The baseline consisted of 1,704 respondents and the end-line of 1,713 respondents, spread equally between the intervention and control areas (Table 2). The male to female ratio was 56:43 at baseline and 51:49 at end-line. The age distribution was similar over time with 37% between 15 and 17 years and 63% between 18 and 24 years at baseline and 39% and 61% respectively at end-line. In the intervention area, most of the sampled youth identified as Muslim, while in the control area, identification as Muslim or Christian was more equal. The percentage of youth who reported being single was 70% in the intervention area and 66% in the control area at baseline, and 82% and 83% respectively at end-line. Similarly, the percentage of in-school youth was 37% in the intervention area and 34% in the control area at baseline, and 57% and 62% respectively at end-line. At end-line, the majority (63%) of youth in the intervention area had heard about GUSO, of which 26% had participated in the programmme. Those in the control area had also heard about it (41%), largely through the radio or schools, and of these, 12% had participated in the programme through these mediums (Table 2).
Sex and relationships in Iganga: Setting the scene
Seventy-six percent (76%) of the youth at baseline reported having engaged in sexual intercourse, compared to 61% at end-line (Table 3). There were no major differences between genders. This significant decreasing trend was observed in both the intervention and control area, but there was no significant difference in the trends between the areas. Being older than 18, a male, out-of-school and in a relationship were significantly associated with ever having sex (Table 4).
As explained by a key informant, those in school were less likely to have ever engaged in sex due to strict monitoring of youth’s movements by school staff. According to many adults and youth, youth in Iganga were curious to engage in relationships during puberty, often influenced by peers. Young women and men looked for various things in a relationship including sex, getting married and having a family/children. Some young people at baseline also shared that they wanted to be understood, loved and respected. At both study phases, particularly at end-line, many young women sought financial support, or items such as sanitary napkins, chapattis or Vaseline, and were willing to engage in sex in return.
“…just have to go look for a boy that will give me 5000 shillings and if he says “I love you”- you just accept because you know he will give you 5000 shillings another time so you can purchase sanitary towels or Vaseline or clothes…..” Young woman, FGD, 15-17 years old, End-line
Young men also recognised that money played an important role for their partners. At baseline, a young man (18-24 years, FGD) explained that young men who were working used money as an incentive ‘to lure women into sex’. Over time, sex in exchange for material goods was mentioned as the dominant form of relationships for both young men and women. While men were expected to provide financially in the relationship, women were expected to be patient, loving and ‘manageable’.
At both base- and end-line and in the intervention as well as the control area, approximately 70% of the young people agreed with the statement that they could ‘express their feelings about sexuality and relationships’ (Table 3). Those who were older than 18, were male and in a relationship were significantly more able to express feelings on this topic (Table 4). This was confirmed by some key informants who shared that younger adolescents found it more difficult to express themselves in relationships compared those who were older, and that gender socialisation enabled boys and young men to better express themselves in relationships compared to girls and young women. This was also confirmed by a younger male adolescent.
Most young people considered issues related to sexuality to be sensitive and hence used metaphors to talk about this with peers, and in some cases their parents. They would approach their parents by framing their problem as one being experienced by a friend or sharing that ‘the moon was out of the sky’ which meant they were menstruating. The survey also explored whom youth felt comfortable with to speak to about sexuality, contraceptives and relationships (Table 3). At both base- and end-line, in both areas, youth found it easiest to talk to others in their age cohort, including their peers and their partner, followed by parents, other family members and teachers. Stakeholders that they found most difficult to talk to were religious, traditional and political leaders. Nevertheless, talking to teachers, parents, other family members, religious and traditional leaders seemed to have become easier over time in both areas. At end-line, a parent shared that friends were sensitizing each other on SRHR as a result of the GUSO programme’s efforts. Likewise, a key informant shared that the intervention was enabling youth to better express themselves. A key informant, two teachers and one young woman (FGD, 18-24) specifically mentioned the positive role of senior female and male teachers, who were linked to the GUSO programme.
“Yes they [referring to the GUSO programme] empower adolescents and youths to speak for themselves if something bad is happening; they encourage them to say it out”- Key Informant Interview, End-line
While a few young participants spoke to their aunties and mothers, youth still felt some fear confiding in their parents at end-line. This was related to the norm that talking about SRHR with elders was considered shameful, and that young unmarried people, especially those under 18, should not engage in sexual relationships. On the contrary, health workers were popular among youth at end-line, and one mother specifically mentioned the GUSO health workers.
At base- and end-line, young people wished to have more autonomy in their decision-making in different aspects of their life including work, schooling and relationships. At end-line, a young man (FGD, 18-24 years) expressed that those who were out of school could make decisions as they needed to earn an income. The perspective of adult participants differed. At baseline, they felt that young people were not old enough to make decisions themselves and needed parental guidance, especially if parents were paying their school fees and the children were under 18 years.
“To me a child is a child, there is no decision I can leave them to make on their own. I make decisions for them because I am still giving them school fees.” - Female parent, FGD, Baseline
At end-line, this perspective changed and parents expressed more flexibility and discussed the importance of guiding youth in decision-making. At end-line, two key informants also acknowledged the role of GUSO in enabling youth to make their own decisions.
“Right now we thank organizations like GUSO and the government via the community dialogues being organized, young people have been able to make their own decisions and as of now cases around sex have reduced.”- Key Informant, End-line
Decisions about dating and choice of partner
Most youth mentioned that they would like to make their own decisions about sex, relationships and marriage at both baseline and end-line. There were marginal improvements over time in the ability of youth to decide whom to date. Ninety-one percent (91%) of the youth agreed that they could decide whom to date over both study areas at baseline, which increased to 94% in the intervention area and 93% in the control area at end-line (Table 3). Although the difference between the trends in the two areas over time was not significant, the difference over time within the intervention area was significant (Table 5). Being older than 18 years and being a male was significantly associated with being able to decide whom to date (Table 4). Youth were also asked if they felt they should be able to decide whom to marry, which most respondents agreed with. There was no significant change over time in both areas. (Table 3). Being in a relationship was significantly associated with being able to decide whom to marry (Table 4). In the qualitative interviews and FGDs, several young women explicitly expressed that it was for them to decide when and whom to marry, and if they wanted to be in a relationship, particularly at baseline.
At end-line, while a few youth mentioned the decision to choose their own partners, few young men also spoke about the importance of education and working (over having relationships). One young man (FGD, 15-17 years) wanted to focus on education and getting a job, while another in the same FGD felt he was too young to be in a relationship. A few youth spoke about autonomy in decisions to marry, but a male parent shared that this was a decision taken by parents after the child turned 18. Some youth and adult participants reiterated that being out of school and older could enable youth to make decisions about these topics. While the quantitative data did not confirm the role of schooling status, it did confirm that being older than 18 years was significantly associated with being able to make decisions about whom to marry, but only within the intervention area (Table 4). A few young men and women also spoke about the decision to not have multiple partners or cheat.
Decisions about sex
The survey data showed that 75% of young people in the intervention area and 78% in the control area were able to decide if they wanted to have sex or not at baseline (Table 3). The increase in the intervention area from 75% at baseline to 78% at end-line was significant (Table 5), while no significant change over time was observed in the control area; and the trends in both areas were not statistically different from each other (Table 4). Those who were older than 18, and those in a relationship were more likely to be able to make decisions around sex (Table 4). Although gender did not play a role as per the difference-in-difference analysis, according to a key informant and a teacher, young women were more restricted in their decision-making concerning sex and were often ‘lured by money’. A few youth at baseline also reiterated that young girls could not easily make decisions whether or not to have sex. According to a 21-year-old young man at end-line, boys did not usually refuse sex, but a girl could if the boy did not use a condom, was not hygienic or was not able to provide money or goods.
Peers influenced young people’s decisions about whether or not to engage in sex. At both base- and end-line, young men would emulate others who had a girlfriend or had already engaged in sexual intercourse. In particular, this was perceived to be a sign of masculinity by a young woman (FGD, 15-17) at end-line, and by a key informant at baseline. More generally, it was also seen by some youth as a sign of maturity for both young women and men at end-line. Many young women engaged in transactional sex when they saw their friends with material goods they did not have. Most adult participants at end-line felt that peers were a bad influence in this regard. The influence of pornographic videos was also cited by a few youth and adult participants at end-line. Moreover, parents also mentioned discos. The descriptive statistics showed that 11% of youth in the intervention and control area at baseline had ever been physically forced to perform sexual acts without their consent. This was still reported by 11% in the intervention area at end-line, but increased to 12% in the control area. Young women were more likely to experience this than young men.
Decisions about contraceptive use
At both base- and end-line, many young women spoke about their choice in using a condom, getting tested and opting for family planning, even if it was without the knowledge of their partner. Young men also talked about safe sex (using condoms and getting tested for STIs).
Young people were aware of a variety of contraceptive methods such as condoms, the pill and injections at both study phases. Young women and men at both study phases shared that they approached their peers for advice who informed and encouraged them about condom use. Adult participants indicated that contraceptives were commonly used by young people, at times without the awareness of their parents. At end-line, one young man (FGD, 15-17 years) shared that it was because of the GUSO programme that youth understood how to protect themselves. However, many youth and adult participants alike shared that abstinence was the first and preferred strategy within the ABC (Abstinence, be faithful, use a condom) messaging promoted by health workers, teachers and parents towards youth at both study phases.
“At school, teachers always talk to us on how to keep safe (ABC) i.e. abstinence being faithful and use of condoms.”- Young women, 18-24, FGD, Baseline
“A good youth / adolescent have manners and she is in position to abstain not to indulge in sexual activities with the boys, doesn’t walk anyhow but keeps always at their home.”- Young woman, 18-24, FGD, End-line
Key informants shared that only abstinence-based information was allowed to be disseminated in schools. This was evident in the increasing percentage of youth who mentioned ‘abstinence’ as one of the pregnancy prevention methods over time, particularly in the intervention area, from 44% to 54%. However, the percentage who mentioned abstinence as a sole method remained steady at 10% at base- and end-line in the intervention area.
At both study phases, youth particularly recognised condoms as a method to prevent pregnancy and transmission of diseases. This was also considered a reason to propose condom use between partners. At baseline, 57% of youth felt confident to propose condom use each time they had sex in the intervention area, which increased significantly to 60% at end-line (Table 3). The control area also saw an increase, however, this was not statistically significant. There were no significant differences between the trends in the two areas over time (Table 4). Young men, and those in a relationship were more likely to be confident in proposing condom use as compared to young women, and those who were single (Table 4). Other descriptive data in the survey also indicated this gender difference. A higher percentage of youth (over 75%) in both areas at base- and end-line found it appropriate for boys to propose condom use while a lower percentage (70%-75%) found it appropriate for girls to propose the same at both study phases (Table 3).
Many young people mentioned that it was possible for a girl or a boy to refuse sex if a condom was not used. However, at baseline, a young man (FGD, 18-24) mentioned that some girls believed that the condom would get stuck in them and hence refused to use them. Proposing condom use could be seen as a sign of being HIV positive or being a sex worker (‘prostitute’). A parent also related a story of a couple where the young woman refused to use a condom while the young man wanted to use one, and they therefore decided not to have sex. Such stories were also related by youth at end-line. Some young men shared that if a girl wished to use a condom and the boy did not have one or did not want to, then boys might go ahead with unprotected sex. However, if the girl would still refuse, then this would lead to separation of the couple.
Although awareness of contraceptives and the ability to negotiate their use was high, access to contraceptives for young people was low. Descriptive data from the survey indicated that the percentage of young people who were worried that they would be denied access to contraceptives increased over time in both areas (Table 3). One young woman (FGD, 15-17 years) mentioned that since she had no money to buy condoms, she used the withdrawal method to avoid getting pregnant.
The percentage of youth who reported using any method of contraception was 38% in the intervention area and 40% in the control area at baseline. There was a statistically insignificant decrease to 36% and 30% respectively at end-line (Tables 3 and 4). Being male, older than 18 years and being out of school were significantly positively associated with contraceptive use. It is worth noting that being in a relationship had no significant association with contraceptive use.
Decisions about SRH service use
Although many young people at base- and end-line shared that HIV could be prevented through abstinence, many young people also found it important to get tested as well as having safe sex. Nevertheless, a lower percentage of youth reported using SRH services over time in both areas (Table 3). The decreasing trends from 83% to 63% in the intervention area (Table 5) and 83% to 60% in the control area were significant over time. There was no significant difference between these two trends over time (Table 4). Being in a relationship, being older than 18 and being out of school were significantly associated with using SRH services (Table 4). Despite the lower percentage who used SRH services at end-line, a lower percentage worried about being denied access to services in both areas (Table 3).
Youth were also asked if they felt supported by various stakeholders around them when accessing sexuality education and SRH services (Table 3). Although the role of health workers was not investigated at baseline, they were most commonly reported to be supportive (86%) at end-line, followed by more than half of the youth feeling supported by their partners, peers, parents and other family members at both study phases. Authority figures such as religious, traditional/community and (local) political leaders were reported to be the least supportive at both study phases. There were increases over time in the levels of support that young people felt they received from all these stakeholders in both intervention and control areas, with the exception of their partners, in which there was a small decrease.
Decisions within relationships and marriage
Married young women (FGD, 18-24 years) at baseline expressed the importance of making their own decisions when it came to sex, choice of clothes, or moving around without the force of a man or their partner. However, the descriptive statistics showed that a relatively high percentage of married youth at end-line felt that (only) men should make decisions in the household.
The survey also explored young women’s decisions about having children. There was a marginal decrease in the intervention area from 54% to 48% and an increase in the control area from 43.5% to 47% in the percentage of young women who had a child and reported that they chose to become pregnant (Table 3). These trends were neither significant over time in each area, nor between the two areas over time (Tables 4 and 5). Being out of school and being older than 18 were significantly positively associated with choosing to become pregnant (Table 4). Descriptive statistics of survey data indicated that more than 90% of respondents at both study phases in both areas felt that a couple should decide together if they wanted to have children.
 In the intervention area, 44% of youth at baseline mentioned abstinence as one of the pregnancy prevention methods, and 10% mentioned it as the sole method. This increased to 54% and remained steady at 10% respectively. In the control area, this was 42% and 10% at baseline, which increased to 46% and decreased to 7% at end-line.
 Prostitute—as mentioned in a KII, HIV positive- according to field notes.