Sexual and reproductive health problems among Ugandan youth during the COVID-19 pandemic lockdown: An online cross-sectional study

The COVID-19 pandemic threatens access to sexual and reproductive health services. With global health emergencies, there is often a total reversal of priorities and access to sexual and reproductive health services may become challenging. The aim of this study was to establish the problems related to sexual and reproductive health among Ugandan youths during the COVID-19 lockdown. This was an online cross-sectional study carried out from April 2020 to May 2020 in Uganda. An online questionnaire was used and participants aged 18years to 30 years recruited using the snowballing approach. The statistical analysis was done using STATA version 14.2. Out of 724 participants, 203 (28%) reported not having information and/or education concerning sexual and reproductive health (SRH). About a quarter of the participants (26.9%, n=195) reported not having testing and treatment services of sexually transmitted infections available during the lockdown. Lack of transport means was the commonest (68.7%) limiting factor to access to SRH services during the lockdown followed by the long distance from home to SRH facility (55.2%), high cost of services (42.2%) and curfew (39.1%). Sexually transmitted infections were the commonest (40.4%) problem related to SRH during the lockdown followed by unwanted pregnancy (32.4%) and sexual abuse (32.4%). The multivariate regression analysis shows that problems were more prevalent among the co-habiting youth [APR: 2.3 (1.6 - 3.29), p<0.001] followed by unemployed (volunteer or unpaid) [APR: 1.6 (1.03 - 2.64), p: 0.037] than in other participants. The ndings of this study show that Ugandan youths have accessing SRH information and services during the COVID-19 lockdown. Cohabiting and unemployed participants were the most affected. Lack of transport means and high cost of services were the major limiting factors to access SRH services among the youths. The ndings call for concerted efforts from the Uganda government and international non-governmental organisations to ensure access and availability of SRH services for Ugandan youths during the COVID-19 lockdown. The world is facing a global health crisis due to the current COVID-19 pandemic. The pandemic is causing disruptions in accessing sexual and reproductive health services with related problems. An online cross-sectional study was conducted to establish the problems to sexual and reproductive health among Ugandan youths during COVID-19 pandemic lockdown. A sample of Ugandan youths lled an online questionnaire and data was analysed to identify the SRH problems and the associated factors. The results showed that Ugandan youths were not able to access information and services related to SRH during the COVID-19 lockdown. Cohabiting and unemployed participants were mostly affected. Lack of transport means and high cost of services were the major limiting factors to accessing SRH services. The above ndings suggest that effective measures should be put in place to ensure access and availability of sexual and reproductive health services for Ugandan youths during the COVID-19 lockdown.


Introduction
On 11 th March, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic [1]. According to the WHO, as of 13 th October 2020, a total of 37,704,153 cases of COVID-19 had been con rmed worldwide (1,594,287con rmed in Africa), with 1,079,029 deaths (38,570 deaths registered in Africa) giving a case fatality ratio of 2.9% globally (2.4% in Africa) , and the numbers continue to rise rapidly [2][3].
Uganda announced a lockdown and dawn to dusk curfew on 13 th October 2020 and as of 29 th September 2020, Uganda had registered 9,945 con rmed cases the gains made in young people's sexual and reproductive health, similar challenges could be expected during the COVID-19 pandemic across different countries [9][10][11]. The United Nations Population Fund (UNFPA) in its COVID-19 Pandemic Global Response Plan elucidated that sexual and reproductive health is a signi cant public health issue that demands urgent and sustained attention and investment [12]. The Inter-Agency Working Group (IAWG) on reproductive health has recommended that comprehensive sexual and reproductive health services should be maintained as long as the system is not overstretched with COVID-19 case management [13] The Government of Uganda issued directives to protect pregnant women's access to maternity services [14]. However, access to essential sexual and reproductive health information and services such as contraceptives and other family planning packages like condoms, comprehensive sexuality education; obstetrics care; menstrual health materials, counselling, gender-based violence support, care for sexual health and wellbeing for young people are not prioritised during the lockdown [14]. The fear of contracting COVID-19 is also discouraging young people from seeking sexual and reproductive health services [15]. The transfer of already limited resources to deal with the pandemic and the absence of health care workers from their original duty may cause interruptions in regular provision of essential SRH services. Furthermore, SRH outcomes may worsen due to gender-based violence (GBV) which can increase the risk of chronic health conditions, disability, HIV transmission, pregnancy complications and even death [16][17]. News reports are con rming a rise in gender-based violence, unwanted pregnancy among young girls, unsafe abortion, closure of antenatal care services in some of the public health facilities, and a sharp decline in women seeking SRH services [14]. Although the Ministry of Health in Uganda and donors had come up with a strategy of establishing youthfriendly corners at health facilities to increase the uptake of SRH services by the Ugandan youths, they are currently closed [14].
Even before the COVID19 pandemic, the Ugandan health system rarely offered young people sexual and reproductive health services designed to meet their needs [18]. The Uganda demographic health survey of 2016 points to over 25% teenage pregnancies, among sexually active young people by the age of 16 years, and the unmet family planning need in the country stood at 28% [19][20]. Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortions, and maternal injury and death [19][20]. This study was carried out to explore the sexual and reproductive health problems among Ugandan youths during COVID-19 pandemic lockdown and to inform appropriate intervention measures to respond to young people's sexual and reproductive health during the health emergencies.

Study design and setting
A nationwide cross-sectional online survey was conducted during the months of April and May, 2020 among the youths in Uganda.

Study Participants
The United Nations de nes youths as those persons between the ages of 15 and 24 years [21] but the African Union de nes youths or young people as every person between the ages of 15 and 35 years [22] and the Uganda youth policy de nes youths as all young persons, aged 12 to 30 years [23]. This study was  [24]. All Ugandan youths able to consent (18 years and above) and with a minimal computer literacy level and able to access and operate WhatsApp, tweeter or Facebook were eligible to participate in the survey. Those who had lled the form but for some reason were unable to submit the questionnaire were automatically not re ected and therefore excluded in the data base for the survey.

Data Collection and Instrument
An online structured questionnaire of the study about sexual and reproductive health needs, of young people in Uganda [25] was developed using Google forms with a required consent form that had to be lled before accessing the questionnaire. As the country was under lockdown, social media was used to conduct the survey. The snowball sampling technique was used to pool the initial eligible respondents who were encouraged to recruit more respondents from their acquaintances in different regions of the country by forwarding to them the link to the questionnaire. The questionnaire was administered for a period of 14 days from 28 th April to 11 th May 2020. On receiving and clicking the link, the participants were auto-directed to the informed consent page of the survey tool. After reading the preamble and accepting to participate in the study, they were directed to the survey questionnaire.
The questionnaire was composed of 22 questions focused on several key constructs. Six questions were related to socio-demographics characteristics (age, sex, marital status, educational level, location, occupation); twelve questions on access to sexual and reproductive health information and services during the COVID-19 lockdown; two questions on limiting factors to access sexual and reproductive health information and services and two questions on sexual and reproductive health problems that Ugandan youths were facing during the COVID-19 lockdown (S1Table).

Data Processing and analysis plan
The questionnaire was pretested and reviewed to ensure correctness and appropriateness to the local context. The statistical analysis was done using STATA version 14.2 (StataCorp, College Station, Texas, USA). Categorical variables were presented using frequencies, graphs and/or gures whereas continuous variables were presented using means, standard deviations (SD).
Multivariate regression analysis of having faced any limiting factor to access sexual and reproductive health information and services, and having had any problem relating to sexual and reproductive health during the COVID-19 lockdown with socio-demographics were done using the Poisson Regression and presented Adjusted Prevalence Ratios (APR).

Ethical Considerations
This study was approved by Kampala International University Institutional Research Ethical Committee (UG-REC-023/202018). Data was collected online and the consent form was attached to the anonymous questionnaire. Only those who voluntarily accepted to participate in the study were able to access and ll the questionnaire.

Results
A total of seven hundred thirty-three (733) participants completed the online questionnaire. Nine (9) participants were excluded from the survey because they were above 30 years of age, thus the nal sample size considered was seven hundred twenty-four (724).

Socio-demographic characteristics of participants
Out of 724 participants, 56.4% were male and 78.0% were living single. As shown in Table 1 below, the mean age of the respondents was 24.4 (SD± 2.8) years. The majority (87.2%) had attained an educational level of college/university while 27.2% were salaried employees.  Of the total participants, 357 (49.3%) con rmed using the family planning methods of whom 320 (44.2%) and 37 (5.1%) were using modern and traditional methods respectively. A half (50.7%) of the participants were not using any family planning method during the study period.
Limiting factors were reported among 453 (62.6%) Ugandan youths of the 724 participants. Figure 3 below shows that lack of transport was the most common (43%) limiting factor to access sexual and reproductive health services and information during the lockdown followed by distance from home (34.5%) cost of services (26.4%) and curfew (24.4%) were the other common limiting factors.
The Ugandan youths reported having problems related to SRH [136 (18.8%) participants]. As shown below in Figure 4, STIs (40.4%) were the commonest problem related to sexual and reproductive health during the COVID-19 lockdown followed by unwanted pregnancy (32.4%) and sexual abuses (32.4%).
Having a limiting factor to access SRH among Ugandan youths with their social demographics during the COVID-19 lockdown The multivariate regression analysis shown in   access to ARVs and menstrual health materials by young people have not been prioritized during the lockdown [14].
In this study, we found lack of access to information and services of SRH among the youths during this lockdown ( Table 2). These ndings further demonstrate the inadequate access to the information and services among youths worldwide [16]. It is reported that less than 10% of adolescent women access health facilities and information about family planning in 70 developing countries despite the momentum in implementing SRH in most countries [27].
With global health emergencies, there is a total reversal of priorities and, as a result, the availability, accessibility and affordability of SRH services has become challenging [16]. During the pandemic, lack of resources may reduce access to SRH and increase maternal and childhood mortality rates [16]. The inadequate access to the information and services among youths was reported in Kenya, Zambia [28], Swaziland [29], and Uganda [30] while studying the attitudes of health professionals to adolescent SRH issues concerning provision of services. Particularly in Uganda, two major surveys conducted among university students indicated that young people had limited access to sexual and reproductive health services and HIV/AIDS-related programmes despite their engagement in high-risk sexual behaviours [31][32]. The West Africa's large, multi-country Ebola Virus Disease (EVD) outbreak of 2014-2016 tells us that there were signi cant impacts on SRH, particularly in the early stages of that outbreak, largely related to health facility closures [33]. In Sierra Leone one study estimated that there were an additional 3600 maternal deaths, neonatal deaths and stillbirths related to the decrease in health service utilization during the EVD outbreak [34]. Another study from Guinea found a decrease of 51% in Family Planning (FP) visits during the outbreak [35]. There is signi cant unmet need for information, education, and services for sexual and reproductive health for married and unmarried young people [36].
The nding from this study reports that family planning was being used during lockdown among which modern methods uptake was 44.2%. We found that condoms were the most modern contraceptive method used followed by emergency pills and IUD during the COVID-19 lockdown by Ugandan youths. These results are similar to the one found in Lao People's Democratic Republic where preventive measures that youth used were condoms, oral pills and emergency pills [37] and also similar to a study done in suburban Shanghai, whereby a youth-friendly intervention program providing information, skills, and services to promote safe sex behaviour (contraception and condom use) compared with a control group [38].
Lack of transport was the commonest (68.7%) of the limiting factor to access SRH services and information during the lockdown followed by distance from home and were to get the services (55.2%), cost of services (42.2%) and curfew (39.1%). The high percentage of no transport as the commonest limiting factors to access the SRH in our study can be explained by the status of lockdown during the study period which was limiting access to private cars and taxis in order to avoid the spread of the COVID-19 in the community as one of the measures implemented by the Ugandan Government. This nding may also imply that the lockdown may have affected more youth from poorer household with no private means of transport. During the lockdown, fewer economic activities were allowed in the country in addition to a curfew between 7 pm to 6am. Having no transport means, a curfew and the high cost of services during the study period meant that most of the participants were unable to access SRH services. In Lao People's Democratic Republic, geographical accessibility was one of the barriers to access SRH among youths [37] but in Rwanda geographical accessibility of SRH services was not seen to be a negative factor in uencing access among young people [39].
Our results show that cohabiting was associated with an increased need for sexual and reproductive health services. Cohabiting, being unemployed and the resultant extreme poverty have been highlighted as factors behind the spike in pregnancy during the Ebola outbreak, with girls reportedly having sex in exchange for water, food or other forms of nancial protection [40].
Our study revealed that STIs were among the commonest (40.4%) sexual and reproductive health related problems faced during the lockdown. This was followed by unwanted pregnancy (32.4%) and sexual abuses (32.4%). Each year, there are over six million unintended pregnancies among adolescents, most of whom do not have access to modern contraceptive methods [41]. In 2008, over 1.2 million unintended pregnancies occurred in Uganda and these accounted for more than half of 2.2 million pregnancies in the country [42]. The Uganda Demographic Health Survey of 2016 points to over 25% teenage pregnancies, among sexually active young people by the age of 16 years, and the unmet family planning need in the country stands at 28% [9]. Studies have shown the importance of SRH services in the prevention of unwanted pregnancies, unsafe abortion, reducing maternal and child mortality as well as reducing poverty and empowering women [43].
Although this study was essential during the lockdown, it had several limitations.
As virtual snowball sampling method was used, the survey was respondent driven; hence it cannot be taken as a representation for general population. The study was limited to youths who have smartphones with internet connectivity and have an understanding of English. Those with no smartphones and internet connectivity were locked out especially the rural population and any other would be participant unable to access the online form. This study only included the educated Ugandan youths, so it cannot be generalizable to the whole youth population.

Conclusion
The ndings of this study show that Ugandan youth have problems to access sexual and reproductive health services during the COVID-19 lockdown.
Cohabiting and unemployed (volunteer or unpaid) participants were mostly affected among Ugandan youths. Lack of transport means and cost of services were the commonest limiting factors to access SRH services among youths. STIs and unwanted pregnancies were the prevalent problems faced by Ugandan youths during COVID-19 lockdown. These ndings could inform policymakers where to allocate resources most e ciently on SRH among Ugandan youths and special emphasis should be put on poorer youth especially women.
There is a need for Uganda government together with other stakeholders to incorporate SRH into responses from the outset. This will support the youths to access information and services related to SRH with the view of having services that would cater for the even unemployed youth, and this could reduce the problems pointed out in the study.

Data availability
The data used to obtain the ndings is available from the corresponding author FKS and the authors SBM and RS on a reasonable request. Authors contributions SBM, FKS and RS were the principal investigators, conceived and designed the survey, supervised the online data collection and critically reviewed the manuscript. YM analysed data; KT, SOA reviewed the manuscript development and revised the data tool. JCR revised the methodology. HW and LKK participated in online data collection; CK and PK critically reviewed the manuscript. All authors read and approved the nal manuscript.