We conducted 30 FGD each with 6-8 participants for a total of 180-240 participants and 56 IDI from three districts of Mwanza region as described in Table 4 and 5 that follows. We further conducted vignettes interview sessions among adolescents who were in schools and out of schools who were between15-19 years. Details of their demographic characteristics are in Table 6. The study drew the participants from the communities where different categories of adolescent were identified. For the FGD, the age category for students and out of school was in the range of 10-19 years while the parents were in the age category of 30-49 years old.
Table 4
Participants socio-demographic characteristics
District | Ward | FGD type | Sex | Average age | Education | Number of Participants | No. of FGD |
Nyamagana | Buhongwa | Boys (10-14) | M | 13 | Primary Out of school | 9 6 | 2 |
| | Girls (10-14) | F | 13 | Primary Out of school | 7 5 | 2 |
| | Boys (15-19) | M | 17 | Secondary Out of school | 8 6 | 2 |
| | Girls (15-19) | F | 17 | Secondary Out of school | 13 6 | 2 |
| | Parents (30-49) | M | 41 | Male | 6 | 1 |
| | Parents (30-49) | F | 41 | Female | 6 | 1 |
Ukerewe | Nansio | Boys (10-14) | M | 13 | Primary Out of school | 8 7 | 2 |
| | Girls (10-14) | F | 14 | Primary Out of school | 8 6 | 2 |
| | Boys (15-19) | M | 17 | Secondary Out of school | 7 7 | 2 |
| | Girls(15-19) | F | 17 | Secondary Out of school | 8 7 | 2 |
| | Parents (30-49) | M | 40 | Male Female | 8 | 1 |
| | Parents (30-49) | F | 40 | Female | 6 | 1 |
Magu | Shishani | Boys (10-14) | M | 13 | Primary Out of school | 6 5 | 2 |
| | Girls (10-14) | F | 13 | Primary Out of school | 8 8 | 2 |
| | Boys (15-19) | M | 17 | Secondary Out of school | 8 5 | 2 |
| | Girls (15-19) | F | 16 | Secondary Out of school | 8 5 | 2 |
| | Parents (30-49) | M | 39 | | 7 | 1 |
| | Parents (30-49) | F | 39 | | 8 | 1 |
Table 5
IDI participants’ socio-demographic characteristics
District | Ward | IDI type | Sex | Average age | Education | Number of Participants | No. of IDIs |
Nyamagana | Buhongwa | District level | M&F | Adult | Unspecified | 5 | 5 |
| | Teachers | M&F | Adult | | 2 | 2 |
| | Religious leaders | M | Adult | | 2 | 2 |
| | Health providers | F | Adult | | 5 | 4 |
| | CHW | M&F | Adult | | 2 | 2 |
| | WEO(Mek) | M | Adult | | 1 | 1 |
| | NGOs | M | Adult | | 2 | 2 |
| | RRCHCo | F | Adult | | 1 | 1 |
Ukerewe | Nansio | District level | M&F | Adult | Unspecified | 5 | 5 |
| | Teachers | M&F | Adult | | 2 | 2 |
| | Religious leaders | M | Adult | | 2 | 2 |
| | Health providers | M&F | Adult | | 4 | 4 |
| | CHW | M&F | Adult | | 2 | 2 |
| | WEO(Mek) | M | Adult | | 1 | 1 |
| | NGOs | M | Adult | | 2 | 2 |
| | WSWo | F | Adult | | 1 | 1 |
Magu | Shishani | District level | M&F | Adult | Unspecified | 5 | 5 |
| | Teachers | M&F | Adult | | 2 | 2 |
| | Religious leaders | M | Adult | | 2 | 2 |
| | Health providers | M&F | Adult | | 5 | 4 |
| | CHW | M&F | Adult | | 2 | 2 |
| | WEO(Mek) | M | Adult | | 1 | 1 |
| | NGOs | M | Adult | | 2 | 2 |
Table 6
Social demographic characteristics of participants in vignettes
Details | Districts | Magu – Rural district | Nyamagana- Urban district | Ukerewe-Island district |
Ward/Gender/age | Education | Gender | Shishani | Buhongwa | Nansio |
Class level | | | Secondary | Primary | Secondary | Primary | Secondary | Primary |
Schooling status | In- school | Male | 1 | | 1 | | 2 | |
Female | 2 | | 1 | | 2 | |
Out-of school | Male | | 1 | | 1 | | |
Female | | | | 1 | | |
Pressing needs of the adolescents
The most important pressing needs of the adolescent in relation to the reproductive and sexual health included health education or advice related to sexual and reproductive health services and care. Adolescent girls needed specific services such as counselling on menstrual health, sexual consent, HIV/AIDS, and prevention of pregnancies. Sanitary pads during menstrual period were very important pressing need of the adolescent girls. Economic hardship placed majority of the girls in risky position as it was hard to get money from their parents to purchase supplies for their menstrual needs.
There was no difference with regards to the pressing needs across the study districts in regards to girls in school and out of school. However, most of boys in FGDs mentioned that they wanted health education and HIV test while in school. It was also reported that the needs of boys were sometimes overlooked by their parents. Participants in FGDs’ sessions mentioned pressing needs for girls as compared to the boys as quoted below: -
“There is a need for the provision of education (advice) and awareness creation on adolescence because many girls do not know about it”. FGD, out of school, girls (10-14), Nyamagana district“I think what is needed is to prioritize the needs of these children especially the boys. The boys form a group that is usually forgotten unlike the girls. The father should be educated so they can provide the basic necessities for the boy when they reach adolescents.” FGD with female parents, Magu district
“You know these are children and they are not at the age of inserting loops or any other thing as a pregnancy preventive measure. What is needed is to educate the child frequently. When a child starts using contraceptives early, she will get complications when she reaches the right age to conceive. So, you need to warn your child from time to time”. FGD with female parents, Magu district
“ We shouldn’t do sexual intercourse while we are young, we need counselling services when we reach our menstrual period, we are supposed to go to the dispensary so as to be educated on how to protect ourselves while in our menstrual period”. FGD, in school girls (10-14), Ukerewe district
“The most important pressing needs here is education”. FGD, out of school boys (15-19), Magu
Yes, they are there; when they pass, they tell us to be against childhood pregnancies, also they encourage us not share men and by doing so we will help to reduce spread of HIV/AIDS. FGD, out of school girls (10-14), Magu district
Adolescent SRH support points
Majority of girls in FGDs mentioned a range of people that they would like to receive the services from that included nurses in health facilities, parents, mothers, sisters, aunties and friends. Some of in-school girls (10-14) reported that they would seek information or guidance from their mothers but were sometimes scared because their parents could sometimes ignore them. The quotes below report that majority of girls would always inform their mothers and friends: -
“The first service I received during my first menstrual circle was from my parents who warned me against talking with men”. FGD, out of school girls (10-14), Ukerewe district
“You might go and tell your parent, but she might not listen or sometimes tend to share what you had told her with her neighbors and you might end up being told just go on”. FGD, in school girls (10-14), Nyamagana district.
“I talk to my sister because most of the time my mother is busy or sometimes, I talk to my friend”. FGD, out of school girls (10-14), Nyamagana district.
“You need to be confident to tell your parents, but you would rather tell a friend that when I woke up yesterday, I found some blood on my bed and a friend would tell my parent. She would explain that I was afraid to tell my mom or Dad so I was ready to help her telling her parents. But on my side when I started my menstrual cycles, I informed my mother and she warned me to be careful and taught me a lot of issues and I am working on the things she was telling me to do”. FGD, out of school girls (10-14), Ukerewe district
While some of the participants mentioned that they would like to receive reproductive health information from the media such as radio, television, magazines, and online platforms, majority said they prefer information from the health facility and specifically from health care providers. There was no variation in the responses in relation to ‘from whom’ they would prefer to get the services in participants of the three visited districts.
“Yes, I can get him easily, because if there is something scared me, I can easily access the health provider”. FGD, out of school girls (10-14), Magu district
“Anyone close to me who will solve my problem even my father I will talk to… some daughters are very close to their fathers; they receive great attention to the extent that a girl child does not feel afraid to tell her father about reproductive health issues”. FGD, out of school girls (10-14), Nyamagana district
“Hospital is better than home because doctors are knowledgeable and can help you. Doing it at home is not helpful, doctors can help you even with little money they won’t let you be humiliated”. FGD, Girls, in school (10-14), Ukerewe district
Majority of the respondents mentioned that they were attracted to services which can be easily obtained at health facilities such as condoms, oral contraceptives, implants, counselling and injectable contraceptives. Most of these services are used as contraceptives and perceived to attract adolescent receiving care in the facilities.
Availability of ASRH education
With regards to the availability of education related to ASRH, majority of the participants in FGD sessions reported to have received information from parents, friends, nurses, teachers, religious leaders and older people. The most general knowledge reported was on adolescent pregnancies, sexual abstinence and menstrual health for girls. Some participants said that there was inadequate support received from the parents as they mainly discussed reproductive health issues with their peers or friends. The participants in the FGD sessions and in-depth interviews reported that there was a gap between parents and children especially the male parents. Here are some quotes:
“…most of us receive advice from our mothers as we find it easy to tell them, another thing is, mother knows that her girl child has grown up so she has to instruct her on what to do, for those living with a male parent they find it difficult to explain about their body changes, they have to approach a close friend sometimes at health center”. FGD, out of school girls (10-14), Nyamagana district.
“For Muslim religion, we provide a lot of teaching about family planning education; for adolescents we ensure that are not part of the peer groups with unwanted behaviors. We control them through giving the Quran teachings; we teach them about family planning by telling them to abstain from sex until she reaches the age of adulthood to get a partner through marriage. We also teach girls on how to protect themselves by covering their bodies and to have self-respect, through this it means she can protect herself and by giving them proper knowledge on reproductive health education. The Quran teaches us a lot of things, since it touches all angles”. In-depth interview with religious leader, Magu district.
“We’re getting education from school and home; parents are also giving us instructions from engaging in sexual relations under early age”. FGD, in-school Boys (15-19), Ukerewe district.
“What I can do is to ask them to abstain from love affairs, to be serious with studying and also stop engaging themselves in risky sexual relationships as they are still young”. In-depth interview with religious leader, Nyamagana.
“We always have a teacher who talks about HIV issues for young people and to guide them on the impact and how to protect themselves from it… But about youth health we really don't know maybe as this has come up now as a new chapter maybe we should start looking at it too”. In-depth interview with teacher, Nyamagana district.
Reason for the choice of the person to talk to
Majority of those who reported to talk with their parents was due to the fact that parents would provide their adolescents with means of getting sanitary pads and advice. For those who reported to have been talking to their mothers said that they are used to such experience of conversation together and it became easier for them to continue with that relationship. Some of the participants would usually talk to their friends because they were not used to talk with their mothers prior to that moment as quoted: -
“Maybe you start menstrual circle and you have a sister who has passed through that stage you will just talk to your sister. You may realize that going to the parents may not help and going to hospital is not an option as it is not an illness”. FGD, out of school girls (10-14), Ukerewe district
“Mother, because we used to have a lot of conversation together”. FGD, out of school girls (10-14), Nyamagana district
Mothers would educate their girls when they start seeing changes in their bodies or when they start getting menstrual period or when they reach puberty. The mothers were quoted saying: -
“I must sit down with her and tell her that you are now a grown up and you have started menstruation period, you have to be very keen because you can make dirty your clothes with blood when you are in the class or any other place and you won’t have any idea that it is happening until somebody else see the mark on the back of your clothes. So, you have to be very careful”. FGD with female parent, Magu
“I will also tell her that you have already become an adult, you have to know that when you do sexual intercourse you will get pregnant. When you start sexual intercourse then that means you will start to be called a mother after you get pregnant. You have to know that sexual intercourse is not a good thing.” FGD with female parents, Magu
Preferred attributes for ASRH service outlet
With regards to ASRH services delivery attributes, majority of the respondents in FGDs reported that provision of friendly health care services in a respectful manner would make a difference. The age was reported as an important factor for accessing reproductive health care at the health facility. Participants in FGD sessions said that it was difficulty for the under 18 years children to get ASRH from the health facilities. However, the majority of participants recommended putting posters at schools and at the dispensaries to inform adolescent about where to get or access ASRH services. Adolescent reported to have wanted a service provider who is generous; who welcomes you well when you arrive at the facility, who responds and advice you well when you ask a question; the one who cares for you and not disclosing your privacy information to other people.
“age is an important factor because someone can be denied reproductive health services if is under eighteen years”. FGD, in school Boys (15-19), Ukerewe district
“I went to hospital seek for condom but they told me that I am still young, Condoms are only provided to those above 18 years old”. FGD, in school Boys, Magu district
Overall, the general remarks from adolescents across the surveyed districts was that they wanted service providers to be compassionate, be generous, be gentle, be understandable, respectful, and with humor.
One of the enablers proposed in female FGD was about creating awareness on adolescent and reproductive health. This could be through displaying posters at school as well as offering it through teachers as explained below in quotes below:
“For those services, they can put some posters at the dispensary and at the school area that “children from standard four can come and get education.” This is very possible. Even when these posters are put in the school area, the children will be aware and the teachers will be the ones providing this education. So, the children can opt to go the dispensary or the school or both to get sexual reproductive health education”. FGD with female parents, Magu district
“I think we need to get reproductive health education from school and specifically from female teachers. If they will ensure privacy and not following us behind, it would be good for us to get reproductive health services from school” FGD with Girls, Magu district
Level of privacy in provision of reproductive health care services
Lack of privacy was another issue reported by participants as an obstacle in accessing reproductive health services in different FGD sessions and IDI. In terms of insufficient privacy in health facilities, the participants reported both, visual and audio privacy must be observed when attended by health care providers. Participants reported that some adolescent cannot express themselves or they may feel shy to ask questions in presence of adults/ parents. The respondents emphasized on separation of adolescents during health education sessions as quoted below:
“I mean, the knowledge provided must be given in different groups because when you provide the knowledge to both parents and adolescents, there is a challenge. When you provide knowledge to all people of different ages some people will feel shy to ask questions. If you want to be understood by someone, let him or her ask questions so that you can explain more. If you mix adolescents with adults/ parents, they won’t be free to express themselves” (Key informant, Magu).
“Sometimes nurses at the hospital use to stay near the window, and some people might be there to investigate where are you going, they will just see you from home they decide to follow to know where are you going, they might be listening outside and when they heard you talking about reproductive health issues they come to spread this into the villagers, like we have been telling you this girl is not good she has been affected she is slimming, you will just feel ashamed and just stay at home just crying” FGD, Out of school girls (10-14), Ukerewe district
“Students (forms two to four) were picked and taken to the playing ground located far away from the presence of people. The discussion could not be heard by the third party. The discussion was between girls' students and the reproductive health service providers”. FGD, out of school girls (10-14), Nyamagana district
“The doctor didn’t talk in public to other people”. FGD, out of school girls, Magu district
“Because of presence of equipment for providing services, also the area prevents you from other people to know who has entered the room to receive services”. FGD, out of school girls (10-14), Magu district