The Journal of School Nursing2022, Vol. 38(2) 148–160© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520947142journals.sagepub.com/home/jsn
Adolescents in rural Uganda face unique opportunities and challenges to their health. The primary goal of this exploratory cross-sectional survey study was to describe the health behaviors of adolescents of age 13–19 living in four Ugandan fishing communities as a foundation for developing programs to reduce risky health behaviors and HIV/AIDS transmission. The majority of boys (59.6%) and one third of girls reported lifetime sexual intercourse; girls reported earlier sexual debut than boys, as well as higher rates of sexual assault, rape, and/or coerced intercourse. Sexually active youth were more likely to have viewed pornography, be tested for other sexually transmitted infections, and attend boarding schools. Alcohol use was prevalent among both sexes; however, the use of other substances was infrequently reported. Since the majority of adolescents in Uganda attend boarding school, there is an opportunity to expand the school nurse scope of care to include health promotion education and counseling.
adolescent, risk behavior, global health, fishing villages, HIV transmission, school nursing
Engaging in unhealthy behaviors can have devastating effects for adolescents. Long-term impacts of unhealthy behaviors include the transmission of sexually transmitted infections (STIs) such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), addiction, violence (Swahn et al., 2018; Swedo et al., 2019), stress and psychiatric diagnosis (Slavich et al., 2019), and complications related to early childbearing (Maly et al., 2017). Understanding risk behaviors in adolescence is a critical first step in intervening to support healthy growth and development, regardless of where on the globe young people live.
HIV/AIDS infection is still a public health problem among the general Ugandan population, and the country as a whole is classified as a “high burden country” (The Joint United Nations Programme on HIV and AIDS [UNAIDS], 2015) despite the World Health Organization’s (WHO, 2016) ambitious goal to end the AIDS epidemic as a public health threat by 2030. Uganda is not currently meeting United Nations (UN) AIDS 90-90-90 goal to have 90% of people know their HIV status, 90% of people diagnosed with HIV receiving antiretroviral therapy (ART), and 90% of people receiving ART with viral suppression (UNAIDS, 2019). Despite efforts for HIV testing, 16% of all people in Uganda still do not know their HIV status (AVERT, 2018) and those living in rural areas are more likely to be disadvantaged and underserved (Mafigiri et al., 2017). For the purposes of the current study, rural is defined by Chomitz et al.’s (2005) concept of rurality as distinguished by two dimensions: low population density and remoteness from large cities.
Rural fishing communities have higher rates of HIV infection than other communities in Uganda, with some HIV infection estimates ranging from three to five times higher than the general population and others ranging from 5 to 10 times higher (Burgos-Soto et.al., 2020; Mafigiri et al., 2017; Opio et al., 2013; Tumwesigye et al., 2012). In fact, Ssetaala et al. (2015) found that women in fishing communities are more likely to be affected by HIV/AIDS. Additionally, Sabri and colleagues (2019) found that being female in a fishing community was correlated with STIs, HIV, and intimate partner violence emphasizing the gender disparities present in health outcomes. Researchers report a large number of female sex workers in rural fishing communities, an increased rate of transactional sex (sex for money, fish, or other goods), and significant alcohol consumption (Mafigiri et al., 2017; Sileo et al., 2016).
Early sexual debut, defined as age 15 or less, is associated with an increase in HIV infection (Pettifor et al., 2009; Wand & Ramjee, 2012). In Uganda, early sexual debut is reported by 13% of Ugandan females and 12% of Ugandan males (Ministry of Health, 2012). In one recent study of sexually active students, 80% reported sexual debut younger than age 16 (Osingada et al., 2016). Despite being sexually active at young ages and the focus on HIV prevention in this country, only four in 10 Ugandan youth and young adults aged 15–24 correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission such as that HIV is transmitted via shared toilets, shared food or utensils, mosquito bites, or witchcraft (UNAIDS, 2015).
Alcohol is a common substance in Uganda and linked to other risky behaviors, particularly sexual risk-taking (Abbo et al., 2016; Lubega et al., 2015). In a recent study among Ugandan youth living in the slums of Kampala, more than half reported alcohol-related, condom-less sexual intercourse (Kumar et al., 2020). To date, there are no similar self-reported data on rural Ugandan youth from fishing villages. The WHO reports the average annual per capita alcohol consumption in Uganda as higher than average for the WHO African Region and further identifies 20.7% of the population as heavy episodic drinkers (drinking 60 g [one quarter cup]) or more of pure alcohol on at least one occasion in the past 30 days (WHO, 2018). Of note, one standard drink has approximately 14 g of alcohol. Subsequently, the overall HIV incidence in a fishing community on Lake Victoria was 3.39/100 person years at risk (pyar; Kiwanuka et al., 2014). For young adults between the ages of 18 and 24 who drank alcohol, HIV incidence was 5.67/100 pyar. Moreover, HIV incidence increased with regular alcohol use (Kiwanuka et al., 2014). Seeley et al. (2012) found that being young (age 13–24) and participating in other risky behaviors (alcohol use, cigarette smoking) was associated with increased prevalence of HIV infection in Uganda.
It is well-documented that substance use is associated with other risk behaviors, particularly unprotected sex (Agrawal et al., 2016; Kumar et al., 2020; Santelli et al., 2015). A survey of youth living in the urban areas of Gulu and Kampala districts found that 70% of youth reported substance use at least once in their lifetime and a third of participants were regular substance users (Abbo et al., 2016). The most commonly used substances were kuber (a nicotine-rich stimulant that is 3–4 times stronger than cigarettes, 10.8%), khat (a chewable plant classified as a stimulant, 10.5%), jet/aviation fuel (which is inhaled, 10.1%), cannabis (9.2%), and cigarettes (5.9%; Abbo et al., 2016). Given the high rates of HIV/AIDS and substance use in Uganda, it is important for nurses and other health care providers to identify risk behaviors that may lead to poor long-term health outcomes.
In Uganda, universal primary school is available to all children. Similar to Britain’s system, primary school includes 7 years of instruction starting often at age 5 or 6, after which leaving exams determine which secondary school a student may attend. Secondary school lasts for a duration of 6 years that includes four lower levels (the Ordinary or O-level period) and 2 years of upper Advanced or A-levels, after which students may sit for the Uganda Advanced Certificate of Education. Although primary school is universal, not all children have access to secondary schools due to a multitude of reasons including financial concerns, lack of supportive relationships, and exposure to violence (Kimera et al., 2020; Meyer et al., 2018). Furthermore, families have the option to send their child to boarding schools (which are typically more expensive) and day schools. More than six in 10 school-attending adolescents in Uganda attend boarding schools (Ministry of Education and Sports, 2016). Classes are not typically based on age because many students drop out and reenter classes based on whether they can afford to pay school fees or not.
Among all primary and secondary schools in Uganda, only 15% of schools have nurses available to students onsite (Ministry of Health, 2008). This proportion reflects the critical nursing shortage in the country with 0.6 nurses and midwives per 1,000 people in Uganda (World Bank, 2019). Given this scarcity, the literature on school-based nurses in Uganda is limited as most nurses work in hospitals and clinics. Registered nurses who work in schools are responsible for the health and well-being of all children within the school (Ministry of Health, 2008). These nurses typically work in boarding schools, given that students are on-site continuously each term; although some nurses are employed in day schools. In 2008, the Ministry of Health published a report on Ugandan school health and noted the “provision of school health services will lead to increased morale, regular attendance, alertness of pupils/students, reduce ill-health related absenteeism from school . . . and foster better school/academic performance” (p. 4).
The government has identified school-based health services for children as a necessity. Personnel from the Ministry of Education note that school nurses are in charge of the sick bay, attend to students when they are sick, keep and dispense medication for common illness, make decisions about students who need referral for health assessment and management, and conduct any health promotion activities (P. Nyamurwa, personal communication, May 26, 2020). The role of the school nurse is critical for providing evidenced-based curriculum to inform and empower adolescents to live healthy lives (National Association of School Nurses, 2018). Yet because of the paucity of school nurses, teachers are expected to provide critical health education curriculum to children often without adequate training (Kansiime et al., 2020; Kemigisha et al., 2019). Although the school nurse is expected to identify health issues and provide health promotion counseling and education, there is underutilization of the role in Uganda.
UNAIDS emphasized the need for researchers to understand community contextual factors for HIV transmission in order to develop effective, targeted HIV prevention interventions (UNAIDS, 2007, 2010a, 2010b). However, there are few research studies focused on adolescents living in rural fishing villages in Uganda. Like any other country, Uganda varies regionally with regard to urban and rural locations, but previous studies have tended to target more accessible, populated areas in the East, North, and South. In fact, most research with participants in fishing villages concentrates on populations in the Lake Victoria region. The multiple fishing villages in Western Uganda near Lake Edward and Lake George, nearly 220 miles away from the largest city, Kampala, are largely ignored. Additionally, research in rural fishing communities has largely focused on the adult (18+) population, particularly fishermen and fishmongers. Data that are available point to high rates of sexual risk behaviors, HIV/AIDS, and substance and alcohol use in the fishing villages; however, a gap in the adolescent health literature exists with regard to rural Ugandan youth. This exploratory survey study aims to fill that gap.
The purpose of this survey study was to describe selfreported health behaviors among adolescents living in four Ugandan fishing communities/villages as a foundation for developing future nursing interventions and programs to reduce risk behaviors and HIV/AIDS transmission. Bronfenbrenner’s (1977) ecological model guided development of the study. The ecological model framed the research questions and informed the choice of data collection tools (see Figure 1). It supported a multifactorial approach to understanding risk behaviors among youth in the fishing villages. Four research questions guided the study: (1) What are demographic and health characteristics of youth living in Ugandan fishing villages, including whether youth have ever been tested for HIV? (2) What are rates of lifetime and past 30-day substance use; (3) What are rates of sexual and other related experiences? and (4) Are there associations between rural Ugandan youth being sexually active and selected behaviors and knowledge around HIV/AIDS and safe sex practices? For the first three research questions, the research team compared and contrasted females’ and males’ experiences given the literature pointing to sex differences in negative health outcomes (Sabri et al., 2019; Vu et al., 2017). For the fourth research question, females’ and males’ responses were pooled together to examine associations.
This was an exploratory, cross-sectional survey study. Selfreported surveys were administered to a nonprobability, quota sample of 145 adolescents in four rural fishing villages. Adolescents were intentionally recruited with attention to age and sex, with an initial goal to collect 32 participants per village with an equal division between males and females, and older (age 16–19) and younger (age 13–15) youth to be surveyed during the course of 1 day per village, due to budget constraints. The institutional review boards of the University of Minnesota and Makerere University approved this study in addition to the Uganda National Council for Science and Technology.
Data collection occurred in four villages located within Queen Elizabeth National Park with shorelines on Lake Edward or Lake George. Most village members participate in fishing or activities that support the fishing economy. Adolescents were eligible to participate in the study if they were between 13 and 19 years of age, lived in one of the four fishing communities, and had parental permission to participate in the research study (if less than age 18). Additionally, participants had to be able to speak English or Runyakitara, the most commonly spoken local language in the four fishing communities.
Research team members in conjunction with village mobilizers recruited participants for the study. Prior to arriving in the villages, the research team worked with village mobilizers in each village to outline plans for the number of participants needed in each village in terms of both sex and age. Village mobilizers informed community members about the upcoming research project and opportunities for their children to participate. When research staff arrived in each village, village mobilizers were prepared to support data recruitment by having the data collection site ready for data collection and accompanying research staff to homes to discuss the study with parents and adolescents.
Data collection occurred during the national school holiday when students were home for the summer 3-week break. All adolescents provided consent or assent (if under age 18) to participate in the project. Parents/guardians of those under 18 provided consent for participation prior to assent begin given by the adolescent. Given the low literacy level in the population, interpreters working with the authors were available to review the consent and assent forms with participants and guardians and reinforce that their decision to participate was voluntary. All forms were available in English and Runyakitara.
Data collection occurred in the local, open-area school buildings which were vacant given the 3-week summer break. Participants had the option to complete the survey independently or with interpreter and researcher support. For those who were unable to read/write, a same-sex interpreter working with the authors was available to read the questions and circle the response on the deidentified survey. This method of data collection has been used in previous work with youth in Uganda (Ankunda et al., 2016). The 52-question survey took approximately 45 min to 1 hr to complete.
Although health care workers are considered mandatory reporters of minor abuse and sexual violence in Uganda, researchers are not. Our study team recognized that a number of adolescents would complete the survey independently, making it impossible to identify all instances of reported abuse in real time. Given the known high rates of violence, the study team included a counselor who was available during data collection for those who reported abuse or who wanted additional information about reporting violence. Additionally, we provided all adolescents who participated in the study an overview of community resources and options for safety at the end of data collection.
Survey measures for this study were adapted from the Youth Risk Behavior Survey (YRBS), an annual survey administered by the Centers for Disease Control and Prevention (CDC). The YRBS was developed in 1990 to better understand health and risk behaviors in adolescents; it is selfadministered by adolescents in U.S. schools every 2 years and demonstrates good reliability for self-reported data (CDC, 2013, 2018). The YRBS survey was modified by the study team to reflect common risk behaviors in Ugandan fishing communities. Questions specific to family, environment, drugs commonly used in Uganda, HIV status of family members (defined as anyone the youth deemed a family member), and HIV knowledge were added. Other YRBS questions related to safety (e.g., helmet and seat belt use) and health promotion activities (e.g., diet and exercise) were not asked. YRBS questions about sexual orientation or gender identity were not asked due to the illegal status of same-sex activity in Uganda. The adapted survey was reviewed by faculty at Makerere University and a University of Minnesota statistician to ensure face validity.
Demographic and HIV characteristics. Youth were asked their age in years, in addition to how many years they lived in their community. As proxy measures of socioeconomic status, participants reported the number of residents and rooms in their home; responses to these two questions were used to compute a measure of the number of residents per room in the house. School status was a categorical variable which grouped youth by whether they reported never attending school, were not currently attending school, attending boarding school, day school, or some other school. Level of schooling reflected the education system in Uganda, with response options responding to ordinal levels of primary school, lower secondary school/Ordinary level, upper secondary/Advanced level, and postsecondary school. Working for money was a dichotomous yes/no variable. With regard to HIV characteristics, students responded to questions about ever being tested for HIV (yes/no) and whether anyone in their family has HIV/AIDS or not (yes/no/unsure). An ordinal variable measuring knowledge of HIV/AIDS transmission and prevention had four response options ranging from “I know a lot” to “I know nothing.” For analysis purposes, response options were dichotomized as “I know a lot” compared to “I know at least some, a little, or nothing.”
Substance use. Youth were asked standard YRBS questions about different substances with regard to establishing ever having used and past 30-day use, using a mix of dichotomous and ordinal response options. Substances included cigarettes, marijuana, khat, kuber, petrol thinner/aviation fuel, and alcohol. Because of low frequencies and skewed distributions, responses were dichotomized for all substances.
Sexual and other related experiences. The survey asked all participants a wide variety of standard YRBS questions about sexual behaviors. Have you ever had sexual intercourse was a dichotomous yes/no question. Youth were asked to indicate whether or not they had ever been tested for other STIs as well as had they ever been pregnant or made someone pregnant. Same-sex sexual contact was assessed by asking, “During your life, with whom have you had sexual contact?” Options were females, males, and females and males. Same-sex sexual contact was operationalized as a dichotomous yes/no measure created through a combination of reported sex and whether youth reported contact with the same sex or both sexes versus opposite sex. It is important to note that the survey included only this one question about the sex of the participant’s sexual partners to understand whether same-sex sexual activity occurred. Past year prevalence of sexual violence questions included assessment of how many times young people (1) been forced by anyone to do sexual things they didn’t want to do (count such things as kissing, touching, or being physically forced to have sexual intercourse), (2) had someone they were dating or going out with force them to do sexual things they didn’t want to do, and (3) had someone they were dating or going out with physically hurt them on purpose (count such things as being hit, slammed into something, or injured with an object or weapon). Due to skewed distributions, response options ranging from “0 times” to “6 or more times” were dichotomized into ever experienced sexual violence versus not. Finally, the research team added a yes/no question to evaluate whether participants had viewed pornography of any kind (magazines, pictures, and videos).
Additional questions were only asked of youth who reported ever having sexual intercourse. Average age of sexual debut was asked as an ordinal variable, with response options ranging from “11 years or younger” to “18 years or older”; however, we assigned numeric values corresponding to the year mentioned and treated this variable as semicontinuous. Number of lifetime sexual partners was an ordinal variable, with responses ranging from “one person” to “six or more people;” this variable was truncated to range between one person and four or more people due to its skewed distribution. Condom use at last sexual intercourse was a dichotomous (yes/no) question. Contraception was assessed by the question, “The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?” Responses were categorized into three groups: (1) birth control pills, condoms, IUD (such as Mirena or ParaGard), implant (such as Implanon or Nexplanon), or injections (Depo Provera); (2) withdrawal or some other method, or not sure; and (3) no method was used. A final question in this section asked participants whether or not they drank alcohol the last time they had sexual intercourse.
Bivariate statistics were used to describe the sample characteristics and youths’ reports to questions about health risk behaviors. Specifically, we used χ2 and t tests to test for differences in demographic and HIV characteristics, substance use, and sexual- and other related experiences between boys and girls, depending on the level of measurement of the variable. Associations between being sexually active and other experiences were evaluated through the use of χ2 tests. Statistical significance was set at p value < .05 for all analyses. Due to the exploratory nature of the study, we did not adjust for multiple comparisons.
More females made up this nonprobability, quota sample of rural Ugandan youth (Table 1). Ages of youth ranged from 13 to 19, and girls were a little over three quarters of a year younger than boys on average. Not unexpectedly, participation of girls and boys significantly varied by village, with the research team not meeting anticipated quotas in Village 2. No significant differences characterized school status for rural girls and boys—most were attending either boarding school or day school. In contrast, girls were significantly more likely than boys to report working for money.
Given the prevalence of HIV in Uganda, it is perhaps not surprising to see greater than 80% HIV testing rates for girls and boys. Girls were significantly more likely to report having a family member with HIV/AIDS than boys; it is interesting to note that a quarter of boys reported being unsure if a family member had HIV/AIDS. In contrast, boys were significantly more likely to report knowing some or a lot about HIV/AIDS transmission, while girls were more split between knowing a lot or a little.
Participants, regardless of sex, reported very low rates of substance use (Table 2), with the exception of alcohol use. Although more boys than girls reported binge drinking in the past 30 days, this difference was not statistically significant. A small number of youth admitted ever smoking cigarettes. Even fewer youth admitted ever using marijuana, although significantly more boys reported use compared to girls. Due to small sample sizes, interpretation of significance tests for rates of substance use should be made with caution.
Youth reports to questions about sexual experiences are shown in Table 3. Girls were far less likely than boys to report ever having sex. Rates of ever having been tested for sexually transmitted diseases other than HIV were low and not statistically different for girls and boys.
Rates of same sexual contact were low in these rural fishing villages; a small number of boys and no girls reported same-sex sexual contact. Girls were significantly more likely than boys to report ever being physically forced to have sexual intercourse and being forced to do sexual things they didn’t want to do in the past year. Sexual and physical violence perpetrated by a dating partner was reported at similar rates for both girls and boys. Finally, viewing pornography of any type was very common for both girls and boys.
Among sexually active participants, the average age of sexual debut was slightly younger for girls (14.42) than for boys (15.16), although this difference was not statistically significant (likely due to more variation in girls’ ages). Boys reported more lifetime sexual partners than girls; due to small cell sizes, these differences were not statistically significant (p = .16).
Among sexually active youth in rural fishing villages, rates of condom use at last sex were low but similar for boys and girls. Unfortunately, over half of sexually active girls and boys reported not using a pregnancy prevention method, were unsure what method they used, or used withdrawal the last time they had sexual intercourse. Small but equal numbers of girls and boys reported having drank alcohol before they had sexual intercourse the last time.
To assess potential points of intervention and prevention, bivariate relationships between being sexually active or not and four other experiences were assessed (Table 4). First, there was a trend-level relationship between being sexually active and school location; more youth who were attending boarding school away from home reported ever having sex compared to peers who were attending day school in their fishing communities. Second, viewing pornography and being sexually active were significantly associated, with over half of youth who had viewed pornography reporting ever having sexual intercourse compared to fewer youth who had not viewed pornography. Third, ever having sexual intercourse was significantly associated with ever being tested for other STDs than HIV. Fourth, there was no significant relationship between being sexually active and a young person’s knowledge level of HIV/AIDS transmission and prevention.
The goal of this study was to describe demographic characteristics and health behaviors of a nonprobability sample of Ugandan youth from rural fishing villages, with a particular focus on their sexual health and substance use with consideration of the high rates of HIV/AIDS in Uganda. There is clearly more work to be done in supporting safe sexual practices among youth in Uganda, and increasing condom use is a national priority (UNAIDS, 2015). Less than half of boys and girls used condoms at last intercourse, which is lower than the national average for men age 15–49 (57%) but slightly higher for girls (37% national average). Despite programs aimed at making condoms more accessible via condom programming (UNAIDS, 2015), there may be barriers to having safe sex in fishing communities. Stigma associated with adolescent sex from community members and lack of accessible health care facilities with free condoms and trained medical providers may impact a young persons’ ability to use a condom at every intercourse. This is particularly important given that sexual debut before age 16 is common in Uganda, and this study found a younger age of sexual debut for girls than boys (Osingada et al., 2016). This young age may mean that necessary sex education has not taken place and that adolescents do not have enough information about preventing STI/HIV transmission and pregnancy. Therefore, researchers working within fishing villages should consider programming that build upon the national priorities and includes earlier education about sexual behavior safe sex practices with school nurses at the forefront of the education.
Surprisingly, despite a national history of criminalizing homosexuality, 8% of boys reported sex with a male partner. This is consistent with the national rate of 13% which includes adolescents and adults and points to the need for additional resources within the Ugandan lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community for HIV prevention including pre-exposure prophylaxis (PrEP), HIV screening, and condom use (AVERT, 2018).
Furthermore, there is a gap in testing for STIs and condom use for those who are sexually active. Despite the fact that almost every participant in the study reported being tested for HIV, there appears to be a disconnect in protection against HIV and other STIs as well as knowledge related to transmission. Although HIV is tested for and discussed, it may be that young people are not receiving comprehensive safe sex education. This study found that sexually active youth reported lower levels of HIV knowledge, consistent with national data (UNAIDS, 2015). It is important for young people engaging in sexual behavior that puts them at higher risk of HIV transmission (e.g., multiple partners, no condoms, men having sex with men) to have robust information about STIs, so that they have tools to protect themselves. Given the Ugandan government’s prioritization of eliminating HIV/AIDS, school nursing interventions to provide comprehensive, medically accurate information may be a cost-effective intervention for future work.
Previous research has found a high rate of sexual assault and rape in Uganda (Birdthistle et al., 2013; Wagman et al., 2009). Twenty-seven percent of women in Uganda report nonconsensual intercourse in their life (Birdthistle et al., 2013), and adolescents in particular report sexual coercion and unwanted touching (Wagman et al., 2009). In this study, girls were more likely than their male counterparts to report forced intercourse or other forced sexual contact. Although not unexpected, it is alarming given the HIV burden status of Uganda and the fact that female survivors of violence are 50% more likely to acquire HIV (AVERT, 2018). Decreasing the transmission of HIV will require programs that target both survivors of sexual assault and violence as well as the assailants. Additionally, programs targeting partner violence may be considered for both sexes in rural fishing communities. Programs, such as the Safe Homes and Respect for Everyone Project, may be adapted for fishing communities given their success in other rural areas of Uganda (Wagman et al., 2016). School nurses, having access to both sexes, may provide an opportunity to implement curriculum to empower and educate both males and females about sexual violence.
The presence of pornography is prevalent among young people in these villages, with 75% of all youth reporting that they had viewed pornography. Predictably, whether a youth had viewed pornography was also significantly associated with ever having sex. Youth who view pornography are more likely to be male, engage in intercourse, and exhibit stronger gender-stereotypical sexual beliefs (Peter & Valkenburg, 2016). This finding points to an area for intervention, including dialogue about pornography and its unrealistic portrayal of sexual behavior, empowering young women in their sexual decision making and working with young men to provide education related to gender equity and appropriate social behaviors. This issue is not unique to Uganda. Principi et al. (2019) note that global consumption of pornography in minors can no longer be neglected. Governmental and nongovernmental organizations must work together to develop content that provides youth the opportunity to critically think about pornography and its impact on their sexual health (Principi et al., 2019).
Although the research team heard from youth anecdotally that students who attend day school exhibit “riskier” sexual behaviors than those who attend boarding school, likely because of the belief that those who attend boarding school are from higher socioeconomic backgrounds, our analysis of the data did not find that association. In fact, there was a trend-level finding of students attending boarding school being more sexually active than those who attend day school in their villages. This is likely due to less adult supervision and monitoring of behavior in boarding school, where youth are living in close quarters to one another. School nurses may be a supportive intervention to improve safe sex knowledge and behavior for youth in both day and boarding schools.
Finally, alcohol use was high among both boys and girls and consistent with other research studies reporting alcohol use in Uganda (Abbo et al., 2016). However, reports of using other substances such as tobacco, marijuana, khat, and kuber were low and did not reflect other studies (Abbo et al., 2016). This discrepancy between other data on substance use and what we found in this study may be related to the difference in enrollment between sexes with girls being the majority of our sample, perceived desirability around providing socially acceptable responses to questions about substances, or could indicate that these particular rural villages do not have high substance use outside of alcohol. Further research is necessary with these communities to better understand substance use.
Limitations for this project include difficulty recruiting and surveying boys in multiple villages. Consistent with other research projects, females were more willing to participate in this study (Ankunda et al., 2016; Ssetaala et al., 2015). This may be related to a primarily female research team with only one male member. Previous work has shown that male research staff are important to gaining access to other males (Claussen, 2018).
Further limitations include a concern regarding participants’ truthful disclosure during data collection. There may have been expectations about social desirability for “correct” responses, particularly related to substance use. This expectation may have been more pronounced in Village 1 with the community mobilizer’s purposeful recruitment. Thus, findings likely underestimate levels of risk. Information on sex and HIV was more readily disclosed, possibly because HIV is tested for and discussed commonly in Uganda. However, this may be village dependent and the small sample size didn’t allow for analysis of individual villages.
A mix of females and males should characterize research teams seeking to conduct similar studies in the future. Researcher should anticipate having more thorough discussions with village mobilizers about the details and goals of study recruitment procedures. This may help mitigate any recruitment bias and recruit more equally among sexes. Additionally, larger representative samples are needed in each village to be able to target specific needs and risk behaviors. This would also allow researchers to adjust for behaviors by village. Finally, future research should include a focus on HIV knowledge and behavior changes among young people, given the high burden status of Uganda.
School nurses in Uganda are necessary to provide comprehensive health services to adolescents. Since more than 60% of school-enrolled adolescents attend boarding schools (Ministry of Education and Sports, 2016), additional services may be required to support healthy adolescent growth and development given the distance from parents and other family members. Currently, sex education curricula are based upon the National Sexuality Education Framework (Ministry of Education and Sports, 2018). Although national curriculum is admirable, the curriculum includes abstinence only and anti-LGBT language. This provides an opportunity for health care providers, specifically school nurses, to fill the gap in knowledge and care for young people. Given that rates of sexual activity and HIV are higher in rural fishing communities as are rates of substance use, school nurses could provide regular HIV and other STI testing, access to condoms, and health information in individual sessions with students or in larger groups.
Given the socioeconomic differences between youth who attend day school and boarding school, school nurses could be particularly important for day school youth. Poor people in Uganda, including youth, encounter more barriers for accessing routine and specialized health services (Nakku et al., 2016; Tirivayi, 2016). Day school enrollment in secondary school may depend on the family’s ability to pay for school; therefore, providing comprehensive health assessment and education to youth when they are at school may be a way to improve health. This supportive nursing relationship may begin in primary school when money is not a barrier to attendance and build over time. One nurse may be able to cover a region and support both primary- and secondary-level students.
Additionally, health care providers in Uganda have a measure of autonomy as evidenced by the assertion by the health minister in 2014 that all people, regardless of sexual orientation, can access free health services (BBC, 2014). Therefore, school nurses are perfectly positioned to provide support and education for adolescents accessing services who have concerns about their LGBT status or questions about their health, sexuality, or HIV status in a confidential manner that a teacher may not be able to provide. School nurses may be able to leverage existing tools such as the HEEADSSS interview instrument to support data collection and intervention to optimize health (Contemporary Pediatrics, n.d.).
Youth in fishing villages in Uganda report high rates of alcohol use and unprotected sexual intercourse. Boys and girls do not consistently use condoms or family planning options and the vast majority have viewed pornography. Girls, in particular, are reporting early sexual debut and significant levels of violence. These health behaviors are not unique to the Ugandan context but have implications for long-term health and well-being. Rural fishing villages are geographically located further away from government and community services, making accessing services difficult for the population. Building the nursing workforce and embedding nurses in schools may be a long-term solution for improving the health of adolescents. Additionally, international partnerships may be necessary to train school nurses to provide evidenced-based care. As the burden of HIV continues to be a focal point of public health efforts in Uganda, it is critical to involve rural fishing villages as a primary point of intervention for risk reduction and healthpromoting behavior, particularly for adolescents.
The data that support the findings of this study are available from the corresponding author [M.A.S.] upon reasonable request.
Tom D. Ngabirano has contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Melissa A. Saftner has contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Barbara J. McMorris has contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Sigma Theta Tau International; Sigma Theta Tau International Zeta Chapter; and the University of Minnesota.
Melissa A. Saftner, PhD, CNM, FACNM https://orcid.org/0000-0003-0385-4864
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Tom D. Ngabirano, MS, RN, is a Senior Lecturer at Makerere University.
Melissa A. Saftner, PhD, CNM, FACNM, is a Clinical Professor at the University of Minnesota.
Barbara J. McMorris, PhD, is an Associate Professor at the University of Minnesota.
1 Department of Nursing, Makerere University, Kampala, Uganda
2 School of Nursing, University of Minnesota, Minneapolis, MN, USA
Corresponding Author:Melissa A. Saftner, PhD, CNM, FACNM, School of Nursing, University of Minnesota, 308 Harvard Street SE, WDH 5-140, Minneapolis, MN 55455, USA.Email: msaftner@umn.edu
