The people of Uganda face multiple health problems and the average life expectancy for the country’s 33 million people is 53 years . Amongst adults aged 15 to 49, 6.5% carry the HIV virus and although this has fallen from the estimated prevalence of 15% in 1995, across the population as a whole 1.2 million still have HIV [2, 3]. Many children die of malaria and malnutrition is also a major concern . On average, each Ugandan woman gives birth to 6.3 children and, as a result, the population is growing at a rate of 3.2% a year with 49% being under the age of 18 . As many Ugandans rely on subsistence farming, they worry about the implications for their children of the fragmentation of their small plots of land.
There are a range of policies and programmes to address these challenges to public health. These include government health services, accounting for about 20% of total expenditure on health , and non-government organisations, some of which are aligned to religious groups. Government health services in Uganda are officially free, although the quality of these is often criticised and free services are not always available [5–7]. For example, in 2009 only half of those with advanced HIV infection who should have received antiretroviral therapy according to the 2006 WHO guidelines did so . There are particular difficulties in delivering health programmes in rural areas because of the widely dispersed population and undeveloped transport infrastructure.
This report is based on a visit to carry out a health needs assessment on behalf of CHIFCOD, (Child to Family Community Development) a local not-for-profit organisation established in 1999 in Kanungu district, South-West Uganda. Situated at an altitude of around 1,600 m, the undulating green hills are mainly farmland, with forest covering just over a quarter of the area. From conversations with community leaders, visits to educational establishments (2 primary schools, 2 secondary schools and the regional college) and health facilities (drugstores, 3 local health centres and a teaching hospital) it became apparent that although there are detailed national policies to address HIV/AIDS, malaria and population growth, many of these policies are poorly implemented.
The Ugandan Demographic and Health Survey (DHS), conducted in 2006, found that although 90% of adults were aware of the components of the national ABC strategy to Abstain from sex before marriage and Be faithful to one’s partner, only 70% were aware of the value of Condoms . Worryingly, only 56% of sexually active unmarried men reported that they had used a condom when they last had intercourse; for unmarried women the figure was even lower at 39%. When asked whether they had used a condom when they first had sex, 28% of those aged 15 – 24 years who had ever had sex said they had done so on the first occasion.
Similarly, although 97% of Ugandan adults said they knew about family planning, only 52% of married women had ever used a method. Furthermore, despite the fact that 24% of married women were currently using some form of family planning, it was notable that a further 41% of married women could be considered to have an unmet need, in that they wanted to delay a further child for two or more years, or regarded their family as complete, but were not using contraception .
Cultural factors are important in shaping sexual behaviour. Many Ugandans are religious, and faith-based organisations played an important role in the community mobilisation that reversed the first wave of the HIV epidemic [2, 9]. At that time, public health campaigns emphasised fidelity, and although the number of reported sexual partners fell and the age of first intercourse rose, concerns remain about how unequal relations between men and women affect reproductive health. The practice of paying a “Bride Price”, refundable if the marriage fails, has been seen by some as treating women as commodities and one of the factors contributing the widespread prevalence of forced sex in marriage [10–12]. Polygamy is not uncommon and for vulnerable women, sex as a transaction for presents, money or security is often a part of life .
Although malaria is common, with recent data showing that the condition accounts for around 42,000 deaths annually (126 per 100,000) , only 10% of respondents in the 2006 DHS said they had slept under an insecticide-treated net on the previous evening . Indeed, only 34% of households owned any type of mosquito net, although the preliminary findings of the 2011 survey show that this had increased to 74% . Given that insecticide-treated nets have been shown to reduce episodes of malaria by half and deaths from malaria in children by one fifth, increasing their use could make a major difference to public health [16, 17].
Across these diverse public health concerns, there is a recurring theme of good intentions not leading to the actions needed to protect health. We therefore sought to explore the gap between public policy and patterns of behaviour in Ugandan society. To investigate this, we organised a workshop with focus groups for young people to discuss their intentions and the barriers they perceived to implementing them with regard to HIV/AIDS, malaria and family planning.