RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT.

BATEGANYA GEORGE M. M P H (D E)

SUPERVISORS: DR. MAINA WAMUYU DR. NOAH KIWANUKA MUSPH MUSPH

A RESEARCH PROPOSAL FOR A DISSERTATION FOR A DEGREE OF MASTER OF PUBLIC HEALTH MAKERERE UNIVERSITY

TABLE OF CONTENTS
TABLE OF CONTENTS...............................................................................................................................................I LIST OF ABBREVIATIONS/ACRONYMS............................................................................................................III LIST OF OPERATIONAL DEFINITIONS.............................................................................................................IV ABSTRACT...................................................................................................................................................................V 1.0INTRODUCTION.....................................................................................................................................................6 1.1TRODUCTION AND BACKGROUND.................................................................................................................6 2.0 LITERATURE REVIEW...................................................................................................................................9 2.1 GLOBAL PICTURE................................................................................................................................................9 2.2 UGANDA PICTURE.............................................................................................................................................10 2.3 BIG POPULATION ..............................................................................................................................................10 2.4 LAWS AND POLICIES ON ADOLESCENT REPRODUCTIVE HEALTH.................................................10 2.5 HIGH MATERNAL MORBIDITY AND MORTALITY..................................................................................10 2. 6 POOR FAMILY AND COMMUNITY INFLUENCE ON ADOLESCENT REPRODUCTIVE HEALTH. ........................................................................................................................................................................................10 2.7 EARLY PREGNANCY.......................................................................................................................................11 2.8 EARLY ADOLESCENT MARRIAGES.............................................................................................................12 2.9 UNSAFE ABORTIONS.........................................................................................................................................12 2.10 EDUCATION OF ADOLESCENTS..................................................................................................................12 2.11 EARLY ADOLESCENT SEXUALITY.............................................................................................................13 2.12 CONTRACEPTIVE USE AMONG ADOLESCENTS...................................................................................16 .......................................................................................................................................................................................19 3.0 PROBLEM STATEMENT, JUSTIFICATION,CONCEPTUAL FRAMEWORK,RESEARCH QUESTIONS................................................................................................................................................................19 3.2 4.0 JUSTIFICATION OF STUDY.......................................................................................................................21 3.3: 46.2 57.0 CONCEPTUAL FRAMEWORK FOR ADOLESCENT PREGNANCY............................24 SPECIFIC OBJECTIVES................................................................................................................................27 METHODOLOGY ...........................................................................................................................................29 3.4 RSEARCH QUESTIONS.....................................................................................................................................26

7.2 STUDY DESIGN...................................................................................................................................................29 THE STUDY IS TO BE CONDUCTED IN PURPOSELY SELECTED HEALTH UNITS IN KIBAALE DISTRICT....................................................................................................................................................................29 5.27.3 STUDY POPULATIONN.................................................................................................................................31 TARGET POPULATION...........................................................................................................................................31 7.5 2.1 INCLUSION CRITERIA................................................................................................................................31 .5.2.2 EXCLUSION CRITERIA.................................................................................................................................31 7.5.2 EXCLUSION CRITERIA..................................................................................................................................32

5.2.3 STUDY DESIGN.................................................................................................................................................32 USING CHI-SQUARE METHODS OF SAMPLE SIZE CALCULATION;........................................................32 5.57.7 STUDY VARIABLES:...................................................................................................................................35 5:6;7.8 DATA COLLECTION..................................................................................................................................36 5.6.1 DATA COLLECTION PROCEDURE.............................................................................................................36 DATA WILL BE COLLECTED FROM THE SELECTED PREGNANT ADOLESCENTS USING STRUCTURED QUESTIONNAIRES,KEY INFORMANT GUIDES AND FOCUS GROUP DISCUSSION GUIDES........................................................................................................................................................................36 5.6.2 DATACOLLECTION TOOLS.........................................................................................................................36 (A)FOR QUANTITATIVE DATA: WE SHALL USE SELF ADMINISTERED SEMI-STRUCTURED QUESTIONNAIRES WITH BOTH OPEN AND CLOSED ENDED QUESTIONS ...........................................36 (B) FOR QUALITATIVE DATA: WE SHALL USE KEY INFORMANTS (KI),AND FOCUS GROUP DISCUSSION GUIDES(FGD).CTION METHODS................................................................................................36 5.7.2 7:9 DATA COLLECTION AND DATA MANAGEMENT.........................................................................37 DATA ANALYSIS.......................................................................................................................................................37 5.7.2.1; QUANTITATIVE DATA...............................................................................................................................37 DATA ANALYSIS WILL BE DONE USING SPSS OR SATA STATISTICAL PACKAGES..........................37 5.8 QUALITY CONTROL..........................................................................................................................................38 5.8.1. PRE-TESTING;.................................................................................................................................................38 ASSURANCES.............................................................................................................................................................38 5.9 8.0 ETHICAL CONSIDERATIONS:..................................................................................................................39 5.10 DISSEMINATION AND USE OF RESULTS..................................................................................................40 REFERENCES.............................................................................................................................................................42 INFORMED CONSENT FORM FOR THE STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT...........................................45 .......................................................................................................................................................................................45 QUESTIONNAIRE FOR A STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT............................................................................47 ACTIVITY PLAN AND BUDGET............................................................................................................................74

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LIST OF ABBREVIATIONS/ACRONYMS CI DHODHS CONFIDENCE INTERVAL DISTRICT HEALTH OFFICER

DIRECTOR OF HEALTH SERVICES DHT DHV FGD HIV IMR MMR UBOS DISTRICT HEALTH TEAM DISTRICT HEALTH VISITOR FOCUS GROUP DISCUSSION HUMAN IMMUNO VIRUS INFANT MORTALITY RATE MATERNAL MORTALITY RATE UGANDA BUREAU OF STATISTICS iii

UDHS UNFPA WHO

UGANDA DEMOGRAPHIC HEALTH SURVEY UNITED NATIONS FUND FOR POPULATION ACTIVITIES WORLD HEALTH ORGANIZATION

LIST OF OPERATIONAL DEFINITIONS

An Adolescent: Adolescence Pregnancy:

A female aged between 17-19 years An act of becoming pregnant during adolescence period

Maternal Mortality Rate (MMR): Is the number of maternal deaths per 100,000 live births over a given period of time. Counseling: Is a face to face communication in which a counselor facilitates the client to identify, clarify and resolve problems in order to make an informed choice or decision and act on it. A peer: Is some one you can identify with easily in terms of age, sex, behavior, personality and hobbies.

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Reproductive Health:

The complete physical, mental and social well being of an individual and not merely the absence of disease or infirmity, in all matters related to reproductive processes, their function and system at all stages of life (WHO, 1998)

A sexual activity: Marriage:

Is vaginal sexual intercourse. A state of being united to a person of opposite sex as husband and wife.

Sex Education:

The process of providing knowledge and skills usually of desirable qualities of behavior regarding sexual intercourse and sexuality.

Poverty:

Total or relative lack of money or materials. ABSTRACT

INTRODUCTION Adolescent pregnancy and motherhood is high in Kibaale District. It predisposes women in this age bracket to morbidity and mortality because their bodies are not developed well enough to stand the physical, psychological and social strains associated with pregnancy and delivery. The main objective of the study is to establish the psychosocio-economic and biological factors responsible for adolescent pregnancy in Kibaale district. METHODOLOGY This will be a cross-sectional study carried out in selected health units in Kibaale District. Data will be collected using quantitative and qualitative methods. A total sample size of 384 participants will be recruited for this study. Utility The findings from this study will be used to formulate appropriate policies necessary to reduce adolescent pregnancies in this area. v

1.0 INTRODUCTION 1.1TRODUCTION AND BACKGROUND

Many studies in developing countries Uganda inclusive indicate that there is a rise in the level of knowledgeconsciousness ofabout reproductivitye and sexuality among the the young people,especially the adolescents. And also that the adverse effects consequences of early sexuality and early marriages like unwanted pregnancies, unsafe abortions, sexually transmitted infections including HIV/AIDS,early parenthood, missed education opportunities, high maternal mortality and homicides and many others are widely known though surprisingly they are on the increase also .on the increase (Ndyanabangi 1996).

Globally about 2314 million births each year are by adolescents (James et al 2008), and that. And thate each year there are an estimated 245 million pregnancies around the world and approximately 87 million of them are unwanted (UNFPA 20091997). In United States of America (USA), almost 24% of all deliveries and slightly over 35% of abortions are among adolescents. Over 100 million adolescents live in developing countries of which a high proportion of them live in Sub-Sahara Africa. In developing countries, incidents of un plannedwanted pregnancies are common and high--38-45% (WHO,2009).

In Kibaale District, adolescents form nearly 25% of the entire district population (National census 2002). aAnd yet of all the11,358 pregnancies recorded in all the health units, nearly 48.5%[5.508] are adolescent pregnancies (District Annual work plan 20083/20094). In Uganda, adolescents form over 24.50% of the entire population (UDHS20071995),. uUnfortunately, most hHealth pProgrammes at all levels of administration have not put much emphasis to the problems that affect the adolescentsse people health policies for adolescents are

not specific, and the health facilities and the health workers are not trained to handle specific problems that affect the adolescentsat this critical age range of growth (MOH Report 20085).

According to Uganda Population Policy 20095, Reproductive Health ought to have beenis one of the key areas addressed and recognized by the Government of Uganda, but it is given a blanket cover that do not clearly address the unique requirements of adolescents.. Through National Family Planning Association (NFPA) and the Ministry of Health (MOH), programmes have been designed to implement reproductive health promotion in the population policy as one of the highest priorities, if the quality of life of the countrys population is to be improved. It is clearly known that when the growth of the population is properly controlled through reproductive health promotion, domestic productivity and quality of lives for the population will improve. As mall health population is more productive than a large unhealthy population (UDHS 2008-20091988 -89). It is these unwanted pregnancies that contribute greatly to the problems that are encountered in maternal health in many parts of the world, and it is worse in the developing countries, Uganda inclusive. These pregnancies pose major health risks to the mothers, not properly timed, are unwanted and the affected mothers often lack legal and safe abortion services incase it is so desired to abort ((UNFPA 1997). Many mothers, especially the adolescent ones have had to terminate unwanted pregnancies using very unsafe methods under hiding which has led to increased morbidity, mortality and residual disability.

According to WHO report of 1997, it is estimated that nearly 50 million unwanted pregnancies every year are terminated world wide, and of these 20 million of them are not safe, and yet 95% of these unsafe pregnancies occur in developing countries causing death to about 200 mothers each day. In Uganda, and especially in Kibaale District, the girls become sexually active by their 14 th birth day and this has exposed them to STIs including HIV/AIDS, unwanted pregnancies and their associated problems (UNDPA 1994). James et al 1998 state that of the entire worlds women population, 10% live in Sub-Sahara Africa, but of the entire worlds pregnant related deaths, this region alone contributes 40%!! All these deaths are as a result of the scarce and yet poor health services available. These deaths are mainly due to preventable causes such as hemorrhage, anemia due to malaria and under nutrition, sepsis and occasionally rapture of the uteri. Most mothers in the developing world are economically poor, not properly learned, suppressed by cultural norms, politics and are not empowered to take their own timely decisions in matters affecting their lives. These, together with poor health services and facilities available, contribute a lot to maternal morbidity and mortality (MMR) observed in these regions (Erosen and Shanty Conley 1998.) Sexual activities and usually early marriages is the order of the day in most countries of Sub Sahara Africa. In eleven countries representing 40% of the population in Sub Saharan Africa, births to adolescents comprise between 15% and 20% of all births (Gray 1972).

2.0 LITERATURE

REVIEW

Adolescence is the transition period from childhood to adult hood. Its definition is not universally the same, but it varies from society to society and from continent to continent (WHO 1997). World Health Organization (WHO) recognizes persons of age range 10 19 years as adolescents, but this differs somehow from that of Uganda which recognizes adolescents as persons 12 19 years (UDHS 1995). Therefore, this definition has a cultural connotation mingled with a scientific approach. This is an age range with lots of dynamism in an individual and characterized with physical, psychological, emotional and social changes within the growing person (WHO1998). 2.1 Global Picture Teenage pregnancy is important because it is associated with higher morbidity and mortality for both mother and the baby being born. In under developed countries, it has also been associated with termination of education for the young mothers, which in it self has a spiral effect on the socioeconomic status of the individual and hence the baby to be born (UDHS, 1995). There is growing concern that sexual activities among unmarried adolescents are increasing around the globe, yet the concern is largely unsupported by hard evidence. The result of the increasing sexual activities is usually unwanted pregnancies, which sometimes lead to illicit abortions, which in turn culminate into infections, sepsis, maternal morbidity and mortality, difficult and prolonged labour and infant mortality (WHO, 1995). Lack of family life education and counseling services keep the female adolescents unaware of the preventive measure against unwanted pregnancies. The young girls through ignorance find themselves pregnant even before they are ready and willing to support the babies.

In Ghana, adolescents have limited programmes offering family life education and counseling. At the same time, the traditional methods of teaching adolescent about sexuality and reproduction are becoming inadequate for dissemination of useful up to- date information (Gyepi, 1987). 2.2 Uganda Picture The problem of adolescent pregnancy is becoming a very serious one in developing countries in general, and in Uganda in particular. The national average adolescent pregnancy rate for Uganda is 38-45% (UHDS, 1995). 2.3 Big Population In Uganda one in every four people (24.3%) is an adolescent. This group of people was until recently believed to enjoy robust health, and as such it was neglected by policy makers in terms of health service delivery. Hence the lack of adolescent specific and gender sensitive health information services in Uganda (UNFPA-UGANDA, 1998). 2.4 Laws and Policies on Adolescent Reproductive Health Adolescent reproductive health which includes teenage pregnancy, abortions, female genital mutilation and STI/HIV/AIDS prevention and control are some of the components of the adolescent health policy for Uganda. 2.5 High Maternal Morbidity and Mortality Very often adolescent girls get complications during pregnancy. They suffer miscarriages, develop anemia, hypertensive diseases of pregnancy and obstructed labour more often than pregnant women in their early twenties. In Kampala hospitals, a survey done revealed that adolescents contribute one third of the total maternal mortality in Uganda (M.O.H/UNFPA, 1998). 2. 6 Poor Family and Community Influence on Adolescent Reproductive Health. In Uganda especially the central region, we had a strong Senga (Aunt) Institution where by a girls paternal aunt took on the responsibility of teaching sexuality and reproductive health issues to the growing girl. With rapid modernization and urban migration, this culture is fading away. 10

This has led to inadequate knowledge of growth and development, poor reproductive health services and their utilization by adolescents. Even where conventional health services exist, adolescents are usually reluctant to use them. Adolescents usually lack money and other resources to access health services. Health services available generally are not user friendly to them. There is lack of respect for them, and their special health needs are usually ignored by health workers. There is also a communication gap between adolescents and healthcare providers. Health workers therefore often find it awkward, difficult and unfamiliar when dealing with adolescents and their needs. Worse still, adolescents are not always straight forward when presenting their health problems to health workers (UNFPA Uganda 1998). 2.7 Early Pregnancy Females in Uganda usually marry very early, and are expected to prove their fertility at an early age. In some instances proof of fertility is required before marriage. The Uganda Demographic and Health Survey (1995) found that over 43% of teenagers had begun child bearing, with 34% having had a child already. This puts Uganda as one of the countries with the highest teenage pregnancy rates in Africa, compared to Nigeria with 36% (1992), Central African Republic with 36%(1995), Tanzania with29%(1992) and Kenya with 21%(1993). Recent report of Uganda demographic health survey puts Uganda to be the 7th in the world with high fertility rate at 6.7 children per mother. An adolescent girl who becomes pregnant before 18 years may be up to five times more likely to die due to pregnant related complications than a pregnant woman aged 20-25 years (Status of Adolescent Health Policy UNPA-Uganda 1998). The overall teenage parenthood is higher among rural women (45%) than their urban counterparts (31%). This is true for both proportions who are already mothers, as well as those that are pregnant with their first child (UDHS, 19995).

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Pregnancy and child bearing in adolescence are associated with health and social risks. world over (WHO/MCH/89.5, 1989).

bibliography of studies demonstrating adolescent pregnancy shows that these risks are the same Pregnancy and childbearing among girls in Uganda start during their adolescent years. There is however, no national quantitative data disaggregated for districts in Uganda on risk factors for adolescent pregnancy and childbearing (WHO/MCH/89.5, 1989).

2.8 Early Adolescent Marriages In the UDHS (1989), it was found that 41% of the females were aged 15-19, 95% were aged 30 years, and 99% of those aged 35 years and above had entered into some form of marital union. This strong emphasis on marriage institution for women results in early marriages, particularly among the less educated and rural females. Early marriage and the consequent adolescent childbearing, predispose the adolescents to obstetric complications and malnutrition that limits their development in other fields (UNFPA-Uganda, 1995). About one quarter (23%) of adolescents are married by the age of 19 years. Female adolescents marry earlier than their male counterparts. Marriage is often culturally arranged by parents and because of the bride wealth involved, girls may be compelled to marry at tender ages. Early marriage interferes with the girls education, reduces their opportunities for career development, and exposes them to the reproductive health risks so commonly associated with early pregnancy and childbearing (UNDPA, 1994). 2.9 Unsafe Abortions The UNFPA (1998) status of Adolescent Health policy for Uganda revealed that of the total maternal mortality, 25-35% is due to complications of abortions and nearly 50% of the abortions occur among adolescents. It is further noted in this report that 94% of the complicated abortions seen in hospitals are done by medical personnel. These abortions are mainly due to unwanted pregnancies by adolescents. 2.10 Education of Adolescents On average the educational level for women in Uganda is very low with 60% of adult female illiterates. About 90% of the Uganda females live in rural areas where schools are scarce, poorly 12

funded with inadequate infrastructure and unqualified teachers (1991 populationand housing census report). In urban areas most of the adolescents are in schools and have completed primary education. In rural areas, however 80% of adolescents have seven or less years of education. Illiteracy is more among adolescent females with 37% compared to 23% illiterate adolescent males (1991 population and housing census report). High urban school attendance among adolescents tends to discourage early childbearing. This accounts for the lower levels of motherhood and pregnancy among urban teenagers. However, it is also possible that higher school attendance is a technical way of avoiding early parenthood. The level of teenage childbearing is strongly associated with the level of education, with 49% having no education and 47% with primary education (UDHS, 1995). About 40% of girls in rural areas have no formal education and only 10% go beyond primary seven. Nationally, 35% of girls of school going age do not attend school. Of the remaining 65% who start primary, 75% drop out before they finish their secondary education (UNDP, 1994). The high enrollment rate for boys compared to girls is partly caused by poverty. When resources are scarce, boys take precedence in school fees payment. This is societys construction based on the roles to be played by boys compared to girls in adulthood. While the girls are expected to marry and raise families, the boys are expected to take up public offices and head households. Pregnancies also contribute to female school dropouts. Education level significantly affects the age of marriage, number of children, socio-economic status and health seeking behavior of women (UNDPA, 1994). 2.11 Early Adolescent Sexuality The average age at first sexual intercourse is 15 years, with many adolescents starting as early as 10-14 years. Of the adolescents surveyed, 75% of adolescent females and 68% of males had at

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least experienced sexual intercourse, exposing them to the risk of early pregnancy and or sexually transmitted infections, including HIV/AIDS (Agyeyi, 1989). According to UDHS (1995), 60% of the females aged between 15-49 years had their first child before reaching the age of 20 years. It was also reported that the age at first intercourse was higher within urban areas than rural areas, although the converse is usually thought to be true. In the same survey, it was found that a large proportion of young males (85%) and females (81%) are sexually active. counterparts. There is a high incidence of pregnancy among female youths. At any one time about 11% of females aged 15-19 years are pregnant. The percentage of pregnant adolescents is higher in rural areas (61%) than in urban areas (34%). In a study of mothers less than eighteen years in Tororo district in eastern Uganda, more than 70% of the girls had their first sexual experience by the age of 14 years, and became pregnant soon after menstruation began (Bachou, 19992). It was further noted that 34% of males and 25% of females initiated sexual intercourse before 15 years of age (CDC, 1992). In the past, traditionally among the ethnic groups such as the Baganda of Central Uganda, an aunt discussed matters related to sexuality with adolescent females and community elders educated the males. This is the Senga Institution. Currently very few parents ever discuss sexual matters with their children (Barton and Wamai, 1994). A survey on fertility among school going adolescents revealed that adolescents are increasingly receiving no instructions from their family members on sex and sexuality. The in-school and out-ofschool adolescents rely on peers to get this vital information. (Otolok, 1988, Kirumira, et.el, 1993). Uganda is one of the countries in Sub-Saharan Africa with the poorest adolescent sexual and reproductive health status, characterized by; early on set of sexual involvement (17 years), high rates of teenage pregnancy (41%), high rates of adolescent motherhood (currently the highest in Africa), high abortion rates, high maternal mortality rates (over 60% of deaths due to maternal complications are contributed by young people aged 20 and below), high incidence of sexually transmitted 14 Adolescents in rural areas are sexually more active than their urban

infections including HIV/AIDS.(A students Handbook for Upper Level Post Primary Education and Training , 2006) In most countries, the median age at first intercourse is the mid-to-late teens. However, sexual activity starts earlier for some young women and men. The proportion of adolescent women who have had sex by age 15 ranges from less than 4% in Rwanda to 36% in Niger, very early sexual initiation is more common in West Africa and Cental Africa than in East and Southern Africa.in most countries, a small proportion of me than of women have had sex by age 15, but in a few-Benin, Gabon and Kenya-the proportion is substantially higher for men. Between ages 15 and 17, the rate of initiation of sexual activity increases rapidly. The proportion of women who have had sex by age 15, but in a few Benin, Gabon, and Kenya- the proportion is substantially higher for men. In every country except Ethiopia, Nigeria, Rwanda, Senegal and Zimbabwe, about 8 in 10 or more women have had intercourse by the time they turn 20. among men, who are much less likely than women to have married, the proportion ranges from about 40-50% in Burkina Faso, Ethiopia, Niger and Rwanda to 80% or more in 9 countries(Akinrinola Bankole, 2003, Susheila Singh et al,2003) Age at first sex was estimated at 16.7 and 18.8 for girls and boys respectively in 2005. it already began child bearing by the age of 19. more than half of young women and 39% of young boys aged 15-19 years have ever had sex while in the age group 20-24, 96.3% females have had sex compared to 87.5% males. There are high levels of intergeneration sex especially among females with most of young women reporting that their first sexual experience was with a partner 3-10 years older. Despite the high levels of early sexual activity, many do not exploit the benefits of safe sex. About 30% of the sexual active people used a condom the first timewhile 47% females and 61% males have ever used a condom. Early sexual activity heightens females vulnerability to consequences of early pregnancy including unsafe abortion and maternal morbidity and mortality. Teenage pregnancy was estimated at 25% in 2006. the median age at first birth has over the last 30 years been at 18.5 years, 44% of the countrys maternal deaths are among the 15-24 years old. In 2001, a UBOS report estimated that among the sexually active and un married women, 52% (1519 years) and 54% (20-24 years) were using some family planning method. The contraceptive prevalence rate among the general population is estimated at 23%, and the rate among 15-24 age 15

groups at 10%. Considering the early age at first birth, this indicates poor utilization of family planning services despite an open policy on family planning eligibility. (Health, HIV, AIDS and Development report, 2007)

2.12

Contraceptive Use among Adolescents

A study on attitudes, knowledge and use of family planning among secondary school girls in Mbarara District western Uganda, revealed that majority (75%) of adolescent girls knew at least one of the family planning methods that included; the pill, foam tablets, Intra-Uterine Devices (UIDs), withdrawal method, condom and injection (Beihemukyi, 1986). Most of the young mothers receive information concerning their reproductive health from their boy friends. Parents also feel uncomfortable to discuss sexual matters with their daughters and sons as they feel such discussions could instead encourage sexual activity (Ssemwogerere, 1994). Adolescent girls are not aware of preventive methods against unwanted pregnancies. Approximately 74% of adolescent girls become pregnant because of their ignorance on contraceptive methods (Mubangizi, 1980).

One fifth of ever married literate women at private reproductive health clinics in Jordan have had their husband or family members interfere with their use of contraceptives to avoid pregnancy, according to a study conducted in 2005. among the 353 women surveyed, 20% reported at least one type of interference in their efforts to avoid pregnancy; 11% reported that their husband had ever refused to use a contraceptive or tried to stop them from doing so, and 13% reported that someone else (usually their mother or mother-in-law) had tried to stop them. Furthermore, 31% had experienced physical violence and 20% sexual violence perpetrated by their husbands during marriage, many also reported that their husbands exhibited controlling behaviors. The authors believe that family planning services should promote husbands support for contraceptive use, and that increasing awareness of the relationship between womens reproductive health and intimate partner violence

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could be an effective first step toward improving womens access to and effective use of contraceptive.(Intenational Family Planning perspectives, 2008) Luke and others have argued that the social economic environment that prevails in most subSaharan countries encourages sexual activity especially among females. Young females tendency to give in to the sexual pressures of older males is influenced by their youth and inexperience, their socialization to acquiesce to male authority and their potential economic dependence on male partners. In Kenya, in qualitative interviews with upper primary school youth, both males and females spoke of financial pressures and motivations to engage in sex with older partners, contributing to both sugar mommy and sugar daddy relationships.(Eric Yeboah et al, 2007) The lack of adequate negotiating and assertiveness skills, especially among girls leads them to indulge in alcohol abuse which paves the way for unprotected sexual practices, leading to STIs/STDs and unwanted pregnancies.(State of Alcohol Abuse in Uganda report, 2008) LOCATION, SIZE,HEALTH FACILITIES AND DEMOGRAPHY OF KIBAALE DISTRICT: Kibaale District which is under study, is in mid- western Uganda, about 2650 km west of Kampala, the capital city of Uganda. It is bordered by the districts of Hoima in the north, Kyenjojo in the south, Mubende and Kiboga in the east and Lake Albert in the west. It is made up of three counties of Buyanja, Buyaga and Bugangaizi which also serve as the three health sub- districts. Kibaale district has 18 sub-counties and 2 town councils of Kibaale and Kagadi, and it is at Kagadi in Buyaga health sub-district where there is the district referral hospital..

The district covers an area of 41,54867 sq.km, of which 345 sq.km.are covered by water.The . population of the district is 567,465 with a population density 135 persons per square km.

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The District is inhabited by various tribes but mainly the Banyoro (48%)- the indigenous people, and other tribes who migrated to the arae include the Bakiga (31%)- , the Bafumbira and the Bakonzo together forming 16 %, and other splinter tribes like Batoroand Baruru.

Of aThe district has a population of 567435,465 people theof which females are 289,407246,342 (51%) and males 278,058[49%] .and ofOf the females, the adolescents are 71,7733,903(24..867%). The population density is 105 persons/square km (projection of 2006 from 2002 census). TThe females that were pregnant were 37,68625,421 (13.20.32%) and of these, adolescent pregnancies were 182781,886 (48.5%) (Projection of 2009 from 2002 Census). (District annual work plan 2005 2006). Kibaale district has 18 sub-counties and 2 town councils of Kibaale and Kagadi, and it is at Kagadi where there is the district referral hospital. The district has 40 health facilities, of which one is a general hospital, three are health centre IVs, sixteen are health centre IIIs and twenty are health centre IIs. Of the fourty Kibaale District is fairly served by health facilitiescenters where delivery and maternal and child health care[MCHC] services are offered in twenty of them. But the Mmaternal deaths are still high at 605585 per 100,000 live births against 435 per 100,000 live births the nNational average, and yet 46% of all these deaths are among adolescents. (District annual work plan 2008/ 2009).

Reasons as to why this is so are not properly known and documented. It is estimated that in this district, over 850% of the pregnant mothers attend antenatal care (ANC) in health facilities andsupervised conducted by trained health personnel, but that less than 35% of these mothers deliver in health units and under the care of trained health personnels (District Population and Housing Census Projection report 20084).

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The District is inhabited by various tribes but mainly the Banyoro (48%)- the indigenous people, and other tribes who migrated to the are include the Bakiga (31%)- , the Bafumbira and the Bakonzo together forming 11%, and other splinter tribes like Batoro, Baruru.

There have been efforts by the District Health Team (DHT) to reduce this problem through provision of counseling and improved health services, training of the village health teams and sensitization of the community, but there seems to be no significant improvement. Reasons responsible for this problem is yet to be ascertained in the District (District population report 2006). The hospital ambulance usually collects mothers in labour from their homes throughout the district to the nearest health facilities for delivery. But in financial year 2003, nearly 60 million Ug. Shs. was used for this problem alone and yet this was 25% of the hospitals years budget. Adolescent pregnant related complications commonly reported in the health units in the district are many and include among others: illegal abortions, loss of school, loss of family income, family rejection and stigmatization, anemia, obstructed labour, ruptured uteri, vaginal fistulae, malaria, eclampsia, STIs including HIV/AIDS and death. (Ekoth 1998). 3.0 PROBLEM STATEMENT, JUSTIFICATION,CONCEPTUAL FRAMEWORK,RESEARCH QUESTIONS 3.1 statement of the problem Because it Early pregnancy and teenage motherhood areis associated with high morbidity and mortality,, early pregnancy and teenage motherhood They haves had major negative impacts on the health, social and economic well being of big populations throughout the world world wide.Early pregnancy and teenage motherhood globally, is a big socio-economic and health problem given the high morbidity and mortality associated with it both for the mothers and the children born. The problem is worse in developing countries Uganda inclusive (James E.ROSEN, Shanty R. Conley 1998). Bu Howevert the problem is worse in under developeddeveloping countries ,Uganda inclusive 19

) Of a population of 567,465 people the females are 289,407 (51%) and males

278,058[49%] .Of the females, the adolescents are 71,773(24..8%). The females that were pregnant were 37,686 (13.2%) and of these, adolescent pregnancies were 18278 (48.5%) (Projection of 2009 from 2002 Census It is estimated that in this district, over 85% of the pregnant mothers attend antenatal care (ANC) in health facilities and conducted by trained health personnel, but that less than 35% of these mothers deliver in health units and under the care of trained health personnels (District Population and Housing Census Projection report 2008).

In Kibaale District, pregnancy among adolescents is 48.5%( in the District( ).(District pop report 2007)

) of all pregnancies

This is higher than the national average of 43% for Uganda and much higher than 40% for the other sister dDistricts in the western region of Uganda (UDHS 20086). Maternal mortality in the District stands high at 585/100,000 live births (District population report 20087) which is much higher than the national average of 435/100000 live births(UDHS 20086) Of thematernal moetality rate MMR of 585/100,000 live births , young mothers below 20 years contributed 49.5% whichThis is quite highbig and raises concern. Pregnant related morbidities like spontaneous and criminal abortions, STIs including HIV, unwanted pregnancies, ectopic pregnancies, homicides have been observed highest among adolescents. Labour related problems like obstructed labours,VVFSs ,/RVFs raptured uterii, fresh still births(FSB), APH,and PPH and deaths have also been observed highest among adolescents. Individuals, families, institutions and communities ,have spent lots of time and resources attending to these ever increasing pregnant related problems which have indirectly affected the economic and social progress of the people in the district. Deaths due to complications ofed labour, criminal abortions and anaemia due to poor nutrition, are commonly reported in many corners of the dDistrict. Over 50% of all mothers who sought medical services due to pregnant related morbidity in the major health units of the district were adolescents Adolescent pregnant related complications commonly reported in the health units in the district are many and include among others: illegal abortions, loss of school, loss of family income, family 20

rejection and stigmatization, anemia, obstructed labour, ruptured uteri, vaginal fistulae, malaria, eclampsia, ) . Adolescent pregnancy is theeforetherefore a public concern that calls for urgent STIs including HIV/AIDS and death. (Ekoth 1998).(

approptiateappropriate intervention. However what exactly predisposes or entices/lures these young girls to becoming pregnant very early in life is not clearly known and documented. No body has made a study in this district to establish these factors. Therefore this study is intended to that. . . In Kibaale district pregnancy among adolescents is a big social, economic and health problem, and it is about 48.5% of all the pregnancies in the district (District Population report 2005). This is higher than the average of 43% for Uganda as a nation, and that of 38% for districts in the western region of Uganda (UDHS 1995). At Kagadi, the main hospital for the district, in 2003 alone, 25 mothers died of pregnant related problems, and of these 13(48%) were among young girls below 18 years. Reasons for their deaths were not very clear. Pregnancy related morbidity and mortality among mothers of that age range was nearly 50% of all the mothers that sought services at the hospital (Hospital HMIS Report 2004). However, the risk factors associated with adolescent pregnancies in Kibaale district are not known. Therefore it is based on this premis to establish these adolescent pregnancy factors. 3.2 4.0 justification of study Maternal morbidity and mortality [MMR] of (585/100,0000 live births in Kibaale district is higher in Kibaale District than most dDistricts in Uganda with a national average According to the national policy guidelines for family planning and maternal health services (1993), the policy on contraception in Uganda is very useful and supportive. It states that All sexually active males and females are eligible for family planning services provided they have been appropriately educated and counseled on all available family planning methods. However, there are no sufficient facilities where adolescents can go and seek counseling and other services pertaining to their sexuality. More to this,

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the fifth millennium goal is to reduce by three quarters the ratio of women dying in child birh. Therefore, the findings from this study will be used to inform policy makers on coming up with appropriate policies in regard to adolescent pregnancy.of 435/100000 live births. A higher proportionbig % of thishigh MMR,is contributed by pregnancies among girls below 20 years(48.5%). The outcome of these pregnancies which include high infection rates ,unsafe abortions malnitrion haemorrhages, obstructed labour,V V Fs, ruptured uteri and deaths in addition to other adverse social effects have had hard devastating effects on the social and economic progress of the communities of this area. Families, institutions and communities have wasted a lot of valuable resources attending to these problems. Many lives have been lost, many families have been psychologically traumatized for losing mothers in labour and especially so when they are young .According to available statistics in the district if an adolescent became pregnant the chances of her havening successful delivery to a live baby that survives one week is only 51.5%.This is a big loss and quite traumatising to the affected homes and needs to addressed. But the factors that lureentice or predispose adolescents to early pregnancies are not yet established. Are they economic factors, social and educational factors,cultural factors, psychological factors, biological and age related factors or other related environmental factors? The high morbidity and other pregnant related mishapenings that the district is experiencing on the rise is being noted mostly among adolescents. Its therefore mojormajor public health concern. This study is intended to establish these factors. Its these factors which are risky for adolescents pregnancies. The policy makers, aAdministrators, cCivic organizations and hHealth managers have been involved in activities aimed at reducing adolescent pregnancies to reduce on mortality and morbidity and other early pregnanant related problems but with little sucources because they have lacked focus of the real issues. This study is likely to bring out the real issues that predispose or lure these young girls to becoming pregnant early in life which predisposes them to the many bad outcomes of early pregnancy and early motherhood. Using the same results generated ,policy makers and other concerned stakeholders will make use of this information to design appropriate by-laws to protect the adolescents from the many risks they encounter that lures them into becoming pregnant a thing that endangers their health and their sicioeconomic well being and that of the community they live in. in life especially those who are pregnant. This is likely to reduce morbidity and eventually mortality in mothers of this age range and their children. 22

Ultimately there will be improved hours of production for the concern mothers and their families,s, reduced health costs, improved general health and eventually the social-economic status of the population will improve. .

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3.3:

CONCEPTUAL FRAMEWORK FOR ADOLESCENT PREGNANCY Social No/Low education for parents COMMUNITY No/Low education for girl child Sex abuse Polygamous home Peer influence Peer influence which is negative Personality and life style of girl Demography Early marriage Family size and instability Age and its consequences Cultural taboos Genetic make up of girl Size make up of family house Sex education School with no seperated social Hormonal influence Religion and related exposure facilities for boys and girls Gender issues
familississ issues Adolescent DEMOGRAPHIC Ppregnancy in Early sexuality Kibaale district Religion among the Age Adolescents 17-19 years of age MImmigrantstion Those environmental Consequences Emigrantstion factors Induces one into Abortions Maternal mortality Maternal morbidity Unwanted children Educational

Economic Inadequate family income In adequate personal effects In adequate family utilities SOCIOAL ECONOMIC In adequate scholastic Employement materials Family Income
Girls-Education CommunityCulture Gender issues

DISTRICT HEALTH partner Girl looks for SERVICES supplement above Awareness on prevention of requirements pregnancy Accessibility to adolescent RH services Family planning services Awareness of dangers of early pregnancies.

to

early sexuality

level

ADOLESCENT Unplanned sexual activities Mmissed opportunities Health Services STDs & HIV/AIDS PREGNANCY Inadequate adolescent tailored reproductive health services Inadequate reproductive health education, counseling, information and guidance. Community/ Culture Unfriendly National Reproductive Community/tribal norms health policies Sexual abuse Inadequate IEC material on Reprod Early marriage Unfair gender issues Consequences Sexual violence, Counseling and education, All types of Maternal Sexual bye laws, morbidities Early sexuality Girls are ignorantly Maternal mortality exposed to early sexuality Unwanted children/family

Missed opportunities Family isolation/rejection Ignorance and poverty

24

Narrative of the conceptual framework

25

3.4 Rsearch questions 1. What are the socio-demographicial factors(educational, age, cultural, religious, peer influence, gender issues)that predispose/lurese/entice adolescents into early sexuality and pregnancyies? 2. What are the economic factors(income levels, family economic status economic empowerment, employement status etc )that predispose/lures/entice adolescents into early sexuality and pregnancies? 3. To what extent does availability and access to adolescent tailored reproductive health among adolescents? 4. To what extent does the availability of adolescents tailored media programs, local by-laws, policies and community attitudes minimize early sexuality and pregnancies among adolescents? . services minimize early sexuality and pregnancies

26

CHAPTER FOUR pregnancies in Kibaale district 4.0 6.0 46:1 STUDY OBJECTIVES GENERAL OBJECTIVE

are the risk factors associated with adolescent

6.1

GENERAL OBJECTIVE

The communities in Kibaale District have realized that pregnancies and motherhood in the early years of lives of their female childrenfe of the families have had divaer stating sociao-l economic,biological, psychological and other enviromentalthe effects on the young mothers ,their babies ,the families and the community in general and would wish through logical means to establish what factors exactly lure ,entice, predispose these young girls into early sexuality and pregnancies so that these risky factors would be used to design and implement appropriate interventional measures to minimize early sexuality ,pregnancies and their consequences.

GENERAL OBJECTIVES (Summerised) To establish as risk factors those social ,economic and policy factors that predispose/lure/entice adolescents into early sexuality and pregnancies and to use these risk factors to design appropriate interventional measures that will help to minimize these pregnancies. o determine the risk factors associated with pregnancies among adolescents in Kibale district 46.2 SPECIFIC OBJECTIVES

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To establish /determine the social factors that predisposes, lure or entice adolescents into early sexuality and pregnancy. To determine/establish the economic factors that predispose/lure/entice adolescents with early sexuality and pregnancy. To establish whether availability and accessibility of to adolescent tailored reproductive health services playswas a role in minimizing early sexuality and pregnancy. To determine whether accessibility of adolescents tailored media programmes, local by-laws, policies and communitiy attitude has a role in minimizing early sexuality and pregnancy. determine the risk factors associated with pregnancies among adolescents in Kibaale district Hypothesis Economic status and age,educational level,cultural and gender issues, peer influence and availability of adolescent tailored accessable reproductive health services and policies are not risk factors for associated with pregnaniescy among of the adolescents in Kibaale district Economic status and age are associated with pregnancy among adolescents in kibaale district

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57.0

METHODOLOGY

7.2 Study design This will be an unmatched Case-Control study, which will be both qualitative and quantitative. Cases will be adolescents who are pregnant attending the antenatal clinic during the study period and controls will be adolescents who will be attending the out patient clinic in Kibaale district. The exposure variables are all those shown in the conceptual framework above. 57.11 Study sitearea and health facilities and communication

The study is to be conducted in purposely selected health units in Kibaale District. Kibaale District is located in mid-western Uganda. It is bordered by the districts of Hoima in the north, Kyenjojo in the south, Mubende and Kiboga in the east and by Lake Albert in the west which lake is bordered by DRC in the west. The District covers an area of 45481567 sq. km of which 345 sq. km are covered by water. The District is made up of 3 counties/constituencies of Buyanja, Bugangaizi and Buyaga which also correspomd to the health sub-districts. These counties are the equivalent of the 3 constituencies and therefore the 3 health sub districts. There are 40 health facilities in the dstrict one of which is aIn addition to the general hospital at Kagadi, there are three are hHealth centre IVs, of which one is a PNFP, sixteen are health centre IIIs and twenty are hHealth centre IIs., giving a total of 40 health facilities in the district. Of these forty health units, at least twenty can offer reproductive health and maternity and child health services.

29

Though these health centers are poorly distributed, mainly with in trading centers, Aat least over 50 % of the people in Kibaale district can easily access health services, and are with in 108 km of walking distance to the nearest health facility. There are also many private clinics and drug shops spread all over the district and most of these serve the very rural populations. All the 40 health units are supported by the government through the Ministry of Health (MOH) and the district administration via the office of the district director of health officer services (DHODHS). There are also many private clinics and drug shops spread all over the district serving the very rural populations. , At least over 50 % of the people in Kibaale district can access health services, with in 10 km of walking distance to the nearest health facility. Usually the Office of the DHODHS supports the private health clinics especially in regulating their activities and licensing them. The District has a population of 435,465 people of which females are 246,342 (51%) and of the females adolescents are 73,903(24.67%) The population density is 105 persons/square km (projection of 2006 from 2002 census). The District is inhabited by various tribes but mainly the Banyoro (48%)- the indigenous people, the Bakiga (31%)- who are settlers , the Bafumbira and the Bakonzo together forming 11%, and other splinter tribes like Batoro, Baruru. Communication is rather poor in the district, with poor road network, unfavorable land terrain and the soils are almost impassable in the wet seasons. Though mobile telephone communication has improved things net work is still in few a places.

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5.27.3 Study Populationn Target population All prime gravida adolescents women of the ages 17-19years infrom Kibaale district attending antenatal care andor out patient clinics in the purposely selected health units during the time of study. Accessible population All adolescent women from Kibaale district attending the antenatal clinic or out patient clinics at all health center IV during the study period Study population All adolescent women from Kibaale district attending antenatal care or and out patient clinics at all selected health centers IV during the study period, who will meet the eligibility criteria START HERE NEXT.

7.5 Eligibility criteria 7.5 2.1 Inclusion Criteria Cases: This will consist of prime gravidaegnant adolescents (17 19 yrs) in Kibaale district attending antenatal care clinics in the purposely selected health units during the time of study. . The pregnancy status shall be determined by history and clinical examination. These should have given informed consent to participate in the study

.5.2.2 Exclusion criteria

31

Controls: This will consist of non-pregnant adolescents (17-19yrs). in Kibaale district attending antenatal care clinics in the purposely selected health units during the time of study but have refused who will be coming to attend routine out patient clinic at the selected health units. These should have given informed consent to participate in the study. 7.5.2 Exclusion criteria Adolescents who are severely ill or who are not pregnant after taking their history and clinical examination at the antenatal clinic 5.2.3 Study design This will be a cross sectional study design which will be both qualitative and quantitative. Sampling procedure Study participants will be picked using consecutive sampling, for which ever adolescent attends any of these clinics and fits the study criteria. 5.3. Sample size estimation Using chi-square methods of sample size calculation;

1 - (proportion of pregnant adolescents in Kibaale District) = 48.5%

0 - (proportion of non pregnant adolescents in Kibaale District) = 51.5%

32

N=

2 (1- 11 )+ ( )+ (11 0001 )

( 1 0)

Z = Value corresponding to desired level of significance = 1.96. Z = Value corresponding t

1 - (proportion of pregnant adolescents in Kibaale District) = 48.5%

0 - (proportion of non pregnant adolescents in Kibaale District) = 51.5%
oO- the desired power of the study =1.645 N = Sample size for the study will besize for each group = 384192.

33

The ratio of Cases: Controls will be 1:1 therefore; the minimum number of correspondents will be 384. Total = 384

5.4.Sampling procedure. 5.4.1.Quantitative data sampling In this study all the the twenty health units that offer antenatal and delivery services in the district will be selected. The health units will be stratified according to level of activity and the number of respondents selected per unit will depend on those levels. From the hospital 46 respondents will be selected, and from each health centre IV, 33 respondents will be selected and from each health centre III only 16 respondents will be selected giving a total of 384 respondents. Mothers will be randomly selected using a sampling frame which will cater for the inclusion cretaria. In the hospital not more than 10 respondents will be interviewed per day and in HC IV not more than 7 respondents will be interviewed daily and in HC III not more than 5 respondents will be interviewewd daily. 5.4.2. Qualitative data sampling 5.4.2.1. focus group discussions Three focus group discussions will be conducted. From each of the three health subdistrict will be a focus group discussion. Each focuss group discussion will comprise of 10 purposely selcected members from the different categories of health workers,administrators,opinion leaders,religious leaders,teachers and politicians.The focus group discussions will be conducted by the principal investigator himself. 5.4.2.2. Key Informant Interviews. Key informants will be purposely selected who are resource persons on the subject. with a composition similar to those members in the focus group discussions.

34

5.57.7 Study Variables: 5.5.1 . Dependent Variable: Pregnancy status of the respondents. 5.5.2 Independent Variables: Sociol-Socio-Ddemographic characteristics: age, tribe, marital status, educational level, residence, and religion,peer influence,cultural set up of the community beliefs and taboos,gender issues,nature of school and infrastructural set up,distance to school.polygamous family, Contraceptive methods: Knowledge and use of contraceptives, Sexual behaviors: Age at first intercourse, sexual education and counseling, type and number of sexual partners, hormonal influence and reasons for having sex, attitude to early marriage,desire for and number of chidren,community perception of sexuality its education and counseling to the youths,. Socio- economicEconomic status:. Family infrastructures and assets,House hold properties,family income, type of employment of household head, number of rooms (privacy), type of house and size, Health sevices and policy: Availability and accesability of adolescent tailored reproductive health services and eduction, adolescent health policy, knowledge and attitude to family planning.

35

5:6;7.8 Data Collection 5.6.1 Data collection procedure. Data will be collected from the selected pregnant adolescents using structured questionnaires,key informant guides and focus group discussion guides. 5.6.2 Datacollection tools. (a)For quantitative data: We shall use self administered semi-structured questionnaires with both open and closed ended questions (b) For qualitative data: We shall use Key Informants (KI),and Focus Group discussion guides(FGD).ction Methods. Data will be collected using questionnaires for both cases and controls from the selected participants, and qualitative data will be collected using focus group discussions. All the data collection tools for both quantitative and qualitative methods are attached in the appendix. Data collection tools will be in English, The research assistants to collect data will be those who can translate the tools in the main local languages the Lunyoro and Lukiga. The Principal Researcher will conduct the Focus group discussions and key informant interviews.The questionnaire will first be pre-tested to ensure that it is able to collect correct, and adequate information to answer the study objectives.

5.7 Data managementand analysis 5.7.1 Data management After collection of data,the principal investigator will read and clean the data. S/he will check for inconsistencies on the very very day of data collection. Data coding,data entryinto the computer, and clearing and finaaaally analysis will be done. Data will be entered into the computer using EPI INFO 6 and then Data analysis will be done using SPSS or stata statistical packages. The results will be presented in text form,proportions,means and percentages. Some data will be tested for statistical significance using K square test and odd ratios. 36

. 5.7.2 7:9 Data Collection and data management

Quantitative data shall be collected using a self administered semi-structured questionnaire, which will be written in the local language. This questionnaire will first be pre-tested to ensure that it is able to collect correct, and adequate information to answer the study objectives. Qualitative data will be collected using focus group discussions and key informant interviews. Key informant interviews will be conducted by the PI of the study and these will include at least 3 head teachers from that area, who will be selected purposively. Focus Group discussions will be held by 3 research assistants; 2 will be writing and the other asking questions and holding the recoder to ensure that every ones voice is heard. Data Analysis 5.7.2.1; Quantitative data. Data analysis will be done using SPSS or SATA statistical packages 5.7.2.2 Qualitative data Univariate analysis will be done by summarizing categorical variables like

maitalmarital status, educational level, religion and others into frequencies pie charts, and percentages for general description. Summarizing of continuous variables like age will be done using means, medians, standard deviations and range. Bi-variable analysis; Statistical significance of associations between pregnancy status and independent variables will be established. Odds ratios will be used to measure the strength of association between the outcome variable (i.e. pregnancy status) and the

37

predictor variables. Chi Square test will be used to test for statistical significance, and confidence intervals will be used also as a measure of the range within with the Odds ratios fall. Multivariable Analysis Independent variables with p value of equal to or less than 0.2 will be selected for multivariate analysis. Logistic regression assumptions will be assessed for suitabilityfor suitability of using logistic regression as on this data. We shall assess the model for interaction by; first forming product terms of the significant variables in the model with the other variables in the model; perform a likelihood ratio test to asses whether there is interaction. If there is interaction, a stepwise will be run to identify the true variables which interact. Confounding will be assessed for variables which are not interacting after running stepwise. Confounding will be considered present if the difference between the adjusted and the crude Odds ratio is greater than ten percent. weWe shall test for goodness of fit of final model for explaining the loss to follow up Typical quotations from FGD and KI will be presented verbatim in the results. 5.8 Quality Control 5.8.1. Pre-testing; Assurances Research assistants preferably midwives will be recruited from the different health centers centers involved in the study and will be trained to acquire skills in interviewing and probing and on how to carry out the study. The training will include practical exercise during pre-testing of the tools. The questionnaires, and focus group discussion guides and kKeyiInformant guides will be translated into the local language and back

38

translated to E nglish ensure that the meaning remains consistent. The questionnaire will be pre-tested. A detailed operational manual will be developed and will be availed to the research assistants. The PI will ensure the operational manual is strictly followed during data collection. All study instruments for data collection will be pre tested on a few people attending these clinics at each of the selected centers... Each day the data collection instruments will be examined to ensure completeness and accuracy then stored safely under lock and key. The PI will hold periodic meeting with the research team members through out this study period. 5.8.2 Training of research assistants: Four Reseach Assistants (RAs), two moderators and scribes will be trained for a period of three days. The moderators will be fuent in English Lumyoro and Lukiga. 5.8.3: Field editing of data. Questionnaires will be checked before leaving the field for correct complition daily. Th Principal Investigator (PI) and the RAs will edit thequestionnaires at the end of each day for completeness and consistency. 5.9 8.0 ETHICAL CONSIDERATIONS: Permission to do this study will be obtained from: Makerere University School of Public Health Higher Degree Research and Ethics Committee (HDREC) the Institutional Review Board (IRB) Uganda National Council of Science and Technology (NCST The Chief Administrative Officer for District Political Leadership) Chief Administrative Officer (CAO) District Health OfficerDirector of Health Services (DHODHS). 39

, The Respondents; will be asked to offer informed consent to participate in the study. The PI will ask for as for permission from the (HDREC)IRB to consider every pregnant adolescent as an emancipated minor. Confidentiality of study participants will be kept with high regard and maintained throughout the study and thereafter. No name will be indicated in the data collection tools. Unique identification numbers will be the ones to be used instead. Respondents will be assured of their rights to accept or refuse to participate in the study without victimization. Benefits and values expected from the study will be discussed with the respondents and assured to the community in which the study will be done.

5.10 DISSEMINATION AND USE OF RESULTS A full report and recommendations will be submitted to: ===All those authorities above from whom permission to carry out the study will have been sought. ===Ministry of Health, === Dissemination workshop for the District Local Leaders and DHT will be held to present the report. ===The Leaders of the community in which the study will be done. 5.11.ANTICIPATED LIMITATIONS OF THE STUDY === Only pregnant adolescents who sought care from the selected units were recruited in the study but left out those who did not thus creating selection bias ===The research assistants used may chose to interview those people they seem to flow with normally at the health centers and or they may present the questions poorly and this may bring about information biase and interviwer biased results. ===In the process of translating the questions, there could be information lost.

40

===Issues of external validity may arise if this study is to be generalized to populations in the urban areas and the whole district. This population is majorly rural and therefore findings can only work in a rural setting and the sample studied is too small to represent the the pregnant women in the district . ===Some respondents may not recall facts or not willing to talk about issues surrounding their pregnancies or families thus creating recall bias. Analytical biases=== He who analyses the data may be biased with stron preconceptions about the girls

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REFERENCES Anonymous Draft Report: Adolescent Reproductive Health in Uganda, 1997. A students Handbook for upper level Post Primary Education and Training . July 2006 (page 21)

Barton T and Bagenda: Family and Household Spending Pattern for Healthcare, National Health Financing Task Force, MOFEP, MOH, UNICEF, MUK/CHDC, 1993. Beihemikyi.J: The attitudes, knowledge and uses of family planning among secondary school girls in Mbarara District, Dissertation B.A(SWASA)Makerere University,1986. Factors influencing the timing of first sexual intercourse among young people in Nyanza, Kenya. (page 177) (authors: Eric Yeboah Tenkorang and Eleanor MatrickTyandale Gary Knual Barker and Susan Rich: Adolescent Fertility in Sub-Saharan Africa. International Centre on Adolescent Fertility (ICAP). VOL. 3, 199 210, 1992 Health, HIV,AIDS AND DEVELOPMENT A case for Uganda (Uganda AIDS commission in partnership with the National Youth council November 2007 page 6) International Family Planning Perspectives volume 34, Number 4 december 2008.page 157 ( authors: I. Clark et al., Intimate partner violence and Interference with womens efforts to avoid pregnancy in Jordan, studies in family planning, 2008, 39(2): 123-132) James E. Rosen, Shanti R. Conly: Africa Population Challenge Accelerating Progrss in Reproductive Health About Population Action International. Pages 30, 35 and 37, 1998.

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Kahoire A. Aboda A. and Edstron K: Study on sexual and Reproductive Health of Uganda, Kampala; Uganda population Secretariat, 1993. Ministry of finance, planning and Economic development. Uganda Demographic and Health Survey, 1995, Statistics Department and Macro International Inc.1996. Ndyanabangi S.Z: Social factors Adolescents Sexual Behaviour and Consequences of Adolescent Sexual activity in Nakawa Division, Kampala, Unpublished Dissertation for the Award of Diploma in public Health Makerere University, Pp 30-32, 1996. Otolok E.T: An Eexploratory Study of the Factors underlying High Adolescents Fertility in Tororo District, unpublished Dissertation for B.A in social work at Makerere University, 1988. Risk and Protection Youth and HIV/AIDS in sub-Saharan Africa Akinrinola Bankole, Sushewa Singh, Vanessa Woog, Deidre Wolf (page 5)

Ssaula: A Study of Reproductive Knowledge, Sexual Attitudes and Behavior among Secondary Schools Students in urban in Kampala, Uganda, Makerere University Department of Sociology, WHO Report, 1991 page 34. State of Alcohol Abuse in Uganda, Young people drinking deeper into poverty. Uganda Youth Development Link. June 2008 (page 3)

UNPA Uganda: A situation analysis of Key Area Affecting the Health and Reproductive Health Status of Women in Uganda, Page 3, 10, 12 and 30, 1995. UNFPA Uganda: Status of adolescent Health Policy in Uganda, Pages 3-30, 1998.

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US Centre for Disease Control and Prevention (CDC). Prevention and treatment of STDs as an HIV Prevention Strategy. Atlanta, CDC, July.24, 1998. WHO, Geneva: A tabulation of available data on frequency and mortality of Unsafe Abortion, 1997(in press).

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APPENDIX 1 CONSENT FORM INFORMED CONSENT FORM FOR THE STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT Introduction: Good morning /afternoon I am of and am part of a research team from the office of the district health officer (DHO) Kibaale. We are carrying out a study intended to establish risk factors for adolescence pregnancies in this district. Records show that there is a high rate (43.5%) of adolescents becoming pregnant in this district and correspondingly a high rate (48.5%) of maternal morbidity and mortality among adolescents. This is of great concern to the stakeholders of the district and they wish something should be done to reverse it. Your loca,l civic and political leaders with whom this issue was discussed are interested and have agreed that we visit this health unit to get information from you that will be used to draw strategies to solve the problem. The questions I will ask you are not difficult, but if you do not understand any of them, please feel free to tell me and I will repeat. It is important to get correct answers. I will be writing down your answers, otherwise I may forget what you tell me or I confuse them with what other ladies will tell me when I visit them. Procedures for the study: This questionnaire will take 30 minutes. No names will be required for purposes of the study; however, I will use a code for the questionnaire. Benefits for the study: There are no immediate benefits to you as a person. However, the information you give will enable us to draw strategies that will help in contributing to the reduction of adolescent pregnancies in the district. Confidentiality of the study: Your answers will be taken generally as a contribution from a resourceful member of the district. The answers will be treated with confidence and used for purposes of this study only. 45

Voluntary consent: You are free to choose whether to take part in the study on not; and you are free to withdraw at any time at your own discretion. Feel free to ask any questions before, during and after the interview. Potential risks: There are no major risks to you in participating in this study apart from taking away your privacy at this time. For any further information concerning this study, you can contact the principal investigator ( Bateganya George) through the office of the DHO Kibaale. Signature of Respondent .. OR Thumb print (Rt)

Reseachers names.. Signature Thank you very much.

46

APPENDIX 2 QUESTIONNAIRE FOR A STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT General Information about the respondent 1 Date ..//... 2 Questionnaire No /Code Interviewers name.. Village of respondent 5. Sub-County of respondent 6. Health Facility

RISK FACTORS
(A) Demographic characteristics of respondent 1. 2. Age of respondent.( in years) Tribe (a) Munyoro (b). Mukiga (c) Mukonzo (d) Mufumbira (e) Others (specify). 9. Occupation of respondent.. (a) Peasant-Farmer (b) Business (c) Student (d) House wife (e) Employee (f) Others (specify).. 10. Parenthood .. (a) Both parents dead (b) single parent (mother) (c) single parent (father) (d) both parents present and stay together 11(i) Religion of respondent (a) Catholic (b) Protestant (c) Muslim (d) S.D.A (e) Mwikiriza (f) Born again Christian (g) Others( specify).. (ii) Of the children at home what is your birth order? .. 47

. Education level of respondent (a) Nil (a) Single (b) Primary (c) Secondary (d) Tertiary 13. Marital status of respondent: (b) Married (c) Separated (d) Widowed. 14. If married, how many years were you at your first marriage?......................... 15. What number is this pregnancy? 16. At what age did you have your first pregnancy? ..... 17 Was that pregnancy of your choice? 19. Have you ever had an abortion? Yes No. 20. If yes was it intentional or a natural process? ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 21. How many children have you ever delivered? . 22.(a) Were the deliveries easy or had some difficulties. (b)Did you deliver at a health unit Yes No Yes No (c) Was your delivery conducted by a trained heath worker (B)Social-Economic characteristics of respondent 23. Where is your place of residence? 1) Urban setting 1) Yes 2) Rural setting 24. (a) Do you stay with your parents? 2) No (b) If yes is it single parent or both parents?...................................... (c) If not staying with parents with whom do you stay (relation)? (d)Do you feel the care, guidance and counseling you get from whoever you stay with is enough and good? Yes No 25. Which economic activity are your parents/guardians engaged in? a) None b) Farming c) Business d) Professional e) Casual employments f) others specify: 26. What is the level of income of your family (parents/guardians/husband)? high b) High c) Medium d) Low e) Very low 48 a) Very Yes No. 18 Was the pregnancy easy or had problems

27. (a) Does the family you stay in have appropriate and adequate social amenities like TV ,radio to occupy you in your leisure times? 1) Yes (b) If not how do you entertain 2) No during your leisure yourself

hours?........................................................................................................................... ..................................................................................................................................... (c) Does the family you stay in have enough family things to use? Yes No 28.(a) Do you have any form of income generating activity as an individual?1) Yes 2) No (b) If yes what type of activity? (c) If no then how do you get money for your personal effects? .. 29(a).Do your parents/guardian etc provide you with adequate personal effects either for school or for your day to day living? 1) Yes 2) No (b) If no how do you supplement to reach the required levels?........................................................................................................................... .................................................................................................................................... 30..How many wives does your father or the person you stay with have? 31. (a) Among these wives in the family is there your biological mother? 1) Yes 2) No (b) If not how do they handle you in relation to their children? 1) Well 2) Poorly 32.(a) How many people are there in the family you live in? M...... F.... Total.. (b) Of these how many are of your age group of both sex?................................... 33.(a) Is food and other edibles always enough in the family? Yes No. (b) If not how do you supplement to satisfy you?.................................................. 34 In the family you live in do you experience any form of violence either among the children or among the parents themselves or parents towards children? 1) Yes 2) No 35.How many rooms are there in the house you live in the family? .? 36 (a) Can sound be easily communicated among the rooms in that house? 1) Yes 2) No 49

(b) If yes why?.............................................................................................................. 37(a).Do family members/visitors of the same age and of different sexes share the same sleeping rooms. Yes No (b)Why. (c) How far was the school you attended before you became pregnant. (d)Was the school you attended having all facilities like friendly toilets etc friendly and encouraging teachers ? 1) Yes (f) How was your performance at school? 2) No 1) Yes 2) No 2) Poor (e) Did you experience any sexual harassment from the teachers etc 1) Good

38. Do you have close friends of your age range of different sexes out side home? 1)Yes 2) No No 3) 39. Do they influence your life style? Yes occasionally, Yes (b) If yes how often 1) Yes 2) No Yes No Yes No 4) rarely No 1) very often 2) often 3) occasionally 4) rarely

40. How often do you associate with them? 1) Very frequently 2) frequently 41. (a) Do you drink, smoke ,enjoy places of entertainments and social gatherings

(c) Have you ever acted under the influence of alcohol or any drug like marijuana? 42. Does the school you attended / or attending now have separate toilets and urinals for boys and girls 43.(a) Are the toilets and urinals of acceptable quality and privacy? school?..................................................................................................

(b) If not how do you solve the need for short and long calls while at

(C) Mass media 44 (a) Do you listen to radios? (b) If yes, how often? 1) Yes 2) No 3) Rarely 50

1) Daily

2) Occasionally

45. Which types of programs are of your interest on radios? 1) Educational b) music c) Politics d) Family issues c) Social (relationships) d) others specify 46. (a) Do you read newspapers or magazines? 1) Yes 2) No (b) If yes, how often do you read them? 1) Daily 2) Occasionally 3) Rarely 5) Pornographic (c) What type of newspapers/magazines do you enjoy reading? 1) Politics 2) Sports 3) Fashion 4) Family any other place? (1) Daily 1) Yes 2) No (3) Rarely 8) 47 (a) Do you watch or given freedom to watch T.V/Video, film at the home you stay or (b) How often do you watch television/video? (2) occasionally (c) What programs do you usually watch on television/video? 1) Politics 2) Sports 3) Fashion 4) Family 5) Pornographic 6) Music 7) Films Others specify (D).Risky Sexual Behaviors 48. Of the following below which one have you ever experienced in your sexual life? 1) Kissing the above 49 50. How old were you at your first sex intercourse?--------------------------------With whom did you have sex on this occasion? 1) Boyfriend 2) Relative 3) Husband 4) Stranger 5) Others (specify) 51. What were the circumstances/conditions that led you to have sexual intercourse on that occasion? (a) Rape (b) Curiosity (c) Reward (d) Alcohols (e) Discovery (f) Others.. 51. (a) Do you have any of your close family members who delivered at your age or below? 1) Yes 2) No 51 2) Hugging 3) Masturbation 5) Oral sex 6) Anal sex 7) None of

(b) If yes who was that?......................................................................................... (c) Did she become pregnant while at home, in school or in marriage?........................................ 52. How often do you have sexual intercourse? 1) Daily 2) very often, 3) often, 4) occasionally 5) rarely 53. How many sexual partners do you have?--------------------------------------If you have more than 1 sexual partner, what are the reasons for having more than one? 1). 2). 3).

(E) Reproductive health issues.

(a) Methods of Contraception 53.(a) Have you ever heard of family planning methods? Yes/No . (b) What family planning methods do you know? 1) Condoms 2) Pills 3) Withdrawal 4) Abstinence 5) Injections 6) Timing cycles 7) Natural 8)Sterilization 9) None 10) Implants 11) others-------------------------------------54. How did you know these methods? (a) Friend (b) Siblings (c) School teacher (f) Posters (g) Parents (d) Radio/TV (e) Newspapers/Magazines using? (a) Pills (b) Condom (f) Sterilization (c) Injection (g) Abstinence (d) Foams (e) Implant (h) None (I) Others

55. If you have had sex before this pregnancy, what family planning methods were you

specify 56. Do you think the use of family planning methods can help to reduce or stop the unwanted pregnancies? 1) Yes 2) No 57. Which are the sources of supply of the Family Planning methods for you? 52

(a) Government H/U (d) Schools

(b) Pharmacy/Drug shops

(c) Friend/Relative (g) others specify

(e) Bars (f) Community distributors

58. Is it easy for you to access family planning services if you want it? 1) Yes 2) No (b) Health education and counseling 59.(a) Have you ever had reproductive health education and counseling? 1) Yes 2) No (b) If yes, who educated you? 1) Parents 2) Teachers 3) Relatives 4) Friends 5) Siblings 6) health 1) workers 7) others----------------------------------------------------------------60. (a) Were you educated with people of your age range only ( 15 to 20 years)? Yes 2) No (b) If not were they much older women than you? 1) Yes 2) No

61. How often were you having these reproductive health education sessions 1) Very often 2) often 3) occasionally 4) Rarely? 62.(a) Were these sessions useful and relevant to you? (b)If not what type of expect. 63. (a) Have you even been educated and counseled about becoming pregnant before 20 years? 1) Yes 2) No (b). If yes, who counseled you? (a) Parents/guardian (b) Teachers (c) Health workers(d) Friends e) Others .. 1) Yes 2) No did you information

(F) Cultural Factors 65. At what age do girls in your community marry.. 66.(a) Do you think this is the right age to marry according to you? Yes No. (b) If not what is the right age? .

53

67. (a) In your community do older males take advantage and entice young girls into sexual affairs without their wish? Yes No. entice them into unwanted sexual (b)If yes what methods do they use to

relations?............................................................................................................................ ............................................................................................................................................ 68.a) In your community do you ever experience rampant cases where men rape women/girls? Yes No displinary action is usually taken against (b) If yes, what

them?.................................................................................................................................. ................................................................................................................................... 69.(a) In your community are young females and males freely allowed and encourage having sex before marriage? Yes No No (b)If no are there punishments to those that are found involved in it? Yes (c) if yes is the punishment. 1) Very severe 2) severe 3) mild 4)very mild

70.In your community are there bye-laws preventing young people from indulging into sexual relationships before they are mature and of right age? Yes No

71. In your community are there cultural activities or functions that can easily entice young people into sexual activities? Yes No.

72. In your community is there a habit of segregating people in whatever form based on differences in sex(gender issues)? Yes No. 73 If yes why?...................................................................................................... Thank you very much for having spared me your precious time. Your cooperation and participation in this study will be useful to you and the district.

THANK YOU. GOD BLESSS YOU. 54

APPENDIX 3: FOCUS GROUP DISCUSSION GUIDE (F.G.D.G) FOR A STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT

Introduction
I am------------------------------------------------------------- from the DHOs Office, Kibaale District. I am part of a team involved in a study of risk factors for pregnancies

among adolescents in this district. Currently, the prevalence of adolescent pregnancy in KIbaale district is 48.5%, which is one of the highest in the country and the sub-region. It is upon this premise that we are interested in finding out the problems that adolescent girls in this community encounter that lures them to becoming pregnant so early in life . What you will tell us will help us to determine these risk factors and then design strategies that will be used to help reduce adolescent pregnancies in the district. Whatever you will share with me will be handled with confidentiality.

Procedures for the study This discussion will take about 30 minutes. No names will be required for the purposes of the study; however I will use a code for the discussion guide.

55

Benefits for the study

There are no immediate benefits to you as an individual.

However the information you give will be used to enable us to find out ways that will help strengthen the communitys involvement in preventing pregnancies among adolescents in this district and elsewhere. You will be a recorgnized and resourceful person in this study in the district. Confidentiality: Your answers will be taken generally as a contribution from resourceful members of the district. The answers will be handled with confidence and used for purposes of this study only. Voluntary consent: You are free to choose whether to take part in this study or not, and you are free to withdraw at any time at your own discretion. Your participation is purely voluntary. Feel free to ask any question before, during or after the interview. Potential risks: There are no major risks to you in participating in this study apart from taking away your privacy at this time. For any further inquiry on this study you can contact the principal investigator (.Bateganya George) through the office of the DHO Kibaale

Discussion questions
1. What are the major problems that female adolescents encounter in this district? Economically, Socially, Culturally, Social- services e.g. education, health, gender issues domestic issues etc 2. Why do girls in this community become pregnant when they are still very young? Economic reasons, Social reasons, Cultural reasons, Demographic reasons, health

56

policy, social services, media reasons, domestic reasons, education reasons, environmental reasons, generation reasons etc

3. How do you and this community feel about girls becoming pregnant at adolescence age? 4. How can a the families,

b the community c d the local government central government

e non-government organizations f schools and churches

help in preventing adolescent girls from getting pregnant in this district? 5. Are the social services that can help adolescents prevent pregnancies in this community available, acceptable and easily accessible? 6. Do you think the school systems and social set up of this community might lure the young girls into early sexuality and marriage? Thank you very much for your time.

57

APPENDIX 4 KEY INFORMANT GUIDE(KIG) FOR A STUDY OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT

Introduction I am from the DHOs office, Kibaale district. We are carrying out a study to determine risk factors for adolescence pregnancy in this district. Currently, the prevalence of adolescent pregnancy in KIbaale district is at 48.5%, which is one of the highest in the country. This is a big concern for the stakeholders of the district. We are not sure of the actual risk factors responsible for this problem. What you will tell us will help us to determine the risk factors which in turn will be used in coming up with ways of

improving on the planning for adolescent reproductive health programs in the district. Whatever you will share with us will be handled with confidentiality. Procedure for study: This interview will take 30 minutes. No names will be required for the purposes of the study; however I will use a code for the interview guide. Benefits for the study: There are no immediate benefits to you as a person. However the information you give will enable us to strengthen prevention of adolescent pregnancies in the district. You will be a recorgnized resourceful person in this study.

58

Confidentiality:

Your answers will be taken generally as a contribution from a

resourceful member of the district. The answers will be treated with confidence and used for purposes of this study only. Voluntary consent You are free to choose whether to take part in this study or not;

and you are free to withdraw at any time at your own discretion. Your participation is purely voluntary. Feel free to ask any question before, during and after the interview. Potential risks. There are no major risks to you in participating in the study apart from taking your privacy at this time. For any further inquiries concerning this study, you can contact the principal investigator (Bateganya George) through the DHOs office. In depth interview questions: 1. What is your opinion about girls becoming pregnant during adolescence? 2. What do you think are the main reasons for girls becoming pregnant early in life in this place? 3. How does your community react to young girls becoming pregnant? 4. Does your community have a system of educating and counseling young girls on sexuality and reproductive issues? 5. Are reproductive health services in your area available and accessible? 6. What is the attitude of your community towards family planning practices? 7. Do you experience sex and gender related violence in your community? 8. Does your culture encourage early sexuality and marriage? 9. In your community how do you ensure that girls are not involved in early sexuality?

59

11 . In your community are there punishments or sanctions young people are subjected to when they get involved in early sexuality or before marriage? 12. Can the set up of your social service; schools and churches alike encourage early sexuality among adolescents? 13. Are there punishments attached to those males responsible for pregnanting young girls? Thank you very much for your time.

APPENDIX 5

TRAINING GUIDE FOR RESEARCH ASSISTANTS FOR A STUDY

OF RISK FACTORS FOR PREGNANCIES AMONG ADOLESCENTS ATTENDING ANTENATAL CARE IN KIBAALE DISTRICT

INTERVIEW TEAM DOS AND DONTS

1) DOS (a) Be courteous and respectful (b) Maintain confidentiality (c) Assure as much privacy as possible during interview to make respondent feel conformable 60

when discussing sensitive issues and to allow participant to give his/her answers without others listening or advising. (d) Use a pencil to write on the questionnaire (e) Write survey ID number on every page (f) Follow the interviewer instruction on the

questionnaire (written in italics) (g) Use only agreed terms to explain questions

2 DONTS (a) Dont write names on questionnaires (b) Dont talk about peoples responses (c) Dont assume that rural or less educated people are not intelligent

INTERVIEWING TECHNIQUES

Beginning the Interview: A respondents first impression of you will strongly affect his/her willingness to cooperate with the surveyor. Therefore it is very important that you approach each interviewee in a friendly and professional manner. Guidelines for good interviewing include the following:

61

1: Always remain neutral:

Your job as an interviewer is to

obtain the facts. An interviewer should be friendly, but firm, neutral and interested. Your tone of voice, facial expressions and even body postures all combine to establish the rapport you create with your respondent. Do not express surprise, pleasure or disapproval at any response or comment made by the respondent. 2: Answer the respondents questions: Some respondents

may question you about the purpose of the survey before agreeing to participate. Answer the respondents questions as directly as possible. However, if a respondent has questions not related to the study, at any time during the interview, politely explain that you prefer to complete the interview first and discuss his/her questions later. Once completed, you may refer the respondent to the supervisor to answer the questions. You may answer simple questios, but you do not have much time to spend

62

answering questions since you must complete a number of interviews each day.

3 Handling reluctant respondents: Occasionally, a potential respondent will refuse to participate in the survey. Do not take the initial unwillingness of a respondent to be interviewed as a final refusal. Try to put yourself in their position and think of factors that may have brought about this reaction. The respondent may not be in the right mood at that particular time or they may have misunderstood the purpose of your visit. Try to find out why the respondent is unwilling to participate, and respond accordingly. Some arguments you can use to persuade a respondent to participate are: (a)The respondent cannot be replaced by anyone else. (b)The information she/he provides will help to develop programs, which assist people like him/her.

63

(c)If confidentiality is an issue assures the respondent that his/her name will not go on the questionnaire. Questionnaires will only be identified by a number. Every one working on the survey has pledged to maintain confidentiality. Never ask the respondents name. (d)However, in some circumstances a respondent may continue to refuse. In this situation, respect the respondents right to refuse and thank the respondent for her time. Do not take these refusals personally. (4) Always interview the respondent in private setting: a respondent is much more likely to respond honestly if the interview is conducted in a private setting. All interviews should be conducted alone with the respondent. Once an interview has began and a third person enters the room or is within the hearing distance, explain to her that it is important that you interview her alone. This is especially important since the questionnaire data source has to be maintained confidential. Do not ask or write

64

the respondents name on the questionnaire. Explain to the respondent that you will not talk about his/her answers with any one and no one will ever be able to know how she/he answered.

(5) Read every question exactly as written and in sequence: The wording of each question has been carefully chosen and for that reason it is essential that you read each question to the respondent exactly as it is written. You should use only those terms decided upon during training for translation. It is very important for this survey that each question is asked to each respondent in exactly the same way.

(6) Listen to the respondent: Listening carefully to what your respondent says is as important as asking the questions on the questionnaire. Some questions in the questionnaire require you to listen to what the respondent says and record it by simply drawing a circle around the number next to a printed response

65

category. Be a good listener. Do not rush in circling the code category before you have listened to your respondent. This may be taken as a sign of disrespect or not paying attention. More importantly, people who rush into coding a response are often in danger of attributing their own biases, preferences and favorite response categories to their respondents.

(7)Probing: Occasionally, a respondent may answer a question incompletely, or seem to have misunderstood the question. The first thing to do is simply to repeat the question as written a second time. If this does not help, you will have to probe to obtain the response. For example, Could you explain that a little more? or Could you be more specific about that? You must never interpret a respondents answer and then ask the respondent if your interpretation is correct. Some questions include probe questions in the interviewer instructions.

66

(8)Others: If, when reviewing the completed questionnaire, the supervisor requests the clarification that the interviewer cannot provide , do re-visit the respondent to try to be sure what is recorded on the questionnaire truly reflects the respondents view. Do not try to guess the respondents answergo back and ask again.

(9) Review questionnaire: Familiarize yourself with questions, response categories and skip patterns before field work begins. If a person answers a specific unrelated or gives a completely different answer among the coded ones on the subject, do not write in as others if it is actually an inappropriate answer is the real answer. Make sure an answer cannot fit into one of the precoded categories before you write it as others.

67

Annex 6: Human Resources and Work Plan for the execution of the research. Each Research Assistant (RA) will conduct KI interviews and administer semi- structured questionnaires. Two will be paid to conduct FGDs. They will report each days activities to the PI who will check tools for completeness and accuracy. The plan for execution of the research is as shown in table 1 below.

Table 1: Work plan for the research implementation

Annex 7: Budget for the research implementation

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Budget justification: Stationary, Printing and Photocopying Once the proposal has been developed, it will need to be printed and photocopied for review by the supervisors at least three times. If approved, the tools like the questionnaire will need to be printed and photocopied for pre-testing. For the questionnaire it will need to be photocopied to get copies up to the targeted 484 respondents. Key Informants and Focus Group Discussion Guides will need to be printed and photocopied as well. File folders will need to be bought too. Training of research assistants

69

The PI will recruit and train four RAs to collect data from the respondents. Prior to data collection, the RAs will be trained for two days on how to collect data and manage it. This is aimed at quality control. This will require an allowance to cater for lunch, work time pay and transport for each RA. Stationary will have to be purchased. Pretesting data collection tools The data collection tools will be pre-tested in three health centers, modified as the need will arise before finally being distributed to the RAs for final use. It will require money for meals and work time pay for RAs.

Data collection by research assistants (RA) This will take about 21 working days. The RAs will need transport. Motorcycles will be hired for each day. Allowances will be required to cater for their meals, drinks and work time pay for the RAs. It will be required to hire a tape recorder from radio stations.

Supervision The PI will ensure that there is quality data collection through effective supervision. This will require transport hire to the field and back to the place of residence.
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Data Analysis The PI will enter data into EPIDATA version 3.1 then exported to STATA version 10.0 for analysis (univariate and bivariate including graphs) in person in consultation with his supervisors. Charts and graphs will be generated using Microsoft Excel software, 2003. Writing report, printing, photocopying and binding the final copy of dissertation After the study is accomplished, a report in form of dissertation will be drafted with guidance from the supervisors. This will be printed and taken for approval by the supervisors. Once approved 10 copies will be photocopied and bound. Principal investigators facilitation allowances The PI will require paying for his accommodation, meals, transport and other inevitable expenses while in the field throughout the period of data collection.

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Annex 9: Map of Uganda showing Kibaale district

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Annex 10: Map of Kibaale district showing sub-counties and their populations

73

ACTIVITY PLAN AND BUDGET

Activity Plan Solicit for permission from; - CAO - Political leaders - DDHS to do the research Identification and selection of research assistants Identification and selection of Time Frame One week Success Indicator Permission in place Responsible Persons Investigator Budget Estimate 20 L x 3000 = 60,000/= Lunch = 4,000/= Fuel 45 L x 3000 = 135,000/= Lunch = 4,000/= 50 L x 3000 =

One week

Research assistants in place Respondents in the;

Investigator

One week

Investigator

74

respondents to be included in;

FGD KI in place One week One week Research assistant trained Logistic in place Investigator

150,000/= Lunch = 4,000/=

Focus group discussion Key informants

Training and orientation of research assistants Assembling of logistics required; Stationery Transport

0.5 million 0.1 million

- Investigator
- Research assistant - Secretary

- Questionnaires etc Testing of the data collection instruments in hospital and one HC IV and re-adjusting where necessary. Data collection; - Questionnaires

One week

Proper data collection instruments in place Questionnaires filled and updated Data by KI in place

- Investigator
- Research assistant - Secretary Investigator, research assistant Investigation and key informants

0.2 million

Weeks

0.1 million

Key Informants and observation FGD and observation

2 Weeks

0.3 million

2 Weeks

Data from FGD in place Filled data collection instruments in place Data instruments in place and organized Analysis in progress

0.3 million Investigator and FGD Investigator 0.1 million

Collecting questionnaires from research assistant Re-arrangement of data collection instruments Handing over data for analysis by experts etc Report writing, editing, proof reading, binding etc.

One week

1 week

Investigator and research assistant - Investigator

0.05 million

4 weeks

1 million

6 weeks - Typed copies of reports in place. 3 weeks - Final reports in place and

Data 1 million

analysts - Investigator - Supervisor - Mentors

- Handing to supervisors the

- Investigator

0.3 million

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final report and signing - Dissemination to stakeholders

dissemination to stakeholders

- Handing into University

76