PhD defense by Ms Elizabeth Kemigisha
March 12th PhD student from Uganda Ms Elizabeth Kemigisha is defending her PhD at Ghent University Elizabeth Kemigisha is PhD student at Ghent University and paediatrician and lecturer at Mbarara University of Science and Technology (South Western Uganda).
Her PhD was based on the project she has been working on since 2015 funded by VLIR UOS entitled "Mitigating adverse sexual and reproductive health outcomes through a comprehensive primary school sexuality education program in South Western Uganda".
The title of her thesis is "Comprehensive Sexuality Education for Young Adolescents in Uganda: Obstacles, Challenges and Opportunities in the Development, Implementation and Evaluation of a Primary School - Based Program" and her supervisors are Prof. Dr. Kristien Michielsen and Dr. Viola Nilah Nyakato.
We wish the best of luck to Elizabeth from the whole ICRH team!
Due to the coronavirus, we have to follow the guidelines given by the government to avoid group settings as much as possible. The defense in the faculty board room (3K3) at University Hospital Ghent will only be attended by the jury.
Find the summary below. Click here for the full text
Introduction: Sexual and reproductive health (SRH) challenges, especially teenage pregnancies and HIV/AIDS, are major public health concerns in developing countries. Since morbidity and mortality among older adolescents is high, they are largely the focus of interventions – including sexuality education. Nevertheless, understanding SRH in young adolescents and intervening at a younger stage, may be more effective from a preventive point of view. While international recommendations call for a focus on this age group, research and programming are still lagging behind. As such, there is limited information related to outcomes of SRH among young adolescents, effectiveness of interventions to improve SRH outcomes and factors that favor or
hinder successful implementation of SRH interventions among young adolescents in varied contexts.
Objectives: The general objective of this thesis is to contribute to the design, implementation and evaluation of comprehensive sexuality education programs for young adolescents (10-14 years) in Uganda. Specifically, this study aimed to describe the current status of sexual health and wellbeing of young adolescents. We further evaluated the context, implementation processes and acceptability of a comprehensive sexuality education program for young adolescents and finally evaluated the effectiveness of a comprehensive sexuality education program delivered to young adolescents in primary level schools in South Western Uganda.
Methods: The project was conducted under a VLIR-UOS funded team project among two universities in Belgium and two in Uganda. The study sites were primary level schools in Mbarara district, South Western Uganda. We used a cluster randomized trial design to evaluate the effectiveness of a comprehensive sexuality education program in primary schools and used mixedmethods research to assess its implementation. The intervention was a comprehensive sexuality education (CSE) program, a set of 11 lessons designed from adaptation of recommended international and national guidelines on sexuality education. The lessons were delivered by trained volunteer university student educators in 15 intervention schools over a period of 9 months. The entire study was guided by a community
advisory board to ensure cultural appropriateness of the program.Monitoring tools were developed at the beginning of the project and data was sequentially captured in the course of the implementation. Evaluation undertook two forms – effectiveness evaluation and process evaluation. A cluster randomized trial design for evaluation of the effectiveness of CSE in 33 primary schools was set up (n=1100). Pre- and post-intervention evaluation surveys were conducted a year apart. A total of 15 schools were randomly selected as intervention schools while 18 were in the control group. Analysis for the changes in selected outcomes was done using ordered logistic regression to compare differences in the change from baseline to end line between the intervention and control arms. In addition to quantitative evaluation, qualitative interviews were conducted among participants to assess CSE effectiveness.
Process evaluation was performed to assess the context, implementation and mechanisms of impact of the intervention as well as the quality of the design and implementation processes. We applied a mixed methods study- quantitative and qualitatiave evaluation. Data sources were project documents, monitoring data and qualitative interviews with stakeholders. Descriptive analyses were made. Qualitative data arising from the effectiveness evaluation and process evaluation was transcribed and analysed by content analysis and deductive approaches.
Results: The main findings for this thesis are presented as follows. Firstly, from the baseline survey, we established that young adolescents are at risk for poor sexual health outcomes as evidenced by inadequate SRH knowledge, insufficient and underutilized information sources, and risky sexual practices among a few who are sexually active. On positive side, the young adolescents had moderate to high scores for developmental assets that contribute to sexual
wellbeing such as self- esteem, body image and gender equitable attitudes. However, especially the latter was noted to reduce with increasing age.
Secondly, from the effectiveness study, we found higher odds of having increase in SRH knowledge among pupils in the intervention schools compared to controls (AOR: 2.18, 95% CI:1.66-2.86) and no significant differences in self-esteem, body image, onset of sexual behavior or gender equitable attitudes. Qualitative analyses indicated perceived SRH knowledge acquisition and intentions to report sexual offences and have safe sexual practices in future.
Finally, findings from the process evaluation indicated feasibility in implementation of a culturally appropriate CSE program for young adolescents in this context with wide acceptance by the stakeholders. The community advisory board played an important role in promoting acceptance on the one hand, while on the other hand affected the program quality due to limitation in integration of certain sensitive topics. Other factors that affected the design and implementation of the CSE program included restrictive socio-cultural norms that hindered inclusion of certain CSE topics, difficult geographical access to schools and school related factors- related to allocation of adequate time for lessons, large numbers of students per class with limited space.
Discussion and conclusions: The findings in this study highlight the fact that very young adolescents are exposed to SRH risks. It is important to recognize these risks and provide timely sexuality education interventions in order to mitigate adverse SRH outcomes. Additionally, very young adolescents have positive sexual health attributes that need support because these are likely to wane as they grow older. Early adolescence presents a window of opportunity for behavioral preparation since most are still abstinent and are receptive of interventions such as school-based sexuality education.
Our study findings show limited effectiveness of the CSE intervention in this age group. This study found that CSE can lead to increase in SRH knowledge among VYAs and importantly there was no significant changes in sexual behavior in the intervention compared to control group as a result of CSE. The fact that we did not observe changes in other outcomes could be attributed to several factors, including the nature of the intervention applied, short interval for the evaluation and lack of appropriate measures for this age group. Measures for sexual activity are limited in a short term due to the fact that a majority of very young adolescents are still abstinent. Newer measures for sexual wellbeing were only being piloted. There is need for further research: - to establish standardized measures for CSE in this age group, conduct long term evaluations to provide evidence for impact of CSE among very young adolescents and alternative interventions best suited promotion of SRH among very young adolescents.
Finally, the findings from the process evaluation identify key factors for successful implementation of CSE including dialogue with community stakeholders, incremental implementation – ‘a foot in door approach’ with ongoing negotiation towards inclusion of sensitive topics and being mindful of context related delivery factors. However, involvement of community stakeholders had an impact on the comprehensiveness of the designed program. More evidence is needed to identify factors that contribute to the success/failure of programs that take a rights-based approach.
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