services in the African context, and on social norms in Uganda. As communication about sexuality between parents and their adolescent children is not common in Uganda, the study design does not include interviews w stead, I included community leaders teachers, and other stakeholders who actively involved in the provision of reprodu ctive health services in the community. I planned to conduct semi structured interviews of 20 30 individuals who were likely to give me the most complete information on the issues from a variety of perspectives, ideally 3 5 people from each of the identified groups to compile balanced information The key informants in the community were : School tea chers in secondary and primary schools Staff of the organization in the host organization office (The Shanti Uganda) Staff of NGOs that provide s ervice s to children in the community Church leaders, community groups and officials from government offices (D istrict Health office, District education office) Health workers in clinics, hospitals, and health facilities Teen girls who participated in the Teen Girl Workshop opinions about general reproductive health issues The questions included information on the following topics:

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Table 7. Example of Semi structured interview questions Topic Focus Core questions (examples) Main sources of information Most frequently used and m ost important sources How have you/young women found out about reproductive health information? Whom or what do you/young people rely on for information? Is there anyone that you/young people do not talk to? Whom or what are the most important sources o f information to young people The role of friends How important are friends as a source of information? What issues do you/young women talk about? Do you/young women talk about reproductive health (sexuality) with friends? Other sources of informatio n Are there any other people/places that you/young women have found useful in finding out about relationships, reproductive health and contraception? Are there other people/places available to you/young women for advice and support? School reproductive health education quantity and quality Have reproductive health issues ever been spoken about at school? How was it taught? What teaching methods were used? How do you feel about the reproductive health education that is provided in school? Could it hav e been better / improved upon? How? Why? Views about services Do young men and women visit the local services for contraception and sexual health advice? What are your general impressions of the services provided for young people? Recommendations/ Sugges tions What do you think are the most important features of a reproductive health education for young people? What will make young people go? be held? Why? Who should provide the inform ation and advice? Implementation The host institution, Shanti Uganda, had their own staff for their reproductive health education program. I cooperated with the institution in managing the needs assessment process, and work with the staff to recruit par ticipants. Key staff members of the Shanti Uganda were

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included in interviews as well. The staff of the institution introduced me to health workers, community leaders and official workers in the community with whom they were working or had worked before. T elephone numbers or email addresses were n ot available in the local areas, s o I visited the sites directly then introduced myself and explained the research effort to identify the key person with whom I should meet Also, the MDP Director at the U niversity of Florida and the D irector of Shanti Uganda wrote letters for research support request to local institutions. There are many schools in Kasana town and nearby villages. I chose five schools close to ted the schools located in Lu weero and brought the research request to conduct research (interviewing and survey) at the schools. Once I had gained permission, I advertised the research a nd teachers interested in participating contacted me directly. Because of limit ed time, in some schools, I interviewed only one teacher who was a senior woman teacher or a biology teacher. The senior woman teacher is mainly responsible to take care of fema le students and provide them reproductive health information. I also visited some local health facilities, churches, mosques, and local institutions located in the community to advertise the study and seek participants. I conducted se mi structured intervi ews with 3 1 main stakeholders and 9 girls (Table 8) utilizing an open and informal interview style. They provided comprehensive information on the issues of interest. This enabled me to list general health issues including reproductive health problems usi ng local terms and prepare a list of services commonly used as well as carry out an exploration of problems, the reasons why they occur, and possible solutions. I explained the purpose of the interview and asked each informant for consent. I nterview s were recorded using a digital device, after indicating that they would be recorded and kept confidential.

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Table 8. Main stakeholders who participated in the semi structured interviews Categories Study Areas (Name of the site) Number of people Total: 40 Schoo l teachers Nsaasi UMEA p rimary school Progressive s econdary school ST KIZITO s econdary School Katikamu Kisule p rimary school Muslim s chool 1 2 3 3 1 10 Staff of organizations Shanti Uganda Concern for the girl chil d Luweero b ranch 6 1 7 Leaders or official workers in the community Parish (Catholic church, Kisule) Luweero district h ealth office Luweero district e ducation office 2 2 2 6 Health workers who serve the community Reproductive h ealth Uganda G ood Samarian h ealth centre III Kasana hospital (Marie Stopes International Uganda) 2 3 3 8 Teen girls Shanti Uganda Teen Girls W orkshop 9 9 Needs Assessment Survey f or Young Women i n General i n The Community Design This survey was intended for female youths to address reproductive health needs. As the study aimed to identify high priority unmet needs, barriers, and constraints with regard to reproductive health services for adolescent girls and young women, and to determine the best ways to meet those needs, the survey health and reproductive health education needs. Also, the survey design focused more on identifying s s to reproductive health services and educations rather than their personal knowled

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Even though the definition of adolescence stops at the age of 19 in Uganda, this study included partic ipants up to 24 years old in order to capture their previous experiences, as well as their suggestions for improving services for younger women. Based on cultural factors, some adolescent girls might fear or feel shy to express their ideas about reproduct ive health and sexual issues. Young women aged over 19 years old might have just passed their teens, and can express more freely their ideas about the obstacles and challenges related to accessing reproductive health services in their teen years. Also, the ir voices can present how young women experienced reproductive health education and how they had the information when they were adolescents. Moreover, there were students who dropped out of school and returned They are often over 20 years old while comple ting their secondary education So this study included women up to 24 years old in the target participant group. Data collection addressed general health issues including reproductive health service needs and services commonly provided. In addition, the s urvey questions inquired about relating to reproductive health, social networks, access to health facilities and reproductive health services, any barriers or obstacles to access them, and possible solutions. Open ended questions focu sed on the following topics: Table 9. Needs assessment survey questions structure Topic Focus Core questions Main sources of information Where you have learned the most about reproductive health and health information With whom do you prefer to discuss these topics (pregnancy, HIV/AIDS, abstinence and family planning)? Barriers or obstacles to access reproductive health service In the past, have you faced any obstacles when accessing reproductive health information or education before? What obstacles have you faced when accessing reproductive health education before?

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Role of friends Do you talk about reproductive health issues with your friends? (Which friends? Male and female friends? Older and younger friends? ) How do you talk about it? Seriously / as a joke / one to one / in groups / showing off (context) etc. Other sources of information Are there other people/places available to you for advice and support? If yes, who and where? School reproductive health education quantity and quality Has reproductive health information ever been spoken about at school? If yes, what information has been given out at school? How do you feel about the sex education that is provided in school? What were your overall impressions? Views about services What ar e your general impressions of health services provided for young people in your community? Recommendat ions/ Suggestions provided (location)? Why? Who should provide the information and advice? What do you think are the best ways to advertise and promote services? Implementation I carried o ut 55 survey s of young women aged 14 to 24. The survey included demographic data questions, 26 open ended and 4 multiple choice questions. The s urvey also included 27 questions with a 5 point Likert scale which I used in the evaluation survey to measure their knowledge, attitude and skill s regarding reproductive health. The survey was conducted in 4 secondary schools, one primary school and one he alth center in Luweero district. I included one health center to meet young women who can give valuable ideas about reproductive health services. Participants from the health center were clients of the Reproductive Health Uganda (RHU) center When I visite d schools and a health center to conduct semi structured interviews, I also asked them to help conduct permission I asked teachers and health workers to help mobilize young women aged 14 to 24 y ears old for participate in the s urvey. The teachers and health workers choose young females

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randomly and distributed the survey questionnaires on paper. There was not enough time to fill out the survey form during the break time or during class. I allowed them to take the survey questionnaire and complete it at home. Participants submitted the surveys to the institutions and I collected them on other days. The questionnaire was written in English so only people who know English were able to take the surve y. Teachers chose students who can read and write official language so many secondary students were able to understand English. At one primary school, I only conducted 2 survey questionnaires as the teacher said that their y oung students were not able to read the questionnaires as well as secondary level The anonymous survey questionnaire informed participants that their information and identities would be kept confidential and they would be assigned a code number. It als o stated that results would only be reported in the form of group data and their name would not be used in any report. Table 10. Participants of the needs assessment survey Study Areas Number of people Nsaasi UMEAPrimary school, Nsaasi 2 Progressive s e condary school Ksana Luweero 19 ST KIZITO secondary s chool, Katikamu, Kisule 15 Everest c ollege, Kasana 6 ollege, Kasana 5 Health center (Clients), Katikamu 8 Total 55 Direct Observation and Secondary Data Collection During visits to key health facilities, clinics and official centers in the village, I made direct observations and collected secondary data. These observations and data collection included the visual confirmation of the existence of services being provided and/or supplies :

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reproductive health information or sexuality education supplies condom or contraceptive methods available youth friendly reproductive health services: Separated room or space, special activities or event for youth, other attractive services for youth co unseling and health service for girls Also, other secondary information related to reproductive health service including statistical data were collected in official centers, schools and health centers in Luweero district. Price of reproductive health serv ices Number/Percentage of teenage women who used/visit reproductive health services Number of school s in Luweero Number of health facilities in Luweero

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Results A nd Analysis Analysis of the Survey Data In this results and analysis section, I integrate results of semi structured interviews and the needs assessment survey by categorizing important findings. I used mixed methods to analyze the needs assessment su rvey because the survey included both qualitative and quantitative data. Q uantitative analyses were useful to better interpret finding generated from qualitative data for example of open ended questions In like manner, qualitative data was useful for interpreting and explain ing statistic al findings For example, the first four multiple choice ques tions are directly related to research objective, focused on the main sources of information and obstacles to access reproductive heal th services and information. Rudimentary data analysis was conducted in by recording the frequency of answers and comparin g the results in tables and graphs. With respect to the 26 open ended questions answers were categorized by coding and were separated into similar themes. I also analyzed word and phrases counts associated with short answer questions. Finally short explan ations provided by the young women were useful for better understanding underlying reasons and opinions of the aforementioned findings Demographic information The survey data include demographic information of 55 respondents such as age, school, school level, religion and village. The demographic data provides basic background information of the respondents. The young women are aged from 14 to 26 and an average age of the respo ndents is 18 years old (Figure 11 ). All respondents are educated in in either primary school, secondary school or university. Most respondents have a religion such as Christian, Muslim or separated them into how the respondents wrote on t he survey. Most of them live in villages located in Luweero district.

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Figure 11 Ages of the young women respondents of the survey. N=55 Table 11. Schools of the young women respondents of the survey. N=55 School Everest College College S T KIZITO Secondary School Nsaasi UMEA Primary school Progressive Secondary school Kyambogo University Kampala Universit y KI Academy Number 6 5 15 2 19 2 5 1 % 10.9% 9% 27.2% 3.6% 34.5% 3.6% 9% 1.8% Table 12. Villages of the young women respondents o f the survey. N=55 Village Katikamu Kavule Bukuma Wobulezi Nsaasi Masindi Others (In Luweero) Number 14 10 3 3 2 2 21 % 25.4% 18.1% 5.4% 5.4% 3.6% 3.6% 38.1% Main source of information Y oung women have received reproductive health and health informat ion mostly at school (87%). Over 40% of the respondents answered that parents and friends were the main source of health information (47% a nd 40%, respectively) (Figure 12 ). When asked in another question about the most influential source of inf ormation fo r young people to obtain general information, 24% of the respondents indicated school and 22% reported television. Thus, the survey results reveal that young women consider school as the most important source of information about 2 0 12 18 11 1 11 0 5 10 15 20 14 years 15 years 16 years 17 years 18 years 19 years Over 20 years Ages of Girls Participants Number of responses

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either health or general t opics for them, despite parents, friends, and mass media having important roles in providing information on health and other topics Figure 12 Main source of information regarding reproductive health N=55 Preference for accessing reproductive heal th services and information According to the needs assessment survey, 32% of the respondents replied that they prefer to discuss with health workers about pregnancy, HIV/AIDS, abstinence and family planning; 23% of the young women preferred to discuss the se topics with their parents (Figure 13 ) M any respondents replied that hospitals and health centers are the primary place in which sexual health services should be provided (54.5%) while 29% mentioned school s and teachers who should provide information a nd advice for young people on sexual health (Figure 14 ) They also mentioned senior women teachers as the people who should guide girls and advise them in school. Thus, the survey reveals that schools and health centers (health workers) are not only the m ost important information sources for reproductive health issues but also the place s where they want to get the services and information in the future. For example, one girl explained on the 0 0 2 3 5 6 9 11 12 14 22 26 48 0 10 20 30 40 50 60 Pamphlets or flyers Boyfriend Church/Mosque Radio Newspapers or magazines Friends School Please circle the three places where you have learned the most about reproductive health and health information. Number of responses

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surve y that some young people fear talk ing to their parents about sexual health so the health workers and teachers should provide informative advice. Moreover, in the survey, some respondents indicated that schools and health centers are safer and there are more trained and speciali zed people for adolescents. O ther youn g women described that schools are approachable in most communities and they can reach a single sex group easily. Also, others girls emphasized that in hospitals and health centers, information is available for everyone and services can be provided on an i ndividual basis as well. Figure 13 Preference of people with which to discuss about reproductive health issues. N=55 0 4 7 11 16 24 36 0 5 10 15 20 25 30 35 40 Other family member Religious leader Other School teacher Friends Your parents Health worker (clinic, hospical) With whom do you prefer to discuss these topics (pregnancy, HIV/AIDS, abstinence and family planning)? Percentage of responses

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Figure 14 Location/people that should provide reproductive health services. N=55 Barriers to access reproductive health ed ucation Fifty five percent of the respondents replied that they have faced some obstacles when attempting to access reproductive health information or education (Figure 15 ) Among the young women who experienced these difficulties, the most common obstac le was that the reproductive health education was not available anywhere nearby (30%). Also, 29% of the respondents said they felt too embarrassed or shy to go anywhere to solicit information. The other main obstacles were the service cost (23%) and low aw areness about the places to get proper information (20%) (Figure 15 ) 5 5 29 55 0 10 20 30 40 50 60 Counselor Home School/Teacher Health center/worker provided (location)? Why? Who should provide the information and advice? Percentage of responses

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Figure 15 Most common barriers to access reproductive health education (Needs Assessment) N=55 Moreover, in the survey, most young women (67%) replied that they do not want t o talk people don't talk to? Don't like talking to about these issues? response contradicted responses to previous questions tha t indicated (Figure 12 and 13 ) that 47% of the young women cited parents as one of the main source s of health and reproductive health information and 23% of the respondents preferred to discuss pregnancy, HIV/AIDS, abstinence and family planning with their parents (Figure 16) One of the re asons for this contradiction 55 40 0 50 100 Q3. In the past, have you faced any obstacles when accessing reproductive health information or education before? Yes No 2 5 13 20 24 29 31 0 10 20 30 40 It is against my religion to know RH in my age I was morally wrong to know about RH in my age My parents didn't want me to know about it I did not know where to get RHE RHE was expensive I was too embarrassed or shy to go anywhere to get RHE RHE was not available anywhere near by Q4. If question 3 is yes, what obstacles have you faced when accessing reproductive health education before? Check up to 3 Percentage of responses

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could be the use of different words in the questions. When the question used indirect words such as reproductive health and health information, more respondents chose parents as a main source be more reluctant to choose parents to talk with those issues. Also, the result might imply that even though the adolescent girls want to learn from their parent s about reproductive health, the cultural barrier and personal fear can serve as an additional constraint to open and frequent communication between children and their pa rents. In other words, there could be a gap between the girls who used to learn from p arents and still wish to discuss with their parents and the social/personal restrictions which still hinder girls because of fear on discussion on issues relating to sexual and reproductive health with parents. Figure 16 P erson s talk to about certain issues. N=55 Information and services that young women need The responses showed that the overall impressions for the sex education provided in school were useful. They also replied that the information received from their frien ds is very important. The information helps them to be aware of what is happening within the community 4 9 13 67 0 10 20 30 40 50 60 70 80 Young people Religious Leaders Others Parents Is there anyone that young people don't talk to about these (sex and related) issues? If yes, who is the one? Percentage of responses

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and the country as well as the similar aged groups regarding health issues. But still most respondents replied that they need better and more improved re productive health education and services through diverse health and counseling programs. In terms of specific services or information needed, the most common responses were more information concerning menstrual cycles reproduction, and sanitary pads. Als o, many girls wrote that they want to know more about how to avoid unwanted pregnancy and sexual transmitted diseases such as AIDS. Some girls said that they need more youth centers in their community and contraceptives and fami ly planning counseling for y ouths who are sexually active. A girl suggested to put sign posters around the hospital and communities about the advantages of these services to increase awareness. Moreover, many girls said the services and programs provided by health centers, community centers and schools should be attractive and interesting. Others also needed more access to radios, magazines, Internet, and diverse social media which can advertise the services and provide diverse useful information. Analysis of the Semi structured In terview Data I used thematic analysis when analyzing interviews by examining commonality, differences and relationships (Harding, 2013, 56 58). Based on thematic analysis, I organized in terviews into some key points to decipher the most relevant informati on or opinion to the research objectives. As I described a bove, the research objectives wer e to identify main sources of reproductive health information and services, to identify priority unmet needs, barriers, and constraints with regard to reproductive h ealth services for adolescent girls and to determine the b est ways to meet unmet needs. I focused on the section that could contribute to answering the What do you t hink are the most important features of a reproductive health education for young

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categorized findings by conceptual themes. Main source of information The inter view results reveal that the main source of information for adolescents is school. Most stakeholders including teachers, health workers, religious leaders and government officials said the young people get information from teachers at schools and some of t hem mentioned mass media such as television and radio to get new information. As most adolescents spend a significant portion of their time in school, this is where they become exposed to basic health and reproductive health information. Some girls replied that they got information from peers or others but recognized that the information was often not very clear or appropriate. Normally, senior women or senior men teachers are mainly responsible for conveying reproductive health messages to them, but most s chool teachers indicated there is often not a defined time communicate these messages. Only basic information such as puberty, body changes, reproductive health system and HIV were covered briefly during biology class or CRE (religion) class. Even though s ome important topics are covered in classes, teachers said, they did not have women teachers said that they brought female students together during break time or lunch time to teach them about menstruation and how to prepare sanitation pads. Importance of school ol is an important place to convey key When inquiring about the place for providing information related to reproductive health, the majority of interviewees and survey respondents agreed that school is the best place to educate adolescents. Youth spend most of their tim e in school, so the information can reach many youths

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at a time. Not all families have televisions, radios or access to other source of information, but primary and secondary school attendance is quite high in Uganda. Thus, many stakeholders believed that school should be the main place to guide and counsel young people. Actually, according to interviewed teachers, some health centers (Good Samarian Clinic and RHU) have offered an outreach program at school and provided reproductive health services coopera progressive secondary school is one of the schools closest to Shanti. Other school t eachers also indicated that this cooperating program will help both teachers and students by providing better health information and services to them. They said that the services provided to teen girls depend on their needs. But they agreed that the basic information about menstruation, family planning, healthy relationship and STIs, HIV prevention should be provided to them appropriately by trained teachers or health workers at school. Barriers to access reproductive health education The interviews reveal that many teen girls are afraid to seek reproductive health information from school teachers or even a health center. There wa s a cultural and traditional barrier that makes it difficult for young women to request this information Also, Ugandan parents o ften did not communicate with their adolescent chi ldren on sexuality because it was regarded as a taboo in many Ugandan cultures Teachers, health workers, and community leaders indicated that parents are uncomfortable communicating openly with their child ren on issues relating to sexuality. Teachers in non secular schools such as Catholic and Muslim school also said that they do not communicate openly with their students on issues relating to sexuality and contraception. Also, for some people, the concept of family planning had a negative connotation.

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These perceptions and social barriers can hinder young women in securing information essential for their health and development. Moreover, limited teaching materials and human resources is another obstacle to providing teenagers proper reproductive health information. In most schools, only teachers had textbooks. Most students could not afford their own textbooks, so they copied what teachers wrote and drew on the board. Biology teachers said it was very diffic ult to explain to students about pregnancy, contraceptive methods or body changes with only words and without the support of visual materials. In the interviews, many stakeholders also mentioned that reproductive health education and opportunities within t he government school system are deficient and taken together the aforementioned factors leave young girls with little understanding of their health and rights. Also, the number of teachers is not enough in many rural areas in the district, so a teacher has to teach several levels of classes, caring for many students at the same time. Thus, some important topics such as pregnancy and reproductive health system of our bodies are skipped or explained in hurry as a time limit, resulting in many students continu ing with misunderstandings on important health issues. These results support findings of evaluation of teen girls workshop and obstacles and barriers to access to pr oductive health services and education. Incomplete knowledge on reproductive health Most health workers and teachers agreed that lack of sex education and information led to incomplete knowledge on reproductive health services. They said many people even adults have misconceptions about sexuality and family planning methods. Also they are now well informed about other useful reproductive health services the health center offers. Some people have the misconception that the health service fee would be expens ive even though it is not. Table 9

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shows the service fee in some health clinics in the Luweero district. The basic health care fee is not very expensive: 3,000 shillings is the average cost for laboratory test (3,000 shilling = 1 dollar, a bottle of soda o r water = 1,000 shilling). However, for poor people or adolescents with little or no cash income, the cost can be expensive and burdensome. According to data of 2011 Uganda Bureau of Statistics, overall the average monthly household income derived from all sources was UGX 303,700 ($ 83.5). The urban monthly household nominal income for household was more than double that of rural (UGX 772,000 vs UGX325,000; $213.1 vs $89.7). Furthermore, in rural areas, substantial household income is generated from informa l activities, therefore, it is unstable ( UBOS, 2012 ) In addition, interview participants including health workers indicated that many women fear using contraceptive methods because it is believed that their use can lead to cancer or permanent infertility Also, interviews with religious leaders and some teachers showed that many schools in Uganda based on religious beliefs such as Catholic schools or Muslim schools had negative perceptions of contraceptive methods. Indeed, they often taught that using con traception goes against their beliefs and recommended natural birth control. These misunderstandings, negative views and fear of family planning methods make it difficult for many women to make good decisions for regarding their health. Table 13. Reprodu ctive health services fee in health facilities in Luweero District (UGX: Uganda Shilling), 2016 Services Name of reproductive health service facilities Shanti Uganda Good Samarian Health center Reproductive Health Uganda Test for Malaria UGX 3,000 = 1 US dollar UGX 3,000 n/a Urine Analysis UGX 3,000 UGX 3,000 Service fee + UGX 3,000 HIV Test UGX 3,000 Free for Pregnant women UGX 5,500

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Hepatitis B Test UGX 3,000 UGX 5,000 UGX 5,000 Antenatal Care After Booking with service fee (UGX 7,000), other vi sits are free UGX 10,000 (First) After booking other visits are free Service fee Delivery Charges Included in service fee UGX 10,000 n/a Immunization for babies Included in service fee Free from Monday to Friday n/a Service fee UGX 7,000 (Only First) n /a UGX 3,000 Importance of youth friendly service s of youth do not use health facilities due to the lack of youth friendly services. MSU states that friendly spaces are meant to engage youth through interaction with peer educator counselors and youth volunteers trained in providing youth Most stakeholders said that youths fear and are embarrassed to discuss reproductive health issues due to stigma from other people. Also, they fear disclosing their conditions due to traditional and cultural factors. To resolve these factors that could undermine reproductive health problems, youth friendly spaces are needed. The Luweero health district offi cer said there is only one health facility which provides youth friendly services in Luweero, namely Reproductive Health Uganda (RHU). I visited the Reproductive Health Uganda (RHU) center in Luweero branch which is located 10~15 min from the town of Kasan a by car. The main activities include delivery of long term and permanent family planning services and information through clinics, community based reproductive health agents and outreach. The health workers and doctor explained that they promote the utili zation of

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high quality, high impact and gender sensitive sexual and reproductive health and rights (SRHR) information and services among young men and women. The RHU health worker also explained that they are providing youth friendly services for teenagers She said there are three components for youth friendly services: attitude, activities and infrastructure. She emphasized that s toward teens dire ctly affect the services. One of the challenges is that young people fear discussing their problems and often pretend not to have sexual challenges. Therefore, health workers should respect them and strive to make them feel free to discuss openly important issues and over time build up a relationship of trust. Second, she said indoor and outdoor activities are important to attract young people. Other health workers and teachers also suggested a ctivities to welcome youths to the health center. RHU in Luweero provides some recreational a ctivities such as net ball, that attract young people t o come to the center. She indicated that boys are coming more than girls, because most outdoor activities are sports and more boys are interested in these activities. She said that different activities are what are needed to attract girls. Recently, Marie Stopes Uganda has set up two youth friendly spaces in Kampala and the Tororo distri ct by Marie Stopes Uganda, that provide sexual and reproductive health services through branch network of 16 cl inical facilities across Uganda (Marie Strops Uganda, 2015) The youth friendly spaces aims to attract you th to provide information and reproductive health services on topics like contraceptives use, condoms and STI management. The facilities are set up in a way that promotes a relaxed atmosphere and are fully equip ped with games like table tennis, quizzes, reading materials, education videos and refreshments. This kind of youth friendly spaces and programs are still needed in rural area like Luweero.

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CHAPTER 6 CHALLENGES AND LIMITATIONS OF THE STUDY Originally, t he evaluation survey was designed to compare the results of the pre workshop and post workshop tests. Some questions were the same to determine to what degree knowledge, attitudes and skills of participants improved due to the workshop. Unfortunately, th e workshop questionnaires. Only post questionnaires were administrated on the last day and we could not see how responses had changed. Therefore, allocating enough time f or the pre workshop questionnaires is necessary for the better evaluation of the program. Additionally, allocating time to administer the questionnaires will mean that the answers are well thought out and not rushed. Moreover, the evaluation method cannot capture the long term changes. While change s in knowledge, attitudes, and skills can be measured during the implementation period (one week), measuring how these factors lead to future changes in sexual behaviors or empowerment of g irls would be more compl icated because of limited time and resources available. Another problem is the language barrier of the questionnaire which caused problems for some of the younger girls. The questionnaires were written in English, and despite translation to Luganda and all owing the girls to respond in Luganda also, language remained a problem. It has been decided that to overcome this, any future surveys would ask questions in Luganda and would be translated during the analysis stage. This will allow the answers to be more detailed and comprehensive from the girls, and give a clearer image of how much they have learned during the week. Furthermore, by having an extra staff member who spoke Luganda meant that all the girls were able to understand the questions and answer to t he best of their ability, without a language barrier.

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Because adolescent pregnancy is the result of diverse underlying societal, economic and other forces, preventing it requires multidimensional strategies. A multidimensional intervention would address di verse areas, such as social isolation, gender based violence, lack of agency and participation, and economic vulnerability for adolescent girls in Uganda. Even though I was aware of the imp ortance of an integrated approach I was not able to cover all thes e issues regarding adolescent pregnancy because of limited time and resources Thus, the suggested findings and recommendation have limited scope in terms of the areas that Shanti Uganda may address. However, to maximize i ts impact, this report suggests th at schools are ideal sites to support adolescents by working against sexual and gender based norms and barriers on an individual level and in broader society.

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CHAPTER 7 DISCUSSION AND RECOMMENDATIONS Right place and right time: School Cooperative Prog ram Schools are thought to have potential to work against sexual and gender based violence (Porter, 2014, p. 271). Most stakeholders such as teachers, health workers and government officials emph chool i s an important plac e to provide messages l is a good agency for change that girls in school are less likely to get married at an early age and mor e likely to decide when to get pregnant if they wish to do so (No belius 2014: 630 631). I f Shanti develops a cooper ative program with schools, Shanti will mobilize more support and reach more teen girls. Shanti can ask to use other teaching materials and human resources specifically teachers and trained volunteers. Als o, by integrating the Teen Girl workshop into a school program, it could be implemented over a longer period of time. Currently, the Shanti workshop is being carried out for only one week or a few days during school holidays. If Shanti were to offer specia l workshops or lessons within the schools, for example, once a week during an entire semester, girls could get proper information for a more extended period which would enh ance the learning process. This would increase accessibility of reproductive health education to more girls. The most promising option to address this issue is to incorporate reproductive health education into schools, leading to broader coverage and an institutionalization of this important facet of education. T here may be a need for tr aining programs for teachers or staff who might assume responsibility for this type of education. Shanti has their own health workers and mid wives, so they could teach the students in school directly or they can train the teachers if necessary.

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Youth Fri endly Services in Safe Spaces As has been discussed, Youth f riendly services can be a powerful way of passing knowledge to youth. These spaces have been shown to improve demand for reproductive health services They enable friendly, non threatening interac tions that facilitates active participation of both service provider and youth participants. Shanti will be able to provide general youth friendly services to young clients, allowing the latter to share their issues within safe space s. Also, recreations, g ames and group activities can be used during the teen workshop. For example, MSU and RHU centers are providing net ball, table tennis, quizzes, reading materials, education videos and refreshments. Along these lines Shanti could provide a n atmosphere of r elaxation combined with diverse activities such as baking, yoga, dancing, se wing machine instruction and other g ame s which they had done before in previous workshops. Also, Shanti could provide indoor activities for youths such as health talks (group talk s ) and individual counseling in separate spaces and not interrupt ed by other adult clients. In the separate youth friendly environment, teens may feel safe and confident to share their health conditions and reproductive issues with the Shanti staf f. These youth where girls can relax and express themselves without f ear of being made to feel shame or unwelcome, and where are strongly encouraged to respect others. It offers girls help t o overcome their social isolation, interact with peers and mentors, and assess alternatives to marriage ( Edilberto & Mengjia, 2013 p. 92). R esearch by Austrian and Muthengi ( 2014: 174) showed that safe space group meetings increased girls' health assets th rough improved reproductive health knowledge as well as social empowerment. A sset building at the community level for girls could be especially effective to change harmful social norms.

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One specific way of using safe spaces can be a weekly girl group me eting with mentors who are Shanti staff or other young women from their community. These regular, stable group sessions can build social assets including friends and trusting relationships. The girls can have more chance s for in depth discussion regarding sensitive topic s related to reproductive health with other youth participa nts This will allow them to share their concerns and problems within trusting relationships Moreover, b ecause mentors are women residing in the same community (Luweero), the mento rs society beyond individuals. The mentors can share the importance of the programs to local people. Effective sharing of information on programs of reproductive health and empowerment for girls and obj ectives is essential for the success of interventions and to reduce traditional and cultural barriers on the community level. Involving D iverse H uman R esources In response to feed aff and interns sugge sted involving diverse internal resources as well as external community ones. M ost staff and interns of Shanti agreed that the Shanti Birth House is a good place to run the workshop because they have many staff and midwives who are well trained and have a great amount of knowledge and experiences about reproductive health. Also, they are willing to be involved and see practical matters such as family planning met hods, maternal care and HIV tests. Thus, involving more staff, midwives and interns would likely lead to more successful workshops. Carrying out the whole workshop with only one instructor might be some what tiring for the

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participants and for the instructo rs Each session such as Yoga, Family planning methods and nutrition topic can be carried out by different instructors. Also, Shanti could invite a guest speaker or other knowledgeable women who can share their knowledge and experience They could teach about specific topics and shape a positive attitude towards health choices not limited to safe sex practices but also healthy life skills and a positive shift in health seeking behaviors for their future. Moreover, most staff thought that an intern could c arry out activities for some specific parts or sessions during the workshop such as empowerment or gender roles. Most girls are eager to talk to the interns and want to learn their personal experiences and ideas from their home countries. Based on this fee d back, Shanti could include one additional session which would be given by interns. I prepared a session guide (two pages) related to gender roles and cultural differences (Appendix 6 ) This guide included an activity and discussion questions. Interns or volunteers from different countries could carry out a session (60~70 min) with this simple guide. If interns are available when th ey have the workshop, they could simply add this session to a as well as the girls. Appropriate Terms a nd Words f or Reproductive Health Education In reproductive health education, it is important to choose the terms carefully. For education. People can have more positive perception in using reproductive health education instead of sex education because it is a more roundabout exp ression. In the evaluation survey of Teen girls workshops, while 44% of participants agreed that sex education is important in Uganda, 32% of participants disagree with this. The use of the term, sex education, can effect

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the same survey, 72% of participants replied that the Teen Girls workshop was helpful and only 6% disagree with this question. Even though the workshop attract more youths and encourage their participation. Improving Planning Organizing a nd Promotion I think the curriculum itself and the workshop handbook which Shanti used are fine with good content. I do not think they need to be changed or have anything added immediately. they deliver. It is important that organizing and pl anning should be done well in advance of the workshop. It has a thread of connection to importance of educational management. In diverse disciplines or field like business, industry, economics and pedagogy emphasize this educational management. Educational management implies ensuring the system to work for achiev ing the goals or objective of educational organization effectively with the process of planning, organizing and directing the activities. How the organization or the instructor arranges the resource s of time, space, and personnel for maximum effect of student learning plays a vital role in most educational programs. Thus, I encourage more staff, midwives and interns to be involved in the workshops in the future. They can meet before the workshop and assign who is to teach what and who is to assume other duties each day. This will improve future workshops. Moreover, all staff and instructors should discuss and be aware of the schedule. For this part, I developed the brief schedule for next Teen Girls Workshop. It includes a time table on

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each day with specific lessons, activities and a person who runs the session. It will help make the workshop much more organized. The schedule table is following. Table 14. Example of Teen Girls Workshop schedule tab le Monday Tuesday Wednesday Thursday Friday 9 am 10 11am Orientation & Checking attendan ce Checking Attendance CH 2: Feeling Good Checking Attendance CH 4: Healthy Relationship Checking Attendance CH 5 Staying Healthy Checking Attendance Story 11 12pm Pre Evaluation Survey CH 2 Activities: Yoga CH 4 CH 5 CH 7 12 1pm I ntroduction, Girls Matter (Handbook) CH 3: Seeing the Moon Guest Speaker Family Planning CH 6 Good Food Whole Food Baking (Cake) 1 2pm Lunch & Break time (Refresh games) Lunch & Break time (Refresh games) Lunch & Break time (Refresh games) Lunch & Bre ak time (Refresh games) Lunch & Break time (Refresh games) 2 3pm CH 1: Unity CH 3 Activities: Pad Making CH 6 Baking (Cake) 3 4pm CH1 Activities (Handbook) Guest Speaker Menstruation Cup Guest Speaker: Intern Culture difference & Gender Roles Discussion Post Evaluation Survey 4 5pm Q&A, Closing Q&A, Closing Q&A, Closing Q&A, Closing Cele brate& Giving Certification, Photo time

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CONCLUSION Young gir ls in Luweero District, Uganda, face diverse vulnerabilities and risks related to reproductive health issues Most health workers and teachers mentioned the lack of sex education and informat ion as the main obstacles. They said many teen girls do not know much about reproductive health services and have misconceptions about family planning methods. Because of cultural and religious aspects, young people also face challenge s to gain the underst anding they need to enhance their ability to make good life choices. For example, Ugandan parents often do not communicate with their adolescent children on sexuality because it is regarded as a taboo in many Ugandan cultures. Moreover, teachers in some no n secular school s (Catholic, Muslim school s ) are uncomfortable communicating openly with their children on issues relating to sexuality and contraceptive methods. Some teen girls fear to ask for reproductive health information even in health centers. These barriers and constraints can hinder young women from making the right decision for their health. This study suggest that sch ools are ideal places to reach individual girl s to as well as broader society. Teen Girls Workshops provided by Shanti Uganda, eve n though carried out over a relatively short period of time, have been shown to generate positive feedback from most of teen girl participants, covering crucial information and skills for adolescent girls. The evaluation results also provide information on crucial characteristics of the participants, effects of the workshop and important feed back from the teen girls. The findings help in the derivation of more specific and clear recommendations for future programs and for potential girls who would receive the services provided by Shanti, supporting and integrating results of the needs assessment. There is much that can be done to improve Shant i Linkages to schools

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Create youth friendly safe spaces Involve divers e human resources such as interns and other knowledgeable women who can share their knowledge and experiences Use appropriate terms and words in health education Improve planning organizing and promotion In conclusion, program and Youth Friendly spaces for girls can improve accessibility of education and ensure that the girls attend more. If Shanti develops a cooperative program with schools, they can reach more adolescent girls and their teen girls program can be imple mented over a long time period. Friendly spaces, which is a powerful way of passing knowledge to youth, allowing active participation of both service provider and yout h participants. In addition, the Shanti mentors can help to create safe spa ces for working with vulnerable adolescent girls to build social supports. situation of ear ly pregnancy directly supporting adolescent girls.

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REFERENCES Atuyambe, L., Mirembe, F., Johansson, A., Kirumira, E. K., & Faxelid, E. (2005). Experiences of pregnant adolescents voices from Wakiso district, Uganda. African health sciences 5 (4), 304 30 9. Baltag, V., & Chandra Mouli, V. (2014). Adolescent pregnancy: sexual and reproductive health. In International Handbook of Adolescent Pregnancy (pp. 55 78). Springer US. Bankole, A., Ahmed, F. H., Neema, S., Ouedraogo, C., & Konyani, S. (2007). Knowledg e of correct condom use and consistency of use among adolescents in four countries in Sub Saharan Africa. African journal of reproductive health 11 (3), 197 220. Bureau of African Affairs. (2008). Background note: Uganda. The United States. Retrieved from http://2001 2009.state.gov/r/pa/ei/bgn/2963.htm Cleland, J., Ingham, R., & Stone, N. (2001). Asking young people about sexual and reproductive behaviours: Illustrative Core Instruments. World Health Organization (Ed.). Geneva Edilberto, L., & Mengjia, L. (2013). Adolescent Pregnancy: A Review of the Evidence. New York: United Nations Population Fund Garenne, M., & Zwang, J. (2008). Premarital fertility and HIV/AIDS in sub Saharan Africa. Afri can Journal of Reproductive Health 12 (2), 64 74. Gibbs, C. M., Wendt, A., Peters, S., & Hogue, C. J. (2012). The impact of early age at first childbirth on maternal and infant health. Paediatric and perinatal epidemiology 26 (s1), 259 284. Porter, H. E. ( northern Uganda. International Journal of Educational Development 41 271 282. Holub, C. K., Kershaw, T. S., Ethier, K. A., Lewis, J. B., Milan, S., & Ickovics, J. R. (2007). Prenatal and parenting stress on adolescent maternal adjustment: identifying a high risk subgroup. Maternal and child health journal 11 (2), 153 159. Austrian, K., & Muthengi, E. (2014). Can economic assets increase girls' risk of sexual harassment? Evalua tion results from a social, health and economic asset building intervention for vulnerable adolescent girls in Uganda. Children and youth services review 47 168 175. Kothari, M. T., Wang, S., Head, S. K., & Abderrahim, N. (2012). Trends in adolescent rep roductive and sexual behaviors. DHS Comparative Reports No.29. ICF International. Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. The lancet 360 (9339), 1083 1088.

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Leerlooijer, J. N., Bos, A. E., Ru iter, R. A., van Reeuwijk, M. A., Rijsdijk, L. E., Nshakira, N., & Kok, G. (2013). Qualitative evaluation of the Teenage Mothers Project in Uganda: a community based empowerment intervention for unmarried teenage mothers. BMC Public Health 13 (1), 816. Lev (2012). Investigating social consequences of unwanted pregnancy and unsafe abortion in Malawi: the role of stigma. International Journal of Gynecology & Obstetrics 118 ( S2), S167 S171 Lloyd, C. B., & Mensch, B. S. (2008). Marriage and childbirth as factors in dropping out from school: an analysis of DHS data from sub Saharan Africa. Population Studies 62 (1), 1 13. Marie Stopes Uganda. (2015). Youth Friendly Spaces Launc hed in Centres. Retrieved from http://mariestopes.or.ug/tag/university/ Neema, S., Musisi, N., & Kibombo, R. (2004). Adolescent sexual and reproductive health in Uganda: a synthesis of research evide nce (Vol. 14). Washington, DC: Alan Guttmacher Institute. Nobelius, A. M. (2014). Adolescent Pregnancy in Uganda. In International Handbook of Adolescent Pregnancy (pp. 627 641). Springer US. Patton, G. C., Coffey, C., Sawyer, S. M., Viner, R. M., Haller, D. M., Bose, K., ... & Mathers, C. D. (2009). Global patterns of mortality in young people: a systematic analysis of population health data. The lancet 374 (9693), 881 892. Shah, I. H., & hman, E. (2012). Unsafe abortion differentials in 2008 by age and d eveloping country region: high burden among young women. Reproductive Health Matters 20 (39), 169 173. The Constitution of the Republic of Uganda. (1995). Article 31. Retrieved from https://dredf.org/international/UgaConst.html The Shanti Uganda. (2014). 2014 Annual Report. The Santi Uganda Society. Retrieved from http://shantiuganda.org/wp content/uploads/2012/11/2014 Shanti Uganda Annual Report.pdf The Shanti Uganda Society. (2016). Shanti Uganda Programs. Retrieved from http://shantiuganda.org/ Uganda B ureau of Statistics (UBOS) and ICF International. (2012). Uganda demographic and health survey 2011. Kampala and Claverton: Uganda Bureau of Statistics and ICF International Inc UBOS. (2015). Statistical Abstract. Kampala: Uganda Bureau of Statistics

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Uga nda Travel Guide. (n.d.). Luweero District. Retrieved from http://www.ugandatravelguide.com/luwero district.html UNICEF. (2015). The National Strategy to End Child Marriage and Teenage Pregnancy: A society free from child marriage and teenage pregnancy. UN ICEF. UNFPA. (2013). Marrying too Young: End Child Marriage. UNFPA. ISBN:168000144 Williamson, N. E. (2013). Motherhood in childhood: facing the challenge of adolescent pregnancy United Nations Population Fund. World Health Organization. (2009). Women and health: today's evidence tomorrow's agenda World Health Organization.

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APPENDIX Appendix 1. Needs Assessment Instrument: Interview Questions INTRODUCTION Hello. My name is ___________________. I am working with The Shanti Uganda and Florida University We are conducting an interview about health in Kasana. The information we collect will help the organization to plan health services. I would like to ask you some questions about your (facility, service, and ideas related to reproductive health service). The questions usually take about 20 to 30 minutes. All of the answers you give will be confidential and will not be shared with anyone. You don't have participate in the interview, but we hope you will agree to answer the questions since your views and op inions are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. Do you have any questions? YES NO May I begin the interview now? YES NO RECORD THE START TIME HOURS _________ MINUTES ________ Interview Questions: Teacher/ Health worker / Offic ial / Others ( ) Reproductive Health Services

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Topic Focus Core questions Suggested expansion material Awareness of services What places and people do young people visit and talk to, to learn about sex, contraception, STIs? How do young men / wom en become aware of these services? Health center s, young clubs and organizations etc School sex education quantity and quality Have relationships, sex and/or contraception ever been spoken about at school? What information has been given out at school? What issues/topics have been spoken about? Who taught it? Have outside visitors/specialists come to the school to talk about these issues ? What was taught and when ? Was this the right time for student? (the right moment in their development) How was it t aught? What teaching methods were used? Single sex / small group discussions / videos / drama etc. What was it like? How did you feel about it? Did y ou feel students c ould ask questions? Did they feel comfortable to do so? Was the informati on appropriate / relevant to them ? Were the classes taken seriously? By whom? What were your overall impressions? What did you most like about the classes? Could it have been better / improved upon? How? Why? use of services Do young men and women visit the local services for contraception and sexual health advice? Why do young men / women take advantage of existing services? What might stop young people from going? Acceptability of young men and women visiting services Triggers and reasons for attending services Barriers to attendance Acceptability of services Impressions of services What do you think are the most important attributes of effective sexual health service s for young people? What do you think are the essential elements of a service? What wil l make young people go? Are there differences in the needs of young men and women? How can they both be provided for? should be offered (location)? Why, Who should provide the information service s and advice? How do you think the services in your locality could be improved upon? What do you think are the best approaches to advertis e and promot e services? Can you think of 3 words which are the most important to use when advertising and promoting se xual health services for young people? The essential elements of a service to which young people will want to go How can the needs of both men and women be catered to

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How do you think the services in your locality could be improved upon? What do young men/women in your area need? What do you need? source: Cleland et al., 2011

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Appendix 2 Needs Assessment Survey Reproductive Health Education Needs Assessment Survey Dear survey participants : The purpose of this survey is to identify priority unme t needs, barriers and constrains with regard to reproductive health service for adolescent girls. This research will help determine the best way to meet those needs and improve reproductive health education. For this research, your opinion is very importan t to address reproduct ive health services for girls. The information that you provide to us in this questionnaire will be used to help us improve the services that we provide to you and the community. Answer the questions as accurately as possible. Your ho nest responses are appreciated and will remain anonymous. Please do not write your name. Your identity will be kept confidential to the extent provided by law. Age: _________________ School: ___________________ School level: ______________ Religion: _____ _____________ Village: _______________________ reproductive health puberty, bodily changes, menstruation (periods, monthly bleeding), the biology of sex/reproduction, pregnancy, sexual i ntercourse, healthy relationships, love, marriage, contraception (family planning), Sexual transmitted Diseases (STDs), HIV etc.

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1. Please circle the 3 places where you have learned the most about reproductive health and health information. If you have learned about these from only 1 or 2 plac es, just check those places. Please circle UP TO 3 a. School b. Television c. Radio d. Doctors e. Church / mosque f. Newspapers or magazines g. Fr iends h. Parents i. Adult relatives j. Sisters, brothers, or teenage relatives k. Boyfriend l. Pamphlets or flyers m. Other (what/who?) _____________ 2. With whom d o you prefer to discuss these topics (pregnancy, HIV/AIDS, abstinence and family planning)? Choose only one answer. a. Your parents b. Other family member c. School teacher d. Friends e. Health worker (clinic, hospital) f. Religious leader g. Other: please specify: _________________ 3. In the past, have you faced any obstacles when accessing reproductive health information or education before? (please ch eck one) Yes ____ No ____ 4. If question 3 is yes, what obstacles have you faced when accessing reproductive health education before? Check up to 3 a. Reproductive health education was expensive b. Reproductive health education was not available anyw here nearby c. d. I was too embarrassed or shy to go anywhere to get reproductive health education e. I did not know where to get reproductive health education f. It is morally wrong to know about reproductive health in my a ge

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g. It is against my religion to know about reproductive health in my age h. Other (please specify) ____________________ Please write your answer 5. Whom or what are the most important sources of information for young people? What 6. Do young people of your age talk openly to other people about sex and related issues? If yes, what issues do you talk about? 7. Is there anyone that young people don't talk to? Don't like talking to about these issues? If yes, who i s the one? 8. Do the sources of information vary for young men and women? If yes, how different? 9. When finding out about reproductive health information what role have your friends played? Do you talk about reproductive health issues with your fri ends? (Which friends? Male and female friends? Older and younger friends? ) 10. How do you talk about it? Seriously / as a joke / one to one / in groups / showing off (context) etc. 11. Do young women of your age talk about sex with friends? Does this tend to be with male and/or female friends? With one person or in groups?

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12. How do you feel about the information you have received from your friends and how much do you value the information you receive from your friends? How accurate is the information? 13. What reproductive health issues do you talk about with your friend? 14. Do you think it's the same for men of your age? Do you think men talk about reproductive health, sex or contraception like women do? How are they similar? How are they different? 15. Have reproductive health information ever been spoken about at school? If yes, what information has been given out at school? What issues/topics have been spoken about? 16. If question 15 is yes, when was it taught? Was this the right moment/time for you? 17. If question 16 is yes, how was it taught? What teaching methods were used? Single sex/ small group discussions/ videos/ drama etc. 18. How do you feel about the sex education that is provided in school? Was it use ful? What were your overall impressions? 19. What did you most like about it?

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20. Could it have been better / improved upon? How could it be improved upon? Why? 21 Are there other people/places available to you for advice and support? If yes, who and where? 22 Where and with whom do young people like yourself visit and talk to, to find out about reproductive health services? 23 Did school ever teach you about the local reproductive health services? 24 What are your general impressio ns of health services provided for young people in your community? From hospital, clinic, pharmacy etc., Good/bad/embarrass/shy/ upset etc. 25 What do young men/women in your area need for your better health or better services? What do you need? 26 Are there differences in the needs of young men and women? How can they both be provided for?

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27 Do you need any other programs for teen girls? What do you think are the essential elements of these services? 28 How do you think the services in yo ur locality could be improved upon? 29 Why? Who should provide the information and advice? 30 What could be done to encourage young people to take advantage of these services? What do you think are the best ways to advertise and promote services? 31 Using a scale of 1 to 5, tell us how much you know about the following topics, with 1 being that you do not know anything and 5 that you know a lot: (Please circle one number for each topic below) Knowledge

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1 I know nothing 2 I know very little 3 I know some 4 I know a good amount 5 I know a lot 1 I know about your menstruation (i.e. missing periods, pain during this time, sanitation). 1 2 3 4 5 2 I know regarding changes that happen during puberty. (i.e. pubic hair growth, body smells, breast development etc.) 1 2 3 4 5 3 I know how to prevent unwanted pregnancy. 1 2 3 4 5 4 I know about preventing STDs including HIV. 1 2 3 4 5 I know about the following family planni ng methods 5 Injection 1 2 3 4 5 6 Implant 1 2 3 4 5 7 IUD 1 2 3 4 5 8 Condom 1 2 3 4 5 9 Pill 1 2 3 4 5 10 I know several ways to make me feeling good and stay healthy (yoga, exercises, songs and dances). 1 2 3 4 5 11 .I know about maintaining healthy relationships with boys. 1 2 3 4 5 12 I know where to seek help and the steps to take if I have been abused or raped. 1 2 3 4 5 13 I know where to get help if I am in an unhealthy relationship and cannot get out 1 2 3 4 5 14 I know about eating healthy foods for proper nutrition. 1 2 3 4 5 Attitude Please circle one number for each topic below 1 Strongly Disagree 2 Disagree 3 Neither 4 Agree 5 Strongly Agree 15 Women have an important role in the world. 1 2 3 4 5 16 Girls are less valuable than boys. 1 2 3 4 5 17 I am very important as a woman. 1 2 3 4 5 18 I think sex educ ati on for students in Uganda is important. 1 2 3 4 5 19 Two people having sex should use some form of birth control 1 2 3 4 5 20 I f I have sex without contraception (family planning), I would probably get pregnant. 1 2 3 4 5 21 If I become pregnant now, it is a lot harder to live my dreams. 1 2 3 4 5 22 If I need to talk with a health care worker about reproductive health issues (pregnancy, sexuality, HIV/AIDS, family planning etc.), I would trust that this information is treated confidentially. 1 2 3 4 5 Skill and Self efficacy 23 I can use/make sanitary products (pads) correctly. 1 2 3 4 5

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24 I can be a good leader and a good role model in the future 1 2 3 4 5 25 I can participate in activities that make me feel good and stay healthy (yoga, exercises, songs and dances). 1 2 3 4 5 26 If I need reproductive health information, I am able to obtain the information i n my community. 1 2 3 4 5 27 It is difficult to access/obtain reproductive health care services in my community. 1 2 3 4 5

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Appendix 3 Evaluation Instrument: Inter view Questions: Staff and instructor of the teen girls workshop Teen Girls Workshop Semi structured Interview for staff and the instructor 1) Did you teach the session/lecture in the order that is stated in the manual? Yes, totally ____ Yes, partiall y ____ Not really ____ Not at all ____ If not, please specify the reason (ex, lack of time, less relevant topic, less interest topics etc ) 2) Of all the assignments/activities/exercises that you taught, did you conduct them in the way they were des cribed in the teacher manual (following the exact description)? Yes, totally ____ Yes, partially ____ Not really ____ Not at all ____ If not, please specify the reason (ex, lack of time, less relevant topic, less interest topics etc) 3) Is there a ny session which you emphasized more to the participants when you taught? If yes, which session and why? 4) Is there any session which you skipped when you taught? If yes, which session and why? 5) Is there any part or content in the manual/student handboo k that are not very relevant to the to pic or that need to be edited? If yes, which part and why? 6) Is there any information you want to add in the manual/ student handbook? 7) Did you experience any challenge to teach and lead the Teen girls workshop? I f you have exp erienced any of following challenges, please check All applied. a. Recruit participants b. Getting permission from parents/guidance c. Finding and contact to place for workshop

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d. Managing and contacting to the participants e. Lack of time f. Time managem ent (starting time, closing time, lunch time etc) g. Lack of staff to teach h. Lack of volunteer to help i. Lack of student manuals j. Not relevant contents in students or staff manual k. Lack of financial resources l. Lack of teaching material resources (pad making, coo king, notes, and others) m. Organize lunch n. Lack of appropriate training o. Lack of parents and community support p. Engage participants to the workshop (raising interests, making them pay attention, enc ouraging them to ask questions, etc.) q. Other (please speci fy): _____________________ 8) What was the most significant challenge up to 3 and why? 9) If you need additional support, what kind of support do you need? please check All applied a nd explain why Support from: a. Parents b. Neighbors and community c. Shanti sta ff d. Other NGOs related to youth education, health programs, etc. e. Health care providers in the community f. School teachers g. Community leader h. Religious institution i. Financial support j. Material support k. Others (please specify): __________________ Why: 10) Any suggestion for improvements in implementing the Teen Girls Workshop Appendix 4 Evaluation Instrument: Survey Teen Girls Workshop P ost Questionnaire

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Dear Teen Girls Workshop participant : The information that you provide to us in this questionnaire will be used to help us improve the services that we provide to you and the community. Answer the questions as accurately as possible. Your honest responses are appreciated and will remain anonymous. Age: _________________ Topics Covered 1. What makes a good role model? Do you have one? 2. What makes for a healthy relationship? 3. What are the benefits of good nutrition and a healthy lifestyle? Knowledge Please circle answer all applied (can be One or More correct answers) 1 The physical changes of pub erty: (check all applied) a. happen in a week or two. b. Happen to different teenagers at different ages. c. Happen quickly for girls and slowly for boys. d. Happen quickly for boys and slowly for girls. 2. During their menstrua l periods (menstruation), girls: (che ck all applied) a. have differ ent monthly cycle for each girl b. sometimes have pain, discomfort or tiredness. c. should not shower or bathe. d. should have caffein e, like in coca cola, chai, b lack tea, chocolate or coffee.

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3 Which behavior could lead to pregnancy ? (check all applied) a. petting b. hugging c. deep kissing d. sexual intercourse (have sex) e. 4. Which is the method of preventing pregnancy ? (check all applied) a. Family planning (Birth control pills) b. Condom c. Not having sexual intercourse d. 5 HIV can be transmitted through: (check all applied) a. Sexual intercourse with an individual who is HIV+ b. Skin to skin contact with an individual who is HIV+ c. Exchanging blood with an individual who is HIV+ d. 6 Most people who have the AIDS virus show sign of being sick right away. a. True b. False c. D 7 A person can get the AIDS virus even if he or she has sexual intercourse just one time without a condom. a. True b. False Using a scale of 1 to 5, tell us how much you know about the following topics, with 1 being that you do not know anything and 5 that you know a lot: (Please circle one number for each topic below) Knowledge Level 1 I know nothing 2 I know very little 3 I know some 4 I know a good amount 5 I know a lot

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8. I know about menstruation (i.e. missing periods, pain during this time, sanitation) 1 2 3 4 5 9. I know about changes that happen during puberty. (i.e. pubic hair growth, body smells, breast development etc.) 1 2 3 4 5 10. I know how to prevent unwanted pregnancy. 1 2 3 4 5 11. I know about STD prevention, including HIV. 1 2 3 4 5 I know about the following family planning methods 12. Injection 1 2 3 4 5 13. Implant 1 2 3 4 5 14. IUD 1 2 3 4 5 15. Condom 1 2 3 4 5 16. Pill 1 2 3 4 5 17. I know several ways to make me feel good and stay healthy (yoga, exercises, songs and dances) 1 2 3 4 5 18. I know about maintaining healthy relationships with boys. 1 2 3 4 5 19. I know where to seek help and the steps to take if I have been abused or raped. 1 2 3 4 5 20. I know where to get help if I am in an unhealthy relationship and cannot g et out 1 2 3 4 5 21. I know about eating healthy foods for proper nutrition 1 2 3 4 5 Attitude Please circle one number for each topic below 1 Strongly Disagree 2 Disagree 3 Neither 4 Agree 5 Strongly Agree 22. Women have an important role in the world. 1 2 3 4 5 23. Girls are less valuable than boys. 1 2 3 4 5 24. I am very important as a woman. 1 2 3 4 5 25. I think sex education for students in Uganda is important. 1 2 3 4 5 26. Two people having sex should use some form of birth control if 1 2 3 4 5 27. If I have sex without contraception (family planning), I would probably get pregnan t. 1 2 3 4 5 28. If I become pregnant now, it is a lot harder to live my dreams. 1 2 3 4 5 29. If I need to talk with a health care worker about reproductive health i ssues (pregnancy, sexuality, HIV/AIDS, family planning etc.), I would trust that this information is treated confidentially. 1 2 3 4 5 Skill and Self efficacy 30. I can use/make sanitary products (pads) correct ly. 1 2 3 4 5 31. I can be a good leader and a good role model in the future 1 2 3 4 5

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32. I can participate in activities that make me feel good and stay healthy (y og a, exercises, songs and dances). 1 2 3 4 5 33. If I need reproductive health information, I am able to obtain the information in my community. 1 2 3 4 5 34. It is d ifficult to access/obtain reproductive health care services in my community. 1 2 3 4 5 Feedback for Shanti 35. 1 2 3 4 5 36. friends and other girls in the community. 1 2 3 4 5 37. O ne week workshop is enough time to cover all the topics 1 2 3 4 5 38. If the workshop was too short or too long, how long would you prefer it to be? ____________________________________________ 39 In the past, what obstacles have you faced when accessing reproductive health education before ? Circle up to 3 i. Reproductive health education was expensive j. Reproductive health education was not available anywhere nearby k. My parents to know about it l. I was too embarrassed or shy to go anywhere to get reproductive health education m. I d id not know where to get reproductive health education n. It is morally wrong to know about reproductive health in my age o. It is against my religion to know about reproductive health in my age p. Other (please specify) ____________________ 40 With whom do you p refer to discuss these topics (pregnancy, HIV/AIDS, abstinence and family planning)? Choose only one answer. a. Your parents b. Other family member c. School teacher d. Friends g. Other: please specify: _________________

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41 What was the highlight of your week at the Teen Girls Workshop? 42 What has the Teen Girls P rogram taught you that you will sh are with your friends? 43 What did you not understand well? Were there word s or things the instructors discussed that you still do not understand ? 44 Is there anything that you would have like d to learn that was not covered in the workshop ? If yes, what is it? 45 Do you have any suggestions that would improve the workshop or make it more fun? Webale Nyo Appendix 5 Teen Girls Workshop Budget Six Workshops x 20 teen girls June 2013 to June 2014 Item Description Budgeted Amount

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Promoti on Material 200 t shirts for six workshops $200 Printing/Stationary printing $5 Facilitator salary Portion of midwives' salary including anyone who contributed to the TGP $50 External Resource Trainer Portion of Ritah's salary $50 Transport Transport f or midwife $25 Menstrual pad supplies Materials and supplies for pad workshop $166 Certificates Printing and laminating $50 M&E Printing and other related costs $16 Airtime Mobilization and coordination $10 TGP Handbook Shanti Uganda Teen Girls Handb ook (55 pages PDF file: printing and binding ) $100 Baking Supplies (Not included in original budget) $17 Refreshments Snacks $25 Total (Six workshops) $714 (CAD) [$532 (USD)] Each Workshop $119 (CAD) [$88.7 (USD)] Teen Girls Workshop Budget for J une 2013 to June 2014, Shanti Uganda

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Appendix 6 Activity with Interns Teen Girls Workshop additional curriculum Activity with Intern s Teen Girls Workshop additional curriculum Background Notes Gender Each describes the ideas and expectations people have about men and women. These include ideas about what qualities and abilities are considered feminine and masculine and expectations about how men roles, duties, a ppearance, speech, movement, and more. Ideas about gender are learned from family, friends, teachers, religious leaders, advertisements, the media, and opinion leaders. What are gender roles? Gender roles are the kinds of activities that are considered a ppropriate for individuals based on their Each community expects women and men to think, feel and act in a certain way, simply because they are women or men. In most communities, for example, women are expected to fetch water and fuel, prepare food and care for their children and husband. Men are often expected to work outside the home to provide for their families and parents in old age and to defend thei r families from harm. Unlike the physical differences between men and women, communities create gender roles, and the ideas and laws, and religions. As the world changes, gender roles also change. Many young people want to live differently from their parents. But they sometimes find it difficult to change, because the family and community expect them to continue following old rules. As women struggle to gain the freedom to redefine their gender roles, they can also gain more control over the things that determine sexual and reproductive health.

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Activity 1. Gender Roles (45 minutes) 1. Ask each learner to write on a piece of paper one thing that women can do that men cannot do. Collect the pieces of paper and put them aside. 2. Ask each learner to write on a piece of paper one thing that men can do that women cannot do. Collect the pieces of paper and put them aside. 3. Divide the board in three parts a nd record the responses under the appropriate columns: What men can do What women can do What both can do each one. Remove any that women can also do and p lace them in the third column. each one. Remove any that men can also do and place them in the third column. 6. What should be left under the first two colu mns will be the biological differences between men and women. 7. Explain to the learners that these biological differences are called sex roles. Emphasize that they do not change over time and apply to all women and all men. 8. Shift the attention to the items that were put aside. Explain to the learners that these are called gender roles. Emphasize that they are created by society and therefore they vary from society to society and change over time as society changes. For example: Men can cut sugarcane but if women want money they can also cut cane. Men can cook meals and clean the house. Men can take care of babies and raise children In some societies, women build the houses whereas in other societies it is taboo. Ask learners to list more examples of how gender roles are different in different communities. Present the following definition of gender. determined. How we are expected to think as men and women because the way society is org anized, not because of our biological if differences. These roles do not arise from biological differences at all. Activity 2. Gender role in different country (30min)

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Facilitate a discussion with the following questions and sharing your home country : France, or anywhere you are come from) Are there jobs only m en or women can or should do? Why or why not? What are the advantages/disadvantages of women/men working in a non traditional career? What is the greatest barrier to women/men working in non traditional careers? Are there clear cut roles in your family as to who provides protection and nurturance? Why ? Is there any family role, which is decided by both males and females? Why?

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Activity with Intern s Teen Girls Workshop additional curriculum Large Group Game: Fertility Myths an d Facts 1. Explain that the group is going to play a game that will focus on signs of female and male fertility, specifically menstruation and wet dreams, and that this game will help them identify and correct myths around the topic. 2. Divide the group in to two teams and place them on opposite sides of the room. Have each team choose a name. Read one of the following statements to the first member of Team A. That person should consult with the rest of the team to determine whether the statement is a 3. Once the first player responds, say whether the answer is correct and mark the score on the board. Award one point for each correct answer. If the answer is correct, ask the player to say why this is correct. If the answer is incorrect, pro vide the right response and briefly explain why. 4. Continue by reading another statement to the first member of Team B, then alternate teams until everyone has had a chance to respond. After you have read each of the myths and facts, ask the teams to com e up with two things that they have heard about menstruation and wet dreams and share these. Have the opposite team state if it is a myth or fact, and again, tell them if they are correct and why. Afterward, add up the score and announce the winning team. MYTH or FACT? The blood coming from a woman during menstruation means that she is sick (MYTH) Cold drinks do not cause menstrual cramps (FACT) Women should not eat spicy or sour foods during menstruation (MYTH) If a woman misses her period, this could mea n she is pregnant (FACT) If men do not ejaculate, sperm will collect and make their penis or testicles burst (MYTH) It is perfectly safe for a woman to wash her hair or take a bath during her period (FACT) Having menstrual blood means a woman is dirty (MYT H) When a boy or a man has a wet dream, it means he needs to have sex (MYTH) When a man has an erection, he must always ejaculate (MYTH) Most boys have wet dreams during puberty (FACT)

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If a penis is touched a lot, it will become permanently larger (MYTH) I f a person jumps over the legs of a pregnant woman the child will look like the jumper (MYTH) If a person masturbates a lot, they will go blind (MYTH) Reproduction Myths MYTH: One cannot get pregnant with one sexual act. FACT: One runs the risk of pregnan cy each and every time one has unprotected sex, even the very first time. MYTH: The safest time to have sex is between periods. FACT: For women with menstrual cycles between 26 to 32 days, they can become pregnant from the 8th to 19th day or halfway betwee n periods. This is the least safe time to have sexual intercourse. health. FACT: Knowledge about contraception can protect against consequences of unprotected sex like unplanned pregnancies and STIs. Knowledge of reproductive health makes one fully aware Adolescent reproductive health and development policy in Kenya gi ves young people the right to access information and services. FACT: Ejaculating while sleeping is normal and natural during adolescence and is not harmful. MYTH: A woman becomes FACT: Menstruation is normal and occurs with all women. The blood that comes out is not dirty. MYTH: One should not take a bath during menstruation. FACT: Menstruation is natural and there is no restriction re garding having a bath. In fact, it is very important to keep the body clean during this time, to avoid infection of the reproductive tract. MYTH: If the hymen is broken then a girl is not a virgin. FACT: The hymen can break even without sexual intercourse, by certain physical activities like sports, exercise, and the use of tampons during menstruation. Sometimes the hymen may be loose or absent and there is no breaking of the hymen. MYTH: Contraceptive methods are harmful to your health.

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FACT: Contraceptive health. MYTH: Contraceptive pills make women barren. FACT: The use of pills does not make a woman barren. Most women find that on stopping the pill, they become pregnant within three months. MYTH: Condoms have holes and are laced with viruses. FACT: Condoms do not have holes and do not allow HIV to pass. HIV can only get through if the condom has been damaged or torn. The presence of microscopic pores in some condoms does not matter much, sin ce HIV cannot move on its own and is often attached to white blood cells, which are much larger than the virus. Condoms have of two or three layers of latex, and pores would have to be lined up in order for the virus to pass through. Then, enough of the vi rus (more than 15,000) would have to pass through to cause infection. The authors of a study investigating leakage concluded that if a condom does not break, it provides 10,000 times more protection than no condom at all. Part 2 Myths and Facts on Drugs 1 Alcohol is an addictive substance, not a drug. Myth. Alcohol is a drug, as is any substance that affects the mind or body. 2. More adolescents use alcohol than bhang. Fact. Alcohol is the most frequently used drug among adolescents because it is readily available. 3. Coffee, tea, and many sodas contain drugs. Fact. Coffee, tea and many sodas and diet sodas contain caffeine, which is a stimulant. Caffeine is addictive; headaches are a common sign of withdrawal when people stop using it. 4. It is rare for a young person to be an alcoholic. Myth. Many young people use alcohol weekly and many are addicted to it. 5. Cigarette smoking can be addictive. Fact. More people are addicted to cigarettes than any other substance. Cigarette smoking is a very difficult ha bit to break but stopping is essential for good health. 6. Many adults addicted to drugs feel like smoking bhang was the first step to their addiction. Fact. Bhang is viewed as a drug that opens the gate to the use of other drugs, by addicts and researcher s alike. 7. Alcoholism is a disease. Fact. Alcoholism is a disease, just as diabetes or epilepsy are diseases. It can respond to treatment, which includes eliminating all alcohol consumption. 8. Drugs help people handle their problems better. Myth. Drugs h elp people forget about their problems or reduce the pain caused by problems. The problems do not go away and often get worse with drug use.

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9. Inhalants are basically harmless even though adults make a big deal about them. Myth. Using inhalants (like glue and petrol) can be extremely dangerous because they can cause permanent damage to organs like the liver, brain or nerves. 10. A cup of coffee and a cold shower will sober a drunkard. Myth. Only time will cause a person to become sober. It takes one hour f or the liver to process onehalf ounce of pure alcohol. 11. Alcohol affects some people more than others. Fact. Factors that influence how alcohol affects the individual include: body weight, amount of alcohol consumed, the presence of other drugs in the sy stem, the general health of the individual at the time and how recently she or he has eaten. 12. Alcohol is a sexual stimulant. Myth. Alcohol, like cocaine and other drugs, can actually depress a person s sexual response. The drug may lessen inhibition wit h a sexual partner, but it causes problems such as a lack of erection, or loss of sexual feeling. In addition, alcohol or drugs may cause a person to do something sexually that he or she would not do when sober. 13. When people stop smoking they can revers e some of the damage to the body. Fact. If there is no permanent heart or lung damage, the body begins to heal itself when a person stops smoking. 14. Cigarette smoking will hurt a pregnant woman, but will not hurt her baby. Myth. Smoking by pregnant women may result in premature birth and low birth weight babies. 15. Drinking only beer will prevent problems with alcohol. Myth. Ethyl alcohol affects anyone who drinks it, and ethyl alcohol is present in beer, as well as in wine and liquor. Drinking beer can cause the same problems as wine or liquor. 16. Smoking cigarettes every now and then is not harmful. Myth. As soon as people start smoking, they experience yellow staining of teeth, bad breath and a shortness of breath that may affect their physical perfo rmance. Addiction to nicotine is quick. People who smoke for any period of time have a greater risk of lung cancer and other lung diseases, cancer of the tongue and throat and heart disease. 17. Bhang is not harmful. Myth. Although research is ongoing, man y experts believe that long term use of bhang is potentially dangerous and may lead to: a decrease in motivation, memory loss, damage to coordination, impaired judgement, damage to the reproductive system, and throat and lung irritation. 18. Drugs like alc ohol, miraa and cocaine wouldn t be a problem for young people if they did not cause addiction. Myth. Drugs interrupt normal growth and development for young people, cause problems with school and in relationships, and often result in unplanned pregnancies or STIs, including HIV, because their use can lead to risk taking behaviour. 19. Alcohol becomes a problem only after years of use. Myth. When a person takes a drink, alcohol immediately slows reaction times, affects balance and decreases coordination. Th at

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means an athlete, student, musician or driver may lose normal ability and performance will be affected. 20. Driving after using miraa is much safer than driving after drinking alcohol. Myth. Like alcohol, miraa affects motor coordination, slows reflexes and affects the way we see and interpret events around us. Any of these changes increases the likelihood of an accident while driving. Part 3. Menstruation and pregnancy 1. A girl can become pregnant if she has unprotected sexual intercourse before she has her first period. Fact Before a girl s first period, her ovaries release the first egg during ovulation. She can become pregnant if she has unprotected sexual intercourse around the time of her first ovulation, even before she ever has her first mens trual period. She also risks getting an STI whether she has menstruated or not. 2. It is unhealthy for a girl to bathe or swim during her period. Myth There is no reason that a girl should need to restrict any activity during her period. She should bathe every day and keep her private parts clean. 3. Abstinence is the only method of contraception that is 100% risk free. Fact Avoiding sexual intercourse of any kind is the only way to absolutely avoid pregnancy or an STI, including HIV. Practicing abstine nce does not require giving up all sexual contact, but it does mean expressing sexual feelings in ways other than having intercourse. 4. A girl can get pregnant if she has sex while she is bleeding. Fact There are two types of bleeding. The first is mens trual bleeding. During menstruation, it is unlikely, though not impossible, that a girl will get pregnant. There may also be bleeding during ovulation. If a girl has intercourse during this type of bleeding, she can get pregnant. 5. A woman is not at risk of pregnancy unless a man ejaculates inside or right outside her vagina. Myth If a man ejaculates near the opening to a woman s vagina or touches her vulva while he has semen on his fingers, it is possible for sperm to find their way inside and fertilize an egg. Girls have become pregnant without ever actually having intercourse. Some STIs can be transmitted if there is an exchange of body fluids with or without penetration. 6. Once a boy is sexually aroused and gets an erection, he has to have sex or it will be harmful. Myth There is no harm in not acting on every sexual urge; semen cannot get backed up and demand ejaculation. Occasionally a boy might feel some discomfort if he is sexually excited for a long period of time. This will disappear when he is able to relax. 7. A girl cannot get pregnant the first time she has sex. Myth It is possible to become pregnant anytime you have unprotected sex, even the first time.

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Part 4 Myths and Facts on STIs Instructions Facts and Myths (50 minutes) 1. Divide learners into four or five groups and have each group sit together. Explain that they are going to play a game. Each team will be read a statement (from the list below) and they must answer it. The team must decide whether the statement is true or false (t hey will receive1 point for a correct answer). The team must explain why the statement is true or false (and can receive another point for a correct answer). If the answer or explanation is incorrect, another team can try for an extra point. Continue until all the statements have been read. When the game is over, announce the points and winning team. 1. A person can always tell if she or he has an STI. False. People can and do have STIs without having any symptoms. Women often have STIs without symptoms bec ause their reproductive organs are internal, but men infected with some diseases like Chlamydia may also have no symptoms. People infected with HIV generally have no symptoms for years after infection. 2. With proper medical treatment, all STIs except HIV can be cured. False. Genital warts and herpes, STIs caused by viruses, cannot be cured at the present time. 3. The organisms that cause STIs can only enter the body through either the woman s vagina or the man s penis. False. STI bacteria and viruses can e nter the body through any mucus membranes, including the vagina, penis, anus, mouth, and in some rare cases, the eyes. HIV can also enter the body when injected into the bloodstream from shared needles. It can also be passed from mother to child during pre gnancy, delivery or through breast feeding. 4. You cannot contract an STI by masturbating, holding hands, talking, walking, or dancing with a partner. True. STIs are only spread by close sexual contact with an infected person. Anyone can be infected by hav ing oral, anal, or vaginal intercourse with a partner who is infected. 5. Practicing good personal hygiene after having intercourse should be encouraged. True. While personal cleanliness alone cannot prevent STIs, washing away your and your partner s body fluids right after intercourse is good hygiene. Washing does not, however, prevent pregnancy or stop HIV from entering the body through the mucus membranes in the mouth, anus, penis, or vagina. 6. It is possible to contract some STIs from kissing. True. It is rare, but possible to be infected by syphilis through kissing if the infected person has small sores in or around the mouth. The herpes virus can be spread by kissing if sores are present. HIV is not passed through saliva, and could only be transmitted through kissing if both people had open sores in their mouths or bleeding gums.

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7. The most important thing to do if you suspect you have been infected by an STI is inform your partner. False. The most important thing to do is seek immediate medical trea tment. Symptoms of an STI may never appear, or may go away after a short time, but the infection continues inside the person s body. After starting medical treatment, the person should inform his or her sexual partner(s). In the meantime, it is also import ant for the infected person to abstain from any sexual contact until the treatment has been completed. 8. Only people who have sexual contact can contract an STI. False. Babies can contract STIs such as herpes, gonorrhoea, and HIV during pregnancy or deliv ery or through breastfeeding. 9. Condoms are the most effective protection against the spread of STIs. False. Abstinence from sexual intercourse is the best way to prevent the spread of STIs. Condoms are the next best thing, but only abstinence is 100 perc ent effective. 10. Using latex condoms will help prevent the spread of STIs. True. Latex condoms can help prevent the spread of STIs, but they must be used correctly for every sexual act. Latex condoms are not 100 percent effective because they can occasio nally break or come off during intercourse. Lambskin condoms are ineffective for protection from STIs and should not be used. 11. A woman using oral contraceptives should insist that her partner use a condom to protect against STIs. True. Oral contraceptiv es do not prevent STIs, so a condom would be necessary for protection unless both partners know they are faithful to one another and are currently infection free. 12. Abstinence is the only method of contraception that is 100% risk free. True. Avoiding sex ual activity is the only way to absolutely prevent pregnancy or STIs. 13. Once you have had gonorrhoea, you cannot get it again. False. A person can get gonorrhoea as many times as he or she has sex with an infected person. It is important that anyone who is treated for gonorrhoea or any other STI make sure that his or her sexual partner is also treated. 14. There is still a significant risk of HIV transmission with condoms, since the pores in the condoms are large enough for the virus to pass through. Fals e. HIV cannot pass through latex condoms. The reason condoms are not 100 percent effective in preventing HIV infection is because they can sometimes come off or break during intercourse because they are not being used properly. Condoms provide over 10,000 times more protection against HIV infection than not using a condom. There is a strict manufacturing process that is followed when making condoms and HIV is too big to pass through latex. 15. There is no known cure for genital herpes. True. While there ar e drugs available to treat the symptoms of genital herpes, there is no cure for the disease.

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16. Condoms have been laced or coated with HIV that causes AIDS. False. Condoms are scientifically tested by the companies that manufacture them. There is strict q uality control. Many more people who use condoms would have already become sick or died if condoms had HIV inside them. 17. You will not get HIV if your girlfriend or boyfriend is clean. False. A person s risk of HIV cannot be determined by looking at a pe rson and checking her or his reputation. Some people get HIV when they have only had sex once or with one partner. 18. It is women who are spreading HIV and STIs. False. Both women and men may have HIV and may pass it to their sexual partner. Our society often blames women for spreading sexually transmitted infections, but a woman must first become infected from her partner before she can pass it to someone else. 19. Having sex with a virgin cleans a man of HIV and cures him. False. There is no cure for H IV. Having sex with a virgin only risks giving HIV to that person and will not cure the man. 20. If you have unprotected sex with a person who has HIV you will definitely catch it. False. Not everyone who has unprotected sex with someone with HIV will beco me infected. Some people can stay in a relationship with a person who has HIV for a long time and not become infected, others catch it the first time they have sex with someone who is infected. Becoming infected with HIV is always a risk but it is importan t not to assume that just because a person s partner has HIV that he or she will have it too. 21. STIs are a curse from god. False. STIs are caused by germs, which are transmitted during sexual contact and can be prevented by abstain ing from or practicing safe sexual practices

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